^■^H V ... ■ • ■ • • ■—' '-?* ' . NATIONAL LIBRARY OF MEDICINE NLM DDlDbbfifi M iimrj ARMY MEDICAL LIBRARY FOUNDED 1836 WASHINGTON, D.C NLM001066884 ' ♦ / A TEXT-BOOK Practice of Medicine BY JAMES M. ANDERS, M.D., Ph.D., LL.D. Professor of the Practice of Medicine and of Clinical Medicine in the Medico- Chirurgical College, Philadelphia ; Attending Physician to the Medico- Chirurgical and Samaritan Hospitals, Philadelphia; etc ILLUSTRATED LIBRARY SURGEON GENERAL'S OFFICE APR. "15.7189K tl>l £67. SECOND EDITION* PHILADELPHIA W. B. SAUNDERS 925 Walnut Stkeet 1898 A54f t \\;1? Copyright, 1898, by W. B. SAUNDERS. ELECTROTYPED BY PRESS OF WESTCOTT & THOMSON, PHILAOA. W. B. SAUNDERS, PHILADA. PREFACE TO THE SECOND EDITION. The first edition of this text-book having been exhausted within five months, I have not found it necessary to make any important alter- ations. Various corrections and a few slight additions, however, have been made, and it is believed that the work has been thereby improved. It gives me pleasure to know that my efforts have met with the favor of the profession, and I venture to hope that this edition may find a like sphere of usefulness. PREFACE. This work is meant to introduce the student to the present state of our knowledge of the practice of medicine in general and of the diagno- sis, differential diagnosis, and treatment of disease in particular. The historic development of the subjects treated has been either briefly given or intendedly omitted, since this scarcely falls within the scope of a prac- tical treatise on medicine. Although the book as a whole is submitted to the critical judgment of a learned profession, it may be pardonable to emphasize, provisionally, a few features pertaining to the mode of treat- ing the separate subjects, or the arrangement of the material under the latter—to indicate some of the more salient lineaments, so to speak, in the general design. Since in medical schools it is taught from a separate chair, the pathology (special) of the individual affections has almost in- variably been taken up before the etiology; from this point the student will find the story of each affection a continuous one. The practitioner, however, must ever aim to associate the clinical symptoms with the morbid lesions. Under special etiology the bacteriology has been prominently men- tioned, since we owe to it the rapid progress that is being made in the study of the causation of disease. The differential diagnosis has in many instances been tabulated—an ear-mark that I confidently believe will be found especially helpful. It may be stated that not less than fifty-six diagnostic tables are scattered throughout the work, and that by far the greater number of these are my own. Such formulae have been introduced into the text, and only such, as a more or less extended experience has shown to be possessed of real thera- peutic importance. Whilst these, and all additional points relating to the treatment of the single affections, may serve as guides, particularly to the beginner, I fully appreciate how often the practising physician is 3 4 PREFACE. placed in a position in which he is compelled to form a therapeutic judgment for himself. Whenever the dosage is stated, the metric equiv- alent is placed in parentheses, the number of grams being stated in round numbers (3j—4.0; gj—32.0) in order to render it of greater practical value. In all instances, however, in which this would involve an im- portant difference in quantity the exact decimal figures are given. A considerable variation from the usual classification of diseases may be observed, but this is accounted for in the text wherever it occurs. Preference has been given to the modern orthography and termi- nology, not only because it is more euphonious, but also because of its adoption by the standard lexicographers. I have gleaned without stint from medical literature with a view to bringing the book up to date, and if I have failed to give full credit in every instance, my grateful acknowledgments are here due and are cheerfully made. The chief results of my personal experience and obser- vation, extending over a period of two decades, and derived from both hospital 'and private practice, will also be found upon these pages. I wish to thank Prof. W. C. Hollopeter, who has written some of the articles upon the diseases of children, as measles, chicken-pox, mumps, whooping-cough, and the acute diarrheas, and who has kindly aided in the preparation of those upon diphtheria and scarlatina. My cordial thanks are due also to Dr. C. L. Furbush for kind aid in preparing some of. the illustrations, to Doctors Robert N. Willson, Howard S. Anders^ and Geo. W. Pfromm for valuable assistance while the work was passing through the press, and to Dr. A. M. Davis for preparing the index. JAMES M. ANDERS. CONTENTS. PART I.—INFECTIOUS DISEASES. PAGE Typhoid Fever.............................. 1? Mountain Fever............................ bo Typhus Fever............................... "7 Relapsing Fever.............................. 72 Malarial Fever.............................. '° Dysentery................................. ™ Catarrhal Dysentery.......................... 98 Amebic Dysentery (Tropical Dysentery)................. 99 Diphtheritic Dysentery.........................102 Chronic Dysentery...........................1^5 Cholera (Epidemic)............................J°8 Yellow Fever.....................•..........11° Cerebro-spinal Meningitis.........................123 Lobar Pneumonia.............................|32 Secondary Pneumonia.........................!«' Influenza................................*™ Dengue..................................]»' The Plague................................J°» Erysipelas................................j7,^ Diphtheria................................j'* Septicemia................................195 Pyemia..................................199 Acute Articular Eheumatism........................202 Subacute Articular Rheumatism.......................213 Gonorrheal Arthritis............................213 Variola..................................215 Vaccination................................2^9 Varicella.................................231 Scarlet Fever.................................234 Measles.........................•'........245 Rubella..................................248 Whooping-cough ........................... 251 Parotitis................................258 Tuberculosis................................260 Tuberculosis of the Lymph-glands....................2^1 Acute Tuberculosis......_.....................'i'_l General Miliary Tuberculosis....................275 Typhoid Form ......-.................275 Pulmonary Form.......................277 Cerebral or Meningeal Form..................278 Acute Pneumonic Phthisis......................282 Chronic Tuberculosis..........................285 Fibroid Phthisis............................™l Tuberculosis of the Alimentary Tract...................^ Tuberculosis of the Serous Membranes..................;*07 Tuberculosis of the Pericardium...................j*«8 Tuberculosis of the Peritoneum................ • • ^°9 Tuberculosis of the Liver.......;................^jl Tuberculosis of the Genito-urinarv System............' ' ' ' tA Tuberculosis of the Fallopian Tubes, Ovaries, and Uterus..........314 Tuberculosis of the Mammary Glands..................j*15 Tuberculosis of the Brain........................ olo Tuberculosis of the Spinal Cord.....................°l° 5 6 CONTEXTS. PAGE Tuberculosis of the Heart........................315 Tuberculosis of the Arteries and Veins..................316 Treatment of Tuberculosis......................317 Syphilis..................................326 Visceral Syphilis...........................333 Syphilis of the Liver..........................334 Syphilis of the Alimentary Tract....................336 Syphilis of the Lungs.........................337 Syphilis of the Spleen........................338 Syphilis of the Circulatory System.....................338 Syphilis of the Arteries........................339 Syphilis of the Kidneys........................33J Syphilis of the Joints.........................339 Syphilis of the Testicles........................340 Leprosy.................................345 Glanders.................................348 Actinomycosis...............................350 Anthrax.................................352 Hydrophobia...............................356 Tetanus................................359 Infectious Diseases of I'nknown Etiology...................363 Muscular Rheumatism.........................363 Chronic Articular Rheumatism.....................366 Weil's Disease.............................368 Schlammtieber.............................368 Malta Fever....................• • •.......369 Febricula.................................370 Milk-sickness...............................371 Miliary Fever...............................372 Foot-and-mouth Disease..........................373 PART II.—CONSTITUTIONAL DISEASES. Diabetes.................................374 Diabetes Insipidus............................• 385 Arthritis Deformans............................387 Gout...................................392 Lithemia...............•.................400 Rachitis.................................402 Scorbutus.................................407 Infantile Scorbutus...........................411 Purpura.................................412 Hemophilia................................415 Hemorrhagic Diseases of the New-born...................418 PART III.—DISEASES OF THE BLOOD AND THE DUCTLESS GLANDS. Anemia...................................419 The Primary or Essential Anemias...................420 Simple or Benign Anemia.....................420 Chlorosis........._....................421 Progressive Pernicious Anemia...................426 The Secondary Anemias........................433 Leukocytosis.......................... 436 Leukocythemia..........................437 Pseudo-leukemia........................444 Anaemia Infantum Pseudo-leukremica................ 448 Chloroma ................................450 Diseases of the Ductless Glands.......................450 Diseases of the Suprarenal Capsules...................450 Addison's Disease......:....... ..........450 Diseases of the Thyroid Gland ...."...................454 Thyroiditis............................454 Goiter..............................455 Exophthalmic Goiter........................457 Myxedema............................461 CONTENTS. 7 PART IV.—DISEASES OF THE RESPIRATORY SYSTEM. I. DISEASES OF THE NOSE. PAGE Acute Rhinitis..............................465 Chronic Rhinitis.............................466 Autumnal Catarrh.............................469 Epistaxis.................................470 11. DISEASES OF THE LARYNX. Acute Catarrhal Laryngitis.........................471 Chronic Laryngitis.............................473 Spasmodic Laryngitis...........................475 Tumors of the Larynx...........................477 Edema of the Larynx...........................478 111. DISEASES OF THE BRONCHI. Catarrhal Bronchitis............................478 Acute Bronchitis...........................479 Chronic Bronchitis...........................483 Brochieetasis.............................487 Bronchial Stenosis.............................490 Asthma..................................491 Fibrinous Bronchitis...........................496 IV. DISEASES OF THE LUNGS. Circulatory Disturbances in the Lungs................... . 498 Congestion of the Lungs........................498 Active Hyperemia.........................498 Passive Hyperemia........................499 Pulmonary Edema.............................500 Hemoptysis............................... . 502 Pneumorrhagia..............................508 Pulmonary Embolism..........".................508 Chronic Interstitial Pneumonia........"...............510 Broncho-pneumonia............................512 Pulmonary Atelectasis...........................519 Emphysema................................522 Interlobular Emphysema........................522 Vesicular Emphysema.........................522 Compensating Emphysema.....................523 Hypertrophic Emphysema . ...................523 Senile Emphysema.........................529 Gangrene of the Lungs...........................529 Abscess of the Lungs............................532 Pneumonokoniosis.............................533 New Growths of the Lungs.........................536 Carcinoma of the Lung.........................536 Sarcoma of the Lung..........................537 Hydatid Cyst of the Lung.......................538 V. DISEASES OF THE PLEURA. Pleurisy.................................539 Acute Plastic Pleurisy........................539 Sero-fibrinous Pleurisy.........................542 Empyema...............................556 Chronic Pleurisy............................560 Pneumothorax.............................562 Hydrothorax...............................567 New Growths of the Pleura.........................568 Diseases of the Mediastinum.....................". 569 Inflammation of the Mediastinum....................569 Tumors of the Mediastinum.......................570 Diseases of the Thymus Gland.....................572 Mediastinal Hemorrhage........................572 8 CONTEXTS PART V__DISEASES OF THE CIRCULATORY SYSTEM. I. DISEASES OF THE PERICARDIUM. PAGE Pericarditis................................573 Acute Plastic or Fibrinous Pericarditis...................573 Sero-fibrinous Pericarditis.......................576 Purulent Pericarditis .........................581 Hemorrhagic Pericarditis........................582 Adhesive Pericarditis.........................582 Hydropericardium...........- ................584 Hemopericardium.............................585 Pneumopericardium............................585 II. DISEASES OF THE HEART. Endocarditis..............................586 Simple Acute Endocarditis.......................586 Ulcerative Endocarditis.........................590 Chronic Endocarditis..........................594 Aortic Incompetency............................597 Aortic Stenosis..........................., . . 603 Mitral Incompetency............................605 Mitral Stenosis..............................611 Tricuspid Incompetency..........................615 Tricuspid Stenosis.............................618 Pulmonary Incompetency..........................619 Pulmonary Stenosis............................620 Combined Forms of Cardiac Diseases.....................620 Cardiac Thrombosis............................634 Hypertrophy of the Heart.........................636 Dilatation of the Heart...........................643 Myocarditis...............................648 Acute Myocarditis...........................648 Chronic Myocarditis..........................649 Disease of the Coronary Arteries......................653 Degenerations of the Heart.........................654 Fatty Degeneration..........................654 Fatty Overgrowth..........................656 Brown Atrophy............................657 Calcareous Degeneration........................657 Amyloid Degeneration.........................657 Hyaline Degeneration.........................657 Cardiac Aneurysm.............................658 Rupture of the Heart...........................659 Minor Affections of the Heart........................660 New Growths.............................660 Parasites...............................ggg. Misplacement.............................ggj Floating Heart...........................ggj III. NEUROSES OF THE HEART. Palpitation............................... gg^ Tachycardia................................gg^ Brachycardia...........................# ggg Arrhythmia.............................\ ggy Angina Pectoris...........................] | ggo IV. CONGENITAL AFFECTIONS OF THE HEART. Arrested Development........................ g^2 Fetal Endocarditis........................' " one, V. DISEASES OF THE ARTERIES Acute Aortitis.............................. gyc Arterial Sclerosis........................... . g7g Aneurysm............................... ggQ CONTENTS. 9 PAGE Aneurysm of the Thoracic Aorta....................681 Aneurysm of the Abdominal Aorta...................690 Aneurysm of the Pulmonary Artery...................691 Aneurysm of the Coronary Arteries...................691 Aneurysm of the Celiac Axis......................691 Aneurysm of the Splenic Artery.....................691 Aneurysm of the Hepatic Artery....................691 Aneurysm of the Superior Mesenteric Artery...............692 Aneurysm of the Inferior Mesenteric Artery...............692 Aneurysm of the Renal Arteries.....................692 Arterio-venous Aneurysm........................692 Congenital Aneurysm.........................692 PART VI—DISEASES OF THE DIGESTIVE SYSTEM. I. DISEASES OF THE MOUTH. Stomatitis.................................693 Catarrhal Stomatitis..........................693 Aphthous Stomatitis..........................694 Membranous Stomatitis.........................696 Ulcerative or Fetid Stomatitis......................697 Parasitic Stomatitis..........................699 La Perleche..............................701 Gangrenous Stomatitis.........................701 Mercurial Stomatitis..........................703 II. DISEASES OF THE TONGUE. Glossitis.................................704 Acute Glossitis............................704 Chronic Superficial Glossitis.......................705 Glossitis Desiccans...........................706 Lingual Glossitis...........................706 Leukoplakia Oris.................•..........706 Angina Ludovici...........................707 III. DISEASES OF THE SALIVARY GLANDS. Hypersecretion..............................707 Xerostoma................................708 Symptomatic Parotitis...........................708 IV. DISEASES OF THE TONSILS. Acute Tonsillitis..............................709 Chronic Tonsillitis.............................715 V. DISEASES OF THE PHARYNX. Pharyngitis................................718 Acute Pharyngitis........................... 718 Membranous Pharyngitis........................719 Chronic Pharyngitis..........................720 Acute Infectious Phlegmon of the Throat ..................721 Retropharyngeal Abscess..........................722 VI. DISEASES OF THE ESOPHAGUS. Esophagitis.................................722 Acute Esophagitis...........................722 Chronic Esophagitis..........................724 Ulcer of the Esophagus...........................724 Carcinoma of the Esophagus........................724 Rupture of the Esophagus.........................726 Neuroses of the Esophagus...............,.........727 Muscular Spasm............................727 Paralysis of the Esophagus.......................727 10 CONTENTS. PAGE Dilatation of the Esophagus.........................^q Esophageal Diverticulum..........................' „ Stricture of the Esophagus......................... VII. DISEASES OF THE STOMACH. 1700 Methods of Diagnosis...........................i.'ZZ Examination of the Gastric Functions..................';?•* Physical or External Examination....................'J** Malposition of the Stomach.........................' Gastroptosis..............................' „ Dilatation of the Stomach.........................„ _ Inflammatory Diseases of the Stomach ... ................'Jy Acute Catarrhal Gastritis........................Jz Toxic Gastritis............................'^ Diphtheritic Gastritis.........................jy\ Acute Suppurative Gastritis....................../51 Chronic Catarrhal Gastritis.......................'J3- Gastric Ulcer................................£61 Carcinoma of the Stomach........................./,„*; Hematemesis...............................(lJt Neuroses of the Stomach..........................'J.' Nervous Dyspepsia...........................''' Neuroses of Secretion..........................nau Hyperchlorhydria.........................J™* Neuroses of Motility..........................782 Increased Peristalsis of the Stomach ..........-•.......782 Diminished Peristalsis of the Stomach................782 Neuroses of Sensation.........................^83 Cardialgia............................'°3 Hyperesthesia of the Stomach....................785 Anorexia.............................'°o Hyperorexia..... .....................786 VIII. DISEASES OF THE INTESTINES. Methods of Diagnosis...........................786 Enteroptosis.......................'.......789 Intestinal Catarrh.............................790 Diarrheas of Children...........................^98 Acute Gastro-intestinal Catarrh.....................798 Celiac Disease.............................802 Phlegmonous Enteritis...........................803 Croupous or Diphtheritic Enteritis......................803 Cholera Morbus..............................804 Intestinal Infarction............................806 Intestinal Ulcers..............................806 Duodenal Ulcer............................806 Follicular Ulcers.................,.........809 Stercoral Ulcers...........................809 Simple Ulcerative Colitis........................809 Solitary Ulcers............................810 Diffuse Catarrhal Ulcer.........................810 Cancerous Ulcer . . .........................810 Appendicitis...............................810 Chronic Appendicitis..........................822 Recurrent Appendicitis.........................823 Intestinal Obstruction.........................• . 826 Carcinoma of the Intestine.........................833 Habitual Constipation...........................836 Dilatation of the Colon...........................840 Neuroses of the Intestine..........................840' Secretory Disturbances.........................840 Membranous Enteritis.......................840 Sensory Disturbances..........................841 Enteralgia...........................841 Diminished Intestinal Sensibility..................842: CONTENTS. 11 PAGE Disturbances of Motility........................843 Nervous Diarrhea........................ . 843 Enterospasm...........................843 Constipation...........................844 IX. DISEASES OF THE LIVER. Anomalies in Shape and Position......................845 Jaundice................................846 Catarrhal Jaundice..........................847 Other Forms of Jaundice........................850 Biliary Calculi.............................851 Chronic Obstruction of the Duct by Gall-stones..............854 Obstruction of the Common Duct..................854 Obstruction of the Cystic Duct...................855 More Remote Effects of Gall-stones...................856 Carcinoma of the Bile-ducts.........................859 Stenosis of the Bile-ducts - • ■ ,.......................860 Icterus Neonatorum............................862 Vascular (Circulatory) Affections of the Liver................863 Anemia ...............................863 Hyperemia..............................863 Acute Hyperemia...........................863 Passive Hyperemia..........................864 Diseases of the Portal Vein.........................865 Thrombosis and Embolism.......................865 Suppurative Pylephlebitis.......................866 Stenosis................................868 Affections of the Hepatic Blood-vessels....................868 Atrophy and Hypertrophy of the Liver...................868 Hepatic Infiltrations and Degenerations...................869 Amyloid Infiltration..........................869 Fatty Infiltration...........................871 Fatty Degeneration...........................872 Perihepatitis...............................873 Acute Perihepatitis..........................873 Chronic Perihepatitis.........................875 Abscess of the Liver............................876 Acute Yellow Atrophy...........................881 The Liver in Phosphorus-poisoning.....................883 Cirrhosis of the Liver...........................885 Carcinoma of the Liver...........................892 Other New Growths in the Liver......................896 X. DISEASES OF THE SPLEEN. Dislocation of the Spleen..........................898 Splenic Hyperemia............................898 Splenitis.................................899 Amyloid Degeneration of the Spleen.....................901 Morbid Growths of the Spleen..................... . . . 901 Rupture of the Spleen...........................901 XI. DISEASES OF THE PANCREAS. Acute Pancreatitis.............................902 Hemorrhagic Pancreatitis........................902 Suppurative Pancreatitis........................904 Gangrenous Pancreatitis........................904 Chronic Pancreatitis............................905 Pancreatic Hemorrhage..........................906 Carcinoma of the Pancrea3.........................907 Pancreatic Cyst..............................909 Pancreatic Calculi.............................910 12 CONTENTS. XII. DISEASES OF THE PERITONEUM. PAGE Acute Peritonitis............................910 Localized or Partial Peritonitis.....................91o Chronic Peritonitis............................"'^ Ascites................................j^" New Growths in the Peritoneum.......................927 Carcinoma of the Peritoneum......................927 PART VII.—DISEASES OF THE URINARY SYSTEM. I. DISEASES OF THE KIDNEY. Mobility of the Kidney..........................929 Circulatory Disorders of the Kidneys.....................933 Active Hyperemia...........................933 Passive Hyperemia...........................933 Special Pathologic States of the Urine....................934 Hematuria..............................934 Hemoglobinuria............................936 Albuminuria.............................93/ Peptonuria and Albumosuria.................. ... 941 Indicanuria..............................941 Pyuria................................942 Chyluria...............................943 Choluria...............................944 Urobilinuria.............................945 Glycosuria..............................945 Acetonuria, Diacetonuria, and Oxybutyria................948 Lithuria...............................949 Oxaluria...............................950 Phosphaturia......•......................951 Leucinuria and Tyrosinuria.......................952 Cystinuria...................,..........952 Various other Conditions........................953 The Nephritides.............................955 Morphologic Constituents of the Urine in Renal Disease..........955 Dropsy of Renal Disease........................957 LTremia................................958 Amyloid Kidney.............................962 Nephrolithiasis.............................964 Acute Nephritis .............................970 Chronic Nephritis (Exudative).......................977 Chronic Nephritis (Non-exudative).....................981 Pyelitis . . . _................................989 Hydronephrosis..............................993 Perinephric Abscess............................996 Cystic Kidney...............................997 New Growths of the Kidney........................999 II. DISEASES OF THE BLADDER. Cystitis.................... .............1001 Acute Cystitis.............................1001 Chronic Cystitis............................1005 Neoplasms of the Bladder.........................1006 Vesical Hemorrhage............................ . 1007 Neuroses of the Bladder..........................1007 Irritability of the Bladder..........,............1007 Neuroses of Micturition........................1010 PART VIII—DISEASES OF THE NERVOUS SYSTEM. Introduction...............................1012 CONTENTS. 13 I. DISEASES OF THE PERIPHERAL NERVES. PAGE Acute Ascending Paralysis.........................1026 Neuritis.................................1928 Neuromata................................1032 Neuralgia...............................1032 Neuralgia of the Head.........................1034 Neuralgia of the Neck and Trunk ...................1034 Neuralgia of the Extremities......................1035 Diseases of the Cranial Nerves.......................1037 Diseases of the Olfactory Nerve.....................1037 Diseases of the Retina, Optic Nerve, and Tract..............1038 Diseases of the Motor Nerves of the Eyeball...............1042 Diseases of the Fifth Nerve.......................1046 Diseases of the Seventh or Facial Nerve.................1048 Diseases of the Auditory Nerve...................• 1050 Meniere's Disease.........................1052 Diseases of the Glosso-pharyngeal Nerve.................1053 Diseases of the Pneumogastric Nerve..........•.......1053 Diseases of the Spinal Accessory Nerve.................1057 Torticollis............................1057 Paralysis of the Spinal Accessory Nerve.................1059 Diseases of the Hypoglossal Nerve....................1059 Diseases of the Spinal Nerves........................1061 Diseases of the Cervical Plexus.....................1061 Diseases of the Brachial Plexus.....................1061 Diseases of the Lumbar and Sacral Plexuses................1063 II. DISEASES OF THE SPINAL CORD AND ITS MENINGES. Diseases of the Meninges..........................1064 Pachymeningitis............................1064 Leptomeningitis............................1065 Acute Leptomeningitis.......................1065 Chronic Leptomeningitis......................1066 Hemorrhage into the Spinal Meninges..................1067 Disturbances of Circulation in the Cord...................1068 Hemorrhage into the Spinal Cord......................1069 Acute Myelitis..............................1070 Chronic Myelitis .............................1073 Anterior Poliomyelitis..........................1074 Essential Paralysis of Children.....................1074 Acute, Subacute, and Chronic Poliomyelitis in Adults...........1076 Abscess of the Spinal Cord.........................1077 Unilateral Lesion of the Spinal Cord.....................1077 Locomotor Ataxia.............................1078 Hereditary Ataxia.............................1083 Spastic Paraplegia.............................1084 Primary Lateral Sclerosis.........................1085 Secondary Spastic Paralysis.......................1087 Congenital Spastic Paraplegia......................1087 Ataxic Paraplegia...........................1087 Combined System Sclerosis.......................1087 Reflex Paraplegia...........................1088 Intermittent Paraplegia.....................• . . 1088 Multiple Sclerosis.............................1088 Bulbar Paralysis..............................1091 Progressive Muscular Atrophy (Myelopathic)...............• • 1092 Syringomyelia...............................1094 Compression of the Spinal Cord ......................1096 Tumors of the Spinal Cord and its Membranes...............1097 Lesions of the Conus Terminalis and the Cauda Equina............1101 III. DISEASES OF THE BRAIN AND ITS MENINGES. Diseases of the Dura Mater.........................1101 Diseases of the Pia.............................1104 14 CONTENTS. PAGE Disturbances of Circulation of the Brain...................110^ Hyperemia..............................1105 Anemia................................HO" Edema of the Brain...................•......1107 Embolism and Thrombosis.......................1107 Vascular Degeneration.........................1111 Inflammation of the Brain.........................1112 Focal Encephalitis...........................1112 Diffuse Encephalitis..........................JH3 Cerebral Hemorrhage...........................1113 Aphasia.................................1H8 Intracranial Growths............................1122 Chronic Hydrocephalus..........................1126 External Hydrocephalus........................1126 Internal Hydrocephalus........................1127 Sclerosis of the Brain............................1129 General Paralysis of the Insane.......................1129 Cerebral Palsies of Childhood........................1131 Acute Delirium..............................1133 IV. DISEASES OF UNKNOWN PATHOLOGY. Epilepsy.................................1135 Migraine.................................1140 Acute Chorea...............................1142 Chronic Chorea..............................1145 Rhythmic Chorea..............................1146 Choreiform Disorders...........................1146 Paramyoclonus Multiplex........................1146 Chorea Electrica............................1147 Fibrillary Chorea...........................1148 Athetosis..............................1148 Habit-spasm.............................1149 Tic Convulsif.............................1150 General Tic..............................1152 Saltatoric Spasm............................1153 Chorea Major.............................1153 Paralysis Agitans.............................1153 Other Forms of Tremor..........................1155 Tetany..................................1155 Infantile Convulsions...............•.............1158 Occupation-Neuroses............................1161 Periodic Paralysis.............................1162 Hysteria.................................1163 Neurasthenia...............................1173 Acromegaly................................1178 Astasia-abasia................................1181 Caisson Disease.............................. 1182 V. VASOMOTOR AND TROPHIC DISORDERS. Angioneurotic Edema . . .........................1183 Hydrops Articulorum Intermittens.....................1184 Raynaud's Disease.............................1184 Progressive Hemiatrophy of the Face....................1186 Scleroderma Diffusum...........................1188 Morphea.................................1189 Ainhum .................................1190 Erythromelalgia...........................■ . . . 1190 Acroparesthesia.............................. 1191 PART IX.—DISEASES OF THE MUSCLES. Myositis.................................1192 Infectious Myositis...........................1192 Progressive Ossifying Myositis.....................H93 Progressive Spinal Muscular Atrophy....................H93 CONTENTS. 15 PAGE Neural Progressive Muscular Atrophy..................1193 Pseudohypertrophic Muscular Paralysis...................1195 Dystrophia Musculorum Progressiva (Erb)..................1196 Dystrophia Musculorum Progressiva (Dejerine-Landouzy)............1198 Hereditary Muscular Paralysis.......................1199 Arthritic Muscular Atrophy................ .......1199 Muscular Atrophies..........................1200 Muscular Hypertrophy.........................1200 Thomsen's Disease.............................1200 PART X.—THE INTOXICATIONS; OBESITY; HEAT=STROKE. The Intoxications.............................1203 Alcoholism...............•..............1203 Ginger and Cologne-water Inebriety...................1210 Morphinism.............................1210 Plumbism...............................1212 Arsenicism..............................1215 Mercurialism.............................1216 Food-infection and Ptomain-poisoning.............. ... 1218 Grain- and Vegetable-poisoning.....................1220 Obesity..................................1221 Heat-stroke.....•............." *...........1226 PART XI.—ANIMAL PARASITIC DISEASES. Psorospermiasis..............................1232 Distomiasis................................1233 Nematodes................................1234 Ascariasis...............................1234 Ankylostomiasis.............-..............1238 Trichiniasis..............................1239 Filariasis...............................1243 Dracontiasis..............,............... 1245 Other Filarise......................•......1246 Other and Uncommon Nematodes....................1246 Cestodes.................................1247 Taenia? or Tape-worms.........................1252 Taenia Nana..............................1256 Taenia Cucumerina...........................1256 Taenia Flavopunctata . .......................1256 Parasitic Arachnida . . . ,........................1256 Other Parasitic Insects..........................1257 Pediculosis..............................1257 Cimex Lectularius...........................1258 Pulex Irritans...........................1258 Pulex Penetrans...........................1258 Ixodes................................1259 Dermanyssus Avium et Gallinae....................1259 Culicidse...............................1259 Hirudo ...............................1259 Estridse................................1259 Muscidse............................... 1259 PART I. INFECTIOUS DISEASES. TYPHOID FEVER. (Enteric Fever; Abdominal Typhus; lleo-typhoid; Nerven Fieber.) Definition.—An acute infectious disease of which the definitive cause is the specific bacillus of Eberth. It is characterized, patholog- ically, by hyperplasia and sloughing of Peyer's patches; and clinically by its slow, insidious onset, peculiar temperature-curve, swelling of the spleen, rose-colored spots, diarrhea, tympanites, and a liability to cer- tain complications (intestinal hemorrhage, peritonitis, etc.). The disease has an average duration of from three to four weeks. History.—Although known beyond the reach of tradition, typhoid fever was clearly distinguished from typhus at a comparatively recent date. Louis of Paris in 1829 proposed the term typhoide, but it re- mained for Gerhard of Philadelphia to discriminate typhoid from typhus fever as the result of his own precise clinical observations. His account of the disease was ably corroborated by the writings of E. Hale and James Jackson, Sr. (1838, 1839). Later, Shattuck of Boston and Jenner of London made important contributions to the subject. Shattuck's experiments on typhus and typhoid fevers at the London Fever Hospital in England, and Alfred Still^'s studies of the former affection in Dublin and Naples, and of the latter in Paris, in- creased greatly our knowledge of these diseases. As a result of the labors of the above-mentioned American authors the true nature and identity of typhoid fever were appreciated in America at an earlier day than in either France or England. Briefly, the decade from 1840 to 1850 witnessed, on the one hand, the overthrow of erroneous notions concerning the similarity of typhoid and typhus fevers, and, on the other, the establishment of their points of dissimilarity. Pathology.—The lesions produced by typhoid fever may conve- niently be divided into two groups: (1) Primary lesions, due to the direct effect of the special bacillus upon the lymph-follicles of the intestines, the mesenteric and other lymph-glands, and the spleen. (2) Secondary lesions, due chiefly to the long-continued fever and to secondary infection, for the occurrence of which the essential lesions of typhoid fever furnish the golden opportunity. (1) The primary morbid changes in the Peyer's patches and solitary glands of the intestines are divided, usually, into four stages: (a) The Stage of Infiltration.—The lymph-follicles become engorged 2 17 18 INFECTIOUS DISEASES. (hyperplasia), particularly Peyer's glands in the ileum and near to the valve, and, to a lesser extent, in the lower part of the jejunum. Fre- quently, the solitary glands in the small intestines, the colon, and rarely the rectum, become similarly infiltrated. In about 33 per cent, of the cases the chief morbid lesions are confined to the large intestines. In mild cases a few Peyer's patches in the lower part of the ileum are alone the seat of infiltration and subsequent changes. The follicles are grayish- white in color, and may project—particularly the patches of Peyer— from 3 to 5 mm. or more. Rarely, the solitary glands, which vary in size from a mustard-seed to a large pea, become very prominent and show a bold attempt at pedunculation. The histologic changes at first consist in a marked dilatation of the capillary blood-vessels, which later are more or less compressed (as a consequence of cell-infiltration), giving to the follicles their whitish, anemic appearance. The cellular elements partake of the nature of lymph-corpuscles. Some of these cells are larger and are epithelioid in character, with ten or more nuclei. The mucosa and muscularis ad- jacent to the glandular structures may be similarly infiltrated. From the eighth to the tenth day the stage of infiltration terminates either in resolution or in necrosis and sloughing. The infiltrated cells may undergo granular or fatty degeneration, followed by absorption. This process—resolution—during its progress produces pitting of the swollen follicles. In consequence of these minute points of necrosis the plaques now present a characteristic reticulated appearance (plaques a surface re'ticule'e). When resolution occurs, accompanied by destruc- tion of the follicles, small hemorrhages may take place into the glandu- lar structure. These hemorrhages may occasion pigmentary deposits in the follicular depressions, giving rise to the so-called " shaven-beard " appearance. Resolution, however, terminates the stage of medullary infiltration with relative infrequency. Far more frequently the hyper- plasia of the lymph-follicles ends in (b) Necrosis or Sloughing.—In all save the milder grades of cell- infiltration the hyperplasia of the lymphatic tissue cannot subside before necrosis occurs. The latter process results partly from com- pression and choking of the blood-vessels by the cell-infiltration, and partly from the direct action of the typhoid bacillus, leading to so-called anemic necrosis. Thus, necrotic crusts (sloughs) are formed, which are gradually separated and cast off. While not all of the glands of Peyer which are the seat of cellular infiltration undergo subsequent necrosis, as a rule those situated in the lower portion of the ileum do, and show the process in its completest development. The depth to which the necrosis extends is quite variable. It may involve only the most super- ficial layers of the mucosa, or it may extend in depth till it reaches, or even perforates, the outer or serous coat; but usually this work' of destruction does not dip below the submucosa or muscularis. The necrosed portions become detached—a process that proceeds from the periphery toward the center—leaving behind the typhoid ulcer. The stage of necrosis and sloughing begins between the eighth and tenth days, and ends on or about the twenty-first day. (c) Stage of Ulceration.—The size and shape of the ulcers corre- spond exactly to the necrosed areas in these respects. A single gland TYPHOID FEVER. 19 of Peyer generally presents several ulcers of irregular outline separated by strips of mucous membrane. Rarely, the entire plaque is implicated, in which case a large oval ulcer is the result, and at the lower end of the ileum the ulcers often coalesce until they almost encircle the bowel. The ulcers of the solitary glands assume a rounded form. The character of the floor of the ulcer will vary with the character of the intestinal coat which forms its base, though usually it is clean and smooth. The edges are usually irregular, engorged, soft, and frequently overhanging. In the lower segment of the ileum ulcers may be numerous, whilst in other portions of the gut Peyer's plaques may be merely hyperemic. In about 25 per cent, of the cases the typhoid ulcers are found in the large intestines—i. e. in the cecum and colon. Perforation of the large bowel is exceedingly rare. Exceptionally, the appendix is the seat of ulcer, Osier having dissected a case that died three months after an attack of typhoid fever, in which he found a localized abscess due to perforation of the appendix. Hemorrhage usually results from erosion of a vessel—an accident which is occasioned by the separation of the sloughs—but small bleed- ings may take place from the swollen, hyperemic edges of an ulcer. Perforation of the bowel occurs in a small percentage of cases (about 6 per cent.). In the majority of instances it is attributed to a perfora- tive necrosis; hence it is that the sloughs are usually found attached to the orifice. Perforation may also occur after the separation of the necrosed portions during the stage of ulceration. The perforations may be multiple, though they are usually single and rarely exceeding two in number. The small, deep ulcers are more apt to lead to complete per- foration than larger ones, and the site of the orifice is usually some- where in the course of the lowTer third of the ileum. The lesions of peritonitis are invariably present, and during the stages of necrosis and ulceration a catarrhal state of the mucosa of the small and large intestines exists. The diarrhea which usually accompanies this affection is to be ascribed chiefly to the catarrhal state of the large bowel. (d) Healing follows promptly upon the formation of the ulcer. At first a granular tissue covers its floor. The mucous membrane is replaced, including the glandular elements and epithelial layer, and, as in the stage of necrosis and sloughing, so the healing process advances inward from the border of the ulcer. Indeed, it is this process that dis- lodges the necrotic crust. Occasionally, ulcers are seen extending in one direction while healing in another. The cicatrix formed by the healing of an ulcer presents a smooth and often pigmented surface. The stages thus far described do not, strictly speaking, follow one another, since two or more may be illustrated at once by a group of ulcers occupying the same section of the intestine. Again, when death occurs during a relapse fresh ulcers are observed by the side of others that are partially healed. The Mesenteric Glands.—Changes in the mesenteric glands occur simultaneously with those in the intestines, and those situated opposite to the lower third of the ileum, the portion of the bowel showing the most extensive ulceration, are most profoundly involved. Hyperemia, and later swelling due to cell-infiltration, are among the earliest 20 INFECTIOUS DISEASES. changes, and correspond with the lesions noted in the intestines (vide supra). The mesenteric glands exhibit great variations in size, rang- ing, as they do, from that of a pea to a hen's egg. Their color-appear- ance is a grayish-red. Resolution occurs quite commonly, but, if it does not take place, then necrosis of the central portion (due, most probably, to the same causes that produce necrosis of the intestinal lymph-follicles) .occurs, and suppuration has been observed in some cases. Still other glands become hyperemic and swollen (retroperi- toneal, bronchial, etc.); but these almost invariably tend toward resolution. The Spleen.—With rare exceptions the spleen becomes enlarged in typhoid fever. At first hyperemic, the tissue then grows soft and gran- ular, and at times is almost diffluent on section. Infarction is not a rare occurrence and may lead to suppuration. In some few cases, either spontaneously or as the result of injury, a rupture of the organ may occur, and the records of 2000 post-mortems at the Munich Patho- logic Institute furnish 5 instances of this nature. (2) Secondary Lesions due chiefly to the Continued Fever and to Sec- ondary Infections.—The lesions in other organs are of subsidiary import- ance, and are, for the most part, secondary in nature, though we can-, not, in the present state of our knowledge, draw a sharp line of dis- tinction between these lesions and those that are primary. AVhile the pathologic changes above described are chiefly due to the direct action of the specific bacillus of typhoid, yet a few of them are ascribed to secondary infection, and, at all events, they do not belong peculiarly to this disease—e. g. suppurative processes, etc. Further, in connection with the clinical history of the affection I shall point out that in a small percentage of cases the initial specific lesions may be localized, either in the throat or in the lungs or kidneys. It is to be emphasized, therefore, that whilst the essential pathologic processes of the disease have been described above, a classification of the lesions into primary and secondary, based upon the involvement of particular organs, can only be approximately correct. The liver early becomes hyperemic, and later is softer and paler than is natural. Handford has described necrotic areas, and Wagner minute lymphomata. Infarction and abscess occur in rare instances. The mucosa of the gall-bladder may show catarrhal inflammation, and in very rare instances a croupous, diphtheritic, or ulcerative inflammation of this organ may occur. The bile is thinner and paler than the normal. The microscope reveals parenchymatous and granular degeneration. The cells contain an abundance of fat, whilst their nuclei have lost, in great part, their outline. The kidneys, like the liver, exhibit parenchymatous degeneration. They are somewhat pale-looking, are cloudy on section, and slightly swollen, and under the microscope granular and fatty degeneration of the epithelial cells of the convoluted tubules is observed. More rarely the lesions are those of acute hemorrhagic nephritis. Small areas of round-cell infiltration may develop late in the course of typhoid, and these may present an appearance similar to lymphomata or may undergo softening and suppuration, giving rise to miliary abscesses. The mu- TYPHOID FEVER. 21 cous membrane of the pelvis of the kidney is not infrequently the seat of a mild grade of catarrh, and, rarely, of diphtheritic inflammation. Vesical catarrh is still more common, and the bladder may also be the seat of diphtheritic inflammation. Rarely orchitis is encountered. On making cultures from sections of the kidneys not a few observers have been able to demonstrate the specific bacillus of typhoid, particularly in the softened areas. In the lungs are found morbid lesions in nearly all cases of typhoid fever, and belonging to the essential pathologic processes is bronchitis, due to a congested and catarrhal state of the bronchial mucous mem- brane. The lesions of lobular pneumonia present a complicating con- dition in many instances ; those of lobar pneumonia also may be present, though less commonly. The so-called hypostatic congestion is often found, but is, I think, less frequent than is supposed by many authors. Embolic infarctions, having their origin in thrombi occupying the right side of the heart, are sometimes present. Gangrene may also occur. Pleurisy is sometimes, though rarely, met with. It is most fre- quently of the plastic variety, although empyema occurred in nearly 2 per cent, of the Munich cases. The larynx and the pharynx may manifest changes. Ulcers have been observed on the epiglottis and posterior wall of the larynx, and I have more than once seen them on the pharynx. When situated in the larynx they may extend in depth till they reach the perichondrium, causing perichondritis, with or without edema of the larynx as an associated lesion. Typhoid bacilli have been found in the ulcers (Eich- horst). Catarrhal, or even croupous, pharyngitis may occur, and a swelling of the follicles of the pharynx and base of the tongue is to be noticed in many cases. True aphthous changes, affecting the mouth and pharynx, may be present as a secondary event. The mucosa of the stomach is sometimes congested, and may even ulcerate, although this is very rarely seen. Peritonitis is always found in fatal cases in which the bowel has been perforated. The condition is a general one, save in the rare instances mentioned below, and there is usually much fibrino-purulent effusion present. Diffuse peritonitis may be present without perforation, and results sometimes from a localization of the typhoid poison in the peri- toneum, from rupture of suppurating mesenteric glands, but more fre- quently, I think, from direct extension of intestinal inflammation to the peritoneum. The heart may be the seat of morbid changes. Acute endocarditis may be a very rare complication, while pericarditis occurs relatively more often—viz. in 14 of the Munich post-mortems before mentioned. Myocarditis is a not uncommon event, the cardiac muscle exhibiting parenchymatous and, less commonly, hyaline, degeneration, and the lat- ter change sometimes leads to sudden rupture of the muscular fibers, with a fatal result (myocardite se'gmentaire). It is, however, a signif- icant fact that in the majority of instances, even of the severest type, the cell-fibers may show slight, if any, noticeable change. Out of 48 cases, 16 showed granular or fatty degeneration, and 3 a proliferative endarteritis in the small vessels (Dewevre). The arteries have, in a number of instances, been found to be the 22 INFECTIOUS DISEASES. seat of two forms of arteritis (Barie): (a) Acute obliterating arteritis, and (b) Partial arteritis. These conditions may affect the smaller ves- sels, particularly those of the heart, but they occur most commonly in the arteries of the lower extremities. Thrombi are found in the right chambers of the heart and in the veins—most frequently in the femoral, and less often in the cerebral sinuses. The voluntary muscles undergo parenchymatous and, occasionally, a hyaline, change, though this is not a feature peculiar to typhoid fever. The latter form of degeneration does not affect the whole muscle, only certain fibers being involved, and as a rule the recti abdominis, the dia- phragm, the adductors of the thigh, and the pectorals are the seats of the lesion. The parts affected are pale and possess a grayish, waxy luster. Histologically, the process implies the transformation of the muscular fibers, and especially the cement substance, into a homogeneous, pliable mass. Regeneration of the fibers thus destroyed occurs during convalescence. The nervous system presents no gross lesions, if we except menin- gitis, the latter occurring as a complication; but it is exceedingly rare, having been present in only 11 of the 2000 Munich cases. In a few instances large cerebral hemorrhages have been met with, but these are apparently coincidental, while capillary hemorrhages into the cortex may be numerous. Meningeal hemorrhages may also occur. Slight edema of the cerebral cortex has been noted. The peripheral nerves are, not infrequently, the seat of parenchymatous change, with or with- out local neuritis, and the ganglia of the trunks of the vagi exhibit an inflammatory change, which Levin feels is the cause of certain symp- toms and conditions, such as laryngitis, pharyngitis, pharyngolysis, arrhythmia, etc. The blood shows few important alterations. The red blood-corpuscles are relatively increased during the febrile period and markedly dimin- ished during convalescence, but the great loss of water during the former period and a reabsorption during the latter will explain these interesting facts (Henry). Leukocytosis is absent, and there is often an actual decrease in the number of leukocytes. The mononuclear forms are more numerous than in health. Etiology.—Bacteriology.—The bacterium which is the specific cause of typhoid fever was discovered by Eberth, whose researches were later confirmed by the careful investigations of Gaffky. It is a short, thick bacillus, about three times as long as it is broad, with rounded ends (Fig. 1). It is motile, due to the presence of cilia on both sides, and when stained exhibits vacuolations that have been mistaken for spores. It is easily stained with all the anilin dyes. It has been found in the intestinal tract, in the lymph-glands, contents of the intes- tine, spleen, liver, and blood; in fact, it has been found in nearly all the organs of the body. Upon gelatin plates it develops in grayish translucent colonies with irregular borders and ridged surfaces. Upon agar the growth is not characteristic; upon the potato, especially if it has been rendered slightly acid, it forms a perfectly transparent growth that is only evident as a slight apparent increase of moisture upon the surface, and as offering a greater resistance to the point of the needle when scraped across it. It neither coagulates milk, liquefies gelatin TYPHOID FEVER. 23 I *; / > Fig. 1.—Typhoid bacilli with flagella; X 1000. nor produces indol. The organism never forms spores. Gaffky de- scribed the formation of spores, and his observation was afterwards con- firmed by Chantemesse and Widal, but Buchner and Pfeil subsequently showed that the suspicious bodies were merely conglomerations of pro- toplasm that had undergone a plas- inolytic process. Moreover, the ba- cillus has no more powers of resist- ance than the ordinary bacteria. Inoculated into lower animals, it fre- quently causes fatal results without producing the lesions characteristic of typhoid in human beings, although occasionally typical typhoid ulcers have been found. The susceptibility of lower animals, though normally slight, can be increased by prelimi- nary injections of saprophytic bacte- ria, this result having been observed by Alessi when he exposed animals to the gases produced by putrefying matters. The poison is probably a toxin, and it is quite possible to render the lower animals immune to disease. LTsually in making a bacteriologic diagnosis the typhoid bacillus is to be separated from those organisms that morphologically resemble it and present almost identical characteristics upon various culture-media. Particularly is this true of the bacterium coli commune, which differs, though not invariably, in the fact that it produces fermentation of the saccharine media, or forms indol in peptone bouillon, and coagulates milk, with the production of an acid reaction. Eisner has proposed cultivation of the fecal organisms upon acid glycerin potato to which 1 per cent, of potas- sium iodid has been added. At the end of twenty-four hours the typhoid bacillus has formed minute, grayish-white points upon the culture-media, while the bacterium coli commune has formed luxuriant colonies. At the end of forty-eight hours the typhoid bacilli appear in clear shining drop-like and finely granular colonies, and the bacterium coli commune in much coarser granular colonies that are brownish in color. Of late this method has been found more or less inaccurate, and Eisner himself admits that it is untrustworthy. The real poison of typhoid fever must, therefore, be a chemical sub- stance secreted by the bacillus—typho-toxin—and Brieger has extracted the latter agent, finding that it produces the fever, nervous symptoms, and the other manifestations characteristic of the affection. Most authors agree that the bacilli cannot maintain a permanent existence outside the human body. From time to time, however, the conditions indispensable to the growth and development of the typhoid germs prevail, and cor- responding with such periods of time more or less extensive epidemic outbreaks of the disease may occur. It is known that the typhoid bacilli may retain their vitality from seven to fourteen days in water, disappearing from the same on account of the presence of saprophytes; but an epidemic or an endemic of typhoid fever implies persistent con- 24 INFECTIOUS DISEASES. tamination of the drinking-water. Multiplication of the bacilli may take place in water, in milk (very rapidly), and in the soil (where they preserve their vitality under favorable conditions for months). Freezing does not kill them, as they may live in ice for several months (Prudden). They have been discovered in infected water, but are thoroughly destroyed by boiling. Predisposing Causes.—Typhoid fever is particularly prevalent in tem- perate latitudes and in every quarter of the globe. Among the influ- ences predisposing to the disease are— (a) Geographic Location.—In temperate zones it prevails con- stantly and to a greater or less extent. But, though the disease occurs most frequently in temperate climates, it cannot safely be inferred that climate per se exerts any marked influence over its appearance. Thus it has been shown in recent times to be comparatively common in the tropics as well as in many cold latitudes (Iceland. Norway, etc.). (b) Seasons exert a decided influence upon the frequency of the occurrence of typhoid. According to the statistics of Murchison, Bart- lett, Osier, Hirsh, and others, the time of greatest liability to typhoid fever is during the late summer and the early autumn, the months in which cases are most frequent being August, September, and October. The remaining summer and autumn months yield a relatively larger number of cases than the winter and spring: again, in winter more cases are met with than in the spring, which furnishes fewer cases than any other season of the year. After dry summers typhoid fever is especially apt to be prevalent, and, according to Baumgarten, a rela- tively^ large amount of dust in the atmosphere may disseminate the typhoid germs. (' t J -ft 3t -^ i -*. -IO ^ ^ «t f ,h ft -s, J /, 1 t 1 -S -t H a. 1: ^ T* / i \ ■> «; ; ; > $ \ A ' tf V •» * / * X .* V * h, • ■ IS • ■ N no.-' -■120 120.---MS ne,-.-120 114.-' .-'no 106.,---'|28 I28,x-.-'112 120,.--''120 120,, .--'120 110.,--'120 no ,-.,-'130 132 ,-' -'140 123,.-.-'130 130,. --'fso 168.- ■24,-' -''38 30,-' .-' 34 30 .'' -''so 2«.---''24 24,," -26 26,--''24 32 .-' --'34 32,.-' -'30 24,-' -''30 r'30 36 ,-' .-'32 38 ,-' -'32 26 . ' --'36 4 < 5 UJ z 5 -5 C5 < I-UJ o O > O Z O UJ Q 1200 1100 1100 1000 1000 900 900 /\ / \ / V 800 I \ 800 / / j 700 / 700 / / / / 600 / 600 / I 500 I 500 I ' j 400 400 I [ I I 300 300 200 100 ■* o m vo o o CO o -r CO X3 0\ us 00 Ol o ■* 0 Fig. 10.—Chart showing the seasonal variations of malarial fever. The line increases in incre- ments of 100. ber, as is shown by the tracing on the accompanying chart (Fig. 10), which is based upon 4841 cases of malaria gathered from the records of the leading Philadelphia hospitals. Authors who state that malaria is more prevalent in the spring and 1 House-plants as Sanitary Agents, by the Author, p. 263. DESCRIPTION OF PLATES I. and II.1 PLATE I. The Parasite of Tertian Fever. 1.—Normal red corpuscle. . ,. - * „ ;*„„ 2 3 4 —Young hyaline forms. In 4, a corpuscle contains three distinct parasites. 5 2L-Beginning of pigmentation. The parasite was observed to form a true ring by the: con- fluence of two pseudopodia. During observation the body burst from the corpuscle, which became decolorized and disappeared from view. The parasite became, almost immediately, deformed ana motionless, as shown m Fig. 21. 6, 7, 8.—Partly developed pigmented forms. 9.—Full-grown body. 10-14.—Segmenting bodies. „ ^, „ , „ . . . 15.—Form simulating a segmenting body. The significance of these forms, several ol which have been observed, was not clear to Drs. Thayer and Hewetson, who had never met with similar bodies in stained specimens so as to be able to study the structure of the individual segments. 16, 17.—Precocious segmentation. 18, 19, 20.—Large swollen and fragmenting extracellular bodies. 22.—Flagellate body. 23, 24.—Vacuolization. The Parasite of Quartan Fever. 25.—Normal red corpuscle. 26.—Young hyaline form. 27-34.—Gradual development of the intracorpuscular bodies. . 35.-Full-grown body. The substance of the red corpuscle is no more visible m the fresh specimen. 36-39.—Segmenting bodies. 40.—Large swollen extracellular form. 41.—Flagellate body. 42.—Vacuolization. PLATE II. The Parasite of ^Estivo-autumnal Fever. 1, 2.—Small refractive ring-like bodies. 3-6.—Larger disk-like and ameboid forms. 7.—Ring-like body with a few pigment-granules in a brassy, shrunken corpuscle. 8, 9, 10, 12.—Similar pigmented bodies. 11.—Ameboid body with pigment. 13.—Body with a central clump of pigment in a corpuscle, showing a retraction of the hemo- globin-containing substance about the parasite. 14-20.—Larger bodies with central pigment clumps or blocks. 21-24.—Segmenting bodies from the spleen. Figs. 21-23 represent one body where the entire process of segmentation was observed. The segments, eighteen in number, were accurately counted before separation, as in Fig. 23. The sudden separation of the segments, occurring as though some retaining membrane were ruptured, was observed. 25-33.— Crescents and ovoid bodies. Figs. 30 and 31 represent one body, which was seen to extrude slowly, and later to withdraw, two rounded protrusions. 34, 35.—Round bodies. 36.—" Gemmation," fragmentation. 37.—Vacuolization of a crescent. 38-40.—Flagellation. The figures represent one organism. The blood was taken from the ear at 4.15 p. m.; at 4.17 the body was as represented in Fig. 38. At 4.27 the flagella appeared; at 4.33 two of the flagella had already broken away from the mother body. 41-45.—Phagocytosis. Traced with the camera lucida. 'These illustrations are reproduced by permission from the article by Drs. Thayer and Hewet- son in The Johns Hopkins Hospital Reports, vol. v., 1895. Plate J. m.*\ The Parasite of Tertian Fever 3 **■ •v-/ • a . /a K •'•'. «S- -r" \ /'* *» 1 ..-•;-].• *V The Parasite of Quartan Fever. 32 L. v«iwV '"#- ^ S* ^Q '•^* 7 Plate II. The Parasite of Aestivo Autumnal Fever 2 3 4 V._. O ^f 30 37 «w^ -^ >A ^•e. -»»*■* w "C> &^ MALARIAL FEVER. 81 autumn than in summer and Avinter in temperate regions are probably in error. An inspection of the tracing will convince the most skeptical that the spring, unlike the autumn, is unattended with increased preva- lence of the disease, which is in abeyance not only during the winter, but also practically during the spring, although the cases are seen to increase during the latter period. In the tropics the case seems to be different, and two maximum periods—spring and autumn—and two minimum—summer and winter—obtain. Autumn has, however, the greater number of cases. (6) Gravitation.—The malarial poison escapes from the soil into the superjacent strata of air. That it does not rise far above the earth's surface is shown by the fact that persons occupying the upper stories of a house or living on slight elevations are affected with relative infrequency. (7) Race exerts little influence in other lands than our own, but in the United States negroes are less susceptible than are the whites. (8) Sex is without effect when men and women are equally exposed. Cases are, however, vastly, more frequent among males because of their increased liability to exposure, and particularly while following certain occupations (agriculture, marsh-draining, etc.). The 5044 cases col- lected by myself gave the numerical proportion of 6 to 1 in favor of males. The Malarial Parasite.—In 1879, Klebs and Tommasi Crudeli isolated a low vegetable organism—the bacillus malarhe—and claimed it to be the special agent producing all forms of malaria. The evidence afforded by subsequent experiments of other observers, however, failed to corroborate their investigations, and it remained for Laveran in 1880 to discover the specific parasite in the blood of patients affected with malaria. The announcement of his discovery failed to attract wide- spread attention until 1883, when Alarchiafava, Celli, and Golgi pub- lished the results of their confirmatory investigations. Since then the claims of Laveran have been abundantly corroborated by Councilman, Osier, James, Dock, Koplik, and others in the United States, by Van Dyke Carter in India, #nd, more recently, by numerous French, Eng- lish, German, and Russian observers. It would seem, therefore, as though the evidence as to the specificity of this organism were almost complete, and, at all events, it has invariably been found to be associated with the different forms of malaria. The malarial parasite belongs to a sub-class of the protozoa known as hematozoa. Of the latter, three varieties, corresponding Avith the three leading clinical forms of the affection, have been distinguished, and the evolution of two of these parasites at least takes place Avithin the red blood-corpuscles. They enter the red cells in the form of small, non-pigmented plasmodia, exhibiting ameboid motion, and then feed upon their host, transforming, at the same time, the hemoglobin of the latter into dark pigment-granules as they develop. When the intra- globular plasmodia have consumed the red blood-corpuscles the granules of pigment accumulate in the center of the parasite, while on its periph- ery the processes of subdivision and sporulation are taking place, forming fresh generations of hematozoa. These young parasites assume the form of minute, more or less spheric, hyaline bodies, which again 6 82 INFECTIOUS DISEASES. enter the red blood-corpuscles and start on a neAv cycle of development. It is probable, as Golgi suggests, that the third variety is not intimately connected Avith the circulating medium, but that its evolution princi- pally takes place in the internal organs (spleen, bone-marrow, etc.). The special varieties of the malarial parasite will be described sepa- rately. (1) The Ameba causing Tertian Intermittent Fever.—This begins its cycle of eArolution in the red blood-corpuscle as a small hyaline ameba. Its development is attended Avith the appearance in its inte- rior of fine, brown, motile granules in the form of pigment, and when matured it about equals the size of a normal red corpuscle. It now assumes a spheric form, the pigment collecting centrally, and sporulation into fifteen to twenty or more segments follows. The tertian parasites are exceedingly numerous in the blood, and pass through the various stages of their life-cycle almost simultaneously, the sporulation of an entire generation occurring Avithin the space of a fe-AV hours (Golgi). The occurrence of the malarial paroxysm folloAvs the process of sporulation, which is attended, most probably, with the development of a toxin, and the symptoms of the disease may be attributable chiefly to the effects of the latter. The red corpuscle that includes the parasite becomes enlarged and decolorized as the latter develops. The parasite of tertian intermittent runs its cycle in about forty-eight hours. Hence infection by a single generation would result in sporulation every second day, folloAved by the malarial paroxysm. Quite commonly, infection by tAvo groups of parasites occurs on successive days, and, since each has a definite period of evolution, a daily malarial paroxysm is the result (quotidian intermittent). Multiple infection with this parasite may occur, but Avith great rarity. (2) The Ameba causing Quartan Fever.—This cannot be distinguished from the tertian parasite at the beginning of its brief career, but later differences are clearly perceptible. Its ameboid movements are more deliberate, and its pigment-granules are coarser, darker, and also less motile than those of the tertian organisms. Unlike the latter, it does not attain the size of the red corpuscles, and during sporulation the seg- ments (five to ten in number) encircle in an orderly way the central pigment-mass or clump, "rosettes " of great beauty thus being formed. The red blood-corpuscle that harbors the quartan parasite contracts upon its destroyer, appears shrivelled, and its color changes at the same time from the normal to a deep greenish or bronzed tint. It sporulates about seventy-two hours after it enters the red corpuscle; hence, if only one group of parasites be present, febrile attacks occur every fourth day, forming the simple quartan intermittent. On the other hand, double quartan infection results in paroxysms on tAvo successive days, followed by an intermission lasting one day, while triple infection, or the presence of three groups, causes daily paroxysms—the quotidian intermittent. Infection by more than three groups of the quartan parasite may occur, but is very rare. (3) The Ameba causing Estivo-autumnal Fevers.—The cycle of this variety is evolved, chiefly, in certain of the internal viscera, and the microscopic examination of the blood in the various stages of the dis- ease does not give a positive result, as in the tertian and quartan types. MALARIAL FEVER. 83 The organism invades the red blood-corpuscle, but to what extent is not definitely known. It is a quite small hyaline body, its size at maturity scarcely equalling one-half the dimensions of the red corpuscle, and it accumulates very feAV fine pigment-granules. The parasite is not to be found in the later stages, except in the blood from certain internal vis- cera, such as the spleen, bone-marroAV, etc. After the condition has lasted a Aveek or more characteristic oval and crescentic bodies, which are more or less refractive, may be observed in the fresh blood. These so-called "sickle-form bodies" sIioav central rods and clumps of coarse pigment, and are especially connected with this category of malarial fevers. The red corpuscle, at whose expense the parasite develops, as- sumes a brassy hue, often becoming shrivelled and sometimes notched. The time occupied by the life-cycle of this parasite is still an un- settled question, but it is generally believed to vary betAveen the ex- tremes of twenty-four and forty-eight hours. In one of my own cases the febrile paroxysms recurred every seventy-two hours. For the differ- ences in the period of evolution there is no satisfactory explanation, though the variation may be connected with the circumstance that it frequently (though by accident ?) penetrates into the red blood-corpuscle. Cilice, or flagellar, exhibiting active motion, may growr from all of the before-mentioned varieties, and not infrequently they become detached and float free in the blood-stream. They are most common in blood aspirated from the spleen, but their true significance is not known. The ciliated forms, according to Manson, probably do not exist in the blood inside the body, but develop very shortly after it is drawn, espe- cially in the estivo-autumnal type. Usually the presence of the cilia is only indicated by occasional oscillatory movements of the red blood- cells surrounding the parasite. Mode of Infection.—The exact manner in Avhich the human subject is infected Avith the malarial parasite is not understood. It is known to a certainty, however, that the disease can be communicated by injecting the blood of a patient into a healthy individual. On the other hand, it is in no sense a contagious disease, since the poison, after it enters the body of a human being or inferior animal, cannot escape in an active form from the latter into the surrounding atmosphere. Most probably the poison enters the system through the medium of inhalation, and rarely through the digestive tract. Immunity.—Persons Avho have had malaria are more liable to fresh attacks than before, although they may experience no inconvenience so long as they reside in a non-malarial district. Incubation.—The period of incubation varies in different cases and according to the different clinical types. Thus it is, on the whole, briefer in the remittent than in the intermittent forms of malarial dis- ease, the time usually ranging from five to tAventy or more days. (I.) Intermittent Fever.—Symptoms.—The clinical history pre- sents itself under tAvo heads: (a) the paroxysms, and (b) the manner in Avhich the paroxysms recur. (a) The Paroxysms.—There may be premonitions lasting from one to several days, and most significant, yet not distinctive, are headache, pain in the nape of the neck, yaAvning, a yellowish complexion, and a slight splenic enlargement. In a large proportion of the cases, howT- 84 INFECTIOUS DISEASES. ever, the onset is abrupt. Typical paroxysms present three stages chill, fever, and sweating. The chill is intense, causing more or less shivering, and often chattering of the teeth. Malaise is marked, the skin is cool and pale, and the face slightly cyanotic. This stage usu- ally occurs in the morning hours, though the time of onset is by no means constant; its duration, also, varies greatly, generally lasting from one to two hours. The internal temperature rises rapidly during the time of the chill. The hot stage succeeds the chill, and, in striking contrast with the first stage, the face Avears a decided flush and the skin is burning hot to M E M E M E M E M E M E M E M E M E N 1 E M E M E M E M E M E M E M E It 1 E UO IVULS Dally Am'l t 3 *4 V ,\ S ■si ^ -^ ^ V s - "& ».\ & ^ * 4 A: . . - fl si^i _^ s ^ r* *> s ^ " ^ ^ -S ^ • r- *»V f _ * ^j — — -^ -^ ^' T-1 ,, "3 C 1$ \% >t *,, 3 ■> H ft V 3- :\ \j sfz ' r L H 1 1 | a i 1 1 S r : I ^ ^ 1 \ *i\ (1 1 \ 1 * J\ >^ i tN 101 ° \ k \ \ \ 1 \ £ 1 *?*_ V \. \ V \ S ' .n" } „ > \^ i ^is J \ S S s T \ A' V •^ / s 98° T i- '\ A /L \ A / £ —* ' it^ j \J "^ i / v «, 97° \ v ■^ —^ Cl DuyofDis Pulse. ,. 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.--" -> 1 M | 1 O F "' •-' 1 1 ! | 1 | j. 3 142 INFECTIOUS DISEASES. cocci, to previous organic disease of the heart, or to some complicating condition (pericarditis, collateral edema, etc.), and the period of great- est liability is in the advanced stage of the disease. At first the pulse is small, but a little later full and bounding. With complete and ex- tensive consolidation the pulse is apt to become small, due to the fact that a lessened amount of blood reaches the left ventricle and the gen- eral systemic circulation. Dicrotism is sometimes noticeable, and an irregularity in the volume and rhythm of the pulse may be observed; it is an unpropitious sign. In the aged and the debilitated a small, feeble, and frequent pulse may be present throughout the attack. The heart-sounds are clear, and owing to increased tension in the pulmonary vessels the pulmonary second sound is accentuated. This is the state of things throughout in favorable cases. With failure of the right ventricle (a not rare event) there arise the signs of dilatation of this chamber (extension of cardiac dulness to the right, epigastric impulse, a Ioav systolic murmur, shortening of the diastole, or fetal heart- sounds, signs of venous stasis, and indistinctness of the pulmonary sec- ond sound). The strength of the right ventricle, upon which so much depends in pneumonia, is indicated by the character of the pulmonic second sound. A soft, low-pitched murmur is sometimes audible in the mitral and pulmonary zones. The blood-appearances are somewhat characteristic. The researches of Lache1 show that leukocytosis is of some value in determining be- tween the crisis and pseudo-crisis, continuing in spite of the fall of tem- perature, etc. in pseudo-crisis, while it disappears with the true crisis. Stienon2 finds that in the febrile stage the polynuclear forms predom- inate, but as soon as these diminish the eosinophiles begin to increase. The red corpuscles and hemoglobin remain little changed during the course of the disease, but show a marked decrease almost immediately after the actual crisis.3 The prognostic significance of absence of leu- kocytosis would seem to be considerable, as this symptom serves to dis- tinguish pneumonia from influenza, in uncomplicated cases of Avhich it does not occur. The blood-plates are also increased in number (Hayem), and the micrococcus has been found in the blood, though rarely. Cerebral Symptoms.—Headache sets in early and may be a prominent and persistent feature. In many cases, and particularly in children, the disease is ushered in by convulsions, this symptom occurring more often in the apical than in the basilar form of pneumonia. Delirium may come on during the acme of the disease and may assume a maniacal form, but more often in my experience consciousness has been retained during the whole attack in all but the severest cases. In the drunkard delirium tremens usually develops, and may anticipate the symptoms referable to the lungs; and I fully agree with Osier in stating that it should be an invariable rule, if fever be present, to examine the lungs in delirium tremens. These cases may often be appropriately termed " walking pneumonia," since they go about until excitement gives way to a coma that deepens into death. In adynamic forms a Ioav, muttering 1 Berliner klin. Woch., 1893, Nos. 36 and 37. 2 La Presse Med., July 13, 1895. 8 Sadler, Fortschritte der Medicin, 1892; Leichtenstein, Ueber der Hamoglobin-gehalt des Blute-<, etc., Leipzig, 1892. LOBAR PNEUMONIA. 143 delirium is frequent, and is sometimes accompanied Avith more or less coma. In the so-called cerebral pneumonia the nervous phenomena are quite pronounced, and simulate closely cases of cortical meningitis. It is often associated Avith excessively high fever, except in the aged, Avhen the cerebral symptoms are also Avell marked, but the fever is moderate. Most authors contend that apical pneumonias are apt to assume the cerebral type, but, according to my own experience, this dictum is cor- rect as relating to children only. Most authors also state that double pneumonias are characterized frequently by severe cerebral symptoms, vet I have seen several instances in the adult Avithout unusual nervous phenomena. The Cutaneous Symptoms.—As stated before, herpes is common and its diagnostic importance is considerable. Naso-labial herpes is but little less frequent in this disease than in malaria, being present in about one- third of the cases. It usually comes out from the second to the fifth day of the disease, and rarely may appear upon the cheek, lobe of the ear, the genitals, forearm, or upon the mucosa of the tongue. Sweats are not common during the height of the disease, but usually accom- pany defervescence, when they may be copious. The deep-red circum- scribed spot upon one cheek (mahogany flush), usually on the side of the affected lung, has already been mentioned. Urticaria has been ob- served, though rarely. Digestive System.—The mucous membrane of the mouth is dry, the tongue has a coating of a yellowish-Avhite color, becoming dry and broAvn in cases representing a low form, and anorexia and thirst are present. Vomiting is not uncommon at the outset, and may be repeated, Avhile constipation is the general rule and diarrhea the frequent exception. The above symptoms spring from the marked fever. Splenic enlarge- ment of slight degree can usually be detected on palpation, but the liver is not perceptibly increased in size. Urinary Symptoms.—The urine is febrile, diminished in amount, and high-colored, the urea and uric acid being greatly in excess. On the other hand, the chlorids are, according to the older authors, either diminished in amount or absent during the febrile stage, presumably for the reason that they pass into the inflamed lung-tissue. They are not, hoAveA-er, constantly absent, and sometimes they are not even lessened, in pneumonia; moreover, their disappearance is not peculiar to this dis- ease. The above-mentioned facts justify tAvo important inferences: (1) The absence of chlorids is a symptom of little diagnostic value ; and (..) their reappearance in the urine toward the close of pneumonia is of small prognostic worth. Slight (febrile) albuminuria is common. Physical Signs.—Stage of Congestion.—The density of the lung is increased, but the involved tissue is not consolidated and the pleura is not yet covered Avith fibrin. Inspection.—The movements of the affected side (especially if the base be involved) are defective, the degree of expansion being much diminished. In double pneumonia the costal type of breathing, com- bined Avith a vigorous play of the abdominal muscles, is observed. Palpation.—There is a slight increase in the tactile fremitus over the congested area. 144 INFECTIOUS DISEASES. Percussion.—The note may be normal, though more often it is briefer, higher-pitched, or even distinctly tympanitic. Auscultation.—The breath-sounds are weak, and sometimes become broncho-vesicular upon deep inspiration, while over the unaffected lung- tissue they are exaggerated. If, as often happens, inflammatory prod- ucts due to associated bronchitis occupy the small bronchi, subcrepitant rales may be audible. The crepitant rale, however, is rarely heard until the close of the first stage or until fibrin coats the pleural sur- faces, and I cannot agree Avith the view of certain authorities who claim that this rale is produced in the air-cells and finer bronchi. Stage of Consolidation.—Inspection.—There is little or no expansive motion of the chest over the affected area, while upon the unaffected side it is increased. The volume of the thorax on the diseased side is increased, as shown by mensuration, but the intercostal depressions are not effaced. Palpation renders clearly perceptible the defect or absence of expan- sion. Vocal fremitus is usually much increased, though in exceptional instances it is diminished or absent—a circumstance Avhich can, as a rule, though not invariably, be attributed to an associated pleurisy with more or less effusion. Frequently a friction-rub is felt before complete consolidation is established. Percussion.—Varying degrees of dulness are obtained in this stage, and before the lung-tissue becomes thoroughly solidified the note may have a tympanitic quality. After complete consolidation there is usu- ally marked or absolute dulness posteriorly, Avhile the note may be more or less tympanitic anteriorly, Avhere the vibrations are more apt to reach the air in the larger bronchi. A sense of resistance is offered to the pleximeter-finger, but not to the same degree as in the case of a pleurisy with effusion. When the latter condition is associated the percussion- note \vill be flat. Deadness is less marked in old people in Avhose ribs senile changes have taken place, Avhich render them more resonant, or in cases in Avhich the consolidated areas occupy the central portions of the lung. Above the solidified part Skodaic resonance is usually obtainable. Auscultation.—Bronchial or tubular breathing is heard, as a rule, over the solidified lung, but it may be absent in consequence of the plugging of the large bronchi Avith exudate (so-called massive pneu- monia). Bronchophony is usually obtainable over the portion of the lung affected, though this may also be absent, and for the same reason as in the case of the bronchial breathing: it sometimes takes the form of egophony. Subcrepitant rales, due to associated bronchitis, are sometimes heard, and the crepitant rale at the end of inspiration, sup- posedly very characteristic, is best heard at the beginning of consolida- tion, when the pleura receives its coat of fibrin and while the lung is yet capable of sufficient movement to produce fine pleural friction. A distinct friction-rub may also be heard occasionally. Stage of Gray Hepatization.—With beginning resolution the solid con- tents of the air-cells liquefy and are removed, so that air noAv re-enters the air-cells and permits a consequent increase in the movement of the lung. Inspection.—The normal expansile movement of the affected side gradually returns. Palpation.—Tactile fremitus progressively diminishes. LOBAR PNEUMONIA. 145 Percussion.—The dull or tympanitic quality of the note is gradually lost, though the fact must be emphasized that the abnormalities in the note vanish more slowly than the other abnormal physical signs. Some degree of deadness often remains long after recovery is apparently com- plete. Auscultation.—With increased movement of the lung there may be a reappearance of the crepitant rale, due to interplay of the pleural sur- faces, and the softened exudate in the air-cells gives rise to subcrepitant rales, heard both on inspiration and expiration, with coarser rales over the bronchi. Bronchial breathing gradually gives place to broncho- vesicular, and the latter in turn to normal breathing. Complications.—Doubtless many of these are due to the primary infection by diplococci. Pleurisy is, of necessity, associated in all instances in which the con- solidation reaches the pleura. It is to be looked upon as a direct result of the pneumonic process, since in a great proportion of cases examined the presence of the diplococci has been demonstrated. Cases are met Avith, hoAvever, in which the truly pneumonic symptoms are overshadoAved by the intensity of the pleuritis, and to these the term pleuropneumonia has been applied. In this form there is often a copious effusion Avhich is exceedingly rich in fibrin—a circumstance which distinguishes it from other forms of acute pleurisy. There may be the ordinary grade of pleurisy on the side affected by the pneumonia, and a severe grade on the opposite side, and Avhen effusion occurs under the latter exceptional conditions it is apt to be purulent. Indeed, empyema has of late been shown to be a frequent complication of pneumonia, but, as far as my own observation goes, it would appear to rank as a sequel rather than a complication, coming on as it usually does several days after the crisis. Its development is accompanied by replacement of ordinary dulness by flatness Avith great resistance, and by the disappearance of rales and breath-sounds, normal and abnormal. Other characteristic features of empyema are present, but in the event of doubt surrounding the diag- nosis the needle should be introduced. There is a prompt rise of fever, the temperature leaping to 103° or 104° F. (40° C.) quickly, after which it is decidedly remittent in type, but there are no hectic chills. Fistulous connection with a bronchus, hoAvever, and the establishment of empyema necessitatis are common events in this form of the disease, and may be preceded by diurnal chills, SAveats, etc. The occurrence of septic phenomena is a certain indication of second- ary infection by streptococci. The pus is absorbed very rarely, and more frequently becomes encysted. I saw one instance in which the effusion measured 8 liters, while ordinarily the amount ranges from 2 to 5 liters. Removal of the effusion by aspiration is promptly folloAved by the disappearance of the fever, but reaccumulation generally occurs, Avith another rise of temperature. Finally, if defervescence takes place by lysis or if the " critical " decline is absent, a residual purulent or sero-fibrinous effusion may be considered as the likely cause. This latter complication is attended by a paroxysmal cough Avhich is excited by movement, and is not usually accompanied by expectoration, while the temperature rises, though not 10 146 INFECTIO US DISEA SES. so high as when the effusion is purulent. It remains to be pointed out that rarely also there is a primary empyema, due to the pneumococcus. Acute general bronchitis may pre-exist or may arise as a complication, and often proves formidable, intensifying the fever and increasing the dyspnea, the tendency to heart-failure, and the cyanosis. The expec- toration of mucus is freer than in uncomplicated pneumonia, and over the bronchi moist rales intermingled with sibilant and sonorous rales are audible. Pericarditis.—This is one of the most important complicating affec- tions. It results from a direct extension of the adjacent pleuritis, and hence is more common in left- than in right-sided pneumonia, and chil- dren are more prone to it than adults. Although generally of the plas- tic variety, it is not infrequently sero-fibrinous, and rarely the effusion is purulent. The diagnosis can be made in the same Avay as when other conditions attend its development, but it may be readily overlooked by the careless observer. I would say, however, that the occurrence of in- creased dyspnea, Avith or Avithout precordial pain, should serve as a warn- ing and lead to a physical examination. Endocarditis.—This is far more frequent than pericarditis, and par- ticularly in the ulcerative form. Out of 209 cases of malignant endocar- ditis collected by Osier, 54 cases occurred in pneumonia, and my experi- ence fully agrees with his statement as to its great relative frequency in this disease. There are no reliable symptomatic indications of this condition, and of those symptoms that do appear the physical signs are least trustworthy. Frequently murmurs are entirely absent; and, on the other hand, the presence of a murmur, even though it be loud and harsh, is by no means diagnostic of the condition. Some claim that a rough diastolic murmur is quite significant; this has not, however, been present in any of my oAvn cases. The development of septic manifesta- tions, especially irregular fever, chills, and SAveats, renders the case highly suspicious, and Avhen in addition there arises distinct evidence of embolic processes the diagnosis becomes highly probable. If, now, the symp- toms of meningitis should supervene, little doubt Avould remain as to the character of the complications, since meningitis and endocarditis are often combined in pneumonia. Netter, Weichselbaum, and Bignami have shown by microscopic examination and cultivation that acute endocarditis may "be caused di- rectly by the diplococcus of pneumonia, and, from the presence of this bacillus in the right ventricle, that it is far commoner than the forms due to other causes.1 Chronic Endocarditis.—This predisposes to acute endocarditis, both simple and ulcerative, but, independently of the acute form, pneumonia arising in the course of chronic endocarditis is apt to be attended by cardiac failure, with venous stasis as the consequence. The murmurs of chronic valvular disease often disappear with the development of pneumonia. Cardiac clots (ante-mortem) may form, but are rare. They result from Aveakness of the ventricular wall, especially in the right heart; and are most apt to arise, therefore, in cases in Avhich the death-agony is much prolonged. Venous thrombosis is rarely seen, and embolism of 1 Practitioner, London, Aug., 1894. LOBAR PNEUMONIA. 147 the larger arteries is a rare complication. Cerebral embolism, causing aphasia and even hemiplegia, has been observed but seldom. Acute purulent meningitis is a comparatively rare but very grave com- plication. It is often related etiologically to pneumonia, and its symp- toms are not clearly defined; particularly is this true Avhen it develops during the inArasion-period and the basilar meninges are not involved. Hence its diagnosis is often impossible. The presence of intense and persistent headache, rigidity of the nucha, wild delirium, folioAved by stupor deepening into profound coma, affords a basis for a probable diagnosis. Its frequent association with ulcerative endocarditis and the symptoms of the latter have already been pointed out. Peripheral neuritis is among the rare complications of this disease. Its presence is attested by the usual symptoms. Parotitis is also sometimes seen, and may cause a fatal termination of the case. I have seen tAvo instances, however, in Avhich this was a complication, and both ended in recovery. It is thought to be associated usually Avith endocarditis, but in neither of my oAvn cases were there any symptoms pointing to the latter affection. Arthritis.—This may arise at any period in the course of pneumonia, and at the start may closely simulate rheumatism. It soon, however, takes the form of a purulent arthritis, and may be associated with other suppurative inflammations (meningitis, endocarditis). The pneumococci have been found in the affected articulation.1 Gastro-intestinal Complications.—Croupous gastritis may rarely inter- vene, but croupous colitis is a more frequent concomitant, giving rise to tympanites and marked diarrhea, and it may prove a serious condition. Peritonitis occurs, but with great rarity. Jaundice may be observed in all types of the affection, though, on the Avhole, it is more frequent in serious than in mild forms of the dis- ease. Apart from the cutaneous and conjunctival discoloration, which is rarely intense, it has no symptoms in the majority of instances, and yet even in such it is most probably obstructive (hepatogenous). I have observed cases in which the evidence of a certain degree of ob- struction Avas unmistakable, and these are to be ascribed to the presence of duodenal catarrh Avith extension into the ducts. Acute nephritis, generally of a mild grade, is a rare sequel or com- plication, and its recognition is entirely dependent upon the discovery of albumin and casts in the urine. Clinical Varieties and Anomalous Types.—(1) Typhoid Pneu- monia.—This relates to an adynamic type of the disease Avith typhoid symptoms, and not to typhoid fever. It is often secondary to Ioav fevers, to septicemia, diabetes, and chronic nephritis, and is also the variety met Avith in drunkards and in persons previously enfeebled on account of unhygienic surroundings. The onset is more gradual than in typical pneumonia. The physical signs may be Avell marked or ill defined, but in either event the general features are at once striking and characteris- tic. Prostration is extreme; there are delirium and often stupor; the temperature may or may not be high ; Avhile the respirations and pulse are almost abvays frequent. The skin is dry, and not infrequently there is a dusky tint or slight jaundice. The tongue is dry, often brown, and 1 Bernheim, La Medecine moderne, Paris, Feb. 21, 1894. 148 INFECTIOUS DISEASES. vomiting is more common than in ordinary pneumonia ; the sputa may be rusty or decidedly hemorrhagic. Splenic enlargement is often clearly perceptible. In this form of the disease there are numerous perils to pass, and when recovery ensues convalescence is long and tedious. This clinical form is not to be confounded Avith pneumo-typhoid, in which typhoid fever begins with pneumonia. (2) Epidemic Pneumonia.—This is often of malignant type. The symptoms exhibit noticeable variations, according to the special etiology and to different epidemics. The pneumonias that have developed so frequently in the course of epidemic influenza have been complicated with or preceded by general bronchitis. The heart-poAver in many cases becomes exhausted early, and then folloAv congestion and edema of the lungs. The physical signs are often slight, even in fatal cases. In certain epidemic forms of pneumonia still other complications may be pronounced (cerebral, intestinal, etc.). In this connection should be mentioned so-called " larval pneumonia," in. which the general symp- toms are mild and the local signs ill defined. This sub-variety is ob- served in those epidemic outbreaks that occur in institutions, tenement- houses, jails, etc. (3) Latent Pneumonia.—To this class belong central pneumonias, which have been described briefly under General Symptomatology. In these instances the sputum is to be stained and examined microscopi- cally, when the pneumococcus will be found. When pneumonia arises in the course of emphysema a physical examination often gives negative results, and hence, the dilated air-cells not being filled Avith the fibrinous exudate, dulness is less marked than in typical pneumonia, and tubular breathing is often absent. The sputum is gummous and rusty, as a rule, and should be studied bacteriologically. Generally, but not al- ways, before the crisis occurs consolidation advances to the periphery, when a physical examination will give positive results. (4) Migratory Pneumonia.—By this is meant an extension of the spe- cific inflammation to other parts of the lungs. This may occur at the time of the appearance of abundant moist rales in, and free expectora- tion from, the lobe first affected. Such extension prevents the occur- rence of the usual crisis, and often occasions an exacerbation of the general pneumonic features. (5) Bilious Pneumonia (" Malarial Pneumonia ").—When lobar pneu- monia occurs in persons who are subjects of malarial poisoning the ini- tial chill is prolonged and the fever paroxysmal or decidedly remittent. Jaundice and vomiting are more common than in the ordinary type. (6) In children, particularly in the very young, the first symptom is often a convulsion. Cerebral symptoms, as delirium, stupor, or even coma, may appear early. The upper lobes of the lungs are more fre- quently involved than in adults. Unless the objective indications be examined for, the disease is frequently overlooked. The characteristic sputum is rarely seen in juvenile pneumonia. (7) In old persons pneumonia runs a peculiar course and is dano-er- ous in the extreme. Most cases begin less abruptly than in younger persons, the initial chill being often absent or replaced by moments of chilliness. There may be nausea and vomiting, and anorexia is usual. Prostration sets in early and is profound, and there is fever LOBAR PNE UMONIA. 149 but this does not range so high, and its type is more irregular than in non-senile pneumonia. Nervous phenomona, sometimes prominent, are not uncommon, but the local symptoms (cough, expectoration, and pain) are feebly developed or wholly absent. The area of lung-tissue impli- cated is often insignificant, the physical signs being slight or even entirely wanting; and when present there is usually dulness on percus- sion (Avith a tympanitic quality), tubular breathing, and a few subcrep- itant rales. The physical signs are often sharply localized and their character variable. This affection, as it occurs in old people, is a most deceptive one, the cases very generally ending fatally after an illness of an apparently mild degree of intensity. Relapses.—These are among the rarest of events, and are usually rudimentary when they occur. Recurrences are ordinary, hoAvever, second, third, fourth, and even more attacks having been noted in the same individual (vide Etiology). Course and Duration.—In cases Avhich recover the febrile stage lasts from three to thirty or more days. In most instances, hoAvever, defervescence occurs on the fifth or seventh day, and resolution is com- pleted about one Aveek later, making the total duration from tAvelve days to two or three Aveeks. Convalescence may be delayed Avhen complica- tions outlast the primary disease or Avhen sequelre arise, and fatal cases are most apt to terminate on the seventh, eighth, and tenth days of the disease. It remains to be added that the regular course of pneumonia is often greatly modified by the various complications (endocarditis, pericarditis, meningitis, etc.). Termination.—(a) Delayed Resolution.—The process of resolution, con- sisting in softening of the exudate and its subsequent removal (partly by absorption, partly by expectoration), may not begin until the fourth, sixth, eighth, or even tenth Aveek. Usually defervescence Avith a mod- eration of the other general features has taken place long before the physical signs indicate resolution. When the latter change occurs it may lead to complete restoration of the functional and anatomic en- tirety of the lung-tissue, or proliferation of the interstitial connective tissue may arise during the period of postponed resolution, producing (b) chronic interstitial pneumonia. This is very rare, however (vide supra, Pathology), (c) Abscess and (d) gangrene are also rare sequelae. For their clinical description the reader is referred to the description of Diseases of the Lung. Diagnosis.—The diagnosis is determined by special local and gen- eral symptoms, together Avith the physical signs. Of these, the abrupt onset Avith rigor, the course of the fever with termination by crisis, the stabbing chest-pains, the dyspnea, the peculiar type of breathing, the abnormal pulse-respiration ratio, the cough, the rusty expectoration, and the signs of consolidation of one or more lobes of the lungs, are the most characteristic. Deviations from the usual type are frequent, and these do not present many of the distinctive features just mentioned. Among the latter the so-called u typhoid pneumonia" and the other clinical varieties whose most valuable diagnostic features have been given, are often difficult of recognition. It must not be forgotten that repeated physical examinations of the chest will often detect more or less extensive consolidation, even though local symptoms are entirely 150 INFECTIOUS DISEASES. wanting. Again, Avhen in the course of certain chronic affections (phthisis, cancer, Bright's disease, diabetes, and organic affections of the heart) more than the customary degree of fever is developed, physical explora- tion of the heart and lungs is imperatively demanded. Be it remembered that in this class of cases " the physical signs are obscured, because respiratory action is enfeebled by the primary condition " (Musser). Differential Diagnosis.—This relates to (a) acute pneumonic phthisis, (b) pneumo-typhoid, (c) meningitis, (d) broncho-pneumonia, (e) acute pleurisy with effusion. Fig. 17.—Lobar pneumonia: 1, unaffected area (upper lobe); 2, consolidated area (middle lobe) 3, resolving area (lower lobe); 4, heart in normal position. {a) Primary Lobar Pneumonia. There may have been prior attacks. Sudden, with severe rigor and rapid rise of temperature. Fever of continued type, terminating by crisis. No drenching sweats, except at time of crisis. Acute Pneumonic Phthisis. Inherited predisposition or previous tu- berculous disease. Generally more gradual—repeated fits of chilliness (rarely severe rigor), often following exposure or " cold." Fever of remittent type, often becoming intermittent, without crisis. Drenching sweats present and oft re- peated. LOBAR PNEUMONIA. 151' Herpes common. Xot much emaciation. Pulse-respiration ratio considerably dis- turbed. Sputum rusty-colored, viscid, and sticky ; contains pneumococcus. Duration of febrile stage shorter. Physical signs, as a rule, first referable to base of lung. Absent. Rapid emaciation. Less so. Sputum may be blood-tinged; is more purulent and more copious, and con- tains numerous bacilli and yellow elas- tic tissue. Duration longer. First referable to apex. Fig. 18.—Acute pneumonic phthisis, posterior view: 1, cavity: 2 and 3, consolidation ; 4, infiltra- tion ; the white spots indicate rftles. Usually limited to one lobe or the lower Usually extension from apex to base. portion of one lung. Signs of consolidation, followed by reso- Signs of consolidation, followed by cavity- lution. formation, with large gurgling rales at apex. Apex of healthy side not involved. Apex of opposite side generally in- vaded. Prognosis not hopeless. Hopeless. Tuberculous disease of other organs does Often does. not follow as a rule. 152 INFECTIOUS DISEASES. (b) Typhoid pneumonia must be diagnosed from pneumo-typhoid, and the blood in the two conditions mav be of service in the discrimination. Leukocytosis usually exists in pneumonia, and there is hypoleukocytosis in typhoid; but this fact is only of value when there is marked increase or decrease of the leukocytes, since figures about normal may occur in either condition. Widal's test will be a decided aid. His assertion that a drop of blood from a patient Avith typhoid, added to a pure culture of typhoid bacilli, causes the cessation of the motion of the bacilli and their collection in clumps, and that this does not occur with blood from other diseases, is, I think, satisfactorily proved. (c) Meningitis is sometimes mistaken for pneumonia, and particularly Avhen the latter occurs in children. The initial symptom of pneumonia in the very young is often a convulsion ; Avhereas, though in meningitis this symptom is not uncommon, it is more apt to manifest itself later. When headache occurs in pneumonia it is frontal. It is almost invari- ably complained of in meningitis, but is occipital, and is associated Avith rigidity of the cervical muscles. Before the occurrence of pressure- symptoms in the latter disease the patient is very restless and morose; his reflexes are exaggerated and there is marked hyperesthesia. The temperature-range is lower, more irregular, and there is no crisis, while the pulse is more variable and often irregular in meningitis. In pneu- monia Avith latent local symptoms the pulse-respiration ratio is greatly altered and the type of respiration peculiar (vide ante). The important rule, to examine for the physical signs in doubtful cases, must not be neglected, and if the subject be young the apex region in particular. The differential diagnosis between pneumonia and broncho-pneumonia and pleurisy with effusion will be found on pages 517 and 551. Prognosis.—The mortality from pneumonia in hospitals averages about 25 per cent. It is less in private practice—about 15 per cent. The death-rate, however, is greatly modified by the type of the indi- vidual epidemic, and by so many conditions and incidents that a pre- cise statement as to the percentage of fatal cases cannot be ventured. The above mortality-rates have been based upon all of the accessible statistics at my command. Wells collected 223,730 cases, which gave a mortality of 18.1 per cent. The elements that enter into a correct prognosis are in the main identical with those in other acute infectious diseases, and concern (1) the severity of the type of infection, (2) the presence or absence of complications, and (3) circumstances peculiar to the individual. (1) Severity of the Type of Infection.—In sthenic cases this is shown by (a) the temperature-range, (b) the degree of heart-power, (c) the in- tensity of the nervous symptoms, and to some extent by (d) the size of the area of lung-induration. It has been demonstrated, experimentally, that the absence of leukocytosis is indicative of a grave type.1 In case the diplococcus be found in the blood, the prognosis must be considered very grave, as it has never been found there during life, except in cases that are in themselves very grave or seriously complicated. A continu- ance of marked leukocytosis Avith a drop in temperature Avould point to a pseudo-crisis, (a) The Temperature-range.—A continued high tem- 1 Von Jaksch and Tchistowitsch, Annual of the Universal Med. Sciences, vol. i. 1893. LOBAR PNEUMONIA. 153 perature, as, for example, 105° F. (40.5° C), on two or three consecu- tive days Avithout material remissions, is ominous, (b) The Degree of Heart-power.—A steadily rising pulse-rate after the fifth day indicates real danger, since it points indisputably to gradual cardiac failure. The same thing is shown by a diminution in the intensity of the second pul- monary sound, particularly the giving out of the right ventricle, (c) The Intensity of the Nervous Symptom*.—Active delirium is not favor- able at any stage, and is particularly unfavorable if it develop early. When it assumes the form of delirium tremens the case has usually passed beyond the hope of recovery, (d) The Size of the Area of Lung- induration.—I have observed that extension of the consolidation at an advanced stage belongs to serious types. The same may be said of double basic pneumonias. Typhoid pneumonia, being of asthenic type, gi\^es an unfavorable prognosis, notAvithstanding an absence of high temperature and of exten- sive inflammation of the lung-tissue. (2) Presence or Absence of Complications.—Cases in AAThich there is involvement of a single lobe or two lobes, if it occur on the right side and without complications, generally terminate in recovery. In nearly one-half of the instances complications occur, and these greatly increase the death-rate. Among the most common is pleurisy, wThich, unless accompanied by considerable effusion, does not add fresh danger; when pleurisy attacks the unaffected side, hoAvever, it does. Empyema, fol- lowing pneumonia, generally terminates in recovery unless secondary septic phenomena appear. Extensive bronchitis is a most perilous com- plication in mv judgment. Pericarditis decreases the chances for re- cover, but by no means to the same extent as endocarditis. Cardiac clots may form, but usually the patient is already moribund. Abscess of the lung and gangrene form highly unfavorable complications. Con- gestion and edema of the uninvaded portions of the lungs render the outlook bad, and these, together with cyanosis, are apt to be dependent upon failure of the right heart. Acute meningitis is exceedingly grave. Fenwick, as the result of an analysis of 10,000 cases, found that the quantity of albumin in the urine is of considerable prognostic value. Gastro-intestinal complications occurring at the outset are unpropitious. (3) Circumstances connected with the Individual.—Of these age heads the list, and after the tAventieth year the mortality increases progres- sively until the seventh decade. It has been claimed that nine-tenths of the deaths after the seventy-fifth year are from lobar pneumonia. Under the tAventieth year, according to the analysis of 708 cases at St. Thomas's Hospital by Hadden, H. W. G. Mackenzie, and W. W. Ord, the mortality is 3.7 per cent., while in infancy it exceeds that of early childhood. Sex has little influence, though the disease is believed by some to be more fatal in females than in males. In the debilitated the danger is greater than in the vigorous, and the alcoholic rarely escapes death. Modes of Death.—Most frequently death is immediately due to heart- failure, Avhich results from two causes: (1) ovenvork, as Avhen an exten- si\-e area of lung-tissue is involved; and (2) the direct effect of the pneumotoxin upon the heart. The complications mentioned mav prove fatal, hoAvever, and in one of my own cases thrombosis of the coronary 154 INFECTIOUS DISEASES. artery killed the patient. This may be a not uncommon terminal con- dition. Treatment.—General Management—The patient should occupy a well-aired apartment, which should be maintained at a temperature of 65° F. (18.3° C), except in pneumonias occurring in the very young, when it should be several degrees higher. The patient should not be allowed to leave his bed for at least one week after the occurrence of the crisis; and as pneumonia is a self-limited affection, the principal object is to support the powers of life until the crisis is passed. To this end nothing contributes so much as proper feeding. The diet should be light, chiefly liquid, but of the most nutritious sort. Alimentation should be especially vigorous when there is the slightest tendency to increasing debility. On the other hand, in un- complicated cases and in those in which the disease is limited to a single lobe there is not the same need of supporting the vital powers, since these cases have an intrinsic tendency to recovery. Milk should consti- tute the chief article of diet; meat-broths or meat-juices, egg-white, and light farinaceous substances may also be allowed. The food, and particularly the milk, is to be administered at stated brief intervals and in definite quantities. When resolution is delayed stronger forms of nourishment (scraped meat, etc.) may be given. After the crisis a gradual return may be made to the usual forms of solid foods. Cardiac stimulants are often indicated. It is well to begin their use as soon as the slightest tendency to cardiac failure is shown. The evi- dences of the latter conditions are to be found in the state of the pulse, the first sound of the heart, and the pulmonic second sound. The pulse becomes more and more accelerated and feeble, the first sound of the heart less distinct on auscultation, and the pulmonic second sound loses its accentuated character. From the first moment that these unfavor- able features or marked nervous symptoms appear alcoholics must be used. At first they are to be employed in moderate doses (J ounce— 16.0—of whiskey or brandy every three hours), to be increased if the favorable effect be proportionate with the urgency of the indication. There is a great tolerance of alcohol in this disease, and in the pneu- monia of drunkards its early and free use is to be recommended. If the alcoholic stimulants fail to meet the above indications, other cardiac stimulants must be administered simultaneously. Of these, strychnin has been the most serviceable in my own hands, its mode of administration following the same rules as have been mentioned for alco- holics—at first in moderate-sized doses, to be increased as occasion de- mands. Should urgent need of stimulation arise, however, either sud- denly or more gradually, strychnin should be exhibited hypodermically. It is my custom in desperate cases to use subcutaneously as much as gr. ^ (0.0043) every two or three hours. So soon as the condition of the heart denotes restoration of cardiac power the size of the dose is to be reduced, but the agent is not to be withdrawn until the disease has run its course. In no other disease does strychnin possess greater potency for good than in pneumonia, if wisely employed. For sudden heart-failure ether, administered hypodermically, is also very efficacious, and digitalis may be combined Avith the strychnin or given separately. Like strychnin, digitalis may become a life-saving drug if its adminis- LOBAR PNEUMONIA. 155 tration be guided by sufficient judgment. Ten minims (0.666) of the tincture may be given every three or four hours internally or hypo- dermically if needful, and I have found that the association of a small dose of nitroglycerin (iflj; 0.033, every three or four hours) consid- erably aids the action of the digitalis. Nitroglycerin is especially in- dicated Avhen the renal secretion is scanty and the urine contains more than the usual trace of albumin. Ammonium, in the form of the aro- matic spirits or the carbonate, is an excellent stimulant to the feeble heart of pneumonia. Respiratory Stimulants.—Beginning cyanosis is the signal for the use of respiratory stimulants, of Avhich the best are oxygen by inhalation, strychnin, and atropin. The oxygen must be administered in large amounts, and if the patient be so severely ill that almost constant inhala- tion of the gas becomes exhausting, it may merely be alloAved to escape near his nose and mouth. Hydrotherapy.—This is especially useful, but I have abandoned the rigid cold-bath method. The gradually-cooled tub-baths are the best, and should be employed, except in cases pursuing a very favorable course or those in Avhich little besides rest and good nursing is neces- sary. In meeting high temperature, marked nervous symptoms, dys- pnea, cardiac Aveakness, etc. they offer many superior advantages, and in pneumonia the effect of the baths upon the cardiac, respiratory, and nervous centers is especially desirable. It is of importance that the patient Avhile being immersed put forth no muscular effort. He must be held and supported while in the bath, and gentle friction to the skin- surface must be made. The temperature of the baths should not be too low at the start: at the beginning it should be 90° F. (32.2° C.), and then be lowered according to the degree of sensitiveness of the in- dividual patient. It is rarely necessary to go beloAv 80° F. (26.6° C), and in the aged, the very young, and in persons previously debilitated it is unwise to use any other than tepid baths. The duration should not exceed ten to fifteen minutes on the average, and more than three —or at most four—baths daily are not required. Cool sponging, com- bined Avith the ice-cap or the wet pack, may serve as a substitute when full baths cannot be employed. Abortive Method of Treatment.—Petresco has found that large doses of digitalis (sj-ij ; 8.0, of the digitalis-leaves in an infusion daily) ad- ministered at the onset Avill jugulate the disease. His experience cov- ered 1192 cases, and shoAved the surprisingly low mortality-range of 1.22 to 2.66 per cent. This plan of treatment is rational, since it aims at meeting the chief pathogenic indication of pneumonia by passing through the lung-tissue an adequate proportion of leukocytes, and thus re-establishing the cardio-pulmonary circulation. In the few instances in Avhich I have adopted the plan it has failed to cut short the disease, though the cases terminated favorably. After the full development of consolidation I Avould urge caution in the use of digitalis unless cardiac failure threaten. Venesection.—It has been claimed by some that free bleedings at the onset will abridge the disease. Doubtless it is a good measure in sthenic cases (which occur with relative rarity in cities, but are not uncommon in rural districts), the temperature falling, the pain, the 156 INFECTIOUS DISEASES. dyspnea, and the nervous symptoms being relieved and the pulse soft- ened. Later in the course of pneumonia venesection is to be resorted to if cyanosis and the signs of collateral pulmonary edema—due to a failing right heart—arise, and if cardiac and respiratory stimulants have proved futile. At this stage, however, bleedings rarely yield good results, though affording temporary relief. Antiseptic Methods.—These aim to destroy the pneumococcus or, at all events, to neutralize the poisonous products of the latter in the blood, thus moderating the general disturbances. The method is based upon etiologic indications, and is most rational. The best antiseptics are car- bolic acid (mj ; 0.066, every four hours), thymol (gr. ij-iij ; 0.129-0.194, every four hours), mercuric chlorid (gr. T^; 0.0006, every four hours). Treatment of Special Symptoms.—The initial pain, which is of an acute, agonizing character, is relieved by the hypodermic use of mor- phin at intervals of six or eight hours, this counteracts the shock pro- duced by the invasion-period, but it is to be omitted if the bronchi con- tain secretory products, since morphin dries these and favors their accumulation rather than their removal. Rarely is it necessary to con- tinue this remedy after the second or third day of the illness. Fever.—The fever of pneumonia is a temporary affair, and instead of being hurtful may prove beneficial, since it furthers tissue-metabo- lism, and this aids in the destruction of the specific poison of the dis- ease. Fortunately, internal antipyretics for the purpose of combating high temperature are not so largely used at the present day as for-. merly. It is true that they possess the power to reduce temperature, but their use is attended with danger from their action as cardiac depres- sants ; while, if it be true, as before stated, that pneumonia usually kills through the heart, it folloAvs that cardiac poAver must primarily be con- served. Apart from the above-mentioned serious objection to internal antipyretics, it is to be remembered that they do not possess the import- ant additional advantages to be derived from cool baths. In my opinion, their use should be limited to those cases in which cool baths or their substitutes (cold pack and cold spongings) fail to effect a reduction of fever. It must not be forgotten that unless the temperature exceed 104° F. (40° C.) it had better be let alone. When called for, however, the best among the antipyretics are acetanilid and phenacetin. The dose of these should be small—gr. v (0.324) of the latter and gr. ij-iij (0.129- 0.194) of the former, to be repeated at intervals of four to six hours if required. Like internal antipyretics, arterial sedatives are to be used sparingly, and when used their effects must be carefully noted. In cases in which venesection is indicated the tinctures of veratrum viride and of aconite have been much vaunted as substitutes. The tincture of veratrum viride produces a good effect upon the local condition, since it relaxes the arterial walls, and thus bleeds the patient into his own vessels, but, since it also acts as a cardiac depressant, it is questionable Avhether its disadvantages do not outAveigh its advantages. The tincture of aconite, owing to its depressing influence upon the heart, should not be employed. The nervous symptoms are successfully met, as a rule, by hydrother- apy (including the ice-cap), by the arterial stimulants, and by the use of morphin, as before recommended. SECONDAR Y PNE UMONIA. 157 Cough during the early stage is controlled by the morphin needed to combat the pain. In the more advanced stages, if there be present numerous moist rales and a scanty expectoration, stimulant expecto- rants (ammonium muriate, terebene) may be employed Avith happy effect; but ordinarily they do harm rather than good. Pilocarpin may aid resolution Avhen "this is delayed (Keiss); the heart, hoAvever, must be carefully watched over. Complications.—The management of the complications does not differ from that which is appropriate Avhen they occur as independent affec- tions, though all depressing measures must be positively omitted. I would add that in pleuro-pneumonia aspiration is not Avell borne, ac- cording to my observations; hence, unless urgently needed, I Avould postpone this procedure until the crisis has passed. Local Measures.—When in doubt as to Avhether venesection should be employed or not, it must be remembered that early local bloodletting (cupping and leeching) is followed by relief from pain and dyspnea, but that these measures should be reserved only for robust persons. Coun- ter-irritation by means of sinapisms is useful at the onset. The cotton jacket has certain advantages in maintaining the free, local action of the skin, and may be employed; before the days of hydrotherapy it Avas quite commonly used. The topical use of cold in the form of ice-bags has been practiced extensively by Lees of England and Mays of America with brilliant success, cold thus applied relieving the pain and dyspnea • and diminishing pyrexia. In my limited experience Avith the applica- tion of cold I have found cases in Avhich it could not be tolerated by the patient, and in such, Avarm applications (poultices, etc.) exerted a sooth- ing revulsive effect. Lepine has used with success very dilute mercuric chlorid injections into the affected lung-tissue. This mode of treatment has not been followed in sufficient cases to Avarrant an opinion as to the extent of its usefulness. Secondary Pneumonia. Pathology.—The lesions are identical in character with those of primary lobar pneumonia, but the areas involved have not always the same regular distribution. Congestion surrounding the hepatized lung- tissue is not infrequently extensive. We see, post-mortem, a tendency to commingling with small areas of lobular pneumonia. Both the strep- tococcus and the micrococcus lanceolatus are frequently found on micro- scopic examination. Etiology.—Most instances are secondary to the acute infectious diseases, and it is probable that the specific causes of certain of the latter (Eberth's bacillus, Pfeiffer's bacillus, etc.) have the power to ex- cite the morbid changes of acute lobar pneumonia. Colon-pneumonia, due to the bacillus coli, is the result of hematogenous infection either from the intestinal or from the urogenital tract. In the majority of instances, however, in which this disease develops in the course of the acute infectious diseases the latter are to be regarded as merely furnish- ing the opportunity for infection by the micrococcus lanceolatus. Symptoms.—The rational symptoms are often absent. Close ob- servation may, hoAvever, detect more or less dyspnea, cough, and in- 158 INFECTIOUS DISEASES. creased fever, and rarely the attack is heralded by a rigor, followed by fever, the pneumonic type of breathing, pain, cough, and the character- istic expectoration. The physical signs, when carefully observed, usually serve to enlighten the physician as to the nature of the affection. Hence it is a natural corollary that repeated physical examination is demanded in all cases in which there is danger of intervening lobar pneumonia. Diagnosis.—This rests chiefly upon the physical signs, which are the same as in primary lobar pneumonia. Obviously, when the local subjective symptoms and the characteristic sputa are present a correct diagnosis is easily made. The fact must be emphasized that broncho- pneumonia arises in the course of infectious diseases far more frequently than does lobar pneumonia. Prognosis.—The occurrence of lobar pneumonia as an intercurrent affection adds greatly to the gravity of the primary disease. It is espe- cially dangerous Avhen it appears as a sequel during convalescence from acute infectious diseases. The treatment is similar to that of primary lobar pneumonia, though less satisfactory. INFLUENZA. {La Grippe; Epidemic Catarrhal Fever.) Definition.—Influenza is an acute contagious disease, caused by the bacillus of Pfeiffer. Its chief symptoms are due to catarrh of the respiratory and digestive tracts, together with profound muscular and nervous prostration, and grave complications (especially pneumonia) often present themselves. The disease may be endemic, though more often it is epidemic or pandemic. Historic Note.—Every quarter of the globe has been the scene of visitations of epidemic influenza. More rapidly than any other dis- ease belonging to the same class does it traverse a region of country, and hence within a remarkably brief period of time a Avhole nation may suffer. As a rule, influenza develops into epidemic proportions in the East, whence it spreads with unparalleled rapidity in a Avesterly direc- tion. The first epidemic of the disease in the United States appeared in 1647, and was subsequently described; and, though it has since then frequently prevailed, the outbreaks have not observed any regular pe- riodicity. The last true pandemic of the affection originated in Bok- hara in May, 1889, reached St. Petersburg in the following October, Paris in November, and London in turn early in December. In Amer- ica the cases began to appear about the middle of December, and rap- idly multiplied into an explosive epidemic, which reached its maximum in January, 1890. Influenza reappeared in epidemic form, though less extensively, during April and a part of May, 1891, and again in a briefer and lighter form in the winter of 1891-92. During the winter of 1892-93 only a few sporadic cases occurred. In the early part of INFLUENZA. 159 1895 the disease assumed epidemic prevalence, and it again appeared at the beginning of the present year (1897). Pathology.—There are no special anatomic lesions that charac- terize the disease. The rare instances in which death occurs in uncom- plicated cases simply show marked catarrhal implication of the respira- torv, and usually also of the gastro-intestinal, mucosa. There are practically no changes in the glands of the digestive mucosa, except in the abdominal type of the affection, in Avhich there may be enlargement of the glands of Peyer and of the solitary follicles. As will be seen hereafter, most of the fatal cases exhibit lesions which are to be ascribed to the complications. Among the latter are pneumonia (either lobular or lobar), with Avhich plastic pleurisy is usually associated, sero-fibrinous pleurisy, empyema, purulent pericarditis, nephritis, and rarely cerebro- spinal meningitis. Etiology.—That the disease is microbic in origin can no longer be doubted. Bacteriology.—Early in the year 1892, Pfeiffer discovered a bacillus Avhich he has shown to be the true cause of influenza—the bacillus of Pfeiffer. It is of about the same breadth as the bacillus of mouse-sep- ticemia, and only one-half the length of the latter. When stained with Ziehl's carbol-fuchsin it may be observed as a small dumb-bell, having knobbed ends connected by a rod-like shaft. These bacilli are obtained from the sputum, and their number bears a definite relationship to the intensity of the disease. They are found only during the attack, and are never present in any other disease. Pfeiffer has shoAvn that they may penetrate the peribronchial tissue and pass out to the pleura. They have also been found in the blood. This bacillus can be culti- vated in agar and other media, but not in gelatin, and when inoculated into rabbits and other animals it causes more or less typical influenza; these experiments, however, are not in themselves conclusive. Modes of Conveyance.—Naturally, a specific germ that is propagated Avith the unusual rapidity that marks the bacillus of Pfeiffer must be air-borne. Even this vieAv, hoAvever, fails to explain satisfactorily the coincidental prevalence of the malady at Avidely-separated points. Pep- per suggests that the micro-organism may be almost universally dis- tributed, but only capable under ordinary circumstances of causing occasional and sporadic cases; and that under certain extraordinary atmospheric or telluric conditions it acquires a degree of virulence that renders all subject to its attack. There is no doubt that influenza is communicable by contagion, and evidence is not wanting even to show that it may be transferred by fomites. Manner of Invasion.—Hoav the contagion enters the system has not been positively determined, though it is probably Avith the inspired air through the respiratory tract. Some authors contend that it may enter through the alimentary canal, Avhile still others believe that the primary point of infection is not rarely the conjunctiva. Predisposing Causes.—These are fe\v and unimportant, since all per- sons are liable to the contagion. Age has slight influence, the period of greatest susceptibility being from the tAventieth to the thirtieth year. The very young are less liable than older subjects, and during an epi- demic are apt to be affected last, while old persons (particularly if debil- 160 INFECTIOUS DISEASES. itated) are frequent sufferers. The same is true of those whose vitality is lowered by neuropathic heredity or chronic maladies, these being among the first to be affected during an epidemic. On the other hand, it is to be remembered' that the healthiest are not exempt. The affection is' only slightly influenced, if at all, by meteorologic conditions. Immunity.—A primary attack of influenza does not bestow immu- nity, since relapses are very common, and sometimes after long inter- vals. Many persons, too, suffer from the disease with the reappearance of fresh epidemics, so that two, three, four, or even more attacks may be observed in the same individual. Antagonism.—Recent investigations have shown that a decided an- tagonism exists between influenza and malaria,1 and that during epi- demic prevalence of the former the latter has repeatedly suffered a great decline. Clinical History.—General Symptomatology and Course.—The in- cubation period is quite brief, rarely exceeding two or throe days. The onset is generally sudden, with either a severe rigor or repeated slight shiverings, accompanied by a rapid elevation of temperature Avhich may touch 104° or 105° F. (40.5° C), intense headache, distressing myalgic pains, and great prostration. The primary fever, however, varies greatly in severity. The same is true of the character of the symp- toms—both local and general—presented by different cases as Avell as by different epidemics. Profound prostration characterizes the vast majority of instances during the invasion period. Depression of spirits, restlessness, insomnia (more rarely undue somnolence), and frequently delirium, are among the more prominent nervous phenomena. In cer- tain epidemics the affection may be ushered in by vertigo—a symptom that sometimes also appears late in the disease. The most striking symptom is pain, Avhich in a certain percentage of cases is referable chiefly to the forehead, temples, occiput, eyeballs, and root of the nose. General neuro-muscular pains, however, are apt to be present. Their principal seat is often in the region of the lumbar spine (rachialgia), Avhence they are apt to dart upward to the neck and downAvard to the loAver extremities. With the universal myalgic pains there is a general soreness, and I have frequently noted cutaneous hyperesthesia. The pains take the form of neuralgia of individual nerves or of pleurodynia stitches, or there are localized areas of burn- ing, boring muscular pain. The temperature may, as before intimated, mount quite high at the beginning, and if so it usually remits during the first night. It subsequently remains at a comparatively Ioav point, with evening exacerbations, until the normal level is reached, which often occurs as early as the second or third day, but may be postponed until the end of a week. The temperature-curve is markedly irregular, and often terminates by an apparent crisis. The pulse is small, feeble, irregular, and even intermittent, and I have sometimes observed it to be unusually slow, cardiac debility being prominent and at times reach- ing a dangerous degree. In many cases dyspnea is a rather conspicuous 1 " A Statistical Study of Influenza; its Potency to Lessen the Receptivity of the Body for Malaria, as well as to Increase the Receptivity for Pneumonia and, probably, Typhoid Fever," by the author—Philadelphia Hospital Report, 1895, vol. iv. INFLUENZA. 161 svmptom. occurring independently of inflammatory pulmonary compli- cations. The same is true of cyanosis. Clinical Types.—Different types have been described based on the differences in the local manifestations. But it is to be mentioned that influenza is remarkably protean in its clinical features, and that the enumerated types quickly and frequently merge into one another, (a) Respiratory Type.—Local catarrhal symptoms usually develop in the course of one or two days. They are, as a rule, evidenced first by a suffusion of the conjunctiva?, with excessive lacrymation, frequent sneezing, and slight pharyngitis. A little later, in most instances, hoarseness and cough come on, the latter being hard, racking, parox- ysmal in character, and resembling whooping-cough. The cough and other local symptoms are due to intense, dry laryngotracheal irritation. In most instances the expectoration is scanty, and in these the physical signs are verv generally negative. In a smaller proportion of the cases there is considerable expectoration, and the physical signs of ordinary bronchitis are manifested, (b) Gastro-intestinal Type.—The catarrhal symptoms sometimes center in the digestive system, and most frequently in children. In such, vomiting comes on early and is apt to be repeated at longer or shorter intervals. There is diarrhea, more or less urgent, with sharp abdominal pain, as a rule, (c) The cardiac group of symp- toms that occasionally supervenes comprises heart-failure and distress, with a rapid, feeble pulse, (d) The typhoid type presents a continued fever, Avith the signs of the typhoid state. Nervous symptoms are very marked, such as stupor or delirium, dry, brown tongue, etc. (e) The rheu- matoid type manifests itself by violent pains in the muscles all over the body. There is no visible change in either the joints or the nerve-trunks. After the temperature has become normal profound prostration is apt to continue, and hence the patient shoAvs no disposition to muscular or mental exertion. In cases of average seA'erity convalescence is usually somewhat protracted, and in the severer forms decidedly so. Complications.—(1) Pulmonary.—An ordinary bronchial catarrh may be properly regarded as belonging to the peculiar processes of the disease, but severe bronchitis, particularly affecting the capillary tubes and leading to broncho-pneumonia, is a common and very serious com- plication. As a secondary result Ave are apt to observe the development of collateral pulmonary edema, with its usual fatal termination; and, whilst this complication is prone to develop in the so-called thoracic type of influenza, it is by no means limited to this class of cases. In the latter it originates apparently in the profound prostration of the nervous system—a condition Avhich also annuls in great part the phago- cytic action of the leukocytes. In nearly all instances, however, this form, as Avell as croupous pneumonia, may be definitely traced to ex- posure. The bronchial glands may become acutely enlarged. Lobar pneumonia is also a frequent and very fatal complication. It may arise early and in rare instances insidiously, but it is much more apt to manifest itself after influenza has about exhausted its force upon the vital organs or during the early part of convalescence. The symp- toms of invasion—severe chill, high temperature, folloAved by the usual physical signs—are sudden in their onset and lead rapidly to an ex- tremely serious condition. n 162 INFECTIOUS DISEASES. When lobar pneumonia develops early in the course of influenza (a rare event), its symptoms are modified, the preliminary chill and pain in the side being often absent, and more frequently still the characteristic crepitant rale. Subcrepitant rales, however, are audible, and the dys- pnea is out of proportion to the area of lung-tissue involved. Most of the peculiar features just pointed out may also be observed in connection with the pneumonia that appears during convalescence, though, accord- ing to my own experience, they are then more feebly expressed. The recognition of broncho-pneumonia is in many instances quite diffi- cult. Here, as elsewhere, it is secondary to general bronchitis affecting the larger tubes. I have observed this condition in cases in which the physical signs of bronchitis were not presented prior to its onset. In other instances, however, a few scattered sibilant and sonorous rales, intermingled Avith a few moist ones—the usual auscultatory signs of severe general bronchitis—are noted, and then broncho-pneumonia supervenes. Immediately preceding the signs of consolidation in broncho- pneumonia (less frequently also in croupous pneumonia) the respiratory murmur becomes exceedingly Aveak, and later an abundance of subcrepi- tant rales becomes audible over the affected area. Bronchial breathing may be associated, though it is rarely marked; but Avhen the spots in- volved are of considerable size, they may give rise to corresponding zones of dulness on percussion. According to some authors, the nature of the condition is variable, and the symptoms that simulate more or less closely those just depicted are ascribed to congestive collapse and other conditions, rather than to the ordinary type of broncho-pneumonia. Congestion associated with edema of the lungs occurs as a complication of influenza, as I have learned from personal observation. Acute enlargement of the bronchial glands may also be noted, and the recognition of this condition may be aided by careful percussion over the upper four dorsal vertebrae, where dulness will be obtained. Plastic pleurisy is commonly an associated condition, especially in cases of lobular or lobar pneumonia. Other forms of pleurisy also occur, though less frequently (sero-fibrinous and empyema). Gangrene and abscess of the lungs may arise as terminal complications. Cardiac Complications.—Heart-failure often manifests itself, and may prove fatal, though rarely. Purulent pericarditis is a rare complication, and is often secondary to pleurisy or pneumonia, while attacks of angina, which usually interchange Avith simple Aveak heart (often associated with arrhythmia), have been noted in certain epidemics (Curtin and Watson). Castro-intestinal System.—There may be severe gastro-enteritis, with frequent vomiting and purging and intense abdominal pains, and, more rarely, hemorrhages occur from the stomach and boAvel. Catarrhal jaundice may appear, due to duodenal catarrh, but these gastro-intes- tinal complications are more apt to be met Avith in young children than among adults. Nervous System.—The most frequent symptom is perineuritis, Avhich probably causes much of the patient's sufferings. Delirium of a most active form sometimes appears, and particularly wlien certain other complications have arisen, such as pneumonia, pericarditis, etc. Cere- bro-spinal meningitis occurs as a rare complication, and when it arises INFLUENZA. 163 is to be attributed to secondary infection with the streptococcus. I have observed symptoms identical Avith those of meningitis appearing suddenly, and in the course of a day or tAvo disappearing just as sud- denlv. The symptoms under such circumstances must be due either to the action of the specific poison upon the nerve-centers or to congestion, and hence a diagnosis of suppurative meningitis is to be made Avith ex- treme caution. In addition to the presence of the symptoms Avhich characterize the affection, Ave should have the existence of suppuration elsewhere in the body (otitis, purulent pericarditis, etc.) or the presence of pneumonia. Cerebral abscesses have also been noted (BristOAve). Genito-urinary Tract.—Renal congestion, and even acute nephritis, may appear as a complication. A case of cystitis Avith hematuria has also been reported (Comby and Le Gendre). The diagnosis of influenza except in ill-defined, sporadic cases rarely presents serious difficulty. In obscure cases the discharges should be studied bacteriologically. (a) Climatic catarrhal affections are sometimes hard to discriminate from sporadic cases of influenza. The former are usually attributed to sudden and great vicissitudes of temperature or exposure to strong drafts of air, while the latter come on independently of seasons of the year and of such agencies. Again, in influenza Ave usually observe the general features (neiwous symptoms and debility) outAveighing the local (catarrhal manifestations). Simple catarrhs do not tend to traverse the entire system Avith the same remarkable rapidity as influenzal catarrhs. {b) Typhoid Fever, particularly in its early stages, is often closely simulated by influenza Avith intestinal symptoms. Danger of confound- ing these tA\T0 affections can be averted by remembering the facts that influenza gives a different history, begins suddenly, does not have the typical temperature-curve of typhoid, may present splenic enlargement —but by no means to the same extent as typhoid—and has no charac- teristic eruption. (c) Pneumonia has quite frequently been mistaken for influenza, and especially Avhen the thoracic symptoms in the latter have been unusually distinct. As already stated, lobar pneumonia may early complicate in- fluenza in rare instances ; but pneumonia is generally unilateral, Avhile the lung-involvement in influenza is generally bilateral. In the former the physical signs indicative of consolidation are clearly marked; in the latter (unassociated with pneumonia) Ave often meet with those sug- gestive of congestive edema (impaired resonance, stationary crepitant and subcrepitant rales). The general features also present dissimilari- ties. Thus the nervous depression and the myalgic and neuralgic pains are more marked in influenza, while the pulse and respiration are apt to be less frequent than in pneumonia. (d) Cerebrospinal meningitis may manifest features that are almost identical with those characteristic of influenza. Thus during certain epidemics many " grippe " patients suffer from intense headache—oc- cipital and frontal—rachialgia, fever, prostration, delirium, and stiffness of the muscles, with slight retraction of the head. There may be con- vulsions and vomiting at the outset. Here the history Avith reference to the character of the prevailing epidemic and the attendant circum- 164 INFECTIOUS DISEASES. stances must be carefully considered, but an absolute diagnosis is some- times impossible unless a bacteriologic investigation of the discharges be made. Sequelae.—Among the pulmonary sequela? are phthisis, chronic bronchitis, abscess and gangrene of the lungs (the latter two being rare), tachycardia, and angina pectoris. Chronic gastro-intestinal catarrh is not rare as a remnant of the acute form Avhen the latter arises during the influenzal attack. Chronic nephritis, and less frequently cystitis, may also be mentioned. Among nervous sequelae which are both numerous and important are to be noted especially insomnia, neuralgia, migraine, melancholia, mania, meningitis, acute ascending myelitis, locomotor ataxia, peripheral neur- itis, and perineuritis. The organs of special sense manifest a great variety of sequelae, such as otitis media, otitis interna, mastoid abscess, conjunctivitis, keratitis, iritis, irido-chorioiditis, acute glaucoma, paral- ysis of accommodation, etc. Prognosis.—The prognosis is, on the whole, good. Almost all fatalities are due to complications, especially pneumonia, and, less fre- quently, pulmonary congestion and edema, pleurisy, pericarditis, cere- bro-spinal meningitis, etc. The circumstances connected with the individual case often affect the outcome. Thus influenza runs a more severe course, and hence offers a correspondingly more serious prognosis in the very young, the very old, and those enfeebled on account of previous chronic disease (phthisis, valvular disease of the heart, emphysema, nephritis, etc.) than at other periods of life. During severe epidemics of influenza the mor- tality-list in the latter diseases is considerably augmented. Though epidemics vary as regards the mortality, the general average death-rate is a little under 1 per cent. In some epidemics it may reach 2 per cent., while in others it may be less than J of 1 per cent. Duration.—The duration of the attack is brief, though subject to variations. In mild forms it is from tAvo to four days, in the severe from seven to ten days; but complications and previous infirmities may greatly prolong the attack. The duration of particular epidemics rarely exceeds from four to six Aveeks. Treatment.—Prophylaxis.—Experience has shoAvn almost conclu- sively that the various drugs which have been counselled for their pre- ventive effect (quinin, salicin, etc.) are devoid of value. The strongest persons are not immune, and those A\ho are at either extreme of life or who are enfeebled by chronic organic disease should be most carefully protected by proper wearing apparel, and should not be exposed to the direct influence of the changes of weather. In this Avay Ave may hope to lessen, in a measure at least, the totality of the cases, since the in- mates of hospitals and prisons have been knoAvn to escape absolutely when the community all around them was suffering from the disease. Isolation should therefore be carried out in hospitals and, under certain conditions, in private families, especially when the disease appears in households in which there are young children and aged persons. Dis- infection of the catarrhal discharges, particularly the bronchial, Avhich, as a rule, abound in the bacilli of Pfeiffer, must be rigidly carried forAvard. INFLUENZA. 165 Treatment of the Attack.—In considering the treatment of the attack the cases may be grouped under three heads: (a) Mild or Rudimentary Form.—The cases belonging to this type re- quire little besides careful hygienic management. HoAvever light the attack, the patient should remain in-doors and, if languid or prostrated, in bed for a period of tAvo or three days. The diet should be light and nutritious (milk, eggs, rice, gruels, fresh vegetables, stewed fruit, etc.), and cooling drinks are to be preferred to hot ones, among the former lemonade or cold oatmeal Avater Avith lemon, and effervescent mineral Avaters (Apollinaris, lithia, Seltzer) being the best. The boAvels should be moved regularly, avoiding, hoAvever, all purgation. Stimulants are not needful, though Avell borne as a rule, and the use of light wines is not objectionable if desired by the patient. In all cases of influenza, even of the mildest grade, I prescribe moderate doses of quinin ( gr. iv —0.2592, three or four times daily), and if there be much headache this drug may be combined with Dover's poAvder and monobromate of camphor (of the first two gr. iij—0.194, each, and of the last gr. j— 0.0648, in capsule), the dose to be repeated at intervals of three or four hours. To overcome the languor and debility, wliich are marked, I have found nothing so successful as strychnin. (b) Cases of Medium Severity.—General 3Ianagement.—This class of influenza patients betake themselves to bed, and should be kept there till convalescence is well advanced. During the febrile period the diet must be light, liquid, yet nutritious, and the food should be given every two or three hours. Although the patient has no desire for food, he should be urged to eat Avith regularity, no matter how small the quan- tity at each feeding. Moderate stimulation is also useful. The medicinal treatment is, for the most part, simple and symptom- atic. The neuralgia and myalgia may be relieved by the use of quinin, Dover's poAvder, and camphor, as before stated, but if the pain be in- tense, morphin administered subcutaneously is sometimes required. The temperature is somewhat reduced by these remedies, and especially by the quinin and Dover's poAvder, the latter of Avhich acts as a diapho- retic. In addition, I am in the habit of ordering cool sponge-baths at intervals of two or three hours if the temperature be above 102° F. (38.8° C). If not controlled in this manner, we may combine with quinin some antiseptic, such as salicylic acid or salol. I have found it necessary to add to the foregoing small doses of phenacetin (gr. ij—0.129), or acetanilid (gr. ij—0.129), the former being preferred, since it is superior to acetanilid in controlling insomnia, which is so often a troublesome symptom. Sleeplessness may, hoAvever, demand other and more potent hypnotics, such as sulfonal, chloralamid, opium, etc. The local catarrhal conditions (coryza, laryngo-bronchial irritation, true bronchitis, etc.) must be treated according to the special indications presented in individual cases. For the coryza inunctions of animal fats over the forehead and bridge of the nose are useful. A flannel cap may be Avorn if agreeable to the patient. Steam inhalations through the nares and mouth often act beneficially, both upon the coryza and laryngo-bronchial irritation. For the latter common condition the fol- lowing formula will be found serviceable : 166 INFECTIOUS DISEASES B/. Codeinae sulph., gr. iv (0.259); Ammon. chloridi, 3v (20.0); Syr. prun. virgin., f.?ij (60.0); Spts. junip. comp., q. s. ad f,liv (120.0).—M. Sig. One teaspoonful every two or three hours. If this prescription fail to mitigate the cough, we may resort to morphin hypodermically, but always in small doses. In the later stages, particu- larly if bronchitis be associated Avith free secretions, the oil of eucalyp- tus (TTLiij to v—0.199 to 0.333), in capsule, every four hours, has in my experience proved useful. To obviate pulmonary complications I have been much gratified Avith the results from the use of strychnin (gr. -fa— 0.0021), combined with vin Mariani (,5ss—16.0) at intervals of three or four hours. Chest-pains may be relieved by the use of turpentine stupes and sinapisms, both of Avhich agents are also valuable in averting the more serious complications. (c) Severe Forms.— The general management is similar to that recom- mended in cases of medium severity, excepting that freer stimulation is usually demanded. The medicinal treatment must also be more active than in the previous form, and often is heroic. Especially must quinin be given in full doses and continued, since it not only serves to reduce the temperature somewhat, but also to control the nervous symptoms and lessen the tendency to inflammatory complications. Nothing that exerts a depressing effect should be thought of, since the cardiac as well as the respiratory forces, must be conserved. Should there be sudden cardiac failure, it must be promptly met by the various forms of stimu- lants, including strychnin and the cardiac tonics. In addition to alco- holic stimulants, the aromatic spirits of ammonia is usually borne well, and should be administered. Strychnin must be given in full doses hypodermically every third or fourth hour. The various inflammatory complications that may arise must be treated as under other circum- stances. The Convalescence.—In all grades of cases the convalescence from influenza demands most rigid supervision, and the greatest injury to patients at this time comes from going out too early. Usually the tem- perature is subnormal for several days—a circumstance due to the weak- ness of the patient—and so long as this condition obtains the patient is highly susceptible to a chill. Hence it is a good rule not to allow ex- posure to the external changes of temperature until the temperature has been normal for several days. The diet should now be more liberal, and tonics, such as gentian, iron, and quinin, may be administered and con- tinued until complete restoration of the patient's health has taken place. In every way possible exposure to reinfection during the period of con- valescence is to be avoided. The treatment of sequela? must be conducted according to general rules. DENG UE. 167 DENGUE. [Break-bone Fever.) Definition.—An acute infectious disease occurring epidemically in tropical and subtropical countries. Its chief symptoms are—a double febrile paroxysm (separated by an interval), arthritic and muscular pains, and a skin-eruption in about one-half the cases. Historic Note.—The disease was prevalent in Java as early as 1779, in India in LS24, and later in the West Indies, Spain, and in some of the southern American States. Mild epidemics have visited Philadelphia, New York, and Boston, but, as a rule, it has not traversed regions beyond 32° N. latitude. Its pathology has not been studied, death being the rarest of events. Htiology.—McLaughlin of Texas has isolated from the blood and cultivated a micrococcus Avhich he claims is the specific cause of the disease. Predisposing Factors.—Its prevalence is favored by the summer sea- son, and also to a slight extent by faulty hygienic conditions. On the other hand, age, race, sex, and social status are all Avithout effect, most persons being susceptible; and, according to Matas, primary attacks are not protective in character, Avhile other authors contend that they even predispose to subsequent ones. The epidemics spread along lines of travel by land and sea, and most authors agree that the disease is con- tagious. Clinical History.—There is a period of incubation that lasts about four days and exhibits no prodromes. Invasion then is abrupt Avith a slight chill; fever follows, the tempera- ture reaching its maximum—103° to 106° F. (39.4° to 41° C.) or over— at the end of the first or on the second day, and is accompanied by head- ache and by muscular and arthritic pains. The patient's sufferings are in- tense, the pains being described as "•breaking"—a peculiarity to Avhich the disease owes the popular name of " break-bone fever." The joints become red, swollen, and very tender to the touch. The respirations and pulse are much quickened; there are anorexia and sometimes slight nausea. Febrile albuminuria is rare, delirium and mental torpor also ; but prostration may become marked, and an erythematous eruption com- monly appears. DeBrun* noted carefully the symptoms of dengue during the epidemic at Beirut (1892), and states that the eruption is roseolar, morbilliform, scarlatinous, or papular. He distinguished three groups of cases: 1. With high fever and marked associated symptoms, and Avith eruption; 2. Fever absent, the symptoms mild, with eruption; 3. The eruption the only symptom. The eruption may appear early, but has no fixed time, is evanescent in mild cases, and is never constant in cha- racter. It is attended Avith burning and itching, and DeBrun noticed desquamation of a varying intensity. Hemorrhages from the various organs (nose, gums, stomach, boAvels, lungs, kidneys, etc.) may occur, and reach even a dangerous extent. The lymphatic glands are often SAvollen; the mucosae of the nose and throat are hyperemic; the eyes are congested and the face flushed. The initial fever lasts three or four days, and ends Avith a deep 1 Rev. de Med., No. 6, 1894. 168 INFECTIOUS DISEASES. remission accompanied by profuse sweating. All the symptoms noAv vanish save a slight soreness and stiffness, but after an interval of two or three days the characteristic symptoms (including the eruption) re- appear. This second febrile paroxysm is usually milder and shorter than the first. The duration of the disease is from seven to ten days, the attack being folloAved by a slow convalescence, which may be interrupted by a relapse. The sloAvness of the recovery is due to persistent mental de- pression and marked physical prostration. Complications.—Meningitis has been noted, but in extremely rare cases. Convulsions sometimes occur in children, and severe catarrhal inflammations of certain mucosae (bronchial, gastric, etc.) may develop. Insomnia is common. Hyperpyrexia and pericarditis occur very ex- ceptionally. Diagnosis.—The diagnosis of the usual form of the disease (epi- demic) is an easy one after observation of the first few cases, but a more difficult task is the discrimination of sporadic cases from rheumatism. The course and degree of the fever, however, differ in dengue and in rheumatism, Avhile the eruption belongs to the former alone. Influenza in many of its manifestations resembles dengue very closely, and the differential diagnosis is a difficult one. In the former condition the herpes is usually the only eruption; the joints are rarely involved; there is neither a remission nor a recurrence of the fever; and serious complications are more frequent. The discovery of the bacillus of in- fluenza is of course decisive, and the existence of an epidemic of either condition strongly suggests the true nature of the disease. Scarlet fever has an erythematous eruption, but the fever is continuous and the arthritic symptoms are usually Avanting. Yellow fever has been mis- taken for dengue, but is characterized by a single paroxysm ; jaundice, black vomit, albuminuria, and grave nervous phenomena are features that are never seen in dengue. The prognosis is Avith rare exceptions favorable, dangers arising only from the extremely rare serious complications. Treatment.—The case presents a double indication : (a) to harbor the patient's strength, and (b) to meet certain leading symptoms. The first is to be accomplished by enjoining rest in bed, by a generous though carefully regulated diet, and by the timely use of stimulants and tonics. Among the symptoms that demand treatment is the fever, and when this is very high hydrotherapy is indicated. When moderate, cold sponging of the general surface, conjoined with internal antipy- retics (phenacetin, acetanilid) in moderate doses, may be resorted to. For the intolerable pains morphin is to be administered hypodermic- ally, this remedy often relieving the insomnia at the same time. If not, chloralamid and the bromids should be tried. Convalescence may be hastened by a suitable change of air. THE PLAGUE. 169 THE PLAGUE. {Bubonic Plague ; Black Death.) Definition.—A specific contagious disease, occurring chiefly in un- sanitary surroundings and characterized by high fever, cutaneous symp- toms (petechias, etc.), and later by an inflammatory enlargement of the lymphatic glands (buboes). It occurs in epidemics. Historic Note.—The plague is an Oriental disease, and has long been endemic in certain parts of India. Most European countries have in the past been visited by epidemics of the malady, but it is at present Avriting almost solely confined to its native habitat (India), to South China, and to parts of Asia. In May, 1894, a severe epidemic pre- vailed in Canton and Hong-Kong, to which cities it Avas imported from Northern India, and in the latter part of 1896 and the early months of 1897 another swept over India with devastating results. Etiology.—Kitasato and Yersin both discovered during the epi- demic at Hong-Kong a special bacillus which is probably the cause of the disease. It stains deeply at the ends, giving the appearance of a pair of micrococci, but is really a short rod-bacillus with rounded ends. Pure cultures are readily made, and Avhen animals are inoculated with these the clinical characteristics of the disease are produced. Modes of Entrance into the Body.—According to Kitasato, the bacil- lus enters either the digestive or the respiratory tract or by means of excoriations of the surface. Predisposing Causes.—These are embraced in the single phrase—un- hygienic conditions. It is safe to assert that Avithout these fostering influences the plague would not prevail. Clinical History.—The incubation period lasts from tAvo to five or six days, and among prominent invasion symptoms are intense pains in the head, back, and limbs, and a dizziness causing the patient to Avalk with a staggering gait as if intoxicated. The temperature rises rapidly, sometimes to a hyperpyrexial level, preceded usually by slight shiver- ings or a chill, and delirium sets in early. There are torturing thirst, anorexia, and not rarely nausea and vomiting. Petechiae, ecchymoses, and, in malignant types, hemorrhage from the stomach, bowels, and kidneys, may occur, and soon a typhoid condition develops with a marked tendency to circulatory collapse. At the end of tAvo or three days, if life be spared until then, buboes appear, and form the most marked and characteristic accompaniment of the disease. The inguinal and femoral glands are most generally swollen and inflamed; the axillary, submaxillary, etc. less frequently. This glandular enlargement may terminate in (a) resolution, (b) suppuration, (c) gangrene (rarely). Suppuration is generally favorable in import. Carbuncles may attend, but are comparatively rare. Diagnosis.—The disease has been mistaken for typhus fever, but in the latter disease there is an absence of the early tendency to collapse, the characteristic buboes, carbuncles, extensive petechiae, and hemor- rhages. On the other hand, in the plague there is an absence of the characteristic typhus eruption. The geographic limitations of the plague should be borne in remembrance. 170 INFECTIO US I) ISEA SES. Duration and Prognosis.—The duration is brief—from three or four to eight or ten days—and extensive suppuration may prolong the attack. The prognosis is a very grave one, and the disease may prove fatal, like cholera, within a feAV hours. Treatment.—This is largely preventive. All hygienic defects are to be corrected as quickly as possible, especially inadequate sewage, un- clean surroundings, and impure water-supply. Isolation of the sick and thorough disinfection of the sick-room, the bed, and bed-linen, the vom- itus, and the stools, are matters of paramount importance. Kitasato advocates steaming the bedding at 212° F. (100° C.) for one hour, or exposure for a few hours to sunlight, and that all infected articles be burned. " After recovery the patient is to be kept in isolation at least one month." The diet should be liquid, concentrated, and nourishing, and stimu- lants are demanded to obviate collapse. So far as known, medicines do not exercise any controlling influence, and hence they are used merely to combat the symptoms as they arise. As it is possible, however, to ren- der animals immune to the disease, it is reasonable to anticipate that an antitoxic serum will soon be available for treatment. ERYSIPELAS. {St. Anthony''s Fire.) Definition.—A specific, acute contagious disease, characterized by a special inflammation of the skin and subcutaneous tissues, Avith a tendency to spread, high fever, moderate prostration, a disposition to mixed infection (suppuration, gangrene, etc.), and an average duration of fourteen days. It usually occurs in persons under forty years of age, and commonly in endemic, though also in epidemic, form. Pathology.—Erysipelas is a specific inflammation involving the skin, subcutaneous and mucous surfaces, but the latter far less fre- quently. If uncomplicated, no other structures are involved. When inflammation extends to the subcutaneous connective tissue, there fol- lows, as a rule, suppuration. The claim, hoAvever, that the inflamma- tion may penetrate the skull and attack the meninges lacks convincing proof. Osier in one case traced the extension from the face along the fifth cranial nerve to the meninges, Avhere an acute meningitis and thrombosis of the lateral sinuses were excited. The specific cocci are found in the superficial lymph-vessels and spaces of the affected skin, being most abundant in the ever-advancing elevated margin. Beyond the border of the inflamed region they occupy chiefly the lymph-vessels, where they are finally overpowered by the phagocytic action of the leukocytes. Microscopic examination of the involved area reveals the changes of simple inflammation. Etiology.—Bacteriology.—The specific cause of the disease is the streptococcus erysipelatis of Fehleisen, which is probably identical with the ordinary pus-producing streptococcus. Frankel and Kirchner have ERYSIPELAS. 171 investigated, experimentally, the streptococcus of erysipelas, and con- tend that their results offer convincing proof of the separate identity of the streptococcus pyogenes ; but most observers hold that the latter can- not be distinguished from the streptococcus erysipelatis by any known test. The streptococci of erysipelas assume the form of a serpent or chain (chain-forming coccus of Cohn), and are very small, someAvhat variable in size, and thrive on all kinds of culture-media. Their favor- ite situations are the lymph-vessels and the cutaneous connective tissue, where they are found in colonies composed of myriads of cocci. They are rarely found in the blood-vessels, and in blood-serum they are caused to disappear by the action of the phagocytes; yet in exceptional cases intra-uterine infection has occurred. That the streptococcus erysipelatis is a saprophytic organism is shoAvn by the fact that the identical cocci have been discovered in inanimate and decomposing animal and vegetable substances. Predisposing Causes.—Among the most important disposing causes of erysipelas are— (1) Season.—In a paper on " Seasonal Influences in Erysipelas, with Statistics "* I have shoAvn, as the result of an analysis of 2010 cases collected from different sources, that the various seasons of the year exercise a potent influence upon the frequency of this affection. Thus month by month the cases increase, in slightly varying ratio, from August to April, the latter month giving the greatest number, and then there is a rapid decrease from April to August, Avhen Ave find the small- est number. Again, one-half of all the cases occur during the months of February, March, April, and May, and 15.9 per cent, during the month of April alone. It Avould appear that the Avinter and spring months, though more particularly the latter, increase the susceptibility to this disease. It was found that a Ioav barometer and mean relative humidity invariably correspond with the annual period in which the greatest number of cases occur, and that the highest percentage of rela- tive humidity corresponds with the months affording the fewest cases. (2) Age.—From the notes of 1894 cases I found that in 25.8 per cent, the age of the patient was between tAventy and thirty years. From thirty to fifty years the cases slowly decreased in number, and after fifty years quite rapidly, while more than 15 per cent, of the cases occurred before the age of twenty. The great liability of newly-born infants is Avell known. (3) Sex.—This factor Avas noted in 1767 cases, and a marked pre- ponderance of the male over the female sex Avas noted (about 3 to 2). (4) Previous Attacks.—Of 450 cases, there had been previous attacks in 39 (8.6 per cent.), in one instance, four, and in another seven, ante- cedent attacks having occurred, while second and third recurrences were not uncommon. (5) Family predisposition exercises a slight though decided influence. It was noted in 4 of the 450 cases. (6) Certain Antecedent Affections.—Dr. M. Booth Miller examined the history of 301 cases, and found that acute coryza preceded the attack in 13 instances. Slight lesions of the Schneiderian mucous membrane may be assumed to exist in such instances, offering a condi- 1 Proceedings of the American Climatological Association, 1893. 172 INFECTIOUS DISEASES. tion favorable to specific infection (vide infra). Testimony confirming the now Avell-knoAvn fact that certain chronic diseases (chronic Bright's, phthisis, organic heart disease, chronic alcoholism, syphilis, etc.) aug- ment a receptivity to the complaint has also been brought to light by my own researches. (7) Slight Injuries, Abrasions, etc.—Erysipelas will not develop on a surface which does not present a break, but with this present may do so though the latter be so trivial as to escape observation. Slight abrasions and fissures, either in the mucous membrane of the nose or in the skin of the face or ear, as well as all forms of slight injuries, are liable to furnish a path of ingress to the specific organism. Yet in 643 out of the 2010 cases mentioned above and examined Avith reference to this point, previous lesions Avere noted in but 13. Women Avho have been recently delivered and persons subjected to surgical operations are pecu- liarly liable, and any deeply-seated focus of irritation, as an area of necrotic bone or a chronic abscess, such as sometimes occurs in sup- purative arthritis, appendicitis, etc., may give rise to repeated outbursts of erysipelas. (8) Antihygienic Surroundings.—These doubtless predispose to the affection, as has been shown by the prevalence of erysipelas in hospitals and institutions in which the sanitary arrangements are markedly faulty. Modes of Conveyance of the Contagion.—The latter may be air-borne. It has been collected from the air of rooms and Avards occupied by ery- sipelas patients; but to what distance and precisely under Avhat circum- stances it can be conveyed is not definitely known. It may also be transferred for a longer or shorter distance by fomites, by instruments, unclean hands, etc., the infection being a result either of contagion or inoculation, and the direct avenue of entrance for the specific coccus being a break in the skin-surface or mucous membranes. Clinical History.—I shall discuss only the so-called medical or idiopathic erysipelas, the traumatic variety falling more properly within the domain of surgical treatises. Incubation.—This is someAvhat varied, though it ranges usually from seven to fourteen days, and the prodromal symptoms are, for the most part, general in character, consisting in headache, restlessness, cough and sore throat, anorexia, and general slight or moderate pyrexia. These endure for a very variable period—from a few hours to several days— when the invasion with its characteristic features develops. Invasion Stage.—The symptoms are—(1) local and (2) general. (1) At first the affected part feels hot, tense, painful, and is tender to the touch. Very soon a small circumscribed area becomes red, swollen, firm, and shining, and simultaneously the subjective symptoms (pain, heat, etc.) become aggravated. The point of election is usually on the nose, but it may be on the ear, the face, or elsewhere about the head, and thence the inflamed, swollen zone spreads, chiefly in the direction of one or the other side of the head. Separating the diseased from the unaffected skin there is a sharp line of demarcation in the form of an elevated brawny ridge, Avhich can be seen and felt. While the inflam- mation is advancing there may be noted, beyond the border of the latter, little red streaks and spots that grow in area till at last they become confluent. The degree of redness increases in intensity as the case ad- ERYSIPELAS. 173 vances, but any natural prominence or fold in the integument may pre- vent further extension of the inflammation (e. g. naso-labial folds, border of the hairy scalp, etc.). In cases of average severity the face is much swollen, the eyes closed on account of tumefaction of the eyelids, the ears greatly enlarged (far better marked on one side than the other, as a rule), the scalp SAvollen and tender, and the facial lineaments often changed beyond recognition. In a minority of the cases the inflamma- torv process extends from the head to the arms, to the trunk, and even to the lower extremities (erysipelas migrans), and in such instances the face may be healed Avhile the disease is yet extending over other por- tions of the body. Even in the ordinary form, which is usually con- fined to the face, ears, and portions of the scalp, those parts first affected pale while yet the local inflammation is extending its boundary lines. When the progress of the inflammatory process has become arrested the peripheral ridge ceases to extend and groAvs pale; the inflammation then subsides, and finally disappears altogether. The epidermal layer may become elevated over circumscribed areas, giving rise to larger or smaller vesicles or bullae (erysipelas vesiculosum). Suppuration may attack these large vesicles, whereupon they fill Avith pus (erysipelas pustulosum). As the result of intense infiltration the part or parts may become gangrenous—erysipelas gangrcenosum. Enlarge- ment of the cerebral lymph-glands is also common. Desquamation fol- lows erysipelas, and the face often presents a more delicate complexion than before the occurrence of the attack. (2) General Symptoms.—With the onset of the local disturbances or even somewhat earlier, the patient is seized Avith repeated fits of chilli- ness or shivering, or, less commonly, there may be a severe rigor. Im- mediately, and more rapidly than before, the temperature rises to a height of 104° or 105° F. (40°-40.5° C.) on the evening of the first day. As a rule, the temperature reaches its maximum (105° to 107° F.—40.5° to 41.6° C.) on the third evening. Marked nocturnal remis- sions of temperature (2° to 5° F.—1.1° to 2.7° C.) are the rule, but the evening temperature may in rare instances be to an equal degree lower than the morning. In a Aveek from the appearance of the eruption the temperature declines rapidly to normal, and usually within twenty-four or thirty-six hours; sometimes, however, the course of the fever is much more prolonged and defervescence may be less critical. In erysipelas migrans a long and decidedly irregular temperature-curve is presented, the period of decline also showing many deviations from the normal curve when complications are present. The pulse is frequent, of good volume, and soft. I have been able to confirm the observations of DaCosta, Striimpell, and others that the cutaneous inflammation in ery- sipelas (particularly erysipelas migrans) may advance to a slight extent even after the temperature has returned to the normal grade. The tongue is furred, the anorexia intensified, and there are apt to be nausea and frequent vomiting. The bowels are usually constipated, though I have observed a feAv instances in which marked diarrhea de- veloped late in the attack. The inflammation may extend to the mucous membrane of the throat and larynx, causing SAvelling and edema of the parts. It may also invblve the serous membranes, though rarely. The nervous symptoms may or may not be conspicuous, but there are apt to 174 INFECTIOUS DISEASES. be intense headache and restlessness, with some mental aberration at night. Actual nocturnal delirium appears in the severer forms, and in erysipelas occurring in drunkards delirium tremens may suddenly de- velop. The urine presents the usual febrile characters (high color with increased urea and diminished chlorids). Quite commonly it contains a little albumin, and rarely acute nephritis occurs as a complication. Abundant observation has shown that there is a direct correspondence betAveen the intensity of the local and constitutional disturbances in this disease. Often in severe types (such as are apt to arise in old, much enfeebled, or intemperate persons) of facial erysipelas the typhoid (adynamic) con- dition is developed. The tongue is dry and broAvn, the lips and teeth are covered with sordes, the pulse grows very rapid and feeble, and the bowels are apt to be loose. Ataxic nervous symptoms shoAV them- selves. Complications and Varieties.—An analysis of 1674 cases of erysipelas Avith particular reference to complications gave an interesting series of results, and one at variance Avith the notions of most authors. Some are given here briefly, the complicating conditions being placed in the order of frequency of occurrence: Abscess, 105; rheumatism, 20; delirium tremens, 10; lobar pneumonia, active delirium, phlebitis, pleu- risy, each 7; acute nephritis, 6 ; synovitis and diarrhea, each 5; ton- sillitis, 3; catarrhal pneumonia, otitis media, pharyngitis, edema of the larynx, acute bronchitis, each 2 ; endocarditis, meningitis, each l.1 The fact that acute articular rheumatism is a relatively frequent complication of erysipelas is Avorthy of special notice, for the reason that the attention of the profession has not hitherto been called to it. The symptoms of rheumatism usually come on several days after the onset of erysipelas. " So long as the specific agent upon which rheu- matism depends is not known, so long must Ave remain in ignorance of the true explanation of this combination of diseases." In a few in- stances pneumonia appeared early, being due most probably to special localizations of the specific streptococcus. To such cases the term " pneumo-erysipelas " may be appropriately applied. The cases—2 in number—in Avhich acute nephritis developed during the first feAV days of the attack should in like manner be termed " nephro-erysipelas." With few exceptions, however, the complications enumerated are second- ary affections. Meningitis Avas present in a single instance only, and hence active delirium in this disease points to a severe type of infection, but not to meningitis as a rule. Many different varieties have been described. Apart from those already referred to more or less at length (cutane- ous, gangrenous, vesicular, "pneumo-," "nephro-," and migratory ery- sipelas), two other forms—namely, phlegmonous, or cellulo-cutaneous, and relapsing erysipelas—should be mentioned. The former exhibits an inflammation of the subcutaneous connective tissue which tends to suppurate, and a glance at the complications of the affection shoAvs that suppuration occurs Avith the greatest frequency among complicating conditions. But the so-called phlegmonous erysipelas cannot be properly 1 " The Complicating Conditions, Associated Diseases, and Mortality-rate in Ery- sipelas," by the Author: The Int. Med. May. for Oct., 1893. ERYSIPELAS. 175 regarded as a distinct type, since the atypical manifestations are due to secondary infection with the pyogenic organism. Relapsing erysipelas, however, constitutes the chronic form of the disease, recurring at longer or shorter intervals, and usually in the same locality. It is commonly due to some deep-seated focus of suppuration. Sequelae.—The hair often falls, but it is usually replaced by a fresh crop. Abscesses in various parts of the body, particularly the eyelids, are of common occurrence (vide Complications), and chronic otitis media and chronic nephritis may date from an attack of erysipelas. Per contra, ervsipelas is reputed to be curative of certain affections (eczema, lupus, carcinoma, sarcoma, rheumatism, etc.). Out of 476 cases collected by me relapses occurred in 54 (11.3 per cent.), and in 1 of these instances 5 relapses occurred ; in 2 others, 4 ; and in 3 patients, 3. First and second relapses Avere still more common.1 The diagnosis is made with ease after the eruption has fully devel- oped, and its appearance, seat, and behavior, particularly the manner of extension of the brawny, ridge-like edge (best marked on the fore- head), are the features that should serve to distinguish it positively from every other disease. First, erythema produces superficial redness, but is not attended with heat, SAvelling, or fever. Urticaria assumes the form of pale-red circu- lar Avheals, which cause marked itching and appear in successive crops, often disappearing in the course of a few hours. Acute eczema of the face, Avhen intense, may somewhat resemble erysipelas, but it lacks the peculiar border and mode of progression so characteristic of the latter disease. Again, eczema produces particularly troublesome itching, and the SAvelling is less than in erysipelas. Chronic erythematous eczema is met with later in life, is without fever, Avithout any considerable swell- ing or pain, Avhile, on the other hand, it excites intense itching. Eczema nodosum is characterized by its nodosities at their usual seat in the vicinity of joints. Course and Duration.—In my own experience, based upon 1880 cases,2 the average duration (including the prodromal stage and period of convalescence) in persons under forty years of age is fourteen days. The course of the disease is much lengthened by complications or by the pre-existence of chronic affections, and increases Avith age after the fiftieth year. The prognosis is favorable, and it is rare for erysipelas to assume a malignant type. Perhaps the chief dangers lie in certain complica- tions, especially extensive suppuration, pneumonia, acute nephritis, de- lirium tremens, etc. Acute articular rheumatism, though relatively frequent, is comparatively harmless ; but previous debility, especially if dependent upon chronic diseases, as syphilis, chronic rheumatism, gout, tuberculosis, organic disease of the heart, and the like, increases the percentage of deaths considerably. Again, age has a positive influence upon the mortality, which it augments moderately after the forty-fifth year, and most decidedly after the sixtieth year. When death occurs it is due to exhaustion. 1 Journal of the American Medical Association, July 22, 1893. 2 " Points in the Etiology and Clinical History of Erysipelas," by the Author: Journal of the Am. Med. Assoc, July 22, 1893. 176 INFECTIOUS DISEASES. The mortality-rate is low, as shown by the results of my own collec- tive investigations into the subject.1 I found the general average death- rate to be 5.6 per cent., while in cases from private practice it was 4 per cent. In persons under forty years of age it was only 3.5 per cent., Avhile in those over seventy years it was 46 per cent. The traumatic cases gave a mortality of 14.5 per cent. Treatment.—The treatment of erysipelas falls naturally into three subdivisions: (1) Dietetic; (2) Constitutional; (3) Local. (1) Dietetic.—Proper attention to the diet is of the first importance. It must be generous and composed of highly nutritious articles, and if the temperature be high, only liquid forms of nourishment should be admin- istered in definite quantities and at regular, brief intervals. Rectal alimentation should be resorted to if the stomach rejects a suitable diet- ary, and I feel confident of the fact that liberal feeding is of greater service to the patient than any of the recognized forms of medicinal treatment. Lack of attention to the patient's diet during the primary attack tends to increase the frequency of relapse. In persons over fifty years of age, and in those in whom the vital processes have been lowered on account of previous chronic diseases, correct alimentation is of para- mount importance, often abridging the otherwise much protracted course of the affection. There can be no question but that the typhoid state of the system met with in many cases of erysipelas is attributable, in- directly at least, to malnutrition. When nourishment is exhibited in a proper manner stimulants are rarely required. (2) Constitutional Treatment.—When, despite an appropriate diet, the pulse becomes very rapid and feeble, the heart's first sound indis- tinct, and the tongue dry or brown, indications for the use of stimulants are present and must be heeded. Alcoholic stimulation is most apt to be required in the aged and in patients previously enfeebled by chronic disease. When needful, the alcoholics may be given with a compara- tively free hand, 12 to 16 ounces (360.0-480.0) of Avhiskey daily in di- vided portions. Strychnin gives prompt results, and may be used in association with the alcoholics. In marked gastric irritability cham- pagne is to be preferred. The tincture of the chlorid of iron was first extensively used in this disease by English authorities, and was formerly regarded by most clin- icians as a truly specific remedy. In 74 cases of erysipelas which were treated by this remedy alone, the average quantity being 1 dram (4.0) daily in divided doses, in the Pennsylvania Hospital by Drs. Lewis, DaCosta, Longstreth, Meigs, and others, the death-rate Avas 4 per cent.2 At the present day the profession are, for the most part, agreed that other preparations of iron are at least equally efficacious. Quinin is a valuable remedy in erysipelas, and during the past twelve years I have employed it in not less than 30 cases, confining its use to instances in which the temperature touched 103° F. (39.4° C), and, Avith a single exception, in uncomplicated cases (22 in number) the nocturnal remis- sions were decidedly greater and the evening exacerbations less marked. In every instance iron in some form was administered simultaneously. J. M. DaCosta first used pilocarpin in erysipelas at the Pennsylvania 1 Loc. cit., p. 3. 2 "The Treatment of Erysipelas," by the Author: Therapeutic Gazette, July 16, 1894. ER YSIPELAS. 177 Hospital. His experience showed that Avhen given hypodermically (gr. ^—0.010) in the very early stage, and repeated three or four times at intervals of tAvo or three hours, it often aborted the attack. If Ave except this use of the drug, it is only in cases attended Avith high tem- perature with slight morning falls that pilocarpin should be employed; and the condition of the pulse and heart can be relied upon as a guide to its administration. Whether or not the favorable results from the use of pilocarpin are to be ascribed to a property possessed by it of stimulating phagocytic action is not yet clear. Numerous antiseptic remedies have been recommended, and I have for a decade and over been exhibiting mercuric chlorid in moderate- sized doses throughout the febrile stage, Avith some amelioration of the symptoms. Of late various bacteriologists have been endeavoring to obtain a serum antagonistic to the toxin of erysipelas. Experimentally, the success has been all that could be desired, but it has been difficult to obtain a serum of sufficient potency for therapeutic purposes. The most successful is that of Marmorek, now manufactured extensively, and, although Petruschky has declared it useless, the results of earlier and later investigators (Bornemann and Merieux) cannot be ignored, and it must be recognized as possessing considerable value. Certain symptoms demand internal medication. When the fever, as sometimes happens, is alarmingly high, its reduction must be accom- plished, and the best method is by means of cold spongings combined Avith the ice-cap, or cold or gradually cooled baths. The happy effects of this agent—cold—are manifold. Guaiacol has recently been em- ployed for the purpose of reducing the temperature, and found highly efficacious. The tendency to spontaneous remission of fever in this dis- ease must, however, be steadily borne in mind. For marked nervous phenomena, such as pain, sleeplessness, and active delirium, hyoscin hydrobromate (gr. jfo—0.0006) has been tried hypodermically in numerous cases at the Medico-Chirurgical, Pennsyl- \ania, and Philadelphia hospitals, and has given promise of being a valuable remedy. It should not be employed Avhen the heart-poAver is found to be deficient, and to fulfil the same indications Ave may utilize the following: Sodium bromid, gr. v (0.324) every tAvo hours, or gr. xx-xxx (1.296-1.944) at night; morphin, gr. \ (0.008), and chloral, gr. x (0.648), in combination every half hour for three doses; potas- sium bromid, gr. x (0.648), and tincture of cannabis indica, ITLx (0.666), in combination at bed-time; atropin, gr. J* (0.0008), and morphin, sr. i (0.0108). hypodermically. The treatment of the various complications must be conducted in accordance Avith general principles applicable to each. (3) Local measures have ahvays held a prominent place in the treat- ment of erysipelas. The list of agents that have been used topically is long and embraces all classes of therapeutic substances. In the paper previously cited it is stated that in the three series of cases (247) that were treated at the Pennsylvania Hospital, together with a few collected from other sources, no less than fifty different remedies and preparations had been employed locally. Among those most frequently used were elm (37 cases); lead-Avater and laudanum (20 cases); carbolic acid (1 to 178 INFECTIO US DISEA SES. 40), injected subcutaneously (18 cases); zinc oxid (14 cases) ; mercuric- chlorid solution (14 cases); ichthyol ointment with lanolin (8 cases), etc. Many of these preparations were prescribed for their effect in excluding the air—a leading indication. This I am in the habit of meeting by the use of carbolized vaselin or cool carbolized oil. A knowledge of the microbic nature of erysipelas has led to the local application of numerous antiseptic remedies, and it is along this line that the greatest advances in the treatment of the disease are to be ex- pected. Mention has been made of the method of injecting carbolic acid. Here the aim is to check the spread of the inflammatory process by inserting the needle at numerous points just beyond the inflamed border. The method (introduced by Heuter) has been much practised by Henry at the Philadelphia Hospital, and more recently by Osier at the Johns Hopkins Hospital, and is especially applicable in erysipelas migrans. In the statistics before given a solution of mercuric chlo- rid (1 : 4000) Avas used locally in 14 instances, to which I can add the results of 12 others at the Medico-Chirurgical Hospital and in private practice. In nearly all of the cases it Avas employed in the form of a lotion over the inflamed surface. In a feAv it Avas injected beneath the skin, as in the case of the carbolic acid. More recently it has been recommended to scarify the affected part and follow Avith the application of a solution of mercuric chlorid. In view of the fact that the strep- tococcus is found chiefly in the more superficial channels of the corium, it folloAvs that it may be attacked directly by the mercuric-chlorid solution Avhen the latter is used after scarification ; and this method of treatment is at once most promising and rational. In 8 instances (3 of which have been previously reported) it Avas attended with brilliant re- sults, limiting the spread and allaying the severity of the local inflam- mation. At the Pennsylvania Hospital uniformly good results were obtained from the local use of ichthyol ointment Avith lanolin (DaCosta and others). ZeleAvsky found ichthyol efficacious in every form of ery- sipelas, being superior to other remedies. He prescribed the agent as follows: If. Ammon. sulpho-ichthyol, Spts. aether., da. 1 part; Collodii elastici, 2 parts. Thomas advocates thorough rubbing of a strong ointment of ichthyol with vaselin or lanolin into the red area and into the adjoining healthy skin, covering the parts Avith lint or the ordinary surgical dressing. Whalen1 has recently reported most strikingly favorable results in 4 cases of facial erysipelas from the use of external applications of guaiacol. Many special modes of treatment in erysipelas have been brought forward recently, but of these only tAvo are deemed Avorthy of brief notice : (a) Method of Koch. By means of a soft brush Ave apply a thin and regular covering of the following pomade: R). Creolin, 1.0; Iodoform, 4.0; Lanolin, 10.0. 1 Journal of the American Medical Association, April 28 1894. DIPHTHERIA. 179 The parts are then covered Avith leaves of gutta-percha, (b) Method of Hallopeau.1 A mask of several thicknesses of linen is soaked in a solution of sodium salicylate (1: 20) and applied over the parts, Avhich are then covered Avith rubber bands to prevent evaporation. Relief is said to be almost immediate, and a cure is had in from three to five days. DIPHTHERIA. {Diphtheritis; Angina Maligna ; Croup.) Definition.—An acute, contagious disease caused by the Klebs- Lbffler bacillus, and characterized, anatomically, by a croupous-diph- theritic inflammation of the mucous membrane of the pharynx and upper air-passages. Clinically, it is characterized by irregular fever, prostration, and, frequently, albuminuria; also by the secondary devel- opment of toxemia, and often of croupous laryngitis or cardiac failure. It is often folloAved by peculiar paralyses. In large municipalities it behaves endemically, and from time to time epidemically. Pseudo-diphtheria.—There are forms of inflammation occurring most frequently in the pharynx and adjacent air-passages (and also in many other parts of the body) that are attended with the formation of a pseudo-membrane, and are not caused by the Klebs-Loffler bacillus. These cases have been studied exhaustively by Prudden and others, Avho have usually found the streptococcus to be the specific cause of infection. The latter, hoAvever, has been found occasionally in the pharynx of healthy children and in the inflamed mucous surfaces met Avith in ery- sipelas and measles. "Pseudo-diphtheria," so called, is very common in scarlatina. Pathology.—The true diphtheritic inflammation has for its chief pathologic peculiarity the production of a fibrinous exudate. When the inflammation is superficial and of a mild grade, a croupous mem- brane is produced which can be easily removed from the mucosa, Avhich it covers. Its formation is accompanied by a necrotic process that does not extend below, but practically replaces the epithelial layer of the mucous membrane. In the severer types of the affection, hoAvever, the fibrinous membrane infiltrates all the layers of the mucosa, Avhich undergoes necrosis more or less nearly complete. In the severest forms the submucous layer may also become necrotic. It is to be borne in mind that the production of the fibrinous exudate in croup or diph- theria is ahvays preceded by coagulation-necrosis of the epithelium. The mucous membrane surrounding the exudate is hyperemic, more or less edematous, and the seat of muco-purulent secretions. The Pseudo-membrane.—Its composition comprises fibrin, pus, disin- tegrated leukocytes, flakes of necrosed epithelium, bacilli, and some- times red blood-corpuscles. The fibrin has tAvo main sources: (a) "The fibrinogen of the inflammatory matter," Avhich transudes through the capillary Avails; and (b) Disintegrated, migratory leukocytes, which form branching fibrillae. Weigert holds that the inflammatory exuda- 1 Journal of the American Medical Association, vol. xv. p. 334. 180 INFECTIOUS DISEASES. tion is coagulated by a ferment derived from the disintegrated leuko- cytes. The Klebs-Loffler bacilli are found, chiefly and in varying relative numbers, in the meshes of the fibrillae, but also in the granular fibrin and on the adjacent mucous membrane. Frequently other micro-organ- isms are associated (streptococci, staphylococci, etc.). The membrane presents a grayish-Avhite color, and, if croupous in character, can, as before mentioned, easily be removed. When the mucosa is deeply involved the membrane is thicker, firmer, and more adherent, so that its removal entire cannot be effected Avithout great difficulty, and Avithout, as a rule, injury to the surface, as shown by bleeding, etc. The character of the pseudo-membrane is affected by the nature of the underlying structure; thus in the pharynx it is firmer and less easily separable than in the larynx and trachea, Avhere a distinct basement membrane is found (Flexner). As the membrane becomes older its color is apt to grow darker, becoming yellow or even dark brown. It sometimes becomes gangrenous, and softens or disintegrates, Avith the production of a very offensive brownish, semi-liquid excretion. The advancing edge of the false membrane is usually thin. On the other hand, when the process has become arrested the edge is apt to look raised or Avrinkled, and later it may be distinctly curled up. The membrane may extend downward into the ramifications of the bronchi. In such cases there is apt to be a lobular pneumonia, and this latter condition may occur Avithout extension of the membrane. Occasionally there is a lobar pneumonia. A generalized bronchitis ex- tending to the smaller bronchi is common from the irritation of aspi- rated substances. In rare cases the membrane has spread into the esophagus and even into the stomach. After separation of a croupous membrane repair consists merely in a restoration of the epithelial layer—a process Avhich is initiated by the fragments of epithelium that remain along the edges of the diseased area, and proceeds centrally. On the other hand, in true diphtheria, with necrosis more or less nearly complete of the mucosa and even the submucosa, sloughing occurs, and the missing structures are replaced by cicatricial tissues. The Heart.—The muscular structure and the nervous mechanism suffer most. The histologic changes may be of the parenchymatous va- riety, but only in mild instances; whereas in severer cases fatty degen- eration is conspicuous. In still other cases the chief pathologic charac- teristic is an interstitial myocarditis, and rarely the lesions of peri- carditis and endocarditis have been noted. The heart is by no means always involved. The spleen is commonly enlarged, though not to an excessive degree. The blood is dark, its coagulability is greatly diminished, and Canon and Frosch have in a feAv cases found the bacilli in the blood of those dying with diphtheria. The red-corpuscles are somewhat decreased in number during the course of the disease, Avhile the white corpuscles are increased. Bouchut and Dulinsay consider the grade of leuko- cytosis of prognostic value, and claim that it varies directly Avith the severity. Grawitz has determined in numerous cases a hio-her spe- cific gravity of the blood during diphtheria. The lymphatic glands DIPHTHERIA. 181 of the neck become swollen as a rule, but they shoAV little tendency to suppurate. The Kidneys.—The kidneys shoAV degenerative changes, the usual kidney-lesion being a hyperemic SAvelling Avith edema of the interstitial tissues, and often hemorrhagic spots in the cortex. Sometimes there is a marked glomerulo-nephritis, and more rarely a diffuse granular degen- eration of the epithelium. Minute areas of necrosis have been observed in the internal organs, in Avhich fibrin has been found deposited (Oertel). Welch and Flexner have produced, by artificial inoculation upon guinea- pigs, kittens, and rabbits, foci of cell-death in the lymph-glands through- out the body, in the spleen, liver, lungs, heart, and intestinal mucosa. When the dose is small and the animal lives several Aveeks, the paralysis Avhich belongs to the disease may develop. The nerves, in cases of paralysis, have shown parenchymatous and interstitial inflammatory lesions. In paralysis of throat-muscles (i. e. those near the locality of the pseudo-membranous inflammation) the latter show also round-cell infiltration and fatty degeneration of the fibers. The gland*, especially of the neck, are often much enlarged, and there is, in pronouncedly septic cases in Avhich a mixed infection is found by culture, a good deal of tumefaction of the neck, this sometimes even obliterating the normal contour from jaw to clavicle. Htiology.—True diphtheria is caused by the Klebs-Loffler bacillus, and all cases of supposed diphtheria in which the bacillus is absent are to be regarded as non-diphtheritic. The etiologic is, therefore, quite different from the pathologic significance of this term. Recent researches have removed all doubt as to the specific nature of the Klebs-Loffler bacillus. Bacteriology.—The bacillus diphtheriae nearly equals in length that of the bacillus tuberculosis, and is twice the diameter of the latter. It has rounded extremities, which are also frequently bulbous, giving it the appearance of a dumb-bell. At times one end only is clubbed, or, more rarely, one or both ends appear pointed. The bacilli are immobile, do not form spores, and stain readily, the best agent being alkaline methyl-blue. Their manner of taking the stain is important. The bacilli show alternating segments of darker and lighter stained areas, and often minute dots shoAving a most intense and deep staining. They grow on most culture-media, but for clinical purposes Ldfller's blood- serum is important (3 parts blood-serum and 1 part neutral or slightly alkaline nutritive bouillon, containing 1 per cent, of glucose). Inocu- lated on this, they outgrow all other organisms that may be present, and Avithin eight hours or less show numerous spots, one-half to one millimeter in diameter, Avhich have a dull surface and a dense white or somewhat yellowish color. There are usually present also smaller points Avhich have different appearances and which are colonies of other organisms. The former are the colonies of the bacillus diphtheria, and from these microscopic preparations and (by further cultivation) pure cultures can be obtained. The bacilli are semi-anaerobic, and thrive at the temper- ature of the human body; a temperature of 122°-136.5° F. (50°- 58° C.) causes their destruction in ten minutes. Pseudo-diphtheria Bacillus or Bacillus Xerosis.—From many cases, 182 INFECTIOUS DISEASES. often showing no lesions, an organism may be obtained that is identical in appearance, manner of culture, growth, etc. Avith the bacillus diphtheriae, but inoculation with it causes no lesions. The works of Abbott, Roux, Yersin, and others seem to shoAV that this is an attenuated form of the true bacillus, and varying grades of pathogenicity may be found betAveen the two. The distinction from the pathogenic bacillus can only be made by determining the lack of infection after inoculation. Site of Infection.—In the human family the seat of election of the bacillus diphtheriae is usuallv the faucial mucosa, and less frequently other mucous surfaces and abraded skin. The bacilli do not penetrate the mucosa, and hence do not find their way into the lymphatic or cir- culatory system, but remain at or very near the site of the local changes. The Toxins.—Toxins are absorbed from the diseased spots by the lymphatics and blood-vessels, and produce the general phenomena in un- complicated cases. They have been isolated from artificial cultivations of the microbe, and when inoculated the chief ptomain of the Klebs- Loffler bacillus so modifies the solids and liquids of the body as to render the subject immune (Behring). Another, however, if employed in like manner, produces dangerous and even fatal symptoms (convulsions, paralysis, etc.). It is certain that the bacillus can maintain an existence for months outside of the body, though its usual habitat is unknown unless it be the organic constituents of the superficial soil. The virulence of its products is modified by many individual conditions, and chief among these is a healthy and intact condition of the mucous membranes, Avhich greatly reduces the susceptibility to the disease. Associated Microbes.—With the Klebs-Loffler bacillus are frequently found other microbes, especially streptococci and staphylococci. These pass beyond the site of local infection, reaching the internal viscera and other structures, and, as will be seen hereafter, give rise to the serious septic element of the disease. Modes of Infection.—When the bacillus leaves the body of the sick it is contained in particles or shreds of the diphtheritic membrane, or in the expired air. Infection may then occur (a) By direct contact with the shreds of membrane thrown off—e.g. Avhen the latter are ejected by coughing and lodge upon the conjunctivae or faucial mucosa of bystand- ers. Under this category come the cases in which the deadly poison is transferred to the physician and attendants, with resulting infection, from the sucking of tracheotomy-tubes, (b) By inhaling the air sur- rounding the patient (contagion). Infection by contagion, hoAvever, does not extend beyond a radius of a few feet from the patient, (c) A very leading manner of conveyance of the bacillus from the sick to the healthy is by fomites. The contagion adheres tenaciously to a great variety of objects (toys, clothing, library books, letters, slates and drinking-cups in the public schools, etc.), and in this way the germs of diphtheria have been transferred over great distances and have given rise to the disease long after. The latter fact renders it difficult to trace certain cases to previous ones, to Avhich they invariably OAve their origin, (d) Sewer gas, per se, is to be regarded as non-pathogenic, or at least so far as this affection is concerned (Laws). It may, however, become a carrier of diphtheritic poison, (e) I regard it as highly DIPHTHERIA. 183 probable that the disease may be communicated by domestic animals (fowls, cats, etc.). As to the exact conditions under which infection occurs, our know- ledge is as yet incomplete. We knoAv definitely the usual point of local infection in man, and also that a catarrhal mucosa or an open lesion of a mucous surface invites infection. It is not certain, however, that even a slight lesion of the mucous surface is essential to infection, though it is very questionable Avhether the diphtheritic germs ever find lodgement in the perfectly healthy mucosa. Some Avriters claim still that the Klebs-Loffler bacillus may enter the blood through the respiratory system and give rise to primary constitutional symptoms, the local manifestations in the throat being secondary. I have met with a single instance that would lend support to this vieAv. Predisposing Factors.—(1) Age.—This is the most important factor, diphtheria being, in the main, a disease of childhood. Most cases occur between the second and seventh years, while the receptivity diminishes rapidly after the tenth year. Instances have, however, been observed up to the fiftieth or even the sixtieth year. During the first year of life also it is rare. (2) Sex.—This is without appreciable influence. (3) Season.—Cases are more numerous in winter and spring than at other seasons. (4) Climate.—Diphtheria is met with less frequently in tropical than in temperate and cold climates. Humidity favors the propagation of the diphtheria germ, and hence damp cellars also promote the spread of the disease. (5) Unhygienic Conditions.—Unfavorable sanitary sur- roundings tend to lower vitality, and in consequence to increase the susceptibility to the specific virus. Most epidemic outbreaks have held more or less intimate relationship with decomposing organic matter, defective drainage and seAvage, cesspools, etc., though it is to be espe- cially remembered that the disease often prevails in sparsely-settled rural districts. Immunity.—A single attack does not confer perfect immunity. Second and third attacks not infrequently occur in the same individual. Symptoms.—Incubation.—The duration of this period is from tAvo to seven or ten days, and in a small percentage of the cases it may be longer. In virulent epidemics and when the disease is produced experi- mentally the incubation-stage is short—from tAvelve hours to tAvo or three days. The prodromal indications of diphtheria are not strikingly characteristic. They may either be acute in character or very mild; but usually the child will complain of feeling weary and indisposed to play, of being chilly and cold, and of pain in the head, back, and limbs. There is nothing in this early stage of the disease to distinguish it from many of the other affections of children, such as simple pharyngitis or tonsillitis. There may be some fever, not very high—an elevation of one or tAvo degrees at most. The child may often complain of dis- comfort in swallowing, and on examination the fauces Avill be found to be reddened, and in a short time the exudate will be found on the ton- sils or soft palate. This is the usual type of simple tonsillar diphtheria. Pharyngeal Diphtheria.—The symptoms are usually slower of devel- opment than in tonsillitis. The child is sluggish, looks heavy-eyed, languid, and pale for several days. The fever may not rise above 101° or 102° F. (38.8° C). On examining the throat, however, it is found 184 INFECTIOUS DISEASES. to be swollen and red, and if lividity is more pronounced than the swell- ing, it suggests the true nature of the disease. The membrane begins on the tonsils in the form of small patches of yelloAV exudate, scarcely distinguishable from the thick, cheesy plugs of inspissated dead epi- thelium and secretion Avhich issue from the mouths of the follicles of the tonsils during the course of acute or chronic tonsillitis. The mem- brane spreads from the tonsils to the soft palate and half arches Avithin a feAV days, and it may also appear on the pharyngeal Avail. During this stage the throat may become much swollen and the tonsils greatly enlarged, frequently meeting in the median line. The glands immedi- ately beneath the angle of the lower jaw on one or usually both sides become hard, painful, and slightly enlarged; the swelling of these glands is not usually great in mild forms, although their presence, in association with the foregoing symptoms, is an infallible indication of the disease. The child, as a rule, shows grave constitutional symptoms for a feAV days, and loses its appetite. The temperature is not charac- teristic, as a rule not being high, and the pulse is rapid and weak, being out of proportion to the general indications of the disease. In mild cases the symptoms abate by the end of the first week, and the pseudo- membrane separates, leaving a red, inflamed surface behind. The child is prostrated for a number of weeks, and in about 20 per cent, of all mild cases the toxic effects of the disease may show themselves in the form of a neuritis, with its accompanying paralysis. Variations in Manifestation.—Diphtheria may exhibit a number of variations as regards the seat of attack and the severity of the poison- ing. In some epidemics the Klebs-Loffler bacillus seems to be more active and more numerous, or perhaps more virulent, than in others. The severity of the attack does not seem to depend on the amount of the pseudo-membrane, but rather, according to Rotch, upon three fac- tors : (1) the virulence of the bacteria; (2) the local resistance; and (3) the general resistance. The false membrane is most frequently seen on the tonsils, spreading gradually to the soft palate and uvula, though the mucous membrane of any part of the body may be the seat of the growth. Malignant Dijohtheria.—The symptoms are severe from the com- mencement. There are one or at most tAvo days of slight illness, and then alarming symptoms manifest themselves, cardiac failure possibly setting in without a specially severe local lesion. Vomiting and high fever, resembling the onset of scarlet fever, may initiate the attack; and Avithin a few hours Ave may find extensive swelling at the angles of the ja\vs, with a feeling of stony hardness, a very offensive, bloody dis- charge coming from the nostrils, accompanied Avith difficulty in opening the mouth. If the throat is examined, there will be found extensive swelling of the tonsils, even to meeting, the uvula and soft palate being edematous and covered Avith much sloughy-looking membrane. The temperature in severe cases soon reaches a point betAveen 103° and 104° F. (40° C), while the heart-beats become exceeding feeble. In a day or t>vo the cellulitis extends, the face becomes edematous, the skin pits all over the face, neck, sternum, and chest-Avails. The patient soon becomes drowsy, cyanotic, and occasionally an erythematous rash appears about the face, neck, and chest, while a purpuric rash is not in- DIPHTHERIA. 185 frequent in malignant cases. Death occurs in such cases Avithin one Aveek from toxic poisoning. Malignant cases of diphtheria resemble verv closely malignant scarlet fever, though the pulse in scarlet fever will be of assistance in the absence of the characteristic rash. Nasal Diphtheria.—In all severe cases of pharyngeal diphtheria the inflammatory process is likely to extend to the nasal mucous membrane. In some cases the nasal mucous membrane is found to be the first in- volved, and it may spread to the tonsils, but in these cases the exudate will be found to involve the back of the soft palate and pharynx as Avell. In many cases of nasal diphtheria no membrane may be found during life; there may be only a purulent discharge Avith blood, the presence of which in the nasal passage obstructs breathing, giving rise to a bubbling sound, and rendering sleep troublesome and noisy. Many cases have also been reported of formation of pseudo-membrane in the nose with mild general symptoms (often insignificant), and from which bacilli identical with diphtheria bacilli Avere obtained by culture, the bacilli often persisting for months. Sometimes the cases have recurring mild attacks of pseudo-membranous inflammation of the nose, while the bacilli may be constantly present. It is probable that these cases may give rise to in- fections of like nature, and even of true diphtheria. In nasal diph- theria the symptoms are quite as severe as in faucial diphtheria, and in cases in Avhich the soft palate, tonsils, and nasal mucous membrane are involved the general symptoms, the depression, and also the albuminuria, are Avell marked. In this place it is Avell to remember that in measles we sometimes have a form of membranous exudation occurring on the nasal mucous membrane and as a primary disease Avhich is not diphtheria. This disorder runs a more favorable course, the membrane being thinner and less adherent, than in diphtheria. " Rhinitis fibrinosis " is of favor- able prognosis. In all cases of coryza with fever we should be guarded as to opinion, especially if an epidemic of diphtheria is prevalent at the time. The diphtheritic inflammation may spread from the nose to the conjunctivae, with the formation of a false membrane, and much purulent discharge may escape from the eyes, the lids of Avhich may be greatly swollen. Wound-diphtheria.—A diphtheritic membrane may grow on the lips, tongue, vulva, or glans penis. The bacillus will not live on normal skin, but when the skin is cut or bruised, as after blistering or an eczematous condition, and when a moist, raw surface is present, the bacillus freely flourishes. Granulations also form a favorable soil. The diphtheritic germs may be introduced into the system during an operation, such as an excision of the tonsils, or even a vaginal examination ; and in new-born infants the granulating surface left after sloughing of the cord may be- come the seat of diphtheritic inflammation. Laryngeal Diphtheria or Membranous Croup.—In many cases the Klebs-Loffler bacillus produces its influence first on the mucous mem- brane of the larynx, and in these cases the mucous membrane of the nose and pharynx may never give evidence of a false membrane. In laryngeal cases the first symptom is a cough of a harsh, metallic, ringing character, and never to be forgotten when once heard. The temperature may be slightly above normal, or even, in many cases, normal. The toxic absorption is slight, on account of the locality affected, and the 186 INFECTIOUS DISEASES. constitutional symptoms are usually mild. The local symptoms, however, are very alarming, as they are the results of laryngeal obstruction, there being marked dyspnea with retraction of the intercostal and supraclavic- ular spaces, and later of the epigastrium and lower chest. These are associated with an increasing cyanosis. The child is soon very restless, is forced to sit up to breathe, and for the same reason bends forward with its head thrown back. In these extreme cases, unless relief is soon gained, the child dies of suffocation. In many cases the slower form of suffocation may result from the extension of the membrane downward to the bronchi. Complications.—Local complications may be mentioned, as when we have hemorrhage from the nose and throat in the more severe ulcera- tive cases. Skin-rashes are not unusual, especially the diffuse erythema. Sometimes urticaria will be noticed, and in very severe cases purpura will mark the skin. Broncho-pneumonia is the most serious pulmonary complication of diphtheria. It is not produced by the Klebs-Loffler bacillus, but by pyogenic cocci which have been taken in during respiration. Broncho- pneumonia is very frequent, and most usually terminates laryngeal cases that have been operated upon. Albuminuria is really a part of the disease, and can scarcely be re- garded as a complication. It is the most constant symptom, and is almost as certain in establishing a diagnosis of true diphtheria as a bac- teriologic examination. It is met with in both mild and very severe cases, and the greater the amount of albumin the more severe the case. When acute nephritis complicates diphtheria it is usually not accompanied by edema or anasarca. Dysphagia may, by its constant existence throughout the disease, pro- duce a profound impression on the general nutrition. Involvement of the conjunctivae is a rare but very grave complication. Otitis media occurs frequently, and may be a very troublesome com- plication as well as a sequela. The most frequent sequelae are anemia, chronic naso-pharyngeal ca- tarrh, peripheral neuritis, and its associate paralysis. Anemia may so prolong convalescence that the child will frequently be exposed to some intercurrent disorder. The chronic naso-pharyngeal catarrh may be so marked as to offer a favorable ground for new diph- theritic invasion. Neuritis and paralysis will not be noticed until the third or fourth week, the paralysis usually being first seen when the child attempts to swallow and the food is regurgitated through the nose. This is due to a paralysis of the muscles of the soft palate, Avhich will also be noticeable owing to a peculiar alteration of the voice. The paralysis may take a general form, such as is seen in multiple neuritis, the lower ex- tremities being affected and the knee-jerk absent. The paralysis is fre- quently quite extensive; it may extend to the external ocular muscles and cause squint, to the ciliary muscles and cause dimness of vision from unequal accommodation, or to the muscles of the trunk in general, pro- ducing a very general paralysis. The child, not being able to hold any- thing, may stagger about as if intoxicated, so much so as to suggest the existence of a cerebral tumor. The disturbance of vision and the ab- sence of the patellar tendon reflex has in adults led to a mistaken diag- DIPHTHERIA. 187 nosis of locomotor ataxia. Loss of taste, deafness, and a disturbance of sensation are not infrequent. Thus, paralysis is to diphtheria what dropsy is to scarlet fever—a proof positive of the disease. To make one step more, in many sudden deaths occurring in early diphtheria we must recognize paralysis of the heart outside of all toxic influence, and the fact that in cases of sudden death, which are by no means uncommon during the disease, Ave have some sudden disturbance of the vagus brought about by means of its cardiac branches. The prognosis in all cases of post-diphtheritic paralysis is very favor- able. Myocardial Aveakness tends to supervene as a sequel. It is evi- denced by the sudden accession of pallor, nausea, sometimes by vomit- ing, and also by weak heart-sounds and a feeble, broken, irregular pulse, etc. Diagnosis.—The diagnosis of a pharyngeal diphtheria (the usual typical form) is not difficult if an epidemic be prevailing. The false membrane on the fauces and the presence of albumin in the urine give us a practically certain diagnosis. From follicular tonsillitis we differ- entiate diphtheria by the seat of the membrane, that of the former being in the tonsils, while diphtheritic membrane is over the tonsils and over the soft palate. Moreover, in follicular tonsillitis the fever is high, the onset is sudden, and it is most usually associated with gastric disturbance. Albuminuria is generally present in diphtheria, while it is present in fol- licular tonsillitis in exceptional cases only. The histories of the two cases are quite different. In many cases clinical distinctions will entirely fail us, it being uncertain whether or not the case is one of mild diphtheria, and then the most certain evidence of the disease is the finding of the Klebs-Loffler bacillus in the membrane. In many cases of so-called diphtheria the membrane is only formed by streptococci or staphylo- cocci. The croupous or membranous angina may offer some doubt, yet in this disease there is no tendency to spread to the nasal mucous membrane or to the larynx ; there is a diminution in the glandular enlargement; there is no albumin and the onset is more sudden. A mild case of diptheria in a house may be folloAved by a malignant one. Moreover, mild cases may not present albuminuria, and fail to shoAV the presence of albumin until later in the disease. Diphtheria frequently is associated with a rash, rendering it difficult to distinguish the condition from scarlet fever ; but in diphtheria the rash is more truly an erythema, while in scarlet fever it consists of slightly raised points betAveen which there may be an erythematous condition. The glandular SAvelling and sloughy condition of the throat, hoAvever, closely resemble diphtheria, and a positive diagnosis Avithout a bacteriologic examination is often impossible. An immediate diagnosis without the use of culture is often possible by making a smear-preparation of the exudate from the throat (see Fig. 19), when the Klebs-Loffler bacilli may be present in sufficient numbers, and may be quite characteristic to an expert. In this connection may be given the following statement by Park, who has had an exceptional experience : " The examination by a competent bacteriologist of the bacterial growth in the blood-serum tube, which has been properly inoculated and kept fourteen hours at the body-temperature, can be thoroughly relied upon in cases in which there is a visible membrane in the throat if the culture is 188 INFECTIOUS DISEASES. made during the period in which the membrane is forming, and no anti- septic, especially no mercurial solution, has lately been applied. In cases in which the disease is confined to the larynx or bronchi, surprisingly accurate results can be obtained from cultures, and although, in a certain Fig. 19.—1, A tube of blood-serum; 2, a sterilized cotton swab in test-tube. Rub the swab gently but freely against the visible exudate, and without laying it down, after withdrawing the cotton plug from the culture-tube, insert it into the latter, and rub that portion which has touched the exudate gently but thoroughly over the surface of the blood-serum Avith- out breaking its surface. Now replace the swab in its own tube, plug both tubes, and place them in the box provided by the health officials. This is to be sent to the bacteriologic expert. In laryngeal diphtheria the swab is to be passed far back and rubbed freely against the mucous membrane of the pharynx and tonsils. proportion of cases, no diphtheria bacilli will be found in the first, yet they will be abundantly present in later cultures. We believe, therefore, that absolute reliance for a diagnosis cannot be placed upon a single cul- ture from the pharynx in purely laryngeal cases." When a bacteriologic examination cannot be made the practitioner must regard as suspicious all forms of throat-affections in children, and carry out measures of isola- tion and disinfection. In this way alone can serious errors be avoided. Mistakes do not usually occur in a more pronounced membranous sore throat, but in the lighter types, many of Avhich are in truth due to the Klebs-Loffler bacillus. Prognosis.—Diphtheria is at the same time the most prevalent and most fatal of all the diseases with which the general practitioner has to deal, and, I may add, the least understood. The mortality is enormous, though it differs widely in different epidemics, and the most fatal variety is unquestionably the laryngeal. In laryngeal diphtheria the mortality may be as high as 75 per cent., and the younger the child the more unfavor- able the prognosis, the strong and healthy seeming to share the same fate as the weakly. Of especially unfavorable prognosis are those cases that shoAV large quantities of albumin in the urine, general adenitis, cervical glandular enlargement, excessive nasal discharge, a necrotic state of the throat, vomiting, and partial or complete suppression of the urine. Al- though the temperature in diphtheria is never very high, yet a sudden fall of temperature to subnormal and an irregular pulse are also very unfavorable symptoms. Recovery from a severe attack in which there is extreme depression and much aibumin is unusual, especially in a child under six years of age, though recovery takes place verv frequently in what Avould be regarded as hopeless cases. Suppression of urine, if it continues thirty-six hours, is generally fatal. A fall of temperature in scarlet fever, if Ave have a strongly-acting kidney, is an encourao-ino- in- dication ; the same, however, is not true in diphtheria if it is associated with vomiting. The results of Morse's extensive observations are opposed to those of Bouchut and Dulinsay, Avho claim that the degree of leukocy- tosis is of prognostic value (see p. 180). The cases of neuritis invariably DIPHTHERIA. 189 recover. A child who has had diphtheria once is most likely to contract it again, and if he recovers is liable to suffer from its effects for years. The causes of death in diphtheria, in their order, are as follows: in- volvement of the larynx ; membranous croup or laryngeal diphtheria ; septic infection, which may be a slow death ; sudden heart-failure—paraly- sis of the heart; broncho-pneumonia, following tracheotomy or occurring during convalescence. Treatment.—Prophylaxis.—The best preventive measures against diphtheria are a clean nose and mouth. Insist upon a careful toilet of the nose in all children. The slightest appearance of a coryza must be overcome at once by the use of a mild antiseptic wash; all accumulations of crusts, dust, dried blood, etc. should be removed from the nose twice daily, especially in children attending school or during the prevalence of an epidemic. The child should be early taught to employ a small anti- septic gargle as a daily routine, using a weak solution of hydrogen dioxid, listerin, or even a mild dilution of alcohol. The teeth should be care- fully cleaned daily, and all decaying teeth should be filled or removed. If it is true, as one authority claims, that over two hundred different spe- cies of bacteria find a happy home in the oral cavity, this fact should make all parents attentive to the proper physiologic condition of the mouths of their children. All cases of sore throat should be examined for the Klebs-Loffler bacil- lus, and, if it is found, the individual should be isolated; and all cases of diphtheria should be kept isolated until the membrane has disap- peared from the nose and throat. This is especially true in schools and asylums. Moreover, the throats of all persons exposed to this disease, and of those caring for diphtheritic patients, should be frequently ex- amined for the Klebs-Loffler bacillus, and if it be found the person should receive immunizing doses of antitoxin. The fact that the Klebs-Loffler bacilli when found in healthy throats may not be active is no argument against isolation, because it is well knoAvn that if the same germs were to find such favorable soil as a broken or catarrhal membrane they would rapidly develop. The seed being there, the soil only requires prepara- tion for its reception. An unrecognized feature in the prophylactic treatment of the disease is seen in the uncertain period of convalescence. It has frequently hap- pened that long after all membrane has disappeared active bacilli may still cling to the throat. This condition may continue froih two to six months, and even longer in deeply fissured tonsils; and the disease may be communicated by such throats in the act of kissing young children or adults with sensitive throats or with a broken mucous membrane of the mouth. For this reason the indiscriminate kissing of young children on the lips should be interdicted by the physician. Sufficient importance has not been been given to the milder cases of diphtheria as to their isolation and disinfection, and this fact explains the occurrence of many house-epidemics. Treatment of the Attack.—The treatment falls very naturally under sev- eral departments: (a) the hygienic measures to limit the diffusion of the dis- ease ; (b) the local management of the throat to destroy early the toxic germs; (c) medication to antagonize the effect of the toxins, and event- ually to overcome the complications and sequelae. 190 INFECTIOUS DISEASES. (a) Hygienic Treatment.—The patient should be in a room well ex- posed to sunlight and fresh air, as diphtheritic germs grow well in poorly- lighted and damp chambers. No stationary washstand should be alloAved in the room, and Goodhart well says that many cases seem to have their orio-in in the proximity to foul-smelling drains. The physician should never consent to be responsible for the recovery of a patient in a room in which there is a washstand with its uncertain connection with the main sewer. If possible, the patient should use two connecting rooms, one during the day and the other at night, so that one while not in use may be thoroughly aired and disinfected. Even in mild cases the patient should be°kept in bed throughout the attack, and in more severe cases also for some time during convalescence. This is especially important when there have been symptoms of cardiac depression during the acute stage. The general comfort of the patient is enhanced by two daily sponge baths of tepid salt-water or of alcohol and water. Feeding.—Nursing infants may be fed on breast-milk obtained by a breast-pump, but should not be placed at the mother's breast (Holt). The feedings should be regular, yet lighter in quality and quantity than in health, remembering the tendency to vomit in all acute febrile affec- tions, and the fact that gastric disturbance is closely associated with diph- theria. The rule must be, less solids and more fluids than in health. Milk in some form being our main dependence, it should usually be diluted, and for young children partially if not wholly peptonized. The greatest difficulty comes in the latter part of the disease, when the child is septic and most likely has a strong objection to be disturbed. At this time vomiting is most easily provoked, and swallowing is rendered very difficult on account of the swelling and pain. We must not neglect the feeding even if it does cause discomfort, and here forced feeding by means of gavage is most valuable. Gavage is more desirable and likely to be more successful Avith children under three years than rectal alimen- tation. In older children, who object to the tube through the mouth, it may be passed through the nose with very little difficulty, and gavage by this route, even in intubated cases, will be extremely satisfactory. Con- centrated broths, meat-juice, and even milk-punch or raw eggs, may be given in this Avay. (b) Medicinal.—Alcohol no longer holds a debatable ground in the treat- ment of diphtheria: it is the most powerful drug in our possession to off- set the ravages of the disease on the nervous centers and for the control of the circulation. Stimulation should be commenced as soon as there is a reasonable certainty as to the correctness of the diagnosis, and by com- mencing early with whiskey or brandy we may prevent the depressing effects of the poison of diphtheria as seen in the pulse and general con- dition of the child. The indications for alcohol are marked prostration, feeble pulse, and a weak first sound of the heart. The quantity must be adjusted to the age and gastric condition of the child, and usually one ounce (32.0) of good whiskey or brandy, well diluted, in twenty-four hours is sufficient for a child four years old. In very bad cases five or six times this quantity may be given, the only limit being the tolerance of the stomach. As a rule, the stimulant should be mingled with the food, as the child may rebel against taking both food and stimulant. Strychnin stands next to alcohol in importance in the treatment of DIPHTHERIA. 191 diphtheria, and usually it is given in too small doses. For a child four years old gr. -£$ (0.0021) may be given every six to eight hours, and may be administered in little tablets by the mouth or hypodermically. Digitalis does not hold an important place in the heart-weakness of diphtheria, and yet it is strongly indicated on theoretic grounds. Clinic- ally, it has been found to have an unfavorable action on the stomach before its good influence can be had on the heart itself. The same may be said of camphor and ammonium carbonate. The aromatic spirits of ammonia is valuable for rapid effects in syncopal attacks. In cases of threatened heart-paralysis occurring late in the disease Holt has found nothing so valuable as morphin employed hypodermically, the drug being given in full doses and repeated every two hours, keeping the child under its influence for some days. Internal medication should be avoided until absolutely necessary, and such symptoms as vomiting or diarrhea are to be met Avith sufficient treat- ment only for their control. (c) Local Treatment.—For the direct attack upon the membrane in the throat nearly all the remedies of the Pharmacopeia have been used. Garg- ling, SAvabbing, painting, spraying, and washing the throat out, all have their advocates, and every physician has his favorite remedy or combi- nation. And, as all adult pharyngeal diphtheria tends to recovery, it would seem reasonable that this form of treatment should not be neglected ; yet since the acceptance of the antitoxin treatment medical opinion has suffered a decided change, especially as to the importance of local meas- ures. The very best local application for pharyngeal or nasal diphtheria consists of hydrogen dioxid, diluted one-sixth, and used both as a gargle and spray as most convenient; this is usually sufficient in the early stage. The tincture of iron and glycerin is a valuable local remedy applied by means of a swrab. The object of local treatment in the light of our neAv pathology is a more thorough cleanliness, and not the destruction of the bacilli, yet it does still more good by preventing the systemic absorption of the ptomains. Hence a careful toilet of the nose and throat is import- ant in preventing the spread of the disease. This part of the work is more easily directed than accomplished, especially in rebellious children, and we have frequently felt that new lesions were created in the mucous membrane of the nose and throat by an undue ardor in making applica- tions. To avoid ne\v lesions the spray alone should be used, and for the nose boric-acid solutions or hydrogen dioxid, 1:10, will be most service- able. In this work the utmost tact and kindness must be maintained, for it is truly pitiable to force a struggling child, endangering the strength to accomplish so little. Warm, weak solutions, most thoroughly applied by means of the fountain syringe, Avill be better than the more frequent use of the hand-syringe. In older children avIio will use it a gargle of boric acid, listerin, or Dobell's solution, well diluted, may be used to keep the nose and mouth clean. In laryngeal diphtheria the child should inhale an atmosphere laden with the vapor of slaking lime, or, whenever practicable, an atmosphere saturated with Lbffler's solution (menthol 10 grams, dissolved in sufficient toluol to make 36 c.c, liq. ferri sesquichlorid, 4 c.c, absolute alcohol, 60 c.c). The development of the signs of actual stenosis, as shown by stridulous breathing, cyanosis, etc., furnishes an indication for either in- 192 INFECTIOUS DISEASES tubation or tracheotomy. According to my own observations, the results of intubation have been quite favorable, and I would strongly recommend Fig. 20.—Temperature-chart of a case of diphtheria. a trial of this procedure before resorting to tracheotomy (see temperature- chart, Fig. 20). (d) External Applications.—External applications to the throat have no effect on the course of the disease. They are useful, however, in relieving the pain and the swelling in the lymph-glands. Careful massage of the neck with camphorated oil, as hot as the skin will tolerate, is very sooth- ing ; and soap liniment may be used in the same way, or if much pain exists chloroform liniment may be substituted. Poulticing for the relief of pain is not desirable, as it seems to favor suppuration. In older chil- dren the ice-bag has been used with good effect, and it soon brings grate- ful relief from the tension and subdues inflammation. All manipulations about the child, however, should be carried on as gently as possible, so that its rest may not be disturbed. Serum-therapy; the Antitoxin Treatment.—This has now passed be- yond the stage of uncertainty and experimentation, and must be regarded as one of the most positive advances made in practical medicine. Its utility rests upon the discovery that animals may be rendered immune to diphtheria, and that the blood of an animal so treated, when introduced into another animal, protects the latter from infection by the diphtheria bacilli. The studies of Behring, Roux, Kitasato, and others have demon- strated that the use of the blood-serum of the lower animals, artificially rendered immune against diphtheria, has a powerful healino- influence upon diphtheria that has been contagiously or spontaneously acquired by man. These experiments were first published in December, 1890. The principle was first shown to be true of tetanus, and, late in 1892, Behring further showed that the blood of an immunized animal had the power DIPHTHERIA. 193 both of protecting and of curing susceptible animals Avhich had been in- oculated either with the toxins or the bacilli of diphtheria. In preparing the blood-serum it is very desirable, of course, to have a uniform strength or standard. One-tenth of one cubic centimeter of Avhat Behring calls his normal serum will counteract ten times the minimum of diphtheria poison, fatal for a guinea-pig weighing three hundred grams. One cu- bic centimeter of this normal serum he calls an antitoxin unit. The serum prepared by his method is labelled in three strengths. No. I. is sixty times the strength of the normal serum ; No. II. is one hundred times as strong; and No. III. is one hundred and forty times as strong. To a child of two years or over not less than 800 or 1000 units should be administered at the first dose; hence solution No. I. is rarely employed at the present day. Should a favorable result not be attained, then, on the following day, 1500 to 2000 units should be administered, and a third dose after a similar interval if necessary. The latter dose should be em- ployed at the outset in very severe cases and in those not seen until they are far advanced. The sites to be selected for injection are various. In very young children either the buttock or thigh is to be preferred, while in older children the flanks or subscapular spaces may be chosen as welL The injections should be made deeply into the subcutaneous cellular tissue. In fortunate cases the influence of the serum soon becomes apparent. Within twenty-four hours the faucial swelling diminishes, the membrane exfoliates, the temperature falls, the pulse becomes slowTer and stronger, and the general condition of the patient quickly improves. In cases of moderate severity and when injections are employed early the improve- ment in the throat and the constitutional symptoms is very decided; and the earlier the case comes under treatment the better are the results. There are, however, many cases of great severity in which the antitoxin has been used early, and yet has not shown any benefit. A danger in serum-therapy may be the development of local abscesses, which, if full antiseptic precautions be taken, must be rare indeed. I have escaped them altogether. Certain skin-eruptions have been observed after injections, mostly urticarial, though sometimes scarlatiniform. The latter form has given rise to apprehensions of scarlatina. Widerhofer had one case which Avas isolated as measles, but never developed any symptoms other than the suggestive eruption. Rarely, joint-pains and swellings, with general prostration, supervene. Two fatal cases have been reported—one1 that of a healthy boy five years old, the result of an injection of Behring's fresh serum as a preventive, dying Avithin five minutes; the other occurred in Berlin.2 For establishing immunity in subjects exposed to infection the injec- tion of 60 units (1 cubic centimeter of the No. I. serum) affords pro- tection. In order to arrest the development of the disease during the period of incubation 100 units (1 cubic centimeter of No. II. serum) is probably sufficient. A large number of preparations are on the market, many of Avhich are good, yet great caution must be exercised in their selection. The use and value of antitoxin in private practice are best shoAvn in 1 Journal of the American Medical Association, April 4, 1896. 2 Medical News, April 18, 1896. 13 194 INFECTIOUS DISEASES. the following summary of the report of the American Pediatric Society's investigation of the subject: 1. The report includes returns from 615 physicians. Of this number more than 600 have pronounced themselves as strongly in favor of the serum-treatment, the great majority being enthusiastic in their advo- cacy. 2. The cases included have been drawn from localities Avidely sepa- rated from each other, so that any peculiarity of local conditions to which the favorable reports might be ascribed must be excluded. 3. The report includes the record of every case returned, except those in which the evidence of diphtheria was clearly questionable. It will be noted that doubtful cases that recovered have been excluded, while doubtful cases that were fatal have been included. 4. No new cases of sudden death immediately after injection have been returned. 5. The number of cases injected reasonably early, and in which the serum appeared not to influence the progress of the disease, Avas but 19, these being made up of 9 cases of somewhat doubtful diagnosis, 4 cases of diphtheria complicating measles, and 3 malignant cases in which the progress was so rapid that they had passed beyond any reasonable pros- pect of recovery before the serum was used. In 2 of these the serum was of uncertain strength and of doubtful value. 6. The number of cases in which the patients appeared to have been made worse by serum was 3, and among these there is only 1 case in which the result may be fairly attributed to the injection. 7. The general mortality in the 5794 cases reported was 12.3 per cent., and, excluding all cases moribund at the time of the injection or dying within tAventy-four hours, it was 8.8 per cent. 8. The most striking improvement was seen in cases that were injected during the first three days. Of 4120 such cases the mortality was 7.3 per cent., and, excluding cases moribund at the time of the injection or dying within twenty-four hours, it was 4.8 per cent. 9. The mortality in 1448 cases injected on or after the fourth day was 27 per cent. 10. The most convincing argument, and, to the minds of the com- mittee, an absolutely unanswerable one, in favor of serum-therapy is found in the results obtained in the 1256 laryngeal cases (membranous croup). In- one-half of these, in a large proportion of which the symp- toms were severe, recovery took place without operation. Among the 533 in which intubation was performed the mortality was 25.9 per cent., or less than half as great as has ever been reported by any other form of treatment. 11. The proportion of cases of broncho-pneumonia (5.9 per cent.) is very small, and in striking contrast to results published from hospital sources. 12. As against the two or three instances in which the serum is be- lieved to have acted unfavorably upon the heart might be cited a large number in which there Avas a distinct improvement in the heart's action after the serum was injected. 13. There is very little, if any, evidence to show that nephritis was caused in any case by the injection of serum. The number of cases of SEPTICEMIA. 195 genuine nephritis is remarkably small, the deaths from that source num- bering but 15. 14. The effect of the serum on the nervous system is less marked than upon any other part of the body; paralytic sequelae being recorded in 9.7 per cent, of the cases, the reports going to show that the protection offered by the serum is not great unless injections are made early. SEPTICEMIA. Definition.—A disease due to an introduction into the system of the products of putrefaction (sapremia) or to a microbic invasion of the blood and tissues (true septicemia), Avith or Avithout the presence of a local seat of infection. Pathology.—After death the body putrefies early. The macro- scopic changes in the viscera are sometimes few and often wanting. The muscles present a brownish color-tint. The pia mater is generally con- gested, and, together with the nerve-centers, may be the seat of ecchy- moses. The blood is dark (" tar-like ") ; its coagulability is diminished, and, microscopically, it shoAvs an abundance of micrococci and bacilli. The spleen is somewhat softened and its lymphoid elements more dis- tinct, and almost invariably ecchymoses are found in the serous mem- branes, especially the pericardium and peritoneum. In protracted septicemia more marked alterations exist, and among them may be briefly enumerated the following: endocarditis (rarely ulceratiAre); gastro-intestinal catarrh (of the duodenum and rectum in particular) Avith punctiform extravasations; enlargement of the lym- phatics and spleen, with softening of the latter; cloudy swelling of the liver (rarely the so-called emphysema of the organ due to putrefaction); edema and catarrhal inflammation of the uriniferous tubules; conges- tion, sometimes associated with edema of the lungs; and inflamma- tion of the pleura, pericardium, and peritoneum, with ecchymoses and trivial effusions. Microscopically, the internal organs show numerous small foci of in- flammation, some of Avhich may be the seat of "coagulation-necrosis." Bacteria are found in abundance in various situations, such as the exu- dations, the capillaries of the inflammatory foci, and especially in the renal glomeruli. Etiology.—Bacteriology.—Septicemia is due to micrococci Avhich Koch has shoAvn to be considerably smaller than pus-cocci, though no one form of bacterium has been found constantly present to the exclu- sion of all others. Besser, as the result of careful experiments, con- cludes that septicemia is caused solely by streptococci, while Rosenbach and others have found both staphylococci and streptococci. Doubtless in many instances of human septicemia the clinical manifestations are due partly to bacterial poisoning and partly to septic intoxication with the poisons (ptomains) developed by the organisms, and the ptomains probably kill the patient before the bacteria can propagate themselves throughout the system. Laboratory experiments teach us that in the 196 INFECTIOUS DISEASES. lower animals septicemia can be produced both by chemical poisons and by bacterial infection, and these two types are observed in human beings. With reference to the bacterial form Warren1 states: " AVhether this process is caused solely by the multiplication of bacteria, or is depend- ent in part upon the liberation of intensely poAverful poisons, or is due to some ferment-like substance capable of reproducing itself like the poison of the serpent, as are diphtheria and tetanus, much more ex- tensive studies upon the human subject will be necessary to enable us to say." Modes of Infection and Introduction of the Poison into the System.—(1) Wounds, either surgical or the result of injury, Avith which we have nothing further to do in this Avork. Since the days of rigid anti- septic precautions this mode of entrance is, comparatively speaking, uncommon. (2) Through the uterus, following labor, miscarriage, or abortion. Generally in these cases there are accompanying local changes, but in a feAV the poison appears to pass the unguarded portals of the organ, Avhile the latter exhibits nothing abnormal. (3) The cases in which the poison gains entrance into the body without obvious wounds or raAV surfaces are relatively more common. When the skin is quite natural, septic infection or intoxication can- not occur, but the slightest abrasion or cut, bed-sore, etc. may serve as a gate of admission. These slight lesions " may be almost com- pletely healed by the time the severe symptoms of the disease are developed" (Strumpell). (4) Mucous membranes often admit the virus, being less protective in nature than the skin. The numerous bacteria—benign and pathogenic —that-are constantly present in the intestinal canal may also find in local lesions (as in typhoid fever, dysentery, etc.), or catarrhal inflam- mation even, points of lodgement and cause a systemic infection. To this category belongs that form of septic infection Avhich folloAvs gonor- rhea. The so-called cases of "spontaneous septicemia" are also usu- ally occasioned by absorption from the mucous surfaces. Rheumatic or septic manifestations often folloAv attacks of tonsillitis, and it is probable that the tonsils are more frequently points of en- trance for the organism than has hitherto been supposed (Wade, Ban- natyne). (5) " Sepsis Intestinalis."—This special form of poisoning is caused by canned meats, ice cream, sausages, and cheese. Vaughan, to whom Ave are indebted for the first description of "sepsis intestinalis," found in cheese a ptomain Avhich he named tyrotoxicon, and which he regarded as the active agent in this group of poisoning cases. The symptoms are due, according to his statement, to poisoning by chemical substances, being instances of sapremia; but it may yet be found that the intes- tinal micro-organisms play a more or less prominent part in the process. (6) Ogston2 recognizes as one of the mildest forms of sapremia the sickness and nausea produced by a bad smell, which, he claims, is but a ptomain of putridity that may, under certain contingencies, produce serious symptoms. On the other hand, persons who are habitually ex- 1 Surgical Pathology and Therapeutics, p. 340. 2 Warren, loc. cit. p. 342. SEPTICEMIA. 197 posed to bad odors (Avorkers in seAvers, in the dissecting-room, etc.) may acquire a considerable degree of immunity against poisoning of this sort. The fever in these cases corresponds in severity to the dose of the poison. (7) Septicemia may be associated Avith or follow osteomyelitis. Clinical History.—(1) Symptoms of Sapremia.—The fact that this form may occur Avithout bacterial infection, either local or general, must be emphasized, but more frequently there will be either local infection or putrefactive changes, Avith the production of a grave general condition due to the absorption of the poisonous chemical products. In certain other acute infectious diseases (diphtheria, tetanus, typhoid fever, ery- sipelas, etc) the general symptoms are similarly engendered. Perhaps the most typical examples of sapremia seen by the physician are those due to tyrotoxicon and to the unaccustomed inhalation of foul odors. At the beginning a chill may occur, but this is more generally Avanting. In " sepsis intestinalis " marked local symptoms may initiate the attack, as nausea, vomiting, colicky pains, diarrhea, etc., and in all forms there is fever, the temperature often rising rapidly to 101° or 103° F. (38.3°- 39.4° C.) and sometimes higher. Prostration and anemia, particularly the latter, may be prominent symptoms. Microscopic examination of the blood generally shoAvs leukocytosis, and always a marked reduction in the number of red corpuscles. Sapremia folloAving childbirth is a most typical sub-variety, and, apart from the special history, the symptoms are much the same as those above detailed. It is the form most amenable to treatment, the removal of the cause being folloAved by a rapid disappearance of all alarming symptoms. (2) Symptoms of True Septicemia.—There is an incubation-period vvhich is of variable duration, though usually averaging several days. The onset is more gradual than in the previous variety, and is rarely marked by a chill. Accession of fever following surgical procedures, Avith head- ache, anorexia, prostration, sometimes vomiting and diarrhea, and espe- cially dulness occasionally amounting to mild stupor, announce the affection: these symptoms should also excite suspicion in the absence of obvious causal factors. They become intensified, and now the attack may closely simulate certain other infectious diseases (typhoid fever, acute miliary tuberculosis, ulcerative endocarditis, etc.), the clinical picture as outlined presenting nothing characteristic. There are, hoAv- ever, more or less distinctive features, which will be considered seriatim. (a) The Fever.—This is usually of the continued type, and tends to increase in degree, fatal cases often terminating in hyperpyrexia. At the beginning the temperature may rise quite rapidly, and in some cases it may even be subnormal. Deep morning remissions may be observed. (b) The Circulatory System.—The pulse is frequent, and near the end becomes very weak. In subacute cases characteristic lesions (endocar- ditis in particular) may develop, but are difficult of recognition, since they do not, as a rule, give rise to audible murmurs or other physical signs. In other instances soft murmurs may be heard, but it is indeed hard to discriminate these from functional sounds. Moderate leukocy- tosis is sometimes observed, and the presence of micrococci in the blood during life has been demonstrated. 198 INFECTIOUS DISEASES. (c) Gastro-intestinal System.—The spleen may become perceptibly enlarged, and gastro-enteritis is usually present, either in an acute form with vomiting and frequent serous discharges or more often merely with a diarrhea of moderate intensity (septic diarrhea). (d) Cutaneous Symptoms.—Punctiform hemorrhages into the skin are of prime importance in the diagnosis. Occasionally more extensive ecchymoses appear, scarlatinal eruptions also showing themselves, but these are less characteristic. Among rare appearances herpes, roseola, edematous inflammations, and faint jaundice (affecting the skin and conjunctiva?) may be observed. The icterus is probably due to disinte- gration of the red blood-corpuscles in the liver. (e) Renal Symptoms.—The lesions constitute the so-called " septic nephritis," the urine often containing a fair amount of albumin, epi- thelium, tube-casts, and red and white corpuscles. Diagnosis.—(a) Sapremia can be distinguished by the history, the immediate appearance of the symptoms, their character, and by the prompt effect of the removal of the exciting cause. The diagnosis often requires a most careful search for the known etiologic factors, though even without the latter we can sometimes arrive at a correct conclusion by a careful process of exclusion. (b) True Septicemia.—Here the existence of an incubation period, the contiued fever, mental apathy, faint jaundice, splenic enlargement, and the characteristics of septic nephritis, all combine to form a well- defined group of symptoms. A careful blood-examination should be made for micrococci, etc., and cultures should be undertaken in spon- taneous septicemia and associated forms (e. g. septico-pyemia). The surgeon should look to the condition of the Avound if one is present. Course and Prognosis.—The course may be brief, virulent at- tacks sometimes terminating fatally within forty-eight hours, this being especially true of sapremia Avhen the dose of the poison is large. The gravity of the case in the latter form is in direct proportion to the amount of virus that enters the system, the outlook being good when the cause is removable. On the other hand, in true septicemia this avails nothing, the progression tending steadily to the end. The mildest types may, in rare instances, reach a favorable end, but the effects are not dependent upon the dose, and the minutest quantity may lead to specific results in their fullest intensity. It must not be for- gotten that septicemia may pursue a chronic course in Avhich the symp- toms are milder, though the termination is very generally unfavorable, as in the acute variety. Treatment.—Of first importance is the removal of the cause when- ever practicable, this part of the treatment often falling within the domain of surgery. The physician must support the patient's strength by a suitable dietary and by the judicious use of cardiac stimulants; the former should consist mainly of liquids (milk, egg-white, meat-juice, etc.), and the latter of alcoholics, together with strychnin and am- monia. Of medicines, internal antiseptics (mercuric chlorid, creasote, etc.) richly deserve a trial, though striking results have not been obtained from their employment. The fever calls for antipyretics, such as quinin, phenacetin, acetanilid, together with hydrotherapy. Cardiac depressants, as acetanilid and phenacetin, should not be resorted to, PYEMIA. 199 however, when great cardiac asthenia exists. To meet the renal condi- tion the free use of water, together Avith the least irritating of the diu- retics, is to be advised and encouraged. The other internal organs should also receive careful attention. PYEMIA. Definition.—A disease of the blood invariably associated Avith sup- puration, and due to an absorption of pyogenic organisms. Pathology.—The cadaver does not undergo putrefaction as early as in septicemia. Briefly considered, the pathologic lesions that fall within the physician's province arrange themselves under the following heads: (1) Thrombosis and Embolism.—At first the veins leading to and from the seat of the local changes from Avhich pyemia arises contain thrombi which may soften into a puriform material. Thrombi are also found frequently in the lungs, a circulating embolus first finding lodgement in the pulmonary artery and its branches; they may be present in the liver, kidneys, spleen, cortical substance of the brain, and in other localities. (2) Abscesses.—These so-called metastatic abscesses are set up by septic emboli or result from the thrombi (chiefly pulmonary and portal), and are found in the various internal organs, mainly, perhaps, in the lungs, liver, spleen, and kidneys. They are not large, but may coalesce and form cavities of the size of an apple. The kidneys are the chief organs of elimination in this disease, and hence it happens that numer- ous clumps of micrococci, producing miliary abscesses, are frequently seen in the regions of the Malpighian bodies. Infarction may be ob- served also. There are many other, though rarer, seats of abscesses, as the muscles, submucous and subcutaneous tissues, bones, the parotid gland, brain (cortical portion), ovaries, and testicles. (3) Lesions of the Skin and of Mucous and Serous Membranes.—At the post-mortem examination hemorrhagic extravasations and pustules are often visible in the skin. The mucous membrane of the alimentary tract is rarely affected, differing in this point from septicemia, though occasionally ulcers may be noted, and most commonly in the stomach near the pyloric orifice (in puerperal cases) and in the large bowel. Prob- ably they are always secondary to the submucous miliary abscesses. The serous membranes (pleura, pericardium, meninges of the brain, synovial membranes) may be the seat of purulent inflammation and of hemor- rhagic extravasations. (4) Cardiac Lesions.—Ulcerative endocarditis forms the chief morbid lesion. It begins in the form of small nodular vegetations upon the valves (most frequently the mitral), Avhich disintegrate and leave ulcers behind (vide Ulcerative Endocarditis). Ktiology.—Bacteriology.—Experimental investigations have shown conclusively that the organisms usually responsible for this condition are the staphylococcus and the streptococcus. Whether the former or the latter be the agent of infection in the given case depends chiefly 200 INFECTIOITS DISEASES. upon the condition of the tissues at the starting-point, especially with reference to the character of the local defensive processes; also, though to a lesser extent, the degree of virulence of the micrococci. Other important pyogenic micro-organisms are the gonococcus, pneu- mococcus, bacillus pyocyaneus, bacterium coli communis, bacillus tetra- genus, and many of the specific micro-organisms. Paths of Infection of the Body.—(a) Almost always the entrance is by the blood-vessels, the special varieties of micrococci that cause pyemia, reaching the veins and producing thrombo-phlebitis. Less frequently they reach the arteries and produce thrombo-arteritis. From the former con- dition emboli may be disseminated throughout the system, while from the latter the emboli are arrested in the neighboring capillaries to which the tributaries of the vessel lead. Micrococci independently of emboli may be found wandering in the blood-stream. (b) Another path of entrance is the lymphatic system, but here the cocci meet with greater forces opposing their attempts to spread than in the blood-vessels, and hence it is a much rarer mode of propaga- tion. (c) In spontaneous pyemia, in which there is no Avound to act as a point of departure, we must presuppose the existence of either a trivial lesion, as in " spontaneous septicemia," or an area of lessened resistance. The latter may be produced by inflammation, by a contusion, and in other ways, and all that seems necessary is a lowering of the tone of the general system (Warren). I am certain that ulcerative endocarditis is not frequently the starting-point, but is usually secondary to foci of inflammation elsewhere, as claimed by Osier. The appendix is often the primary or original focus in this category of cases, micrococci local- izing themselves here in consequence of a preceding disturbance of the circulation or catarrhal inflammation. I recollect one case in which no original abscess was found at the post-mortem. Predisposing Causes.—(a) Epidemic Influence.—It has been proved by abundant experience that certain seasons are characterized by epi- demic outbreaks of the disease. (b) Cases have sometimes been noticeably more frequent in the early months of the year (February and March) than in other seasons. (c) Age and Sex.—Males are more frequently affected than females, and most cases occur about the middle period of life or at the time of greatest danger from traumatism. Clinical History.—Incubation.—The disease sets in from a week to ten days after the reception of the wound or even earlier, and always develops secondarily to suppuration somewhere in the body. A most conspicuous symptom, and usually the first, is the chill: it may, however, be preceded for a variable time by fever of a continued or intermittent type. The fever of pyemia is of the suppurative type. Profound prostration develops early; the skin presents an icteroid appearance; and gastro-intestinal symptoms may appear, but are not prominent. The signs of abscess of the lung, liver, and other organs may develop in some cases, while in others the whole clinical picture is colored by the ill-defined characters of ulcerative endocarditis. (a) The Chill.—This may be mild, though oftener it is quite severe. It is repeated at somewhat irregular intervals, and rarely it may recur PYEMIA. 201 several times on the same day. Chills are most apt to occur during the daytime. (b) The Fever.—A rapid rise of temperature accompanies the chill. The fever-curve is of the irregularly intermittent or profoundly remit- tent type, Avith intervening periods, shoAving slight or marked variations, and as decided deviations may occur Avithin a short space of time, a two-hour record should be kept. The temperature rarely falls to the normal level; it may do so, hoAvever, and remain there for one or tAvo days. To explain the peculiarities of the curve in this disease Ave need only recall the great variety of pathologic processes before noted. With the sharp fall of temperature sweating occurs, and leaves the patient more or less exhausted, though only temporarily so as a rule. (c) Respiratory System.—Symptoms referable to the organs of respi- ration appear early. The pulmonary abscesses are usually latent, but may give rise to dyspnea, cough, and occasionally a purulent expectora- tion. Pain is present if they are superficially located, and under such circumstances the physical signs of cavity or of pleural effusion may be noted. The signs of pneumonia at one or both bases may also develop, the expectoration now becoming rusty. (d) Splenic and Hepatic Symptoms.—The foci of suppuration in the liver are difficult of recognition unless they become large as the result of coalescence and are superficially located (see article Hepatic Abscess). Splenic infarction may also be safely diagnosed if there are pain and great tenderness (due to localized peritonitis) in the left hypochondrium, with progressive enlargement of the organ. In one case I detected distinctly crepitant sounds over the site of the spleen during life. (e) Cardio-vascular Symptoms.—The pulse at first is accelerated, but moderately full and regular; later it becomes exceedingly rapid and feeble. Frequently cases in Avhich ulcerative endocarditis develops are apparently of spontaneous origin. (For a discussion of this grave con- dition the reader is referred to the description of endocarditis in the sec- tion on Diseases of the Heart.) Among the blood-appearances during life are leukocytosis and a rather marked reduction in the red corpus- cles, with moderate poikilocytosis. The blood-plaques are increased. (/) Cutaneous Symptoms.—The most prominent is a mild yet decided grade of jaundice, that is probably hepatogenous in nature. Sweating has already been alluded to as a troublesome symptom, between the febrile paroxysms as Avell as immediately after. The skin finally shrinks from emaciation. Skin-eruptions are common, and particularly in the form of erythema, purpura, and pustules, and the general surface is often decidedly hyper esthetic. (g) Genito-urinary Symptoms.—The urine is concentrated and urates are copiously deposited. There is albuminuria which may be due to the pathologic changes or may be, to some extent at least, ascribable to the febrile movement. The microscope discloses the presence of tube- casts, micrococci, pus- and (more rarely) blood-corpuscles. Albumose has been found in the urine. (h) Nervous Symptoms.—The mind generally remains unclouded un- til an advanced stage is reached; then delirium sets in, and is followed by a terminal coma. This order of clinical events is not observed Avhen metastatic purulent meningitis exists, the symptoms of which (hemi- 202 INFECTIOUS DISEASES. plegia, strabismus, ptosis, deafness, etc.) may appear at any period of the disease. (i) Symptoms may be presented by the joints and bones. Metastatic arthritis, usually suppurative, is a not unusual concomitant, and in some cases it is combined Avith similar involvement of the long bones. In- deed, an acute osteomyelitis may be the only ascertainable source of the pyemia. Differential Diagnosis.—The disease is often confounded with malarial intermittent fever, the distinctive features of which have been given under the differential diagnosis of the latter disease, but a diagnosis may always be made from the effect of quinin upon the fever. A few points of contrast, by means of which septicemia and pyemia may be differentiated, are tabulated below: Pyemia. Septicemia. Always associated with suppuration. Suppuration may be absent, but there may be a sloughing wound. Multiple chills. A single chill. Irregularly intermittent fever-curve. Continued type of curve. Profuse sweats accompanying febrile Absent. attacks. Rapid emaciation and profound prostra- Less marked. tion, Nervous symptoms usually come on Earlier. late. Hyperesthesia. Absent. Slight jaundice. Less marked (very faint). Metastatic abscesses. Absent. Prognosis.—Pyemia may kill after an illness lasting but a few days. On the other hand, it may become more or less protracted, so that a chronic form has been distinguished. In this variety the symp- toms are milder in character, and the tendency to the formation of metastatic abscesses is not as great in the acute form. Hence, while the prognosis is on the whole very bad, not a few of the more chronic cases terminate in recovery. Treatment.—So far as the physician's province extends, the treat- ment is identical with that of septicemia. His efforts must be directed toward assiduously maintaining the vital powers. For the sweating the best agents are aromatic sulphuric acid and atropin ; the latter may be given with agaricin (atropin, gr. -j-1-^—0.0005; agaricin, gr. |- to \— 0.008 to 0.016), at bedtime. Prompt surgical interference must be re- sorted to, not only with a view to asepsis of the primary wound, but also to evacuating the primary and all secondary foci of suppuration. ACUTE ARTICULAR RHEUMATISM. [Rheumatic Fever.) Definition.—An acute febrile disease, the exact nature of which is unknown, though it is probably infectious. The chief local manifesta- tion is a multiple arthritis, and its. chief complications are cardiac (endo- and pericarditis). Hueter first advanced the germ-theory to account for ACUTE ARTICULAR RHEUMATISM. 203 the disease, and, although the specific causal agent has not as yet been discovered, this view is the only one that offers a satisfactory explana- tion for the production of the lesions, the acute onset, the clinical course, and the complications of the disease. Rheumatic fever is sub- ject to, and apparently obeys, the laws of infectious maladies in general, and the frequent involvement of the joints in many diseases belonging to this class may properly be regarded as supporting this theory. The disease is, in numerous localities, endemic, and at times also epidemic; but, on the other hand, in not a few regions (especially European) is practically unknown—e. g. England, Belgium, and Russia. Striimpell points out the fact that in Leipsic, where articular rheumatism is one of the most frequent of acute diseases, it has been observed for years that at certain times there are only a few cases, while at others there is a striking increase in the number. Pathology.—The disease does not show peculiar lesions, and, al- though the joints are the chief seats of invasion, still in many instances, and even in aggravated cases, the changes presented are slight or alto- gether wanting. Usually the synovial membranes of the affected joints are injected and swollen, and their surfaces may be more or less coated with fibrin. The effusion is mainly serous, but contains fibrin and often leukocytes, and occupies the joints. A similar exudate infiltrates the periarticular tissues. The tendinous sheaths may also be inflamed; the cartilages in protracted cases may become eroded; and rarely a purulent exudate may be seen. Fatal cases, except when death is due to hyperpyrexia, usually show the changes peculiar to endocarditis, pericarditis, or myocarditis, and less frequently those of pneumonia or pleurisy. The fibrin-factors of the blood are augmented. Etiology.—Bacteriology.—Maragliano1 has found in the blood of typical cases of acute articular rheumatism two micro-organisms—one resembling a bacillus and non-pathogenic, while the other is a micro- coccus and (he thinks) the special infective agent of the disease. This organism resembles the staphylococcus aureus, but it is only half its diameter (0.5//), and is massed in groups of six to ten. It is motile, is stained easily by anilin dyes, and is readily cultivated on gelatin. It develops at the usual temperatures, and especially at or about 98° F. (36.4° C). Upon injection into rabbits the symptoms of acute articu- lar rheumatism (polyarthritis, endocarditis, pericarditis, etc.) were re- produced. Guttmann, Collin, and Sahli have found the staphylococcus in the articular exudate of patients suffering from complicated or recur- rent cases of acute articular rheumatism, and Sahli is inclined to include the disease in the group caused by this organism. Netter, however, has found the streptococcus, and Lang a peculiar bacillus. Singer has no- ticed a relation between the number of pathogenic bacteria in the urine and the severity of the symptoms in cases of acute rheumatism; but Chvostek has not been able to confirm this result. A number of cases have been reported in Avhich there is some evidence of direct contagion. Predisposing Causes.—(1) An infective lesion (septic Avound, attacks of angina, etc.) that has preceded for some time the appearance of the pain and articular manifestations may often be found, and this may be 1 Gaz. degli Ospedale e delle Clin., June 20, 1896. 204 INFECTIOUS DISEASES. conceived to form a portal of entry for micro-organisms (Sacaze). The frequency with Avhich an attack of tonsillitis precedes the development of acute articular rheumatism almost indicates a pathological relation between the two diseases (Cheadle, Wade, Gerhardt). (2) Seasons.— The months of February, March, and April furnish the largest percent- age of cases, though the disease is also quite prevalent in the remaining cold months; on the other hand, the disease may sometimes be espe- cially frequent in summer. (3) " Catching cold" was formerly classed among exciting causes, but while this affection often follows exposure to abrupt changes of temperature, it merely predisposes to the disease. (4) Climate.—The disease is most prevalent in temperate latitudes, being rare both in the cold and tropical zones. (5) Occupation is of primary importance, especially if it entail oft-repeated or prolonged exposure to the influence of Avet and cold or to severe changes of temperature. Hence those Avho follow certain avocations are attacked with great relative fre- quency—e. g. coachmen, laborers, sailors, and servant-girls. (6) Age.— Primary attacks are most common from fifteen to thirty-five years of age. Out of 655 cases, 80 per cent, occurred between the twentieth and fortieth years (Whipham). Cases are also rather numerous between ten and fifteen years, and I have met with 4 under the former age. Suck- lings rarely suffer. (7) Sex.—Acute articular rheumatism is somewhat more common in men than in Avomen, and possibly owing to the fact that the former sex more often follows predisposing occupations. (8) Hereditary influence can be traced in many families, and if chorea, re- current tonsillitis, and chronic heart-disease are accepted as evidences of the rheumatic diathesis, it unquestionably plays a very important role. (9) Conditions of ill health, particularly digestive and hepatic disturbances, seem to exert a slight though decisive effect. (10) Chronic endocarditis renders its victims very prone to attacks of acute articular rheumatism, and some contend that the two diseases are etiologically one and the same. An attack of acute articular rheumatism is not protective in charac- ter, and rather renders the individual more susceptible than before. In this respect the disease resembles certain other infectious diseases (pneu- monia, erysipelas, etc.). Clinical History.—Of the incubation period nothing is known, though prodromata, both local and general, may be observed. There may be malaise, slight fever, angina, laryngitis, etc., and last from a few hours to a day or t\vo. The invasion is usually abrupt, Avith fever and synovitis, affecting one or oftener several joints, and a chill or a series of chilly sensations may accompany or precede the rise of temperature. The involved joints are tender, often red and SAvollen, and exhibit the local signs of a rapidly developed inflammation. Pain is a most promi- nent symptom. The medium-sized or larger joints (knee, ankle, and wrist) are first involved, and especially those of the inferior extremities; next the shoulder-, elbow-, and hip-joints; and lastly the fingers, toes, and intervertebral articulations. Quite unusual articulations may become implicated (vide infra). One of the chief peculiarities of the disease is in the fact that the joints that are affected are not all the seat of ana- tomic changes simultaneously, but that the process migrates from one joint to another from day to day, and often crosses from one side of the ACUTE ARTICULAR RHEUMATISM. 205 body to the other. Sometimes this occurs at longer intervals. Hence the number of joints involved at one and the same time may be either few or many. In cases of average severity the general features are subordinate to the local symptoms. The fever is usually moderate, the temperature not exceeding 103° F. (39.4° C), and the temperature-curve is of the irregularly remittent type, corresponding in severity with the joint- symptoms. Defervescence is by lysis. The skin is bathed in a copi- ous perspiration Avhich is not dependent upon a previous fall of temper- ature. Nervous symptoms are rarely observed. The general course of the disease exhibits Avide variations, both as to the duration and intensity of the symptoms. It may not outlast several days, appearing Avith mild symptoms; on the other hand, cases sometimes persist for six to eight Aveeks. The latter instances, and even typical cases, are apt to shoAV brief periods of marked improve- ment, alternating with equally marked exacerbations of someAvhat longer duration. Cases in which the symptoms are distinct from the start may terminate in recovery Avithin a shorter time than those in Avhich the features are of mild character. As will be seen hereafter, the disease frequently manifests complications, especially cardiac. Leading Symptoms and Complications in Detail.—(1) Joints and Sur- rounding Structures.—As I have stated, pain is much complained of, and is greatly augmented by motion and by pressure of any sort. It may be out of all proportion to the degree of the anatomic changes. The joints affected are generally SAvollen (most markedly in the knees), and the SAvelling is due partly to effusion into the joint and partly to inflammatory edema of the periarticular structures. The sheaths of the tendons, the bursae, and often the adjacent muscles and fasciae exhibit inflammatory changes ; hence it is usual to see an extension of the SAvell- ing for a variable distance from the joint, the backs of the hands often showing this to a marked extent. The skin may present a pink or rose- colored blush, often limited to circumscribed areas or taking the form of streaks. In even mild cases there are usually two, three, or more joints in- volved, though it often happens that one bears the brunt of the disease, little complaint being made of others less severely implicated. Hence it should be a golden rule to examine carefully all the joints at each visit. Involvement of a single articulation (monarticular rheumatism) does sometimes occur, but the diagnosis of these cases offers great diffi- culties. On the other hand, an existing polyarticular rheumatism may become centered in a single joint and there linger with great obstinacy. In severe cases numerous joints may be invaded, with an involve- ment of the joints of the symphyses, of the jaw, of the ribs, and the sterno-clavicular articulations. Under these circumstances the patient assumes a dorsal decubitus, and seeks to relieve his excruciating pain by holding his limbs in a semiflexed position and absolutely motionless. If now an attempt be made to change his posture, he complains pit- eously of darting pains in the affected joints. The fugacity of rheumatic arthritis has already been alluded to. The inflammation, hoAvever intense, may quickly subside in one joint, while at the same time an acute disturbance appears in another. Usu- 206 INFECTIO US DISEASES. ally resolution is complete, no trace being left of former inflammation, though the disease may recur in the joints primarily involved. Suppu- rative arthritis may supervene, though rarely, and its occurrence points indisputably to mixed infection. This complication may lead to anky- losis—a sequela which does not belong to pure rheumatism. (2) The Cardio-vascular Symptoms.—The pulse is quickened to 100 beats per minute or over, but is soft and full, and Avhen cardiac or other complications arise it sIioavs special characteristics Avhich are described in appropriate sections of this Avork. In rare instances it is Arery rapid, feeble, and irregular, apart from the influence of the cardiac involve- ment. The results of a careful blood-count show a high grade of symp- tomatic anemia, which may develop Avith marvellous suddenness. Leu- kocytosis is also present. Great importance attaches to the cardiac affections that so frequently complicate this disease. They may arise in any case, even the mildest, or at any stage of the disease, and hence the conscientious physician cannot afford to neglect the matter of closely and regularly examining the heart. It must be recollected that the symptoms announcing the development of cardiac disease are neither constant nor characteristic. At first we may note an increase in the febrile movement, more or less palpitation, sometimes dyspnea, and precordial pains, Avhich often do not amount to more than a sense of soreness. There may also be attacks of angina pectoris of apparently purely nervous origin (Striimpell). (a) The most frequent cardiac complication is acute endocarditis, which is present in 25 to 30 per cent, of the cases. We are, hoAvever, sadly in need of reliable statistics upon this point. It usually takes the form of simple (verrucose) endocarditis, and affects most frequently the mitral valves. But, though usually indicated by an apical systolic mur- mur, it is hard indeed to eliminate the functional murmurs that may also develop in the course of this disease. Unless combined with the symptoms detailed above, the presence of a blowing systolic murmur does not afford trustAvorthy evidence of the existence of acute endo- carditis. While it rarely endangers life and may leave no trace, in the majority of instances the acute endocarditis does not undergo complete resolution, but leads to sclerotic changes and terminates in incurable chronic valvular disease. (b) Next in the order of frequency is pericarditis, which may or may not be combined with the former. Its nature may be sero- fibrinous or plastic (less frequently), and in children the exudate is sometimes purulent; it is distinguished chiefly by its pathognomonic friction-sound, though also by other characteristic signs (vide Pericar- ditis. It is of graver import than endocarditis, so far as immediate danger to life is concerned, though it rarely proves fatal. I have wit- nessed two instances in which endocarditis preceded the arthritic mani- festations, and the same observation has been made by others with reference to this complication as well as to pericarditis. (c)^ Myocarditis is often present to a slight extent in rheumatic endo- carditis and pericarditis Avhen these occur independently of each other, but more often and to a more marked degree when endo-pericarditis ex- ists. Hence it is far less common than either endocarditis or pericar- ditis. The changes and symptoms occasioned will be discussed under ACUTE ARTICULAR RHEUMATISM. 207 Mvocarditis. In this connection it should be pointed out that the con- dition Aveakens the cardiac Avails and leads to dilatation of the ventri- cles (usually the left). If we consider rheumatism an infectious malady, we can readily un- derstand Avhy the local manifestations should appear not only at the dif- ferent articulations, but also in the cardiac structures, and, as Ave shall see, in other viscera. (3) The Skin.—Rheumatism produces copious perspiration. The sweat emits a sour odor and gives at first an acid reaction, though later it may be neutral, and rarely alkaline. The temperature-curve in most cases is not materially influenced by the SAveats. Occasionally the drops in temperature and the free SAveats are concurrent, but the latter svmptom is apt to persist despite the oscillations in the temperature. Sudamina appear, often in extensive crops. Among other skin-erup- tions less frequently observed are forms of erythema (especially E. nodosum) and urticaria, which latter may be associated Avith purpura (urticaria hemorrhagica). The association of the latter condition Avith polyarthritis is knoAvn as peliosis rheumatiea. though, according to some Avriters. this is not rheumatic in nature. Cutaneous ecchymoses, and even extensive hemorrhages into the skin and from the mucous mem- branes—a general hemorrhagic diathesis—may also be encountered. Subcutaneous Rheumatic Nodules.—In 1881, Barlow and Warner called attention to the fact that during and after acute articular rheu- matism, particularly in children and young adults, small subcutaneous nodosities attached to the tendons and fasciae may in exceptional in- stances be observed. These nodules are rather firm, somewhat mova- ble, and usually painless. The skin over them is simply elevated, Avith no traces of inflammatory action. They are most frequently found at certain points of election (fingers, Avrists, edge of the patella, malleoli, and over the back of the elbow), though also seen less frequently else- where ; they may disappear, and after a brief interval reappear. On microscopic examination it is seen that round and spindle-shaped cells enter into their composition. I met with one case of the sort which occurred in a male aged forty-two years, in which acute articular rheu- matism AA-as also complicated Avith endo-pericarditis and pneumonia. Most of the nodosities were of the size of a bitter almond, a few being even larger, and the crop was extensive. The case proved fatal. (4) The Fever.—The fact that the fever fluctuates materially in this affection has already been noted. It remains to be pointed out that if suppuration occur as a complication, the fever may be of the hectic variety; also that rarely hyperpyrexia is suddenly developed, and with it marked cerebral symptoms (restlessness, delirium, and sometimes com-ulsions, finally merging into stupor) are usually, though not neces- sarily, associated. This serious condition usually develops after several days of illness. Delirium may be present from the time of onset, though more often it comes on either shortly before or after the acute deAelopment of the hyperpyrexia. The pulse becomes excessively rapid and feeble and physical prostration extreme. The temperature may rise rapidly Avith slight interruptions until it touches 108° or 109° F. (42.7° C), and as the fever reaches its maximum death usually ensues. The temperature may continue to rise after death. The cause of " hyper- 208 INFECTIOUS DISEASES. pyretic rheumatism " is not definitely knoAvn. It has been claimed that the intemperate are most apt to be attacked, but this belief is not cor- roborated by many clinicians. In a case of my own, however, of acute articular rheumatism, in which pericarditis with hyperpyrexia occurred, the patient Avas an " alcoholic." It is reasonably certain that the symp- toms are due to an intense infection, with concentration of the poison upon the nerve-, and especially upon the thermal, centers. (5) The Muscular and Nervous Symptoms.—It has been stated that the adjacent muscles and fasciae may exhibit inflammatory changes. They may also shoAV more or less swelling, and are often very tender to the touch, while in long-continued cases muscular atrophy ensues. The cause of this change is not clear, but the most likely view is that it re- sults not so much from disuse of the muscles (the old theory), as from some trophic disturbance due either to the arthritis, or peripheral neur- itis, or, to some extent at least, from extension of the rheumatic inflam- mation from the nearest articulation. Other theories have been advanced, but are scarcely tenable. Mention has been made of the grave nervous symptoms that are at- tendant upon hyperpyrexia, but, independently of the latter condition, nervous phenomena may be present. There may be restlessness, sleepless- ness, and active delirium, the latter being usually associated Avith a tem- perature of 104° F. (40° C.) or higher. In adynamic types, which are rare, low muttering delirium merging into stupor, and even coma, may be observed. Active mental symptoms are sometimes due to cerebral embolism secondary to acute endocarditis. When pericarditis is a com- plication, wild delirium, Avith or Avithout hyperpyrexia, or the low mut- tering variety with stupor, is not unusual. The drunkard may develop delirium tremens. Coma, leading quickly to a fatal result, may develop without other previous or associated nervous symptoms, and DaCosta has reported cases in which a fatal coma was of renal origin, and hence uremic. Rarely coma develops during the period of convalescence. Convulsions may be noted, generally preceding the coma, though rarely as an independent symptom. Melancholia may arise in the course of the disease, but more frequently at its close. Meningitis must be numbered among the rarest of complications. Chorea is a not infrequent sequel of this disease in children, and more rarely is associated with it. Of 554 cases analyzed by Osier, in only 88 were chorea and rheumatism associated. These instances may or may not be accompanied by acute endocarditis. (6) Pulmonary Symptoms.—Pleurisy occurs, and is generally excited by an extension of inflammation from the pericardium, and from the pleura the inflammatory process may be propagated through the dia- phragm to the peritoneum. Bronchitis is sometimes present, but is rarely a part of the rheumatic morbid process; it is secondary, and in most instances is occasioned by the co-operation of the factors that are at work in every disease in which enforced recumbency and great prostra- tion coexist. In like manner, broncho-pneumonia may be produced. Lobar pneumonia rarely occurs, and is confined to aggravated cases, but pulmonary congestion is occasionally seen, and may prove fatal. Pul- monary complications are also prone to develop secondarily to pericar- ditis, and especially to endo-pericarditis. ACUTE ARTICULAR RHEUMATISM. 209 (7) The Renal Symptoms.—The urine is diminished in amount, is high-colored, and of high acidity and density. The standing specimen deposits urates. As in other infectious diseases, there is commonly present a slight febrile albuminuria, but acute nephritis is extremely rare. The chlorids are sometimes diminished, but rarely absent. (8) The spleen is slightly enlarged in some cases. The saliva has sometimes an acid reaction, and, according to certain Avriters, the sul- focvanids are in excess. Clinical Peculiarities of Acute Articular Rheumatism in Children.—The arthritic symptoms in children are in abeyance while endocarditis and pericarditis are predominant, and these cardiac conditions may appear before the joint-lesions are observed, but it is quite probable that endo- carditis follows the joint-lesions twice as frequently in children as in adults. Parsons lays stress upon reduplication of the cardiac second sound, audible at the apex only, as an indication of the development of endocarditis. This sign is to be distinguished from reduplication heard at the base, sometimes as the result of Bright's disease and sometimes as the consequence of pulmonary obstruction. Acid SAveats are slight in children. Rheumatic tonsillitis is quite common, and may precede, accompany, or follow7 attacks of rheumatism in children. Erythema is a frequent concomitant, and is often mistaken for scarlatina. The fe- brile movement lasts usually but a few days. Diagnosis.—The acute development as a primary affection of poly- arthritis Avith fever is a combination of symptoms on Avhich a diagnosis can be usually based with considerable reliance. Pyemia must be care- fully separated, since here also Ave have the implication of the joints with fever. In pyemia, hoAvever, the general condition is more grave as a rule; fever is more apt to precede the local manifestations, and the curve is irregularly intermittent, Avhereas in rheumatism it is irregularly re- mittent. Rigors also occur in pyemia at irregular intervals, accompa- nied by a rapid rise of temperature, and are absent in rheumatism; sup- purative processes are early set up in the various viscera and skin, which latter also shoAvs slight but decided jaundice. The symptoms, both gen- eral and local, in acute articular rheumatism fluctuate greatly, Avhile this is not so in pyemia. The multiple SAvelling of the joints Avhich develops after labor is to be regarded as septic in nature. Gout will be distinguished from rheuma- tism in connection with the consideration of the former disease (vide p. 398). Monarticular rheumatism is with difficulty differentiated from a group of affections which simulate it closely. (1) The so-called gonor- rheal rheumatism often affects a single joint, especially the knee; but in this disease there is usually a definite history of recent infection, and the local features (pain, swelling, etc.), unlike true rheumatism, are far more pronounced than the general. The course of gonorrheal arthritis is longer in duration, and is generally connected only with a single joint from the start; while acute articular rheumatism almost always begins as a polyarthritis, with subsequent fixation in one articulation. Cardiac complications are rare in the former disease. (2) Acute osteomyelitis is generally single, and is sometimes mistaken for rheumatism, from which it differs, however, in the localization of the 14 210 INFECTIOUS DISEASES. lesions in a single joint from the start, the greater prominence of the local symptoms, and in the implication of the epiphyses and the shaft of the afi'ected bone rather than the joint, and in the graver general symptoms from the time of onset. (3) There is a liability to mistake the acute arthritis of infants for rheumatism. This attacks by preference the hip or knee, and is a puru- lent inflammation due to pyemia (Townsend), hence having no relation to the disease under consideration. (4) Scrofulous arthritis, particularly in children, has been confounded with rheumatic monarthritis. The former is less indurating, the swell- ing presented is less symmetric, and the course is far less acute than that of the latter. (5) In the course of the hemorrhagic diseases, scurvy, purpura, and hemophilia, effusion into the joints, either hemorrhagic or serous in nature, occurs with great frequency and is associated Avith rheumatic pains. The differential diagnosis is to be made from the tendency to hemorrhage, and in scurvy by the lesions of the gums. The absence of fever is usually decisive: unfortunately, it is frequently present in these joint-affections. Prognosis.—Recovery is the general rule. As in other infectious diseases, so in rheumatism, the chief immediate danger springs from the great intensity of the type of infection, as manifested in hyperpyrexia with grave nervous symptoms, the development of the general hemor- rhagic diathesis, etc.—happily rare occurrences in this disease. Certain complications, such as pericarditis, endo-pericarditis, pneumonia, etc., may render rheumatism grave or even hopeless, and rarely the endocar- ditis that complicates the disease is of the ulcerative variety and leads to fatal pyemia. Pulmonary embolism may occur during the course of acute articular rheumatism, causing speedy death. The influence of personal factors may impede recovery, such as in- temperate habits, great obesity, the existence of previous organic dis- ease of the heart or Bright's disease, etc. Treatment.—(1) Sanitary Environment, Diet, and Stimulants.—The sick-room should be well ventilated, and its temperature maintained at 65° to 70° F. (18.3°-21.1° C), but draughts should be avoided. The patient should be lightly dressed in flannels and covered Avith a sheet of the same material. The diet should be liquid and nourishing, milk be- ing the best food-article as a rule, and being well borne. Skimmed milk, milk and Seltzer Avater, buttermilk, milk and lime-Avater, meat- juice, egg-white, and solids (other than animal) may all be employed if ordinary milk cannot be taken in adequate amount. I begin the use of the more nutritious and easily digested forms of animal food as soon as defervescence has occurred. Stimulants may be employed if indica- tions for their use are present, and the customary mode of administra- tion may be followed. Fortunately, these do not arise as often as in many other affections belonging to the class. (2) Internal Therapeutics.—There has been of late a surprising unanimity among clinicians in commending the use of the salicylates in the treatment of this disease—more so than at any previous time since their introduction. They are employed in most of the larger hospitals both in Europe and America. Differences hoAvever ACUTE ARTICULAR RHEUMATISM. 211 relating to the mode of administration and the particular salt to be selected still exist. Wood' favors ammonium salicylate, for the reasons that it is freely soluble, is rapidly absorbed, and Avhen given in sufficient amount quickly produces the symptoms that mark salicylic action, while, in addition, it is less depressing than the other salts of salicylic acid. It is best given in milk and is usually well borne. My experience Avith this salt in acute articular rheumatism, though as yet someAvhat limited, has been satisfactory. Until the present time sodium salicylate has met Avith more general favor than any other single salt of salicylic acid. The pure acid is also used, though not to any great extent at the present day. As regards the mode of administration, the total daily amount taken is of higher importance than the size and frequency of the dose. The amount given in tAventy-four hours should not exceed 2 drams (8.0), while often 1^- drams (6.0) of the sodium or ammonium salicylate is sufficient. My method is to give gr. x (0.648) every two hours during the first day, or until the pain and other local features have largely dis- appeared ; then the remedy is given at longer intervals, but not omitted entirely. In this manner fresh exacerbations are most probably averted. If the latter occur, however, larger doses must be instituted, so as to cut them short. Some recommend that the medicine be stopped as soon as the pain has been controlled. If salicylic acid be employed, it should be given in capsules. According to certain observers, salol is to be pre- ferred to either the pure acid or the salicylates : in my experience, how- ever, the use of this drug has not been folloAved by good results in the severe acute forms of the disease. Doubtless the reason for this lies in the fact that salicylic acid can neither be introduced into the system in sufficient amount nor rapidly enough in the form of salol. Kinnicut has recommended the employment of the oil of winter- green, a salicylic compound Avhich does not generally produce the un- pleasant toxic symptoms so apt to be excited by the salicylates or sali- cylic acid. The dose is TTLx-xx (0.60-1.25), given in capsules or in milk, to be repeated every two hours. Salicin (gr. x—0.648, every hour, increased to gr. xv—0.972) is sometimes efficacious and invariably agrees. Salophen, in daily doses of 1 dram (gr. xv—0.972, every four hours) until pain is relieved and temperature reduced, has been warmly advocated. Though almost specific in its effects, the drug does not pre- vent either the spread of the disease to newT joints, fresh exacerba- tions, or cardiac complications. Sodium salicylate enemata (;?j—4.0— of the salicylate and TTLx—0.60—of the tincture of opium in each in- jection) may be of advantage in certain cases. The remedy is absorbed from the rectal mucosa, though more slowly than from the stomach. The treatment with the salicylates or salicylic acid mitigates the fever, relieves the pain, and shortens the stay in bed by a few days, but does not curtail convalescence. The statistics of Williams go to show that the salicylate treatment also tends to protect against the develop- ment of cardiac complications, though it does not seem to influence the course of the complications once they are established. In my experi- ence the alkaline treatment operates potently to obviate the occurrence of* the heart-complications and shortens the period of convalescence, but exerts slight, if any, influence upon the fever-curve and pain. These 1 University Medical Magazine, Jan., 1895. » 212 INFECTIOUS DISEASES. facts led me long since to use the specific and alkaline treatment in com- bination, giving, in addition to salicylates or other salicylic compounds, as above indicated, an alkaline remedy, such as sodium bicarbonate, potassium citrate, etc., in sufficient doses to render, and then maintain, the urine of slightly alkaline reaction. There are a few other remedies that should be referred to, and, although more or less serviceable, they are without specific influence. The foremost among these is antipyrin, which may be used advantage- ously during the acute period of the disease, the heart being at the same time watched over carefully. Loomis says of the drug: " I have come to employ it almost to the exclusion of all other remedies for the relief of the arthritic pain, and in many cases it has seemed markedly to shorten the duration of the disease." Potassium iodid and the prepa- rations of colchicum also belong to this category, and should be tried. Their effects are most beneficial in cases that drag on after the acute stage is over. Recently lactophenin has been brought forAvard by Roth as a most useful remedy in acute rheumatism, but it does not rival the salicylates. (3) Local Measures.—These occupy a subordinate place in the man- agement of acute articular rheumatism. Their number is legion, but only a few of the more valuable can be adduced here. In mild cases the affected joints should be wrapped in cotton batting or in flannel. If the pain is severe despite the use of the salicylates internally, fomen- tations as hot as can be borne or hot cloths lightly wrung out of Fuller's lotion (sodium carbonate, 3yj—24.0; laudanum, sj—30.0; glycerin, §ij—60.0; and water, gix—270.0) are beneficial. As salicylic acid is absorbed through the skin, it has been combined with other agents for local use in the following formula: B/. Acid, salicyl., Lanolini, da. ^iij (11.65); 01. terebinthinae, siij (11.25); Adipis, 3iij (11.65). M. et ft. ung. Sig. Rub freely over the affected joints and follow by wrapping in cotton. Cold compresses and the ice-bag to the joints have been strongly ad- vised, particularly by German authors. The affected joints should be kept at perfect rest, and this is best accomplished by padded splints and a roller bandage. Blisters near to the joints involved and the light application of the Paquelin thermo-cautery are sometimes serviceable, but they are to be thought of only Avhen the above-mentioned local means have failed. The treatment of the complications will be considered under their appropriate headings. I desire, however, to emphasize the fact in this connection that should hyperpyrexia occur during the progress of the affection, it is to be relieved by cold baths, since large doses of antipyrin or other internal antipyretics are of themselves dangerous. It may also be stated that the cardiac complications—endocarditis, pericarditis, and endo-pericarditis—rarely require special remedies. If marked cardiac asthenia appears, as indicated by the feeble first sound, the salicylates GONORRHEAL ARTHRITIS. 213 may be replaced by salicin, Avhich is less depressing in its effect upon the heart. Cardiac stimulants may be required. A copious pericardial effusion calls for paracentesis (vide Scro-fibrinous Pericarditis). During convalescence the patient should not be alloAved to get out of bed too early. My OAvn rule has been to keep him in bed for a Aveek after the temperature has returned to the normal and after the pain has disappeared, except it be during the hot season. These precautions are taken to avoid the occurrence of relapses. After the patient goes into the open air he should be told to avoid cold, and Avet in particular. During this period iron is to be employed until the blood-examination fails to shoAV anything abnormal. For the stiffness and swelling that sometimes persist, or disappear very sloAvly after the acute attack, massage and the application of hot Avater or warm baths seem to yield the best results. SUBACUTE ARTICULAR RHEUMATISM. This is, as a rule, a sequela of acute rheumatism, and may occur, though rarely, in persons who have not had a previous acute attack. Both the local and general features are of a mild type, but the course is apt to be prolonged into tAvo, three, or more months. Usually the local symptoms are confined to one or tAvo of the larger joints, Avith little SAvelling or redness, and the pain is slight except on movement. The temperature rarely exceeds 101° F. (38.3° C), and at times may be practically normal. Though the course is prolonged, the joints usually return to their normal state; occasionally, hoAvever, the disease becomes chronic. As in the acute form, so in the subacute, anemia becomes Avell marked and cardiac complications are not uncommon, particularly when the disease occurs in children. The treatment embraces, in addition to the usual antirheumatics, the use of iron, quinin, cod-liver oil, and, when practicable, a change to a warm climate. The affected joints demand hot applications and massage. GONORRHEAL ARTHRITIS. Definition.—A septic synovitis caused by the gonococcus, and hence having no connection with true rheumatism. It usually manifests itself toAvard the close of an attack of gonorrhea, but it may develop during the active stage of the disease or at any period during the course of gleet. Pathology.—The signs of ordinary synovitis are generally found in the affected joints, though, not rarely, the inflammatory process is periarticular rather than articular. Under these circumstances the in- flammation may travel along the sheaths of the tendons for a consider- able distance. Synovial effusion may occur, and rarely may be puru- lent, this being most frequent in gonorrheal inflammations affecting 214 INFECTIOUS DISEASES. the Avrist and hand. Gonococci have been found in the effusion, though this is not generally the case, and it is now thought by many Avriters (Finger, Councilman, and others) that the gonococcus may be the only infective agent concerned in the morbid process. Others contend that the metastatic inflammation of the joints is due to the presence of pyo- genic cocci, since they have been found to be frequent companions of the gonococcus. In this and other forms of secondary inflammation it must not be forgotten, however, that gonorrheal arthritis may be due in great part to the absorption of ptomains from the urethra. The disease occurs much more frequently in men than Avomen, and some claim that it may follow any urethral discharge in the male or may be associated Avith menstruation or leukorrhea in the female. Clinical Symptoms.—Two leading varieties, acute and chronic, are encountered. (1) Acute Gonorrheal Arthritis.—This may be very mild, amounting merely to slight fugitive pains and some stiffness of one or more joints, without noticeable SAvelling or redness. The typi- cal, acute form, however, presents the symptoms of a severe fibrinous or sero-fibrinous inflammation of a single joint, developing quickly. The pain is often violent; there is swelling of the joint with extension along the course of the tendons, and the condition is obstinate. Unless pus be present (a rare event) the constitutional features do not corre- spond in severity Avith the local, there being little fever and slight im- pairment of the general health. There are many instances in which the complaint begins as a polyarthritis, with subsequent concentration upon one or two of the larger articulations, especially the knees or ankles. Fibrinous ankylosis usually remains as the resulting condition. Acute endocarditis may be of gonorrheal origin. In the inflamma- tory products of this condition Hering has found the gonococci, as has also Councilman, in the heart-muscles (gonorrheal myocarditis). Rarely, gonorrheal endocarditis assumes the ulcerative or malignant form. As the result of invasion of the blood by the gonococci suppurative arthritis may also be occasioned, and now the clinical picture is that of general septico-pyemia. I observed one case in which pleurisy was associated, and among the numerous Avidespread complications iritis deserves special mention. (2) Chronic Gonorrheal Arthritis.—This occurs (a) as a serous effu- sion (hydrarthrosis), and (b) as a chronic inflammation of the articular and periarticular structures (synovial membranes, bursae, periosteum, and tendons with their sheaths). The former is usually monarticular, settling with especial frequency in the knees, and may be Avholly pain- less. The latter is more or less painful—causes dense swelling of the joint, and frequently of the structures for some little distance above and beloAV the latter. Both forms lead to great restriction of motion. The diagnosis cannot be determined positively apart from the his- tory of urethral infection. The acute form is distinguished chiefly from acute articular rheumatism by the intense pain, the extent to Avhich the periarticular tissues are involved, and the negative character of the general symptoms. The chronic variety must be discriminated from chronic synovitis due to other causes, and this often proves a difficult task. Treatment.—I have never seen the slightest benefit from internal VARIOLA. 215 medication in gonorrheal arthritis, except possibly from the use of mer- cury until the patient was brought decidedly under its influence. Local measures, however, are of paramount importance. Absolute rest to the part is indicated, and the limb should be placed upon a splint; then, after making an appropriate anodyne application (ungt. ichthyol or ungt. bella- donnae), it should be bandaged as firmly as possible. Before doing this in acute cases the patient should be anesthetized", and after the procedure, if pain be great, a hypodermic injection of morphin may be given. In chronic forms the aim should be to remove the effusion (if present) and the swelling, and to restore the natural motility so far as possible. For the latter 1;avo indications massage and passive movements are best. Swell- ing may also be diminished by the use of the thermo-cautery at intervals, and blisters are highly serviceable in causing a disappearance of the effusion. Careful surgical attention should be bestowed upon the urethral or vaginal condition. VARIOLA. {Small-pox.) Definition.—Variola is an acute contagious disease, characterized by its sudden onset and severe period of invasion, followed by a remis- sion of the fever and an eruption of papules, which pass through the stages of vesicle, pustule, and scab. The stage of pustulation is accom- panied by secondary fever. Historic Note.—Small-pox has existed from the earliest anti- quity in India, Africa, China, and other Eastern countries. During the thirteenth century (1241) it entered England, in the early part of the fourteenth Ireland, and in the latter part of the fifteenth Germany. In 1507 it was imported to America, and first appeared in the West Indies; a little later (1520) the Spanish troops conveyed the disease to Mexico, where it destroyed not less than three and a half millions of people in its pestilential march. It was brought to the United States from Europe in 1649, and gained its first foothold in Boston, Avhence it progressed at intervals in a westerly direction till it finally reached the western coast-line nearly a century after its first introduction. At the present day there is a very limited opportunity to observe the affection except in its modified form (varioloid), since small-pox certainly does not prevail in an epidemic form where vaccination is practised with fidelity, and only among uncivilized peoples Avho are ignorant of or in- different to this certain prophylactic power. Pathology.—The eruption of small-pox consists in an inflammatory cellular infiltration of the rete mucosum and has four successive stages— (1) Papular, (2) Vesicular, (3) Pustular, and (4) Scab. (1) The Papule.—At first there is a hyperemia of the papillae of the skin appearing as small red spots. These soon become round, discrete patches that may be rolled like shot under the skin, and then, becoming elevated, owing to the increase in the cells in the rete mucosum, they form the typical papule. 216 INFECTIOUS DISEASES. (2) The vesicle appears at the apex of the papule, and results from a circumscribed elevation of the superficial layer of the epidermis in con- sequence of the mechanical pressure exerted by the fluid exudate, Avhich is excited by active peripheral inflammation. The vesicle is not uni- cellular, but is loculated (by fibrinous reticuli), and contains serum, leukocytes, fibrin-filaments, etc. If a section of a vesicle in the very early stage be made through the deeper layers of the rete mucosum, an area of coagulation-necrosis is observed, which is due to the presence of micrococci (Weigert). The vesicle shoAvs central umbilication, which corresponds with the necrotic area, and is well marked just before the pustules are formed. (3) The pustule is formed by the filling of the reticuli with leuko- cytes. Cellular infiltration and swelling of the true skin beneath the pustule occurs, as a rule, as the result of diapedesis. Moreover, sup- puration may involve the cutis vera, and as a consequence scarring re- sults. When the suppuration is limited to the rete mucosum pitting does not take place. In hemorrhagic small-pox the reticuli are occupied by an abundance of red corpuscles which have passed in from the adjacent blood-vessels, and may infiltrate the upper as well as the deeper layers of the epidermis surrounding the vesicles or pustules. The pustules may dry up, but commonly rupture, and in either case the result is (4) scabbing. The mucosa of the mouth, pharynx, and, rarely, the esophagus and the rectum may be the seat of a variolous eruption, and the plaques of Peyer may be somewhat swollen. The eruption also appears in the larynx, the trachea, and bronchi, where ulcers rather than true pustules are seen, and the conjunctiva and nasal mucosa frequently show the specific lesions. Hemorrhagic small-pox presents extravasations occurring in the serous and mucous membranes, the connective tissue, the parenchyma of the various viscera, and also, though much less frequently, in the nerve-sheaths, bone-marrow, blood-vessel walls, and the muscles. In this form the spleen is firm (Ponfick, Osier), and the liver is sometimes enlarged and the subject of fatty degeneration. Hemorrhagic infarction of the lung occurred in 5 out of 7 cases examined by Osier. " In 4 instances the pelves of the kidney were blocked with dark clots, which extended into the calyces and down the ureters," and in a proportion- ate number of cases Peyer's glands were swollen. Secondary Lesions.—The catarrhal inflammation of the larynx may extend in depth till it touches the perichondrium of the cartilages (peri- chondritis), and a croupous exudate in the larynx may often coexist with edema. Lesions are present in the lungs, some of them frequently (general bronchitis, broncho-pneumonia), and others rarely (hypostatic congestion, lobar pneumonia), and a Ioav type of inflammation of the pleura may be observed. Cloudy swelling, diffuse inflammation, and sometimes fatty degeneration of the liver, have been noted, the spleen being enlarged and pulpy as a rule. The heart may show myocardial alterations—chiefly parenchymatous and fatty—and rarely endocarditis and pericarditis occur in the nature of true complications. The kidneys shoAV cloudy swelling, and occasionally nephritis develops, although not until quite late. Attention should be called to the observation of Wei- VARIOLA. 217 gert, who found that at the commencement of the stage of suppuration the microscope revealed "small-pox cylindric masses" in the various organs (liver, spleen, kidneys, and lymphatic glands). The cylindric masses are in reality capillaries filled Avith micrococci, which are derived from the eruption, and probably find their Avav into the circulation through the lymphatics. These small areas of coagulation-necrosis may be the seat of leukocytic infiltration, which in turn may result in a cir- cumscribed miliary abscess if septic material be also absorbed from the pustules. No special microscopic appearances are presented by the blood. Etiology.—Bacteriology.—Loeb and Pfeifferl have described certain protozoa found in the blood or in local lesions, to Avhich they attribute an etiologic significance. J. Christian Bay2 has isolated from small- pox lymph and vaccine points an organism (dispora variolar) which he believes to be the causa morbi of small-pox and vaccinia. The long diameter of the bacterium measures 0.6p-lp, and the short diameter from 0.2/Z-0.3/*. The organisms contained tAvo spores, one at either end, and Avhen reared on artificial media developed in colonies, and were readily stained with anilin blue or violet. A further study of the dis- pora, hoAvever, is essential, and experiments having for their object the reproduction of the affection in the lower animals have not been suc- cessfully conducted as yet. Hence the exact role played by the organ- ism in the causation of variola has not as yet been definitely determined. Predisposing Causes.—The receptivity for variola is Avellnigh uni- versal, though in rare instances persons are insusceptible, and among the feAV who have enjoyed complete immunity against small-pox were three distinguished physicians—Diemerbroeck, Boerhaave, and ■ Mor- gagni. It may be said that one attack confers permanent immunity, but in rare exceptions a second or even a third may occur. Vaccination, also, if successful, affords future protection against variola, but to this rule exceptions are not infrequent. Age.—All periods of life are liable to the disease, but the very young are affected in a relatively larger proportion than older persons. During the entire puerperal stage there is an increased liability to the disease. It rarely affects the fetus in utero, and most babes even, Avho are ex- posed to the virus at the time of birth, will not take the disease if immediately and successfully vaccinated. Sex is Avithout influence. Race.—Among uncivilized peoples variola spreads with frightful rapidity, the negro and other very dark races being affected in larger numbers and more severely than whites. A dread of the infection pre- disposes to its occurrence. The Contagion; where Found; Modes of Conveyance and of Infection.— One case of variola is primd facie evidence of the existence of another, and that the poison from the latter Avas somehow transferred to the former. The specific poison exists in the blood and in the secretions and excretions (most probably), but mainly in the pustules and dry scabs and in exhalations from the lungs and skin. Its conveyance from the sick to the healthy or from one person to another is not a difficult 1 Loeb, Ceiitralbl. fiir Bacteriologic und Parasitenkunde, ii. 353, 1887; Pfeiffer, ibid., ii. 126, 1887. 2 Medical News, January 26, 1895, vol. lxvi. p. 94. 218 INFECTIOUS DISEASES. matter, and may take place in one or other of the several following Avays: (a) Inoculation Avith either the blood or the contents of the erup- tion or the dissolved dry scabs is folloAved by variola, (b) Contact with, or proximity to, a patient suffering from small-pox is very apt to convey the poison, with resulting variola in the person thus exposed. To what distance the contagion can be conveyed through the air is not known, but it is probably considerable; and all authors are agreed that it is one of the most infective diseases with which we are acquainted. It is contagious from the earliest active stage to the end of convalescence, and, according to some observers, even during the stage of incubation. (c) Transmission by fomites is common, the poison adhering to clothes, body- or bed-linen, etc., and evidence is not Avanting to show that the poison is highly tenacious of pathogenic power. Its vitality is retained after death, and the room occupied by a patient, the bedding, and the articles of furniture all serve to convey the disease unless thorough dis- infection be enforced. The avenue of entrance for the poison into the system is not known, but it is most probably the respiratory tract, the poison being inhaled and thence taken into the general circulation. Clinical History.—Incubation.—This stage varies with the mode of communication of the poison. If following inoculation, the symp- toms appear in six or seven days; when originating in infection, usually in twelve days, though this stage may be either lengthened by a day or tAvo or shortened to an equal extent. During a portion of this period complaint may be made of certain ill-defined symptoms, but these are usually absent, and the onset is sudden and accompanied by character- istic signs. These are—a severe rigor, high fever, headache, and intense lumbar pains. Instead of the usual severe rigor, repeated chills, ex- tending over tAvelve to twenty-four hours, may occur, the headache, intense pain in the loins, and the fever continuing for several days unless relieved. During the same period the respirations are accelerated, the pulse becoming decidedly more rapid, and there may be general bron- chitis. The tongue is coated and the patient may make complaint of slight pharyngitis. There is anorexia (often complete), generally vomit- ing, and constipation or rarely diarrhea. Restlessness, wakefulness, delirium, and stupor are the most important nervous symptoms observed. Infective albuminuria is not uncommon, and in the female menstruation is apt to be brought on. The physical signs are few, and consist of a few dry and, later, moist rales, heard on auscultation. Palpation detects splenic enlarge- ment. From the second day the so-called initial rashes may appear: (a) the diffuse scarlatinous eruption, which in no way differs from ordi- nary scarlatina; (b) the measly eruption, Avhich may be diffuse and identical with that of true measles. Either associated Avith these or occurring independently there may be a hemorrhagic eruption (usually purpura), the petechiae coming out by natural selection, mainly upon the hypogastric region or the inner surfaces of the thighs and in the axillae (Simon). Rarely the knees, elbows, and extensor surfaces pre- sent this eruption. The initial rashes occur in a considerable propor- tion of cases (10-15 per cent.), and of these the petechiae outlast the other pre-variolous eruptions. The stage of invasion just depicted lasts three days as a rule, and the intensity of the symptoms is generally in VARIOLA. 219 direct proportion to that of the stages that follow. At the end of the third day or on the fourth the temperature declines rapidly, Avhile at the same time the true variolous eruption appears upon the skin and mucous surfaces. Now begins the stage of eruption, Avhich develops first upon the face, particularly upon the forehead and the hairy scalp, and spreads in a dowmvard direction till it reaches the legs, Avhere it last appears. The skin in the femoral triangle rarely shoAvs the true variolous eruption. Each pock passes through the various stages noted in the pathologic description—viz. papule, vesicle, pustule, and scab; and Avhen the stage of pustulation has been reached a secondary fever develops. During the following remission of fever the headache, lumbar pains, etc. subside. The fever of suppuration which then succeeds is accompanied once more by marked constitutional disturbances, particu- larly nervous derangements (wild delirium, etc.), and at this time com- plications are also apt to develop. On the eighth or ninth day of the eruption (the twelfth or thirteenth day of the disease) the pustules begin to dry up, forming yellow crusts; the redness and swelling of the skin subside; and two or three days later the scabs loosen and are throAvn off. During this stage the fever again declines in company with the con- stitutional symptoms, and convalescence ensues. As previously stated, Avhen suppuration involves the true skin scars are the inevitable result, and these remain to the end of life. The hair drops off sometimes, even to the extent of total alopecia, but is generally renewed. Leading Symptoms and Complications.—(a). Eruption.—As before stated, the eruption makes its appearance at the end of the third or on the fourth day, coming out first upon the forehead, particularly along the border of the hairy scalp, and spreading in a downward direc- tion in regular progression. It appears in the form of slightly elevated maculae, Avhich are at first of a pale-red color, and later assume a darker red hue, resembling small fleabites. These increase in size during the next forty-eight hours, at the end of which period they are developed into (1) papules. The change of character is accompanied by itching and burning of the skin-surface. To the feel they are papular—like shot under the skin—and if the finger-tips be rubbed over them lightly they are distinctly satin-like. The eruption is always most abundant upon the face and scalp, while the hands and fingers are the next most favored seats. At the end of the third day (the sixth day of the disease) the conical apices of the papules contain liquid, forming thus (2) vesicles. The latter increase in size till the entire papule is converted, at the same time acquiring more and more decidedly a central umbilication. Punc- turing a vesicle does not cause it to collapse, but allows only a small por- tion of its liquid contents to escape, owing to its reticulated character. As the vesicle increases in size its contents become opaque, and in three days more, or about the sixth of the eruption, the vesicles become (3) pustules. Umbilication now disappears, and the pustule looks full and well rounded, and is surrounded by a red border or "halo." If the pocks be close set, as on the face, wrists, and fingers, the intervening skin is inflamed and SAvollen and the itching and burning become almost intolerable. The pustules may coalesce along their edges, and thus the eruption becomes confluent. The eyes are closed as the result of swell- ing and tumefaction of the face, and the hands and feet assume a rounded, 220 INFECTIOUS DISEASES. ball-like appearance. The face, as a whole, is markedly misshapen and is ultimately disfigured. When the pus is not liberated (a comparatively rare event), its desiccation begins on the ninth day (the twelfth day of the affection); if the pustule is ruptured earlier (as when confluence occurs), it begins at an earlier day. (4) The scabs now form, and remain until about the tAvelfth day of the eruption, and when pits or scars result they are at first distinctly hyperemic, but gradually fade until at last they remain as permanent Avhitish spots. The eruption upon the mucous membrane develops simultaneously with that of the skin, and among favorite surfaces for its appearance are (as pointed out under Etiology) the mouth, tongue, soft palate, and pharynx (causing dysphagia), the nasal chambers (causing coryza), the larynx (causing hoarseness), the trachea and bronchi (causing bronchitis). This mucous efflorescence does not proceed to the development of pustules, but forms ordinary ulcers as a consequence of early maceration of the super- ficial layers of the mucosa, and these ulcers also may become confluent. The skin also presents certain complications that are always secondary and are deserving of mere mention (erysipelas, abscess, gangrene, bed- sores, etc.). (b) The Fever.—The temperature at the onset rises rapidly, and may touch 103° or 104° F. (40° C.) on the first day, its range being high and of the continued type during the invasion period. Evening tem- peratures of 105° F. (40.5°.C.) or higher may be observed, and in three days (or with the first appearance of the papules) the temperature remits, but does not intermit in true variola. It remains at a low elevation till the stage of suppuration is reached, when a fresh rise, sometimes to its Fig. 21.—Temperature-chart of a case of variola, from a patient in the Municipal Hospital, Phila- delphia. A. F---, aged three years; not vaccinated. original height, occurs. This secondary fever-curve is apt to show a decided irregularity, with exaggerated points of elevation and deep re- missions. The latter may be due to complications, but are most gener- ally the result of septic absorption (the fever of suppuration). This period lasts from one to three or four days in typical cases. When desic- cation of the pustules begins defervescence also commences, and proceeds in a gradual manner by lysis. There may be a post-variolous rise, and if so its presence is to be attributed to some sequel or other. VARIOLA. 221 (c) The Circulatory System.—The pulse is soft and much accelerated (100 to 130) and of good volume during the invasion stage. It is slower during the period of remission, only to be greatly increased in frequency during the second stage of fever. During the latter period it may, owing to cardiac failure, become very rapid, much enfeebled, and finally irregu- lar or even intermittent. The pulse-rate will vary according to differ- ences in the previous general condition of the individual. Simple endo- carditis rarely, and pericarditis someAvhat more frequently, occur as complications. (d) Respiratory Tract.—The laryngitis and pharyngitis which are due to the presence of pocks in the mucosa of the respiratory passages have already been mentioned. The most serious events, hoAvever, connected Avith the respiratory system originate in secondary infections, if Ave except laryngeal perichondritis Avith edema of the glottis, the latter perhaps being the result of a direct extension of the pock-ulcers to the perichon- drium. Chief among the secondary complications is broncho-pneumonia (inhalation pneumonia), and lobar pneumonia also occurs, though rarely. Pleurisy, however, is not infrequent, particularly as an associated condition in broncho-pneumonia. (e) The Digestive System.—A frequent seat of the variolous efflorescence is in the buccal and pharyngeal mucosae, where it causes exceedingly un- pleasant symptoms (vide ante). It may also be an agency in predisposing to a secondary inflammation in adjacent organs—e.g. suppurative otitis media, suppurative parotitis, pseudo-diphtheria, etc. Palpation almost always shoAvs an enlarged spleen, and not infrequently an enlarged liver. The vomiting Avhich is usual at the onset is not due to the presence of pocks in the stomach, but to a catarrhal condition of the organ. Consti- pation is common, but diarrhea is also sometimes met with, being excited by a catarrh of the large intestine, and is especially common in children. The pocks may, however, be found in the rectum, where they sometimes excite dysenteric symptoms. (/) The Nervous Symptoms.—The chief of these have been already pointed out, as well as the fact that complications and sequehe are by no means rare. Violent delirium (previously referred to) may be followed by fatal coma, and in children convulsions may be seen. Very rarely para- plegia has been observed during the attack, though it is more common during the convalescence, and is then due to different causes, such as peripheral neuritis and disseminated myelitis (Westphal). Multiple neur- itis may be a sequel or the pharyngeal nerve may alone be affected. Among other conditions rarely arising during convalescence are insanity, epilepsy, and hemiplegia. (g) The joints may be swollen and painful after small-pox, the con- dition being secondary and rheumatic in nature, and in rare cases peri- ostitis may be observed. (h) Renal Symptoms.—Apart from the febrile albuminuria already re- ferred to, renal complications are of great rarity, and, with one exception (hemorrhagic nephritis), are of little practical import. Hemorrhagic nephritis may occur, and is always of a serious character, though, for- tunately, it is very rare. (i) The Special Senses.—The pustules may form upon the conjunctivae and eyelids, and several important conditions result from this variolous 222 INFECTIOUS DISEASES. involvement of the eye—viz. conjunctivitis, keratitis, choroiditis, and panophthalmitis. Hebra met with ocular complications in 1 per cent, of 5000 cases of small-pox. Otitis media has already been mentioned. Special Clinical Forms.—There are two unusual types of variola that are important in being severer than the moderate (discrete) form already described. (a) The Confluent Form.—This is the result of an abnormally severe infection, but cannot be said truly to be atypical. The ushering-in symptoms are very severe, and the eruption may appear as early as, or even before, the third day, when the temperature remits, though not to any great degree. The separate papules are, perhaps, somewhat smaller than in the discrete variety, and vastly more abundant and close-set; and after the stage of pustule is reached the face and hands present an unin- terrupted area of suppuration. The deformity of the countenance is correspondingly pronounced. Naturally, the local symptoms are intense and the fever and its concomitants are in exact proportion. The nervous symptoms often predominate. Salivation is frequent, and vomiting is excessive in adults, while diarrhea is equally so in children. The erup- tion may also entirely cover the mucous surfaces. The lymphatics of the neck may be greatly swollen—a circumstance that contributes to the patient's unparalleled disfigurement. The various complications previously adduced are of comparatively frequent occurrence, and following these a general pyemic process may then develop. When death occurs it is usually preceded by the development of the symptoms that belong to the typhoid state (typhomania, tremors, subsultus tendinum, a rapid, feeble pulse, dry, broAvn tongue, and diarrhea). On the other hand, if recovery ensues, it is tardy and often interrupted by complications and sequelae. (b) Black Small-pox.—In this form the blood is much changed, so that hemorrhages into the skin, mucous membranes, and various viscera occur. It is important to distinguish several sub-varieties, as follows: (1) A benign form, in which blood is infused into the pustules when patients are alloAved to leave their bed too early in convalescence. Here the condition is due to the effect of gravitation, and hence is confined almost solely to the lower extremities. (2) Doubtless the ordinary variolous eruption may become slightly hemorrhagic without aggravating the constitutional con- dition. Often this is seen in debilitated and intemperate subjects. (3) In the same class of subjects a dangerous hemorrhagic tendency may be manifested. During any of the eruptive stages—papular, vesicular, or pustular—hemorrhages may occur into the eruption, and, moreover, free bleedings may take place from the various mucous surfaces (hematuria, epistaxis, hematemesis, enterorrhagia, etc.). The initial symptoms are usually intense, the eruption abundant, and in consequence of the hemor- rhages collapse often occurs. The most serious complications, pneumonia, diphtheria, and nephritis (followed by uremia), are also apt to develop and terminate life, and even should recovery ensue it is very tedious. This and the subsequent sub-variety are truly anomalous. (4) A not uncommon form of hemorrhagic variola is met with in which the acute hemorrhagic diathesis develops during the period of invasion. Its onset is characterized by the usual symptoms intensified, and as early as the second day ecchymotic patches appear upon the skin-surface and grow rapidly by peripheral extension, the mucous surfaces also showing more VARIOLA. 223 or less extensive ecchymoses. The regular variolous eruption rarely ap- pears, though occasionally shot-like papules may be detected here and there. The temperature may be slightly elevated, but is rarely high, and not infrequently it may remain normal or subnormal. Death often occurs before the time for the appearance of the characteristic eruption, and very rarely does the patient survive the fourth or fifth day. There are also varieties of small-pox that pursue an abnormally mild course. Of these (c) varioloid deserves first place. By this term is usually meant small-pox occurring in individuals who have been protected by a successful vaccination, but it may also be the result of natural insuscepti- bility. Hence variola and varioloid are one and the same affection, the latter name, however, representing a milder form of the disease than the former. The initial symptoms of varioloid do not differ either in charac- ter or severity from those of true variola, but the general course of the attack is peculiarly prone to manifest irregularities. , In the pre-eruptive stage an erythematous rash is very common, and its appearance is regarded by many as being of value in discriminating varioloid from variola. When the regular eruption appears the fever falls to normal and re- mains there. The rash comes out by the end of the first or on the second day, the papules being scanty, and quite as liable to appear first upon the trunk^ as upon the face. They are identical with the papules of variola, as is true also of the vesicles; but pustulation rarely develops, for the reason that resolution takes place, as a rule, before the latter stage is reached. The secondary fever is either very slight or entirely wanting. The mucous surfaces are affected but to a correspondingly slight degree, and thus the general course of the disease is characterized by irregularity. Papules and vesicles may be found in close proximity; not so in variola. Desiccation begins between the fifth and seventh days of the eruption (the eighth and tenth of the disease), and hence, as compared with variola, the course is cut short and serious complications almost never occur. (d) An abortive form is occasionally observed. It is characterized by the great intensity of the invasion symptoms, but these promptly subside, and the patient enters at once upon a stage of speedy recovery. An exceedingly mild type may arise during seasons of epidemic preva- lence of the disease, either with or without a scanty and undeveloped erup- tion, when the diagnosis is made entirely from the etiologic circumstances. Diagnosis.—With a clear history and the presence of the character- istic features a positive diagnosis is a simple problem. But at any period before the papules are fully developed it may be confounded with certain other acute infectious diseases, notably cerebro-spinal meningitis, pneu- monia, typhus fever, scarlatina, and measles. Differential Diagnosis.—In typhus fever the onset is very like that of small-pox. The former may, however, be distinguished by its peculiar etiologic factors, especially its origin by importation or its non-prevalence in the vicinity ; the appearance of the eruption, first upon the trunk (chest and abdomen) in the form of maculae, and later becoming petechial; and by the fact that it is neither papular, vesicular, nor pustular, as in small- pox. Moreover, in typhus the temperature does not remit with the appear- ance of the eruption, but persists, and may even rise higher. From hemorrhagic small-pox typhus is sometimes distinguished with great difficulty. In the most virulent type of the former death often 224 INFECTIO US DISEASES. occurs before the eruptive stage is reached. When it does not, the causal data are most important factors in making a discrimination. In typhus shot-like papules are never detected upon the skin-surface of the hands and head, whereas they are sometimes found in hemorrhagic small-pox. The diagnosis from scarlatina may early be made from the erythema- tous (scarlatinous) rash which often precedes the appearance of the vario- lous eruption. This is, as a rule, neither so intense nor so uniformly dis- tributed over the skin-surface of the body as in true scarlatina. Lobar pneumonia begins with many of the symptoms that character- ize the initial stage of small-pox, but in addition there are sharp pain in the side, cough Avith rusty sputum, acceleration of the respirations out of proportion to the temperature and pulse, and the cheeks are bedecked with the typical mahogany flush. Meningitis may be eliminated if the patient has been exposed to small- pox, and if, being unprotected by vaccination, he suddenly develops the symptoms of the initial stage of this disease—severe rigor with high fever and intense pain in the loins. To confirm the discrimination from men- ingitis we may note the absence of involvement of the ankles and other joints, the irregular temperature-curve, the herpes and opisthotonos, and marked hyperesthesia. The macular stage of the eruption may be confounded Avith measles. The absence of the characteristic prodromes and symptoms of invasion belonging to the latter disease, the redness and swelling of the conjunctivas, the photophobia and marked coryza, the stubborn cough, and increased fever after the eruption appears, make the separation easy. In measles the maculae do not develop into hard, shot-like, conical papules as in variola. Nothing, however, could be more difficult than to differentiate certain mild cases of discrete small-pox (in the non-vaccinated) and varioloid from varicella. In the table below, however, may be found a few con- trasted points of distinction, which, I trust, may prove helpful: Variola. Varicella. History. Absence of previous attack. Same. Previous or present case in the vicinity. Traceable to previous or present case of varicella. Not successfully vaccinated. Negative. Occurs at any age. Almost always in childhood. Characteristic pre-eruptive stage — rash Eruption not preceded by prodromes. on the third day. Eruption. Appears first upon the forehead, extend- Appears first upon the neck and trunk— ing downward. no regular progression over the body. Vesicles uniform in size, umbilicated, and Vesicles vary much in size, are rarely deeper seated. umbilicated, and are more superficial. Eruption contains serum, later pus. Only serum. Most abundant on face and fingers. Most abundant upon back and lower ex- tremities. Various stages of eruption observed at Various stages side by side. points removed from each other. Pin-prick does not cause collapse of ves- Does cause collapse, being unicellular. icles, being multicellular. Secondary Fever. Usually present. Absent. VARIOLA. 225 Prognosis.—The prognosis depends upon (a) the degree of severity of the type, Avhether mild or intense, the severer forms (confluent and certain of the hemorrhagic) being grave. The hemorrhagic variety, in which large cutaneous ecchymoses suddenly develop, is almost invariably fatal, and often before the cases have advanced to the eruptive stage. The aggregate number of pocks that appear and the gravity of the infection are, as a rule, proportionate. (b) The prognosis is modified by individual peculiarities (age, race, in- temperance, etc.). Thus it is much more fatal in the very young than in older subjects, much more fatal in dark- than light-complexioned races, more fatal in the intemperate than in the temperate, and so on. (c) Complications increase the death-rate considerably. Of these, broncho-pneumonia, lobar pneumonia, acute nephritis Avith uremia, septico- pyemic conditions, pseudo-diphtheritic angina, and pericarditis are most potent for evil. Among the foremost serious symptoms may be mentioned excessive vomiting, wild delirium, coma, a temperature of 106° F. (41.1° C.) or over, urgent diarrhea, and dysentery. The death-rate has been computed to be between 15 and 30 per cent., varying, however, with each epidemic, and thus rendering an exact esti- mate out of the question. Treatment.—The varied indications in the treatment of small-pox will be considered separately : (1) Prophylaxis.—The rules that have been laid down elseAvhere [vide Treatment of Typhoid Fever) for disinfection in infectious diseases must be rigidly enforced in this affection. Quarantine (public and pri- vate) must be secured if the deadly progress of small-pox is to be averted, and it would seem altogether unnecessary to adduce arguments to show the correctness of this dictum. In the homes of the poorer classes, however, and even in those of the higher, absolute isolation cannot be carried out successfully, and in view of this fact special, well-equipped hospitals should be provided for the reception of the disease. Without a rigid en- forcement of these hygienic rules the spread of small-pox cannot be pre- vented. It is important also to remember that persons who have been afflicted Avith the disease cannot, Avith safety to others, resume their former places, either in the family or in society at large, before they are completely convalescent. The best means of prevention, however, is vaccination, and this subject will receive separate consideration (vide p. 229). (2) General Management.—Apart from perfect isolation and thorough disinfection, there are other hygienic requirements that must be complied with. The room occupied by the patient should be large and freely ven- tilated (an essential matter, though strong drafts are to be avoided), and all carpets, curtains, and articles of furniture not absolutely needful should be removed. The diet is an element of treatment that demands most careful atten- tion, and should be varied according to the stage of the affection. During the initial stage it must be restricted to liquid nourishment (milk, animal broths, etc.), and in addition cooling drinks, including ice, lemonade, and other of the various fruit-juices (diluted). During the stage of remission of fever Ave may add soups, jellies, eggs, toast, etc., and with the onset of the stage of suppuration a supportive diet, reinforced by the judicious use of stimulants, is a highly essential part of the treatment. Light forms 15 226 INFECTIOUS DISEASES. of nourishment must now be given in definite quantities at short inter- vals, and stimulation carefully carried forward in accordance with the rules that ordinarily govern this class of affections. (3) The fever and associated symptoms during the invasion stage are best controlled by the cold or gradually cooled baths, which possess all the advantages in this disease that they command in typhoid fever. Their effectiveness, together with the fact that in some of the various forms of variola the temperature-chart registers a normal or even a subnormal grade of body-heat, shows the fallacy of regarding temperature as the sole, or even the chief, indication for the use of the Brand method. Cold sponge-baths, the ice-cap, or the cold pack may be resorted to if cold immersion baths are not accessible to the patient. The internal antipy- retics must be given Avith a sparing hand, if at all, and should be em- ployed as antiseptic agents rather than as direct antipyretics, on account of their depressing effect. The therapy of this stage also embraces the treatment of certain symptoms. The vomiting may be incessant and exhausting, and chipped ice, champagne, dilute hydrocyanic acid, and cocain hydrochlorate should be tried in the order mentioned. If diarrhea be severe, it should be checked (though neither wholly nor suddenly) by the use of arsenite of copper, the acetate of lead (gr. ij—0.1296) and opium (extr., gr. |— 0.0162), in combination, or by bismuth salicylate (gr. v—0.324) and /3-naphtol (gr. iij—0.1944). The nervous symptoms are usually re- strained by the cold-bath treatment, but occasionally a wild delirium may necessitate further therapeutic interference, and at such times a com- bination of sodium bromid (gr. x-xv—0.648-0.972) with the deodor- ized tincture of opium (TTtv—0.333), given every two or three hours, is of signal value. Very often the wise administration of stimulants re- moves all necessity for the use of further means of overcoming the ner- vous symptoms, and in maniacal delirium ether may be cautiously admin- istered with great benefit. The catheter must be used if retention of urine should occur. For the intense pains that belong to this stage no other remedy can be compared with morphin sulphate (gr. \ to \—0.008 to 0.016), to be administered hypodermically, and repeated if neces- sary ; this measure also ensuring good sleep, which would be otherwise impossible. (4) As previously stated, the eruption appears with the termination of the initial febrile period, and deserves the closest attention. The indica- tions are twofold: (a) to limit the eruption as far as is possible, and (b) to modify its course, so that extensive suppuration and consequent dis- figurement may be prevented. Ablutions with lukeAf arm water, to which may be added some antiseptic (carbolic acid and glycerin, or, better, a mercuric-chlorid solution—1 : 5000 or 1 : 10,000) will be found of great use. To prevent pitting many local applications have been used. For- merly, a common mode of treatment was to open the pustules as early as possible and touch them with silver nitrate—either in the solid stick or brushed over in a strong aqueous solution. Painting the skin with the tincture of iodin was a practice frequently followed in the past. The formula of Schwimmer, herewith given, gave excellent results in a case of my own : VARIOLA. 227 B/. Acid, carbolici, 4.0-10.0 ; 01. olivse, 40.0; Cretae praeparat., 60.0. M. et ft. pastamollis. Another serviceable combination is one of equal parts of carbolic acid and glycerin, to be applied only to the pustules. It has also been recom- mended to touch each pustule Avith carbolic acid, and then to apply this agent in equal parts with the oil of thyme (Sansom). It is important that only a certain proportion of the pustules be touched at once, this to be followed by an equal number on successive occasions. The parts must be kept aseptic and clean, while irritation from scratching, etc. must be carefully avoided. Moore of Dublin and Fingen have recently recom- mended the use of red curtains or shades to cut out certain chemical rays. This treatment was first practised by John of Gaddsden, a court physician of the fourteenth century. During convalescence, or as soon as the general condition of the patient will admit of it, warm baths, with the free use of carbolic soap, are to be given at intervals of two days until several baths have followed the separation of the crusts. Any cutaneous sequelae that may present themselves must be attacked in accordance with ordinary principles. (5) The Period of Remission of Fever.—There are very rarely any symptomatic indications apart from those presented by the eruption. It is of first importance, however, to thoroughly support the powers of the system by means of tonics, and especially by quinin, in addition to an appropriate diet and the moderate use of stimulants. (6) The Suppurative Stage.—All measures tending to support the strength of the patient are needed—the mineral acids, with the elixir of calisaya, quinin, strychnin, etc. Stimulants are often required, and it may become necessary to give them unsparingly, the character of the pulse and of the first sound of the heart, as well as the nervous symp- toms, being the physician's guides. Gradually cooled baths of the usual duration or Avarm baths somewhat more prolonged give excellent results. In this stage certain symptoms may require special treatment. The ulcers in the mouth and throat are best relieved by the use of a saturated solution of chlorate of potash in water as a gargle or in the form of an atomizer spray. Ice allowed to melt in the mouth is also valuable. Hemorrhages demand prompt interference, and full doses of ergot must be given subcutaneously. Internally, large doses of the tincture of the chlorid of iron, gallic acid, the mineral acids, or turpentine may be administered. The complications, as before intimated, are not numerous, and are for the most part secondary in nature. Those connected with the respiratory passages should be prevented if possible, and, owing to the fact that they indicate danger, should receive active treatment if they occur. By fre- quently changing the position of the patient when bronchitis is present, and by encouraging him to cough frequently, as well as by the timely use of stimulants and the proper care of the mouth, pulmonary complica- tions can often be obviated. Should lobular pneumonia occur, the plan of treatment Avhich is likely to meet Avith most success may be briefly put thus: Free stimulation, the assiduous use of the cold or gradually cooled 228 INFECTIOUS DISEASES. baths, tonics, and nourishing foods. Laryngeal perichondritis with edema of the glottis may suddenly demand tracheotomy. To avoid the develop- ment of bed-sores an air-cushion or a water-bed should be provided, if needful. Care should also be exercised to prevent ocular complications, and their occurrence demands a vigorous form of supportive treatment. I have much confidence in the use of cold compresses, instilling into the eyes at the same time a solution of boric acid (gr. x to xv—0.648 to 0.972—to f 3j (30.0). (7) Special Modes of Treatment.—These would be found to be numer- ous were Ave to enumerate all of them, but only those based on the prin- ciple of antisepsis are worthy of notice. According to one plan, which has many advocates, antiseptic agents are administered internally. The remedies that have been most frequently employed in this manner, and with perhaps the most promising results, are the sulphocarbolates, salol, sodium salicylate, carbolic acid, creasote, mercuric chlorid, and the sul- phites. Zuelzer states that xylol given internally is potent in coagu- lating the contents of the pustules, but experience does not corroborate this opinion. Kinyoun, Lundmann, and Be'clere have used the serum from vacci- nated subjects (human beings and the lower animals) or from variolous patients in advanced stages of the disease in the treatment of small-pox. The cases, hoAvever, are insufficient to warrant deductions. Special Methods of External Medication.—Dr. Galewouski1 reports brilliant results in the treatment of variola Avith baths of potassium per- manganate. The salt is added till the water is of a rose-red color, and Galewouski claims that by its application the temperature is lowered, the pustules disappear, and recovery speedily ensues. Talamon2 recommends a special plan of external medication in the form of a mercuric-chlorid spray for small-pox vesicles and pustules, his object being to keep the surface under the influence of an antiseptic. The mercuric-chlorid solu- tion is prepared after the following formula : B/. Mercuric chlorid, gr. xv (1.0); Tartaric acid, gr. xv (1.0); Alcohol (90 per cent.), f^jss (6.0) ; Ether to make fgjss (45.0). Sig. To be applied as a spray three or four times daily for one minute. It is essential to exercise the precaution to protect the eyes, which may be covered by layers of cotton dipped into a saturated solution of boric acid. Talamon advises the commencement of his method on the first day of the eruption, the application to be preceded Avith a vigorous Avashing of the face with soap, which may be rinsed off with boric acid and then dried with absorbent cotton. After the spray has been used the face should be covered Avith a layer of a 50 per cent, glycerolate of mercuric chlorid in order to keep the skin continuously aseptic. After the fourth day the number of sprayings per diem is gradually lessened, so that by the seventh day they may be discontinued; but the application of the glycerolate should be continued. 1 Med. Press and Circular, 1890. 2 Journal of Cutaneous and Venereal Diseases, February, J891. VACCINATION. 229 Talamon added, in the confluent and other grave forms of the disease, general mercuric-chlorid baths, lasting for three-quarters of an hour to an hour. The buccal and pharyngeal eruption is to be treated by gargles and lotions of boric acid. Internally, the therapy is limited to sustaining the strength of the patient by means of alcohol (§iij-iv ; 90.0-120.0 daily), according to the gravity of the case. VACCINATION. Historic Note.—One of the first steps in preventive medicine was the practice of inoculation as a method of protection against the in- fection of small-pox. It had been practised in China and other Asiatic countries for centuries, and Lady Montague, the wife of an English am- bassador to Turkey, early in the eighteenth century introduced it into England, after which time and until vaccination was known, it was very extensively practised there. Pus taken directly from a small-pox pustule was introduced beneath the epidermis, and the person inoculated developed variola, though in a milder form than Avhen arising from ordinary infection. The attack ran a more rapid course, having fewer pustules, rarely terminating fatally, and protected the individual from subsequent attacks. The objections to this method were that it did not always produce a mild form of variola, a small percentage of cases having a fatal termina- tion, and that, however mild the attack, other unprotected persons brought in contact with it were as liable to contract small-pox in as virulent a form as if contracted in the usual way. In a paper published in 1798, Edward Jenner, a physician of Glouces- tershire, England, and a pupil of John Hunter, first made known to the world the value of vaccination. Twenty years previous he had observed that persons employed in dairies, who were accidentally inoculated with cow-pox, Avere insusceptible to the contagion of small-pox, and, after ex- perimenting all these years, he became satisfied that inoculation with the vaccine lymph was a preventive against small-pox. After the publication of his paper he was subjected to ridicule and abuse by the profession, but through his persistence he was finally allowed to practise his method of vaccination in the wards of a hospital, and in the course of a few years it became generally recognized and was practised in France and America, as well as in England. Later, the method fell into disrepute for a time, oAving to the fact that certain persons who had been vaccinated subse- quently contracted the disease, it not being knoAvn then that a revaccina- tion Avas necessary from time to time. Strange to say, however, in the century that has passed since the first vaccination by Jenner there has practically been no change or improvement either in the method or the vaccine used. Vaccinia, or cow-pox, is a mild eruptive disease that occasionally occurs among cattle, a similar disease being produced in them by inocu- lation Avith the small-pox virus from man. It is communicable by con- tact only, and is usually carried from one cow to another by the hands of the milkers; hence being usually found on the udder or teats of milch 230 INFECTIOUS DISEASES. coavs. Since Jenner's time many theories have been advanced as to the exact nature of this disease in cattle, and at the present day the subject is still in dispute. It is now, however, generally conceded that if coav- pox is a distinct disease, originating only Avith the coav, the eruptive dis- ease produced in this animal either by inoculation of small-pox virus from man or of " grease " from the horse is, at least in all essential respects, a disease not to be distinguished from primary or idiopathic vaccinia. Guarnieri has described certain parasitic organisms, the Cytorectes Guar- nieri, found in corneal lesions produced by the injection of vaccine lymph. This observation has been confirmed by Pfeiffer and others, but the pathogenic nature of these protozoa has not been determined. The vaccine virus consists either of the liquid contained in the ves- icle or of the scab resulting from the desiccation of the pustule. The former is furnished from vaccine farms, of Avhich there are several in this country, is then dried on ivory points, and, if kept in a cool place, re- tains its virtue for a week or ten days, or, possibly, longer, but should be used as fresh as possible to ensure a successful result. It is also some- times preserved in capillary glass tubes, sealed at both ends, or between glasses, and kept in this way it is less liable to infection through unclean- liness in handling. The scab from the cow is not used. The Site.—The point usually chosen for vaccination is on the arm over the insertion of the deltoid muscle; but in girls, for cosmetic reasons, it is sometimes preferred on the leg, and the most common site is over the junction of the two heads of the gastrocnemius muscle. Technique in Vaccination.—The part selected should be made sur- gically clean ; then gently scrape the skin with a lancet or other in- strument, which has also been made aseptic, until serum begins to exude. If, by too vigorous scraping blood should be drawn, it should be care- fully dried with a piece of sterile cotton before the lymph is applied. The charged end of a point, which has been previously dipped in tepid water, is now gently rubbed over the abraded spot and the limb left exposed to the air until the lymph, has been dried upon it. It may then be protected by a piece of gauze strapped on it or by one of the shields made for the purpose. Some physicians still prefer the humanized lymph, and when this is used the " arm-to-arm " vaccination is best. The lymph is taken from a characteristic vaccine vesicle (from the fifth to the seventh day of its de- velopment) of a healthy child and applied directly to the arm of another. When this method is not practicable, hoAvever, the virus may be dried and preserved for use just as in the case of bovine virus. The scab resulting from a vaccine vesicle on a healthy child was for- merly quite generally used, and it could be kept a long time without losing its virtue. It Avas sure in its action, and offered the advantage to the physician of being easily preserved; but it was more liable to become infected than the lymph when preserved in the usual way, and, since the vaccine farms are so conveniently located, lymph may be obtained from them at any time without delay. There are no valid reasons why the humanized should be preferred to the bovine lymph, and the possible danger of conveying syphilis or other constitutional disease from one person to another by means of the former should be sufficient reason for the use of the latter. VARICELLA. 231 Period of Life for Vaccination.—It is usually advised to vaccinate infants within a few weeks or months after birth, but, unless small-pox is prevalent, it is best to Avait until the latter part of the second or the beginning of its third year, as the child has then passed through its teething period and'will be better able to resist the effects (slight though they may be) consequent upon vaccination. Time for Revaccination.—To ensure the individual against infection he should be revaccinated at puberty and every few years afterward, or at any time when small-pox is epidemic or liable to become so. Symptoms.—After vaccination no local or constitutional effects— except the slight irritation due to scarification—are noticed until the third day, when a small red papule appears. By the fifth or sixth day a vesicle appears. By the ninth day it is fully developed, and, like the vesicle of variola, is filled with colorless lymph, is umbilicated, multi- locular, and has a distinctly inflamed areola of deep red color, accom- panied by heat, itching, and tenderness. By the tenth day this may ex- tend an inch or two from the vesicle. Quite frequently the axillary or inguinal glands (depending upon the location of vaccination) are swollen and tender, and in a tubercular child they may go on to suppuration. After the tenth day all these symptoms gradually decline; the pustule dries up, and then forms a brown scab which is usually detached in the third or fourth week, leaving a permanent cicatrix. Complications.—Occasionally one or more additional vesicles are formed at a little distance from the point of inoculation, and, rarely, there is a general vesicular eruption, due to absorption of the lymph. An erythematous rash is not uncommon, and appears, if at all, about the sixth day. Erysipelas may occur as a complication, and, if it is preva- lent in the house, vaccination should, as a rule, not be performed; if deemed necessary, however, the greatest care should be taken to ensure cleanliness. Sometimes, owing to injury to the vesicle or to uncleanliness, an ulcer forms, which may be weeks in healing. Eczema and other skin-affections are usually aggravated during the course of vaccination, and it should not be forgotten that it is possible for syphilis to be inoculated with the vac- cine virus. Any of these complications call for the same treatment as when occurring independently. VARICELLA. {Chicken-pox.) Definition.—An acute, contagious disease, characterized by a cutane- ous eruption of papules, passing into vesicles and pustules; also by slight fever and mild constitutional symptoms. For a long time it was con- founded with varioloid, but its distinct character has now been recognized for many years. Complications and sequelae are infrequent. Etiology.—It is Avell established that the contagium of varicella is found in the vesicles, as the disease has been communicated by actual 232 INFECTIOUS DISEASES. inoculation with their contents. The specific poison has not been satis- factorily isolated, although it is suspected that certain protozoa are the direct cause, but, as in the case of vaccinia and small-pox, positive proof is wanting. Varicella may be transmitted by exposure to another case or possibly through the medium of a third person, the school and asylum being the most frequent points of its origin. It affects children of all ages, and usually one attack is protective. It closely resembles measles in its contagiousness. Symptoms.—The incubation period is uniformly from fourteen to sixteen days. If there be a prodromal stage of the disease, certainly in the vast majority of cases it cannot be recognized, though a slight fever and general indisposition may be noticed for twenty-four hours before the appearance of the eruption. In many cases the eruption is the first symptom. This occurs in the form of small reddish puncta, from which rapidly develop rosy-colored maculations, and these become tensely dis- tended, transparent, or slightly yellowish vesicles of the average size of a split pea. The eruption appears first upon the upper part of the body, the chest and back, neck, scalp, and face (on the latter quite sparingly), and always upon the hairy scalp. Frequently the vesicles form on the mucous surface of the lips, inside the cheeks, on the tongue, palate, con- junctivae, and in the progenital regions of both sexes. At times the glands of the throat become slightly enlarged and painful, the vesicles are superficial, the child has the appearance of having received a shower of boiling water, and the firm papule which precedes the variolous rash is altogether wanting. The vesicles are at first transparent, and their contents plainly show through their translucent roof-wall Avhich is com- posed only of the stratum corneum of the epidermis. Umbilication rap- idly occurs at the apex, and the contents of the vesicles become lactescent, and gradually sero-purulent. The areola is most distinct when the vesicle is fully formed and fades as the latter dries. Crusts form which drop off in from five to twenty days, depending upon the depth to which the skin has been involved. On the trunk, as a rule, no mark is left, but after the more severe attacks, Avhen the true skin has been involved, scars remain, and frequently there is quite deep pitting. The marks are usu- ally on the face when the skin has been unprotected. On the hands and feet the vesicles appear without having been preceded by a papule, and sometimes there is no areola, each vesicle resembling a drop of water upon a healthy skin. Pustules may develop in consequence of irritation or infection, as the result of scratching, or in feeble or poorly-nourished children and in unhealthy children deep ulceration may occur, lasting for weeks. In rare cases there may be necrotic inflammation about the site of the pox (varicella gangrenosa). In mild cases only ten, twenty, or thirty spots may be found on the body, but in severe cases the skin may be almost covered in certain regions. The eruption, however, is never confluent. The temperature is highest on the second or third day, Avhen the eruption is appearing. In mild, uncomplicated cases the thermometer registers 101° or 102° F. (38.8° C.) for two or three days at most, but in severe cases the tempera- ture may be as high as 104° F. (40° C). This is usually due to broken health prior to the acute illness. The temperature falls gradually as the rash fades, and presents a temperature-curve similar to that of measles. VARICELLA. 233 There is usually neither coryza, vomiting, cough, nor diarrhea, and in their place is only the general indisposition which is associated with any febrile disease. Complications.—Erysipelas occasionally acts as a serious compli- cation in delicate children. It may develop about the pocks, particularly Avhen they are deep and associated with some ulceration, and scratching with unclean fingers is its prime causal factor. Adenitis, mild and isolated, and suppuration with abscesses in the deeper cellular tissue are occasionally seen. Nephritis is infrequent, but may occur in unhygienic surroundings or in carelessly managed cases, just as it may follow scarlet fever or measles. Varicella is also quite frequently complicated with other infectious diseases, and varicella, scarlet fever, and measles have been seen curiously blended in epidemic form. Varicella and measles, however, are most frequently associated. The diagnosis of varicella offers no special difficulties. The erup- tion comes out sloAvly and in crops, so that papules, vesicles, and crusts may be seen upon the skin in close proximity. Again, it should be noted that the umbilication is due only to the fact that the drying up of the vesicle begins at the center, and that the pocks may appear on the mucous membrane. Varicella is distinguished from urticaria by the presence of fever, and from eczema pustulosum by the mild febrile symptoms of the latter, the discreteness of its pustular lesions, the absence of itching and of infiltration of the skin in patches, and by its tendency to symmetric development. Variola and varioloid of infants are to be distinguished from varicella by the prodromal symptoms, and by the greater rise of temperature, though the distinction between mild varioloid and severe varicella in infancy and childhood will always tax to the utmost the skill of the keenest diagnostician. The sooner it is understood that intermediate forms are likely to occur, which cannot be positively assigned to one or the other category, the better it will be for both the profession and the laity. The prognosis in private practice is always favorable. Only in the slums or in hospital cases complicated by erysipelas, adenitis, or nephritis may grave results be anticipated. The milder cases may, however, leave slight monuments of their existence in the form of one or more depressed cicatrices which may mar an otherwise beautiful face. Treatment.—Isolation should be enforced in schools and in all in- stitutions containing many young children. In private houses, unless the younger children are delicate, quarantine is unnecessary. The disease may be transmitted to others as long as the crusts are present, and hence isolation should be maintained until they have fallen off. In most cases constitutional symptoms of the disease are so mild as to require no treat- ment. It is best at the outset to place the child in bed for a few days, and sponge daily with warm carbolized water; the local itching may be allayed by sponging with a weak solution of carbolic acid or by the use of carbolized vaselin. When the crusts have formed, especially on the face, an ointment of zinc oxid containing ichthyol (2 per cent.) should be applied, and care should be exercised to keep the skin clean and to prevent scratching. In all cases the urine should invariably be examined several times during and following the attack. 234 INFECTIOUS DISEASES. SCARLET FEVER. [Scarlet Rash; Scarlatina.) Definition.—Scarlet fever, or scarlatina, is a self-limiting, acute, con- tagious disease, characterized by vomiting, fever (more or less typical), angina, and in twelve or twenty-four hours by a diffuse, punctiform, scar- let eruption, followed by membranous desquamation and, frequently, by nephritis. It is a disease of childhood, but may occur at any time of life. Scarlatina is a widespread disease, though perhaps less universal than measles. It is endemic in all the large cities of the globe, and at inter- vals the cases multiply into more or less extensive epidemics. Smaller towns and rural districts are visited, and the epidemics are usually trace- able to importation of scarlatinal poison, so that it may be stated that they never originate de novo. Pathology.—There are no pathognomonic changes. When death occurs early the chief lesions are presented by the throat, while in addi- tion engorgement of the viscera is noted, especially of the brain. The exanthem is rarely visible. In malignant types, however, in which the eruption is not seen during life, it makes its appearance rarely after death, and this aids in establishing the nature of the affection. When death occurs at an advanced stage the lesions are those either of nephritis (with dropsy), or of septico-pyemia, or of inflammation of one or more of the serous surfaces (pleurisy, pericarditis, endocarditis, menin- gitis, etc.). Additional changes in the various viscera are, for the most part, identical with those met with in other acute infective diseases, and hence need not be described here. The blood, it should be pointed out, is dark, fluid, and coagulates feebly, owing to a decrease in its fibrin fac- tors. The process of desquamation may be observed, together with more or less emaciation in protracted cases. Among other lesions which are more or less peculiar to the disease are (a) The eruption, which is a dermatitis of very mild grade, (b) Scarlatinal angina, which in its mildest form presents hyperemia and a slight swell- ing of the mucosa of the tonsils, soft palate, and pharynx. In the severer grades the inflammation is phlegmonous (scarlatina anginosa), and some- times terminates in ulceration. There is great SAvelling (especially of the tonsils), and the formation of abscesses, due to secondary infection, is com- mon. Extension of the purulent inflammation to the connective tissue of the neck produces marked induration, and more or less extensive ab- scesses may take place. Gangrene sometimes supervenes, (c) In certain epidemics a membranous exudate accompanies the scarlatinal angina, and this may or may not be truly diphtheritic. When it appears early it is non-diphtheritic, as a rule, the streptococcus of erysipelas being often found; on the other hand, when it comes on late it is often diphtheritic in nature and shows the presence of the Lbffler bacillus. Other second- ary inflammatory processes occur that are due either to direct extension or to metastasis, but these will be considered later at sufficient length (vide Clinical History), (d) The Nephritis.—The renal lesions, so prom- inent and so common in scarlatina, are included in the description of "Acute Bright's Disease." Etiology.—The bacteriology of the affection is unknown as yet, al- though the fact that it depends upon a special poison cannot be doubted. SCARLET FEVER. 235 As early as 1892, Doehle described a peculiar variety of protozoa which he found in the blood of patients suffering from some of the eruptive fevers, and among them scarlet fever. He found a ciliated and a con- tractile form, occurring both within the red blood-cells and free in the plasma, and staining Avell with methylene-blue. This observation, how- ever, has not been confirmed, and as the streptococcus pyogenes has been found in nearly all the inflammatory complications of the disease, espe- cially scarlatinal pneumonia and angina, some pathologists (Babe's, Berge", Klein) have held it to be the cause. Marmorek, Raskin, and Mosny, however, believe that it is an example of mixed infection, the streptococ- cus being merely a secondary factor, and Marmorek has been confirmed in this view by the results of his experiments with antistreptococcus serum. The general receptivity for scarlet fever is not so great as in certain other exanthemata (e. g. small-pox, measles); hence in a household in which there are several children some are apt to escape the disease, even though all have been equally exposed. The virus is probably contained in the excretions from the throat and in the epidermal scales thrown off from the surface of the body. It is also present in the blood of scarlatina patients. Modes of Conveyance.—The majority of the cases are produced by con- tagion, and I have observed that in many instances a single contact of a healthy child with a scarlet-fever patient has sufficed to convey the dis- ease. It is also communicated by fomites, and the poison of scarlatina contained in clothing retains its infective power for months—a fact that shows conclusively its great tenacity of life. The patient himself is a center of infection until the end of the period of desquamation. Again, any objects (furniture, utensils, library books, toys, etc.) which the patient has touched or handled may serve to communicate the poison to healthy children. The disease may also be transferred by persons who have been in the sick-room, while they themselves escape. Transmission through milk has been observed, infected dairies having been known to dissemi- nate the poison and give rise to epidemics. The infection may also be air-borne, though not for any great distance. Mode of Infection.—The precise way in which the infection of a healthy person takes place is not quite clear. Most probably the poison is inhaled into the throat, where infection usually occurs, but it may gain entrance to the body through the alimentary tract. Infection may also take place through the blood, as is shown by the fact that children have been born in all stages of the disease. Artificial inoculation with the blood of scar- latina patients has resulted in more or less typical forms of the complaint. Whether or not an open lesion of the mucous membrane of the throat or other surfaces is necessary for the entrance of the poison into the circula- tion has not been determined positively, but fresh wounds always predis- pose to infection. Predisposing Causes.—(1) Age.—The period of chief liability is from the second to the tenth year, after which it diminishes. It is rare under the age of one year, and especially so under six months. (2) Recent wounds—accidental or surgical—increase the susceptibility to the pecu- liar poison. (3) Women in childbed, for the same reason as (2), but care must be exercised, lest this class be confounded with septic affections. (4) Season.—The autumn and winter months furnish the most cases. 236 INFECTIOUS DISEASES. Immunity.—Single attacks during the life of a person form a rule to which there are rather frequent exceptions. Clinical History.—The incubation period is extremely brief, lasting usually from two to three or four days. It may rarely, hoAvever, be longer—five to eight days—or more rarely still shorter—less than twenty-four hours. The invasion of scarlet fever is generally quite sudden and, as a rule, active. The child feels uncomfortable, looks stupid, complains of sore throat and decided nausea, and in the great majority of the cases vomits. The tongue is furred. If he be very young, nervous symptoms are prom- inent, and he may exhibit convulsions. The pulse, which is a strong diagnostic factor, is rapid and hard, reaching 140 to 160 at the very on- set. The temperature rises quickly to 104° or 105° F. (40.5° C), and remains high. Eruption.—Within the first twenty-four or thirty-six hours the charac- teristic rash appears, and is, as a rule, first seen on the neck ; there is no certainty about this, however, as it may first come out on the abdomen or back of the hands or on the thighs, and not be seen on any other part of the body. Frequently it is found on the dependent portions of the trunk. At first it is slight, but perfectly characteristic, and usually takes two days to mature. In mild cases it disappears within thirty-six to forty- eight hours, and at no time is more than a • very fine rash, but when typical it cannot be mistaken, especially if accompanied by the premoni- tory symptoms. When seen from a short distance at the end of the first twenty-four hours of its appearance the whole body (except the face) is of a uniform bright scarlet color. If we examine more closely, we find that the eruption consists of a multitude of red points that correspond to the hair-follicles. These points are surrounded by zones of erythem- atous redness, which, joining with one another, give a generally diffuse red appearance to the whole skin. Frequently, however, the rash con- sists of points representing the hair-follicles without the erythema, and in rough skins the rash may be more punctiform—that is, more strictly a condition of "goose skin." Sudamina are quite frequent. Pressure by the finger causes a pallor which at once disappears when the finger is removed. The patient's lips and chin are pale and in striking contrast with the vividly scarlet cheeks. In some cases the rash is patchy, espe- cially on the limbs, and in these cases it may suggest measles, the patches consisting of clusters of fine papules or points with much surrounding erythema, Avhile normal skin is present between the patches. In severe cases the rash may be hemorrhagic in character, minute extravasations of blood taking place in the skin; this may occur even in mild attacks, and not be seen until after death, but more frequently it is seen in malignant cases. Purpuric patches are frequently found after death when even in life they did not appear. There is itching, which may be either mod- erate or intense throughout the eruptive stage. By the end of the first week the rash, which has been fading for sev- eral days, is succeeded by a desquamation that will be extensive or slight according to the intensity of the fever. In mild cases the tonsils, palate, uvula, and pharynx are deeply congested, and the mucosa of the cheeks, palate, and tonsils may show the eruption. In severer forms the tonsils are red and inflamed, and covered with tenacious secretions, SCARLET FEVER. 237 Avhile minute yellow points corresponding to the tonsillar crypts are usually prominent. ( Vide Malignant Scarlatina.) The nasal chambers are swollen, producing a free discharge, and the deeper cervical glands at the angle of the jaAv are frequently enlarged. The tongue is coated with a thick, dense Avhite fur (dead epithelium), and frequently shows a dry, glazed central band. In a few days the dead epithelium is cast off, clearing the tongue, when Ave have a red, clean, glazed tongue with greatly enlarged fungiform papillae, giving us the strawberry tongue of classical history. The eyes are frequently swollen and the conjunc- tivae injected. Sleeplessness and mild delirium often mark a typical case, suggest- ing a congested state of the meninges, but it is neither usual for the child to be violent nor for the delirium to continue long. The pulse is usually a strong diagnostic feature, and is always hard, quick, and wiry, varying from 140 to 160; it is out of proportion to the temperature and the general condition of the child. Leukocytosis is commonly noted. The temperature in. average cases reaches 104° or M E M E M E M E M E M E M E M E M E M E M E M E M E M E UOWKI.S / / / / / / / / / / / / Urine DMy Ativl 104° 103° 102° 101° 100° 99° 98° DapofDis Pulse. Resp. Date. K A \ A '" i_j A \I \\ \ A ,_v K j Y V > / v r / v. J Y \ A v I M | \i V, A 1 V V \ 1 A L /\ ' A A \ i \k 1 Y A \i '\ V 1 A i t '\ \J 1 Y \ 1 \, A v \ \, / V / 2 3 ^ 5 6 7 8 9 /o // /z /3 /❖ ■■iHO % 4fc >% % 'Mk ys> %6 -10 m % *6, 8& ,y" X' / .s ,/ s /'' Fig. 22.—Temperature-curve of a case of scarlatina with favorable course—William C---, aged seven years. 105° F. (40.5° C), and in severe forms it may touch 106° F. (41.1° C), the nocturnal remissions being slight and defervescence gradual (vide Fig. 22). The urine is scanty, thick, and contains urates, Avith a small quantity of albumin. Within one Aveek, if no complications have occurred, the attack "will have reached its height and the symptoms have begun to decline. The 238 INFECTIOUS DISEASES. rash gradually fades, temperature falls, the tongue is less red, the throat less injected, and the child seems more natural. If at the end of one week the fever continues, it suggests the many possible complications, the most frequent of Avhich is a throat or tonsillar ulceration, inflammation of the cervical glands, otitis, or, most probably, acute nephritis. It must be well understood that no two cases of scarlet fever are alike. Clinical Types.—Mild Scarlet Fever.—In very many cases of scar- let fever all the premonitory symptoms are absent, and the rash is the only indication of the trouble. There is neither vomiting nor fever to be recognized, and no tonsillar trouble of any importance, while the rash is neither uniform nor well marked. In these cases we must be very careful not to confound the eruption Avith urticaria or some of the many medicinal rashes. The most difficult cases of all to diagnose are those in which sore throat is present without a rash, inasmuch as there is nothing characteristic about a scarlatinal tonsillitis. During house epidemics when several children are affected it fre- quently happens that a child has sore throat and the " strawberry tongue " Avithout a development of the rash. This may also occur in adults, and is the so-called scarlatina sine eruptione. These very slight cases of the fever are the most to be dreaded, as they may be folloAved by the most severe attacks of nephritis. Malignant Scarlet Fever.—Death occurs usually by the end of the first week in severe cases, Drs. Ashby and Wright reporting a death within the first twenty-four hours (atactic form). In malignant cases, such as usually occur among the unhygienic and delicate, the tonsils may be covered by a membranous exudate, and the system quickly receive an overwhelming dose of the poison ; death then results from septic causes (anginose form). In cases in which death occurs early a child soon be- comes cyanotic, restless, or more frequently somnolent. In all these cases the temperature remains high—105° to 106° F. (41.1° C), and very frequently 107° F. (41.6° C). Diarrhea is frequently a trouble- some factor in severe cases; coryza is very abundant; there is much glandular swelling and cellulitis, the neck becoming enormously enlarged and hard, the skin dull and livid in color; the extremities grow cold; the heart gradually becomes irregular, losing a beat, and finally fails. If life is sustained through such an ordeal, the' tonsils slough and the lungs may eventually become the seat of a septic pneumonia. In many desperate cases when life is prolonged to the end of the second or even third week general septicemia is most likely to occur. In this condition the tonsils ulcerate, sloughing patches appear on the fauces, the glands about the neck become enlarged and doughy, and the nasal mucous membrane gives out a purulent secretion in abundance. The temperature may remit, but continues high; the urine is albuminous; pus wells from both ears; and thus the child is gradually consumed and perishes. In all these cases pleuro-pneumonia will be found, together with hemorrhagic kidneys, and most probably small abscesses will be found in the latter at the post-mortem. A third variety (hemorrhagic) shows at first cutaneous petechia?, which grow rapidly into large ecchymotic patches. Hemorrhages also take place from the mucous surfaces, epistaxis and hematuria being very common. Death, as a rule, follows in tAvo or three days. SCARLET FEVER. 239 Desquamation.—By the end of the first week the rash commences to disappear, the skin is (or soon becomes) mottled, dry, and rough, and gradually the scarf skin begins to separate. This process usually begins about the neck and trunk, and frequently large flakes are de- tached, the whole cuticle of the hand or foot sometimes coming off in one mass like a glove. The degree and character of the desquamation bear some relation to the severity of the eruption. In some cases the hair and nails have been cast off. In many cases desquamation is pro- longed to the eighth week; it is usually longest on the hands and feet. Complications.—Otitis.—The inflammation may extend from the throat along the Eustachian tubes to the middle ear, and pus be formed in the tympanic cavity, making its exit by perforating the membrane. This complication may occur either during the fever or at some time during convalescence. Suppuration in the middle ear is one of the common causes of a continued high temperature after the disappear- ance of the rash. Pain in the ear may not attract our attention to this unfortunate complication; most frequently, however, the child will place its hand on the ear and shake its head, as if to get clear of some source of irritation. Pyemia.—Pyemia and abscess of the lungs may folloAv, and throm- bosis of the lateral sinus may occur. The tonsils may be the seat of deep ulceration, and the soft palate may slough and show cicatrization of the soft parts of the throat in cases Avhich may yet recover. The cervical glands may become enlarged and suppurate, .either during the fever or while the child is convalescent. In debilitated or strumous children this complication may be very troublesome, Avith the formation of deep ragged ulcers, slow to heal, and in rare cases exposing the larger blood-vessels. Broncho- or lobar pneumonia may occur, and is most usual during the second week, being due to extension downward of the lesion from the throat. Pneumonia followed by empyema may also occur during convalescence. Arthritis, Synovitis, and Rheumatism.—In unhygienic surroundings or Avhere careful nursing is not carried out the joints are likely to be- come swollen and tender at the end of the first or the commencement of the second week. The wTrist and the small joints of the fingers are most prone to be affected; the synovial membranes and the sheaths of the tendons at the back and in the palms of the hands are attacked. The elbows, the joints of the vertebrae, the ankles, the knees, and soles of the feet may be affected; movement causes pain, and these parts are generally swollen, red, and very tender. The trouble is not severe, being fugitive and seldom returning to the same joint. Etiologically, this form of trouble is not true rheumatism, but is analogous to gonor- rheal synovitis. The knees may be most severely affected, remaining swollen for several weeks, and in unusual cases suppuration may take place and be folloAved by pyemia. Such cases are usually fatal. Nephritis.—No other complication of scarlet fever can equal nephritis in importance or interest, this condition ahvays giving rise to anxiety in othenvise mild and hopeful cases. During the height of the fever, as is the case in all exanthemata, there is a trace of albumin in the urine that has no special significance, and it is possible for the kidneys to escape without greater damage than occurs in other acute febrile affec- 240 INFECTIOUS DISEASES. tions. Independently of this febrile albuminuria, there are two forms of nephritis which it is important to bear in mind, though they have been frequently confounded: (a) Septic Nephritis.—In severe forms of scarlet fever, when the throat symptoms include sloughing tonsils, involvement of the soft palate, and general adenitis, the urine quickly becomes loaded with albumin, but shows scarcely any blood and but feAV casts. No renal symptoms will be recognized, and if present they may be masked by the general condition of septicemia. There may be neither dropsy nor uremic phenomena, but the patient usually dies by the end of the second week, when a typical pyemic kidney is found containing minute abscesses. This condition of the kidney is only one part of the general pyemia, and merely illustrates the fact that this organ suffers during the course of the general inflammation. (b) Post-scarlatinal nephritis is the form most likely to occur about the third or fourth week, and is the one generally known as scarlatinal nephritis. The kidneys are undoubtedly involved in an active sympa- thetic inflammation, and at the end of the fever, more than at the be- ginning, are engaged in carrying off waste products of the fever itself. From the nature of the disease they are in an irritable condition and prone to take on inflammatory changes, just as the bronchial tubes and the lungs are left in a very susceptible condition folloAving measles and whooping-cough. In this way the uriniferous tubules become choked up by the desquamation that is going on inside. The number of cases that suffer from post-scarlatinal nephritis varies according to social con- ditions, the nature of the epidemic, the season of the year, the nature of the treatment received during the disease, and especially the care received throughout convalescence. Ashby and Wright fix the rate of those who suffer at 6 per cent, of hospital cases, but this is, undoubtedly, too high, since hospital cases receive better care during convalescence than private cases. The usual time for this form of nephritis to occur is from the end of the second up to the fourth Aveek, but it usually begins very insidiously. Traces of albumin may be found for a few days be- fore the blood and larger quantities of albumin occur, but it is often im- possible to date the commencement of an attack. Usually after the fever has subsided the patient for a feAV days feels well, but very suddenly grows restless, is feverish at night, is thirsty, has a quick, hard pulse, and passes a small quantity of dark-colored urine. If care has been exercised, it will be found that the urine has been gradually diminishing for several days, and a slight puffiness about the face frequently an- nounces the beginning of the trouble. Later the face becomes pale and puffy, while there may be edema of the feet and scrotum, and some vomiting. Under favorable treatment improvement may take place, large quantities of urine may be passed, and the child resume convales- cence. The nephritic symptoms may, hoAvever, deepen until uremia appears, the pulse becoming slow, the temperature subnormal, and the tongue dry and brown. Vomiting is now a frequent occurrence; diar- rhea is not unusual; nose-bleed and hemorrhages from the various mu- cous surfaces, and muscular twitchings may be noted, and most likely the end may be reached in a general convulsion. In all cases of nephri- tis great care must be taken to recognize heart-changes, and fatal results SCARLET FEVER. 241 are more frequent from cardiac failure than from the uremic convulsions. The constant effect of nephritis is to raise the blood-tension, and this continued tension in the blood-vessels is followed by dilatation of the heart. Another not unusual result is endocarditis or pericarditis, with possible embolism. Sudden death frequently occurs during the course of nephritis. The child may be doing well, possibly sitting up in bed and playing with its toys, when an attack of dyspnea occurs; the face becomes livid, the pulse disappears, and death quickly takes place. Death in such cases is usually said to be due to edema of the lungs: the dilated heart, Iioav- ever, has been overlooked, and, Avhile edema of the lungs is present, it is only secondary to the cardiac failure. It is not unusual for a false membrane to form upon the larynx. This is not infrequently due to the streptococcus pyogenes, but the Klebs-Loffler bacillus is oftener found (Ranke found it in more than half of 92 cases). A bacterial examination should always be made early in the disease, and if the diphtherial nature of the infection has been determined the serum-treatment should be employed at once. Diagnosis.—A typical form of scarlet fever offers feAV difficulties in diagnosis. The period of incubation is short in comparison with that of any of the other exanthemata, particularly variola, measles, and varicella. The vomiting, which is almost a constant factor in the early stage, associated Avith high fever, would also exclude the other eruptive diseases. The pulse in itself is most strongly diagnostic, being quick, hard, and Aviry, striking the finger at the rate of 140 to 180 per minute; no other disease has a similar pulse. The early sore throat and the in- tense hyperemia of the Avhole mucous membrane, associated Avith severe constitutional symptoms, make it easy to differentiate from measles, varicella, and variola. The punctate erythematous lesions that appear during the stage of efflorescence of scarlet fever are not found in any of the other eruptive diseases. (Vide table on page 247.) The differential diagnosis embraces the discrimination of those rashes that follow the use of certain drugs (quinin, belladonna, potassium bro- mid and iodid, chloral, etc.). The characteristic invasion-symptoms (vomiting, angina, etc.) of scarlatina are absent; also the high fever and frequent, hard pulse of the latter disease. Drug-rashes are seldom so vivid or diffuse as the eruption of scarlatina. Scarlatina. Acute Exfoliating Dermatitis. Onset is sudden, with vomiting, angina, Sudden, with fever only. fever, and frequent, hard pulse. Eruption appears first on neck, face, and Appears first on trunk. chest, soon becoming diffuse. Duration, three or four days. Duration, five or six days. Desquamation begins after eruption has Desquamation begins earlier, often before faded, often one week later. eruption has faded, and involves the hair and nails. Ear and throat complications common. Absent. Nephritis is a common sequel. Not so. Relapses exceptional. Relapses common. The prognosis in regular, uncomplicated scarlet fever is in almost every case favorable, and, unless the treatment is unusually indifferent, 16 242 INFECTIOUS DISEASES. the patient will recover. Severe types, however, and especially malig- nant scarlatina, are very fatal. Complications arise that will most seriously endanger life. The treatment of scarlet fever is that of the symptoms, together with an attempt at arresting the complications. Prophylaxis.—The patient should be strictly quarantined in an upper room for at least eight weeks or until desquamation has been completed. A competent nurse should be put in charge, and, whether a member of the family or otherwise, she should Avear a washable dress, and should not mingle Avith the family, except her clothing be changed or thoroughly disinfected. The room is to be stripped of all superfluous hangings and furniture. Inunctions are required as soon as desquamation commences, Avith a vieAv to preventing the diffusion of the dried epidermal scales; and the best preparation for this purpose consists of cosmolin, menthol, and carbolic acid, ten grains each of the latter to one ounce of cosmo- lin, after the plan of J. LeAvis Smith. Carbolized water, 1: 40 (thor- oughly shaken), may be used to sponge the surface and may be agree- ably folloAved by cocoa-butter. The disinfection of the physician himself, I am sorry to state, is fre- quently neglected. He should generate chlorin gas by the folloAving simple method, and allow it to permeate his clothes thoroughly before going into other families: A dram of powdered potassium is placed in a saucer, and a small quantity of hydrochloric acid added. The dish is then placed on the floor, and the physician stands over the vapor chlorid as it arises until it penetrates all his clothing. This, with the free use of the Avhisk and thorough hand-Avashing, renders him non-contagious and safe in entering any home or sick-room. Perhaps a less disagree- able method is to have in the patient's house a linen duster or surgeon's apron that has been dipped in a bichlorid solution and alloAved to dry. This is slipped over the clothing before entering the sick-room, and is removed after leaving. In the room, if the case be a severe one involving the throat, I keep the gas or an alcohol lamp burning under a small dish of water, so that steam may be constantly generated. To the boiling Avater I frequently add carbolic acid or oil of eucalyptus; this saturates the room very pleasantly, and at the same time, I believe, limits the extent of the contagion. General Management.—The sick-room should be large and Avell ven- tilated, and should be kept at a uniform temperature (68° to 70° F.— 21.1° C). A light flannel night-dress should be worn by the child, and the bed-clothing should be light as well. The diet should consist of milk, broths, egg-Avhite, and fruit-juices, and after the temperature has declined soft diet may be alloAved. A few days later the return to ordi- nary solid foods may be complete. The evidences of heart-enfeeblement often arise and call for the judicious use of stimulants. It is to be pointed out that this class of agents is remarkably well borne in this affection, and hence may be freely administered. To a child of four years I give one dram (4.6) of brandy or Avhiskey every second hour, and often increase the dose as required. The preparations of ammonium, particularly the carbonate and the aromatic spirits, have also been warmly recommended as stim- SCARLET FEVER. 243 ulants in this affection. They should be administered in milk as the vehicle to prevent gastric irritation. Special Treatment.—Bathing is recommended in scarlet fever by the best Avriters, yet often in such an indefinite and uncertain manner as to give the busy practitioner neither any encouragement to resort to it nor anv guidance in the matter of technique and mode of procedure. In the classical work of Thomas Watson, noAv over fifty years old, he hints in his treatment of scarlet fever " that, if the heat on the surface be very great and distressing, he should not recommend the cold effusion, but cold or tepid sponging Avould be very refreshing and beneficial." This senti- ment finds its echo in most works on practical medicine at the present dav. Unfortunately, the majority of medical practitioners do not give their instructions for the thorough sponging of their scarlet-fever cases, chiefly through fear of objections from the family. The physician must quietly but firmly insist upon the patient being most thoroughly sponged three or four times daily, according to the severity of the individual case, using carbolized Avater (1: 60), mercuric chlorid (1 : 8000), salt Avater, or alcohol and water, at a temperature of 70°-100° F. (21.1°-37.7° C). Systematic bathing in this manner and inunctions as above described protect the body from certain disas- trous complications and sequelae. The ice-cap may be combined with cool spongings. In extreme cases, Avith marked nervous symptoms and high temperature, the cold pack, Avith cold affusions applied to the head and nape of the neck, may be cautiously employed, and a description of the method of giving a cold pack may be found under the treatment of Typhoid Fever. The gradually cooled bath may be substituted if open objection is made by the parents to the cold pack. In regard to the use of internal antipyretics, I prefer phenacetin for older children, combined with quinin in capsules. Acetanilid is better for younger children, and I generally give one-half as many grains as there are years in the child's life. When medicine can be exhibited in the form of capsules, I always prefer to combine it Avith quinin or strychnin to overcome the tendency to depression. Phenacetin and acetanilid act successfully in controlling the nervous element, relieving headache and fever, promoting diaphoresis, and inducing refreshing sleep. Acetanilid is much more prompt in its action than phenacetin, but its effects are not so lasting. I therefore choose it for young children, and exhibit it in small doses in the form of a poAvder, and if the boAvels are torpid I combine with the acetanilid small doses of calomel and soda. These agents are rarely required, and are not comparable in their good effects to hydrotherapy. Internal Antiseptics.—Those remedies that are purely antiseptic, administered internally, have not given proof of their utility as yet. The sulphocarbolates of zinc and of sodium, on account of their breaking up in the system and liberating carbolic acid, cannot be used in a suf- ficiently large dose to meet with success. The syrup of phenic acid is used by many physicians, but their success does not as yet seem to war- rant its being classed as an efficient remedy. Marmorek has used his anti streptococcus serum extensively, and, although it does not act as a specific, he claims that it prevents the serious complications and invari- ably renders the attack very mild. 244 INFECTIOUS DISEASES. The care of the nose and throat, and eventually of the ears, will re- quire all the skill of the medical attendant, and by commencing early in the case to give careful and constant attention to these parts we may prevent much trouble and danger later on. The attendant should use a small atomizer filled Avith warm Avater containing a solution of sodium bicarbonate (gr. xv-|j—0.975-32.0). If decided inflammation should occur, a solution of hydrogen peroxid and cold water or glycerin (1: 5) may be used, and then be folloAved by an oily preparation, such as liquid albolene containing menthol (a 5 per cent, solution). If the patient cannot tolerate an atomizer, an application of the anti- septic oil directly to the posterior nasal spaces, by means of an aluminum applicator, may be made. Faithful attention to the removal of the secre- tion from the nose and throat will prevent accumulation, and thus pre- vent regurgitation up the Eustachian tube Avith its associated ear-troubles. In this way diphtheria can be prevented from gaining its full lodgement, and, if it gains ground at all, little trouble is experienced Avith this dreaded disease. For the appropriate treatment of this complication the reader is referred to the treatment of Diphtheria. If pain in the ear should indicate the extension of the trouble up the Eustachian tube, we must redouble our efforts, even though the desquamation Avithin the Eustachian tube itself may be quite beyond the reach of our detergent wash. The external auditory canal may also become blocked by desquamat- ing epithelium, and this must be removed by gentle sponging. If the tension of the ear-drum becomes very great, it must be punctured. The crude method of dropping laudanum and sweet oil in the ear is to be condemned, as it serves as a nidus for a collection of dust and dirt, inde- pendent of the rapid accumulation of dead epidermis. Scarlatimd rheumatism I have encountered in but a small proportion of cases, and then it Avas of a transient character, leaving no damaged heart-valves behind. I am inclined to attribute this fortunate result to the faithful use of daily bathing and inunctions, long continued and at least until after completion of desquamation. The most constant complication of scarlet fever is nephritis. The specific poison of scarlet fever is peculiarly obnoxious to the kidneys, and is largely eliminated through them; and upon this fact hinges the scientific part of the treatment of this disease. The more active we render the skin the less likely will there be danger to the kidney. If the urine is examined throughout the whole course of the disease, we Avill find in the earlier stage that it grows less in quantity and becomes more laden with the waste of the body, at times being nearly suppressed by mechanical blocking of the uriniferous tubules. If now the skin is not invited to act to its fullest extent, we will soon find our patient re- duced to a comatose state. Free bathing has the happy effect of vica- riously eliminating the poison, and in this Avay it removes the undue pressure placed upon the kidneys. (For the treatment of nephritis the reader is referred to the discussion of acute Bright's disease under Dis- eases of the Kidneys.) MEASLES. 245 MEASLES. Definition.—An acute contagious disease, characterized by an initial coryza, general catarrhal symptoms, fever in the earlier stage, followed by a peculiar papular eruption on the face and body. Pathology.—In uncomplicated measles we have no pathologic lesions. The only post-mortem changes found, as a rule, are those of catarrhal pneumonia and acute nephritis. All the internal organs are gorged with blood, and minute hemorrhages are found on their surfaces, Avhile occasionally croupous pneumonia may be found inArolving a lobe or small portions of a lobe of the lung. Etiology.—Measles occurs in epidemics, yet we have frequent sporadic cases in the larger cities. There is an epidemic prevalence in large centers of population every eighteen months or two years, but the different epidemics vary in their extent and fatality. It generally happens that Avhen once the disease enters a home, street, or small court, scarcely any one escapes Avho has not been protected by a pre- aIous attack, those Avho suffer being for this reason, in nearly all cases, young children. The adults and older children may enjoy immunity in consequence of a prior attack, although this does not always follow. The susceptibility to measles in children, however, is very great. A most notable example of this Avas the epidemic that occurred in the Fiji Islands in 1875, and raged for four months, 40,000 of the natives dying out of a population of 150,000 (Corney, quoted by Callir). Biedert1 found that only 14 per cent, of unprotected children escaped. In the Faroe Islands, under similar conditions, only 1 per cent, escaped (Madsen, Pannum). There is the same experience in schools and hos- pitals : when a case incubating the disease is admitted, the whole un- protected junior population is attacked. The epidemics occur mostly in the fall and winter, yet the season seems to have but little influence. Bacteriology.—Micrococci, especially streptococci, have often been found in the secretions of the respiratory tract, but they have not been proved to be specific, as they are not always found and cultures from them do not cause the disease. Canon and Pielicki2 found in the blood of 14 cases, as well as often in the sputum and nasal and conjunctival secretions, a special bacillus of irregular size, Avhich colored irregularly with methylene-blue. It was decolorized by Gram's method, did not groAV on solid media, but did occasionally on bouillon. Czajkamski3 described motile bacilli, 2.5 to 5 micromillimeters in length, which did not color by Gram's method. They could not be cul- tivated on gelatin or agar, but grew on glycerin-agar, bouillon, and blood-serum, and killed mice by producing septicemia. Neither of these obserArations has been advanced to any firmer position in the eti- ology of the disease. One attack of measles does not seem always to exhaust the soil, as in the other exanthemata: one, two, and in several cases families of children, including the parents, have had four attacks in successive years. 1 Jahrbuch. fiir Kinderheilkunde, vol. xxiv. p. 94. 1 Berliner klinische Wochenschrift, 1892, S. 377. 3 Centralblatt fiir Bacteriologie, vol. xviii. Nos. 17 and 18. 246 INFECTIOUS DISEASES. Clinical History.—The period of incubation is from seven to four- teen days, and in inoculated cases from seven to ten days. Catarrhal Stage.—The early symptoms are those of a cold Avith some fever. The child has marked coryza, watery eyes, sneezes, and has a dry, croupy cough. Frequently the symptoms are those of a catarrhal laryngitis and bronchitis, the fauces and tonsils being hyperemic, with abundant secretion ; and, in addition, an examination of the eyelids reveals a conjunctivitis. The patient may be acutely ill, the tempera- ture rising several degrees in the evening, and falling slightly in the morning; the fever continues high until the rash is fully developed. The rash, consisting of one or more distinct papules, may be seen on the hard palate fully twenty-four hours before it appears on the face. The eruptive stage is very characteristic, and usually makes its appear- ance at the end of the fourth day. The neck, face, forehead, and trunk receive the eruption in the order of mention. The whole physi- ognomy of the child is so characteristically altered that a well-marked case may be diagnosticated at a glance. The face is flushed; the eyes are red and watery; a short, dry cough, frequently metallic in ring, is present; and the nose and cheeks are covered with crops of dusky-red papules surrounded by a zone of erythema which sharply contrasts with the normal skin betAveen the patches. The rash on the face is both dis- crete and confluent, or may be arranged at times in small crescents, and in the course of a day or tAvo the whole trunk is invaded, but in a slighter degree. By the fifth, and seldom the sixth day, the eruption has reached its height, and commences to fade, first on the face and neck, then on the body and limbs, followed by a fine desquamation. By the seventh or eighth day the rash is nearly gone, leaving a blue, mottled stain over the body. The temperature, Avhich has reached 103° F. (39.4° C.) or even 105° F. (40.5° C), falls when the rash is fully estab- lished—i. e. on the fifth or sixth day—while the headache, the severe bronchial cough,v and the general features subside with the fever. If the temperature continues high after the rash is out, we may look for some com- plication, such as severe bron- chitis, pneumonia, or acute ne- phritis (vide Fig. 23). Complications.—In some initial fever. Erupti,e fever. epidemics the character of the Eruption. \ Fig. 23.—Temperature-curve of a case of measles. disease is very severe, being marked by high fever (105°- 106° F.—41.1° C), a dry, broAvn tongue, delirium and convulsions, and feeble heart-action, due to the intense hyperemia of all internal organs—lungs, brain, kidneys, etc. I have observed cases in Avhich the eruption was petechial. The main complications are presented by the lungs. The accompa- A 40.0° \ '\ h j A ' v A \ A r V 39.0 / , A / ^ J \ A , / V V V , 38.0° i / / i V ^s 37.0° s IfiQ MEASLES. 247 nying bronchitis manifests a strong tendency to extend to the bronchioles, Avith resulting broncho-pneumonia. The extent and seriousness of this complication are largely dependent upon the degree of the previous de- bility. Lobar pneumonia is rarely met with. Catarrhal or membranous laryngitis is frequent in the pre-eruptive stage or as a sequela. Quite rarely edema of the glottis occurs. Oph- thalmia may occur in anemic and strumous children if strict eye-toilet is not enforced. Glandular involvement may take place in the cervical glands. Otitis is frequent during desquamation, suppuration taking place in the middle ear and the membrane being perforated. This may be avoided, hoAvever, by cleansing the post-nasal spaces frequently dur- ing desquamation. Cancrum oris and noma pudendi may also appear as complications of the disease. Diarrhea is frequent at the end of the eruptive period and as a sequela. The health of the child often remains impaired for a long time after an attack of the measles : it is at this period that whooping-cough, diph- theria, nephritis, and, later on, acute tuberculosis, may arise. Tuber- culosis very frequently gains entrance into the system from the existence of enlarged and cheesy bronchial and mediastinal glands. Nervous sequelae occur, but are very rare. They usually take the form of paral- ysis (hemiplegia, paraplegia, etc.). Diagnosis.—The disease is the most variable of all the exanthem- ata. Epidemics may be characterized by irregular forms of the disease, and the diagnosis of sporadic cases is often very difficult. We cannot recognize it by its dermal lesions, but by the prodromal symptoms, by the fall of temperature after the eruption is well out (differing here from scarlet fever), and by the character of the pulse, tongue, and desqua- mation. A feverish period of four days, associated Avithout catarrhal symptoms of the eyes, nose, and upper air-passages, a few papules on the hard palate, folloAved Avithin twenty-four hours by a papular efflor- escence on the face, will differentiate the disease from variola, varicella, scarlet fever, and rubella. The accompanying table, from Rotch, gives the diagnosis betAveen the eruptive diseases at a glance: Measles. Variola. Varicella. Scarlet Fever. Rubella. Incubation . . . 10 days. 12 davs. 17 days. 4 days. 21 days. Prodromata . . 3 days. 3 davs. A few hours. 2 davs. A few hours. Efflorescence . . Papules. Macules. Papules. Vesicles. Pustules. Vesicles. Erythema. Papules. Desquamation . Purpuraceous. Large crusts. Small crusts. Lamellar. Complications and Eye and lung. Larvnx. Kidney, sequelae . . . Lungs. ear, and heart. The mortality differs according to the surroundings of the patient. In healthy children under favorable environment the mortality is prac- tically nil, while in tuberculous and Avasted children it is very large, this being especially due to complications and sequelae. Infants may be born with the rash on them.1 1 Hem. Med- Chronicle, May, 1890; Brit. Med. Journal, vol. i. p. 612, 1890. 248 INFECTIO US DISEA SES. Treatment.—Measles is a self-limited disease, and Ave are unable to shorten its duration, nor is there any means of producing immunity from the attack. The treatment is necessarily symptomatic ; hence our efforts should be directed to protecting the various organs that are most likely to become involved by complications, remembering at the same time that the nose, ears, eyes, and throat are involved during the fever- ish stage, and that the skin is in a very susceptible condition. The patient should be placed in a large dark, Avell-ventilated room, with a uniform temperature between 68° and 70° F. (21.1° C). He should remain in bed until the temperature has been normal for one week, and until the efflorescence has nearly faded and the desquamation is almost complete. The diet during the period of fever should be milk, bread, and light soups. Near the end of desquamation, if all symptoms are favorable, a more generous dietary may be allowed. The bronchial cough, which may be very troublesome during the first few days, can be readily relieved by some simple expectorant mix- ture, as— By. Potassii citrat., 3ss(16.0); Succi limonis, |j (32.0); Tr. opii camph., 3ij (8.0); Syr. ipecac, 3ij (8.0) ; Syr. tolu., q. s. ad gij (64.0).—M. Sig. 3ss-3J every tAvo or three hours, according to the age and condition of the patient. This will serve as a fever mixture as well as an expectorant. For the coryza I have found that atomizing the nares with some oily vehicle (oleum petrolatum album, etc.) is advantageous. The skin is in a state of great irritation, and from the very com- mencement of the disease until the end of desquamation a daily warm bath (95° to 100° F.—35° to 37.7° C.) should be given the patient. The body should be carefully dried and cocoa-butter then thoroughly rubbed over the entire surface. The child should live in an equable temperature for at least three weeks, and longer if desquamation has not then ceased. For months he should be protected from sudden atmo- spheric changes in order to avoid general respiratory troubles. If he be predisposed to tuberculosis, cod-liver oil and creasote should be pre- scribed for a period of two months or more. RUBELLA. [Rotheln; Rubeola Notha; German Measles ; French Measles.) Definition.—An acute contagious disease. It has no prodromal stage, and is characterized by slight fever, coryza, and an efflorescence upon the skin. Htiology.—Rubella was not distinguished from measles and scarlet RUBELLA. 249 fever until about the middle of the eighteenth century. Since then con- siderable controversy has arisen at different times as to its nature, the theory being at one time strongly advanced that it was a combination of these two diseases, as many of the milder cases have symptoms com- mon to both. That there is a difference, however, in the character and course of these diseases has been proved beyond doubt to careful ob- servers by the facts that rubella occurs independently of either measles or scarlet fever; that contagion from this disease produces a similar dis- ease ; that one attack affords immunity to subsequent seizures (although those Avho have had other eruptive diseases are as liable as those that have not to contract this disease during an epidemic); and that its onset and clinical course are characteristic. Rubella is contagious, and may occur epidemically or sporadically. It is like measles and the other exanthemata in its being of undoubted microbic origin, although, as is the case with them, the specific organism has not been isolated. When that is accomplished the diagnosis will be more easy and certain. In hospitals or where persons are crowded and living under unhy- gienic circumstances the disease is very contagious and the epidemic Avill be quite general; but in family practice it is but slightly so, and the epidemics are limited, often being confined to a single household and attacking perhaps but one or two of the family. As stated by Edwards, it is spread by the cutaneous exhalations, breath, fomites, and clothing, and is probably contagious from the period of incubation until far into convalescence. Clinical History.—The incubation stage lasts from ten to twelve days, though this period may vary and the disease appear three or four days after exposure. On the other hand, cases have been reported in which it Avas as long as three Aveeks. As a rule, the period of incuba- tion is longer perhaps than in measles. The stage of invasion covers from one to three days, but in mild cases the rash is very often the first indication we have that the child has developed an infectious disease. For a period of a feAV days before the rash appears there will be noticed chilliness, pains in different parts of the body, a dull, heavy feeling, perhaps feverishness, accompanied by sore throat, enlarged ton- sils, coryza, and suffusion of the eyes, constriction over the chest, and a dry cough and bronchitis. Enlargement and induration of the cervical and other lymphatic glands, together Avith the sore throat, are common symptoms. Just before, or with the appearance of, the rash there is a rise in temperature to 99° or 100° F. (37.7° C), or in severe cases as high as 103° F. (39.4° C.) or more. Again, the invasion symptoms may be absent or so mild as to escape notice, and the first sign of infection be the appearance of a rash which first shows itself on the face and extends doAvnvvard over the body. In some cases the eruption does not follow the regular course, and is confined to one part of the body, and cases have been reported in Avhich it only appeared on the roof of the mouth or on the tonsils. In other cases every part of the body, including the palms of the hands and the soles of the feet, may be covered. The eruption consists of papules, is multiform, confluent, and of a pale or rosy-red color. The patches do not assume any regular shape 250 INFECTIOUS DISEASES or form, and the skin between them may become hyperemic and cause itching. The rash reaches its height on different parts of the body in succession, fading in one part while appearing in another. Its duration is from two to five days, and possibly longer in some cases. A slight desquamation usually occurs, and a slight pigmentation of broAvnish color after the rash fades is frequently noticed, disappearing after a few days. The temperature-curve is variable, but as a rule it remains between 100° F. (37.7° C.) and 102° F. (38.8° C.) while the eruption is present. As mentioned above, sore throat is nearly always present, with enlarged tonsils, a dry cough, and bronchitis. The glan- dular enlargement will also continue with the rash, and in severe cases the axillary and inguinal glands may become involved. The pulse varies with the temperature and respiration. Vomiting has been noticed as occurring during the eruption in severe cases. After a period varying from three days to a week, with the disap- pearance of the rash, convalescence begins and the child rapidly regains its former health, and the whole course of the disease may be so mild that the patient cannot be persuaded to remain in bed. Complications.—The most common are affections of the respir- atory tract (pneumonia or severe bronchitis), and in some cases we have a gastro-intestinal catarrh of a troublesome character. Diphtheria or other contagious diseases may occur. A relapse is not uncommon, and may be as severe as the initial attack. Diagnosis.—Rubella may be distinguished from measles by its less severe onset and course, by the lighter color and more diffuse character of its rash, and by the irregular shape which the patches assume. The presence or absence of an epidemic is an important factor in the diag- nosis, and in cases occurring when there is no epidemic the diagnosis between this disease and measles of a mild type is difficult if not alto- gether impossible. From a well-marked case of scarlatina the diagnosis offers no diffi- culty. The absence of its initial vomiting, the strawberry tongue, the character of the rash (which in scarlet fever is erythematous), and the shorter duration and milder course of rubella, all help to render the diagnosis easy. Rubella. Erythema. Urticaria. Occurs first on the face. On the hands and feet. In wheals on arms and legs. Marked coryza present. No coryza. No coryza. At first no itching. Burning pain. Intense itching. Contagious. Not contagious. Not contagious. Microbic origin. Reflex origin. Gastric origin. The prognosis in uncomplicated cases is invariably good, but Avhen the surroundings are unhygienic, or in cases in which the child has been delicate previously, it is more serious. Complications, especially pneu- monia or diphtheria, may prove fatal, and in some cases the mortality reported has been as high as 9 per cent. Treatment.—-The treatment is simple and principally symptomatic. A mild cough-mixture, such as is recommended in measles for the bron- chitis, nutritious but easily digested food, and medicine to regulate the bowels when necessary, fulfil all the indications for internal medication. WHOOPING-COUGH. 251 As in measles, cool sponging should be resorted to before and during the rash; and, Avhen the fever is high, a cool tub-bath, Avhere practicable, Avill be found to reduce the temperature, quiet the patient, and hasten the appearance of the eruption. During convalesence, if the child does not rapidly regain his appetite and strength, tonics, such as tincture of nux vomica and syrup of hydriodic acid, are indicated. The complications are to be treated as they arise, but the sponging should not be discontinued until the temperature reaches its normal level. WHOOPING-COUGH. [Pertussis ; Tussis Convulsiva; Keuchhusten.) Definition.—Whooping-cough is a highly contagious disease Avhich is characterized by a catarrhal inflammation of the respiratory tract, associated with a peculiar spasmodic cough, ending in a whooping inspiration. Pathology.—There is no lesion that can be considered characteris- tic of Avhooping-cough, and there is no distinct causal lesion around which all the symptoms and complicating lesions are grouped. In the beginning there is catarrh of the naso-pharynx, and this may be the only lesion coincident with the development of the characteristic cough. In advancing cases this naso-pharyngeal catarrh becomes generalized by extension to the lachrymal ducts, the conjunctivae, the Eustachian tube and the middle ear, to the glottis, trachea, large and small bronchi, and the air-vesicles. The more decided pulmonary lesions—emphysema, pulmonary collapse, pulmonary congestion and edema, and broncho- pneumonia—are advanced pathologic conditions accompanying the later stages or more intense forms of the disease (W. W. Johnston). The post-mortem table does not give us much information as to the pathology except as to the sequences of the disease. In the early stages swelling and redness of the respiratory and digestive tracts will be found, together with a large quantity of viscid mucus. Ktiology.—The disease occurs in epidemics, yet occasionally may appear sporadically. Pertussis seems to have a tendency to occur in epidemics every two years, although in large cities the disease is gener- ally endemic. There is no doubt that it should be classed with the spe- cific diseases, yet for a long time, like mumps, it hovered between the specific and the catarrhal diseases for a home. Pertussis is directly contagious, though scarcely so in houses and school-rooms unless it be for those of a specially susceptible nature. It is possible, however, for the disease to be propagated in schools, though not to the same extent as measles and scarlet fever. It seems that a more decided and pro- longed personal contact must be made, as Avith members of a family, to ensure transmission. One attack practically protects the child, yet ex- ceptions to this rule may be found. The influence of the seasons does not seem to have any effect, though perhaps fall and spring are the more frequent periods; the station in life, Avhether hygienic or unhygienic, does 252 INFECTIOUS DISEASES. not modify the disease. Bad ventilation, however, may propagate the disorder, and cause additional cases by favoring the increase of germs in the immediate surroundings. The previous condition of health, espe- cially of the respiratory mucous membrane, seems to possess some pre- disposing influence, weak, delicate children with an irritable digestive tube associated with a catarrhal state of the respiratory passages, more readily contracting Avhooping-cough than those in robust health. There seems to be an intimate association between Avhooping-cough and measles, and it is a Avell-recognized fact that an epidemic of measles will be folloAved by whooping-cough in the same sufferers. This is pos- sibly due to the sensitive condition of the mucous membrane left by the measles, which is so favorable to the lodgement of the germs of pertus- sis ; and the association of the two diseases must be more than acci- dental. There exists a certain individual susceptibility to Avhooping- cough, as Avell as to other infectious diseases, and yet many children never contract them, though frequently exposed. Age exercises some influence on the development of Avhooping-cough, most cases occurring before the tenth year ; after this time the frequency of the disease rapidly diminishes. West states that one-half of all cases develop under three years, but he must have based his knowledge upon an experience in hospitals and children's homes, as the experience of others does not sustain his statement. The disease occurs in adults but rarely, this being due partly to the fact that so many have suffered from it while young, and partly because of a lessening of the suscepti- bility with advancing years. It occurs frequently before the first year, and when it does it is the most fatal of all the diseases of childhood (Goodhart). The sexes are about equally divided as regards susceptibility; many writers, however, seem to think that girls are most liable. Ofttimes one close exposure in a susceptible child is sufficient to ensure an attack. The germs seem to be located at first in the secretions of the respiratory tract, and are thus disseminated through the air, the disease being most highly contagious, therefore, during the paroxysms of coughing. Good- hart reports a case in which a third party was the medium in conveying the disease from one child to another, thus suggesting a possibility of the contagion being ponderable. The highway of the contagion of whooping-cough into the system is evidently through the respiratory tract, though this fact has not yet been definitely settled. Published cases of pertussis in the new-born would even seem to make its transmission possible through the fetal circulation, yet the reports are neither numerous nor satisfactory, and cannot be depended upon. Nature and Bacteriology.—The true nature of whooping-cough has been thoroughly discussed, but is not, as yet, fully settled. Many writers claim it to be a simple bronchitis due to " cold " associated with a certain nervous habit or mimicry. The cough is started by the bron- chial irritant, and soon tends to .become a habit, thus returning again and again, until it dies out in the oblivion engendered by more healthy and regulated discharges of nervous energy (Goodhart). This theory fails to account for the nerArous element and the decided paroxysmal character of the cough. It has been held that the disease is a lesion of WHOOPING-CO UGH. 253 either the pneumogastric, phrenic, sympathetic, or recurrent laryngeal nerves, or perhaps even of the medulla. If this ground is valid, it is simply a neurosis. Eustace Smith says it is caused by the pressure of the enlarged tracheal and bronchial glands upon the terminal filaments of the pneumogastric nerve. Whatever the direct cause, the highly contagious character of whooping-cough, its appearance in epidemics, its incubating period, and the possible immunity from subsequent at- tacks seem to prove beyond argument that it should be classed among purely infectious diseases. WThile this is generally accepted as true by the most recent inves- tigators, it is not a new idea, and science only repeats herself in this instance. Linnaeus (to quote Dr. J. P. C. Griffith in the American Text- book of Diseases of Children) attributes pertussis to the presence in the nose of the larva* of insects. Poulet discovered bacteria in the expired air of patients suffering Avith the disease. Letzerich found a micrococ- cus in the sputum which he believed to be the specific germ, and claimed to have been able to produce the disease in animals by introducing the secretion into the trachea. Deichler-Kurlow claimed that there was always present in the sputum an organism of the nature of a protozoon which possessed ameboid motion. And, Avhile other investigators have repeatedly described various organisms as existing upon the respiratory mucous membrane, the researches of Afanassieff in 1887 have attracted the most attention. This observer isolated a short bacillus, which he named the bacillus tussis convulsive, and of which he was able to obtain pure cultures upon various media. Animals inoculated upon the respir- atory mucous membrane Avith these cultures exhibited some of the symptoms of the disease and developed catarrhal conditions of the respiratory tract, with a tendency to broncho-pneumonia. These ob- servations have been confirmed by others, and a toxin has also been reported as present in the urine of patients suffering Avith pertussis which is identical with that produced by Afanassieff's bacillus. Even though it be admitted as most probable that some micro-organism is the cause of the malady, it is by no means clear hoAV the symptoms are pro- duced or Avhere the principal seat of the infection arises. Some writers have claimed that the trigeminal nerve is in a sensitive state, and that it is the irritation of its terminal filaments by the infectious catarrhal pro- cess on the nasal mucous membrane which brings on the paroxysms by a reflex action.. The careful investigations of Myer-Huni and of von lleroff, however, indicate that the catarrhal inflammation is most pro- nounced in the mucous membrane of the nose, larynx, and trachea down to the bifurcation, but especially so on the posterior wall of the larynx in the interarytenoid region, the so-called "cough region." Kuoloff believes that the parasite of whooping-cough is a specific micro- organism, a protozoon, and has found uniformly in the fresh sputa of patients ameboid organisms with spheric spores characterized by con- centric laminations.1 Undoubtedly we have in Avhooping-cough an in- fectious catarrhal process which affects the mucous membrane controlled by the superior laryngeal nerve, and the value in many cases of purely local treatment indicates that the abode of the germs is in this region, Avhence the poisonous products of their groAvth are absorbed. 1 Medical News, Nov. 9, 1896. 254 INFECTIOUS DISEASES. The nature of the " Avhoop " has been frequently discussed to show the nervous origin of the disease, yet the infantile larynx is capable of responding to purely neutral stimuli owing to the flexible nature of the young cartilage. If we carry a young sleeping child from a warm room out in the cool air, the same characteristic Avhoop may be produced, showing that this reasoning cannot be depended upon. Clinical History.—The period of incubation varies from four to four- teen days according to the extent of catarrhal trouble in the child existing at the time. Goodhart gives several authenticated cases in Avhich the in- cubation ended on the eighth day. In the beginning the symptoms are those of a slight bronchial cough, which has a tendency to be more pro- nounced during the night. After a few days the cough assumes an in- fluenzal character, and at the same time it gradually grows metallic in ring and shows a laryngeal type. There is some fever present. This catarrhal or feverish stage lasts for a week or more, when it is followed by the paroxysmal stage, and these stages are divisions of the symptoms Avorthy of recognition, as the treatment in the first is not applicable to the second. Many authorities speak of a third stage as one of decline, which does not sharply occur, but includes the sequence of the disease. The catarrhal stage lasts about one week or ten days, during which the child is ill at ease, is feverish, and has a hoarse, dry cough. The symp- toms may either be entirely laryngeal at first or bronchial, with a loss of appetite and broken rest at night. Auscultation at this time will reveal a few moist or dry rales in the larger bronchial tubes, but there is very little secretion. The cough seems to be out of proportion to the physical signs. As the catarrhal stage proceeds the cough commences to indicate its character by becoming more noisy, increasing especially at night. The physiognomy of the child commences to change, the face is swollen, the eyes suffused and watery, the under lids swollen and pink in color. This is one of the most decisive indications of the trouble, and may be recognized by a careful observer a few days before the " whoop " begins which stamps the disease and ushers in the second stage. The commencement of the paroxysmal stage is quite different from the easy and more constant coughing of the first stage. If the child is in bed, the onset of a paroxysm is usually quite sudden, but if he is up and playing, there is a period of restlessness, a premonition of the coming storm similar to the aura in epilepsy, and the child may even have time to run to his mother or nurse before the paroxysm comes on. Usually the paroxysms are induced by a quick inspiration, as during drinking, eating, or crying. The first (expiratory) part is short, and followed by a short whoop; this is very quickly followed by a long series of short expiratory efforts and a second and longer whoop, when the paroxysm may cease. In some cases a third and a fourth may quickly follow, un- til the child is quite exhausted. The paroxysms, Avhether short or long, generally terminate with vomiting or eructation of a quantity of stringy mucus. Food is ejected, and in most cases a little blood is mixed with the vomited mucus. At this stage of the disease, if at all severe, the countenance of the child is characteristic, and so much so that a mistake is no longer pos- sible : the features are swollen, puffy, and dusky in color ; the eyes are injected, the lids swollen and pink ; the skin livid, due to a minute WHOOPING-CO UGH. 255 ecchymosis of the smaller capillaries. In many cases there will be ex- travasation of blood beneath the conjunctiva, due to the violence of the congestive cough. If the chest be examined at this stage, it will tell but little, provided Ave have no broncho-pneumonia, though a few moist rales may be found scattered through the larger tubes. The spasmodic stage of Avhooping-cough has no set duration and varies frequently in intensity. In severe cases it may consist of twenty to forty paroxysms during the twenty-four hours. Some spasmodic coughs are not accompanied by a Avhoop, and the absence of this sign may be noted in very young children, as Avell as in those that are very ill with broncho-pneumonia. Some children vomit after a coughing spell without the Avhoop. It is frequently observed that long after the spasmodic spell has come to an end the paroxysms return again and again, perhaps years after- ward, with almost characteristic features, evidently acting under the stimulus of some perfectly neutral catarrh. Complications.—In severe cases the complications are likely to be numerous. Epistaxis often occurs in children; hemoptysis when vomiting is fre- quent ; ulceration of the frenum linguae in violent coughing; convulsions in vigorous children; and broncho-pneumonia, pleurisy, pericarditis, laryngitis, and hernia in severe, prolonged coughing. Convulsions and broncho-pneumonia are alarming; in young children a profound stupor takes the place of the convulsions, and the latter then become of graver significance. Sequelae.—Acute nephritis frequently occurs, and is as severe as that found in scarlet fever, although the condition has not received the recognition it should from the authorities. In a series of over 200 cases I have found the kidneys affected in 20 per cent. Emaciation is a very important sequence of pertussis. All the viscera are liable to fatty de- generation, and nutritional changes open the door to cheesy, glandular alterations, and eventually to a secondary tuberculosis. Atelectasis, by curtailing lung-space, frequently brings about a general collapse, and this condition very frequently explains the flattened chest found in young adults. Emaciation may also be due to mucous disease, a chronic gastro-intestinal catarrh of long standing. Prognosis.—Associated Avith its complications, pertussis is a very fatal disease, especially in children under two years of age. Dolan re- gards it as third in rank among the fatal diseases of England, Avhere the death-rate per million is five thousand annually. The deaths occur chiefly among children of the poor and in bottle-fed infants. Goodhart regards Avhooping-cough as the most fatal of all the dis- eases in children under one year of age. He places the mortality as high as 12 per cent., and thinks that this is not too high ; his state- ment, however, is hardly Avarranted, as he includes the deaths from the many sequelae which Ave cannot estimate. Ashby and Wright place the mortality at 7.6 per cent. Diagnosis.—Young infants usually do not "whoop," but cough spasmodically. Children with pleurisy or pneumonia do not whoop, yet Ave diagnose Avhooping-cough by the preceding catarrhal fever. From influenza in its early stages it is most difficult to differentiate the 256 INFECTIOUS DISEASES. affection. The pink under eyelid has to me been the most certain sign. When the whoop appears and during the existence of an epidemic, how- ever, the diagnosis may be rendered certain. The diagnostic points prior to the Avhooping stage, enunciated by Eustace Smith (viz. " If a child be made to bend back the head, so that his face becomes almost horizontal, and the eyes look straight upward at the ceiling above, a venous hum, varying in intensity according to the size and position of the diseased glands, is heard with the stetho- scope placed upon the upper bone of the sternum. As the chin is now slowly depressed the hum becomes less loudly audible, and ceases shortly before the head reaches its ordinary position ") has not been very satisfactory. It is true that we do recognize the hum caused by the enlarged bronchial gland, but it occurs long after other symptoms are manifest, and thus its importance is much lessened. I have for several years been able to place considerable value on the peculiar puffiness of the mucous membrane of the eyes and the swollen or edematous condition of the Avhole face and almost dusky color. This condition may exist for days before the catarrhal symptoms have ex- tended throughout the respiratory mucous membrane. The cough at this stage may not be at all suggestive: it may be, in fact, purely bronchial. This symptom of fulness about the eyes, which is quite as constant as in measles, would in fact suggest that disease, and must be differen- tiated from it. As we are able to diagnose measles by its appearance first on the hard palate, so I contend we may diagnose whooping-cough in its earliest stage by the characteristic SAvollen condition of the eyes and face. I insist upon this factor as of the greatest importance, as its recognition will enable us to institute specific treatment early, when the disease is yet local and may be brought more speedily under control. Treatment.—The gravity of pertussis is scarcely appreciated either by the general physician or the public, and there is more crim- inal neglect in connection with whooping-cough than with any other disease. Medicinal treatment is exceedingly unsatisfactory, although the therapeutic measures are boundless: just as in phthisis and diph- theria, they cover the whole domain of the Pharmacopeia, and we have as yet found no specific. The remedies most in use are the antispas- modics and the germicides. Whooping-cough has a striking parallel in diphtheria, in that it has in its early stages a local manifestation in its strong tendency to fasten itself upon the throat. How long this period exists we know to a certainty no more than we know just how long diphtheria is purely a local throat-poison; yet there is undoubtedly a period in whooping- cough, as there is in diphtheria, long or short, in which the virus—if it could be recognized—could be destroyed and the disease terminated. To abort cases thus Avithin tAvo Aveeks is not unusual, and this explains the number of reported cures made by germicidal remedies. I have notes of 2 recent cases in which the characteristic Avhoop com- menced at once with the general catarrhal symptoms, and was cut short by a hydrogen-peroxid gargle. I think these 2 cases illustrate very clearly the fact that the germs of the disease will locate on the mucous WHO 0PING-CO UGH. 257 membrane of the respiratory passages and bring about a nerve-discharge which ends in the characteristic whoop. In my treatment of this dis- ease I find the greatest necessity of recognizing the nature of the trouble earlv in the catarrhal stage. If I can satisfy myself that I am dealing with a case of earlv pertussis, my methods of procedure are much differ- ent from what they would be if the case were well advanced. A\ e must remember that the two stages are not sharply defined, and that many cases entirely lack the catarrhal stage, just as there are many cases that do not whoop. Pertussis, as Ave all knoAv, is a notoriously unsatisfactory disease to manage, and if we put our whole confidence on a single remedy, Ave are likelv to meet with keen disappointment. The drugs I have found most efficient in the catarrhal stage have been hydrogen peroxid in sterilizing the nasopharynx, and asafetida, occasionally used for the paroxysms. Belladonna is to a high degree beneficial in young children. I push this drug until I get the full toxic effects, Avhen I am generally reAvarded with a diminution of the suggestive characteristics of the cough. To be more explicit, I will detail the methods of procedure in a fam- ily in Avhich I have instituted my plan of thorough treatment: A child of four years attending kindergarten Avas brought to me Avith a suspicious cough. The history was given of an exposure of over tAvo Aveeks prior. The child had coughed for a feAV days, more at night than in the daytime ; was feverish during the evenings; showed slightly swollen eyelids, thus suggesting the nature of the impending trouble. I ordered hydrogen peroxid and pure glycerin 'in equal parts, which Avere Avell diluted and thoroughly sprayed through the naso-pharynx every four hours. The diet was light and digestible; out-door life Avas encouraged, except on windy days. All excitement was avoided, so as to avoid the precipita- tion of any additional paroxysms. At night the child was placed in a large, Avell-ventilated room, and over its cot was erected a mosquito net- ting, so as to prevent any unusual draught—a procedure which I have found highly beneficial, as it materially lessens the number of the noc- turnal paroxysms. When the cough Avas fully established and was accompanied by eructations of stringy mucus, I commenced the exhibi- tion of the mixture of asafetida J dram (2.0) every tAvo hours. The record of the paroxysmal stage was as folloAvs: The first Aveek averaged six coughing spells per day; the second week averaged ten per day; the third Aveek, four paroxysms; and the fourth and fifth weeks aver- aged about two paroxysms during the twenty-four hours. When the younger brother, but eight weeks old, commenced to show evidences of the disease, I first used hydrogen peroxid as in the older brother, and immediately followed it Avith asafetida. This case continued scarcely four weeks when all symptoms subsided. Mistura asafretida, however, is at times disappointing, even in younger children. My second choice is the tincture of belladonna, exhibited in doses of one drop for every month of the child's life, the doses being rapidly increased until toxic effects are reached. Then I gradually in- crease the amount as tolerance of the drug seems to be established. In \rery young children I have obtained good results from the use of a freshly-prepared belladonna plaster placed between the scapuhc, and the physiologic action of the drug seems thus to be more constantly 17 258 INFECTIOUS DISEASES. maintained. The plaster may be changed at the end of one Aveek. In a number of very troublesome cases in young children I have gained a decided advantage by an application of a 2 per cent, cocain solution directly to the naso-pharynx. This treatment, hoAvever, does not pre- clude the use of hydrogen peroxid, which should be continued through- out the catarrhal stage. Bromoform Avas resorted to in fully 20 per cent, of my cases, and was a keen disappointment; it seemed merely to stupefy the patient and did not apparently shorten the progress of the disease. The coal- tar products, pushed to the toxic limit, modified the disease but slightly. Belladonna and antipyrin in combination gave better results than either alone. Quinin, chloral, creasote, carbolic acid, I found to be of little practical use, owing largely to difficulty in administration. This out- line of the drug-treatment in whooping-cough has reference solely to the catarrhal and paroxysmal stages of the disease. As important ad- juncts to the management of the disorder careful hygiene must be en- forced, and a diet of the simplest character and a uniformly quiet life maintained. Throughout the whole course of the disease out-door life, as far as possible, should be encouraged, and if convenient a sojourn at the sea-shore will shorten the progress of the trouble and limit to a great extent the number of sequelae. PAROTITIS. {Mumps; Parotiditis; Epidemic Parotitis.) Definition.—An acute contagious disease, characterized by an in- flammation and SAvelling of the parotid gland, and occasionally by an involvement of the salivary glands, the testicles, and in the female the mammae. Pathology.—Opportunities for post-mortem examinations are rare, leaving in some doubt the pathologic course of the disease; but it probably begins as a catarrhal inflammation of the ducts, involving the periglandular connective tissue. The inflammation is seldom severe enough or of such a nature as to produce suppuration. Etiology.—Mumps is undoubtedly a constitutional or blood-disease with local manifestations. "It is a question," Goodhart says, "with mumps whether this disease shall be placed with the specific diseases or with those affecting the parts or organs with which the symptoms more particularly concern themselves." The disease is no doubt of microbic origin, but the specific organism has not yet been isolated, and, while there has been some reason°to be- lieve that it is a bacillus, this has not been proved and is still doubtful. It is highly contagious, and at times, usually during the spring and autumn, becomes epidemic. It is communicated principally by the breath and exhalations, the greatest source of contagion being the salivary secretions. It may, however, be carried by a third person or by fomites, and is most liable to be communicated during the begin- PAROTITIS. 259 ning of the attack, although the contagiousness continues until after the subsidence of the febrile symptoms. It occurs mostly among children and voung adults, infants and old persons being rarely affected, Avhile males are more liable than females. One attack usually gives immunity from a second attack in the same gland. Clinical History.—The average period of incubation is fourteen days, but it may develop as early as ten or as late as tAventy days after exposure. The invasion is marked by languor and a temperature from '101° to 103° F. (3S.3°-39.4° C), with possible headache and vomit- ing; the patient complains of pain at the angle of the jaAv, and this is greatly increased if an acid (such as vinegar) is SAvallowed. With these svinptoms is noticed a pyriform SAvelling of the parotid glands, the one on the left side usually appearing first, and the other one soon following. Occasionally cases are seen in which but one gland is involved, or the swelling may begin in both at the same time. This increases gradually until some time betAveen the third and sixth days, involving the other salivary glands and causing marked disfigurement; the swelling fills the depression beneath the ear and extends to the cheek and neck, the most prominent part being just below and pressing outward the lobe of the ear. The salivary secretions are generally much increased, though there may be the opposite condition of marked dryness of the mouth. When the swelling has reached its height, pres- sure on the adjacent tissues causes a disagreeable sensation of tension, and chewing, SAvallowing, and even speaking, are at times painful and difficult. The skin over the affected part may be of a pale or of a dull- red color. Ringing in the ears and a dulling of the hearing is common. The neiwous system may be affected, causing headache and delirium, or a low typhoid state may be present. The duration is about one week (six to ten days), after Avhich time the SAvelling subsides, and by the tenth or tAvelfth day entirely disappears. Diagnosis.—The diagnosis is easy, the nature and position of the SAvelling and the course of the disease being characteristic, Avhile the fact that the tonsils are seldom involved prevents a diagnosis of acute tonsillitis. Occasionally, however, in the course of septic infection or after operations, or OAving to the extension of inflammation along the duct from the mouth, the parotid gland becomes the seat of an acute inflam- mation at first hardly distinguishable from mumps. The existence of a possible source of infection, and the fact that the gland under these circumstances usually undergoes suppuration, should lead to the recog- nition of the true nature of the case. Complications and Sequelae.—Mumps, as a rule, runs a mild course without any serious symptoms, but occasionally complications arise that tax the skill of the physician to the uttermost. The most common of these are orchitis in the male, which may be followed by atrophy of the testicle; and mastitis, ovaritis, or vulvo-vaginitis in the female, especially after puberty. These complications appear after the subsidence of the swelling of the glands of the neck, only occasionally developing Avhile the glands are still affected, though cases have been reported in which the disease first manifested itself by involvement of the sexual organs. This complication lengthens the course of the attack 260 INFECTIOUS DISEASES. and increases the constitutional symptoms, but the rule is complete re- covery. Otitis media sometimes occurs, and a lesion in the auditory nerve, with more or less deafness (which, unfortunately, may be perma- nent), has been observed. Meningitis, with active brain-symptoms, facial paralysis, convulsions, albuminuria, and arthritis, have all been noted in certain cases. Treatment.—The patient should be kept in a well-ventilated room of even temperature, and in bed if the fever is at all severe, and should be isolated from those who have not had the disease. Either hot or cold applications to the swelling will often give relief, and support to the SAvollen gland by means of cotton and a bandage is very comforting. Saline laxatives may be given, and aconite or some simple fever-mixture at the beginning of the attack is usually indicated. These simple measures are all that are required in an ordinary case, while complica- tions or unusual conditions must be treated as they arise. TUBERCULOSIS. Definition.—A chronic (less frequently acute) infectious disease, caused by the bacillus tuberculosis. This organism produces specific lesions, taking the form either of separate nodular masses or diffuse growths, infiltrating the tissues, while aggregations of these element- ary tubercles give rise to large tubercular masses. Tubercles undergo caseation and sclerosis, followed in turn by ulceration (in consequence of secondary pyogenic infection), or, more rarely, calcification. Historic Note.—Prior to the discovery, in the early part of the nineteenth century, by Bayle and Laennec, of the tuberculous new growth as a distinctive body, this disease had been studied chiefly from a clinical point of view. At this early period the disease Avas believed to consist chiefly of a suppurative process, and in its observation the physician was unaided by auscultation. Later, the tubercle Avas recog- nized as a small rounded nodule without any special histologic cha- racteristics. Villemin in 1805 performed his epoch-making experi- ments, and the tubercle was no longer distinguished by its anatomic characters alone. Though the theory of the infectious nature of tuberculosis had been previously advanced by Buehl and others, it was first clearly demonstrated by Yillemin's beautiful inoculation- experiments upon rabbits and guinea-pigs with particles of tubercular and cheesy substances, producing the characteristic lesions of tubercu- losis. It then remained for Koch to discover (in 1881) the specific cause of the most important of all human ills—the tubercle bacillus. So soon as the specificity of the disease was definitely established it became clear that the associated inflammatory processes, that Avere for- merly believed to be primary and to hold first place, Avere secondary. The important role, however, played by the latter, particularly in the production of the general features of the disease, will be shown here- after. Geographic Distribution.—Tuberculosis prevails in almost every TUBERCULOSIS. 261 quarter of the globe, but is more prevalent in certain latitudes than in others. Thus, in general terms, it may be said to prevail more exten- sively in warm than in cold countries, though it lessens in frequency as we approach either pole. Local conditions, however, exercise a more decisive influence in engendering predisposition than mere geographic position. It is of quite frequent occurrence in all densely populated municipalities, and more especially in the overcrowded sections of the latter; this fact explains why the inhabitants of cities of the North are but little less spared than those of the cities of the South. On the other hand, residents of mountainous countries, owing to the purity of the atmosphere and the elevation, are rarely among its victims. The influ- ence of race in predisposing to tuberculosis should also be mentioned here, the South Sea Islanders, the Indians, and the colored race being peculiarly liable. General Pathology of Tubercular I,esions.—Distribution of the Lesions in the Body.—Tuberculous neAv growths elect, most fre- quently, the lung, and Avhen the disease occurs in the adult this organ is almost invariably implicated. Next in frequency follow the larynx, intestines, peritoneum, urogenital organs, and the brain. The other chief viscera of the body (spleen, liver, heart, etc., particularly the lat- ter) are less frequently the seat of tuberculosis. In children the lesions exhibit a different distribution, the favorite seats being the lymph-glands, intestines, bones, and joints. In them the distribution corresponds pretty closely, if we except the bronchial and mesenteric glands, to that of surgical tuberculosis. The Elementary (Nodular) Tubercle.—This may be developed in any tissue to which the tubercle bacillus has found its wray, and the presence of the bacillus is its sole distinguishing feature, since the self-same bodies are generated by other micro-organisms—e. g. certain of the worms (eggs of the distoma), actinomyces, aspergillus glaucus, and even as a result of irritation by certain foreign bodies (podophyllum). Various forms of pseudo-tuberculosis have been described, but all are due to bac- teria that differ from the bacillus tuberculosis. Mallassez and Vignal described a form produced by a micrococcus occurring in a zooglea, and this observation Avas later confirmed by Nocard, Eberth, and others. Charrin and Rogers have described still another form, in which they found bacilli about lp long, actively motile, and growing freely upon ordinary media, but not growing upon glycerin and agar, and not lique- fying gelatin. The various stages in the development of a tubercle are— (a) Proliferation of the fixed-tissue elements (connective tissue, en- dothelium of the capillaries, etc.) of the part infected, due to the local, specific irritant action of the bacilli. These anatomic products are transformed into epithelioid and giant cells. The epithelioid cells assume various shapes, chiefly rounded and polygonal; they have vesic- ular nuclei, and soon show tubercle-bacilli in their interiors. A certain proportion of the epithelioid cells, as the result of increase in their size and a repeated division of their nuclei, become giant cells. The latter occupy the center of the tubercle, and also contain bacilli, the number of giant cells and of the bacilli being largely reciprocal. Thus, the giant cells are numerous in tubercular lymph-glands, joints, etc., in 262 INFECTIOUS DISEASES. which the bacilli are relatively few; on the other hand, they are scanty in miliary tubercles, in which the bacilli are numerous—two facts that lend support to the view held by many authors that giant cells display phagocytic action. (b) About the site of infection a diapedesis of leukocytes occurs in the nature of a defensive inflammatory process. At first the leukocytes are of the polynuclear variety and are quickly destroyed; but later mononuclear leukocytes (lymphocytes) appear. These latter resist the action of the bacilli, and I think their true function is a phagocytic one. The various forms of cells described are connected and sur- rounded by a reticular stroma "formed by the fibrillation and rarefac- tion of the connective-tissue matrix " (Baumgarten). The fully-developed tubercles are small, nodular bodies Avhose diam- eters range from ^ to 2 or 3 mm. At first they are almost transparent, but soon lose this quality in consequence of the further changes de- scribed below. They are non-vascular bodies, and invariably undergo (a) caseation and (b) sclerosis. (a) Caseation.—This implies "coagulation-necrosis"—a destructive process proceeding from the center toAvard the periphery of the tubercle, and the result of the local action of the bacilli or their chemical secretions. The cells are thus transformed into a uniformly yellow- ish-gray, structureless matter. When the foci are numerous and closely set, fusion may occur, with the production of larger or smaller homo- geneous masses (cheesy pneumonia). The latter may soften, resulting in the formation of cavities: this is due, usually, to secondary pyogenic infection, causing ulceration. Less frequently the cheesy masses under- go calcification or become encapsulated. Such masses may remain in- definitely and are practically harmless. (b) Sclerosis.—Preceding and during the time that cell-destruction is going on in the center of the tubercles the protective forces of nature are asserting themselves, though too often Avithout avail. In the first place, hyaline transformation, with conversion of the cellular elements into fibrous tissue, occurs. Frequently, now, the center of the tubercle is caseous and contains bacilli, while the peripheral parts are quite hard and do not contain bacilli. The fibroid change may pervade the entire tubercle. Again, the fibroid element in the tissues immediately sur- rounding the tubercle may be greatly increased and form new connective tissue, and this process be followed by secondary contraction, convert- ing the tubercle into a firm fibrous nodule. The fibroid change in its completest development is observed in tuberculosis of serous membranes, especially of the peritoneum. Whether in any given case the destructive forces, on the one hand, or the conservative, on the other, shall come off victorious depends upon several conditions. Though natural immunity is probably unknown, yet under certain circumstances and at certain times tissue-soils may successfully resist bacillary invasion. The bacilli of tuberculosis doubt- less produce special toxins (vide Etiology), and hence there is a reason- able probability that the tissues and liquids of the body manufacture an antitoxin. The latter agent may therefore constitute one of Nature's chief means of defence. There are also soils that are moderately recep- tive, and these may become infected; but sooner or later the destruction TUBERCULOSIS. 263 of the invading parasite may be determined by altered soil-conditions— changes induced by Nature's benign and curative efforts. It is prob- able that in such instances the favorable issue is sometimes to be ascribed to the fact that relatively feAV bacilli find lodgement, so that the average phagocytic activity and other protective processes suffice. But when the bacilli fall upon a soil that is altogether favorable to their groAvth their pernicious influence cannot be arrested, since the means that usually turn the scales in favor of a cure are Avanting. We are noAv prepared to understand the coarser appearances pre- sented by tuberculous lesions, especially of the lungs. Fusion of mi- nute centers of infection or of miliary tubercles results in the formation of larger nodules or areas, Avhich lead by a process of local extension to diffuse tuberculous infiltration (gray infiltration of Laennec). An entire lobe may become similarly involved (tuberculous pneumonia), and " there may also be a diffuse infiltration and caseation Avithout any special foci, a Avidespread tuberculous pneumonia induced by the bacilli " (Osier). The term " gray infiltration " is misleading from a pathologic point of vieAv, since the morbid changes differ in no essential manner from those described as occurring in the miliary or nodular tubercle. More- over, the latter also presents a grayish appearance. The apparent dif- ference between a miliary tubercle and diffuse tubercular infiltration lies in the fact that the latter displays a greater tendency to spread by direct extension. Associated Inflammatory Processes.—The tubercle bacilli excite asso- ciated inflammatory processes in the organs affected, and if the tubercu- lous lesions run a slow course, a limiting wall of true fibroid induration circumscribes the area iiiAolved. By means of this induration the nat- ural protective forces, either temporarily or permanently, check the progress of the local lesions, and the change is strictly analogous to the sclerosis that takes place in the peripheral parts of the elementary tubercle or immediately surrounding the latter, as in tuberculosis of serous membranes. On the other hand, when the tuberculous infiltra- tion is less tardily developed the secondary inflammatory processes may show changes similar to those of catarrhal or croupous pneumonia. It is a noteAvorthy fact that the constitutional features in tuberculosis are not so much dependent upon the primary as upon a secondary infection, chiefly with the streptococci. The latter are responsible for the seri- ous septic element in certain varieties of tuberculosis (especially pul- monary), and some contend that the tubercle bacilli can excite suppura- tion directly. The pus, however, in this instance does not contain the streptococci, and is sterile. Mixed infection is, I believe, the rule (vide Pathology of Pulmonary Tuberculosis). Etiology.—The Specific Cause and its Physical Characteristics.—In 1881, Koch discovered the tubercle bacillus, Avhich is the sole cause of the disease. This bacillus is rod-shaped, straight or somewhat bent, and slender, its length equalling about one-third or one-half of the diameter of a red blood-corpuscle (Fig. 24). Its extremities are slightly rounded, it is non-motile, and on the interior of the bacilli small colorless spots can be observed on microscopic examination; these clear spaces in the bacilli represent plasmolysis, and have nothing to do Avith spore-forma- tion. Spores undoubtedly do occur, but have not yet been demonstrated. 264 INFECTIOUS DISEASES. Fig. 24.- -Tubercle bacillus in sputum (Frankel and Pfeiffer). When stained the bacilli have a someAvhat beaded appearance, this being probably due to slight bulgings caused by the presence of spores. The tubercle bacillus is one of the few varieties of bacteria that retain the anilin dye after washings with acids. Biology.—The bacilli can be grown on culture-media, but not without difficulty, since they demand an even temper- ature between 98° and 100° F. (37.7° C), or that of the hu- man body. The best soil is blood-serum previously coag- ulated by heating. Over the latter may be gently rubbed tuberculous tissue, which is then allowed to remain on the surface. The growth of the bacilli requires about two weeks, when colonies appear as dry, grayish-white or gray- ish-brown, thin scales or masses on the surface of the culture-medium. From such cultures others may be grown on glycerin-agar or on the potato. Inoculations into the guinea-pig and other animals are succeeded in two or three weeks by the appearance of elementary tubercles—first, locally, and then in other organs of the body. Chemical Products.—The growth of the bacilli is probably attended by the formation of secretory products. Thus an albuminoid substance has been separated, and this when injected into the body of an animal produces fever, lasting a day or two. The albuminoid sepa- rated for cultures of tubercle bacilli is a nuclear proteid, and not a spe- cific toxin. There have also been isolated a ptomain and, some contend, an extract which displays pyogenic properties (Koch's tuberculin). The constitutional features of the disease may be ascribed, in part, to the circulation of these poisons in the blood, but they are probably infinitely less important in this direction than the products of suppuration. Sources of the Bacilli.—The chief source of the bacilli is the sputum of tuberculous patients. It has been shown that in the advanced stage of pulmonary tuberculosis several billions of bacilli are expectorated daily (Nuttall), and the desiccated sputum is wafted into the atmosphere in the form of dust-like particles containing innumerable bacilli. When the facts that tuberculosis is almost universally prevalent, and that each patient throws off countless millions of bacilli are remembered, it is clear that abundant opportunity is everywhere presented for infection, or, in other words, that secondary sources of infection are numerous and varied. Distribution of the Bacilli.—The tubercle bacillus is exceedingly tenacious of life, this being its chief distinguishing characteristic. Hence it is found in a viable condition, both (a) inside and (b) out- side of the body. TUBERCULOSIS. 265 (a) Inside of the Body.—As before stated, the number of bacilli found in tuberculous growths varies within wide extremes. In general terms, it may be said that the more rapidly the process advances the greater the number of parasites present. It must not be forgotten, however, that the activity of the tuberculous processes is intimately con- nected with the degree of resistance offered by the tissues. A chronic tuberculous focus may establish a fistulous connection with a vein or a lymph-vessel, and thus scatter the bacilli to the remotest parts of the body; and in such instances (as the direct effect of the original number of bacilli present) a chronic is quickly converted into an acute form of tuberculosis. The bacilli may also be found in the bodies of non- tuberculous persons. Strauss * demonstrated virulent bacilli within the nasal cavities of healthy persons whose positions necessitated their asso- ciation Avith, and frequent presence in rooms occupied by, tuberculous patients. (b) The Bacilli Outside of the Body.—Tubercle bacilli can maintain their existence almost indefinitely outside the body. On the other hand, they probably do not develop or multiply under the usual external influ- ences, though, as I have said, their vitality is extraordinary. Their destruction cannot be effected by freezing nor by desiccation, and they survive for months in Avater. Their power to resist chemical agents (nitric acid, etc.) is also very great, but they may be destroyed by boil- ing for four or five minutes or by exposure to the direct solar rays. Tubercle bacilli are undoubtedly present in all inhabited places, and it is obvious that they may be conveyed for long distances by means of water, milk, and in many other Avays. The sputum dries and flies into the atmosphere in the form of dust, Avhich not only floats in this medium, but also settles upon articles of furniture, the floor, the walls of living-rooms, hospital wards, draperies, clothing, bed-linen, etc.; and from these resting-places it may be con- veyed back into the atmosphere. It has been shown, experimentally, that the dust obtained from the walls or from the air of rooms and hos- pital Avards occupied by tuberculous patients is frequently, though not invariably, infected. It is the in-door atmosphere, laden with bacilli, that is especially liable to excite tuberculosis when breathed more or less constantly. In places only rarely frequented by consumptives the dust is usually free from virulent bacilli. Modes of Infection.—(1) Inhalation of the Bacilli.—In the vast ma- jority of instances the bacilli are inhaled with the inspired air, but it is important to recollect that the exhaled breath of tuberculous patients is not infectious. It is the dried sputa floating in the atmosphere that are pathogenic ; and occasionally, Avhen infection occurs in this manner, the bacilli may attack first the upper respiratory passages, producing primary tuberculosis of the larynx and nose. Almost invariably, how- ever, primary infection takes place in the smaller bronchi, or less fre- quently in the lungs ; and that these are the points of election is shown by the fact that healed tuberculous lesions are often met with on post- mortem examination in the bronchi and lungs of persons who died of other diseases. Under similar circumstances the bronchial glands may be found to present tuberculous lesions. Thus, in 8 out of 30 cases in 1 Miinchener medicinische Wochenschrift, Munich. 266 INFECTIOUS DISEASES. which both old and recent tuberculous lesions were absent H. P. Loomis found the bronchial glands infective to rabbits. It is obvious that the bacilli wrhich cause fresh cases come indirectly from other tuberculous subjects, and it has long been supposed that tuberculosis is a contagious affection; unlike small-pox, scarlatina, and other acute contagious diseases, however, tuberculosis is not trans- mitted by a single contact with a person ill of the disease. On the other hand, Flick and others have shown that persons who come into contact Avith, or who live in close proximity to, affected persons fre- quently fall victims to the same affection. (" The latter is as truly con- tagious as the former, differing only in degree.") We can safely say, therefore, that, though less liable to be transferred by contact than certain other affections, yet on account of the fact that tuberculosis usually pur- sues a chronic course there is every opportunity for prolonged or re- peated contact with resulting infection. Flick's elaborate topographic study of phthisis in the Fifth Ward • of the city of Philadelphia, extending over a period of twenty-five years, shows conclusively that consumption obeys the laws of infectious and contagious diseases. His researches furnish incontestable proof that the tuberculous virus is limited to centers, and that the latter owe their existence to previous cases in the same house or locality; that a house which has had a case of consumption a\111 probably have others within a few years, and may have a very large number of cases in rapid succes- sion ; and that approximate houses are considerably exposed to the con- tagion. The contagious theory of tuberculosis gains support from the fact that husbands have been frequently observed to contract the disease from their wives, and the latter, since they are more constantly con- fined in the house, to become infected yet more frequently from the former. Weber has observed the case of a tuberculous husband Avho lost four wives in succession, another Avho lost three, and four others who lost two each. In like manner, the statistical studies of Cornet, Niven, Baer, and others show that the disease spreads through factories, prisons, cloisters, and even among the physicians, nurses, and attend- ants in hospitals for the reception of tuberculous patients, producing a mortality-rate from this disease ranging from 45 to 75 per cent. Sev- enty-three per cent, of nurses up to the age of fifty die of tuberculosis (Whittaker). It is obvious that those who are engaged in making the beds, dusting and sweeping the rooms of patients, are most exposed; and on the other hand, better hygienic living among these classes of individuals, and improved hygienic arrangements in prisons, institutions, and hospitals, have been found to reduce, decidedly, the death-rate from this dread affection. This result is to be accounted for by the following facts : (a) There is thus established a greater tissue-resistance to the bacil- lus tuberculosis on the part of the persons exposed; and (b) The germs are thus to a greater extent disseminated. Obviously, then, in institutions in which the proper sanitary precautions are used there may be few if any instances of communication by contagion; and from the records of the latter, facts opposed to the contagious theory of the disease can readily be furnished. (2) Infection by Swallowing.—(a) That the milk of tuberculous ani- TUBERCULOSIS. 267 mals contains the bacillus, and that the use of contaminated milk may- infect the human subject, are av ell-established facts.1 Gerlach and Klebs long since observed the occurrence of the disease in animals fed Avith milk from cows affected Avith the so-called "pearl disease." It is not even necessary that the animal infected should have tuberculous mammitis (Ernst), though some are of contrary opinion (Flick, Sidney Martin, and others). The exact frequency of this mode of infection is not known, but there is some little clinical evidence to support it. Infected animals, especially coavs and pigs, that suckle their young very frequently trans- mit the disease to the latter, the infection usually resulting in intestinal and mesenteric tuberculosis. Hence it is obvious that the bacillus of tuberculosis is, in this instance, SAvalloAved and finds lodgement in the primce vice. Bang has even shown that butter made from the milk of tuber- culous coavs may be infectious. It is entirely analogous in the human race, bovine and human tuberculosis being one and the same affection; and hence the tuberculous mother is likely to transmit the disease to her suckling offspring. This explains, adequately, why abdominal tuberculosis is frequent in children. (b) The meat of a tuberculous animal may rarely be infectious, but the bulk of experimental evidence would seem to show that, unless the parts consumed are the seat of tuberculous deposit, infection does not foliOAv. The authentic instances that have been recorded in which human tuberculosis Avas the result of the use of infected meat are rare indeed; but that this is a possible source of tuberculous infection in man must not be forgotten. Again, the possibility of contamination during the course of preparation for the market, as well as during its transportation, must also be recollected. The experiments of Aufrecht, Chauveau, Klebs, Trappeiner, Parrot, and others show that tuberculosis may be communicated by incorporating Avith the food the expectoration from tuberculous patients. (3) Infection by Inoculation.—Tuberculosis may be transferred by direct inoculation, as shoAvn originally by Villemin's beautiful experi- ments upon the eyes of guinea-pigs. Infection may take place, though this is rare, through slight cutaneous lesions (cuts, fissures, excoriations, etc.), but only as the result of accidental inoculation of tuberculous matter. In this manner there is produced a local tuberculosis of the skin, as a rule. Rarely, the contagion is conveyed by the lymphatics to the glands in the vicinity of the point of infection. Persons who folloAv certain occupations are more or less liable to this mode of infec- tion—e. g. butchers, handlers of hides, dissectors of dead bodies, and, rarely, surgeons. Tuberculous virus may be introduced into the tissues through any open lesion, and the characteristic local change follow; thus, quite rare instances of transmission by inoculation occur in divers wTays (the v bite of a consumptive, a cut from the broken spit-glass of the latter, or even from his pocket-knife, as I have seen in one instance). The handkerchiefs, body- and bed-linen of the patient may infect by inoculation those Avho handle or Avash them frequently, if they chance to have a fissure or excoriation upon the hand. No doubt lupus also 1 See the elaborate statistical studies of Dr. George Cornet: " Die Tuberkulose in den Strafanstalten," Zeitschrift fiir Hygiene, Bd. x., 1891. 268 INFECTIOUS DISEASES. arises in the same Avay. Czerny has reported 2 cases of infection by transplantation of the skin ; Collings and Murray, 3 cases by tatooing (?). The contact of the lips of tuberculous operators with surgical wounds (as in sucking the latter) may be the means of transmitting the disease; in this way tuberculosis may be, and undoubtedly has been, communi- cated during the performance of the rite of circumcision. (4) Direct Hereditary Transmission.—In exceptional cases the bacillus is found in the fetus in utero. In such instances the disease may re- main latent, to break forth during childhood or later in life; and even though the fetus itself may display no evidence of tuberculosis, the fetal viscera may yet be infective to guinea-pigs (Birch-Hirschfeld). Lehmann 1 has reported an undoubted instance of intra-uterine infec- tion. The tuberculous mother died of tuberculous meningitis three days after the birth of her child, and the child lived twenty-four hours. In its spleen, lungs, and liver were found nodules resembling tubercles and containing tubercle bacilli in large numbers. Galtier has inocu- lated a pregnant animal with the disease, and found that the offspring was, in consequence, tuberculous at birth. The views of Baumgarten upon this question should be accorded careful consideration. This author believes that the contagion may be transmitted and become pathogenic at a variable period after birth—first, because the affection is very frequent in young children, even during the first months or weeks of life; and, secondly, because certain structures, not apt to be accidentally infected, are commonly the seat of tuberculous lesions in children—the bones and joints. He states that hereditary infection may occur in three ways: by the passage of bacilli through the pla- centa; by infection of the ovum from the internal tissues or fluids; and by infection carried in the fructifying sperm. After birth the ba- cillus may at any time either lose its vitality or take on a luxuriant growth. It is not known, hoAvever, in what percentage of these cases the lungs, intestines, peritoneum, and lymph-glands are free from tuber- culous lesions. Again, there are certain interfering conditions that must be borne in mind. Of these, two deserve to be emphasized: (a) the fact that a child born of tuberculous parents is more receptive to the tubercle bacillus than one born of healthy stock, and (b) that it is more liable to accidental infection, as by swallowing the virus (particularly if breast- fed) or by inhalation. The instances of direct transmission that have been traced definitely have occurred through tuberculous mothers. The observations of Csokor2 upon hereditary tuberculosis in cattle also corroborate this dic- tum ; but as the result of carefully conducted experiments by Vignal3 it is reasonably certain that invasion by heredity is very rare. Predisposing Causes.—(1) Race and Nationality.—The effect of nation- ality upon the receptivity to tuberculosis can be studied advantageously in America on account of the cosmopolitan character of the population. The tuberculous tendency on the part of Indians of this continent, among whom the death-rate from this disease is not less than 25 per 1 Berlin, klin. Woch., July 9, 1895. 2 Deutsche medizinal Zeitung, Berlin, Jan. 29, 1892. 3 La Semaine medicate, Paris, Aug. 1, 1892. TUBERCULOSIS. 269 cent., even in the most favorable climates, has been observed repeat- edly, and the fact that the negro race is highly receptive to tubercu- losis is also well knoAvn. Osier 1 gives the following corroborative sta- tistics : " Of the 427 cases of pulmonary tuberculosis at the Johns Hop- kins Hospital for the two years ending June 1, 1891, there Avere 41 cases in the colored—i. e. about 1 : 10. The ratio of colored to white of all patients in the wards has been 1:7." Sears 2 found that in 200 cases of tuberculosis nearly 50 per cent, belonged to the first and second generation of Irish immigrants. Such facts serve to show that differ- ences unquestionably exist as regards certain nationalities. (2) Hereditary Predisposition.—The percentage of cases in Avhich heredity can be traced has been variously estimated at from 10 to 40. As before intimated (vide Direct Hereditary Transmission), a child reared by tuberculous parents runs great danger of being infected acci- dentally ; and again, a person living in an infected house (with or with- out the presence of a tuberculous patient) is very liable to become infected, whether his antecedents give a tuberculous history or not. It follows that a correct estimate of the number of cases of phthisis in Avhich hereditary influence plays an etiologic part cannot be obtained. Too much importance has heretofore been attached to the influence of inherited constitutional peculiarities to the exclusion of other potent factors. Moreover, the latter may be acquired as the result of certain debilitating influences (childbirth, defective food-supply, close living- or working-rooms, etc.). An inherited tendency to tuberculosis is more unfailingly transmitted through the mother than the father. Children begotten of parents who are drunkards, or Avho suffer from certain chronic incurable diseases (syphilis, cancer, etc.) at the time of the birth of their children, are liable to inherit a condition of the system which renders them peculiarly liable to tuberculosis, unless the tend- ency is overcome by a proper environment, together with systematic physical training, during the first years of life. Moreover, persons who have the so-called tuberculous diathesis are frequent sufferers from catarrhal affections, especially of the respiratory organs. The latter condition forms a marked predisposing factor; yet, on the other hand, tuberculosis is met with in persons who are robust and have apparently well-formed chests and lungs. The older authors of medical text-books describe two types of con- formation—the tuberculous and the scrofulous. The latter has a heavy figure, thick lips and hands, large thick bones, and an opaque skin ; the former, a light figure, bright eyes, thin skin, oval face, and long, thin bones. The phthisical type of the chest will be referred to in connec- tion with the physical signs of pulmonary tuberculosis. In this connec- tion emphasis should be given to Cohnheim's view, which is for the greater part correct, to the effect " that the so-called phthisical habit is not an indication of a tendency to, but actually of the existence of, tuberculosis." Whilst the recognition of the tubercular diathesis has its practical bearing, it must be recollected that the term implies merely a " delicacy of constitution, incomplete growth, and imperfect develop- ment " (Fagge). 1 Text-book of Medicine, p. 204. 2 Boston Medical and Surgical Journal, April 4, 1895. 270 INFECTIOUS DISEASES. (3) Previous Infectious Diseases.—That there is no tendency to the tran- sition of other diseases into tuberculosis, as Avas formerly supposed, cannot now be questioned in view of the undoubted specific nature of the latter disease. Tuberculosis is, however, embraced among the sequelae of such affections as acute infectious and chronic diseases—influenza, measles, whooping-cough, typhoid fever, cirrhosis of the lungs, and diabetes mellitus (the latter disease involving a predisposition to the former)—for the reason that they render the tissue-soil, especially that of the respira- tory tract, more favorable to tubercular infection. It seems proper to mention here the fact that certain other diseases display an antagonistic effect (chronic valvular disease, pulmonary emphysema, etc.). Our know- ledge of the subject is as yet quite incomplete, but of an affection which occurs so very frequently and carries off so large a percentage of the population as tuberculosis a more accurate and extended knoAvledge would be welcomed by the profession. (4) Age.—This affects predisposition decidedly, though tuberculosis may occur at any or all times; and the relation between age and the distribution of the lesions has been previously indicated. Certain forms of tuberculosis are especially frequent in young children (meningeal, mesenteric, and lymphatic). Pulmonary tuberculosis is most common between twTenty and thirty. It is more rare during early childhood and in the aged, but may appear at any period of life, and the cases that occur in young children are apt to be more rapid in their progress. (5) Sex.—Predisposition has but slight relation to sex. Females are, however, somewhat more liable than males, and pregnancy in particular is a disposing factor. Again, when tuberculous females become preg- nant the progress of the affection is accelerated, and even more so by the period of lactation. Regarding tuberculosis as being pre-eminently a house-disease, females are more exposed to contagion than males, because they are more closely confined in-doors. (6) Climate and Soil.—Humidity of the soil and abundant atmospheric moisture increase the prevalence of tuberculosis. It is especially com- mon in regions where sudden variations of temperature, or protracted cold Avith dampness, prevail. This increase is most probably associated with a heightened vulnerability, due to an increased tendency to ca- tarrhal affections of all kinds (Osier). It has been shown that proper drainage of marshy districts has diminished, to some extent, the fre- quency of this disease (Buchanan), and, on the other hand, mountainous districts are often remarkable for freedom from the disease. Local Causes.—(1) Occupation.—Persons whose employment exposes them to different forms of irritating inhalations are particularly liable. In such, however, there is usually first developed a fibroid induration, and the latter in turn is folloAved by pulmonary tuberculosis. The con- tinual inhalation of an atmosphere laden Avith noxious particles, such as is met with in ill-ventilated and overcrowded working or living apart- ments, renders the tissue-soil more vulnerable. (2) Bronchial Catarrh.—An acute catarrh of the small bronchi pre- pares the soil for tuberculous infection. Frequently, hoAvever, this is the first step in tuberculosis, since the latter disease almost invariably begins as a local catarrhal process, involving the smaller apical bronchi. TUBERCULOSIS OF THE LYMPH-GLANDS. 271 The fact may here be pointed out that gastro-intestinal catarrh increases the bodily receptivity for tuberculosis. (3) Tubercular Pneumonia.—In like manner, pulmonary tuberculosis may follow an unresolved pneumonia, but such cases are, as a rule, in- stances of tuberculous pneumonia primarily. (4) Hemoptysis.—According to some authors, hemoptysis is potent in producing pulmonary tuberculosis. It is, however, certain that in most instances in which it appears to precede phthisis, and have a causal con- nection with it, it is in reality a symptom of existing pulmonary tuber- culosis. (5) Pleurisy may be, though rarely, the starting-point of phthisis. Its predisposing effect may be attributable to compression of the lung, thus interfering Avith the respiratory excursions, or to the bronchitis which is frequently associated. Pleurisy sometimes initiates fibroid in- duration, which may then terminate in a tuberculous affection; but the fact is to be emphasized that a very large proportion of the cases of apparently primary pleurisy are tuberculous in nature. (6) Intrathoracic Tumor.—Tuberculosis is often associated Avith intra- thoracic tumors, and especially Avith aneurysm. Fehde1 has reported 3 interesting cases of the kind. (7) Congenital or acquired contraction of the orifice of the pulmonary artery predisposes markedly to tuberculosis. (8) Trauma.—Injuries to the chest-wall, with or without laceration of the lung, are frequently followed by pulmonary tuberculosis. The explanation of this association is to be found in the fact that trauma increases largely the susceptibility of the parts injured by diminishing phagocytic activity—the natural power of resistance. It is a familiar observation in surgical practice that after injuries to, or operations on, joints, tuberculosis frequently ensues. Again, operations upon tuberculous lesions are succeeded by general tuberculosis—often acute—in about 8 per cent, of the cases. Tuberculosis of the Lymph-glands. (Scrofula.) Scrofula implies tuberculous infection, and scrofulous material inocu- lated upon susceptible lower animals, especially guinea-pigs and rabbits, in\rariably causes tuberculosis. The virus is, however, less virulent than that derived from other sources, and this explains the slow progress and often latent character of tuberculosis of the glandular system. A major predisposing factor is age, this form of tuberculosis preponderating in children. Hecker, from an examination of the records of the Munich Pathological Institute, found that in 147 cases of tuberculosis among children the lymphatics Avere affected in 92 per cent.; and it is generally conceded that in young adults tuberculous adenitis is not uncommon/and that it is rarely met with during and after the middle period of life. The lesions generally remain limited to the glands first infected—i. e. the cervical, mesenteric, etc., as the case may be—and this for the reason that the natural powers of resistance in the tissues are often able 1 " Lungentuberculose mit Brusthohlengeschwulste," Inaug. Diss., Leipzig, 1894. 272 INFECTIOUS DISEASES. to oppose the march of the destructive forces. Another predisposing condition is an acute or chronic catarrh of the mucous membranes. The cases are all divisible into tAvo groups: (1) Local tuberculous adenitis, and (2) general tuberculous adenitis. (1) Local Tuberculous Adenitis.—(a) Cervical.—This is the most fre- quent form, and is especially common among children. Of 2035 per- sons examined by Valland, enlarged cervical glands were found between the ages of seven and nine in 96 per cent.; between ten and twelve in 96.1 per cent.; betAveen thirteen and fifteen in 84 per cent. ; between sixteen and eighteen in 69.7 per cent.; and between nineteen and twenty-four in 68.3 per cent. Tubercle bacilli were found in the cer- vical lymph-glands in about 68 per cent, of adults. Negroes are found to be more prone to the affection than whites. Etiology.—I have stated before that tubercle bacilli are sometimes found on the nasal mucous membrane of healthy persons. The pres- ence of an acute or chronic catarrh of the nasopharynx may now lower the resistance of the tissue-cells, so that the bacilli may gain access to the lymph-current, and through the latter to the neighboring glands, setting up tubercular adenitis. Though often the seat of tuber- cular invasion, the cervical lymph-glands do not furnish a highly favor- able soil for the groAvth and development of the bacilli, and hence the tendency toward latency of tuberculous disease of these organs. The tonsils, OAving to their free communication with the atmosphere, in which there is a wide diffusion of tubercle bacilli, may be primarily infected. But here also, as in the case of other glandular structures, there is a tendency for the affection to become latent, for the reason that the tissue-soil after a prolonged contest generally gains the ascendency over the invading bacilli. The latter may, hoAvever, under certain favorable conditions, break doAvn the barriers opposed by nature and effect a lodgement elsewhere, or even become widely diffused through the economy. Thus Kinckmann in 64 autopsies found 25 cases of tuberculosis, in 12 of Avhich the tonsils Avere affected. A third mode of infection of the cervical lymph-glands is through the medium of slight injuries and abrasions of the skin or certain forms of skin-eruptions (eczema, etc.). These serve as doors of entrance for the bacilli, which find their way into the neighboring lymph-glands through the lymph-channels. Compared with infection from within, this mode is most probably much less frequent. Symptoms.—The main feature is a visible enlargement of the af- fected cervical glands, chiefly the submaxillary. At first the glands are too small to be even palpated ; later, they can be felt as small, firm tumors underneath the skin. By and by they appear as visible protuber- ances, ranging in size from that of an English walnut to that of a hen's egg or even larger. The skin over the enlarged gland is freely mov- able, as a rule ; less frequently it becomes adherent—an indication of suppuration. When an abscess forms and is alloAved to open spontane- ously, there remains a chronic discharging sinus. Suppuration is at- tended with fever, anemia, and emaciation. In well-marked cases the separate tumors coalesce, forming large and irregular masses. The affection is usually bilateral, though almost invariably it is more marked on one side than on the other. TUBERCULOSIS OF THE LYMPH-GLANDS. 273 Not infrequently, in addition to the enlargement of the submaxillary, post-cervical, and supraclavicular glands, there is also involvement of the axillary, as was the case in a fatal instance in my own practice. The patient was a male child, eight years of age, who developed pul- monary tuberculosis. In such instances it may reasonably be assumed that the bronchial glands also become implicated, and frequently become the exciting cause of the lung-tuberculosis. The diagnosis is based upon the history, the associated evidence of the tuberculous diathesis (keratitis, conjunctivitis, eczema of the scalp or face, nasopharyngeal or bronchial catarrh, etc.), together with the enlargement of the superficial cervical glands. Bacilli have occasion- ally been found in the purulent discharge from abscesses. The course of this affection is exceedingly sIoav, often extending over a number of years. Many cases, however, recover if surgical in- terference be employed. On the other hand, neglected cases are a menace to the life of a patient, since they may be followed by diffusion of the bacilli, with the development of a fatal form of disease. (b) Bronchial.—Tuberculosis of the bronchial glands may be primary, or secondary to infection of the lungs, and it is commonly preceded by or associated with bronchial catarrh, Avhich is its chief predisposing cause. The primary form is met Avith frequently in young children, the medias- tinal lymph-glands being affected uniformly in 127 cases at the New York Foundling Hospital (Northrup). The bronchial and tracheal glands are the receptacles for all foreign substances, including the tubercle bacilli that are not dealt with by the broncho-pulmonary phagocytes. After infection Avith tubercle bacilli the lymph-glands become swollen, tumefied, and are the seat of caseous change; later they may undergo calcification or proceed to abscess-for- mation. The latter may rupture either into the lungs, into the trachea or the bronchi, or into a pulmonary blood-vessel. Symptoms.—If a fistulous communication be established with the air- passages, cough and expectoration of purulent material, blood, and caseous matter containing bacilli will be noted. Secondary infection of the'lung may occur in this manner. When rupture takes place into a vessel systemic infection promptly follows. Tubercular adenitis involving mediastinal lymph-glands may also lead to infection of the pericardium and then proceed to tuberculous peri- carditis. (c) Mesenteric (Tabes Mesenterica).—This may be primary or sec- ondary, the latter being very common and a secondary infection to intestinal tuberculosis. The former is rare, however, and the intestinal catarrh with Avhich it is associated is doubtless tuberculous in the vast majority of cases. The mode of infection has already been pointed out. The lesions pre- sented are similar to those met Avith in tuberculous bronchial glands. The symptoms are not always distinctive, and may be entirely nega- tive during the life of the patient; hence the condition is often incident- ally discovered during the post-mortem examination. The local symp- toms when marked are due in the main to an associated peritonitis. The abdomen is painful and more or less swollen. Peritoneal effusion is present, and sometimes sufficient in amount to be detected by the cus- 18 274 INFECTIOUS DISEASES. tomary physical signs. Large and small nodules may sometimes be felt, Diarrhea is a marked and obstinate feature and is usually due to tubercu- lous intestinal ulcers. Fever of an intermittent type is almost constantly present, causing emaciation, and the objective changes (pallor of skin, mucous membrane, etc.) due to anemia become pronounced. This form ■of tuberculosis may persist as a local condition, but there is danger of extension to other organs (pleura, lungs, etc.). On the other hand, in the adult pulmonary tuberculosis may be followed by involvement of the mesenteric glands without involvement of the intestines, and in such in- stances there occurs an extension by contiguity along the course of the lymphatics that pass through the diaphragm, and finally, in adults, pri- mary tuberculous new groAvths may be met Avith in the mesenteric glands. Diagnosis.—A probable diagnosis can usually be made if careful at- tention be paid conjointly to the symptoms, physical signs, and course of the affection. The detection in a child of a tumor Avhich may be moderately hard, doughy, or even fluctuating will aid materially in the diagnosis, and Avill also afford evidence of tuberculous disease in other organs. (2) General Tuberculous Adenitis.—This term implies tuberculous dis- ease of the lymph-glands throughout the body, Avith little if any involve- ment of other organs; this is a rare condition. The affection may begin as a local tuberculous lymphadenitis, nearly all of the rest of the glands of the body becoming secondarily implicated. The primary seat of the trouble is perhaps most frequently the cervical lymph-glands, though in one instance observed by myself the mesenteric glands first became affected, the case terminating in pleuro-pulmonary tuberculosis. Symptoms and Diagnosis.—There is protracted fever, the tem- perature being of the remittent or intermittent type. Wasting and debility are progressive until the patient presents a decidedly puny aspect, while the lymph-glands that are accessible to inspection and palpation are more or less enlarged and manifest a marked tendency to suppuration. The affection is usually chronic, though very exception- ally it may exhibit an acute course. One of the chief dangers over- hanging the sufferer in this affection is that, owing to liberation of the bacilli, the meninges or the lungs may become tuberculous; these cases may also terminate unfavorably from asthenia. Cases in Avhich the glands are but little enlarged, Avhile the general features are marked, are puzzling. On the other hand, when the superficial lymph-glands are greatly enlarged the affection may bear a striking resemblance to Hodgkin's disease. Acute Tuberculosis. This form of tuberculosis is characterized anatomically by the rapid development of miliary tubercles in many and widely-separated parts of the body. In some instances the new groAvths are pretty evenly distrib- uted through all the organs of the body, manifesting the clinical symp- toms of an acute general infection. In other instances there is a tend- ency to centralization of tuberculous growths, as, for example, in the lungs (pulmonary variety) or in the meninges of the brain and spinal cord (meningeal variety). ACUTE TUBERCULOSIS. 275 Pathology.—The fact is to be emphasized that someAvhere in the body there is an old tuberculous focus. Apart from this primary lesion, the anatomic changes consist in the Avidely disseminated miliary tuber- cles. Their most frequent seats are the lungs, liver, and spleen ; less frequently, the marrow of the bones, the heart, the choroid, and the meninges. In some of the organs, particularly the meninges, lungs, etc., the tubercles may be readily perceived by the naked eye, Avhile in others they frequently cannot be detected Avithout the aid of the micro- scope. It must not be forgotten that in some of the more protracted cases the nodular tubercles may groAv into foci of considerable size, ranging from that of a lentil to that of a pea. Etiology.—This has been, in the main, given in connection with the general etiology of tuberculosis (vide supra), though a feAV special points remain to be adduced. The acute forms of tuberculosis are decidedly more frequent during infancy and childhood than during adult life, and with feAv exceptions the cases are secondary to a local tuberculous focus in one or more lymph-glands (tracheal, bronchial, mesenteric, etc.) or in the lungs. More rarely a pre-existing tuberculous focus in the kidneys, the bones, or the skin may give rise to the affection, as may the occur- rence of certain other acute infectious diseases—such as measles, whoop- ing-cough, and influenza, in children, and typhoid fever and lobar pneu- monia, especially Avith delayed resolution, in adults. Modes of Infection.—Most frequently there is established a fistulous connection between the local tuberculous focus and a vein. The tuber- cle bacilli thus find their way into the circulation, and general infection promptly folloAvs. This occurs in a great proportion of the cases in the thorax, a pulmonary vein being opened in such instances. A second mode of infection, though decidedly more rare than the above, is the rupture of a tuberculous focus into the thoracic duct, in Avhich case the tuberculous material passes almost directly into the subclavian vein. In these cases, according to Ponfick, the disease is less rapid in onset and less acutely evolved. Clinical History.—That miliary tubercles may exist in many organs of the body (liver, heart, etc.) without giving rise to symptoms is a noteworthy fact. Cohnheim and Manz have discovered miliary tu- berculosis of the choroid Avhen the condition Avas only detectable Avith the aid of the ophthalmoscope. The following forms of the disease may be distinguished: General Miliary Tuberculosis. (a) TYPHOID FORM. The symptoms are those of a general infection of the body, there being in most cases a period of incubation, during which the patient complains of malaise, headache, chilliness, feverishness, and increasing debility. Rarely, the onset is comparatively sudden. The reaction of the nervous system against the poison, which is now scattered to all parts of the body, is shown by such symptoms as the fever, which rapidly increases, a rapid, feeble pulse, and mental dulness or delirium. The tongue becomes dry, and sometimes also brown. The respirations are accelerated, and there is more or less cyanosis, with which symptom is 276 INFECTIOUS DISEASES. associated a peculiar and characteristic pallor of countenance. Coinci- dently with the febrile exacerbations the cheeks may wear a circum- scribed blush. Among the rarer early symptoms is epistaxis. The patient soon becomes profoundly prostrated or experiences a feeling of anxiety: if, as sometimes happens, the course is protracted, weakness, anemia, and especially emaciation, are well marked and assume diag- nostic importance. These cases sometimes pass into the pulmonary or the meningeal form, the patients often succumbing speedily to such localized developments. Fever.—The temperature usually pursues a high range, although there are not a few cases in Avhich the entire course is afebrile. Again, it occurs not infrequently that the temperature is normal or nearly so for a short period. The usual temperature-curve ranges at first between 102° and 104° F. (38.8°-40° C), and then continues to rise, with the development of the serious general condition in a Avay exactly similar to that observed in typhoid fever. In many instances the fever is irregularly remittent, at least at intervals, if not so constantly. Thus, periods of irregular fever may alternate Avith others of continued, and later deeply remittent or distinctly inter- mittent, fever. Nervous Symptoms.—In most cases the nervous symptoms are not prominent. In a smaller number headache, vertigo, delirium, and often stupor, become marked at an early stage and may persist. They are due to the general infection. Circulatory System.—The pulse is small, and its rate is out of pro- portion to the fever, varying from 100 to 140 or higher. It may be- come irregular, particularly if the meninges be involved. Respiratory System.—The breath is someAvhat hurried and labored; there is a cough, but it is not annoying as a rule; and there is a slight expectoration, which is not characteristic. If there be present simul- taneously in the lungs an old tuberculous focus, the expectoration may be more profuse and typical. The bacilli are also absent from the spu- tum unless an old tuberculous lesion pre-exist in the lungs. The physical signs are those of a moderate, diffuse bronchitis, though local signs of consolidation or pleurisy may develop late in the course of the affection. On the other hand, such signs may be evidences of an old tuberculous affection. Digestive System.—As before noted, there are anorexia and a dry tongue (symptoms due to the systemic infection), Avhile A'omiting may occur at the outset and excessive thirst is common. The spleen usually becomes enlarged, though only to a moderate extent. Ocular Symptoms.—The important symptom presented by the eye is the presence of choroid tubercles, which may be determined by a care- ful ophthalmoscopic examination. Their absence does not militate against the diagnosis of general miliary tuberculosis, since they may be too few to be detected, or possibly absent altogether. Their demon- stration is always exceedingly difficult, and only possible with the skilled ophthalmologist. Diagnosis.—This form of tuberculosis is often with difficulty dis- criminated from typhoid fever, but in the following table I have endeav- ored to contrast points of dissimilarity : ACUTE TUBERCULOSIS. 277 Acute General Miliary Tuberculosis. Typhoid Fever. Family history of tuberculosis, or pres- Coexistent with an epidemic or following ence of a pre-existing focus. previous cases of typhoid. Evolution of the disease not characteris- Evolution of the disease is character- tic, istic. Epistaxis rare. Epistaxis a common early symptom. Fever-curve of decidedly irregular type. Temperature-curve of the continued type. Pulse rapid, out of proportion to fever. Pulse often dicrotic ; slow in proportion to fever. Respirations rapid and labored. Respiration moderately increased. Face dusky, with peculiar pallor. No duskiness of face. Abdominal symptoms are not suggestive. Abdominal symptoms (stools, enlarged spleen, tympanites, etc.) suggestive. No characteristic eruption. The eruption (appearing in successive crops) is pathognomonic. Knee-jerk present or absent according to Knee-jerk never wanting. involvement of meninges. Leukocytosis present (if there be sup- Leukocytosis absent. puration). Choroid tubercles may be detected. Choroid tubercles absent. Tubercle bacilli rarely demonstrable in Cultures from punctured spleen may the blood. show typhoid-bacilli (dangerous pro- cedure). Hemorrhage from bowels very excep- Hemorrhage from the bowels common. tional. Perforative peritonitis absent.1 Perforative peritonitis often present. (b) PULMONARY FORM. Though all gradations betAveen the typhoid and the pulmonary types occur, the latter should be recognized and briefly described. It may develop suddenly, the ushering-in symptom being sometimes a chill, though more frequently there is a premonitory period, during Avhich the general health fails materially. The affection may follow promptly upon some acute illness, such as measles or Avhooping-cough, in children, in which there has been marked catarrhal bronchitis. The respiratory symptoms are early prominent, and later preponder- ate in the clinical picture. From the start there is dyspnea, and this gradually increases until the respirations become rapid (40 to 60 per minute). When dyspnea becomes pronounced the face assumes a cha- racteristic cyanotic pallor. The cough, at first, is moderately severe, but soon it becomes troublesome, being noAv frequent and attended with a slight expectoration, which is non-characteristic. The physical signs are those of broncho-pneumonia, and the latter may or may not be preceded by the signs of general bronchitis. With the onset of broncho-pneumonia there appear spots that yield either dulness or a tympanitic resonance on percussion, and broncho-vesicular breathing with numerous subcrepitant rales on auscultation. The general symptoms are marked from the beginning. The fever is high—from 103° to 105° F. (39.4c-40.5° C.) or often higher. The pulse ranges from 100 to 140, is small, feeble, and sometimes irregular, and it may be more rapid still during the advanced stage of the affec- tion (see Fig. 25). Cerebral symptoms rarely appear. 1 See also Differential Diagnosis of Typhoid Fever. 278 INFECTIOUS DISEASES. The course, as a rule, is more prolonged than that of general miliary tuberculosis, except in children, in whom it often runs an exceedingly acute course. As the end approaches the signs of suffocation are gradu- ally intensified, and finally lead to a fatal termination. Diagnosis.—The diagnosis is difficult; but a family history of tuberculosis, a knowledge of the pre-existence of a tuberculous focus or of an antecedent predisposing affection, Avill aid in its recognition. Tubercle bacilli are perhaps not demonstrable in the sputum unless an old tuberculous lesion coexist. In doubtful instances, however, an attempt should be made to detect the bacilli in the blood. Occasionally either tuberculous meningitis or peritonitis supervenes, and aids in removing the doubt, and in a small percentage of the cases choroid tubercles are detectable. These points, together with the more marked general symptoms, will usually aid the clinician in distinguishing this variety of tuberculosis from non-tuberculous broncho-pneumonia. (c) CEREBRAL OR MENINGEAL FORM (TUBERCULOUS MENINGITIS). This variety is of quite frequent occurrence, appearing in not less than 50 per cent, of the cases of miliary tuberculosis. When it devel- ops the symptoms referable to other organs than the meninges are in abeyance. With reference to the etiology of this form one fact needs to be emphasized—namely, that most cases are observed between the ages of two and seven years ; it may, hoAvever, be met Avith at any time of life. The affection frequently has its origin in tuberculous bronchial glands (Jacobi), and the history of a fall is common. A fe\v cases have been found to be associated with erythema nodosum. Exceptionally the meninges are primarily involved. Pathology.—The chief site of the tubercles in children is the pia mater at the base of the cerebrum (basilar meningitis), whilst in adults the pia at the vertex is more apt to be involved. The membrane sur- rounding the tubercles may not be inflamed, there being a simple tu- berculous deposit. On the other hand, more or less inflammation, with sero-fibrinous or fibrino-purulent exudation, is generally present in the region of the base. This exudate is usually abundant in the Sylvian fissures, and may find its way to the external surface of the hemispheres. It is gray in color, transparent, and gelatinous, and contains in its meshes the tubercles, which appear as grayish-white bodies, and which, in cases of equal severity, may be either numerous or scanty. They may be scarcely visible to the naked eye, but may vary from the size of a pinhead to that of a French pea. The branches of the Sylvian artery may be implicated, either oAving to the direct pressure of the exudate or to the obliterating arteritis produced by a tuberculous infil- tration. The pia looks like wet blotting-paper over the quadrangle at the base (Gray). Elsewhere it is thickened and opaque, though easily detachable. Osier says: " The arteries of the interior and posterior perforated spaces should be carefully withdraAvn and searched, as upon them nodular tubercles may be found Avhen not present elseAvhere. In doubtful cases the middle cerebral arteries should be very carefully re- moved, spread on a glass plate with a black background, and examined Avith a Ioav objective. The tubercles are then seen as nodular enlarge- DAY OF DISEASE XI XII XIII XIV XV XVI XVII XVIII XIX XX XXI XXII XXIII XXIV TIME OF DAY A. M. 6 12 6 12 6 it 6 12 6 ,2 6 12 6 12 6 12 6 12 6 12 6 12 6 12 6 12 5 12 P. M. 6 12 6 12 6 12 6 12 6 12 6 12 6 12 6 12 6 12 6 12 6 12 6 .2 6 12 & RESP. PULSE TEMP. 43 170 108 A 42 160 / J / «< 5 41 107 l / / I \ ',, r L / 40 \ / t k h 150 \ __, 1 t \ I A- ^ 39 \ :z \ * A 106 J f\ ~L 1 7j 1 ll J. 38 1 T L_ 27 1, j( 1. 1 l- r f r - p if 37 140 - — 1 V P v v "A zf =t r r 1 36 105 \ X T «\ i z \ I it / xlAjaJ Aj_L HM 35 r -11 1 / i ST / 1/ Tl V V 130 IT A IJ 3 £ "-^ , |//l l\/ -4- 34 / ^s '' ' 4 104 A . / 3 I ^ , , / — 33 M \ i, I -2 ¥ V / ~f w/ I I 32 120 / \ - M1 ' A V H j i I I / : /II i 31 103 ( A T - A /-|j—f- / \ ' I / iii i A—1 = —I i r~\ 'A I I 30 J_ \ ~t ~if/-lr 1 \ M J-j 110 - A-\ 1—1 — "/ \ it —V' -V 29 102 | \ /, I "V ~ /-|—' \ r\ ---^"|- 1" -j: 1 -/'— i / \" 28 / 1 \ 1 1 \ X V P \7u — /;-■" —LA J-j----j— 1 27 100 - j- --Ii-- V -fr- -— —T~ "r~T~ ~ r ■ 28 101 - ----;!/ I --;- |- :xzl" m '.',£jE. =H ■ l/ !l _. — I L i~_L -1 4 fZ 1 3 - - — _________ i 24 90 T n "I" — 1 r" ■ i ■ 100 ' :/'m=E ~i~"l~ ~i~ ~f'<'' ■;j"H~ n 23 i i I I i - 4- — 22 80 / - -j- - |- - f-. ■:— 2 i 21 99 1" T"'l" 'M i 1" i 1 i -- — i "_ "TV ~ i r i i -|— n - i _r_. i !-i- $. i 20 - 70 - i i 19 i i i i i NORMAL 98 1 I " M "1 ~ 1 " ~i'—r 18 i i _[_ t 17 60 i "' I i 16 97 1 I I - - i i - - -\- 1 I I H-4- — i _ ._ 1j 1 i i r~ 1 1 — "' -1-1- —i— 1 i i 1 1 i i 1 1 i Fig. i">.—Chart of a case of acute pulmonary tuberculosis. Mrs. M---, aged twenty years. respirations. Black, temperature ; red, pulse ; blue 280 INFECTIOUS DISEASES. ments on the smaller arteries." Involvement of the chief vessel- that nourish the walls of the ventricles and the ependyma. and stretch from the vermis cerebelli forward over the quadrigemina, explains the con- stant presence of a turbid fluid in the ventricle-, with softening: of their walls. As the result of undue intraAentricular pressure the cerebral convolutions become more or less flattened, with effacement of the sulci. The cortex, to a variable depth, is generally the seat of red softening, and more rarelv of white softening alone. The tuberculous infiltration involves the cranial nerves. Histology.—The tubercles grow in the perivascular sheaths, which are often distended with lymphoid and epithelioid cells, and there is observed not infrequently a thrombosis of the arteries and of the venules of the pia. obliterating their lumen. The pia mater is gradu- ally thickened through cellular infiltration, and in a small proportion of the cases the spinal meninges are similarly involved, chiefly in the cer- vical portion of the cord. Symptoms.—There is a prodromal period which lasts one or more weeks, during which the patient (usuallv a child) is pale, peevish, bas headache and photophobia, and grinds its teeth during sleep ; the tongue is coated, appetite impaired, and there may be occasional vomiting. either propulsive or regurgitative. Constipation is present and may be marked. Among rare premonitory symptoms are slight hyperesthesia of the abdomen and a diminished urinary secretion. A tendency to emaciation is quite constant. These prodromal symptoms present varia- tions as to their number and combinations in different cases. In feAV instances only is the onset acute. The symptoms usually indicate basic meningitis, and at first there is associated considerable mental excite- ment ; later there are pressure-symptoms (caused by the exudate), with total loss of the mental faculties. (1) Stage of Cerebral Excitement.—The invasion is generally gradual, or even quite insidious, its most characteristic phenomena being severe vomiting, marked headache, and chills followed by fever. Certain other symptoms now arrest the attention, such as extreme irritability, scream- ing, and great obstinacy, and occasionally drowsiness appears early. When the onset is sudden the disease may be disclosed by convulsions, paral- ysis, wild delirium, or coma. The established disease exhibits certain distinctive features. The pain is often most excruciating, causing the child to utter short penetrating screams (hydrocephalic cry), and in rare instances the sharp cries may be continuous and lead to physical exhaus- tion. The headache is increased by light, noise, or movement. Vertigo is common; the pupils are contracted at this period; the face pales and then flushes; the pupils alternately dilate and expand; and the expres- sion is sometimes sad. though more often stupid. Generally hyperes- thesia or dysesthesia may appear, and there may be a slight mind-wan- dering at night, though active delirium is rare.' Tdches cerebrales may be obtained, but are not characteristic. The patient is intolerant of every form of disturbance. All the symptoms of the prodromal stage are now aggravated; slight muscular twitchings and sleep-starts occur; the vomiting is apparently causeless, and may be frequently repeated: and constipation persists. Fever is present, but is of slow development, and rarely rises higher ACUTE TUBERCULOSIS. 281 than 102° or 103° F. (39.4° C.) in the evening. The skin is dry and harsh, as a rule. The pulse is slow or moderately accelerated, but soon quickens to 120 or even 130, and later it may be irregular. At times the pupils are unequally contracted, and ptosis may also be looked upon as an early sign. (2) Second or Transitional Stage.—The symptoms of cerebral irrita- tion now abate, the patient becoming more quiet, Avhile mental dulness often supervenes. The vomiting and headache subside gradually, and the child cries out only occasionally. The abdomen is now distinctly scaphoid and the head occasionally retracted. Constipation is obstinate. The evidences of localized organic foci, such as slight tAvitchings of the muscles of the face, followed by strabismus, ptosis, or paralyses of the face or limbs, may appear. Generalized convulsions may occur, and muscular tremors and athetoid movements may appear. Both pupils (or one only) may be dilated as intracranial pressure develops; patchy flushing of the face is common. The respiration is now irregular and sighing. (3) The Stage of Paralysis.—On account of the exudation the mental faculties are abolished, so that the patient is comatose, though convul- sions or localized spasms of the muscles in different parts of the body (neck, back, limbs, etc.) may be observed. Optic neuritis develops, Avhile the paralysis of the ocular muscles above noted deepens. The pupils are dilated, the eyes are partly closed, and the eyeballs at inter- vals sloAvly and alternately move in a lateral direction. Hemiplegia sometimes develops, and more rarely monoplegia, affecting the face or one of the extremities. There may be paralysis of the third nerve, with involvement of the face, hypoglossal nerve, and limbs on the opposite side (a combination of symptoms first observed by Weber), consequent upon a lesion localized in the internal inferior portion of the crus. Monoplegia of the right side of the face has been observed in a few instances, associated with aphasia. Exceptionally aphasia and brachial monoplegia have been combined. The temperature in the early part of this stage usually rises to 103° F. (39.4° C.) or higher, but later it may drop to a subnormal level, and in rare instances as low as 94° F. (34.4° C). Immediately preceding the fatal termination the temperature may rise to 106° or 107° F. (41.6° C), the pulse becoming frequent, small, and irregular. Gradual anesthesia comes on with general muscular relaxation. Occasionally a typhoid state (great prostration, dry tongue, diarrhea, etc.) may develop, and Cheyne-Stokes respiration is almost invariably present, preceding the fatal event. Leukocytosis has been observed in all stages of the disease. Ophthalmoscopic Examination.—The ophthalmoscopic appearances sometimes form important points in the diagnosis. At first hyperemia of the disk is noted, and later the changes belonging to neuritis (swell- ing and striation) appear, while rarely tubercles may be detected in the choroid.1 Clinical Types.—(a) Mild Type.—The marked or alarming symp- toms (tetanic rigidity of the muscles, convulsions, and paralysis) develop at a late period. In this class should be placed those cases in which the 1 The differential diagnosis is given in the section on Meningitis. 282 INFECTIOUS DISEASES. meningitis is but feebly indicated—e. g. when it is but a small factor in the condition of acute general tuberculosis. (b) Malignant or Rapid Form.—This type is comparatively rare, oc- curring most frequently in adult life, while the lesions have their seat almost exclusively upon the convexity. The onset is marked by the most frightful tetanic convulsions, wdiich precipitate a fatal termination in a couple of days. (c) Chronic Type.—Cases pursuing a chronic course are rarely en- countered, and the symptoms usually point to localized cerebral lesions (Jacksonian epilepsy, etc.). Prognosis.—The disease lasts from two to four or five weeks, though chronic cases may continue for several months. When the con- vexity is implicated, however, the duration is only one or two Aveeks. It should be emphasized that frequently in the course of well-marked cases a decided remission in the leading symptoms occurs, so that con- valescence is suggested; but this is deceptive, and is almost invariably followed by a renewal of the unfavorable features of the affection. A few cases only are recorded in medical literature as ending in recovery. Freyhan has reported a case with recovery in Avhich the diagnosis was proved by puncture of the spinal canal and the withdrawal of fluid, in the sediments of which tubercle bacilli were found. A. Jacobi has met with 2 cases that terminated favorably, and Leube has also reported a case in which the symptoms were characteristic, and at the autopsy, some years later, old tuberculous lesions wTere found in the meninges. It is to be recollected, however, that the course of tuberculous menin- gitis is probably uninfluenced by human agency. Acute Pneumonic Phthisis. [Acute Phthisis ; Florid Phthisis; Galloping Consumption.) This may be primary or secondary, the latter form being consequent either upon a localized tuberculous area in the lung, tuberculous pleurisy (acute or chronic), tuberculous peritonitis, or tuberculous disease of some other organ. Acute phthisis may occur at any age, though it is rela- tively more frequent in childhood and early adult life, but Avhether primary or secondary, the infection of the lungs is rapid. Pathology.—Two forms may be recognized: (1) This reveals the appearances of an acute lobar pneumonia, one lobe only being impli- cated, as a rule, though sometimes the whole lung is involved. The process leads to a destruction of lung-tissue, so that a section may show the existence of cavities. The latter are usually small, while surround- ing them may be seen tubercles in hepatized tissue, and here and there caseous masses of a yellowish-white color may be visible. These often indicate old or pre-existing foci. It is sometimes exceedingly difficult to distinguish a tuberculous croupous pneumonia from the ordinary form, and the most careful inspection may fail to reveal the presence of ele- mentary tubercles in the acutely consolidated tissue. In cases in which this disease is suspected, however, the opposite lung, the bronchial glands, the peritoneum, and other organs should be carefully examined. The lesions presented by cases that have run a long course are somewhat characteristic, though not always the same. If the case has ACUTE PNEUMONIC PHTHISIS. 283 had a duration of eight or ten weeks, apical softening with more or less extensive cavity-formation often occurs. Less frequently, a lobe or an entire lung is found to be consolidated throughout, u and converted into a dry, yellowish-white, cheesy substance, in which condition it may remain till the end." (2) Presenting the Appearances of Broncho-pneumonia.—This vari- ety is more common than the previous, especially in children. The evidences of bronchitis affecting the finer tubes, together with con- solidation of the lobules to Avhich the tubes lead, are striking. As in ordinary broncho-pneumonia, so here, the solidified areas appear as grayish-red masses in the early stage, while later they are of an opaque- Avhite. The products that fill the air-cells may caseate and break doAvn, with the formation of irregular cavities that vary in size. When large areas are involved they are the result of the fusion of contiguous smaller areas of hepatized tissue. The trouble often begins in the upper lobes and spreads doAvnward, though not infrequently the loAver lobes are most extensively involved. In not a few cases the masses are small, multiple, and Avidely dissem- inated throughout the lungs, and miliary tubercles in the lungs or pleurae are associated Avith the broncho-pneumonic lesions before de- scribed. In nearly all cases signs of pleurisy may be noted, as is shoAvn by pleural adhesions or by .deposits of lymph on the pleura. The bronchial glands are also usually infected, and, particularly in chil- dren, are the seat of tuberculous processes. Baumler has called attention to a type of tuberculous inhalation pneumonia consequent upon hemoptysis, the blood and contents of the cavities being draAvn into the finer tubes in respiration. This form of broncho-pneumonic phthisis sometimes folloAvs pulmonary tuberculosis in the early, though more often in its late, stage. On microscopic ex- amination tubercle bacilli are found, though rarely in abundance, in the infiltrated masses and in the walls of the cavities. Clinical History.—(1) Acute Cases.—Preceding the attack, the patient may have " taken cold " or have been in a run-doAvn state; more often, hoAvever, he has been apparently healthy. The onset is sudden, marked by more or less rigor, pain in the side, fever, cough, and great prostration, and there may be bronchial hemorrhage which may last one or more days. The total amount of blood expectorated may be consid- erable. In the majority of cases the expectoration is mucoid at first, and then becomes rusty-colored, often containing tubercle bacilli, though at first they may be absent, and indeed not appear until late in the disease. Dyspnea appears early, and may soon become extreme, and the fever quickly rises to 104° F. (40° C.) or over. It may be of the continued type or it may early assume the remittent or hectic type, and Avith the latter forms of fever, which usually begin about the end of the first week, are associated night-sweats and rapid emaciation. The prostration of the vital poAvers is now extreme. The expectoration is more abundant, muco-purulent, and often greenish-yellow in color. In the course of one or tAvo days after the onset we obtain physical signs that vary Avith the extent of the lesions. Usually, as before stated, these cases present the anatomic appearances of acute lobar pneumonia—viz. the complete consolidation of one or more lobes, which 284 INFECTIOUS DISEASES. is usually followed by signs of softening, provided the patient survives the first Aveek or ten days. The physical signs during the stage of con- solidation are precisely the same as in lobar pneumonia. The signs of softening and of cavity Avill be given in detail in the description of Chronic Phthisis. The course is usually rapid, occupying from two to six weeks on the average, though rarely cases that reach the stage of cavity-formation are protracted to three or even four months. Considering the brevity of the attacks, the extreme degree of emaciation (shown especially by the hollow cheeks and temples, pinched nose, and thin hands) is truly remarkable. The patient usually maintains a hopeful state of mind, notwithstanding the rapid doAvmvard course of the affection, and it may be admitted that recovery is possible. The parts involved are in such cases destroyed and replaced by fibrous tissue, and it should be remem- bered that the apex is involved in most cases. It sometimes happens that consolidation only is present in the second lobe affected, Avhile in the upper lobe one or more cavities have already been developed. The pleural crepitating friction is often audible before consolidation is complete. Diagnosis.—The onset, symptoms, and course during the first week may be those of ordinary lobar pneumonia, but in some cases certain symptoms may arise which will excite suspicion of their tuberculous character in the early stage. Thus, hemoptysis rarely occurs in a pneumonia due to pneumococcus infection, and, what may also serve as a point in diagnosis, the appearance of the patient, as Avell as his pre- vious and family history, may be suggestive. The points of discrimi- nation have been fully set forth in the section on Lobar Pneumonia (pp. 150, 151). (2) Subacute Cases (rarely acute).—The onset is less sudden than in the former type, while the patient's antecedent condition may either be good or below the standard. At the beginning he has repeated chills, though hemoptysis may be the first symptom Avhich indicates a pre- existing tuberculous focus. The fever rises high, and is apt to be irregu- lar from the start; the pulse and respirations are rapid, and there is a muco-purulent expectoration which may either be profuse or scanty. Occasionally it is fetid, and the sputa may early contain elastic fibers and tubercle bacilli, though more often these are noted after the affection has become fully established. During the progress of the case, also, hemoptysis may arise. Later, drenching night-sweats increase the exhaustion and emaciation, which speedily reach an extreme degree, and soon or late a typhoid condition of the system is developed. The physical signs are, at first, those of general bronchitis, with or without indications of pleurisy. Later, small areas of consolidation, which often increase in size, are indicated by impaired percussion reso- nance or dulness and by broncho-vesicular (rarely tubular) breathing, with subcrepitant rales. These signs may be unilateral, though more often they occur bilaterally. In many cases softening with cavity-for- mation ensues, with the usual physical signs of this condition. Course and Duration.—For some time the patient may remain out of bed, though in most instances the disease constantly progresses. Less . frequently there are exacerbations and remissions. A small CHRONIC TUBERCULOSIS. 285 percentage of these cases recover Avith a loss of more or less lung-tissue, though the condition may pass into chronic phthisis. It is important to recollect that the local lesions may become extensive, as the result of fusion of small consolidated masses, until an entire lobe is involved, and Avhen this occurs the symptoms and course simulate those of the acute type. The duration ranges from two to eight weeks or more. Diagnosis.—This variety is frequently confounded with non-tubercu- lous broncho-pneumonia, and the chief distinctions will be mentioned in connection with the latter disease. Bronchiectasis may be accom- panied by emaciation, fetid expectoration, night-SAveats, and the signs of cavity, and these cases have been mistaken for acute phthisis. Im- portant in the recognition of the latter, hoAvever, are marked fever and emaciation. Moreover, the physical signs are more frequently referable to the apices, and the disease is more steadily progressive, running a shorter course than bronchiectasis. Acute Broncho-pneumonic Phthisis in Children.—The belief that the form of broncho-pneumonia that so frequently follows certain infec- tious diseases (measles, Avhooping-cough, e.tc.) is in the majority of instances tuberculous has been steadily gaining. Osier recognizes three groups of cases: (a) Those in which the child suddenly becomes ill Avhile teething or during convalescence from fever, with high tempera- ture, severe cough, and the signs of consolidation of one or both apices. Death may occur within a feAV days. To the naked eye the lesions do not appear to be tuberculous, (b) In this group the children show the ordinary symptoms of broncho-pneumonia, and the cases are more pro- tracted, death occurring about the sixth week, (c) The child feels ill during convalescence from an infectious disease, fever, cough, and dys- pnea being present. The intensity of the symptoms abates within a fort- night, and the physical examination shows the presence of diffuse bron- chitis Avith scattered minute areas of consolidation. Many of these cases develop into chronic phthisis. Chronic Tuberculosis. [Chronic Pulmonary Tuberculosis; Chronic Ulcerative Phthisis!) This form is much more common than the acute, the term embracing sub-varieties to Avhich attention will be incidentally directed. Its most typical clinical form folloAvs a mixed infection as a result of a septic ele- ment superadded at some time to the primary tuberculous infection. The Causal Factors have been detailed under General Etiology. Pathology.—The pathologic characters of tuberculosis in general have been already presented, but it will be necessary to describe briefly the special anatomic conditions met with in chronic ulcerative phthisis. The post-mortem appearances of the lungs in chronic pulmonary tuberculosis are remarkable for their great diversity, not only in the extent of tissue involved, but also as to the character of the morbid processes. Often the associated lesions form no unimportant part of the picture. In nearly all fatal cases the most advanced and extensive lesions are found near the apex, and, as a rule, the entire upper lobe of one of the lungs is implicated. In addition, it is observed that the destructive process has extended to the loAver lobe of the same side as 286 INFECTIOUS DISEASES. well as to the apex of the opposite lung, the loAver lobe of the primary lung generally being invaded before the upper part of the other. Though both lungs are affected in fatal cases, they represent different stages of the disease. The case is very different in an old and cured tuberculosis of the lungs, such as is frequently met with in persons who have died of some other affection. Here the lesions may occupy but a small part of one lung, and usually near the summit. Kingston FoAvler has investigated the question of the points of elec- tion and paths of distribution of the lesions in chronic phthisis, and has found that the primary lesion is not, as a rule, at the summit of the upper lobe, but that it occurs from 1 to LJ inches (3.79 cm.) beloAv this point and near the postero-external borders. Favored by normal respiration, the lesions advance dowmvard, so that on physical examina- tion the first evidences of disease are to be found posteriorly over the lower part of the supraspinous fossa, Avhile anteriorly the early signs are met with immediately below the middle of the clavicle, extending along a line running about 1^- inches (3.79 cm.) from the inner end of the second and third interspaces. The starting-point, though less fre- quently, may also be indicated by physical signs in the first and second interspaces below the outer third of the clavicle, with subsequent doAvn- ward extension. From personal observation of the post-mortem lesions of this disease, and from my studies at the bedside, I feel convinced that the initial lesion is frequently located anteriorly and near the apex, corresponding on the chest-walls to the clavicle and the supraclavicular spaces. This site has seemed to me to obtain more often on the right side than on the left. Kingsley has shoAvn that when the loAver lobe becomes involved the consolidation begins about 1|- inches (3.79 cm.) beloAv its apex pos- teriorly, and corresponding externally to a spot opposite the fifth dorsal spine. From this point it spreads dowmvard and laterally in a line fol- loAving the border of the scapula " when the hand is placed on the oppo- site scapula and the elbow rests above the level of the shoulder." The middle lobe on the right side is usually invaded by direct extension from the upper. The seat of primary infiltration may even be the lower lobe, but this is an occurrence of great rarity. The relative frequency of involvement of the two sides varies accord- ing to different authorities. A careful analysis of my oAvn records, and the results of some statistical investigations into the subject, shoAV that out of a total of 1236 cases 726 occurred on the left side and 510 on the right. In all cases the primary lesions are due to tuberculous infiltration, which at first is confined to certain lobules, though it may later involve extensive areas of lung-tissue (tuberculous broncho-pneumonia.) In most instances the starting-point of the morbid changes is in the smaller bronchi and also, according to Payne, the inside of the alveoli. Soon the bronchioles and the corresponding air-cells become blocked Avith in- flammatory products. These areas then undergo caseation and present the usual opaque, grayish-yellow appearance, a cross-section of these yellow nodules showing the central bronchus usually plugged with exu- date and surrounded by caseous matter. Softening and sometimes complete liquefaction, Avith expectoration or absorption of the altered CHRONIC TUBERCULOSIS. 287 morbid products, may take place, and this disintegration is associated Avith ulceration in the Avail of the bronchus, consequent upon secondary pyogenic infection, and a resulting formation of small cavities. Ulcers may form in the bronchioles before necrotic processes supervene, and they are generally shallow, with sharply-defined edges. Recovery may ensue as the result of calcification Avith encapsulation of the cheesy masses, or the affected area may undergo fibroid transformation—a con- servative process and one that may lead to actual cure. It often happens, hoAvever, that old and apparently healed tuberculous lesions undergo ulceration, Avhen the calcareous masses (pulmonary calculi) may be dis- lodged and expectorated, and the more rapidly the caseous masses are formed the more liable are they to softening. Surrounding the healed areas the tissue may be the seat of atelectasis, though more often of emphysema. Destruction of lung-tissue also results from interstitial inflammation with the formation of neAv connective tissue, the latter in turn compressing and finally obliterating the alveoli. Cavities ( Vomica?).—These result chiefly from progressive necrosis and ulceration. They are formed mostly by dilatation of the bronchi, whose Avails are tuberculous and suppurating. But they may also arise independently of the bronchi. Cavities vary largely in number, size, form, and in other characteristics. They are often multiple, though usually not far removed from one another, and unite as they increase in size. In this Avay large cavities, involving the Avhole of one lobe and even an entire lung (except the extreme anterior margin), may be formed, and a variable number of small pockets connecting with the bronchus may thus originate. The walls of the cavities are almost invariably irregular. Vomicae may be classified as (1) progressive and (2) non-progressive. (1) The progressive are divisible into (a) New cavities and (b) Old cavities. (a) New cavities have soft, necrotic, friable walls so long as the de- structive processes are rapidly progressing, and the same state of things prevails in the cavities of acute phthisis. They may develop near a healed focus or near old cavities Avith limiting Avails, and Avhen situated near the periphery of the lung they may rupture into the pleura, caus- ing pneumothorax. (b) Old cavities, as a rule, have sharply-defined Avails that vary considerably in thickness. At first they consist of a fibro-vascular zone, Avhich has an inner suppurating surface; subsequently the lining of this zone is converted into an exfoliating membrane. The contents of vomicae are muco-purulent or purulent, and often consist of a shreddy and sometimes a bloody fluid. Rarely they are gangrenous. Cavities also contain tubercle bacilli and other micro-organisms. Percy Kidd has studied the question of the relation of tubercle bacilli to tuberculous pulmonary lesions, and states that they are invariably present in newly- developed tubercles and fresh cavities, but frequently absent in old nodules. Trabecule composed of blood-vessels and remnants of pul- monary tissue often traverse the cavities. In old cavities excavation may be complete, not a vestige of normal or diseased tissue remaining in them, though the blood-vessels, many of which are beaded by small aneurysmal dflatations along their course, are the last to disappear. 288 INFECTIOUS DISEASES. Their removal is effected by an obliterating inflammation. Rupture of these miliary aneurysms or the erosion of a large vessel is an event that gives rise to copious hemoptysis. Cavities having dense walls may also increase in size by encroaching upon and destroying the surrounding tissue, huge cavities often having thin, tense walls. But, wherever situ- ated, they usually begin toward the summit of the upper lobe. Another common seat is the mid-dorsal region. (2) Non-progressive Cavities.—Quiescent cavities are usually small, though variable in size, according to the stage at which the process of contraction is arrested. Medium-sized and large vomicae do not be- come totally occluded. They may be multiple, though more often per- haps single, and associated with them may be observed dense, fibrous nodules representing healed foci. Their interior may be lined with a smooth, cuticular structure resembling mucous membrane. Interstitial Pneumonia.—In the course of chronic phthisis interstitial inflammation of two sorts will most probably arise: (a) A consolidation excited by the tubercle bacilli themselves, and hence manifesting a de- structive tendency; (b) A slowly-developed interstitial pneumonia Avhich aims at arresting the progress of the affection. It develops in close proximity to caseous masses and around cavities. The new connective tissue thus formed in obedience to the well-known pathologic law tends to contract secondarily, and thus vomicae are often partly, though sel- dom entirely, obliterated. The shrinking of the connective tissue may also result in compression, and finally in the destruction of pulmonary tissue, just as in a tuberculous inflammation. The process in this in- stance, however, is on the whole conservative and calculated to repair tuberculous lesions. Disseminated Tuberculosis.—Miliary Tubercles.—This form has for its chief characteristic miliary tubercles, which are scattered not only about the tuberculous area, but also throughout the rest of the lung, and usually in the loAver lobe. Most of the tubercles undergo fibroid or fibro-caseous change. These minute, hard gray or grayish-yellow nodules vary in size from a mustard-seed to that of a pea, and lung- tissue that is more or less studded with chronic miliary tubercles is apt to look pale, while the surrounding air-cells are emphysematous. The condition may lead to pneumonia, and the whole aspect then becomes altered. Here, as before described, fusion of miliary tubercles results in larger masses Avhich become caseous, and hence the method of cavity- formation is identical with that observed in tuberculous broncho-pneu- monia. In the disseminated form tubercles may also be found in many other organs than those indicated (pleura, trachea, larynx, bronchial and other lymphatic glands, peritoneum, spleen, kidneys, liver, brain, mu- cosa, testes, etc.). Lesions of the Pleura.—This membrane is hyperemic and coated with fibrinous exudation coextensively Avith the affection of the parts in chronic ulcerative phthisis. The pleural membranes are only more or less thickened by organized adhesions, but in the latter and also in the pleura tubercles or cheesy masses may be found. Simple and other forms of pleurisy are also met with—sero-fibrinous, purulent, and hem- orrhagic. Lesions of the Bronchial Glands.—At first these are enlarged and CHRONIC TUBERCULOSIS. 289 edematous, containing tubercles, and later they present foci which often undergo purulent disintegration and sometimes calcification. Other lymphatic glands than these may be affected (mesenteric, etc.). Lesions of the Larynx.—The larynx is frequently the seat of tuber- culous infiltration and ulceration, particularly in certain parts, such as the vocal cords, posterior Avail, ary-epiglottidean folds, etc. Lesions of the Heart.—Tuberculous endocarditis is present in about 5 per cent, of the cases, and congenital stenosis of the pulmonary ori- fice is noted in not a few instances (Chevers). The right heart is often hypertrophied or dilated. Other organs may present lesions in chronic phthisis, and these will be spoken of in connection Avith the clinical history. Tuberculosis of the intestinal canal is a common though late lesion. Amyloid degeneration of certain organs is a not unusual secondary event, especially of the kidneys, liver, spleen, and intestinal mucosa, and in like manner enlargement of the liver due to fatty infiltration is noted not infrequently. Clinical History.—The modes of invasion are quite diverse, but with few exceptions the onset is either (1) gradual or (2) abrupt, and, as a rule, the health has been previously undermined for a longer or shorter period. (1) Gradual Onset.—(a) Most frequently the disease originates in a manner similar to the origin of ordinary bronchitis, and often, com- bined with the symptoms of broncho-catarrh, are those of pleurisy. Tuberculous bronchial affections often follow certain acute infectious diseases—influenza, typhoid, measles, whooping-cough, etc.—and in this form are rarely curable. The physical signs may be negative for some time, and then appear at the apex of the lung. Over a small area there may now be slightly impaired resonance on percussion, with harsh broncho-vesicular breath-sounds and Avith or without subcrepitant rales. The expansion, as noted on inspection and palpation, over the affected spots is more or less defective, while the vocal resonance and fremitus are either increased or unaltered; and the fact that the lesions are more commonly detectable in the suprascapular fossa than anteriorly must be remembered. At this period obvious constitutional disturbances are present (debility, emaciation, fever, etc.). (b) Onset with Pleurisy.—This may be sudden, as in an acute pleu- risy with effusion, but often the latter condition develops insidiously. Of 90 cases of pleurisy with effusion, one-third terminated in chronic phthisis (Bowditch). It may begin as a dry pleurisy at the apex, either anteriorly or posteriorly, or the evidence of pleurisy may be associated with the more common or bronchitic onset. (c) With Gastro-intestinal Symptoms.—There is impaired digestion, and soon the patient becomes anemic, loses flesh, and is debilitated. Later, the first indications of pulmonary tuberculosis develop in the lungs. (d) With indefinite peritoneal symptoms, lasting for months or even years. (e) With Laryngeal Symptoms.—This is a rare form. It begins with hoarseness, more or less aphonia, and considerable cough; there is also a slight muco-purulent expectoration. Laryngoscopic examinations may 19 290 INFECTIOUS DISEASES. detect tuberculosis of the organ, and tubercle bacilli may be found in the sputum before involvement of the lungs is discoverable. (2) Cases with Abrupt Onset.—(a) The most important group under this category is heralded by the symptoms and signs of acute pneumonia, more commonly of the lobular variety. As compared with ordinary pneumonias, these present some peculiar features: the fever is irregular and the expectoration is more abundant, is blood-stained, and contains bacilli. The signs are usually located in the apical region. Resolution may occur, but recovery is not complete, and the condition is likely to pass into chronic phthisis. (b) Onset with Fever.—Chills and fever are apt to arise in all instances in the advanced stage of pulmonary tuberculosis, and these symptoms may also initiate the attack. There is no mistake in diagnosis more commonly made in malarial regions than to ascribe such cases to pal- udism. (c) With Hemoptysis.—This symptom may be the first to invite at- tention to lung-trouble. In the majority of cases the amount of blood lost is considerable, and, less frequently, repeated slight hemorrhages occur. Pulmonary symptoms may be absent, sometimes temporarily, and in rare instances, perhaps, permanently; but in a great proportion of cases the clinical picture of incipient pulmonary tuberculosis is re- vealed pursuing its accustomed course immediately after the occurrence of the hemorrhage. The physical signs may be latent for a time, and, Avhilst they are usually found to be at the apex, they may assume the guise of a pleurisy in the scapular or infrascapular region. A slight tuberculous lesion is most probably present in these cases before the occurrence of the hemorrhage. The symptoms are (1) local and (2) general. (1) Local.—(a) Pain.—This is absent in many cases of chronic phthisis and in others it may be moderately severe. It is seated usually at the base, laterally or anteriorly, and not rarely there is pain of a lancinating character in the interscapular region in the early stages of the affection. This symptom is of diagnostic Avorth only after other forms of pain (rheumatic, neuralgic, etc.) have been excluded. The most common cause of pain is pleuritis, Avith or Avithout pleuritic adhe- sions; it is increased on deep breathing and coughing. Intercostal neuralgia and pleurodynic stitches may also develop in the course of this disease. (b) The Cough.—This may be looked upon as an essential feature, though in a few instances it may be slight or even wanting throughout. Its severity bears no constant relation to the extent of the pulmonary lesions, but rather to the degree of sensitiveness of the patient. It is dry and hacking at the beginning, and, if the larynx be involved, the cough is marked and takes on a hoarse quality. It is most pronounced at certain periods of the day—viz. on lying down at night and on awaking from sleep. Paroxysms may also occur after meals, and these occasionally induce vomiting. The cough is at times distressing and debilitating in its effects. ( ■a." 40 K f\ r^ _, r a \ oz. (70.0-100.0) per diem, according to Ebstein. I have observed that occasionally patients do best on albuminoids, while, on the other hand, Avith about equal frequency they improve on a vegetable diet; but I am convinced that a mixed diet, such as has just been indicated, is best adapted for the vast majority of the cases. Among articles to be avoided are pastry, tea and coffee, hot bread and cakes, sweet puddings, cheese, dried meats, and all highly seasoned dishes. It may become necessary, though rarely, to administer alcohol. This is especially the case in suppressed gout, and when needed whiskey or gin (diluted) is to be preferred. 3Iineral waters, particularly the alkaline, are highly advantageous, and sometimes are even curative. Their value, like that of the Avarm baths and systematic exercise, is dependent upon their poAver to increase renal elimination. Whether they promote solubility of the uric acid in the blood is questionable; moreover, according to the observations of Klemperer, this is not a rational indication. The carbonate and citrate of lithium are efficient diuretics, but have no other claim to virtue in this disease. Among natural waters of special value abroad are Vichy, Carlsbad, Homburg, Ems, Kissingen, Aix, Buxton, and Bath, and in this country Saratoga and Bedford. These waters are to be taken when the stomach is empty and in large quantities. (b) Medicinal Treatment.—During an acute attack the pain, if ex- cruciating, is to be relieved by a hypodermic injection of morphin, Avhich is to be folloAved by a purgative dose of some mercurial. Colchicum is the specific remedy, and must be administered, in the form either of the Avine or the tincture, in doses of ITLxx-xxx (1.333-1.999) every four hours. It alleviates the inflammation and promptly relieves the pain, but its effects during the attack should be carefully noted. After the paroxysm it should be continued, though in small doses, combined with the citrate or bicarbonate of potassium or lithium. The limb should be raised and the affected joint or joints Avrapped in flannel or cotton-wool. Warm alkaline solutions or hot fomentations often afford relief in the Avorst cases, and anodynes may be tried locally. The diet should con- sist chiefly of milk, animal broths, and egg-white during the attack, Avhile after the latter rice, eggs, fish, and other light forms of meat may be added, the more liberal dietary previously indicated being slowly resumed. 400 CONSTITUTIONAL DISEASES. In the intervals betAveen the acute attacks the prophylactic and dietetic measures previously mentioned are to be resorted to Avith a view to preventing recurrences of the disease, and in addition the alkaline diuretics and saline laxatives, together with Avarm bathing, will be found of the utmost value. In chronic and irregular forms of gout medicines are of subsidiary importance, and are in no Avise comparable in their beneficial effects to the previous recommendations. Tavo agents deserve prominent mention, however. They are piperazin and the extract of thymus gland. The ingestion of the latter, as obtained from the calf, is followed by an in- creased excretion of uric acid. Piperazin has been warmly advocated in all forms of gout for its supposed effect as a solvent of uric acid, and clinicians are almost unanimous in reporting its favorable results. Its beneficial effects are probably due to its diuretic action. The dose is gr. v-x» (0.324-0.648) thrice daily, freely diluted with water. Some authors highly recommend the salicylates for acute attacks of gout, both primary and intercurrent, in the course of the chronic form. In my own experience they have been less effective in this disease than colchi- cum, though ammonium salicylate or salicin may be tried if there be present marked gastric disturbance, since it is better borne under these circumstances than colchicum. If nephritis or a failure of compensa- tion be present, even the former remedies should be administered with extreme caution. For chronic gout potassium iodid has been much used, though with slight advantage to the patient, I think. The bitter tonics, combined with a vegetable salt of iron, should be resorted to in the anemic, debili- tated class of gouty patients, and a change of climate often serves to improve bodily vigor in the same category of cases. LITHEMIA. Definition.—A condition due to the faulty oxidation of nitrogenous matter. It is characterized chemically by an excess of uric acid in the blood, and clinically by various digestive, circulatory, genito-urinary, and nervous phenomena. My chief purpose in describing lithemia separately is that the common error may be avoided of attributing the symptoms of this condition to other causes. Pathology and Etiology.—The deficient oxidation or the tissue- metabolism is dependent upon the same causes as in gout, but lithemia dif- fers in being, comparatively speaking, a latent condition. The excess of uric acid may be for a time eliminated through the natural channels (kid- neys, lungs, skin, etc.) without the occurrence of symptoms. On the other hand, when as the result of too little exercise, impaired elimination, high living, the use of sweet wines, combined with the neurotic temperament, uric acid is allowed to collect in different parts of the organism, marked disturbances—nervous, gastro-hepatic, etc.—follow. We are not here concerned with the articular type. Among other factors that predispose to the onset of lithemia are alcoholism, heredity, climate (temperate or cold climates favor diminished actions of the skin), and the male sex. LITHEMIA. 401 Symptoms.—The nervous, circulatory, respiratory, integumentary, and genito-urinary symptoms are practically the same as those described under Irregular Gout, but I would here emphasize the broad clinical fact that the urethral and genital mucous membranes often become inflamed on slight provocation, producing urethritis, cystitis, orchitis, epididymitis, vaginitis, endometritis. These conditions resist treatment obstinately. Gastro-intestinal Symptoms.—The earliest symptom-complex is usually presented by the gastro-intestinal tract. The appetite is variable, some- times voracious, and at other times it is impaired or perverted. The tongue is coated, particularly in the mornings, and a metallic taste is often complained of, while various forms of indigestion attend. There may be a delay in the conversion of the albuminoids, in which cases such symptoms as pyrosis, gastric oppression, fulness, and sometimes nausea and vomiting, appear soon after the ingestion of food. These symptoms, together Avith marked flatulence, are manifested at a later period after meals if there be failure in the digestion of the carbohydrates. The boAvels Avork irregularly, constipation alternating with brief attacks of diarrhea, Avhich may be attended by colicky pain, the discharges being often frothy and ill-smelling. Hemorrhoids are usual, and melena may occur, though often independently of the hemorrhoids. The liver is some- what enlarged and often tender. A few prominent cardio-vascular symp- toms should be mentioned, such as palpitation, Avhich is common, appear- ing particularly after eating. More rarely it occurs while the patient is at rest or even lying abed, the attacks lasting from a few minutes to as many hours. Increased arterial tension develops early, but may not be constant, and is due probably to the action of the uric acid in the blood upon the vaso-motor nerves, exciting universal contraction of the arteries. This condition may be present for a long time before actual arterio-scle- rosis is in evidence. The latter complaint invariably follows, hoAvever, and sooner or later the well-known group—chronic gout, arterio-sclerosis, and granular kidney—will be presented. Prognosis.—This is ordinarily favorable if the condition is recog- nized and properly treated before irreparable changes have taken place in the arteries, joints, and kidneys. Treatment.—(1) Prophylaxis.—The patient should be taught the lesson of thorough mastication, and robust, plethoric persons should exer- cise with method in the open air, with a view to consuming the fats in the body. For this purpose cycling, horseback-riding, roAving, and Avalk- ing are all excellent. Nervous persons, however, demand rest (Gray). The constant use of lithia-water, more particularly in the spring of the year, is warmly advocated by Wilcox. (2) Diet.—As in gout, so in the preliminary stages of lithemia, no sin- gle dietary suits all cases, though I agree with those Avho contend that a diet consisting chiefly of albuminoids is proper in most cases. It has been shown that a vegetable diet overtaxes the oxygenating power of the sys- tem (Porter). The lighter forms of albuminous articles of diet are to be preferred, and, if well borne, fruits and green vegetables may be added; but fried meats of all sorts and made-over dishes are to be eschewed. There are cases in which the gastric digestion is feeble, and in such the carbohydrates are better borne than the albuminoids. Cream and good 26 402 CONSTITUTIONAL DISEASES. butter are the only forms of fat to be allowed. Highly-seasoned articles must be avoided, and in the use of alcohol lithemics should be guided by the same rules as gouty subjects. (3) Medicinal Treatment.—If the patient be robust, it is well to begin with a saline laxative, such as Carlsbad Spriidel salt (3J-ij—4.0-8.0), moderately diluted and taken before breakfast. If necessary, the hepatic function may be stimulated still further by a mild mercurial or by podo- phyllin. On the other hand, the neurasthenic, delicate sufferer must use a milder form of laxative, such as Rochelle salts in the same dose, or sodium phosphate in the morning, or a rhubarb pill at night. This class of lithemics also requires nerve-sedatives (sodium bromid, phenacetin, etc.), and diuretics to aid in the excretion of uric acid. If it be true, as some claim, that the sodium phosphate is for the greater part excreted by the urine, and that it holds in solution more uric acid than any other salt, it is one of the foremost remedies in the treatment of the affection. Per- sonally, I have found it to be a most useful agent. To reduce acidemia and to gently stimulate hepatic activity the salts of lithium, highly di- luted, may also be tried. To aid in the digestion of the albuminoids hydrochloric acid may be needful, and if the appetite be impaired it may be combined with a simple bitter or with nux vomica (Hlx-xv—0.666- 0.999) thrice daily. Nitro-hydrochloric acid should be given a trial in cases in which the hepatic symptoms are prominent. RACHITIS. [Rickets.) Definition.—»A constitutional disease of childhood, exhibiting gross nutritive changes, chiefly in the bones and cartilages, causing deformities, and also in the ligaments, muscles, and other anatomic structures. Pathology.—A mere summary of the anatomic characters can be given here. There is a derangement of the nutritive processes which retards and otherwise modifies the growth of the bony skeleton, particu- larly of the skull, the ends of the ribs, and of the long bones. The latter soften or remain unduly flexible as the result either of the absorp- tion of ossified structures or of the greatly diminished deposition of lime- salts. Longitudinal section of the long bones shows the seat of the chief changes to be at the junction of the epiphysis Avith the shaft. In health we note at this point two thin layers, of which the outer (next to the epi- physeal cartilage) is the proliferative or hyperplastic zone. It presents a bluish color, and it is here that the cartilage-cells undergo division. The inner layer, exceedingly narrow and of a yellowish hue, is the so-called zone of ossification. These two narrow bands lie side by side and present perfectly regular and parallel outlines. On the other hand, in rachitis, both zones, though more particularly the proliferative, are greatly thick- ened, much softened, and their margins irregularly notched. The peri- osteum is thickened and easily separable from the shaft. A consideration of the histo-pathologic changes readily explains the gross changes just enumerated. A microscopic examination shows an increased rate of pro- RACHITIS. 403 liferation of the cartilage-cells Avith a scanty, fibroid matrix, while the ossific layer presents disseminated and imperfectly calcified areas. Simi- larly, the deeper (osteoblastic) layer of the periosteum is thickened, and remains spongoid, Avhile the cortical layer of the bones may lessen in dimensions, OAving to absorption of true bone-tissue. The above facts render easy the comprehension of the coarser changes produced by rickets. Thus we note great enlargement of the epiphyses of the long bones, obviously due to the increased activity of'the prolifer- ative layer. The cranial bones present areas of the so-called craniotabes, and yield to the pressing finger in consequence of delayed ossification or of resorption of the lime-salts in completely organized bones. The latter processes may lead to a disappearance of the cranium in certain areas, causing depressions, while flattened protuberances may develop over the antero-lateral regions as the result of augmented proliferation—changes which constitute the rachitic type of skull. When cases terminate in recovery the bones become hard and ossify, although the deformities per- sist. The chemist has shoAvn us that rachitic bones may contain less than half the normal percentage of lime-salts. The liver and spleen are mod- erately enlarged, and rarely the mesenteric glands are increased in size. Etiology.—(1) Rachitis may occur in the new-born. Schwartz states that among 500 new-born children in Vienna, 75.8 per cent, show dis- tinct signs of rachitis. Doubtless this estimate is too high, and entirely at variance with the experience of clinicians in general; but I believe that congenital rickets is by no means a rare condition. Many of the cases are still-born, and those that outlive childhood become peculiarly dwarfed {micromania). (2) Heredity.—The instances in which rachitis de- velops at an early period of life, due to ante-partum causes, are not rare, but it must not be forgotten that it is extremely hard to estimate the influence of heredity where both parent and child are exposed to similar unfavor- able hygienic and dietetic conditions. Ill-health, malnutrition, close con- finement, lactation, and syphilis may all act as predisposing factors dur- ing pregnancy. Setting aside syphilis, and perhaps phthisis, the state of the health of the father has little if any effect in the causation of rachitis in his offspring. (3) Geographical Distribution.—The disease is more common by far in large cities than in rural districts, and in European countries—Russia, Germany, Great Britain, and Italy more especially— the disease prevails more extensively than in America. (4) Pace.—The colored race furnishes a preponderance of rachitic subjects. The reason for this may be a racial need of warmth that is not supplied by the tem- perature of more northerly latitudes, their native habitat being in a more southerly climate. The Italian race also suffers inordinately. (5) Sta- tion.—It is especially among the ranks of the poor children in large cities that rachitis is seen. Joukownski, from personal observations in over 3000 poor children in St. Petersburg examined for rachitis, found that from the working classes come the greatest number of cases. The quarters of the cities in Avhich the poorer classes live are densely crowded, the dwellings are insufficiently ventilated, and there is a great lack of sunlight. (6) Diet.—The disease is dependent largely upon improper or insufficient food, and among hand-fed children the disease is much more common than among those at the breast. It also occurs in breast-fed infants when the mother's milk is poor in quality as the result of pre- 404 CONSTITUTIONAL DISEASES. vious ill-health or too long-continued lactation. The view was at one time widely held that rickets was produced by a farinaceous diet, and that the active agent was lactic acid, produced by the fermentative pro- cesses set up by the starch. Even granting, however, that the lactic acid forms a soluble salt by union with the lime of the bone, thus re- moving it from the system, this does not explain the productive lesions described under Pathology. According to another view, rachitis is apt to develop when the system is deprived of an adequate amount of fat, and for this belief there is considerable experimental proof. Whilst, therefore, certain forms of diet predispose to rickets, they do so chiefly for the reason that they either are defective in certain particulars or do not supply certain necessary articles in adequate proportion. (7) Age.— Of 903 cases, more than 75 per cent, occurred before the end of the sec- ond year, but of these only 99 commenced during the first half year. The third year of life furnished 134 cases (Bruennische, Von Rittershain, Ritsche). (8) Sex is without effect. (9) Syphilis.—Divers views are entertained regarding the role played by syphilis as a cause of this dis- ease. Doubtless the two affections are sometimes associated, and it can- not be denied that syphilis brings about a marked impairment of nutri- tion both in the mother and the child, so that the disease may engender a predisposition to rickets. (10) Mircoli contends for the microbic nature of the disease, believing that it is produced by the action of ordinary pyogenic organisms upon the osseous and nervous systems. He adduces clinical and pathological evidence in support of this position. Symptoms.—The onset is slow, and the symptoms of gastro-intes- tinal catarrh, with their usual effect upon the general nutrition, may pre- cede or accompany the true rachitic symptoms. At the beginning the infant is restless, irritable, and sleeps poorly, and slight fever is present in some cases. About the head and neck the child perspires freely, espe- cially when asleep, wetting his pillow while the rest of the bed is dry. It is also annoyed by the bed-clothes, which it continually throws off, lying exposed even in a cool temperature. Among the earlier symptoms is a tenderness both over th'e bony surfaces and the soft parts, so that the patient wishes to keep still and dreads to be handled. The cause of this general soreness is not known, though the periosteal changes may be the main factor. The child is languid and disinclined to move his limbs or to walk or play, even if he have done so previously. The symptoms are progressive in their development, rachitis being ordinarily a chronic disease, so that after many months more pronounced features, including various bone-deformities, appear. Owing to the im- pairment of nutrition of the muscles the use of the limbs may become impossible, and these cases have been spoken of by writers as " rachitic paralysis ;" this, however, is a misnomer. Cases have been reported by Berg and others that resembled spastic paralysis, pseudo-hypertrophic paralysis, and other conditions of nervous origin, but their true nature is made apparent by the associated symptoms and history. The first rachitic osteal changes are presented by the cranial bones, the ribs, the radius, and the ulna. The cranium appears enlarged, though this enlargement is more apparent than real, being due to the backward growth of the facial bones. The sutures remain open, the fontanels are large, and their closure is delayed, sometimes until the fifth or even the RACHITIS. 405 eighth year. Craniotabes is most frequently seen in infants under one year of age. This soft, thin condition of the bones is due to pressure both from within and without, and is hence observed over the posterior and lateral aspects of the skull, or on the surfaces on which the head of the child rests while lying. To detect the presence of craniotabes light pressure with the fingers is to be made in a direction away from the su- tures. A rachitic head generally approaches a square in outline, or it may present marked angularities, with an increase in the antero-posterior diameter and a flattened top. Hyperostoses may cause prominence of the parietal and frontal eminences, giving the forehead a square, broad out- line. The veins of the scalp are enlarged, and the hairy grow7th is usually scanty, being often removed from the back of the head by rubbing. Drs. Whitney and Fischer first called attention to the fact that the ear placed over the anterior fontanel often detects a systolic murmur, Avhich they regard as peculiar to rickets. A considerable patency of the anterior fontanel both in health and disease allows of detection of this murmur, however, and hence its diagnostic value is slight. A prominent feature of the disease is delayed teething, the teeth that appear being deficient in enamel, ill-shapen, and prone to early decay. The ribs become affected very early. Anteriorly, where they join the costal cartilages, SAvellings occur, causing the "rachitic rosary." This is composed of nodules corresponding with the costo-chondral articulations, and these can generally be seen and always felt under the skin. They rarely outlast the fourth or fifth year. The ribs present two short curves —one at the junction of the dorsal and lateral parts of the thorax, and the other in front, where they turn sharply inward toward the sternum. This deformity is the result of the atmospheric pressure upon the softened bones, a shallow groove usually being produced in the line of the costo- chondral articulations or obliquely from the second or third rib downward and outward. These changes lessen the transverse diameter of the thorax in front and interfere with the lung-expansion in the antero-lateral por- tions of the chest. They also produce bulging of the sternum, resulting in the so-called pigeon or chicken breast. On both sides, from a point corresponding to the anterior end of the eighth or ninth rib, there passes outAvard toward the axilla a furrow (Harrison's groove) Avhich is caused by an eversion of the lower part of the thorax, and is heightened by atmo- spheric pressure, particularly during inspiration. This thoracic deformity is not peculiar to rickets, but is met with in all cases in which there is moderate obstruction to the ingress of air into the lungs. Among the first indications of rickets is an enlargement of the lower end (junction of the shaft and epiphysis) of the radius. The radius and ulna are sometimes twisted and deflected outward, owing to the fact that some of the body-weight is supported by the hands when sitting or crawl- ing. The clavicle may be thickened and curved near either end, and occasionally the scapulas may be enlarged, but deformities of the upper ex- tremities are rare as compared with those of the lower. Occasionally the vertebras and intervening cartilages soften, with a resulting spinal curva- ture, and in such instances there is usually an antero-posterior curvature with which lateral deflexion may be associated. Pelvic deformities are not uncommon, and are of no little importance in female children as bearing upon the questions of marriage and subse- 406 CONSTITUTIONAL DISEASES. quent labor. The femora may be curved, often forward and more rarely out- ward ; swelling of the lower end of the tibia is, however, the first change to be observed in the loAver extremities. In some well-advanced cases the heads of the bones forming the knee-joints are also enlarged, and outward curvature of the femora and tibia is common, especially under the age of one year (see Fig. 32). After the child begins to walk a forward bowing of these bones, due to the weight of the body and to muscular action, occurs. Knock-knee is sometimes observed. It is worthy of mention that persons who have suffered from rickets in infancy usually fall short of the aver- age stature on reaching adolescence, rickets stunting the growth of the skeleton, and especially of the bones of the face, pelvis, and legs. These skeletal changes sustain a causal relation to many, and some serious, affections, chiefly nervous. Thus, craniotabes is supposed to in- duce laryngismus stridulus, though this condition may also arise in the rachitic without cranial softening. In like manner, rickets predisposes to tetany, which affects most commonly the upper extremities. Convul- sions are also prone to occur in this disease. The reflex nervous excita- bility is unquestionably exaggerated in rickets, and another exciting cause for the eclampsia so often met with is the gastro-intestinal catarrh that is quite generally present. The abdomen becomes greatly enlarged, chiefly by flatulence, though to a less extent also by the swelling of the liver and spleen and the contraction of the thorax. Chest complications are common. Most of them are due primarily to a mechanical interfer- ence with a cardio-pulmonary circulation, and Avith the function of res- piration as a consequence of the thoracic deformity. Among these are atelectasis, bronchial catarrh, broncho-pneumonia, and emphysema. Prognosis.—The evolution of rickets is a long process, accompanied by a slowly progressive impairment of the general nutrition; and hence most patients become weak, anemic, and emaciated. The so-called " fat rickets," however, is not rare. Innately, the disease tends to spontaneous cure, which is attained from the end of the second to the fifth year; but its course may be abridged to a few months by appropriate treatment. When death occurs it is usually occasioned by one or other of the com- plications before mentioned, and especially by laryngismus stridulus or pneumonia. Treatment.—Prophylaxis.—The institution of preventive measures is a matter of first importance, and by simple means directed to the ante- partum causal factors in the mother rickets may in a large proportion of the cases be prevented. Prophylaxis also embraces appropriate feeding and other agencies that tend to maintain the normal nutrition of infants. Hygienic Management.—As faulty diet is in a great measure responsi- ble for rachitis, proper feeding is an important factor, and if the child cannot be satisfactorily nursed by its mother and if it is under the age of six months, a wet-nurse should be procured. Should this not be prac- ticable, it must be hand-fed, and the best artificial food is cow's milk, if properly prepared. In cities it is to be sterilized, and then diluted to suit the age, and I have found that barley-water, when made in the man- ner recommended by J. Lewis Smith, may be added to milk, replacing the water most advantageously. A heaping teaspoonful of barley-flour is poured into 25 teaspoonsful (§iij—96.0) of water, and wlien the mixture is lukewarm 10 or 15 drops of diastase (Forbes) are added to it, the gruel Fig. 32.—Outward curvature of tibia and fibula (Willard). SCORBUTUS. 407 in a few minutes becoming much thinner from the digestion of the starch. The physician must regulate with much precision the frequency of the feeding, and the amount of food taken according to the age of the child. The stools are also to be inspected. If they are green or if curds appear, either digestion is imperfect or the child is being over-fed. Older children may be given the lighter meats, green vegetables, and fruits, but these must be carefully selected. Other hygienic details are of little less importance than a proper diet. The decubitus of the child must be changed frequently, so as to prevent bony deformities; moreover, the rickety child should not be allowed to walk, and to prevent his doing so splints extending beyond the feet have been recommended. A tepid bath, warm clothing, and a prolonged daily stay in the open air are measures that should not be neglected. Of medicines, those that rank highest are phosphorus, the hypophos- phites, iron, and cod-liver oil. The officinal oleum phosphoratum (gr. ^ —0.0021) is used by Jacobi. Phosphorus is highly spoken of by many, and I have found it quite serviceable in my own practice. It may either be given pure (gr. ^ to ^—0.0003 to 0.0006) or preferably in the form of an emulsion with sweet oil or cod-liver oil: Rp. Phosphori, gr. i (0.00648); Olei olivse, gij (64.0); M. et ft. emulsio. Sig. 3j three times a day, after meals, for a child under the age of one year. When it is desired to administer cod-liver oil and it is not tolerated by the stomach, it may be rubbed gently into the skin of the thighs and trunk. Arsenic in small doses has proved to be a capital remedy in selected cases; and iron, particularly in combination with arsenic, is in- dicated if anemia be pronounced. The numerous complications to which rachitic subjects are liable pre- sent special indications which are to be met by the same measures as when they arise under other circumstances. The condition of the diges- tive organs must be kept constantly in mind; and no remedy, however promising, that is designed to assist the general condition should be con- tinued if it tends to aggravate the digestive disturbance. A proper regulation of the diet will often correct the latter, but if not, suitable remedies directed to the gastro-intestinal catarrh must be employed. The treatment of the rachitic deformities belongs to the domain of the ortho- pedic surgeon. SCORBUTUS. {Scurvy.) Definition.—A constitutional disease, caused by a lack of fresh vegetables in the diet, and characterized by anemia, excessive weakness, spongy gums, a tendency to muco-cutaneous hemorrhages, and a brawny induration affecting chiefly the muscles of the calves and the flexor muscles of the thighs. 408 CONSTITUTIONAL DISEASES. Pathology.—We know nothing concerning the pathogenesis of scurvy. Evidences of profound anemia are found upon microscopic ex- amination of the blood, which is thin and dark, but there is no leukocy- tosis. The skin may shoAV spots of subcutaneous hemorrhage (ecchy- moses), but the most characteristic hemorrhage is that under the periosteum of the femora. Bleedings into the articulations and muscles may also at times be noted, and occasionally the serous membranes are the seat of hemorrhages, as well as the internal organs. Submucous hemorrhages are extremely common. The intestinal mucosa may also present ulcers. The gums are swollen, spongy, dark in color, and sometimes ulcer- ated, and the teeth may be loose or missing. The epiphyses, par- ticularly of the lower end of the femora, may be congested, and rarely they are detached. The spleen is soft and swollen. The heart, liver, and kidneys sometimes show fatty and usually parenchymatous degeneration. Etiology.—In former times scurvy was very prevalent among sol- diers in the field and sailors at sea, and epidemics were common. Doubt- less, however, it has declined in importance as a disease incident both to sea-life and to armies, but, as pointed out by Wise, it would seem that changing physiological and economical conditions may cause it to be dreaded on land as it has hitherto been on sea. According to my own observations, there certainly has been no increase in the frequency of its occurrence in Philadelphia during the last decade; but Osier states that the disease is not infrequent among Hungarians, Bohemians, and Italian miners in Pennsylvania, and I am inclined to believe that among this class of laborers the disease may have increased in frequency within recent times. It is rarely epidemic at the present day. Endemic ap- pearances of scurvy are still common, particularly in portions of Russia (Hoffman) and elsewhere also, sweeping through prisons, barracks, alms- houses, and other institutions of like kind. The majority of cases met with, however, are sporadic. The above and many other facts point to the infectious origin of this disease. Testi and Beri have isolated a micro-organism which has been cultivated and inoculated into guinea-pigs and rabbits, producing in the latter pathologic lesions and symptoms simulating closely those of scurvy. The microbe is perfectly round and is a diplococcus. These experiments have not as yet been confirmed by other investigators. The chief disposing factor is the long-continued use of a dietary de- ficient in fresh vegetables. Precisely what there is in the latter, the absence of which in the system produces scurvy, is not known to a cer- tainty, but it is probable that it consists of the organic salts present in the fresh vegetables, Avhich elements are requisite to normal histogenesis. Albertoni has recently shown that in scurvy of a protracted course free hydrochloric acid is absent from the gastric juice, and that the total acidity is much reduced, but this is neither so in every case nor at all stages of the disease. He found no deficiency of chlorids in the body. Peptonization is feeble. Debilitating influences, as unhygienic surroundings, excessive muscu- lar exercise, humidity, and cold, often play no mean role in causing scurvy. Mental anxiety and depression seem to have etiologic signif- icance. The old are very susceptible, and all ages are liable to the dis- SCORBUTUS. 409 ease. Sex has no special influence upon scorbutus. Starvation does not predispose to the disease. Symptoms.—Scurvy has a slow onset. The earliest symptoms are generally a swelling around the eyes, over which the skin has the color of a bruise, and a pale face, which looks bloated and wears an apathetic expression. There is noticeable almost from the start a gradually in- creasing debility, emaciation, an inability to perform mental or physical labor, and despondency. The patient experiences arthritic and muscular rheumatoid pains and dyspnea on slight exertion. With rare exceptions the gums swell, sometimes enormously, and be- come spongy, bleeding most readily. They may become ulcerated, and may be, though rarely, fungoid in appearance. The teeth often become loose, and in rare cases drop out. The breath emits an offensive odor, that is sometimes due to necrosis of the jaAv. The tongue swells, though it is usually clean and often pale. In the mouth may be observed sub- mucous hemorrhages in many cases. There is loss of appetite, but the digestion is usually good; there may, however, be constipation or diar- rhea, more frequently the former. Scorbutic dysentery has been de- scribed by certain writers. The skin is dry and of a muddy color, blended occasionally with a greenish or greenish-yellow tinge. At the end of a week or ten days petechiae and ecchymoses appear upon the legs, arranging themselves about the hair-follicles. These may also come out later on the trunk and upper extremities. Submucous hemorrhages may give rise to circumscribed swellings, and subperiosteal hemorrhages may occur and engender node-like protuberances. There may be frequently noticed a peculiar brawny induration, due to extensive hemorrhagic infil- tration of the muscles and subcutaneous tissues, most marked in the hams and calves. The condition is not without considerable pain, particularly if the parts be touched, and in severe cases bullae and vibices may be seen, as in a recent case of my own. Hemorrhages from the mucous channels of the body occur, and epistaxis is frequent. In bad cases hematuria, also melena and rarely hematemesis, may be observed. Blood may be effused into the serous membranes, accompanied sometimes by inflamma- tory changes in the latter; also into the lungs, which are rarely the seat of secondary pneumonia. Pulmonary infarction occurs, but is a rare event. Hemoptysis may be a symptom of the lung-complications or may occur as an independent phenomenon. The heart may present symptoms, such as palpitations, feeble impulse, arrhythmia, and sometimes a basic blood-murmur, but these are without diagnostic importance. The pulse is soft, small, and on exertion much accelerated. The temperature is sometimes subnormal, and the presence of fever is a certain indication of the existence of some complication. The nervous symptoms, aside from the profound mental depression, are not prominent. Insomnia may be a distressing symptom. Delirium (late) is sometimes witnessed. Meningeal hemorrhage may supervene. Both night-blindness and day-blindness are among the rarer and extraordinary ocular features. The urinary symptoms vary in different cases. Albuminuria is, how- ever, common. The specific gravity of the urine is increased, the color high, and the solid constituents diminished, except the phosphates, which are abundant. Albertoni found the proportion of chlorids less than the 410 CONSTITUTIONAL DISEASES. normal, while other investigators claim that the percentage is high. The bones in long-standing cases may be intensely congested and sometimes necrotic, and the epiphyses may separate from the shafts. In one of my own cases an old cicatrix reopened. Diagnosis.—This rests upon the folloAving points : the history, the peculiar facies, the spongy and swollen gums, the gingival and cutaneous hemorrhages, the progressive loss of strength and energy, great mental depression, and the speedy recovery after an appropriate regimen. Scurvy will be distinguished from purpura under the description of the latter disease. Prognosis.—Unless far advanced, the prognosis generally becomes good upon the institution of correct dietetic principles. If the disease have made extensive inroads, the danger to life is considerable. The gravity of the internal symptoms (particularly pulmonary) is far greater than of the external, and, indeed, the presence of the latter is a favor- able omen. Certain complications augur a serious termination, such as pneumonia, hemorrhagic infarctions of the lung, pleurisy with bloody effusion, dysentery, acute nephritis, etc. Treatment.—Prophylaxis.— By carrying out the known means of prevention the disease has been diminished more than 90 per cent. among mariners and soldiers. This change has been brought about by the enforcement of governmental regulations which demand that an ade- quate supply of antiscorbutic articles of food must be provided for military campaigns and for long sea-voyages. Fresh fruits and vegetables can be readily transported in hermetically sealed jars or cans. Treatment of the Attack.—The chief indication is to be met by the use of fruits and fresh vegetables. Of the former, two or three lemons daily or oranges and other fruits suffice to work a surprising de- gree of improvement in a short space of time. Antiscorbutic vegetables (potatoes, water-cresses, raw cabbage, lettuce, saur-kraut) in liberal quan- tity should also be given. Meats, eggs, milk, and farinaceous dishes are not to be prohibited, since the patients require all forms of food to invig- orate the system and to render normal the constitution of the blood; but if the digestive power be feeble, it is advisable to begin with the juice of oranges or lemons, conjoined with meat-juice, egg-white, milk, and light farinaceous articles, adding the stronger forms of animal food and fresh vegetables when improvement is noted. We may assist the digestive function by the use of simple bitters, strychnin, and hydrochloric acid (after meals), but these remedies are not needed in the majority of in- stances. Special symptoms may call for appropriate measures. Constipation requires simply an enema. On the other hand, diarrhea presents an in- dication for intestinal antiseptic and astringent remedies. The oral con- dition varies, hence the measures to relieve it vary also; but if ulcers be present, the solution of potassium chlorate is best. For swelling of the gums the application by means of a cotton swab of tannic acid (2 per cent.) or a solution of silver nitrate (2-5 per cent.) is serviceable. A combination of boric and carbolic acids in a solution of suitable strength may be used as a mouth-wash. If copious hemorrhages occur, hemostatics are eminently useful. The various complications must be met by the usual measures, according to their nature. SCORBUTUS. 411 Infantile Scorbutus. Definition.—A constitutional disease, characterized by the same symptoms as scurvy in adults, except that in many instances undoubted evidences of rachitis are associated. Pathology.—The bones are thickened and excessively sensitive, owing to a marked subperiosteal hemorrhage, Avith more or less macera- tion, and want of firmness betAveen the epiphysis and shaft. The muscles may also be the seat of effusion. The characteristic lesions of rickets are often associated. The nature of the affection may be regarded as being someAvhat ob- scure. Originally looked upon by most observers as acute rickets, it was subsequently described by Cheadle (from the clinical side) and Barlow (from the anatomo-pathologic side) as infantile scurvy. On the other hand, Ashby of Manchester, Fiirst and other German writers, are in- clined to the view that the affection should be considered a hemorrhagic form of rachitis. Northrup has reported 36 cases. The belief that rickets predisposes to scurvy, but that the two diseases are not regularly combined, is probably the correct one. Rachitis and scorbutus both occur in children of about the same age, and their causes are in some re- spects the same. Thus the dietetic factor is the chief in both diseases, but disproving the identity of rickets with scurvy is the fact that the former does not develop unless the diet fails to supply some elements contained in fruits and fresh vegetables. Etiology.—Scurvy is almost solely confined to hand-fed infants, especially those reared upon the numerous infant foods which have been foisted upon the market, including condensed milk, etc. Louis Starr, Jacobi, and others have shoAvn conclusively that it sometimes follows the prolonged use of sterilized milk, either exclusively or in combination with artificially prepared foods. It develops usually between the sixth and eighteenth months of age. Symptoms.—The skin presents the muddy color peculiar to the dis- ease in adults. The patient may be well nursed, but more often there is a tendency to wasting, and other symptoms of impaired nutrition appear, particularly irritability and disinclination to exertion. The more cha- racteristic features appear after one or tAvo months, and the child cries when handled, especially on touching the lower limbs. About the same time there is an irregularly cylindrical swelling of one of the thighs, due to subperiosteal effusion. Soon the other limb is similarly involved, though not always to a like degree. At first the legs are flexed, but later they become straightened and slightly everted on account of the progres- sive hemorrhage or separation of the epiphyses. The bones in other por- tions of the body may be involved secondarily in more or less rapid suc- cession, but the swellings are less marked than in the lower limbs. Later, if teeth be present, the gums may swell and become spongy. Ecchymoses in the form of petechiae appear upon the skin-surface, and particularly about the eyes. BarloAv describes a remarkable ocular phenomenon : " There develops a rather sudden SAvelling of one eyebrow, with puffiness and very slight staining of the upper lid. Within a day or two the other lid presents similar appearances, though they may be of less severity. The ocular conjunctivas may show a little ecchymosis or may be quite free." 412 CONSTITUTIONAL DISEASES. Hemorrhages from the mucous surfaces may finally put in an appearance. To complete the statement of characteristic features, it should be men- tioned that rapid improvement invariably follows an antiscorbutic regimen. Diagnosis.—To distinguish rickets from infantile scurvy Barlow's brief though clear aggregation of the characteristics of the latter disease may be quoted: " (1) Predominance of lower-limb affection, in which there is immobility going on to pseudo-paralysis; excessive tenderness; general swelling of the lower limbs; skin shiny and tense, but seldom pitting, and not characterized by undue local heat; on subsidence reveal- ing a deep thickening of the shafts, also liability to fracture near the epiphysis. (2) Swelling of the gums about erupted teeth only, varying from definite sponginess to a minute, transient ecchymosis." Prognosis.—Favorable, even in well-established instances, if brought under the proper regimen. Treatment.—An antiscorbutic dietary—fresh milk, meat-juice, and orange- or lemon-juice—meets the main indication. If there be sys- temic exhaustion—a condition that is not infrequent—gentle stimulation with brandy (highly diluted) and an abundance of fresh air are pre-emi- nent among the measures to be employed. Iron, arsenic, and cod-liver oil may be needful to complete the cure, but usually the simple means already mentioned will prove effective. The limbs, especially the lower, may claim attention. Local treatment, however, is rarely necessary, ex- cept there be separation of the epiphyses, when suitable splints are to be applied. PURPURA. Two main groups are to be distinguished: (1) Secondary purpura, which occurs from a great variety of causes and in numerous affections, in which its clinical significance has been pointed out in appropriate sec- tions of this work. It seems pertinent, however, to enumerate the chief among the diseases and conditions under which it may arise, as follows: (a) scurvy; (b) acute, infectious diseases (cerebro-spinal meningitis, vari- ola, measles, septicemia, ulcerative endocarditis); (c) hemophilia; (d) numerous chronic affections, as nephritis, leukemia, pernicious anemia, jaundice, Hodgkin's disease, and tuberculosis; (e) malignant sarcomata; (/) nervous affections, as locomotor ataxia, acute and transverse myelitis, and hysteria; (g) mechanical causes, straining efforts, intense paroxysms of whooping-cough, and violent convulsions ; (h) certain drugs may pro- duce a petechial eruption—quinin, copaiba, belladonna, ergot, mercury, and the iodids ; (i) snake-poisons produce rapid and extensive hemorrhagic extravasations, as shown by the careful studies of S. Weir Mitchell. (2) Primary or idiopathic purpura forms the second group. It is di- visible into (a) simple purpura (purpura simplex); (b) arthritic purpura, of which two varieties may be recognized : (1) peliosis rheumatica, and (2) Henoch's purpura; (c) hemorrhagic purpura (purpura hemor- rhagica). (a) Simple Purpura.—The cause is unknown. Among predisposing PURPURA. 413 influences, however, is age, the condition being most common in children about the time of puberty. It may be a sequel of the acute, infectious diseases, and in not a few cases develops in seemingly healthy subjects. Symptoms.—This is the mildest variety of primary purpura. The hemorrhages into the skin take the form of petechiae, vibices, or ecchy- moses. The first are extravasations of blood in the form of minute points, that appear, as a rule, in the hair-follicles, and, unlike the ery- themas, do not disappear upon pressure. The vibices receive their name from the fact that the hemorrhages occur as streaks, while the ecchymoses are larger, but similar in nature and behavior to the petechiae. They may exceed in size that of a split pea, and their hue ranges from a deep red to a livid bluish tint. As they fade a\vay they assume at first a yel- lowish-brown, then a yellow color, and finally disappear. The eruption appears in a series of crops, and its seat of election, often favored by the erect posture, is the legs. Bloody serum may be effused into bullae or large blebs. Shepherd and others have reported cases in which the purpuric eruption ended in gangrene, though in Shepherd's case the gan- grene Avas believed to be due to the use of sodium salicylate. (b) Arthritic Purpura.—(1) Peliosis Rheumatica (Schonlein's Disease). —The cause of this remarkable disease is unknown. Formerly many writers inclined to the vieAV that it is of rheumatic origin, and since en- docarditis and pericarditis are occasionally observed in association with peliosis rheumatica, considerable coloring is given to this belief. On the other hand, the fact that the cardiac complications are rare in arthritic purpura shows that not all cases of the latter disease are genuinely rheu- matic. It occurs chiefly in males from the twentieth to the thirtieth year of age. Among the prodromata are angina, slight articular pains, headache, loss of appetite, and fever ranging from 100° to 102° F. (37.7°-38.8° C). The affection is especially characterized, however, by polyarthritis, the joints being swollen, painful, and very tender; also by purpura, associated or not with urticarial wheals or erythema exudativum ; and by subcutaneous edema. The purpuric eruption is the only symp- tom that has pathognomonic significance, and in this affection it shows a strong preference, as regards distribution, for the affected joints and the legs. The eruption, as already intimated, does not display constant cha- racteristics. It may not differ from that of simple purpura, and the rash consists of petechiae, ecchymoses, streaks, and rarely of bullae (pemphi- goid purpura); or it may be made up of wheals of urticaria, attended with intense itching; and, finally, it may be identical with erythema nodosum. These forms of eruptions may be variously combined. Hemorrhages from the mucous surfaces rarely occur, though epistaxis is the most common. The extent of the edema varies greatly, in rare cases being quite extensive and overshadowing all other symptoms (febrile pur- puric edema). Albuminuria may be noted, and accompanying the pur- puric eruption there will be a mild febrile movement. Convalescence is usually protracted (even into years), and is often interrupted by recur- rence of the characteristic features. The diagnosis is made from the presence of three characteristic symp- toms—polyarthritis, a purpuric rash, and edema. The combination of purpura and urticaria is one of the chief distinguishing features. It is not always possible to eliminate rheumatism, but the non-rheumatic cha- 414 CONSTITUTIONAL DISEASES. racter of some of the cases may be clearly shown by the therapeutic test, as happened in one of my own patients. Prognosis.—This type of the disease is generally benign, death being very rare. Complications, however, may prove serious, especially the cardiac. The throat-condition may outlast the attack, and terminate in gangrene of the uvula or tonsils. (2) Henoch's Purpura—Henoch and Couty have described a form of rheumatic purpura occurring chiefly in children, and characterized by painful and sometimes swollen joints; by a purpuric eruption, plus ery- thema multiforme; by vomiting, diarrhea, and intestinal pain ; by local- ized edema of the skin ; and by hemorrhages from the mucous membranes and sometimes into the kidneys. The diagnosis is difficult in proportion to the scanty development of the purpuric symptoms, some of which are often wTanting. The prognosis is favorable, though complications of more or less seri- ous import may arise. One of Osier's cases proved fatal with the symp- toms of acute hemorrhagic Bright's disease. (c) Purpura Hemorrhagica (Morbus Werlhofii).—This is the severest form of purpura, and its apparent etiologic connection with certain infec- tious diseases, particularly rheumatism, malaria, etc., is interesting, but not well understood. The disease is perhaps most common in young females, particularly if they have fallen into general ill-health; but all persons are liable, and post-mortem anatomo-pathologic pictures of the disease leave little room for doubt that it is an infectious complaint. Symptoms.—Prodromal symptoms, such as malaise, headache, depres- sion, and anorexia, generally appear, and last one or two days. The invasion is moderately abrupt, with fever, and soon cutaneous ecchymoses appear upon the skin, quickly growing larger in size as well as multiply- ing in numbers. Slight hemorrhages from the mucous membranes into the internal organs occur. Epistaxis generally comes first; it tends to persist and to recur frequently, and the same peculiarities pertain to bleedings from other points. Prostration now becomes rather marked, the patient complaining of pains in the limbs, loins, abdomen, and chest, and the latter often presage a fresh hemorrhage. There is moderate fever, as a rule, the temperature during the height of the attack ranging from 101° to 103° F. (38.3°-39.4° C). or it may reach 104° to 105° F. (40.5° C), though rarely. The pulse is accelerated (120 to 130 per minute), but full and regular, though in the worst cases it becomes small and very rapid. The mind is usually clear. Hematuria occurs when hemorrhage has taken place into the kidneys, and may lead to nephritis. There is anemia varying in intensity with the extent of the hemor- rhage and the severity of the type, and showing the characteristics of symptomatic anemia. The face may be exceedingly pale and anxious. The course is run in from seven to ten days in mild cases, while the severer attacks pursue a longer course. It is to be recollected, however, that the type of the disease may be malignant (purpura fulminans) and arrive at a speedy fatal termination. The diagnosis of purpura haemorrhagica rarely presents any difficulty. Scurvy may simulate it in some particulars, but is distinguished by its chief etiologic factor—a diet deficient in fresh vegetables and fruits—by the spongy, swollen condition of the gums, the loosened teeth, and brawny HEMOPHILIA. 415 induration of the limbs. Moreover, in purpura hgemorrhagica the hair- follicles do not occupy the centers of the ecchymotic spots, and the hemor- rhages from the mucous membranes are more copious than in scurvy. Malignant types of the eruptive fevers distinguish themselves by the his- tory of the prevailing epidemic, by the characteristic prodromes and in- vasion, and by the high temperature. It must be remembered, hoAvever, that variola purpura often pursues an afebrile course. Prognosis.—Grave, except in mild cases. In the malignant type death may come before hemorrhages from the mucosa appear. Certain com- plications may prove fatal—cerebral hemorrhage, inundation of the lungs with blood, Bright's disease, and shock from rapid, profuse bleedings. Death may also be the result of exhaustion due to protracted bleedings. Treatment.—(a) The management of secondary purpura is em- braced, in other portions of this volume, in connection with the treatment of the diseases and conditions Avhich it accompanies. (b) Simple purpura demands arsenic, first in moderate doses, and then increased until slight toxic effects are noticeable. Legroux speaks in warm terms of the iron compounds, and especially of iron perchlorid in doses of 3ss-j (2.0-4.0) daily, and if the child is somewhat anemic, the inhalation of oxygen will promote hematosis. The disease also requires fresh air in abundance and a generous diet. (c) In peliosis rheumatica, in addition to the measures recommended in purpura simplex, the salicylates may in some cases influence the affec- tion of the joints. (d) Purpura Hcemorrhagica.—I have found that an abundance of nourishment, by supporting the patient's power, is of the greatest service. Internally, ergot, turpentine, tincture of the chlorid of iron, acetate of lead, and dilute sulphuric acid enjoy the widest reputation. The follow- ing combination, recommended by Hardaway, I have found to be very useful: B/. Ext. ergotae fl., Tr. ferri chlorid., da. fgij (64.0).—M. Sig. Three to ten drops in water, t. i. d. HEMOPHILIA. [Bleeder's Disease.) Definition.—An hereditary affection, transmitted by females who are themselves not affected (Nasse's law). It is characterized by fre- quent uncontrollable hemorrhages that are either spontaneous or due to slight traumatism. Pathology.—The constitutional changes or peculiarities on which the disease depends are to be found in the blood-vessels rather than in the blood itself (Henry); microscopic changes have been found in the arterioles, the middle muscular tunic being either absent or much atro- phied. Vaso-motor influences also play an important part in causing an attack, as is shown by the frequent flushings of the face preceding an 416 CONSTITUTIONAL DISEASES. attack, and also by the fact that bleeding may follow emotional excite- ment (Henry). Synovitis with hemorrhages into the joints may some- times be observed. The blood presents no appreciable change. Etiology.—Hemophilia is more distinctly hereditary than any other known disease, but Nasse's law is not of such universal application as is generally supposed. R. Kolster found that of 50 hemophilic families, 18 cases followed this la\v, 16 others with some exceptions to its provis- ions, and 12 without any regard to it. The law embraces the folloAving points : The daughter (not herself affected) of a bleeder transmits the tendency to her sons, who become bleeders ; her daughters do not suffer, but in turn transmit the disease to their sons. Females, howeArer, may be bleeders, and, according to Virchow, one woman is affected to every seven men. The disease has been traced for centuries in a few families. The disposition may be acquired, but of the conditions that may lead to its development we are entirely ignorant. It is observed in all classes of society, and is most frequent in families Avhose members are large, vigorous, and have delicate complexions, the complaint usually manifest- ing itself before the end of the second year of life, though exceptionally as late as puberty. Symptoms.—The occurrence of profuse and persistent bleedings that are either spontaneous or the result of slight injury characterizes hemophilia. The character of the injuries that lead to dangerous bleed- ings is often exceedingly trivial; thus a slight scratch, cut, blow, the ex- traction of a tooth, and other minor surgical operations (e. g. circumcis- ion) may be followed by severe hemorrhage. If we include spontaneous hemorrhages, bleedings take place most frequently from the nose. Legg has made three clinical groups, based on the intensity of the symptoms, as follows : (1) Seen most frequently in men, and characterized by external and internal bleedings of all kinds and by joint-affections ; (2) most frequent in women, and distinguished by spontaneous hemorrhages from mucous membranes only ; and (3) cha- racterized simply by ecchymoses. The capillaries ooze blood—a process that may vary in duration from a few hours to as many Aveeks. A fatal result may thus occur in a few hours, while, on the other hand, recovery may folloAv a slow ooz- ing of blood that has continued for many days. In the latter instances profound anemia folloAvs, the blood, however, being rapidly replaced. Extensive blood-extravasations (hematomata) usually follow contusions. Petechias, when they occur, are apt to be spontaneous. The blood coagulates, except in long-standing hemorrhages, when it becomes thin and watery (late). Arthritic symptoms are common, the larger joints, and especially the knees, being most frequently affected and shoAving swelling that is due chiefly to hemorrhages into the joints. In other instances febrile syno- vitis may be present, resembling rheumatism. The joint-symptoms may either announce an approaching hemorrhage or pain alone may be ex- perienced. The attacks are liable to recur, especially in cold, damp Aveather, and may result in stiffened, deformed joints (Musser). Diagnosis.—When persistent capillary oozing occurs in a person Avith a clear, hereditary disposition the diagnosis is clear. Without an inherited tendency we cannot be certain of the diagnosis unless pro- HEMOPHILIA. 417 tracted hemorrhages from insufficient causes are repeatedly manifested. The presence of joint-involvement is very helpful. Differential Diagnosis.—Peliosis rheumatica is an affection which, as Osier remarks, touches hemophilia very closely, particularly in the re- lation of the joint-swelling. It is true that the former may also show itself in several members of a family, but the presence in this affection of more or less edema, and often of wheals of urticaria, accompanied by intense itching, aids greatly in its elimination. Prognosis.—In undeveloped forms the outlook is not particularly grave, since in these the tendency may either lessen or become alto- gether arrested after childhood. In the majority of well-marked cases the children do not survive this period. On the other hand, those who live to become full-grown shoAV a diminished, and in a small class of cases an absolute, disappearance of the tendency. The first hemor- rhage rarely proves fatal. Boys suffer from a more serious form than girls. Moreover, menstruation, though sometimes very copious, does not to any great extent endanger the life of a hemophilic woman. Of 130 cases of pregnancy and labor, the death of the mother occurred in only 3, and abortion in 16 cases (Kolster). Treatment.—The physician can do most in the direction of pro- phylaxis. All surgical operations that are not absolutely necessary must be aAxoided ; neither should the teeth be erupted nor the operation of circumcision be permitted, nor are leeches permissible. Females who belong to bleeder families, as well as males Avho have had hemophilia, should not marry. During the attack absolute rest—mental and bodily—must be en- joined, and light compression, and if this fail strong pressure or styp- tics, should be tried. It is, however, a great question how far agents that destroy the already weakened tissue are useful. In epistaxis ice, tannin, and turpentine should be tried before using nasal plugs; and if the latter prove indispensable the lightest only should be employed. J. Greig Smith regards lint saturated with spirits of turpentine as the best local application in epistaxis. Internal medicines are of secondary importance, though they may be tried, and opium is unquestionably of signal value, since it tends to quiet the patient, thus favoring repose. The remedies that have been given are various. Delafield, Fiirth, and others have used successfully the fluid extract of hydrastis canadensis, the dose being from 20 to 40 drops daily ; among other hemostatics, gallic acid, turpentine, and iron perchlorid produce the best results. The dose of the latter should be 3ss (2.0) every two hours, with a purge of sulphate of soda (Legg). During convalescence arsenic, iron, and the bitter tonics, together with a liberal dietary, will aid recovery. 27 418 CONSTITUTIONAL DISEASES. HEMORRHAGIC DISEASES OF THE NEW-BORN. (a) Epidemic Hemoglobinuria (Winckel's Disease).—This affection, which is septic in nature, is occasionally met with in lying-in hospitals, and occurs in children from one to ten days after birth. The infants refuse the breast and show hematogenous icterus; gastro-enteric ca- tarrh is an attendant of the disease. The stools are meconic; the urine is scanty, dark-colored, often albuminous, and may contain casts and epithelium. Hemorrhages occur into organs other than the kidney and into the mucous membranes, there also being mild fever, rapid ema- ciation, and often mild convulsions. Recovery may take place, though it is a very fatal disease. Bacteriological experiments have shown that the disease may be produced by the growth of the colon bacillus in the buccal epithelium of infants, but these investigations need confirmation before Ave accept their results as conclusive. (b) Acute Fatty Degeneration of the New-born (Buhl's Disease).— This disease may be similar to Winckel's in nature. It was first de- scribed by Hecker and Buhl as an infectious disease of the new-born, characterized by cyanosis, jaundice, and copious visceral hemorrhages. The chief pathologic change is an acute fatty degeneration of the inter- nal organs. (c) Syphilis Hemorrhagica Neonatorum.—Either at birth or soon thereafter bleedings take place into the skin (ecchymoses) and from the mucous surfaces and the navel. Jaundice may be associated. The viscera are found upon post-mortem examination to be the seat of syphi- litic lesions. (d) Morbus Maculosus Neonatorum.—Hemorrhage from the gastro- intestinal mucosa of the new-born (melaena neonatorum) occurs, and may be due to intracranial lesions during birth; it may also take place independently of the latter. Preuschen has collected the reports of 37 cases, in 5 of which the brain was examined, and all of these showed cerebral hemorrhages. The latter may occur in spontaneous births and give rise to melaena neonatorum. Gartner believes the dis- ease to be an infectious one, and claims that in 2 cases he was able to identify a bacillus for Avhich the navel is believed to be the entrance- point. The blood may also come from the mouth, nose, navel, etc. Townsend found morbus maculosus neonatorum in 45 cases in 6700 deliveries, and in most of these instances the bleeding Avas general. The hemorrhage usually sets in during the first Aveek, rarely later, and the du- ration of the disease is between one and seven days, the mortality being a little over 50 per cent. Vomiting of the blood which the child has drawn from the breast must not be confounded with true melena. The treatment is by gallic acid and ergotin, the latter hypodermically; stim- ulants may also be required, and warmth to the extremities if the per- ipheral circulation be feeble. PART III. DISEASES OF THE BLOOD AND THE DUCTLESS GLANDS. ANEMIA. Definition.—A pathologic condition, characterized either by a diminution in the quantity of blood or by a deficiency in one or more of its constituents. Anemias may be subdivided into—I. Primary or Essential (simple, chlorotic, and pernicious); II. Secondary (symptom- atic); III. Leukocytosis; IV. Leukocythemia (splenic, myelogenic, and lymphatic). Pathology.—Anemia, in its different forms, is characteristic of dis- eases of the blood or of the blood-making organs. It may be manifest, on examination, as a diminution of the total quantity or body of the blood (oligemia); of the number of red corpuscles (oligocythemia); of the hemoglobin (oligochromemia); and of other constituents, as albumin (anhydremia). The diminution of hemoglobin gives rise to the most obvious sign of anemia or impoverished blood—namely, the pallor of the cutaneous surface—but it is important to point out here that the quan- tity of hemoglobin in the blood is not necessarily proportionate to the number of red corpuscles. Thus the percentage of hemoglobin con- tained by the red corpuscles may vary in disease, so that a reduction in its amount does not necessarily involve a corresponding decrease in the number of red corpuscles. Conversely, a diminution in the number of the latter may not be accompanied by a proportionate diminution in the amount of hemoglobin, the corpuscular richness in coloring-matter being quite normal. As a matter of fact it frequently happens that oligo- chromemia is associated with a certain degree of oligocythemia, and vice versd, though Avhere they coexist the degrees of reduction may neither be relatively nor proportionately equal. Anemia can be positively ascertained only by an adequate examina- tion of the blood. It may be inferred from the presence of pallor, languor, dyspnea, palpitation, etc.; but it should be borne in mind that not every pale person has anemia, since pallor of the face may be hered- itary, and, at the same time, perfectly consistent Avith good health, a normal number of corpuscles, and a normal percentage of hemoglobin. Conversely, a person Avith marked vascularity of the face, and a rosy complexion even, may have anemia. The anemias embrace those conditions, also, in which there are changes in the shape of the red corpuscles (poikilocytosis), and in their size (micro-, macro-, or megalocytosis). 419 420 DISEASES OF THE BLOOD AND THE DUCTLESS GLANDS. I. THE PRIMARY OR ESSENTIAL ANEMIAS. Primary anemias constitute those forms in which, so far as our pres- ent knowledge of their etiology and pathology goes, no other tissues or organs than the blood and the blood-making organs are either at fault or are directly affected. Future investigations of the life-history of the blood may reveal the exact causation of Avhat are now regarded as pri- mary or essential anemias, and thus permit of a clearer discrimination and a more accurate classification. SIMPLE OR BENIGN ANEMIA. This form is not infrequently met with as a congenital, constitutional affection, without any assignable cause, and is entirely free from per- nicious manifestations or tendencies. There is no discoverable element of relationship betAveen simple benign anemia and chlorosis, nor is the former symptomatic of any disease in which anemia is common, such as tuberculosis, carcinoma, and nephritis. Etiology.—Simple constitutional anemia is often met with among the poorer classes, and from this fact it is probable that living or work- ing in a vitiated atmosphere, as Avell as deficient sunlight and nutriment, is primarily active in reducing the general health. In this way is often caused a lifelong pallor, due to an interference with the normal process of blood-making (hemogenesis). There are also certain individuals in whom slight pallor and systemic feebleness have existed from infancy (thus probably congenital), and whose modes of life and environment have been more or less uniformly hygienic and provident. In such cases we may assume that there is some innate imperfection—anatomic or physiologic, or both—in the blood-forming organs. Finally, in the later manifestations of slight general anemia a devel- opmental strain or abnormality may start a disorder of hematopoiesis in organs congenitally insufficient for new and greater demands for blood made by the system. Symptoms.—There is some pallor, often with languor, slight pal- pitation, and dyspnea, occasional headache, and a tendency to fatigue. The general health is not otherwise disturbed, and an active life may be enjoyed for many years. Examination of the blood shows a slight re- duction in the number of the red cells and of the hemoglobin (rela- tive). This degree of anemia persists without aggravation or amelio- ration. It may be found to affect males and females, and is observed principally in adult life. The diagnosis of simple, benign, or constitutional anemia should be made with considerable caution and reserve, and it should be arrived at only after the closest scrutiny of all the symptoms and signs, the most careful study and judicious balancing of the data entering into the previous history of the patient. If there be a latent or incipient tuberculosis, carcinoma, or nephritis, a previous attack of some infec- tious fever, rheumatism, etc., this fact clearly bears upon the case, and the diagnosis of simple anemia is precluded. The prognosis is usually favorable. On account of the possible existence of one of the above-mentioned diseases, or from the fact that CHLOROSIS. 421 a grave variety of anemia may be superadded, however, it should be guarded in the mind of the physician, at least. The treatment of simple, benign anemia is an expectant one in most instances. Hematinics (iron, arsenic, etc.) are seldom required, as they have little if any influence upon the blood or upon the pallor or other symptoms. A rigid system of hygiene, together with attention to proper food and drink and to the manner of eating and drinking, will probably ensure to the patient all the benefit that may be obtained. Cardiac tonics (digitalis, strophanthus) may be useful in controlling the palpitation. It is Avorse than futile to attempt to eradicate any con- genital defect of the blood-vessel system or hematopoietic organs. CHLOROSIS. [Green Sickness.) Definition.—A blood-disease, occurring chiefly in adolescent fe- males, and characterized principally by a deficiency of hemoglobin in the red corpuscles. It runs a mild course, though Avith a tendency to relapse. Pathology.—It is so seldom that death occurs in cases of chlorosis that autopsies of this disease have not been frequent enough to determine definitely the nature of the findings. There is no loss of fat in the body, but signs of physical degeneration and disorders of development are quite common, hypoplasia of the vascular system and of the genital organs seeming to be the most prominent. Incurable cases of chlorosis are nearly always characterized by anomalies of the blood-vessels and genitalia (Rokitansky). VirchoAV has also shown that congenital arrest of development of the aorta and larger arteries, as indicated by their small size, their soft and elastic walls, is quite constant in chlorotics. The uterus (especially) and adnexa manifest the hypoplasia, and yellow- ish spots and streaks of fatty degeneration are sometimes seen in the intima of the arteries. The cardiac muscle is softened, the whole heart is dilated, and the left ventricle is usually somewhat hypertrophied. Etiology.—Chlorosis occurs most frequently in girls at or near puberty, and also may appear betAveen that period and twenty or twenty-five years of age. It usually happens that the condition dates from a scanty menstruation, beginning late in the " teens," but it should be recollected that amenorrhea is not, as formerly supposed, a cause, being rather an effect of the underlying blood-disorder. Blondes are oftener affected than brunettes. In males the disease is rare, though cases may develop at puberty or during adolescence. The influence of heredity in the causation of chlorosis is undoubted in those cases described by Virchow, in which congenital hypoplasia of the blood-vessels and genitalia is found to exist. Other cases, moreover, in which such anatomic evidence is Avanting, also bear the stamp of hered- ity, in that their mothers have been, and their sisters are, chlorotic. A family tuberculous taint may predispose to chlorosis (Jolly). Such un- hygienic conditions as bad air, dimly-lighted rooms, a lack of nutritious food and out-door exercise, a sedentary occupation, hasty and irregular eating, excessive tea- and coffee-drinking, irregular and insufficient hours of rest and sleep; bodily fatigue, as from stair-climbing and standing in 422 DISEASES OF THE BLOOD AND THE DUCTLESS GLANDS. constrained positions without intervals of rest,—all these predispose to the disease. And yet girls living amid the most luxurious and favor- able surroundings have had chlorosis. It is not at all improbable that, as the late Sir Andrew Clarke believed, copremia—the absorption of the toxic ptomains and leucomains from the colon in constipation—is often the cause of chlorotic symptoms and signs, though physiological chemists fail to find in the urine the evidences of intestinal putrefaction (/. e. an increase of the aromatic sulphates). Sometimes a previously existing simple constitutional anemia appears to be an underlying cause for an exacerbation of genuine chlorosis. In such instances, however, I be- lieve additional exciting causes to be operative. Sudden emotional excitement and prolonged mental over-exertion operate as causative agencies. Shock from bad news, such as loss of relatives, crosses of various kinds, home-sickness, disappointment in love, rankling grievances, and perhaps ungratified sexual desires or masturbation, may contribute to the " neuropathic " origin of chlorosis. A change of climate seems to operate as a cause, and is manifested especially in the case of girls emigrating from Ireland to enter domestic service here (Townsend). Symptoms.—A brief outline of the more frequent and prominent general manifestations of chlorosis—or " green sickness "—may be nar- rated at the outset. The gradual onset is usually marked by languor, indisposition to either physical or mental exertion, motor Aveakness, irritability or inertia of mind, depression of energy, and a more or less constant fatigue. Palpitation of the heart and dyspnea on slight exer- tion are much complained of in most cases; headache is also an early symptom, and may be accompanied by vertigo in some cases; and dys- pepsia and constipation occur in 65 per cent, of cases (ToAvnsend). Probably in one-half of all cases cessation of, or scanty and irregular, menses may form the burden of complaint. There are also certain special symptoms, among Avhich the following may be mentioned: The appetite is either poor or perverted, and a ca- pricious desire for such innutritious substances as chalk, slate-pencils, and even bits of earth (pica), or for sour, highly spiced, and unwhole- some articles of food (malacia), is not uncommon. Morning vomiting or regurgitation of food and eructations occur in some cases, and dilata- tion of the stomach and high position of the diaphragm are found in many instances. The tongue is pale, flabby, often dry, and the edges show indentations. Constipation is usually present, though sometimes diarrhea, lasting for a day or two, may alternate, as after the ingestion of some unwhole- some article that has been eaten to satisfy the perverted appetite. The general appearance is distinctive. The subcutaneous fat is not only well retained, but in many cases is even increased, and the rotund- ity of the body and members preserved. The peculiar greenish-yellow tint of the complexion is, however, the most striking manifestation to the eye. It differs thus from the muddy pallor of cancerous anemia, from the lemon-yellow tint of pernicious anemia, from the saffron hue of jaundice, and from the blanched pallor after severe hemorrhages. The sclerae are often pearly- or bluish-white (" cerulean hue "), and, though this is considered by many the earliest positive indication of anemia, when the CHLOROSIS. 423 skin-tint is not characteristic, yet, according to Townsend's analysis of 87 cases of chlorosis, it is not the most constant. The nails showed pallor in 95 per cent, of the cases; the cheeks, tongue, and lips were paled in 89, 84, and 76 per cent, respectively, while the sclerae were pale in but 64 per cent. On exertion the cheeks and lips may become quite ruddy in cases of moderate anemia (chlorosis rubra). Besides the breathlessness, palpitation, and the tendency to vertigo and syncope complained of in the majority of cases, other circulatory disturbances may occur. The skin is often cool, and the extremities are frequently cold, OAving to sluggish heart-action. The pulse is usually full and easily compressible, and, OAving to its excitability, it may be accelerated for the time being by various external influences (see Fig. 140 136 132 128 124 120 118 112 108 104 100 96 92 88 84 80 76 72 A. M. ■» <° - <■ « 2 „ ,/,xA. , '! kr ^"V ^' V --£ y i k\ a . i • V £*$4 1 A 990 // V.A i /\ ,£>"x/ r V-!* V 1 A~2„*5r. s / \ f \*-i \ \ * Z £ ' Z £* ^ / y \ t ^ ^ f^ -*jt 3 * NORM. J ' V \ 1 2 ' ^—* - ■ Y 21 J_ V 98° ] \/ p \ 1 [ 1 ' 1 97° AFTER AF1 EATING EXER "ER AFTER TION EXCITEMENT Fig. 33.—Pulse- and temperature-chart of a case of chlorosis, showing the effect exerted upon the pulse by eating, exertion, and excitement. 33). Visible undulating pulsations of the carotid vessels are frequent, and a pulsation in the peripheral veins is also observed at times. Phys- ical examination shows the heart to be slightly dilated. Systolic mur- murs, soft and " whiffing " in character, are heard at the base, though in severe cases they may be heard at the apex of the heart also. Sys- tolic blowing murmurs of hemic origin are not infrequently heard over the carotid arteries. More common and characteristic, however, is the venous hum or bruit de diable—the soft continuous murmur heard over the large cervical veins. Thrombosis of the larger veins, or of the fem- oral, or of a cranial sinus, may occur and is always of serious import. Of the nervous manifestations that are often present, neuralgias of the head, mental depression, hyperesthesia of the skin, particularly of the abdomen, gastralgic attacks, and hysteria, are most frequently met Avith. Tinnitus aurium and anemic amaurosis have been knoAvn to occur. Edema of the ankles is found in perhaps one-third of the cases. The urine is generally pale, free in quantity, and its specific gravity is some- what lowered; and according to recent studies there is a diminished 424 DISEASES OF THE BLOOD AND THE DUCTLESS GLANDS. excretion of nitrogen in the form of urea, despite the abnormal destruc- tion of albuminoids. Blood-examination.—The blood flowing from a punctured finger-pulp or ear-lobule is pale, though seldom thin or hydremic, and the paleness is due to a qualitative rather than a quantitative change. There is a disproportionate reduction of the hemoglobin as compared with the number of the red cells. The hemoglobin may range from 50 per cent. to as low as 16 or 17 per cent, in severe cases, the average quantity being about 38 or 40 per cent. On the other hand, the number of red corpus- cles is not greatly reduced, and may even be normal. The moderate oligocythemia and marked oligochromemia are almost distinctive of chlorosis: these features, however, may be closely simulated by the chloroanemia of syphilis or early tuberculosis. The average number of red corpusles is from 3,700,000 to 4,000,000 per cubic millimeter of blood, but the count in very severe cases may be as low as 1,900,000. Approximately, the number of red corpuscles is from 70 to 85 per cent. of the normal, while the leukocytes are only slightly increased in num- ber (8000 to 8500 per c.mm.). Microscopically, the red cells are seen to be paler than normal, and somewhat altered in size and shape. Some are distinctively larger than is usual (macrocytes), but the majority are slightly undersized (microcytes). Irregularity in shape (pokilocytosis) is seen in quite a number of the red cells in the severe cases, and an occasional normoblast (small nucleated red corpuscle) may be noted. Diagnosis.—When the greenish pallor of the face is marked this can often be correctly made at a glance. The blood-examination must be made, however, to completely establish the diagnosis, even when dis- tinctive symptoms are present, such as the shortness of breath, palpita- tion, Aveakness and languor, faintness, amenorrhea, capricious appetite, together with a well-nourished appearance of the body. The bluish- Avhite sclerae and pallid nails are confirmatory when observed, and the physical signs should also be sought for. The primary character of the anemia may be determined in doubtful cases, or in those in which incipient tuberculosis or Bright's disease may be suspected, by exclusion. Here the physical examination of the chest and urinalysis should supplement the blood-examination. Organic dis- ease of the heart may be simulated by the breathlessness, palpitation, vertigo, and edema. According to F. P. Henry, the following blood- variations may be considered in the diagnosis of chlorosis: (1) the red corpuscles may be normal in number and in size, the only change being a deficiency of the hemoglobin; (2) the corpuscles may be normal in number, but diminished in size, while the percentage of hemoglobin is normal; (3) the corpuscles may be diminished in number, with either a diminished, normal, or perhaps an increased percentage of hemoglobin. Prognosis.—This is always favorable, except in those cases in Avhich congenital or developmental anomalies of the vascular system are associated. The discontinuance of proper treatment before a substan- tial cure is effected is often followed by a relapse, and even after appar- ent cure one or more recurrences may be Avitnessed before the age of thirty. The average duration of a case of chlorosis is from two to three months. In cases of very severe type, in which the diAriding-line CHLOROSIS. 425 between this disease and pernicious anemia may not be marked clearly, the prognosis should be made Avith due reserve. Treatment.—While the treatment of chlorosis by the administra- tion of iron is Avellnigh specific, the hygienic measures are also import- ant, and particularly in order that relapses may be avoided. Pure air, wholesome food, and plenty of rest and sleep, with reg- ular habits, are prime requisites. Sometimes a change of occupation, even temporary, Avhere confinement may be replaced by an out-door life, fresh air, and sunshine, as in the case of store-girls and mill-operatives, is of great value in bringing about a rapid improvement. Patients in better circumstances may be sent to rural districts, the mountains, or sea-shore. In cases marked by much palpitation, dizziness, and dyspnea, rest in bed for a week or so is often imperative at the outset. As im- provement goes on, however, light and then moderate exercise may be permitted out of doors, and the increasing appetite should be gratified by a generous, easily assimilable diet (milk, meat, eggs, fish, purdes of green vegetables, steAved fruit, apples, etc.). Fats and carbohydrates, however, should generally be avoided. Ferruginous mineral waters when procurable may be freely drunk, but coffee, tea, and alcoholics Fig. 34.—Chart of a case of chlorosis, showing the improvement following the administration of iron. Convalescence almost complete; relapse. Black, red corpuscles; red, hemoglobin; blue, white corpuscles. do more harm than good. The one remedy, par excellence, on both rational and empirical grounds, is a good preparation of iron. This should be given methodically and persistently, until the percentage of 426 DISEASES OF THE BLOOD AND THE DUCTLESS GLANDS. hemoglobin is 90, and then maintained there by continuing the admin- istration of the iron for several weeks to prevent a recurrence (Fig. 34). Exactly how the iron acts in curing chlorosis has not been definitely proved, but its almost specific action is indubitable. Not all prepara- tions of iron are equally well borne by the stomach, however, and sev- eral changes may be necessary during the course of a given case. Prob- ably the best form for general use is the dried sulphate, usually given together with potassium carbonate in the well-known Blaud's pills—2 grains (0.129) of each to the pill. Starting with one pill thrice daily for a week or ten days, the daily dosage is increased until nine pills daily are administered in the third week, and continued for several weeks or as long as the case may require. It is very important, meanAvhile, that the bowels should be kept soluble by the use of cascara sagrada, salines, and the like. A preliminary course of intestinal antiseptics for a Aveek or so is strongly advised by some authorities, and is worthy of recom- mendation. Beta-naphtol, thymol, guaiacol, and salol are used for this purpose. The hematinic effect of the iron seems to be produced earlier and better when this plan is followed ; and this fact seems to give cor- roborative evidence to Bunge's theory of the absorption of the iron in chlorosis—in a certain class of cases at least. Other iron preparations of value in this disease are the citrate, protoxalate, lactate, carbonate, the succinate, and the reduced iron. The albuminates of iron, so much vaunted for a time, are practically Avorthless. In severe cases Quincke uses at first a 5 per cent, solution of the ferric citrate, hypodermically (Ttlvijss-sijss—0.5-10.0, daily). The preparation known as ferratin is also highly recommended by some, and the therapeutic efficacy of gly- cerin extract of bone-marrow in chlorosis is as yet doubtful. Bitter tonics and dilute hydrochloric acid are indicated in a certain number of cases in which indigestion is troublesome. The acid tincture of iron chlorid. is sometimes used in such cases. Mild cases often yield to the simple use of remedies for the cure of gastro-intestinal derangement. Adjuvants in the treatment of chlorosis that may be of use are arsenic, manganese, mercuric chlorid, and arsenite of copper in minute doses. PROGRESSIVE PERNICIOUS ANEMIA. [Idiopathic Anemia.) Definition.—A grave blood-disease characterized by a great de- struction of red corpuscles, and a persistent tendency from a bad to a Avorse condition. It usually ends in death, and seldom exhibits causal lesions other than those of the blood or blood-making organs. The term "idiopathic anemia" applied to this disease by Addison, whose first clear description of its clinical history has become classical, is applicable to a proportionately smaller number of cases to-day than during his time. This is owing to the later discovery (post-mortem) of adequate causes for the pernicious anemia that during life could not be found. Thus, while still a primary essential anemia in most cases, and whilst future investigations may show the true Addisonian type of pernicious anemia to be a severe secondary anemia, for descriptive pur- poses it will nevertheless be convenient to classify both groups under the title of progressive pernicious anemia in order to describe the PROGRESSIVE PERNICIOUS ANEMIA. 427 invariable tendency of both. Under Diagnosis (vide infra), however, will be found some differential clinical features. Pathology.—As in chlorosis, the subcutaneous fat is rarely dimin- ished, so that emaciation is exceptional. The skin is pale and of a lemon-yelloAv tint, and most of the tissues and organs are anemic, ex- cept the muscles, which are often decidedly red in color. The fat is usually pale and yelloAvish, and fatty degeneration is one of the most striking changes in this affection. The heart is usually large and flabby, and on section of the ventricular walls there is a marked pallor, as well as a friability, and a fatty change shown by the yellow tint. Micro- scopically, the fibers or columns of heart-muscle are seen to be distinctly fatty. The heart-cavities contain very little light-colored blood. Other organs shoAving the fatty degeneration (of the epithelium) are the liver, kidneys, gastric and intestinal walls, and the intima of many of the smaller blood-vessels (in patches). This general fatty change is prob- ably directly due to the deficient oxygenation of the tissues and to the anemic blood-supply. Owing to the above degenerative change, and consequent weakening in the vessel-Avails, small extravasations of blood are found in dif- ferent parts. Most frequently these punctiform hemorrhages are seen in the retina and on serous membranes, as on the inner surface of the dura mater, the pericardium, and the pleura. Ecchymoses are also ob- served occasionally on the mucous membranes and on the skin. More or less general edema and dropsical accumulations in the serous cavities are not uncommon. The spleen and liver are seldom and only very slightly enlarged. The lymph-glands are often somewhat SAvollen and intensely red in color, owing to the unusual number of red corpuscles, some of which are nucleated. A marked and important pathologic feature of pernicious anemia is the presence of abundant deposits of iron-pigment, especially in the liver, but also in the spleen, kidneys, pancreas, and other organs. The fact that the abnormal quantity of iron in the liver is peculiarly distrib- uted about the periphery and middle zone of the lobules is particularly noteworthy, and quite characteristic of pernicious anemia. The origin of this iron is doubtless the enormous destruction of red corpuscles, and that the pigment in the hepatic lobules is ferruginous may be determined by a micro-chemic test with ammonium sulphid, granules of black sul- phid of iron being formed. Of special interest are the lesions found in the bone-marrow on account of its hematopoietic function. This is virtually hypertrophied, and is in many cases deep-red instead of yelloAv, and more like the hemoblastic marrow of childhood (H. C. Wood). Indeed, the fat-mar- row of the long bones is often entirely replaced by the red marrow, which makes evident the contrast betAveen it and the icteric pallor of the fatty tissues elseAvhere in the body. Cellular hyperplasia may be seen microscopically in the great number of large and small granular medul- lary cells, and also in the nucleated red cells. An atrophied and polypoid condition of the gastric mucosa, more or less extensively involving the gastric tubules, is noticed in some cases. The sympathetic ganglion cells may also show changes. More constant, hoAvever, is the sclerosis of the posterior columns and, to some extent, 428 DISEASES OF THE BLOOD AND THE DUCTLESS GLANDS. of the lateral columns of the spinal cord: this is especially marked, according to Burr, in the cervical swelling. These sclerotic changes are probably secondary either to the blood-state or to minute hemorrhages. Etiology.—There are three etiologic categories into Avhich cases of pernicious anemia may be grouped: (1) those cases in Avhich no discov- erable cause for the hemolysis (blood-destruction) is ascertained, either during life or after death—i. e. the idiopathic variety of Addison ; (2) those in which an adequate cause is found post-mortem only; (3) those that are plainly traceable, ante-mortem, to some sufficient primary causal condition acting directly or indirectly. (1) As regards the obscure cases of idiopathic anemia—or cachexia— the essential cause of the symptomatic condition is evidently an actively increased hemolysis. The blood-destruction is so great that blood-gen- eration (hemogenesis) is overbalanced. The latter may be normal in power or there may be a congenital or acquired underlying deficiency in hemogenetic poAver; but in either event the hemolysis far exceeds the hemogenesis in pernicious anemia, the liver being the principal seat of the hemolytic changes—in the final stages, at least. Stengel believes that the hemolysis originates in the gastro-intestinal capillaries, and de- pends upon poisons generated or absorbed from that tract—an auto- intoxication. (2) Apparently causeless cases of progressive pernicious anemia may be found post-mortem to have been caused by (a) obscure malignant dis- ease ; (b) parasites, especially the Anchylostoma duodenalis, and rarely by the Bothriocephalus. Not infrequently, by a careful study of the anamnesis of a patient, aided by modern methods of examination, the cause of pernicious anemia may be detected during life. Atrophy of the stomach and chronic gastritis, with polypoid groAvths of the mucosa, may be included in this category. The Bothriocephalus latus may be discovered during life, though more frequently only after death. (3) Certain exhausting causes, operating directly or indirectly, may precede this affection, as severe or prolonged hemorrhages, or diarrhea, fevers, mental shock, profound chlorosis, pregnancy, and parturition. Unfavorable hygienic surroundings and insufficient nourishment, habitually kept up, may also favor the development of the disease; but, as in chlorosis, the most favorable environment is not by any means preventive of its development. Males are more frequently affected than females, and especially does it occur during middle life, though occa- sionally cases are seen in those beloAv twenty years of age. The disease is widely distributed, and, whilst it has been observed to behave almost endemically at times, as in Switzerland and Leipsic, no infectious origin has been shown to exist. Symptoms.—Idiopathic pernicious anemia develops so sloAvly and insidiously that it is hardly ever possible to fix upon any precise date as the commencement of the disease. The transition from health to pro- gressive pernicious anemia, particularly in persons previously feeble and pale, is usually too gradual to be demonstrable ; though a rapid and acute onset is rare, it may occur in pregnant or puerperal women. Pallor is soon noticed and gradually increases, or when there has been a previous pallor, this becomes more marked. Shortness of breath and palpitation of the heart, especially on exertion, are complained of; PROGRESSIVE PERNICIOUS ANEMIA. 429 the patient is also easily fatigued, and becomes quite languid. Occa- sional nausea may come on early in those cases in Avhich a previous gastro-intestinal disturbance has been noted, and headache, vertigo, tin- nitus aurium, and anorexia ensue and grow progressively worse. Gen- eral weakness increases, and occasional attacks of faintness and vomit- ing supervene. Meanwhile, the skin takes on a bloodless, waxy appear- ance, and soon the characteristic lemon-yellow tint appears. The mucous membranes (lips, gums, conjunctivae) are likewise pale and colorless. Prostration in bed gradually becomes almost absolute as the feebleness and flabbiness of the tissue increase. Malleolar edema is sometimes noticable, and ecchymoses—mucous and cutaneous—though not so com- mon as retinal hemorrhages, are seen in profound cases of anemia. Although the intellect is not impaired, except that mental exertion becomes irksome, the tone and manner of speech are feeble, slow, and apathetic. As the debility becomes severe the mind wanders, and, to use Addison's Avords, the patient " falls into a prostrate and half-torpid state, and at length expires." Emaciation is rare, the fat being preserved and sometimes increased in quantity. Pulsation in the large arteries is abnormally visible, and a diffuse, exaggerated cardiac impulse is felt. The pulse early in the case may be strong, and generally it is rapid (100-120), soft, and com- pressible, and as full and quick, often, as the water-hammer pulse of aortic regurgitation. Auscultation reveals the constant and character- istic hemic murmurs, best heard at the base of the heart, and the bruit de diable in the veins of the neck. There may also be visible pulsations in the latter. Gastro-intestinal symptoms may be the most prominent signs in cases Avhere gastritis polyposa and gastritis atrophica are causal. Diarrhea, dyspepsia, nausea, and vomiting are then present throughout the long course; otherwise, constipation, eructations, and simple anorexia are most common. An ophthalmoscopic examination shows the cause of the anemic amaurosis, in the profound cases of anemia, to be one or more retinal hemorrhages. The liver and spleen are rarely palpable. The bones, and especially the sternum, are sometimes sensitive to pressure. Respiratory Symptoms.—The breathing is accelerated, and the anemic dyspnea may become very pronounced and stertorous, accompanied by a sense of oppression in the chest and a "hunger for air." Near the end pleural and pericardial serous effusions and pulmonary edema tend to appear. The urine is of Ioav specific gravity, and, on account of its pigmenta- tion Avith pathologic urobilin, dark in color. The urobilin is detected both by chemic and spectroscopic examination. In the former the addi- tion of a feAV drops of an alcoholic solution of zinc chlorid to the urine gives a green fluorescence. Peptonuria is of doubtful significance. Albumin and glucose are absent, but uric acid and urea are both in- creased in amount, the former occasionally and the latter usually. Fever of a moderate degree is commonly, though not invariably, present, the evening temperature sometimes reaching 102° F. (38.8° C). Previous to death the temperature may be subnormal. Nervous Symptoms.—Paresthesia, spastic paralysis of the limbs, and 430 DISEASES OF THE BLOOD AND THE DUCTLESS GLANDS. a loss of control of the sphincters indicate the paralytic tendency of those cases in Avhich sclerosis of the cord occurs. Tabetic symptoms are sometimes marked. Blood-examination.—The blood is usually pale, though sometimes dark and watery, and the oligocythemia is distinctive of pernicious anemia. The number of red corpuscles may be reduced to less than 200,000 per c.mm., and is seldom more than 1,000,000; in severe cases about half a million is the usual count. There is ordinarily no increase in the number of leukocytes; on the contrary, they may be somewhat diminished. The percentage of hemoglobin may be approximately pro- portionate to the number of red corpuscles, but more often it is relatively increased, so that the individual corpuscles are rich in hemoglobin. In other words, although there is a reduction in the total amount of hemo- globin, it is usually not so great as the reduction in the number of ery- throcytes; therefore, the percentage of hemoglobin is nearly always relatively higher than that of the red globules (see Fig. 35), a condition Fig. 35.—Blood-chart of a case of progressive pernicious anemia. Black, red corpuscles ; red, hemoglobin. in marked contrast with chlorosis. Macrocytes, microcytes, and poi- kilocytes are abundant, and the macrocytes are supposed to give rise to the relatively larger percentage of hemoglobin. The presence of nu- cleated red corpuscles is also a striking characteristic of pernicious anemia. When normal in size they are known as normoblasts; when very large, as gigantoblasts. In the former, according to Ehrlich, the eccentrically-placed nuclei stain deeply; in the latter the large nuclei stain faintly. The former are typical of those nucleated red globules found in the hematopoietic organ of adults; the latter, of those found in the blood-development of embryonic life. The gigantoblasts are numerous in this disease. There are other and various forms of degen- eration of the red cells, but these are of minor import. There may be an increase in the small lymphocytes at the expense of the polynuclear cells; and, according to Cabot, the presence of large numbers of poly- chromophilic red cells has been noted in a series of 50 cases. The blood-plates are generally fewer than normal. The relative proportion of the proteids in the blood-plasma is altered (Adami). Diagnosis.—It is important to determine, if possible, whether the PROGRESSIVE PERNICIOUS ANEMIA. 431 anemia is truly primary (or idiopathic) or secondary. Moreover, the possibility of hidden carcinoma, gastric atrophy, the anchylostoma or other parasite, and incipient tuberculosis should be borne in mind. Intestinal parasites may be inferred from the microscopical examination of the feces after a brisk purge if the eggs of the parasites or the para- sites themselves be found. Atrophic gastritis may be discriminated by examining the viscus and gastric juice by modern methods. The fol- loAving table will permit the elimination of obscure gastric carcinoma: Progressive Perniciocs Anemia. Obscure Gastric Carcinoma. The blood shows characteristic changes, Blood shows characteristics of secondary and the red corpuscle count falls to or anemia,- and the count does not fall to below 1,000,000 per c.mm. 1,000,000, as a rule. Found earlier in life. Occurs after middle life. Gastric symptoms not so prominent. Gastric symptoms more suggestiATe. Lemon-tinted skin common. Skin of & pale, muddy-color, or only slightly jaundiced (saffron-yellow). Adipose tissue fairly well preserved. Progressive emaciation. No glandular enlargements palpable. Supraclavicular or inguinal glands may be palpable. No physical signs over stomach. There may be an area of increased re- sistance over the stomach. Examination of gastric contents after Examination of gastric contents shows test-meal usually negative. deficiency or absence of free hydro- chloric acid and presence of lactic acid. Some improvement may be brought about Condition becomes steadily worse until —even cure, though very rarely. death ends the case. From chlorosis the affection may be differentiated easily by the blood- examination. The relative increase in hemoglobin, the presence of gi- gantoblasts and many macrocytes, and the severe oligocythemia are pathognomonic of pernicious anemia, and are in marked contrast to the oligochromemia, and slight, if any, reduction in the number of red globules of chlorosis. Again, the progressive pernicious character of the former and the tendency to hemorrhage should be remembered, as well as the contrasting factors of age and sex in the two affections. Prognosis.—The disease, as a rule, terminates fatally, though not so frequently now as at one time, for obvious reasons. The course of pernicious anemia is usually slow and gradual, and may be interrupted by improvement or apparent recovery. Recurrences, hoAvever, are prone to occur, even after intervals of several years, " attacks of anemia " alternating with periods of improvement, accompanied by enlargement of the spleen. Idiopathic anemia is therefore almost hope- less, although a few apparently substantial recoveries have been reported. The duration of the disease is seldom more than a year, and may not be more than two or three months. Death may be caused either by syncope, cerebral hemorrhage (most commonly), or by slow asthenia. Treatment.—Hygienic measures must be regarded as of signal im- portance, and rest in bed, together with light nutritious food given at short regular intervals, is indicated first of all. Salt-water baths and gentle and systemic massage Avhen the patient is at absolute rest and is not too weak, are useful adjuvants. The value of arsenic in this disease is, I think, analogous to that of iron in chlorosis. The best action of the drug will be ob- 432 DISEASES OF THE BLOOD AND THE DUCTLESS GLANDS. tained by the administration of gradually ascending doses of Fowler's solution or of arsenous acid. Beginning with four or five drops of the former, three times daily during the first week, and thereafter adding one drop to the dose every day or two up to the point of tolerance, as much as twenty or thirty drops, well diluted, may be taken (see Fig. 36). Evidences of gastro-intestinal irritation should be watched for, 100,-J 90* 80* 70* 60* 50% 40* 30* 20* 10* MONTH SEPT. OCTOBER NOVEMBER DECEMBER JANY. MONTH 100* 90* 80* 70* 60* 50* 40* 30* 20* 10* DAY t s s s s t » « t 5 S « t £ s « » « z. 2 2 2 s s s - * " £ 2 2 2 S S S - * - » 5 DAY 5,000,000 5,000,000 4,000,000 4,000,000 3,000,000 3,000,000 / 2,000,000 2,000,000 -^ y 1,000,000 1,000,000 600,000 500,000 Fig. 36.—Chart of a case of progressive pernicious anemia, showing the improvement following the administration of arsenic. Black, red corpuscles ; red, hemoglobin. and the arsenic either discontinued or the daily dose reduced should they appear. Sometimes it is advisable to use the remedy hypodermic- ally. Arsenous acid is given in pill form, commencing with -^ or -£-$ gr. (0.0021-0.0032). The introduction by Fraser of Edinburgh of bone-marrow in the treatment of pernicious anemia has been followed by various results: some cases have been reported in Great Britain and in the United States in which it has seemed to do good, while in others it was found to be useless. While the glycerin extract is the preparation generally used, it is not so reliable as the raw red bone-marrow, or that freshly prepared each day by mixing with it an equal quantity of glycerin ; an ounce or two may be administered daily. The remedy is worthy of trial, and if found to be non-efficacious in the given case, arsenic may either be com- bined with it or used alone. Near the end of the disease the danger often greatly increases, OAving to the marked reduction in the quantity of the blood (oligemia). This may be combated by the injection of Avarm Avater or a weak saline solu- tion into the colon (enteroclysis) and also into the subcutaneous tissue (hypodermoclysis). Both the former procedure and gastric lavage are of value in preventing and ameliorating the gastro-intestinal disturbance from fermentation and putrefaction. Intestinal antiseptics (thymol, guai- acol carbonate, salol, beta-naphtol, and hydro-naphtol) should be given by the mouth in conjunction with the injections, and lavage of the tract should be employed for the same purpose. Anthelmintics must be used in those cases of pernicious anemia in which intestinal parasites are associated. Dilute hydrochloric acid, nux vomica, and bitter tonics are serviceable in cases in which gastric diges- tion is impaired. THE SECONDARY ANEMIAS. 433 During the convalescence in favorable cases iron seems to be pecu- liarly valuable, sometimes alone and frequently in conjunction with arsenic. Thus, arsenious acid and either the carbonate of iron or re- duced iron may be combined in pill form, or Fowler's solution and the tincture of the chlorid of iron, or Blaud's pill, may be used with satis- factory results. Recurrences will yield to the same treatment, if they yield at all, except that the doses may have to be increased according to the tolerance of the individual case. II. THE SECONDARY ANEMIAS. The secondary anemias are symptomatic of abnormal processes or of existing disease, whether acute or chronic, and their causes are numer- ous and various. I have already stated that secondary anemia may occur when the true primary form cannot readily be determined and when the course of the anemia is progressive and pernicious. Further- more, several possible causes may exist in a given case of symptomatic anemia, and it may be quite difficult to discover which of these is the active factor in the condition. In certain secondary anemias, also, the associated impairment of the blood-making organs is so evident that the anemia may assume almost a primary importance. This was exemplified in Striimpell's case of carcinoma and anemia, Avith secondary implication of the bone-marrow. The variety and uncertainty of the causes of secondary anemias thus prevent a satisfactory classification. The Blood.—In most cases this distinctly differs in character from the blood of the primary or essential anemias. There is oligocythemia, usually of a moderate degree, about 3,000,000 red corpuscles per cubic millimeter being noted, though in cases of severe hemorrhage the reduc- tion may be as great for a time as in pernicious anemia. There is also a relative decrease in the amount of hemoglobin, and sometimes the per- centage may be relatively loAver even than is compatible with the de- crease in the number of the red corpuscles. There is a relative, and often an absolute, increase in the number of leukocytes (vide Fig. 37). Either a few or many poikilocytes, a feAV macrocytes, microcytes, and normoblasts are found, depending upon the severity of the anemia. Gigantoblasts are not seen, and the relative increase in the percentage of hemoglobin is also absent in secondary anemia. The most important etiologic groups of secondary anemias are as folloAvs : (1) Hemorrhage.—Hemorrhages occur under a great variety of circumstances, and if copious result in an acute secondary anemia. Thus there may be the rupture of an aneurysm, menorrhagia, post- partum hemorrhage, hemoptysis, gastrorrhagia, enterorrhagia, etc., all of which produce the same general effect upon the system. Repeated small hemorrhages may finally produce the same result as a single large one, and spontaneous hemorrhages or epistaxes, such as occur in persons of a hemorrhagic diathesis (hemophilia) or in purpura and scurvy, may cause profound secondary anemia. Females are most tolerant of losses of blood, but infants of both sexes bear depletion very badly. The total mass of blood may be much diminished (oligemia), and the sudden loss of a great volume of blood may prove fatal in a few moments; but 434 DISEASES OF THE BLOOD AND THE DUCTLESS GLANDS. it is often surprising how recovery can take place, and often does, after the rapid loss of several pounds of blood—e. g. in hemoptysis, hematem- esis, or menorrhagia. Sometimes the source of bleeding is obscure, as in cases of intestinal parasites, hepatic cirrhosis, or duodenal ulcer; or it may be intentionally kept sub rosa by females having uterine dis- order or bleeding hemorrhoids. The quick blanching of the counte- nance, the Aveakness, the coldness of the skin, faintness, dimness of vision, tinnitus aurium, sighing respiration, and feeble, rapid pulse are charac- teristic symptoms of acute anemia. Unconsciousness and epileptiform 100* 90* 80* 70* 60* 50* 40* 30* 20% CORPUSCLES 6,000,000 FEBRUARY MARCH APRIL MAY CCflPLSCLFS 100* 90* 80* 70* 60* 50* 40* 30* 20* 2J2 t 2|2i§ v,S:SS~-"°«22;2 2gSiS;S;S;S'"' ».: i 4,000,000 3,000,000 1,000,000 10,000 /• / 10.000 r A ' _7 8,000 | b,UJJ I 4.000 Fig. 37.—Blood-chart of a case of symptomatic anemia. Black, red corpuscles; red, hemoglobin; blue, white corpuscles. convulsions precede death in cases in which the total volume of blood lost is sufficiently large. When recovery takes place the blood-regen- eration goes on rapidly, so that within from one to three weeks restitu- tion is complete. The normal volume is soon restored—first by the absorption of Avater, hydremia existing for several days before the saline and albuminous elements are reneAved. The Avhite corpuscles are earlier restored than the red, so that there is a temporary relative leukocytosis. The hemoglobin is restored still more slowly than the red corpuscles. (2) Inanition.—Anemia from inanition may be caused by a food- supply that is insufficient either in quantity or quality, or both; or, even Avith abundant food of sufficient nutritive qualities the digestive power may be so impaired as to cause defective assimilation. Esophageal THE SECONDARY ANEMIAS. 435 carcinoma and chronic gastritis, especially of the atrophic variety, may thus cause anemia from inanition. The reduction of the blood-plasma forms a feature, Avhile the corpuscles may be affected but slightly. (3) Excessive albuminous discharges, as in chronic Bright's disease, prolonged suppuration, long-continued lactation, chronic dysentery, etc., drain the system so that marked anemia may be produced. (4) Toxic Agents.—The poisons may either be organic or inorganic, though toxic anemias are most common from the absorption of lead, arsenic, mercury, and phosphorus. The poisoning is usually chronic, and affects principally the corpuscles. Anemia due to the poisons of acute or chronic infectious diseases is also frequently met Avith, and may thus be observed after typhoid fever, diphtheria, yellow fever, and in- flammatory (articular) rheumatism among the acute diseases, and during chronic malaria, tuberculosis, and syphilis ("syphilitic chlorosis"). There is considerable destruction of the red corpuscles in some of these diseases, either directly or indirectly, and the greater the pyrexia the greater the action upon the blood or blood-making organs. Symptoms.—The common indications of secondary anemia are the pallor of the face and mucosae, muscular and mental weakness, loss of nerve-function, neuralgias, coolness of the skin, dyspnea on exertion, cardiac palpitation, impaired appetite and digestion, and a Aveak pulse. The physical signs are those of the primary or essential anemias. Diagnosis.—Here may be advantageously contrasted the distin- guishing features naturally grouping themselves under symptomatic and essential anemias, respectively : Symptomatic or Secondary Anemia. A symptomatic blood-condition secondary to disease elsewhere. Occurs at any age. Previous or associated history of trau- matic or spontaneous hemorrhage, chronic suppuration, prolonged lacta- tion, chronic Bright's disease, carci- noma, chronic lead-poisoning, chronic malaria, etc. Blood-changes not so marked and more variable. Moderate reduction in both, merely the relative proportion being maintained. General symptoms and signs usually sub- ordinate in manifestation to those of the primary disease or lesion. Gravity of anemia depends on that of the primary disease. Often responds to treatment, depending on the cause ; in a few instances, as in hemorrhage, it is short in duration. Idiopathic or Essential Anemia. A primary disease of the blood and blood-making organs. Occurs principally during adolescence and early middle life. Previous history negative in its bearings upon the disease. Distinctive blood-characteristics, and often profound changes, both as to blood-cells and hemoglobin. Marked reduction in either the hemo- globin percentage or in the number of red corpuscles. General symptoms and signs also more characteristic of the respective form of anemia in the case. Gravity depends on type of blood- changes and progressiveness of dis- ease. One variety (chlorotic) quite curable, the other (progressive pernicious) com- monly fatal. The prognosis depends upon the cause of the anemia. Treatment.—Symptomatic anemia is amenable to treatment accord- 436 DISEASES OF THE BLOOD AND THE DUCTLESS GLANDS. ing to the cause. The traumatic acute variety does Avell under simple hygienic measures after the urgent indications have been met. Plenty of pure air, Avholesome food, and graduated rest and exercise may suf- fice, and drugs not be needed. Cases in which it is difficult or wellnigh impossible to remove the cause of the anemia of course do not improve under any treatment other than that which may favorably influence the primary affection. Nutritious aliment, iron in some form, a judicious hygienic regimen calculated to increase the assimilation, and stomachic and general tonics are required in the majority of cases. Toxic sub- stances must be eliminated, their re-introduction into the body prevented, and the repair of the blood and tissue actively promoted. LEUKOCYTOSIS. Definition.—A temporary increase in the number of leukocytes in the blood, especially of those of the polynuclear variety. These in normal blood constitute about three-fourths of all the leukocytes. The number of Avhite corpuscles in a moderate leukocytosis would be about 10,000 per cubic millimeter; in marked leukocytosis there might be as many as from 20,000 to 40,000; a count of over 50,000 leukocytes to the c.mm. may, however, usually be considered to indicate leukemia. Von Limbeck, notwithstanding, reported a case of leukocytosis accom- panying carcinoma of the kidney with metastasis, in which there were 80,000 white corpuscles per cubic millimeter. Physiological leukocytosis occurs in infants during the first few days after birth, in pregnancy, during digestion, and after exercise. Accord- ing to Carter, the " digestion leukocytosis is present after a meal of proteids or hydrocarbons, but not after a meal of carbohydrates."' Massage and cold baths also produce leukocytosis, probably by stimula- ting the circulation, and not by increasing the actual number of leuko- cytes, some of which have simply become stagnated. Pathological leukocytosis is secondary to various affections. It may be temporary, as in the curable primary diseases, or permanent, as in those that do not permit of recovery. It is also found to be Avell marked in acute inflammations and in infectious febrile diseases accom- panied with exudation, such as pneumonia and diphtheria. In pleuritis, peritonitis, pericarditis, erysipelas, and in all suppurative processes there is an excess in the number of polynuclear neutrophiles. Inflam- mations of the serous membranes, when not tuberculous, cause leukocy- tosis, so that a purulent meningitis may be differentiated from tubercu- lous meningitis by the pronounced leukocytosis in the former and its absence in the latter. As a rule, the greater the local reaction and the stronger the resistance to severe infections the greater the leukocytosis. As is well knoAvn, the pus-cells of an abscess consist almost Avholly of dead Avhite corpuscles—phagocytes—that have been overcome or ex- hausted, directly or indirectly, in the struggle against the toxin of the infection. Cachectic states, as in cases of malignant tumors, are often attended Avith an increase in the number of colorless corpuscles in the blood, especially in the region of the tumor and Avhere the lymph- glands are involved. Leukocytosis may be very marked in carcinoma, 1 Univ. Med. Magazine, vols, vii and viii, p. 181, Dec, 1894. LE UKOCYTHEMIA. 437 the ratio of reds to whites being, in some cases, 25 to 1. Chemical irritants, such as turpentine, may also produce leukocytosis, and whatever the substance causing the condition it is spoken of as positively ehemo- tactic—attractive to the white blood-corpuscles—in contradistinction to negatively chemotactic substances, which repel the white corpuscles. In non-leukocytotic infectious diseases, such as typhoid fever, the diagnosis of a complicating pleuritis, for example, may be confirmed, even at its onset, by the detection of the leukocytosis. Leukocytosis under such circumstances has prognostic importance. Diminishing leu- kocytosis during the height of a grave disease may be significant of less- ening poAvers of resistance, though this is not an invariable rule, since just before the crisis of a pneumonia or Avhen there is marked emacia- tion, as in typhoid fever, a diminution of the leukocytes is apt to occur. The object of the leukocytosis is naturally protective, beneficent, and reparative. It is accomplished either by direct antagonism or by the formation of substances that enter the fluids and tissues of the body, and counteract the influence of the toxic substances causing the disease. The existence of leukocytosis can best be determined by the examination of stained specimens of the blood. Physiologic digestion leukocytosis is to be discriminated from the pathologic variety by making the ex- amination several hours after the last meal has been taken. LEUKOCYTHEMIA. {True Leukemia.) Definition.—A blood-disease, usually chronic, characterized by a peculiarly marked and persistent increase in the number of leukocytes, associated Avith lesions occurring either respectively or unitedly in the spleen, bone-marrow, and lymphatic glands. Pathology.—Bodily emaciation and pallor are pronounced, and edema, with dropsical effusions in the serous cavities, is by no means uncommon. The cardiac chambers and principal veins are distended with large blood-clots of a greenish-yellow or, in extreme cases, yellow- ish-white, purulent appearance. Subserous ecchymoses of the pericar- dium and endocardium are frequent, and the myocardium is often found to have undergone a moderate degree of fatty degeneration. Various abnormal substances have been found in leukemic blood, and among them the following may be mentioned: hypoxanthin, leucin, tyrosin, acetic, formic, and lactic acids, and certain albuminous substances (deutero- albumose and nucleo-albumin) resulting probably from the destruction of blood-corpuscles. The alkalinity and specific gravity of the blood are both diminished. The minute, colorless, octahedral, so-called Charcot's, crystals are found most abundantly in settled leukemic blood, and have also been detected in the spleen, bone-marrow, and liver, as Avell as in other affections. Their composition is not clearly known. Although the spleen, bone-marrow, or the lymph-glands may alone shoAV the pronounced pathological changes of leukemia, it is usual to find all more or less affected. Purely splenic or myelogenic leukemia, and the latter especially, are rarer than the lymphatic type, so that it is customary to speak of two principal groups: (1) splenic-myelogenous (or spleno-medullary) leukemia, the most frequent variety; and (2) lym- phatic leukemia. 438 DISEASES OF THE BLOOD AND THE DUCTLESS GLANDS. There is nearly always some splenic enlargement, and in many cases the enlargement is considerable, as in spleno-medullary leukemia. Leu- kemic spleens sometimes weigh as much as from eight to eighteen pounds, and their lengths may vary from six to twelve inches. The enlargement is generally uniform, and the notches upon the anterior border may be much exaggerated. White patches of perisplenitis and a thickened capsule adhering to the surrounding organs and the abdom- inal wall may also be noticed. The consistence of the spleen is firm and resistant to the knife, though in the earlier stages it may be quite soft and pulpy. The cut surface is either of a uniformly brown color or mottled by the presence of grayish- or yellowish-white circumscribed lymphoid tumors, or by deep-red or brownish-yellow hemorrhagic in- farcts. The Malpighian bodies may or may not be visible. The blood- vessels at the hilum are enlarged. Microscopic examination shows the change to consist in a true hyperplasia of the organ, there being an in- crease in all the normal histological elements. The cells of the pulp sometimes show granular and fatty degeneration, and in advanced cases the trabecule may be thickened by a considerable amount of firm con- nective tissue. In the majority of cases the bone-marrow is affected as well as the spleen, and a purely myelogenous leukemia is extremely rare. Indeed, the few reported cases of the latter may be doubted. The medullary substance, instead of being fatty, is rich in lymphoid and blood-cells in various stages of development, and is either reddish-brown or greenish- yellow in color. Neuman regarded the marrow-change as a constant and essential lesion of leukemia, and called the former transformation 'llymph-adenoid," and the latter "pyoid." The pus-like marrow and the dark-red may exist side by side, although the former is more common. A fine reticulum may be seen between the cells, especially in the dark-red variety, and small hemorrhagic infarcts may also be noted occasionally. Microscopically, the medulla contains an abundance of lymphoid cells and nucleated red corpuscles. Eosinophile, mononuclear, and polynuclear leukocytes are also present, the first-named being quite numerous, as are also certain myelo-plaques and cells showing karyo- kinetic figures. The lymphatic glands are more or less enlarged in the splenic and medullary forms of leukemia. In the lymphatic variety, especially when acute, an early and marked hyperplasia of all the glands takes place. The cervical, axillary, in- guinal, and mesenteric glands are usually involved, and may form dis- tinct, soft, and movable tumors, their color being a reddish-gray, and section often shoAving hemorrhagic points. The histological examination shows an increase in the cellular ele- ments. A similar hyperplasia occurs in those glandular tissues that are allied to the lymphatic glands, such as the tonsils, lymph-follicles, the tongue, mouth and pharynx, thymus gland, and the solitary and Peyer's agminated intestinal glands. The liver may be greatly enlarged; indeed, some of the instances of greatest enlargement of this organ have been those due to leukemia, the weight being as much as fourteen pounds. The enlargement is uniform and due to a diffuse leukemic infiltration. The capillaries and inter- lobular tissue are distended with leukocytes, and disseminated whitish LE UKOCYTHEMIA. 439 or grayish nodules, usually quite small, consisting of lymphoid cells undergoing indirect division of their nuclei, are frequently found. Sometimes these leukemic nodules appear as definite growths, with an adenoid reticulum betAveen the cells, on account of which they have been called lymphomata or lymph-adenomata. Similar changes are observed in the kidneys, enlargement, paleness, and diffuse and circumscribed leukemic infiltration of the capillaries and intertubular tissue all being noted. Leukemic nodules may also be found in other parts of the body, such as the retina, brain, serous mem- branes, lungs, testicles, and skin. Karyokinetic figures are numerous in the cells accompanying these leukemic groAvths. Utiology.—The primary cause of leukemia is unknown; that it directly affects the blood-forming organs, however, is most probable, though with differences of selection and co-ordination and with different degrees of intensity. The combination of lesions in the spleen, lymph- glands, and bone-marroAv, along with the histologic similarity of the leukemic growths to the infectious granulomata, and the clinical history of cases of acute leukemia, Avould seem to point strongly to the microbic origin of the disease. Moreover, various cocci and bacilli have been found, but not one of them has been definitely proved to be the specific cause of the disease. Auto-intoxication by toxic albuminoids from the digestive tract is believed by Vehsemeyer,1 who analyzed 600 cases, to be the important point of departure of the disease. It is likely that the direct cause of the leukocythemia is a simple increase of the cytogenic function of one or more of the hematopoietic organs. Kottnitz held leukocythemia to be a reactive condition following auto-intoxication Avith peptones, and consequently a leukolysis, the over-action of the hematopoietic organs leading to hypertrophy. Whether the reduction of the erythrocytes is due to diminished production or to increased destruction is not positively known, although the former factor is more probably operative. The disease has often been preceded by an injury or a blow in the splenic region, but its direct traumatic origin is hypothetic only. In- testinal ulceration has been a frequent feature prior to leukemia, and undoubtedly affords a source of possible infection from the tract. Stomatitis also may furnish a means of entrance for the infectious agent. The causal relation of pseudo-leukemia and true leukemia is uncertain, although a few cases of the one have been observed to pass into the other. In a considerable proportion of cases leukemic patients have had malaria of some form. Syphilis may be associated Avith the disease, but it is not probable that it acts in a causative manner. Hereditary influences undoubtedly play a part; a " lymphogenous diathesis " may thus be transmitted, and several generations may be affected by the disease. Adverse hygienic and social conditions may also predispose to leukemia. It may also develop after pregnancy, or more commonly at the climacteric. Anxiety, worry, and mental depression have been mentioned as predisposing causes, with doubtful justification. Leukemia occurs most frequently in males during the middle period of life, and is apt to attack young persons. It has occurred during in- fancy, and as late also as the seventieth year, but the average age ranges 1 International klin. Rundsch., Vienna, Nov. 25, 1894. 440 DISEASES OF THE BLOOD AND THE DUCTLESS GLANDS. from twenty-five to forty-five years. Sometimes the previous condition was one of apparently perfect health. Symptoms.—Acute leukemia, although comparatively rare, may be described briefly first. It usually occurs in an adolescent Avho may have enjoyed previous good health. Its onset is sudden, and usually begins with prostration, hemorrhage of the mucous membranes, and high fever. Acute splenic tumor rapidly develops; the lymphatic glands may en- large ; and palpitation, dyspnea, and gastro-intestinal symptoms of a severe type appear. The blood shows a marked increase in the num- ber" of leukocytes, the ratio to the red corpuscles being 1 to 30 or 1 to 50, instead of the normal 1 to 350 or 1 to 600. In acute lymphatic leukemia the lymphocytes are very numerous. Large mononuclear leukocytes and myelocytes are also numerous, Avhile the eosinophilic cells are few in number compared with those found in the blood of chronic leukemia. The case groAvs progressively Avorse; hematemesis, cerebral or retinal hemorrhages, and petechiae supervene perhaps, and the clinical features may then resemble an infectious disease with hemor- rhagic and purpuric manifestations. In chronic leukemia the onset is generally slow and insidious and its development imperceptible, and the earlier symptoms may not differ from those of simple anemia for many months. Languor, a deranged appetite, dizziness, noises in the ears, faintness, breathlessness on exer- tion, and palpitation may all appear. Sometimes, however, not even these symptoms are present, common as they are to most anemic cases, and the patient may first consult the physician, because of a swelling or distress in the left side of the abdomen—the enlarged spleen. Early manifestations may be hemorrhagic in some cases (epistaxis, hematem- esis, enterorrhagia), Avith nausea, vomiting, and diarrhea; or increas- ing pallor of the countenance or troublesome priapism may be the first indication. As the disease progresses the anemia becomes more marked, edema of the dependent portions of the body mav appear, and fever, though slight at first (99.5° F.—37.5° C), may gradually rise to 102° or 103° F. (39.4° C), either remaining constant or alternating with periods of apyrexia. The pulse-rate is increased; in quality it is soft and compressible, though sometimes full in volume. The dyspnea may be aggravated by the hydrothorax of a general dropsy in advanced cases, or by the up- ward displacement of the diaphragm OAving to the increasing splenic and hepatic enlargement. Epistaxis may become obstinate. Bleeding from the gums into the retina (leukemic retinitis) and brain, as wrell as from the mucous membranes, is common. Hemic murmurs are quite constant. Ulcerative processes in the bowels may give rise to severe dysenteric diarrhea. Ascites is usually present in advanced cases on account of the splenic tumor, or owing to pressure upon the portal vein by enlarged glands. Jaundice is an occasional event. Leukemic peritonitis may occur from the presence of lymphomatous growths in the membrane. Nervous symptoms, such as headache, vertigo, and syncopal attacks, are liable to recur as the anemia and prostration increase and the lia- bility to hemorrhage becomes more frequent. Sudden coma and hemi- plegia folloAving upon the rupture of a cerebral vessel (apoplexy) may be the immediate cause of death. Priapism may be very troublesome. LEUKOCYTHEMIA. 441 Peripheral paralysis of several cranial nerves, due to hemorrhages into their sheaths, has been reported. Cutaneous ecchymoses are sometimes observed, and sometimes there is a troublesome pruritus. The urine contains an excess of uric acid, but albuminuria does not occur, except as a complication. Along with the anemia and debility are the signs of splenic and lymphatic involvement, and rarely of the bone-marrow. The liver may also become enlarged. Leading Symptoms in Detail.— The Spleen.—This organ is generally enlarged in all forms of leukemia, but especially in the spleno-medullary, the most frequent form. It is a prominent feature, both on account of its being the first subject of complaint, and because of the huge size it frequently attains. The enlargement is gradual, and there may be neither pain nor tenderness over it. The tumor may cause a visible projection beloAv the ribs, and in marked cases great abdominal disten- tion may be produced, pushing up the diaphragm and thoracic organs, and extending to the navel in the median line and to the pelvis below. The edge and notch or notches may be felt easily in such instances, while the surface is smooth and the consistence firm. A friction-fremi- tus is felt sometimes during respiratory movement. The tumor may vary in size, and after severe hemorrhage or diarrhea it may become SAvollen. Gastric distress after eating and obstructive constipation are usually complained of in cases of great splenic enlargement. Pulsation has been noted and a systolic murmur—"splenic souffle"—has been heard at times over the tumor. The percussion-note is dull. Lymphatic Glands.—In the splenic-lymphatic variety, Avhich is less common than the splenic-myelogenous, and in the still rarer purely lymphatic leukemia, the superficial lymph-glands may be both visibly and palpably enlarged, though not in bunches as in Hodgkin's disease. They are soft, resilient, and movable. The Bones.—Purely myelogenous leukemia is very rare, and local bone-symptoms are scarcely ever manifested. There may be some ten- derness on immediate percussion over the sternum or some of the long bones, and slight swelling, irregularity, or deformity of the ribs, the sternum, or other bones may result from leukemic hyperplasia. The Blood.—It is by the blood-examination alone that the pathog- nomonic features of leukemia are determined. The blood is paler than normal, and sometimes has a broAvnish-red or chocolate color. Upon a microscopic examination of the blood in the spleno-medullary form of the affection the striking increase in the number of leukocytes is ob- served at once. The count shoAvs usually from 85,000 to 500,000 white corpuscles per cubic millimeter, and the ratio of the Avhite to the red cells may thus vary from 1 to 150 down to 1 to 10 or 1 to 5 in the aver- age case, instead of the normal, 1 to 500 (see Fig. 38). In extreme cases the number of leukocytes may be equal to, or even slightly greater than, that of the erythrocytes, and such an instance has been recorded by Sb'rensen, in which the proportion of whites to reds was 3 to 2. Stained specimens of the blood enable us to recognize the variety of leukemia (see Fig. 39). Thus, in the ordinary splenic-myelogenous form the characteristic change is the presence of the abnormal myelocytes— large, mononuclear leukocytes with the protoplasm filled with fine neu- 442 DISEASES OF THE BLOOD AND THE DUCTLESS GLANDS. trophilic or occasionally eosinophilic granules. These may make up 25 per cent, of the white cells, whereas they do not occur in normal blood, and very rarely, and only in small numbers, in leukocytosis. They probably correspond to the cells found in the bone-marrow, the large, 100% 90% 80% 70% 60% 60% 40% 30% 20% MONTH SEPTEMBER OCTOBER NOVEMBER MONTH 100% 90% 80% 70% 80% B0/5 40% 30% 20% DAY - - - - . - 5 5 t 2 S S S 5 S - * . - o - * . „ g S a g g s - - - - . : 5 S t S 5 S g ~ s DAY 5,000,000 5,000,000 4,000,000 4,000,000 3,000,000 2,000,000 2,000,000. 1,000,000 L 1,000,000 WHITE WHITE 500,000 500,000 400,000 400,000 300.000 300,000 275,000 275,000 250,000 250,000 225,000 225,000 200,000 200,000 175,000 175,000 150.000 150,000 125,000 1 25j 000 100,000 100,000 95,000 95,000 90,000 90,000 85,000 85,000 80,000 -^ 80,000 75,000 v 75,000 70,000 v 70,000 65,000 65,000 60,000 60,000 55,000 55,000 50,000 50.000 45,000 I 45,000 Fig. 38.—Blood-tracing of a case of leukemia. Black, red corpuscles; red, hemoglobin; blue, white corpuscles. oval, and eccentrically-placed nuclei of both blood- and marroAV-cells showing karyokinetic figures. The polynuclear leukocytes may be nor- mal in number, but usually they are relatively diminished to about 65 per cent, instead of 75 per cent., as in normal blood. The lymphocytes are also relatively less in number, making up but 1 or 2 per cent., in- stead of the normal 15-30 per cent. The bright, acid-stained eosino- philes, though absolutely increased, are not always relatively so, though this relative increase may occur. Basophilic leukocytes are rare. Moderate oligocythemia is noted, the reduction being seldom lower than to 2,000,000 per c.mm. The percentage of hemoglobin may also be reduced relatively or in slightly greater proportion. Nucleated red corpuscles, chiefly normoblasts, are frequently found in considerable numbers. Osier asserts that blood of the type of pernicious anemia has subsequently developed a true leukemia. Litten and Musser have also described such cases. In lymphatic leukemia, which is rarer and more quickly fatal than the preceding variety, the blood-changes are also different. The lym- phocytes—small, mononuclear leukocytes—are the ones increased, all other leukocytes being relatively much diminished in number. Instead of the normal percentage (15 to 30 per cent.), the lymphocytes may number from 90 to 97 per cent, of all the leukocytes. Nucleated red Fig. 39.—A Fresh preparation from the blood of a case of leukemia (X 550); large mononu- clear leukocytes of immature form; /;. Preparation of a case of the lieno-myelogenetic variety iKhrlicli s riple stain); numerous eosinophile and immature leukocytes, myelocytes, and nucle- ated red blood-cells (Grawitz). LEUKOCYTHEMIA. 443 corpuscles and myelocytes are absent as a rule, unless the bone-marrow happens to be diseased at the same time. Mixed forms of leukemia are, however, not at all uncommon, so that the proportions of the various types of normal and abnormal cells are quite variable. The blood-plates may be quite abundant in many leukemic cases, and Charcot's octahedral crystals appear in specimens of the blood if allowed to stand for any length of time. An unusually dense and thick fibrous network is also often found. Complications.—Fatal hemorrhages may occur at any time, and pulmonary tuberculosis, pleuritis, pneumonia, septico-pyemia, renal dis- ease, severe diarrhea, and edema may complicate leukemia and cause death. Diagnosis.—This can be made easily and accurately by the blood- examination alone, the distinguishing characteristics of the blood having been enumerated above, both as to the existence of leukemia and the dif- ferentiation of its several varieties. It may be necessary in doubtful cases to examine the blood by Ehrlich's staining methods, since the mere ex- cess of leukocytes alone is not proof of leukemia, and also because the disease may exist Avithout an excess, owing either to previous medicinal treatment or to natural temporary improvement. Leukemia is differentiated from a marked leukocytosis by the fact that in the latter there is usually a more moderate increase in the number of leukocytes, and this increase, as a rule, is principally of the polynuclear neutrophiles. Hodgkin's disease may be simulated by the purely lymphatic leu- kemia on account of the enlarged glands; but in leukemia the lymph- glands are not found in such large bunches, and the blood-examination will shoAv the characteristic changes of lymphatic leukemia if that dis- ease be present. Simply a leukocytosis is present in pseudo-leukemia. Splenic anemia and lymphatic anemia have not been established as distinct affections, but formerly much time and ingenuity were ex- pended in discriminating them from leukemia and other blood-diseases. Some are cases of pernicious anemia, some of Hodgkin's disease, and some, I find, are instances of secondary anemia. Malignant growths of the spleen and lymphatic glands, and also a malarial and passively congested spleen with anemia, may simulate leu- kemia. The simple leukocytosis here Avill exclude leukemia. Prognosis.—Many cases are mild and gradual in their progress; children, however, when affected, succumb more rapidly than do adults. Lymphatic leukemia is always fatal earlier than the spleno-medullary variety. Although recovery does occur occasionally, most cases of leu- kemia, of whatever form, prove fatal certainly within five years, gener- ally in two or three years, and sometimes in seven or eight months or even less (from two Aveeks to two or more months) in acute leukemia. In an advanced case the prognosis is hopeless. It should be borne in mind that apparent improvement is usually only temporary, and that a fresh exacerbation is apt to follow. Grave symptoms heralding an early termination are profound debility, anemia, emaciation or edema, severe and obstinate hemorrhages, cerebral apoplexy, persistent diarrhea, and high fever. Intercurrent affections not infrequently cause death, while, on the other hand, cases are recorded in which the appearance of inter- current infectious diseases has favorably affected the course of leukemia. 444 DISEASES OF THE BLOOD AND THE DUCTLESS GLANDS. Treatment.—At present no remedies are known to have any per- manent curative effect, although several agents are used for their favor- able influence. The aim should be to improve the general condition of the patient and endeavor to prolong life by hygienic and medicinal means. The environment should be made as favorable as possible—physically, mentally, socially, and morally. Out-of-door life in a mild, dry climate, an abundance of nutritious and easily digestible and assimilable food, calm and moderate exercise of mind (depending upon the strength and endurance of the patient), should all be advised and encouraged. On the other hand, traumatism and inflammation, irregular habits of body, worry, excitement, and passionate emotions and appetites should be regulated and aAroided. Arsenic gives the best results in most cases, and should be pushed to the limit of tolerance, as in pernicious anemia. It should be given con- tinuously, regardless of apparent improvement under its use, as the lat- ter may be only the natural remission—a not uncommon incident in the disease. Quinin, iron, and the oil of eucalyptus have been recommended in those leukemic cases in which a clear history of malaria has been obtained. Bone-marrow, either raw and spread upon bread or in the form of a glycerin extract, may be tried Avhen arsenic fails. Oxygen- inhalations and blood-transfusion have been suggested. The so-called "splenic remedies," Avhether systemic or local, have no controlling in- fluences upon the disease. Electricity may afford some local comfort or contribute to psychic ease. Complications and intercurrent affections may often be greatly relieved by appropriate treatment. PSEUDO-LEUKEMIA. {Hodgkin's Disease; Adenia; General Lymphadenoma; Multiple Malignant Lymphoma; Malignant Lympho-sarcomp,.) Definition.—An anemic disease characterized by the anatomical peculiarities resembling those of lymphatic leukemia—viz. progressive hyperplasia of the lymph-glands, occasional secondary lymphoid groAvths of other organs (liver, spleen); and by the absence of the destructive blood-changes of true leukemia. Varieties.—Although the disease that bears his name was first de- scribed by Hodgkin of Guy's Hospital in 1832 as an affection of the lymphatic glands and spleen, tAvo varieties are included under the title of pseudo-leukemia (or Hodgkin's disease), as folloAvs : (1) that which presents simply an enlarged spleen (the less frequent one); and (2) tbat in Avhich the lymphatic glands are chiefly involved. Pathology.—The lymph-glands show different degrees of hyperplas- tic enlargement and consistency. In the earlier stages they are small, isolated, and movable, Avhile in advanced and Avell-developed cases of the disease they are larger, fused together into great bunches, and more or less fixed by fibrous investment. As a rule, the glands are soft and elastic, though sometimes they are hard and dense, and masses as large as an orange or pineapple may be seen. Single glands may be as large as a hen's egg, and the gland-capsules may shoAv connective-tissue pro- liferation and a thickening periadenitis. Extension of the lymphatic PSE UDO-LEUKEMIA. 445 growth into the surrounding tissues by perforation of the capsule may occur. As a rule, the overlying skin is freely movable, though it may rarely be adherent. On section the tumors display a smooth white or reddish-gray surface in the case of the soft and almost fluctuating glands, and a grayish or a yellowish-Avhite color if they are firm. The fusion of the SATollen glands into nodular masses is also seen, and Avhen ulceration through the skin has taken place suppuration of the glands may be re- vealed. In the harder tumors areas of necrosis having the appearance of caseation may be visible, and shining, more or less hyaline masses of fibroid tissue may also be detected. Microscopically, there is a typical hyperplasia of the lymph-cells, often obscuring completely the reticulum of the gland, except in the harder enlargements, where the fibrous proliferation shows a very dis- tinct netAvork. The arrangement of the lymph-tracts is distorted and disturbed in the larger groAvths only. The cervical glands are most prominently involved. The superficial chains of glands—axillary, mediastinal, scapular, and pectoral—especi- ally along the great vessels, are often found connected, and the inguinal, bronchial, and lumbar glands are also affected, though less frequently. The retroperitoneal glands are more frequently affected than the mesen- teric, and sometimes the thoracic vessels are completely surrounded by enlarged lymph-glands; they have occasionally projected externally by perforation through the sternum. The abdominal vessels, nerves and nerve-plexues, and ducts may be compressed also by huge groups of en- larged glands. The spleen is enlarged in about four-fifths of the cases, but only slightly. In the majority of cases there are disseminated throughout the organ Avhitish, lymphomatous growths or nodules from the size of a pea to that of a nut. Their histological structure is like that of the lymph-glands. Occasionally the spleen alone is hyperplastic. Lymphomata may also develop in the tonsils, lingual follicles, intes- tinal lymphatics, liver, kidneys, lungs, brain, heart, testicles, retina, and skin. Invasion of the spinal cord may occur by erosion of the ver- tebrae or through the blood-current by metastasis. The bone-marrow often has the same appearance as in pernicious anemia. Etiology.—There are no well-established predisposing conditions to Avhich Hodgkin's disease is referable. In the larger number of cases males are affected, and young and middle-aged persons—between the age, of ten and forty years—seem to be attacked in about 70 per cent. of the cases. Heredity may possibly be a cause. Neither has an ex- citing cause been discovered as yet. The disease would seem to belong to the group of infectious granulomata, but the infectious agent is not knoAA-n. Flexner thinks that certain protoplasmic foreign bodies (found in the larger nodules of two cases) may possibly have a causal relation to the disease. Malaria, syphilis, chronic skin-diseases, and various irritative conditions, especially of the mouth, giving rise to local gland- ular swellings, have also been assigned as causes. In undoubted in- stances of Hodgkin's disease the lymphatic glands frequently harbor tubercle bacilli; hence it has been thought that the latter exercise a dis- tinct causative influence. It must be remembered, however, that some of these may be examples of secondary accidental infection; others of 446 DISEASES OF THE BLOOD AND THE DUCTLESS GLANDS. primary diffuse lymphatic tuberculosis, indistinguishable from or mis- taken for Hodgkin's disease. It is not uncommon to find pseudo-leu- kemia developing in a person who immediately preceding the beginning of the disease was apparently in perfect health. Symptoms.—Usually the first thing to attract attention is the en- largement of the submaxillary and cervical glands, often on one side of the neck alone. These groAV gradually until they may finally appear on both sides as large as a fist, and produce considerable disfigurement. Sometimes several years may elapse before other glandular groups are affected, but, as a rule, it is a matter of months only before the axillary, then the inguinal, and perhaps the internal, glands are invaded. The changes vary greatly in rapidity and extent. At first the general health may be but slightly affected. A little constitutional disturbance and some pallor may be complained of, though seldom before the glandular swellings are noticed. Then as the disease progresses the paleness increases and all the symptoms of a marked anemia appear—languor, failure of physical strength, beginning emacia- tion, gastro-intestinal derangement, headache, giddiness, palpitation, dyspnea, and edema of the legs. Later, the serous cavities contain MONTH MARCH APRIL MONTH DAY 19 20 21 2i 23 24 25 26 27 23 29 30 31 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 DAY TIME M E M E M E M MEMEMEMEM MEMEMEMEMEMEMEMEME MEMEMEMEMEMEMEMEMEM M E M E M E ME TIME 1 41&C. _1__ 104 * .__________ _ ____L -1 '- 'I ° I t E - 103 t h A « tV l~ ._ ____. ______J_.t _ 1 - - - P \ 1C T j -t A ° 4 -E5- jP - -tl , _ ±, ___________jq. . _1 ,___ lJ__ __. _ ' I 1 C3 ^_ __ -t Az L t - -*- L I -X T -* --hh- -. " \-L- 4 -i -B -\i * \ I -A -4- .c^_.x_______t _. " \ ! 4. - . 4 . C A """ til M I I | I l I I | Jl 1 - A t %- C4 - w-t I J- il ± - M -t - r I f i i . i \ A __;_ _f___ ._ 8_ _ __ I ft i i i ; j\ ; -Z^ !TJ ^ ^ 1 y t- znts . _ r_____ iz: 98 *4 ____i 97 i i ...... i i Fig. 40.—Temperature-chart of a case of pseudo-leukemia. effusion and there is a tendency to hemorrhages. Epistaxis and metror- rhagia are apt to occur, and petechial spots, especially on the lower ex- tremities, are not infrequent. The physical signs of anemia—hemic murmurs—are also present. An irregular slight or moderate pyrexia is common to most cases. Fever of a peculiar intermittent type has been observed, the intermissions and paroxysms each lasting for several days or Aveeks (see Fig. 40), and the term " chronic relapsing fever " PSE UD 0- LE UKEMIA. 447 has been applied in consequence. When these pyrexial exacerbations occur the cases generally run a more acute course. The symptoms due to mechanical compression by the lymphomata are varied and numerous, depending upon the number, size, and distri- bution of the tumors. Hundreds of tumors may be present through- out the body, but, unless they press upon the adjacent nerves, the glands are not usually painful. Enlargement of the tracheal and bron- chial glands may cause dysphagia, dyspnea, thoracic pain, disturbed phonation, and venous congestion, by pressure respectively upon the esophagus, trachea, bronchi, thoracic nerves, recurrent laryngeal nerves, superior vena cava, and the jugular veins. The obstruction to respira- tion may become so great as to produce death by suffocation. Conges- tion of the head and upper extremities may be quite marked, and in such cases compensatory dilatation of the superficial veins is observed. Edema of the hand and arm may result from venous obstruction due to the pressure of very large axillary glands. Deafness may be produced by growths Avithin the pharynx. The heart's action may be disturbed by pressure on the pneumogastric, and the heart itself may be dislocated by great gland-tumors Avithin the chest. Under such circumstances the latter may be detected by dulness on percussion over the anterior medi- astinal space. Inequality of the pupils and unilateral sweating of the face, owing to glandular pressure upon the cervical sympathetic, may be noticed in some cases. Edema of the feet and legs may be an early indication of enlarged abdominal glands pressing upon the femoral veins. Sharp lancinating pains along the nerves may also be felt. Jaundice is sometimes attrib- uted to pressure upon the bile-duct. Gastro-intestinal disturbances may be troublesome, and are usually symptomatic of lymphoid growths in the stomach and bowTels. In thin individuals gland-masses may be pal- pable over the abdomen. It has been suggested that the bronzing of the skin sometimes seen in Hodgkin's disease may be due to the pressure of enlarged glands upon the suprarenal capsules. The slightly or mod- erately enlarged spleen can usually be felt just below the ribs, project- ing toward the navel. Pressure-paraplegia and neuralgic pains variously distributed throughout the body should also be mentioned among the nervous manifestations. Tenderness over the spleen and bones may be elicited. An intense pruritus has been complained of, and the skin may be erythematous. Albuminuria is not uncommon; ascites and hydrothorax are late conditions, and occasionally the thyroid and thy- mus glands are involved. The characteristic feature in splenic pseudo- leukemia is the decided enlargement of the spleen without involvement of the lymphatics. The blood shows a moderate diminution in the number of red cor- puscles, and a corresponding diminution in the hemoglobin, the former in most instances numbering from 2,000,000 to 4,000,000 per cubic millimeter. There may be more or less leukocytosis, and sometimes the lymphocytes may preponderate relatively; if the latter be present in great numbers, the blood may show great similarity to that of lym- phatic leukemia. An occasional normoblast may be seen. Diagnosis.—Pseudo-leukemia is more readily confused with tubercu- lous adenitis than any other disease, particularly at the outset. Although 448 DISEASES OF THE BLOOD AND THE DUCTLESS GLANDS. an acute tuberculous adenitis may very closely simulate Hodgkin's dis- ease and render a diagnosis almost impossible, more often the glands of tuberculous adenitis are slower in enlarging and extending than in this disease. In fact, extension of the lymphatic enlargements of tuberculo- sis is rarely seen as compared with pseudo-leukemia. Again, tuberculous adenitis is most common in the young, is unilateral rather than circumfer- ential in the neck, and attacks the submaxillary glands oftener than the cervical chains along the sterno-cleido-mastoid. Again, periadenitis, adhesion, and suppuration of the glands occur in tuberculosis. Tubercu- lous foci in other organs may also be found. Intermittent attacks of pyrexia are an indication favoring Hodgkin's disease. In doubtful cases a gland may be removed for microscopic examination. The blood should be examined in order to differentiate from leukemia. Syphilis must be carefully excluded by the history, symptoms, and therapeutic test. Neoplasms of the lymph-glands may sometimes be difficult to distinguish from pseudo-leukemia. Prognosis.—This affection runs an almost invariably fatal course. The variability of the symptoms, of the rate of growth, size, and ex- tension of the lymphatic enlargements, and the remissions and exacer- bations of the disease are, however, notable. In some cases the termi- nation may occur in a few months, but usually death ensues after the lapse of two or three years. Recovery is not impossible in the early stages of the disease, but in fully-developed cases the prognosis is absolutely unfavorable. It should be remembered that some instances of Hodgkin's disease seem to merge into a true lymphatic leukemia. Grave indications are the rapid extension of the glandular enlarge- ments, great debility, anemia, emaciation, steadily increasing and con- tinuous pyrexia, thoracic pressure-symptoms, hemorrhages, and marked anasarca. Sometimes the tumors diminish greatly before death. In certain cases general streptococcus infection, hydrothorax, edema of the lungs, mechanical compression, hemorrhage, intercurrent diseases, or such complications as empyema or nephritis, often preceded by coma, may be the immediate cause of death. Treatment.—Local or surgical treatment is of no avail. Hygienic measures and the use of all possible agencies to support the strength of the patient should be resorted to, and the administration of arsenic in gradually ascending doses, as for pernicious anemia and leukemia, should be begun as soon as the diagnosis of pseudo-leukemia is made. The value of arsenic is undoubted in many cases, and Fowler's solution is very generally used. Phosphorus has also been recommended. In- unctions of ichthyol, iodoform, or green soap may be tried for their psychic effect, and the galvanic current may also be applied topically. Tonics and nutrients may be of temporary service. AN.EMIA INFANTUM PSEUDO-LEUK^JMICA. Definition.—The above title Avas given by von Jaksch to a form of anemia occurring in childhood that bears certain similarities to leu- kemia, but is without the tendency to a fatal end. It is probably the same class of cases that Italian writers have classified under the name of ancemia splenica infettiva dei bambini. ANAEMIA INFANTUM PSEUDO-LEUKMMICA. 449 Pathology.—Splenic enlargement is the most striking lesion. The organ is hard and dark red, and perisplenitis may be observed. The histologic examination shoAvs a uniform hyperplasia of the tissue, such as is witnessed in ordinary splenic hypertrophy due to various conditions. The liver is enlarged in most cases, but presents practically normal ap- pearances on section ; slight enlargement of the lymphatic glands may also occur, though never lymphomatous tumors. Diffuse reddening of marroAv has been described. Etiology.—Children under the age of four, and particularly during the second half year of life, are especially prone to this condition. It is equally common in the two sexes, and is most often met Avith in rachitic infants, 16 of 20 cases collected by Monti and Berggriin having exhibited this etiological factor. Hereditary syphilis, intestinal dis- turbances, and other diseases doubtless play a part in the etiology. The disease is a rare affection, occurring very seldom even in the largest children's clinics. Symptoms.—The onset is gradual. The child becomes pale, Aveak, and often emaciated, and enlargement of the spleen is the most strik- ing feature. Sometimes this reaches such a grade that the left half of the abdomen is practically filled, variations in its size being observed from time to time. Hepatic enlargement is frequently present, but does not correspond to that of the spleen, and the lower border of the organ is found to be sharp instead of rounded, as is the case in leukemia. Gastro-intestinal disturbances may occur in the course of the disease, and gradually increasing Aveakness may lead to a fatal end; death may also occur from peritonitis, bronchitis, or pneumonia. Blood.—An examination of the blood will in many cases shoAV an in- ordinate reduction in the number of red corpuscles. Nearly ahvays the number is beloAv 3,000,000. Degeneration of the corpuscles, poly- chromatophilia, and poikilocytosis are seen in the severer cases. Large numbers of nucleated erythrocytes, especially the normoblasts, may be found, and karyokinetic figures are frequently observed in the nuclei. A marked increase in the number of leukocytes is one of the characteris- tics, the number ranging from 40,000 to over 100,000, and the proportion of the red to the Avhite at times being as Ioav as 12 to 1. Considerable fluctuations in the number of leukocytes may occur from time to time. Von Jaksch insisted that the different forms of leukocytes occur in their usual relative proportions, or that the polymorphous forms are specially increased. Cases have, however, been described in Avhich the mononu- clear elements wTere particularly increased. The nature of the disease is difficult to determine, though the favor- able termination of many cases, the lesser grade of hepatic enlargement, and the character of the leukocytosis distinguish these cases from leukemia. It is not even certain that it is a special disease-entity, and the evidence is in favor of its being a type of secondary anemia with peculiar features, due perhaps to the constitutional condition and the age of the patient. Diagnosis.—Some points of distinction from leukemia have been referred to above. In addition I would say that the absence of hemor- rhages, purpura, and lymphomatous enlargements, and the presence of abundant nucleated corpuscles showing karyokinesis, together with the existence of rickets, point to a non-leukemic affection. 29 450 DISEASES OF THE BLOOD AND THE DUCTLESS GLANDS. Prognosis.—The disease tends to a progressive increase of the anemia, but under treatment the majority of cases terminate favorably. Treatment.—Hygienic measures together with the administration of remedies directed to the anemia constitute the treatment. CHLOROMA. Owing to its clinical resemblance to leukemia and pseudo-leukemia a brief reference to this comparatively neAv and rare affection may be made here. Pathologically, it consists of a sarcomatous growth, the pri- mary seat of which is in the periosteum and bone in and about the orbit. The growth shows a pea-green pigmentation. Secondary growths may be widespread, the metastatic nodules being also green in color, but more circumscribed than are the lymphatic infiltrations of ordinary leukemia. In 2 cases reported recently, 1 by Dock and the other by Ayers,1 the ages were fifteen and seven years respectively. Pain in the orbital region, exophthalmos, and deafness Avere noted early, and severe conjunctival hemorrhages and epistaxis occurred. Rounded elastic swellings were observed in the temporal and parotid, as well as in the orbital regions, corresponding to the chloromata. The blood Avas pale and watery, and leukocytosis Avas present, multinuclear leukocytes being noted. The eosinophiles Avere slightly reduced. The course of the disease—spoken of by French writers as " green cancer "—is rapid, and death usually comes on within a few months. DISEASES OP THE DUCTLESS GLANDS. DISEASE OP THE SUPRARENAL CAPSULES. ADDISON'S DISEASE. Definition.—A constitutional disease, characterized by a degenera- tion of the suprarenal capsules or semilunar ganglia, a bronzed or pig- mented skin, great bodily and mental asthenia, feeble circulation, and gastro-intestinal irritability. This affection is named in honor of its discoverer, Thomas Addison of Guy's Hospital, London, Avho first described it in a monograph pub- lished in 1855, entitled " The Constitutional and Local Effects of Dis- ease of the Suprarenal Capsules. Pathology.—Addison emphasized the fact that while the supra- renal bodies were affected with a fibro-caseous alteration in many cases, the anatomical changes were by no means ahvays the same. Both supra- renal capsules are usually diseased at the same time. Tuberculosis is the commonest condition, and is often associated with tuberculous lesions in other parts of the body, as in the lungs, bones, and other glands. Rarely, it seems to be primary, no other evidences of tuberculous infiltra- tion being found. The capsules are enlarged, firm in places, and nodu- lJour. Amer. Med. Assoc, Nov. 7, 1896. ADDISON'S DISEASE. 451 lated on the surface, owing to the caseous masses surrounded by fibrous tissue. Sometimes there is marked cicatricial contraction of the adrenals, and the adjacent structures may be found matted together Avith the cap- sules. Microscopic examination shoAvs a reticulum of connective tis- sue surrounding a soft cheesy, granular, and fatty detritus, lymphoid cells, and some giant cells. Other morbid processes in the adrenals that are non-tuberculous in nature have also been found associated with Ad- dison's disease, such as atrophy of one or both glands from interstitial cirrhosis, carcinoma or sarcoma, and chronic inflammation. Especial attention has recently been given to the condition of the solar plexus and semilunar ganglia of the abdominal sympathetic, and implication of these nervous structures by compression, cicatricial con- traction, or by chronic inflammation, is not infrequently discovered, to- gether with a degeneration of the nerve-cells. Enlargement of the solitary and agminated follicles of the intestine, and slight enlargement and some softening of the spleen are noted at times; parenchymatous or fatty degeneration of the heart, liver, and kidneys has also been noted in some instances. The thymus gland may be found to haAre remained normal, or even to have enlarged, perhaps. The deposition of pigment is in the same anatomic elements as in the negro—in the lower layers of the rete Malpighii. The pathological connection between the symptomatic phenomena of Addison's disease and the anatomical lesions has not been satisfactorily made out. The experimental evidence regarding the functions of the adrenals is imperfect; but it seems quite probable that some essential "internal secretion," influencing the normal metabolism of the skin and muscles, is diminished or absent in Addison's disease. On the contrary, cases exhibiting the clinical phenomena of this affection have occurred in Avhich no suprarenal morbid processes could be found post mortem. Again, marked changes have been observed in these glands, while dur- ing life no symptoms of the disease had been noted. Hence, it is maintained by some that the abdominal sympathetic nerves and ganglia are directly concerned in producing the clinical manifestations, either by an independent morbid process or by extension from some adjacent organ. Others hold that Avhen both the adrenals and sympathetic ganglia are the seat of pathologic changes, the latter directly and the former indirectly lead to Addison's disease. The data are not sufficient, hoAvever, to determine Avhether the principal involvement is nervous or secretory, and to future investigations must be left the decision in regard to this point. Etiology.—This is obscure. It has been held that some infection of the blood from without precedes the suprarenal and nervous lesions of Addison's disease. A tuberculous diathesis or infection has also been emphasized by some investigators, and a history of injury to the trunk has been noted in several cases. The disease is more common in Europe than in America, though it is rare everyAvhere. Sixty per cent, of the cases occur in males, and while the disease may affect all ages (it may even be congenital) it is usually found in early or middle life— betAveen fifteen and forty years of age. That Addison's disease is due either to a general neurosis or to disturbed hematopoiesis is merely hypothetic. 452 DISEASES OF THE BLOOD AND THE DUCTLESS GLANDS. Symptoms.—While it does not seldom happen that tuberculosis or carcinoma affects the adrenals, the purest and most typical symptoms of Addison's disease are apparently primary in their development, and not those that usually attend the course of the former diseases. The gradual pigmentation of the skin of various parts of the body may be one of the first evidences of the affection. This pigmentation may have either a dusky-yellow, bronze or yellowish-brown, olive, deep or greenish-broAvn, or even black color. Although sometimes diffuse, the discoloration is not uniform over all parts of the body, but com- mences earlier and becomes deeper especially on the exposed parts and where the normal pigmentation is marked, as the face, neck, backs of the hands, the axillae, abdomen, groins, genital regions, and the areolae of the nipples. Pigment-spots, often somewhat bluish in color, are also found on the mucous membranes of the mouth, lips, conjunctiva, and vagina. On the lips the discoloration takes the form of a dark streak, running lengthwise, near the junction of the skin and mucous membrane; or brownish patches or streaks corresponding to points of pressure by the teeth may be noticed. Irregular stains with ill-defined borders may also be shoAvn on the skin, corresponding to the lines of pressure ex- erted by garments, strings, suspenders, garters, etc. (Greenhow). White patches of leukoderma may be seen here and there in marked contrast to the pigment-deposits. The constitutional symptoms may exist in a slight degree before the pigmentation first attracts the patient's attention. There is gradual and progressive asthenia without apparent cause, great lassitude and loss of physical and mental energy, breathlessness, palpitation, headache, dizzi- ness, tinnitis aurium, sighing and fatigue, and the functional murmurs that are observed in the anemias. The blood-examination, however, rarely shows any marked reduction of the erythrocytes or hemoglobin; nor is there any leukocytosis. The heart's action is weak and the pulse small and feeble ; attacks of faintness on exertion are common, and coldness and clamminess of the extremities are often complained of. The general nutrition may suffer considerably, though often the fat, particularly of the abdomen, is well preserved. Gastro-intestinal symptoms are usually prominent. There is a loss of appetite, and nausea and vomiting may occur early and either be paroxysmal or persistent. The tongue may be clean, and the gastric disturbances do not seem to follow errors in diet. Diarrhea may be troublesome in the latter stage, and is often associated with intractable vomiting. Neuralgic attacks of either sharp or dull, aching pain are referred to the epigastric, hypochondriac, and lumbar regions in about one-third of the cases. The mind is usually clear until near the last, but mental weariness is constant, and, as the later stages of the disease come on, the patient often lies in a somnolent, semi-comatose state. The physiognomy expresses fatigue, dejection, and apathy; the speech be- comes slow and incoherent, and in many cases the patient passes into delirium. Prostration is profound, the weakness being disproportionate to the general condition. Polyuria is sometimes evident, but albumin is seldom present. The amount of indican is increased, as it is in the urine of all of the cachectic diseases associated with destruction of albuminoids. There ADDISON'S DISEASE. 453 is usually a diminished excretion of urea, but urobilin and uromelanin may be present in abnormal quantity. Tubercle bacilli may be found in the sputum. Diagnosis.—The principal error in diagnosis is in the assumption that the case is one of Addison's disease, simply from the presence of patches of pigmented skin. Other conditions in Avhich the discoloration may simulate that of Addison's disease are the following: (1) Carcinom- atous and tuberculous disease, particularly when seated in the abdomen and when involving the peritoneum ; (2) Hepatic disease, such as the cirrhosis of diabetes, protracted jaundice, chronic congestion, and lith- emia (" liver-spots "); (3) Pregnancy, and uterine disease, in which the patchy discolorations (chloasmata) appear principally upon the face; (4) Irritation of lice and dirt and exposure, as in the case of tramps and vagrants ("vagabond's disease"); (5) Tinea versicolor; (6) Melanotic sarcoma; (7) Exophthalmic goiter; (8) Post-eruptive staining of syphilitic eruptions; (9) The administration of silver nitrate for a long time (argyria); (10) Marked brunette complexions and racial admixture. When the pigmentation is scanty, of course the diagnosis is more difficult; but in all cases of pigmentation in which other causes may be excluded the progressive asthenia, unaccountable vomiting and diarrhea, easily compressible pulse, great bodily weakness, mental hebetude, and lumbar and epigastric pain render the diagnosis of morbus Addisonii, or melasma suprarenale, justifiable. It is to be remembered that the bronzing of the skin may precede as well as follow the constitutional symptoms. In the negro the diagnosis of this affection is extremely difficult, both on account of the naturally dark skin and because of the dark dis- colorations of the oral mucous membrane, found even in health in many individuals. Prognosis.—The course of Addison's disease is almost always chronic, though cases have been reported occasionally in Avhich the on- set has been sudden, with febrile phenomena and a comparatively acute course of a few months, or weeks even. Usually the disease lasts about one year, although some cases may continue over five or even ten years. Temporary remissions may be observed, but death is inevitable in by far the majority of instances. The termination is gradual, and by profound asthenia, or sometimes by coma, delirium, or convulsions (epileptiform). Treatment.—The hygienic and medicinal treatment must have vir- tually the same objects in view as in the other grave cachectic diseases, and is both sustentative and symptomatic. As quiet a life as possible should be strictly enjoined, owing to the dangers of a sudden and fatal syn- copal attack. Rest in bed is necessary in moderate and advanced cases during a part of the day for the former and constantly for the latter. The diet should be restricted to light nutritive, concentrated, and easily assimilable food, and particularly to the nitrogenous or proteid sub- stances. An absolute milk diet may be necessary in some cases. Iron and arsenic may be administered in the anemic cases, and strychnin, guaiacol carbonate, phosphorus, and the nuclein preparations may also be given, along with bitter tonics. Bismuth and salol may be 454 DISEASES OF THE BLOOD AND THE DUCTLESS GLANDS. of great service in controlling the diarrhea that often occurs. The nausea and vomiting may be relieved by unfermented grape-juice, albumin-water, champagne, cracked ice, cerium oxalate, creasote, and the like. Electricity is often a valuable adjunct in the treatment of the muscular weakness and nervous exhaustion, and even in reducing the pigmentation. Loss of sexual desire and poAver were also restored in a case reported by Flint. It seems quite probable that the administration of the extract of suprarenal capsules Avill prove to be of considerable value in causing marked improvement, if not a permanent cure, in a certain percentage of cases. The therapeutic efficiency of this more or less physiologic remedy is still to be proved, but several cases have been reported in which distinctly good results have been obtained. In one instance men- tioned by Osier, in Avhich a glycerin extract of a pig's suprarenal Avas given at first in doses of half a glass three times a day, improvement was noted in the temperature, pulse, weight, and physical and mental vigor from the first week of the treatment, which Avas continued for three months and a half. Eight months after the treatment was begun the patient appeared to be well and strong, and attended to business; the pigmentation, however, was not removed. In a recent case of my own this remedy produced like results. For the present, however, too positive a value should not be attributed to the suprarenal extract, owing to the meager data at hand. DISEASES OP THE THYROID GLAND. THYROIDITIS. Definition.—Acute inflammation of the thyroid gland. The gland may either have been previously healthy or the seat of a goitrous en- largement ; Avhen inflammation attacks previously diseased or enlarged thyroid tissue the term strumitis is often used. Pathology.—The gland is swollen, boggy, and the seat either of a single large or of multiple small abscesses; the numerous large blood- vessels are engorged; and hemorrhages, thrombi, and areas of tissue- necrosis are frequently found. Sometimes evidences are seen of the burrowing of the abscess around the trachea and esophagus, and erosion of the laryngeal cartilages and perforation of the respiratory and digest- ive tubes have also been noted. Gangrene of the cervical tissues may follow an intense inflammation. Etiology.—Thyroiditis is seldom primary in origin. It may be caused by traumatism, but usually it is secondary to one of the infectious diseases, such as small-pox, typhus, typhoid fever, or malaria. Rheu- matism has also been given as a cause. Hemorrhages into the substance of a goiter, Avhether apoplectic or traumatic, may predispose to a strum- itis that may be excited by the introduction of streptococci by an unclean needle, etc. Repeated congestions of the thyroid or a simple acute congestion may also dispose to thyroiditis. Thus, abrupt suppression of the menses and sexual excitement may cause an acute goiter (con- gestion) ; the gland is also found engorged in many pregnant women, and is at such times more susceptible to inflammations. Symptoms.—There are fever, pain, swelling, and suppuration in GOITER. 455 one or the other lobe of the gland. Venous obstruction may be serious and give rise to vertigo, headache, cyanosis, and epistaxis ; and compres- sion of the windpipe by the great SAvelling may cause death before the abscess bursts. Resolution occurs infrequently, especially in the " strum- ous " cases. Indeed, the symptoms of a strumitis are usually more severe, OAving to the greater size of the thyroid, a tendency to metas- tasis, and to the burrowing of pus into adjacent tissues leading to per- foration and rupture of the abscess into the trachea or esophagus. Diagnosis.—Thyroiditis must be differentiated from the laryngeal perichondritis that is also seen in the course of infectious diseases, as typhoid fever and small-pox. The higher and more median position and the smaller SAvelling of laryngo-chondritis are distinctive points. Prognosis.—The outcome is usually favorable in all cases in which spontaneous rupture occurs externally or when evacuation of the pus is effected. Strumitis runs a less favorable course for the reasons men- tioned above, and from the fact that the constitutional vitality in such cases is less resistant and the probability of cure is to that degree dimin- ished. Extension of the suppuration into the deeper tissues of the neck is of grave import. Treatment.—This is antiphlogistic and surgical. The pus must be evacuated freely, and sometimes tracheotomy or thyroidectomy may be necessary in order to save life. GOITER. {Bronchocele.) Definition.—A chronic hypertrophy and hyperplasia of a portion or the whole of the thyroid gland. It is of obscure origin, involving one or more of the structural tissues, and is subject to various degen- erative changes. Pathology.—Several different varieties are described. In the simple hypertrophic or parenchymatous form there is a hyperplasia of all the original tissue-elements. The follicular form shoAvs an increase of the true glandular elements alone. Fibrous goiter is that variety in which the interstitial tissue or stroma is increased out of all proportion to the hyperplasia of the follicles, Avhich are also involved in a much slighter degree. This variety of goiter may have an inflammatory origin (thyroiditis). In old cases marked sclerosis may be assumed. There is also a vascular variety, in which the blood-vessels are enormously dilated. More commonly the veins are affected; but in the so-called aneurysmal variety the arteries are chiefly involved. The intense venous variety of vascular goiter has been de- nominated " cancerous tumor of the thyroid," and the whole gland may in such cases be quite elastic and like spongy erectile tissue. Follicular hyperplasia is often associated Avith vascular enlargement. The special varieties of goiter due to degenerative changes are the cystic, amyloid, colloid, and calcareous, and of these the first named is the most common. It consists in the development in a large goiter of one or more large or small cysts filled with different kinds of fluid of varying consistency. Sometimes the liquid is colloid or mucinous in nature, and it may be chocolate-colored and contain the residue of hemor- 456 DISEASES OF THE BLOOD AND THE DUCTLESS GLANDS. rhages (cholesterin, fatty products, and albumin). Amyloid changes affect principally the vessels; colloid changes are also frequent, while calcareous infiltration is seen in very old fibrous goiters. Inflammation and suppuration of the goitrous gland may ensue. Etiology.—Goiter may occur anywhere sporadically. Endemically and in its Avorst forms it occurs in the mountainous districts of Europe, Asia, Mexico, and South America, particularly in the Alps, Pyrenees, and Andes. It has also appeared in certain limestone regions, such as NeAV England and Ontario, Canada, Avhere the habitual use of limestone- water for drinking purposes seems to induce the disease. Heredity undoubtedly plays a part in its causation, certain children having been born with goiter. Occasionally it has become epidemic in certain sec- tions of the goitrous districts in Europe where military garrisons have been stationed, thus indicating the possibility of some infectious influ- ence. Women are more liable to goiter than men, and it is more com- mon to find it after ten or tAventy years of age. It has been alleged that pregnancy also influences the development of this condition. Symptoms.—The enlarged thyroid is readily recognized and felt, though the patient may complain of nothing but the disfigurement, ex- cept when the tumor is of sufficient size to cause symptoms of compres- sion. The goiter develops very gradually, and may vary in dimensions from the merest perceptible enlargement to a growth that overhangs the chest and greatly hinders the movements of the head. It may or may not be uniform in its development, and is often more enlarged on the right side and in front than on the left side. It is not infrequently observed to increase in size Avith each succeeding pregnancy and during or after each menstrual flux. The tumor is painless, is not adherent to the overlying skin or to any of the neighboring bones, and rises and falls during the act of swalloAving, moving with the larynx. The veins covering it are swollen and prominent. It interferes Avith respiration oftener than with deglu- tition, causing dyspnea; alteration or loss of the voice may also ensue. Displacement and distortion of the trachea, the vessels, and other cer- vical tissues may be produced. Large pendulous growths usually cause less serious discomfort than the small encircling tumors that extend dowmvard into the thorax. Headache, somnolence, and marked cere- bral symptoms, such as tetany and convulsions, have been described as due to compression of the carotids. The general health or nutrition seldom fails unless inflammation and suppuration (strumitis) attack the goiter during the course of some in- fectious disease, as not infrequently happens, or in cases in which the thyroid function is abolished, leading to the profound nutritional and cerebral disorders of cretinism in children or myxedema in adults. Dettrich and Osier have each reported an instance of a goitrous groAvth affecting aberrant portions of thyroid found in the upper region of the pleural cavity, one on the right and one on the left side. Sudden death may ensue in a feAV cases, either from pressure on the vagi, from a severe intraglandular hemorrhage, or from a hemorrhage into the adjacent cellular tissues. Auscultation often reveals a loud blowing murmur, especially marked in the vascular bronchoceles. Palpation over the tumor often shows EXOPHTHALMIC GOITER. 457 the bossellated surface present in cystic goiter; fluctuation may also be detected in such cases, as Avell as over the abscess of a strumitis. Diagnosis.—Goiter is easily differentiated from other enlargements. The constant location and the character and course of growth of the bronchocele are distinctive. If both lobes of the thyroid are affected, making a symmetric swelling, the diagnosis is almost assured. Bron- chocele is not easily confounded Avith other cervical tumors, such as lymphadenoma, glandular tuberculosis, carcinoma or abscess of the thy- roid, or sebaceous cysts. A characteristic feature of tumors of the thy- roid is their vertical movement during the act of deglutition. Prognosis.—This is guardedly favorable as to life, but unfavorable as to cure. The course is chronic, but the possibility of a sudden fatal termination should be borne in mind. Treatment.—Prophylaxis should be practised in goitrous districts by the drinking of boiled Avater only, and removal to a non-goitrous region is advisable. The majority of drugs recommended for internal and ex- ternal use have been proved valueless, though in the parenchymatous and follicular forms potassium iodid by the mouth and the vigorous and methodic use of iodin over the tumor have been much lauded. Mer- curial ointment—the red or biniodid especially—has also been recom- mended for local application. Ergot or belladonna in progressively increasing doses may do good in vascular goiters. The younger and softer goiters may also be benefited by electrolysis, needles attached to the negative pole being inserted into the substance of the tumor while a large sponge or clay positive electrode is placed in the vicinity. In the older, fibrous, and degenerated goiters surgical treatment alone may be of service. Injections of iodin, tapping of cysts, incisions of the isthmus, and ligature of the thyroid arteries have been practised among the lesser operations. Thyroidectomy, or a partial extirpation of the thyroid, is the radical and final operation. Recently, the fresh, chopped thymus gland of the sheep, spread on bread, Avas given in 20 cases of follicular and parenchymatous goiter with gratifying results. The pressure-symptoms were relieved and a perceptible diminution in the size of the goiter was demonstrated by actual measurements. Complete recovery, in an anatomical sense, how- ever, was realized in two cases only. EXOPHTHALMIC GOITER. [Gi'aves's Disease; Basedow's Disease.) Definition and Nature.—Although the view cannot be unreservedly accepted, exophthalmic goiter is probably of thyroid origin and is de- pendent upon an abnormal action (or over-action) of the thyroid gland; it is characterized clinically by tachycardia, tremors, enlarged thyroid, and exophthalmos. Among other leading theories the following may be briefly stated: (1) that it is due to disturbed innervation (Buschan); (2) that the seat of the disease resides in the medulla oblongata; (3) that it is an affection of the sympathetic nerves ; and (4) that it is a disease of the central nervous system associated with a chronic intoxication. The theory held by Mdbius, that exophthalmic goiter is attributable primarily to a disturbance of the function of the thyroid (" hyperthyroid- 458 DISEASES OF THE BLOOD AND THE DUCTLESS GLANDS. ation "), a condition directly opposed to the lack of thyroid function, as in myxedema, is amply supported by clinical evidence, the complex symp- tom-group of the former being directly antagonistic to that of the latter disease. Thyroid-feeding, moreover, while it sometimes causes paren- chymatous goiters to disappear rapidly, usually aggravates the symptoms of Basedow's disease. Regarding the pathologic changes in the thyroid little is known. Brissaud1 found in 25 cases of various chronic diseases changes in the thyroid, and, although the glands in exophthalmic goiter showed no changes peculiar to that disease, yet quantitatively the lesions were always such as to make " hyperthyroidation " possible. Etiology.—It is more common in women than men, and, although it has been met with at both extremes of life, it is seen usually in adults. The influence of heredity is undoubted, and several members of a family may suffer, persons that possess a sensitive nervous organization being especially prone to the disease. Among direct causes are emotional disturbance, worry, severe acute disease (noted in a recent case of my own), and prolonged mental or phys- ical strain. The disease may also occur as a secondary complication in the course of simple goiter, affections of the nose, and pregnancy; this variety, hoAvever, is to be distinguished from the primary or essential form. Symptoms.—The development of the characteristic symptoms is generally gradual, though it may rarely be rapid. In the so-called abor- tive form the symptoms arise somewhat rapidly, but early subside. In acute Basedow's disease the symptoms consist of an excessively rapid action of the heart, incessant vomiting, purging, and marked exophthalmos, with or without pronounced cerebral symptoms. J. H. Lloyd's case proved fatal after an illness of three days. In the chronic form heart-hurry is almost constantly a conspicuous early symptom, and not seldom have I found that it precedes for a long period of time the appearance of the remaining characteristic features. The pulse remains at or over 100 beats per minute, and upon unusual ex- ertion or excitement the heart's action becomes violent and irregular, the pulse even reaching 160 or over. Palpitation, often with breathlessness, is a distressing symptom. Cardiac Physical Signs.—Inspection reveals a forcible impulse that is not displaced, though late in the affection it may be much extended in superficial area. The carotids and the abdominal aorta beat more or less violently, and the capillaries and veins of the hands may also pulsate visibly. Palpation detects an increased force of the cardiac impulse. The area of percussion dulness may be somewhat increased, as hyper- trophy and secondary dilatation supervene. On auscultation, blowing murmurs over the heart and the great vessels, as well as an increased accentuation of the valvular sounds, may be audible. Protrusion of the eyeballs (exophthalmos) is usually present, and with rare exceptions follows the tachycardia. The degree of exophthalmos varies greatly from time to time in the same case—a fact that points to an increased amount of blood or lymph in the orbit as its cause. In ad- vanced cases permanent prominence of the balls may be attributable to augmentation of the orbital adipose tissue. On closing the eyes a rim of 1 Mercredi med., No. 34, 1895. EXOPHTHALMIC GOITER. 459 white is visible above and below the cornea, and Graefe's sign, immobility of the upper lid Avhen the eye is turned dowmvard, are two symptoms of great diagnostic importance. Mobius has called attention to the inability to converge the eyes upon near objects, and Stellwag to an apparent sep- aration of the eyelids, due to spasm or retraction of the upper lid. The pupils and the vision are unaffected. Abnormalities are rarely presented by the optic nerves, and ulceration of the cornea may supervene. The retinal arteries pulsate. The thyroidean enlargement either accompanies or folloAVS the exoph- thalmos, and has for its cause the great dilatation of the vessels, and par- ticularly of the arteries. The enlargement is usually moderate and may be general or partial, the size of the gland exhibiting sudden variations, since it is dependent upon the circulatory disturbance. Inspection may also shoAV visible pulsation ; palpation feels a thrill, and auscultation renders audible a double systolic murmur. The latter sign is probably present in most instances, though not constantly. Muscular tremors form an early symptom ; they are involuntary, and fine in character, numbering about eight to the second (Osier). The cha- racteristic features of neurasthenia appear and gradually increase in intensity. Mental disturbances, particularly marked depression or great excitability, are common, and even mania (which may prove speedily fatal) or melancholia may be observed. Muscular weakness, either local or general, is pronounced ; the patient becomes anemic and is at last ex- tremely emaciated. The temperature may at intervals be moderately ele- vated, and this symptom may be associated with profuse sweatings. Among other cutaneous phenomena, though these are for the greater part occasional, are pigmentation (Avhich, in the case of a physician whom I recently saw suffering from Basedow's disease, was as pronounced as in typical Addison's disease), scleroderma, urticaria, and circumscribed solid edema. In the advanced stage malleolar edema sets in and may become general. A marked diminution in the cutaneous resistance to the elec- tric current has been noted by Charcot. Vomiting and purging may appear at different times and assume great gravity, and in some cases hemorrhages (epistaxis, hemoptysis, hematemesis) tend to supervene. Albuminuria and an increased amount of urine, with glycosuria, are among the commoner complications. Louise Bryson has maintained that diminution in the chest-expansion is a characteristic sign of exophthalmic goiter, and Patrick,1 who examined 40 cases, found that there was an average diminution, but believed it to be proportionate to the amount of general muscular weakness. Rarely a myxedematous condition is associ- ated ; probably the disease is also remotely related to scleroderma. Diagnosis.—The diagnosis of Graves's disease may be made when tachycardia or delirium cordis and fine, general muscular tremors are present. Exophthalmos and enlargement of the thyroid are often late- appearing symptoms, and are as often temporarily lacking even in fully- developed cases. Rarely, either or both of these signs may be permanently absent. On the other hand, in a few cases exophthalmos is the sole cha- racteristic feature for a long time, though it is eventually folloAved by an unmistakable symptom-group. Parenchymatous goiter presents a non- pulsating tumor, and hence is easily distinguishable from the thyroid 1 Deutsche med. Wock, Dec. 20, 1894. 460 DISEASES OF THE BLOOD AND THE DUCTLESS GLANDS. enlargement of Basedow's disease Avith its additional unequivocal symp- toms. Course and Prognosis.—The chronic form of the disease endures, as a rule, for a fe\v years. A gradual subsidence of the cardinal symp- toms for a long period has been noted, and in such cases complete recov- ery may be claimed. In fully-developed cases the prognosis formerly was almost hopeless, but since the introduction of the operative treatment many cases have been greatly benefited, and others, though constituting a smaller number, have been entirely cured. Treatment.—This is (a) Hygienic, (b) Medicinal, and (c) Operative. (a) Hygienic.—The environment, both physical and mental, should be made as favorable as possible. A change of climate, and especially mod- erate elevation, in cases not too far advanced, bring about beneficial re- sults. Such elevation (3250 feet) produces a sedative effect upon the nervous state that reacts most favorably upon the circulatory organs, while the purity and tonic quality of the air have a general strengthening and restorative effect (Yeo). Among other promising measures may be mentioned the wet-pack, methodical hydrotherapy with massage, and a continuous galvanic current. The electric treatment should be given a thorough trial over three or four months (Osier). The local use of an ice- bag to the precordium has acted admirably in reducing the heart-hurry in a few cases of my own. I have also observed favorable results from care- fully graduated physical exercise. Rest in bed for a few weeks at a time, at intervals, is often folloAved by improvement, though I have never seen complete cure follow this plan of treatment. (b) Medicinal Treatment.—This is probably secondary to the hygenic and operative measures. In two cases of my own, hoAvever, recovery fol- lowed the persistent use, for about six months, of the following prescrip- tion : If. Extr. digitalis, gr. iv (0.259); Extr. ergotse (Squibb), 3ss (2.0); Strychninse sulph., gr. ss (0.032) ; Ferri arsenias, gr. ij (0.129). M. et ft. capsular No. xxiv. Sig. One t. i. d. after meals. In 2 other cases (one, a trained nurse) the use of sodium salicylate (gr. x- 0.648—four times a day) was followed by almost total relief. L. Webster Fox also warmly advocates the latter remedy in this affection. Trachewsky, in Kocher's clinic, found that sodium glycerophosphate (gr. xx—1.296— three or four times a day), had the effect of diminishing the size of the enlarged thyroid glands, and Starr1 has also found this remedy of great service in several cases. Other therapeutic agents that have been exten- sively employed, but with doubtful advantage, are aconite, veratrum viride, and belladonna. From all of the clinical testimony at hand I feel con- vinced that thyroid-feeding is contraindicated in the treatment of Basedow's disease, unless a myxedematous condition be associated, when it may prove efficient. From personal observation thyroid extract increases the circu- latory disturbance and excites unpleasant headache. (c) Operative Treatment.—Starr2 has collected 190 cases in which 1 Medical News, April 18, 1896. 2 Loc. cit. MYXEDEMA. 461 some form of operation was performed. Of these, 74 are reported as com- pletely cured, many of them having been watched two to four years before the result was published; 45 of the cases were improved, and 23 died immediately after operation. The symptoms preceding the fatal result are sudden hyperpyrexia, with rapid pulse, nervous dis- tress, sweating, cardiac failure, and collapse. The statistics of Kinni- cutt and of Abramx (particularly the latter) show less encouraging re- sults from operation, though they warrant the opinion that if cure is not obtained by medical measures, an operation should be undertaken. It is to be remembered that under the most favorable circumstances a com- plete cure will not be attained immediately, and frequently not for several years. I am convinced that removal of the entire gland is not to be ad- vised, since myxedema will likely result. Whether partial removal—one- half to three-fourths of the gland—is to be effected, or mere ligation of the thyroid arteries, must be decided by the surgeon. MYXEDEMA. [Sporadic Cretinism.) Definition.—A general nutritional disorder, consequent upon atro- phy and loss of function of the thyroid gland, and characterized by a myxedematous infiltration of the subcutaneous tissue and a cretinoid cachexia. Three varieties occur, as follows: (1) True myxedema; (2) Cretinism (the absence of thyroid function—congenital, or lost during childhood); (3) Operative myxedema, due to total removal of the glands for surgical reasons or in experiments upon loAver animals. Nature of Myxedema Proper of Adults.—Charcot, Avho gave the name of cachexie pachydermique to this disease, believed it to be of tropho- neurotic origin. Atrophy of the thyroid is pretty constantly present, and the gland may either be converted into a small fibrous mass or be entirely absent, so that the causal relation betAveen myxedema and functional and structural alterations of the thyroid seems to be conclu- sive. Moreover, the therapeutic test of improvement under the admin- istration of thyroid extract sustains this vieAv. It is probable that the active thyroid supplies some essential secretion which maintains normal metabolism, though this product has not been isolated. Its existence being inferred,.hoAvever, it has been called thyroidin.2 Others suggest that a substance called ihyro-proteid is formed in excess in myxedema OA\lng to a disturbance of glandular function, and this accumulating in the body produces the disease by a toxic action upon the metabolism. Etiology.—The thyroid Avas destroyed by actinomycosis in a case of myxedema reported recently. Myxedema may also be secondary to exophthalmic goiter, but it is then, as in the case of a simple acute goiter, only a transient condition. Women are much more frequently affected than men, and a neurotic condition may precede some cases. The dis- ease may affect several members of a family, and hereditary transmission 1 American Year-Book of Medicine and Surgery, 1897. 2 The term " thyroidin" has also been given to a substance possessing specific therapeutic activities that has been obtained from the thyroid gland of the sheep by Baumann. 462 DISEASES OF THE BLOOD AND THE DUCTLESS GLANDS. through the mother has been observed. Pregnancy may cause a disap- pearance of the myxedematous symptoms (Osier). Symptoms.—The myxedematous condition is most plainly noted in the face, the skin being swollen, but inelastic, rough, dry, and firm. The lines of facial expression are obliterated, and the features are broad, coarse, immobile, and bulky. The physiognomy is stupid, dull, and phlegmatic, and simulates imbecility. The hair falls out, owing to deficient nutrition, and the general bulk of the body is markedly in- creased. Pressure does not produce pitting, as in true edema. Accord- ing to Ord, the local tumefaction of the skin and subcutaneous tissue is most frequently prominent in the supraclavicular regions. The mucous membranes are also infiltrated, and the teeth may become loosened. The tongue, lips, and nose are thickened, and the voice is monotonous, slow, and has a "leathery tone," " Avith curious nasal explosions at short in- tervals during speaking." Bodily movements are sIoav, and the gait is heavy and uncertain on account of disturbed co-ordination. Mental perception and thought are also slow, and the memory is defective and slow to respond. Not infrequently there may be considerable irrita- bility, or hebetude alternating with sudden excitability. The patient may become suspicious, and later is subject to delusions and halluci- nations ; or the apathy may pass into a melancholia, ending at last in dementia. Ord mentions "the aggravation of all symptoms during low climatic temperatures; " and " among the minor or accessory signs may be quoted abnormal subjective sensation, belonging particularly to taste and smell; occipital headache; marked alterations of temper; and a curious persistence of thought and action, overriding all attempts at interruption by friends or observers." The temperature in myxedema is usually either normal or subnormal. Albumin and sugar are occasionally found in the urine, but the quantity of nitrogen excreted is small, owing to the diminished metabolism of proteids. Hemorrhages from the nose, gums, and boAvels sometimes occur. Ascites also may be present in some cases, and may simulate ovarian tumor. The thyroid is not palpable, partly because of its atrophy, and partly because of the thickened myxedematous tissues of the neck. The diagnosis is not difficult if one bears in mind the character- istic manifestations described above. Mxedema could hardly be mistaken for acute or chronic nephritis in the absence of pitting, etc., as some have supposed. The prognosis is guardedly favorable in a majority of the cases since the introduction in the treatment of thyroid-feeding. The course of the disease is slow and progressive, however, often lasting from five to fifteen years, and death from intercurrent disease is not uncommon. Treatment.—Until the advent of thyroid-feeding the treatment of myxedema Avas palliative, and usually unsuccessful. A warm and equable climate is very desirable, owing to the sub- normal temperature from which the patients frequently suffer. The various warm baths—as the Turkish, Russian, and electric—should be employed for the same reason. Pilocarpin has been recommended, and strychnin and arsenic have been administered for their tonic effect. MYXEDEMA. 463 Since the brilliant results obtained by Murray, however, the internal use of the thyroid gland of sheep or calves has come into a well- deserved favor in the treatment of all cases of myxedema, whether of the so-called true form, of sporadic cretinism, or of the cachexia strumipriva. The gland may be given raw or cooked, in the form of the glycerin extract, or in the dried and powdered extract; the last named is sometimes put into tabloid form. If cooked, the gland should be only partially "done." The fresh thyroid is minced and often spread on bread, and from one quarter to half a gland may be taken daily. The glycerin extract is readily made. " Several dozens of thyroids of young sheep or calves are carefully separated from the connective tissue, cut into small pieces about the size of a bean, and then put into a jar and covered Avith glycerin of the best quality, allowing 2 c.cm. of glycerin for each lobe of the thyroid used. The mixture is permitted to stand for twenty-four or thirty-six hours, and is then squeezed through a cloth, so as to get out as much liquid as possible. Of this, 2 c.cm., corresponding to about half a gland, may be given at a dose. If used for hypodermic injection, to a dram (4.0) of the glycerin extract is added half a dram (2.0) of a 1 per cent, solution of carbolic acid in distilled water, of Avhich mixture from 10 to 15 minims (0.66-1.0) may be in- jected three or four times a week."1 It is safest—for reasons that will be pointed out beloAv—to begin with quite small doses, and gradually increase, especially if there is much gastric irritation. Not more than 5 minims (0.333) of the glycerin extract should be given at the start. This dose may be increased grad- ually until 15 or 20 minims (1.0-1.33) are taken three times daily. From 3 to 5 grains (0.194-0.324) of the powdered gland or tabloid form will be a safe commencing dose in adult myxedema: a caution, however, is necessary regarding the various manufactured preparations of the thyroid gland, some of Avhich are impure and even dangerous, OAving to the careless handling or fraudulent substitution in order to meet the demand for thyroid extracts on trial in other affections (as obesity and psoriasis). The toleration of thyroid-feeding does not depend upon the volume, but upon the functional activity, of the gland, and this fact, together Avith the evidences of toxic action reported in some instances of the administration of thyroids to a maximum degree, make it important to urge again—as intimated above—the necessity of small dosage at the beginning of treatment, the most careful and judicious increase in the quantity given, and the closest observation of symptoms indicative of hyperthyroidization. The additional fact of an occasional cumulative action should also be emphasized. Should vomiting, renal pain, tachy- cardia, suffusion of the face, syncope, vertigo, or marked headache supervene, the remedy should be stopped at once. Epileptiform con- vulsions have also occurred. The treatment may be resumed again cautiously, alternating Avith intervals of cessation. Good results are obtained usually Avithin a month, though it is probable that even after all the symptoms have subsided the treatment may have to be continued off and on if the thyroid gland seems to be permanently atrophied. 1 Osier in the Amer. Text-book of Therapeutics, pp. 926, 927. 464 DISEASES OF THE BLOOD AND THE DUCTLESS GLANDS. Cretinism, Sporadic and Endemic.—Here there is a congenital atrophy or absence of the thyroid gland, or an enlargement by the growth of fibrous tissue at the expense of the glandular elements. Cretinism may also develop in early infancy. The patients are often the children of parents noted for violent emotion and having various neuroses and goiter, and syphilis has also been supposed to have a causative influence. Congenital myxedema is quite common only in regions where goiter is endemic, and hence it is rare in America. A marked sporadic case has, however, been in the Philadelphia Hospital for many years. Symptoms.—Cretins are dwarfs Avith large heads and faces, thick lips, thick protruding tongues, broad bodies and members, and promi- nent abdomens. The subcutaneous tissues are myxedematous. Umbili- cal hernia has been noted. The mental condition is that of idiocy, and physical growth is retarded and slow. Speech is unintelligible or nearly so, and the voice harsh. Walking may never be accomplished, and is always slowly developed. There is anemia, the blood being of a fetal type. Rheumatic symptoms sometimes occur. Prognosis.—The disease is progressive until about the fifteenth year in those cases developing during early childhood. Congenital cases usually die shortly after birth. At the twentieth or thirtieth year "the mental and physical characters are those of childhood." Treatment— Thyroid-feeding has been followed by beneficial results, the checked growth having recommenced and the cretinic aspect having been largely lost. Operative Myxedema, or Cachexia Strumipriva.—Extirpation of the thyroid for surgical reasons has given rise to the gradual production of symptoms and conditions identical either with true myxedema or with the cretinoid state. Partial removal of the gland is not followed by cachexia strumipriva, nor is complete thyroidectomy when accessory glands are present elseAvhere. The administration of raw or broiled thyroids, or of their various extracts or preparations, must also be employed in this form of myx- edema, and should be continued throughout the rest of the patient's life, perhaps with intervals of withdrawal of the feeding until the im- provement gained begins to lapse. PART IV. DISEASES OF THE RESPIRATORY SYSTEM. I. DISEASES OF THE NOSE. ACUTE RHINITIS. {Acute Nasal Catarrh; Acute Coryza.) Definition.—An acute catarrh of the Schneiderian membrane, some- times tending to involve the adjacent sinuses and passages. It is known to the laity as " cold in the head." Etiology.—Its most conspicuous cause is exposure to draughts of air and to the influence of the atmospheric vicissitudes that are espe- cially prevalent during the winter and spring seasons. It often results from the inhalation of irritants (physical, chemical, or biological). It may also display epidemic behavior, and this fact seems to point strongly to its microbic origin. Hence local disturbances of the circulation due to exposure are to be regarded as the accidental means of preparing the soil for bacterial invasion. Acute rhinitis may be also secondary to, or propagated from, inflammations of the faucial mucosa by contiguity. Symptoms.— Sensations of chilliness, succeeded by feverishness (the temperature reaching 100° to 101° F.; 37.7°-38.3° C), frequent sneezing, headache, and a feeling of general ill-health are among the prominent features that attend the development of coryza. Pains in the extremities and back tend to appear only in severe cases. The pulse is frequent, the skin dry and unduly warm, thirst is increased, while the appetite is impaired, and constipation often attends. The nasal mucosa is swollen, and thus interferes both Avith the nasal respiration and the senses of smell and taste ; its color is deepened, its surface covered at first with opaque mucus, and later with a muco-purulent secretion. Among early symptoms is the discharge of a watery, irritating secretion from the nares and a maceration of the epidermis, with resulting abrasions. On account of the swelling of the mucosa of the lacrymal ducts the tears flow down over the cheeks. Adjacent mucous surfaces then become in- volved, giving rise to conjunctivitis, catarrhal pharyngitis, laryngitis, and finally, in the severer types, bronchitis. Naso-labial herpes is not uncommon. As the affection progresses the secretion becomes more abundant and turbid and more or less pyoid. The symptoms due to extension of the catarrhal inflammation vary Avith the organs or struc- tures involved. The disease runs its course within five or six days, but 30 465 466 DISEASES OF THE RESPIRATORY SYSTEM. the nasal discharge, Avhich gradually diminishes, usually persists for a few days longer. Diagnosis.—In the presence of the above-mentioned symptoms the disease is readily recognized. In Avell-marked cases, however, the pos- sibility that an infectious disease may be developing, the beginning of which is characterized by nasal catarrh (measles, influenza, etc.), is to be recollected. Prognosis.—Except in neglected cases, which result in bronchitis, and occur at one or other extreme of life, the disease is free from dan- ger. The nursing infant may have to be fed with a spoon temporarily. Treatment.—At the outset a purge, consisting of calomel (gr. ij— 0.129), or a pill of blue mass (gr. v—0.324) at night, followed by a Seidlitz poAvder in the morning, is advisable. To children a dose of castor oil may be given. The early administration of a diaphoretic, such as Dover's powder (gr. v-x—0.324-0.648) at night may arrest the complaint, and quinin in a large dose (gr. xij—xv—0.777-0.972) at night may cut short the course of the disease. When the above-mentioned abortive measures fail, the folloAving tablet produces good results: B/. Quinin. sulphat., gr. ijss (0.162); Extr. belladonna? fl., TUjss (0.099); Sodii salicylatis, gr. xxx (1.944); Camphorge, gr. ijss (0.162). M. et ft. tablet No. x. Sig. One tablet every hour or two. For the fever aconite may be employed, and, if the throat be involved, bryonia may be given in conjunction. Local Treatment.—This aims at soothing as Avell as at reducing the swelling of the Schneiderian membrane. The compound tincture of benzoin forms a soothing inhalation (jjij to a pint—8.0 per half liter— of water) when raised nearly to the boiling-point; the vapor is inhaled for ten or fifteen minutes at a time. With a view to reducing the swell- ing a solution of cocain (strength 2 to 4 per cent.) may be temporarily used; Mackenzie recommends this admirable combination : Menthol, gr. v (0.324); Pinol mv (0.324); Benzoinol, fgj (32.0). In severe cases the patient should be kept in-doors and in an atmosphere of even temperature. CHRONIC RHINITIS. {Chronic Nasal Catarrh.) Two forms are recognized, the hypertrophic and atrophic, and these, though, as a rule, occurring separately, may be found in combination. Pathology.—The morbid changes in hypertrophic rhinitis consist in an enlargement of the lower turbinated processes, together with red- ness and swelling of the nasal mucosa that may be general or limited CHRONIC RHINITIS. 467 either to the anterior or posterior nares. As the disease progresses the thickening of the membrane increases, until it finally encroaches upon the nasal chambers at eArery point. In addition to the nasal obstruction there is a hypersecretion of mucus. Opposite changes occur in atrophic rhinitis, such as thinning or atrophy of all the structures, with enlarge- ment of the nasal cavities. The nasal mucosa is coated with thick, yel- lowish-green, decomposing crusts, Avhich emit a characteristically fetid odor, and the frontal, ethmoid, or other accessory sinuses may, by an extension of the inflammation from the nasal chambers, be invaded by mucopurulent inflammation. The atrophic process does not affect the glandular structures of the upper third of the nose, and this fact ex- plains the most unpleasant feature of the affection—namely, the hor- rible secretion. Etiology.—Frequently occurring attacks of acute rhinitis may pro- duce the chronic form, and syphilis and, less commonly, tuberculosis are also among its causes. Abel * regards atrophic rhinitis as infectious, claiming that the cause is the bacillus mucosis ozena?, which resembles closely the pneumobacillus, but is distinguishable from it. Symptoms.—(a) In the hypertrophic form nasal respiration is im- peded, OAving to the hypertrophy of the turbinated bodies. The sense of smell is impaired, and there is a discharge of secretion from the nares, particularly the posterior, inducing " haAvking." The diag- nosis is set at rest by a rhino- scopic inspection of the parts. While this is a common affec- tion everyAvhere, it is Avellnigh universal in this country. (6) In chronic atrophic ca- tarrh there is some degree of nasal obstruction, occasioned by the presence of the thick crust, but the most conspicuous symp- tom is the disgusting odor, which makes the patient re- pellent in society. The sense of smell is lacking. After cleansing the membrane the rhinoscope will show the nasal chambers to be unduly capacious. Treatment.—(1) Chronic Hypertrophic Rhinitis.—The treatment is divisible into general and local. The physician should procure an envi- ronment for his charge most favorable for promoting the general nutrition, which is often below the health-standard. The selection of a suitable climate, then, forms an important part of the management, and a resi- dence in a locality that possesses a mild, equable, comparatively dry and pure atmosphere is to be advised and encouraged. Various tonics may then be demanded by the general condition of the patient, and strychnin and electricity are useful in restoring the loss of power in the contractile elements of the intercellular walls. Local measures are employed to facilitate thorough cleanliness and 1 Zeit. f. Hyg. u. Infektionskrank., Bd. xxi. H. 1. Fig. 41.—Apparatus for cleansing the nasal passages in chronic rhinitis. 468 DISEASES OF THE RESPIRATORY SYSTEM. disinfection of the affected parts, though in incipient and mild cases energetic treatment is scarcely needful. The best method of cleansing the nasal passages is by means of the coarse spray (Fig. 41). The apparatus of Lefferts is also to be employed when the secretion is in- spissated or tightly adherent. An excellent combination for use in this manner is the following: Rj. Sodii biborat., Sodii bicarb., da. 3j (4.0); Acid, carbolici, gr. viij (0.518); Listerin., SJ (32.0); Aquae destillat, q. s. ad §iv (128.0).—M. Sig. Use as a spray three times daily. It is often desirable to use warm or even hot liquids, in which case the application is made by the use of the anterior and posterior nasal syringe. Powders are harmful, and, as the nasal douche is dangerous in unskilled hands, these should both be abandoned. In hypertrophic rhinitis the obstruction to nasal breathing is to be removed, and to accomplish this caustics (chromic, glacial acetic, and nitric acids) are used, of which the most efficacious is chromic acid. This should be applied by means of a pointed glass rod, the application being followed by a sloughing away of the diseased tissues. Among other modes of removing the nasal obstruction that may be mentioned are the galvano-cautery, the thermo-cautery, and the cold-wire snare; these modes, hoAvever, are practised chiefly by the specialist. (2) In atrophic rhinitis a cure is to be despaired of, but the patient can be rendered free from the offensive discharge, and hence to a great degree comfortable. As this is often but an advanced stage of hyper- trophic nasal catarrh, the general treatment is similarly directed: it is therefore well to overcome, as far as possible, by a mental stimulus, the depressed mental state due to the fetor. If the diathesis be tuberculous, cod-liver oil, iron, arsenic, and strychnin, together with a generous diet, are to be advised. If syphilis is associated, appropriate measures must be instituted. Moreover, since a subject of atrophic rhinitis is a fertile source of atmospheric contamination, his living and sleeping apartments must be highly ventilated. Local Measures.—An antiseptic spray of Seller's or Dobell's solu- tion, and oiling the nasal cavities, are measures to be first tried If they prove non-efficacious, the crusts may then be removed with a cotton applicator coated with a solution of hydrogen peroxid. We may then use a spray of liquid albolene and menthol; this serves not only to lubricate, but to supply moisture, both of which are important thera- peutic indications. Small ulcerations occur in this affection and induce oft-repeated epistaxis ; consequently, an attempt should be made to heal the latter and to obtain an even, moist surface. To accomplish this the method of Clarence C. Rice may be folloAved—i. e. to rub the ulcer- ations thoroughly by means of a cotton-carrier with a small hard pledget of cotton moistened with listerin or borolyptol for a few sec- onds at a time. These antiseptic frictions are made at intervals of two or three days for two or three weeks. AUTUMNAL CATARRH. 469 AUTUMNAL CATARRH. [Hay Asthma ; Hay Fever.) By this term is meant a form of asthma that seems to be dependent upon an idiosyncrasy. It occurs exclusively during the Avarm season, and is caused by the odorous principles given off from certain plants (the pollen of the Anthoxanthum odoratum, of the rose, etc.), by inor- ganic dusts of various sorts, and, occasionally, by psychical influences. In some instances it appears to arise without obvious exposure to a spe- cial irritant. Predisposing Factors.—The male sex suffers more frequently than the female. Age has a slight though decisive influence, more than 33 per cent, of the cases occurring before the tAventieth year. The inhab- itants of cities are more liable than those in rural districts, though the air of agricultural regions intensifies the condition. Perfect immunity is enjoyed by the dAvellers in certain climates—chiefly mountainous and marine. Symptoms.—The symptoms are (et) local and (b) general. (a) Local.—Hay fever has an abrupt onset, and the attacks return annually at or about the same time. The invasion is marked by pro- nounced coryzal symptoms, with much sneezing, stoppage of the nasal passages, copious rhinorrhea, the discharge being thin and watery as a rule, and rarely mucopurulent. Suffusion of the eyes, with itching of the lids and free lacrymation are constant features; the decided itch- ing sensation of the palate and pharynx is also at times a very distress- ing symptom. The sense of smell may be lost, and taste and hearing are often impaired. The course as regards the local symptoms is marked by alternate amelioration and aggravation of the symptoms, the exacerbations being due to exposure to the open air, especially in changeable weather. Later the catarrhal process invades the bronchi, and cough and asthmatic seizures appear, these often becoming very distressing. (b) General disturbances are varied, and comprise subjective sensa- tions, such as anorexia, insomnia, lassitude, and chilliness alternating Avith slight feverishness. The course is usually run in from four to six weeks, and cases that occur in the early autumn are usually terminated speedily by the occur- rence of a decided frost. Diagnosis.—The recognition of hay asthma is unattended Avith difficulty, provided that such facts as the time of their occurrence and their annual periodicity are carefully noted. Prognosis.—This is favorable both as to life and length of days, though a permanent cure is among the rarest events in medicine unless permanent removal from the influence of the specific causes can be effected. Treatment.—Whenever possible the patient should travel till he finds a locality in which he ceases to suffer, and subsequently he should there spend the period of annual attack, and by these means escape the exciting causes. The Adirondacks and White Mountains usually bestow immunity. If the patient cannot make the necessary change, the gen- 470 DISEASES OF THE RESPIRATORY SYSTEM. eral nutrition is to be improved by the use of such measures as phos- phorus, strychnin, quinin, and arsenic. Much is to be gained, more- over, by hygienic means, especially avoidance of physical and mental overwork and the adoption of a proper mode of life. The local symptoms demand the topical application of various agents to the nasal chambers. A solution of cocain hydrochlorate (1 per cent.), applied directly to the nasal passages by means of a probe, around the end of which is loosely Avrapped a little absorbent cotton, affords tem- porary relief, and the period of palliation may be very much prolonged by using a 4 per cent, solution of antipyrin immediately after the cocain solution (Gleason). These applications should be made two or three times daily, according to the severity of the individual case. The local symptoms are also greatly benefited by the internal use of atropin, Avhich allays the irritability of the mucous membrane involved and diminishes the rhinorrhea, thus indirectly mitigating the constitutional disturbances and sometimes directly relieving the asthmatic paroxysms. When given internally the dose should not exceed gr. -^ (0.0002), to be repeated every hour till dryness of the throat appears. My own best results have been derived from the hypodermic use of this drug (gr. ^ro—6.0003) at intervals of three to four hours till the desired effect is produced. Thorough destruction of the vessels and sinuses is also advised (Osier). EPISTAXIS. {Nose-bleed.) Etiology.—The causes of nose-bleed are various, and a convenient grouping is the following: (a) Affections of the nasal mucosa (e.g. ulcer, polypi, intense hyperemia). (b) Injuries, either external, as from a blow, or internal, as from plugging with a foreign body, nose-picking, etc. In this category may also be included epistaxis due to fracture at the base of the skull, (c) Acute infectious fevers, particularly typhoid (at the onset) and influenza, (d) Chronic affections, such as pernicious anemia, leukemia, arteriosclerosis (with Avhich cardiac hypertrophy is associated); also the hemorrhagic diathesis or hemophilia, (e) Vica- rious menstruation. (/) Rarefaction of the air. (g) Plethora; here may be mentioned cerebro-congestion Avith intense headache, (h) Severe over-exertion. Symptoms.—Except when due to traumatism the blood usually drops slowly from one and occasionally from both nostrils. Rarely, the blood may Aoav as a continuous stream or the nares may present a pro- jecting coagulum. The blood may also gravitate into the pharynx and be coughed up, or it may be swalloAved and vomited. A rhinoscopic examination often reveals the source in cases in Avhich a previous diag- nosis of hemoptysis or hematemesis has been made. The immediate results of nose-bleed are Aveakness and a moderate anemia, but these are not prolonged unless the epistaxis be oft re- peated. Cases arising from fracture at the base of the skull will gen- erally prove fatal. DISEASES OF THE LARYNX. 471 Treatment.—A careful search for a local cause is especially de- manded in cases in which there are frequently recurring attacks. In most cases a spontaneous arrest occurs, but if not, a resort to simple household measures, such as the application of ice to the nose or to the back of the neck, holding the hands up, or the injection of very cold or very hot Avater into the nares, are to be encouraged. Various astrin- gents (tannic acid, acetate of lead, alum, zinc) may be employed, and a saturated solution of antipyrin is also highly praised. When an ulcerated bleeding point can be reached, there may be applied to it a solution of chromic acid or it may be cauterized by solid silver nitrate. Prolonged pressure applied upon the facial artery as it passes over the inferior maxilla may be efficacious. The late D. Hayes Agnew success- fully employed a bougie made of a long strip of the rind of bacon, " passing it through the nostril and allowing it to stay there some time." I have little confidence in internal astringent remedies, such as ergot, acetate of lead, or gallic acid, as a means of arresting nose-bleed. The oil of origanum, administered in large doses, has seemed to do good in a few of my own cases, but when the epistaxis tends to prove obsti- nate, the posterior nares should be plugged. II. DISEASES OF THE LARYNX. ACUTE CATARRHAL LARYNGITIS. {Acute Endolaryngitis.) Definition.—An acute catarrhal inflammation of the larynx, cha- racterized by cough, hoarseness, and painful deglutition. Pathology.—The anatomic changes present during life are all lacking post mortem. The laryngoscopic appearances will be given among the Clinical Symptoms. Etiology.—Acute laryngitis may be a primary affection—and par- ticularly laryngitis sicca (Molinie)—but oftener it is associated with and secondary to catarrh of the nose and nasopharynx. Wright attributes laryngitis sicca to the coccus of Lowenburg. Catarrhal laryngitis has for its chief direct causes traumatism, ex- posure to cold and dampness, the inhalation of irritating vapors or gases, rheumatism (rarely), and the corrosive effect of certain poisons and hot fluids. A certain degree of predisposition is engendered by immoderate smoking, particularly by the cigaret-habit, and by the use of concentrated alcoholic drinks. These agencies induce hyperemia of the laryngeal mucosa, which is easily converted into active inflammation. Acute laryngitis is often associated with acute infectious diseases. Symptoms.—There are two conspicuous symptoms—alteration in the voice (hoarseness) and cough. At first there is merely a huskiness of the voice, but later there may be pronounced hoarseness or even com- plete aphonia. The cough is dry and characteristically painful until secretion is free. In the early stages the patient complains of sensa- 472 DISEASES OF THE RESPIRATORY SYSTEM. tions of tickling or the presence of some small object in the larynx, causing a frequent desire to clear the throat. In severe instances deg- lutition is painful. Edema of the larynx may tend to supervene and cause intense dyspnea, Avith a feeling of distressing oppression. There is, as a rule, a slightly elevated temperature. Fig. 42.—Method of making a laryngoscopic examination. The patient is placed in front of the operator, on an arm-chair, with the back of the chair high enough to afford his head a comfortable rest, and with the source of the light over the right shoulder. The operator then adjusts the head-mirror (the fixed apparatus), warms the throat- mirror over a light sufficiently to prevent the moisture of the breath from being deposited upou it, and touches the hand with the mirror before passing it into the mouth, so as not to use it too hot. The patient's tongue is then protruded, and by means of a napkin is seized between the thumb and the fore-finger and drawn well forward to lay the fauces open to observation. The throat-mirror is then held in the right hand in the same way as one holds a pen. " Finally, it is introduced into the mouth, its handle being inclined downward and outward, its base being parallel with the dorsum of the tongue; it is then passed backward without altering this relation until the edge of the mirror nearly touches the soft palate, the shaft of the mirror in this move- ment striking the angle of the mouth as a resting-place and fulcrum. The subsequent movement consists in turning the mirror by twisting its shaft between the fingers until it is inclined at an angle of 43 degrees to the line of vision ; then it is carried backward and downward until the uvula rests upon its posterior surface, when it is lifted boldly upward and backward until ita lower edge comes entirely into view again and rests firmly against the posterior wall of the pha- rynx. The patient should then be directed to sound in a somewhat high key ' a,' which lifts the larynx and at the same time the epiglottis, and exposes and brings into view the laryngeal cavity" (Bosworth). It is important that the mirror itself should be kept in the median line, with its plane always at right angles with the field of vision, as shown in the illustration. In making a laryngoscopic examination we note any abnormalities of color-appearance (the natural being a rose-pinkish tint), of the outline of the different parts, and the deviations from the symmetrical movements of cords, if any, etc. The laryngeal mirror brings to view a characteristic picture—a swollen, tumefied, and reddened mucosa. These changes affect the vocal cords (whose pearly-white appearance is now lacking) and the ary- epiglottidean folds. It is usual to note also redness and SAvelling of the epiglottis above and of the trachea below. After secretion has occurred a mucoid covering in streaks or patches is noticeable. CHRONIC LARYNGITIS. 473 Diagnosis.—This is easy in the presence of marked hoarseness, dry cough, and the image afforded by the laryngeal mirror (Fig. 42). In very early life the larynx cannot be successfully examined ; still, laryngis- mus stridulus (oAving to the absence of fever, coryza, etc.) could hardly be mistaken, as has been supposed, for acute catarrhal laryngitis. The same is true of membranous laryngitis, if we bear in mind the charac- teristic local features and the more intense constitutional disturbances of the affection. Treatment.—The physician must enjoin against the use of the voice. The very young and the aged should, in severe or even moderate cases, be kept in bed, and should occupy a single apartment in which the at- mosphere is uniformly moist and warm, the temperature ranging from 75° to 80° F. (23.8°-26.6° C). Inhalations of moist air or steam are of great service, and I have long been in the habit of recommending the folloAving simple apparatus and method of carrying out this mode of treatment: An ordinary tin cup, small pitcher, or other vessel is filled Avith boiling Avater to which 1 or 2 drams (4.0-8.0) of the com- pound tincture of benzoin have been added; the steam is then collected by inverting over the vessel an ordinary funnel. The patient is alloAved to inhale the steam by placing the mouth over the narrow neck of the funnel above, or a piece of rubber tubing may be attached to the end of the funnel that is uppermost. Steam atomizers admirably meet the necessities of the case; and in the case of children the vapor of benzoin, eucalyptol, and other equally sedative and stimulating substances may be diffused in the air of the sick-room. Concentrated solutions or insufflations of powders are not Avithout harmful influence, and neither the cotton-carrier nor the mop should be allowed to enter the larynx in this affection. The external application of the ice-bag or cold compress tends to mitigate the inflam- matory process and to obviate spasm. The general treatment differs with the special stages of the com- plaint. If the case is seen early, a full dose of quinin (gr. xij-xvj— 0.777-1.036) may serve to successfully abort the attack, and, in con- junction Dover's powder (gr. v-x—0.324-0.648) may be prescribed. Codein sulphate may be given at prolonged intervals during the attack, and frequently at night, to allay cough; this remedy may be combined Avith ipecac, aconite, and liquor ammonii acetatis to facilitate secretion and render the cough humid. If we except the abortive measures, the constitutional is wholly inferior to the topical treatment of this variety, though the existence of any particular diathesis may require special in- ternal remedies. CHRONIC LARYNGITIS. (Chronic Endolaryngitis.) Pathology.—The laryngeal mucosa is thickened and somewhat reddened, and erosions amounting to superficial ulcerations are sometimes seen, though they are infrequent. A prominence of the mucous glands, especially of the ventricles and epiglottis, is noticeable. Fine villous 474 DISEASES OF THE RESPIRATORY SYSTEM. projections from, and nodular swellings in, the vocal cords are among the rarer morbid changes. Etiology.—Oft-repeated acute attacks frequently cause chronic laryngitis, and the long-continued use of the voice (as in public speak- ing or singing), the inhalation of an atmosphere laden Avith mildly irri- tating impurities (tobacco smoke, etc.), and an immoderate indulgence in alcoholic stimulants, respectively or unitedly, predispose to, if they do not excite, the disorder. Symptoms.—As in the acute form, hoarseness and cough are the two especially prominent symptoms. The former may be so slight as to present merely a rough tone, or it may involve an almost total loss of voice. The cough shows similar variations in severity, sometimes con- sisting of a short hack, and again occurring in spasmodic and ringing paroxysms, due to a sense of tickling in the larynx. There may be a small amount of mucous or muco-purulent expectoration, but for pro- longed periods the cough may be dry and ineffectual. Local pain and discomfort sometimes supervene, and are excited generally by attempts at speaking or singing—events that aggravate all the other symptoms. To complete the diagnosis, the laryngeal mirror is required to show a swollen and slightly red membrane, with a distention of the mucous glands in the immediate vicinity of the epiglottis and ventricles, and occasionally superficial erosions. Prognosis.—This is unpromising as to complete recovery, although it presents no grave dangers. It is incurable in those instances in which the causal influences cannot be removed, and in all cases in which the patient fails to lend hearty co-operation. Treatment.—This is (a) hygienic and (b) medicinal, (a) The sani- tary measures embrace preventives that are directed to the removal of all the etiologic factors, whether merely predisposing or exciting. The voice demands rest and the prohibition of smoking and the use of alco- holics in excess, and the patient must also avoid the close, contaminated air of the crowded hall, theatre, and like places. In addition, a tonic regimen, with a view to energizing the nutritive processes, is to be en- couraged. In many instances the environment is best arranged with reference to the commonly associated conditions—especially the morbid processes in the nasal and naso-pharyngeal cavities. " A sea-voyage or residence at the sea-shore is, in the large majority of instances, pro- ductive of good, and the effects of surf-bathing are often magic" (Mackenzie). My own practice has been to send subjects of chronic laryngitis to pine-forest resorts at low elevations that afford a pure, equable, and somewhat stimulating atmosphere, and I have found that in many cases the selection of a proper climate constitutes the most im- portant part of the treatment, (b) The medicinal treatment is both local and general. The latter should include creasote, cod-liver oil, and other tonics. Expectorants are of little if any value. The local meas- ures, however, are important. Moderate exposure of the neck and daily ablution with cold water are to be advised, and attention to the nose and naso-pharyngeal cavity is of prime importance.1 A long list of applications to the larynx from Avithin, including local astringents, disinfectants, and alcoholics, might be enumerated. Of 1 J. C. Wilson's American Text-book of Applied Therapeutics, p. 791. SPASMODIC LARYNGITIS. 475 astringent solutions, however, the best are tannic acid (1-2 per cent.) or alum (.5-1 per cent.) and zinc sulphate (3-5 per cent.). These may be sprayed into the larynx by means of a compressed-air machine with spraying-tubes, although all of the different kinds of inhaling apparatus more commonly used will ansAver the purpose. If the ordinary hand- atomizer be used, the patient should be taught to draw the vapor into the larynx by gentle and frequent acts of respiration. Disinfectants, such as creasote, potassium chlorate (the latter if ulcerations be present) in solutions of suitable strength, may be used in like manner. I can confidently advise as useful alteratives both iodin and silver nitrate, commencing with a Aveak solution of the latter (gr. v-3j—0.324-4.0), and the strength being gradually increased until the maximum strength that can be endured Avithout distress is reached (gr. xx-3ij—1.296-8.0). These topical applications should be made directly Avith a cotton-carrier or brush at intervals of three or four days, preceded by the use of a cleansing spray. Many astringent and sedative lozenges are to be found in the market, but they are only slightly palliative in their effects, and their prolonged use tends to excite gastric disturbance. I am unalter- ably opposed to the insufflation of poAvders, believing that they are capable of augmenting the laryngeal irritation and of adding fresh irritation in adjacent parts, particularly in the tracheo-bronchial tract. SPASMODIC LARYNGITIS. {Laryngismus Stridulus; False Croup.) Definition.—An affection peculiar to children, chiefly of nervous origin, though also, according to Striimpell and others, often associated Avith acute catarrhal laryngitis. Etiology.—The affection is almost solely limited to children be- tAveen six months and five or more years of age. It is sometimes ex- cited by strong passion or emotion, and it may be associated with tetany. Rachitic subjects are peculiarly liable. The causes of spasmodic croup are in great part those of acute laryngitis. The mode of action of the direct causes is unknown, but the spasm of the adductors that causes the urgent dyspnea is probably reflex and due to peripheral irritation. Symptoms.—Two clinical varieties are to be distinguished: (1) that in Avhich the larynx is free from catarrhal inflammation, or the purely nervous type. This is especially characterized by sudden brief attacks of dyspnea, either by day or night (often on aAvakening), that terminate in a high-pitched crowing inspiration (" child-croAving"). The face during the spasm is cyanotic. General convulsions have been noted, but there is neither cough, fever, nor hoarseness. The attacks may be frequently repeated within a single day. (2) Spasm of the larynx, associated with mild catarrhal laryngitis. The attacks generally begin suddenly, about midnight or toward morn- ing on awakening from a sound sleep. Positive evidence of the affection is afforded by the croupy, ringing cough, combined Avith the hard, strid- ulus breathing. An approaching spasm may be announced by a harsh 476 DISEASES OF THE RESPIRATORY SYSTEM. cough and slightly stridulous breathing in the sleeping child. During the attack the countenance may be cyanotic and the breathing most dis- tressing, but these and the above-mentioned severer symptoms generally cease abruptly in an hour or two, and the child resumes its slumber. In my experience the attacks have been repeated for two or three nights in succession, and rarely oftener except in the severest cases. Not infre- quently the child manifests the symptoms of mild catarrhal laryngitis between the attacks. A brassy, croupy cough may also attend. Diagnosis.—Membranous laryngitis may be mistaken for spasmodic croup. The development of the dyspnea, however, is more gradual, is without intermission, and without relation to the period of the day. Albuminuria and a false membrane in the throat or nares are usually present in laryngeal diphtheria. Prognosis.—Although the appearance of a paroxysm is alarming, the disease is practically free from danger. Treatment.—1. The treatment of laryngismus stridulus is quite similar to that of infantile convulsions. A warm bath at a temperature Fig. 43.—Croup-kettle in use. Four upright rods (5.7 inches in length) are fastened to the legs of the bedstead by a wire or string. Two side-rods are tied on the uprights, and two end-rods (length dependent on width of bed) rest upon the side-rods, These rods form a complete framework for the sheets to hang upon. Four sheets are required (11-4 size)—three to cover the ends and sides, and one to be placed on top. One side should be completely closed, while the opposite is to be left open for ventilation or to be adjusted according to Circumstances. of 98° to 105° F. (36.4°-40.5° C.) is the best means of breaking up the spasm. While in the bath cold sponging of the back and chest is ser- viceable. The finger may be passed into the fauces, and should the epiglottis "become wedged in the chink of the glottis, it must be re- leased by the finger." After the attack active treatment should be di- rected at the discoverable causes, and I have been in the habit of giving TUMORS OF THE LARYNX. 477 small doses of the bromids thrice daily, together with warm cod-liver oil inunctions, with striking^ effect. 2. In spasmodic croup an emetic is to be given at once, the best be- ing a mixture of alum and syrup of ipecac, of which the dose is 3j (4.0), to be followed by irritation of the fauces with the finger in order to facilitate emesis. In severe paroxysms a hot bath may be given to aid the emetic. In case the dyspnea is not checked by the above meas- ures, chloral hydrate may be exhibited by enema (gr. ij-v; 0.129- 0.324) or a Avhiff of chloroform may be given. The local application of cold (ice-collar, ice-water cloths) is useful, and sinapisms placed around the throat and over the chest also tend to arrest the spasm. I am con- vinced that the use of steam-inhalations from the so-called croup-kettle (Fig. 43) is of signal service, and should be more Avidely employed, particularly when it is inconvenient to use the hot-bath. Between the paroxysms the patient should receive a mild laxative, such as calomel or castor oil, and, in addition, the treatment appro- priate in acute catarrhal laryngitis. To prevent recurrences an envi- ronment calculated to increase the nervous tone of the child is to be pro- cured, and it is especially advisable to accustom him to the outer air, though protected by suitable dress and without undue exposure to draughts. TUMORS OF THE LARYNX. These may be either benign (fibroma, myxoma, lipoma, chondroma, adenoma, angioma, cyst) or malignant (sarcoma, carcinoma). Of these, fibroma occurs most frequently, and with an especial frequency in in- fancy. Navratill records 42 cases of multiple laryngeal papilloma in children Avhose larynges were extensively filled. These groAvths may also occur in chronic laryngitis, and, like other tumors of the larynx, they commonly spring from the vocal cords. Their shape, size, and tendency to pedunculation do not differ from their characteristics when noted else- where in the body. Symptoms.—Small tumors may occupy the larynx without produ- cing symptoms. The first feature then noted is hoarseness, which gradu- ally grows worse and may end in complete aphonia. If situated in the upper larynx, cough is common, and when the tumor causes obstruction of the larynx dyspnea supervenes and tends to increase in severity. A mobile growth may cause sudden occlusion of the glottis, exciting orthopnea and threatening asphyxiation. To confirm the diagnosis a laryngoscopic examination is required. The prognosis is favorable in the benign, but unfavorable in the malignant forms. Treatment.—This is altogether surgical, though Delavan states that 3 cases of papilloma have been cured by frequently repeated sprays of absolute alcohol. Curetting is often followed by a recurrence, while laryngo-fissure and thorough removal of the growths restore speech and prevent recurrence. 1 Berl. klin., Woch., Mar. 9, 1896. 478 DISEASES OF THE RESPIRATORY SYSTEM. EDEMA OP THE LARYNX. Definition.—An infiltration of the mucous membrane of the larynx Avith serum, affecting mainly the region of the epiglottis and of the ary- epiglottic folds. Etiology.—Two chief classes of causes are operative: (1) Those that excite inflammation. The condition may complicate acute laryn- gitis, though oftener it appears in chronic affections of the larynx, and particularly if ulceration be associated (e. g. tuberculosis, syphilis); it may also appear in connection with certain infectious diseases, such as erysipelas or diphtheria. The inflammation inducing the edema may extend from adjacent parts, as the neck, pharynx, and other organs. (2) Factors that tend to excite dropsical effusion. These may be gen- eral, as Bright's disease, which may cause a quickly developing edema of the lungs, heart-affections, etc.; or they may be local. Among the latter are enlargements of the cervical and mediastinal lymphatics, aneurysm of the arch of the aorta, thyroid tumors, etc.—i. e. conditions that exercise pressure upon the jugular veins. Symptoms.—In acute cases the initial disturbance is both sudden and severe. There is dyspnea that tends to increase rapidly, accompa- nied by a husky, suppressed voice, with augmenting obstruction. The respiration may become stridulous, but there is no cough. The laryn- goscope reveals marked SAvelling of the epiglottis and of the ary-epi- glottic folds, and rarely the swelling occurs in or even wholly beloAv the vocal cords. The inserted finger may detect the swollen epiglottis, which may also be seen if the tongue-depressor be used. Diagnosis.—This can be made with ease from the rapidly develop- ing dyspnea soon reaching the climax, the absence of cough and hoarse- ness, and by the use of the laryngoscope. In cases in Avhich the epi- glottis can be felt or seen a laryngoscopic examination is superfluous. The prognosis is decidedly unfavorable except in the event of early operative interference. Treatment.—If of inflammatory origin, the ice-bag should be ap- plied to the larynx, and ice should be allowed to constantly dissolve in the patient's mouth. Local depletion, preferably by leeching the front of the neck, is also to be tried, and Levy and Laurens1 record a case in Avhich a cure followed this measure. If intense dyspnea tends to per- sist, scarification of the edematous parts Avith a curved bistoury, the point of which is covered with adhesive plaster, must be promptly insti- tuted, and, if asphyxia threatens, tracheotomy must immediately be per- formed. Dropsical edema demands scarification, and, if relief does not follow, tracheotomy. III. DISEASES OF THE BRONCHI. CATARRHAL BRONCHITIS. (Tracheo-bronchitis.) Definition.—A catarrhal inflammation of a part or the whole of the mucous membrane of the bronchial tubes. The mucosa of the 1 Arch. gen. de. Med., Dec, 1895. ACUTE BRONCHITIS. 479 trachea is also involved to a greater or lesser extent, and hence the term tracheo-bronchitis is quite appropriate, being descriptive of the seat and character of the disease. Involvement of the bronchioles may also take place, but this does not occur Avithout an involvement of the correspond- ing alveolar structure, the condition being then, Avith propriety, termed "broncho-pneumonia." Hence the term " capillary bronchitis," wliich is still often employed to describe the latter condition, is not pertinent. A certain class of cases is met Avith, hoAvever, in which the catarrhal inflammation, as the result of dowmvard extension, implicates the smaller bronchial tubes without involving the bronchioles ; to such the term " capillary bronchitis " might be appropriately given. The disease may be acute or chronic, both of these forms occurring either as a primary or secondary affection. ACUTE BRONCHITIS. Pathology.—The portions of the mucous membrane of the trachea and bronchi that are implicated become reddened and swollen; they are covered with mucus and mingled Avith epithelial cells, and later muco- pus. Some of the smaller bronchial tubes are dilated. The mucous glands are swollen. The histological changes may be briefly stated as follows : desquama- tion of the ciliated epithelium, edema and SAvelling of the submucosa, and, in the severer grades, infiltration of the latter with leukocytes. Etiology.—With rare exceptions tracheo-bronchitis is produced by the direct extension of a catarrhal inflammation from the nares, phar- ynx, and larynx. Rarely the bronchi are the seat of primary acute catarrh, and in some of the latter instances the upper air-passages are implicated secondarily, constituting a reversal of the usual direction of extension above referred to. The immediate causes are mechanical, chemical, and biological irri- tants, which act directly upon the tracheo-bronchial mucosa; and that bronchitis is frequently due to infection at a time when the resisting poAver of the system is reduced there can be little doubt. The circum- stances disposing to bronchitis are numerous, those pertaining to the in- dividual being—(1) Age, the old and very young being most liable ; (2) Debility; (3) Occupation, as in certain trades that expose to irritating vapors. Among the external conditions are—(1) Climatic factors, par- ticularly variability of temperature and humidity; (2) Seasons of the year. " Catching cold " often results from exposure during the spring and autumn months, Avhen the meteorological elements, humidity and temperature, exhibit greatest variability. These two conditions depend substantially upon the same factors. Acute tracheo-bronchitis arises as a secondary condition in a great variety of diseases, as, for example, the exanthemata and other acute infectious diseases. As shown elsewhere, in certain instances among this large class of diseases the bronchitis is dependent upon the primary infectious process, but in many others it is due either to the inhalation of pathogenic irritants from the throat and higher air-passages or to the retention of bronchial secretions that are apt to accumulate and decom- pose with resulting bronchitis. The accidental inhalation of particles 480 DISEASES OF THE RESPIRATORY SYSTEM. of food and saliva may also lead to secondary bronchitis, or the condi- tion may be secondary to chronic affections (e. g. Bright's disease, chronic valvular disease of the heart). Symptoms.—Bronchitis of the larger tubes, which extends down to about the second division of the bronchi, is spoken of usually as a " cold." In such cases the onset is marked by recurring sensations of chilliness and by coryza, slight sore throat, and hoarseness, while in young and feeble children convulsions may occur early. Mild febrile symp- toms may appear, the temperature ranging from 101° to 103° F. (38.3 -39.4° C.), with slight acceleration of the pulse, and there may be aching in the limbs and lumbar region. With the fully-developed attack substernal soreness, sometimes amounting to pain, is experienced, especially on coughing, and the pain may be referred to the intercostal muscles and the line of insertion of the diaphragm. The respirations are increased in frequency, but there is no dyspnea. There may be thoracic oppression and discomfort until the bronchial secretions become free, and there is a cough which is at first dry and hard. It often man- ifests itself in longer or shorter paroxysms, particularly on lying down and on rising after a full night's sleep. At the end of one, tAvo, or more days the cough is moist and attended Avith an expectoration Avhich is at first mucoid and scanty, then muco-purulent and free ; later still it is sometimes distinctly purulent. With free expectoration comes relief to the patient. Histologically, the sputum consists mainly of pus-corpuscles Avith large cells, in which may be seen the so-called my- elin droplets of Virchow and carbon particles. Physical Signs.—Upon laryngoscopic examination the mucous mem- brane of the larynx and trachea may be seen to be reddened and cov- ered by more or less secretion. Inspection and palpation of the chest are negative, except when the finer tubes become implicated or fever is present, in which case the res- pirations may be observed to be slightly accelerated. In children the increased rapidity of the respirations is more common and reaches a higher degree. Bronchial fremitus may sometimes be felt. Percussion yields negative results, save in very rare instances, in Avhich there occurs a decided accumulation of secretion in the tubes, when there may be found impairment of resonance posteriorly below the scapula?. Auscultation usually renders audible a harsh respiratory murmur, and less frequently piping, sibilant, and sonorous rales. In the advanced stage large and medium-sized mucous rales are frequently present, but are by no means ahvays discernible. The rales appear in different seats from time to time, and after coughing may altogether disappear, but only to reappear later. The prognosis varies with the previous constitutional state of the individual. In healthy adults, after a period ranging from a feAV days to two weeks, the fever subsides, but the cough, though less marked, and the expectoration usually continue for a variable length of time. In old persons and in those greatly debilitated, as well as in those of a gouty or tuberculous diathesis, the cases pursue a more protracted course. There is also in these subjects a tendency on the part of the catarrhal process to extend downAvard until the finer tubes are impli- cated. Under these circumstances life may be endangered, and even, ACUTE BRONCHITIS. 481 rarely, terminated. In the old and very young the bronchial secretions are imperfectly expectorated, hence they gravitate to the most depend- ent parts, and tend to induce bronchiectasis. In young children this doAvnward extension of the affection, with resulting broncho-pneumonia and areas of collapse in consequence of dilatation and occlusion of the bronchioles by muco-pus, is a not uncommon and serious event. The diagnosis is reached Avithout difficulty through the symptoms (slight fever, cough, and expectoration), the acute course, and the physi- cal signs (harsh respiratory murmur, dry folloAved by moist rales, heard on both sides of the chest). The recognition of the long list of cases that constitute the secondary forms Avill be made easily possible by noting the circumstances under Avhich they arise. Differential Diagnosis.—Bronchitis can readily be separated from pneumonia and from pleurisy with effusion by its history, by its lighter course, and by the different character and general distribution of the physical signs, especially by the absence of the signs of effusion and consolidation. When broncho-pneumonia develops in the course of bronchitis, dys- pnea and fever are increased and the general condition becomes much more grave. There are small patches that yield dulness on percussion, and broncho-vesicular breathing Avith moist rales can be detected on auscultation. Bronchitis cannot be separated from the early stage of whooping- cough, but Avhen the characteristic cough of the latter is heard all doubt vanishes. The bronchitis of measles before the characteristic eruption appears is distinguished by the red spots upon the anterior half-arches of the soft palate. Localized tuberculosis of the lung and acute miliary tuberculosis are apt to be confounded Avith bronchitis. The points of difference have been given in the discussion of the former diseases. Treatment.—Xot infrequently a "cold " passes through its several stages Avithout rendering the patient ill enough to cause him to seek the advice of a physician, and there are many instances in Avhich but little treatment is required, apart from the usual household measures and pro- tection against cold and damp. If seen early, while the coryza is pres- ent, the attack may often be aborted by the use at bedtime of a Dover's powder in combination Avith quinin (gr. iv-viij—0.259-0.518); this may be seconded by a glass of hot lemonade, Avith or Avithout a portion of whiskey, and either a hot bath or a mustard foot-bath. The folloAv- ing morning a saline laxative should be taken. To children a mild calomel purge folloAved by a dose of castor oil may be administered. The patient should be kept in a Avarm, moist, equable atmosphere— preferably in-doors—and during this period he should take divided doses of quinin for a day or two. If the above mode of treatment fail or if the patient does not come under observation early, the main objects of treatment should be (a) to render the secretions free, and (b) to hasten the expulsion of the sputum after it has been loosened. The first leading indication is to be met by the use of diaphoretics, diuretics, and relaxants. The subjoined formula combines these classes of agents, and Avill be found to be highly serviceable: 31 482 DISEASES OF THE RESPIRATORY SYSTEM. B/. Potassii citrat., 3yj (23.3); Liq. ammonii acetat., §v (148.0); Spt. geth. nit., 3j (30.0); Vini ipecac, 3ij (2.0); Syr. pruni virg., q. s. ad gviij (236.0).—M. Sig. ,§ss (2.0) in Avater every tAvo hours until the secretions are loosened. If the temperature in any given case be maintained at a consid- erable elevation, such as 102°-103° F. (38.8°-39.4° C.) or over, tinc- ture of aconite (TTLxvj—1.065) may be added to the above mixture; and if there be present much tickling with distressing cough, due to irrita- bility of the affected mucosa, codein (gr. ij-iij—0.129-0.194) may be added to the same. For the incessant irritative cough which is present in severe forms of catarrh opium alone is really effective. When the above prescription is not productive of free secretion and troublesome cough continues, I employ the folloAving : B/. Ammon. muriat., 3v (20.0); Codeinge, gr. iv-vj (0.259-0.388); Spt. junip. co., Iss (16.0); Mist, glycyrrh. comp., ^iiss (80.0); Syr. pruni virg., q. s. ad siv (120.0).—M. Sig. 3j (4.0) every two hours. Apomorphin is also excellent as a soothing relaxant in doses of gr. To t° to (0-003 to 0.006) every two hours. Mild counter-irritation by means of mustard-paste, folioAved by the application of iodin once daily, is also helpful. The patient should keep to his room, in Avhich the at- mosphere should be kept moist and of even temperature. The expul- sion of the sputum may demand stimulating expectorants, though rarely. It is to be recollected that Avhen the tracheal secretion becomes copious the period of convalescence is usually reached, and stimulating expec- torants are then entirely unnecessary. When, on the other hand, the cough is no longer dry, and on auscultation the rales are found to be moist, and whilst, at the same time, the expectoration is expelled with difficulty, or if the bronchitis tends to become chronic, then such stim- ulating expectorants as senega, squills, and ammonium muriate are to be employed. In cases in which expectoration continues to be too abundant terebene, tar syrup, and oil of sandal are to be resorted to, the choice of the special remedy being governed by the requirements of the individual instance. Debility and secondary anemia must be speedily overcome by exhib- iting quinin, bitter tonics, iron, and arsenic, and a suitable change of air often yields prompt and excellent results in protracted cases. The treatment of the various forms of secondary bronchitis will be consid- ered in their appropriate connections in this Avork. Apart from the method above given, of attempting to abort the attack in children, acute bronchitis is in the main to be treated in the same manner as Avhen it occurs in the adult. Opium, however, is to be used very sparingly, and generally in the form of paregoric. If the secretion is abundant and imperfectly raised, it is well to administer an CHRONIC BRONCHITIS. 483 emetic, such as the Avine of ipecac (3ss-j—2.0-4.0), and repeat in ten minutes if necessary. If dyspnea be urgent and cyanosis be marked in the lips and finger-tips, a prompt emetic is then imperative in order to save life. A child suffering from acute bronchitis should be kept in bed until the fever subsides. The diet during the dry stage should consist of liquid forms of nour- ishment, which should, for the greater part, be taken hot. After the " cold " has been loosened solid food should be resumed. CHRONIC BRONCHITIS. Pathology.—The lesions of chronic bronchitis manifest considerable variety both as regards their nature and extent. The epithelial layer is, in great part, missing, and sometimes the mucous membrane is quite thin. In consequence the longitudinal elastic fibers appear unduly prominent. The mucous glands and the muscular coat undergo atro- phy in long-standing cases, and the bronchial tubes are dilated (bron- chiectasis). In another large group of cases the mucosa is irregularly thickened or infiltrated and granular. Small ulcers corresponding to the mucous follicles are common, and almost constantly emphysema develops in consequence of secondary changes in the vesicular structure. Etiology.—Chronic bronchitis may either be primary or secondary. The affection is, hoAvever, almost always a secondary one, and, though sometimes the result of repeated attacks of acute bronchitis, it is much more frequently caused by certain chronic complaints and certain diath- eses, such as chronic alcoholism, rheumatism, gout, syphilis, pulmonary tuberculosis, pulmonary emphysema, organic valvular affections of the heart, and chronic Bright's disease. The primary form, Avhich is rare, is the result of exposure to wet or cold or to the daily inhalation of some irritant that produces and maintains a Ioav grade of catarrhal in- flammation (dust, vapors). When chronic bronchitis folloAvs the acute form, we are often able to detect the operation of some favoring cause, as age, climate, and season. It is most common in the aged, though younger persons occasionally suffer, and it occurs by preference during the cold season, often recurring regularly in the cold and variable Aveather of autumn, winter, and spring, and disappearing in summer. Symptoms.—The symptoms are similar to those of acute bron- chitis, though rather less severe. Pain is rarely present, the patient complaining merely of a feeling of substernal constriction. There may be soreness at the base of the chest if the cough be frequent and severe, and occasionally in the epigastrium as a result of traction of the dia- phragm on the ribs. Cough is not a constant accompaniment, hoAvever, but is paroxysmal and varies in severity and frequency. The degree of the violence of the paroxysm depends upon tAvo factors—the charac- ter of the bronchial secretion and the seat of the catarrhal inflammation. Thus Avhen the expectoration is tenacious and small in quantity, and Avhen the small-sized tubes are affected, cough is most violent. It also A'aries both Avith the weather and the season, as is evident from the fact that there is often an absence of cough in summer, Avhile it returns un- failingly with each winter. 484 DISEASES OF THE RESPIRATORY SYSTEM. The expectoration differs Avidely in different cases. It is sometimes abundant and sero-mucous in character. On the other hand, there are cases of dry cough in which there is little or no expectoration. As a rule, however, it is rather copious, and either muco-purulent or dis- tinctly purulent in character. Fever is usually absent, though there may rarely occur a slight exacerbation at night. The appetite remains good as a rule; the bodily Aveight is also Avell maintained, and the nutrition may manifest little or no impairment. Physical Signs.—On inspection we usually note undue enlargement of the thorax, with a decrease in expansile movements that is due to the associated emphysema. The dyspnea observed is due either to the same cause or to associated asthma. Percussion yields a clear or hyperresonant note. Dulness or im- paired resonance is sometimes met Avith, however, during acute exacer- bations, and especially over the bases, and is due to congestion and edema (Fox). On auscultation rhonchi of various forms and moist rales are heard, their number and size being in proportion to the extent of the swelling of the mucous membrane and the amount and fluidity of the secretory products. The respiratory murmur is somewhat enfeebled, though roughened, and the expiratory sound is prolonged and wheezy. Clinical Varieties.—Special forms, depending largely upon spe- cific causal factors, remain to be described: 1. The commonest variety of chronic bronchitis has been called the " winter cough of the aged," and, as before intimated, is usually accom- panied by emphysema and cardiac disease. For this form the gouty diathesis is often responsible. The cough occurs in paroxysms that are most severe at night, and during the early morning hours it is attended with free expectoration of the secretion that has accumulated during the night. 2. Bronchorrhea.—In this form there may be an abundant bronchial secretion, composed largely of serum (bronchorrhoea serosa), but more frequently perhaps the expectoration is purulent and thin, containing greenish or greenish-yelloAV masses. It may at times be thick and puru- lent. Dilatation of the tubes and resulting fetid bronchitis may be de- veloped as secondary conditions. 3. Fetid Bronchitis.—In this variety the expectoration emits the characteristic odor of decomposing animal substances. The fetor may indicate gangrene of the lungs, abscesses, bronchiectasis, decomposition of matter within phthisical cavities,, or empyema with perforation of the lung. It may, however, occur independently of the above-mentioned conditions, and hence these must be carefully excluded before the diag- nosis of true fetid bronchitis is made. In the latter disease the expec- toration is usually copious, and on standing separates into three layers, of which the uppermost is composed of frothy mucus, the intermediate of a serous liquid, and the lowest of a thick sediment, that presents a granular appearance and is made up chiefly of small yellow masses—the so-called Dittrich's plugs. These plugs are characteristic of fetid bron- chitis, and are the cause of the fetor. On microscopic examination the Dittrich's plugs are seen to be composed of micro-organisms, chief among which is the Leptothrix pulmonalis; they may also contain pus- corpuscles, fat-granules, and crystals of margarin. CHRONIC BRONCHITIS. 485 The condition may be a grave one, and associated with it may be observed ulceration of the bronchial tubes, with dilatation, pneumonia, abscess, gangrene, and rarely metastatic cerebral abscesses. When putrefactive changes take place in the bronchial secretion in the course of chronic bronchitis a new group of symptoms, as a rule, immediately appears. This comprises rigors that occur at irregular intervals and are associated with high fever and increased prostration. Cough and pain in the chest also become aggravated, but these acute symptoms may shortly subside and the usual course of chronic bronchitis be resumed. Even under the latter conditions fetor of the breath and sputum may persist. 4. Dry Catarrh.—The cough is both severe and paroxysmal, and there is little or no expectoration. When expectoration is present the sputum is very tenacious and is expelled with great difficulty. An asthmatic disposition is sometimes noticeable in this variety, and emphys- ema is commonly associated. The dry condition of the bronchial mu- cosa is evidenced by sibilant and sonorous rales. This form occurs in old persons, as a rule. 5. Osier has described a form of chronic bronchitis that occurs* most frequently in Avomen, and dates its onset from a comparatively early period of life. It does not undermine the general health. The cough is most pronounced in the morning, and is accompanied by a rela- tively small amount of muco-purulent expectoration (§iv-vj—120.0- 178.0 daily). An examination of the chest yields negative results. The etiology is as yet uncertain, although the condition seems to proceed from a gouty or tuberculous diathesis in some instances. I have had under observation for several years a young woman, noAv aged tAventy- eight, who has from time to time during the last five years suffered from eczema of the face, and in the intervals, when not afflicted with this dis- ease, has manifested the symptoms of the form of chronic bronchitis under discussion. She comes of arthritic stock. Diagnosis.—The diagnosis of chronic bronchitis is rarely difficult. Since it is usually a secondary condition, it is of the utmost importance to determine the nature of the primary affection. An examination of the heart and of the urine should not be overlooked. Pulmonary tuberculosis is to be discriminated from chronic bronchi- tis, and the distinctive points are—(1) A clear tuberculous history. In phthisis there are fever and loss of flesh and strength, while in chronic bronchitis fever is absent and the general health is not impaired. (2) In pulmonary tuberculosis the signs of localized consolidation (usually at one or other apex) appear early, while in chronic bronchitis the vesic- ular structure is not imrolved. (3) In phthisis the sputum, when examined microscopically, shoAvs the presence of the tubercle bacillus. In acute pulmonary tuberculosis the fever, dyspnea, cyanosis, and in- creased prostration constitute a group of features that should serve to avert the danger of its being confounded with chronic bronchitis. Co- existing pulmonary emphysema is to be recognized by the characteristic symptoms and signs of this complaint. Primary fetid bronchitis must be differentiated, as must also the other conditions previously mentioned, in which the breath as well as the sputum may emit the characteristic fetor. In abscess of the lung the sputum contains shreds of lung- tissue, including elastic fibers, crystals of hematoidin, cholesterin, and 486 DISEASES OF THE RESPIRATORY SYSTEM. amorphous blood-pigment; usually localized dulness and broncho-cav- ernous breathing coexist. In gangrene there are contained in the spu- tum shreds of lung-tissue, but separate elastic fibers are often absent, on account of the presence of a ferment that causes a solution of the elastic tissue (v. Jaksch). Bronchiectasis is usually unilateral, and gives rise to areas of dulness and other physical signs that are confined to limited areas, while in chronic bronchitis the signs are general. Prognosis.—Recovery is the exception, though improvement may frequently be observed. The course of chronic bronchitis is exceedingly protracted, and the danger from the late development of certain compli- cations and sequels, such as emphysema or right-sided cardiac disease, must be constantly borne in mind. Since the disease is generally a secondary affection, the prognosis in most instances depends upon the outlook in the primary disease. Treatment.—The treatment falls naturally under tAvo main heads —(1) Hygienic, and (2) Medicinal. 1. Hygienic.—This has reference, frequently, to the removal of various noxious influences. When the patient cannot make a suitable change of air during the cold season, he must keep his room during in- clement weather; he should, however, be alloAved to spend as much time as possible in the open air during clear and pleasant Aveather. The vitiated atmosphere of saloons or public halls is to be avoided. The patient should be carefully clad; he should Avear flannels next the skin during all seasons of the year, but his outer clothing need not be unu- sually cumbersome. If the case be of an aggravated type and the cir- cumstances of the patient permit, he should be sent to a warm latitude in the autumn, in order thus to escape the effects of a severe northern Avinter. It is an excellent rule to send patients in whom the bronchial secretions are abundant to a dry, wTarm climate or to a region Avhose atmosphere is impregnated with the balsamic vapors of the pine. On the other hand, patients with dry bronchial catarrh are most relieved by an equable, moist, warm climate. Among suitable resorts, those that should be mentioned are the Riviera, Cannes, San Remo, Sicily, and Algiers abroad, and Florida, Southern Georgia, and Southern California at home. Change of air becomes not only a means of relief, but also an effective means of prevention if resorted to at the proper time. Prophylaxis also includes the removal of any diseased conditions that are causally related. The coexistence of cardiac disease, the gouty diathesis, albuminuria, etc.'call for the primary treatment of these conditions. The diet should be generous, but not stimulating, and articles easy of digestion should be selected. Wines and liquors are to be avoided unless special indications for their use exist. Special conditions, how- ever (e. g. albuminuria), may render necessary a special dietary. 2. Medicinal.—In this disease medicines are palliative in their effects rather than curative. Relaxing expectorants are to be avoided, owing to their depressing action, and the stimulating expectorants are, in a majority of cases, not only valueless, but hurtful, since they are liable to lessen the appetite and disorder the digestion. When, hoAvever, the sputum is muco-purulent in character and is dislodged Avith difficulty, expectorants of this class (squills, senega, ammonium muriate) may be BR ONCHIECTA SIS. 187 tried. I have obtained good results from the use of the folioAving in cases attended Avith severe paroxysms of cough : R>. 01. eucalypti, Sjss-siij (6.0-12.0); Codeine, gr. vj (0.388). M. et ft. capsulte No. xviij. Sig. One every four hours, as required. Occasionally potassium iodid exerts a curative influence, but its use may be limited to cases that are due to the syphilitic, rheumatic, and gouty diatheses. Five or ten grains of the iodid four times daily may be exhibited, and should there be present a syphilitic taint the remedy should be pushed to the limit of tolerance. The balsam of copaiba is sometimes efficacious, several instances in my OAvn experience having yielded to the following combination: B/. Balsami copaibae, 3J~3ij (4.0-8.0); Ammon. muriat., 3ij (8.0); Extr. glycyrrh. pulv., 3j (1-6). Mist, ammoniaci, q. s. ad fsiij (96.0).—M. Sig. 3ij (8.0) every four hours. Other remedies that possess great value in certain cases are creasote (in ascending doses), turpentine, terebene, tar, the balsams of tolu and Peru, and sandal-wood. II. C. Wood praises sulphuretted hydrogen in cases in which there is profuse expectoration : " From two to four ounces of the saturated watery solution may be administered by the mouth four or five times a day or until the breath has a perceptible odor." If the vital poAvers are poor, bitter tonics, as iron, quinin, and strychnin, and other measures calculated to invigorate the system, are indicated. When the sputum is excessive in amount, astringents (zinc sulphate and oxid) are sometimes useful. Astringents may also be used Avith advantage in the form of a spray Avhen the expectoration is too free. On the other hand, sprays from properly selected solutions (e. g. am- monium muriate, gr. v-x ad §j—0.324-0.648 ad 32.0) are valuable in assisting expectoration. In fetid bronchitis sprays of antiseptic solu- tions are to be used, and the folloAving will be found serviceable : B>. Acidi carbolici, gr. ij-iv (0.129-0.259); Olei eucalypti, TT1 ij-iv (0.133-0.266); Aquae, Ij (32.0). Sig. To be inhaled from a steam- or hand-atomizer three or four times daily. Pneumato-therapy has given brilliant results in certain instances, and more particularly in those of asthma and emphysema. BRONCHIECTASIS. Definition.—The universal or circumscribed dilatation of the bron- chial tubes. Pathology.—Two main forms are recognized—the cylindrical or simple, and the saccular, and both of these may be met with in the same 488 DISEASES OF THE RESPIRATORY SYSTEM. lung. Rarely the condition is congenital. It may be general or par- tial, the former variety being always unilateral, the latter sometimes bilateral. In universal bronchiectasis the bronchial tubes, throughout their extent, are the seat of numerous sacculi communicating with one another. These present smooth, shining Avails, except in the most de- pendent parts, where ulcers are sometimes seen. Extreme conditions of dilatation may take the form of huge cysts, Avhich may extend to the periphery of the lung; the lung-tissue lying between the sacculi then becomes cirrhotic as a rule. In partial dilatation the bronchial mucous membrane is implicated, with an occasional narrowing of the lumen. Most commonly these narroAvings are cylindrical, though they may be saccular, and rarely fusiform. The partial is much more common than the general variety. Histology.—When the Avails of the larger dilatations are examined microscopically, the cylindrical epithelium is seen to be replaced by a pavement epithelium. The elastic and muscular layers are thin, and the fibers are usually separated. Contained in these dilatations are frequently found secretions that may be fetid. Etiology.—The manner in which bronchiectasis is produced may vary, though in the majority of instances the condition doubtless arises from an involvement of the bronchial mucosa that extends to the sub- mucous tissues and leads to muscular, fibrous, and cartilaginous atrophy. These changes render the wall of the tube unable to resist the pressure of the air in violent paroxyms of cough, and, once the process of dila- tation is commenced, the accumulated secretions tend by their weight to further distend the already weakened walls. Thus the elasticity of the latter is impaired, and finally destroyed. The etiological factors show the affection to be secondary as a rule, and are—(1) Chronic bronchitis and emphysema, chronic phthisis (usually Avhen the seat of the dilatation is at the apex), broncho-pneumonia (in children), and compression of a bronchus by a solid tumor or aneurysm. (2) Great thickening of the pleura, especially when associated with bronchitis or interstitial pneumonia, with contraction of the lung. (3) Rarely it is a congenital lesion, and is then usually unilateral. Among predisposing conditions are—(a) Age, bronchiectasis being most common in adult or middle life; and (b) Sex, it being more com- mon in males than females. Symptoms.—There is always cough, and this usually occurs in prolonged and severe paroxysms. The attacks take place most gener- ally after the dilated tubes fill in the morning, and a change of posture may excite them. Accompanying the cough there is profuse expectora- tion, which may amount to a pint or more in tAventy-four hours. The sputum is grayish-brown in color and muco-purulent, emitting a sour or, more frequently, a horribly fetid odor. On standing, the expectoration separates into three strata—the uppermost, of brownish froth ; the mid- dle, of a thin, sero-mucous fluid; and a thick sediment, of cells and granular de'bris. Examined microscopically, the sputum is seen to be composed chiefly of pus-corpuscles, with which are intermingled Char- cot-Leyden and fatty-acid crystals, the latter being arranged in the form of bundles; also leptothrices, vibrios, and bacteria are found. Elastic fibers may be observed if ulcers be present. BR ONCHIECTASIS. 489 Dyspnea is noted, but is not a prominent symptom, unless some other chronic affections of the chest already coexist or some compli- cation arises. Hemoptysis occcurs rarely, and may be due to the bron- chiectatic lesion. Physical Signs.—These differ in character according to the size, situ- ation, and nature of the dilatation, and also according to the condition of the surrounding lung-tissue. On inspection retraction of the chest-wall may be noted wlien chronic pleurisy and interstitial pneumonia are associated. The tactile fremitus is usually increased, but may rarely be diminished. The percussion resonance is impaired or even flat, and on auscultation bronchial breath- ing is heard, with occasional rales that have a metallic quality. A sac- cular dilatation immediately beneath the pleura may give a tympanitic note, and may also give typical cavernous or amphoric respiration. These signs are generally discoverable at the base of one or other lung. Diagnosis.—Simple dilatation of slight degree may exist without appreciable signs, and in other instances the breathing is broncho-vesic- ular over localized areas, with rales displaying increased metallic quality. Saccular Bronchiectasis. Pulmonary Tuberculosis. History of chronic bronchitis, chronic History of cough, hemoptysis, with pro- pleurisy, and interstitial pneumonia, or gressive loss of flesh and strength. of foreign body. Family history. Cough is paroxysmal, and sputum cha- Cough less paroxysmal. Sputum num- racteristic and copious. mular in the stage of cavity. Tubercle bacillus absent. Tubercle bacillus present. Course longer, with little impairment of Course relatively shorter, powers of the the general health. - system progressively undermined. Physical Signs. The condition is persistent, but non-pro- Generally progressive, more frequently at gressive. Usually located near base one or other apex. posteriorly. Circumscribed empyema with a fistulous connection with the lung may simulate bronchiectasis. There is often in such cases a clear his- tory of an acute illness with a sudden onset, the symptoms pointing to pleural inflammation; or there is a period of gradually increasing ill- health with thoracic oppression and dyspnea, especially on exertion. In either event the patient suddenly expectorates, at irregular intervals, large quantities of purulent matter. Actinomycosis may also cause conditions that simulate bronchiectasis. The diagnosis may be made by finding granular particles containing the actinomyces in the sputum. Prognosis.—Apart from certain remote dangers (e. g. abscess, gan- grene), these cases pursue a favorable but exceedingly protracted course. Treatment.—The lesion being a permanent one, there is no knoAvn remedy that will either abridge or influence the course of the affection. Again, since the cough is protracted and attended with profuse expec- toration, sedatives and ordinary expectorants are contraindicated. For the fetor, antiseptics are to be employed both topically and internally, and a solution of carbolic acid (1-3 per cent.) or thymol (1:1000) is to be used by inhalation. Internally, terebene (Tflv-x—0.333-0.666) in capsules every four hours is valuable; also creasote in increasing 490 DISEASES OF THE RESPIRATORY SYSTEM. doses (TTlj—0.066, increasing by TTLj each day, till Hlvj—0.399—are taken three times daily) is to be persistently employed. Should the above methods prove unavailing, intrathoracic injections of disinfectants are often resorted to with gratifying results. In instances in which the dilatation is situated superficially and is not amenable to therapeutic measures, it may be freely opened and thoroughly drained. BRONCHIAL STENOSIS. Definition.—Narrowing of the bronchus, due either to constriction or to compression. Pathology and Etiology.—(a) Stenosis due to Constriction.— This form is most frequently occasioned by the presence of foreign bodies; by neAv growths (polypoid) within the bronchi, or by growths without, extending from the lung to the bronchi, and in the case of the smaller bronchi by swelling of the mucosa. The bronchial walls also sometimes become thickened by inflammatory exudates in certain acute and chronic affections, such as syphilis, tuberculosis, and glanders. (b) Stenosis due to Compression.—Compression of one or more bron- chi may be met with in a variety of enlargements involving the organs Avithin the thorax, among which are aneurysm, echinococcus cyst, solid tumors, enlarged glands, mediastinal and pulmonary abscesses, and ex- tensive pleural effusion. Symptoms.—The symptoms do not depend upon the cause of the obstruction, but their extent and character are in proportion to the size of the bronchus affected and the degree of stenosis. Dys- pnea is the most conspicuous symptom, and when this is marked the accessory muscles of respiration are brought into active play, and still the proper filling of the lungs with air is not accomplished. Under these circumstances the air in the lungs becomes rarefied, and instead of normal expansion everyAvhere the lower part of the sternum and the lower ribs are retracted on inspiration, and expiration is accomplished only with difficulty. Obstruction of the primary bronchus on either side of the chest Avould naturally be followed by inspiratory retraction of the inferior part of the chest-wTall and intercostal spaces upon the affected side. It is to be recollected that the movements of the larynx are slight in bronchial stenosis, while they are marked in laryngeal ob- struction. Cough and expectoration are sometimes present, and febrile development of moderate severity is often noted. Physical Signs.—Inspection shows defective respiratory movement upon the side involved. The local tactile fremitus is diminished or absent upon the affected side, owing to the obstruction to the passage of the vibrations of the voice to the pulmonary periphery. The per- cussion-note remains unaltered, though less influenced by forced respira- tion, and particularly expiration, than in health. Pulmonary atelectasis may occur as a secondary event, and is shown by dulness on percussion. The auscultatory signs consist of a greatly diminished vesicular murmur on inspiration, due to the diminished amount of air entering the air- ASTHMA. 491 cells during inspiration, and the presence of rales, sibilant and sonor- ous in character, at the seat of obstruction. Obstruction of a small bronchus may, hoAvever, be present Avithout appreciable physical signs, owing to the fact that the surrounding lung-tissue may take on com- pensatory emphysema. Diagnosis.—The nature and site of the affection may be determined by auscultation, and sibilant and sonorous rales will be conspicuous at the point of constriction. A clear history, together Avith a careful in- vestigation of antecedent affections of the thoracic organs leading up to the stenosis, are factors that must furnish the etiological data in indi- vidual cases after the exclusion of foreign bodies as the possible cause. Tracheal or laryngeal stenosis may be eliminated by careful laryngo- scopic examination. Prognosis.—The duration is indefinite, though usually protracted, and most cases yield an unfavorable prognosis. In those instances, however, in which the narrowing is due to foreign bodies the latter may rarely be dislodged and fortunately ejected, thus averting danger to life. Treatment.—The treatment must be addressed to the cause in in- dividual cases. Obviously, the question of the removal of foreign bodies from the bronchi falls Avithin the domain of surgery, though the administration of an emetic has been folloAved by complete success in certain instances. Obstruction due to stenosis of a main bronchus may be treated by dilatation Avith bougies, the treatment of course being carried out by a specialist. ASTHMA. {Bronchial Asthma.) Definition.—A chronic affection, characterized mainly by paroxys- mal dyspnea, due to contraction of the muscles of the smaller bronchi. The paroxysmal dyspnea produced by arterial contraction is also termed asthma by many writers. Pathology.—True asthma is a neuropathic disease. In a majority of the cases, hoAvever, there is more or less hyperemia of the bronchial mucosa, due to pneumogastric or vasomotor functional disturbances, and also a characteristic exudate of mucin. In a smaller number there may be no lesions Avhatsoever, and the condition is a pure neurosis, often of reflex origin. Instances that come to autopsy present the morbid changes peculiar to chronic bronchitis, pulmonary emphysema, and right- ventricular hypertrophy Avith dilatation. Etiology.—There is present either a constitutional peculiarity or a singular susceptibility of the local muscular fibers to spasmodic con- traction, both of which are of unknown nature. The exciting factors are very various, but may be grouped under four heads : (1) Acute Bronchitis.—It must not be forgotten, however, that a bronchitis may be set up by the paroxysms. Curschmann has observed also a local croupous inflammation of the smaller bronchioles in some 492 DISEASES OF THE RESPIRATORY SYSTEM of his cases, which he describes as bronchiolitis exfoliativ v, and which seems to have given rise to the seizures in grave cases. (2) The inhalation of numerous and widely various irritants, as chemical vapors, smoke, fog, dust, and emanations from plants or cer- tain animals. (3) Reflex Causes.—The causal connection betAveen chronic inflam- mations, nasal polypi, and other obstructive affections of the nasal chambers and asthma is a subject that is appreciated by the specialist. In the same Avay, gastric disturbances and, as I have observed in a few instances, intestinal irritation are productive of this complaint. (4) Asthma may be secondary to, and most probably excited by, cardiac disease, emphysema, gout, rheumatism, syphilis, Bright's dis- ease, emotional excitement, and irritating lesions in the region of the medulla. Possibly, some of the latter affections merely constitute pre- disposing factors. In this connection it is to be pointed out that indi- vidual liability to the disease depends upon the special etiologic factor. Predisposing Causes.—Heredity takes first place, and is, when discov- erable, well marked ; it is noted in about 50 per cent, of all cases. The complaint is about twice as frequent in males as in females, and, if we except hay asthma, it is more prevalent in winter and early spring than during the warm season. Clinical History.—Hyde Salter's collective statistics show that prodromal symptoms appeared in about one-half the instances (in 111 out of 226 cases). They differ widely, but are chiefly nervous in a great proportion of cases, and appear as irritability of temper, either depression or unusual buoyancy of spirits, headache, neuralgia, drowsi- ness, and vertigo. Abundant diuresis and digestive disturbances tend to appear. The attack usually comes on in the night during sleep, and at a definite time. It may develop, however, while aAvake or, again, though rarely, during the day. The onset may be sudden, but perhaps more frequently the patient first experiences a moderate grade of dyspnea and thoracic constriction. This augments with unwonted rapidity, and often attains to an inordinate degree, until the patient feels smothered, sits up, grasps his knees with his hands, or places the palms upon the bed so as to raise the shoulders and thus reinforce the accessory mus- cles of respiration. If the attack be severe, he rushes to an open win- doAV when able to leave his bed, or sits on a chair and places his arms on the back of another chair, so as to fix the shoulders and thus give purchase to the auxiliary muscles of respiration while frantically en- deavoring to maintain the act of breathing. The face is pale, anxious, and soon is bedewed with cold perspiration, while the lips, eyelids, and finger-tips are livid, owing to defective oxygenation of the blood. The temperature becomes subnormal and the pulse feeble and rapid. The clinical picture Avears an alarming aspect, but in uncomplicated cases death never supervenes. Physical Signs.—Inspection shows enlargement of the chest, which in the advanced stage becomes barrel-shaped. The reason for this is the presence of an increased amount of air in the thorax with a total inabil- ity to expel it. The respirations are diminished in frequency to 12 or 10 per minute. The natural rhythm is also greatly disturbed, and in- ASTHMA. 493 spiration is seen to be short and gasping, and followed immediately by expiration, Avhich is greatly prolonged. The expansile movement of the chest is very limited, and in inverse ratio to the patient's efforts at breathing. There is loAvering of the diaphragm. Palpation is negative in its practical results. Percussion yields a hyper-resonance; in ad- vanced cases with associated emphysema semi-tympanitic resonance is common. On auscultation the inspiration is found to be short and feeble, and the expiration much prolonged and accompanied by a Ioav- toned Avheezing sound that may also be audible to onlookers. A great variety of dry rales are heard, chiefly high-pitched, sibilant, and sonor- ous, that are more marked on expiration than inspiration. They also change their character and situation frequently. At the close of the attack moist rales may be heard, and occasionally, when bronchitis complicates asthma, the moist rales may be combined throughout the paroxysms. The duration of the attack is various, ranging from a feAV minutes to several hours, though rarely it may endure a Aveek or two, Avith spontaneous remissions during the day (e. g. when chronic bronchitis coexists). Usually it subsides abruptly, Avith the expectoration of rounded gelatinous masses and, later still, of muco-purulent material. The former, when floated in Avater, are found to be composed of the so- called Curschmann's spirals (mucous moulds of the smaller tubes), and the spiral character of these small, ball-like pellets may even be detect- able Avith the naked eye. When examined microscopically their spiral structure is evident. Two forms are recognized: (1) Composed of mucin, arranged spirally; in its meshes may be observed alveolar cells, many of which have undergone fatty degeneration. (2) A perfectly clear and translucent filament that is most probably composed of trans- formed mucin and occupies the center of the coiled spiral of mucin. In the early stage of the attack Curschmann's spirals (Fig. 44) are invariably Pig. 44.—Curschmann's spirals. present in the expectoration, and in many instances Leyden's octahedral crystals are also visible. For a time the latter were supposed, though erro- neously, to excite the paroxysms by means of their irritating character. Similar crystals are found in the semen, as Avell as in the blood in cer- tain conditions (e. g. leukemia). Miiller, Fink, Leyden, and others have demonstrated extremely large numbers of eosinophile leukocytes in the 494 DISEASES OF THE RESPIRATORY SYSTEM. sputum. Fink and GabritcheAvski likeAvise have found a large excess, up to 15 per cent., of eosinophile leukocytes in the blood. V. Noorden and SwercheAvski found the same increase, but only at the times of the attacks. Diagnosis.—A clear history, together with the physical signs and a microscopic examination of the sputum, should lead to correct results. The history alone is inadequate to put the physician upon the right track. Laryngeal affections, Avhich give rise to spasm of the glottis and dyspnea, are to be eliminated by the alteration of the voice and the aphonia Avhich are usually present, Avhile the characteristic physical signs of asthma are absent. Again, the dyspnea is inspiratory, not expiratory as in asthma. Emphysema may be confounded Avith asthma. The presence of recog- nized causes, of typical physical signs, and the paroxysmal dyspnea in asthma are the chief points of distinction from emphysema. The spu- tum should be examined microscopically if doubt remain. Course and Prognosis.—In mild cases of asthma there may be but one or two nocturnal paroxysms, Avith entire freedom from cough and dys- pnea during the following day. On the other hand, in severe cases there is a repetition of the paroxysms from three to five or six nights. Under these circumstances in the intervals (usually corresponding to the period of day) there are slight wheezing and some cough. In long-standing cases asthma leads constantly to the development of chronic bronchitis and emphysema, and in such these affections are invariably combined. The paroxysmal character of the affection is often partly or wholly lost, the patient rarely being entirely free from asthmatic dyspnea, combined with cough and muco-purulent expectoration. The periodicity of the attacks varies greatly ; in some it recurs monthly or at even shorter intervals, and in others only annually. There is rarely any danger to life, except when the secondary affection is emphysema and its remote consequence is dilatation of the right ven- tricle ; but the percentage of cases in Avhich recovery actually takes place is comparatively small, since the affection may reappear long after the paroxysms have ceased to recur in the usual manner. Treatment.—The indications for treatment are—(1) to cut short the paroxysms, and (2) to prevent a recurrence of subsequent attacks. (1) To bring relief during the paroxysms we should ascertain the ex- citing cause, and remove it promptly if possible to do so. In one of my OAvn cases a prolonged paroxysm was cut short by a calomel purge fol- lowed by an enema. An overloaded stomach calls for an emetic, and other causal factors are sometimes removable (e. g. congestion of the nasal mucosa, dust, animal and vegetable emanations). If the cause is irremovable, the patient should be kept in a large and freely ventilated apartment, and everything that tends to impede respiration must be re- moved. The choice of posture as affording the greatest relief may usually be left to the patient. To cut short the paroxysms: The particular mode of treatment that Avill afford most speedy relief differs widely in different cases, and not infrequently the patient, as the result of experience, is aware of the rem- edies that are most efficacious for good. As a rule, hoAvever, sedative antispasmodics, relaxants, and stimulants are the classes of medicinal ASTHMA. 495 agents from which a careful selection is to be made; and whilst a great variety of these have been employed, I shall content myself by adducing here only the most valuable and their mode of administration. In the hands of some observers a few whiffs of chloroform have proved highly efficacious, but in my own they have produced only momentary good effects ; ether is the safer remedy and may be tried in like manner. In a certain proportion of the cases from four to six drops of amyl nitrite throAvn upon cotton-wool or a handkerchief, and inhaled, bring speedy and permanent relief. Of stimulants, coffee is the best: immediately upon the appearance of the paroxysm about one pint of strong coffee is to be taken hot (without cream or sugar), and in this Avay the seizure may sometimes be arrested. Alcohol when given hot and in sufficiently large doses to induce mild intoxication may be found very useful; and by adding to " hot toddy " a dose of spirits of chloroform an efficient combination is the result. The inhalation of the fumes of niter-paper1 often gives quick, tempo- rary, and, less frequently, permanent relief. When employed, the atmo- sphere of the room occupied by the patient must be well filled with the fumes. Among depressant antispasmodics are belladonna, hyoscyamus, stra- monium, and lobelia, and these seem to be of most value when used in the form of cigarets. The leaves of the plant employed are first steeped in a concentrated solution of potassium nitrate or chlorate, and a trial should be made of different sorts of cigarets or pastilles (which are simi- larly prepared), since all cases are not benefited by the same brand. The inhalation of tobacco-smoke is equally beneficial in a limited number of instances. A large number of cases, despite the use of the measures above indi- cated, exhibit an obstinate tendency, and for their treatment no remedy bears favorable comparison Avith morphin, administered hypodermically, for potency and permanency of its beneficial effects. It is best given in full doses (gr. ^—\—0.0216-0.0324), and may be combined with atropin or cocain. Strychnin also has its warm advocates (Mays and others). The use of opium, oft repeated, has occasionally led to the establishment of the morphin-habit, as in a case that recently came under my obser- vation ; hence it must not be used indiscriminately. I have for a num- ber of years been in the habit of supplementing the action of the first dose of morphin with the folloAving formula : B/. Tr. lobelia?, 3J (4.0); Tr. nitro-glycerini (1%), ULxvj (1.06); Sodii bromid., 3v (20.0); Vini ipecac, 3v (20.0); Ext. hyoscyami, gr. viij (0.518); Elix. simplicis, q. s. ad giv (128.0).—M. Sig. 3j (4.0) every one or two hours in water. In the protracted cases of old asthmatics, associated with chronic bronchitis and emphysema, the above mixture may be also employed, though sodium iodid (gr. v—0.324) should be substituted for the bromid, and the same dose should be given at intervals of three or four hours. 1 Niter-paper is prepared by dipping bibulous paper (filter- or blotting-paper) in a solution of saltpeter. 496 DISEASES OF THE RESPIRATORY SYSTEM. (2) In order to prevent subsequent attacks: The history of each case should be carefully inquired into during the intervals, with a view to as- certaining whether any of the numerous causes (bronchitis, gastric disor- ders, dust, emanations from plants) are discoverable; and if so, efforts to re- move them should be instituted. A methodical interrogation of the vari- ous organs of the body and their functions must be carried out, and the therapeutic or hygienic indications presented by them, if any, must be met judiciously. The nasal passages should be examined by a specialist, and any causal conditions found therein are to be promptly removed. If the affection be a pure neurosis or due to bronchitis, a suitable climate may often be found in which the patient will enjoy complete immunity from asthma. The choice of the locality cannot, howrever, be determined by any known rules. The patient must travel from place to place until he finds the climate that possesses preventive properties in his particular case. To those Avho cannot adopt this plan potassium iodid offers the best hope of relief, though its use must be long continued (gr. x-xx— 0.648-1.296, three times daily). The systematic use of compressed air in the pneumatic cabinet, and also the inhalation of oxygen, are Avorthy of trial. The presence of any conditions of ill-health calls for treatment directed to their removal. There are also certain means of prophylaxis for impending attacks. Thus, if there be premonitory symptoms, the use of such measures as strong coffee or the " hot toddy " above mentioned, Hoffman's anodyne, stramonium or belladonna cigarets, the inhalation of the fumes of niter- paper or of a few drops of amyl nitrite, or the removal of the sources of irritation, may suffice to ward off the attack. FIBRINOUS BRONCHITIS. {Plastic Bronchitis ; Croupous Bronchitis.) Definition.—A rare acute or chronic catarrhal affection of the bron- chial mucosa, attended with the production of fibrinous casts that are ex- pectorated in severe paroxysms of cough and dyspnea. These casts, when unfolded, are found to be solid moulds of the bronchial tubes from which they come, being shaped like the branches of a tree, and thus proving that a bronchial tube and its subdivisions had been blocked. When the moulds are large or medium-sized they are hollow, and when from the smaller bronchi they are solid. Pathology.—The pathology is but little understood, but in my own studies I have found the composition of these casts to be identical with that of croupous exudates met with elsewhere, though more dense, per- haps, than the latter. Croupous bronchitis is attended with loss of epi- thelium in the implicated bronchi, as is the case in croupous inflamma- tion wherever it occurs, but the answers to the questions, " Why should the affection be limited to a definite portion of the bronchial tree?" and "Why does it recur from time to time?" are obscure indeed. In fatal cases the lesions of associated or antecedent complaints, such as chronic pleurisy, pneumonia, and pulmonary tuberculosis, have been found. FIBRINOUS BRONCHITIS. 497 Etiology.—What the irritant is that causes the condition is un- known, though streptococci have been found in the moulds and in the mucosa. Some of the predisposing causes, however, have been recog- nized, and are—(1) Sex: it being about twice as frequent in males as in females. (2) Age: though met with at all periods of life, it is relatively more frequent from the twentieth to the fortieth year. (3) Season: the seizures are most common in the spring months. (4) Epidemic influ- ences : Pichini has described a group of instances that occurred in indi- viduals in the same locality. (5) Hereditary influence has been trace- able in a few cases. (6) Other affections, as tuberculosis (quite fre- quently), chronic pleurisy, and certain skin-affections, as herpes, im- petigo, and pemphigus, form antecedent and coexistent conditions. Symptoms.—(a) The acute form is rare. It begins with rigors and fever that are soon followed by urgent dyspnea and severe paroxysms of cough, which are usually attended, soon or late, by the expulsion of fibrinous casts, and sometimes rather profuse hemorrhage. Abundant expectoration usually causes amelioration of the severer symptoms. On the other hand, urgent dyspnea, oppressiveness, and severe cough, with little expectoration, are grave symptoms, often leading to fatal asphyxia. (b) The Chronic Form.—The paroxysms recur at irregular intervals and are less severe than in the acute form, the interim varying from one week to a year or more. In a case observed by myself the patient has experienced a recurrence once annually (on or about May 1st), commen- cing three years ago. Other instances are on record in Avhich the parox- ysms have occurred at regular though much briefer intervals. The cases usually manifest ordinary bronchitic symptoms, with or without fever at the onset. The cough soon becomes troublesome and is paroxysmal in cha- racter. There is expectoration in the form of rounded masses, Avhich, when unravelled, are found to be true moulds of the affected tubes that exhibit a laminated structure. The larger casts (Avhich are of the size of a goose-quill or even larger) may be hollow, while the smaller ones are quite solid. They are of whitish or grayish-Avhite color. When ex- amined microscopically they are seen to consist of a fibrillated base, a few scattered leukocytes and mucous corpuscles, and, rarely, gland- and blood- cells. Occasionally Leyden's crystals and Curschmann's spirals have been found. Not infrequently the sputum is blood-stained, and occasion- ally there is profuse hemorrhage. Physical Signs.—Owing to the obstruction offered by the casts, there is a diminished amount of air entering the corresponding part of the lung. As a necessary result the tactile fremitus, local expansion, and respira- tory murmur are diminished over the affected area. The note on percus- sion over the uninvolved portions of the lung is clear or hyper-resonant, though if the portions of the lung supplied by the affected tubes collapse, there is dulness on percussion. Dislodgement of the casts is folloAved by a return of the normal respiratory murmur. Diagnosis.—From ordinary bronchitis it is to be distinguished by the presence of the fibrinous casts, which alone are sufficient for a positive diagnosis. The fibrinous moulds met with in diphtheria and pseudo-mem- branous croup, with extension into the bronchi, must also be eliminated. The history and course of the latter will, as a rule, suffice to make a positive discrimination, but if doubt remain a bacteriological examination 32 498 DISEASES OF THE RESPIRATORY SYSTEM. of the membranous casts should be made. If the Klebs-Loffler bacilli are then found, all doubts as to its diphtheritic nature are set at rest. Prognosis.—The prognosis in the acute form is quite grave; the chronic variety, though pursuing an exceedingly long course that ranges from five to fifteen years, rarely terminates fatally. Treatment.—This is to be conducted on the same principles as those in simple acute bronchitis. In the acute form an attempt should be made to soften and separate the casts by the topical application of steam, by inhalation, and alkaline sprays (e. g. lime-water). Pilocarpin Avas em- ployed in one instance under my own observation Avith apparent good results; it tends to excite free bronchial secretion. Emetics should be resorted to ■ without delay when the signs of cyanosis show themselves. In the chronic form nothing can be accomplished by treatment, dur- ing the intervals between the acute exacerbations, that will tend to obviate a recurrence of the attacks or to mitigate their severity. IV. DISEASES OF THE LUNGS. CIRCULATORY DISTURBANCES IN THE LUNGS. CONGESTION OF THE LUNGS. [Hyperemia of the Lungs.) Definition.—The surcharge of the pulmonary vessels with blood. Two forms are recognized: (1) Active hyperemia, and (2) Passive hy- peremia. ACTIVE HYPEKEMIA. Pathology.—The blood-vessels in the bronchial mucosa often appear intensely injected, and the capillaries in the alveolar walls are prominent, while on section a scarlet-colored, frothy liquid flows. The alveolar epi- thelium may become SAvollen and granular. Etiology.—Active hyperemia is usually a symptomatic condition, though rarely it may arise as a distinct primary affection. Active con- gestion of the lungs exists as an associated condition in many pulmonary affections, as pneumonia, pleurisy, bronchitis, and tuberculosis. On the other hand, active congestion of the lungs may be engendered as an independent affection by the inhalation of hot air, highly irritative sub- stances, as well as by violent physical exercise, the ingestion of large amounts of alcohol, and strong mental emotion. Active hyperemia has, however, little clinical significance. Symptoms.—The capacity of the air-cells is diminished; hence the oxygenation of the blood is markedly interfered with. This embarrass- ment of the function of respiration is compensated for in part by accel- erated breathing, there being a degree of dyspnea proportionate to the extent and intensity of the congestion. There is some cough, accompanied by frothy, bloody expectoration. The physical signs are bilateral, as a rule, and are generally confined CONGESTION OF THE LUNGS. 499 to the bases. Palpation shows increased tactile fremitus. The percussion- note is impaired or, rarely, dull, and it is generally exceedingly difficult to determine the pitch of the note, owing to the fact that both sides are usually involved. On the other hand, when the condition is unilateral and not associated with diseases of the opposite side, the impairment is readily appreciated. The vesicular element of the respiratory sounds is diminished, and the bronchial element relatively increased (broncho-vesic- ular breathing). Less frequently there is bronchial breathing. Diagnosis.—In the presence of the etiologic factors the sudden development of dyspnea, cough, and a frothy, bloody expectoration, and in the absence of fever and the physical signs before enumerated, the diagnosis is easy. Prognosis.—Active hyperemia is frequently followed by collateral edema. Its course is brief, and terminates either fatally in a few hours, in perfect recovery in a few days, or in pneumonia. The condition is therefore ominous. Treatment.—Prompt measures must be instituted in order to arrest the active fluxion. The special causal factors must be actively treated, so as to diminish the quantity of blood in the pulmonary vessels ; dry and Avet cups over the entire seat of congestion must be tried ; and in the worst cases venesection is demanded. Following the application of the cups, turpentine stupes, sinapisms, and linseed poultices may be em- ployed. I have observed excellent results from the use of veratrum viride combined with saline purgatives. Other cardiac sedatives may also be employed, including nitroglycerin in full doses. PASSIVE HYPEREMIA. Passive, unlike active, hyperemia is always a secondary condition, and is quite common. Two forms are distinguishable : (a) Mechanical, and (b) Hypostatic. (a) Mechanical Hyperemia (Brown Induration).—Pathology.—The pulmonary vessels are distended, the lungs as a whole enlarged, and the air-cells crepitate but little, OAving in great part to the encroachment upon the air-spaces by the dark venous blood. The lungs are of a reddish-brown color and afford increased resistance to efforts at cutting or tearing. On section the reddish-broAvn tint rapidly changes to a vivid red, from oxi- dation of the hemoglobin Avhen exposed to the atmosphere. The process commences at the extreme base, extends upAvard, and may finally become general. The interstitial connective tissue is increased, and is often edem- atous, Avhile the epithelial cells of the alveoli show altered blood-pigment, usually in the form of hemosiderin and responding to the usual tests for iron. Etiology.—Mechanical hyperemia results from the obstruction of the return of blood to the left heart, and among special causative conditions are mitral constriction, mitral regurgitation, dilatation of the right ven- tricle, and certain cerebral injuries and diseases. It may also be a symp- tom of asphyxia, and rarely it arises from pressure of tumors. Symptoms.—The most marked feature is dyspnea, particularly when secondary to organic cardiac diseases with failure of the right ventricle. Cough is common, and an expectoration of frothy serum or blood (hemop- 500 DISEASES OF THE RESPIRATORY SYSTEM. tysis) containing pigmented alveolar epithelial cells, is the most cha- racteristic clinical feature. Diagnosis.—-With a clear history, in addition to the dyspnea, cough, and the characteristic expectoration, the recognition of passive hyper- emia of the lungs is a simple matter. The prognosis and treatment will be considered in connection with the causative affections. (b) Hypostatic Hyperemia.—Pathology.—The parts of the lung that are affected are dark in color and the vesicles distended with a transudate of blood and serum. In this way the air-cells may become emptied of air (splenization, hypostatic pneumonia), and the resulting condition is in most instances to be regarded as a mild grade of lobular pneumonia. This view is confirmed by the fact that the same etiologic conditions that favor the development of hypostatic congestion also favor to an equal extent the development of hypostatic pneumonia. Etiology.—Feeble cardiac action, as in long-continued fevers, debili- tating chronic affections, and in old persons, combines with a prolonged dorsal position of the body (gravitation thus favoring its development) in producing.the condition. This explains why the condition is found usu- ally at the bases of the lungs, and is most marked posteriorly. It is common for the same reason in carcinoma, tuberculosis, paralysis, chronic rheumatism, typhoid fever, etc. Symptoms.—The symptoms are wholly indefinite; indeed, none may be present. Priory has pointed out that old persons in the incipiency of the disease begin to sleep with the mouth open, so as to effect the entrance of more air. Commencing cyanosis may indicate the development of hy- postasis, and a careful physical examination of the lower lobes of the lungs will show increased fremitus, slight dulness, diminished vesicular murmur, and, in the higher grades, bronchial breathing, with liquid bub- bling rales. The prognosis is based upon the character of the underlying affection. Treatment.—This is an affection in which the treatment of causes alone will suffice, save in instances that are secondary to organic heart- affections, in which prompt bleedings are to be advocated. From a pint to a quart of blood should be taken, and I have seen happy results from the employment of this measure in extreme cases. Tapping the right auricle Avhen the blood refuses to flow from an arm vein has also been successfully accomplished by competent surgeons. The patient's posture must be changed from the dorsal to the lateral, and even ventral, and as soon as possible he should be gotten out of bed. PULMONARY EDEMA. {Edema of the Lungs.) Definition.—An effusion of serous fluid into the air-vesicles and in- terstitial lung-tissue. Pulmonary edema is scarcely to be regarded as an independent affection, but as a secondary condition, being in most in- stances associated with pulmonary congestion. Pathology.—It consists of a transudation of serum into the alveolar walls, interstitial connective tissue, and air-cells, and rarely the process is limited to the interstitial tissue. Two forms may, for the sake of con- venience, be recognized : PULMONARY EDEMA. 501 (a) Collateral Edema (Inflammatory Edema).—This is usually local in character, circumscribing an area of the lung that is affected by pneu- monia, abscess, or pulmonary infarction, and is the result of a mild in- flammatory process affecting the vessel-walls. When the condition follows hypostatic congestion the terms " hypostatic edema " and " splenization " have been applied. (b) General Pulmonary Edema.—If congestion be not associated, the portions of the lungs involved by this type look pale; when pulmonary congestion or pigmentation of the tissue is present, the lung appears darker than the normal and the serum is blood-tinged. The Aveight of the lung-tissue, owing to the more or less airless condition of the alveoli, is increased, and yet, though heavier than the normal lung, the affected tissue does not sink in water. To the feel it is boggy, and pits on pres- sure, while on section a serous or sero-sanguinolent (if congestion be pres- ent) fluid of low specific gravity, and poorer in albumin than plasma, flows from the cut surface. Edema is most frequently observed at the bases of the lungs, though it may become general, and as a rule the surface of the pleura is moist; hydrothorax may be present. The mode of production of pulmonary edema is not definitely known. Increased fluidity of the blood on the one hand, and increased tension in the pulmonary vessels on the other, seem to be influential factors in many cases. The heightened blood-pressure may be in great part due to a fail- ure of cardiac poAver, and particularly to failure of the left ventricle (Welch). When weakness of the left is out of proportion to the weak- ness of the right ventricle, we are apt to have the tension in the pulmo- nary capillaries greatly increased, at least until transudation of serum is induced. Edema also occurs as a result of weakness of the right ven- tricle alone, possibly in consequence of the resulting stagnation of the pulmonary circulation. Obstruction to the outflow, such as occurs in weakening of the left ventricle, or even obstruction in the aorta, leads to heightened tension and, secondarily, to paralysis of the right ventricle. The third and most important factor entering into the production of pul- monary edema is the increased permeability of the vascular walls, due to morbid changes that are the result of impairment of their nutrition. This usually arises in connection with toxic and infectious diseases, when the blood also exhibits more or less change, as in cachectic states, uremia, gen- eral septicemia, or some of the infectious diseases. Local edema also occurs in the neighborhood of inflammatory foci, as in pneumonia. Etiology.—Pulmonary edema is secondary to pneumonia and acute and chronic affections, but not with any degree of constancy; nor is it especially liable to be associated with congestion or with Ioav grades of inflammation of the lungs. Among the diseases of which it forms a ter- minal condition are—valvular affections of the heart, fatal forms of anemia, acute and chronic Bright's disease, cerebral lesions (hemorrhage, trauma- tism), and acute infectious fevers with failure of cardiac power. Symptoms.—In edema of the lungs the air-space is lessened in di- rect proportion to the amount of serum occupying the alveoli; hence dyspnea is always present and is often a conspicuous symptom. There are cough and bronchorrhea. The sputum is usually abundant and frothy, and is expectorated Avith difficulty. At times, and especially in the acute forms, it is tenacious and may give rise to alarming laryngeal obstruction. 502 DISEASES OF THE RESPIRATORY SYSTEM. It is blood-stained if congestion be combined. The condition does not give rise to elevation of temperature, except in the inflammatory type, in which fever is.constantly present. The pulse is accelerated and feeble, and cyanosis, particularly in cases of collateral edema, usually appears. The extremities are cool and often livid. Physical Signs.—The reasons adduced to explain the dyspnea likewise render intelligible the physical signs encountered. There is dulness, though rarely complete, over the areas involved; the vesicular murmur is feeble or absent, or there may be broncho-vesicular breathing. Since the bron- chioles contain serum, small rales, having a liquid character, are audible with inspiration and at the beginning of the expiration over the seat of the edema. Vocal resonance and tactile fremitus may be present. The diagnosis, with a clear history, is based upon the incomplete dulness that is usually bilateral and most marked at the bases, upon the bubbling rales heard over the corresponding area, and upon the absence of any febrile movement, except the latter be due to some underlying affection. Hydrothorax bears some points of resemblance to edema of the lungs, but in this condition the upper level of dulness is movable in con- sequence of change of position of the patient, as is not the case in edema of the lungs. On the other hand, in the latter affection moist rales are present, while they are absent in hydrothorax. Broncho-pneumonia may be mistaken for pulmonary edema, though it has a different mode of onset. It is also accompanied by fever, glairy, tenacious expectoration, and more sharply-localized areas of dulness then appear in edema. The prognosis is governed by the pre-existing condition to which the edema is due. Thus, if secondary to a general dropsy due to renal or cardiac disease, it often destroys life with great rapidity. Inflammatory edema, following lobar pneumonia, is also grave in the extreme. Treatment.—The treatment does not differ materially from that of the associated or causal affections. The conditions on which a pulmonary edema depends must, however, be sedulously treated, and the limitation of the transudation and the direct removal of the serous effusion from the lungs is of great importance. We should not fail to frequently change the position of the patient's body, so as to prevent the gravitation of blood to the dependent portions of the lungs. I have witnessed excellent results from the use of dry cups placed over the thorax, particularly over its posterior and lateral aspects, and renewed at intervals of six to eight hours. The number applied should range from one and a half dozen to three dozen. In aggravated forms that develop quickly prompt venesec- tion is imperatively demanded. This is a measure which, if resorted to at the proper moment, will often rescue the patient from imminent danger. The condition of the heart and kidneys must be carefully investigated, and any indications presented by them for treatment must not go unheeded. HEMOPTYSIS. {Broncho-pulmonary Hem orrhage.) Definition.—An expectoration of blood. Its source may be the bronchial mucous membrane (usually the small bronchi), and less fre- quently it comes from eroded vessels in lung-cavities or their walls; rarely from the larynx, trachea, and larger bronchi. When from the bronchial tubes the term bronchorrhagia should be applied. The source HEMOPTYSIS. 503 of the hemorrhage, however, is not always easily demonstrable, even when it has resulted fatally and the lungs are minutely examined. Pathology.—The lesions are often microscopic, and,consist for the most part of ruptured capillary blood-vessels, though larger vessels may also become the seat of erosion or rupture. After death the bronchial mucosa is sometimes found to be swollen, bleeds easily, and is of a dark-red color —soon becoming decidedly pale. The lung-tissue proper may look paler than in the sound lung. When hemoptysis occurs in advanced pulmo- nary tuberculosis the lung-cavity may contain a ruptured aneurysm, or mere ulceration of an exposed vessel may be observed. I have Avitnessed small, dark-red, dense masses in the air-sacs scattered throughout the lung whence came the hemorrhage. Doubtless these are blood-coagula, which result from the clotting of the blood after the latter has been carried into the alveoli. Various associated lesions may be observed. Etiology.—(1) Pulmonary Affections.—(a) Pulmonary congestion from Avhatever source may result in hemoptysis, though the amount of blood lost under these circumstances is usually small. There are many causes that excite congestion of the lungs, some of which reside in ad- jacent organs, it being common in organic disease of the heart, and par- ticularly in disease of the mitral segments. That form of pulmonary congestion Avhich is associated Avith other affections of the lungs, as well as primary active congestion due to inhalation of hot air, irritating substances, and violent physical exercise, may also result in hemor- rhage, (b) Hemorrhagic infarction may lead to slight hemorrhage (vide Pulmonary Embolism). (c) Croupous Pneumonia.—In this disease hemorrhage is caused by the rupture of the capillaries, and the blood, when expectorated, has undergone a change, becoming rusty-colored. (d) Pulmonary Tuberculosis.—This is pre-eminently the most common cause. Hemorrhage may take place early when it originates from a sharply-limited and minute tuberculous focus, and it may also be attrib- utable to congestion. Undoubtedly its exact source is the mucosa of the small bronchi; later it is the direct consequence of the ulceration of an artery or of the rupture of an aneurysmal sac that has its seat in a branch of the pulmonary artery. After the tuberculous cavities have healed or while quiescent, calcareous masses are, from time, to time, expec- torated, together with more or less blood, (e) Ulcers of the Larynx, Trachea, or Bronchi.—Rarely ulcers in adjacent structures erode the larger branches of the pulmonary artery and cause copious and speedily fatal hemorrhages. Osier observed a fatal hemorrhage in a case of chronic bronchitis with emphysema. (/) Fibrinous bronchitis induces hemop- tysis by rupturing the capillaries in the bronchial mucosa at the time of separation of the bronchial casts, (g) Carcinoma of the lung produces frequent expectoration of blood. (h) Gangrene of the lung. (2) Diseases of Other Organs than the Lung.—(a) Affections of the heart act as a cause, and especially advanced mitral disease when it is due to pulmonary congestion. It not infrequently develops during the stage of adequate compensation. In a preponderating proportion of the latter instances the hemorrhage is slight, but it may be profuse and recur at intervals for many years, (b) Aneurysm of the branches of the pulmo- nary artery and of the arch of the aorta (usually with rupture of its coats) is a rare cause of hemoptysis. 504 DISEASES OF THE RESPIRATORY SYSTEM. (3) Certain diseases, such as purpura hcemorrhagica, scurvy, anemia, hemophilia, and malignant forms of certain acute infectious diseases (e. g. yellow fever), cause hemoptysis. In this class of cases the hemor- rhages are due either to a diseased condition of the vessel-walls or to blood-changes. (4) Vicarious hemoptysis is not uncommon during menstruation or when amenorrhea is present. Unless occurring at the time of the regular menses it is not to be regarded lightly, and is of the same significance as when taking place in the male. I cannot agree Avith those authors who contend that hemorrhage from the lungs in women is without the same dire significance as in the opposite sex. (5) Arthritic (Gouty) Endarteritis.—According to Sir Andrew Clarke and others, this is a common cause of recurring hemorrhages in aged per- sons (over fifty years). Symptoms.—Hemoptysis is so commonly a symptom of that most frequent and dread disease, phthisis, as to raise suspicions of the latter in the minds of the patient and physician as soon as it occurs. It is ap- propriate, therefore, to note, first, the features of hemoptysis when depend- ent upon pulmonary tuberculosis, and then to point out its clinical peculiarities when due to other conditions. In incipient pulmonary tuberculosis hemoptysis develops suddenly as a rule, a warm, saline taste, lasting but a few moments, generally preced- ing the expectoration of blood. The blood is coughed up, and the bleeding may last only a few minutes or may continue for days, the sputum being apt to remain blood-stained for a longer interval. The immediate effect of the hemorrhage, hoAvever slight, is to alarm the patient, inducing, besides mental agitation, cardiac palpitation and other nervous concomitants. A small hemorrhage is not attended Avith any other results, but large ones give rise to the symptoms of shock, com- bined with those of symptomatic anemia. When the hemorrhage is large, blood to the amount of a mouthful may be ejected with each cough, and in these instances the effect of the profuse bleeding is evidenced by such symptoms as vertigo, syncope, cold extremities, excessive pallor, perspi- ration, and a rapid, small, feeble pulse. This is followed, if the attack does not prove speedily fatal, by considerable restlessness, and later not infrequently by mild delirium and more or less fever. In comparatively rare instances the same patient has a single hemor- rhage ; more frequently he has several at shorter or longer intervals. Large or small bleedings may precede by weeks, months, or even years any rational symptoms or physical signs of pulmonary tuberculosis. In such instances latent foci of disease may be assumed to have pre-existed. In quantity the hemorrhage varies greatly: there may be less than one ounce ejected or it may amount to a pint or more before the bleeding ceases. In advanced cases in which cavities have formed large vessels may become eroded, followed by copious and dangerous hemorrhage. Fatal hemorrhage may take place into a cavity without the occurrence of hemoptysis, as in a case dissected by Osier at the Philadelphia Hospital. The distinctive characters of the blood discharged are mainly as follows: bright color, very frothy (being mixed with air), and not clotted. A rare exception to the rule may be noted in the case of hemorrhage proceeding from a large cavity, the blood pouring forth in a free, dark stream. HEMOPTYSIS. 505 Physical Signs.—These are, for the most part, negative: Quite com- monly moist bronchial rales are audible on auscultation ; palpation and percussion should not be practised during nor immediately after the hemoptysis. Hemoptysis not Due to Pulmonary Tuberculosis.—[a) In affections of the mitral and aortic valves, especially in mitral stenosis, hemorrhage from the bronchi is not uncommon, and the Avay in which these lesions lead to pulmonary congestion is explained in the discussion of Organic Affections of the Heart. During the progress of these cases, hemorrhages often occur at considerable intervals; they may either be slight, lasting only a few minutes, or quite free, extending over periods of a feAV days or a Aveek. (b) As a rule, in the beginning small hemorrhages occur for several weeks from pressure of an aneurysmal dilatation upon the bronchial mu- cosa, or there may be Aveeping of blood through the exposed layers of fibrin composing the walls of the sac. The bleeding point can be dis- covered with the laryngscope, when an aneurysm of the innominate or of the aorta impinges upon the trachea. A large and often quickly fatal hemorrhage occurs from rupture into the respiratory tract. (c) "Arthritic hemoptysis" is undoubtedly associated with gouty, degenerative changes in the terminal blood-vessels of the lung, though no coarse pulmonary lesions are induced by the recurring hemorrhages. Though the hemorrhages may occur at intervals for years, as a rule they finally become arrested, and only rarely lead to a fatal issue. I have never observed this form of hemoptysis occurring independently of chronic bronchitis. In emphysema and chronic bronchitis small hemorrhages may occur, and occasionally coagula in the form of casts are formed in the bronchi and afterward ejected. It is probable that the source of the large bleedings that occur under these circumstances is an ulcer in the bronchial mucosa. (d) The hemoptysis that is connected with the menstrual function is of frequent occurrence. I saw recently a patient in whom free bleeding has occurred at intervals of four Aveeks for a couple of years, with an absence of the menses during the same period of time. In another in- stance, a patient of Dr. Byers, recurring hemorrhages of the lungs took place instead of the regular menstrual discharge for three successive months, and a comparatively rapid form of phthisis was developed. This class of cases must be regarded as grave. (e) The preceding group is to be distinguished from those cases in which trivial bronchial hemorrhages sometimes occur and in delicate, hys- terical females. Though these bleedings are accompanied by cough, it is not uncommon to find, upon careful examination, that the blood comes from the upper air-passages. (/) Hemoptysis may result from severe injuries inflicted upon the thorax, and last for days together. (g) A person may have a single or many recurring attacks of hemop- tysis without assignable cause, if we except severe muscular strain or in- tense mental excitement. Although pulmonary tuberculosis does not supervene in instances of this sort, yet not a few may be excited by a permanently limited tuberculous focus which may be indeterminable by the usual methods of examination. I have more than once seen a cure 506 DISEASES OF THE RESPIRATORY SYSTEM. result from &n active course of treatment with creasote and appropriate hygienic measures. In well-marked instances of the kind a complete arrest of the trouble resulted from a change of climate. Differential Diagnosis.—A reliable diagnosis necessitates the cer- tain exclusion of hemorrhage from the higher air-passages, pharynx, esophagus, and stomach. In epistaxis the blood may directly enter the naso-pharynx, exciting cough and being discharged as in hemoptysis. A careful examination of the nasal chambers should be made, however, in cases in which the symptoms are suggestive of epistaxis. Bleeding may take place from the gums, from chinks in the pharynx, or from varicose veins. If the seat of the bleeding be the pharynx, the hemorrhage is not free, the blood being commingled with a preponderating proportion of mucus; if from the gums, it may be more copious (as in ptyalism or scurvy), and the hemorrhage then simulates that of pulmonary hemoptysis. An inspection of the mouth will disclose whether or not the gums are the source of the hemorrhage. The distinctive points between hemoptysis and hematemesis will be found in the discussion of the latter affection. Prognosis.—The gravest apprehensions are constantly entertained by sufferers from hemoptysis, but immediately fatal results are of rare occur- rence ; and of this fact the patient should be repeatedly assured by the attending physician. In case, however, the existence of thoracic aneur- ysm is definitely known, the consequences of hemoptysis are certainly fatal. With reference to the effect of hemoptysis upon tuberculous pulmo- nary disease opinions differ widely ; I am of the belief, however, that prior to the existence of cavities it exerts a favorable rather than an unfavor- able influence upon the course of the disease. On the other hand, in cases in which cavities exist at the time of the occurrence of hemoptysis an opposite effect is observed. The fact that hemoptysis often precedes by prolonged intervals of time the development of pulmonary lesions is no argument in favor of Niemeyer's view, that phthisis is caused by hem- optysis. There can be no doubt, however, that some blood finds its way into the bronchi below the point of bleeding and into the air-cells, setting up in the latter places irritation and even lobular inflammation. In this way hemorrhages may aid in rendering the tissues more susceptible to tuberculous infection. In cases of profuse hemorrhage, due to aneur- ysm or to the erosion of large branches of the pulmonary artery in phthisical cavities, death may be suddenly induced, and is caused largely by inundation of the lung and the consequent impossibility of respiration. Treatment.—Since the hemorrhage is ascribable to (1) congestion of the bronchial mucosa, (2) erosion of the vascular walls, and (3) blood- changes, obviously the treatment of individual cases must be modified according to the character of the causal condition. In many instances of hemoptysis due to congestion of the bronchial mucosa the hemorrhages are, comparatively speaking, slight; hence, apart from keeping the patient at absolute rest, little treatment is re- quired. If not excessive, they are often salutary in their effect. If free, the physician's aim should be to decrease the power of the heart's contraction, and to accomplish this end the patient should be placed in bed, and not allowed to change his position or to speak above a whisper. The diet should be light, nutritious, and non-stimulating, all hot drinks HEMOPTYSIS. 507 and alcoholics being prohibited. Among cardiac sedatives to be em- ployed with a vieAV to reducing the rapidity of the heart's action and low- ering the blood-pressure, if the patient be neither feeble nor anemic, the ice-bag to the precordia is most valuable; if the pulse be full and strong, we may use aconite and other arterial sedatives. Arthur Foxwelll recom- mends venesection in cases in which venous congestion is present, and also lays stress upon measures that confine the blood to the systemic circula- tion—i. e. nutritious food, large doses of the nitrites, hot foot-baths, leeches to the anus, and ligatures applied to the thighs and arms. The pulmonary capillaries may also be effectually depleted by the use of salines, which should be given in full doses. In my own experience dry cupping over the chest has been of the greatest service in cases dependent upon pulmonary congestion. Eating ice and partaking freely of iced drinks are also useful measures. If the attack tends to become prolonged and exhausting, Ave may increase the coagulability of the blood by the use of such remedies as gallic acid, acetate of lead, or calcium chlorid. Hemoptysis is usually accompanied by cough, that constantly disturbs the vascular serenity and excites fresh bleeding. For this symptom opium, and in the worst cases morphin hypodermically, should be freely administered. When hemoptysis is associated with organic disease of the heart, the main indication is to strengthen that organ by bodily rest and quiet and by the use of cardiac tonics, especially digitalis. I have had under ob- servation and treatment for several years a young physician Avho has been suffering from frequent, marked hemoptysis, due to mitral regurgitation, and in whose case the bleedings are readily controlled by the free use of digitalis. When in thoracic aneurysm or advanced pulmonary tuberculosis the blood is ejected in mouthfuls, we may safely infer that erosion of a ves- sel or rupture of the aneurysm has taken place. Here the object is to bring about the formation of a thrombus that will arrest the hemorrhage. Perfect quiet in the horizontal position tends to allay the vascular excite- ment, and the induction of fainting by venesection is a measure worthy of a trial, though efforts at treatment are unpromising. Opium is contra- indicated in the latter class of cases, owing to the fact that if cough be checked inundation of the bronchial system with the blood (the chief danger) will be favored. In all instances of hemoptysis treatment should not cease Avith cessa- tion of the hemorrhage. A tendency to recurrence is manifested in many cases, and hence measures calculated to avoid this event must be brought into play. The patient should not be allowed to indulge in a stimulating diet; he should eschew tobacco and alcoholic stimulants, and avoid all physical and mental strain. Every source of bronchial irritation should be carefully avoided, and attacks of bronchitis, however mild, should re- ceive the most careful attention. Moderate exercise is serviceable, as well as a liberal amount of nutritious food. 1 British Medical Journal, 1894, p. 194. 508 DISEASES OF THE RESPIRATORY SYSTEM. PNEUMORRHAGIA. {Pulmonary Apoplexy.) Definition.—An escape of blood into the air-cells and interstitial tissue, with or without laceration of the pulmonary parenchyma. Pathology.—It may be, though rarely, (a) diffuse, Avhen the lung- tissue is lacerated, as in cerebral apoplexy ; or it may be (b) circum- scribed, as when the blood is effused into the air-cells and the interstitial tissue, with rupture of the parenchyma. The latter form will be consid- ered in the discussion of Pulmonary Infarction. Etiology.—Diffuse pulmonary apoplexy is caused by the rupture of a thoracic aneurysm that has become adherent to the surface of the lung. Its most common cause is traumatism, especially penetrating wounds of the lung, but adult life and the male sex are to be regarded as predisposing factors. The lung-tissue is sometimes the seat of diffuse hemorrhagic infiltration in septico-pyemia and cerebral disease. Symptoms.—These are ill-defined. Profuse hemoptysis, urgent dyspnea, and cyanosis, followed by increasing evidences of collapse, together with a clear history, should raise suspicions of the existence of diffuse pneumorrhagia. The physical signs are indicative of extensive consolidation arising suddenly, and not of the nature of the lesion. The prognosis is practically hopeless, and abscess or gangrene may result if these cases recover from the immediate effects of the hemorrhage. Treatment.—Absolute rest of the body in the horizontal position is the one measure that offers a slight prospect of alleviation, for thus the formation of a clot, followed by arrest of the hemorrhage, is encouraged. It is unwise to use opium to allay the cough, since the action involved assists in ejecting the extravasated blood, which Avill, in consequence of gravitation and the effect of respiration, submerge speedily so much of the lung-tissue as to hasten the fatal termination. Ergot is not to be given hypodermically, since it raises the blood-pressure in the lesser cir- culation, but the internal and external use of cold has been highly recom- mended. With the onset of collapse cardiac stimulants become absolutely necessary, though many cases are so rapidly progressive as to reach a moribund state before remedial agents can be applied by the physician. PULMONARY EMBOLISM. {Hemorrhagic Infarction; Embolism of the Lungs.) Pathology.—Embolic infarctions are firm, airless, brown or black, wedge-shaped masses, with their bases usually at the pleura, which soon becomes lustreless and covered with a delicate layer of fibrin. The in- farctions may be single or multiple, and sometimes occupy the greater portion of the lobe; in the majority of cases, however, their size equals that of a walnut. Their most frequent seat is at the back of the lower lobe. The microscope shows the presence of leukocytes and red blood-corpuscles in the air-cells and in the alveolar septa. Collateral congestion and edema are frequent concomitants, and, less frequently, pneumonic consolidation appears. PULMONARY EMBOLISM. 509 Etiology.—The condition is produced by the blocking of the pulmo- nary arteries by an embolus or thrombus. When the circulation in the pulmonary capillaries is feeble, hemorrhagic infarction may be the result of stasis, and this is probably the most frequent form. It is met with in connection with diseases of the lungs, and also with mitral stenosis or re- gurgitation. The plug that occludes the blood-vessel may be composed of leukocytes, as in leukocythemia, and the chief sources of the matter that enters into the emboli are the thrombi in the right side of the heart and in the systemic veins. Infectious emboli, resulting in abscess, will be considered in connection with Abscess of the Lungs. Occlusion of a branch of the pulmonary artery cuts off completely the circulation to the territory supplied by that branch, and hemorrhagic infarction occurs as a result, just as elsewhere. Symptoms.—Not all infarctions give rise to symptoms ; on the con- trary, occlusion of a main branch of the pulmonary artery usually ter- minates life speedily. The latter accident occurs not infrequently in con- nection with organic disease of the heart, and if death be not the imme- diate result or if a smaller branch be occluded, the most alarming symp- toms ensue, such as syncope, urgent dyspnea, and convulsions with un- consciousness. The first and most distressing symptom is dyspnea, which is attended by frantic efforts at breathing and by great mental anxiety. Occasionally hemoptysis is an early symptom, and of primary significance if it occur in a patient suffering from mitral disease. If, together with these symptoms, loss of consciousness with convulsions occurs, the diagnosis becomes wellnigh complete. Cough usually supervenes, accom- panied by the expectoration of dark, gelatinous, mucoid masses. Large lymph-cells Containing blood-corpuscles are found in the sputum, these giant-cells being most commonly seen in instances of organic cardiac affec- tions. They are supposed to transform the blood-corpuscles into pigment- matter. The physical signs may either be negative—as, for example, when the infarctions are small or deeply located—or they may give information as to the seat and extent of the affected part. When present they are the symptoms of sharply-localized consolidation (increased fremitus, resonance, percussion-dulness, moist rales, and bronchial breathing), and it is not improbable that in many cases the physical signs are due, in great part, to associated conditions, such as bronchitis, edema, or collateral consoli- dation. The appearance of the friction-sound in the course of suspected cases is a great aid in diagnosis. The heart's action becomes enfeebled, the pulse is small and frequent, and the surface of the body is cool and frequently bedewed with cold sweat. Fever may either be present at the onset or absent throughout. The signs of embolic abscesses in the lungs will be elsewhere detailed (vide Pulmonary Abscess). Diagnosis.—To establish the diagnosis of pulmonary embolism there must be a clear history of some etiologic condition, and the sudden appear- ance of such symptoms as dyspnea, cough, bloody expectoration (in par- ticular), chest-pain, loss of consciousness, and convulsions, corroborated by the physical signs of a sharply-defined spot or spots of consolidation. Prognosis.—The prognosis differs with the character of the primary condition. On the Avhole, it is exceedingly grave, though the absorption of an embolism, followed by the disappearance of the urgent symptoms, 510 DISEASES OF THE RESPIRATORY SYSTEM. is not impossible. In case death does not occur soon, infarcts may give rise to abscess or gangrene, the result either of the presence of bacteria in an original embolus or of their entrance through the air-passages. In other cases an infarct may undergo fibroid change and contraction, and may even calcify. Treatment.—Beyond procuring absolute rest of the body and a re- lief from the distressing symptoms, the treatment should be aimed at the affections on which this form of embolism depends. Dyspnea and pain may require the hypodermic use of atropin and morphin, preferably in combination. CHRONIC INTERSTITIAL PNEUMONIA. {Fibroid Induration ; Cirrhosis of the Lung.) Definition.—A chronic inflammation of the lungs, characterized by the formation of fibrous or connective tissue. It may occur as a primary or as a secondary affection. Pathology.—Two leading forms of cirrhosis of the lung may be recognized: (a) Local, and (b) Diffuse, though these do not demand sep- arate description. It is a unilateral affection, and the lung of the side involved is much shrunken, its dimensions in some cases being incred- ibly small. I have seen one instance in w7hich the organ measured four inches in its longest and less than three in its shortest diameter. It lies tightly against the spine, and has frequently been overlooked, the heart occupying the affected side, being drawn in that direction during the progress of the disease. The heart is enlarged, chiefly due to hyper- trophy of the right ventricle, and the pulmonary artery is the seat of atheromatous change. The other lung is overdistended (compensatory emphysema), and may encroach upon the mediastinum. Intrapleural and pleuro-pericardial adhesions may be exceedingly firm and thick on the one hand, and only moderately so on the other, though rarely the pleurae are intact. The cut surface of the affected lung is hard, dry, airless, shiny, and usually light-gray in color (rarely, reddish-yellow), and the lung- tissue cuts Avith great resistance. The mouths of the blood-vessels and bronchi, which are often greatly dilated (bronchiectatic), may be observed gaping in the cut section. Cavities may be wholly or in part due to the superaddition of a tuberculous process, though even Avhen the affection is non-tuberculous they may be quite numerous. Phthisical cavities may often be discriminated by their usual situation at the extreme apex. The lung that is unaffected by the fibroid process is also quite often the seat of tuberculous change. Etiology.—The disease is almost invariably secondary, and very generally accompanies prolonged inflammatory and chiefly local changes in the lungs. It may also follow acute inflammatory processes. Ex- amples of localized interstitial pneumonia are seen in connection with pul- monary tuberculosis, emphysema, syphilis, hydatids, and fibroid indura- tion secondary to thickening of the pleura. Diffuse interstitial pneumonia has a variety of causes : (a) It may fol- low acute lobar pneumonia in cases in Avhich resolution is delayed, and CHRONIC INTERSTITIAL PNEUMONIA. 511 here the fibrinous exudate filling the air-cells becomes organized into connective tissue. Fibrous tissue is also substituted for the alveolar walls. The condition is exceedingly rare, and no instance of the sort has fallen under my own observation. (b) Pneumonia, appearing as a complication in influenza, is very liable to produce chronic interstitial pneumonia. (c) The disease may also result from atelectasis due to compression, as by aneurysms or neoplasms. (d) It most frequently, hoAvever, follows broncho-pneumonia in either its acute or subacute form (Charcot). The process starts in the bronchi and extends to the surrounding lung-tissue, till finally an entire lobe, or even an entire lung, may become involved. Tuberculous broncho-pneu- monia also leads to the production of newT fibrous tissue, but here the pro- cess is a conservative one (vide Pulmonary Tuberculosis), and hence is not to be classed with chronic interstitial pneumonia. (e) The initial lesions may be located in the pleura, and the lung be- come involved as a sequel, and the chief lesions may be located in the adherent pleural membrane, with bands of connective tissue extending into the lung. The bronchi are inflamed and sometimes dilated. Chronic interstitial pneumonia may, however, exist without implication of the pleura, and in view of this fact the primacy of pleural thickenings cannot be granted unqualifiedly when they form a part of the lesions of fibroid induration. The various forms of the disease thus far described arise secondarily. It may also occasionally originate as a primary affection (1) from the inhalation of different forms of dust (vide Pneumonokoniosis). (2) Delafield describes "a special form of lobar pneumonia." He contends that lobar pneumonia terminates only in resolution or in death, and that this special disease, with its production of newly-formed connective tissue, is from the first a special form of inflammation of the lung. This variety runs a subacute or even chronic course, and terminates by crisis. It is an exudative inflammation, with the formation of new tissue from the onset; but the consolidated areas are not so large as in ordinary pneu- monia, and cut sections lack the granular character of the latter. Symptoms.—The patient suffers from cough, which increases in in- tensity with the progress of the affection. There is a mucous, sero-mu- cous, or rarely bloody expectoration; dyspnea occurs early, and fre- quently is present only on ascending heights; and uneasiness, or even pain, OArer the side of the chest involved may be experienced. In cases in which the bronchi become dilated the characteristic symptoms of bron- chiectasis are superinduced. The general symptoms consist merely in a loss of flesh and of strength. Fever is altogether absent. Physical Signs.—Inspection.—The chest-wall of the affected side is re- tracted, while the healthy lung is enlarged (compensatory emphysema). The spinal column is curved laterally. The affected side is fixed during respiration, and the heart is displaced by traction toward the affected side. If the left lung be involved, the apex-beat will be displaced to the left and slightly upward; if the right, the apex-beat will be observed to the right of the sternum. The ribs approximate, thus obliterating the inter- spaces, and the shoulder droops over the shrunken chest-wall. Palpation.—The tactile fremitus is usually increased ; if the pleura be 512 DISEASES OF THE RESPIRATORY SYSTEM. much implicated or thickened, however, fremitus may be decreased. Pal- pation discovers no expansile motion. Percussion.—The percussion-note varies. Dulness is common, owing to consolidation of the lung, but flatness is occasionally met with, and a tympanitic or amphoric note is sometimes elicited over a dilated bronchus. Auscultation.—The breathing is bronchial or more or less sonorous as a rule, and over bronchiectatic cavities it is cavernous or, rarely, amphoric. Near the base it is frequently feeble, distant, and even altogether sup- pressed. Subcrepitant, sonorous, sibilant, or gurgling rales may be audi- ble, and dry, creaking, or leathery friction-sounds may also be heard. Prognosis.—The course of the complaint is exceedingly chronic, and lasts over many years. Death may result from an intercurrent attack of acute pneumonia affecting the other lung. The disease always shortens the duration of life, and less frequently is the direct cause of death. Rarely a fatal issue is due to dilatation of the right heart, followed by tricuspid regurgitation. Treatment.—The condition is incurable. The patient should, how- ever, be placed under the best sanitary conditions, and if practicable he should make a permanent change of climate. A suitable resort should be selected in accordance with the rules indicated in the treatment of Pulmonary Tuberculosis, and every effort should be put forth to improve the general nutrition of the patient. Due attention should be given to the associated bronchitis, as well as to any symptoms that may arise during acute exacerbations. BRONCHO-PNEUMONIA. [Capillary Bronchitis; Catarrhal Pneumonia.) Definition.—An inflammation of the minute bronchi and air-vesi- cles, due either to the extension of inflammation from the capillary bronchi to the air-vesicles or to an inflammatory process set up in ate- lectatic lobules. Pathology.—Macroscopically, the lungs present decided variations in persons who have died of broncho-pneumonia. On the pleural sur- face may be noticed purplish or slaty patches, often sunken (atelectasis), intermingled Avith the more elevated patches of healthy lung and gray- ish consolidation, and smoother and more moist than croupous pneu- monia. Similar appearances are presented by the cut surface. On pressure fluid exudes—edematous from the healthier areas, and gray- ish and puriform from the consolidated areas. The mucosa of the large bronchi may look natural, though frequently it is congested, while the small bronchi usually contain more or less muco-purulent mate- rial. Their walls are greatly thickened, and on section the cut sur- face presents a nodular appearance. Dilatation of the smaller bronchi may be observed, and minute consolidated areas, varying in size from that of a pin's head to that of a pea, may be seen surrounding the thick- ened Avails of the bronchi. When, as frequently happens, they become confluent, large areas—an entire lobe and even an entire lung—of lung- BR ONCHO-PNE UMONIA. 513 tissue may become consolidated. The solidified zones are firm to the touch, being destitute of air, and at first they contain blood ; hence their color is a dark-red, but later it presents a grayish hue. The condition is usually bilateral. As a rule, the bronchial glands are SAvollen and in- flamed. In the non-consolidated portions of the lung the air-cells are found to be considerably dilated. The pulmonary pleura is often coated Avith fibrin, but less regularly than in croupous pneumonia. The essential lesion is a productive inflammation of the bronchi and of the immediately surrounding air-spaces. The inflammation is from the first not exudative, but productive; that is, with the formation of neAV tissue (Delafield). This form of inflammation naturally lasts for a longer time than, would the exudative, and merges into a chronic pro- ductive inflammation of the lung, it may be Avith subsequent sclerosis or chronic thickening of the pleura. The exudate is always more marked toAvard the center of the process, while the air-cells toAvard the periphery shoAV much less exudate. The latter consists of serum, some mucus, and many SAvollen cells from the alveoli (soon showing fatty degeneration), leukocytes, and also red blood-cells in small numbers. Fibrin is seen in small quantity if at all. In deglutition and aspiration pneumonia the leukocytes are in much larger number, and the exudate tends to suppuration, Avhile in the more hemorrhagic forms the red blood-cells are present in larger numbers. Kikodse1 found the blood in broncho-pneumonia to contain an in- creased number of Avhite corpuscles, except in fatal or very severe cases. The cause of this increase appears to be the return into the cir- culation of the corpuscles that have passed into the alveolar spaces; hence it ceases after the fever declines. Among the associated lesions that remain to be mentioned are—(a) Catarrhal inflammation of the mucous membrane of the bronchi; and (b) Exudative inflammation of the air-cells, which become filled Avith epithelium, fibrin, and pus, Avith resulting consolidation of the lung. The epithelial cells lining the air-sacs, since they are more numerous in young children than in adults, form a larger part of the inflammatory exudate in the former than in the latter. Etiology.—(1) A marked predisposing influence is age, the disease being most prevalent amongst young children. In them it may appear in association Avith measles, Avhooping-cough, scarlet fever, and diphtheria, but not infrequently it is entirely independent of these diseases. Infants are especially susceptible to the affection, most instances of pneumonia at this period of life being of the lobular form. Other conditions that act as predisposing factors in children are improper exposure to cold, unsanitary surroundings (especially impure air), rickets, and chronic diarrhea. Broncho-pneumonia is also frequent in the aged, often being occasioned by certain debilitating causes and chronic diseases that are common to advancing years. (2) Season.—The affection prevails especially in the Avinter and spring months; particularly is this the case in those forms that are unassociated Avith the acute infectious group of diseases. (3) It also supervenes as a complication in such acute infectious dis- eases as influenza, typhoid fever, erysipelas, and small-pox, and is of 1 Annual of the Universal Medical Science*, 1892, vol. i. sec. A. 33 514 DISEASES OF THE RESPIRATORY SYSTEM. serious import. According to my own observations, it is more com- monly met with in the diseases above mentioned than is lobar pneumonia. (4) The inhalation of food-particles and other substances often serves to convey the agents of inflammation to the lobules of the lungs. Thus a long-continued recumbent posture disposes the patient to broncho- pneumonia, since it affords a ready entrance to inflammatory irritants. It is, however, in conditions in Avhich the larynx and bronchi have totally or in part lost their sensitiveness—as in coma due to apoplexv, uremia, and allied cerebral states—that retention of bronchial secretions occurs, and that, owing to gravitation, these secretions reach the minute bronchi. Particles of food and drink are also inhaled. Inhalation pneumonia may follow operations upon the nose, mouth, larynx (trache- otomy particularly), and is often secondary to carcinoma of the larynx and esophagus. It is also the pneumonia of neAv-born children. (5) It must not be forgotten that very frequently broncho-pneumonia is caused by the tubercle bacillus (vide Pulmonary Tuberculosis). A sub- acute type may also occur in the course of vesicular emphysema. (6) The Avork of Weichselbaum has shoAvn the presence of strepto- cocci Avith the greatest frequency. The pneumococcus has frequently been found, and in a goodly number of cases the staphylococcus aureus (Neumann, Birch-Hirschfeld), while in influenza the specific organism may itself cause broncho-pneumonia (Pfeiffer and others). Numerous other organisms have been found, and it seems a Avell-established fact that various pathogenic bacteria may cause the disease. Symptoms.—Two clinical forms may be distinguished : (a) primary; and (b) secondary. (a) Primary broncho-pneumonia is met with most frequently in adults, and presents, for the great part, the symptoms of an acute bronchitis of severe grade (cough, dyspnea, pain, fever, and prostration). When oc- curring in subjects previously enfeebled the onset may be someAvhat gradual. The cough is attended with a catarrhal expectoration that is glairy and tenacious, and may be tinted with bright-red blood in the form of droplets or points. The fever is moderate, the temperature rang- ing from 101° to 104° F. (38.3°-40° C), and is of irregular type; in severe cases, hoAvever, continued high temperature may occur. Physical examination gives the same result as in the secondary form (vide infra). The duration is from tAvo to four weeks, the fever terminating by lysis. (b) Secondary broncho-pneumonia is the variety usually met Avith. The symptoms are frequently veiled by those of the primary affection, and, indeed, a moderate grade of lobular pneumonia is frequently unsuspected during life when arising in the course of other grave diseases. It is usually preceded by bronchitis affecting the larger bronchi, and in this common event the first symptom that directs attention to the dis- ease is the sudden increase in the frequency of the respirations, which rise as high as 60 or even 80 per minute. An initial chill is rare. Fever develops suddenly, or, if previously present, increases rapidly. An early symptom is the cough, which is usually hard, harassing, frequently pain- ful, and accompanied by expectoration. The pulse-rate is abnormally fre- quent, and in the later stages may be quite rapid, feeble, and irregular. The type of the fever is similar to that of the primary form. Physical Signs.—At the beginning of the attack the only sign is the BR ONCHO-PNE UMONIA. 515 presence of subcrepitant and sibilant rales, pointing to a general capil- lary bronchitis. Shortly larger or smaller areas of consolidation become manifest. At first rapid breathing, and soon cyanosis, affecting first the lids and conjunctivae, may be observed ; later, the face becomes dusky Fig. 45.—Illustrating broncho-pneumonia. The dark spots represent the consolidated areas; the white dots indicate rales : A, coalescence of two areas of consolidation. and the finger-tips blue. Palpation shows defective expansion and in- creased tactile fremitus over the consolidated areas. The percussion-note is dull or, less frequently, hyperresonant if the area be small. Auscul- tation reveals numerous fine, subcrepitant rales, corresponding to the con- solidated portions. The respiratory murmur may be bronchial, though more often broncho-vesicular. The signs are usually noted in both lungs. Duration.—(1) In children this varies considerably in different cases. Rarely do fatal instances last more than two or three weeks, while they may be as brief as tAvo or three days. On the other hand, cases in which recovery ensues frequently last from six to eight weeks, though in some instances from one to three weeks only. Tavo special forms demand brief description : (a) The cerebral, in which restlessness, convulsions, and delirium be- 516 DISEASES OF THE RESPIRATORY SYSTEM. come so marked as to overshadow entirely the pulmonary symptoms*. Not infrequently the onset is characterized by convulsions, high fever, pros- tration, and alternating stupor and delirium. After such symptoms have continued for from tAvo to five days, pulmonary symptoms appear, while the cerebral decline. (b) Other cases may manifest a subacute onset, in which there is ano- rexia and occasional vomiting, with the nervous symptoms before noted. (2) The protracted forms are those in which (a) the symptoms of acute broncho-pneumonia give place to those of a similar though chronic state. The general disturbances may not be marked in some in- stances, but usually there are cough, loss of appetite, or inability to gain in flesh and strength, and the signs of consolidation persist. (b) Those presenting fever of an irregular type, together with decided prostration, in addition to the symptoms of the preceding variety. In many of the latter instances the lesions are tuberculous in nature. In adolescence the cerebral symptoms are not as well marked as in children. Two anomalous varieties are met Avith in practice that demand brief separate description : General Broncho-pneumonia.—The attack develops suddenly and is severe. There are chills, high fever, marked prostration, headache, chest and loin pains, a rapid pulse (soon becoming feeble), rapid and labored respirations, cyanosis, restlessness, delirium, and cough that is at first dry, and followed by mucous, muco-purulent, blood-tinged sputum. The physical signs are defective expansion and an increased tactile fremitus. The percussion-note may be either normal, tympanitic, or dull ; the auscultatory signs are large moist, subcrepitant, crepitant, sib- ilant, and sonorous rales over both lungs, and a harsh or broncho-vesicular respiratory murmur. The affection is very grave. Resembling Tuberculous Broncho-pneumonia.—The symptoms appear sloAvly, and the case pursues a subacute or even chronic course. Cough, catarrhal expectoration, moderate fever*(often of a hectic type), and night- sweats are noted. Physical examination discloses general bronchitis, together with cir- cumscribed areas of consolidated lung-tissue. Resolution may take place at the end of eight or ten weeks, and complete recovery ensue; when, how- ever, this favorable event does not occur, the case drags on for an indefinite period, and finally terminates fatally. There are no bacilli in the sputum. Diagnosis.—This can be arrived at by considering— (a) The nature of the antecedent affections and their etiologic circum- stances ; (b) The distribution of the consolidated areas in both lungs; (c) The fact that the physical signs of consolidation are subsidiary to those of general bronchitis ; (d) The intense dyspnea and cyanosis ; (e) The type of the fever, irregular as a rule, and its gradual decline; (/) The frequent long duration. Differential Diagnosis.—Doubtless, lobar pneumonia is constantly mis- taken for broncho-pneumonia, and particularly when, in the latter disease, a large portion of one or both lungs becomes inflamed in consequence of the coalescence of small areas of consolidation. The points of distinc- tion may be tabulated as follows : BRONCHO-PNEUMONIA. 517 Broncho-pneumonia. Lobar Pneumonia. Etiology. Presence of pathogenic organisms*l (strep- Presence of the Diplococcus pneumoniae. tococci). Usually secondary to bronchitis and acute Usually a primary disease. infectious diseases {e.g. measles, whoop- ing-cough). Clinical History. Onset gradual. Onset abrupt; previous health generally good. Fever is, in proportion to the extent of Fever is high, of continued type, and inflammation, of irregular type, and falls between the fifth and ninth days declines by lysis after a variable dura- by crisis. tion. Sputum glairy, tenacious, and in adults Sputum characteristic (rusty or prune- may be blood-tinged. juice). Dyspnea and evidence of carbon-dioxid Respiration panting, but dyspnea and poisoning prominent. cyanosis relatively less marked. Physical signs of general bronchitis Signs of bronchitis generally absent, always marked, and usually preponder- those of lobar consolidation always ating over those of consolidation. preponderating. Consolidation commonly bilateral. Commonly unilateral. Duration indefinite, often extending over Duration definite as a rule, convalescence many weeks. following crisis. Consolidated areas liable to become the Far less likely to become the seat of tu- seat of tuberculous infection. berculous infection. It is also difficult to distinguish tuberculous broncho-pneumonia from the disease under consideration. Indeed, a non-tuberculous broncho-pneu- monia may be located at the apex of the lung and accurately simulate the symptoms and signs of the tuberculous form. The differentiation is to be based upon the presence or absence of the signs of softening, and upon a microscopic examination of the sputum (Avhich in a child may be vomited). The softening in tuberculous pneumonia does not, however, begin very promptly; but if elastic fibers and tubercle bacilli be found, the diagnosis is at once set at rest. Prognosis.—In broncho-pneumonia the severity and gravity of the symptoms and the extent of the involvement of lung-tissue are propor- tionate to one another ; hence it follows that the disease may either be devoid of serious import or it may be fraught Avith great danger to life. Its course is subject to decided fluctuations, the periods of exacerbation in the symptoms often marking the time of the development of the gravest features. Apart from the extent of the lung-tissue involved, hoAV- ever, we must consider especially the condition of the patient at the time of invasion. If the constitution has been previously undermined, as is frequently the case in children, broncho-pneumonia is very -apt to be fatal. The disease is less dangerous Avhen it develops in the course of, or follows, measles than when secondary to whooping-cough, influenza, or diphtheria. Wiry, thin children seem to stand broncho-pneumonia better than fat, flabby ones (Osier). Deglutition and inspiration lobular pneu- monia, especially Avhen occurring after operations upon the larynx or 'The diagnostic value of the discovery of streptococci is not pronounced. Numer- ous other organisms have been found in broncho-pneumonia in their absence, and a sim- ilar organism {Streptococcus pneumoniae, YVeichselbaum) has been found in a number of cases of croupous pneumonia. 518 DISEASES OF THE RESPIRATORY SYSTEM. trachea, are frequently fatal. The mortality-rate in this disease varies from 25 to 50 per cent. Treatment.—Prophylaxis.—There are few diseases that can be so effectually prevented as can broncho-pneumonia. In the first place, proper attention to the mouth as well as to the position of the patient (Avhich should be changed frequently) during attacks of acute infectious diseases will prevent its development in a great proportion of this large' class of cases. Adequate protection against exposure to cold during con- valescence from measles, whooping-cough, etc. is also a potent factor in preventing the disease, as is the timely handling of catarrhal affections of the nose, pharynx, larynx, and larger bronchi. Treatment of the Attack.—Certain sanitary arrangements are of the utmost practical importance. The sick-room should be Avell ventilated and its atmosphere kept at a uniform temperature—68° to 70° F. (2<)°- 21.1° C). The air of the room should also be Avell laden with moisture, which may be generated from a croup-kettle or other suitable vessel. Local Measures.—In young children the chest should be enveloped in a jacket-poultice of linseed meal, Avhich should be covered Avith a layer of oiled silk or Avaxed paper so as to prevent its growing cool. This should be reneAved at intervals of about six hours. After the more active symptoms have subsided the linseed jacket-poultice may be re- placed by one of absorbent cotton, Avhich should also be covered Avith oiled silk or Avax paper. In older subjects the application of iced poultices to the chest exercises a most favorable influence, not only upon the local inflammation, but also upon the fever and the nervous system. " In cases in which there is a high fever, tub-baths should be em- ploved, the temperature of the water at first being about 95° F. (35° C), and then gradually cooled to about 80° F. (26.6° C). The gradually cooled bath or the cold pack may be used tAvo or three times daily. The effects are to reduce temperature, to promote re- freshing sleep, and to improve the character of the respiration. This mode of treatment is especially effective in cases that begin abruptly. In such the tincture of aconite or veratrum Alride may be employed temporarily. In cases presenting modern pyrexia cold spongings, com- bined Avith the use of the ice-bag to the head, may suffice. The follow- ing fever-mixture may be employed, though it is not to be regarded as a substitute for the cold-Avater method of treatment, but is merely sup- plemental to the latter : T^. Potassii citrat., sijss (10.0); Spts. ammon. aromat., f.^ij (8.0); Spts. aether, nitrosi, fgss (16.0); Liq. ammon. acetat., f§iij (96.0); Glycerini, q. s. ad fgiv (128.0).— M. Sig. 3J (4-0) every two hours for a child of five years. In children a mild mercurial purge at the outset is advantageous, and subsequently by the use of salines or glycerin suppositories a daily evacuation of the boAvels is to be secured. The bodily strength is to be maintained by careful, methodical feeding, milk, eggs, albumin, and broths being the best forms of food. The milk should be predigested PULMONARY ATELECTASIS. 519 if there be marked pyrexia, and egg-Avhite may be given in cold Avater with a small amount of sugar or in the form of egg-lemonade. The cough is often wellnigh constant and very distressing. Fre- quently the use of remedies that promote secretion, combined Avith a small dose of opium, will, under these circumstances, afford relief. A useful formula is the folloAving: T^. Vini antimonii, 3j (1-0); Spts. seth. nit., sijss (10.0); Tr. opii camph., 3ijss (10.0); Liq. ammon. acetat., q. s. ad £ij (64.0).—M. Sig. 3j (4.0) every tAvo hours, diluted, for a child of from three to five years. Dover's poAvder is also of value in relieving the cough. When the expulsion of the sputum is attended with great difficulty the preparations of ammonium often meet the indications. Of these the muriate is the most effective, but, unfortunately, this is often objected to, and Ave must then rely upon the carbonate or the aromatic spirits. The bronchi may contain an abundance of secretion that cannot be expelled, despite the use of the above measures. Under these circumstances an emetic may be given, composed of the wine of ipecac (sj—4.0), combined with alum (gr. xx to xxx—1.296-1.944), and administered to a child every ten or fifteen minutes until emesis occurs. Cardiac stimulants must be employed as soon as the pulse shoAvs signs of failure, and alcohol and strychnin are required in serious cases. The preparations of ammonium OAve much of their reputation in this disease to their stimulating properties. These agents Avhen boldly used may suffice to re-establish the cardio-pulmonary circulation, but if they fail in this and cyanosis supervenes, oxygen should be used in addition. Sudden heart-exhaustion may occur, associated Avith mu- cous rales in the larger bronchi and rapidly increasing cyanosis. In such instances prompt relief is to be afforded if Ave would save life. Alternating douching Avith hot and cold Avater and electricity should be given a trial. PULMONARY ATELECTASIS. (Collapse of the Dungs ; Compression of the Lungs.) Definition.—Atelectasis of the lungs is a condition occasioned by the removal of the air from the air-cells—a state directly the opposite of emphysema. The air disappears largely in consequence of the process of absorption. Pathology.—The affected lung-spots sink in Avater, being non-crep- itant. They also present through the pleura a bluish-red tint, and on cross-section a brownish-red color. The surface of the affected areas is smooth and depressed beloAv the level of the adjacent lung-structure. The bronchi supplying the collapsed parts are frequently occluded by inflammatory products, but in all cases; as showTn by Legendre and Bailly, the latter may be inflated by means of a blowpipe. 520 DISEASES OF THE RESPIRATORY SYSTEM. Apart from more or less distention of the pulmonary capillaries with blood, there are no histologic changes in the atelectatic areas, though they are of firm consistence (splenization, carnification). There can be no longer any doubt as to the entire propriety of the pathologic distinc- tion between lobular pneumonia and atelectasis. Htiology.—The condition occurs most frequently in the new-born, and is then due to defective respiration. Thus in children dying soon after birth the lower lobes may be found to be atelectatic. When ac- quired, however, there are three modes of production: (1) The first step consists in a more or less complete plugging of the smaller bronchi with muco-pus and other products of bronchial inflammation. If complete, air can no longer enter on inspiration, and as the contained air gradu- ally becomes absorbed atelectasis is the natural result. This condition is very commonly associated Avith broncho-pneumonia, especially in chil- dren. (2) A frequent mode of origin is through compression of the lungs, resulting from positive intrathoracic pressure, after the normal contractility of the lung has been overcome. Instances of this may be produced by pleural effusion, hydrothorax, pneumothorax, pericardial effusion, great cardiac hypertrophy, a solid tumor, or an aneurysm of the arch. Not infrequently abdominal tumors, excessive meteorism, and ascites make sufficient upward pressure against the diaphragm to cause compression of the lower lobes of the lungs. (3) Conditions that Aveaken and obstruct the inspiration may produce this disease, such as certain brain-affections, paralysis of the pneumogastric, and paralysis of the chest-walls. Thoracic deformities may produce pulmonary atelectasis, and in extreme grades of kyphoscoliosis the lung occupying the side cor- responding to the convexity of the spinal column is small. Whilst the lung-expansion and the growth of the organ are greatly interfered with, hoAvever, and particularly if the condition arises in youth, true atelec- tasis rarely occurs from this cause, owing to the natural retractility of the lung. Among conditions arising from deformities of the chest is the so-called aplasia of the lungs. Symptoms.—Atelectasis is a secondary condition, and its symp- toms are very generally veiled by those of the primary disease. It arises frequently in the course of broncho-pneumonia, but passes unno- ticed unless it becomes very extensive. Respiration is carried on by the upper and anterior portions of the lungs, and is increased in frequency and labor. The pulse is small, rapid, and feeble; the skin-surface, especially that of the extremities, is cool. The form presenting the most typical symptoms is that occurring in the neAv-born. It is evidenced by shallow, rapid breathing, livid- ity, cold extremities, a faint Avhining cry, drowsiness, and sometimes by evidences of motor irritation, such as muscular tAvitching and con- vulsions. Congenital anomalies of the circulatory organs are asso- ciated. Physical Signs.—When it involves a goodly portion of the lower lobes posteriorly, as frequently happens, there is marked retraction during in- spiration over the lower portion of the thorax, due partly to external atmospheric pressure, and partly to the contractile efforts of the dia- phragm. Dulness on percussion is revealed, though only when the ate- lectasis is extensive, and the tactile fremitus, though very various, is PULMONARY ATELECTASIS. 521 generally decreased. Localized compensatory emphysema may present semi-tympanitic resonance over small areas of collapse. Auscultation sIioavs a greatly diminished or absent vesicular murmur, and, if the area of collapse be large, bronchial breathing. Among asso- ciated sounds is the subcrepitant rale, due to broncho-pneumonia, and, indeed, capillary bronchitis and atelectasis are often combined, there being, moreover, no reliable signs that Avill separate them clinically. The aplasia of the lung that is produced by spinal curvature (kypho- scoliosis) richly deserves brief separate description, owing to its clinical importance. In many instances the chest is more or less twisted on its OAvn axis, shortened in the vertical diameter, and thoroughly fixed. Under these circumstances lung-expansion is impossible, and hence res- piration is purely diaphragmatic. In many other patients life may be prolonged for an indefinite period, nothing more being observed than slightly labored breathing. Such persons, hoAvever, upon great physi- cal exertion suffer from urgent dyspnea, and the development of an ordi- nary bronchitis may lead to similar results, and even to speedy death. The physical signs are those of localized emphysema, combined Avith those of more or less compression of the lungs. There is an extension of the cardiac dulness to the right, and other evidence of right ventricu- lar enlargement, to which may succeed dilatation Avith the usual clinical events produced by the latter condition. Death is not rarely due to this failure of compensation. Autopsies have shown the lungs to be small and more or less com- pressed, some portions being almost airless. Areas of emphysema of the lungs are often associated. The right ventricle may be found to be hypertrophied merely, or dilatation may also have taken place. Con- genital atelectasis, by keeping up high pulmonary pressure, may lead to a persistence of the ductus Botalli and of the foramen ovale. Diagnosis.—Atelectasis may be distinguished from lobar pneu- monia by the absence of an initial rigor, fever, crepitant rales, and the pain of the latter disease, and by the characteristic inspiratory retrac- tion of the lower portions of the chest and the smaller areas of dulness. Pleuritic effusion gives a flat percussion-note, the upper level of which varies Avith a change in the position of the patient—a sign that is Avanting in atelectasis. Prognosis.—When the condition is limited to small areas it is rarely serious, but equally seldom does extensive atelectasis lead to recovery. The outlook depends to some extent upon the nature of the associated affections; thus, when it is secondary to Avhooping-cough and widespread broncho-pneumonia, it is very fatal. Other diseases that may complicate and increase the gravity of the atelectasis are pleurisy and pulmonary tuberculosis. On the other hand, compensating emphysema often coexists, and is to be regarded as salutary in its effects. When due to compression by pyo-pneumothorax, tumors, and the like, the prognosis is especially gloomy. Treatment.—The treatment corresponds with that of the primary disease. Capillary bronchitis, Avhich is so apt to be folloAved by collapse of the lobules, must receive active treatment, and prophylactic measures are of the utmost practical importance. The patient should be instructed to practise full inspiration at regular intervals ; he should not be alloAved 522 DISEASES OF THE RESPIRATORY SYSTEM. to lie continuously'in the dorsal decubitus, but should be told to change his position frequently. Another measure that may effectually pre- vent the development of a serious condition is the use of cold shoAver- baths (i. e. a stream of cold water poured over the region of the neck), and this can, in some instances, be depended upon as a curative agency Avhen the condition already exists. Tonics and the judicious use of stimulants, together with a nourishing diet, are invariably required. I have also seen good results follow the inhalation of compressed air. In kyphoscoliosis tepid baths are indicated. The heart-condition de- mands careful attention, and cardiac stimulants are to be resorted to at the first loss of compensation or when compensation fails to become established. EMPHYSEMA. Definition.—In general this term implies the presence of air in the interstitial alveolar tissue. As applied to the lungs, however, two forms are recognized: (1) Interlobular; and (2) Vesicular, an abnormal dila- tation of the alveoli. INTERLOBULAR EMPHYSEMA. This is produced by the rupture of the air-cells, the air contained in the lung escaping into the interlobular connective tissue. Among its causes are—(a) Injuries of the lung (usually by a fractured rib) and perforating wounds of the chest; (b) Violent paroxysms of coughing, as in Avhooping-cough ; and rarely defecation, parturition, and hysterical convulsions. When arising in this Avay its favorite situation is the an- terior margin of the upper lobe. Pathology.—In the interlobular septa immediately beneath the pleura air-bubbles are sometimes seen to be arranged in Avell-defined roAvs. The pulmonary pleura may become detached, and the air-tumors may then become as large as an English walnut or even of greater size. Unlike the condition in vesicular emphysema, these sacs are freely mov- able, and the air may find its wTay from the root of the lung into the mediastinal connective tissue, and thence into the subcutaneous tissue of the neck and the Avail of the thorax. Rarely these air-sacs perforate the pleura, setting up pneumothorax, Avith or without pleuritis. Interlobular emphysema is sometimes associated Avith advanced vesic- ular emphysema. VESICULAR EMPHYSEMA. [Alveolar Ectasis.) Definition.—Dilatation or enlargement of the alveoli and infundib- ular passages. Varieties.—The cases are classified into—(1) Compensating, (2) Hypertrophic, and (3) Atrophic forms. HYPERTROPHIC EMPHYSEMA. 523 COMPENSATING EMPHYSEMA. This variety is limited to certain parts of the lung, and arises in consequence of pathologic changes in other parts of the same organ that prevent full expansion of the lung on inspiration. Hence a vica- rious increase in the volume of the air-cells is observed in circumscribed morbid processes such as occur in pulmonary tuberculosis, lobular pneu- monia, cirrhosis, and pleurisy Avith adhesions (particularly when the latter is situated at the inferior border of the lung). An entire lung, unaffected by the primary disease, may be the seat of compensating em- physema Avhen the causal disease invades the Avhole or a greater portion of the other lung, as in cirrhosis, extensive pleurisy with effusion, lobar pneumonia, and pyo-pneumothorax. When, hoAvever, the latter condi- tions are confined to a portion of one lung, the remainder of the same organ becomes distended also. As a rule, this pulmonary change is physiologic and beneficial: only rarely secondary atrophy of the Avails of the air-cells develops, Avhen the latter may coalesce. Symptoms are not presented by the lungs in consequence of the changes met Avith in compensating emphysema. The condition is some- times recognizable by means of the usual physical signs, but even these are not always to be relied upon. Fortunately, its existence may be safely inferred Avhen there is conclusive evidence of the presence of the local causal diseases (broncho-pneumonia, pulmonary tuberculosis, pleur- isy, lobar pneumonia). HYPERTROPHIC EMPHYSEMA. Nature of Emphysema.—The symptoms are dependent upon a loss of elasticity in the lungs, and, the latter condition being the result of overstretching, the contractile energy of the lungs is in great part destroyed; hence they become permanently enlarged. Nor do the em- physematous lungs contract Avhen the thorax is opened, as they do ordi- narily. We may in some cases account for the loss of elasticity in the lungs by the operation of causes that produce an abnormal degree of stretching, either temporarily or constantly; but under these circum- stances emphysema would be developed despite the pre-existence of nor- mal contractility of the lung. In true emphysema, hoAvever, Avhich de- velops at a comparatively early period in life, Ave may safely assume that the retractile energy is defective (probably a congenital condition), and hence in such cases the action of the usual causal factors Avill speedily engender over-distention, or emphysema may develop even in the ab- sence of the usual causal factors. In these instances there is probably a quantitative as Avell as qualitative defect in the elastic-tissue element of the lungs. Pathology.—The thorax is enlarged (barrel-shaped), and upon re- moving the sternum the lungs are found to completely fill the mediasti- num, and do not retract as in health. They present a pale, anemic appearance, and may shoAV dark pigmented patches and streaks, Avhile to the feel they appear soft and feathery, though dry. They readily pit on pressure (a leading characteristic). 524 DISEASES OF THE RESPIRATORY SYSTEM. Immediately beneath the pleura enlarged air-cells can be distinguished macroscopically, and air-sacs as large as a Avalnut or even larger mav present irregular projections above the lung-surface. Occasionally they may be so far detached as to be pedunculated. At the anterior borders a series of air-blebs, resembling a frog's lung, may be observed. In these situations, as well as near the root of the lung, distention is usually more marked than elsewhere. The pleura is also pale, and in patches the pigment may be entirely absent (Virchow's albinism). Upon microscopic examination it is observed that the dilatation starts in the infundibular and alveolar passages. The septa are partially obliterated, the alveolar walls thinned and, lastly, perforated, Avhile in consequence of these changes the air-cells communicate with one another, and thus form larger or smaller air-sacs. The process is an atrophic one, in Avhich the smaller elastic fibers at first disappear, while the larger be- come l#ss prominent and often ruptured. After the latter changes have begun the capillaries likewise disappear, and the epithelium of the air- cells undergoes fatty degeneration, though in the larger bullte a pave- ment layer is retained. The smooth muscular element may also occa- sionally be seen to be hypertrophied (Rindfleisch). The condition from which the clinical phenomena arise is most probably the loss of the capillary blood-vessel system. The bronchial mucous membrane is usually the seat of chronic inflam- mation. It may be roughened and thickened, or the submucous elastic tissue may present prominent longitudinal lines, Avhile the bronchial mucosa is covered with muco-pus. The smaller tubes may be dilated (bronchiectasis), and this condition may be associated Avith hyperplasia of the peribronchial connective tissue. The diaphragm is loAvered and the subjacent viscera correspondingly displaced. The heart is pushed downward and somewhat backAvard, the right side shoAving Avell-marked changes; the caAlties are dilated and hy- pertrophied, due to obliteration of the pulmonary circulation ; and in long- standing cases hypertrophy of the left chambers may also develop. The pulmonary artery and its branches are enlarged and the seat of athe- romatous degeneration. The liver, kidneys, and other viscera present the changes that belong to long-continued venous engorgement. Btiology.—The affection is often secondary to, and develops in consequence of, other affections of the lung—notably, chronic bronchitis and whooping-cough. The dry form of chronic bronchitis, in particu- lar, is apt to generate pulmonary emphysema. Under these circum- stances the disease is directly attributable to the mechanical influences to which the alveolar walls are subjected during respiration. This ab- normal strain attends inspiration to some extent, but mainly expiration, owing to the obstruction to the egress of the air in the smaller bronchi, Avith increased intra-alveolar air-pressure. The increased tension in the air-cells may be accounted for, partly, by the severe and persistent cough, the air being forced during violent coughing into the upper part of the lungs, forcibly expanding them and causing emphysema. Bronchial asthma, on account of the obstruction of the exit of the air from the lungs, produces during the attacks an acute emphysema that may result finally in a condition of permanent over-distention. Certain occupations, such as bloAving Avind-instruments, or those that HYPERTROPHIC EMPHYSEMA. 525 entail severe muscular strain (e. g. blacksmithing), act as predisposing causes, and hence emphysema is of common occurrence among the working classes, and is more common in males than females. The dis- ease is often hereditary, there frequently being several sufferers in the same family. During advanced years the lung-elasticity often dimin- ishes, and as a consequence a disposition to emphysema is engendered. On the other hand, emphysema is not infrequently met with in children, and in such there may be a respite during early adult life, Avith a recur- rence at a later period. An emphysematous tendency also results from congestion of the lungs associated Avith mitral valvular disease. Clinical History.—In nearly all cases the disease develops insidi- ously, the symptoms being gradually added to those of the primary affec- tions (chronic bronchitis, asthma, etc.). When due to the occupation of the patient its development is also sIoav, and not infrequently its origin dates back to childhood or beyond the recollection of the patient. Rarely it may exhibit a more acute development, as, for example, after Avhoop- ing-cough. The first symptom is a variable degree of dyspnea, and to this may be added temporary cyanosis and cough. The severity of the dyspnea varies Avith the degree of distention of the air-cells, even though addi- tionally aggravated by the coexistence of chronic bronchitis, asthma, etc. In moderate emphysema the dyspnea is only apparent on going up stairs, running, Avalking rapidly, or after a hearty meal; on the other hand, in advanced grades of the affection it is constant, and is intensified by the slightest exertion, even to orthopnea. Speech is inter- fered Avith, the patient's utterances taking the form of fragmentary sentences or syllables. The labored breathing is shoAvn particularly in expiration, and, as in asthma, in Avhich the alveolar spaces are acutely distended, so in emphysema the rhythm of the respiration is changed. The inspiration is shortened, and the expiration is greatly prolonged and accompanied by Avheezing Avhen chronic bronchitis coexists. In the later stages cyanosis becomes more marked, and is noticeable in proportion to the loss of compensation and interference Avith the car- dio-pulmonary circulation. It often attains to an extreme degree, and the patient's alarming appearance may be in striking contrast Avith his apparent degree of comfort. In mild forms the cyanotic tint is con- fined to the lips, lobes of the ears, and the extremities. Any increase in the degree of dyspnea after exertion results in an increased blueness of the surface. The cough is dependent upon the presence of chronic bronchitis, and the latter disease is frequently found in combination, particularly during the Avinter. There is also an expectoration that is identical Avith that of chronic bronchitis, and when this disease reaches an advanced stage the cough persists throughout the year (vide Chronic Bronchitis). In- tercurrent acute attacks of bronchitis are often followed by temporary attacks of asthma; and since chronic bronchitis in its highest grades is met with at an advanced period of life, so, as Avould be expected, the cases of advanced emphysema are also met Avith at the same period. Osier has described a group of cases occurring in patients " from twenty- five to forty years of age Avho, winter after winter, have had attacks of intense cyanosis in consequence of an aggravated bronchial catarrh." 526 DISEASES OF THE RESPIRATORY SYSTEM. These patients are short-breathed from infancy, and their condition is attributed to a primary defect of structure in the lung-tissue. General Symptoms.—There is an absence of febrile movement; the pulse is not increased in frequency, though sometimes feeble; and the temperature of the body is generally subnormal. There is a very gradual loss of flesh and strength, and the patient is stoop-shouldered, present- ing a peculiar cachectic appearance—a condition that is in strong con- trast with the dusky appearance of the face, the SAvollen neck, and the enlarged chest. Finally, other symptoms may be mentioned that are for the most part secondary to hypertrophy, folloAved by dilatation, of the right ven- tricle. This hypertrophy is the result of pulmonary congestion and obliteration of the pulmonary capillaries induced by the emphysema. Under these circumstances severe attacks of cough occur, attended with extreme dyspnea and lividity, and later the conditions that usually suc- ceed a moderate grade of tricuspid insufficiency supervene, such as con- gestion of various viscera and edema of the feet. Anasarca is rare. Physical Signs.—The shape of the chest is much altered: owing to the increased antero-posterior diameter, it becomes barrel-shaped (Fig. 46), and the sternum bulges, as do also the costal cartilages. The infraclavicular and mam- mary regions are also promi- nent, and give the thorax an abnormally rounded appearance. The episternal notch is deeper than the normal, the clavicles and muscles of the neck are unduly prominent, and the neck itself appears to be shortened, OAving to the elevated position of the clavicles and the ster- num. There is an antero-pos- terior curvature of the spine and a winged condition of the scapulae—changes to which the stooping posture is ascribable. BcIoav, the thorax appears con- tracted. The intercostal spaces are Avidened and depressed, and a network of dilated venules fre- quently extends laterally above the inferior costal border, but is by no means characteristic of the affection. The movements of the chest are vertical rather than expansile, and the lungs are constantly in a state approaching full expansion; in the lower thoracic and upper abdominal regions there may be observed retraction rather than expansion during the act of inspiration. The respiratory acts, as a Avhole, are labored, and the diaphragm and ab- dominal muscles are seen working with relative violence. The heart's apex-beat is invisible, but marked epigastric pulsation is frequently Fig. 46.—Barrel-shaped chest in emphysema. HYPERTROPHIC EMPHYSEMA. 527 noticeable. A transverse linear depression across the abdomen, on a level Avith the loAver ribs, may also be present during inspiration. Ven- ous pulsation may be seen in the neck after failure of the right ventricle has occurred. On palpation the character and direction of the chest-movements may be accurately appreciated. The tactile fremitus is decreased, but not absent. In adAranced cases the apex-beat cannot be felt, and even in the earlier stages it becomes more and more enfeebled. OAving to displacement of the heart and engorgement of the right ventricle there is a distinct systolic shock over the ensiform cartilage, and also a pul- sation in the epigastrium. Percussion yields a characteristic hyper-resonance. This may be distinctly " Skodaic " or semi-tympanitic, and in extreme dilatation of the air-cells the tone may be Avoodeny. The area of cardiac dulness, OAving to the fact that the lungs overlap the heart, becomes lessened and finally obliterated ; Avhile the upper limit of liver-dulness, both ante- riorly and posteriorly, is found to be one or two interspaces lower than normal, OAving to the fact that the diaphragm is depressed. The upper level of splenic dulness is also loAvered, and the area of percussion- hyper-resonance extends higher above the clavicle than naturally. On auscultation the inspiration is short and feeble, while the expira- tion is greatly lengthened, the ratio of these sounds as to duration being reversed as compared Avith the normal. Their pitch is someAvhat Ioav- ered, particularly that of expiration; and Avhen rales are present the respiratory murmur (particularly the inspiratory) may be scarcely audible. In Avell-marked instances of emphysema inspiration and expiration may rarely be of equal length. It is a fact Avorthy of emphasis that the parts of the lungs that are not so markedly emphy- sematous as others give a harsh, exaggerated vesicular murmur, owing to the great efforts of breathing. Rales of various sorts are frequently audible, due to bronchitis, Avhich, it must be recollected, accompanies emphysema in a majority of instances ; less frequently the auscultatory signs of asthma, pleuritis, and phthisis are encountered. Rarely, rub- bing sounds, that have been attributed to the friction of enlarged air- cells against the pleura, are audible, and Avhen the interlobular variety supervenes upon vesicular emphysema a crumpling sound is heard. The so-called " Laennec's rdle," which resembles someAvhat the subcrepitant rale, is not infrequently present. The vocal resonance varies from an almost total absence to a greatly increased intensity. The tricuspid in- sufficiency that develops late in this affection is betrayed by its charac- teristic murmur. Diagnosis.—A positive diagnosis may be arrived at from a consid- eration of the history, including such points as heredity, occupation, the long duration of the condition, together Avith the most characteristic symptoms (dyspnea, cyanosis, signs of chronic bronchitis), and from the physical signs. In a case of beginning emphysema, particularly among children, a certain diagnosis is not to be attempted. Differential Diagnosis.—Pneumothorax is the disease most apt to be confounded with emphysema. It develops suddenly, however, while emphysema is of slow development, and the rational symptoms of pneumothorax are more constant and urgently distressing than those of 528 DISEASES OF THE RESPIRATORY SYSTEM. emphysema. Pneumothorax is unilateral, and gives a purely tympanitic percussion-note, while hypertrophic emphysema is bilateral and its per- cussion-note is hyper-resonant. Auscultation in pneumothorax usually gives amphoric breathing, metallic tinkling, the characteristic succussion splash, and an absence of the vesicular murmur; all of which symp- toms are very unlike the auscultatory signs of emphysema. Another affection giving rise to dyspnea, cough, and cyanosis is pleurisy with effusion, but the sIoav course, the absence of fever, and the universal hyper-resonance that characterize emphysema do not be- long to pleurisy. The latter affection is usually unilateral, and over its seat a flat percussion-note is obtained. Prognosis.—Hypertrophic emphysema of acute form (e. g. result- ing from Avhooping-cough) is often curable; but the usual slowly- generated variety, so far as recovery is concerned, gives a totally un- favorable prognosis. In many cases, however, life is not materially shortened. Temporary improvement is possible when the lesion con- sists merely of a distention of the air-cells, and this is shoAvn by a corresponding improvement in the physical signs. The effect of frequently recurring attacks of bronchitis is only to intensify the symptoms of a disease that is innately progressive. Intercurrent affections, however, such as pneumonia (lobar and lobular) and pulmo- nary tuberculosis, may prove fatal. Dropsy, following broken compen- sation, is often a late and dangerous complication; other late accidents of the disease are hemoptysis and sudden dilatation of the right heart. Individual circumstances, such as the patient's social condition, the stage of the affection in which he comes under proper treatment, and the degree of care he is willing to exercise, greatly influence the out- come of the case. Treatment.—The treatment is to be directed toAvard the removal of the causes of emphysema, and chiefly of the chronic bronchitis. From personal observation I am fully convinced of the fact that the progress of the disease can be arrested, and that the condition is some- times improved, by relieving the chronic bronchitis. The iodids (po- tassium, sodium, and ammonium) will sometimes produce effects that are truly remarkable, and the syrup of hydriodic acid may be employed Avhen the iodids are not Avell borne by the stomach. If the occupation of the patient tends to aggravate the disease, it must be forsaken for one that is less harmful. Violent paroxysms of cough also contribute to the production of alveolar distention, and hence must be alleviated promptly. Intercurrent attacks of asthma have a similar effect, and must be relieved as speedily as possible by a resort to appropriate ther- apeutic measures. Attacks of acute bronchitis are to be prevented, if possible, by suitable clothing, by avoidance of exposure to inclement weather, dust, and the vitiated atmosphere of overcroAvded halls, churches, and the like; Avhenever practicable the result can be most successfully obtained by a residence in an equable climate. Since a severe bron- chitis is apt to increase the severity of the emphysematous symptoms, it must be cured as rapidly as possible. As soon as passive congestion, flatulence, and constipation, with other gastro-intestinal symptoms, appear, the diet will demand careful regulation, and especially a restriction in the use of carbohydrates. GANGRENE OF THE LUNGS. 529 The bowels must also be moved regularly with a view to obviating the flatulence and portal engorgement. The heart needs to be carefully Avatched, and as soon as signs of broken compensation appear digitalis and strychnin will be found highly useful. Diuretics and cathartics may also become necessary. The sudden development of urgent dyspnea (or orthopnea) and extreme lividity, especially if associated with weak cardiac action and a rapid, feeble, irregular pulse, calls for free bleedings, and more than once in the course of my hospital practice have I seen the lives of patients suffering from emphysema saved by timely venesection. Besides meeting the pathologic and symptomatic indications, we should aim to assist the patient in expiration, and Gerhardt has sug- gested systematic mechanical compression of the thorax during expira- tion as a useful measure. This external pressure must be made by an attendant, Avho places his hands flat on the lower lateral portions of the thorax, and the manipulation is to be continued for from ten to fif- teen minutes daily. The results obtained by certain German authors have been encouraging, but in my OAvn hands the method has failed, except in tAvo instances occurring in young adults with yielding chest- walls, in Avhom it Avas of the greatest service. The pneumatic treatment, comprising the inhalation of compressed air and the breathing into rarefied air, richly deserves further trial,1 its use having been productive of permanent improvement in a number of cases, as shown by physical examination (including mensuration). SENILE EMPHYSEMA. This variety is in reality a senile atrophy of the lungs, and has been appropriately termed " small-lunged emphysema " by Sir Wm. Jenner. In consequence of the complete atrophy of the alveolar Avails, coalition of the air-cells takes place, with the production of large air-sacs. The lungs contain less than the normal volume of air, instead of an abnormal quantity as in true hypertrophic emphysema, and as a result occupy less space in the chest-cavity than do healthy lungs. The pulmonary tissue elements are deeply pigmented. The condition does not produce right ventricular hypertrophy. The Symptoms are negative, although subjects in whom senile em- physema develops may have previously had chronic bronchitis Avith more or less dyspnea. They quite frequently present a withered ap- pearance, and the chest on inspection is seen to be contracted, owing to the fact that the ribs approximate more closely and take a more oblique direction than in health. Treatment is unavailing. GANGRENE OF THE LUNGS. Pathology.—The affection presents itself in two forms—as a (a) diffuse, and a (b) circumscribed process. (a) The diffuse variety is rare. It may, however, be met with in 1 Waldenburg's portable apparatus is convenient for use. 530 DISEASES OF THE RESPIRATORY SYSTEM. lobar pneumonia, and very rarely in consequence of occlusion of the large branch of the pulmonary artery; it may also be secondary to the circumscribed form. The greater part of the lobe, or even an entire lung, may be involved, the pulmonary parenchyma degenerating into a putrid, greenish-black, pulpy mass, with no obvious line of demarcation. (b) The circumscribed form may involve either one or both lungs, though the right is affected someAvhat oftener than the left. To this category belongs the so-called embolic gangrene, the nodules of Avhich have their favorite seat in close proximity to the pulmonary pleura. All etiologic varieties of the circumscribed form more frequently implicate the lower than the upper lobe of the lung, occurring in sharply defined areas, which may either be single or multiple. The affected area first presents a greenish-broAvn appearance; its central portion soon under- goes softening, and a cavity is thus formed Avhose Avails are ragged and irregular and contain a foul-smelling, dark, greenish liquid. The sur- rounding lung is inflamed, and the air-sacs contain inflammatory prod- ucts (fibrin, epithelium, pus), while the highly-irritating and putrid material sets up an intense bronchitis. These gangrenous foci may in- crease in size by a peripheral extension, and thus the adjacent veins may become plugged Avith infectious thrombi or the vessels may become eroded. Emboli may then be detached from the infectious thrombi, and, entering the circulation, may set up foci of septic inflammation in re- mote organs. A truly remarkable connection exists betAveen circum- scribed gangrene of the lung and cerebral abscess. When the gangren- ous spot is situated near the pleura, simple or gangrenous pleurisy may arise as a complication, or the pulmonary pleura may be_ perforated and pyo-pneumothorax result. When recovery ensues the cavities formed as the result of the conversion of lung-tissue present a limiting wall of dense connective tissue. Such cavities may remain permanently or may slowly become contracted. Etiology.—Gangrene of the lungs is caused by the bacteria of putre- faction (probably the staphylococcus albus or aureus). The disease is rare, even though the opportunity for inhaling the bacteria that cause it is a constant one. It is only Avhen the lung-tissue has become im- paired or peculiarly altered that the specific bacteria are capable of pro- ducing gangrene. It may occur in several Avays : (1) Secondary to lobar pneumonia, hemorrhagic infarctions, cavities in the lungs, bronchiectasis, Avounds of the lung, contusions of the thorax, carcinoma of the esophagus, or to compression or embolism of the pulmonary artery or of the bronchial vessels. (2) As an embolus, derived from a gangrenous area in some other organ of the body, it may lodge in the lung and set up putrefactive changes. (3) Pressure from a thoracic aneurysm may give rise to gangrene. (4) The most important causal factor, hoAvever, is the entrance of foreign bodies, especially bits of food, into the bronchi and lungs. Whether or not the specific bacteria of putrefaction enter the lungs with the foreign bodies, the latter render the tissue-soil receptive to the former, and once the process has been initiated it is apt to extend itself. There are several ways in Avhich these foreign particles gain entrance into the bronchi and lungs: (a) By a faulty swallowing of the food; (b) GANGRENE OF THE LUNGS. 531 By inhalation; (c) By a carcinomatous perforation of the esophagus into the bronchus or into the lung. (5) In the course of debilitated states of the system, as during con- valescence from protracted fever (rarely), and in diabetes mellitus (frequently). Symptoms.—These are local and general, the former alone being diagnostic. Local Symptoms.—There is cough accompanied by an exceedingly fetid expectoration that is usually quite profuse. When abundant, and Avhen expectorated into a conical glass and alloAved to stand for a time, it separates into three layers: (a) the uppermost, being frothy, opaque, and of a grayish-yelloAv color; (b) the middle, clear and Avatery ; and (c) the loAvest, appearing as a greenish-brown sedi- mentary layer containing shreds of lung-tissue and sometimes blood. The microscope shows it to consist of numerous elastic fibers, bacteria, fat-crystals, muco-pus, granular matter, and leptothrices. Small quan- tities of blood in the sputum are very common. Kannenburg and Streng have also described ciliated monads as occurring in the sputum. The patient's breath is, as a rule, intensely fetid, even though there be no expectoration, but this fetor of breath may be absent, as in a case of my own (Avhich came to autopsy), in which the localized gangrenous process had no fistulous connection with the bronchus. It is to be recollected that if any of the large branches of the pulmonary artery be eroded, free and even fatal hemoptysis will result. Physical Signs.—The physical signs are sometimes obscure, as when the areas involved are smaller and deeply situated, and in such instances signs of bronchitis only may be detectable. When large and favorably situated, hoAvever, the affected spots usually give signs of consolidation, rapidly folloAved by those of cavity. In addition bronchial rales—usually moist—and coarse cavernous rales are usuallv audible. It is obvious that Avhen the pleura is implicated the signs of pleurisy are added, and if pneumothorax be present those belonging to the latter condition also. The chief general symptoms are irregular fever, emaciation, and profound prostration. A septic condition of the system is commonly developed, and the patient sinks from exhaustion. Rarely there may be an almost total absence of constitutional disturbances, and such instances terminate in recovery. Diagnosis.—The distinctive feature is the intense fetor both of the sputum and the breath. The physical signs may readily determine the existence of the pulmonary lesion, but it is difficult to eliminate abscess and fetid bronchitis associated with bronchiectasis. The results of a careful examination of the sputum, together Avith the less horribly fetid odor of the breath, in abscess Avill usually suffice to eliminate the latter affection. In fetid bronchitis the fetor of the breath and sputum is also less marked than in gangrene, while its course is slower and more favor- able than that of the latter affection. Prognosis.—The prognosis is always grave, though rarely recovery in circumscribed gangrene of the lungs ensues. The chief dangers are exhaustion and hemorrhage. Improved methods of surgical treatment, however, have saved life in a few instances, and promise to reduce still further the mortality-rate of this serious affection. 532 DISEASES OF THE RESPIRATORY SYSTEM. Treatment.—The leading indications are— (a) The disinfection of the gangrenous focus or foci in the lungs. This may be accomplished by the internal administration of creasote or carbolic acid or by the use of the antiseptic spray. In a recent case the employment of Robinson's inhaler, charged with equal parts of creasote, alcohol, and chloroform, gave encouraging results. (b) The patient's nutrition must be maintained, if possible, by a con- centrated liquid diet, administered in fixed quantities and at regular intervals; also by the judicious cultivation of the digestive functions, together Avith the use of stimulants and tonics. For a description of the surgical treatment of gangrenous cavities of the lungs the reader is referred to special Avorks on surgery. It is the physician's duty, how- ever, to determine Avhether or not the patient's general condition will admit of surgical interference, and also to localize as nearly as may be the affected zones for the surgeon's guidance. ABSCESS OF THE LUNGS. {Suppurative Pneumonitis.) Pathology.—This affection is characterized by the formation of pus and the degeneration of lung-tissue. It may be (a) a mere infiltra- tion of the blood-vessels, bronchi, or interstitial tissue, but more fre- quently purulent inflammation of the lungs takes the form of (b) an ordinary abscess. In size the abscesses range from that of a walnut to an apple, and I have observed in one case inflammation of the Avhole of the middle lobe of the right lung. The abscess-walls are irregular and decidedly ragged; and in the case of old lesions there is a dense fibrous wall; the contents are purulent and rarely necrotic. If the contour of an abscess touches the pleura, empyema is the usual result, though sero- fibrinous pleurisy may rarely follow. Rupture of the abscess into the pleura may also occur. Utiology.—Streptococci are found, though they are not the only direct causes of abscess of the lung. The diplococcus pneumoniae and Friedliinder's bacillus have been noted, as well as certain other pyogenic organisms. Predisposition is noted in certain conditions, as (1) during or folloAving the occurrence of inflammation, as in lobar and lobular pneumonia. Suppurative infiltration, however, more frequently arises under these circumstances than abscess, and in the rare instances in Avhich the latter occurs it is apt to be comparatively small and multiple. In all forms of inhalation and deglutition broncho-pneumonia, hoAvever, abscess of the lung is a frequent sequela. (2) Perforation of the lung from Avithout or from adjacent organs, as in carcinoma of the esophagus, abscess of the liver, or suppurating hyda- tid cyst. (3) Infectious emboli, found in connection Avith septico-pyemia, fre- quently cause metastatic abscesses in the lungs. In a mechanical manner they may produce hemorrhagic infarctions, followed by suppuration, or the latter process may occur independently of the former. The abscesses PNEUMONOKONIOSIS. 533 are usually situated close to the pleura, and are frequently Avedge-shaped; thev vary in number from one to several hundred, and in size from a pin's head to an orange. (4) Abscess of the lung may result from imvard extension of a puru- lent pleurisy; and, oppositely, purulent pleurisy may result from an extension of abscess of the lung. (5) As elseAvhere stated (vide Pulmonary Tuberculosis), suppuration is quite generally associated Avith chronic pulmonary tuberculosis. Symptoms and Diagnosis.—The examination of the sputum is of the greatest value in the diagnosis of this disease, since, being puru- lent, it usually presents a yellow, or less frequently a greenish- or broAvnish-yellow, color. It emits a fetor that is less pronounced than that of either gangrene or putrid bronchitis. Particles of lung-tissue may be visible in the pus, and on microscopic examination of the latter, elastic fibers, the presence of which is of the utmost importance in the diagnosis, may be found in profusion. Next to the investigation of the sputum, the physical signs of cavity are of the greatest assistance in distinguishing abscess of the lung; these, hoAvever, are wanting unless the abscess is of a considerable size. By themselves, the signs of cavity do not suffice for the recognition of abscess, but AAThen combined with the characteristic sputum leave no room for doubt. The history of indi- vidual cases is of considerable importance, as confirming the more characteristic features. Thus antecedent pneumonia or septico-pyemia would be strongly corroborative. Prognosis.—The prognosis is often hopeless, as, for example, when the disease is associated with pyemic processes in other parts of the body. On the other hand, those rare instances in Avhich it is secondary to pneumonia give a comparatively favorable prognosis. Treatment.—The chief aim in the therapeusis should be to sup- port the system by the administration of tonics, stimulants, and anti- septics, as Avell as by methodic feeding Avith light and concentrated forms of nourishment. Inhalation of antiseptic sprays (creasote, thy- mol) should be tried. When the abscess is situated near the periphery of the lung, surgical interference is to be advised as soon as the first indications of increasing weakness appear. For the details of the ope- ration of pneumonotomy for pulmonary abscess the reader is referred to special works on surgery. The statistics of Eichhorst,1 shoAving its favorable results, may, however, be mentioned, as follows : in 13 opera- tions recovery or improvement Avas noted in 6, while fatal terminations occurred in 7. PNEUMONOKONIOSIS. {Anthracosis, Chalicosis, etc.) Definition.—A form of chronic interstitial pneumonia that arises from the inhalation of dust-like particles. Different terms have been applied to the condition according to the nature of the dusts inhaled, the chief among these being—(1) Anthracosis (coal-miner's disease), 1 Specielle pathologie, Bd. 1, S. 519. 534 DISEASES OF THE RESPIRATORY SYSTEM. due to the inhalation of coal-dust; (2) Chalicosis (stone-cutter's phthi- sis), caused by the inhalation of mineral dusts; and (3) Siderosis, caused by inhaling metallic particles, particularly iron oxid. (1) Anthracosis.—Among dwellers in cities a moderate degree of pigmentation of the lung-tissue with coal-dust is the rule, while in those residing in rural districts the condition is decidedly less common. True anthracosis, hoAvever, has reference to such an accumulation of the car- bon particles as can be due only to the inhalation of a well-laden atmo- sphere, or under circumstances when the mucous membrane is unhealthy or without perfect ciliary action. Under such circumstances the normal scavengers of the respiratory organs—the mucous corpuscles lining the trachea, the bronchi, and the alveolar cells—fail to deal successfully with the numerous dust-particles that gain entrance along with the inspired air; hence some of the latter pierce the mucosa and reach the lymph-spaces and lymph-vessels. On reaching the bronchial mu- cosa they become enclosed in leukocytes, mucous corpuscles, and alve- olar cells, and are conveyed by the latter to a more remote destination. Arnold shows that after the particles enter the lymph-system they are carried " (a) to the lymph-nodules surrounding the bronchi and blood- vessels; (b) to the interlobular septa beneath the pleura, where they lodge in and betAveen the tissue-element; and (c) along the larger lymph- channels to the substernal, bronchial, and tracheal glands, in which the stroma-cells in the follicular cord dispose of them permanently and pre- vent them from entering the general circulation." Rarely the carbon particles may find their way into the general circulation; this may occur, as shown by Weigert, when the pigmented bronchial glands be- come adherent to the pulmonary veins, thus giving opportunity for the escape of the carbon granules into the blood. Anthracosis leads, primarily, to chronic bronchitis, to be soon fol- lowed by emphysema; but it must be recollected that extensive anthra- cosis may be present without any other changes in the lung than the presence of carbon particles stored in the protoplasmic cells. The lung- tissue presents great variations in its degree of susceptibility to these foreign particles. Sooner or later, there is usually produced, as the result of their irritant action,1 a proliferation of the connective-tissue elements—i. e. a chronic interstitial inflammation. This fibroid change usually starts in the peribronchial lymph-structures, though the bronchial and tracheal glands are, as a rule, similarly involved at a comparatively early period. The affected lung-tissue is frequently coal-black, dense, and airless. The pneumonokoniotic areas vary greatly in size and numbers, and not infrequently they coalesce, in which case large portions of the lung-tissue may become the seat of fibroid change. The alveolar walls are observed to be much thickened in some instances, and firm pleuritic ad- hesions exist. Bronchiectatic cavities may be present, and later necrotic softening of the indurated areas occurs, leading to the formation of small cavities that contain a dark fluid. When the latter communicate with the bronchi their walls are prone to ulcerate. I have noticed that the process almost invariably terminates in pulmonary tuberculosis, and par- 1 Cohnheim contends that coal particles do not produce irritative changes in the lung, and that the latter are due to irritating substances inhaled with the particles of coal. PNE UMONOKONIOSIS. 535 ticularly is this true of cases that folloAv the inhalation of mineral and vegetable dusts. (2) Chalicosis.—Changes similar to those previously described are in- duced in the pulmonary connective tissue by the inhalation of stone- dust by those who follow certain occupations, such as stone-cutting, knife- and axe-grinding, and millstone-making. The irritating proper- ties of this form of dust cannot be denied, as shown by the great dispo- sition in this subvariety of pneumonokoniosis to the formation of fibrous nodules and diffuse areas of sclerosis in the lungs. The nodules have a gray center and a darker periphery; they are exceedingly dense, and sections are made Avith much difficulty. The cut surface may present a grayish and distinctly glistening appearance. (3) Siderosis.—This term implies a collection of iron oxid in the lungs, also due to the pursuit of certain occupations (dyeing, iron- smithing, etc.). Cases of much the same nature are caused by the in- halation of vegetable dusts by grain-shovellers, cotton-spinners, cigar- makers, etc. The pathologic changes are identical Avith those in anthra- cosis, though the color-appearance is red instead of black. Symptoms.—Rarely the onset is marked by the symptoms of acute, followed by those of chronic, bronchitis; but in a vast majority of in- stances chronic bronchitis gradually develops after long exposure to the action of the exciting cause. The symptoms of emphysema are soon superadded, the patient now suffering from dyspnea, and less frequently from asthma. The sputum is diagnostic in anthracosis, being quite dark; in chalicosis a microscopic examination is essential to show the particles of silica; while in siderosis the expectoration presents a red- dish color. Apart from the foreign particles, the sputum is for a long period of years muco-purulent in character, and later it often contains the tubercle bacillus. The physical signs are not distinctive, being identical with those met with in chronic bronchitis associated with emphysema, and folloAved by .those of interstitial pneumonia, and sometimes by those of cavity. The diagnosis is to be made both from the history and from a gross or microscopic examination of the sputum. It may be confirmed by the invariable presence of the signs of bronchitis and emphysema, as Avell as by the effect of removal to an atmosphere free from dust. In the later stages the detection of infallible evidences of phthisis only serves to corroborate the earlier diagnosis of pneumonokoniosis. The prognosis is favorable in hygienic surroundings until the more advanced stage is reached. The condition favors the invasion of new groAvths (lympho-sarcoma, or cobalt-miner's disease; vide infra). Treatment.—A change of occupation or several hours of exercise in the open air daily for those who are exposed to dust in work-rooms should be advocated. The active treatment is the same as for chronic bronchitis and em- physema from other causes, and is to be appropriately modified when pulmonary tuberculosis develops. 536 DISEASES OF THE RESPIRATORY SYSTEM. NEW GROWTHS OF THE LUNGS. CARCINOMA OF THE LUNG. All varieties of carcinoma have been met Avith in the lung, but, with rare exceptions, carcinoma of this organ is secondary to similar groAvths in other parts of the body. To explain its origin it may safely be assumed that the primary new growth involves a vein or lymph-channel, and that the latter carries the germ of the disease to the lung. It is also to be recollected that it may result from extension, or by contiguity from neighboring organs (as the esophagus, mamma, pleura, or mediastinum). Etiology.—The causes of primary carcinoma of the lung must be, in the main, identical Avith those of carcinoma in general, and are as yet unknoAvn. Most cases occur in middle-aged persons, and, Avhile sex has no influence upon the appearance of the primary form of the disease, the secondary form is more frequent in the female than in the male. In the female secondary carcinoma of the lung is often preceded by car- cinoma of the breast. We may also regard hereditary influence as a potent predisposing factor. Secondary carcinoma of the lung is most commonly consecutive to primary carcinoma of the bones, and of the digestive and urinary tracts. Pathology.—The pathologic varieties of the primary form are scirrhous, encephaloid, and epithelioma, and of these the latter is the most common. Primary carcinoma is usually unilateral, the tumors at- taining to a massive size and frequently involving the greater part of one lung. Their favorite seat is in the upper part of the right lung, though the pleura is quite often invaded by the carcinomatous process. Less frequently there is pleurisy with sero-fibrinous exudate, which may be hemorrhagic. Carcinomatous involvement of the cervical, bronchial, and tracheal lymph-glands is quite usual, and rarely even the inguinal glands become implicated. Secondary carcinomata are, as a rule, multiple, and may be miliary in size. They are disseminated Avidely throughout both lungs, though in the rarest instances they may be unilateral. In the softer varieties the central portion of the tumor-mass may undergo fatty degeneration, with subsequent discharge through adjacent bronchi. Symptoms.—The symptoms of carcinoma of the lung vary accord- ing to the location and extent of the disease. Among the most marked symptoms belongs pain, particularly when the pleura is implicated. As a rule, for a considerable period of time the symptoms of bronchitis obtain, and later the breathing-space is diminished sufficiently to excite dyspnea and cyanosis. With the increase in size of the neAv growth compression of the heart, aorta, and large veins may result, whereupon disturbances of the circulation will arise. The new growth may exert pressure on the esophagus, causing dysphagia; or upon the recurrent laryngeal nerve, causing aphonia and hoarseness; or on the trachea or a main bronchus, followed by the symptoms of stenosis of those organs. There are cough and expectoration, the latter frequently containing blood-corpuscles with mucus, and resembling in appearance currant- jelly; the sputa may also rarely exhibit a grass-green color, due to trans- formation of the blood-pigment. In carcinomatous lungs putrefactive changes sometimes take place, and if so the expectoration and breath SARCOMA OF THE LUNG. 537 emit an offensive odor, while a microscopic examination of the sputum frequently discloses the presence of carcinomatous elements. The well- known cancerous cachexia invariably develops. Physical Signs.—These will naturally depend upon the extent and location of the neAv growth. Inspection.—If the lung-tissue be exten- sively involved, the Avails of the thorax become unduly prominent and fixed over the seat of the tumor. Indeed, the tumor may, though rarely, protrude between the ribs. The intercostal spaces are widened, and the superficial veins, in vieAv of the fact that they cannot empty themselves into the internal veins, appear engorged; from the same cause edema affecting the thorax, neck, face, and arms may be noted. SAvelling of the lymph-glands in the neck or axilla is often Avitnessed, and is a" symptom of high importance. On palpation the tactile fremitus may be found to be diminished or absent. The percussion-note will be flat, since the air-vesicles and smaller bronchi are replaced by the solid growth. On auscultation friction-sounds are the rule. The respiratory sounds may be greatly enfeebled or absent; but if the carcinomatous tumor communicates Avith a wide-mouthed bronchus, bronchial breathing may be audible, and the usual physical signs of lung-cavity may be developed. The signs of general bronchitis are present in most instances, being most pronounced in the secondary or disseminated form of the disease; in the latter variety the lung may shrink, forming a condition in which retraction of the chest-walls on the affected side must ensue. If pleurisy with effusion occurs as a secondary event, the detection of the charac- teristic cancer-cells in the contents of the pleural cavity will show the • precise nature of the thoracic affection. Diagnosis.—The following symptom-group will pretty well estab- lish a diagnosis: A peculiarly shaped dull area (as when it extends under the sternum), perhaps a marked prominence over the site of the tumor, enlarged and hard lymphatic glands in the vicinage, and more or less of the compression-symptoms—circulatory, nervous, bronchial, or trachial stenosis. In rarer instances the diagnosis may be made by the occurrence of metastasis to the chest-wall. Again, the discovery of cancer-tissue in masses accidentally detached gives reliable indication of the disease. The differential diagnosis between pulmonary carcinoma and pul- monary tuberculosis can be made with positiveness only by a careful microscopic examination of the sputum. From fibroid induration of the lung it is easily discriminated, OAving to the history and slower course of the latter affection. Prognosis.—This is bad, as death may occur suddenly from abun- dant hemorrhage or more frequently from either exhaustion or asphyxia. The duration of the affection varies from six months to a year, or, rarely, even two years. Treatment.—The treatment must be addressed solely to the relief of pain and other subjective symptoms. SARCOMA OP THE LUNG. Primary sarcoma of the lung is rare, but in instances of generalized sarcomatosis the lungs show larger or smaller nodules " in almost every 538 DISEASES OF THE RESPIRATORY SYSTEM. case " (Birch-Hirschfeld), occurring in connection Avith osteo-sarcoma of other organs or in lympho-sarcoma of the cervical glands. " Secondary sarcoma, occurring in consequence of invasion of the root of the lung by sarcomatous disease of the post-bronchial glands, is also a not uncommon condition. Neoplasms occurring among the cobalt-miners of Schneeberg were described by Hesse and Tragner as lympho-sarcomata—slowly groAving masses that attained to a large size and gave metastasis to lymph-glands, pleura, liver, and spleen. In a majority of these cases there was an asso- ciated pneumonokoniosis, which had probably predisposed to the new ^growth. HYDATID CYST OP THE LUNG. Hydatids in the lungs may either be primary or secondary, the former variety being exceedingly rare, and the latter somewhat less so. Almost invariably the echinococci are developed in other organs—the liver in particular—and find their way to the lungs, either by direct perforation through the diaphragm or by entering through the blood-current. The etiology and pathology will be considered at sufficient length in connection with Hydatid Cysts of the Liver. Symptoms.—The clinical manifestations are quite varied, even though the cyst may entirely conceal itself. It is important to recollect that similar involvement of the liver usually coexists; and in addition to the symptoms of the latter affection there may be pain in the chest, dyspnea, considerable cough, and, rarely, blood-stained expectoration. The physical signs, when present, are as follows: Diminished vocal fremitus, defective expansion, dulness on percussion with an absence of the respiratory murmur, and later signs of cavity-formation may appear. A positive diagnosis of hydatid cyst of the lung can be made only when the scolices, pieces of membrane, and the hooklets of the echinococcus are demonstrable in the sputum. Besides being evacuated into the bronchi, the cysts may rupture into the adjacent serous sacs (pleura, peritoneum, pericardium), or externally, the latter being the most favorable mode of termination. Unless they are discharged early by ulceration into the bronchi or externally, they are apt to excite in- flammation of the adjacent lung-tissue and tubes, accompanied by an active febrile movement and an aggravation of the symptoms before de- tailed : these complicating conditions may assume a dangerous form, or the patient may, if the groAvth attains large dimensions, become asphyx- iated. Prognosis.—The affection is always attended with great danger, and is of more serious import when secondary to involvement of the liver than when primary. Treatment.—When it can be shown that the growths are situated at the periphery of the lung operation should be carefully considered. The physician stands powerless to do more than to relieve urgent symp- toms in special cases and to support the vital functions. DISEASES OF THE PLEURA. 539 V. DISEASES OF THE PLEURA. PLEURISY. {Pleuritis.) Definition.—An inflammation, either local or general, of one or both pleural membranes. The disease, as shown by postmortem exam- inations, is of great frequency. Varieties.—Pleurisy has been variously classified. Etiologically, the distinction betAveen primary and secondary forms of the disease should be made, as Avell as a division into tuberculous, carcinomatous, septic, etc. Pathologically, all cases may be summarized under the following heads : Localized and generalized and dry (plastic) pleurisy and pleurisy with effusion (sero-fibrinous, purulent, hemorrhagic). They may also be classified according to their duration into acute, subacute, and chronic pleurisies. I shall describe the folloAving forms, Avhich are based partly upon their etiologic and clinical course, though mainly upon their pathologic manifestations—viz. (a) acute plastic pleurisy ; (b) sero-fibrinous pleurisy; (c) purulent pleurisy (empyema); and (d) chronic adhesive pleurisy. Bacteriology.—In all forms of the disease the immediate causes are various micro-organisms or their irritating chemical products. Con- spicuous among these is the bacillus of tuberculosis, even, though rarely, found in the pleuritic exudate. Inoculation of guinea-pigs with the latter by Eichhorst gave positive results in 15 out of 23 cases that Avere considered to be of the primary form. Although rarely containing bac- teria, Netter, Prudden, and others have found in the exudation of fibrino-serous pleurisy the streptococcus pyogenes, the staphylococcus, the typhoid bacillus, and the diplococcus of pneumonia. The micro- organisms most commonly present in empyema are the micrococcus lanceolatus and the streptococcus, the former especially in the pleurisy associated with pneumonia (in two-thirds of the cases occurring in children—Levy), and the latter in those independent of pneumonia, particularly in adults. Among other bacteria that have been found rarely in the effusion are the colon bacillus, the proteus vulgaris, the gonococcus, Friedlander's bacillus, and various saprophytic bacteria. Except in the case of the pleuritic exudation (usually purulent) in pneu- monia, in which the diplococcus is alone present in about one-half of the cases, the afore-mentioned micro-organisms are generally found in asso- ciation. ACUTE PLASTIC PLEURISY. {Dry, Fibrinous Pleurisy.) Pathology.—The lesions are usually circumscribed, the part in- flamed being intensely injected. It has lost its natural lustre, and instead has a dull, non-glistening surface "like a tarnished mirror," due to a slight fibrinous exudate. Minute ecchymoses are seen at dif- ferent points. Later the exudate may become more copious, when the 540 DISEASES OF THE.RESPIRATORY SYSTEM. pleura presents a rough, shaggy appearance. On account of the fric- tion between the tAvo pleural membranes in high grades of dry plastic pleurisy, the exudate may be very thick, and its color-appearance is then yellowish- or reddish-gray. This sheeting of fibrinous exudate entangles in its meshes numerous embryonic round cells, out of Avhich blood-vessels and connective tissue are developed. The opposing sur- faces of the pleura adhere. Occasionally, in the lighter grades, the disease does not advance to firm adhesion, and in such instances the products of the exudate undergo fatty degeneration and are absorbed. The respiratory movements are but little disturbed in these cases. Etiology.—The affection may be (a) primary or (b) secondary. (a) By the primary form is meant an inflammation of the pleura occur- ring in previously healthy persons. It is exceedingly rare; and doubt- less many instances of true secondary pleurisy are regarded as belong- ing to this category, inasmuch as pleurisy may exist for an indefinite period without exciting noticeable symptoms. Of great etiologic prom- inence is exposure to cold and wet, and next to this stands mechanical injury. It is more common in men than in women, and especially during the time of active life, on account of the greater degree of ex- posure of the former than the latter sex. In almost all instances a careful search will disclose the existence of some diathesis (tubercu- lous, gouty, rheumatic) that may be properly regarded as the favoring cause. The changeable Aveather of the winter and spring augments the proportion of cases during these seasons as compared with sum- mer and autumn. (b) The secondary form of dry plastic pleurisy arises from extension of acute and chronic inflammatory affections of the lungs and other neighboring organs. Hence it frequently follows croupous pneumonia, somewhat less frequently broncho-pneumonia, and more rarely still hemorrhagic infarct, abscesses, and pulmonary carcinoma and gangrene. When pleurisy occurs on the right side it must be recollected that it may have originated in inflammation of the liver. Plastic pleurisy sometimes arises in acute articular rheumatism, to which it may essen- tially belong. It is an almost constant secondary process in chronic pulmonary tuberculosis, and may, though rarely, even constitute the primary lesion (primary tuberculous pleurisy). The disease may appear as a complication in chronic alcoholism and in chronic Bright's disease. Finally, inflammation of other serous membranes, as of the pericardium and peritoneum, by direct extension through the lymphatics of the diaphragm, invade the pleura. Symptoms—The affection may vary in intensity between the ex- tremes of mildness and great severity, though, as a rule, well-marked local symptoms attend the onset. Among the latter a sharp " stitch " in the side, that is usually referred to the nipple, is the most prominent. The pleural pain is increased by inspiration as well as by voluntary mo- tion of the affected side, and hence the patient assumes a fixed position in which he favors the affected side by leaning toward it. There is a dry, distressing cough that is restrained for obvious reasons, and the respiration is somewhat hurried, painful, and jerking in character until the exudation is poured out, when relief from this and other local symp- toms ensues. ACUTE PLASTIC PLEURISY. 541 The general symptoms are not pronounced, and, save in compara- tively rare instances, do not correspond with the local signs. The tem- perature is not typical, rarely exceeding 103° F. (39.4° C), and more often it is below 101° F. (38.3° C). The pulse is usually small and tense or soft in character, registering from 90 to 120 beats per minute. Not infrequently the cases are so mild as to be attended by few, if any, subjective symptoms. The patient may complain of ill-defined, uneasy sensations in the affected side, but does not discontinue his usual occu- pation. On the other hand, the Avorst cases of acute plastic pleurisy— Avhich, fortunately, are rare—manifest violent symptoms: there is a distinct chill, a speedy development of high fever (104° F.—4.0° C), and profound prostration, and the general and local symptoms are pro- portionately aggravated. The illness then is often a fatal one. Physical Signs.—On inspection the movements of the chest-wall on the affected side are observed to be much restricted, particularly during the first day of the affection. During a later period palpation confirms the results of inspection, Avhile percussion yields a normal note. Aus- cultation renders audible a grazing friction-sound, which, though audi- ble, is most intense at the end of inspiration. With the occurrence of fibrinous exudation palpation detects over the corresponding area a diminution of the tactile fremitus. On percussion there is, as a rule, a slight though variable degree of dulness; and on auscultation the crepitating or rubbing friction-sounds are heard both on inspiration and expiration, being intensified by deep breathing. These sounds frequently endure for a day or two after the other symptoms have disappeared. Very rarely the plastic exudation may be so extensive as to cause compression of the lung, in which instance the breath-sounds may become bronchial in character; and I have known a case of this sort to be mistaken for lobar pneumonia. In addition, the breath-sounds will be feeble and distant. Diagnosis.—By exercising ordinary care the clinician can scarcely mistake other thoracic affections for dry pleurisy, the latter being diag- nosticated to a certainty by the presence of the characteristic friction- murmur. Intercostal neuralgia may present features not unlike those of acute pleurisy. In both affections there is frequently a history of exposure, followed by severe chest-pains that are excited by coughing and deep breathing. In neuralgia, however, there are painful pressure- points, and the pleuritic friction-sound does not occur. Pleurodynia may also give a history very similar to that of acute pleurisy, but the presence of the characteristic physical signs of pleurisy are absent. Prognosis.—The duration of the affection varies from a few days to three weeks, and the immediate outcome is favorable as a rule. It cannot be doubted, however, that a primary attack predisposes to subse- quent attacks, and thus, as a result of repeated seizures, pleural thicken- ing and intrapleural adhesions often arise. Lung-expansion may in this manner be restricted, with the gradual development of interstitial pneu- monia as a consequence. Acute plastic pleurisy is not infrequently a terminal condition in serious forms of illness (e. g. septicopyemia and chronic nephritis). Treatment.—The first object in the treatment is to relieve the pain, and this can best be accomplished by the hypodermic use of mor- 542 DISEASES OF THE RESPIRATORY SYSTEM. phin. The inflammatory process is best controlled by absolute rest in the recumbent posture, alloAving the patient to assume that position which gives him most comfort. I am also in the habit of administer- ing moderate-sized doses of quinin (gr. iv—0.259—three times daily). After the exudation has appeared, the iodids of iron and potassium, in combination, may be employed. Locally, nothing is so effective as cold in the form of the ice-Avater bag or Leiter's coil, preceded, in robust patients, by the local abstraction of blood (3iij to vj—!M!.0- 192.0) by leeches. At the end of one week the morphin may usually be discontinued. During convalescence the patient should be instructed to take deep inspirations several times in succession, not less than a dozen times each day, with a view to obviating so far as possible the pleural adhesions and other unfaArorable consequences. Symptomatic anemia may be present at this time, and should be met by iron given internally. At this time iodin may be used locally with great benefit; I have not, hoAvever, seen any favorable results from blisters. For the pain which continues in the side after all detectable physical signs have disappeared the use of the constant current over the seat of the pleur- isy for twenty minutes at a time gives almost instantaneous relief (Loomis). SERO-FIBRINOUS PLEURISY (PLEURISY WITH EFFUSION, SUBACUTE PLEURISY). Pathology.—During the first stage of sero-fibrinous pleurisy the changes are the same in character as those met with in dry pleurisy, though of severer grade, and usually involving the greater portion of the pleura on the side affected. There is an abundant exudation of serum, and usually the entire pleura becomes coated with a fibrinous exudate, that varies greatly in thickness and arrangement. The latter is thin and smooth in some instances, though more frequently it forms a thick layer, presenting a shaggy surface on the one hand or an irregular, honeycombed surface on the other. Lymph in the form of flocculi is rather abundant in the serous effusion. The interlobu- lar pleural surfaces are also invaded as a rule, in consequence of Avhich they become adherent. The fluid exudate varies greatly in quan- tity (J to 8 pints—4 liters), is often of a citron color, and is, in the ma- jority of instances, clear or slightly turbid. Rarely it is of a dark- brown color. Unless adhesions between the pleural surfaces have previously existed the effusion gravitates to the most dependent portion of the pleural cav- ity. Microscopically, there are found leukocytes, red blood-corpuscles, endothelial cells, threads of fibrin, and, rarely, crystals of cholesterin and uric acid. The composition of the fluid is almost identical Avith that of blood-serum, and on boiling it is found to be rich in albumin. Spon- taneous coagulation may take place on standing. Changes in the Neighboring Organs.—So long as the normal retrac- tility of the lung is not overcome by the fluid that collects in the pleural caAlty, the latter does not produce positive intrathoracic pressure, and hence does not produce displacement of adjacent organs. It may be assumed that until the pleural sac is at least one-half filled Avith sero- SER 0-FIBRINO US PLE URISY. 543 fibrinous exudate the natural contractility of the lung is not destroyed. At this period there may be a slight displacement of the mediastinum toward the opposite side, due to traction exerted by the normal retrac- tility of the sound lung. Obviously, large effusions must in a mechani- cal manner displace the pleural membranes, thus causing compression of the pulmonary structures lying above the effusion. A very copious effusion may push the lung up and back against the vertebral column and convert it into a small, flat, bloodless, and airless mass (atelectasis). While a total absence of air in the collapsed lung is due chiefly to com- pression by the fluid, to some extent, hoAvever, the air may be absorbed by the vessels or even by the effusion (Strumpell). Together Avith compression of the lung by the effusion, pressure is also exerted by the latter against the mediastinum, causing displacement of the heart. The mediastinum also loses the normal traction-force of the lung upon the affected side, and hence the lung on the sound side draws the mediastinum toward itself by its OAvn retractile energy. Osier shows that even in the most extensive left-sided effusion the heart's apex is not rotated, but that the normal relative position of the apex and base obtain, though the apex is in some instances lifted, and in others the heart lies more transversely. The right chambers of the heart occupy most of the anterior part of the organ, shoAving that the displacement of the mediastinum Avith the pericardium and its contents to the right involves no appreciable tAvisting of the heart itself. Downward displacement of the diaphragm takes place in extensive effusion, and shoAvs itself on the right side by the loAvering of the liver to a variable distance below the inferior costal border; on the left side large effusions produce pressure-displacement of the stomach and the transverse colon, and, to a slighter extent, of the spleen. It must be recollected that adhesions may prevent displacement of any of the adjacent organs. Etiology.—In the present state of our knoAvledge the causal factors are identical in nature with those producing dry plastic pleurisy, the pathologic differences being attributable to the differences in the inten- sity of the processes. It is highly probable that the degree of severity is dependent upon the previous condition of the patient, whether he be suffering from some other affection or not, and upon the amount of specific poison gaining access to the pleura. The affection may be primary, but is much more often secondary; and this fact may be explained by reference to any of the specific micro-organisms producing the affection. Many of the cases follow quickly upon exposure to cold or wet or an injury to the thorax. I thoroughly agree Avith those authors Avho contend that about three- fourths of the cases of sero-fibrinous pleurisy are induced by tuber- culous infection of the pleura. The tuberculous process may invade the pleura primarily, but more often it is secondary to tuberculosis of the lungs; less frequently, though oftener than is generally sup- posed, it is secondary to tuberculous peritonitis. In these instances the tubercle bacilli probably find their way from the peritoneum to the pleura by traversing the lymphatics in the diaphragm. I am con- vinced that a large percentage of apparently primary cases of tubercu- lous pleurisy have their origin in a circumscribed and more or less 544 DISEASES OF THE RESPIRATORY SYSTEM. latent tuberculous focus in the lungs. It is not improbable also that tuberculous processes in other viscera may furnish the tubercle bacilli for secondary pleural infection. Moreover, the fact that many cases of sero-fibrinous pleurisy recover does not disprove their tuberculous nature. The typhoid bacillus of Eberth has also been known to pro- voke pleurisy (Bozzolo, Fernet, and others).1 The affection is not infrequently secondary to acute articular rheu- matism, which is itself most probably a microbic affection. It also arises as a complicating condition in the course of various acute and chronic affections of the chest, as pericarditis and catarrhal pneumonia, and may develop in acute infectious diseases, as typhoid fever or lobar pneumonia. It may occur as a complication in the chronic affections of various viscera (chronic nephritis, cirrhosis and carcinoma of the liver). The predisposing causes are the same as for the dry plastic form. Symptoms.—The description here refers particularly to primary sero-fibrinous pleurisy, and it is important to recollect that when second- ary to other acute and chronic affections characterized by great bodily weakness the pleuritic symptoms may be more or less completely veiled. With few exceptions the onset is insidious, the symptoms being quite mild, but rarely there is a sudden onset with active symptoms (rigor, high fever). In the majority of instances the patient first complains of a stitch-like pain in the side; this is rarely pronounced, but is aggravated upon deep breathing and upon any muscular exertion. Dyspnea soon arises and gradually increases in intensity. Cough may be present or absent, and in some instances is attended by a scanty mucoid expectoration that may rarely be blood-streaked. The constitutional symptoms are of correspondingly slow and gradual development. From the commencement of the attack a moderate febrile movement at night may be observed, and the pulse will be found to be frequent, small, and compressible, or, more rarely, tense. At the time of the patient's first visit to his physician he may give a history of having gradually lost flesh and strength for a period of weeks together, though he*may not have been obliged to abandon his vocation. He looks pale, his countenance wears an anxious expression, and he is without appetite. These cases frequently drag along from two to four weeks before con- sulting a physician, the local symptoms going unnoticed, and the patient making complaint only of weakness, anorexia, headache, etc. Sometimes the more acute symptoms characterize the period of invasion, and, after lasting a few days, exhibit a decided remission; but at another subsequent period there may be a sudden recurrence of the local and general phenomena, and particularly of the dyspnea. The pleural cavity, which may have been one-half or two-thirds full, now becomes completely filled. Special Symptoms.—Pain.—Chest-pain is an almost constant but not highly characteristic symptom, and, though usually among the earliest symptoms, it may not be present until a few hours or a day after the commencement of the affection. It may be described as a sharp, shoot- ing pain, and is popularly termed a "stitch in the side." It may, how- ever, be tearing or dragging in character. Its intensity is not a safe in- 1 Annual of the Universal Medical Sciences, 1892, vol. ii. p. 12. SER 0-FIBRINO US PLE URIS Y. 545 dication of the severity of the disease. It is usually referred to a small spot beloAv the nipple or to the mid-axillary region; exceptionally, hoAV- ever, it is more diffuse, and in my experience it has not infrequently been retrosternal or referred to limited areas below the inferior costal border. When absent it may be excited by coughing, sneezing, deep inspiration, and stooping. With the appearance of the effusion the pain diminishes, and, as a rule, soon disappears. Dyspnea.—The respiration is shallow, catching in character, and hurried in consequence of the severe pleural pain; in copious effusions, that render one lung almost or wholly functionless, the dyspnea may become intense, even attaining to well-marked orthopnea. It reaches its most pronounced form in persons Avho have previously been robust, and in those in Avhom the effusion has developed rapidly. On the other hand, Avhen the pleural sac fills sloAvly dyspnea may be absent, except on exertion. This symptom appears frequently before the effusion takes place, and is then due partly to the fever and partly to the pleuritic pain. Following marked disturbances in the respiration, cyanosis ap-. pears and may become quite pronounced. Cough and, Expectoration.—Little need be added to Avhat has already been stated. When there is present much expectoration it is most fre- quently due to associated bronchitis or to pulmonary tuberculosis; there may, hoAvever, be a total absence of expectoration, and in such instances the exciting cause of the cough is probably the pleuritis. Both the cough and expectoration are apt to be increased during the process of resorption of the exudate as the result of a catarrhal bronchitis that is apt to develop in the re-expanding lung. Fever.—The rise of temperature is not rapid as a rule, nor does it reach a high point (101.5° to 103° F.—38.6°-39.4° C). At the end of a variable period—usually one to three Aveeks—the temperature falls by lysis, and soon touches the normal. The temperature may be of the continued type in many acute cases. In subacute forms the temperature may rarely rise above 101° F. (38.3° C), or may, finally, assume a hec- tic type. The surface-temperature of the affected side is from one-half to two degrees (.4°-1.6° C.) higher than that of the normal side. Pulse.—The pulse is quickened, beating 100 or more per minute, and its volume and tension are diminished. Irregularity both of the volume and rhythm of the pulse may also be observed. These pulse- characteristics are to be attributed to the pressure of the effusion upon the heart and great vessels. Gastro-intestinal Symptoms.—Loss of appetite is commonly present, and more rarely nausea and occasional vomiting may be met with at the outset. Constipation is the rule. Renal Symptoms.—The amount of urine is diminished both during exudation and while the exudate remains at the same level. The daily quantity may not exceed eight or ten ounces, but the specific gravity is increased, ranging from 1018 to 1028. An increase in the daily amount of urine excreted is frequently the first sign of commencing absorption of the exudate, and the rapid resorption of the copious effusion may greatly augment the Aoav of urine to 80 or 100 ounces (2.5 to 3 liters) daily (Striimpell). The cause of the diminished secretion of urine is, in the main, diminished arterial pressure. 35 546 DISEASES OF THE RESPIRATORY SYSTEM. Physical Signs.—The physical signs of sero-fibrinous pleurisy differ with the amount of effusion present, and also Avith the particular stage of the affection : those of the first stage, however, are identical Avith the signs pointed out in connection Avith dry plastic pleurisy, and need not be restated here. We will note the physical signs (1) during the sta^e of effusion, as well as (2) those presented Avhen resorption of the effusion has taken place. (1) Stage of Effusion.—When the pleural sac is only partly filled there is noted, on inspection, but little change in the thoracic contour. The respiratory movements are, hoAvever, restricted, OAving to mechani- cal hindrance to the lung-expansion. In the majority of instances the effusion increases until positive intrathoracic pressure and noticeable bulging in the middle and loAver third of the chest-Avail on the affected side take place; the intercostal spaces beloAv are widened and more or less nearly effaced. The apex-beat of the heart is displaced, being visible in right-sided pleurisy to the left of the vertical mammary line in the fourth and fifth interspaces, and in left-sided pleurisy to the right of the right mammary line, or even beyond, in the third and fourth in- terspaces. The apex of the heart may take a position behind the ster- num, when no impulse will be visible. Palpation.—The limited movement of the chest is readily appreci- ated on palpation, and in large effusions the chest-wall is practically fixed. The separation of the ribs and the obliteration of the intercostal spaces are easily made out in the same manner. Edema of the chest- wall is rarely present, and fluctuation almost never. An important and early physical sign is the diminished tactile fremitus, Avhich is soon abolished, except in infants, in whom it may be excited on crying. This is a less valuable sign in women than in men, owing to the differ- ences in the vocal vibrations in the two sexes. In copious effusions tac- tile fremitus may sometimes be obtained when bands of adhesion, which serve as a medium for the transmission of local fremitus, connect the pulmonary with the costal pleura. The apical impulse can also be readily located by palpation. The displaced spleen or liver can be read- ily felt through the abdominal wall, and must not be mistaken for an actual enlargement of these organs. Mensuration.—It must not be forgotten that in right-handed adults the right side is, normally, slightly larger than the left; and it is only after the effusion is considerable in amount that the cyrtometer shoAvs any alteration in the thoracic contour or an enlargement of the affected side. The tape, however, exhibits the difference in expansive motion of the two sides early, or Avhen there is a moderate amount of fluid. At the end of expiration the circumference of the affected side will be found to be one or two inches greater than that of the left side, while at the end of inspiration the difference will be but slight. The cyrtometric tracing also shows a discrepancy betAveen the horizontal outlines of the two sides. Percussion.—At first the percussion-note is impaired, either poste- riorly or in the infra-axillary region, and a little later there is dulness, tending toward flatness (deadness), with increasing effusion. The resist- ance to the pleximeter-finger becomes greatly augmented. In cases in which the effusion rises to the fourth rib anteriorly there is dulness OA'er SERO-FIBRINOUS PLEURISY. 547 the fluid above and absolute flatness beloAv. Since both the flatness and dulness are due to the fluid, it is obvious that the upper level of the latter must, Avhenever free, change Avith the posture of the patient; hence the limit of dulness will be higher in the sitting than in the re- cumbent position. When the pleural sac is filled or Avhen the effusion is confined by adhesions, the latter sign is not obtainable. If the upper level of the fluid reaches the loAver border of the third rib, the percus- sion-note above the line of dulness is tympanitic or vesiculo-tympanitic [Skoda s resonance). This note is most readily elicited in front, though it may also be present behind and above the level of effusion. In copi- ous exudations the cracked-pot sound may be elicited immediately be- Ioav the clavicle in the usual manner, and " Williams's tracheal tone " may sometimes be obtained in large exudations. This may also be ob- tained near to the spine on the affected side or at a point corresponding to the seat of the compressed lung. When the patient is sitting or in the erect posture, the upper limit of dulness in large effusions is not a horizontal line, but is highest at the spine and falls as Ave proceed to the front, Avhich is its loAvest point. On the other hand, the upper line of dulness in moderate effusions begins "relatively Ioav doAvn in the back, passes upward from the vertebral column, and soon turns upAvard and proceeds obliquely across the back to the axillary region, where it reaches its highest point; thence it advances in a straight line, but with a slight descent, to the sternum" (Ellis). This curved line resembles the italic letter S (Garland). On the right side the flatness is con- tinuous with that of the displaced liver; on the left it passes into and may obliterate Traube's semilunar space. Auscultation—The signs of the first stage have already been de- scribed (vide Plastic Pleurisy). With the appearance of the effusion the breath-sounds become weak, distant, and have a bronchial quality. Soon the respiratory sounds over the affected side Avill be entirely ab- sent, except near the upper level of the fluid posteriorly, Avhere distant bronchial breathing and, less frequently, diffuse vocal resonance are audible. The latter sounds may exhibit a metallic or amphoric quality, and may be accompanied by rales (pseudo-cavernous signs). The latter are more frequently met Avith in children than in adults, and often give rise to a false diagnosis. Above the level of the fluid there is broncho- vesicular breathing, and on the opposite side intensified breath-sounds may usually be noted. The vocal resonance may manifest a nasal or metallic quality, simulating someAvhat the bleating of a goat (Laennec's egophony). This is best obtained near the upper level of the fluid in large effusions, and at or above the angle of the scapula when the effusion is moderate. (2) Stage of Resorption.—With resorption of the fluid there is a de- crease in the size of the affected side, together with a return of the nor- mal appearance of the intercostal spaces and the respiratory movements. In many instances there is positive retraction, leading to thoracic defor- mity with displacement of neighboring organs toward the affected side; and this retraction may be either general or circumscribed. The infe- rior intercostal spaces are more or less narroAved; the shoulders droop; the nipple approaches the median line; the spine may be curved, the convexity being directed toward the sound side (quite rarely toAvard the 548 DISEASES OF THE RESPIRATORY SYSTEM. affected side); and the scapula projects from the chest-wall on the af- fected side. In children, and even in adults, the lungs and thorax grad- ually expand in order to overcome this chronic deformity. On the other hand, the extensive adhesions between the pleural membranes produce permanent shrinkage of the thorax and embarrassment of respiration. Palpation.—The tactile fremitus closely folloAvs the fluid as it sub- sides from above doAvnward Avithout any extreme degree of thickening of the pleural membranes, though cohesion of their surfaces may pre- vent its return over the loAver segment. The inspiratory movement of the chest-Avail gradually returns, but not to its former limit. Mensuration shows a steady diminution in the size of the side in- volved, which finally becomes smaller than its fellow. Percussion.—The dull or flat note gives wray to normal percussion- resonance, proceeding from above doAvnward in a gradual manner; but the latter is not renewed over the loAver portion of the pleural cavity for a long period after the exudation has disappeared. The abnormal areas of flatness due to displacement of organs (liver, spleen, heart) also disappear. Auscultation discloses most important signs during the stage of re- sorption. The breath-signs reappear at first above, and then loAver down, until the base is reached. With commencing subsidence of the fluid the respiratory sounds are feeble and distant, but later they resume their natural distinctness; and partly as a result of the revival of the natural muscular tonicity, and partly in consequence of the disappear- ance of the fluid, the two roughened pleural surfaces come in contact and play upon one another, giving rise to a rubbing, creaking friction- sound on auscultation. These friction-murmurs may persist for months after the effusion has been absorbed. Occasionally the lower portion of the compressed lung remains permanently inexpansile, and usually in such circumstances the upper portion of the lung is the seat of com- pensatory emphysema, which is recognizable by the customary physical signs. By auscultation Ave may note the return of the heart-sounds to their normal position. Special Clinical Forms of Acute Sero-fihrinous Pleurisy.— The separate varieties are dependent upon the nature of the effusion and the character of the etiologic factors, and in this connection the main clinical features of a few special types may be briefly described. They are as follows : (1) Tuberculous Pleurisy.—This is, in the majority of instances, second- ary to pulmonary tuberculosis. On the other hand, the primary lesions may be situated in the pleural sac and give rise to (1) Acute sero-fibrinous pleurisy (with the usual course); (2) Subacute pleurisy (with insidious course), leading to tuberculous invasion of the lungs; and (3) Chronic adhesive pleurisy, in Avhich the course and physical signs correspond with those that will be depicted in a special section on Chronic Pleurisy. The morbid lesions are similar to those met with in other forms, plus the specific tubercles, Avhich may be exceedingly numerous (miliary tubercles) on the one hand, or confined to a feAV circumscribed areas on the other. This variety of pleurisy has no special etiologic connection Avith empyema, and the effusion is usually sero-fibrinous and often blood- stained. Brief reference should be made to those instances in Avhich tubercu- SERO-FIBRINOUS PLEURISY. 549 lous pleurisy is folloAved by tuberculous pericarditis or peritonitis, or both. The two latter affections will be considered elsewhere. Suffice it to state here that tuberculosis of the serous membranes usually pursues a chronic course, lasting a year or more, and exhibits Avidely varying degrees of intensity in its symptoms in different cases, and from time to time in the same sufferer. We must grant that tuberculous pleurisy may pursue a favorable course Avith apparent recovery, though too often, after a variable interval of time, tuberculous symptoms are manifested. (2) Diaphragmatic Pleurisy.—This term is applied to those instances in Avhich the diaphragmatic portion of the pleura is involved, either alone or in part. There occurs an exudate that may be either plastic or sero- fibrinous, though rarely large in amount. The symptoms are acute, and the pain, Avhich is lancinating in character and situated in the epigastric region, is the most prominent feature. Geuneau de Mussyl holds that pain along the tenth rib, extending from the anterior extremity to the sternum and xiphoid cartilage, is pathognomonic. It is increased by deep inspiration and by pressure over the insertion of the diaphragm at the tenth rib, and often abates Avhen effusion takes place. Dyspnea is a marked symptom in most cases, and the patient may be forced to assume a stooping or sitting posture, the respirations being superficial, purely thoracic, and "catching." Cough, nausea, and even vomiting, may occur. In a case under my own care vomiting, due most probably to associated peritonitis, Avas a troublesome symptom. The constitutional features are quite pronounced, and particularly the fever, Avhich exceeds that met Avith in other forms of pleurisy. The patient's anxiety is extreme. The effusion may be purulent, and if so bulging of the loAver intercostal spaces, followed by edema, may occur. The physical signs are for the most part negative. (3) Encysted Pleurisy.—This term has reference to effusions that are circumscribed in consequence of adhesions between the pleural mem- branes. There may be two or more pouches, with or Avithout communi- cation. This so-called encapsulated pleurisy may occupy any part of the chest, and is exceedingly variable in extent. The symptoms and physical signs are rarely trustAvorthy for diagnosis, but should usually afford ground for suspicion, and hence should lead in every instance to the employment of the exploratory puncture. (4) Interlobar Pleurisy.—This variety is usually secondary to, or associated with, the ordinary type of acute sero-fibrinous pleurisy. The serous surfaces, dipping between the lobes, are involved in the inflam- matory process, and the fluid becomes encapsulated in this position in consequence of interlobular pleural adhesions. It is more frequent on the right than on the left side, and its favorite seat is near the root of the lung, betAveen the upper and middle lobes. Osier2 met with a case folloAving pneumonia in which there was between the lower and upper and middle lobes of the right side an enormous purulent collection that looked at first like a large abscess of the lung. Fistulous connection with a bronchus often occurs, and the purulent expectoration that folloAvs may be the first symptom to attract the attention to the process of sup- puration in the thorax. Prior to the occurrence of this accident the patient gives evidence of indisposition Avithout definite symptoms. The 1 Arch. gen. de Med., 1853, vol. xi., quoted by Fox. 2 Practice of Medicine, p. 567. 550 DISEASES OF THE RESPIRATORY SYSTEM. patient may or may not give a clear history of antecedent pleurisy. These cysts contain, as a rule, but a small amount of fluid, and do not cause much bulging of the intercostal spaces. Indeed, in a case of my own at the Philadelphia Hospital there Avas actual retraction, though the aspirating needle showed' the presence of effusion.1 (5) Hemorrhagic Pleurisy.—By this term is meant an admixture of Fig. 47.—Illustrating pleurisy with effusion : 1, compressed lung-tissue, giving dull tympany on per- cussion ; 2, fluid exudation obliterating intercostal spaces ; 3, depressed liver; 4, displaced heart. blood with the exudate in acute sero-fibrinous pleurisy, in quantities suf- ficient to be detectable by the unaided eye. The condition must be sep- arated from hemothorax. The causes of hemorrhagic pleurisy are—(1) Tuberculous infection, either of the miliary or the chronic (circum- scribed) form, folloAving tuberculous disease of the lung; (2) Carcinoma of the pleura ; (3) Bright's disease, and cirrhosis of the liver ; (4) Ady- namic states of the system associated Avith malignant forms of acute infectious diseases. 1 International Clinics (1894), vol. i. p. 39. SERO-FIBRINOUS PLEURISY. 551 In a certain proportion of the cases no assignable cause can be found, and if the condition be observed for the first time after aspiration, the fact that it may have been engendered by an accidental Avound of the lung must be remembered. Diagnosis.—In diagnosticating pleurisy our attention must be directed chiefly to the physical signs. Unfortunately, in vieAv of the fact that the rational symptoms are often ambiguous, a physical explor- ation of the chest is apt to be neglected. The chief difficulties are encountered in distinguishing this affection from conditions in Avhich the lung is either consolidated, retracted, or compressed by solid neAv groAvths, etc. Chief among the former is croupous pneumonia, and I have tabulated below the most important distinctions between it and pleurisy. The reader will be further aided by comparing Fig. 47 (Avhich shoAvs the physical conditions in pleurisy) Avith Fig. 17, on page 150, Avhich shoAvs the physical conditions in pneumonia. Pleurisy with Effusion. Primary Lobar Pneumonia. Onset marked by chilliness persisting for a few days. The pain is sharp, " stitch-like," and strictly localized. Cough frequent and irritating ; no ex- pectoration. Moderate fever of continuous type ; de- cline by lysis. Systemic prostration of medium sever- ity. Countenance pale and anxious. Herpes does not appear. Rational Symptoms. 1 severe rigor, lasting about one hour. Acute pain, similar, but soreness more diffused. Cough accompanied by rusty or bloody expectoration. Intense fever ; decline by crisis from the fifth to the ninth day. Prostration marked. Countenance congested ; mahogany flush on the cheeks. Herpes quite common. Physical Signs. Inspection. Marked distention of the thorax. Palpation. Diminished or absent tactile fremitus. Xone. Marked tactile fremitus (absent only when a bronchus is plugged). Percussion. Flatness, with great resistance to the Dulness less complete, less resistance, pleximeter-finger. and sometimes a tympanitic note. Shows displacement of neighboring or- No displacement of neighboring organs, gans. if uncomplicated. If the sac be partly filled, there is a Absent. change in the line of flatness on change of position. Auscultation. Diminished or absent breath-sounds, Harsh bronchial breathing and presence bronchial breathing frequent, but dif- of rales in first and third stages, unless fused and distant and unaccompanied by rales, as a rule. Vocal resonance diminished or absent. Friction-sound in early and late stages. Aspiration. Yields serum. a bronchus be plugged. Bronchophony, unless a bronchus be blocked. No friction-sound, except crepitant rales in the first stage. Yields a few drops of thick blood. 552 DISEASES OF THE RESPIRATORY SYSTEM. Consolidation of the lung, due to tuberculous infection, may be dif- ferentiated from pleurisy with effusion by means of the physical signs contrasted in the foregoing table, by the history of the case, and by the discovery of the tubercle bacillus in the sputum. Hydrothorax presents physical signs that simulate strongly those of pleural effusion. Hydrothorax, however, gives the history of cardiac or renal disease, is usually bilateral, and is unassociated with a rise in temperature or with the pain or friction-sounds peculiar to pleurisy. In obscure instances some of the fluid should be AvithdraAvn and chemi- cally examined. Tumors and cysts of the thorax will give complete dulness, will dis- place the heart, and compress the lung on the affected side, thus caus- ing an absence of the respiratory murmur, etc. But the history of the case, the situation of the dulness (usually over the upper or middle parts of the lung), the absence of uniform distention extending to the base, and the exaggerated tactile fremitus and vocal resonance Avill serve to distinguish these affections from pleurisy with effusion. Echinococcus cyst of the liver, or abscess of this organ, pushing up- Avard, will cause retraction or even compression of the lung, and hence will also produce most of the physical signs of pleurisy with effusion. The former affections can be discriminated only by a correct appreciation of the history, by the presence not infrequently of a friction-sound on auscultation, and by the immovable, fixed upper level of dulness. If doubt remains, an exploratory puncture should be made, and the fluid Avithdrawn should be subjected to a chemical, microscopic, and bacterio- logical investigation. An enormous pericardial effusion may be mistaken for a pleural effu- sion on the left side. In the former, hoAvever, there is commonly a his- tory of rheumatism, and dyspnea is the most urgent symptom, while the heart-sounds are greatly enfeebled; moreover, the heart is not dis- placed to the right as in pleural effusion. Again, flat tympany is ob- tained in the posterior portion of the axilla and good pulmonary reson- ance at the base in the postero-lateral region of the chest, differing from the results of percussion in pleurisy Avith effusion. For practical purposes it is desirable to distinguish the tuberculous from the rarer forms of pleurisy. This is sometimes possible by paying due regard to the previous history of the patient, including hereditary taint, by noting certain clinical peculiarities (such as associated dis- ease of other serous membranes and of the lung and bilateral inflam- mation .of the pleura), and by the results of an examination of the exudate. In dubious cases the guinea-pig should be inoculated Avith the exudate, and if the patients are tuberculous positive results may be confidently expected. Duration and Prognosis.—This depends largely upon the cause. The course of acute sero-fibrinous pleurisy is not definite, but is made up of tAvo parts—the febrile folloAved by the non-febrile stage. The fever lasts from one to three Aveeks, and is due to inflammation; it corre- sponds to the period Avhen the effusion occurs, and the appearance of a non-febrile period indicates the subsidence of the inflammatory action. The effusion may be poured out rapidly, and is removed by absorption not less rapidly; more frequently, hoAvever, the effusion takes place SER 0-FIBRINO US PLE URIS Y. 553 rather gradually, and the same is true of resolution. Again, large effusions may persist in consequence of a purely mechanical hindrance to resorption; and finally, the course may become subacute or chronic in consequence of the development of empyema. Such facts as these constitute an explanation for the great differences in the duration of the cases. Simple sero-fibrinous pleurisy has a comparatively favorable prognosis. In rare instances, hoAvever, death ensues suddenly, Avith- out adequate lesions to explain its occurrence. Moreover, the fact that a sero-fibrinous effusion may be converted into a purulent one is not to be forgotten. Again, the crippling influence upon the lung- tissue of previous attacks, owing to resulting adhesions, must be borne in mind, since chronic bronchitis and emphysema are often thus pro- duced. Lastly, it is to be restated that most cases of pleurisy are tuberculous in origin, even though it cannot be denied that complete recovery may take place. Treatment.—In the first stage the treatment is the same as for dry or plastic pleurisy. During the second stage, that of effusion, the objects of treatment are threefold: (1) To limit the extent and intensity of the inflammatory process; (2) To accomplish the removal of the effusion; and (3) To support the strength of the patient. (1) To Limit the Extent and Intensity of the Inflammatory Process.— To this end t\vo classes of agents are employed—namely, (a) Internal, and (b) External. Among the latter are counter-irritants, as sinapisms and iodin, by means of Avhich gentle but constant counter-irritation is to be main- tained. Another agent of great Avorth is cold, applied by means of the ice-bag or ice-Avater bag, and if the temperature rises to 102° F. (38.8° C.) cool spongings of the surface of the body, together with the use of the ice-cap, Avill be found highly useful. Roberts recommended keeping the affected structures at complete rest by fixing in a mechanical manner the side affected. For this purpose strips of adhesive plaster must be firmly and evenly applied to the chest, and by this means the pain is relieved and the amount of inflammatory product poured out is greatly limited. The internal remedies embrace quinin, the salicylates, and opium. Opium and quinin are potent in controlling inflammation of serous membranes; the former being given preferably either in the form of suppositories or hypodermically, and the latter in divided doses, in cap- sule, followed by a few drops of mineral acid, administering gr. xvj to xx (1.036-1.296) daily.1 I have observed good results from the salicy- lates (3j-ij—4.0-8.0, daily), Avhich have been warmly advocated by Fiedler, Koester,2 and others, as valuable in mitigating or even aborting the inflammation of the pleurae, and thus in limiting the amount of effusion. It must not be forgotten that the effusion is due to an inflam- mation, and not to a simple transudation. The use of mild diaphoretics and diuretics, together Avith repeated small doses of salines, also aids in reducing the inflammation in the pleura. With a subsidence of the inflammatory process the temperature falls, and, when the latter reaches a point near to the normal, our efforts should be directed toward the 1 International Clinics (1892\ vol. i., second series. 2 Annual of the Universal Medical Sciences (1893), vol. i. (A-31). 554 DISEASES OF THE RESPIRATORY SYSTEM. fulfilment of the second leading indication, (2) the removal of the effusion. Little is to be accomplished by local means, though iodin, per- sistently employed, sometimes does good. The following ointment may also be tried: R/. Ung. ichthyol. (12 per cent.), Ung. iodini comp., da. 3vj (24.0); Ung. belladonnse, q. s. ad sij (64.0).—M. Sig. Apply twice daily. Blisters are not admissible. Mild hydragogue cathartics, and especially the salines, after the Matthew Hay method (i. e. 3ij to §ss—8.0-16.0, in the smallest possible amount of water, on rising in the morning), stimulate absorption from the pleural cavities by draining the blood of a certain amount of serum. Unirritating diuretics may also be employed, but I have found no appre- ciable advantage from their use. Free diaphoresis (from the use of pilo- carpin) sometimes assists in the absorption of the exudate, but it should not be employed in the presence of feeble heart-action or marked dis- placement of the organ. Among measures to promote absorption, the best, in my own experience, is the following combination: B/. Potassii iodidi, 3j (4.0); Syr. ferri iodidi, 3ij (8.0); Syr. sarsap. comp., 3j (32.0); Ess. pepsinae, q. s. ad §ij (64.0).—M. Sig. 3j (4.0) every four hours, diluted; the dose to be doubled at the end of four days if well borne by the stomach.1 The patient should be put upon a dry diet in order to increase the plasticity of the blood, Avhich is thus induced to absorb the liquid exu- date from the pleural cavity. The modus operandi of this treatment is different, but the effect aimed at is the same as when saline purgatives are given. The exudation, however, defies all efforts at removal in about 33 per cent, of the cases, and in such the withdraAval of the liquid by aspiration (thoracentesis) must be practised. The indications for thora- centesis arise at two different periods in the course of pleurisy with effusion: (1) During the febrile stage, while efforts are being directed to com- bating the inflammatory process. The object during this stage is to avert imminent danger to life, and not merely to remove the fluid. The conditions demanding immediate thoracentesis are—(a) when one pleural sac is completely filled or when Skoda's resonance extends from the clavicle downward no farther than the second interspace; (b) in double pleurisies, when both sides are half filled, since death may occur from rapid filling of one or the other side; (c) in cases of copious effu- sions, upon the first signs of involvement of the unaffected side, such as moist rales, broncho-vesicular breathing, and impaired resonance; {d) the appearance of serious symptoms, such as orthopnea or syncopal attacks with cyanosis; (e) marked displacement of the heart, especially if one or more murmurs develop in the organ. 1 The author has employed this formula in more than 50 cases with very good results. SERO-FIBRINO US PLEURISY. 555 (2) The indications for aspiration during the second or afebrile period, when the main object is to remove the exudate, are—(a) if no diminution in the quantity of liquid effusion takes place one week after the temperature has reached the normal; (b) in subacute cases, in which there is little, if any, temperature from the beginning; aspira- tion should not then be Avithheld longer than three weeks. The operation is free from danger if carried out under antiseptic pre- cautions and if a modern aspirator is employed. The instrument should ahvays be tested before it is used. The patient rests in bed in the semi-re- cumbent posture, the arm of the affected side being brought fonvard with the hand placed on the opposite shoulder, so as to separate the ribs from one another. The point of puncture is in the sixth interspace on the right- hand side and the seventh interspace on the left, in the mid-axilla, or just beloAv the outer angle of the scapula in the seventh right and eighth left interspaces, respectively. An assistant draAvs up the skin from the interspace, Avhile the operator uses the fore finger of his free hand as a director. The needle should be introduced Avith a quick thrust, hug- ging the rib below the interspace, but endeavoring to avoid striking its periosteal covering. The fluid may not be obtained at the first opera- tion, and the reasons for this failure are several. The costal pleura may be excessively thickened, or Ave may meet Avith a much-thickened fibrous band. Again, the fluid may be encapsulated; and, lastly, the needle may become blocked. Under these circumstances repeated trials should be made. The amount of fluid withdraAvn at one time should never be large (sxij to xxiv—384.0-768.0), though a relatively larger quantity may be taken during the febrile stage than during the afebrile, since in the latter instance the lung has been compressed for a longer period of time. The fluid is alloAved to drain away sloAvly, a small needle being used, so as to invite the lung to expand in a gradual manner. If this precaution be not taken, the paretic pulmonary capillaries are apt to become the seat of sudden fresh congestion, folloAved by edema, and often by a speedily fatal termination. Thoracentesis is to be repeated at intervals of several days if nature does not take up the work of absorption, fol- lowing the first operations. If during the operation incessant cough, dyspnea, a tendency to syncope, marked thoracic constriction, or sudden intense pain be developed, the needle must be withdrawn instantly. Thoracentesis should not be resorted to in cases in which croupous pneumonia is associated, and never in very aged and excessively feeble persons. (3) To Support the Strength of the Patient.—The powers of the sys- tem are to be maintained by a nutritious diet, bodily rest, and other hygienic measures. The lighter forms of solid food may be alloAved Avhenever they are found to agree, and it is important to promote the digestive poAver, should the latter be weak, by the administration of suitable remedies. During the stage of convalescence, therefore, tonics (strychnin, quinin, and arsenic) are to be administered. The dietary should be liberal, though composed of Avholesome articles. Gentle exer- cise in the open air is to be encouraged, and massage of the muscles of the affected side tends to re-establish their usual vigor. To bring about the best possible chest-expansion nothing is so good as light gymnastic 556 DISEASES OF THE RESPIRATORY SYSTEM. exercises, together with the methodical practice of deep inspirations for a minute or tAvo at intervals of three or four hours. I am of opinion that the management of the third stage, or that of convalescence, is about the same as that of tuberculosis. EMPYEMA (PURULENT PLEURITIS). Definition.—A suppurative inflammation of the pleura. Pathology.—On opening the pleural sac after death Ave may find a thick, creamy pus, though more frequently it is sero-purulent and sepa- rated into two layers—an upper, clear, greenish-yelloAv serous, and a loAver, thick, purulent layer. In a smaller proportion of cases the exu- date is fibrino-purulent. The odor emitted from the purulent collection is either sweetish or fetid (e. g. Avhen due to wounds), and, Avhen the condition is associated with gangrene of the lung or pleura, horriblv offensive. Microscopic examination shows that the inflammatory prod- ucts are identical with those of purulent inflammation in general. The pleural membranes are the seat of a more intense inflammation than in acute sero-fibrinous pleurisy, and are greatly thickened (1 to 2 mm.). They present a granular suppurating surface, and both visceral and costal pleurae exhibit perforations, and the latter, quite frequently, erosions. Histologically, the altered membranes consist of new connective tis- sue, new blood-vessels, and numerous leukocytes. Etiology.—The following are the chief circumstances under which empyema arises: (1) As a sequel of the acute, sero-fibrinous variety. However clear the effusion may be, it always contains corpuscular ele- ments, which in the further progress of certain cases undergo coincident increase in numbers until the effusion presents a milky aspect, Avhen it is said to be purulent. Thoracentesis may be responsible for this change, though never if performed under rigid aseptic precautions. (2) In children the effusion early becomes purulent in many instances, and in some cases may be so from the start. (3) Secondary to the acute and chronic infectious diseases (pyemia, scarlatina, pneumonia, tuberculosis, and dysentery most frequently; typhoid fever, measles, whooping-cough rarely). (4) The disease may folloAv malignant affections of the thoracic organs (lungs, esophagus), or tuberculous pulmonary cavities Avhich perforate into the pleura. (5) Injuries to the chest may set up empyema (fracture of the ribs, stab or other penetrating wounds). Bacteriologic investigation has shown that the organisms most fre- quently present are the micrococcus lanceolatus, streptococcus, staphy- lococcus, and tubercle bacillus. The cases due to pneumococci usually pursue a favorable course. The leptothrix pulmonalis is often found in putrid effusions. Clinical History.—The symptoms vary with the cause. The on- set may be characterized by acute symptoms, such as rigor, followed by high temperature and signal prostration, and in the affected side there may be severe pains, aggravated by deep breathing and bodily move- ments. EMPYEMA. 557 If the exudate becomes gangrenous, a typhoid state develops early, and the case is apt to prove fatal in the course of a few weeks. It is quite a common event for the acute symptoms that characterize the in- vasion to be replaced at the end of a Aveek or more by the more obscure rational symptoms of chronic empyema. The latter, hoAvever, may de- velop very insidiously as a secondary affection. The rational symptoms in a well-marked case should always excite a suspicion of the presence of the affection, but cannot set the question of diagnosis at rest. The local symptoms (pain, cough, and expectoration) are of a mild charac- ter ; the dyspnea, however, that is usually present may be more or less intense. I have on more than one occasion found an utter absence of these symptoms. The general symptoms are those of septic infec- tion—diurnal chills occurring at irregular intervals, followed by great paroxysms of fever and profuse SAveating—and such patients lose flesh and become pale and Aveak. The temperature is higher than in pleurisy with effusion, and is intermittently, though irregularly, elevated. Peptonuria is a symptom of purulent pleurisy that is not Avithout diagnostic value. It, however, also occurs in suppuration associated with the third stage of pulmonary tuberculosis, and in suppuration due to other causes. While not indicative of empyema, however, it serves sometimes to eliminate sero-fibrinous pleurisy. The urine also contains indican in excess in the various suppurations, at least from time to time, if not constantly. Blood-examination invariably shows leu- kocytosis. If the pus is not removed artificially, it frequently breaks' into the lung, penetrates it, and finally discharges through a bronchus. Pneu- mothorax now tends to supervene. Traube contends that necrosis of the pulmonary pleura may alloAv of the soaking of the pus through the spongy lung-tissue into the bronchi, without the establishment of a fis- tulous connection betAveen the latter and the pleural sac, and hence Avithout the formation of pneumothorax. Besides rupture into the lung and external rupture, empyema may perforate through neighbor- ing organs, as the esophagus, pericardium, stomach, and peritoneum. In rare instances the pus burrows along the spine behind the peritoneum and the psoas muscle, reaching, finally, the iliac fossa and simulating psoas or lumbar abscess. Physical Signs.—These are, for the greater part, identical Avith those of pleurisy with effusion. Attention w ill therefore be called only to such as are more or less distinctive of the affection. Slight edema of the chest-Avail over the seat of effusion, especially in children, is often present, and if the pleural sac be not aspirated, the abscess may point externally and evacuate itself spontaneously. In the latter event a pro- trusion betAveen the ribs shows itself: this may be the seat of fluctua- tion, and present an inflammatory appearance prior to its rupture, with subsequent discharge of its contents. The opening is usually found in the fifth interspace in front, and less frequently in the third and fourth interspaces or beloAv the angle of the scapula behind. The upper level of the fluid does not change so readily on changing the posture of the patient, but requires a longer period of time. Baccelli's sign, or the transmission through a serous exudate of the whispered voice, is sometimes an aid in the discrimination of pleurisy 558 DISEASES OF THE RESPIRATORY SYSTEM. with effusion from empyema. According to my OAvn observation, though it is not invariably propagated by large serous exudations of the pleura, it is yet detectable in a large majority of instances, whilst I have never found it to be obtainable in chronic empyema. Pulsating Pleurisy.—Pulsation synchronous Avith the cardiac beat in pleural effusion has received various designations (pulsating empyema, empyema necessitatis, pulsating pleurisy). The latter term is the most appropriate one, in vieAV of the fact that its course takes place not only in empyema necessitatis, but also in empyema (Avhich manifests no tend- ency to point externally) and rarely in sero-fibrinous pleurisy. Its etiology is not definitely knoAvn. The principal causal factors, hoAvever, seem to be—(1) a copious effusion; (2) paresis of the inter- costal muscles, inducing relaxation of the thoracic Avail; (3) a someAvhat forcible heart-beat (Henry). The rational symptoms of empyema are present. The physical signs are also identical Avith those of the latter affection, with the pulsation superadded. There are instances in which palpation alone detects the systolic pulse in the pleural effusion. With rare exceptions the effusion occupies the left pleural sac. The pulsation may be limited to two or three interspaces or it may be visible over the entire antero-lateral aspect of the chest; pulsation at the back, hoAvever, is rare. Differential Diagnosis.—An absolute distinction between empy- ema and pleurisy ivith effusion rests solely upon the results of exploratory puncture. For this purpose the needle attached to the ordinary hypo- dermic syringe, or, preferably, the surgeon's exploring needle, may be employed, withdrawing but a very small quantity of the fluid, which should be examined both macroscopically and microscopically. Pulsating pleural effusion simulates closely aneurysm of the thoracic aorta. When pulsation occurs in empyema, however, it is seen to be to the left of the normal course of the aorta: the rational symptoms and usual physical signs of purulent pleural effusion are usually present also, while the vascular symptoms and signs of aneurysm of the aorta (thrill, bruit) are absent. Prognosis.—Empyema is a serious disease, but, obviously, the out- look Avill be modified by the special etiology. Spontaneous absorption may occur, though it is extremely rare. The discharge of the contents of the pleural sac through the bronchial tubes is a comparatively favor- able event, some cases in which this occurs recovering, Avhile in others death follows in consequence of the sudden inundation of the bronchi. An empyema may, in rarer cases, empty itself externally Avith favorable issue (empyema necessitatis). Evacuation of the pleural cavity is often folloAved by a continuous discharge of pus for an indefinite period, but the pus cannot be alloAved to remain within the thoracic cavity with im- punity. As a result of the long-continued suppurative process, death may take place by slow asthenia. It must not be forgotten, however, that an unfavorable termination may be, in part at least, ascribable to certain associated affections (phthisis, pericarditis). Among children the outlook is much more favorable than among adults. The prognosis has, hoAvever, been rendered less serious by the application of surgical principles in the treatment of the disease. In all cases in which recovery ensues there is a progressive obliteration of EMPYEMA. 559 the pleural cavity, owing to adhesions, which finally become universal and lead to marked retraction of the affected side. Treatment.—The treatment of empyema is chiefly surgical. In a child the condition may terminate in recovery Avithout operation, and hence may, at this period of life, be alloAved to run for tAvo or three weeks, thoracentesis being resorted to if suffocation be threatened. In an adult, hoAvever, if the purulent effusion be copious, aspiration should be per- formed at once as a temporary means of relief. Empyema following pneu- monia may terminate favorably after one or more tappings; but unless contraindicated by an unfavorable general condition of the patient, such as is met Avith in the closing stages of pulmonary tuberculosis, free incision should be made Avithout delay. The pleural sac should be opened in the fifth or sixth interspace to the left of the mammary line, the incision being from 2 to 3 cm. in length. Resection of a rib is advocated by most surgeons, but if the drainage afforded by free incision be complete resection is unnecessary. It is only indicated when, by approximation of the ribs, the free exit of the pus is hindered (Verebeylil). Opinions are divided as regards the value of irrigation of the pleural cavity. When the pus emits an offensive odor irrigation with a disinfecting solution is imperative. Carbolic acid should, however, not be used. In rare instances accidents arise during irrigation (sudden collapse, convulsions), and I have repeatedly observed a dangerous, and in one instance a fatal, collapse as the result of irrigation in children. The careful insertion of a roll of iodoform gauze is a method to be preferred to irrigation, except when the effusion is stinking. For further details in the operative treatment of empyema the reader is referred to text- books on surgery. Every effort should be made to favor obliteration of the cavity during post-operative treatment. The indication is to bring about the best possible degree of re-expansion of the compressed lung, and in order to accomplish this the method advised by Ralston James has been practised with great success in the surgical wards of the Johns Hopkins Hospital. The patient daily for a certain length of time, in- creasing gradually with the increase of his strength, transfers water by air-pressure from one bottle to another. The bottles should be large, holding at least a gallon each, and by an arrangement of tubes, as in the Wolff bottle, an expiratory effort of the patient forces the Avater from one bottle into the other. In this way expansion of the com- pressed lung is systematically practised. The abscess-cavity is gradu- ally closed, partly by the falling in of the chest-Avail and partly by the expansion of the lung.2 In long-standing cases, in Avhich the lung cannot expand on account of thick bands of adhesion, the pleural layers can- not be brought into juxtaposition Avithout more or less sinking in of the chest-Avail. This retraction of the thorax is probably hastened by timely resection of one or more ribs, the amount of bone to be removed depending upon the " expansive poAver of the lung and elasticity of the thorax." The duration of empyema is longer than in pleurisy with effusion, and the former affection tends to exhaust to a greater degree the powers of the system than the latter; hence the physician's attention should be 1 Quoted in Annual of the Universal Med. Sciences, 1892, vol. i. sec. A. 2 Osier's Text-book of Medicine, p. 605. 560 DISEASES OF THE RESPIRATORY SYSTEM. directed chiefly to the support of the vital forces, modified to some extent by the special etiology in the individual cases. CHRONIC PLEURISY (CHRONIC ADHESIVE PLEURISY). Definition.—Chronic inflammation of the pleural layers—(a) with effusion, and (b) without effusion. (a) Chronic Pleurisy with Effusion.—This sub-variety may follow acute sero-fibrinous pleurisy, and less frequently it has an insidious develop- ment. The morbid lesions, including the character of the exudate, may also be identical Avith those of the acute or subacute forms of the affec- tion. Fibrin and serum are present in varying relative proportions, the latter, however, as a rule, in preponderating proportion Avhen compared with the composition of the exudate in acute pleurisy. The secondary consequences of copious acute effusions also are met Avith—i. e. displace- ment of adjacent organs (liver, spleen, heart) and unilateral dilata- tion of the chest. When the fluid is either absorbed or removed and the case ends in recovery, marked contraction of the affected side re- sults, since the lung, Avhich is covered by thick, organized bands of adhesion, cannot re-expand. Symptoms.—But for slight dyspnea upon muscular exercise the subjective symptoms are frequently av anting. The pulse is compressible and accelerated, as a rule, and there is a trifling rise of temperature in the evening hours. If the effusion becomes purulent, hectic fever develops, leading to asthenia, and the latter con- dition eventually terminates life. Death may also be due to secondary suppurations (abscess of brain, etc.). In most cases occurring in chil- dren the effusion early changes to pus. The physical signs do not differ from those in acute sero-fibrinous pleurisy. The duration of the cases varies from three months to several years, or intercurrent pulmonary tuberculosis may shorten the course of the affection. {b) Chronic Dry or Adhesive Pleurisy.—(1) This may succeed to the acute or chronic sero-fibrinous pleurisy. If the liquid portion of the exudate is absorbed, the pleural membranes come into more or less close apposition, being separated only by fibrinous elements that become organized into a layer of firm connective tissue. Hence the two layers of the pleura, that are greatly thickened, cannot be separated, owing to the firmness of the adhesions. Most frequently the autopsy shoAvs the latter condition to be most pronounced at the base, while the lung is found to be compressed and the seat of fibroid change. If it follows the acute form, the extent of retraction is slight, since there are no dense fibrous bands to prevent a fair degree of lung-expansion; if it succeed the chronic form, however, or empyema, the extent of retraction and flattening will be quite marked. The exudate may undergo cal- careous degeneration, and occasionally little pouches of fluid may be found betAveen the false bands. There is a large class of cases that are dry from the onset (idio- pathic dry chronic pleurisy), and this variety may either be a sequel of acute plastic pleurisy or primarily tuberculous. The condition i3 very commonly met with at autopsy in subjects Avho during life had never presented symptoms of pleurisy Avith effusion. The plastic exu- date, hoAvever slight, invariably tends to become organized, with result- CHRONIC PLEURISY. 561 ing fibrinous adhesion of the two layers of the pleura. Most generally the adhesions are circumscribed, and if tuberculous in origin are most frequently apical and often bilateral. Under these circumstances small caseous masses and little tubercles may be found embodied in the some- what thickened pleura. General synechia is, however, not rare, par- ticularly unilateral. Symptoms.—Definite rational symptoms are rarely present, and the physical signs lack uniformity or may be entirely negative. In other cases of a mild grade the main characteristics are restrained mobility of the affected side and feebleness of the respiratory murmur. In rarer cases the weakness of the breath-sounds is out of all proportion to the expansive motion of the chest. In still another category—composed of a considerable number of instances—certain physical signs are quite pronounced. Inspection reveals decided contraction, Avith immobility of the affected side and a compensatory distention of the healthy side. The heart is displaced, and the apex-beat may be missing (e. g. Avhen the heart is drawn or pushed behind the sternum, or over- lapped by the emphysematous lung). The spinal column is curved, the scapula dislocated, the shoulder ill-shapen and drooping, and the lower part of the thorax shrunken, Avhile the ribs are obliquely placed and closely approximated, or even overlap one another. The tactile fremitus is decreased or absent over the loAver portion of the chest, and there is impaired percussion-resonance or dulness over the same area. The breath-sounds on auscultation are exceedingly feeble, and in some instances an occasional dry, leathery, or creaking friction-sound is audible. Rarely, and particularly if the case be tuberculous, vasomotor symp- toms arise in chronic pleurisy, such as unilateral flushing or sweating of the face, or dilatation of the pupil. Doubtless some of the instances belonging to this affection merge into the pleurogenous type of cirrhosis of the lung, and fatal complica- ting conditions may arise in connection Avith the general circulation. Thus I have observed in one instance enlargement followed by dilatation of the right ventricle, and in turn by general dropsy, with fatal result. Treatment.—In the treatment of this affection tAvo objects must receive especial attention: (1) the removal of any effusion that may be present; and (2) the improvement of the nutrition of the patient. The first indication is presented only by a limited number of the cases, and the rules for meeting it have been stated in the treatment of sero-fibrin- ous pleurisy and empyema ; the second indication is presented by all cases. Careful regulation of the diet is of the utmost importance: it must be generous, with modifications to suit special diatheses (as the gouty or tuberculous), if they be present. Lung-gymnastics are most useful if methodically pursued. The method of Ralston James (pre- viously described) richly deserves a trial in suitable cases. It is to be borne in mind, however, that in old cases efforts at overcoming the lung-pressure will be unsuccessful. Climato-therapy is advantageous for this class of sufferers, particularly if the slightest tendency toward tuberculosis exists; and in my own experience low, mountainous eleva- tions combined with purity of atmosphere have given the best results. Of medicines little need be said. It is especially important to promote 36 562 DISEASES OF THE RESPIRATORY SYSTEM. the digestive power of the patient to the greatest possible extent. In cases in which the digestive function has been feeble I have observed excellent results from a brief stay at any well-regulated seaside resort or in the country. We may also try, with a probability that the effect will be beneficial, small doses (§j—4.0) of cod-liver oil, three times daily after meals, or the following formula: B/. Acidi muriat. dil, sijss(lO.O); Pepsini pur., 3ij (8.0); Tinct. nucis vom., 3iss (6.0); Glycerini, . 3iss (48.0); Aquae, q. s. ad gij (64.0).—M. Sig. 3j (4.0), well diluted, ten minutes after each meal. Intercurrent catarrh of the stomach may sooner or later become a troublesome feature, and in combating it lavage is frequently our most effective measure. PNEUMOTHORAX. [Sero-pneumothorax; Pyo-pneumothorax.) Definition.—A collection of air in the pleural cavity. Since the latter, as a rule, contains at the same time serum or pus, the terms sero- and pyo-pneumothorax are frequently employed to describe the same condition. Pathology.—When the pleural sac is punctured air usually escapes, accompanied sometimes by an audible hissing sound. The pleural sac in pure pneumothorax is greatly distended, and the lung is impacted against the spinal column. Other organs (spleen, heart) are also dis- placed, OAving to positive intrathoracic pressure. The heart is not ro- tated, however, and the relation of its parts is maintained much as in the normal condition (Osier). The air may occupy but a portion of the pleural cavity, on account of previous firm adhesions (circumscribed pneumothorax). The point of perforation, as a rule, can be easily found, and most frequently corresponds to the seat of rupture of the tuberculous cavity or superficial caseous mass. In other instances the cause of pneumothorax cannot be discovered. Inflation of the lung under Avater may reveal the aperture, Avhich is usually quite small, by the escape of air-bubbles at the seat of puncture. Occasionally a fistulous connection betAveen the pleural sac and the bronchi can be readily traced. Simple pneumothorax is, however, of rare occurrence. The air that gains admission into the pleural sac is laden with micro-organisms, which set up various forms of inflammation, accompanied by equally various exudations. Hence the cavity is usually filled, in part, with an effusion that is purulent or sero-purulent, as a rule, and rarely serous or sero-fibrinous. Btiology.—There are both predisposing and exciting causal influ- ences, and among the former are—(a) age ; the condition occurring in PNEUMOTHORAX. 563 adults as a rule, though instances are also observed in young children; (b) sex ; males suffer more often than females ; (c) the left side is affected nearly twice as often as the right; (d) emphysema, in which the super- ficial air-sacs are dilated and atrophied, rendering the latter liable to rupture from excessive muscular exertion. The exciting causes are—(1) Perforation of the lung and pulmonary pleura (the most frequent cause), arising in one or other of three Avays —(a) From the rupture of a tuberculous cavity into the pleural cavity. This accident rarely occurs at the apex of the lung, but commonly near the upper border of the lower or middle lobe; and less frequently near the loAver border of the upper lobe. A caseous focus immediately be- neath the pleura may also, during the process of softening, puncture the pleural sac and invite the entrance of air: From this cause we sometimes see pneumothorax developing during a very early stage of pulmonary tuberculosis. It cannot occur, hoAvever, except in cases in which previous adhesions have failed to form at the point of perforation. (b) As the result of necrotic processes, in connection Avith certain other lung-affections, as gangrene, broncho-pneumonia, suppurating bronchial glands, abscess, and echinococcus cysts, (c) From rupture of the normal air-sacs in consequence of severe muscular effort (S. West, DeH. Hall). This accident is sometimes ascribable to the violent paroxysms of cough in pertussis. (2) Some cases of empyema, by perforating the visceral pleura, the lungs, and bronchi. (3) Perforations of the pleura in malignant disease and abscess of the esophagus. (4) A peripheral bronchiectasis may open the pleural space and thus establish a communication between it and a bronchus. (5) Pyo-pneumothorax may be of subdiaphragmatic origin, consec- utive to perforation by malignant disease or ulcer of the stomach or colon. (6) Pneumothorax may be occasioned by gases resulting from the decomposition of a pleural exudate. (7) Wounds causing direct or indirect perforative lesions of the lungs. Fractures of the ribs may produce laceration of the visceral pleura, and afford an opportunity for the ingress of air into the pleural sac. Symptoms.—The earliest symptoms vary according to the cause or causes that produce the condition. When it develops, as it does so often, in the course of pulmonary tuberculosis, the first symptom is a sudden agonizing pain in the side, accompanied by marked dyspnea and frequently cyanosis. The dyspnea is often accompanied by a sense of impending suffocation. The severity of the pain and the degree of op- pression depend largely, however, upon the amount of air that gains entrance into the pleural sac, the rapidity with which the air escapes into the pleural cavity, and the condition of the latter as regards the presence or absence of previous pleuritic adhesions. If the orifice be large and valvular, the air cannot escape, but rapidly accumulates and forces all the air out of the lung by compression ; the patient then sinks rapidly into collapse from shock, and sudden death ensues. Fortunately, the latter event is rare. The respirations are frequent (60 or more per minute); the pulse is also frequent and feeble, sometimes reduced to a 564 DISEASES OF THE RESPIRATORY SYSTEM. thread; and cold sweats are not uncommon. The temperature at first is apt to fall one or tAvo degrees beloAv the normal, owing to sudden col- lapse ; fever, however, follows almost invariably, and frequently is of the hectic type. Its cause is pleuritis, often of a purulent form, and if this be the case, the dyspnea may be due in part to the increasing effusion. The patient now also suffers from the grave symptoms of empyema above described. Edema of the hand of the affected side is sometimes present Fig. 48.—1. Air in the pleural sac; 2, fluid exudate at base of pleural sac; 3, compressed portion of lung; 4, displaced heart; 5, depressed spleen; 6, mediastinum pushed toward the right. as an early manifestation, and, as a rule, rapidly disappears (^ eil). When pneumothorax develops in the last stages of phthisis acute symp- toms are often entirely absent. Physical Signs.—These are marked (see Fig. 48). Inspection shows marked distention and immobility of the affected side; also some degree of distention with unnatural mobility of the healthy side. Palpation shows the tactile fremitus to be diminished above and greatly diminished or Avholly absent over the effusion below. Edema of PNEUMOTHORAX. 565 the chest-Avail can frequently be made out. The impulse-beat of the heart is found to be feeble and displaced. On percussion a modified tympanitic note (bell-tympany) can usually be elicited over the area corresponding to the contained air, and the ex- cessive tension in the pleural sac, due to the enormous amount of air contained therein, causes an elevation in the pitch of the percussion- note even to dulness. The "cracked-pot sound" is audible Avhen the air in the pleural cavity freely communicates Avith the external air. Wintrich's sign, or a change in the pitch of the percussion-sound Avhen the mouth is open or closed (being raised Avhen the mouth is closed and loAvered Avhen open), may also be observed. In pyo-pneumothorax a flat note is elicited from the base upAvard as far as the fluid extends, and there is a more marked change in the upper level of flatness than in simple pleurisy, on changing the posture of the patient. Modifica- tions in the pitch of the percussion-sound result from an alteration in the form as well as in the dimensions of the air-space. OAving to dis- placement of the heart, there is, as a rule, resonance over the normal cardiac region, and particularly Avhen the patient assumes a recum- bent posture. The liver and spleen, according to the side affected, are displaced doAvmvard to a greater degree than in simple pleural effusion. Auscultation discloses a greatly Aveakened or altogether suppressed respiratory murmur when collapse of the lung is incomplete. Not in- frequently amphoric breathing is audible and bronchial rales possessing a metallic quality are sometimes heard, as Avell as metallic tinkling on deep inspiration or on coughing. The metallic tinkling is caused fre- quently by drops of fluid falling from above upon the surface of the effusion; less frequently by a re-echoing of vibrations of moist bron- chial rales communicated to the air in the pleural chamber. The vocal resonance is enfeebled, as a rule, and evinces the same metal- lic quality. The so-called coin test is a pathognomonic sign, and is elicited in the following manner: An assistant places one coin on the front of the chest and taps it with another Avhile the ear is placed on the thorax posteriorly, Avhere will be heard the intensified echo of the coin- sound thus produced. Another most characteristic sign is the so-called Hippocratic succussion, Avhich is elicited by placing one ear upon the patient's chest Avhile the latter's body is shaken, and a distinct splashing sound is heard. Diagnosis.—When the attack is of ordinary severity, pneumo- thorax is diagnosticated by the history of one or other of the causal factors, together with certain physical signs that do not belong to any other affection (coin-sound, succussion-splash). It is only when the air and fluid in the pleural sac are encapsulated that it may become difficult to eliminate (a) a large pulmonary cavity; (b) excessive gaseous distention of the stomach; (c) an abscess below the diaphragm into Avhich air has entered (pyo-pneumothorax subphrenicus); (d) a diaphrag- matic hernia; (e) emphysema; and (/) pleurisy with effusion. (a) A Large Pulmonary Cavity.—The " cracked-pot sound " and Wintrich's sign are more frequent in cavity than in pneumothorax, and the former condition does not tend to dislocate the adjacent organs. There is no response to the coin test and an absence of the succussion- 566 DISEASES OF THE RESPIRATORY SYSTEM. splash ; both of which signs are often present, even in circumscribed pyo-pneumothorax. Tabulated, these points of difference are— PYO-PNEUMOTHORAX. LARGE PULMONARY CaVITY. Immobility and bulging of the inter- Immobility, flattening of the chest, and spaces. The apex-beat is usually dis- depression of the interspaces. Apex- placed, beat not displaced. Diminished vocal fremitus. Fremitus usually increased. Tympanitic percussion-note. The effu- Percussion gives tympany or a "cracked- sion sinks to the base, and yields dul- pot sound," and Wintrich's change of ness, the outline of which changes with sound as a rule. the posture of the patient. Respiratory murmur and vocal resonance Bronchial breathing is heard, and the usually absent. Amphoric breathing vocal resonance is increased. Crack- may be heard if the opening in the ling, gurgling rales, cavernous or am- lung is patulous. The coin-sound and phoric breathing,and pectoriloquy may Ilippocratic succussion-splash are be present. Absence of bell-tympany noted. and succussion-splash. (b) The possibility of excessive gaseous distention of the stoma eh is to be eliminated by the history of the case and by the happy results af- forded by the application of the therapeutic test, evacuation of the stomach and bowels. (c) Subphrenic Abscess containing Air.—This is exceedingly rare, and occurs relatively oftener on the right than on the left side (Leyden). Its leading causes are ulcers of the stomach or duodenum, followed by circumscribed peritonitis, perforation, and abscess, the latter occupying a position immediately beneath the diaphragm and above the liver. The gases that gain admission to the abscess-sac from the intestines force the diaphragm upward, and thus cause retraction or even compression of the lung The symptoms and signs are noAv identical with those of circum- scribed pyo-pneumothorax, limited to the base; but a knowledge of the steps in the production of subphrenic abscess, the symptoms and history of ulcer of the stomach or intestines, succeeded first by peritonitis and then by symptoms of pyo-pneumothorax on the one hand, and a know- ledge of the etiology of pneumothorax on the other, should lead to a correct inference. (d) Diaphragmatic Hernia.—This either results from a severe injury or is congenital, and the most valuable point of difference between hernia of the diaphragm and pneumothorax is the peculiar cause of the former. The next most valuable point is the fact that the hernial protrusion may return suddenly to its normal position, whereupon the patient Avill be re- lieved ; the condition may then reappear not less suddenly. The third distinctive feature is the presence of rumbling sounds in the protruded bowel. All other signs and symptoms of one affection may have their counterparts in those of the other. (e) Pneumothorax may be confounded Avith emphysema by the care- less obserA^er; but the latter affection is slow in onset, free from serious shock, is bilateral as a rule, and does not exhibit the distinctive physical signs of pneumothorax (metallic tinkling, coin-sound, succussion-splash). In pleurisy with effusion hyper-resonance may be noted above the fluid, but it lacks the bell-like tympany of pneumothorax. Over the same area there is diffuse, distant, bronchial breathing (at times slightly am- phoric), whilst the metallic tinkling, coin-sound, and succussion-splash are totally wanting. HYDROTHORAX. 567 Prognosis.—This depends solely upon the cause. The cases at- tributed to advanced phthisis usually reach a fatal issue in the course of one, tAvo, or more Aveeks, and rarely they run a very rapid and fatal course. On the other hand, the pulmonary condition seems to be favor- ably influenced by its occurrence. FolloAving empyema, pneumothorax sometimes takes a favorable course. It is fraught Avith especial danger when it is the resultant condition of some acute lung-disease (gangrene, abscess, broncho-pneumonia). Treatment.—The leading indication is the alleviation of the pa- tient's sufferings by a prompt resort to morphin, and it often becomes necessary to administer it hypodermically. If the patient's previous strength has been moderately good, the question of operative interfer- ence should be seriously considered, the nature of the surgical proced- ure then depending upon the character of the effusion. If this be sero- fibrinous, aspiration, as in simple pleurisy, must be performed to relieve the urgent dyspnea and the embarrassed cardio-pulmonary circulation ; if purulent, permanent drainage should be procured for the same indi- cations. Wrhen pneumothorax develops late in phthisis, radical meas- ures are not to be thought of, and the physician must rely upon aspira- tion (when necessary) to oppose urgent symptoms. Wre may also tap the air-chamber above the fluid Avith a fine needle, with a vieAv to lessen- ing the excessive tension. Unverricht has recently reported good results from a someAvhat novel mode of treatment. When there is a pulmonary fistula present, he inserts a tube into the pleural sac. This alloAvs free entrance of air, the lung collapses completely, and the fistula has a chance to heal. For the dyspnea, atropin administered hypodermically is valuable; for the feeble cardiac action, alcoholic stimulants, aromatic spirits of ammonia, strychnin, ether, and other cardiac stimulants should be employed. Locally, cutaneous irritants may be applied (turpentine stupes, mustard pastes). HYDROTHORAX. [Dropsy of the Pleura ; Thoracic Dropsy). Definition.—A collection of transuded serum in the pleural cavity. Pathology.—Hydrothorax is generally a bilateral condition. The transudate is a clear, amber-colored liquid that is free from fibrin, but may contain cholesterin and a few endothelial cells. It has an alkaline reaction, a comparatively Ioav specific gravity (1009 to 1012), and is non- inflammatory. The pleural surfaces are usually smooth, though some- times decidedly pale and edematous. The mechanical effects of hydro- thorax upon the lungs and other thoracic and abdominal viscera are similar to those of the exudates that accompany inflammation of the pleura, though they are rarely so marked as in sero-fibrinous pleurisy. Etiology.—Hydrothorax is a secondary affection, and is usually connected Avith one or other of the various forms of general dropsy (hemic, renal, cardiac). The cases that are due to blood-impoverish- 568 DISEASES OF THE RESPIRATORY SYSTEM. ment are more numerous than is generally indicated by writers upon the subject, and not infrequently is hydrothorax symptomatic of either chronic dysentery, chronic diarrhea, leukemia, pernicious anemia, car- cinoma, malaria, syphilis, or scurvy. Strictly local causes may also induce it, as carcinoma of the pleura, or the compression of the superior vena cava or of the thoracic duct by a tumor. Symptoms.—The subjective symptoms are attributable to the me- chanical effects of the fluid, and the causal affection may have symptoms quite in common; these are dyspnea (often culminating in orthopnea), cyanosis, asthmatic seizures, and a feeble circulation. The general symp- toms arise from the primary affection. Physical Signs.—The physical signs are much the same as in pleurisy Avith effusion—with this difference, that they are more often present on both sides of the chest. Hydrothorax is often unilateral, hoAvever, and an enlarged right auricle may be the cause of this condition in some instances. The right side is the one usually affected. I have also ob- served that quite frequently the tAvo sides of the chest exhibit great variations as to the relative amount of fluid contained.1 . Prognosis.—This depends upon the nature of the primary disorder that causes the dropsical transudation. Treatment.—The treatment of hydrothorax has intimate relations with the indications presented by the underlying affection. If the meas- ures directed toward the removal of the general dropsy, of which hydro- thorax is a part, are unsuccessful, and the amount of transudation in the pleural sac interferes Avith the functions of the heart and lungs, then aspiration must not be too long delayed, and must be repeated as often as occasion demands. NEW GROWTHS OP THE PLEURA. Almost all instances of new growths developing in the pleura are secondary to primary carcinoma of the lung, the pleura being invaded by the direct extension of the neoplasm. It may also arise by meta- stasis from carcinoma of the lung, mammary glands, etc. The pleura presents circumscribed areas of thickening, or the groAvth takes the form of papular projections from its surface, and as these enlarge they become pedunculated. Their size varies from that of a pea to that of an orange. The adjacent pleura is inflamed, often adherent, and much thickened, and an effusion into the pleural cavity is often observed. Primary carcinoma of the pleura is very rare indeed, and E. Wag- ner, Avho first described it, called it endothelial carcinoma. Most pa- thologists of to-day, however, look upon endothelioma as a variety of sarcoma. It OAves its orgin to a proliferation of the endothelial cells of the connective tissue and the lymph-apparatus of the pleura. This in- variably assumes the diffuse form, and by metastasis we have involve- ment of the other organs (lungs, lymphatics, liver). Spindle-cell sarcoma of the pleura, as well as the round-cell variety, is occasionally met with. ] For the differential diagnosis between pleurisy and hydrothorax see Pleurisy, p. 552. DISEASES OF THE MEDIASTINUM. 569 Symptoms.—The subjective symptoms are slight in cases in which there is a single circumscribed carcinomatous mass in the pleura; but they are quite severe in the diffuse form, particularly Avhen, as com- monly occurs, it is of a secondary nature. The symptoms are now those of plastic or sero-fibrinous pleurisy, in addition to those of pri- mary carcinoma of the lung, and the former may oftentimes more or less completely overshadow the latter. Diagnosis.—The circumstances under which the condition arises often throAv the strongest light upon its nature. The symptoms of slowly developing pleurisy, either plastic or sero-fibrinous, folloAving carcinoma of the lung or the breast, and accompanied by the cancerous cachexia, Avould point strongly to the existence of carcinoma of the pleura. Characteristic cancerous elements may also be found by micro- scopic examination of the fluid obtained on exploratory puncture, and this should never be neglected in suspected instances. The difficulties surrounding the diagnosis of primary carcinoma of the pleura are great and usually insurmountable. The cases are very similar in their clinical manifestations to chronic pleurisy with or without effusion. Pain is always a more prominent symptom, however, than in simple chronic pleurisy, and this fact, when combined Avith evidences of a cancerous cachexia, should excite strong suspicions. The prognosis is Avholly unfavorable, and the treatment merely palliative. DISEASES OF THE MEDIASTINUM. The affections of the mediastinum may be divided into four classes: (a) Inflammation, (b) Tumors, (c) Diseases of the thymus gland, and (d) Mediastinal hemorrhage. (a) Inflammation.—This may affect (1) the glands or (2) the connec- tive tissue. Lymphadenitis of moderate grade is found in association with broncho-pneumonia and the various forms of bronchitis. The con- dition appears in its most pronounced form in the bronchitis of measles, influenza, and whooping-cough, and De Mussy held that enlargement of the glands in the posterior mediastinum is potent in exciting parox- ysms of whooping-cough. According to De Mussy and Guite'ras, these glands Avhen greatly enlarged give rise to dulness in the upper part of the interscapular region or down to the fourth dorsal vertebra in cases of influenza and Avhooping-cough. I have, moreover, been able to con- firm this dictum in cases of influenza, though aware of the fact that many authorities consider it questionable. Tuberculous lymphadenitis is elseAvhere described (vide Tuberculosis, page 271). The mediastinal lymph-glands may undergo suppuration in consequence of local specific infection, and, though not recognizable during life, it should be recollected that the condition may lead to perforation into either the esophagus or a bronchus, Avith serious results. In other instances spontaneous absorp- tion occurs, leaving behind inspissated contents that undergo calcareous change. 570 DISEASES OF THE RESPIRATORY SYSTEM. Abscess of the Mediastinum.—This is of rare occurrence, its most frequent seat being the anterior mediastinum. Of the commoner causes may be mentioned traumatism and the infectious diseases—erysipelas, rheumatism, measles, and small-pox in particular. It may also be the result of an extension of a suppurative process from neighboring struc- tures. Pulmonary tuberculosis is the most potent factor in producing chronic abscess in this situation. Symptoms.—Acute Abscess.—Pain and tenderness in the sternum are the most prominent features, the pain being acute and often of a throbbing character. Cough and dyspnea are usually present. The general features are fever, frequently accompanied by rigors and pro- fuse sweats and considerable physical prostration. The chief physical sign is dulness upon percussion, usually found anteriorly and increasing gradually Avith the development of the abscess. Later, the tumor may reach the surface of the body, and rarely the sternum is eroded. Pal- pation noAv detects pulsation and fluctuation. The abscess may either find its way doAvmvard into the abdomen, or it may perforate the trachea or the esophagus. In chronic abscess the symptoms bear a closer similarity to those of solid tumors than those in the acute form. Fortunately, chronic abscess quite often results in spontaneous cure, in Avhich case it is in part ab- sorbed, and the remainder of its contents become inspissated. In obscure cases an exploratory puncture Avith a small needle may be safely prac- tised, and with definite results, as a rule. Diagnosis.—Abscess must be differentiated from solid mediastinal tumors and aneurysm. The more acute onset and general symptoms of the suppurative process (hectic type of fever, chills, sweats) and the more rapid course will serve to distinguish abscess from aneurysm on the one hand, and solid tumors on the other. Further, the absence of strong expansile pulsation, diastolic shock, and the aneurysmal bruit aid materially in eliminating aneurysm of the arch. The treatment is mainly surgical. (b) Tumors of the Mediastinum.—Two forms only demand practical consideration—carcinoma and sarcoma. Hare's analysis of 520 cases gave the folloAving ratio: of carcinoma, 134; sarcoma, 98; lymphoma, 21; fibroma, 7 ; dermoid cyst, 11; hydatid cyst, 8; and feAver cases of ecchondroma, lipoma, and gumma. In 48 of the cases of carcinoma and in 33 of sarcoma the tumor occupied only the anterior mediastinum. It is quite certain, however, that sarcoma, and not carcinoma, is the com- moner neoplasm of this region. The clinical term " cancer " Avas formerly used promiscuously by many authors, and the pathologic diagnosis was then difficult, so that statistics are notoriously fallacious. Upon inves- tigating 25 of the older reports of tk cancer," Pepper and Stengel found in 13 unquestionable evidence that the growth was sarcoma, while in the remaining 12 they could not, for the greater part, decide to Avhich form the disease belonged. Primary sarcoma may spring from the rem- nant of the thymus gland, from the lymphatic glands, the pleura, or lungs, or from the fibrous tissues of the mediastinum. Primary carcinoma may originate in the esophagus, bronchi, lungs, or rarely in the thymus gland. Secondary mediastinal tumors are most apt to have their seat in the lymphatic glands. Carcinoma is less frequently primary than sar- DISEASES OF THE MEDIASTINUM. 571 coma. Among predisposing causes are sex and age—males being more prone to the affection than females, and the period of chief liability is betAveen the thirtieth and fortieth years. Symptoms.—The earlier symptoms are quite indefinite. The patient complains of slight substernal pains, slight dyspnea, and general languor. Later, Avith the sIoav increase in the size of the tumor, pressure-symp- toms gradually become more pronounced. The pain may or may not be severe, but is invariably accompanied by a feeling of oppression. Its chief seat is in the upper sternal region, but it may radiate to the sides of the chest and even down the arms (in which case it is due to pressure on the brachial plexus). Dyspnea appears early, is constant, and may become most intense. It is caused by pressure either upon the trachea, upon a primary bronchus, or upon a recurrent laryngeal nerve. Asthmatic seizures may occur before there is constant dyspnea and before the tumor has reached notable size within the chest. Less frequently, and to a less extent, the dyspnea is depend- ent upon dislocation of the heart or upon accompanying hydrothorax due to venous stasis. There is cough, which may be paroxysmal and of a brazen character, and as in aneurysm it may manifest implication of the recurrent laryngeal; for a like reason aphonia may be present. There may be dysphagia from pressure upon the esophagus, though this is rare. If, as may happen, there is an inflammation of the vagus or sympathetic nerve, the rate of the pulse may be affected, and the latter be either slowed or markedly quickened as a result. Owing to implica- tion of the sympathetic there may be local hyperemias and pupillary changes, and particularly an inequality of the pupils. Rarely, by making external pressure upon the sternum, dilatation of the pupil may be produced. Compression of the superior vena cava or of the subclavian vein may be followed by cyanosis and edema of the parts drained by these vessels, and the early occurrence of venous occlusion and marked dilatation of the superficial veins is quite characteristic. But if the degree of pressure increase slowly, collateral circulation may be established com- pletely. Less frequently the inferior cava may also be pressed upon. Physical Signs.—Inspection.—In advanced cases a swelling, usually someAvhat irregular and often diffuse, appears in the sternal region. The tumor may cause erosion of the sternum, and a little later occupy a position immediately beneath the skin, Osier* being of the opinion that the rapidly-growing lymphoid tumors, more commonly than others, perforate the chest-wall. I saw a case in Avhich the perforation occurred at the right edge of the sternum, precisely at the point at Avhich aneur- ysms of the ascending arch most frequently appear. In the early stages, hoAvever, this prominence is not present. Palpation.—When a tumor is present it may pulsate distinctly, and the heart's apical im- pulse may be detected in various abnormal positions. Tactile fremitus is absent over the seat of the growth if the latter be in contact Avith the chest-wall. On percussion dulness is noted, and this is true even in many instances that do not present a visible swelling. The dull area varies in outline with the size and position of the tumor. Auscultation usually reveals 1 Practice of Medicine, p. 579. 572 DISEASES OF THE RESPIRATORY SYSTEM. no sounds over the dull area, except a bruit in rare instances. The heart-sounds are inaudible over the tumor-site as a rule, and the breath- sounds and vocal resonance are feeble or absent. To the above physical signs are frequently added those of pleural effusion. The diagnosis of mediastinal growths is made, if at all, chiefly by exclusion, but it is manifestly impossible before the development of the tumor has progressed to considerable dimensions. Aneurysm is differentiated from solid mediastinal tumors with only slight success in many instances. It is most valuable to note carefully the length of time the condition has lasted, since aneurysm runs a longer course, on the average, than mediastinal tumor, though to this general rule there are many exceptions. The tumor when due to aneurysm communicates a strong, heaving, expansile pulsation—a characteristic that is absent or only feebly manifested in the case of solid mediastinal groAvths. The severe diastolic shock, as noted both on palpation and auscultation in cases of aneurysm, is also absent in solid tumor. The bruit in aneurysm has often a booming quality that does not belong to the bruit of solid growths. Pain is more pronounced in aneurysm. The duration of the disease is rarely less than six, and quite as rarely it is more than eighteen, months. The prognosis is absolutely hopeless, except in the case of benign tumors, which may be removed in some instances. The treatment is directed toward the relief of the most urgent symptoms. Anodynes are required sooner or later, and should not be withheld if indicated. As a routine the preparations of iodin and mer- cury are employed, but, as these are useless, they are unwarranted. Arsenic has sometimes seemed to influence sarcomatous and lymphade- nomatous groAvths favorably, though only temporarily. (c) Diseases of the Thymus Gland.—Nothing is knoAvn definitely concerning the functions of the thymus gland, and the diseases of this organ are without special clinical significance. Tumors may have their origin in the thymus gland, and the organ may become enlarged on ac- count of the presence of true hypertrophy or abscess; these conditions are indistinguishable from mediastinal tumor or abscess as above described. Persons who manifest the hemorrhagic diathesis or those Avho suffer from hemorrhagic affections may also show hemorrhage into the thymus gland —a condition that is identical with that produced by hemorrhage into the mediastinum. (d) Mediastinal Hemorrhage.—This term signifies hemorrhage into the mediastinal connective tissue. It oftenest results from the rupture of aneurysms of the arch or of the large vessels within the thorax, or it may be of traumatic origin (wounds, fractures). PART V. DISEASES OF THE CIRCULATORY SYSTEM. I. DISEASES OF THE PERICARDIUM. PERICARDITIS. Definition.—An inflammation of the serous covering of the heart. Varieties.—(a) Plastic, or fibrinous; (b) sero-fibrinous, or subacute; (c) purulent; (d) hemorrhagic; (e) adhesive. There is also'a tuberculous pericarditis Avhich has been described (vide Tuberculosis, page 308). ACUTE PLASTIC OR FIBRINOUS PERICARDITIS. Pathology.—The morbid changes are frequently localized, and less frequently are general. At the onset the membrane is smooth, swollen, and injected, and punctured ecchymotic spots may be visible; soon it presents a grayish, roughened appearance in consequence of a deposition of a thin layer of fibrin. In the severer types the fibrinous deposit in- creases in thickness for a time, and the natural movements of the peri- cardial surfaces upon one another sometimes cause the exudate to assume a honeycombed appearance. Most examples that I have seen, however, have resembled the roughened surfaces produced by separating two slices of bread that had been thickly buttered; the surfaces are grayish-yellow in color. In the later stages the exudation becomes partly organized, and as the result of friction produced betAveen the opposed surfaces by the incessant action of the heart, the pericardial surface may present a villous appearance; hence the term "hairy heart " Avhich was employed by ancient authors. For like reasons we may see the exudate arranged in the form of little ridges, forming a " tripe-like membrane." Though invariably present, the amount of serous effusion, as the term would in- dicate, is never large in dry or plastic pericarditis. Myocarditis may frequently be found as an associated condition. Etiology.—In each variety of pericarditis there are factors that cause the particular form Avith such relative frequency as to make it desirable to give its etiology separately, except in the sero-fibrinous and acute plastic types, which have practically the same etiology. The two latter are the more common forms of the disease. Acute plastic peri- carditis frequently occurs in the young and middle-aged, and is only 573 574 DISEASES OF THE CIRCULATORY SYSTEM. rarely a primary process, being secondary to acute articular rheumatism (in more than one-half the cases), to chronic nephritis, and, rarely, to the acute infectious diseases. It may be caused by direct extension of in- flammation from adjacent structures, and in this manner it may be a sequel of simple pleurisy; more frequently the extension occurs from a pneumonia or tuberculous pleurisy, or the condition may complicate new groAvths and inflammatory conditions affecting the esophagus and bron- chial glands. It may also be secondary to chronic disease of the aortic valve, the pericardium becoming involved by extension through the Avails of the aorta. Finally, it may be the result of traumatism, and in this connection it should be pointed out that this factor may under certain conditions cause any of the other forms of pericarditis. Bacteriology.—Rudini's experiments have shown that the staphylo- coccus aureus may be a cause of pericarditis, but they have not con- clusively demonstrated that it is the specific cause, as is evidenced by the fact that the disease is sometimes caused by other organisms and found in diseases in Avhich other organisms are active. Moreover, sta- phylococci have not been encountered without demonstrable cause, so that a distinctiArely specific cause has, as yet, scarcely been proved. Among other organisms, pneumococci, streptococci, and the bacillus coli may be named. Clinical History.—Owing to the fact that acute plastic pericarditis is usually a secondary affection, the symptoms that enable one to recog- nize it are obscured by the disease of which it is a sequel. This is par- ticularly true of that large class of cases that develop in acute articular rheumatism, in which subjective symptoms are often entirely wanting. It is only in the severest types of this sort that the symptoms referable to the heart are well enough marked to arrest the attention. There may be a feeling of distress or constriction with or without slight pain in the precordium. During the first stage or prior to the pouring out of the effusion the pain is most marked, extending sometimes into the left arm or the back, and at others to the ensiform cartilage or even to the abdomen. This pain is, rarely, increased by pressure over the pericardium. Palpi- tation and dyspnea may be present, and the pulse is increased in fre- quency and strength, as a rule, except in the later period, when it may be weak and slightly irregular, particularly if the muscular tissue of the heart be involved. There is some fever, but the degree of elevation of temperature perhaps never exceeds 102° F. (38.8° C). In this class of cases the urinary features depend largely upon the character of the lead- ing etiologic factors, though in many instances the urine is scanty, high- colored, and acid in reaction. Physical Signs.—Inspection discloses an increased vigor of the apex- beat. Friction fremitus (due to the rubbing of the altered pericardial layers upon one another) may sometimes be felt during the earlier and later courses of the disease or when the membrane is comparatively dry, and is usually most intense near the base, just to the left of the sternum. Percussion gives negative results. Auscultation usually reveals a double friction-sound over a limited area in the precordia—a characteristic sign, though one on which sole reliance must not be placed in this disease. The friction-rub is caused partly by the exudate and partly by the dry state of the membrane. Its usual seat of maximum pronunciation is in ACUTE PLASTIC OR FIBRINOUS PERICARDITIS. 575 the fourth and fifth interspaces and the adjacent portions of the sternum —i. e. that portion of the heart which is most closely in contact with the front of the chest (Osier). Another favorite point is the cardio-aortic junc- tion. It is usual to hear the rub over small areas, though occasionally it is audible over the whole precordia, and its distinguishing feature is its superficiality, being generated close to the ear. Pressure Avith the steth- oscope, which approximates the layers, increases its intensity, though if too much force be exerted the murmur may disappear entirely. In like manner the friction-sound is influenced by respiration and change of pos- ture. The quality of the sounds, like their position, exhibits great variability. They are sometimes soft, but most frequently are grat- ing or rubbing, and in the later stages I have noticed that they may have a loud creaking quality, closely simulating the bending of new leather. Though with few exceptions they are double, and are primarily produced by the rhythmic movements of the heart, they do not always occur synchronously with the heart-sounds, and usually exceed the latter in duration—facts that go to show that the quality, location, or super- ficial area of a given murmur in no wise indicates the extent of the pathologic process. Complications.—There may be an extension of the inflammatory process to the external surface of the pericardium, either from the deeper pericardial structures or from the pleura, particularly the left. This is a complicating condition termed " external pleural pericarditis " or " medi- astino-pericarditis," in which the mediastinal connective tissue is also, as a rule, involved. It is most frequently secondary to tuberculous pleurisy (tuberculo-mediastino-pericarditis), sometimes also to pleuro-pneumonia, and rarely to simple pleurisy or plastic pericarditis. The recognition of these combined lesions rests chiefly upon the detection of a friction-mur- mur that is partly dependent upon the cardiac and partly upon the respi- ratory movements. These sounds are most distinctly heard along the left edge of the heart. Momentary arrest of breathing suppresses the pleuritic friction-sound, there remaining merely the sounds produced by the rhythmic cardiac action, and even these may be absent. On the other hand, during forced respiration nothing is audible, as a rule, except the strong pleural rub. In normal respiration the inspiratory movements decrease while expiratory movements increase the intensity of the sounds. During inspiration the pulse may become small and slow, owing to the partial occlusion of the aorta, brought about by the traction of fibrous bands of adhesions which pass over the vessel, being at the same time connected with the pleura. When these bands pass from the exterior of the heart-muscle or pleura, they may cause, as first pointed out by Riegel, an absence of the apex-beat during expiration. Instances of this sort are not uncommon. Diagnosis.—Although the presence of a to-and-fro friction-sound is, as a rule, indicative of plastic pericarditis, it is an error to regard it as an infallible sign, since complete calcification of the coronary arteries, as well as excessive dryness of the pericardial surfaces, may rarely produce friction-murmurs. Differential Diagnosis.—The harsh double murmurs due to chronic val- vular lesions can be eliminated if it be recollected that they are more constant, more distant, and that each has its area of transmission beyond 576 DISEASES OF THE CIRCULATORY SYSTEM. the limits of the precordia. The sitting posture, leaning forward, or moderate pressure with the stethoscope, all fail to produce or to increase endocardial murmurs, whether acute or chronic. A double aortic mur- mur is associated with cardiac hypertrophy, the Corrigan pulse, and sys- tolic flushing of the capillaries. Prognosis.—The termination is always favorable as to life. Com- plete resolution does not often occur, but the exudate becomes connective tissue, and agglutinates the two layers of the pericardial sac. The acute may merge into the chronic form, and dry, plastic pericarditis often con- stitutes the first stage of severer grades of the disease. Treatment.—Absolute quiet in the recumbent position should be enjoined. The diet should be composed chiefly of light, easily digested solids, allowing as little drink as is practical, and thus endeavoring to avoid an overfilling of the vessels. With the same object in vieAv, if the patient's strength be good, a half-dozen leeches should be applied over the heart, followed by the use of the ice-bag; the bowels are to be kept soluble by using stewed fruits or saline laxatives if needful. Calomel in doses ranging from gr. \ to \ (0.016-0.032) every hour or two, com- bined with a little opium to prevent purgation, is serviceable. At the beginning veratrum viride may also be cautiously administered, with a view to dilating the arterioles throughout the rest of the body, and thus virtually " bleeding the patient into his own vessels." Later, digitalis in combination with the iodids of potassium and iron should be substituted for the purpose of absorbing the effused material. Tonics and a chauge of air may be required during convalescence. SERO-FIBRINOUS PERICARDITIS. Pathology.—The anatomic changes may be grouped into three stages—the first being characterized by a plastic exudation (correspond- ing with the lesions in dry, plastic pericarditis, though more pronounced); the second stage, by a variable amount of effusion composed largely of serum. The exudation usually begins about the origin of the great ves- sels springing from the base of the heart, and ultimately forms a thick covering of fibrin, especially on the visceral layer. The quantity of serous effusion may be from 2 to 10 ounces (64.0-320.0), but occasionally it is as much as 3 pints (1|- liters). The admixture of a slight amount of blood- or pus-corpuscles sometimes occurs in this form of the complaint. The third is the stage of absorption in the most favorable cases. Perfect resolution rarely takes place, but, instead, the liquid effusion is alone ab- sorbed, and the lymph causes firm adhesions of the visceral and parietal membranes. If, as sometimes happens, the serum remains, the acute passes into a chronic condition. The muscular tissue of the heart may become involved by an extension of inflammation from the visceral layer which lies in contact with it; it is always the seat of more or less col- lateral edema. The grade of the myocardial inflammation will depend much upon the extent and duration of the pericarditis, though usually it is moderate in the fibrino-serous variety. Etiology.—The disease is most frequently observed to be associated with acute rheumatism, Bright's disease, and pulmonary tuberculosis. Respecting the causal relation of acute rheumatism, two facts should be SERO-FIBRINOUS PERICARDITIS. 577 stated—viz. that pericarditis arises as a complication in about one- third of the cases (Bamberger), and that it may rarely precede, by a feAV days, the articular disturbance. I am of opinion that in excep- tional instances both sero-fibrinous and plastic pericarditis may occur secondarily to the rheumatic dyscrasia Avithout the slightest evidence of arthritis. The disease also occurs in the course of the eruptive fevers, and sometimes as a complicating affection due to extension of inflamma- tion from neighboring parts. Clinical History.—When, as rarely occurs, a primary pericarditis develops, the initial symptoms common to inflammation of other serous membranes manifest themselves, as anorexia, sometimes nausea and vom- iting, chills, fever, increased respiration and pulse-rate, together with local pain. The pain is usually of a dull, aching character, and less fre- quently merely a slight soreness, or it may be absent altogether. Acute pain is experienced only when the pleura is implicated. When pericarditis is secondary to an existing febrile affection there are, in many cases, no subjective symptoms to indicate its presence. In other instances there may be precordial oppression with or Avithout slight pain or a feeling of soreness. Hence the rule should be absolute that in all affections in Avhich pericarditis is likely to arise physical examinations of the heart should be frequently made, and particularly during the height of the disease. Dyspnea comes on simultaneously with the appearance of the effusion and may lead to actual orthopnea. Pressure is exerted upon the left lung if the effusion be large—a fact that explains in part the presence of dyspnea. The cardiac muscle, especially the right ventricle, is also pressed upon by the effusion, thus impeding to a greater or lesser extent the cardio-pulmonary circulation as Avell as the cardiac diastole. We have here an additional reason Avhy dyspnea occurs, and also Avhy deficient aeration of the blood and a feeble peripheral circulation are found in this complaint. Prior to the occurrence of the effusion the circulation is too actively carried on, the pulse being full and strong. It is clear from the above explanation relative to the mechanical effects of large effusions that during the second stage the pulse is small, feeble, and irreg- ular. When the liquid effusion is not large the heart-action may be ap- parently feeble, Avhile the pulse remains strong—a valuable rational sign. On the other hand, an excessive amount of fluid may cause the radial pulse to become quite small or even to disappear during inspiration (the pulsus paradoxus). Fever is present, as a rule ; the temperature is irregularly elevated, ranging from 101° to 103° F. (38.3°-39.4° C). In favorable cases defervescence takes place by lysis. Nervous symp- toms, as headache and mild delirium, often appear, and sometimes give place to stupor or even coma. Physical Signs.—Inspection.—The skin-surface and mucous mem- branes are observed to be pale and more or less cyanotic. The neck- veins are prominent, and sometimes exhibit undulatory movements or pulsations. The face wears an anxious expression; the respirations are increased, labored, and at times irregular. The decubitus is dorsal; the head and shoulders are elevated, and the patient may be forced to assume the sitting posture. In young subjects precordial prominence, with efface- ment or even bulging of the intercostal spaces, may result from the pres- 37 578 DISEASES OF THE CIRCULATORY SYSTEM. ence of a moderate effusion. In adults, however, a large collection is indispensable for the production of this effect. If the lung be shrunken or if there are pleuritic adhesions, expansion of the pericardium, and hence also bulging, will be prevented. The distended pericardium may depress the diaphragm. Elevation of the left nipple in consequence of marked anterior expansive bulging has been observed. In the first stage the apical beat is intensified, but as the effusion increases (forcing the heart backward and upward) it is displaced in an upAvard and outward direction, at the same time becoming Aveaker as well as more diffused, since with expansion of the sac comes greater mobility of the organ. When the pericardial sac becomes filled the impulse-beat disappears, for the reason that the fluid now completely surrounds the heart and pushes it aAvay from the chest-wall. Palpation confirms the result of inspection. The apical beat is dif- fused and feeble or lost. When detectable it is found to be displaced upAvard and to the left. Altering the patient's posture changes the seat of the apex-beat (Oppolzer), and if the shock has been lost, turning the patient on his left side or bending his body forward may cause its return. The cardiac impulse disappears earlier when, on account of myocarditis, the systole is greatly enfeebled. On the other hand, old adhesions may retain the apex-beat in contact Avith the chest-Avail, despite the presence of a large accumulation. Hypertrophy of the organ Avould act in a similar manner, though less potently. A friction-rub can be felt occasionally over the base of the heart even Avhen there is a copious effusion present, and, if absorption takes place, the friction fremitus becomes more marked, simulating the first or dry stage. Percussion.—The area of cardiac dulness is greatly increased, and assumes a characteristic triangular form with the base downward and the apex extending up to the third or even second interspace to the left of, though near, the sternum. The lateral border-lines of dulness obviously diverge from above downward, the right passing to a point corresponding with the right edge of the sternum, along which it runs to the seventh rib ; the other to the left, finally intersecting the base-line at the left anterior axillary line. The lower level of the fluid, being continuous with the liver dulness, is not definable. Even in moderate effusions there is flatness in the fifth interspace to the right of the sternum (Rotch). The margins of the lungs surrounding the heart may be retracted and the heart carried fonvard or dilated, owing to the presence of adhesions; the dull space will then appear larger than is justified by the amount of fluid. Retraction or moderate compression of the lung may, however, give rise to a modified tympanitic resonance to the left of the flat area. Occasionally the lung is attached anteriorly, and then the heart is crowded backward by the effusion, while the area of flatness on percussion is relatively diminished. The triangu- lar shape of the flat space, noted when the patient is in the sitting posture, is to a considerable extent lost and its area diminished when he changes to the supine position or lies on either side, the effusion obeying the laAVS of gravitation. When the feeble impulse can be felt by the clinician occupying the center only of a dull area, he has good evidence of the existence of pericardial effusion. Auscultation.—The characteristic friction-rub of the first stage has SERO-FIBRINOUS PERICARDITIS. 579 already been described. It may, however, also be audible over the base during the stage of effusion, and always returns, after absorption of the fluid, for a brief period. The heart-sounds groAV more and more distant, faint, and muffled, though the second sound, as heard over the extreme base of the organ, may remain clear. Over the area of dull tympany corresponding to the lower antero-lateral portion of the left lung (Avhich, as before pointed out, is more or less compressed) may be heard broncho- vesicular breathing. Course and Duration.—It will appear obvious that the course must vary in individual cases with the cause and severity of the special type of infection. Observation has shown that in one class of cases the three stages (dry, effusion, and absorption) are passed through in rapid succes- sion, while in another class each stage is proportionately lengthened. The latter type has been termed "chronic" by some and "subacute " by others. The acute may also be followed by the chronic variety. Usually sero-fibrinous effusions complicating rheumatism are absorbed Avith rapidity once the process has begun, seldom requiring more than two weeks. When recovery is about to occur the temperature falls by lysis; the dyspnea gradually disappears, and with it the effusion is gradually ab- sorbed. Convalescence is further indicated by a return of the appetite, normal heat of the skin, and a less frequent, full, and regular pulse. In cases that tend to a fatal termination either the fever continues or there is suddenly developed hyperpyrexia, as may happen when pericarditis occurs in the course of acute rheumatism; in such cases the dyspnea is urgent and cyanosis is often marked, with signs of failing circulation. Nervous symptoms, as extreme restlessness, insomnia, and active delir- ium, may be present. Under these circumstances death usually ensues at the end of a week or ten days. In a fatal case of acute articular rheumatism which I saw, complicated by pericarditis, with hyperpyrexia, death occurred on the sixth day. Rarely acute pleuritis Avith effusion is a complication, and its occurrence usually lengthens the course of the pericarditis and renders the outcome of the latter condition uncertain. When there coexists extensive myocarditis, syncopal attacks often endan- ger the life of the patient. Copious effusion may, by causing pressure upon the recurrent laryngeal nerve, produce paralysis of the vocal appa- ratus ; or, as the result of pressure upon the esophagus, difficult deglu- tition may be a troublesome concomitant. Prognosis.—In sero-fibrinous pericarditis recovery is the rule under favorable conditions. The outlook, however, becomes gloomy when the above-mentioned complications arise, and particularly when there is hyper- pyrexia in connection Avith acute rheumatism. Occurring as a secondary event in serious acute diseases, as pneumonia, or in chronic diseases, as Bright's, or organic affections of the heart, the pericarditis often precip- itates a fatal termination. The strong possibility that these cases may only partially recover or assume a chronic form must be recollected in making a prognosis. Diagnosis.—The disease is often overlooked, because unsuspected. Ordinarily the recognition of pericarditis by the characteristic triangular area of percussion-dulness and by the friction-sound i3 not difficult. Atypical cases or those first seen during the stage of effusion can only be correctly diagnosticated by exclusion. 580 DISEASES OF THE CIRCULATORY SYSTEM. Differential Diagnosis.—Acute pleurisy of the left side may simulate pericarditis with copious effusion, and, as before stated, these diseases may coexist. Acute pain, hovvever, belongs to pleurisy alone. In peri- carditis the characteristic physical signs are elicited over the precordia; in pleurisy they are apt to occupy not only the anterior but also the axillary and posterior aspects of the chest; hence the percussion-flatness in pleurisy extends to the left, far beyond the boundary-line of the per- cussion-flatness in pericarditis. The pericardial friction-sound has a dif- ferent situation usually from the pleuritic, and the latter is heard syn- chronously with the respiratory movements, while the former is intimately related to the time of the cardiac movements. The friction-murmur of pleurisy ceases if the breathing be momentarily suspended. Encapsulated pleural effusions that are limited in area to the antero-lateral portion of the chest are exceedingly difficult of elimination, and especially in the absence of pleuritic friction. In the latter complaint, hoAvever, the heart- sounds are clear and the apex-beat often pushed some little distance to the right; on the other hand, in pericarditis the general disturbance is usually greater, while a friction-rub may be detectable over the base. The heart-sounds are distant and muffled. The diagnosis is often aided by a consideration of the previous history and the bearing of any facts thus obtained upon the known etiology of these affections. We encounter intricacies when we attempt to exclude cardiac dilatation, though the fol- lowing brief table will be of assistance in the diagnosis: Pericarditis with Effusion. Cardiac Dilatation. {Previous History.) Recent history of gout, acute rheumatism, Usual history of chronic valvular disease acute infectious or septic disease, scur- of the heart. vy, chronic nephritis, or tuberculosis. {Clinical History.) Fever and slight pain are usually asso- No fever or pain, as a rule. ciated. Nervous symptoms are often present. Absent. {Physical Signs.) Inspection often reveals bulging (more Apex-beat usually visible, wavy, and marked in the young). Apex-beat diffused. pushed up, is feeble, and later absent. Heart's impulse usually absent. Friction- Though feeble, the impulse is palpable. fremitus may be present over the base. Percussion shows a triangular flat area, Dull area varies with chambers dilated; and the boundary-line above changes usually it is coextensive with a wavy on altering the position. There is dull impulse, and does not extend so high tympany in the axillary or subscapular (except in mitral stenosis), and does not region. vary with change of position. Xo dull tympany. Auscultation shows the first sound distant First sound clear, short, and sharp. >o and muffled; the friction-rub is often friction-murmur present, but an endo- double over the base. cardial murmur or murmurs may appear. Treatment.—The management of the first (or dry) stage is identical with that detailed in discussing the plastic variety. During the stage of effusion the patient should be kept at absolute rest in the recumbent pos- ture, and mental excitants should be rigidly prohibited Avith a view to PURULENT PERICARDITIS. 581 minimizing the labor of the heart. The diet is to consist mainly of easily digested albuminous articles; fluids are not to be given in large amounts, since this tends to overfilling of the vessels, increases the arte- rial tension, and delays absorption. Local Measures.—Flannel should be kept over the precordia, so as to avoid exposure and undue chilling. The ice-bag or Leiter's coils (to be used in the first stage) should be cautiously employed during the second stage, until the temperature has defervesced considerably, thus indicating a sub- sidence of inflammation in the pericardium.1 Subsequently, if absorption does not proceed satisfactorily, blisters may be applied over the pre- cordia, and, should the patient's general condition be markedly asthenic, an ointment containing iodin, lanolin, and ichthyol may be substituted Avith advantage. The therapeutic measures must be chosen with sole reference to the primary disease, which the physician must continue to treat Avhile he attempts by other means to relieve certain symptoms and promote absorption. For example, if the pericarditis be due to rheu- matism, the use of the salicylates must be persevered in, and opium may be added to quiet restlessness and procure relief from pain. In my own experience absorption has been best promoted by the use of the double iodid of potassium and iron or of iron and manganese. These agents are seldom contraindicated unless they are badly borne by the stomach. Diuretics and saline purgatives are not Avithout value, but do good only in the later stages. Depressing measures of whatever sort are not to be resorted to unless the circulation be good. If the pulse be small, weak, and rapid, with marked cyanosis, stimulants are indicated and are to be given in moderate quantity ; the pulse will then be found to grow stronger and the dyspnea and cyanosis less marked. The nervous symptoms are also benefited as a result of the action of these agents. Strychnin and the salts of ammonium will be found to be useful. Digitalis and strophan- tus are not to be thought of when myocarditis is associated ; at other times they often improve the peripheral circulation and increase the urin- ary secretion. When the breathing becomes greatly embarrassed and the circulation fails, as shown by the feeble, broken, rapid pulse and the cyanotic hue of the lips, eyelids, and finger-tips, cardiocentesis is indicated, and in sero-fibrinous effusion aspiration has, in recent years, given good results if not too long delayed. If the slightest doubt arises as to the character of the fluid, a preliminary puncture with a hypodermic needle should be made. The point for puncturing is the fourth interspace, 1 inch (2.5 cm.) from the parasternal line, or the fifth interspace, 1\ inches (3.7 cm.) from the left edge of the sternum. The operation must be per- formed Avith the strictest asepsis, and the amount of liquid withdrawn at any one time should not exceed two or three ounces. It would be better to repeat the puncture several times than to remove the pressure too sud- denly from the damaged heart. PURULENT PERICARDITIS. [Empyema of the Pericardium.) Pathology and Etiology.—The condition often follows the sero- fibrinous form. Septic and tuberculous processes involving the pericar- 1 If the pericarditis be secondary to an acute febrile disease, this fact must modify the method here recommended accordingly. 582 DISEASES OF THE CIRCULATORY SYSTEM. dium are also apt to cause purulent effusion, and many of the cases that arise in the course of the acute infectious diseases belong to this category. The membrane is much thickened and presents a gray, granular surface, and the myocardium underlying the visceral layer is softened, fragile, and pale-looking—changes that are in the main due to fatty degeneration. Clinical History.—The local subjective symptoms and physical signs are the same in kind as in the former variety, but the amount of exudation is frequently less. At the onset rigors often occur, and may be repeated at varying intervals. The temperature-curve is of the sup- purative type ; the pulse is small, rapid, and irregular; and physical prostration is pronounced. Purulent pericarditis runs a comparatively rapid and an almost uniformly unfavorable course. Diagnosis.—The chief clinical features are often referable to the primary or causal disease; hence in every instance in which purulent pericarditis is apt to arise a physical exploration of the chest is impera- tive. The purulent character of the effusion cannot readily be ascer- tained, as a rule; but the history of an affection having etiologic im- portance, the observance of rigors, and the presence of the fever-curve peculiar to suppuration would all point strongly to purulent effusion, and should lead to aspiration with the hypodermic needle—a harmless pro- cedure if carefully performed, and one that almost constantly gives relia- ble results. Treatment.—It is Avithin the physician's province to treat the pri- mary disease assiduously, but he should not undertake to treat complica- ting pericardial empyema by the application of therapeutic measures. A surgeon's aid should be invoked. HEMORRHAGIC PERICARDITIS. In purulent pericarditis the effusion may be hemorrhagic, and par- ticularly Avhen it is of tuberculous origin. In non-purulent tuberculous pericarditis also the exudation is apt to be hemorrhagic. In the non- purulent instances that are due to chronic Bright's disease or that occur in the aged the effusion is sometimes blood-stained; and future ob- servation may shoAV that the hemorrhagic variety is of more frequent occurrence than has hitherto been supposed. Here may be pointed out that even in ordinary serous pericarditis there is apt to be much more blood than in serous pleuritis. M. T. Ferrier has found 5 examples in 9 collections. This etiologic variety scarcely calls for separate clinical con- sideration. ADHESIVE PERICARDITIS. {Chronic Pericarditis.) Pathology and Etiology.—Chronic pericarditis follows the acute forms, and, as in the case of the latter, it may be partial or general. The effusion may rarely remain as a permanent condition, though not infrequently a clear history of the preceding acute attack is wanting. In most instances the opposed surfaces of the membrane are either univer- sally or over a limited area firmly adherent. The amount of new con- nective tissue present or the degree of thickening of the layers varies greatly, and is dependent upon the type of the primary acute attack. If ADHESIVE PERICARDITIS. 583 the latter is of mild grade—as, for example, in the case of the sero-fibrin- ous variety, complicating rheumatism—then not much thickening is en- countered in the resulting chronic form. Chronic tuberculous pericarditis is not uncommon, and may be pri- mary, though more commonly it is secondary, in its origin. The disease is not invariably preceded by the acute form, but may be chronic from the time of onset. I have noticed that often more or less effusion pre- vails unless artificially removed. The layers become enormously thick- ened, and total obliteration of the sac by agglutination of the surfaces is not infrequent. In the dense exudate that remains after complete absorption of a peri- cardial effusion calcareous depositions occur, forming a bony casing, as it Avere, which either partially or totally encircles the organ. The external surface of the pericardium may become united either with the costal or pulmonary pleura, the chest-Avail, or the mediastinal tissues. The myo- cardium is the seat of atrophic and degenerative changes. Symptoms.—Autopsies frequently reveal a chronic adhesive peri- carditis that has not given rise to a single recognizable symptom during life. Hypertrophic dilatation of the chambers usually develops sooner or later, and is due to adhesions that interfere Avith the free action of the organ as wTell as with its systole. WThen present the subjective symptoms point to enfeeblement of the cardiac muscle, as shoAvn by the universal venous stasis. The symptoms of bronchial and gastro-intestinal catarrh are often prominent; rational symptoms indicative of adhesion are, how- ever, scanty and unreliable. The pulse is rapid, of Ioav tension, and irregular, and, though not diagnostic, the pulsus paradoxus has been noted. Physical Signs.—Inspection.—Depression or pitting of the intercostal spaces over the position of the heart may be noticed. Synchronous with the systole there is also a retraction of the chest-wall in the apical area, and less frequently over the whole precordia, the latter being an unerring sign of universal adhesions. The degree of systolic retraction is slightly influenced by the respiration, inspiration increasing it, and it is best appreciated on palpation Avhile the patient is in the semi-supine position. During the diastole the heart forcibly rebounds, causing the so-called diastolic shoek, which is of the utmost diagnostic worth when associated with marked systolic retraction. Though not ahvays visible, it can be readily felt on palpation. Friedrich's sign (the sudden collapse of the jugulars during diastole) may frequently be observed, but I have also noticed this in cardiac dilatation without adhesions. Prior to the onset of dilatation the apex-beat may be forcible and visible over an increased area, indicating hypertrophy; but after the myocardium is weakened (from interference with its nutrition) and dilatation comes on, the impulse-beat is faint or wanting, and in marked systolic retraction may be seen to be vibratory. The fixed position of the apex-beat Avhen the patient is turned over upon his left side is a confirmatory sign of con- siderable value. Percussion.—The area of cardiac dulness is increased, especially upward and to the left, owing to the associated hypertrophy and pleuro-pericar- dial adhesions, and, since the adhesions between the pleura and the peri- cardium do not allow the lungs to come forward and overlap the heart 584 DISEASES OF THE CIRCULATORY SYSTEM. during inspiration, the upper and left lines of dulness remain fixed (C. J. B. Williams). Auscultation.—When dilatation reaches a high degree the auscultatory signs peculiar to that condition appear. In many cases no murmurs are detectable, but in a third group loud murmurs, quite independent of any value as regards cardiac lesions, are audible; these murmurs may be due to the vortiginous movements in the endocardial blood-current occa- sioned by the jogging cardiac action. Finally, it is to be noted espe- cially that chronic adhesive pericarditis may exist Avithout giving rise to any physical signs. Differential Diagnosis.—The condition is apt to be confounded Avith chronic myocarditis and simple hypertrophic dilatation. As before stated, chronic pericarditis may be associated Avith effusion, and in such instances it is important to distinguish from the adhesive type, if Ave Avould institute a proper treament. In chronic pericarditis with moderate effusion the seat of the apex-beat is higher and less un- dulatory, and when the amount of effusion is large the impulse is absent and there is bulging. Adhesive pericarditis with hypertrophy causes bulging in young subjects, but the apical beat is retained. In pericar- ditis with effusion the upper and left limits of dulness are not stationary, and there is an absence of systolic retraction and diastolic concussion. Course and Prognosis.—The hypertrophy that comes on early in consequence of the obstruction offered to cardiac action is compensatory, and this harmonious balance may be maintained for a long period of time with apparent comfort. After myocardial degeneration, followed by atrophy or dilatation, has occurred, the condition becomes quite serious, and death usually ensues amid signs of extreme cardiac dilatation. The treatment must be ordered chiefly with reference to the nutri- tion of the heart-muscle, following the principles noted in dealing with the management of valvular affections of the heart. If chronic effusion be present early, operative measures are to be warmly advocated. HYDROPERICARDIUM. {Dropsy of the Pericardium.) Definition.—A condition in which the pericardium contains a serous transudation, while the membrane itself shows no signs of inflammation. Etiology.—(a) Hydropericardium is usually associated with general cardiac or renal dropsy, of which it forms a component part. Under these circumstances it develops late, and frequently follows hydrothorax, on account of which condition it is liable to be overlooked. It may also occur suddenly in chronic nephritis, and particularly in the scarlatinal variety, (b) It arises not infrequently from local mechanical causes, as the pressure of mediastinal tumors, aneurysm, or thrombosis of the car- diac veins. Symptoms.—No subjective symptoms are present, save perhaps dyspnea, and the diagnosis rests upon the history and the physical signs. None of the latter, however, are particularly significant. They point to HEMOPERICA RDIUM—PNE UMOPERICARDIUM. 585 the presence of fluid, and the area of percussion-dulness assumes the same form and exhibits even greater change, with alteration of the patient's posture, than in pericarditis. No friction-murmurs are heard and no bulging of the pericardium is observed. It is rare indeed, I have found, to see an excessive amount of serum in the pericardium at the postmortem. The symptoms and signs of hydrothorax generally precede and accompany hydropericardium, and the latter condition tends to intensify the effect of the former. The condition, per se, is rarely of serious import. Osier remarks: " Naturally there are in the pericardial sac a few cubic centi- meters of clear, citron-colored fluid, which probably represents a post- mortem transudate." In rare instances the transudate has a milky appearance (chylo-pericardium). The treatment suitable for cases of general dropsy, as a rule, affords relief. In large serous accumulations aspiration should be practised. HEMOPERICARDIUM. By the term " hemopericardium " is meant hemorrhage into the peri- cardial pouch—a rare event. Among the causes are—(a) perforation by aneurysms of the aorta and the coronary arteries into the sac; (b) rupture of the heart, due to injuries or cardiac aneurysms and fibrous formations from myocarditis; (c) direct injuries, especially stab- and bullet-wounds. The symptoms and course depend greatly upon the nature of the exciting cause. The most frequent factor, rupture of an aneurysm, proves quickly fatal from overcrowding of the heart. In rupture of the heart-muscle there is sometimes a slow outpouring of blood, with a correspondingly slow course, varying from a few hours to a couple of days in duration. The physical signs of effusion come on with dyspnea and failing circula- tion, which lead to cardiac exhaustion and death. The blood-stained effusions, before considered, that are met with in certain forms of peri- carditis, are not to be regarded as instances of hemopericardium. PNEUMOPERICARDIUM. [Air in the Pericardium.) Ix this complaint, besides air or gas, there is usually present pus, and less frequently blood ; hence an appropriate term in most instances would be pyo-pneumoperieardium. When the pericardium is perforated puru- lent pericarditis results. The causes are the following : (a) wounds ; (b) a fistulous connection between the adjacent air-containing organs and the pericardium as the result of diseased processes, such as pulmonary tuberculosis or empyema; (e) rarely decomposition of liquid pericardial effusions. The symptoms are equivocal. In the main they do not differ from those of pericarditis Avith effusion, excepting that dyspnea is more intense than in the latter affection. By attention to the physical signs 586 DISEASES OF THE CIRCULATORY SYSTEM. the distinction from pericarditis can rarely be made. In pneumoperi- cardium there is tympanitic percussion-resonance over the precordia, though the fluid, when present, gives rise to a boundary-line of dulness. The change of the patient's posture alters markedly the area of the tym- panitic note. On auscultation may be heard loud, rasping, friction- sounds having a metallic quality, intermingled Avith churning, splashin" noises, or the so-called " water-wheel sounds." I have, however, occa- sionally found the apex-beat and heart-sounds exceedingly feeble. Pneumothorax when encysted in close proximity to the heart, displacing the latter organ, must be eliminated. The latter complaint gives cardiac dulness in an abnormal position and a metallic sound synchronously with the respiratory movements—two signs diagnostic of pneumothorax that are absent in pneumopericardium. The prognosis is grave, death coming on most commonly in a day or two. The admission of air might alone result in a spontaneous cure, as occurs rarely in pneumothorax. The treatment is the same as has been recommended for purulent pericarditis. II. DISEASES OF THE HEART. ENDOCARDITIS. Definition.—Inflammation of the lining membrane of the heart. The process is usually confined to the valves, though the cardiac layer may also be affected. Varieties.—(a) Simple acute endocarditis ; (b) ulcerative endocarditis; (c) chronic endocarditis. The pathologic processes involved in the first two, the acute forms, are identical in nature, though they differ in severity. I have met with two instances that could be referred to neither sub-variety, apparently occupying a middle ground. SIMPLE ACUTE ENDOCARDITIS. {Endocarditis Verrucosa.) Pathology.—The disease is characterized by the formation of small vegetations on the segments, varying in size from excrescences that are scarcely visible to those the size of a pea. They are found chiefly on surfaces that are opposed to the blood-current, near the margin of the valve, and " forming a row of bead-like outgrowths." Their seat corre- sponds to the point of maximum contact (Sibson), but the mitral valve is much more commonly affected than the aortic. With the segments the chordae tendinese are sometimes affected, and very rarely the latter are alone involved. The left side of the heart is much more frequently the seat of acute endocarditis than the right, except during fetal life, when the right side is almost exclusively involved. To account for the greater frequency of occurrence on the left side after birth, it has been suggested that freshly oxygenated blood affords the most favorable condition for the multiplication of the micro-organisms that are concerned in the inflamma- tory process. As corroborating this view, the fact is adduced that during SIMPLE ACUTE ENDOCARDITIS. 587 fetal life the blood in the right chamber is the more completely oxygen- ated. It has also been pointed out that before birth the right side, and after birth the left side, is the more active, and that the active side is apt to suffer on account of higher pressure. Obviously, the vegetations form an obstruction to the current of the circulation as it flows through the valvular opening. In the early stage the membrane in the vicinity of these excrescences shows a bright-red color, Avhich has usually disappeared in fatal cases before they come to autopsy. The histologic changes con- sist in a proliferation of the subendothelial tissue (small-celled infiltra- tion), Avhich forms the principal component part of the vegetation. On this basal mass of granulation tissue there is deposited fibrin from the blood, the latter being separable from the former in acute forms of the complaint. Micro-organisms have repeatedly been found in the fibrinous depositions, but the specific causal irritant has not as yet been discovered. In favorable cases either the vegetation is ultimately absorbed or there remains a small indurated mass. When the vegetations are of consider- able size emboli may become detached by the force of the blood-current, and be carried to the vessels of the extremities and to the various viscera, particularly the brain, spleen, and kidneys, giving rise to embolic infarcts. The latter event is frequently observed in cases in which acute endocar- ditis is engrafted upon chronic valvulitis. Simple acute endocarditis may end in the more serious or ulcerative variety. Here the cellular proliferation proceeds actively, leading to necrosis of the newly-formed tissue and to the production of an ulcer. Much more commonly, however, does the simple form terminate in chronic (sclerotic) valvulitis with deformity. Etiology.—The most frequent cause of acute endocarditis is acute articular rheumatism, Avhich induces the disease in not less than 40 per cent, of the cases. In young subjects suffering from rheumatism the liability to the complaint is particularly pronounced. The severity or mildness of the rheumatic attack does not, however, influence the appear- ance of the cardiac complication. Cases of acute endocarditis of rheu- matic origin are met Avith in which the arthritic phenomena are secondary. It may complicate tonsillitis Avhen the latter is due to or associated with rheumatism. In specific fevers it is also encountered, and found to be common in scarlet fever, but rare in typhoid fever, diphtheria, measles, erysipelas, variola, and varicella. It is not uncommon as a complication in pneumonia and pulmonary tuberculosis, and Osier, as the result of 100 autopsies in cases of pneumonia, found it present in 5 instances, while in 216 postmortems upon phthisical cases it was present in 12 instances.1 It has frequently developed in the more serious forms of chorea, and inter- current acute endocarditis may result from chronic diseases attended with emaciation and general weakness or suppuration, such as ulcerative carci- noma, gleet, gout, chronic Bright's disease, and diabetes. Lastly, acute endocarditis may occur as a secondary event in pre-existing sclerotic endocarditis, when it is termed acute recurrent endocarditis. In chronic endocarditis the liability to the acute form is greatly in- creased by the puerperal state, and also, though to a lesser extent, by pregnancy. It is highly probable that the micro-organisms of inflamma- tion, assisted fjy the friction between the blood-current and the surfaces 1 Text-book of Medicine, Osier, pp. 628, 629. 588 DISEASES OF THE CIRCULATORY SYSTEM. of the valves, fix themselves upon the latter and there set up the charac- teristic lesions. Indeed, the disease has of late been excited by injecting into the blood the streptococcus pyogenes, staphylococcus aureus, and other micrococci. Frankel and Sanger are of the opinion that the sta- phylococcus pyogenes aureus is the chief specific agent in causing acute endocarditis, but their claim has not as yet been satisfactorily established. Clinical History.—It is only occasionally that definite subjective symptoms, as precordial pain (sometimes extending doAvn the left arm), dyspnea, and cardiac palpitation, are complained of by the patient. In the vast majority of instances the condition is discovered accidentally in the course of an examination of the chest. This being true, not only its frequent occurrence in acute articular rheumatism, but also the possi- bility of its occurrence in the other diseases mentioned under "Etiology," should ever be kept in remembrance. The symptoms of embolism, which will be detailed presently, are rarely observed in this form of endocarditis. The physical signs by which acute endocarditis is recognizable are dependent upon the valvular insufficiencies caused by the morbid lesions previously described. Hence there must be not a small proportion of mild cases, including those in which the valves are not affected, that give rise to no physical signs. On inspection the area of visible impulse may be seen to be increased, though, as a rule, it is normal. The impulse is sometimes forcible and often irregular during the initial period, but later it becomes less distinct and more feeble. Palpation confirms the result of inspection. I have found the impulse to vary at each visit, with a general tendency to lessen in intensity in the later period of the disease. A very weak impulse is indicative of associated myocarditis or of the poisonous effect of a severe type of primary infection. In recurrent endocarditis the apical impulse is often heaving, on account of pre-existing compensatory hypertrophy, and its area is exceedingly variable. A systolic thrill is sometimes felt. On percussion the area of the heart's dulness is found to be almost uniformly normal, except in cases of intense myocardial involvement, when acute dilatation of the chambers may supervene, giving rise to an increased area of percussion-dulness in the transverse direction. In re- current acute endocarditis the area of dulness corresponds to the increased area of the apical beat. Auscultation.—Acute endocarditis is usually attended with a soft blowing, systolic murmur, which, owing to the fact that the mitral seg- ments are the favored seat of the disease, is heard much more frequently at the apex than at the base. The point of maximum intensity of this murmur is often movable, but its area of transmission is usually quite limited. In rheumatic endocarditis this murmur is preceded by a pro- longation of the first sound and the consequent shortening of the interval between the first and second sounds. The murmur is sometimes heralded by a feeble or muffled first sound, with intensification of the second, and sometimes by a pronounced accentuation or roughening of the normal sounds. In acute endocarditis affecting the mitral valves aortic murmurs may coexist, but their true nature is more than doubtful. There is also a short, low-toned, and double systolic murmur over the tricuspid orifice in a small proportion of the cases; this is due most probably to a relative incompetency. When acute endocarditis arises in connection with chronic SIMPLE ACUTE ENDOCARDITIS. 589 valvular disease, the auscultatory signs of the latter are but little changed, and hence a positive diagnosis is not possible. Complications.—There may be developed by direct extension sec- ondary myocarditis, a disease that Avill receive separate consideration. The diagnosis is based principally on the physical signs, though these are by no means trustworthy. The points gained by careful inspection and palpation are as significant as those learned by auscultation, as is also the previous history of the patient. The soft bellows murmur is often present in acute febrile diseases in which the autopsy fails to reveal the lesions of acute endocarditis. The functional murmurs that arise in the specific fevers, however, are perhaps oftener heard over the aortic area, while those occurring in endocarditis are heard best over the mitral area. Leube1 points out that if the dulness is slightly increased to the left, there is fever; in fact, if there is infectious disease present, a diag- nosis must be made of acute insufficiency of the ostium mitralis occurring in the course of acute endocarditis. The distinction between simple acute endocarditis and pericarditis should be categorical, in view of the manifold differences between their signs. But the fact that these two affections may be associated, more especially when they are of rheumatic origin, must be steadily borne in mind, and also that when combined the signs belonging to the endocarditis are not open to observation, owing to the pericardial friction-sound, and later the presence of the effusion. I have found, however, that, fortunately, endocarditis usually precedes pericar- ditis. The murmurs present must be called accidental if the area of car- diac dulness is normal, the second pulmonary sound not accentuated, and if the murmur be heard only at the pulmonary cartilage, or at this point and at the apex, and, at any rate, more distinctly at the pulmonary car- tilage (Leube2). The elimination of old endocarditis or chronic valvular disease—a matter of importance—may be accomplished by attention to the character of the murmur in acute endocarditis, as well as to its limited area of diffusion, and by the absence of the signs of hypertrophy and of accentuation of the second pulmonary sound. ""A relative insufficiency distinguishes itself by a pure systolic murmur, loud and not invariably uniform, by a weak cardiac impulse, a slight ac- centuation of the second pulmonary sound, and a comparatively small and often irregular pulse. It is met Avith in excessive dilatation of the left ventricle, in anemia, " and particularly in certain changes of the A'alvular muscles, due to myocarditis " (Leube). Prognosis.—The immediate dangers are few, and depend largely upon the primary disease. In many instances, hoAvever, acute endocar- ditis initiates permanent lesions of the valves. Treatment.—Prophylaxis.—The prevention of acute endocarditis in rheumatism has been dealt with in discussing the latter disease. No knoAvn direct measures can prevent the development of this condition in the course of the specific fevers, though absolute rest in bed and protection of the body against "cold" may diminish somewhat the tendency to it. The Attack.—The sick-room should be free from draughts, though well ventilated, and flannel is to be applied to the chest. The diet may be liberal, but should be composed chiefly of milk and other light nutritious substances. Stimulants are required in most instances, and 1 Deutsch. Archiv f. klin. Med., Nov. 5, 1896. 2 Loc. cit. 590 DISEASES OF THE CIRCULATORY SYSTEM. in abundance should the heart be failing. Digitalis is to be emploved cautiously if at all. When the myocardium is involved, its use is not without danger; under these circumstances the drug increases the sufferings of the patient by throAving the inflamed and Aveakened car- diac muscle into firm contractions. The salts of ammonium, particu- larly the carbonate, should be given continuously with a vieAv to obvi- ating intracardial coagulation of blood; and should the latter accident occur despite all efforts to prevent it, the carbonate, together with strvch- nin and alcoholic stimulants, should be freely administered. I am con- vinced that in endocarditis due to acute articular rheumatism it is wise to continue the exhibition of the salicylates, though in moderate doses, pro- vided that the heart is guarded by the use of stimulants. During con- valescence from an acute endocarditis the patient should be kept at rest, so as to minimize the strain upon the affected valves; even after he has apparently recovered, and particularly should the murmur still be present, perfect quiet is to be enjoined for a period of several Aveeks. ULCERATIVE ENDOCARDITIS. {Malignant or Infectious Endocarditis.) Malignant endocarditis is variously characterized, though usually either by perforative ulceration, by suppuration of the valves, or by both, giving rise to the physical signs of acute endocarditis. These develop amid the symptoms of a severe type of some primary infectious or septic disease. There is at hand sufficient clinical evidence to Avarrant the assumption that ulcerative endocarditis also occurs, though very rarely, as a primary affection. Pathology.—(a) Valvular Endocarditis.—In its early development the valves are the seat of vegetations (such as are met with in simple acute endocarditis) which later undergo necrosis. The latter process manifests a tendency to spread, destroying more or less of the endo- cardium. In the interior of the vegetations the process of suppuration not infrequently takes place, and the abscesses thus formed rupture and produce various lesions according to their size and situation. The vegetations take on a grayish- or yellowish-green appearance. Histo- logically, they are composed of granulation tissue, veiled by granular and fibrillated fibrin that contains numerous micro-organisms. At the base there is usually developed more or less reactionary inflammation. After rupture the blood-current may enter the abscess-cavity, and, if there be no complete perforation, the endocardium will be pouched out, and an aneurysmal dilatation of the valve will result. Ulcerative lesions are most frequently observed. They may be mere erosions of the endo- cardium, but, as a rule, are penetrating in character and often result in complete perforation. I have seen repeated instances in which the three classes of lesions above depicted were all present. Osier, in an analysis of 209 cases examined by him with a view to ascertaining approximately the relative frequency with which the different parts of the heart were affected, obtained this result: Aortic and mitral valves together, 11; aortic valves alone, 53; mitral valves alone, 77 ; tricuspid in 19, pul- monary valves in 15, and the heart-wall in 33 instances. In 9 instances the right heart alone was involved.1 1 Text-Book of Medicine, p. 631. ULCERATIVE ENDOCARDITIS. 591 (b) Malignant mural endocarditis gives the same set of changes as the valvular form ; indeed, the latter may be combined with the former throughout. It is a comparatively rare condition, as is shoAvn by the foregoing figures of Osier. The ulcerative process may invade the chorda? tendinese and the valves, and may perforate the septum or even the ventricular wall itself. The vegetations are detached in small or large masses, and are conveyed by the circulating medium to various distant organs, especially to the spleen and kidneys, less frequently the intestines, meninges of the brain, and the skin. Their site is determined largely by their size, and they may be so large as to plug vessels of the caliber of the external iliac. When found in the lungs they may originate in endo- carditis affecting the right heart. These emboli, containing, as they do, the agents of inflammation, form suppurative infarcts that may be either Avhite or red in color. The detached vegetations are sometimes so laden Avith irritants as to cause rapid softening of the coats of the vessel at the point where they become arrested, with consequent aneurysmal dilatation directly opposite their seat. As to number, the infarcts vary greatly in different cases; thus there may be only one or two, as in a case in my own knowledge in which the spleen alone contained tAvo small infarcts, or there may be more than a thousand minute abscesses Avidely scattered throughout the body. Etiology.—It is to be kept in remembrance that the condition is, with feAV exceptions, most probably a secondary one. The disease, there- fore, arises in consequence of secondary infection, and this explains why the lesions peculiar to simple endocarditis usually precede and accompany those of the ulcerative form. The specific irritant is probably the streptococcus pyogenes (Frankel and Sanger); and if this be true, the diseases in which ulcerative endocarditis occurs as a complication merely furnish the opportunity for the invasion of the streptococcus. The bacillus diphtheriae, however, as well as the bacillus coli, the bacillus anthracis, the pneumococcus, the gonococcus, and other organisms, have been found in some cases in the absence of the streptococcus. In purely septic diseases ulcerative endocarditis forms but a part of the serious gen- eral condition. Here the cardiac element serves to facilitate the genera- tion and rapid diffusion of the poison ; and, since the latter is prone to attack the valve-segments, the morbid lesions within the heart not rarely constitute the chief pathologic factor in septico-pyemia. Instances, how- ever, are met with in Avhich the segments present slight changes. The malignant form occurs, in connection with acute articular rheumatism, in about 10 per cent, of the cases in which acute endocarditis appears. Among many other diseases that furnish occasional instances of this serious complication are diphtheria, scarlet fever, typhoid fever, erysip- elas, small-pox, chorea, tuberculosis, and chronic Bright's. In some of these, simple acute endocarditis, it will be remembered, occurs with rela- tive frequency. In lobar pneumonia the ulcerative type is common, occurring almost as frequently as the simple variety, and was found by Osier in 11 out of 23 cases. The septic processes that arise from the puerperal state or from gonorrheal infection may also be complicated with ulcerative endocarditis. Clinical History.—That form of ulcerative endocarditis which is a more or less prominent factor in septic diseases has been considered in 592 DISEASES OF THE CIRCULATORY SYSTEM. connection Avith septicemia. Malignant endocarditis being usually a secondary event, its clinical features must not be confounded with those of the primary affection in the course of which it occurs. It is, hoAvever, often impossible to clearly separate the former from the latter, and the original disease often appears to be but slightly modified. Local symptoms are often entirely wanting, or, when present, consist merely in slight precordial pain and oppression, and are not sufficiently well pronounced to arrest attention. Subjective symptoms are, however, connected with other organs than the heart, and are due to the irritating effects of emboli that occupy the various organs of the body. Gastro-intes- tinal disturbance, as shown by the occurrence of vomiting and diarrhea, is common. Pain that is ascribable to local peritonitis over the spleen, and sometimes also over the liver, is observed. Hematuria and dimness of vision are also frequent concomitants, and are due to renal and retinal hemorrhages. The urine may be scanty and albuminous. The more gen- eral features that are the result of the local embolic processes and, in part, of the valvular lesions, are serious and for the most part typhoid in character. The onset is usually signalized by a severe rigor that may be repeated at intervals varying from one to several days, and the disease presents an irregularly remittent temperature-curve, often touch- ing a high mark (105° or 106° F.—40.5° or 41.1° C). I saw a case recently in which the febrile movement pursued the continued type for seven Aveeks. The pulse is rapid and irregular, though frequently be- coming sIoav within a brief period'. The patient rapidly emaciates, and from the earliest development is profoundly prostrated, and nervous symp- toms, as headache, mild delirium, folloAved by somnolence, and sometimes even coma, appear. Profuse sweating sets in and persists, and as a result the skin may be covered by sudamina. An ecchymotic eruption due to cutaneous emboli is also common, this being often found associated with a papular or a diffused roseolar rash. Physical Signs.—These may be negative as regards the heart. In the majority of instances, however, a systolic murmur is present, which, Avhen associated with other clinical indications that point to this affection, is valuable for diagnosis, and especially so if developed while the patient is under treatment for the primary attack. The second sound is some- times accentuated even when no organic lesions have previously existed. The physical signs of pneumonia and pleuritis (particularly the latter) may not infrequently be noted. Cases occur in Avhich gangrenous in- farcts of the right lung give rise to signs of localized consolidation ; the spleen becomes considerably swollen, as can be easily demonstrated by palpation, and is quite tender as a rule ; and the liver is likewise mode- rately enlarged and slightly sensitive. Cerebral Variety.—In a-small though decided percentage of the cases all the clinical features of acute suppurative meningitis are presented, and sometimes to the almost total exclusion of symptoms pointing to the primary disease or to the more typical typhoid form of ulcerative endo- carditis. For a description of the symptoms that characterize the cere- bral form the reader is referred to the discussion of Purulent Meningitis. Recurrent Malignant Endocarditis.—By this term is meant an acute ulcerative endocarditis coming on in the course of chronic valvular dis- ease. As has been pointed out, simple acute recurrent endocarditis is ULCERATIVE ENDOCARDITIS. 593 common, though difficult of recognition. The latter condition, as well as the lesions in chronic valvular disease, predisposes to secondary infec- tion by the streptococcus and other organisms. The onset is usually abrupt and marked by a chill. The patient has fever, which may be quite high (104° F.—40° C, or over), and may present either the irreg- ularly intermittent type or the truly intermittent. The latter is often asso- ciated with recurring chills. In either of the above groups the course is apt to be acute. In some cases the character of the pre-existing mur- mur is changed, becoming louder and more decidedly blowing ; in many other instances, however, there is no appreciable alteration in the murmur. The condition may arise suddenly, amid the signs of failing compensa- tion, as in a fatal case reported by Dr. H. P. Loomis,1 in Avhich the patient was semi-conscious, cyanotic, and suffering from intense dys- pnea and general dropsy. It was impossible to diagnosticate the cardiac lesions by the murmur present. Occasionally these severe intercurrent feb- rile attacks end in recovery, and such cases probably belong to the benign form, though closely simulating the malignant in their clinical character. There is a third class of cases that run a subacute or even chronic course, with more moderate elevations of temperature, or, as rarely hap- pens, none at all. Mullin of Hamilton has reported a case that lasted more than a year. Here the other clinical phenomena, especially those referable to the heart, are often scanty and indefinite. Diagnosis.—It is of paramount importance to consider the previous history and all the circumstances under which individual cases occur. These points, together with the symptoms attending the onset and the first three or four days of illness, more particularly the severe rigor, early high temperature, and profound prostration, the sweatings, the various embolic phenomena, and the presence of cardiac symptoms, are often adequate for a positive diagnosis. With a clear history and the presence of the more characteristic general symptoms (in particular, the signs of embolism), a correct diagnosis is possible, even though cardiac murmurs be absent. Instances in which no data can be found to explain the occurrence of the disease are especially puzzling, and these will re- main unrecognized if at the same time the lesions in the heart fail to be manifested by special symptoms. The existence of a chronic valvular affection would, in itself, under the latter circumstances afford strong probability of the presence of recurrent malignant endocarditis if the other significant clinical symptoms above mentioned were present. Differential Diagnosis.—There is a group of cases in which either the history fails to furnish the essential causal factors on the one hand, or there is an absence of definite heart-symptoms on the other ; this group cannot sometimes be separated from cases of typhoid fever. The sub- joined table will, I feel, be found valuable as an aid in eliminating the latter disease from the typhoid form of malignant endocarditis : Ulcerative Endocarditis. Typhoid Fever. Previous or associated disease, as acute Health good before the time of onset of rheumatism or pneumonia. the attack. History of epidemic. Very rarely a primary affection. No Always idiopathic, with a prodromal prodromes observable. stage. 1 Transactions of the New York Pathological Society, 1890. 38 594 DISEASES OF THE CIRCULATORY SYSTEM. Ulcerative Endocarditis. Typhoid Fever. Ushered in suddenly by a severe rigor, Invasion marked by slight recurring which may recur. chilly sensations. (Severe chill very rarely.) The fever rises rapidly. More gradually, in step-like fashion. Profound prostration as early as third Profound prostration not earlier than day. seventh day. The fever is markedly irregular from Less so, especially in the first week. time of onset, as a rule. Embolic symptoms (hemiplegia, etc.) may Extremely rare. appear. Cardiac symptoms, especially loud sys- Sometimes a soft systolic murmur. tolic murmur, often present. The blood usually shows signs of septic The blood shows a decrease in the num- leukocytosis. ber of leukocytes. The cerebral form can only be distinguished from purulent meningitis due to other causes if there be a history of definite causal factors or if there be present distinct cardiac symptoms.1 Prognosis.—Most cases that run an acute course terminate in death, and when supposed instances of malignant endocarditis recover they are usually to be regarded as being of benign character. Subacute or chronic varieties, however, such as are most frequently met Avith in connection with organic heart-disease, sometimes reach a favorable issue. Treatment.—This is largely supportive. The feeding is to be pushed vigorously, and concentrated forms of liquid food should be given at regular, brief intervals. Arterial stimulants in liberal quantities are also demanded, and in addition quinin and antiseptics may be tried. For the embolic symptoms the salts of ammonium give slight promise of ben- eficial results, and I prefer the carbonate for this purpose. Anti- streptococcus serum has recently been used and has proved efficacious in certain cases. CHRONIC ENDOCARDITIS. (Chronic Interstitial Endocarditis.) Two clinical varieties are met with—one following the acute form, the other beginning as a chronic inflammation. Pathology.—The lesions may be limited to the valvular endocardium (their most common seat), or the mural endocardium may also be involved. In not a few instances the lesions are confined to the edges or bases of the segments, and when seen in the early stages there may frequently be observed merely a slight thickening of the free border of the leaflets; in most cases small prominences appear near their free margins. The endocardium looks opaque and its normal elasticity is lost quite early. When the auriculo-ventricular valves are affected the primary seat of inflammation is the auricular face, but when the semilunar valves are dis- eased the morbid changes begin on the ventricular side and implicate the Aurantian body. Extension of the morbid process to other and all parts of the valvular curtain is common, and it is in cases of this sort that the greatest degree of shrinking and crumpling occurs. The most character- istic lesions consist of inflammation and exudation, which produce cohe- 1 The septic form may simulate malaria in its general course. The points of dis- similarity may be found in the discussion of Septicemia. CHRONIC ENDOCARDITIS. 595 sion of the segments, roughen the surfaces, and lead to the deposit of fibrin upon them. The histologic alterations consist in a proliferation of the endothelial and a round-cell infiltration of the subendothelial connective tissue. Organization of these products of inflammation into connective tissue, with resulting induration and contraction, is the necessary subse- quent pathologic event. In old cases calcification of the diseased struc- ture is frequent. The shrinking shortens the curtains or curls their free edges, and produces insufficiency in either case, since on dropping into the plane of the valvular orifice they fail to close it perfectly. Valves thus deformed may also obstruct the blood-stream. As before mentioned, cohesion of the invaded segments takes place, particularly at their bases, and may extend upward for a considerable distance, leading to constric- tion or stenosis. Involvement of the semilunar (aortic) segments in the ways previously described opposes an obstruction to the outfloAving blood-current on the one hand, and, OAving to the inability of the segments to effect perfect closure of the aortic orifice, allowrs on the other hand a diastolic reflux of blood into the left ventricle. The aortic ring to Avhich the semilunar segments are normally attached becomes sclerosed, and finally the seat of atheromatous changes, either fatty or calcareous. Again, chronic inflam- mation of the intima of the aorta produces a similarly thickened condi- tion of this layer in spots, folloAved by atheroma. These changes are most prone to take place in the course of the ascending arch of the aorta or just above the aortic segments. The fact of really vital importance in this connection is that from the aorta and sub valvular ring the diseased processes before described may extend to the coronary arteries. Hence sclerotic and atheromatous alterations are found frequently in association with organic valvular defects. The great clinical significance of the implication of these vessels Avill be emphasized hereafter. Much less commonly similar lesions are noted at the orifice of the pul- monary artery. A similar involvement of the auriculo-ventricular valves also causes regurgitant and obstructive deformities at the mitral orifice, and in advanced cases the chordae tendineae, and even the papillary muscles, are almost invariably invaded by direct extension from the valves. As these structures undergo marked thickening with subsequent contraction, they become shortened and rigid, causing an actual narrowing of the cardiac orifice. In mitral stenosis during the early stages or in the mildest types a more or less complete ring of vegetations encircles the mitral orifice on its auricular aspect. The margins of the orifice also become hardened and roughened, these changes frequently extending to the valvular curtains and the chordae tendineae. Under such circum- stances the thickened valve could not, during the ventricular diastole, be forced back against the ventricular Avail, but would occupy a nearly cen- tral position. Owing to cohesion of the free edges of the valvular struc- tures and to contraction of the chordae tendineae drawing the leaflets toward the apex of the heart, the transition from this condition to the formation of a hollow cone (funnel mitral) is accomplished by natural, easy stages. Extensive union of the segments along their free margins may reduce the aperture to a mere button-hole slip (button-hole mitral) as viewed from the auricular aspect. The last two forms of lesions are far less commonly met Avith at the aortic orifice, though they occur rarely in 596 DISEASES OF THE CIRCULATORY SYSTEM. moderate degree; on the other hand, curling of the valvular edges is far more commonly seen at the aortic than at the mitral orifice, if we except the cases that occur in children. The curtains of the thick, rigid valves may also permanently occupy the plane of the orifice, presenting a small ring-like opening (annular mitral). Fatty degeneration leading to the formation of necrotic (atheromatous) ulcers is common ; and calcareous deposits are frequently seen in old cases, either in localized areas or coextensive with the diseased tissue, converting the entire valve into a calcified mass, with loss of the valvular outlines. In chronic mural endocarditis the lesions exhibited are grayish-white, slightly elevated patches that are usually found to invade the underlying muscular structure to a greater or a less extent. Under such conditions of the valves the deposit of fibrin would be greatly favored, and the presence of an ulcerative surface or of a fibrous deposit on the valves affords a ready and satisfactory explanation of the occurrence of embo- lism in these cases. Emboli may also become detached from cardiac thrombi or from thrombi formed in the peripheral veins. For anatomic reasons the favored seats of embolic processes are, as in acute endocar- ditis, the spleen, brain, and kidneys, and irritants that cause acute endo- carditis find here a tissue-soil whose capacity for resistance to invasion is greatly lowered. Chronic mural endocarditis and chronic myocarditis are, as a rule, due to the extension of the inflammation from the valves, though the ventricular endocardium may be invaded independently of the valvular affection. In one instance of mitral stenosis I observed an enormous calcareous mass partly in the sub valvular tissue and partly in the wall of the ventricle, the segments remaining altogether intact. In advanced stages of most cases of chronic endocarditis myocardial degen- eration occurs. It takes the form of fibroid change or fatty degeneration, or both. Aortic-valve involvement, especially when complicated with ath- eromatous change in the coronary arteries, is most prone to these forms of myocardial disease. Chronic endocarditis may be said to persist until death. The effect of the valvular deficiencies that have been described upon the several cardiac chambers and the muscular structure of the heart will be most advantageously studied when the individual lesions of the segments are considered. Etiology.—There can be no doubt that most cases of organic heart- disease occurring in children and young adults are caused by primary acute rheumatic endocarditis ; and, although the latter affection cannot in truth be said to invariably terminate in chronic endocarditis, it probably does in most instances. This result, in my opinion, is more frequent in children suffering from acute endocarditis than in adults. On the other hand, not a feAV cases of chronic endocarditis originate in a very mild grade of acute valvular inflammation, which may be, though itself mute, reinforced by a rheumatic diathesis. Indeed, acute endocarditis may be the sole expression of rheumatic disease. Not less than one half of all cases of organic val- vular disease are caused by rheumatism, and more than one half of the total number occur between twenty and thirty years of age. Acute endo- carditis complicating other acute infectious diseases than rheumatism (e. g. measles, chorea, pneumonia) may also be followed by the chronic variety ; but it is quite questionable whether this occurs as frequently as in the case of acute endocarditis of rheumatic origin. AORTIC INCOMPETENCY. 597 The second variety, in which slow interstitial changes occur from the beginning, is dependent upon—(a) biologic irritants (e. g. syphilis, malaria, and chronic rheumatism); (b) chemical irritants (uric acid, alcohol, lead) ; and (c) mechanical influences. Doubtless the influence of repeated strain- ing efforts is the most potent cause of this class of cases. Heavy muscular labor increases constantly the tension in the arterial system, and this acts injuriously upon the valve-segments, setting up a gradual sclerotic change. In like manner, arterial sclerosis and Bright's disease may cause chronic interstitial endocarditis by increasing constantly the vascular tension, though the fact that these affections may in turn result from the action of some of the leading causes of organic heart-disease must also be recol- lected. Trauma has produced in valves previously healthy a sudden, incontestable proof of valvular paresis or laceration, that has persisted in a few well-attested cases. This accident is of course much more fre- quent where the valves have been already diseased, and particularly if they have been the seat of lacerative processes. The predisposing causes of organic valvular disease may be discussed briefly. Hereditary influence, as pointed out by Virchow, is especially potent in persons in whom there is hypoplasia of the heart and aorta (e. g. in chlorosis). It may be said that any malformation of a valve is certain to throw an undue strain upon certain portions, and hence is likely to be followed by interstitial change. Osier, in 17 cases of bicuspid aortic valve, has reported the segments to be uniformly sclerosed. The cases of supposed hereditary transmission are doubtless, however, for the most part, due to the causes before mentioned, and particularly to rheumatism. Age exerts a predisposing influence, its effects, however, varying with the valve implicated. During fetal life this is on the right side of the heart in a vast majority of cases; during childhood, adolescence, and early adult life, when the infectious diseases and rheumatism are frequent, it is the mitral valve in most instances; and finally, during middle and espe- cially during advanced life the aortic segments are especially involved. I have, however, found aortic disease to be more common in young adults than most writers are ready to admit, and that it is favored especially by an occupation involving muscular strain (e. g. blacksmiths, draymen, sol- diers during campaigns). Sex per se has little if any effect, though, owing to the greater frequency of certain well-known causes of valvular disease (chorea and rheumatism) in girls and young women, females may be more frequent sufferers than males. AORTIC INCOMPETENCY. {Aortic Insufficiency; Aortic Regurgitation.) Definition.—The failure of the aortic valves to prevent a return flow of blood into the ventricle, owing, as a rule, to a diseased condition of the aortic leaflets (sclerosis) that is followed by crumpling and attended with contraction, shortening, or curling of the edges, and finally calcification. Pathology.—The aortic orifice may be enlarged (relative insuf- ficiency), and here the normal cusps fail to effect complete closure of the 598 DISEASES OF THE CIRCULATORY SYSTEM. orifice. The flaps of the diseased aortic valves sometimes adhere to the intima of the aorta, and laceration of the semilunar segments, which are the seat of diseased processes (particularly ulceration), is sometimes found post mortem, and may be the chief factor in determining the develop- ment of the condition. This accident may very rarely occur as a result of a severe straining effort in the case of valves previously healthy. Occasionally, also, the chief factor in the production of this valvular lesion is a congenital malformation of the segments whereby they are rendered very prone to chronic endocarditis in consequence of the undue strain to which they are subjected. The lesions that give rise to stenosis may coexist with simple aortic incompetency, and, though the latter con- dition frequently occurs alone, stenosis is quite as often combined with regurgitation. Mechanical Influence of the Lesion.—The reflux current passes from the aorta backward through the imperfectly closed semilunar valve into the left ventricle during the diastole of the heart or while the left ventri- cle is being filled by the normal blood-flow from the auricle. It is clear that over-distention of the left ventricle must result at once from tAvo simultaneous influx currents of blood, with a tendency to an increasing dilatation, especially since the lesion itself is steadily progressive. To expel the increased amount of blood from the left ventricle demands in- creased cardiac power, and the over-exertion causes dilatation, followed by a compensatory hypertrophy. Dilatation and hypertrophy of the left ventricle develop pari passu until the left ventricle reaches enormous dimensions, forming the cor bovinum, Avhich weighs 1000 grams or more (30 to 50 ounces). Under these circumstances the arterial system is overfilled at each ventricular systole. In the very early stage the reflux of blood from the aorta into the ventricle tends to lessen the volume of the circulating medium in the arterial tree, but this depleting influence is successfully counterbalanced by the augmented column of blood thrown from the ventricle during cardiac systole. Hence the requirements for bodily nutrition are, for a longer or shorter time, satisfied. The abnor- mally large amount of blood that is thrown into the arteries with undue force subjects them to increased tension, and as a result arterio-scle- rosis, leading sometimes to atheroma, is commonly developed, and pre- sents its ulterior dangers (aneurysm, apoplexy). The coronary arteries are similarly involved, their caliber being reduced, and particularly at the point of origin. Soon or late the blood-supply to the heart-muscle may become inadequate, and nutritional disturbances now manifest themselves in fatty and fibroid degeneration of the cardiac muscles ; these pathologic changes are attended with secondary dilatation, which soon predominates over the hypertrophy. The imperfect blood-supply to the ventricular tissue may be accounted for, in great measure, by the narroAved lumen of the coronary vessels, and also in part by the inelasticity of the walls of the latter and by the inefficiency of the aortic recoil. Furthermore, it is to be recollected that, in obedience to the laws of nature, overuse of any single group of muscles, while productive of marked hypertrophy in the first instance, is followed eventually by atrophy and loss of poAver. In consequence of the increased tension to which they are constantly sub- jected the mitral leaflets may become the seat of sclerotic endocarditis, and this may lead to the development of mitral insufficiency (usually of AORTIC INCOMPETENCY. 599 mild grade); or there may be a displacement of the mitral segments in the direction of the auricle, thus creating incompetency at this orifice. There is to be observed in many instances a marked degree of fatty degeneration of the papillary muscles, which also exhibit more or less flattening. Again, secondary dilatation may produce relative insufficiency at the mitral ori- fice. When incompetency has been established here, impeded pulmo- nary and general venous circulation, together with the secondary lesions in the left auricle, pulmonary vessels, and right ventricle that are cha- racteristic of that valvular lesion, are the necessary result. The blood- current through the mitral ring may be retarded, owing to the simultane- ous influx into the left ventricle from the aorta, thus causing pulmonary congestion without organic change in the segments. Special Etiology.—(1) Acute Endocarditis.—Incomplete resolution of the acute form of endocarditis leads to progressive chronic valvular dis- ease. In the young it is caused with comparative frequency by rheu- matic endocarditis. Thus, aortic regurgitation may arise, though rarely, in the course of acute endocarditis, as, for example, when the latter is attended with destructive ulceration. Such instances usually terminate in speedy death. (2) Chronic Infectious Irritants.—I have found syphilis to be a factor (though rarely the sole cause) in a considerable percentage of cases. Aortic regurgitation is a frequent complaint in sailors and soldiers, among whom it is worthy of notice that syphilis is particularly common. (3) Chemical Irritants.—(a) Uric Acid.—In chronic and irregular forms of gout the irritating qualities of uric acid give rise to interstitial endocarditis and arterial sclerosis. It is quite probable that chronic rheumatism has a similar influence, though brought about in a somewhat different manner, (b) By favoring the accumulation of uric acid in the blood, lead-poisoning may be indirectly responsible for the disease, (c) Alcohol by its irritant action may excite chronic valvulitis. (4) Augmented Aortic Tension.—The excessive functional activity of the heart occasioned by the immoderate use of cardiac stimulants (alcohol) tends to raise the blood-pressure above the normal point, and thus sclerotic endocarditis may be developed very sloAvly. The effect of occupation in causing this disease, by increasing the vascular tension, is more notable than in the case of alcohol, though both of these factors are found not infrequently to be present in the same case. It is undeniably true that strong-bodied men in the middle period of life and those engaged in heavy manual labor are the most frequent sufferers from organic disease of the heart, and that such occupations as demand the repeated putting forth of strong efforts are powerful factors in causing aortic incompetency. (5) From personal observation I feel convinced that chronic endo- carditis (affecting the aortic valves) may be secondary to aortic end- arteritis as the result of direct extension. It must be borne in mind, hoAv- ever, that arterio-sclerosis is also often secondary to chronic valvulitis. (6) Relative insufficiency is caused, in rare instances, by pronounced dilatation of the ascending portion of the arch near to the valve, or by an aneurysm just beyond the aortic orifice. Among the more effective predisposing factors are age and sex. The disease occurs much more often in males than in females, chiefly on 600 DISEASES OF THE CIRCULATORY SYSTEM. account of the fact that a greater percentage of the former than of the latter are engaged in occupations that are causally related to the dis- ease. As to age, a preponderating proportion of the cases arise during advanced middle life, and a comparatively smaller number at a more advanced period than in young adult life. Symptoms.—So long as the hypertrophy of the left ventricle suc- cessfully overcomes the otherwise injurious consequences of the valvular defect the harmonious balance of forces is maintained, and there is an almost entire absence of symptoms. I have observed, moreover, that compensation does not fail so early in young subjects as in those more advanced in years, this being probably due to the fact that the disease is frequently associated Avith, or secondary to, atheromatous changes at the latter period of life. With the development of marked hypertrophy severe muscular exertion and strong mental excitement will, by excit- ing over-action of the powerful heart, bring on a train of symptoms, as throbbing headache, vertigo, and tinnitus aurium. The clinical mani- festations of arterial anemia, particularly of the brain, and also those of general arterio-sclerosis, frequently coexist. The patient's counte- nance exhibits pallor, and he complains of headache, flashes of light be- fore the eyes, and dizziness. Dilatation of the peripheral vessels often leads to hot flushes and drenching SAveats. Cases exhibiting the latter symptoms have been mistaken for phthisis. Dizziness is often distress- ing, and is most marked upon rising from the recumbent to the erect posture. Shortness of breath may come on early, but this rarely hap- pens except upon inordinate exertion or great mental excitement—con- ditions that cause strong cardiac action and prohibit the discharge of blood from the left auricle into the left ventricle, thus causing pulmo- nary congestion. Oppression in the precordial region and cardiac pal- pitation are commonly present, as is a dull aching pain; the most con- stant seat of the latter is the precordia, but it radiates not infrequently to the shoulders, and thence down the arms, particularly the left. Gen- uine angina pectoris may be a concomitant. I have also seen a couple of instances of aortic regurgitation in which severe pain Avas located in the left shoulder-joint, the condition simulating very closely rheumatism, though the latter affection could be readily excluded both as a causal factor and a complication. Following immediately upon failure of compensation the cardio-pul- monary circulation is retarded, and there is increased dyspnea, the latter symptom being greatly intensified by undue exertion. There may be cough, and not rarely hemoptysis, though less frequently than in simple mitral disease. Later on, general venous congestion of a moderate grade follows pulmonary congestion, and the dyspnea noAv becomes severe. It is nocturnal, and often compels the patient to assume a semi-erect pos- ture in bed. In the later stages the symptoms are due to mitral incom- petency, followed by failure of compensation. Edema of the feet appears, and rarely goes on to general anasarca. In aortic incompetency a higher grade of symptomatic anemia is reached than in any other cardiac lesion —a recent blood-count showing 2,800,000 red corpuscles to the c.mm. Hence slight edema of the feet may be due solely or in part to anemia. The intercurrence of acute endocarditis, as evidenced by prostration and AORTIC INCOMPETENCY. 601 irregular fever, is observed, and not infrequently as a terminal condition. The symptoms of cerebral, splenic, and renal embolism may arise. Prob- ably sudden death ensues, as the result of involvement of the coronary arteries, with greater frequency in this than in all other forms of val- vular disease combined; and yet this accident is by no means of fre- quent occurrence. Instances of aortic incompetency, in Avhich nervous phenomena, as peevishness, irritability, or melancholia, manifest them- selves, are too common to be looked upon as mere coincidences. Many patients are doubtless led to commit suicide because of their cardiac lesion when other and erroneous explanations are given to account for their acts. Physical Signs.—Inspection brings to light an enlarged area of the apex-beat; this is displaced downward, being visible in the sixth and seventh interspaces and to the left, and most marked betAveen the mammary and anterior axillary lines. The entire precordial zone may be distended, particularly in young subjects, and the systolic pulsation is usually more or less heaving in character. The carotids throb for- cibly, as do the temporals, brachials, and radials, though less vio- lently. These abnormal pulsations are due chiefly to hypertrophy of the left ventricle, though frequent factors of lesser influence are asso- ciated—an arterio-sclerosis and a regurgitant blood-stream from the aorta into the left ventricle. The impulse becomes diffused and wavy with the progressive enfeeblement of the left ventricle, and venous pul- sation due to tricuspid insufficiency may be associated with arterio-pul- sation later in the affection. Epigastric throbbing may also be noticed, and on gently rubbing a spot upon the forehead an alternate paling and blushing appear (Quincke's capillary pulse)', this may also be noted in the finger-nails. It is not peculiar to aortic insufficiency, however, and may be observed in cases of decided neurasthenia and in anemia. Very rarely the pulse-wave is propagated from the capillaries to the veins of the hand and back of the foot, giving rise to a visible venous pulsation. L. Webster Fox informs me also that the retinal vessels are seen to pul- sate quite commonly in this disease. On palpation a forcible heaving impulse is usually felt. When, how- ever, dilatation predominates over hypertrophy, the impulse is weak and undulating. A diastolic thrill just to the left of the mid-sternum may be detected in many instances, and a presystolic thrill is also dis- coverable very rarely. The pulse is characteristic ; it is quick, jerking, and full, but, upon striking the finger, recedes abruptly, and is known as the Corrigan or water-hammer pulse. This sudden collapse of the pulse is most decided when the arm is held in a vertical position. Its distinctive characters are not ahvays appreciable after compen- sation is lost. A glance at the sphygmographic tracing will show a sudden rise and fall, Avith absence or delay of the secondary wave (vide Fig. 50). Percussion.—Cardiac dulness is coextensive with the impulse, ex- tending downward to the eighth rib, and to the left as far as, or even beyond, the anterior axillary line. Later, enlargement of the left auricle may cause dulness upAvard and to the left of the sternum. En- largement of the right ventricle causes an increase of dulness to the right. When the dilatation exceeds the hypertrophy the area of dul- 602 DISEASES OF THE CIRCULATORY SYSTEM. ness will be much extended transversely and slightly upAvard, the apex now being more rounded.1 On auscultation a diastolic murmur becomes audible below and to the left of the aortic cartilage over the mid-sternum, and down along its left edge; this is produced below the aortic valve and in the left ven- tricle. From the xyphoid it may be transmitted to the left as far as the spinal column. It may be heard in the vessels of the neck and, very Fig. 49.—Normal pulse-tracing. rarely, in the radials; occasionally its seat of greatest intensity is at the aortic cartilage, and, rarely, at the apex, as in a case under my own care at present. The rhythm of the murmur can be most readily de- Fig. 50.—Pulse-tracing in a case of aortic regurgitation (William Hoffman). termined by ausculting over the base, for while the pulmonic second sound is usually audible at the apex (the murmur appearing to follow it), it is not so when, as sometimes happens, the murmur is quite loud. The first sound is often dull, indefinite, and Avidely diffused, owing to left ventricular hypertrophy. In quality this murmur is usually soft in character, blowing (long-draAvn), and frequently musical; sometimes, however, it is someAvhat rough and loud. In most instances a systolic murmur, brief and harsh in character and transmitted into the vessels of the neck, is also discovered over the aortic region (double aortic). The presence of the murmur with the first sound is not diagnostic of actual aortic stenosis. It is more often due to a mere roughening of the semilunar segments or of the intima of the aorta. In advanced cases a soft systolic murmur is commonly heard at the apex ; it is readily distinguished from the diastolic murmur by its rhythm, and is occasioned in most instances by a relative mitral incompetency. Still another mur- mur, of rare occurrence, is rolling in character and generally presystolic in time, and maybe heard at the apex over a limited surface-area. This may be accounted for by the presence of excessive dilatation of the left 1 A dilated aorta with thickened walls—a condition sometimes associated with aortic regurgitation—may also give rise to abnormal dulness under the manubrium and to the left of the sternum. AORTIC STENOSIS. 603 ventricle, in consequence of which the mitral leaflets must remain free in the blood-stream during the diastole, and here they set up vortiginous movements that cause the presystolic (Flint) murmur. Duroziez dis- covered a double murmur in the arteries (femoral), which is quite fre- quently present, and, in view of its duplex character, possesses con- siderable diagnostic import. Traube has described another arterial phenomenon of interest—a systolic sound in the leg, somewhat resembling a heart-sound, but exceedingly short and sharp. It is probably due to sudden systolic distention of vessels that were previously empty. The diagnosis demands the presence of a diastolic murmur, the signs of left ventricular hypertrophy, the peculiar arterial pulsations, and the characteristic Avater-hammer or Corrigan pulse. The differential diagnosis will be considered in connection with the description of those complaints with which aortic incompetency is apt to be confounded. (See Aneurysm of the Arch, Hypertrophy, Dilatation of the Heart, etc.) AORTIC STENOSIS. Definition.—A narrowing or stricture of the aortic orifice, due to thickening or adhesion of the valve-segments, and causing an obstruc- tion to the flow of blood into the aorta. Simple aortic stenosis may be met Avith, though it is a great rarity. Its development is soon folloAved by more or less valvular incompetency, and hence these affections often coexist. It may be secondary to aortic insufficiency, but only rarely, the conditions in the latter disease being unfavorable to the development of the former. Special Etiology.—Rarely rheumatic endocarditis, and still less frequently other forms of acute endocarditis, cause union of the semi- lunar segments, Avith resulting stenosis. The most common immediate causal factor is a slow sclerosis of the aortic valve, followed by cal- careous deposits. The more or less immobile, rigid valves obviously narroAv the aortic orifice and oppose a barrier to the outfloAving blood- current from the left ventricle into the aorta. The aortic ring may be the seat of changes similar to those just described, resulting in a moderate grade of stenosis, though the leaflets themselves remain intact. The lesions are most frequently to be regarded as a part of the general process of arterial sclerosis, which is most marked in the region of the thoracic aorta; and sometimes, as Peter contends, they are distinctly secondary to sclerotic changes at the root of the aorta. The coro- nary arteries may be the seat of changes similar to those noted in aortic regurgitation. The condition is also rarely congenital. Males Avho have reached advanced years are especially prone to aortic stenosis, for the reason that atheromatous processes belong peculiarly to that sex and period of life. Mechanical Influence of the Lesion.—To propel the normal volume of blood through the constricted aortic orifice requires increased strength on the part of the left ventricle, and, as a consequence, the latter hyper- trophies. This hypertrophy develops very slowly, and keeps pace with the 604 DISEASES OF THE CIRCULATORY SYSTEM. progress of the valvular lesions. The undue ventricular tension sometimes induces more or less sclerotic change in the mitral valves. Hypertrophy of the left ventricle eventually gives Avay to extreme dilatation, and also to relative mitral incompetency with its unfavorable influence, first upon the pulmonary and, secondly, upon the general venous circulation. Symptoms.—The symptoms date from the commencement of failure of compensation, often many years after the onset of the disease. Their first appearance will be found to follow some unusual muscular effort or the operation of some depressing influence, as the too free use of to- bacco or alcohol. They are due to disturbances of circulation arising from a gradual secondary dilatation of the left ventricle, which is now unable to propel the normal quantity of blood into the arterial tree. Hence anemia, especially of the brain and peripheral parts of the body, becomes pronounced, and is evidenced by such symptoms as syncope, dizziness, headache, and pallor. Since aortic incompetency usually manifests itself secondarily, the clinical features of both affections are sooner or later variously commingled. In cases in Avhich mitral lesions develop they are overcome by compensatory enlargement of the right ventricle: the latter chamber may then become dilated secondarily, in which event tricuspid regurgitation and the symptoms of general venous engorgement appear. As in the case of aortic regurgitation, so in an aortic constriction, slight edema of the feet is common as a terminal symptom; marked dropsy, however, is uncommon. From the fibrous deposits on the segments, as Avell as from any small clots behind the valves, emboli are apt to become dislodged by the forcible .blood-stream and be conveyed to the brain (cerebral embolism), to the spleen (splenic embolism), to the kidneys (renal embolism), or to other organs. Physical Signs.—Inspection.—The apex-beat is gradually displaced downward and to the left, owing to left ventricular hypertrophy. It is, as a rule, slow, forceful, and heaving, but less frequently it may be lack- ing in strength. It may be enfeebled, diminished in area, or even absent, owing to associated emphysema. Palpation discloses the forcible and heaving impulse-beat, unless emphysema be present, Avhen the heart and its movement may be con- cealed and the apex-beat become impalpable. A marked systolic thrill, Fig. 51.—Sphygmogram of aortic stenosis, from a man aged sixty years. with the seat of greatest intensity in the aortic region, is quite gener- ally present. I have frequently felt this thrill in the apex region, though not so intensely as at the base. The pulse, in this disease, is small, regular, not compressible, and of normal or slightly lessened fre- quency. The sphygmographic tracing shows sloAvness of the ascending curve and a gradual formation of the descending line (vide Fig. 51). MITRAL INCOMPETENCY. 605 Percussion.—Though there is developed in all cases hypertrophy of the left ventricle, the area of cardiac dulness is almost entirely depend- ent upon the degree of emphysema, if any be present. In the absence of this condition the dulness is increased to the left and downward, and especially so when insufficiency of the valve supervenes. Auscultation.—A systolic murmur, harsh in quality, most audible at the aortic cartilage (the second right), and transmitted into the carotids, is present in typical aortic stenosis. When non-compensation is ad- vanced the murmur is neither so rough nor so loud, and quite late it may be missing altogether. As aortic imcompetency is commonly associated, a regurgitant or diastolic murmur is also heard, forming a double or seesaAV murmur, the stenotic bruit more or less completely masking the regurgitant. A soft, bloAving apical murmur (with the systole) is not infrequent in the advanced stage or after relative insuf- ficiency of the mitral valves has appeared. The second sound is faint or inaudible on account of the diminished blood-tension in the aorta and the character of the valvular lesion. The diagnosis demands the concurrence of the following signs: a systolic thrill, most marked at the base ; a tense, small, somewhat slow pulse; indications of left ventricular hypertrophy (unless emphysema be present); a rough, loud, systolic murmur at the aortic cartilage and propagated into the vessels of the neck. Differential Diagnosis.—A calcareous plate lying on the intima of the aorta and a markedly roughened condition of the aortic segments are conditions frequently mistaken for aortic stenosis, since they give rise to a murmur possessing many of the characteristics of the one above described. These murmurs, hoAvever, are seldom musical, while the murmur of aortic stenosis is often distinctly so; moreover, the second sound is decidedly accentuated, while in aortic stenosis it is faint or absent. In chronic Bright's disease with arterial sclerosis and left ventricular hypertrophy a murmur of maximum intensity may be devel- oped at the base ; but here the urinary symptoms, together with inten- sification of the second sound, are sufficient to establish a positive dis- crimination. In aortic regurgitation a systolic murmur frequently co- exists, but it cannot be reckoned as indicating actual stenosis unless it has a musical quality and unless a systolic thrill can be felt on palpa- tion. In chlorosis and other forms of anemia basic murmurs are con- stant concomitants ; the anemic murmurs are soft and distant, and not harsh ; the intense thrill and hypertrophy are absent also. The venous hum may also be heard in the veins of the neck. MITRAL INCOMPETENCY. {Mitral Regurgitation ; Mitral Insufficiency.) Definition.—Imperfect closure of the mitral valve due to rupture or contraction of the mitral leaflets. It is also caused by dilatation of the left ventricle and by a diseased condition of the chordae tendineae. Pathology.—This is the most frequent form of organic disease of 606 DISEASES OF THE CIRCULATORY SYSTEM. the heart. Thomas G. Ashton,1 from clinical observation of 1012 cases of heart-affection, comprising all the different varieties, found that 54.4 per cent, were instances of mitral regurgitation. The predominating lesions are of three kinds: (a) Acute or chronic endocarditis, leading to contraction and deformity, particularly curling, of the margins of the valve; (b) contraction (shortening) of the chordae tendineae; and (c) relative insufficiency from excessive dilatation of the left ventricle (the segments being healthy). Adhesion of a segment with the Avails of the ventricle occurs rarely, but may result in incompetency. Mechanical Influence of the Lesion.—The mitral leaflets normally close, and prevent the reflux of the blood from the left ventricle into the left auricle with each cardiac systole. Hence incomplete closure of the mitral segments allows a portion of the blood to return into the left auricle during the systole. This regurgitant wave meets and offers an obstacle to the normal blood-current coming simultaneously from the pulmonary veins into the left auricle. It is clear that vortiginous move- ments must result under these circumstances and give rise to a murmur. The double blood-current, entering the left auricle during the systole of the left ventricle, causes over-filling (hence dilatation) of the left auricle, and thus induces compensatory hypertrophy of the left auricle, since its labor has been increased. During the next diastole the abnor- mally large contents of the auricle are passed under increased pressure into the left ventricle, producing over-distention (dilatation) of that chamber. This increased volume of blood in the ventricle is not all expelled into the aorta, but a portion of it returns into the left auricle. Thus the left ventricle, in consequence of its increased labor, becomes hypertrophied as Avell as dilated. Under these circumstances the volume of blood that is poured into the aorta remains about normal, and hence the arterial tension for a longer or shorter period is also normal. Soon the cardio-pulmonary circulation becomes impeded. The blood that returns into the left auricle must, by reason of pressure, offer increased obstruction to the outflow of blood from the pulmonary veins, and the pressure in the latter must, in turn, be similarly increased. The cur- rent of the blood through the pulmonary capillaries and branches of the pulmonary artery is thus retarded, owing to extension of the process of over-filling in a backward direction. The walls of the lung-vessels are the seat of a sclerotic process, and present an abnormal obstacle to the passage of the systolic Avave from the right ventricle to the distal end of the cardio-pulmonary arc; in consequence of this the right ven- tricle becomes dilated and hypertrophied. The abnormally increased tension in the pulmonary vessels is shown by the accentuated pulmonic second sound. Thus the right heart compensates the lesion in the left, though to supply an adequate amount of blood to the peripheral arteries the left ventricle must maintain its proper degree of hypertrophy. As soon as this harmonious balance is disturbed, either as the result of in- crease in the degree of incompetency or of failure of muscular power, the progress of the blood from the right auricle to the right ventricle is hindered. Increased pressure in the right auricle produces dilatation of its chamber, Avith subsequent general venous congestion as a natural backward effect (vide Tricuspid Regurgitation). It is now seen that 1 Medical News, June 30, 1894. MITRAL INCOMPETENCY. 607 Avhen the right heart fails a lessened amount of blood reaches the left ventricle, and- hence an abnormally small amount finds its Avay into the aorta; this fact explains the presence of the Ioav arterial tension late in the disease. Hypertrophy of the left ventricle in this disease has also been attributed in part to the augmented tension in the general capillary vessels that is occasioned by the venous stasis. Special Etiology.—(a) Rheumatic endocarditis is the most fre- quent cause, though mitral regurgitation also results less frequently from acute endocarditis due to other causes, (b) It may be a part of a general arteriosclerotic process, this group of cases being caused, not rarely, by syphilis and alcohol, (c) A diseased condition of the columnce carneee or chorda? tendinece, if it weakens their structures so as to alloAV the free edges of the segments to pass beyond the plane of the orifice, produces mitral insufficiency, (d) It may arise in the course of aortic valvular disease (a secondary mitral affection), and is then excited mainly by undue tension of the blood in the left ventricle. Here the lesion is of a mild grade, as a rule, (e) It is frequently occasioned by enlargement of the left auriculo-ventricular ring, resulting from excessive dilatation of the left ventricle, as in aortic incompetency, aortic stenosis, long-continued fevers, and the graver anemias (relative incompetency). (/) Ulcerative endocarditis, either by perforating or producing rupture of the valve-curtains or by destroying the chordae tendineae, may bring about mitral incompetency. Among predisposing factors age and sex are worthy of special mention, the incompetency occurring with greatest relative fre- quency in young adults (from twenty to thirty years of age, according to Ashton's figures), and somewhat more commonly in males than females. Symptoms.—During Compensation.—In healthy persons the com- pensatory forces keep pace Avith the valvular lesions for an indefinite and usually lengthy period, during which time there may be an entire absence of symptoms. When present they are dependent upon dis- turbances of the cardio-pulmonary circulation that are occasioned by trivial causes, such as excitement, going up stairs, or other forms of active physical exertion. Under these circumstances the force of the regurgi- tant current is increased (by the hypertrophied left ventricle), thus pro- ducing more or less pulmonary congestion that may proceed to edema of the lungs or hemoptysis. The condition is usually a temporary one, and is attended by dyspnea, palpitation of the heart, a short, hacking cough, and expectoration of a frothy serum that may be blood-stained. The relation existing between the severity of the dyspnea and the degree of active physical exertion is positive and vital. Shortness of breath may be the sole feature during a long period. The rational symptoms rarely warrant a suspicion of the existence of mitral disease until compensation has failed, but the patient's appearance often indicates heart-disease. The face is pale and the features peaked, the eyes, lips, and ears are dusky, and the minute vessels of the cheeks are prominent. Clubbing of the finger-nails is observed most frequently in the young. After Failure of Compensation.—Failure of compensation implies failure of the right ventricle to force the normal quantity of blood through the left heart, with accompanying congestion of the lungs, folloAved by engorgement of the systemic veins. The latter process begins at the right heart and proceeds toAvard the periphery, involving 608 DISEASES OF THE CIRCULATORY SYSTEM. the viscera, mucous membranes, and extremities until it is universal. The pulmonic symptoms above detailed are noAv more marked, particu- larly the dyspnea (Avhich may be constant), cough (Avith expectoration of alveolar epithelium containing brown pigment-granules), and cardiac palpitation with arrhythmia. Pain is rare unless stenosis coexists. General venous engorgement manifests itself by an enlargement of the liver and of the spleen, in the features of gastro-intestinal catarrh, in hemorrhoids, in marked cyanosis of the surface, and in the passage of a scanty albuminous urine containing tube-casts and blood-corpuscles. Dropsy follows, beginning in the feet and progressing upward, until finally the trunk and the serous sacs are involved. By stimulation the heart may be reinforced, and all of the unfavorable symptoms disappear in consequence, but this is not for long, as a rule. I have at present under observation a case in which not less than half a dozen instances of broken compensation have occurred at intervals of six to eight months, all of Avhich have been successfully overcome.1 All finally prove fatal, and there comes a time when compensation cannot be re- stored and the end is reached by an uninterrupted dowmvard course. Physical Signs.—Inspection.—The precordia is prominent, particu- larly in children, and the area of the apex-beat is enlarged, later becom- ing diffuse and Avavy. It is carried to the left and doAvnward, corre- sponding with the degree of hypertrophy of the left ventricle. A pul- sating epigastrium is in frequent association, particularly after dilata- tion of the right ventricle appears. With the failure of the right heart also come wavy pulsations in the cervical veins, and occasionally a mild grade of jaundice. Palpation sometimes discovers a thrill at the seat of the apex-beat, that is synchronous with the first sound. The impulse during the stage of full compensation is forceful and heaving, but with the beginning of failure of compensation it grows feeble and irregular, and late in the affection is excessively weak and arrhythmic. The pulse bears a defi- nite relation to the apical impulse. Thus it is regular and full dur- ing the compensatory period (though at times the tension is slightly lowered), but becomes small, easily compressible, and exceedingly irreg- ular during the period of broken compensation. The latter pulse- characteristics become especially pronounced near the close. Percussion.—The dull area is increased to the left, extending fre- quently to the anterior axillary line ; and also to the right, frequently from ^ to 1 inch (1.2-2.5 cm.) beyond the right sternal margin. Dila- tation of both ventricles exerts a widening influence; hence cardiac dulness is increased more laterally than, vertically. Auscultation reveals a systolic murmur, which exhibits its greatest intensity at the apex (see Fig. 52). Unquestionably, this murmur is also conducted, though rarely, to the tricuspid and pulmonary valves. Balthazar Foster first called attention to the fact that the murmur of mitral regurgitation may be loudest at the base of the heart and at times audible only in that situation—an occurrence that has since been confirmed by a number of authorities. It is sometimes audible in the recumbent posture and inaudible in the erect. From the apex 1 Neglect of hygienic precautions, and intercurrent complaints of various sorts, often determine the occurrence of failure of compensation. MITRAL INCOMPETENCY. 609 it is transmitted to the left as far as the angle of the scapula, with progressively diminishing clearness. It has a blowing quality, and fre- quently ends in a musical tone. Over the third left costal cartilage, and frequently at the apex, there is heard the accentuated pulmonic second sound, due to the increased tension in the pulmonary vessels that is engendered by the hypertrophy of the right ventricle. Combined murmurs may be heard, and not infrequently a rough, rolling, or rum- bling presystolic murmur is detected. A frequent late occurrence is the secondary dilatation of the right ventricle, causing relative tricuspid insufficiency with its characteristic soft, low-pitched, systolic murmur, heard best at the ensiform cartilage. A spurious diastolic murmur may Fig. 52.—1, Seat of greatest intensity; 2, direction of chief transmission; 3, boundary line of rela- tive dulness; 4, boundary-line of absolute dulness (modified from Sahli). be noted, though rarely, when the sounds are timed with the pulse. This is due to the fact that occasional systoles are too weak to cause a radial pulse. Diagnosis.—In the presence of the following group of features the diagnosis is set at rest: A marked broadening of the area of cardiac dulness; a systolic, apical murmur that is conveyed to the left axilla and may be heard even at the back; and a decided accentuation of the pulmonary sound. Obviously, the latter sound becomes feeble after dilatation of the right ventricle has occurred. A systolic thrill is of the highest diagnostic importance, but is unfortunately absent in perhaps a majority of the cases. Free regurgitation through the mitral orifice may be safely inferred Avhen the following signs are concurrent: 39 610 DISEASES OF THE CIRCULATORY SYSTEM. (a) An absence of the sound of mitral-valve tension, a murmur replacing the first sound; (b) accentuation of the pulmonic second sound; (c) an enlarged area of the left cavity; (d) an enlarged area of the right cavity (Sansom). Differential Diagnosis.—There are two organic lesions of the heart that are sometimes mistaken for mitral incompetency, since both are ac- companied by a systolic murmur—the one aortic stenosis, and the other tricuspid regurgitation. Hoav to distinguish mitral from tricuspid in- competency is a question that will receive due attention when the latter disease is considered. Aortic stenosis generates a systolic murmur, but it is loudest over the base, and is transmitted through the great vessels of the neck; while the mitral systolic is most intense over the apex and is transmitted far to the left. In mitral incompetency the pulmonary second sound is accentuated; in aortic stenosis it is not. In mitral in- competency both ventricles are enlarged, as shown by percussion and other signs; in aortic stenosis the left is chiefly enlarged during almost the entire course. In mitral incompetency a thrill, most marked over the apex-beat, may be felt; in aortic stenosis a thrill, rough and having its chief seat at the base, is common. Other minor points of distinction are furnished by the peculiarities of the pulse, the age of the patient, and other etiologic factors. Functional and other harmless murmurs are often confounded with mitral insufficiency. The considerations on which the greatest depend- ence is to be placed in the differentiation are to be found in the sub- joined table: Mitral Incompetency. Functional and Harmless Murmurs. History. Previous history of rheumatism or other History of causal factors of one or other disease causally related. form of anemia, or of Graves' disease. Frequently there is definite knowledge of No such association. rheumatism and organic heart-disease, in combination in the same individual. Physical Signs. Inspection.—Dusky lips, ears, etc.; later Pallor of skin and mucous surfaces com- wavy pulsation in veins of neck. mon. Palpation.—Finger-tips placed over apex- Finger not lifted by the impulse, which beat forcibly lifted. Pulse-tension some- often cannot be felt. Pulse-tension pro- what lowered and not prolonged. Im- longed and arterial pressure increased pulse displaced. generally. Impulse not displaced. Percussion.—Evidence of dilatation of Dilatation of right auricle, but only in both ventricles. about one-half of the cases, giving rise to dulness above or to the right of the right edge of sternum. Auscultation.^—A systolic apex-murmur Soft systolic murmur at apex (maybe, (often musical), with characteristic area though rarely, transmitted to axilla), of transmission. usually preceded by or associated with a basic systolic murmur and a venous hum in the veins of the neck. To differentiate the murmur of relative mitral incompetency is diffi- cult, though in many instances it can be accomplished with reasonable certainty. It rests upon two points : (a) the character of the murmur, MITRAL STENOSIS. 611 which is, as a rule, softer and less intense than that due to valvular lesions; and (b) the antecedent history of the patient. Thus, relative insufficiency of the mitral segments probably exists in patients in the middle period of life, and particularly in those in Avhom the previous history furnishes such etiologic factors as renal disease, syphilis, or alcoholism; or in persons Avho exhibit arterio-sclerosis or organic dis- ease of the aortic valve and an apex-systolic murmur. On the other hand, if the signs of mitral regurgitation occur in a younger subject or in one Avho has been afflicted with acute or subacute rheumatism, it is highly probable that the mitral-valve segments are the seat of chronic endocarditis of rheumatic origin. Again, if present in chronic renal disease, Avith concurrent symptoms of high arterial tension and of left ventricular hypertrophy—accentuation of the aortic second sound, a mitral systolic murmur—it is to be regarded as being due to relative in- sufficiency. I believe that a rare sequel of mitral incompetency is mitral stenosis, OAving to the contraction of the auriculo-ventricular orifice, Avith, in some instances, progressive cohesion of the free edges of the leaflets from the base upAvard. MITRAL STENOSIS. Definition.—Constriction of the left auriculo-ventricular orifice, due either to a thickening or adhesion of the segments. With fe\v exceptions adhesions of the free borders of the valve or of the chordae tendineae obtain. Special Pathology and Etiology.—It is to be recollected that the constriction may be almost inappreciable, and yet that an uneven, roughened surface be presented, producing a murmur as the blood-stream enters the ventricle; on the other hand, a high degree of constriction may be encountered. Thus, in the funnel-shaped form of mitral stenosis the aperture may be so small as scarcely to admit the passage of a goose- quill. When moderate in degree the tip of the index finger is admissi- ble ; in the button-hole form the slit may be so narroAv as not to alloAv an object larger than a shirt-button to pass through it. The funnel vari- ety is common in children, and, in occasional instances, is possibly a congenital condition, Avhile the button-hole variety is comparatively rare in childhood. In adults, hoAvever, the funnel-shaped constriction is rare, Avhile the button-hole valve is quite common; in 62 postmortem exam- inations only 3 shoAved funnel-form contraction (Hayden and Fagge). Mitral stenosis is, as a rule, dependent upon a mild or limited endocar- ditis that is usually of rheumatic origin. It is more common in young adults and in children after the fifth year than in older persons, and it is more frequent in females than in males, for the reason that the affec- tions that are causally related to endocarditis occur more frequently in the former sex (rheumatism, chorea, chlorosis). The endocarditis of measles and scarlatina may also lead to narrowing of the mitral orifice, and I quite agree Avith Osier in the belief that whooping-cough, owing to the great strain that it imposes upon the heart-valves, may be account- 612 DISEASES OF THE CIRCULATORY SYSTEM. able for certain cases. In adults arterio-sclerosis and chronic nephritis may induce fibroid changes in the mitral leaflets, Avith resulting stenosis. Mechanical Influence of the Lesion.—On account of the obstruction of the blood-stream at the mitral orifice during diastole, the task of the left auricle becomes greater than normal, and in consequence of this its Avails hypertrophy. They may be found to be one-fourth or even one- half inch (1.2 cm.) in thickness, the normal thickness being only three- twentieths of an inch (3.7 mm.). Under these circumstances dilatation of the auricle comes on early, and in the later stages it may be extreme, the Avails now becoming much thinner than in the normal heart. For a varying period of time the increased power of the heart due to hyper- trophy of the left auricle and that due to an increased resistance to the circulation that is the result of the mitral lesion are exactly balanced. At a comparatively early period, however, the auricle can no longer main- tain this, equilibrium ; and then, owing to retardation of the current from the pulmonary veins to the auricle, the vascular tension in the lungs and right ventricle is increased. The right ventricle, in seeking to overcome the obstruction, becomes greatly hypertrophied and dilated, and late in the disease tricuspid incompetency supervenes Avith its usual sequences. The hypertrophy of the latter chamber counterbalances the lesion during the greater part of the period of compensation. For a brief time the left ventricle exhibits no abnormal proportions. Later and at autopsies its cavity is found smaller and its walls thinner than the normal, these conditions being due to its abnormally light labor. The apex of the heart is formed almost exclusively by the greatly enlarged right ven- tricle. If the left ventricle be hypertrophied, it is OAving to the existence of associated mitral incompetency. Symptoms.—The subjective symptoms are scanty and of slight value in forming the diagnosis. During the period of full compensation there may be an entire absence of symptoms except on going up stairs or on attempting some unusual muscular effort, Avhen dyspnea appears. The vegetations previously described are sometimes quite friable, and when so, may be swept from the valves into the circulation and give rise to the phenomena of cerebral embolism (aphasia and hemiplegia). The same conditions may arise, and in the same Avay, from recurring endo- carditis, to which such patients are specially liable. The patient in well-marked cases presents an anemic appearance: a stitch-like pain in the apex-region is frequently present, and active exertion, by overtax- ing the left auricle, induces cardiac palpitation and dyspnea. After failure of compensation the symptoms referable to the pulmo- nary system are almost identical with those manifested in mitral incom- petency. Owing to the pulmonary engorgement the dyspnea is constant, and is increased by over-exertion. After severe or prolonged physical ex- ercise congestion, folloAved by edema of the lungs, may supervene, attended by a copious blood-stained, serous expectoration. True hemoptysis may arise from time to time. The increased tension in the pulmonary vessels being practically constant, sclerosis, folloAved by atheromatous degenera- tion of their walls, is a frequent occurrence, and may accidentally result in pulmonary apoplexy. Intercurrent febrile attacks (due usually to re- curring endocarditis) are common, particularly in the later stages, and are attended with marked aggravation of the circulatory disturbances. MITRAL STENOSIS. 613 Among other things, mitral stenosis differs from mitral incompetency in that general anasarca is rare, though enlargement of the liver and other evidences of portal congestion (including ascites) are not wanting. Physical Signs.—Inspection.—The apex-beat is not displaced un- less there be excessive enlargement of the right ventricle or associated hypertrophy of the left. There is usually present a visible pulsation in the second left intercostal space, and sometimes in the third and fourth interspaces, occasioned by increased tension in the pulmonary artery; and there is also a diffuse impulse along the right border of the sternum. Epigastric pulsation is common. A prominence having its seat over the fifth and sixth left costal cartilages and the loAver half of the sternum is observed, particularly in children. After failure of compensation the impulse is feeble and undulates, with engorgement and pulsation of the jugular veins. Palpation discovers a presystolic thrill in a great proportion of cases. In certain instances active physical exertion may render this appreciable, or Avhen in the recumbent posture on the left side the ele- vation of the arms may accomplish the same result. It is, however, absent in rare instances before failure of compensation occurs, and more frequently by far after the latter event. This fremitus is best felt over the third and fourth (less frequently the fifth) interspaces, just within the nipple, and during expiration. It commences after the second sound (during the diastole) as a purring fremitus, increasing steadily in Arolume and intensity, and terminates abruptly with the severe shock of the new impulse. The fremitus is pathognomonic, and may be relied upon in the absence of the murmur. The heart's impulse is most forcible over the lower portion of the sternum and along the right border, being due to the enlarged right ventricle; in a smaller proportion of cases, in the Pig. 53.—Sphygmograms in a case of mitral stenosis treated by extract of convallaria, and sub- sequently by digitalis: A, before treatment, showing the interpolated pulsations ; B, after treat- ment (Sansom). fourth and fifth interspaces to the left of the sternum. The radial pulse is small, compressible, and markedly irregular as the propulsive power of the right ventricle diminishes. The sphygmographic tracing is not- ably irregular (vide Fig. 53). Percussion shows an extension of heart-dulness to the right, fre- quently 5 centimeters (2 inches) beyond the sternal margin, as a result of hypertrophy of the right ventricle, and upward as high as the sec- 614 DISEASES OF THE CIRCULATORY SYSTEM. ond rib on either side of the sternum. Increase in the cardiac dulness to the left also occurs not infrequently, and is attributable to excessive enlargement of the right ventricle, though more often of the left ven- tricle in consequence of associated mitral insufficiency. Auscultation reveals a rough, presystolic murmur, which may be characterized as churning or rolling, acquiring increased intensity toAvard its termination. Its point of greatest pronunciation is just above and about one inch within the normal apex-beat. The area of trans- mission is generally quite limited, not exceeding a couple of inches in any direction. Griffith, hoAvever, has shoAvn that the murmur is not seldom widely transmitted. This murmur sometimes exhibits atypical characters: it may be brief and loAA-toned, and may be audible on one occasion and then disappear for a considerable period. After the right ventricle becomes weak the murmur may lose its characteristic sudden termination, or may entirely absent itself either temporarily or per- manently. In most cases the clear, accentuated first sound is retained, even though the murmur disappears. Improvement in the muscular power of the heart as the result of judicious treatment may cause the murmur to reappear, and I have seen such an occurrence in a case asso- ciated with mitral incompetency at the Philadelphia Hospital. For purposes of diagnosis, nothing is so vitally important as the time or rhythm of the murmur, and in his examination the observer must there- fore palpate the heart, and not the radial pulse, Avhile practising aus- cultation. The finger as well as the ear will thus become sensible of the systolic shock which replaces the cardiac impulse, and it will be noted that the murmur terminates at the same moment. In cases in which the impulse cannot be felt the finger should be placed over one or other carotid, since here the pulse is practically synchronous with the systole of the ventricle. In the vast majority of the cases the murmur occupies only the latter half of the diastole, though occasionally it is sustained throughout the whole of the long pause. Owing to the pres- ence of right ventricular hypertrophy the pulmonic second sound is greatly accentuated, being distinctly audible at the apex, while the aortic second sound is often absent or only feebly marked. Redupli- cation of the second sound is not rare, and is quite characteristic when it occurs. Secondary Murmurs.—As previously pointed out, the murmur of mitral stenosis may succeed that of mitral incompetency, but this is comparatively rare. Neither does the mitral stenosis follow aortic valvular disease, save in the rarest instances, and in the vast majority of instances it is a primary affection. Secondary murmurs are not un- common, however. Among these the bruit of mitral incompetency is relatively frequent. After compensation is ruptured the murmur of tricuspid insufficiency usually becomes audible at the lower end of the sternum, and persists until the end. At this period the presystolic murmur undergoes certain modifications, as already indicated. Diagnosis.—The distinctive features of mitral stenosis are—(1) A presystolic thrill at the apex. (2) An increase in the precordial dul- ness upward and to the right. (3) A murmur Avhich (a) has its seat above, yet near, the normal apex-beat; (b) is usually localized; (c) is presystolic in time, terminating abruptly with the systolic shock (sharp TRICUSPID INCOMPETENCY. 615 impulse); and (d) is "churning" in character. (1) A marked accen- tuation of the pulmonic second sound. Differential Diagnosis.—When the murmur of mitral stenosis is very brief, it is difficult to eliminate a mere roughening. In the latter con- dition, hoAvever, there is no increase in intensity of the murmurs on ex- ertion or Avhen the arms are uplifted, and there is no right ventricular hypertrophy. From simple mitral stenosis the lesion of mitral incom- petency is easily distinguished by its systolic rhythm, greater area of transmission, and by the soft, more flowing character of its murmur. A combination of the two lesions, however, is a more frequent occur- rence than that of pure mitral stenosis; and under such circumstances it is with great difficulty that the two murmurs are separated. The presence of the systolic murmur is distinguishable by its synchronism with the impulse or carotid pulse, and by its area of transmission to the left as far as the axilla. If now the stethoscope be applied just above and to the right of the normal apex, a limited superficial area will be found where a presystolic murmur is distinctly heard. Points can also usually be found where one continuous bruit, covering a portion of the period of diastole and of systole, is audible. The presystolic murmur is sometimes, and especially after failure of compensation, entirely veiled by the systolic. In aortic regurgitation the presence of a presystolic thrill and mur- mur has rarely been recorded, and Fisher, Phear, and others have called attention to their presence in adhesive pericarditis as Avell as in simple dilatation. When, as is usual, a purely diastolic murmur is also present in the aortic area, together with strong correlative evidence of aortic regurgitation, the diagnosis of mitral stenosis must be made with ex- treme caution. TRICUSPID INCOMPETENCY. {Tricuspid Regurgitation.) Definition.—An imperfect closure of the tricuspid valve, due either to a dilatation of the right ventricle that is secondary to mitral or lung- disease, or, less frequently, to an inflammatory shortening of the valves. Pathology and Etiology.—As a primary disease tricuspid in- competency is rare. It, however, is not uncommonly due to chronic organic changes, though originating in fetal endocarditis. After birth this variety is most common during childhood, and the frequency of occurrence is in inverse ratio to the age. At any period of life, how- ever, chronic affections of the lungs or organic disease of the left side of the heart may, by augmenting the tension in the right ventricle, pro- duce chronic interstitial changes in the tricuspid segments. These lat- ter, however, are usually of mild grade. I have observed in autopsied cases of chronic bronchitis associated with emphysema, and in pulmonary tuberculosis, that the chief reason why extensive lesions of these valves are seen so rarely is to be found in the fact that dilatation of the right ventricle is soon followed by relative insufficiency, and thus the strain 616 DISEASES OF THE CIRCULATORY SYSTEM. is in great part removed from the valves themselves. And yet, accord- ing to the statistical studies of Byron Bramwell, the tricuspid valve is implicated in 50 per cent, of all cases of acute endocarditis, notwith- standing the rarity of sclerosis of these segments. He suggests that the acute form frequently results in cure because of the relatively diminished right intraventricular tension. In rare instances one of the leaflets has been ruptured by straining. The relative tricuspid in- sufficiency, produced in a manner analogous to mitral insufficiency, is an exceedingly common secondary condition in affections of the lungs and heart that cause hypertrophy and dilatation of the right ventricle (mitral incompetency and stenosis, emphysema, sclerosis of the lung). Secondary Alterations.—In tricuspid leakage every systole of the right ventricle is accompanied by a reflux of venous blood through the imperfectly closed tricuspid orifice into the auricle, and thence into the veins. This causes venous stasis and gives rise to visible pulsation, and in this manner the engorged pulmonary circulation is relieved to some extent. A necessary unfavorable consequence, hoAvever, on account of the reflux current from the right ventricle, is the lessened blood-supply to the pulmonary arteries, even though the latter are found to be en- gorged. The already hypertrophied and dilated right heart now under- goes further enlargement in the same manner as in the hypertrophy of the left ventricle following mitral incompetency, though not to the same extent. In mitral incompetency the right ventricle compensates the mitral lesion after failure of the left auricle, but there can be no such effective compensatory reinforcement after failure of the right auricle in tricuspid incompetency, since the right heart is not reanimated by a fellow as is the left. The blood-stream flowing into the right ventricle during the period of diastole, however, is abnormally large, OAving to moderately increased tension. When the right ventricle fails to main- tain the pulmonary circulation, progressive dilatation of its chamber occurs, with a proportionate thinning of its walls until its dimensions are enormous. Symptoms.—In most instances the indications of the primary or causal affection must be noted, though these are often more or less screened by the more characteristic features of the disease under con- sideration. The symptoms of tricuspid incompetency point to passive congestion of the lungs and engorgement of the systemic veins, and they have been described in connection with mitral lesions. Cardiac dropsy is common, though present in by no means all cases. Frederick Taylor1 contends that ascites is absent frequently, because the liver acts as a diverticulum to accommodate the excess of venous blood. Physical Signs.—Inspection.—Yenous pulsation, caused by the back- ward blood-wave from the right ventricle at each systole, is a path- ognomonic sign. It is confined to the lower portion of the jugular veins so long as the valve that lies above the jugularis remains closed, but soon this yields, and then the veins seem to pulsate through their entire course with each cardiac systole. This is best seen when the patient is in the semi-recumbent posture, and is more marked in the right than in the left side. The subclavian and axillary veins may also be seen to pulsate, but rarely. The veins appear to be everywhere en- 1 Lancet, Nov. 22, 1890, p. 1126. TRICUSPID INCOMPETENCY. 617 gorged, producing a cyanosis that is more noticeable if the breath be held when in full respiration. Tricuspid incompetency may be shown by pressing on the vein with the finger rather firmly, commencing just above the clavicle and passing upward, thus emptying it of blood. If, noAv, the right ventricle be capable of producing a return wrave suffi- ciently powerful to overcome the valve in the external jugular, pulsation is seen to take place—also from beloAv—in the vessel slowly and in- creasingly until the vein, as far as the point compressed, becomes filled. The vein fills "by jets synchronous with the heart-beat" (Sansom). Again, an impulse may be communicated to the jugulars from the underlying carotid artery; if this be the true explanation in any given case, the light pressure upon the vein below does not arrest the pulsa- tion above, as is the case in tricuspid incompetency. Not rarely there is noticeable a feeble presystolic venous pulse, due to the weaker contrac- tion of the right auricle as compared with that of the right ventricle (anadiehrotic venous pulse). The area and seat of the apex-beat vary Avith the nature of the positive affection: in mitral incompetency, for example, the beat is displaced to the left and downward, while in un- complicated mitral stenosis no appreciable displacement occurs. To the right of the sternum an undulatory pulsation is seen, due to contraction of the right auricle and ventricle, but this is not characteristic, since it may take place in simple mitral stenosis without tricuspid regurgitation. Epigastric pulsation is almost invariably observed. Palpation detects the heaving impulse of the right ventricle in the upper epigastric region. Rhythmic expansile pulsation of the veins of the liver is quite characteristic and is usually detectable. To obtain this sign the patient should lie on the back with the arms raised, and the examiner should place the palm of his left hand over the right mid- axillary region, and that of the right hand over the upper abdomi- nal region. He will thus be enabled to feel an expansile pulsation of the liver synchronously with the ventricular systole. This is to be carefully distinguished from mere systolic depression of the organ due to the impulse of an enlarged right ventricle, transmitted through the diaphragm and left lobe of the liver to the epigastrium. Popoff and others have also noted an inequality in the radial pulses in tricuspid regurgitation. This is probably due to the pressure of the enlarged auricle. Percussion.—The extent and form of precordial dulness are variable according to the nature of the causal disease, but a dulness extending far beyond the right edge of the sternum is especially indicative of this lesion. Auscultation.—A systolic murmur having its seat of greatest inten- sity at the base of the ensiform cartilage (vide Fig. 54) is almost con- stantly audible. It is clearly conveyed to the left one inch beyond the lower sternal margin, and to the right and upward for an equal dis- tance beyond the limit of cardiac dulness. It is soft in character, short, and low-toned. Additional murmurs, due to primary lesions, are often heard, and usually at other orifices. The pulmonic second sound is accentuated. Diagnosis.—I believe that the most valuable symptom for diag- nosis is the venous pulse, whether observed clearly in the neck or de- 618 DISEASES OF THE CIRCULATORY SYSTEM. termined positively by bimanual palpation of the liver, as before described. Either of these signs alone suffices. The murmur is gen- erally audible, and when so is a most valuable aid to the diagnosis. The differential diagnosis between mitral and tricuspid regurgitation is easy Avhen either exists alone, if it be remembered that the seat of greatest pronunciation, the area of transmission, and the character of the respective murmurs are Avidely different. But it is sometimes ex- Fig. 54.—1, Seat of greatest pronunciation; 2, chief direction of conveyance; 3, boundary-line of absolute dulness; 4, boundary-line of relative dulness (modified from Sahli). tremely difficult to discern positively a faint tricuspid murmur Avhen it develops secondarily to the more pronounced murmur of mitral incom- petency. If a careful observation of the murmur fails to establish the diagnosis of tricuspid insufficiency, as sometimes is the case, absolute reliance should, in my opinion, be placed upon the venous pulse when present, and the absence of the latter sign should exclude this disease. TRICUSPID STENOSIS. This is a rare condition, occurring as a congenital and an acquired disease with about equal frequency. As a primary, independent dis- ease tricuspid stenosis is very rare, being usually seen in association with organic disease of the left side of the heart. The lesions of mitral and tricuspid stenosis are observed to be combined most frequently, PULMONARY INCOMPETENCY. 619 Avhile those of tricuspid stenosis and aortic insufficiency coexist less frequently. The morbid changes are practically identical with those of mitral stenosis, the right auricle becoming dilated, and this being fol- loAved by general venous stasis. The effect of tricuspid stenosis upon the right ventricle is the same as that of mitral stenosis upon the left ventricle. The right ventricle, hoAvever, is usually hypertrophied, OAving to the obstruction in the pulmonary circulation that results from the combined valvular deficiencies. Special Etiology.—The fact that mitral and tricuspid stenosis fre- quently have a common cause, acting concurrently, can scarcely be doubted in view of their frequent association and pathologic identity. Hence the statement that rheumatic antecedents are furnished by the history in from 30 to 10 per cent, of the cases of tricuspid stenosis need excite no surprise. As in mitral stenosis, so in tricuspid, sex is a po- tent factor, the statistics of Bedford, Fenvvick, and of Leudet (which embrace a total of 160 cases) shoAving a ratio of 5 to 1 in favor of the female sex. Symptoms.—The symptoms are those of the combined affections. Physical Signs.—Inspection sometimes reveals a feeble venous pulse in the jugulars, due to right auricular systole, and hence presystolic in time. Palpation may detect a presystolic thrill over the body of the right ventricle. Percussion may enable the observer to indicate the enlarged right auricle. Auscultation gives usually an audible pre- systolic rolling murmur, Avhich is best heard over the lower sternum and along its right border. The above physical signs are to be relied upon in uncombined cases, which are exceedingly rare. On the contrary, it is difficult in the extreme to differentiate the signs of tricuspid stenosis from those of the lesions Avith Avhich it is almost uniformly associated— viz. mitral stenosis and aortic insufficiency. Hence a positive diagnosis of tricuspid stenosis is impossible save in the rarest cases. PULMONARY INCOMPETENCY. {Pulmonary Regurgitation.) This is an exceedingly rare complaint that results from acute (ma- lignant) or chronic endocarditis after birth; it is also rarely due to a congenital malformation. In the latter form union of tAvo of the seg- ments is often observed ; in the former, the usual sclerotic processes, with the occasional adhesion of one or more segments Avith the pulmo- nary artery Avail, may be noted. The effect of the lesion is to cause hypertrophy and dilatation of the right ventricle. The physical signs furnish no diagnostic characteristics. There is developed a diastolic murmur Avhich is most audible in the second pulmonary interspace, and is transmitted to the lower sternal region. This is indistinguishable from the murmur of aortic regurgitation. The water-hammer pulse and marked hypertrophied dilatation of the left ventricle are present in the latter complaint, however, and are absent in pulmonary regurgita- tion. In pulmonary insufficiency, on the other hand, hypertrophy and dilatation of the right ventricle ensue. 620 DISEASES OF THE CIRCULATORY SYSTEM. PULMONARY STENOSIS. A quite frequent form of congenital malformation of the heart is the narrowing of the pulmonary orifice. In the rarest cases it is of post-natal date, and may result in induration, contraction, and fusion of the segments. In one of Osier's cases the orifice " Avas only tAvo milli- meters in diameter, with vegetations of acute endocarditis on the seg- ments." Even in cases occurring in after-life it is to be borne in mind that the etiologic factors are in all probability chiefly operative during fetal existence. I saw one case in Avhich the pulmonary artery near the valve was contracted to one-half its normal caliber. Myocarditis with resulting contraction of the conus arteriosus may cause pulmo- nary stenosis, and some of the cases that originate during adolescence and later in life are due to atheromatous change, Avhile others possibly are the result of chronic endocarditis or direct violence. Ulcerative endocarditis is occasionally responsible for the condition. The lesion is compensated by an hypertrophy of the right ventricle, folloAving Avhich dilatation and tricuspid incompetency may appear. Symptoms.—Cyanosis and distention of the systemic veins are observed. Physical Signs.—A systolic thrill may be felt at times over the base. There is considerable enlargement of the right ventricle, as elicited by percussion and palpation, and a systolic murmur of greatest distinct- ness is audible, as a rule, in the second left intercostal space near the sternum or at the junction of the third left costal cartilage Avith the sternum. It is harsh, superficial, and transmitted a short distance up- ward and to the left. Occasionally this murmur is heard best at the aortic valve, but it is never conveyed to the vessels of the neck, and hence is easily distinguished from the aortic systolic murmur. Its harsh character and loudness would serve to obviate confusion so far as func- tional or anemic murmurs are concerned. The pulmonic second sound is weak, and, not rarely, there is a diastolic murmur of the same cha- racter, indicating pulmonary regurgitation. Sansom holds that disease of the pulmonary artery (contrary to other forms of organic heart-dis- ease) predisposes markedly to pulmonary tuberculosis. I have at pres- ent under my care a tuberculous patient in wThom there is a double murmur audible at the pulmonary orifice. COMBINED FORMS OP CARDIAC DISEASES. Various and frequent combinations of organic lesions occur, and it may be asserted safely that in more than one-half of all the cases com- bined murmurs are exhibited, and that a much higher percentage ap- pears before the fatal termination. As I have already stated, stenosis of an orifice when due to valvular disease is associated with incompetency of the corresponding valve. Thus aortic stenosis is constantly combined with or followed by aortic incompetency, and in like manner mitral stenosis by mitral incompetency. The association may also have refer- ence to lesions at tAvo or more different Aralves, and according to the CHRONIC VALVULAR DISEASE. 621 elaborate table of F. J. Smith, the relative frequency of the chief mur- murs found in combination is as follows : Aortic diastolic and systolic and mitral systolic, 16.55 per cent. Aortic stenosis and mitral stenosis, 6.12 " Aortic diastolic and mitral systolic, 5.21 " Aortic diastolic and systolic and mitral presystolic and systolic, 3.77 " When two lesions coexist at the same valve, the one may compensate, in part at least, for the other, as, for example, in the case of aortic ste- nosis in association Avith aortic regurgitation. Here the stenotic deficiency lessens the reflux current from the aorta into the left ventricle during the diastole; hence the latter receives a correspondingly diminished amount of blood. During the contraction of the ventricle undue distention of the aorta is prevented, both on account of the narrowing at the aortic orifice and the relatively lessened contents of the hypertrophied ventri- cle. Similarly, in dominating mitral incompetency an associated mitral stenosis by loAvering the strength of the regurgitant current renders the conditions more favorable. Relative insufficiency at the mitral valve, following aortic insufficiency, is most probably salutary in its effects, preventing, as it does, over-distention of the left ventricle, and also the over-filling of the arterial tree and the possible rupture of the blood- vessel. On the other hand, mitral incompetency is sometimes second- ary to aortic stenosis; and when so the latter defect hastens the unfavor- able tendencies in the former. Relative tricuspid incompetency, secondary to mitral disease, usually results in the development of a serious impediment to the systemic ven- ous circulation, and often heralds a speedily fatal issue. It is probable that in advanced mitral disease the occurrence of a slight leakage at the tricuspid valve may be the means of obviating disastrous consequences to the right ventricle in case of undue strain. Physical Signs.—These are confusing, but a systematic analysis often leads to the correct inference. That one of the valvular lesions pre- dominates over all others is a fact of paramount importance for the solu- tion of these cases. The chief lesions can usually be determined by noting the seat, the area of transmission, and the character of the most pronounced murmur; and more important still is the correct timing of any murmur that may be audible. The secondary alterations in the heart frequently coincide with the predominating murmur, and it will therefore be an aid to the observer to recollect the familiar fact that mitral murmurs are often secondary to aortic, and that tricuspid mur- murs point to the coexistence of mitral disease. Unquestionably, a single observation of these cases, however carefully made, is often profit- less, whilst repeated observations may be productive of tangible results. Complications of Valvular Disease.—Most of these have already been spoken of at sufficient length, but to restate them col- lectively in this connection may prove useful to the student and phy- sician. They are—(1) acute endocarditis (including the ulcerative form); (2) acute pericarditis; (3) pleurisy ; (4) pneumonia ; (5) nephritis, folloAved by uremia; (6) local or general arterial sclerosis; (7) chronic gastric or intestinal catarrh with intercurrent acute attacks; (8) embolic 622 DISEASES OF THE CIRCULATORY SYSTEM. processes; (9) angina pectoris; (10) edema of the lungs; (11) hypo- chondria and melancholia; (12) rupture of the skin of the extremities in consequence of excessive edema, Avith erysipelatous inflammation; (13) synovitis, a not uncommon complication; fever, SAvelling of one or more of the joints, and pain are the usual symptoms. The muscles of the extremities may also be involved simultaneously. It is highly probable that these manifestations are to be regarded as being of a rheumatic nature, though they are also met Avith in ulcerative endocar- ditis. (14) Febrile paroxysms occur at varying intervals of time, and are due to a variety of causes, as rheumatism, acute endocarditis, and pericarditis., Ulcerative endocarditis may also occur and be attended with an irregular type of fever. Course and Duration.—When valvular disease consists in rupture of a segment the course is brief and usually proves quickly fatal. Apart from these exceptional instances the duration is measured by months, or more often by years or even decades. Statements applicable to all cases cannot be made, however, owing to the wide differences in different cases. Among the circumstances affecting the duration I would men- tion in particular the patient's mode of life, the hygienic conditions under Avhich he lives, his occupation, mental condition, and the severity of the morbid processes. Every experienced physician has doubtless met with a small class of cases that have terminated fatally in from six months to a year, having developed in that period all of the serious phenomena and complications of the more chronic forms of organic heart-disease. In the preponderating proportion of cases, however, the course is exceedingly sIoav, and often cases have existed many years before they have finally been recognized. In numerous instances the patient folloAvs his usual avocation, which may even be laborious, for years, and without discomfort. In other instances symptoms, as dysp- nea on exertion, are so slight as not to excite suspicion. Facts such as these render it obvious that the period of compensation is long, though its exact limits are indeterminable. In 12 instances of chronic endocarditis that have developed under my observation (some having lasted ten or tvvelve years) only 3 have reached the stage of broken compensation. The progress after failure of compensation is more definitely knoAvn, since frequent opportunities for observation are afforded. At this time the cases also exhibit AAlde differences respecting their duration; in my own experience they have varied from tAvo to three months to as many years (rarely even longer), depending much on the patient's mode of living. The course may be shortened by severe external injury, intercurrent acute illness (especially febrile disease), vicious habits, straining efforts, and the like. Prognosis.—The detection of a cardiac murmur should not alone lead to a gloomy prognosis. Says Osier: "With the apex-beat in the normal situation and regular in rhythm, the auscultatory phenomena may be practically disregarded." Individual cases require separate and careful consideration. It is well not to advance positive assertions until all the circumstances that may influence the prognosis of any given instance have been well weighed. Observation of a case for some weeks and months enables the physician to speak Avith greater ■confidence and knowledge concerning the probable outcome; and hence CHRONIC VALVULAR DISEASE. 623 it is the part of prudence to delay giving a positive prognosis for a considerable length of time. Prior to the occurrence of disturbances of compensation the prognosis is measurably favorable. After this pivotal event the prognosis as to life becomes Avholly unfavorable, though the end is not necessarily near at hand. Disturbances of com- pensation that are attended with marked arrhythmia, urgent dyspnea, and general dropsy may, under proper treatment, admit of even complete relief. Later on, hoAvever, restoration of the balance of forces becomes only partial, and finally the above-mentioned symptoms become more pronounced; Cheyne-Stokes' breathing may then develop, and, after a prolonged and distressing struggle for breath, the patient succumbs. Death may also occur suddenly from cardiac paralysis. Among ominous and yet common complications and intercurrent affections may be cited again extensive edema of the lungs, pneumonia, typhoid fever, embolic pro- cesses, ulcerative endocarditis, acute endocarditis, obstinate gastritis, and nephritis. On the contrary, favorable indications are sound general bodily condition, good external conditions (absence of poverty, hunger, etc.), strong and regular action of the heart, absence of arterio-sclerosis and of rheumatic antecedents, and correct habits of living. Age influences the prognosis to some extent. In children under ten years the lesions are usu- ally somewhat more rapidly progressive than in adults, and the compen- satory hypertrophy is developed with corresponding rapidity; hence the period of failing compensation is reached earlier. This may be said to be a broad general rule, and I have found that it is one to which there are many exceptions. Among other reasons for the more gloomy prospect Avhen heart-disease occurs in young children are the following: the mitral valve is generally implicated, the liability to rheumatic inter- currences is great, and children, unless carefully controlled, overtax at play the reserve cardiac power when indulging in running and other forms of exercise. After the twelfth year the prognosis becomes more favorable. Sex is also a modifying prognostic factor, women bearing valvular lesions better than men, apart from the influence of childbear- ing, though even this is an influence the significance of which has been greatly magnified by many writers. To explain the more fa Adorable out- look in Avomen we have two main facts—viz. a less laborious as well as a more quiet life, and a diminished liability to arterio-sclerosis and in- volvement of the coronary vessels. The particular valve involved has some influence on the prognosis. Aortic regurgitation gives, on the whole, the most favorable prognosis, particularly in those cases that begin in early adult life, granting, of course, that the patient regulates wisely his manner of living. Under such circumstances the lesion may be compensated for many years or even decades. The increased vigor of the left ventricle as compared with the right is conducive to longevity in this disease. After failure of compensation, I admit, the prospect is not as hopeful in aortic regurgi- tation as in mitral regurgitation, since restoration of compensation is not as readily accomplished in the former as in the latter variety. In the lesion under consideration a chief danger arises from associated arterio-sclerosis—a rather frequent occurrence in advanced life—and from implication of the coronary arteries. Much depends upon the condition of the latter vessels. When their lumen is narrowed starva- * 624 DISEASES OF THE CIRCULATORY SYSTEM. tion of the heart-muscle quickly ensues, followed by myositic degenera- tion. Blocking of one of the branches of the coronary artery is the most frequent cause of sudden death in this affection. In aortic stenosis equally favorable predictions are warrantable when the disease is un- complicated. Mitral regurgitation, when a primary lesion, is propitious, except in the very young, and not infrequently the progress of the morbid process is apparently arrested. In a considerable proportion of cases the dis- ease does not materially shorten the life of the sufferer. In a larger percentage, however, there is special liability to a renewal of the causa- tive affections (e. g. rheumatism) and to pulmonary conditions of serious import, producing exacerbations and permanent aggravations of the disease. The gravity of these intercurrent complaints is also increased by the existence of the cardiac lesion. Failure of compensation at once renders the prognosis decidedly unfavorable. In mitral stenosis com- pensation of the right heart fails someAvhat earlier than in mitral insufficiency, and hence the accidents and conditions referable to the lung (diffuse pulmonary apoplexy, edema) are not so long delayed as in the latter disease: this is also true of the later, more serious manifestations. I have learned by experience that mitral stenosis is better borne by women than by men, and better during adolescence and early adult life than during more advanced years. The congenital forms are comparatively benign. It should not be forgotten that mitral stenosis causes sudden death more frequently than any other form of organic disease of the heart except aortic regurgitation. Tricuspid incompetency, whether secondary to disease of the lung or of the left side of the heart, is extremely grave. It is usually indicative of dila- tation folloAving hypertrophy of the right ventricle. The vigor of the ventricle, however, can be re-established, and sometimes repeatedly. Treatment.—This falls naturally into three subdivisions: (1) pro- phylaxis ; (2) management during the stage of compensation ; (3) treat- ment of the stage of non-compensation. (1) Prophylaxis.—It can scarcely be doubted, as shoAvn by the statis- tics of Sibson, that complete rest and protection of the surface during an attack of acute articular rheumatism lessen the average percentage of cases in which acute endocarditis develops. When the latter com- plication occurs in acute rheumatism the patient should keep to his bed for some time after all rheumatic symptoms have disappeared (two to six weeks) or until the improvement in the cardiac condition has ceased absolutely. This precautionary measure will often lessen the extent of the ensuing chronic endocarditis, and also increase the proportion of perfect recoveries. Suitable dietetic and medicinal treatment must necessarily be combined. When the physician is cognizant of hered- itary predisposition to organic heart-disease, or has to deal Avith the arthritic diathesis (gouty or rheumatic) or the alcoholic habit, he can frequently, by timely advice and hygienic suggestions, direct his pa- tient to adopt measures that will obviate the occurrence of valvular disease. All persons predisposed by heredity or otherwise should be told of the probable effect of muscular strain, alcohol, and other excit- ing factors; too often, hoAvever, when he sees his patient for the first time the physician is confronted by an already incurable malady. CHRONIC VALVULAR DISEASE. 625 (2) Management during the Stage of Compensation.—Three main ob- jects are to be accomplished: (a) The avoidance of every agency that tends to aggravate or maintain the lesion or lesions. Under this head the detection and removal of all causal factors is imperative. Thus, if the patient's avocation entails undue muscular effort, it must be aban- doned ; violent exercise, as running up flights of stairs, heavy lifting, or straining at stool, is also dangerous and must be prevented. If alcohol has been a factor, it must be discontinued ; if syphilis, it must be treated specifically. If there be present a rheumatic or gouty taint of the system, it must be overcome as far as possible by special meas- ures. The recognized causes of rheumatism, as fatigue and exposure, must be avoided, particularly if the patient be comparatively young. Mental excitement and strong mental effort injuriously affect the cardiac lesion; therefore tranquillity of mind should be insisted upon, though moderate and systematic mental exercise has no risks for the patient. In the case of children at school careful supervision of their studies as Avell as of their recreative exercises is essential. Fright and sudden emotion must be avoided if possible. The use of tea, coffee, and tobacco should be rigidly prohibited. (b) The diet of the patient demands careful regulation. Only a very moderate amount of food, composed for the most part of readily digested albuminous articles (milk, eggs, the lighter forms of meats, and steAved fruits), is to be taken, since overloading the stomach will disturb the action of the heart; particularly is this true at night. The carbohy- drates may be alloAved only in limited quantities, since they are apt to decompose and form gases that distend the stomach and intestines. For the same reason the coarser and more indigestible food-stuffs should be avoided. Small meals at short intervals is a plan of feeding that I can highly commend. The amount of liquids taken should not exceed the actual requirements of the patient, inasmuch as over-filling of the blood- vessel system increases the work of the already overburdened cardiac forces. Alcoholic beverages should not be used as a rule; but if the patient has been moderate in the use of alcohol, and particularly if he be advanced in years, light Avines may be alloAved in moderate quantity to aid digestion, (e) Carefully regulated exercise is beneficial, but it must be gentle and should be taken out of doors. As before intimated, a good general muscular development is an aid of no mean value to the conservative poAvers of the heart. Oertel, with a view to assisting the compensatory forces of the heart, has recommended graduated physical exercise; he advises that patients be instructed first to ascend Ioav ele- vations, and later mountains of a considerable height, the object being to bring about full compensation. Great caution is to be exercised by the physician, hoAvever, since this method has been found to be inapplicable to a large percentage of cases. Cardiac distress, palpitation, and dys- pnea are complained of by this large group of patients if other" than the gentlest forms of exercise be undertaken. With respect to exercise, then, the sensations and experiences of each patient must be consulted before the physician can advise judiciously. Woollens should be worn next to the skin during both the Avarm and the cold seasons. The skin should be kept clean by daily sponge baths, and if these be followed by friction of the surface, the bodily nutrition will be improved and the 40 626 DISEASES OF THE CIRCULATORY SYSTEM. liability to intercurrent attacks of bronchitis greatly lessened. The boAvels should be moved each day, and usually the use of stewed fruits suffices to accomplish this end; if not, salines, Rochelle or Carlsbad salts, and the bitter Avaters (Friedrichshall, Hunyadi-Janos) must be brought into requisition. In winter a Avarm climate may prove ad- vantageous, though long journeys are often illy borne, OAving to the fatigue induced thereby. If, despite the measures above indicated, the patient becomes anemic or his nutrition is notably impaired, a suit- able change of air,1 or the use of quinin, mineral acids, arsenic, small doses of mercury, and cod-liver oil, is to be recommended. Digitalis should not be employed when compensation can be preserved in other ways, (3) Treatment of the Stage of Non-compensation.—The chief object to be kept in view in this stage is the reinvigoration of the exhausted cardiac muscle, and thus to relieve the impeded circulation. Sudden death may, though rarely, occur from the blocking of a branch of the coronary artery or from acute dilatation. Failure of compensation, however, begins gradually as a rule, the condition often existing without marked or characteristic symptoms; but its early recognition is import- ant from the stand-point of therapy. Increased dyspnea on exertion, and nocturnal seizures of shortness of breath and irregular action of the heart (arrhythmia), are among the earliest clinical features. The latter symptom may have been present before, and particularly during active exercise in mitral disease, but noAv it is more marked, and may be con- stant. The patient's nutrition often suffers, and he is pale and rather feeble. Absolute quiet, liberal feeding with suitable food, and iron may in a little Avhile restore the impaired cardiac tone. If this treat- ment fails, by the end of a fortnight a small dose of digitalis should also be exhibited (5 minims—0.333—of the tincture three times daily); the latter should be promptly AvithdraAvn upon the disappearance of the symptoms. Decided indications of lost compensation are marked dys- pnea and arrhythmia ; the canter rhythm ; an irregular, small, compres- sible pulse; and cyanosis, Avith or Avithout the presence of dropsy. To meet the latter serious condition we must have recourse to the following means : (a) Absolute rest in bed. This diminishes greatly the Avork of the heart, and thus enables it to regain largely its former vigor. Rest joined Avith careful yet liberal feeding and attention to the boAvels will often restore disturbed compensation in from one to tAvo weeks. In 3 cases recently treated at the Medico-Chirurgical Hospital this method succeeded admirably. (b) Cardiac stimulants and tonics. Of these, when occasion demands, the most important is digitalis, and this may be tried in any case in which dilatation exists. By stimulating the pneumogastric, by increasing the blood-supply to the heart-muscle, by causing the systole to be more com- plete and the period of diastole to be lengthened, digitalis becomes an in- valuable aid to the nutrition of the cardiac muscles. In addition, the heart contracts more regularly and the blood-pressure in the peripheral circulation is raised. As a result of the use of this drug the tissue-calls 1 Observation and experience have confirmed my belief that sea-air during the warm season and high altitudes at all times are injurious in their effects in valvular disease of the heart. CHRONIC VALVULAR DISEASE. 627 upon the cardiac forces from the outlying portions of the body are satisfied and the reserve energies of the heart-muscles are maintained. In mitral disease the influence of digitalis is most beneficial, the pulse becoming slower, of better tension, and more regular as a rule, Avhile the urine increases in amount. The dropsy, when present, often disappears under its employ. In mitral incompetency its good effects are ascribable to the poAverful contractions of the left ventricle, Avhereby the normal blood-stream from the ventricle to the aorta is greatly increased, Avhile the regurgitant current is not proportionately increased, because of the fact that the mitral defect is minute as compared with the aortic. On the contrary, the patient's condition is occasionally aggravated by the drug, because " the leak is increased as much as the normal flow " (Hare). In mitral stenosis digitalis, by lengthening the period of diastole, alloAvs time for the blood to pass from the auricle through the narroAved mitral orifice into the ventricle. Slight toxic effects may sometimes result from digitalis, the pulse becoming thread-like and irregular, the urine scanty, and, as pointed out by Broadbent in connection with mitral stenosis, there may be tAvo heart-beats to one pulse. In aortic regurgitation digitalis exercises as great, if not as wide, an influence as in mitral disease: the theoretic view, hoAvever, that by pro- longing the diastole digitalis causes overfilling of the left ventricle rests on too slender a foundation to be regarded as a valid objection to its use. It may, however, produce excessive hypertrophy if used continu- ously for too long a period. Hence its effects should be carefully noted, and the drug promptly Avithheld should over-hypertrophy be engendered. In all forms of organic heart-disease, though most frequently in aortic regurgitation, nausea and vomiting sometimes follow the administration of digitalis: when this is the case it should be stopped and other car- diac stimulants substituted, or the dose reduced to the point of toler- ance, Avhen it may be continued if adequate to maintain a proper effect. When secondary dilatation comes on in aortic stenosis, digitalis is needed to increase left ventricular poAver. The dose is to be calcu- lated according to the degree of existing dilatation. AVhen tricuspid incompetency is secondary to disease of the left heart, striking results are obtained from the use of digitalis; but Avhen it exists alone—e. g. folloAving emphysema or cirrhosis of the lung—digitalis often fails. The cardiac contractions, if they have previously been irregular, may become somewhat more regular, but the precordial distress will often be increased, Avhile the circulatory disturbance, as evidenced by the objective signs, will remain unrelieved. If dropsy be slight or absent, 10 minims (0.666) of the tincture or 2 to 3 drams (8.0-12.0) of the infusion, three or four times daily, Avill suffice. If symptoms of decidedly unfavorable import be present, including marked dropsy, the dose should then be larger (of the tincture, minims x to xv—0.666 to 0.999; of the infusion, §ss— 16.0—every two or three hours) for two or three days, Avhen the dose must be diminished or given at longer intervals. Quantitative estimations of the urine should be made during the use of the drug, and if the effect be good the daily amount will often be greatly increased; if bad, there will be a diminution rather than an increase in the amount. Other fav- orable influences and disadvantages have already been adduced. There are not a feAV patients in whom the symptoms of commencing failure of 628 DISEASES OF THE CIRCULATORY SYSTEM. compensation recur as soon as the drug is discontinued. To such digi- talis may be administered continuously or until toxic symptoms are mani- fested. I believe that the solid preparations (powder and extracts) can be taken for longer periods than the liquid forms Avithout exciting unto- ward symptoms. This suggestion should be followed particularly in cases that are seen at long and irregular intervals of time. Evidences of fatty degeneration and atheroma are not contraindications to its use, but are signals for the observance of extreme caution. It should, hoAvever, be a rule never to be broken to discontinue the digitalis when the symptoms of disturbed circulation have vanished. When it fails of its effect or is not well borne, and Avhen, as often happens, the arrhythmia is not favor- ably influenced by it, the physician is compelled to resort to other car- diac stimulants. These are numerous, and, whilst their good effects are not comparable to those of digitalis in every respect, some of them seem to meet certain indications that are not met by this drug. Among the more important are nitroglycerin, strophanthus, strychnin, cocain, spar- tein, and caffein. Nitroglycerin in small doses is at the same time a car- diac stimulant and an arterial relaxant, and hence is more often useful in aortic than in mitral valvular disease. In larger doses, when left ven- tricular hypertrophy is excessive, as may occur when general arterio- sclerosis is associated with aortic regurgitation and also (though rarely) aortic stenosis, it is highly useful, Avidening the blood-paths, and causing less powerful contractions of the heart. Strophanthus should be em- ployed in instances in which digitalis must be interrupted, since the action of these tAvo remedies upon the heart-walls is very similar. The tincture is usually employed, the dose (varying with the indications of each case) being from 4 to 10 minims (0.266-0.666) every three or four hours, and in controlling the irregularity or intermittency of cardiac action it is sometimes better in its influence than digitalis. Many cases of marked arrhythmia will not yield to either when but one is given ; and in such I have occasionally obtained good results from digitalis and stro- phanthus in combination. Caffein citrate is also a good cardiac stimu- lant, but is superior as a diuretic. It should be stated that, rarely, stro- phanthus, like digitalis, does harm rather than good, being sometimes badly borne by the stomach. Under these circumstances I have em- ployed, both in hospital and private practice, the folloAving combination: Py. Caffein. citrat., 3j (4.0); Strychnine sulphat., gr. j? (0.021); Spartein. sulphat., gr. ij (0.129). Ft. capsulse No. xij. Sig. One every three or four hours. The above prescription is not only a good heart-tonic and stimulant, but also an equally good diuretic. Spartein is a potent diuretic and heart-stim- ulant when employed in doses of gr. ^ to \ (0.010-0.016) every four to six hours, and is especially serviceable in organic heart-affections when dropsy as a symptom and nephritis as a complication exist. Strychnin, when given hypodermically in full dose, gr. -^ to TV (0.002-0.004), is the most efficient cardiac stimulant known to medical science. It should be em- ployed in this manner in cases in which there is sudden failure of heart- power with the development of serious symptoms. Given in doses of CHRONIC VALVULAR DISEASE. 629 average size, per oram, its effects in chronic valvular disease are not very striking. Atropin may be advantageously combined Avith it. When the indications are urgent and the above agents are not avail- able, diffusible stimulants, as ether or ammonium, may be used until more suitable remedies can take effect. Cocain simulates strychnin in its action. The dose is gr. \ (0.016) every four hours, and the drug may be given with digitalis in pill-form. Later, systemic tonics are often de- manded by the anemia and other constitutional indications, and here iron and quinin should be joined with strychnin. Unquestionably, the value of iron in full doses as an aid to the completion of the Avork of restoring broken compensation has been and is still scarcely appreciated by the profession at large. When iron disagrees, arsenic may be given instead. In many cases of failure of compensation the restoration of the balance of the cardio-systemic circulation can be greatly assisted by AvithdraAving a portion of the blood-vessel contents; and in other instances the heart cannot be stimulated to regain adequate poAver until the overfilled venous system is depleted and the intracardiac pressure thus reduced. There are two ways in which to attain this end: (a) Venesection.—When the right heart is over-distended, as shoAvn by its very feeble efforts at contraction, and the Avhole venous system is intensely engorged, as shown by marked cyanosis and orthopnea, bleeding directly from a vein is not only warrantable, but often imperatively de- manded in order to save life. From 16 to 30 ounces (473.0-887.0) may be removed safely, and the heart's action will almost immediately be obsenred to grow stronger and more regular, and the pulse fuller and of better tension. As before intimated, the form of dilatation of the right ventricle that follows emphysema is disinclined to yield to digitalis. In such instances, folloAving the suggestion of Osier,1 I have obtained bril- liant results from free bleedings. (b) Depletion by purgation affords less pronounced relief to the heart, though it is of the greatest value in cases in which a moderate grade of cyanosis and dropsy exists. As in the case of venesection, a feeble, irregular pulse is not a contraindication to the use of purgatives, since the latter remove directly a considerable portion of the heart's burden. The purgative to be used will vary with different cases. I select at the outset Rochelle or Epsom salts, employing them after the method of Matthew Hay—i. e. from 1 to 2 ounces (32.0-64.0) of Rochelle or 1 to 1^- ounces (82.0-48.0) of Epsom salts, in concentrated solution, to be given from a half to one hour before breakfast. Watery evacuations (three to six in number daily) usually folloAv the administration of the saline ; but, unfor- tunately, one meets with many patients in whom it produces symptoms of marked catarrhal irritation. Next to salines, the most satisfactory results have been obtained from the use of elaterium ; I often combine this with podophyllin and belladonna. I have never seen good results from the use of mercurials when the object has been to procure venous de- pletion, but they are of service in dropsy, and particularly in ascites. Schott of Nauheim has introduced a special plan of treatment that is applicable to most forms .of valvular disease, simple dilatation, and nervous affections of the organ. Twenty-one baths are given in one month, drop- 1 For illustrative cases from Prof. Osier's wards see article by Leufler, Medical News, July, 1891. 630 DISEASES OF THE CIRCULATORY SYSTEM. ping one every fifth, fourth, third, and second days. The water contains sodium chlorid, calcium chlorid, and carbon dioxid, and the temperature ranges from 82°-95° F. (27.7°-35° C). The first bath lasts seven or eight minutes; the time is then gradually lengthened, the temperature loAvered, and the carbon dioxid increased. After the bath the patient is rubbed and allowed to rest for an hour. Artificial Nauheim baths are successfully employed in certain Ameri- can hospitals at the present time. They are prepared as follows: Five pounds of sodium chlorid and eight ounces of calcium chlorid are dissolved in one half bath (30 gals.—111 liters), the temperature of the Avater being 95° F. (35° C). In a feAV days the bath is charged Avith carbon dioxid by adding sodium bicarbonate (1 lb.—453.6) and HC1 (| lb.—226.8), the latter just before the bath is taken. The effects are to lower the pulse- rate, to decrease the size of the heart, to stimulate the nerves, and, indi- rectly, the cardiac nutrition. There is also a tendency toward improve- ment of the skin and an increase of the urine. Oentle resistance exercises (consisting of all the more reasonable move- ments that a person naturally makes, and resisted by an attendant) form an important element of the treatment, since they tend to stimulate the muscles and nerves and propel the blood from the congested veins. The Nauheim treatment is not suitable in aortic regurgitation, aneurysm, or fatty degeneration of the heart. Individual symptoms frequently become so conspicuous as to demand special treatment. (1) Dyspnea and Orthopnea.—When these conditions are caused by engorgement of the pulmonary vessels, the cardiac stimulants above detailed usually afford relief. Frequently the patient cannot lie doAvn, in Avhich case a suitable bed-rest often gives immediate comfort and support. For the severe attacks of nocturnal dyspnea (amounting some- times to orthopnea), particularly when accompanied by cardiac palpita- tion, the subjoined formula has proved itself of great benefit: R/. Sodii bromidi, gr. xv (0.972); Tr. opii deod., TTTx-xv (0.666-0.999).—M. Sig. To be taken in one dose at bed-time. In the late stages of heart-disease morphin, given hypodermically, is to be preferred in combating this symptom, and is entirely free from the usual objections to the habitual use of the remedy. Its influence for good is inestimable. Dyspnea may also be produced by associated bronchitis, edema, emphysema, and hydrothorax—conditions that must be treated according to the customary rules. Frequent physical explorations of the chest should not be omitted. Hydrothorax demands aspiration, and this repeatedly in some instances.1 In valvular disease (particularly aortic), OAving probably to coronary arterio-sclerosis, paroxysms of severe dyspnea (cardiac asthma) are apt to arise. These are best overcome by nitroglycerin in combination Avith sodium bromid at bed-time, to be repeated as needful. (2) Cough.—Cough is common after failure of compensation, and is due to bronchitis resulting from stasis in the pulmonary vessels. In 1 AVhen the chambers of the heart are greatly dilated care must be exercised in insert- ing the aspirating needle, lest the left ventricle be entered. CHRONIC VALVULAR DISEASE. 631 mitral disease it may come on before the rupture occurs. Beyond the treatment directed to the causal condition (the cardiac failure) nothing is needed to relieve the cough. It should be remembered, hoAvever, that these subjects are very liable to suffer from catarrhal bronchitis due to cold, and that unless the condition be promptly controlled, the compen- satory power of the heart will suffer. (3) Hemorrhage may take place, and generally from the lungs, though it may also proceed from the nose, stomach, boAvels, or uterus. In a recent case of double aortic and relative mitral insufficiency attended Avith marked dropsy, rather copious hemorrhages occurred from the boAvel, but Avith apparent relief to the patient. The hemoptysis, Avhich is a rather frequent accompaniment of mitral lesion, is rarely excessive, and is probably ahvays beneficial. I Avould advise against active treat- ment unless the hemorrhage is actually copious in amount, and Avould apply this statement with equal force to hemorrhage from other mucous surfaces in connection with organic heart-affections. (1) Palpitation may be due to different causes, the recognition of Avhich in each case is important if we Avould institute appropriate treat- ment. At times undue hypertrophy maintains a constant throbbing and distress in the precordial region, the former being distinguished by the strength of the impulse and by the full, tense pulse at the Avrist. Palpitation is best met by the use of the tincture of aconite, fllj-iv (0.066-0.266) every four hours. With the aconite I frequently asso- ciate the bromids Avith excellent effect. Unless the patient's discomfort is significant, however, this symptom does not call for active treatment. The administration of a saline purge not infrequently serves to quiet the heart. The patient may suffer from pure nervous palpitation, in Avhich case the diet and the condition of the stomach must be carefully looked to, while for the throbbing the bromids of ammonium and sodium, together with preparations of valerian, are the most reliable. (5) Anginose Pains.—These are seen in aortic incompetency accom- panied by sclerotic vessels, and more especially in mitral stenosis. When dependent upon rigid blood-vessel walls nitroglycerin should be tried; if the attacks be severe, amyl nitrite by inhalation deserves a trial, and, this failing, morphin and atropin may be employed hypodermically. The latter measures, as a rule, promptly relieve the patient's suffering. Local measures alone are sometimes sufficient Avhen the pain is only moderately intense, and the ice-bag or Leiter's coils may be tried. The sedative effect of a blister (4 by 6 in.—10 by 15 cm.) has more often proved effectual in my experience, though its use should be limited to patients whose general strength is not impaired to a great extent. (6) Pain referred to the stomach, and less frequently to the abdomen also, occasionally assumes prominence and is relieved Avith great diffi- culty. It is dependent, in part at least, upon obstinate subacute gas- tritis, and I have quite recently seen an instance of the sort verified by autopsy. Among many drugs tested in this case, opium alone gave relief. Usually the pain results from gaseous distention of the stomach and boAvels, and is not intense, a mild laxative frequently relieving the pain. Should this fail, hoAvever, trial should be made of the carmin- atives in combination Avith some antiseptic agent, as salol or creasote. (7) Gastric Symptoms.—Soon after compensation is broken the ap- 632 DISEASES OF THE CIRCULATORY SYSTEM. pearance of mild symptoms of catarrh of the stomach may be said to be the rule, and these yield to simple measures in addition to the cardiac stimulants and laxatives already indicated. But there are not a few instances in Avhich such symptoms as gastric distress and,uneasiness, constant nausea with frequent vomiting, particularly after food, take on an ao-o-ravated form. This condition is scarcely amenable to treatment. Such patients cannot, as a rule, take digitalis or strophanthus by the mouth; they sometimes, hoAvever, do wrell on the capsules before adduced composed of strychnin, spartein, and caffein. When the latter cannot be borne I employ hypodermically digitalin and strychnin or caffein citrate, the latter being made soluble by the addition of sodium benzoate in solution. Cases of this class reach an early fatal termination, as a rule. The symp- toms may be partly due to gastric catarrh and partly to uremic intoxication. (8) Nervous Symptoms.—Insomnia and internal restlessness are almost constantly present at some period in the course of heart-disease, and notably in the more advanced stages. The restiveness is rendered more distressing on account of hideous dreams and cardiac palpitation on awaking. For these phenomena stimulation often answers a better purpose than sedation. Hoffman's anodyne (3j—4.0—Avell diluted), spirits of chloroform (Kitxv—0.999), or ether (^ss—2.0), taken in whis- key (§j_32.0) are serviceable. The elixir of ammonium valerianate is also of value when given in full doses. AVhen a hypnotic is required to afford sleep, I prefer sulfonal in combination Avith camphor monobromate or the folloAving powder: B/. Sulfonal, gr. xv (0.972); Sodii bromidi, gr. xx (1.296). M. et ft. chart No. 1. Sig. To be taken at 8 p. m. In the later stages there is no objection to the use of morphin hypo- dermically. Headache due to uremia may frequently be a troublesome symptom in connection Avith sleeplessness, and in such cases morphin is the remedy par excellence ; it is to be supplemented by free purgation and cardiac stimulants. Should the right heart be found flagging, venesection may be practised. (9) Dropsy.—Among the symptoms requiring special treatment in advanced valvular disease dropsy easily assumes the lead. As above pointed out, rest Avith attention to the diet and state of the boAvels wi 11 often restore defective compensation even Avhen accompanied by a mod- erate degree of dropsy. In the severe grades of failure of the balancing forces the cardiac stimulants and purgatives before mentioned often suffice to remove the dropsy for a considerable period of time. Later, hoAvever, it becomes obstinate, and refuses to yield to any of the knoAvn methods of treatment. The therapeutic indications, so far as the symp- tom under consideration is concerned, are for the use of diuretics and purgatives. Diaphoretics, particularly the hot-air and vapor baths, are not to be thought of, since they tend to depress the already weakened heart. While describing the action of digitalis as a cardiac stimulant, incidental allusion Avas also made to its action as a diuretic. In view of the fact that it raises the blood-pressure in the peripheral vessels and capillaries by contracting their Avails, and because of its stimulating CHRONIC VALVULAR DISEASE. 633 effect on the heart, digitalis in large doses becomes a most efficient diu- retic in cardiac dropsy. When the renal secretion is not free under its use, or when for some good reason it cannot be taken, I have frequently found that a combination of strychnin, spartein, and caffein (vide supra) will excite free diuresis. Nitroglycerin may also be prescribed, espe- cially in cases presenting evidences of advanced arterio-sclerosis. An unirritating yet highly effective diuretic mixture in these cases is the folloAving: R/. Potassii acetatis, 3j (4-0); Inf. digitalis, gij (64.0).—M. Sig. §ss (16.0) every three hours. Purgatives are of the utmost value. Frequently, after a few copious watery evacuations as the result of the action of hydragogue cathartics, a free discharge of urine can be established, Avhen before the latter event it has been impossible. Salines and elaterium, Avith podophyllin and belladonna, are agents that have been already recommended as purga- tives (to deplete the venous system), and these should be first employed in the order named. Compound jalap poAvder may also be combined Avith the elaterium. A course of calomel, followed by salines until free catharsis is set up, is valuable from time to time. Mercury is especially applicable Avhen the liver is much enlarged and ascites is a marked fea- ture, or when the history of syphilitic infection is obtainable. It may be combined with cardiac stimulants and other diuretics as follows: B/. Pulv. digitalis, Pulv. scillae, act. gr. xij (0.777); Hydrarg. mass., gr. xxiv (1.555); Ext. belladonnse, gr. ss (0.0324). M. et ft. pil. No. xij. Sig. One every three or four hours. When efforts at relieving the dropsy by means of medicines fail, then the most dependent parts, of the body, or those most swollen, should be scarified under strict aseptic precautions. Fine silver trocars Avith rubber tubes attached (Southey's tubes) may be inserted and the liquid allowed to drain off in a gradual manner. Means to Prevent Recurrence of Broken Compensation.—When the compensation has been successfully established, the after-treatment must be prosecuted Avith vigor for at least a year. The cause of the rupture of compensation is most probably fibroid and fatty degeneration of the cardiac muscle, and hence the mere restoration of the compensatory poAver of the heart does not imply a complete cure of the impaired mus- cular structure of that organ. Much can be done, however, to overcome the tendency to degeneration by the persistent use of certain tonic rem- edies, as iron, cod-liver oil, arsenic, and mercuric chlorid, the latter two in small doses. I have obtained excellent results from the use of the following prescription in these cases: B/. Liq. arsenici chlor., Tfl.xlviij (3.186); Tinct. ferri chlor., §ss (16.0); Hydrarg. bichloridi, gr. ss (0.0324); Glycerini, q. s. ad fgiij , (96.0).—M. Sig. 3J (4-0) after each meal, well diluted. 634 DISEASES OF THE CIRCULATORY SYSTEM. This preparation may be taken indefinitely Avith occasional brief inter- ruptions. The patient should lead a very quiet life, and folloAv rigidly all hygienic rules that tend to prevent the production of valvular disease, and avoid Avhatever tends to aggravate in the slightest degree the lesions that may already exist. Appropriate diet, it should be emphasized, is not inferior to appropriate medication in its salutary effect. Should the faintest evidence of failure of the right ventricle manifest itself, the pa- tient must be put to bed immediately, and the foregoing treatment is to be carried out. I am of the opinion that the plan herein advocated not only renders the course of recurring attacks of failing compensation milder, but that, in a considerable proportion of the cases, the much- dreaded recurrence is thus prevented. CARDIAC THROMBOSIS. Pathology.—True cardiac thrombi are seen most frequently on the right side of the heart, in the auricular appendices, and, less commonly, in the right ventricle near the apex. They are of firm consistence, and are tightly adherent to the endocardium, considerable force being re- quired to dislodge them. The color, Avhile generally grayish-broAvn or red, Araries with the age of the thrombus, being more colorless as it be- comes older. Cardiac thrombi may be pedunculated or sessile, and their contour is, as a rule, more or less rounded. Recklinghausen and others have observed globular masses, the so-called " ball-thrombi," in the auri- cles, without the slightest endocardial attachment. They vary greatly in size, from a mustard-seed to a hen's egg, and sometimes exhibit cal- careous degeneration. Cardiac thrombi may occur singly or in groups of considerable numbers. From the cavity in Avhich they have their primary seat they may project into other chambers of the heart, or from the left ventricle into the aorta for a considerable distance. It is evi- dent that fragments detached by the blood-stream from these cardiac blood-concretions will tend to lodge in various viscera and in the per- ipheral tissues, and set up embolic processes. Examined microscopically, degenerate round cells and detritus are revealed, but pus-cells are not seen. Secondary degenerative changes, and later softening, may take place in the central portions of a thrombus, and these areas may contain a reddish-broAvn liquid. Etiology.—The causes of cardiac thrombosis are to be found chiefly in some previously diseased or injured condition of the endocardium, though sometimes alterations of the blood constitute a factor of consid- erable importance. The condition may occur in the course of both acute and chronic diseases, in which the intracardiac conditions favor the formation of a blood-clot. Hence it is seen in connection with organic diseases of the heart in Avhich the valvular and often the mural endocardium are roughened, and the obstructive and regurgitant lesions at the various valves cause retardation in the blood-current. Chronic obstruction in the lungs may contribute to the result by slowing the cir- culation in the heart. Cardiac thrombosis has been observed in many CARDIAC THROMBOSIS. 635 of the acute affections, and almost invariably there is a loss of endocar- dium, due to inflammatory action (endocarditis) at some point in the cavities of the heart. This becomes the seat of the fibrinous deposit Avhich is subsequently imperfectly organized. Among the most import- ant of these acute primary diseases are rheumatism, diphtheria, lobar pneumonia, and pyemic and puerperal conditions. It may be questioned whether, given a healthy endocardium, as contended by some Avriters, sloAving of the circulation alone suffices to cause true cardiac thrombi. Symptoms.—These will depend very much upon the rapidity Avith Avhich the thrombus is formed, as Avell as upon its seat and dimensions. Thrombi invariably lack definiteness, and, as their effects are largely mechanical, signs of obstruction to the cardiac circulation and failure (more or less gradual) of the cardiac muscle are developed. The pulse becomes Aveak, rapid, and irregular; dyspnea, vertigo, and attacks of syncope are frequent; and later cyanosis may appear. It is probable that at times the liquefied products of a clot maybe absorbed, producing blood-poisoning. When the thrombus is formed rapidly, all of the symptoms enumerated are suddenly developed and quickly assume a most serious phase. Rarely a valvular orifice, an efferent vessel, or the coronary artery may become blocked and instant death folloAv. Since the right heart is the most frequent seat for these thrombi, pul- monary embolism, attended Avith its usual symptoms, is a common event. When portions of a clot are broken off and SAvept into the systemic cir- culation, the clinical phenomena of cerebral, splenic, or renal embolism are exhibited. The physical signs consist of a feeble impulse Avith marked arrhyth- mia; the area of dulness is someAvhat increased to the right, and often upAvard; and the heart-sounds are greatly enfeebled and quite irregular, with marked change in any murmurs that may previously have been audible. In this condition a systolic pulmonary murmur may rarely be engendered. Differential Diagnosis.—It is important to distinguish true car- diac thrombi, such as are above described, from the less dense and usu- ally darker clots that are formed either immediately before or after death. The latter may seldom show an attempt at a very low grade of organization, and may present a someAvhat decolorized appearance, but they do not adhere firmly to the endocardium. Moreover, antemortem and postmortem clots, as the latter may be appropriately termed, have a different causation from true thrombi. For instance, they are apt to form in diseases in Avhich the fibrin-factors of the blood are greatly increased, as in pneumonia. Perhaps a more potent causal element is the progressive Aveakening of the heart-muscle, resulting in partial ex- pulsion of the contents of the right ventricle; the blood that remains in the chamber is merely Avhipped up, and the deposition of its fibrin must thus be greatly favored. Such heart-clots may be generated if the endocardium be healthy, and cannot be separated positively from true cardiac thrombi by clinical observation. The prognosis is uniformly bad and sudden death may be expected. Treatment.—Beyond measures calculated to meet the symptomatic indications nothing can be suggested. 636 DISEASES OF THE CIRCULATORY SYSTEM. HYPERTROPHY OF THE HEART. [Hypertrophia Cordis.) Definition.—Hypertrophy is an increase in the muscular structure of the heart, evidenced usually by an increased thickness of its Avails. It is almost invariably associated Avith dilatation of the chambers. Pathology.—When the tAvo processes—hypertrophy and dilatation —coexist, they cause great enlargement of the organ. To this condition the term " eccentric hypertrophy" has been given. Hypertrophy Avith- out dilatation receives the name " simple hypertrophy," and hypertrophy Avith diminution in the size of the cavities Avas formerly described as " concentric hypertrophy," but this term should noAv be regarded as ob- solete, inasmuch as the abnormally small chamber is knoAvn to be due to postmortem contraction of a normal or hypertrophied ventricle. The increase in size may affect either the Avhole heart, one chamber on either side, one Avhole side, or but a single cavity (general and partial hypertrophy). The process may also be limited to a minute division of the heart (circumscribed hypertrophy). OAving to its important physio- logic function the left ventricle is more frequently enlarged than the right, and though the auricles are not as often the seat of hypertrophy as the ventricles, the right auricle is more frequently involved than the left. The weight of the normal heart in a man of average size is approxi- mately 9 ounces (255.0); in a woman it is 8 ounces (226.0). In bilateral hypertrophy, however, the weight of the heart may be greatly increased, though wide variations are exhibited; hearts weighing from 15 to 2") ounces (425.0—710.0) are seen in moderate grades of hypertrophy, and those of from 40 to 50 ounces (1134.0-1420.0) in extreme cases (cor bovinum). Measurements showing the thickness of the Avails also indi- cate the degree of hypertrophy 1 and the exact seat of the enlargement Avhen not general. The normal diameter of the left ventricular wall is from K to 12 mm. (^-^ in.); that of the right ventricle, from 5 to 7 mm. (-5--^ in.); that of the left auricle, about 3 Q- in.), and of the right, 2 mm. (^j in.). Suffice it to state in this connection that under condi- tions of cardiac hypertrophy the normal thickness of the various cavity- Avalls is usually doubled, not infrequently trebled, and, rarely, even quadrupled. It must be noted, moreover, that in cases in Avhich there is a concomitant dilatation the walls may appear thinner than is normal, Avhile the measurement a\1U show them to be in reality thickened. The shape of the heart is also altered according to the seat and ex- tent of the hypertrophy. If both ventricles are enlarged, the apex is Avidened and appears flattened; if only the left ventricle is involved. the apex is lengthened and is more or less pear-shaped; and if the right ventricle alone is hypertrophied (as in pure mitral stenosis), it may form the largest part of the apex, but the latter will be less conical than in health. The papillary muscles and columnse carneae are greatly thickened, and, particularly in the eccentric form of hypertrophy, they are often decidedly flattened. In this form the septum frequently shoAvs increased 1 Measurements should not be attempted until the rigor moi-lis has been overcome by soaking the organ in water. HYPERTROPHY OF THE HEART. 637 thickness—a condition that I have never observed in simple hypertrophy. The muscular trabeculse generally assume greater prominence on the right than on the left side. The muscular structure is usually of a deeper red color and also firmer than normally. The hypertrophied left ventricle can, as a rule, be lacerated readily, Avhile the right, as first pointed out by Rokitansky, may be tough and leathery. As the heart continues to enlarge it sinks loAver in the chest-cavity; this is not, hoAvever, OAving to an increase in size alone, but more particularly to an increase in Aveight. In hypertrophy of the heart there is a multiplica- tion of muscular fibers, to Avhich alone the enlargement of its walls is attributable. Etiology.—Hypertrophy of the left ventricle (sometimes termed general hypertrophy) results from obstructions to the arterial circula- tion of whatever sort. These may be classified, according to their seat, into—(1) Lesions of the Heart.—(a) Aortic incompetency and aortic stenosis; (b) Mitral insufficiency ; (c) The fibroid form of myocarditis; (d) Pericardial adhesions, particularly in the young. Late in life the heart may become atrophied. In such cases the rhythmic play of the ventricle is impeded, the adherent pericardium exerts a counter-traction force during the systole, and thus the work is increased beyond the capacity of the normal heart-: in order to maintain a proper circulation, therefore, the muscle hypertrophies. There is no obstruction either at the orifices or in the arterial tree. In fibrous myocarditis a portion of the muscular tissue is more or less functionless, though compensated for by other healthier portions, Avhile the rhythm of the heart is also greatly disturbed. In valvular disease the augmented tension in the ventricle induces the hypertrophy. (2) Abnormal Conditions of the Blood-vessels.—(a) NarroAving of the aorta—e. g. congenital stenosis, external pressure, and the development of an aneurysm ; (b) General arterio-sclerosis, by raising the pressure; (c) Increased arterial pressure, due to the contraction of the peripheral vessels in consequence of the local action of certain chemical and bio- logic irritants (lead, Bright's disease, gout, syphilis). In all of these cases, Avhether the blood-pressure is raised in larger or smaller vessels, increased cardiac action is essential to meet the demands of the system- circulation. Attention should be called to the causes of the so-called "primary idiopathic hypertrophy," in Avhich variety the above-mentioned etiologic factors are absent. The main causal conditions are—(1) Prolonged physical exertion, such as is necessary in certain occupations (black- smiths, locksmiths, draymen, and athletes). (2) Constant over-disten- tion of blood-vessels, as in the case of excessive beer-drinkers (beer- heart). Here the direct action of the alcohol upon the heart-muscle must also be taken into account. (3) Functional disturbances (neuroses), constant over-action of the heart, and even paroxysmal tachycardia— Conditions excited by excessive mental excitement or emotion—tea, cof- fee, and alcohol may give rise to primary and general hypertrophy. In the latter category of cases it is the excessively rapid action of the heart that produces the hypertrophy. Hypertrophy of the right ventricle develops secondarily to any condi- tion that offers obstruction to the pulmonary circulation or to the blood- 638 DISEASES OF THE CIRCULATORY SYSTEM. current through the right ventricle. Among them may be mentioned— (1) mitral incompetency and stenosis ; (2) emphysema, or cirrhosis of the lung (producing compression or obliteration of the vessels); (3) ri^ht- sided valvular lesions, particularly obstruction at the pulmonary orifice; (4) it is doubtful Avhether, on account of the normal situation of the right ventricle, pericardial adhesions induce hypertrophy of this chamber, as is sometimes claimed. Hypertrophy of the Auricles.—Hypertrophy Avith dominant dilatation of the left auricle occurs in mitral disease, and especially in mitral ste- nosis. The right auricle hypertrophies, though not invariably, Avhen the blood-pressure in the pulmonary vessels is pronounced from any cause. Stenosis of the tricuspid orifice is occasionally the sole cause of thicken- ing of the right auricular Avail, Avhich also becomes hypertrophied in tricuspid incompetency. Symptoms.—There may be an entire absence of subjective symp- toms, since hypertrophy of the heart may be said, Avith rare exceptions, to be protective in character. When present, their intensity varies with the degree of the hypertrophy, Avhich is then pronounced, as a rule, and often already attended by incipient dilatation. They may be local en- tirely, though frequently general as well. Of the former, precordial fulness and uneasiness are the most conspicuous. They are usually most annoying Avhen the patient is in the recumbent posture, particularly on the left side, and Avhen the hypertrophy is dependent upon nervous causes. Pain and palpitation are seldom complained of except by neur- asthenics and patients suffering from enlargement due to tobacco and excessive muscular exertion. Decided aggravations of the local mani- festations may folloAv the operation of influences that create a demand for increased cardiac action, such as undue mental emotion or excite- ment, physical exhaustion, active bodily exercise, and gormandizing. The general symptoms, Avhen present, may fluctuate or even intermit. Those most frequently observed are fulness in the head, often amounting to actual headache, tinnitus aurium, carotid pulsations, flushing of the face, flashing of light before the eyes, and often prominent eyeballs. These symptoms are attributable to the increased vigor of the cerebral circulation. Remote Effects.—General or total hypertrophy promotes abnormal fulness of, and increased tension throughout, the arterial tree. Endar- teritis and arterio-sclerosis are, as a consequence, frequent consentane- ous developments in advanced cases, especially Avhen the cause of the enlargement has been increased tension in the peripheral vessels, as in Bright's disease. With a circulation too forcibly carried on, as in hy- pertrophy, the sclerotic vessels are overstrained, especially the large ones near the heart, and are apt to rupture. The break often occurs in the brain (apoplexy) or in the lung (pulmonary apoplexy), and hemorrhage from the lungs (hemoptysis), due to left ventricular hypertrophy, is of greater frequency, I believe, than most Avriters are ready to admit. Physical Signs in Left-sided Hypertrophy.—Inspection.—In females and in young children Avith yielding ribs there is seen precordial bulg- ing. The intercostal spaces are much broadened and the visible apex- beat covers a greatly increased area, the extension being doAvmvard and to the left. The whole body of the patient, and even the bed on which he may be lying, may share visibly in the cardiac impulse. HYPERTROPHY OF THE HEART. 639 Palpation.—In pronounced grades the impulse may be felt as Ioav doAvn as the seventh interspace and as far to the left as the axilla. In simple hypertrophy it is carried dowmvard to the sixth intercostal space and outAvard to a point near the anterior axillary line. The impulse is sIoav, forcible, and heaving, lifting the fingers of the examiner at each systole. In eccentric hypertrophy (hypertrophy Avith dilatation), though heaving and forcible, it is somewhat more abrupt, and, partakes of the nature of the impulse in cardiac dilatation. Over the aortic orifice or second interspace, to the right of the sternum, a short diastolic impulse may also be felt occasionally (double impulse). The pulse in pure hypertrophy is full, strong, regular, and of normal rate; it is also pro- longed, OAving to increased tension. In eccentric hypertrophy it is soft, full, and someAvhat accelerated. Percussion.—The area of cardiac dulness is enlarged both in its vertical and transverse diameters. Traced upAvard, dulness may ter- minate in the second interspace, Avhilst to the left it may extend 1 or 2 inches (2.5-5 cm.) beyond the mid-clavicular line. When hypertrophy is of moderate extent, the left limit of dulness corresponds Avith the results of palpation and inspection; but when it is of immoderate ex- tent, the extension of dulness does not keep pace Avith the systolic im- pulse, Avhich is diffused to points beyond the limits of contact of the heart Avith the thoracic Avail. If concomitant hypertrophy of the right ventricle be present, dulness will also extend to the right for 1 inch (2.5 cm.) or more beyond the right edge of the sternum. Auscultation.—The sounds vary with the grade of the morbid pro- cess and the variety. In simple hypertrophy of marked type a pro- longation of the first sound is always appreciable, and usually it is duller than the normal. The second sound (aortic) is intensified, clear, and often ringing. The degree of accentuation depends partly upon the vigor of the left ventricle, though chiefly upon the condition of the blood-vessels. Reduplication of the second sound, due to high tension, is common (e. g. in Bright's disease). In dilated hypertroph}T the first sound is clearer and more abrupt, Avhile the second sound is less marked or even faint. Modification of the sounds just described occurs when hypertrophy is dependent upon chronic valvular disease. Hypertrophy of the Right Ventricle.—One or more of the causal fac- tors that produce augmented tension in the pulmonary vessels are pres- ent, and, if properly appreciated, will throw light upon the condition. There may be an absence of all symptoms if the hypertrophy exactly balances the result of the obstructive forces, and this state may be main- tained for a long period of time. Undue exertion, hoAvever, soon leads to temporary dyspnea in many cases. When secondary to emphysema or cirrhosis of the lung the symptoms occasioned by the latter diseases, such as cough and dyspnea, may completely veil any symptoms that may be due to the hypertrophy. Discomfort in the cardiac region should, hoAvever, arouse suspicions of the existence of the latter con- dition. When dilatation of the ventricle supervenes, as is usual, and the clinical evidences of tricuspid incompetency develop, then pulmo- nary symptoms, due to venous congestion, are prominent; these are bronchial catarrh, shortness of breath, and the like. Later, general cyanosis and edema appear. As pointed out in the discussion of Mitral 640 DISEASES OF THE CIRCULATORY SYSTEM. Stenosis Avith permanently heightened tension and overgrowth of the right ventricle, the lung-vessels become atheromatous and the lun^- tissue the seat of broAvn induration. Owing to the fact that the scle- rotic vessels are easily ruptured, hemoptysis—a not uncommon event after sudden great exertion—is to be expected; intense pulmonarv congestion and apoplexy may also be met Avith in hypertrophy with dominant dilatation. Physical Signs.—These have been in the main detailed in speaking of affections of the. mitral valve. Inspection discloses bulging of the sixth and seventh left costal cartilages and of the loAver sternum. In the angle betAveen the ensiform cartilage and the seventh rib an epigas- tric impulse may be visible, but more commonly the impulse is in the sixth interspace, close to the left edge of the sternum. It is also very generally seen to the right of the sternum, in the third and fourth interspaces, and particularly is this the case in eccentric hypertrophy, forming a highly characteristic sign. The apex-beat is therefore diffuse, the radial pulse is small, and in dilated hypertrophy it is increased in frequency, and is small and irregular. Percussion shoAvs the extension of cardiac dulness to a point an inch (2.5 cm.) or more beyond the right sternal border. When there is great increase transversely, dilatation is most probably associated and may predominate over hypertrophy. The auscultatory signs are not distinct- ive unless dilatation also exists, Avhen the first sounds are clear and sharp. In simple hypertrophy the first sound is slightly prolonged and loAver than in health. OAving to the high vascular tension throughout the lungs the second sound at the pulmonary valve is accentuated, and reduplication of the second sound may occur for the same reason. It must be kept in remembrance that Avhen advanced emphysema is present all the physical signs will be greatly modified, and may even be entirely negative, though the heart be of large size. Under these cir- cumstances venous pulsation in the neck would be diagnostic of dilated hypertrophy of the right ventricle. Hypertrophy of the Left Auricle.—This may be assumed to occur in mitral stenosis and incompetency in order to compensate for these lesions : it cannot, however, be recognized positively by physical signs. When the chamber is at the same time extensively dilated, the dulness may be extended upward to the left of the sternum, passing over the third and even second interspaces. At this point—the second inter- space—a presystolic wave may noAv be noticeable. Hypertrophy of the right auricle, associated Avith dilatation, is per- haps more common than its counterpart on the left side. It is secondary to tricuspid incompetency (rarely stenosis) and enlargement of the right ventricle, and hence has the same etiology as the latter conditions. The physical signs are—systolic jugular-pulsation, sometimes a pre- systolic wavy pulsation over the third and fourth interspaces to the right of the sternum, extension of cardiac dulness to the same interspaces, and other signs of tricuspid regurgitation. Diagnosis.—The recognition of cardiac hypertrophy is possible only, by attention to the physical signs. Next to these, in point of diagnostic value, come the causes, Avhich should therefore be diligently searched for; the rational symptoms are least in value, though usually HYPERTROPHY OF THE HEART. 641 corroborative. It is difficult to establish a diagnosis, even approx- imately, Avhen extensive emphysema coexists. As before pointed out, venous pulsation in the neck would point indisputably to right ventric- ular hypertrophy. Differential Diagnosis.—Conditions that cause an increase in the pre- cordial area of dulness, except hypertrophy, must be eliminated. (1) Pericardial Effusion.—A careful analysis of the physical signs and the history will suffice. (2) Aneurysm.—In this affection the enlargement is altogether upAvard and to the left or right. This fact, joined with the other evidences of aneurysm, should obviate error. (3) Mediastinal growths also enlarge the dull space mainly upAvard and to the right or left, though the point of cardiac contact may be increased and the heart carried forward. (4) Displacement of the heart does not give a heaving impulse nor an increased area of dulness; moreover, it usually furnishes its special cause (pleural effusion). (5) Abnormally narrow-chested persons present a considerably increased superficial zone of dulness, partly OAving to the position assumed by the lungs and partly (perhaps chiefly) to their imperfect development. Since there is usually an entire absence of all other physical signs of hypertrophy, ordinary caution will exclude the latter complaint. (6) Affections of the Lungs and Pleurce.—Left-sided pleurisy Avith retraction may, by exposing a large part of the anterior surface of the heart, give rise to signs of moderate hypertrophy. The presence of the former condition, the lack of expansion on deep inspiration, the displacement of the heart to the left and upward, and an absence of the causes of the latter should lead to a correct conclusion. (7) Phthisis and cirrhosis of the lung, with or without pleurisy, may in like manner produce apparent enlargement of the heart. It must also be remembered that cirrhosis of the lung is one of the causes of right-sided hypertrophy, and that the latter condi- tion may therefore be present. Prognosis and Course.—The course that will be pursued depends largely upon the stage at which the case has arrived and the character of its special cause. I have repeatedly found postmortem evidence of a moderate grade of hypertrophy in persons who died of other affections, and with especial relative frequency in those who had constantly fol- lowed manual pursuits. Simple cardiac hypertrophy, being compensa- tory as a rule, exerts in nearly all instances a salutary influence, and if the processes that constitute the causal factors are not steadily pro- gressive, life may not only not be curtailed, but be greatly lengthened by its existence. Even in organic valvular disease of the heart hyper- trophy prolongs life by overcoming the ill effects of the valve-lesion and by maintaining the normal circulatory equilibrium. But since in this class of cases the lesion is progressive despite treatment, a limit is reached sooner or later beyond which the increased vigor on the part of the heart cannot be maintained. The nutritive functions become inade- quate in obedience to a natural laAv, and muscular degenerations then occur, followed by disturbances of the circulation due to cardiac weak- ness and secondary dilatation. It must, however, be recollected that the heart may at no time, in the course of certain cases, fully compen- sate for the causal condition—e. g. as Avhen a valve ruptures with start- ling suddenness. Failure of the cardiac nutrition at once renders the 41 642 DISEASES OF THE CIRCULATORY SYSTEM. prognosis unfavorable. Serious symptoms, Avidely distributed, that have been previously mentioned as characterizing broken compensation, are certain to arise and gradually prove fatal, though, as a rule, temporary restoration of the cardio-circulatory system is obtainable. Occasionally, as the result of undue muscular exercise, acute dilatation, folloAved by a speedy termination of life, is observed. I believe that hypertrophy of the left ventricle Avarrants a more favorable prediction than can be made in hypertrophy of the right, and this for tAvo reasons: first, the increased capacity for Avork of the left ventricle; second, the milder character of the many factors that are productive of left ventricular hypertrophy, as compared with those of the right. In special instances, however, the reverse may obtain, as Avhen left-sided hypertrophy is asso- ciated with or caused by general arterial degeneration. It may be of advantage to the student and junior physician to recapitulate here a few of the chief points that are prognostically favorable as Avell as those that are unfavorable: Favorable Conditions.—(1) When the hypertrophic development fully compensates the causal lesion; (2) when the causes are removable or more or less amenable to treatment; (3) when the ex- ternal conditions under which the patient lives, his habits, and general nutrition are good. Unfavorable.—(1) When signs of imperfect nutrition of the heart arise; (2) when evidences of advancing cardiac dilatation (dyspnea, rapid, irregular pulse, edema) show themselves; (3) when poverty, poor food, intemperate habits, and an unhygienic environment are all combined; (4) when apparent cardiac vigor suddenly gives place to dilatation and great cardiac Aveakness. The treatment has for its prime objects the establishment of full, and the prevention of failure of, compensation (vide Chronic Valvular Disease). Over-hypertrophy, as indicated by certain cerebral and thoracic symptoms, may result from the exercise of improper notions respecting the treatment of the causative lesions and of organic disease of the heart in particular. It requires careful dietetic and hygienic manage- ment rather than therapeutic activity. Briefly, the diet should be nutritious, but the more concentrated forms of food should be used very sparingly, and the daily quantity should be slightly less than that re- quired in health. It must be non-stimulating, and tea, coffee, alcohol in all forms, and smoking must be prohibited. The physical exercise should be moderate in amount and of the gentlest sort, and if the patient's occupation tends to stimulate the heart, it must be immediately abandoned. A mild saline purge (3ij to 3ss—8.0 to 16.0—of Rochelle salts once daily) is quite beneficial. For the relief of the symptoms referring to the head (tinnitus aurium, vertigo, fulness) and to the precordia (\veight and discomfort) arterial relaxants are the best, particularly wlien arterio-sclerosis is causing car- diac overstrain. Among them nitroglycerin in full doses and veratrum viride are most useful, though the efficacy of both may often be enhanced by the addition of the bromids. In cases of nervous origin the bro- mids, Avith preparations of valerian, are the most valuable agents. Nothing, however, is of higher importance than the determination and removal of the cause when possible. After compensation has failed the further treatment is identical Avith that of cardiac dilatation. DILATATION OF THE HEART. 643 DILATATION OF THE HEART. Definition.—By dilatation of the heart is meant an enlargement of its various cavities. The Avails of the chambers may in consequence be thinner than in health, but much more commonly they are thicker, as in dilatation with hypertrophy. Both hypertrophy and dilatation are rela- tive terms, but the latter has reference to that condition in which the cavities are distended out of proportion to the diameter of their Avails. Varieties.—(1) Dilatation with Hypertrophy.—Here there is a pro- gressive increase in the capacity of the chambers until they attain to large dimensions. The cardiac walls continue of abnormal thickness, yet the vigor of the divisions affected may be relatively diminished to a remarkable degree, OAving to the weakening influence of the degenerative processes that attack the hypertrophied muscles. In eccentric hyper- trophy the heart-cavities are dilated, but the hypertrophied cardiac walls are sufficiently vigorous to meet the demands of the circulation. This condition should not be regarded as identical Avith dilatation with hyper- trophy, but frequently merges into the latter, the size of the cavities now being proportionately greater than is the thickness or the functional power of their walls. (2) Dilatation with Thinning of the Heart-walls.—The diminution in the diameter of the cardiac muscles may be slight if the capacity of the chambers involved be only moderately increased. Instances of this sort are sometimes seen to folloAv prolonged fever (typhoid). On the other hand, the process of attenuation may reach a high grade, the greatly thinned cardiac wall being scarcely capable of holding the weight of the contained blood. (3) Dilatation with little or no variation from the normal cardiac wall has also been described by some authors. It is to be observed, however, that stretching of a cavity whose walls are normal must be attended with thinning of those walls, unless there has been pre-existing hypertrophy. Pathology.—Dilatation with hypertrophy is generally secondary to valve-lesions, and affects more than one cavity as a rule. It may happen, as in advanced aortic regurgitation, that all the divisions are dilated. The right ventricle is someAvhat more frequently dilated than the left, however, for reasons previously adduced. The auricles (espe- cially the left) are more frequently expanded than the ventricles ; hence of all the chambers the left ventricle is least apt to dilate. The extent of the relative increase in the capacity of the cavities is variable, and often remarkable. As an example of extreme dilatation of a chamber, the left auricle in cases of mitral stenosis may be singled out; I have seen an instance in which this auricle Avas capable of containing twenty- two ounces of blood. The septum may be seen to bulge Avhen one ven- tricle only is stretched. Extensive dilatation of the chambers produces a dilated condition of the auriculo-ventricular rings, Avhich in turn gives rise to relative incompetency. Other cardiac orifices are found to be similarly dilated. Dombrowskil has drawn attention to the fact, first pointed out by Wolf, that the surface of the mitral leaflets greatly ex- ceeds the orifice, and Kirschner and Garcin contend that the anterior 1" Functional Insufficiency of the Valves of the Left Heart," Revue de Medecine, Sept. 10,1893. 644 DISEASES OF THE CIRCULATORY SYSTEM. flap alone suffices to close the mitral orifice, " even when the left heart is considerably dilated." Dombrowski believes that functional incom- petency is due, in many cases, "to muscular dilatation, producing a separation of the insertions of the papillary muscles, which in systole cannot approach each other near enough to allow the valves to close, the contraction of the papillary muscles only increasing the difficulty." Great dilatation of the left auriculo-ventricular ring is, however, prob- ably an important factor in the causation of relative mitral incompetency. The tricuspid valves, being scarcely competent to cover the correspond- ing orifice normally, are unquestionably incompetent when that orifice is considerably dilated. The shape of the heart is altered according to the seat and extent of the dilatation. When all the cavities are dilated the organ assumes a globular form, while dilatation of the ventricles only produces broaden- ing of the apical region. Condition of the Endocardium and Cardiac Muscle.—The muscular tissue generally exhibits degenerations (fibroid, fatty, or parenchyma- tous), but in some cases even microscopic changes are entirely Avanting. Important as is the part played by the ganglia in maintaining the nu- tritive integrity of the heart by supplying nervous force, our knowledge of the alterations that may occur in them in this condition is as yet very imperfect. Ott and others have, however, found them to be degenerated. Opacity and patchy roughening of the endocardium are common. Etiology.—Entering into the causation of cardiac dilatation, there are two essential factors: (1) increased endocardial tension; (2) dimin- ished resistance, due to weakened cardial Avails. Each of these may be the sole cause, though more often they act together. (1) Increased Endocardial Tension.—It is to be premised that a pri- mary and a secondary form occur, the latter being of greater importance clinically than the former. - Primary dilatation occurs from a recent ob- struction to the circulation of considerable magnitude and at any point throughout the blood-vessel system. A good example is afforded by aortic constriction, in which condition the obstruction of the aortic ring engenders dilatation of the left ventricle by raising the intraventricular pressure ; this is, hoAvever, quickly overcome by compensatory hyper- trophy. In the vast majority of these instances, after a long interval of perfect compensation, a nutritive break-down takes place, with ensu- ing secondary dilatation. Other causes of augmented endocardial pressure have been considered in the discussion of Hypertrophy and Chronic Valvular Lesions. In eccentric hypertrophy both dilatation and hypertrophy go hand in hand, until finally the cardiac nutritive funtions fail and dilatation at once predominates (dilatation with hypertrophy). Compensation has now been ruptured. Among the exciting factors that may precipitate this accident may be briefly stated—recurrent endocarditis, intercurrent febrile affections which over-stimulate the heart and tend to impair its muscular tissue, general disturbances of nutrition, and, lastly, physical and mental overstrain. Acute primary dilatation may be brought about by sudden, great ex- ertion, as in ascending mountainous elevations. Under these circum- stances the heart palpitates violently, there is epigastric pulsation, and DILATATION OF THE HEART. £45 often pain in the cardiac region—evidences of dilatation of the right ventricle. Although in these cases the heart's reserve capacity for work has been exceeded, rest and then quite moderate exercise often restore the conditions to the normal. I have seen acute primary dilatation produced b.y strong emotion; in such cases sudden contraction of the peripheral vessels occurs, attended Avith arrest of the heart's action; this soon gives place to violent palpitation and rarely to dilatation. Sudden fright may also, by inducing organic changes, cause acute dilatation. The remarkable endurance of the athlete and the gymnast is in part OAving to the abnormal amount of physiologic cardiac reserve force Avhich they naturally possess, but it is mainly due to the invigorating effect of training. If, hoAvever, the training be not so conducted as to symmetrically develop the entire muscular system, or if the exertion be in excess of the reserve functional poAver of the heart, then acute dila- tation may suddenly arise. From this accident recovery may, after a time, take place ; sometimes, however, it initiates organic valvular dis- ease, and thus prohibits the further undertaking of unusual feats. The cardiac muscle may be impaired by pericardial adhesions from the ex- tension of fibrous overgroAvth to the adjacent myocardium. Apparently idiopathic cases of cardiac dilatation of indeterminate etiology rarely occur. (2) Diminished Resistance owing to Weakened Cardiac Walls.—The occurrences that wreaken the cardiac Avail are numerous, and not a few lead to acute primary dilatation, such as myocarditis due to acute specific fevers (scarlatina, typhoid, typhus). It is especially prone to occur in rheumatic endocarditis and pericarditis. The chronic degen- erations (fatty, fibroid) impair the contractile poAver of the heart. Nu- tritional disturbances of varied origin may induce enfeeblement of the cardiac muscle, such as digestive disorders, ill-ventilation, lack of open- air exercise, and improper or defective food-supply. Dilatation is met with also in diseases of the blood (chlorosis, anemia, leukemia). Clinical History.—In acute dilatation the onset is sudden. It is accompanied by such symptoms as dyspnea and cardiac palpitation (both speedily becoming aggravated), and frequently by pain in the precordial region. The physical signs may be incontestable. They are venous pulsation in the neck, a rapid, feeble apex-beat, and a systolic murmur at the tri- cuspid valves, all of which declare the presence of tricuspid regurgitation. Among signs of subsidiary value are a venous turgescence, a marked epigastric pulsation, and a sudden extension of dulness to the right; the pulse is small, irregular, and exceedingly rapid. In the more chronic form, which arises from slowly-acting causes, or in that which accompanies eccentric hypertrophy or folloAvs simple hypertrophy due to left-sided heart- or lung-trouble, the manifestations that characterize the earliest stage are not at all striking. They indicate weak heart-walls, and such chambers are soon unable to expel their contents during systole. Hence with each subsequent diastole the abnormal amount of blood contained in them is increased. From these facts it is readily seen that the essen- tial causal conditions—increased endocardial pressure and weakened heart-walls—are present and active in facilitating the process of dilata- tion, once it has commenced. This blood-stasis, as previously pointed 646 DISEASES OF THE CIRCULATORY SYSTEM. out, often extends from the left heart to the pulmonary vessels, from the latter to the right heart, and finally to the general venous system. Both in the acute and chronic forms, however, failure of the right ventricle more often constitutes or determines rupture of compensation and is the harbinger of serious symptoms. Obviously, the symptoms must be those described as belonging to organic diseases of the heart (tricuspid incom- petency, in particular). Physical Signs.—Inspection in dilatation of the left ventricle shows a diffuse, weak, fluttering, and often a distinctly undulating impulse. The apex-beat will show a greatly diminished vigor in its normal area, or there may be no recognizable area of strongest impulse, as in health. Distinct pulsation in the second left interspace is not rare, and is of ventricular origin. Its feebleness and diffuse character are confirmed by palpation. It may be quick and sharp, though always lacking in power. Walsh first made the capital observation—since abundantly corroborated—that the impulse may be visible, yet not palpable. There may be an utter absence of the apex-beat in marked cases. The pulse is small, often rapid, and lacks regularity. Percussion shows a lateral increase in dulness to the left, to or even beyond the mid-clavicular line, upward to the second rib, and downward as far as, though rarely below, the sixth interspace, except perhaps, in rare instances, in dilatation with hypertrophy. The lungs in emphysema may to a great extent overlap the heart, with a corresponding diminution in the area of dulness. Dilatation of the right ventricle demands separate consideration so far as the impulse and percussion-dulness are concerned. The normal impulse is largely replaced by the abnormal apex-beat of the right ven- tricle, Avhich advances to the anterior chest-wall. The chief impulse is now seen and feebly felt, as a rule, below the xiphoid cartilage, or, less commonly, to the right or left of the latter. A wavy pulsation is seen to the left of the sternum, over the fourth, fifth, and sixth interspaces and close to its right edge. If dilatation of the right auricle be asso- ciated, as is often the case, a distinct pulsation also occurs in the third right interspace. Dulness reaches to a point 1 inch (2.5 cm.) or more beyond the right sternal border on a level with the fourth interspace. If both ventricles are extensively dilated, dulness extends bilaterally in a transverse direction. On auscultation variable results are obtained according to the state and diameter of the cardiac walls. When thin and not much disorgan- ized, the first sound is much shorter, sharper, and more ringing than in health. In advanced cases the systolic sounds may be feeble and indef- inite, and sometimes the first closely resembles the second sound, the long pause being shortened (fetal heart-sounds). The canter rhythm, however, is more common. Irregular and intermittent cardiac action are usual phenomena. The abnormal conditions of the tAvo ventricles often differ, or either ventricle may be implicated alone. Hence sounds may differ in intensity. Reduplication may occur, but is not frequent. Pre-existing organic murmurs obscure the sounds due to dilatation, and, on the other hand, the dilatation may also alter the murmurs (pre- viously audible), and even cause them to disappear, as, for example, in mitral stenosis. Again, dilatation may induce relative incompetency or superadd a murmur, as in cases of chronic valvular disease at the auriculo- DILATATION OF THE HEART. 647 ventricular orifices. It is interesting to recall here that proper treat- ment may remove a murmur due to relative insufficiency, and that this treatment may, in turn, reproduce an organic murmur. Diagnosis.—This is made readily when there is obtainable a clear history, together with the following characteristic features : a weak, irreg- ular heart-action ; an extended, wavy impulse; a small, vigorless, irreg- ular, and intermittent pulse; often an indistinct apex-beat; an outward, upAvard increase in the percussion-dulness on one or both sides, causing the outline to resemble a square; and a brief, sharp, yet feeble first sound that strikingly resembles the second, which is itself enfeebled. Differential Diagnosis.—Hypertrophy, like dilatation, gives rise to an extended area of impulse and of percussion-dulness; hence by the care- less observer these conditions are sometimes sadly confounded. From dilatations, where the diagnosis rests upon the points above enumerated, hypertrophy is to be distinguished by symptoms of an opposite nature, such as indicate increased vigor on the part of the heart. The latter are—a slow, heaving impulse; a slow, full, regular pulse; an increase in the area of dulness, chiefly outward and downward; abnormal position of the apex-beat; and the prolonged, dull first and accentuated second sounds. To determine the point at Avhich eccentric hypertrophy ends and dilatation (with hypertrophy) begins is often difficult, but a careful discrimination must be attempted, and I have already discussed the ushering-in symptoms of dilatation following hypertrophy (chiefly of the right ventricle) in connection Avith Chronic Valvular Disease. Oc- curring in left ventricular hypertrophy, dilatation first betrays itself by a change in the position of the visible apex-beat and the impulse on pal- pation. Thus, the maximum point of the apex-beat of hypertrophy very early becomes rounded and indefinite, and later is diffuse and wavy. Its strong, long-drawn, heaving, yet well-defined impulse gives place to the shorter, more sudden shock of commencing dilatation, indicating weakness. These signs, together with a reduction in the strength and an increased frequency or irregularity of the pulse, show the condition to be dilatation with hypertrophy. The prognosis is bad, as a rule, though it may depend upon the causative factors in numerous instances. Treatment.—This in all essential particulars is identical with the treatment of organic heart-affections after rupture of compensation. The etiology in many cases differs from that of the organic valvular affections of the heart, since, next to rest and cardiac stimulants, the removal of the remote and near causes of the dilatation is the most important part of the treatment. Individual cases frequently present special indications, hoAvever, and these must be met according to the usual principles, which may be found in appropriate sections of this work. In cases of non-val- vular origin digitalis and other heart-stimulants may be omitted, though they should be promptly employed if demanded by a recurrence of the symptoms indicating dilatation. When the dilatation has been over- come, careful attention is to be bestoAved upon all the details of the patient's life and sanitary surroundings in order to force his bodily nutrition to the highest point. Every precautionary measure having for its aim the prevention of a recurrence of the dilatation must also be enjoined. 618 DISEASES OF THE CIRCULATORY SYSTEM. MYOCARDITIS. (Carditis.) Definition.—An inflammation of the muscle-substance of the heart. It may be acute or chronic. ACUTE MYOCARDITIS. Pathology and Varieties.—(1) Acute Parenchymatous Myocarditis. —This is characterized by a granular degeneration of the muscular fibers of the parenchyma of the organ, with a numerical increase in their nu- clei. The muscle-structure throughout looks pale, is turbid, and very soft. Many cases of a severe type terminate in fatty degeneration. (2) Acute Diffuse Interstitial Myocarditis.—Here the primary altera- tions affect the connective tissue of the myocardium; the histologic changes consist in round-cell infiltration. (3) Acute Circumscribed Myocarditis.—In this variety the degenerative processes result in necrosis of the tissues over large or small areas, with abscess-formation. Though usually multiple, these abscesses vary con- siderably in number, and may rupture either into the various cardiac chambers or into the pericardium. Thus, the purulent contents of the abscess, when there is established a fistulous communication Avith an endocardial chamber, find their way into the blood-stream and are con- veyed to all parts of the arterial system, frequently setting up, here and there, embolic processes of an infectious nature. The blood in turn enters the abscess-cavity, exerting pressure on the Avails, and may either produce an acute aneurysmal dilatation of the heart-wall or occasion fatal rupture into the pericardium. More frequently, perhaps, the con- nective-tissue wall of the abscess yields gradually during the ventricular diastole, when the cardiac aneurysm is formed with corresponding sIoav- ness. Occurring in the vicinity of one of the auriculo-ventricular valves, abscesses may cause mitral or tricuspid incompetency. Owing to their tendency to burrow, they may perforate the interventricular septum, thus creating a fistulous connection between the tAvo sides of the heart, and resulting in an intermingling of venous and arterial blood. The abscess may become encysted, then caseous, and finally undergoes a calcareous process. Etiology.—The causes of myocarditis are—(a) endo- and pericar- ditis in the course of rheumatism: it is probable that rheumatic myo- carditis may also exist Avithout involvement of the endo- or pericardium; (b) the infectious processes in acute specific fevers; (c) infectious emboli, lodging in the branches of the coronary arteries in connection with sep- ticemia, pyemia, and acute ulcerative endocarditis, and commonly termi- nating in abscesses (circumscribed myocarditis). The first two of these causes give rise to acute diffuse interstitial and acute parenchymatous myocarditis as a rule. As compared with the female sex, the male suffers much more frequently. Symptoms and Diagnosis.—The symptoms are practically nega- tive. They point to great cardiac enfeeblement, but do not furnish any information beyond exciting a suspicion as to the true nature of the CHRONIC MYOCARDITIS. 649 attack. When cardiac weakness, as shown by a rapid, small, compres- sible, and irregular pulse, and by attacks of cardiac palpitation and syncope, comes on suddenly in the course of rheumatism, septicemia, or other causal affections, myocarditis may be suspected. Later, signs of venous stasis appear. The physical signs simulate those of dilatation, and may, indeed, be largely dependent upon the presence of the latter condition. Early the action of the heart is tumultuous; the sounds on auscultation are short, sharp, and finally very feeble. Murmurs in myocarditis are not rare, and are not necessarily dependent upon dilatation. Kiehl's work shows the dependence of the valves for their complete closure upon a normal state of the different portions of the heart-muscles, and thus explains these murmurs. Their great variability as to presence or absence is an important point, especially in the diagnosis from murmurs due to endo- cardial changes. The latter usually coexist with an accentuated pul- monary second sound, Avhile the myocardial murmurs usually do not appear, owing to weakness of the right heart. The special conditions rendering the murmurs audible are great dilatation, softening of the papillary muscle, and abscesses near the valves. The recognition of cardiac aneurysm is made possible by the manner of increase in the percussion-dulness (upward and toAvard the left) with coextensive pulsation. The symptoms of visceral or cutaneous embolic processes, especially when corroborated by the simultaneous development of a murmur and a septic type of fever, should excite strong suspicion of the existence of circumscribed myocarditis. Prognosis.—The diffuse forms are fatal; the circumscribed form may, however, end in recovery. Myocarditis may terminate life sud- denly if violent or even active exertion be made. The treatment is identical with that indicated for endocarditis and pericarditis—diseases of which myocarditis is often a complication. The effects of digitalis, particularly when myocarditis supervenes upon old heart-lesions, are quite unsatisfactory. When myocarditis is suspected as an independent condition, absolute rest must be enjoined, the general nutrition energetically maintained, and the more urgent symptoms relieved. CHRONIC MYOCARDITIS. [Fibrous Myocarditis.) Definition.—A gradually developing inflammation of the cardiac interstitial connective tissue, resulting in induration. Pathology.—The characteristic changes may be diffuse, though most frequently they are confined to certain portions of the muscular structure, the left ventricular wall, the septum, and the papillary muscles being the three favorite seats of the process. This is sometimes of ante- natal development, and then its usual seat is near the apex of the right ventricle. The hardened spots take the form of more or less rounded patches or broad lines. In color they are gray, grayish-white, or gray- ish-yellowy the latter tint being due to the intermingling of fibers that have undergone fatty degeneration. Their size is exceedingly variable, some being so minute as to elude detection by the unaided eye, while others measure 1 or 2 inches (2.5-5 cm.) in diameter. Inflamma- 650 DISEASES OF THE CIRCULATORY SYSTEM. tory induration (contraction) of the conus arteriosus of either ventricle causes narrowing of the pulmonary and aortic orifices, with the usual signs and symptoms. Similar changes, by disturbing the functions of the papillary muscles, produce valvular incompetency. Compensatory hypertrophy of the uninvolved portion of the heart is also observed, both the size and weight of the organ thus being increased; the hyper- trophic enlargement may frequently be accounted for in part by an associated chronic endocarditis. Sometimes, however, the hypertrophy is occasioned in great measure by general arterial sclerosis. Dilatation of the ventricles folloAVS soon or late, with fresh and grave disturbances of the circulation. Chronic inflammation usually attacks early the intima of the coro- nary arteries, and leads to thrombosis, with the formation of anemic infarcts that subsequently undergo sclerotic changes in the muscle- structure. It is probable that most cases of localized fibrous myocar- ditis have their origin in an obliterating endarteritis. The calloused zone may yield to the endocardial blood-tension, and thus slowly pro- duce saccular dilatation (aneurysm). Microscopically, the affection is characterized by hyperplasia of the interfibrillar connective tissue with subsequent development of neAv fibrous tissue. Fatty degeneration and atrophy of the muscle-fibers (the latter in consequence of compression by the fibroid degenerated tissue) are also observed. Fragmentation of the muscle-fibers has also been observed. This occurs as a postmortem change, and is due to a softening of the interfibrillar substance (the etat sSgmentaire of Renant). Ktiology.—The disease is most commonly traceable to the action of one or more of the following factors: an excess in the use of alcohol or tobacco, lead-poisoning, gout, rheumatism, diabetes, chronic nephritis, malaria, and syphilis. Thus, it may be produced by many infections and chemical irritants, the latter, in most cases, first causing a sclerosis of the coronary arteries, to which the patchy fibroid degeneration is secondary. Some of the causes of acute diffuse interstitial myocarditis may by their more slightly irritant effect (owing to the minuteness of the dose of the specific poison) lead to the subsequent development of the general chronic form (e. g. rheumatism). Certain irritants that usu- ally engender localized lesions of chronic myocarditis may also affect, though less frequently, the entire myocardium, such as syphilis, alcohol, and gout. Chronic myocarditis may also arise in consequence of a direct extension of the infective inflammatory processes in chronic endo- and pericarditis. It may also follow injuries of the antero-lateral tho- racic region. Sex and age possess a predisposing effect, the disease being more common in males than in females, and after middle life than before that period. The right ventricle is apt to be the seat of chronic myocarditis during fetal life, if at all. Symptoms.—Extensive indurated myocarditis has been met with postmortem in numerous instances that have been unattended by per- ceptible symptoms during life. In many of these cases the presence of compensatory hypertrophy accounts for the absence of any symptoms, and it may, therefore, be inferred that mild grades that fail to manifest themselves must frequently exist. The symptoms when present are, almost without exception, untrustAvorthy for diagnostic purposes, since CHRONIC MYOCARDITIS. 651 they bear a striking resemblance to those of the organic valvular dis- eases, minus their more characteristic physical signs. Among the earliest phenomena that point merely to failing heart-poAver are dys- pnea, and sometimes also, on exertion, palpitation and a sense of heavi- ness or constriction in the precordia. The patient suffers from marked general debility, and becomes fatigued in consequence of the slightest physical exertion. Mental inertia is the rule, and chronic mania may come on and last to the close. Later, more positive disturbances of the circulation gradually arise, and Avhen the breathing becomes more diffi- cult (cardiac asthma) signs of venous stasis affecting the liver, gastro- intestinal tract, and kidneys, and edema finally appear. Two symptoms that are frequently manifested, and not without some diagnostic import, remain to be mentioned: (1) Angina pectoris, Avhich is attributable to the sclerosed condition of the coronary arteries. It occurs in the form of paroxysms of severe pain in the cardiac area, that shoot into the back and doAvn the left arm, accompanied by great anxiety of mind, an anxious countenance, moderate dyspnea, marked precordial pressure, and a feeling of constraint. It is often followed by some form of arrhythmia. Cases occasionally occur in Avhich recurring paroxysms of angina pectoris, Avith or Avithout arrhythmia, are the only phenomena of the disease. (2) Cardiac Arrhythmia.—Brachycardia is associated as a rule, there being a reduction in the pulse-rate to 50 or even 40 beats per minute. With this decreased rate intermittency is often combined, and various other forms of disturbed rhythm are also observed, though they are less frequent and less significant. SloAving of the pulse does not, hoAvever, prohibit the cardiac palpitation that is especially apt to arise during anginal attacks. Disturbance of the rhythm may, on the other hand, be entirely absent. The pulse is slow, irregular, and of Ioav tension if cardiac atrophy be present. Should fatty degeneration be conjoined, the pulse Avill be quickened and irregular, and this effect likeAvise obtains when the patient escapes sudden death and the usual dilatation supervenes. Chronic myocarditis may be the sole cause of the pseudo-apoplectic seizures that often terminate life abruptly. Preceding the unexpected attack the patient, usually advanced in life, may have experienced from time to time slight vertigo, syncope, and oppression. These seizures may also be caused by a heavy meal or intense mental or physical exertion, and may consist in a momentary loss of consciousness, paralytic symp- toms then being usually absent. At other times they last a number of hours, and are accompanied by paralysis which outlasts the coma, as a rule, by a feAV hours only. Convulsive tAvitchings may be present. During the attack cerebral hemorrhage occurs, and may leave the patient hemiplegic. It is highly characteristic of these pseudo-apoplectic seiz- ures that they tend to recur, sometimes at intervals of a feAv hours for a day or two, but more frequently at longer intervals during many weeks or months. Physical Signs.—The impulse may be feebly heaving (sometimes ab- sent) ; the apex-beat is displaced downward and to the left, Avhile the dull area is enlarged correspondingly in the same direction. Quite early the heart-sounds may be clear and strong, but subsequently they 652 DISEASES OF THE CIRCULATORY SYSTEM. become weak and muffled. A contraction of the papillary muscles and of the chordae tendineae may cause mitral incompetency with its customary murmur. With the occurrence of dilatation also comes an apical, systolic mur- mur (due to relative incompetency), with a gallop rhythm of the heart. Differential Diagnosis.—(1) Chronic valvular disease can, as a rule, be eliminated prior to the occurrence of secondary dilatation. During this period murmurs do not occur unless the valvular adnexa (the chordae and papillary muscles) are affected. In the latter event the secondary alterations in the heart, the symptoms, and whole course of the complaint are the same as in certain chronic valvular lesions. (2) Hypertrophy and Dilatation.—In chronic myocarditis hyper- trophy does not usually reach as high a grade of development as in the majority of the organic valvular complaints and other causal conditions. But after the occurrence of dilatation, following indurated myocarditis, the differential diagnosis between the latter and eccentric hypertrophy is purely conjectural. (3) Fatty overgrowth must be distinguished from fibrous myocarditis, and is met with chiefly in brewers, publicans, and butlers. The disease is also found to be specially related to obesity, and sometimes to over- eating and drinking, combined with indolent habits. These subjects suffer more frequently from bronchitis, emphysema, and nocturnal asthma than patients having chronic myocarditis alone. Slight vertigo is com- mon, but true syncopal attacks are rare, according to my observation. In fatty overgroAvth the heart-sounds are weak and decidedly muffled throughout; the pulse is weak, though regular as a rule. Marked obesity, however, often obscures the local signs. The prognosis is grave, chronic myocarditis being a fatal disease. Its course and duration, however, are subject to great variations. Among unfavorable surroundings are certain causal and associated conditions, particularly arterio-sclerosis, chronic interstitial nephritis, and diabetes mellitus. On the other hand, if syphilis has been the cause, hope for temporary improvement, if not for actual cure, may be reasonably entertained. Treatment.—The treatment should be managed according to the considerations pointed out in the treatment of Organic Valvular Dis- ease. Rest of body and mind is imperative. Next to this come the dietetic and hygienic details. Residence in a mild climate in winter and a change to the country or to a moderate elevation in summer are matters of the greatest moment to the Avelfare of the patient. Those rather frequent cases that present, among other complications, such closely united conditions as arterio-sclerosis, gout, and chronic nephritis sometimes do well while sojourning at certain mineral springs, such as Marienbad, Carlsbad, Kissengen abroad, and Bedford or Saratoga at home. These waters must, however, be cautiously used. When dilatation arises cardiac stimulants are called for, but must be used with an unusual degree of caution. Strychnin has proved itself to be valuable if perseveringly exhibited, and here, as elsewhere, digi- talis deserves a trial; its careless administration, hoAvever, may give bad results if the pulse be much retarded or arterio-sclerosis coexist. For the angina pectoris morphin, administered hypodermically, is to be pre- DISEASES OF THE CORONARY ARTERIES. 653 ferred. Recurrences of this distressing symptom may be averted by the cautious use of nitroglycerin, the use of Avhich should, however, be limited to cases that seem to be dependent upon arterial degeneration with high tension. Attacks of syncope are most successfully met by the hypodermic use of the diffusible stimulants (ammonia, ether), and at the same time by putting the patient at rest with the head loAvered. DISEASES OP THE CORONARY ARTERIES. It has previously been noted that in pyemia and allied disorders septic emboli may block the branches of the coronary arteries, causing suppurative infarcts (acute circumscribed myocarditis). It has also been shown that one of the chief effects of sclerosis affect- ing the coronary arteries is the production of chronic myocarditis. The fact that the sudden blocking of one coronary artery by an embolus causes instant death should also be emphasized. In numerous instances in which death has occurred suddenly either thrombotic or embolic obstruction has been the only discoverable postmortem lesion. In others the pathologic evidences of local or general atheroma have coex- isted. There is at hand much experimental testimony tending to show that ligation or plugging of the coronary vessels in the lower animals causes arrhythmia or even an abrupt arrest of cardiac action; a partial or even slight reduction in the lumen of the coronary vessels by diminish- ing the supply of blood to the heart-muscle induces degenerations in the latter. In this connection the anatomic peculiarity of the coronary arteries in that they are end-arteries is to be noted, since it affords a ready interpretation of the notable effects following total or partial occlusion. The blocking of the terminal branches by emboli or by the more gradual formation of thrombi produces the so-called anemic necrosis or white infarct—a condition that richly deserves brief description : Anemic necrosis (anemic infarct) is met with most frequently in the left ventricle and septum, which receive their blood from the ante- rior coronary artery. The involved areas are small and circumscribed, and present irregular margins that project slightly above the surface. Rarely the infarct is wedge-shaped. Its color is grayish-white or gray- ish-red, while the central portion is often distinctly white and firm; less frequently it breaks down into a soft detrital mass (myomalacia cordis). When softening does not occur the fibers in the affected area lose their nuclei, becoming first hyaline and subsequently sclerotic. The chief histologic changes are of two sorts: (a) the striae of the muscle-fibers are lost, the latter becoming granular and breaking down; and (b) the fibers assume a homogeneous hyaline appearance, the nuclei having dis- appeared. The symptomatic consequences of the lesions are often obscure and unreliable. Sudden death may take place, and rarely this accident may be due to rupture of the heart. Weak and irregular action of the heart, evidences of embarrassed circulation (especially in the cardio- 654 DISEASES OF THE CIRCULATORY SYSTEM. pulmonary area, as shown by cough and dyspnea), and finally angina pectoris, are among the chief features observed. Death may ensue in the first attack, but more often the patient survives the first and has repeated subsequent seizures. The paroxysms are presumed to be due to sudden occlusion of a branch of the coronary artery, but it should be stated that occasionally in fatal instances of true angina pectoris a total absence of lesions, including emboli, has been noted. DEGENERATIONS OP THE HEART. (a) Fatty.—The term " fatty heart " includes tAvo pathologically dis- tinct affections: (1) Fatty degeneration, in AAThich the cardiac muscle- fibers have been converted into fat; and (2) Fatty overgrowth, in which an abnormal quantity of fat is deposited in and about the heart. FATTY DEGENERATION. Pathology.—The condition may be either general or localized. Its most frequent seat is in the left ventricle, the papillary muscles and trabeculae, first appearing as yelloAvish spots or stripes beneath the en- docardium. The affected portions are light yellow or yellowish-brown (faded leaf) in color, due to an associated broAvn atrophy; they are also soft and friable, and are easily lacerated. The heart is enlarged, and often decidedly so if the process be general, and its Avails lack firmness. The microscope reveals characteristic changes: the striae and nuclei begin to fade, oil-drops and granules appear in the fibers, and finally the latter are occupied throughout by minute globules. Etiology.—Fatty degeneration has already been mentioned as occurring in both the primary and secondary forms of cardiac hyper- trophy. It is found also in association Avith fatty change in other organs in severe forms of primary and secondary anemias. It is most commonly encountered, hoAvever, in the cachectic states produced by such chronic diseases as carcinoma and phthisis, and in the course of acute infectious diseases of intense type, all of Avhich may produce the condition. In poisoning by arsenic and phosphorus and in pernicious anemia it advances to a high grade. The various lesions of the coronary arteries previously considered bear a special causal relation. Predisposing causes are—(a) age—it being most common after forty years of age; (b) sex—it occurs someAvhat more frequently in men than in women, notwithstanding the fact that there are predisposing influ- ences at work in the latter that do not obtain in the male sex, such as childbirth and amenorrhea; and, lastly, (c) Avhatever may be its apparent etiology, it is invariably preceded by a defective nutritive supply to the muscle-cells: this may be dependent on mechanical causes, such as narrowing of the lumen of the coronary vessels, or upon impairment of the oxygen-carrying poAver of the blood, as in the anemias. Symptoms.—The disease may exist in an athanced form without FATTY DEGENERATION OF THE HEART. 655 noticeable symptoms, though the conditions under Avhich it is most liable to occur often afford premises for suspicions; only rarely is anything more tangible offered than this. The evidences of cardiac enfeeblement are usually present, but in pernicious anemia the pulse may*even be full and regular. Dilatation is apt to supervene early, OAving to the Aveakened state of the heart; and hence it is probable that many of the symptoms that have been ascribed to the fatty change are in reality due to secondary dilatation. Among these are palpitation, dyspnea, a small, irregular, and somewhat quickened pulse, and cool and clammy extremities. The heart-sounds are weak, as a rule, and the action of the heart often irregular; later the physical signs of dilatation are almost invariably present, and, as a rule, are progressively intensified. Sometimes sud- den, great physical exertion produces equally sudden dilatation, where- upon a canter rhythm and an apical systolic murmur speedily develop. In most instances, hoAvever, the symptoms are more gradually brought to light. Breathlessness on exertion is often a striking feature, and syn- copal attacks are sometimes troublesome. The pulse, in consequence of irritation of the inhibitory center in the medulla, often becomes greatly retarded, dropping from the normal rate to 30 or 40 beats per minute, and, in rare cases, to 10 or 12 beats. The fatty arcus senilis is devoid of diagnostic value. There are frequent attacks of cardiac asthma in the mornings, and these are apt to be accompanied at intervals by angina pectoris. Disturbances of the intellect, sometimes taking the form of maniacal delusions, may come on and persist for Aveeks or even months. Pseudo-apoplectic attacks, such as have been described in connection Avith Chronic Myocarditis, are also concomitants that point to dis- turbance of the cerebral circulation. Cheyne-Stokes breathing is among the later manifestations, and I have noticed that these symptoms often occur together, rather than separately, in a given case. The diagnosis is sadly obscure. The history (of the utmost im- portance), the age of the patient, and the symptoms of cardiac Aveakness and subsequent dilatation, together Avith retardation of the pulse, apo- plectic attacks, and Cheyne-Stokes breathing, in the absence of prece- dent hypertrophy merely justify a probable diagnosis. With a clear history and the presence of the more significant symptoms, including the signs of dilatation following hypertrophy, fatty changes may be inferred with some degree of assurance, and yet even this state of affairs should not lead to a positive statement of opinion. The prognosis is as varied as the etiology. Death may come quickly, though oftener the end is reached in a gradual manner, the signs and symptoms of advanced dilatation closing the scene. Treatment.—The cause in each individual case should be deter- mined Avith as much precision as possible, and when ascertained a bold attempt should be made to remove it. This course often places the patient in the most favorable position for the successful treatment of the cardiac condition; and the method embraces many hygienic and dietetic considerations that assist in improving the nutrition of the cardiac tissue—one of the cardinal aims of a proper system of treatment. An- emia in one form or other plays an important role in the majority of the cases, and the particular variety present in each instance must deter- 656 DISEASES OF THE CIRCULATORY SYSTEM. mine the character of the remedies to be employed. In that large cate- gory of cases occurring in certain cachexias (cancerous, tuberculous) the following formula has given gratifying results: B/. Acidi arsenosi, gr. j (0.0648); Ferri sulph. exsic, gr. xxx (2.0); Strychnines sulph., gr. j (0.0648); Quininae sulph., 3j (4-0); Papoid, gr. xxx (2.0). M. et ft. capsulae No. xxx. Sig. One after meal-time, t. i. d. A frequent, irregular pulse and other signs of cardiac failure indicate commencing dilatation, and under these circumstances digitalis should be employed in small doses. When used with perseverance it is of the greatest service in many cases of this sort, and in the form of the poAv- der or the aqueous extract it may be conveniently combined with the above prescription. For the treatment of the more serious evidences of failure of the circulation the reader is referred to the discussion of the organic valvular diseases. I believe that gentle indulgence in physical exercise and light gym- nastics is beneficial, since it tends to invigorate the heart-muscle; it is to be increased in proportion to the manifest improvement in the patient's condition. It sometimes happens, however, that even gentle exercise is badly borne, and it should then be discontinued. I have been in the habit of advising daily inhalations of oxygen gas in this class of cases with good results. Recourse to massage is also in the line of sound practice, but the sittings should not exceed half an hour in duration at the start. The more prominent symptoms may require special measures. The syncopal and anginal attacks are to be handled in the manner indicated for the same symptoms in chronic myocarditis. For the pseudo-apoplectic attacks rest in the recumbent posture, with the head slightly elevated, is useful. Therapeutic agents, as digitalis, ammonia, and ether, may be used hypodermically to stimulate the heart; it is also good practice to withdraw from 12 to 24 ounces (355.0-710.0) of blood directly from a vein. If the arteries be hard and tense, nitro- glycerin is of service. A strictly horizontal posture and the application of ice to the pre- cordial region often quickly terminate the attacks of cardiac asthma, and spartein sulphate, with nitroglycerin, is Avorthy of a trial. Hot toddy and other diffusible stimulants are valuable adjuvants. Should these remedies fail, hypodermic treatment by morphin is then to be adopted. FATTY OVERGROWTH. Pathology.—The characteristic change consists in a marked in- crease in the normal fat, particularly in the auriculo-ventricular fur- roAvs. This over-production of fat takes place to a greater or lesser extent in every obese person, and may become so excessive as to form a complete enveloping mantle measuring an inch or more in thickness. In these extreme grades the muscular fibers of the organ may, from too great pressure, undergo atrophy and thus become' Aveakened. Dilatation FATTY OVERGROWTH OF THE HEART. 657 often supervenes, and it is quite probable that in most cases the symp- toms, Avhen present, date from the time of its occurrence. In the ca- chexias of carcinoma and phthisis the general atrophy of old age, fatty overgrowth, and fatty degeneration coexist. The diagnosis rests upon the presence of marked obesity combined with cardiac enfeeblement. Treatment.—I wish to Avarmly advocate the system of treatment introduced by Oertel, as I have seen excellent results from its faithful employment. It should not be resorted to in chronic valvular disease, especially in cases that have passed into the stage of broken compen- sation, nor should it be used if the arteries are markedly atheromatous. Oertel's method comprises three parts: (1) The reduction of the amount of liquid taken Avith the meals and during the intervals, the total for each day being 36 ounces (1064.0). Frequent bathing (includ- ing the Turkish bath in suitable instances) and pilocarpin are employed to promote free diaphoresis. (2) The diet is composed largely of proteids, as follows: Morning.— A cup of coffee or tea, Avith a little milk—about 6 ounces (178.0) alto- gether; bread, 3 ounces (93.0). Noon.—Three to 4 ounces (90.0-120.0) of soup; 7 to 8 ounces (218.0- 248.0) of roast beef, veal, game, or poultry, salad or a light vegetable, a little fish; 1 ounce (32.0) of bread or farinaceous pudding; 3 to 6 ounces (93.0—186.0) of fruit for dessert. No liquids at this meal, as a rule, but in hot weather 6 ounces (178.0) of light Avine may be taken. Afternoon.—Six ounces (178.0) of coffee or tea, with as much water. An ounce of bread as an indulgence. Evening.—One or two soft-boiled eggs, 1 ounce (32.0) of bread, per- haps a small slice of cheese, salad, and fruit; 6 to 8 ounces (178.0- 236.0) of Avine, Avith 4 or 5 ounces (120.0-148.0) of water (Yeo). (3) Graduated exercise up inclines of various grades. The distance to be undertaken each day is to be carefully specified and frequently, though gradually, increased. A like plan is to be pursued with refer- ence to the degree of inclination. This is the most important part of the system, since it directly invigorates the heart-muscles. (b) Brown Atrophy.—A form of degeneration in which accumulations of yelloAvish-brown pigment-granules occur in the muscular fibers. The color exhibited by the heart-muscle is a reddish-broAvn, and in pro- nounced cases a dark-red broAvn. Brown atrophy is most commonly seen in the hearts of the aged, though also quite often in cases of chronic valvular disease that have reached an advanced period before the time of the fatal issue. (c) Calcareous Degeneration (Calcification).—Calcareous infiltration of the muscular fibers of the myocardium has been noted, though very rarely. SomeAvhat more common are the bony callosities that result from the inspissation and calcification of the purulent contents of former myocardial abscesses (vide Circumscribed Myocarditis). (d) Amyloid Degeneration.—This form of degeneration is rarely met with. It is limited to the blood-vessels and interstitial connective tis- sue, the muscular fibers escaping, and its causes are the same as those of amyloid degeneration of other viscera. 42 658 DISEASES OF THE CIRCULATORY SYSTEM. (e) Hyaline Degeneration.—This is sometimes seen in association with amyloid change. It also occurs independently in prolonged fevers (hyaline transformation of Zenker). The fibers are swollen, translu- cent, and homogeneous, and their striae almost entirely disappear. CARDIAC ANEURYSM. {Aneurysm of the Heart.) A cardiac aneurysm may, in the first place, involve the whole diameter of the myocardium (aneurysm of the Avails).1 Secondly, it may merely implicate the valves, together with a few myocardial fibers (valvular aneurysm). Aneurysm of the Walls.—This is not of frequent occurrence. Its most common seat, hoAvever, is the Avail of the left ventricle near the apex; it is quite generally a sequel to chronic myocarditis, Avhich, as before stated, occurs oftenest at this point. Anything that produces a decided localized weakness of the ventricular parietes (other forms of degeneration and endocardial and pericardial inflammations) may, hoAv- ever, lead to its development. In size cardiac aneurysms are exceed- ingly variable, and may either be very small, or as large as the average- sized head of an adult. As to form, two types should be recognized: (a) an equable dilatation of a part of the ventricular Avail, and (b) the sacculated form, which communicates Avith the chamber by a compar- atively small orifice. Layers of fibrin are often found in these aneur- ysmal dilatations as an indication of Nature's attempt at a cure, and occasionally they may completely efface the sac when the attempt is successful. In most aneurysms non-laminated blood-clots are also found. It must not be forgotten that, once an aneurysmal distention has begun, a straining effort may cause a sudden great increase of the dimensions or even rupture it. The structures adjacent to the gradu- ally formed aneurysm exhibit fibroid overgrowth and other kinds of degeneration, these changes being secondary and most probably con- servative processes. Diagnosis.—Aneurysm of the myocardium has no characteristic features. Usually the symptoms and local signs of chronic myocarditis or dilatation are more or less conspicuous, but the presence of the aneurysm is not even suspected unless certain physical signs develop in the course of the former complaints. These are—a pulsating prom- inence in the apex-region that may even perforate the chest-wall, and a coextensive dulness. The abnormal area of dulness is best appreciated early by stethoscopic percussion, but unless peculiarly circumscribed the condition cannot be distinguished from hypertrophy or dilatation. The course of these cases is unfavorable, death ensuing (rarely) from rupture of the sac or (more frequently) from gradual cardiac exhaustion. Valvular aneurysms sometimes arise in acute ulcerative endocarditis, which destroys the segmented endocardium and permits of dilatation as the result of the intracardial blood-pressure. They occur with much 1 Of 87 cases collected by Pelvet, 57 were in this situation, and of 90 collected by Legg, 59. RUPTURE OF THE HEART. 659 greater frequency on the aortic than on the mitral valves. They are spheroid in shape, and project into the left ventricle Avhen found at the aortic segments, and into the left auricle when at the mitral. Though usually single, they are multiple in a few instances. Rupture of these aneurysms is common, Avith the subsequent development of extensive valvular incompetency. They cannot be diagnosticated during life. RUPTURE OF THE HEART. This rare and serious accident may either be complete or partial. The term partial rupture implies laceration of the trabeculse ventriculi, Avhereby the chordae tendineae are liberated, or, more seldom, of the papillary muscle. The muscular structure may be involved to a slight extent. Valvular incompetency is the consequence of partial rupture. Complete rupture consists in a solution of continuity of the total diam- eter of the myocardium. Pathology.—The chief seat of rupture is the anterior wall of the left ventricle, though it may also occur in the right ventricle and in the auricles, but Avith great rarity. The rent runs parallel with the mus- cular fibers, and is to a certain extent the result of laceration, though chiefly of a separation, of the fibers. The fissural communication pre- sents irregular edges, and at autopsy is seen to contain blood-clots ; the pericardial sac is also occupied by coagula, often in great numbers. If pericardial adhesions have previously obliterated the cavity, the es- caped blood-clots may occupy the pleural cavity. Histologic examina- tion of the muscle-structure surrounding the fissure shoAvs the charac- teristic changes of fatty and other forms of degeneration. Etiology.—Both predisposing and exciting causes may be at work. The former are the more important and always obtain, and, named in the order of their frequency of occurrence, the predisposing factors are disease of the coronary arteries (thrombotic and infectious embolic pro- cesses which produce anemic necrosis and abscesses), fatty degeneration,1 chronic myocarditis, parietal tumors, and parasites in the heart-wall. The influence of age as a predisposing factor has not been determined ; rupture of the heart usually occurs after the sixtieth year has been passed, however, for the reason that the myocardial changes that cause rupture belong to that period of life- Males suffer someAvhat more frequently than females. The exciting cause is, as a rule, some form of muscular exertion, though it may occur spontaneously during sleep. Symptoms.—In the majority of instances rupture of the heart re- sults in sudden death. Sometimes, however, the patient survives the accident for several hours or even for as many days. The symptoms are those of internal bleeding, in addition to pain that may be agonizing and is referred to the heart. The body-temperature falls, the skin-sur- face becomes pale and cool, and it may be covered with cold perspiration, while the pulse grows small, very frequent, and finally almost vanishes. Occasionally gastro-intestinal symptoms and syncope tending to convul- 1 According to Quain's statistics, about 75 per cent, of the cases are due to this cause. 660 DISEASES OF THE CIRCULATORY SYSTEM. sions appear in consequence of the irritation of the vagus centers due to cerebral anemia. The physical signs of cardiac failure rapidly develop, and, if the leak be not too large, those of pericardial effusion more gradually. Diagnosis.—A certain diagnosis is rarely possible. Heart-anguish, rapidly progressive cardiac failure, the evidences of internal hemor- rhage, and the speedy development of the signs of pericardial effusion should, however, ahvays excite a strong suspicion of rupture, and in many cases suffice for a correct inference. The prognosis is hopeless. When immediately fatal, death is the direct result of heart-shock ; Avhen delayed, the sad issue takes place in consequence of anemia of the brain or of compression of the heart by the blood that pours into the pericardial cavity. Treatment.—Prophylaxis is of the utmost importance. In all conditions of the cardiac parietes in Avhich this accident is liable to occur the physician should not fail to give ample Avarning of the dangers con- nected with muscular strain of Avhatever sort. If rupture has occurred or is suspected to have taken place, the patient must be put at complete rest in the horizontal position. Full doses of morphin should be given hypodermically, and the ice-bag locally applied. Warmth to the ex- tremities may be useful, but applied to the heart-region can be only harmful. The use of pure cardiac stimulants will be attended with in- creased bleeding from the rent, but agents that relax the peripheral arterioles, such as nitroglycerin, may be employed with a view to dimin- ishing the heart's labor without diminishing its power. Should the rup- ture be partial and the hemorrhage slight, the patient's life may be pro- longed, or even saved, by keeping him at absolute rest for a long period or until Nature effects recovery. MINOR AFFECTIONS OF THE HEART. (a) New Growths.—Primary carcinoma or sarcoma is rare indeed. Metastatic groAvths occur, but are very rarely sufficiently large (except perhaps the colloid variety) to be detected by physical examination, or to give rise to symptoms. Very large tumors may, by interfering with cardiac nutrition, weaken the heart-muscle, but this must be an extremely rare occurrence. The separation of portions of the tumor may, if of considerable size, block one of the valvular orifices and cause sudden death, or more minute portions, becoming released, may give rise to embolism in distant parts. Tuberculosis and syphilis have been con- sidered elsewhere. (b) Parasites.—Four forms may invade the heart-muscle—the taenia echinococcus, actinomyces, cysticercus cellulosae, and the pentastomum denticulatum. The former two are alone productive of mischievous re- sults. The echinococcus groAvths may attain to considerable dimensions and are often multiple; they are secondary to echinococcus-cysts in other organs. Their effects are produced in a purely mechanical man- ner unless fragments become detached, Avhen they may excite embolic NEUROSES OF THE HEART. 661 lesions at different points in remote organs. Embolic abscesses have occasionally been observed, appearing like degenerations due to the actinomyces fungus. (c) Misplacement (Transposition of the Heart).—During intra-uterine life the heart (and rarely all the other thoracic and abdominal viscera) may either be transposed to the right side of the thorax, or the fetal position—in the median line—may be retained. The sternum may be missing in Avhole or in part, and the heart, Avhich noAv lies immediately beneath the skin, can be seen and felt as a throbbing tumor. Recently a man of about forty years applied at the Medico-Chirurgical Hospital in Avhom the loAver half of the sternum Avas absent; his heart occupied a position in the median line directly underneath the skin, Avhere its strong pulsations could be felt. The patient Avas of the opinion that the condi- tion Avas congenital, and stated that it had given him no inconvenience. Very exceptionally other anomalous positions are acquired during ante-natal development, and the heart may become displaced upward in the chest-cavity even to the neck or dowmvard into the abdominal cavity. (d) Floating Heart.—The structures that serve to maintain the heart in its normal anatomic relations may become Aveakened or unduly lax, in consequence of Avhich the organ may exhibit increased motility. III. NEUROSES OF THE HEART. PALPITATION. Definition.—A more or less rapid action of the heart that is per- ceptible to the patient, and usually accompanied by an increased force of the cardiac contractions or a disturbance of the rhythm, and often also by precordial distress, anxiety, and dyspnea. Etiology.—Chronic valve-disease and other organic affections of the heart seldom produce palpitation, numerous conditions outside of the organ being more frequently related causatively. Among these are—(1) Mental excitement, depression or emotion; (2) Anemia (from the local irritant action of the altered blood-state); (3) The acute in- fectious diseases, in Avhich the toxins in the blood irritate the cardiac accelerating nerves; (4) Dyspepsia, even in robust-appearing persons (as in the gouty) who Avillingly or unAvillingly commit dietetic errors. Special articles of diet may excite over-action (e. g. strawberries, shell- fish), the palpitation thus arising from reflex irritation being de- pendent upon gastric catarrh. (5) The use, and more especially the abuse, of tea, coffee, alcohol, and tobacco. These agents are injurious largely through their effects upon the nerves. (6) The female sex mani- fests a greater disposition to the complaint than the male, especially about the period of puberty and the menopause. In the male it is most common at or after the middle period of life, a time when the effects of the work and Avorry of life sIioav themselves. (7) Disturbances of the ovaries and other pelvic organs may induce palpitation reflexly. Symptomatology.—Cardiac over-action may, though rarely, be 662 DISEASES OF THE CIRCULATORY SYSTEM. constant, but, as a rule, it displays a definitely paroxysmal character. The onset is sudden, and immediately preceding the attack there are often a blanching of the face and a sloAving of the cardiac action, svmp- toms due to the momentary inhibitory effect of the nerve-affections that cause the "palpitation." The patient's perception of increased force and rapidity of the heart's action is the essential symptom. Great mental anxiety is common, and more or less dyspnea, and the latter symptom may assume curious phases. In a recent case, occurring in my OAvn practice, the patient Avould attempt at intervals of three to five minutes a forcible, long-draAvn inspiration, Avhich AA'ould sometimes suc- cessfully relieve his respiratory difficulties for a feAV minutes; at other times repeated efforts of the sort would prove ineffectual. Physical Signs.—Inspection shoAvs the impulse to be someAvhat diffuse and forcible. Visible throbbing of the superficial vessels is also common. The finger-tips easily appreciate the increased strength of the impulse. At the Avrist the pulse, though strong and full, as a rule is rapid, the rate varying from 120 to 160 per minute. Percussion may show the area of cardiac dulness to be enlarged, Avhile auscultation reveals louder sounds than the normal. The attack is usually of brief duration—but a few minutes—though sometimes it may last for hours or days. Attention should here be called to the irritable heart described by DaCosta—a form of palpitation common among young soldiers during the late Civil War. It was caused partly by mental excitement and partly by inordinate muscular exertion. A minor part in its production was also played by the diarrhea that was so often present. The leading symptoms were palpitation, a very frequent pulse, dyspnea, and cardiac pain of varying intensity. Differential Diagnosis.—Nervous palpitation must be distin- guished from the comparatively rare cases" in which the heart contracts rapidly, but does not excite subjective sensations. Some of the latter instances of increased frequency are to be looked upon as physiologic, while others are due to exhaustion from overwork and dyscrasial debility. They do not constitute cases of palpitation, since they are unperceived by the patient, but are in reality cases of tachycardia. Palpitation due to chronic valve-disease should also be differentiated from the purely nervous form. Here chief reliance is to be placed upon the presence of a murmur and other physical signs during the intervals between the attacks. Anemic murmurs are sometimes present, and must not be confounded Avith those of organic nature. Prognosis.—The condition is free from real danger to life. Most authors, however, are agreed that cardiac hypertrophy may be a sequel. Treatment.—The chief indications for treatment are—(1) The arrest of the paroxysm. The patient must be put at absolute rest in bed in a large, well-ventilated, darkened chamber, and his clothing loosened so that the respiration is unimpeded. Pressure upon the vagus in the neck or upon special points on the abdominal parietes (the ovarian region in particular) sometimes arrests the attack promptly. In my OAvn hands the best results have been obtained from the application of the ice-bag to the precordial region. If this does not succeed in cutting short the paroxysm in the course of a couple of hours, the ice-bag should be removed every third hour. In conjunction Avith this measure the TACHYCARDIA. 663 patient should be told to take large draughts of cold water or to SAvallow bits of ice. On the other hand, I have observed a feAV instances Avhich Avere speedily relieved by the ingestion of hot and someAvhat stimulating drinks. It is, however, not possible to formulate general rules that will be applicable to all cases, and there are rare instances in Avhich the local application of ice cannot be borne. Among the many therapeutic measures that have been employed, none have gained enduring professional favor save the use of morphin, which has given quite constantly good results, and particularly when administered hypodermically. However, before employing morphin, other sedatives and narcotics should be tried, such as the bromids (in large doses), hyoscyamus, hyoscin, and camphor monobromate. In neur- asthenic and hysteric subjects the bromids and the preparations of vale- rian are highly serviceable. The tincture of valerian or the elixir of valerian ammoniate may be used, and I have found the folloAving cap- sule of great utility: Rj. Zinci valerianate gr. x (0.648); Strychninae sulph., gr. £ (0.0216); Ext. sumbul., gr. x (0.648); Ext. hyoscyami, gr. v (0.324); M. et ft. capsulae No. x. Sig. One after meal-time. If a special article of diet or an overloaded state of the stomach is the cause, an emetic may be given and the attack thus speedily con- trolled. (2) To prevent a recurrence of the paroxysms, the causal conditions, some of Avhich may long antedate the occurrence of palpitation, must be removed, if this be possible. All exciting factors must also be avoided. The use of tea, coffee, and tobacco must be discontinued, and alcohol should be allowed only in small amounts. The general health must be consid- ered, and anemia, chlorosis, neurasthenia, or hysteria must each receive appropriate treatment Avhen present. When cardiac palpitation occurs in neurasthenia and hysteria the Weir Mitchell rest-cure should be advised, its results often being strikingly good if rigidly practised. Galvanism of the pneumogastric is sometimes useful, the positive pole being placed under the angle of the jaAv, and the negative lower doAvn, over each side of the neck. The removal of certain local conditions that sustain a causal relation, as gastric catarrh or intestinal parasitic diseases, is a question that must not be overlooked. If the heart be weak, digitalis may be exhibited for a long time in small doses, and it may in some cases be combined advantageously with iron, arsenic, and strychnin. TACHYCARDIA. (Tachycardia Paroxysmalis ; Synchopexia; Rapid Heart.) Definition.—A rapid movement of the heart occurring in parox- ysms of variable duration, and directly dependent upon either paralysis of the pneumogastric or stimulation of the sympathetic nerves. It is 664 DISEASES OF THE CIRCULATORY SYSTEM. not dependent upon chronic valvular disease, nor upon other gross organic lesions, nor is it generally accompanied by notable subjective sensations. Martius believes that the condition is attributable to sud- den dilatation. Pathology and Etiology.—It occurs as a physiologic condition in a certain proportion of the human family; in such cases the pulse may range from 90 to 100 beats per minute or over. Certain individuals can increase the pulse-rate by their own volition. The pathologic forms are divisible into—(1) Essential or neurotic tachycardia, and (2) Symptom- atic tachycardia. (1) Neurotic Tachycardia.—The causes of this variety are identical with many of those that excite palpitation. Thus, among disposing fac- tors are hysteria, anemia, neurasthenia, chlorosis, and toxic agencies (tea, coffee, tobacco, the poisons of febrile conditions). Aiolent exercise, intense mental agitation, fright, grief, and other forms of shock are the chief determining influences. Not a few cases are obscure as to their etiology. (2) Symptomatic Tachycardia.—The lesions that induce this form are —(a) central, and (b) peripheral. In the former group are especially to be placed tumors, clots (due to hemorrhage), and softening of the me- dulla and cord; and in the latter, tumors, aneurysms, enlarged lymph- glands (Avhich paralyze the vagus by exerting pressure upon it either in the neck or thorax), and neuritis, affecting the pneumogastric nerve. The latter lesion may be associated with polyneuritis (alcoholic or infec- tious). Rapid heart is sometimes due to reflex irritation from gastric, intestinal, arterial, uterine, and ovarian affections. Symptoms.—The clinical picture in most instances of the com- plaint is made up of recurring paroxysms of heart-hurry (paroxysmal tachycardia). These attacks come on Avith great suddenness, and, as a rule, without prodromes or forebodings. If the latter occur, they con- sist of vertigo, tinnitus, and a sense of impending danger, and some- times persist to the end of the attack. With the onset of the parox- ysms the cardiac movements leap to 150, 175, 200, and 250, or even J\A/WW\AAAA/\AA/\AA^^ Fig. 55.—Radial pulse during an attack of paroxysmal tachycardia. to 300, beats per minute. The pulse is feeble, small, readily compress- ible as a rule, and sometimes irregular (Fig. 55). Rarely it is full, strong, and of good tension. The respiration may or may not be in- creased in frequency, but dyspnea is not common. Actual thoracic con- striction and smothering are seldom Avitnessed in genuine tachycardia. At first pale, the skin soon becomes flushed, and the countenance may wear an anxious expression ; but unless " palpitation " is associated there are no symptoms present that denote an intense degree of suffer- ing. In many cases the patient is not conscious of palpitation, or there may be a sense of sloAving of the heart, Avhen in reality the cardiac con- BRACHYCARDIA. 665 tractions may be increased to 200 or more ; this is typical tachycardia. In a chlorotic girl I found that the pulse-rate increased to 200 beats, and lasted for a feAV minutes at each visit to my office. During the intervals between the visits the pulse Avas apparently normal in fre- quency. H. C. Wood, reports a truly remarkable case occurring in a physician in his eighty-seventh year, Avho has had attacks at intervals since his thirty-seventh year. Following a sudden onset, the pulse rises quickly to 200 beats per minute. The attacks can be averted by the taking of ice-water or strong coffee. Physical Signs.—A diffuse, rapid, and sometimes irregular impulse may be observed on inspection and palpation, but seldom is there an enlargement of the heart. The sounds are slightly modified, the first being accentuated, and the second aortic greatly diminished in intensity, OAving to the lessened amount of blood throAvn into the aorta Avith each ventricular systole; the intensity of the second pulmonic, however, may be increased. An apical systolic murmur is occasionally audible. The carotids pulsate, and on auscultating over them a murmur is sometimes heard. The duration of these recurring cardiac paroxysms varies from one to two or more decades. Diagnosis.—I Avould restate the fact that a high pulse-rate (200 or over a minute) and an absence or only a slight sense of palpitation or rapid heart-action are the distinctive features of true tachycardia. In palpitation (previously considered) the pulse-rate is not usually so high as in tachycardia, Avhile the associated phenomena of dyspnea, precor- dial constrictions, smothering, and painful anxiety are correspondingly more pronounced. Prognosis.—In the majority of cases no serious impairment of the general health follows, though the course is exceedingly chronic and recoveries are comparatively rare. When symptomatic tachycardia is due to lesions that are removable, it is often curable, though not invari- ably so. In sufferers who are advanced in years, hoAvever, the cerebral vessels may rupture at the onset of an attack or sudden death from cardiac paralysis may ensue. Bouveret analyzed a number of cases, 4 of Avhich proved suddenly fatal in consequence of heart-failure. The treatment is to be conducted on precisely the same lines as those advanced for "Palpitation" (vide p. 662). BRACHYCARDIA. {Bradycardia.) Definition.—Slowness of the pulse. The condition may be physio- logic, the rate of the pulse being sometimes 60 or less, and very rarely as low as 40 per minute during perfect health. All cases of pathologic brachycardia fall naturally and conveniently into twro groups: (1) those that are secondary to other complaints (symp- tomatic brachycardia); and (2) those that are due to, or associated with, a neurosis. Pathology and Etiology.—Symptomatic Brachycardia.—(a) Aris- ing during convalescence from acute infectious diseases, especially pneu- Q6Q DISEASES OF THE CIRCULATORY SYSTEM. monia, typhoid, diphtheria, erysipelas, and acute rheumatism. Accord- ing to Riegel, who analyzed 1047 cases in Avhich the pulse-rate Avas less than 60, the acute fevers must be awarded the first place anions the causal factors. I have met with 3 cases of diphtheria in Avhich the pulse in convalescence fell to 30 a minute. That such instances are, as Traube contends, due to exhaustion is true of some cases, but not of all, and doubtless there are other changes in a certain proportion. The sloAving of the pulse that is observed after premature or full-time delivery is sim- ilarly produced, (b) The second place belongs easily to gastro-intestinal and hepatic disorders (chronic gastro-intestinal catarrh, ulcer, or carci- noma of the stomach), (c) Brachycardia occurs in diseases of the circu- latory system—in coronary disease, fibroid and fatty myocardial change, most frequently; and chronic valvular disease much less frequently, if we except aortic stenosis, (d) Pulmonary complaints (emphysema and asthma), (e) Toxic agencies, as in jaundice, blood-poisoning, al- coholism, the unwonted use of tea, coffee, tobacco, and a feAV drugs (e. y. digitalis, strophanthus). (/) Certain constitutional affections (anemia, chlorosis, diabetes), (g) Rarely skin-diseases and affections of the sexual organs are accompanied by brachycardia. In various organic nerve-affections (apoplexy, meningitis, epilepsy, tumors of the cerebrum, and the medulla in particular, injuries and diseases of the cervical por- tion of the cord). In such cases the brachycardia is due chiefly to direct or reflex irritation of the center or of the peripheral portion of the vagus system. Indeed, brachycardia is produced in one or other of these Avays, whatever may be the nature or seat' of the primary condition, except in those cases in which it is brought about by exhaustion of the automatic motor apparatus of the heart. (2) Brachycardia associated with a neurosis may be found to be marked in epilepsy, less so in hysteria, melancholia, mania, and gen- eral paresis of the insane. It precedes palpitation. Symptoms.—The sole characteristic symptom is the slow action of the heart, and this may either be temporary or permanent. If paroxys- mal, both the onset and termination are apt to be sudden. A slow emerg- ence is, however, more common than a slow beginning, though a small group of prodromes appears, comprising vertigo, tinnitus, and a sense of impending danger. During the paroxysm the patient may repeatedly suffer from syncopal attacks or become unconscious for hours at a time; physical prostration may also be marked, and especially when secondary to chronic valve-disease. The pulse is Aveak and small, and the beats per minute vary from 50, 40, 30, 20, to 10, or even 8. When the con- dition arises in the course of organic valve-lesions the cardiac contrac- tions, as a general rule, may be increased in power, though greatly reduced in frequency. Thus, I observed this occurrence in a patient under my care at the Philadelphia Hospital suffering from a double mitral lesion and aortic constriction. The pulse fell from 70 to 28 per minute, but the systole Avas more powerful than before brachycardia was developed. The pulse at the wrist does not show the rate of cardiac contractions (when the heart is weak), since the latter do not ahvays emit a pulse-wave that can be detected at the Avrist; hence the heart- action must be noted by auscultation, and the rate compared with that of the peripheral pulse. The impulse and the heart-sounds are feeble. ARRHYTHMIA. 667 Diagnosis.—A pulse beloAv 48 beats per minute, with correspond- ing sloAvness of the systole, suffices for a positive diagnosis. The prognosis is governed by the cause, being very grave in cerebral and advanced cardiac diseases. When fatal, sudden death is the rule. Treatment.—Rest in the lying posture, particularly if the condition has come on in organic heart-disease, and such remedies as atropin, strychnin, caffein, nitroglycerin (in small doses), and ammonia are to be given a trial. If the ventricular contractions are very feeble and not beloAv 30, small doses of digitalis will be found useful, though the effect must be closely Avatched. In the intervals betAveen the attacks the gen- eral health must be improved and the causal states eradicated. ARRHYTHMIA. {Irregular Heart- and Pulse-beat.) (1) The irregularity may affect only the volume and force of the pulse. Here the intervals betAveen the beats are equal, but in regard to fulness and strength the beats are unequal. Instances of irregularity in the volume and strength of heart-beats may give rise to the condition known as pulsus alternans (Traube), in which fuller and stronger pulse- beats regularly alternate Avith those of lesser volume and strength (see Fig. 56). (2) Irregularity in Time.—(a) Intermittent heart-beat. This Fig. 56.—Pulsus trigeminus alternans (Eichhorst). is but an exaggerated degree of the first variety, and signifies a missed or dropped beat. This occurs at irregular intervals in most of the cases, though sometimes a cyclical irregularity is observed—i. e. every four, six, eight, or ten beats being-marked by an intermittence. (b) T\vin- pulse (coupled beats, allorrhythmia). When tAvo beats follow each other quickly (the diastole being shortened), and the next two not so quickly (the diastole being lengthened), we have produced the pulsus bigeminus. The first and second beats may be of equal strength, but often the second is relatively feeble. This is best determined by auscultation of the heart, since the second systolic contraction (of the ventricle) may indeed be so Aveak as not to give rise to a palpable beat at the Avrist. I have frequently observed the pulsus bigeminus in mitral disease. With 668 DISEASES OF THE CIRCULATORY SYSTEM. respect to the diastole, the pulsations may be in blocks of three (pulsus trigeminus), or even of four (pulsus quadrigeminus). (3) Combined irregularity of time and volume. Whilst the forms of irregularitv above described should be distinguished from one another whenever possible, yet this is sometimes unattainable, particularly in the last stages of val- vular disease and in the acute infectious diseases—conditions in Avhich the heart-muscle fails in consequence of degenerative changes. (4) The paradoxical pulse of Kussmaul also consists in irregularity of volume, strength, and time, though not indicative of so great peril as the preced- ing. It is dependent upon the act of inspiration—" normal as well as forced"—the beats during respiration being more rapid, though Aveaker, than during expiration. This is met with in chronic adhesive pericarditis, in cases of pressure upon the root of the aorta by bands, in pleuro-peri- carditis, and in a very weak heart. (5) Delirium cordis is a term verv appropriately given to great irregularity and inequality of the pulse-beats. It is seen in extreme dilatation and advanced exophthalmic goiter. (6) Embrocardia or Fetal Heart-rhythm.—There is a shortening of the long pause with a striking similarity of the first and second sounds, as in the fetal heart. I have already pointed this out in connection with dilatation, though it also sometimes attends the advanced stages of grave fevers. (7) Cantering Rhythm (bruit de galop).—The sounds simulate the triple footfall of a horse at canter. The interpolated sound is due to a redupli- cation of the second, though rarely it is the first that is doubled instead. The third sound, however, may occur at any period of the diastole. The condition is developed frequently in the hypertrophy of arterio-sclerosis and Bright's disease, in profound anemias, and in the myocarditis of certain acute infectious diseases. Etiology.—Baumgarten's classification of the causes of arrhythmia (quoted by Osier) is the best, and is here given: (1) Those due to central—cerebral—causes, either organic disease, as in hemorrhage or concussion, or more commonly psychical influences. (2) Reflex influences, such as produce the cardiac irregularity in dys- pepsia and diseases of the liver, lungs, and kidneys. (3) Toxic influences. Tobacco, coffee, and tea are common causes of arrhythmia. Various drugs, as digitalis, belladonna, and aconite, may also induce it. (4) Changes in the heart itself, (a) In the cardiac ganglia. Fatty, pigmentary, and sclerotic changes have been described in cases of this sort, and these may have an important influence in producing disturb- ances in the rhythm, but as yet we do not knoAv their exact significance. They may be present in cases that have not presented arrhythmia, (b) Mural changes are common in conditions of this kind. Simple dilata- tion, fatty degeneration, and sclerosis are most commonly present, the tAvo latter being usually associated Avith sclerosis of the coronary arteries.1 Symptoms.—Arrhythmia, particularly when functional or of reflex origin, may exist for years together, without associated symptoms refer- able to the heart, and hence is often discovered accidentally. When it is combined with palpitation or extreme Aveakness or dilatation of the organ, it is apt to arrest not only the attention of the observer in many instances, but that of the patient also. 1 Transactions of the Association of American Physicians, vol. iii. ANGINA PECTORIS. 669 Physical Signs.—In given cases the cause will be found to govern the character of the physical signs, which are often scanty or sometimes practically wanting. Those usually present have been indicated in speaking of the different varieties. Diagnosis.—Palpation and auscultation of the heart Avhile examin- ing the pulse are matters that should never be neglected if reliable results are to be obtained. It is especially in this class of cases that the sphyg- mograph renders invaluable aid. Sphygmograms will often shoAv the kind and degree of arrhythmia Avhen all other means of examination have failed, and also distinguish marked dicrotism from irregularity. It is important to differentiate functional arrhythmia or that of reflex origin from arrhythmia due to more or less grave myocardial disease. This can be accomplished only by a careful exclusion of the varied eti- ologic factors that produce the functional form, and by a careful revieAV of the cardiac symptoms. The prognosis is as variable as is the causation of the complaint. A gentleman with whom I am well acquainted Avas rejected by a leading life-insurance company twenty years ago on account of occasional inter- mittence and irregularity of the heart, though he is still in active busi- ness life and apparently in vigorous health. When the myocardium becomes involved, either secondarily to chronic valvular or coronary disease or in association Avith the acute infectious diseases, the prospect is gloomy ; but when it folloAVS the action of mental influences and remains as a permanent condition, or when it is due to other causes outside of the heart itself, the course pursued is, on the Avhole, much more favorable. Treatment.—There are many cases of the more benign form in which little, if anything, can be accomplished save to benefit the patient's general health, and this, I take it, is of paramount importance. Removal of the causal forces, as tea, coffee, alcohol, indigestible food-stuffs, con- ditions acting in a reflex manner, must be executed promptly. When the condition is due to changes in the heart-structure, cardiac in addition to the general tonics should be prescribed. I prefer strychnin, arsenic, and the dried sulphate of iron in combination as being both local and general in their effect. If the arrhythmia be due to excessive cardiac dilatation, digitalis should be employed. In purely functional cases, in which there is a predominating neurotic element, not infrequently the subjoined formula has been useful in my hands : B/. Ferri valerianatis, Zinci valerianatis, ad. gr. xxx (1.94); Strych. sulph., gr. j (0.0648); Pulv. digitalis, gr. viij (0.518). Ft. capsulse No. xxx. Sig. Take one after meal-time. ANGINA PECTORIS. (Stenocardia, Breast-pang.) Definition.—A paroxysm of violent precordial pain extending into the neck, back, and arms, and at times attended by a sense of impending 670 DISEASES OF THE CIRCULATORY SYSTEM. death. It scarcely deserves to be classified as a separate disease, beinf merely symptomatic of several cardiac lesions already described. Pathology.—Concerning the nature of angina, Ave possess few, if any, positive data. Many theories have been advanced, but to adduce them here could serve no useful purpose, and conclusive postmortem evi- dence in support of the various theories that have been and are advocated is, as yet, wanting. Neither does any single hypothesis fit the group of symp- toms so constantly observed in cases of angina. It is to be recollected, however, that it is a neurosis affecting the cardiac sensory filaments that are given off chiefly from the pneumogastric, and in many cases the vasomotor apparatus is also involved. Nothnagel has described a form distinct from the above in which the vasomotor apparatus is chiefly in- volved (angina pectoris vasomotoria). Etiology.—Cases of angina unassociated with arterial sclerosis, hypertrophy, or aortic regurgitation are rarely encountered. Hence it is quite probable that certain cardio-vascular lesions in some way, as yet undetermined, dispose to the disease under discussion. This vieAv also receives some degree of color from the fact that angina usually occurs after the fortieth year, and principally in the male sex. The determining factors of the attack are undue exertion and mental emotion. Symptoms.—The paroxysm begins quite suddenly during the action of one or other exciting cause. The suffering is excruciating and of a grip-like character, affecting the entire chest and rendering the body mo- tionless. The pain radiates most frequently to the left shoulder, though also at times to the right, and thence to the back, neck, and down the arms to the fingers. Coldness and numbness of the fingers or in the precordial area may be present. Not less agonizing than the pain is the awful sense of impending death. The countenance is frequently pale, and may assume a leaden hue, and is usually bathed in cold perspiration. The respirations are exceedingly shalloAv or even temporarily arrested, and the patient's anxiety is extreme. The heart's action may be regular, and the arterial tension, as shown by the pulse, is generally increased. The duration of the paroxysm varies from a few seconds to a minute or tAA'o, and after the pain is over gaseous eructations, vomiting, or the dis- charge of a large amount of clear urine may occur. With the cessation of the attack comes instant relief from the cardiac symptoms. On mak- ing a careful examination of the heart subsequent to the seizure there may be an utter absence of signs, and, though there is weakness, this soon disappears. The attacks may recur at intervals varying from a few days to many years. I have usually found that cases associated with aortic regurgitation give the shortest intervening periods as a rule. In angina vasomotoria the pain in the heart-region is preceded for a feAV minutes by pallor of the face, coldness and stiffness of the limbs, due to spasm of the peripheral vessels. The painful paroxysms are less severe than in the form above described. Pseudo-angina.—This is also a paroxysmal affection, occurring usually in hysterical females, though occasionally also seen in neurasthenic males. Its symptomatology is given beloAv. Diagnosis.—The characteristic events are a sudden, most intense pain in the substernal and left parasternal regions, with marked constric- tion of the chest, the peculiar manner of radiation of the pain, and the ANGINA PECTORIS. 671 sense of impending death. Less diagnostic, though of considerable value, are the brevity of the attack, the sudden onset and cessation of the pain, the age and sex, and the anxious, moistened features. There are also lighter forms in Avhich one or more of the diagnostic phenomena above described are absent. If they occur between the ages of forty and sixty years in persons in whom either arterial sclerosis or aortic regurgitation is present, this disease should be thought of; and after the exclusion of certain com- plaints in which paroxysmal pain is prominent, such as gastralgia and locomotor ataxia, the diagnosis of angina becomes reasonably positive. The distinction betAveen true and pseudo-angina pectoris is not always easily draAvn, but the most important points for discrimination may be found in the tabulated statements below : Angina Pectoris. Pseudo-angina. Etiology indeterminate, though generally The causes are—hysteria, neurasthenia, associated with arterio-sclerosis (in- toxic agents, and reflex irritations. eluding coronary disease) or aortic regurgitation. Occurs after the fortieth year, usually in Occurs at any age (over six years), and males. usuallv in females. Paroxysms, provoked by exertion or men- Paroxysms arise spontaneously, are peri- tal emotion, are rarely periodic and noc- odic and often nocturnal. turnal. Pain intensely severe, and constricting, Less intense pain, more diffused over the its chief center being to the back of the thoracic region: sensation of cardiac mid-sternum and toward the left. distention. Duration of attack from a few seconds to From a half to several hours. one or two minutes. Patient silent and body fixed. Restlessness and emotional symptoms of causal conditions associated. Arterial tension increased as a rule. Usually not increased. Prognosis unfavorable. Entirely favorable. The vasomotor form of angina must not be confounded with pseudo- angina, Avhich is infinitely more common. The prognosis is bad, yet uncertain. I recall tAvo instances that occurred ten and tAA'elve years ago respectively : the first attacks were survived with no recurrence up to the present, and neither case presented any evidence of cardio-vascular disease. When the arteries are sclerosed (particularly the coronaries) life is often suddenly terminated during the course of the attack. Occasionally the sufferer dies of syncope. The nature of the causal and associated lesions must, therefore, be considered in making a prediction. In the vasomotor angina of Nothnagel the out- look is less grave, Avhile in pseudo-angina it is always bright. Treatment.—Prevention of the attacks in persons who are subject to them is of the most importance. In order to do this all knoAvn excit- ing factors are to be rigidly avoided. The patient should be instructed to carry constantly in a convenient pocket such agents as nitroglycerin and amyl nitrite, beads or perles (strength 3 to 5 drops), and also how to use them with judicious care immediately upon the first indication of an approaching paroxysm. The treatment of the attack must be prompt and energetic, though carefully conducted, amyl nitrite being inhaled at once from a handker- chief in doses of 3 to 5 drops according to the severity of the attack. The patient should then be placed in a cool apartment free from disturbing 672 DISEASES OF THE CIRCULATORY SYSTEM. sounds. Locally, the use of the ice-bag may prove efficacious and should be tried at first. There are cases, however, in which hot applications (hot cloths or sinapisms) give better results than cold. If the pain is not controlled promptly by this method, the nitrite should be reinforced by the hypodermic injection of morphin (gr. |—0.0216) combined with atro- pin (gr.T^o—0.0005). This rarely fails of bringing speedy relief, and is best suited to those instances in which there is no increase of arterial tension. In cases exhibiting high arterial tension, to the treatment advo- cated above may be added the tincture of nitroglycerin, employed hypo- dermically (dose Tflj—0.066—to be repeated once in a minute if the pain continue). During the intervals betAveen the attacks the aim should be not only to obviate the action of the exciting causes, but also to overcome any dis- posing influences that may exist. Obviously, then, the nature of the causal conditions, hoAvever remote, will govern the treatment. In cases in which the arterial tension is habitually exalted nitroglycerin in in- creasing doses is to be used perseveringly, beginning Avith TTlj (0.066) and increasing by Hlj (0.066) every five or six days until the physiologic effects are produced. Sodium nitrite may be employed similarly, the dose being gr. j-iij (0.0648-0.184) three or four times daily. Marked arterial sclerosis, particularly if there be a syphilitic history, is more favorably influenced by a long course of potassium iodid than by any other remedy. It may be prescribed in doses ranging from gr. v to xx (0.324- 1.296) three times a day. When, as happens in aortic regurgitation, the hypertrophy of the left ventricle is excessive, the use of the following formula is effective: B/. Tr. aconiti rad., ITlxlviij (3.10); Sodii bromidi, gss (16.0); Elix. simplicis, q. s. ad 3iij (96.0).—M. Sig. 3j (1.0) t. i. d. It may be omitted at the end of every tAvo weeks for two or three days. The presence of a gouty diathesis would call for special treatment. In the vasomotor form amyl nitrite and nitroglycerin are most valuable. Additionally, hot foot-baths, followed by friction of the extremities, are also of the highest utility. The treatment of pseudo-angina must be directed at the cause of the complaint—the neurotic condition. IV. CONGENITAL AFFECTIONS OF THE HEART. These result from two leading causes : (1) Arrested development, and (2) Fetal endocarditis. Occasionally, both these factors are operative. (1) Arrested development may produce a great variety of anomalies, some of Avhich may be briefly enumerated: (a) Acardia, absence of the organ, (b) Cor biloculare, or reptilian heart, in which the septum be- tween the auricles and ventricles is absent, thus reducing the number of chambers to two. This is an instance of reversion to a lower type, (c) CONGENITAL AFFECTIONS OF THE HEART. 673 Absence of the interventricular septum, the heart consisting of three chambers (cor triloculare). More frequently there is a mere perforation in or an incomplete development of the septum, and this is usually situ- ated in the upper portion. Obstruction of the pulmonary orifice or of the conus arteriosus of the right ventricle are frequently conjoined con- ditions, (d) Patency, or incomplete closure of the foramen ovale. Per- sistence of the foramen is, in the majority of cases, associated with ob- struction of the pulmonary valve, though it may be solitary, (e) An anomaly knoAvn as ectopia cordis deserves mention. This is a condition in which the sternum is usually divided vertically, and the heart is either entirely exposed or beating just beneath the skin in the cardiac, thoracic, or abdominal region. In this connection another and the most common form of malposition may be added—namely, dextrocardia. Here the heart occupies the right side, with reversion of the arch and displacement of the descending aorta to the right of the spinal column. Transposition of other viscera is usually associated. (/) Anomalies of the valves.—There may be either a numerical increase or decrease of the cardiac valves, par- ticularly the segments of the semilunar valves of the aortic and pulmo- nary orifices. Supernumerary segments are usually rudimentary, and at the pulmonary valve one, two, or more are most commonly seen. A de- crease in the number of segments is also most frequently observed at the arterial orifices, the aortic and pulmonic semilunar valves then being composed of two segments (bicuspid). This condition may be due to de- fective development on the one hand, or to endocarditis with resulting cohesion of segments on the other. (2) Fetal endocarditis leads to valvular deficiencies in a manner sim- ilar to what occurs during the whole post-natal period. The valve- lesions originating during fetal life are most frequently situated on the right side, probably for the reasons that the ante-natal circulation is more actively carried on in the right than in the left heart, and that the former receives the oxygenated blood from the placenta. They may occur at the pulmonic, the aortic, or the auriculo-ventricular orifices. The changes are of the sIoav sclerotic form as a rule, and their character is determined largely by the antecedent anomalies that predispose to them. The leaflets present smooth, thickened, and contracted borders. Union of the mitral segments is common, and the chordae tendineae are often thickened and contracted. The small rounded bodies that are normally present on the mitral and tricuspid segments (nodules of Albini) must not be confounded with pathologic verrucosities. The most frequent congenital valvular lesion is stenosis of the pulmo- nary orifice as the result of chronic endocarditis. Rarely, it is due directly to defective development, and perhaps more rarely still to endo- carditis verrucosa. Pulmonic constriction of ante-natal origin may be an associated lesion in other forms of valvular disease in the young adult. With stenosis at the pulmonary orifice, there usually coexist stenosis of the conus arteriosus of the right ventricle, an open foramen ovale, and a patent ductus arteriosus; according to Peacock, " in 86 per cent, of the patients with congenital heart-disease living beyond the twelfth year the lesion is at this orifice." Atresia of the pulmonary orifice occurs, though less frequently than stenosis. At the tricuspid orifice there may be stenosis or contraction of the 43 674 DISEASES OF THE CIRCULATORY SYSTEM. valves, producing either obstruction or regurgitation. Similar lesions of the aortic orifice are infrequent. Congenital mitral disease also occurs, but only exceptionally; it is then usually associated Avith tricuspid stenosis. Boys are somewhat more liable to congenital affections of the heart than girls. Symptoms.—Though the precise nature of the anomaly differs widely in different cases, there is one almost constant and strikingly dis- tinctive symptom in congenital heart-disease—the cyanosis. The tint of skin observed is variable, being at one time a general duskiness, at an- other a deep violet, and rarely almost black. This coloration is most noticeable about the lips and mucous membrane of the mouth, the nos- trils, conjunctivae, the fingers, toes, and lobules of the ears, and as a rule is general, though it may be a local condition. The tint may groAV less distinct, and even almost vanish, when the child is in perfect repose or sleeping ; excitants or efforts at coughing, hoAvever, increase the in- tensity of the discoloration. The cyanotic hue comes on almost invari- ably during the first week of life. The fingers present a decidedly clubbed appearance, and the nails are thickened and curved like the claws of certain animals. The temperature is subnormal, while the ex- tremities are cool to the feel. Dyspnea on exertion and cough are usual concomitants. Cyanosis may be due to numerous causes that may act either singly or more often concurrently. The leading factors are an ex- tensive intermingling of venous and arterial blood, obstructive to the flow of the venous blood-stream to the lungs or through the latter organs —a condition usually resulting in cyanosis in consequence of deficient ox- idation of the blood. Physical Signs.—In the very young the impulse is feeble (with an ab- sence of a palpable thrill), the percussion-dulness is increased, especially to the right, and a loud systolic murmur is audible at the pulmonary ori- fice. When the auriculo-ventricular valves are the seat of endocarditis the murmur may be apical. In pure pulmonary stenosis the second sound is feeble. In older children the area of dulness is only slightly extended, partic- ularly to the left, while the murmurs heard are loud and often musical. It is interesting to note that in rare instances cerebral abscess is an associated condition. Differential Diagnosis.—The distinction between congenital and acquired lesions in children may be assisted by a reference to certain points tabulated below: Congenital Lesions. History of almost constant cyanosis, be- ginning in the first week after birth. Slight enlargement of the heart. It is of the right ventricle, chiefly non-progres- sive. Loud and musical murmurs present, au- dible over upper third of sternum, with small area of transmission upward and to the left; second sound weak. Deficient bodily development. Mental faculties in abeyance. Acquired Lesions. Not so; history of endocarditis or of rheumatism or other complaints in which endocarditis occurs as a com- plication. Enlargement marked, frequently involv- ing the left ventricle, and progressive. Audible over apex or base ; definite large areas of transmission. Second sound frequently accentuated. Bodily deArelopment good, as a rule. Mental faculties normal. DISEASES OF THE ARTERIES. 675 Prognosis.—The prognosis is exceedingly grave. Many succumb within a few days after birth, more than one-half before the expiration of one year, and not less than three-fourths before the end of the third year. FeAV survive the first decade of life, and fewer still reach full adolescence. Among the forms giving the most favorable prognosis are pulmonary stenosis, especially Avhen of moderate grade, and defective auricular and ventricular septa. In those instances in which life is spared in the first weeks after birth there is a disposition to affections of the lungs (phthisis, hemoptysis), nerve-complaints (convulsions), cerebral hemorrhages, etc. Treatment.—The treatment is, in the main, hygienic. The body must be warmly clad, flannels being worn next the skin, and every source of cold should be carefully guarded against. The diet is to be judiciously arranged, yet liberal, preference being given to the carbohydrates. Gentle exercise Avhen it can be taken is valuable, as are also daily spongings of the surface followed by friction. Special therapeutic indications may arise, and must be met in accordance with general principles, Avhile tonics, such as iron, arsenic, quinin, nux vomica, and cod-liver oil, are frequently applicable. V. DISEASES OF THE ARTERIES. ACUTE AORTITIS. Pathology.—The morbid changes coincide Avith those noted in acute endocarditis, including the ulcerative variety. Aneurysmal dilatation, or even rupture of the aortic coats, may be observed as a sequel. Htiology.—The causes are not clear, but the condition most generally folloAvs many of the acute infectious diseases (typhoid fever, pneumonia). Infectious emboli have been discovered to be causal irritants. Symptoms.—The symptoms are local and general. Of the former, diffuse thoracic pain (sometimes severe and throbbing, though more often slight), with more or less substernal tenderness under pressure and cardiac palpitation, are the chief. Among the general symptoms a moderate feb- rile movement is almost constant. In a certain percentage of cases em- bolism is betrayed by the usual signs, as rigors, accompanied by a steep temperature-curve. These forms are analogous to the malignant variety of endocarditis. A cardiac murmur may be heard over the upper part of the sternum. Diagnosis.—All that the best clinicians can do is to establish a probable diagnosis even in the presence of the most frankly expressed features of the affection. From acute endocarditis aortitis is to be dis- criminated by its diffuse and severe pain and by the higher seat of its murmur Avhen present. The prognosis is serious, owing to the greater liability to infectious emboli and the possibility of aortic rupture. The treatment is to be conducted on the same general plan as in acute endocarditis. 676 DISEASES OF THE CIRCULATORY SYSTEM. ARTERIAL SCLEROSIS. [Arteriosclerosis; Arterio-capillary Fibrosis; Endarteritis Chronica Deformans; Atheroma.) Definition.—An overgrowth of the connective tissue of the arterial coats (chiefly and primarily of the intima), followed by calcareous deposi- tions. The process may, though seldom, extend to the veins. Pathology.—The most frequent seat of the sclerotic process is the aorta, and the next most common the coronary arteries. Other vessels implicated are the arteries of the brain, the temporals, radials, brachials, ulnars, femorals, and iliacs. On the other hand, certain arteries, as the gastric, hepatic, and mesenteric, are rarely affected. Two forms may be recognized: (a) the circumscribed, and (b) the diffuse. (a) Circumscribed Arterio-sclerosis.—Naturally, the intima presents a smooth internal surface, but when atheromatous changes occur it shows localized areas of thickening. These patchy prominences are often hemi- spheric in outline, yelloAvish-white in color, and their favorite seats are the orifices of the branches. They increase in depth and superficial area, and on reaching an advanced stage their interior disintegrates into granular material (atheromatous abscess). In circumscribed or nodular atheroma the microscope discloses the fact that the middle and external coats are the primary seat of the changes, which consist of localized infiltrations. These lesions weaken the media and adventitia, and then (as shown by Thoma) compensatory processes are set up in the intima which lead to the formation of the so-called atheromatous button. The latter consists in a hyperplasia of the intima Avith a deposit of round cells, wThich causes a gradual increase in thickness; in this way the groAving Aveakness of the middle and outer coats is com- pensated. When the prominences in the intima undergo softening or liquefaction, rapid dilatation of the affected vessels is apt to occur. The same accident may arise early, or before the intima has reinforced the other layers by its increased thickness and strength. (b) Diffuse Arterio-sclerosis.—In this form the morbid process is dis- tributed throughout the greater part of the arterial system, the nodular or circumscribed form being usually combined with it in the aorta. Dila- tation of the aorta and of its branches commonly coexist. Apart from the yellowish, translucent, elevated areas, the intima may be smooth and the naked-eye appearances almost normal. The coats, however, and par- ticularly the intima, are very much thickened. Microscopic examination brings to light an extensive proliferation of the subendothelial connective tissue and a hyaline transformation of the entire media, particularly in the larger vessels. The muscular fibers and elastic tissue have in advanced cases almost totally disappeared. Necrotic degeneration of the media, especially in the smaller arteries, is also observed, and calcareous deposits, causing rigidity of the walls, occur among the later changes. This is particularly true of the so-called senile arterio-sclerosis. Atheromatous abscesses that burst from atheromatous ulcers are likewise common pathologic events in the aged. There may be associated atrophy of the heart, liver, and kidneys, due to a lack of nutritive supply in consequence of the narrowed tissues of the vessels. More commonly, however, in this, and constantly in circumscribed and diffuse sclerosis, the heart is moder- ARTERIAL SCLEROSIS. 677 ately hypertrophied. When coronary disease is associated, fibrous myo- carditis and sclerosis of the aortic flaps may be found associated. The kidneys may also become sclerotic—a condition which will be described hereafter (vide Diseases of the Kidneys). Sclerosis of the pulmonary artery, previously referred to in the dis- cussion of the Diseases of the Heart, exhibits all the changes observed in connection with atheroma of the systemic arteries, including aneurysmal dilatation of the trunk and rarely of the main branches. From the ter- minal tributaries the process may extend to the capillaries, and even to the pulmonary veins (angio-sclerosis). The effect of arterio-sclerosis upon the physiologic functions of the vessel-walls, and the pathologic and clinical results are of the utmost im- portance. The elastic coat is destroyed, and hence the walls cannot bear the blood-pressure as well as in health. This predisposes to dilatation of the vessels (aneurysm). Another result of extensive atheromatous degeneration of the vessels is an increase in the resistance to the blood-current, and a consequent elevation of the arterial pressure. Furthermore, the loss of elasticity in the coats of the medium-sized and smaller arteries removes an important factor in the propulsion of the-blood. The left ventricle, in consequence of this fact, almost invariably becomes hypertrophied in cases of extensive arterio-sclerosis, provided the general nutrition of the patient is still well maintained (Striimpell). The reduction of the lumen of the vessel, owing to the thickening of the intima, must lessen the blood-supply to the various viscera, and thus in part are explained such secondary affections as fibrous myocarditis, cirrhosis of the kidneys, and cerebral softening. Sclerosis of the veins (phlebo-sclerosis) has rarely been observed as a sequel to arterio-sclerosis. It is, however, not infrequently found in asso- ciation with hepatic cirrhosis and mitral disease when the portal system and pulmonary veins are involved. It is occasioned by increased intra- venous pressure. Microscopically, thickening of the intima and atrophic degenerative changes in the media are commonly observed. Calcification and hyaline degeneration of the layers also occur, and I have observed them in one of my own cases. Moderate dilatation is not exceptional. Etiology.—The diffuse form has, in part, a special etiology. It may appear in the young, though rarely; I have met with a case in the Medico-Chirurgical Hospital in a man aged twenty-four years. It is, hoAvever, most frequent in the middle-aged who are able-bodied and in the aged. In old persons atheroma is often physiologic and characterizes the natural involution-period of life. Heredity may play no inconspicuous part in arterio-sclerosis dependent upon the age. This fact furnishes, to some extent at least, the reason why senile changes in the arteries occur at a much earlier period of life in some instances, and even throughout whole families, than in others. Negroes are more liable than whites to this form of atheroma, and males than females, though it is more frequent in the latter sex than the circumscribed variety. Muscular overstrain, which augments the blood-pressure while at the same time obstructing the peripheral circulation, is a leading factor. The general causes of arterial sclerosis are—(1) Biologic irritants, 678 DISEASES OF THE CIRCULATORY SYSTEM. as the specific micro-organisms of malaria, rheumatism, and syphilis. (2) Chemical irritants (chronic alcoholism, lead-poisoning, uric acid in gout). The above toxic agents produce their effects partly by their direct irritant action, and partly by increasing the resistance in the peripheral vessels and thus raising the arterial pressure. Syphilis, saturnine-poison- ing, and chronic rheumatism may produce the affection in young subjects. (3) Bright's Disease.—It must be admitted that there is a class of cases in wliich arterio-sclerosis is secondary to Bright's disease, but when found in association the former is more frequently the primary disease than the latter. The chief causes of chronic nephritis are also capable of setting up atheroma, and hence it must not be forgotten that the two diseases may develop independently of one another, and yet simultaneously, in conse- quence of the action of a common cause. (4) Constant overfilling of the blood-vessels, resulting from excesses in eating and drinking, in the opinion of certain authors also causes arterio-sclerosis. A predisposing effect is exerted by advancing years and by the sex, more males being affected than females; it must be recollected, however, that males are more often subjected to the influence of the leading causal factors than females. The main causes of sclerosis of the pulmonary artery are mitral disease and emphysema. Clinical History.—The disease may exist for years without becom- ing apparent, or it may be discovered incidentally at autopsy while pal- pating the arteries during the course of an examination for some sup- posed local visceral affection. The accessible peripheral vessels (radial, temporal, femoral, and brachial) should be carefully felt when the pres- ence of the disease is suspected. The walls of the affected artery feel hard, and the pulse, owing to increased tension, is incompressible; as a result of this rigidity of the arterial walls the degree of vascular tension is difficult of estimation. In marked cases the sensation is similar to that perceived when grasping a goose's neck, and in such instances the pulse- wave may not be detectable on palpation. Again, the tension may be high, and yet sclerosis of the vessel-wall be slight or absent. When doubt arises as to whether or not sclerosis exists, the pulse should be pal- pated by means of two fingers. If now, while compression of the pulse is made with the index finger, the middle finger detects a pulse-wave, arterio-sclerosis is present. On account of the loss of elasticity of the vascular walls the pulse is retarded, and the sphygmogram shows a short sloping ascent, a wide top, and a slow, gradual descent, with almost an effacement of the dicrotic notch. The opposition of the increased resistance to the circulating medium (due to the rigid vessel-wall) in the outlying portions of the body calls forth a correspondingly increased cardiac action, and thus hypertrophy of the left ventricle is engendered, with its customary symptoms and physi- cal signs, including the ringing, accentuated second sound. The balance of the cardio-vascular forces may thus be maintained for a long period of time, during which the health of the patient often remains unimpaired. It happens sometimes that hypertrophy preponderates and veils com- pletely the symptoms of arterio-sclerosis. In elderly persons suffering from atheroma the first sound is often surprisingly feeble. Myocardial degenerations frequently come on in the later stages, when dilatation of the left ventricle, accompanied by a mitral systolic murmur and marked ARTERIAL SCLEROSIS. 679 rapidity of the pulse, may supervene. The aorta may be so dilated as to give rise to an abnormal area of dulness in the upper sternal region. Palpitation, dyspnea on exertion, a feeling of precordial constriction, and light febrile attacks are not uncommon. Angina pectoris is an infrequent symptom except in coronary atheroma. It cannot be stated absolutely that involvement of the external arteries implies a serious involvement of the aorta and its main branches. On the other hand, the circumscribed variety is not attended with charac- teristic alteration of the pulse. The pathologic, and more particularly the clinical, events above described may be more pronounced at one por- tion of the body than at others, and this fact has given rise to several distinct or special types (apart from the general or cardio-vascular form first depicted) according to the seat of the most marked symptoms and lesions. Among the latter I would mention the (a) cerebral, (b) pulmo- nary, (c) renal, and (d) peripheral types. (a) Cerebral Type.—In the milder grades of this type such symptoms as headache, tinnitus, vertigo, syncopal attacks, and local palsies are variously blended as a rule. I have had under my care for two years a case of marked arterio-sclerosis in a man aged eighty years in whom tin- nitus aurium and vertigo, with mild melancholia, are the only constant symptoms; on two occasions temporary aphasia was superadded. Especially in the aged, the condition is apt to lead to thrombosis or cerebral embolism, small emboli being detached from the aortic area and conveyed to the brain, with the development subsequently of the symp- toms of anemic softening of the latter. The loss of elasticity of the vessel-walls in atheroma renders them more liable to rupture than normal arteries, while the tension is much increased. Under these circumstances the danger from apoplexy is quite obvious. (b) Pulmonary atheroma is considered in its clinical relations in con- nection with the diseases of the heart and lungs. (c) The renal type includes those instances of kidney-lesion that are associated with or follow general arterio-sclerosis. The condition is essen- tially an atrophic nephritis, due to the diminution of the blood-supply to the organs in consequence of the narrowedlumen of the renal arteries. The reader is referred to the discussion of Nephritis for the symptom- atology of this variety. (d) In the peripheral type the arteries leading to the extremities be- come obliterated to such an extent as to cause starvation of the tissue, with resulting gangrene. Diagnosis.—Hardened arteries, increased arterial tension, left ven- tricular hypertrophy, and marked accentuation of the aortic second sound form a grouping of clinical characters that leaves no doubt as to the diag- nosis. Not infrequently it is the occurrence of apoplexy, acute cardiac dilatation, or of some other such accident that leads to the discovery of general arterial sclerosis. To differentiate the murmur of dilatation of the left ventricle follow- ing the hypertrophy of this disease from organic valvular lesions is only possible by the history or the results of treatment. The systolic mur- mur over the aortic area in atheroma may suggest aortic stenosis. In such cases, however, the second sound is loud, and the pulse more voluminous than in aortic constriction (vide Aortic Stenosis). 680 DISEASES OF THE CIRCULATORY SYSTEM. Prognosis.—Arterio-capillary fibrosis is an exceedingly chronic, though usually a progressive disease, and frequently it terminates life. The axiom that a man is as old as his arteries has been borne out bv the test of extensive clinical observation. The condition may prove fatal either with great suddenness, as Avhen it occasions apoplexy, or with un- wonted slowness. Very rarely the aorta ruptures at the seat of an athe- romatous ulcer, causing instant death. Treatment.—Though the progress of the disease cannot in most in- stances be successfully stayed, it can be retarded frequently by correcting aggravating habits and by removing the influence of ascertainable causes. Any degree of syphilitic taint that may be present should be assailed immediately by a liberal use of the iodids. The diet must be simple and free from stimulating properties; skim-milk is excellent, particularly if renal symptoms be manifested. Perhaps no other agent is so generally serviceable in all cases as potassium iodid, which should be administered continuously in doses ranging from gr. x-xx (0.648-1.296) three times daily. For the increased arterial tension nitroglycerin or the other nitrites should be employed. The former should be given in increasing doses until an impression has been made upon the blood-pressure, after which this effect should merely be maintained. For the local aortic symptoms (fever, pain) absolute rest, a liquid and unirritating diet, and a small blister are most efficacious, together with internal minute doses of calomel, quinin, and potassium iodid. ANEURYSM. Definition.—A true aneurysm is a circumscribed dilatation of an artery, formed of one or more of its coats. Classified according to their form, aneurysms are—(1) sacculated, (2) cylindric, and (3) fusiform. They are termed axial when the complete circumference of the vessel participates in this dilatation, and peripheral when a single sac is confined to the side of the vascular duct. Miliary aneurysms occur along the course of the cerebral vessels, and are so termed on account of their minute size. On the other hand, they may attain the size of the human skull. A false aneurysm is one that, owing to laceration of the internal coat, dissects between the layers of the vessel-wall. For its seat it usually selects the aorta, and may traverse its entire length. An arterio-venous aneurysm arises from a direct fistulous connection between an artery and a vein (aneurysmal varix), or an aneurysmal sac may intervene (varicose aneurysm). Pathology and Etiology.—The wall of the aneurysm is quite often the seat of arterio-sclerosis, and its poAver to resist the blood-stream is thus reduced. The media probably weakens first in most cases, and extreme atrophy of both the intima and media is not uncommon in the later stages, so that the wall of the sac is often formed almost exclusively of the adventitia. The intima or media may become lacerated, and finally the external coat yields; this results in rupture unless the adherent neighboring structures compensate for the natural wall. ANEURYSM. 681 The blood in the aneurysmal sac is partly fluid and is composed of old and new thrombi. The latter when comparatively recent may be soft, and when old may be firm or even calcified, yellowish in color, and ad- herent to the wall. With the progressive enlargement of the aneurysm surrounding organs are apt to be compressed and their functions disturbed, and pressure upon the bony walls of the thorax (ribs, vertebrae) results in their atrophy and final disappearance. Other remote pathologic con- sequences Avill be referred to in connection with the clinical history. Among recognized causes are—(1) Arterio-sclerosis.—It follows that the same conditions that originate the latter must also tend to bring about aneurysms. Chief among these is syphilis. Less potent, though still active, are gout and alcoholic excesses. (2) Sudden Great Strain.—Though this may not be productive of aneurysm, except some previous local impairment of the arterial walls has been present, yet it must be granted that a sudden strain is powerful in producing aneurysm when com- paratively slight antecedent changes have existed. In this way only can the fact that most instances of aneurysm occur during the period of greatest activity, or from thirty to fifty years, be accounted for. (3) Embolic plugging of a vessel, if complete, may cause aneurysmal dilata- tion on the proximal side of the point of obstruction. The development of aneurysm may under these circumstances be facilitated by the mechani- cal effects of the embolus, which may be of calcareous hardness, as when it comes from diseased heart-valves. Infectious emboli set up inflamma- tion and softening. (4) Mycotic Aneurysms.—That aneurysms sometimes owe their existence to mycotic origin was first pointed out by Osier, who found an abundant growth of micrococci in the aneurysmal sacs. They are met with in ulcerative endocarditis, and are often small and usually multiple. (5) Age and Sex.—Aneurysms are most frequent betAveen the thirtieth and the fiftieth years, this being the period of greatest physical exertion. After the fiftieth year cases occur with somewhat diminished frequency, whilst under thirty years they are quite rare. The male sex is more frequently affected than the female, and chiefly for the reason that arterio-sclerosis, sudden strain, and other leading factors that engender the disease are more apt to be operative in the former sex. ANEURYSM OF THE THORACIC AORTA. {Aneurysma Aortce.) The thoracic portion of the aorta is involved in about 75 per cent. of the cases, and the abdominal aorta and its branches furnish about 25 per cent. Within the thorax nearly 60 per cent, of the cases originate in the ascending portion of the aorta, while nearly 30 per cent, are seated upon its arch (Lyman). Symptoms.—Intrathoracic aneurysms may exist, particularly if they are small, without symptoms or noticeable physical signs. When they attain to any considerable dimensions, hoAvever, they usually excite characteristic signs and distressing symptoms, the latter being the results of direct pressure, and hence varying with the seat and direction of the progressive enlargement. In a few instances truly diagnostic symptoms are present in the absence of a detectable tumor or physical signs. Finally, the more characteristic features—the tumor inclusive—may be 682 DISEASES OF THE CIRCULATORY SYSTEM. more or less nearly intermittent. It is important to note the condition of the neighboring organs upon which pressure is exerted by the growing aneurysm, as well as the symptoms and signs thus occasioned. Aneurysms of the ascending portion of the arch usually compress the vena cava, causing distention of the veins of the head and arms, though in a pro- portionately small number of cases the subclavian may be the only vein compressed, with resulting enlargement and edema of the right arm. The largest aneurysms may even compress the inferior vena cava, causing edema of the lower extremities. The heart is displaced outward toward the left pleura, usually forward and upward, and rarely causing erosion of the ribs and sternum. The right recurrent laryngeal nerve may be implicated, giving rise to dyspnea and aphonia. Pain is a constant feature. When a tumor appears, it occupies the upper two or three intercostal spaces near the right border of the sternum. Aneurysms of the transverse portion of the aorta, when they attain any considerable size, cause the most intense" symptoms, owing to the relatively shorter antero-posterior diameter of the chest at this point, in consequence of which greater compression of the neighboring tissues takes place. By protruding backAvard they may exert pressure upon the trachea, causing paroxysmal cough and dyspnea, or on the esophagus, causing dysphagia; these are common events. The pressure may fall also upon the bronchus, inducing dyspnea, bronchorrhea, and dilatation, the latter in turn sometimes leading to circumscribed abscess. The left recurrent laryngeal nerve may be implicated, with resulting aphonia. Upward extension of the aneurysmal process, with involvement of the coats of the carotid and subclavian on the left side, or of the innominate and carotid on the right, may occur. The sympathetic nerves in the cer- vical region may be irritated, causing dilatation, or they may be para- lyzed, causing contraction, of the pupils. Compression of the thoracic duct may occur with resulting rapid emaciation. A tumor may appear in the jugular fossa. The aneurysm may grow forward, in which event it lies directly behind the manubrium, which from the pressure becomes eroded and may finally disappear in part. In aneurysms involving the transverse portion of the arch lateral pressure in either direction is also effected, causing recession and compression of the lungs. When the descending portion of the arch is affected, the pressure is ex- erted upon the spinal column to the right, and upon the tissues as far as the shoulder-blade to the left. As a consequence of destruction and ab- sorption of the vertebrae compression of the spinal cord may ensue, and is an intensely painful process. Pressure may be made upon the esophagus, causing dysphagia, or upon the left bronchus, causing bronchiectasis, with its usual sequelae (bronchorrhea, fetid bronchitis, gangrene of the lung). The sac may in consequence of the slow ulcerative process that attends its progress, rupture eventually into the bronchus or the esophagus, with sudden death as the result. Frequently repeated small hemorrhages, due to weepings from the thinned walls, may precede the fatal rupture. I saw a case of aneurysm of the transverse portion in which rupture into the esophagus resulted from a sudden though not severe exertion, with instan- taneous death. When the tumor has reached the subcutaneous tissue and bulges ex- ANEURYSM. 683 ternally, the skin covering it becomes tense and shining, and with in- creased pressure the surface becomes reddened and finally necrotic. The necrosed area is bedecked with a dry brown scab, which later is thrown off, leaving an oozing surface. Rupture soon follows. Among the symptoms that demand special description pain stands primarily, being the first and most constant. It is of two kinds : (a) Due to direct pressure upon and stretching of the nerves. When aneurysm is developed suddenly, a sharp, excruciating pain is felt in the upper sternal region, accompanied by a feeling of "something giving way." In consequence of the stretching of the nerves a constant pain is expe- rienced that is subject to exacerbations when the intra-aneurysmal pressure is raised. Pressure against the bony structures causes erosion, and usually produces a continuous boring pain. In a recent case of aneurysm shown in clinic at the Medico-Chirurgical College, how- ever, a tumor that had eroded the right half of the sternum, and of the size of a goose's egg, had given rise to no suffering whatever. In latent aneurysm there is an absence of pain until the growth terminates life. Anginose attacks sometimes occur when the sac has its seat near to the heart, (b) Reflected pains of a neuralgic character may be excited by aneurysm. This is true, in particular, of aneurysms situated in the transverse portion of the aorta, in which instances pain is frequently felt in the region of the neck and occiput and down the left arm. When the growth is situated along the course of the descending aorta, intercostal neuralgia may be excited, and it is probable that pain of this sort is due to pressure upon the nerve-trunks. Cough.—The cough is paroxysmal, and frequently has a peculiar brazen, ringing character that points to its laryngeal seat. Pressure upon the windpipe excites a paroxysmal dry cough. Compression of a bronchus may lead to bronchiectasis, and the cough then occurs only in long and severe paroxysms which recur at intervals of a day or even longer, and are attended with copious, thick, ropy expectoration (vide Bronchiectasis). Dyspnea is a conspicuous symptom in aneurysm of the transverse por- tion of the aorta. It arises (a) most frequently in consequence of pres- sure upon the recurrent laryngeal nerve, (b) direct pressure on the trachea, and (c) from pressure on the left bronchus. Marked stridor may accom- pany the first variety. Paralysis of the vocal bands is occasioned by compression of the recur- rent laryngeals, particularly the left, while a slight degree of compression or irritation of the same nerve causes spasm of the vocal cords. The symptoms indicating the presence of these conditions are hoarseness, cough, and aphonia respectively. The laryngoscope should be employed, since paralysis of one of the abductors may be present without giving rise to appreciable symptoms. Hemorrhage may occur as a slow oozing, either from the point of com- pression in the trachea or externally; in either case the amount of blood lost is small. Profuse bleedings (often producing sudden death) take place in consequence of rupture of the sac into the lung, the bronchus, or the trachea. Deglutition may be difficult, owing to compression of the esophagus. When an aneurysm has been diagnosticated or even suspected, the esoph- 684 DISEASES OF THE CIRCULATORY SYSTEM. ageal sound should not be passed for purposes of exploration, on account of danger of rupture of the sac. Compression and irritation of the sympathetic system of nerves cause pupillary changes that have already been mentioned. With dilatation of the pupil there may be observed pallor of one side of the face, due to stimulation of the vaso-dilator fibers ; on the other hand, with contraction of the pupil (due to paralysis of the dilator fibers) there is hyperemia of one side of the face and unilateral sweating. Clubbing of the fingers and incurvation of the nails are not rarely met with in thoracic aneurysm. Physical Signs.—Inspection.—Visible pulsation is one of the earliest appreciable signs. It is most frequently observed at the right side of the sternum, above the level of the third rib (second interspace), and much less frequently on the left side over a corresponding area. In aneurysm of the transverse portion pulsation may be seen at the episternal notch, though an impulse here may also be due to nervous palpitation, and have no connection with aneurysmal growths. The pulsation may occur in the absence of the slightest bulging ; when associated with swelling, however, its diagnostic value is infinitely greater. Involvement of the innominate artery produces pulsation in the neck above the sterno-clavicular junction, or less commonly above the sternum. Corresponding to the site of visible impulse, there is, sooner or later, bulging in most instances. It may, however, be so slight as to elude de- tection unless the keenest observation be practised, and in not a few instances the tumor itself is invisible from the front of the body, but is recognizable looking from behind or from either side. Again, on alloAV- ing the light to fall obliquely upon the chest slight prominences may be brought to view that would otherwise be inappreciable. When the aneurysm is situated in the ascending part of the arch, the most frequent seat of the bulging—Avhich varies in size from a hen's egg to a cocoanut—is over the first and second right interspaces near to, and frequently involving, a portion of the sternum ; when seated just beyond the aortic orifice, a pulsating prominence may occupy the third interspace along the left sternal border; situated in the transverse section of the aorta, bulging of the upper part of the sternum is a frequent event, or a projection into the cervical fossa may occur, though with comparative rarity. In the descending portion the swelling, when present, is in the second and third left interspaces near to the sternum, or very rarely in the left scapular zone. The skin over the tumors has been described. The apex-beat is displaced downward and outward, chiefly from pressure, though to a lesser extent also from hypertrophy (functional). Palpation.—The protrusion presents a more or less yielding and elastic mass, and when superficially seated fluctuation may be obtainable. The degree, and the rhythmic expansile character of the pulsation are to be noted, and also the fact that there is an alternate contraction and dilatation of the sac in every direction—a distinctive feature. If the aneurysm is largely concealed, bimanual palpation should be employed, the palm of one hand being placed over the spine and that of the other over the sternum. In an inconsiderable number of cases aneurysmal pulsation is only yielded when the finger-tips are used, and quite rarely only at the end of expiration. A diastolic shock is often ANEURYSM. 685 perceived, and forms a physical sign of no little value. A distinct sys- tolic shock, sometimes accompanied by a purring fremitus, can also be felt over the aneurysmal sac. Percussion.—If the growth be deep-seated, percussion may give neg- ative results; when, however, the tumor causes bulging or comes in con- tact with the chest-wall, a proportionate area of flatness is presented. The abnormal field of dulness may be the only symptom present, as in an instance of suspected aneurysm that recently came under my care. Aneurysms of the ascending arch give flatness to the right of the ster- num ; those of the transverse arch, over the upper part of the sternum and to the left; Avhile those of the descending portion are revealed by a flat area betAveen the spine and the left scapula. With flatness of the percussion-note there is a sense of increased resistance. The shape of the flat area is to be noted at the end of both inspiration and expiration. Auscultatory percussion (practised after the method of Sansom and Ewart) quite often gives valuable results. Auscultation.—Since murmurs owe their origin, in great part, to the presence of fibrin in the sac, they may often be absent, and this even in the case of large aneurysms. When, as is usual, a murmur is present, it is systolic in rhythm, heard with greatest intensity over the flat area or body of the tumor, and is transmitted in the direction of the blood-stream, being, therefore, distinctly audible in the vessels of the neck and along the course of the aorta. The chief characteristic of this murmur is its booming quality. Aortic regurgitation may be considered as associated with aneurysm near the aortic ring when a double murmur is heard. In a few instances the diastolic bruit is alone detectable. A much intensified, ringing sec- ond sound is present (unless marked aortic regurgitation coexists), and is a sign of the utmost significance for diagnosis. The Peripheral Arteries.—The pulse in the vessels beyond the aneurysm is slowed. Hence the tAvo radial pulses may exhibit differences in time. The volume of the pulse beyond the aneurysm is also lessened, and in cases Fig. 57.—Sphygmogram of a case of aneurysm of the left subclavian artery (Foster). of aneurysm of the abdominal aorta or the femorals it may be obliter- ated. Such differences as these will not only point to the existence of thoracic aneurysm, but also may indicate its seat. Thus, if there be dilatation of the transverse arch with no implication of the innominate, the pulse at the right wrist is strong and almost simultaneous with the cardiac impulse, while that on the left side is small, weak, and more re- tarded. If the reverse be true, then the aneurysm may be near to or in- volve the innominate. The sphygmogram exhibits a slanting up-stroke Avith obliteration of the secondary wave (Fig. 57), though its characters are by no means constant. 686 DISEASES OF THE CIRCULATORY SYSTEM. Tracheal Tugging.—This sign may be practised while the patient is sitting or standing with the chin slightly elevated. The cricoid cartilage is then grasped between the thumb and forefinger and pushed gently up- ward so as to stretch the trachea. The patient must at the same time be told to cease breathing momentarily, when, if this sign be present, there will be a downward dragging or tugging at each systole. The trans- mitted pulsations from the cervical vessels synchronous with the tug- ging must not be confounded with the up-and-down movement of the trachea. A new method of eliciting tracheal tugging, first suggested by Ewart,1 has been pretty widely adopted, and possesses the advantage of ensuring greater delicacy of touch than the old. He stands behind the patient, supporting the head of the latter against his body, and the cricoid is then grasped firmly between the tips of the forefingers. The method is in other respects similar to that previously described. Diagnosis.—In the presence of the following points the existence of thoracic aneurysm may be confidently inferred: (1) Antecedent arterio- sclerosis (with the appropriate causes of the latter); (2) History of other etiologic factors, as age (between thirty and forty-five years) and occu- pation (such as entail unusual muscular strain); (3) Pressure-symp- toms, as pain, dyspnea, aphonia, cough (either laryngeal or bronchial), bronchorrhea, dysphagia, edema, vasomotor disturbances; (4) Physical signs of a pulsating tumor (including the abnormal area of dulness, sys- tolic murmurs, the systolic and diastolic shock, and tracheal tugging) somewhere along the course of the arch or its great branches, with or without differences in the volume and time of radial or carotid pulses. There are, however, several classes of cases which offer difficulties that are sometimes insurmountable: (a) Those in which the aneurysm is small and deep-seated. Here the symptoms and physical signs are indefinite. There may be thoracic oppression, in Avhich pain may radiate to the left shoulder, and mild pressure-symptoms—a group of suspicious features merely—sometimes appear. I have under my observation noAv a patient suffering from aneurysm of the ascending aorta in which for a long time left-sided intercostal neuralgia was the only symptom, (b) Aneurysm of the transverse arch, in Avhich the pressure-symptoms are more or less pro- nounced, but with no physical signs. In such, a clear history suffices to complete the diagnosis. Pressure-symptoms, on the other hand, without etiologic factors are just as likely to be due to other causes, (c) Those cases in which the more characteristic features are manifested intermit- tently. The distinction betAveen the latter two groups and the conditions with which they are apt to be confused will be pointed out incidentally in connection with the differential diagnosis. Extremely obscure are many of the cases in which the only symptoms manifested point to irritation of the trachea or bronchial tubes, with par- oxysmal cough, bronchorrhea, and sometimes the signs of bronchiectasis. In a recent case of this sort tracheoscopic examination revealed com- pression of the windpipe, making clear the nature of the affection. In still another instance, in which laryngeal dyspnea and cough, with bron- chorrhea, were the only symptoms, a laryngoscopic examination determined the diagnosis, in that it brought to view bilateral paralysis of the abduc- 1 British Medical Journal, March 19, 1892. ANEURYSM. 687 tors of the vocal bands. Subsequent events proved its correctness when the characteristic physical signs appeared. Differential Diagnosis.—The affections from which intrathoracic aneur- ysm must be distinguished in cases presenting a complexity of features are pulsating empyema, abnormal pulsation of the aorta, and solid tumors. Of the latter, those simulating aneurysm are carcinoma, sarcoma, and en- larged lymph-glands. These mediastinal tumors may duplicate all of the pressure-symptoms, though they are less apt to cause bulging, and less apt still to excite abnormal pulsation; when pulsation is noted it is observed to be quick, and not heaving and expansile as in aneurysm. Solid growths also lack the characteristic shock—both systolic and diastolic—of aneur- ysm. The cardio-vascular symptoms are usually wanting in the case of solid tumors, especially cardiac hypertrophy, accentuation of the second sound, tracheal tugging, and the difference between the radial pulses. Carcinoma of the mediastinum usually gives a history of the disease in other parts of the body, with enlargement of the axillary or other super- ficial lymphatic structures, and later the characteristic cachexia, this being particularly marked in carcinoma of the esophagus. Abnormal pulsation in the aorta is noted in neurotic subjects, mostly females, and in aortic regurgitation; less frequently it is associated with retraction of the right lung, with spinal curvature, and with displacement of the aorta. In the case of the latter two conditions a careful considera- tion of the causal states and the absence of the characteristic physical signs would lead to a correct diagnosis. Aortic regurgitation is frequently associated with aneurysm of the arch, and in its course there is developed, not infrequently, a dilatation of the ascending portion of the aorta. The diagnosis of aneurysm of the arch of the aorta should not be made, even when all the characteristic physical signs of aortic regurgitation are present in any given case, unless the signs of the pulsating tumor above the heart be unmistakable. Dynamic pulsation of a neurotic origin is seen and felt in the episternal notch, as a rule, and a correct appreciation of the nervous element, whether inherited or acquired, will prevent the observer from committing an error. Pulsating empyema can only be confounded with large aneurysmal growths, and, as pointed out by Wilson, it does not have the same definite relation to the central long axis of the body as do aneurysms. The abnormal area of dulness is situated at the base of the lung in empyema, and usually extends over a larger superficial area or is less circumscribed than in aneurysm. In empyema, moreover, the pulsation is not expansile, but is caused by pressure on the respiratory movements. Auscultation in empyema renders audible neither a bruit nor the double shock of aneurysm; the pressure-symptoms and pulse-characters are also entirely wanting. Pulmonary tuberculosis may be mistaken for thoracic aneurysm. When an aneurysm compresses a bronchus, bronchiectasis, attended Avith cough, bronchorrhea, fever, and emaciation, may be the result; but in phthisis the fever and emaciation are more pronounced, tubercle bacilli are pres- ent, whilst the characteristic cardio-vascular signs of aneurysm are absent. Prognosis.—The existence of aneurysm without producing any symptoms, as well as the possible occurrence of perforation and conse- quent speedy death, must be recollected. At least, some of the features 688 DISEASES OF THE CIRCULATORY SYSTEM. previously adduced may be present in aneurysm for a long period of time (even years), when sudden death may ensue. In other instances the end is approached in a very gradual manner, and cases in which rup- ture does not supervene sometimes pursue the general course of chronic valvular affections of the heart. The fact that aortic regurgitation may coexist has been referred to; in such cases there may develop at any time failure of compensation, with its usual serious phenomena. The condition ends in death as a rule, and the immediate causes of the fatal issue are as follows : (1) Rupture of the aneurysm, followed by hemorrhage into any of the adjacent cavities or organs (pericardium, heart, large vessels, mediastinum, trachea, a bronchus, esophagus, lungs, pleura, spinal canal); it may, though rarely, rupture externally, in which case slight hemor- rhages occur and life may last for weeks; (2) Gradual asthenia; (3) Direct pressure; (4) Independent diseases, either primary or secondary to, and induced by, the aneurysm. Treatment.—There are two chief indications around which all others center in the management of this disease—first, the promotion of coagu- lation of the blood, and secondly, the contraction of the sac. The clotting of the blood within the growth may be greatly favored by retarding the blood-current. Nothing so well accomplishes this object as absolute rest in the recumbent posture. This cannot always be rigidly enforced, but muscular exertion must be minimized, and mental application and emo- tional excitement must also be avoided; stimulants, arterial and nervous, are to be eschewed for like reasons. Palpitation of the heart, when present, is best allayed by the local use of the ice-bag. The coagulability of the blood is also increased by removing as far as possible the liquid portion of the diet. The measures already indicated tend to lessen the volume of blood and the intra-aneurysmal pressure, thus inviting contraction of the sac as well as coagulation of its contents. Among medicinal agents, ergot and potassium iodid have been employed, the latter with good effects. The exact manner in which the iodid produces its favorable results in these cases is unknown, though most probably it acts upon the vascular Avails, and hence Avould be most efficacious when the disease is of syphilitic origin; this view accords Avith my own personal experience. I would advise against the internal use of ergot, which can have little to recom- mend it, and the prolonged use of Avhich may be attended with unpleasant effects. Langenbeck and others have obtained good results from the direct injection into the sac of the aqueous extract of ergotin dissolved in water or glycerin, every day or two. When employed in this manner ergotin induces contraction of the smooth muscles in the wall of the aneurysm. The injection of chemical substances, as the tincture of the chlorid of iron, for their effect in promoting coagulation of the blood is not free from dangerous consequences, and in my opinion the risk of engendering embolism of the peripheral vessels with detached fragments of the clot should not be assumed. Other observers have resorted to the use of horse-hair, fine wire, fine catgut, slender watch-springs, with a view to coagulating the blood as it comes in contact with these foreign bodies. Combined with the insertion of wire the use of electrolysis is a method that has been warmly advocated (Loreta). A piece of fine, slender wire, several feet in length, is passed directly ANEURYSM. 689 from a spool through a hypodermic needle, so that the Avire curls up within. This is noAv attached to the positive pole, Avhile the negative is connected with a surface pad placed over the abdomen or with an insulated needle inserted into the sac, and the current is then passed through. It is import- ant to test the strength of the current beforehand by inserting the needle attached to the positive pole into the white of an egg and observing its power to coagulate albumin. Each application of the current should last from one to two hours. This plan of treatment has in some instances given striking results, though a more extended trial is needed before its true value can be estimated. The author saAv a case that Avas successfully treated in this manner, the solidification of the sac being apparently com- plete. Knerr and Rosenstein have also reported cures from the employ- ment of this method. It is not, however, without serious dangers (hemor- rhage and embolism). After the same method galvano-puncture has long been resorted to, and in the hands of some clinicians with encouraging results. The cases that receive most benefit from the above measures belong to the saccular vari- ety ; this is also true of the special plan first commended by Tufnell, Avhich is especially applicable in the earlier stages. Tufnell's method is founded upon two main principles—absolute rest in the recumbent posture, and a much-restricted, dry diet. With physical rest a quiet mental state should be conjoined. The diet is as follows : Breakfast, 2 ounces (64.0) of bread and butter and 2 ounces (64.0) of milk ; for dinner, 2 or 3 ounces (64.0- 96.0) of meat and 3 or 4 ounces (96.0-128.0) of milk or claret; for supper, 2 ounces (64.0) of bread and 2 ounces (64.0) of milk. The chief advantages growing out of this method are the lessened number and decreased force of the heart-beats in consequence of the posture and bodily rest, and the diminution of the blood-volume in consequence of the dietetic restrictions. It should be persevered in for several months. When, as often happens, the plan cannot be rigidly enforced, the great benefit to the patient of quiet of mind and body and a suitable, though less exclusive, diet should not be lost sight of. His bowels should be regulated, and he should be told not to strain while at stool. A. E. Wright has particularly insisted upon the value of calcium salts in increasing the coagulability of the blood (gr. x to xv—0.648 to 0.972, t. i. d., may be given). A number of investigators have confirmed Wright's findings, but others have met Avith contrary results. Special Symptoms.—Pain is often relieved by potassium iodid. When marked arterial sclerosis is present I have seen relief from pain afforded by the internal use of nitroglycerin (TTLj to ij—0.066 to 0.133, three or four times a day). In the later stages morphin should be given to allay suffering. When there is bulging the pain may be assuaged by the local use of the ice-bag or by a belladonna plaster. Dyspnea and great venous congestion are to be met by free bleedings from a vein, and tracheotomy may be required if the dyspnea be shown to be due to bilateral paralysis of the abductors. In dyspnea arising from pressure on the trachea or bronchus, however, tracheotomy Avould be a valueless expedient. When the aneurysm forms a large external tumor the application of an elastic bandage to the chest may be both agreeable and advantageous, as in a case referred to by Osier. 44 690 DISEASES OF THE CIRCULATORY SYSTEM. ANEURYSM OP THE ABDOMINAL AORTA. The vicinity of the celiac axis is the favorite seat of abdominal aneur- ysm, which is by no means as common a condition as intrathoracic aneur- ysm, though not rare. It may assume a fusiform or saccular nature, and is sometimes, though rarely, multiple. Symptoms.—The tumor may grow backward, but more frequently its growth is in a forward direction. Projecting from the posterior wall, it usually erodes the vertebrae, and compression of the cord is apt to take place, producing paraplegia, preceded by tingling and numbness of the legs. Pain is the leading symptom. It may be neuralgic or of a boring or gnawing character, due to destruction of the bone. Rarely, the aneurysm perforates the diaphragm, and finally ruptures into the lungs or pleura, causing death quickly. Arising from the anterior wall, it may early form a well-defined tumor. It may, however, when situated high up or near the diaphragm, conceal itself until it has attained a comparatively large size, as in a case recently under my care at the Medico-Chirurgical Hospital. Vomiting and gastralgic seizures may be troublesome, and the fact that embolism of the superior mesenteric artery may occur and give rise to severe colicky pains must be recollected. Jaundice has been observed. Physical Signs.—Epigastric pulsation may be visible, and occasionally an epigastric swelling. The palpating hand detects a heaving, expansile pulsation that may be accompanied by a thrill. When the tumor hugs the diaphragm, the pulsation may be double. The femoral pulse is diminished in volume and delayed. If the groAvth be large, an abnormal area of dulness may be present on percussion. In most instances a soft bruit is audible on auscultation. The diastolic murmur and shock of intra- thoracic aneurysm are quite usually absent. Diagnosis.—A certain diagnosis demands the presence of a definite growth that is seizable and has a heaving, expansile pulsation. Mere pulsation attended with a thrill and a systolic murmur may be simulated by other conditions. Differential Diagnosis.—A throbbing aorta, as met with in neurotic females and in anemia (particularly in instances of the traumatic form), is not infrequently distinguished from aneurysm of the abdominal aorta with great difficulty. It does not, however, present a tumor that can be grasped, and which possesses an expansile, heaving pulsation, as is true in the case of aneurysms that are at all recognizable. When solid growths lie upon the aorta the latter may manifest pulsa- tion, a thrill, and a systolic murmur, but the very general absence of pulsation, owing to the fact that the tumor falls forward when the patient is placed in the knee-elbow position, suffices usually to differentiate the condition from genuine aneurysm. Again, expansile pulsation is not evinced by a solid growth. The prognosis is very gloomy. Very rarely, hoAvever, nature effects a cure if the conditions be favorable. " Death may result from (a) the complete obliteration of the lumen by clots; (b) compression-paraplegia; (c) rupture either into the pleura, retroperitoneal tissues, peritoneum, the intestines, or, very commonly, into the duodenum ; (d) embolism of the su- perior mesenteric artery, producing infarction of the intestines " (Osier). ANEURYSM. 691 Treatment.—Apart from the measures indicated for thoracic aneur- ysm, there is one means of cure that may be tried if the groAvth be low doAvn—viz. pressure. This must be maintained for tAventy-four hours at least under an anesthetic. It is best to make steady pressure on the proximal portion of the vessel, and unless practised with great care the sac will be damaged and death ensue. ANEURYSM OP THE PULMONARY ARTERY. Dilatation of the pulmonary artery is of frequent occurrence in affections that oppose obstruction to the lesser circulation (e. g. mitral disease, emphysema, phthisis). Very rarely extreme dilatation of the vessel is followed by semilunar incompetence, when a diastolic murmur at the pulmonary orifice (second left interspace) becomes audible. Aneurysms involving the pulmonary artery are quite rare: such as occur are small and of the saccular and fusiform varieties. The Symptoms resemble those of intrathoracic aneurysm, though they are rarely well marked, owing to the fact that they remain of small size as a rule. Physical Signs.—Pulsation (and, rarely, a small tumor) is detectable in the second left interspace. Palpation may also render appreciable a thrill and a diastolic shock. Coextensive with the area of pulsation there may be dulness on percussion, and over the second interspace to the left of the sternum a loud superficial systolic murmur is heard on auscul- tation, together with a diastolic shock. Before attaining to a large size, these aneurysms usually rupture into the heart itself. The prognosis is altogether unfavorable, the treatment having refer- ence to the principles that are appropriate in thoracic aneurysm. The coronary arteries may be the seat of aneurysm, though exception- ally. The condition arises in consequence of weak points (due to arterio- sclerosis) in the course of the vessels, and is unrecognizable during life. ANEURYSM OP THE CELIAC AXIS. This condition is sometimes observed in combination with aneurysm of the upper portion of the abdominal aorta. ANEURYSM OP THE SPLENIC ARTERY. This branch of the celiac axis is occasionally the seat of aneurysmal dilatation. It may be single or multiple, and, whilst it is small as a rule, may in rare cases be quite large. The Symptoms are indefinite, but distressing. Deep-seated abdomi- nal pain, which shows a tendency to radiation, forms, with vomiting, and rarely hematemesis, the main features. By careful percussion a tumor may be mapped out in the left hypochondriac region, the dulness merging with that of the spleen and the left lobe of the liver. Usually, pulsation, and, rarely, a tumor, can be felt, and a systolic murmur is often, though not invariably, heard. The condition must not be confounded with gastric ulcer. ANEURYSM OP THE HEPATIC ARTERY. This is exceedingly rare, the total number of cases on record being about 20. H. B. Schmidt has recently reported a case associated with 692 DISEASES OF THE CIRCULATORY SYSTEM. symptoms of gall-stones, in Avhich, as shown by the autopsy, death was caused by rupture of the sac into the bile-ducts. Schmidt found records of but 5 cases of this mode of termination. Osier and Ross have reported an instance associated with multiple hepatic abscesses. The symptoms are, in the main, colicky pains, vomiting, hemateme- sis, and obstructive jaundice. A tumor is rarely discernible, though an abnormal area of pulsation is relatively more frequent. The recognition of the condition during life is entirely conjectural. Aneurysm of the superior mesenteric artery is of rare occurrence. Pain in the epigastric and lumbar regions, and a demonstrable tumor near to or directly over the median line of the abdomen, are the symptoms dis- played. Detached fragments of the clot may produce embolism of the terminal branches of the mesenteric arteries. The condition terminates usually in rupture into the peritoneal cavity. Aneurysm of the inferior mesenteric artery runs a course similar to that of the superior mesenteric, but is so rare as to possess little or no clinical interest. Aneurysm of the Renal Arteries.—Small multiple dilatations are occa- sionally seen, but large ones are of great rarity. They are prone to rupture into the retroperitoneal cavity. ARTERIO-VENOUS ANEURYSM. Definition.—An artificial communication between an artery and a vein. A sac may intervene between the two vessels (varicose aneurysm) or there may be a direct fistulous communication without an intervening sac (aneurysmal varix). In varicose aneurysm the sac is developed from the structures that mark the boundaries of the communicating duct. The majority of cases are caused by the simultaneous wounding of an artery and a vein during venesection. Hence their most frequent seat is at the bend of the elbow. Pepper and Griffith have analyzed the records of 29 cases in which the ascending portion of the aortic arch had opened into the vena cava. Symptoms.—The symptoms are to a large extent aneurysmal, and in addition there appear in rapid sequence great SAvelling of the veins, cyanosis, and edema of the upper portion of the body. A continuous thrill and buzzing murmur, with systolic intensification, are the chief physical signs. In the treatment of thoracic arterio-venous aneurysm the same gen- eral plan is to be pursued as advised in the purely arterial variety. The management of both forms belongs to the domain of surgery. CONGENITAL ANEURYSM. This condition arises because of a defective ante-natal development of the elastic coat. It is often multiple, and the tumors are, as a rule, small, in size ranging from that of a pea to a hazelnut. The most common situations for these groAvths are the coronary and pulmonary arteries. To Eppinger belongs the credit for having pointed out the fact that the aneurysmal walls consist only of the adventitia and intima. The condi- tion may be met Avith in children, and rarely in adults. PART VI. DISEASES OF THE DIGESTIVE SYSTEM. I. DISEASES OF THE MOUTH. STOMATITIS. CATARRHAL STOMATITIS. {Stomatitis Erythematosa.) Definition.—A simple, acute inflammation of the buccal mucous membrane. It is more commonly met Avith in children than in adults. Htiology.—As a primary affection its causes are mainly mechanical and chemical irritation, such as the presence in the mouth of hard and sharp bodies, dental caries, acids, hot or cold food, condiments, tobacco, certain drugs (as mercury), eruption of teeth, and bad feeding, par- ticularly in illy-nourished children. It is the result often of a neglect of the mouth-toilet, leading to the decomposition of accumulated bits of food and mucus and to the production of fungous and bacterial irrita- tion. Secondarily, catarrhal stomatitis may be associated with certain of the eruptive fevers (scarlet fever, measles, typhoid), also Avith gastro- enteric derangements, and may follow, by direct inflammatory extension, upon ulcerative tonsillitis, pharyngitis, and the like. Symptoms.—The local symptoms of this affection are those usually seen in an inflammation of a mucous membrane—redness, heat, SAvell- ing, and dryness, soon followed by increased secretion and soreness. The lips and gums only, or the membrane of the Avhole mouth, may be inflamed, and the SAvollen lips, cheeks, and furred tongue may be indented by teeth-marks. Enlarged and reddened papillae on the tongue and minute vesicles inside the cheeks and lips from projecting mucous follicles are sometimes seen. These, later, may terminate in simple small ulcers. A craving for cold drinks is nearly always noted, as Avell as distress and even pain on suckling, mastication, or touching with the inspecting finger, and there is a disagreeable taste due to the perverted buccal secretions. Chemical examination of the dribbling saliva shoAvs an acid reaction, Avith the presence, microscopically, of an excess of des- quamated pavement epithelium that has undergone partial fatty degen- eration. Leukocytes, micrococci, the leptothrix buccalis, and the re- mains of food may also be seen (Striimpell). Aside from restlessness and the symptoms common to slight febrile disturbances, the constitu- tional condition is rarely disturbed, except when the stomatitis is sec- 693 694 DISEASES OF THE DIGESTIVE SYSTEM. ondary either to inflammations lower doAvn in the digestive tract, or to the specific infectious fevers. The course of the disease is usually acute, and the duration about one Aveek. The differential diagnosis of catarrhal stomatitis is easily made by inspection of the membrane. The prognosis, though favorable, Avill vary as to time and severity according to the cause. Treatment.—After proper attention to the hygienic surroundings of the patient and the removal of all irritant influences, the treatment is mainly local. The first indications are to cleanse the mouth and allay the pain, and these may be met by the use of cool solutions of boric acid, sodium bicarbonate, or potassium chlorate, 5 and 10 grains (0.324 and 0.648) respectively to the ounce (32.0) of glycerin and rose-Avater, as mouth-washes, or for swabbing in the case of infants. When iced drinks are ungrateful and the inflammation is more intense and protracted, the use of hot milk and lime-water, mucilaginous decoctions, and sedative and antiseptic sprays of 1 or 2 per cent, solutions of cocain or carbolic acid are often beneficial; Or mild astringents may be needed, as \ to 1 per cent, solutions of silver nitrate, alum (5 to 10 grains—0.324 to 0.618 —to the ounce—32.0—of honey), and glycerite of tannin (2 drams to the ounce—8.0 to 32.0—of Avater), especially if there is a tendency to chronicity of the trouble, as in topers and inveterate smokers. Tender and spongy gums may be relieved by the application of equal parts of the tinctures of myrrh and rhatany on a camel's-hair brush (Striimpell). General symptoms as they arise must be met by the remedies rationally indicated. Small doses of aconite or potassium citrate for the pyrexia, with a minimum dose of bromid for irritability and sleeplessness, may be all that is required. The internal use of potassium chlorate in chil- dren is not to be recommended in this affection, both because of its deleterious action upon the kidneys, and also because it seems to be unnecessary (Forchheimer; Backader). Sometimes an associated gastro-intestinal catarrh needs correction by the use of laxatives. The administration of bland foods and mild ferruginous tonics should be continued throughout convalescence. APHTHOUS STOMATITIS. {Follicular Stomatitis; Stomatitis Aphthosa.) Definition.—A variety of catarrhal stomatitis that is characterized by the eruption of one or more vesicles upon the edges of the tongue, the cheek, or the lips, rapidly passing into small round, or oval discrete spots that are slightly raised and surrounded by yelloAvish-white bases with narroAV red areolae. Etiology.—Though more common in children between the ages of tAvo and six years, they are by no means rare in adults. Predisposing influences may be found in the seasons (spring and autumn), malnutri- tion, tuberculosis, dentition, persistent gastro-enteric disorders, anemia, and the acute exanthemata. The exciting causes are supposed to be certain deleterious substances, bacterial or toxic, though no special par- asite has yet been isolated. A PHTHO US STOMA Til IS. 695 Symptoms.—The herpetic vesicles soon rupture, leaving the aphthous ulcers as described above. They are found singly, or at times as many as tAventy in number, pin-head to split-pea in size, inside the lips, espe- cially near the frenum, along the tongue-edges, and sometimes inside the cheeks near the edges of the back teeth. They are exquisitely tender, so that almost any motion of the affected parts causes sharp burning pain; nourishment is therefore difficult. Patches of catarrhal stomatitis, and even of gingivitis, are seen adjacent to the aphthous spots. There is an increased flow of the secretions of the mouth, and the breath is heavy, though not offensive. General symptoms, as slight fever, anorexia, and furred tongue, constipation or diarrhea, and irrita- bility, are usually present, Avith the additional symptoms of any associated disease that may coexist. Gastro-intestinal affections, though often associated with aphthous stomatitis, are most probably due to the common cause, and are not necessarily the cause of the stomatitis in these in- stances. In some of the specific infectious fevers many aphthae may appear and tend to run together; these form large irregular ulcers, and give rise to the confluent form of stomatitis aphthosa. The special form known as Bednar's aphtha?, occurring in young marantic babes, is a rare condition in America. Large white patches are seen on both halves of the posterior part of the hard palate near the alveolar processes, and these may cause large ulcers and involve the bone. Pressure of the tongue upon the thin mucous membrane during nursing, or some other such form of traumatic irritation, appears to act as the cause. Recovery from this type is rare. The average duration of the ordinary discrete aphthous eruption is from four to seven days; in very ill-nourished and poorly cared-for cases the appearance of successive crops of aphthae will prolong the distress. Diagnosis.—This is based upon the characteristic appearance of the ulcers and the degree of soreness. Aphthae must be differentiated sometimes from thrush, and the distinguishing features will be dwelt upon in the description of the latter affection. Herpes of the mouth, so called, and aphthous vesicles are probably identical in most cases ; and the pres- ence on the lips of herpetic vesicles in some of the grave constitutional diseases indicates simply the severity of the common cause of the aphthae. Prognosis.—The discrete form is mild, and favorable in its course toward recovery; confluent aphthae is more troublesome, and folloAvs a prolonged course on account of the general debility induced by the associated disease (Starr). In certain adults, as well as in children, the affection is apt to recur; relapses are also frequent in those having Aveak digestive and imperfect assimilative functions. Treatment.—It is first necessary to remove all irritating influences, and in order to minimize the intense pain of the aphthous spots the blandest liquids and the softest foods that are consistent with the sus- tenance of the patient are imperative. Absolute cleanliness of both the foods and the vehicles of administration, especially in bottle-fed children, is not less important than the thorough cleansing of the mouth, par- ticularly after taking nourishment. Local applications are of obvious value. Demulcents, as mucilage of sumac, or of marshmallow, with boric acid (gr. v to 3j—0.324 to 32.0), sodium bicarbonate (gr. v-x to .Ij— Q.324-0.648 to 32.0), carbolic acid, or potassium permanganate (gr. iv 696 DISEASES OF THE DIGESTIVE SYSTEM. to 5J—0.259 to 32.0), are invariably useful. Swab-applications of Avine of opium (iTlv to §j—0.333 to 32.0) or of cocain (4 per cent, solution) may be necessary Avhen the pain is intense, and prior to taking food. To promote the healing of the ulcers a very light touch with the silver-nitrate stick or solution (gr. x-xxx to 3j—0.648-1.91 to 32.0) is often beneficial. Much favor is deservedly given also to potassium chlorate in solution (gr. x to 3j—0.648 to 32.0), or applied in the dry powdered form. In the confluent aphthous ulcer the use of sodium salicylate (sj to §j—4.0 to 32.0) has been recommended, while an ethereal solution of iodoform (sij to 3j—8.0 to 32.0) has been advised by J. LeAvis Smith. For bleeding and spongy gums the mild astringents mentioned in the treatment of catarrhal stomatitis are indicated. Stronger astrin- gents may answer for application to sluggish ulcers; thus copper sul- phate, either solid or in solution (gr. x to ij—0.648 to 32.0), and zinc sulphate (gr. xv to §j—0.972 to 32.0) are useful. Potassium chlorate acts as a specific in ulcers of the mouth, and is eliminated by the buccal secretions, which keep the ulcerated surfaces constantly bathed with the drug, so that its internal use is to be recommended, though in very small doses in children, being given Avell diluted, as in the following formula: B/. Potassii chlorat., gr. xxiv (1.55); Tinct. myrrhae, gtt. x (0.666); Syr. acaciae, f^ij (64.0); Aquae dest., q. s. ad fgiij (96.0).—M. Sig. Teaspoonful every three hours for a child three years of age. Constitutional symptoms are to be combated on general principles and require careful attention. Remedies directed to the correction of digestive derangements and to the stimulation of assimilation are also often required. Good food and ferruginous tonics are frequently necessary. MEMBRANOUS STOMATITIS. {Stomatitis Crouposa.) Definition.—In this form of stomatitis the inflammation is more intense and more extended in area than in the aphthous form, being also attended with the formation of a false membrane, which, when separated from the subjacent mucous surface, leaves a deeper and larger ulcer than does aphthous stomatitis. The pathology of these membranous patches, which are very sel- dom confined to the mouth alone, is embraced in the article on Diph- theria. If in the latter disease the typical false (diphtheritic) mem- brane is removed, it leaves a deeper ulcer than does the removal of a croupous membrane, in which the coagulation-necrosis involves the more superficial layers. In cases in Avhich necrosis of the upper layers of the oral mucosa folloAvs from the application of caustics, the coagula- tion-process extends inward from the surface, forming yelloA\ish-white patches of dead tissue, Avhich, on separation, leave an ulcer (Allchin). Membranous stomatitis may also be due to gonorrheal or syphilitic in- fection of the neAV-born. The etiology of membranous stomatitis is, then, either specific (diphtheritic,) or non-specific, due to chemical or physical irritants. ULCERATIVE OR FETID STOMATITIS. 697 The account of the local symptoms and treatment is also included in the description of the causal diseases. ULCERATIVE OR FETID STOMATITIS. {Stomatitis Ulcerosa.) Definition.—A specific ulcerative inflammation of the buccal mu- cous membrane and gums, attended Avith marked fetor of the breath, and having a tendency to extend Avidely and deeply. Etiology.—The predisposing causes of this malady are principally as follows: Childhood, after the commencement of the first dentition, and usually betAveen the ages of three and eight years; damp Aveather, especially during spring and autumn; unhygienic surroundings, partic- ularly the lack of pure air, of good and abundant food and clothing, and the added detriments to health for Avhich neglect and filth, specific in- fectious diseases, uncleanliness of the mouth, caries and loosening of the teeth, and congenital heart-disease (DuckAvorth) are responsible. An endemic type of this affection has been observed among soldiers in camps and barracks, among children in croAvded eleemosynary institu- tions, and in jails, and may be accounted for by unsanitary conditions affecting communities alike; its epidemic and contagious character like- wise points to a microbic origin. The specific exciting cause, it has been held, corresponds to the hoof-and-mouth disease of cattle, the poison being conveyed in milk. Payne suggests the identity of the virus Avith that of impetigo contagiosa. The careless administration of mercury, especially to susceptible adults, may also be followed by a severe mer- curial stomatitis that is typically ulcerative. Scurvy (scorbutic stoma- titis) and the persistent use of lead and phosphorus are also excitants of this disease. Clinical Symptoms.—Locally, the disease starts, as a rule, at the edges of the gums opposite the lower incisor teeth, gradually spreading backward and to the adjoining portions of the lips and cheeks. The gingival mucous membrane is deeply red and SAvollen ; the gums soon become spongy, bleed easily, and break down into thick, soft, grayish sloughs, Avhich leave deep and ragged ulcers surrounding the necks of the teeth. The latter even become loosened, and in protracted cases the alveolar periosteum may become inflamed and cause necrosis of the bone. Profuse salivation, a foul breath (that once earned for the con- dition the term of " putrid sore mouth "), occasional slight hemorrhages from the gums, and excessive discomfort, or even pain, on mastication are nearly always present. The tongue is coated, SAvollen, and tooth- marked; aphthae are sometimes seen, and the submaxillary glands are generally SAvollen. The general symptoms attending this ailment are those of a lowered state of vitality, produced by an unhygienic envi- ronment, or cachexia, or severe illness primary to it, with, usually, mod- erate fever. Nausea and vomiting or an offensive diarrhea may super- vene as the result of SAvalloAving the putrid discharges. Course and Duration.—Though acute in its course, the highly debilitating character of the disease may tend to make it chronic, espe- cially Avhen there is alveolar necrosis and a neglect of proper treat- ment. Ordinarily, Avith careful management, convalescence may be 698 DISEASES OF THE DIGESTIVE SYSTEM. established in from four days to a Aveek. Goodhart regards the occa- sional termination of the pyrexia by lysis, with an accompanying im- provement of the local symptoms in such cases at least, as suggestive of the specific nature of ulcerative stomatitis. Diagnosis.—Upon examining the mouth and noting the character- istic ulceration, the fetid breath and saliva, and the cachectic appear- ance, the disease is usually recognized, and should not be confounded with the dark, extensive, gangrenous sloughs of noma. The prognosis is favorable in typical cases, though less so in marasmic and neglected cases and when cancrum oris or necrosis of the jaw are superadded; in such cases recurrence, chronicity, deformity, and even death, may take place. Treatment.—It is Avell in nearly all ill-nourished, uncleanly-kept, and sickly children, as well as in cases in which mercury is to be admin- istered for any length of time, to prescribe mouth-washes of potassium chlorate (gr. xv to ij—0.972-32.0), in order to prevent the occurrence of mercurial or ulcerative stomatitis. The hygienic treatment of ulcer- ative stomatitis is important. On account of the contagiousness of the disease cases occurring in a family or in institutions should be isolated, and fresh air, light nourishment, and cleanliness are sine qud non of recovery. The local treatment is virtually a specific one in the use of potassium-chlorate Avashes (gr. x-xx to ij—0.648-1.296 to 32.0— of rose-water or demulcent), aided by the internal administration of the same salt in small doses. For the disagreeable fetid odor the alter- nate use of antiseptic washes is indicated. Solutions of carbolic acid or potassium permanganate, in strength equal to or slightly over that indicated in the treatment of aphthae, or hydrogen peroxid (3J-hj to ij ; 4.0-12.0 to 32.0), or listerin and water (equal parts), are useful. Pencilling the spongy gums with such astringents as tincture of rhatany, silver nitrate (gr. x to ij—0.648-32.0), alum, and also with tannic-acid solutions, may be necessary. Loosened teeth should not be disturbed, as they may grow firm with convalescence, though surgical interference may be required in cases of necrosis of the alveolar process. Until the patient has regained considerable vigor the use of mild antiseptic mouth- washes should be continued regularly, so as to effect thorough cleanliness and rid the oral cavity of lurking germs. Careful attention to the teeth is always requisite. During the height of the disease constitutional treatment may have to be directed toAvard stimulating the languid and lowered vitality. For this purpose either whiskey or brandy, in half or one teaspoonful doses in milk, is extremely useful; the elixir of cinchona, Avith some vegetable salt of iron, as the citrate or tartrate, also forms a useful combination. When there is pyrexia or a diminished urinary secretion the internal use of potassium chlorate is dangerous and must be cautiously employed. The folloAving prescription is tonic and almost specific, and may be recommended : B/. Potassii chloratis, gr. xlviij (3.11); Acidi hydrochlor. dil., ftj (4.0); Syrupi, ftvj (24.0); Aquae destillat., q. s. ad fiiij (96.0).— M. Sig. Teaspoonful diluted, every two hours for a child three years old (Starr). PARASITIC STOMATITIS. 699 The prolonged use of tonics and cod-liver-oil emulsion with lime- salts in scrofulous, rachitic, and scorbutic subjects must be carried on in order to prevent relapses of ulcerative stomatitis. PARASITIC STOMATITIS. {Thrush; Stomatitis Mycosa.) Definition.—A specific, contagious furigous disease, characterized by the rapid formation upon the oral mucous surfaces of small, whitish, soft, and lightly adherent spots or flakes, tending to coalesce and spread throughout the entire buccal cavity. Etiology.—Predisposing causes are—infancy with its concomitant disorders of the gastro-intestinal tract (especially Avhen unhygienic sur- roundings and a consequently impaired vitality and malnutrition prevail), also congenital syphilis, tuberculosis, and the exanthemata. The dis- ease may attack adults and complicate the typhoid and cachectic states, as in the final stages of Ioav fevers, carcinoma, chronic tuberculosis, and diabetes. The growth of thrush-patches is due, specifically, to the sac- charomyces albicans (formerly o'idium albicans). It is a characteristic of this fungus to develop from round or oval spores in the formation of long- branching mycelium filaments, from the ends of Avhich a multiplication of ovoid torulae-cells takes place by the process of simple budding. These mycelia exhibit a tendency to penetrate the deeper layers of the mucosa of the mouth and also into the mucous glands (Starr). Since the growth of this organism requires both an altered condition of the mucous membrane and an acid medium, the primary or exciting cause of thrush is to be found in Avhatever produces such a favorable nidus. Most important in this connection is uncleanliness, particularly in the case of poorly-nourished and bottle-fed children. The development of catarrhal stomatitis and the acid fermentation of remnants of food (especially of saccharine substances), which prevent the nutrition of the mucosa and acidify the normally alkaline oral secretions, are common causes of thrush. The further groAvth of the fungous patches also contributes to the acid state of the already abnormal buccal fluids. The fact that the spores of thrush may be transferred to other cases by bottle-tips, spoons, and ill-kept feeding-bottles is Avell recognized as an explanation for the occasional endemic character of the malady. Symptoms.—Any marked local symptoms are due rather to the coexisting stomatitis than to the thrush itself (Allchin). There will be some soreness, heat, persistent dryness, and lividity of the mucous mem- brane. Thrush-spots, slightly raised above the surface, begin to appear on the tongue, and grow into patches that may coalesce and spread to the cheeks, lips, and hard palate: they may even invade the tonsils, pharynx, and esophagus, and, rarely, the true vocal cords, the stomach, and cecum (Parrot). At first pearly-white in color, the curd-like flakes may become yellow and even brown, owing to slight hemorrhages caused by the irritation. Though early adherent, in a few days they become loose, and when brushed off leave a smooth surface ; when complicating some serious gastro-intestinal disease or dyscrasia, hoAvever, their attach- ment is deeper, and the deposit may sometimes appear in successive crops. A microscopic examination of the thrush-patches shows inter- 700 DISEASES OF THE DIGESTIVE SYSTEM. lacing, irregular, and branched mycelial threads, spores, occasional bacilli, and leptothrix-filaments imbedded in a mass of granular debris and fetid particles. The buccal fluids are acid in reaction. The Gen- eral symptoms depend upon the associated disease, and are usually those of wasting, artificially-nourished children having digestive troubles or a constitutional taint. Diagnosis.—This may be accurately made upon the discovery of the fungus by microscopic examination. Only very rarely are portions of the thrush-organism found in the false membrane of diphtheritic stomatitis. Milk curds may be readily removed, and are not necessarily associated Avith the stomatitis accompanying thrush or the grave sys- temic states. The only important point of differential diagnosis arises in the case of aphthce. The following table will express the main points upon Avhich a safe discrimination may be based: Parasitic Stomatitis (Thrush). Aphthous Stomatitis. Dryness of the mouth. Salivation. Whitish, raised spots or patches with no An ulcer with a yellowish-white, de- red areola ; these are easily removed, pressed base, surrounded by a red are- leaving no ulcer and causing no bleed- ola. The base is removed with diffi- ing. culty by forceps, and bleeding results. Spots are numerous. Usually few in number and discrete. Begins in the form of minute spots. Not so ; ulcers appear, preceded by the formation of herpetic vesicles. Ulcers not painful. Discomfort depends Ulcers exquisitely tender. on the associated stomatitis. The characteristic thrush-fungus is al- No specific micro-organism determined, ways present in the deposit, and can be though probably present. seen with the microscope. Prognosis.—This is favorable as regards the thrush alone, but, occurring in marantic children and cachectic adults, its appearance is of grave significance, and it is even suggested by some that it portends a speedy death. Treatment.—Prophylaxis is of great moment, since it is much easier to keep the mouth clean and the secretions normal, and to attend to proper food, and thus avoid creating a soil for the growth of the vegetable parasite, than it is to prevent absolutely the entrance of thrush-spores. Efforts directed toward preventing acidity are especially indicated. This is to be done by the use of mild alkaline mouth-washes, as soda- Avater and lime-water. The dietary should be carefully looked after, and should exclude sugars and all starchy food; the addition of lime- water to the milk (about one part to four) is a desirable precaution to take, particularly Avith children. Cleansing the feeding-apparatus and the mouth after each feeding is essential, both in the prevention of the formation, and in decreasing the further growth, of thrush when pres- ent. The local treatment consists in the use of alkaline and antiseptic applications, preferably by means of the spray. Solutions of boric acid or sodium hyposulphite (sj—4.0—of either to ij—32.0—of water, Avith the addition of a little glycerin), potassium permanganate, or hydro- gen peroxid, are useful. Syrupy excipients are to be excluded. Potas- sium chlorate may exert a beneficial effect in those cases in Avhich stom- atitis is associated, as may also pencilling with a solution of silver nitrate (gr. v to ij—0.324 to 32.Oj over the inflamed mucosa. GANGRENOUS STOMATITIS. 701 When esophageal obstruction exists it maybe necessary to gently force a rubber tube through the mass of thrush-deposit in order to give nourishment (Forchheimer). Medicinal treatment embraces the administration of nourishing and easily digestible food, occasional stimulation, and the correction of gastro-intestinal disorders. Attention must also be paid to the pri- mary affections to Avhich the thrush is superadded. Iron, cod-liver oil, and acid and bitter tonics in palatable form are usually indicated in debilitated subjects, along Avith general hygienic measures. The inter- nal use of small doses, frequently repeated, of calomel or mercuric chlorid may also be tried for a possible specific effect in combating thrush. LA PERLECHE. This contagious disease is confined to the angles of the mouth. It was first described in 1886 as prevalent among the children of Limousin in France by Lemaistre. It was found that the drinking-water in that locality contained cocci similar to the spherobacteria that infested the epithelial thickenings, and that these were probably conveyed to human beings by drinking-vessels. Little elevations and fissures, said to resemble those of congenital syphilis, were seen around the oral angles. The latter were the seat of smarting pain, particularly on opening the mouth sud- denly or too far, and caused the patient to lick (perlicher) them con- stantly. The disease seemed to be entirely local, and lasted from two to three weeks. Alum and copper-sulphate solutions were most useful. GANGRENOUS STOMATITIS. [Noma; Cancrum Oris.) Definition.—A rapidly-spreading gangrenous affection of the cheek and gums, of rare occurrence, usually asymmetric, and ending fatally in most cases. Pathology.—In addition to the necrotic changes in the cheeks, the process may extend to the jaws and lips. The blood-vessels contain thrombi, thus preventing hemorrhage from the sphacelus. The submaxil- lary and cervical glands may be slightly enlarged and soft. Blood-changes of an uncertain character have been noted. Hemorrhagic infarctions, aspiration broncho-pneumonia, or gangrene by inhalation of gangrenous particles or metastasis, may be met in the lungs. Wharton has described an associated membranous form of colitis, and a metastatic infiltration of the cardiac muscle and purulent pericarditis may also be seen post- mortem. Klementorosky met Avith a peculiar and fatal form of gangrene limited to the gums of babes and occurring a feAV days after birth. Etiology.—Predisposing Causes.—This uncommon affection attacks girls more frequently than boys, usually betAveen the ages of tAvo and five years; it appears to be endemic in Ioav, moist countries, as Holland, though apparently it is not contagious. Sickly and ill-nourished chil- dren suffering from the effects of overcrowding and previous disease are especially liable to noma. Most often, hoAvever, it is secondary to measles; it may also follow scarlet fever, typhoid, small-pox, or less fre- quently pertussis. Boydon reported a case associated Avith erysipelas 702 DISEASES OF THE DIGESTIVE SYSTEM. in an adult. The causative influence of mercurialization and ulcerative stomatitis has been overrated. The primary exciting cause of cancrum oris is probably microbic, and Lingard has found "long thread-like groAvths made up of small bacilli at the line of extension of the necrotic patch." Symptoms.—The mucous membrane of one cheek, near the corner of the mouth, is usually first affected, a dark, ragged, sloughing ulcer appearing and spreading insidiously for tAvo or three days before the substance of the cheek is involved. A hard and sensitive nodule may then be felt by grasping the cheek betAveen the thumb and finger on placing the one Avithin the mouth over the ulcer and the other outside. Brawny induration of the skin over this nodule soon becomes manifest, and then there appear collateral edema and an unctuous-looking, deeply livid, gangrenous spot, soon becoming bullous and leaving a black eschar. Perforation of the cheek may occur on the third day, though usually not until a week has passed. There is an ichorous dis- charge of shreds of gangrenous tissue from the unhealthy Avound. The fetor of the breath is almost intolerable and characteristically gangren- ous. The necrosis may extend over one-half the face of the side affected, and may involve the gums and jaws, but seldom does it attack the opposite side of the face. The general symptoms of such a grave mal- ady may be slight at a very early period, but with the formation of the eschar they become rapidly severe and typhoid in type. Great prostra- tion, delirium, pyrexia (104° F.—40° C), diarrhea, and edema of the feet are common. The course is actively acute; the duration rarely extends beyond tAvo Aveeks. Complications.—Septic lobular pneumonia may occur from aspira- tion of gangrenous particles; colitis and gangrene of the genitalia in females (noma pudendce) are also seen. In those very rare cases that recover granulations form, the gangrenous edges become clean, and cicatrization, with great disfigurement of the face and even restricted jaAv-motion, is then apt to follow. Diagnosis.—The disease when fully established is easily diagnosed by its characteristic origin, the gangrenous ulcer-nodule, the eschar-for- mation, and perforation, associated Avith a previous history of measles or other acute infectious fever of childhood. The offensive fetid odor and severe constitutional depression are also of great value. Differential Diagnosis.—From anthrax it differs in that the latter affection is more common in adults, with a history of contagion, and in the fact that malignant pustule starts on the exterior of the cheek, and perhaps in a previous abrasion in the skin. The discovery of the bacillus anthracis in the blood and discharges is conclusive. Ulcerative stomatitis of a severe and neglected type may be confounded with can- crum oris, but in the former the destruction of tissue is mainly of the gums and alveoli, the cheeks being simply ulcerated and no extensive sloughing taking place; the breath, though fetid, is not gangrenous, and the oral discharge, though sometimes bloody, is not mixed with shreds of gangrenous tissue (Starr). Finally, the course of ulcerative stomatitis is less severe, a fatal termination being extremely rare. Prognosis.—Noma is seldom recovered from, the mortality being about 80 to 90 per cent. (Bogel). When recovery does take place the MERCURIAL STOMATITIS. 703 development of ectropion, facial deformity, and local disability, with a protracted convalescence, render life burdensome. Treatment.—This embraces the prevention of gangrenous stoma- titis by means of a proper management of the diseases that are knoAvn to cause it; careful hygiene and the avoidance of mercurialization Avill also be of undoubted use. The primary indication in the local treat- ment is the arrest of the gangrenous process, thus causing, if possible, a healthy reaction on the part of the surrounding tissues. All dead sloughs should be cut away before using escharotics, and with this end in view some recommend the prompt application of strong caustics, as fuming nitric acid, the acid nitrate of mercury, solid zinc chlorid, silver nitrate, carbolic acid, a concentrated solution of perchlorid of iron, Vienna paste, and the actual cautery. For the protection of the healthy parts and for efficiency the Paquelin or the galvanic cautery is prob- ably best. Anesthesia is requisite for such strong measures. Milder applications, however, seem to be quite adequate in some cases. Thus, bismuth subnitrate, potassium chlorate, and aristol, or the folloAving for- mula by Dr. Coates, may be tried: B/. Cupri sulph., 3ij (8.0); Pulv. cinchonae, iss (16.0); Aquae, q. s. ad fiiv (128.0).—M. It is essential, for the prevention of septic infection to ensure cleanli- ness of the wound and of the mouth, and to promote the separation of the sloughs. To effect the former Ave employ mild antiseptic Avashes of carbolic acid, hydrogen peroxid, Labarraque's solution, potassium per- manganate, etc.; for the latter and for the diminution of the fetor, anti- septic charcoal poultices containing boric or salicylic acid are useful. Mild antiseptic and astringent lotions of boric acid, zinc sulphate (gr. ij to ij—0.129 to 32.0), or balsamic ointments with vaselin, may aid in healing the granulating surfaces in favorable cases. The internal treat- ment must be directed toward sustaining the strength of the patient by the administration of the most nourishing food, stimulants, and tonics, especially quinin, iron, and strychnin. Rectal feeding may be neces- sary. Plastic operations are sometimes needful after recovery to miti- gate oral disabilities or facial deformities resulting from cicatricial adhe- sions and contractions. MERCURIAL STOMATITIS. {Mercurial Ptyalism.) Definition.—An inflammation of the mouth and salivary glands, caused by the excessive use of mercury; it is rarely seen as a result of the therapeutic use of other drugs. Etiology.—Predisposing causes are dyscrasia and occupation, mainly. The peculiar individual susceptibility of these subjects to dyscrasia will not permit the use of even minimum doses of mercury without serious and almost immediate symptoms of ptyalism. This is also seen in barometer-makers, mirror-silverers, chemists, and others who handle mercury in their daily work. The exciting cause of ptya- lism is the ingestion, inhalation, or cutaneous absorption of mercury. 704 DISEASES OF THE DIGESTIVE SYSTEM. Symptoms.—A metallic taste in the mouth is first noticed by the patient. Soon the gums become "touched"—i. e. red, SAvollen, tender to the touch, and sore during the act of mastication. A marked secre- tion and flow of saliva, with a fetid breath and swollen tongue, folloAv. Very rarely in this disease the affection passes into an ulcerative stoma- titis, and causes loosening of the teeth and necrosis of the maxilla. General symptoms, as constitutional depression, anorexia, diarrhea, mental anxiety, and nervousness, may supervene. The recognition of the foregoing causal factors—predisposing and exciting—renders the diagnosis easy. The prognosis is favorable, and, although the local symptoms may be harassing, recovery is attainable within a few weeks as a rule. Treatment.—The toxic action of mercury in the production of ptyalism can be avoided by a knowledge of individual susceptibility and by the local and internal use of potassium chlorate. Upon the first appearance of the symptoms there must be a prompt AvithdraAval of the mercurial influence, and a change of occupation if that be the predis- posing cause. Locally, soothing, alkaline, and mildly antiseptic mouth- washes, as in the treatment of catarrhal stomatitis, may be all that is necessary. For the fetid breath solutions of boric acid or potassium chlorate may be used. Ulcers may be brushed Avith silver-nitrate solu- tion. The internal treatment should be directed toward keeping the bowels soluble; in addition, alkaline mineral Avaters may be used, and in severe cases potassium chlorate in 5- to 10-grain (0.324-0.648) doses. Atropin (gr. -j-j^—0.0006) and opium have been recommended to de- crease the excessive salivary secretion and to allay pain, and hot baths Avill aid the treatment materially. In severe cases the resulting debility and anemia should be met by the use of highly nourishing liquid foods and by tonics. Osier points out that the condition of the teeth knoAvn as erosion, which sometimes folloAVS infantile stomatitis, and especially the mercurial form, is to be discriminated from the deformed teeth of congenital syph- ilis. In the former the first permanent molars, and then the incisors, are observed to have small pits or discolored and eroded spots, due to a morbid deficiency in enamel-formation. The notched and irregular teeth of hereditary syphilis in children (Hutchinson) are sufficiently distinctive. II. DISEASES OF THE TONGUE. GLOSSITIS. ACUTE GLOSSITIS. {Glossitis Acuta.) Definition.—An acute parenchymatous inflammation of the tongue, sometimes ending in abscess. Etiology.—Predisposing causes are supposed to be an impaired gen- eral health and exposure to cold, humid Aveather. The exciting causes CHRONIC SUPERFICIAL GLOSSITIS. 705 are most frequently the stings and bites of insects, or burns, scalds, and the action of corrosives. I believe that many cases folloAv slight in- juries to the tongue that alloAV of the introduction of inflammatory poisons or microbes. Symptoms.—These come on rapidly and with more or less local severity and danger. The tongue becomes much SAvollen, and may even protrude beyond the lips. It is very tender and painful, and coated with a thick, soft yelloAvish-Avhite fur, and it may also be dry, cracked, and ulcerated. Catarrhal stomatitis is often associated, salivation is usually profuse, and talking, swTallo\ving, and even breathing, are ren- dered difficult and distressing. Dyspnea, even to suffocation, may be imminent. The cervical and sublingual glands may be SAvollen, mode- rate fever is always present, and the obstruction to breathing and admin- istration of nutriment may assume a dangerous aspect. The inflammation reaches its height in about three or four days, tending to subside almost entirely about the seventh day. Not rarely the inflammatory infiltration passes into suppuration Avith the formation of a circumscribed abscess of variable size in one-half of the tongue; fluctuation may not, hoAvever, be obtainable, spontaneous rupture being sometimes the first indication of abscess. The prognosis is favorable, except that serious obstruction is likely to remain. Treatment.—When the case is seen quite early and during the congestive stage, the topical use of ice, allowed to slowly dissolve in the mouth, may be both grateful and of service in preventing the swelling. Mucilaginous mouth-washes, containing some mild antiseptic, as sodium borate with sodium bicarbonate (gr. v-xx to ij—0.324-1.296 to 32.0), should also be employed. A brisk saline purge, given early, will aid in reducing the inflammation, and should the tongue become alarm- ingly swollen, deep scarification and the use of half a dozen leeches be- tween the hyoid bone and the jaw-angles may be of decided service. Steam-atomization, medicated with the compound tincture of benzoin or ammonium chlorid (3j to ij—4.0 to 32.0), favors resolution (Cohen). Abscesses must be incised and washed out with antiseptic solutions. Tracheotomy is rarely called for to relieve the dyspnea. Rectal ali- mentation with predigested foods may be necessary, and during con- A'alescence ferruginous tonics in glycerin and bland foods should be con- tinued for some time, in order to prevent chronic inflammation and thickening. Any local source of irritation, as from carious or sharp teeth, should be removed. CHRONIC SUPERFICIAL GLOSSITIS. Definition.—A chronic inflammation of the mucosa of the tongue. Etiology.—This disease is often preceded by several acute attacks, the habitual use of tobacco, both in smoking and chewing, and of strong spirituous liquors being mainly productive of the original affection. The frequent use of irritating foods is also a prominent factor in some instances. Symptoms.—The surface of the tongue is continually sensitive and more or less reddened. Often there are seen ovoid patches of various size, smooth and shiny, on account of the loss of papillae, and separated 45 706 DISEASES OF THE DIGESTIVE SYSTEM. by furrows that extend to the depth of the mucosa itself. The tongue may also be slightly furrowed in intervening spaces, especiallv at the base. The general health is somewhat deteriorated. Diagnosis.—This rests upon the history of the case and upon the results of examination of the organ. The prognosis is favorable as to alleviation, but guarded as to cure. Treatment.—The blandest dietary must be insisted on, as Avell as absolute abstention from the causal irritants, exacerbations being prone to occur. The local use of demulcents and of mildly alkaline and anti- septic lotions, such as Seller's tablets in solution, and of solutions of chromic acid or silver nitrate (gr. v-x to ij—0.324-0.648 to 32.0) in glycerin or honey, applied once or twice daily by gentle brushing, is to be recommended. General tonics and the avoidance of irritating drinks will be indicated. GLOSSITIS DESICCANS. A rare disease, chronic in nature and of unknown causation. It is characterized by " the gradual development upon the surface of the tongue of a number of deep fissures and indentations, giving the organ an uneven and ragged look. The pain is due to the frequent presence of excoriations and ulcers in these fissures " (Striimpell). The prognosis of the affection is favorable as regards any danger. The treatment is hygienic, consisting of cleanliness of the mouth and the use of disinfect- ant mouth-lotions, together with the topical use of alterative or astrin- gent applications, as silver nitrate or chromic acid, to any ulceration. LINGUAL PSORIASIS (TYLOSIS LINGUA)). In this disease there are small regular areas of hyperplasia of the glossal epithelium, eventually causing a map-like appearance of the sur- face of the tongue—"lingua geographica." The trouble is obscure in its etiology and persists for years. Seldom is there any discomfort asso- ciated, although mental anxiety or hypochondriasis may develop. LEUKOPLAKIA ORIS (BUCCAL PSORIASIS). In this affection the mucous membrane of the mouth and tongue may be involved. On the lateral borders of the tongue white or bluish-white scar-like spots or patches, often slightly notched, make their appearance. Some of these pass away to be replaced by others, and the affection pro- gresses despite all attempts to cure it. The true cause is unknoAvn, but it has been suggested that some irritant, as the use of a pipe, may account for the condition. The malady has, hoAvever, been seen in women. A syphilitic taint is said to especially predispose to the dis- ease (Striimpell). The affection must be carefully diagnosed from the oral manifestations of syphilis, if for no other reason than to relieve the mind of a morbidly anxious patient. Excepting some pain con- nected with possible ulceration, there are no annoying symptoms, and the treatment further than that suggested for glossitis desiccans is usually of no value. DISEASES OF THE SALIVARY GLANDS. 707 In children a similar tongue-affection has been named "wandering rash." The whitish patches are circinate and enlarge peripherally, forming rings of epithelial hyperplasia, Avithin Avhich is a red, glossy center " devoid of filiform papillae, though the fungiform remain " (All- chin). The affection is regarded as a tropho-neurosis. ANGINA LUDOVTCI. {Ludwig's Angina.) Definition.—A rare acute phlegmonous inflammation of the floor of the mouth. Etiology.—The condition may be idiopathic, but more often it is secondary to specific infectious diseases, as scarlet fever and diphtheria. Undoubtedly it is directly caused by a streptococcus and by an extension of the infection from adjacent glands (Osier). Symptoms.—These are intense at the outset, and begin with swell- ing in the region of the submaxillary gland, with a rapid involvement of the cellular tissue of the floor of the mouth as well as of the anterior portion of the neck. Pain is marked, and this, with the acute swelling, renders articulation, mastication, and deglutition extremely difficult. Compression or edema of the larynx may often cause dangerous dyspnea. The constitutional disturbance is usually febrile, and may either approach the typhoid type or may be septic. The condition generally terminates either in abscess or extensive sloughing (cynanche gangrenosa), and only rarely does resolution take place. The diagnosis is easily made when complicating a specific fever. The prognosis is always guarded, since death sometimes occurs. Relapses are likeAvise apt to follow in weakly and strumous subjects. Treatment.—The most that can be done is to sustain the strength of the patient and secure prompt surgical interference when the process has reached the point of beginning suppuration or gangrene. Trache- otomy may be demanded if asphyxia threatens life. III. DISEASES OF THE SALIVARY GLANDS. HYPERSECRETION. {Ptyalism.) Definition.—An abnormal increase in the secretion of saliva. Etiology.—Salivation as an idiopathic affection is rare, and as such is considered to be a neurosis. Thus, it has been seen in emotional children of from twTo to eight years of age, though apparently in perfect health. According to Bohn, the secretion in these cases is mostly in- creased during active exercise, is reduced on lying doAvn, and absent during sleep. Spontaneous recovery takes place in a few years. As a deuteropathic disease ptyalism may be the result of oral disease (e. g. noma, ulcerative stomatitis), and also of gastro-enteric, pancreatic, 708 DISEASES OF THE DIGESTIVE SYSTEM. uterine (as gestation), centric (as diseases or tumors of the medulla or of the facial nerve), toxic, systemic (as small-pox, the use of mercury, iodids, pilocarpin, tobacco), and hydrophobic irritation and disease. Diagnosis.—It should be pointed out that a failure in swalloAving the normal quantity of saliva may cause dribbling from the mouth and simulate true hypersecretion. The prognosis is favorable in itself, but dependent on the gravity of the cause. Treatment.—The causes are to be removed and the general health toned up. For stomatitic salivation potassium chlorate is first in rank as an internal and local remedy. Iron and arsenic are valuable in neur- otic cases, and the bromids or hyoscin may be of supplemental use. Atropin (gr. ^fa to jfo—0.0003 to 0.0006) and belladonna are almost uniformly successful in idiopathic as well as in central ptyalism. XEROSTOMA. {Aptyalism; " Dry Mouth.'1'') Definition.—A morbid suppression or arrest of the salivary and buccal secretions. Etiology.—Most of the cases of dryness of the mouth have been observed in women in conjunction with nervous or sudden mental phe- nomena, and only as a temporary condition. Centric involvement con- nected with the secretion of saliva is probable in some cases (Hadden). Much more commonly xerostoma is an effect of the febrile state, of mouth-breathing (due to nasal obstruction), and of diabetes. Symptoms.—Apart from the sensation of dryness, mastication, deglutition, and articulation are difficult. The local appearances show a glazed, shiny, red, and sometimes cracked condition of the tongue and labial and palatine mucous membrane. The absence of saliva may per- mit the remnants of food to collect around the gums and harden (Osier). The diagnosis is made on inspection, the prognosis depending on the removability of the cause, and rightfully being guarded on account of the frequent obstinacy of the trouble. Treatment.—Attention to the systemic condition, whether diseased or merely debilitated, is requisite. Small doses of potassium iodid and pilocarpin (gr. -^—0.003) in gelatin lamellae or in lozenge form, allowed to dissolve in the mouth with the aid of a sip of Avater, have been pro- ductive of relief. In cases of obscure or of centric origin the galvanic current should be tried. SYMPTOMATIC PAROTITIS. {Parotid Bubo.) Definition.—A secondary inflammation of the parotid gland, gen- erally due to septic infection, usually unilateral, and tending to suppu- ration. Etiology.—Not being a primary affection, the causes giving rise to DISEASES OF THE TONSILS. 709 it may be mentioned as folloAvs: (a) Acute infectious fevers, as typhoid, typhus, pneumonitis, pyemia, erysipelas; (b) Injury or disease of the abdomen or pelvis (Stephen Paget), especially when associated with the genito-urinary tract, as mild traumatisms or derangement of the testes or OAraries, the use of a pessary, or even menstruation or pregnancy; gastric ulcer may be accompanied by it; (c) Peripheral neuritis Avith facial paralysis (Gowers). Most of the cases are probably septic and indicative of an unfavor- able course in the progress of the associated disease, and especially of the fevers mentioned. The symptoms, diagnosis, and treatment of the parotitis itself fall more properly \inder the scope of surgery. IV. DISEASES OF THE TONSILS. ACUTE TONSILLITIS. Definition.—An acute inflammation of the tonsil or tonsils, affect- ing either the mucous membrane, the follicles, or the parenchyma, and ending either in resolution, suppuration, or chronic enlargement. Pathology.—In the superficial variety of acute tonsillitis the mu- cosa is simply red, swollen, and sometimes covered with a thin, soft exu- date of muco-pus. The tonsil itself may also be SAvollen. In follicular tonsillitis the lacunae become filled with a cheesy exudate Avhich often protrudes from the tonsillar crypts; epithelial and pus-cells, cellular debris, and occasional cholesterin-crystals are found in these cheesy masses. In older, darker-hued masses an offensive odor is given off, and numerous micrococci and bacteria are found. In adults, calcareous infiltration of the cheesy little masses may be met Avith. Parenchyma- tous tonsillitis is shown by a greater enlargement of the tonsil, due to a marked infiltration of all the tissues. Suppuration in the tonsil is frequent, the follicles usually bursting and uniting in abscess-forma- tion. Pus may burrow into the cellular tissue surrounding the tonsil, and find its way even doAvn to the clavicle. The herpetic or ulcero-mem- branous form of tonsillitis described by Rilliet and Barthez, DaCosta, and others, in which an eruption of herpetic vesicles on the tonsils is followed by their rupture and the formation of a lightly adherent, membranous covering, is rarely met with. It is said to complicate superficial or ca- tarrhal tonsillitis (Allchin). In necrotic tonsillitis (Striimpell) a grayish- white adherent necrotic membrane is observed, that is limited by the in- flamed membrane surrounding the mucosa covering the tonsils, Avhich are moderately SAvollen. After the removal of the slough a dirty and often deep ulcer remains. Etiology.—Predisposing causes are age, sex, temperament, and atmospheric conditions. The disease is more common in youth and in early adult life than during infancy, although enlarged tonsils are fre- quently met Avith at this period of life also. Boys and young men ap- pear to be attacked more often than the opposite sex. An individual susceptibility is most distinct in lymphatic and strumous constitutions; 710 DISEASES OF THE DIGESTIVE SYSTEM. this may be simply hereditary, or in certain cases it is aggravated by or tends to recur especially in the rheumatic diathesis. It is certain also that one attack of acute tonsillitis predisposes to subsequent ones, par- ticularly when the first attack has left some enlargement or hypertrophy of the tonsils. Sudden, rapid, and extreme climatic changes, and the special local and atmospheric conditions sometimes seen in connection with outbreaks of scarlet fever, measles, and diphtheria, have an un- doubted influence predisposing to epidemic tonsillitis. The exciting causes of acute tonsillitis are most commonly the follow- ing : (a) exposure to cold and dampness, or talking in a cold, moist at- mosphere; (b) exposure and talking in an overheated atmosphere viti- ated with smoke or other poisonous and irritating vapors or gases; (c) bad drainage, sewer-gases; (d) specific infectious fevers, as scarlatina, measles, and erysipelas; (e) irritation from hard and sharp foreign bodies or chemical irritants; (/) the presence of microbes. Clinical Symptoms.—Three principal varieties of acute tonsillitis occur clinically, the symptoms of which will be described under their respective headings: (a) Acute Catarrhal or Superficial Tonsillitis.—This form is often associated with acute pharyngitis. The earliest local symptoms are pain and difficulty in swallowing, the former often becoming quite acute and radiating to the ear and lymphatics at the angle of the jaw, where ten- derness on pressure may also be elicited. In speaking a nasal twang is often noticed. During the laborious act of SAvallowing the sensation of a lump in the throat, especially when the mouth is dry, is commonly complained of. Simple stomatitis, Avith its discomforts, may be associated, and rarely there is a slight cough with the painful expectoration of a sticky mucus which accumulates in the throat (BroAvne). There may be salivation, and usually there is a bad taste in the mouth, with fetor of the breath. Inspection shoAvs the tonsil to be red and SAvollen. Though dry and glazed at first, the surfaces soon become covered Avith a thin exudate of muco-pus, which is easily detached by brushing, gargling, or "hawking" the throat. There is usually some accompanying red- ness, and also a tumefaction of the uvula and faucial pillars. The con- stitutional symptoms of simple erythematous tonsillitis at the outset are mildly febrile. The attacks usually come on rapidly, and last but a few days, subsidence taking place rapidly also. Otitis media may follow the extension of the tonsillar inflammation, and acute pharyngitis is a more common complication; endocarditis and pericarditis rarely also occur. (b) Acute Lacunar or Follicular Tonsillitis.—In this form, which is quite common in children, not only the mucous membrane lining the crypts is inflamed, but that covering the surface of the tonsils also, giv- ing rise to more or less associated catarrhal tonsillitis. The local sub- jective symptoms in this disease are pain, tenderness, and difficult deg- lutition, the counterparts of those of the preceding form. The tonsils are seen to be covered with small, slightly prominent, whitish-yellow spots or patches of a characteristic creamy exudate corresponding to the position of the crypts and numbering from two to eight or ten or more. These little masses or. plugs may be pressed out of the follicles with a spatula. A predominance of pus-cocci and cells may rarely forerun the further formation of little follicular abscesses, and even of slight erosions ACUTE TONSILLITIS. 711 and ulceration of the mouths of the lacunae. Unlike simple catarrhal tonsillitis—at least in so far as simultaneous involvement is concerned (Cohen)—both tonsils are usually affected in this trouble, though one to a greater degree than the other. The Avhole tonsil is considerably swol- len, and in severe cases the cervical lymph-glands also. The constitu- tional symptoms of follicular tonsillitis may be quite severe. The disease may be ushered in with a pronounced chill, headache, aching of the back and limbs, marked anorexia, a heavy deposit of urates, and in- somnia, along with a rapid rise in the temperature to 103° or 104° F. (39.4°-40° C.)—in children as high as 105° F. (40.5° C). The gen- eral depression'may be so great as to simulate adynamia. Though sud- den in its onset and rapid and often intensely acute in its progress, the disease seldom lasts more than five or eight days. Follicular abscesses, febrile albuminuria (Hais-BroAvn), may appear and complicate the case, Avhile chronic swelling of the tonsils, desiccation, and bacterial degen- eration of the lacunar masses may be sequelae. The latter give rise to an offensive odor when crushed, and often cause hypochondriac patients needless anxiety by being mistaken for tuberculous deposits. The re- tained follicular exudates may undergo calcification, and may be expec- torated along Avith concretions or chalk-plugs. (c) Acute Parenchymatous Tonsillitis (Tonsillar Abscess or Quinsy). —In this form of tonsillitis, which occurs most often during adolescence and early adult life, the symptoms reach the most pronounced and severe types. The stroma is inflamed and the tendency is toAvard suppuration. Local Symptoms.—Complaint is first made of dryness of the throat, with painful and difficult deglutition. The pain is a prominent subjec- tive sign, and may be referred to one or both ears according as one or both tonsils are inflamed. The secretion of a viscid mucus soon takes place, and as the tonsillar SAvelling increases, the husky voice of sore- throat and difficult articulation supervene; in cases of aggravated swelling dyspnea may often appear later. On examining the tonsils they are found to be greatly enlarged, deeply reddened, and edematous. The surrounding soft parts, the faucial arches, pillars, and the uvula, also manifest a deep congestion. The swollen tonsils may cause a bulging forAvard of the anterior pillars of the fauces, and push the often elongated and edematous (jelly-like) uvula to one side; or if both tonsils are affected, they may grasp or push it forAvard. In severe cases the tonsils may meet in the median line. They are firm to the touch. Patches showing follicular tonsillitis are not infrequently seen associated with the trouble. The submaxillary glands may be engorged, and open- ing the mouth is often performed Avith difficulty; it is usually only par- tial, on account of the fixation of the ja\v. In a few days, perhaps, softening and fluctuation may be detected in the tonsils, and spontaneous rupture and discharge of the pus may occur, Avith almost instant relief to the patient. Suppuration and tonsillar abscess are not always the termination, however, of parenchymatous inflammation, resolution sometimes taking place in the milder cases. The abscess may open in one or more places, and rupture during sleep may rarely cause suffocation by the entrance of pus into the larynx. The tonsil may regain its original size in a few days after the discharge of pus, and all the symptoms subside. The constitutional phenomena 712 DISEASES OF THE DIGESTIVE SYSTEM. of parenchymatous tonsillitis are usually severe from the start, even in children, and more so than in the follicular form (Mackenzie). The tem- perature rises to 104° or 105° F. (40° or 40.5° C), and the pulse-beats may reach 130 per minute. The usual symptoms accompanying inflam- matory fever are marked. There may be delirium, and the symptoms generally increase until the abscess bursts or is opened, when the con- stitutional as well as the local disturbance rapidly abates. Course, Duration, and Terminations.—Though often severely acute in its course, quinsy seldom goes on to rupture in children, usually end- ing in resolution in from three to five days. If both tonsils are inflamed, only one suppurates as a rule, or but one at a time. The duration of an attack ending in tonsillar abscess is about eight or ten days in adults. Complications and Sequelce.—The tonsillar suppuration may invade the cellular tissue between the tonsil and the pterygoid muscles; a peri- tonsillar abscess may then result that may open even above the clavicle. Deep involvement of the tonsil may also cause ulceration into the in- ternal carotid or internal maxillary arteries, and fatal hemorrhage occur, though these accidents are, fortunately, rare. Edema of the larynx is also an infrequent complication. French Avriters, as Guble, Germain Sde, and others, have reported cases of paralysis of the soft palate and pharynx following inflammatory throat-diseases. On subsidence of the tonsillar inflammation the trouble becomes evident in the difficult swal- lowing and partial regurgitation of liquids and solids into the nasal passages, and in the nasal intonation of the voice. A frequent sequel, especially in those predisposed by heredity, is chronic enlargement of the tonsils. (d) Necrotic Tonsillitis.—This affection is considered by Striimpell to be in some instances entirely distinct from diphtheria in its etiology, although he admits that quite frequently it is simply a mild form of the latter disease, and that often it is impossible to distinguish between the local appearances of the two conditions: these have been referred to under the heading of Morbid Anatomy. The constitutional disturbances are severe, especially in children, though they seldom last longer than a week, and are followed by a rapid convalescence. The cervical glands are not swollen to the same extent as in diphtheria. The occurrence later of palatal and pharyngeal paralysis in a supposed case of necrotic tonsillitis would point to its true diphtheritic origin. Diagnosis.—The appearance of the several forms of acute tonsil- litis, associated with the clinical history of each case, should enable a ready diagnosis to be made in the majority of cases. A difficulty may, however, arise in discriminating follicular tonsillitis from diphtheria, especially when the pseudo-membranous exudate of the latter is limited to the tonsils. The appended table gives the important points of differ- entiation between these diseases: Follicular Tonsillitis. A soft, pultaceous, yellowish-white de- posit occurs in spots or patches situated over the mouth of the follicles, with areas of redness intervening. The exudate is easily removed, leaving a smooth surface. Diphtheria. A tough, ashy-gray, continuous, and uni- form pseudo-membranous deposit cov- ers the tonsils. Very adherent, and can be torn off in strips only, leaving a bleeding erosion. ACUTE TONSILLITIS. 713 Follicular Tonsillitis. Diphtheria. The deposit is limited to the tonsils (im- The pillars of the fauces and uvula are portant). involved as well. If the creamy deposits unite to form a Removal of the membrane is followed by continuous layer, removal is either not re-formation within twelve to twenty- followed by re-formation, or very late. four hours. May have high temperature, but lasting Persistent elevation of the temperature; only a day or two. Albuminuria ex- more or less albuminuria is common. tremely rare, if present at all. Cervical lymphatic glands seldom or Usually markedly swollen glands. slightly swollen. Complications rare and mild. Complications frequent and grave. Cellular detritus, bacteria, etc. in deposit. Fibrinous exudate, etc. containing the Klebs-Loffler bacillus. Cases seen early, Avith severe constitutional symptoms and red and swollen tonsils having no deposit, may give rise to the question whether simple angina or scarlet fever is to follow. In such cases the latter dis- ease may be excluded by a negative history of exposure to contagion, by the absence of a very high pulse-rate, and by the non-appearance of the scarlatinal eruption. Necrotic tonsillitis may be discriminated from the lacunar variety in the same manner as diphtheria—i. e. by its local manifestations, a full description of which has already been given under the heading of Morbid Anatomy. The prognosis is good as regards life, and favorable as regards complete recovery. The occurrence of either fatal hemorrhage or asphyxia in quinsy is extremely rare. In debilitated and strumous in- dividuals relapses are prone to occur, and successive acute attacks of tonsillitis tend to cause permanent hypertrophy of the tonsils. In cases of necrotic tonsillitis, especially during the earlier periods, the prog- nosis should always be guarded. Treatment.—Particularly in the lacunar and necrotic forms of ton- sillitis the patient should be kept apart from others as much as possible, since both types appear to be contagious to a certain degree ; or, if other persons in the house are subject to a common source of infection —not human—their frequent nearness to a given case only serves to augment their own liability to similar attacks. Individual susceptibility to frequent attacks of sore throat may be lessened by systematic cold bathing of the neck. Constitutional and local rest is a first and con- stant requisite. Efforts at swallowing and talking should be reduced to a minimum, and in marked cases of follicular or suppurative tonsil- litis rest in bed is often sought Avithout direction. Bland nourishing liquids, as milk, broths, and the like, should constitute the only nutri- ment during the stadium of the tonsillar inflammation. Early in the case a free evacuation of the bowels should be obtained, and small doses of calomel (gr. \-\—0.008.-0.010, repeated hourly until about gr. 1 —0.0648—has been taken), folloAved by a Seidlitz powder or Rochelle salts in hot water, will be effective in most cases. In severe cases of quinsy relief from the pain is urgently called for, and either a Dover's poAvder or a hypodermic injection of morphin (gr. \—\—0.010-0.016) and atropin (gr. jfa—0.0006) will probably suffice for their relief. A high temperature must be combated by small doses of aconite, fre- quently repeated: this drug has been much used in the follicular ton- 714 DISEASES OF THE DIGESTIVE SYSTEM. sillitis of children. Quinin, in solution with dilute sulphuric acid, is also often given. The administration of sodium salicylate or benzoate, of salol, or of the ammoniated tincture of guaiac in 1-dram (4.0) doses (Sajous), seems to lessen the duration and severity of tonsillitis, and even to cure some cases of the lacunar form within forty-eight hours and without local applications. The tincture of the chlorid of iron in glycerin (4 or 5 drops to the dram—4.0—given every two hours) is regarded by Bos- worth as almost specific at the commencement of an attack of acute follicular tonsillitis. During convalescence semi-liquid and soft, light foods may be allowed gradually; and bitter tonics and iron are to be administered if there are depression and anemia. The following is a favorite prescription : B/. Strychninae sulph., gr. ss (0.032); Syr. acaciae, 3ss (16.0); Liq. ferri et ammon. acetat., q. s. ad §iij (96.0).—M. Sig. 3j (4.0) t. i. d., in water, after meals. If the case is seen quite early during congestion, the use of cold is of great value in giving local relief and in shortening the attack. Ice may be sucked, and flannel dipped in ice-water and wrung out may be applied around the neck, or an ice-bag used. Lozenges of guaiac (gr. ij—0.129) or the ammoniated tincture in 1-dram (4.0) doses in milk, and used as a gargle, are indicated early, and, according to Sajous, seldom fail to control or arrest the inflammation. Equal parts of the tincture of the chlorid of iron, glycerin, and w-ater, applied gently with a camel's- hair brush, have long been used locally on the surfaces of the tonsils, and with marked benefit. Alkaline and mild antiseptic solutions, used as gargles or sprays (preferably the latter), are generally useful. Thus, Dobell's solution, or Seller's tablets dissolved in water, or borax and thymol, or carbolic acid, or potassium permanganate in weak solution, may be serviceable. Mild counter-irritation at the angle of the jaw by means of iodin or slightly irritating embrocations is helpful. Early scarification of the tonsils as a depletory measure, and painting with cocain (10 per cent.) sometimes bring about quick resolution. Astringent sprays containing alum or silver nitrate are often effica- cious after a day or two. When the case is first seen and fully devel- oped, the atomization of a warm solution of cocain (4 to 8 per cent.) or lime-Avater, with the external application of heat by means of poultices, is indicated. Should gargling be possible, nothing is better than hot water or milk. If, in parenchymatous tonsillitis, fluctuation be detected or suppuration be even suspected of commencing, the prompt use of the bistoury (the blade being guarded by wrapping with cotton or adhesive plaster), with the production of free bleeding or the discharge of pus, will give great satisfaction and relief. The patient's head, especially if it be a child, should be tilted forward during the operation, so as to allow most of the blood and pus to pass into the mouth. When incision of the tonsil fails to bring pus, it has been advised to puncture through the anterior pillar, where pus may be formed in the cellular tissue in front of or behind the tonsil. When the tonsillar enlargement threatens life through suffocation, CHRONIC TONSILLITIS. 715 excision of the tonsils, laryngotomy, tracheotomy, or intubation may have to be performed. CHRONIC TONSILLITIS. {Hypertrophied Tonsils; Adenoid Vegetations.) Definition.—Enlargement of the tonsils (faucial and pharyngeal), due to chronic inflammation or hypertrophy, and usually associated Avith or causing a perverted local and systemic condition. Pathology.—The faucial tonsils show a true chronic hypertrophy of the lymphoid and fibrous elements. According to the hyperplasia of the latter the organs will be smaller and more indurated. They may be rough on the surface from " distended lacunae or ruptured follicles " (Berkley Robinson), the latter being in a state of chronic inflammatory thickening, and shoAving caseous degeneration of their contents. The growths in the vault of the pharynx are adenomatous papillomata; they are either sessile or pedunculated, and are fleshy in appearance and con- sistence and very vascular. They range in size from a grain of wheat to an almond-kernel (Allen), and project from the pharyngeal vault, lying in the depression posterior to and on a line with the fossa of the Eustachian tube (Rosenmiiller's fossa). " Hypertrophy of the pharyn- geal adenoid tissue may also be present without great enlargement of the tonsils proper" (Osier). A congestive type of nasal catarrh in adults often accompanies, or is the result of, neglected adenoid growths and hypertrophied tonsils that date from childhood. Chronic pharyn- gitis is also not infrequently associated. Etiology.—The predisposing causes of chronic hypertrophy of the tonsils are—(a) heredity, especially in the scrofulous and syphilitic diath- eses ; (6) age, most frequently between five and fifteen years; (c) sex, boys appear to be affected more frequently; (d) hygienic surroundings. The exciting causes are usually previous attacks of acute tonsillitis, either simple or that which is symptomatic of diphtheria or scarlatina. According to Harrison Allen, adenoid growths from the normal lymph- oid tissue of the vault of the pharynx (pharyngeal tonsils) may be con- genital, and are " in some wTay associated with the canal which is found in early fetal life penetrating the brain-case and uniting the anterior part of the pituitary body to the lining membrane of the pharynx." Symptoms.—Local.—With slight or even moderate tonsillar en- largement there may be fe\v or no symptoms attributable to it. There may be simply an increased secretion of mucus, and a susceptibility to fresh anginal attacks or to severe tonsillar manifestations in diphtheritic or scarlatinal attacks. The first symptom to attract the attention is the direct effect of naso- pharyngeal obstruction—i. e. oral respiration. This mouth-breathing is visibly labored and abnormally audible, and is especially marked at night, the child's respiration being noisy, snorting, and irregular. Sleep is disturbed by paroxysms of dyspnea, sometimes due, perhaps, to reflex spasm of the glottis. Nightmare follows as a result of imperfect aera- 716 DISEASES OF THE DIGESTIVE SYSTEM. tion of the blood which supplies the brain on account of the obstruction to perfect respiration. The act of SAvalloAving is rendered difficult by the faucial obstruction, and is often painful, OAving to the superadded acute tonsillar trouble that is so liable to occur in the hypertrophied glands. Indirect results of chronic tonsillar enlargement are a laryngeal stridor and a croupy cough. Sometimes asthmatic attacks coexist, and seem also to be due to the hypertrophy. An excessive secretion of mucus in the pharynx is a common symptom, and causes hawking in subjects past young childhood. The hearing is often impaired, and tinnitus aurium is complained of, being the result of pressure of the growths against the orifice of the Eustachian tube or of clogging of the tube with mucus, due to the extension of inflammation from the naso- pharynx. Absolute deafness may result, and the senses of taste and smell are likewise diminished or perverted. The signs of chronic tonsillar enlarge- ment and pharyngeal adenoid growths are interesting and important. Inspection of the fauces will show the tonsils bulging as two lumps cov- ered with thick mucus, or the latter may ooze around the uvula from the pharynx. In mouth-breathers of long standing the superior dental arch is narrowed and the hard palate is highly arched. The breath is fetid, owing to the cheesy, inspissated exudate in the tonsillar crypts. In very old cases a tonsillar calculus may be felt, and is the result of cal- cification of the secretion. The facial expression is characteristically stupid and pathetic; the disposition is dull, irritable, and stubborn; the lips are thick, and a vacant stare is in the eyes. Speech is slow, phonation nasal in quality, and articulation of the nasal consonants n and m, I and o, is changed or muffled. Stammering is not rarely associated with tonsillar hypertrophy. The anterior nares may be dilated and present a pinched appearance above their openings. The prolonged interference with normal respiration gives rise to a peculiar chest-conformation, simulating that of rickets (chicken-breast). The ribs are prominent anteriorly, and there is a marked forAvard angle at the manubrio-gladiolar junction, as Avell as a grooved depression at the ensiform cartilage. Depressions between the Avidely-separated ribs exist anteriorly also. Posteriorly, and at the base of the chest in par- ticular, the intercostal spaces are practically absent on account of the closeness of the ribs. The upper part of the chest is very narrow and the shoulder-bones quite prominent; the antero-posterior diameters of the thorax are less than normal; the sides are unusually curved. On percussion the hepatic area of dulness is diminished on the chest- wall, but increased downward and to the left. The first cardiac sound is weak. On inspiration there is a retraction of the intercostal spaces in the lower and lateral thoracic regions. The lymphatic glands of the neck may be moderately SAvollen. The general symptoms of tonsillar hypertrophy are more marked when the growths exist in the pharyngeal vault alone. Developmental processes in children, such as dentition, and at puberty, particularly when the voice-changes are looked for, are often retarded or perverted. Anemia, headache, especially during study, cardiac palpitation, enuresis, and habit-chorea of the facial muscles, may be associated Avith general CHRONIC TONSILLITIS. Ill capriciousness, mental dulness, indisposition to intellectual exertion, drowsiness, and sullen irritability. The term aprosexia has been given to the loss of power to concentrate the mind for any length of time that is so characteristic of these cases. Diagnosis.—Inspection of the fauces will reveal enlarged tonsils. It should be borne in mind, hoAvever, that the act of gagging often causes the tonsils to rotate forward and inward, making them appear larger really than is the case. Adenoid groAvths of the pharyngeal vault may exist without tonsillar enlargement, and can be detected by posterior rhinoscopy or by the insertion of the finger into the naso- pharynx; the vegetations may thus be felt blocking the vault. Differential Diagnosis.—It is important not to attribute the obstruc- tive symptoms to nasal hypertrophies or atresia or to malignant growths in the naso-pharyngeal space. The latter are infrequent at the ages at which chronic tonsillar enlargement of the fauces and pharynx is most apt to occur—i. e. early in life. Again, palpation of sarcomatous or carcinomatous growths gives marked differences in consistence, and there are usually spontaneous hemorrhages and local pain in attendance upon these neoplasms. " Thumb-suckers " differ from mouth-breathers in that in the former the incisors are inclined forAvard and cause slight protrusion beneath the upper lip; the dental arch is flat. In mouth- breathers, hoAvever, the incisors are vertical or nearly so, or incline so as to overlap each other; the dental arch is high and curved (H. Allen). Retropharyngeal abscess may be confounded with tonsillar enlargement, especially in children. But in this disease the attacks of dyspnea, the dysphagia, and the local distress are more marked. Again, in the pharyngeal disease the swelling is in the median line, pushing the soft palate forward perhaps, and on palpation it may give a sense of elas- ticity or fluctuation to the finger. Slight fever may also be present. Prognosis.—Tonsillar hypertrophy is not a severe disease as re- gards life. There is, however, an increased liability to contract colds, recurrences of follicular tonsillitis, attacks of diphtheria, and severe scarlatinal angina. The prognosis in acute respiratory affections asso- ciated with chronic tonsillar enlargement is always more or less grave. Adenoid growths, even when neglected, tend to lessen in size after puberty, with a subsidence of local and reflex symptoms. After removal the growths, as a rule, do not return. Treatment.—The old-fashioned use of astringent applications is probably useless when there is any marked chronic enlargement of the tonsils, and active surgical treatment alone is to be recommended for the condition. The use of absorbents and caustics, either externally or by parenchymatous injection, is also of doubtful value, and is objection- able on account of the necessarily protracted and painful course of treatment. There are no more satisfactory means of doing radical good in cases of this kind than the galvano-cautery, scarification, and the removal of the tonsils with the tonsillotome, snare, or bistoury. In offensive fol- licular disease applications of chromic acid may give good results. Ade- noid growths may be removed by means of the finger, curet, or forceps. Constitutional treatment is often necessary in improving the nutrition of the patient. Good food, a change of air, systematic bathing, prudent 718 DISEASES OF THE DIGESTIVE SYSTEM. habits, careful dress, and medicinal tonics and alteratives, as cod-liver oil, iodid of iron, and the hypophosphites, are usually indicated. V. DISEASES OF THE PHARYNX. PHARYNGITIS. ACUTE PHARYNGITIS. [Pharyngitis Acuta Simplex.) Definition.—An acute catarrhal inflammation of the mucous mem- brane of the pharynx. Pathology.—The mucous membrane is congested diffusely or in patches, and there may be an inflammatory exudate in, and a consequent swelling of, the submucosa and the contained glandular structures. The surface of the membrane is more or less coated with a viscid muco-pus. Etiology.—Predisposing causes are—age, it being more frequent in adolescence and young adult life; a depraved constitution; digestive disorders; and a rheumatic, gouty, or scrofulous diathesis. The usual exciting cause is exposure to cold or sudden changes of temperature and climate and to irritating vapors. An acute naso-pharyngeal catarrh, by bathing the pharyngeal mucosa with its irritating secretions, may set up the trouble. " Epidemic pharyngitis " is probably a manifesta- tion of influenza. Acute simple pharyngitis may be a complication of scarlatina, measles, and small-pox (exanthematous pharyngitis) and of erysipelas (erysipelatouspharyngitis); in the latter disease, moreover, it may become gangrenous or suppurative. Symptoms.—Locally, the affection is ushered in with a feeling of dryness and soreness, especially on swallowing. With the production of the muco-purulent secretion a tickling sensation provokes haivking or a slight "throat cough" and efforts at exspuition. The catarrhal pro- cess may extend to the larynx and cause some hoarseness, or to the Eustachian tube, causing dulness of hearing. Movements of the neck are painful and stiff, particularly if there is, as is often the case, slight involvement of the lymph-glands. Inspection of the throat shows the pharynx, often the posterior pillars of the fauces and the soft palate, and even the anterior pillars and tonsillar surfaces, to be deeply red- dened and tumefied ; the coursing veins are enlarged, and particles of a yellowish-Avhite secretion appear here and there. Sometimes the phar- yngeal follicles become subject to acute inflammation, and appear as elevated, discrete, shiny spots (herpetic pharyngitis—Mackenzie). At the onset of this affection there may be chilliness, folloAved by slight fever, headache, an accelerated pulse, a dry skin, and anorexia. The pharyngeal symptoms seldom last more than from three to five days, when resolution takes place, some tenderness of the pharynx, however, remaining for a time. Diagnosis.—On examination of the throat there should neither be any difficulty in diagnosing the affection nor any likelihood of confound- ing the affection Avith simple tonsillitis. MEMBRANOUS PHARYNGITIS. 719 The prognosis is always favorable. "In weakly patients, however, there is a liability to subsequent attacks. Treatment.—In the early stages sucking of small pieces of ice does much to allay the congestion and irritability. A spray of cocain or menthol in albolene (2 per cent.) may also be used, followed by a 4 per cent, solution of antipyrin; Dobell's solution is always to be recommended for its alkaline, sedative, and antiseptic action. Swabbing the pharynx with a silver-nitrate solution (gr. xl to the ounce—2.59 to 32.0) is, according to Sajous, of great benefit. When the disease is Avell established relief is often obtainable by medicated steam-inhalation, as with the compound tincture of benzoin. In rheumatic cases lozenges of guaiac (gr. iij—0.194) are useful. The sipping of hot milk in which sodium bicarbonate has been dissolved is very soothing to the inflamed mucosa. The general treatment embraces measures directed at the fever and the diathetic condition. A hot foot-bath and a calomel purge, with belladonna, acetanilid, or aconite for the fever and pain, and sodium salicylate (gr. lx-lxxx—4.0-5.1—in the twenty-four hours), may be re- quired. The diet, of course, during the height of the attack, should either be liquid or semi-solid. Persons susceptible to repeated attacks must exercise caution in regard to exposure to severe cold and Aveather-changes, irritating vapors, and the like. Daily cold sponge-baths may be used to harden the skin. Tonic, nutrient treatment is also frequently called for. MEMBRANOUS PHARYNGITIS. {Pharyngitis Crouposa.) Definition.—An acute superficial inflammation of the pharyngeal mucosa, characterized by the formation of a whitish false membrane, due usually to the streptococcus. Etiology.—The principal causes of this form of pharyngitis are exposure of persons in debilitated health to cold or an impure or a septic atmosphere, particularly during epidemics of such diseases as scarlatina. Symptoms.—The local and general symptoms are those of ordinary sore throat, though of a more severe type. Diagnosis.—The pseudo-membrane is thin, of a yellowish-white color, and appears in small patches over the pharynx; it is easily de- tached, and is thus distinguished from diphtheria, with which alone it might be confounded. The presence of small vesicles or ulcers and the absence of grave constitutional disturbances are also features in this affection that serve to differentiate it from diphtheritic pharyngitis. The prognosis is favorable. Treatment.—Local applications of solutions of hydrogen peroxid or potassium permanganate (gr. x to the ounce—0.648 to 32.0) are very satisfactory. For the painful dysphagia the sedative and soothing rem- edies suggested for simple acute pharyngitis may be used. Internally, sodium benzoate (gr. v-xv—0.324-0.972) in glycerin, elixir of calisaya, and salol have each been recommended. Tonic treatment is nearly always needed. 720 DISEASES OF THE DIGESTIVE SYSTEM. CHRONIC PHARYNGITIS. Definition.—A chronic inflammation of the mucous membrane of the pharynx. It may consist of either a hypertrophic or an atrophic involvement of the follicles, or both processes may coexist. Varieties.—(a) Chronic naso-pharyngeal catarrh; (b) chronic hyper- trophic pharyngitis or naso-pharyngitis (pharyngitis sicca); (c) follicular or granular pharyngitis. The last named is probably the result of, and nearly always is associated with, chronic simple (or hypertrophic) pha- ryngeal (or naso-pharyngeal) catarrh. Pathology.—The mucous membrane in simple chronic pharyngitis is either reddened, thickened, and viscid (hypertrophic form), or pale, thin, and dry (atrophic form); in both instances dilated and tortuous veins are prominently shown. In the follicular variety the pharyngeal mucous glands are swollen into little red, glistening nodules studding the congested membrane. The enlarged follicles are due to a hyperplasia of lymphoid cells and an accumulation of retained dried-up secretions. Etiology.—A protracted impairment of the general health, espe- cially in those who over-exert mentally and are of sedentary habits, is a common predisposing cause of chronic pharyngitis. Repeated acute attacks may precede the affection, or it may develop subacutely and almost imperceptibly. It is most common in adolescent and middle life. The exciting causes are frequent and prolonged over-use and strain of the voice in clergymen, singers, teachers, army-officers, and street- venders ; irritation from tobacco-smoke, chemical vapors, and continued exposure to cold air; and perhaps the persistent swalloAving of very hot or cold foods, stimulants, or spicy articles. Symptoms.—In all varieties of chronic pharyngitis the local dis- comfort is often very slight, and more annoying than painful, except when an exacerbation takes place. It is a particularly uncomfortable condition in those whose occupation requires more or less constant use of the voice. There is a sensation of dryness and tickling or burning in the throat and the desire to clear the throat of sticky mucus by hawking or a short cough. These symptoms are usually Avorse on rising in the morning, especially if some unfavorable influence has been ex- erted during the night previous, the throat being dry and a viscid secre- tion having collected. Swallowing is seldom interfered Avith. If the larynx is somewhat affected by extension of the pharyngeal inflammation, hoarseness and a dry, hacking cough are produced. After using the voice there is a sense of fatigue, with huskiness and quite often some irritability. The local appearances of chronic pharyngitis vary according to the form of the affection present in the case. In chronic catarrh of the pharynx a considerable collection of muco-pus is seen adhering to the mucosa and extending doAvnward from the posterior nares. The senses of hearing and taste may be impaired. The uvula is frequently elong- ated, and its tip may rest on the base of the tongue. A nasal intona- tion of the voice is sometimes provoked. The posterior nares as seen by the rhinal mirror are often stopped up by foul secretions or by hypertrophy of the nasal mucous membrane. Headache and attacks of vertigo may occur. ACUTE INFECTIOUS PHLEGMON OF THE THROAT. 721 Chronic hypertrophic pharyngitis and follicular pharyngitis (" clergy- man's sore throat ") are commonly associated. The thickened, reddened, pimply, vein-coursed appearance of the mucosa is characteristic. The follicles may be seen sometimes as polypoid elevations, and the pharyn- geal tonsil may be found by the finger to be enlarged (Kolliker). In the dry, atrophic pharyngitis that occurs more often in later life, and as a sequel of the simple chronic or follicular variety, a pale, smooth, relaxed, lustrous, and often quite painful membrane is observed. The general symptoms are usually those of a weak, debilitated, nerv- ous constitution, though in mild cases the general health may be unim- paired. In atrophic pharyngitis considerable cachexia may be present. Diagnosis.—Care should be exercised in discriminating the variety of chronic pharyngitis present in any given case, so that the treatment may be planned accordingly. Careful and repeated inspection of the throat must render the diagnosis easy unless ulceration has taken place: in such cases a tuberculous or syphilitic sore throat must be eliminated.by the superficial character of the ulcers, by their ready response to proper treatment, by the history of the case as to specificity, and by the ab- sence of marked pain or constitutional or pulmonary symptoms pointing to tuberculosis. Prognosis.—This should be guarded as to cure, on account of the stubborn resistance to treatment and the difficulty in removing unfavor- able influences. Acute exacerbations are liable to recur unless rigid prudence and caution are practised at all times in avoiding the cause of the trouble. Treatment.—The local use of astringent and alkaline antiseptic sprays or of the nasal douche is usually recommended, but has only a palliative effect. Silver-nitrate cauterization may be tried. The only effectual means, hoAvever, of curing the follicular or hypertrophic variety is that used by most throat-specialists—namely, the wire galvano- or actual cautery. Applications of silver nitrate (gr. x to the ounce—0.648 to 32.0) and the internal use of the oleoresin of cubebs have been recom- mended for the atrophic pharyngitis. Insufflation of powdered tannin or alum is also of service. Systemic disturbances need attention according as they present them- selves. Mineral baths are sometimes of great benefit, and tonics are usually indicated. It is of prime importance that all irritating causal factors be removed or avoided before any favorable results can be hoped for from local applications. Tobacco-smokers and topers must deny themselves their habitual luxuries. Krause and Heryng recom- mend Avith favor curetting and the application of lactic acid to super- ficial tuberculous ulcers. ACUTE INFECTIOUS PHLEGMON OP THE THROAT. Definition.—An inflammation of the pharyngeal mucosa that passes rapidly into a suppurative process. Its etiology is not definitely knoAvn. I have met with no cases except in my hospital wards, though they doubtless occur in general medical practice. The clinical features have been described by Senator. The Symptoms are sudden in their onset and quite intense. They 46 722 DISEASES OF THE DIGESTIVE SYSTEM. are severe soreness of the throat, dysphagia, and hoarseness, as a rule: in advanced cases there has been difficult respiration. Inspection shows the pharynx to be deeply injected and the seat of marked inflammatory edema, the neck appearing greatly SAvollen as well. The general dis- turbance is correspondingly severe. The treatment is Avholly symptomatic. RETROPHARYNGEAL ABSCESS. Definition and Pathology.—A suppurative inflammation of the connective tissue lying anterior to the cervical spinal column. The disease is rare, though it is relatively most common before tAvo years of age. It is usually a primary affection, occurring Avithout assignable cause, but a certain proportion of instances are doubtless caused by caries of the cervical vertebrae. It may rarely be secondary to any of the specific fevers. The symptoms are pain in SAvallowing, impeded respiration, soon becoming stertorous in character, the dyspnea meanwhile constantly in- creasing. There may be cough, and the voice may present abnormal characteristics. The signs of stenosis finally declare themselves with considerable violence, and an examination of the pharynx usually serves to make the diagnosis positive; the projecting tumor is visible, and the palpating finger readily detects fluctuation. In infants, however, this procedure may be attended Avith great difficulty. The course of the disease may be acute, lasting one or two Aveeks; more frequently, however, it is subacute (rarely chronic), as, for example, Avhen it is due to caries of the vertebrae. The prognosis is favorable in all cases that are early and properly diagnosticated. If unrecognized until the later stages have been run, suffocation may ensue, or in the event of spontaneous rupture pus may pour into the larynx and cause death by asphyxia. Treatment.—As soon as fluctuation is detected the abscess should be freely opened, and preferably, as a rule, through the mouth by means of a guarded bistoury. The throat, after the abscess is thoroughly evacuated, should be washed out Avith some mild antiseptic solution (salicylic acid 2 per cent, or boracic acid 2 per cent.). When pointing occurs at the side of the neck, as sometimes happens, the incision should be made through the skin in that locality. Constitutional indications are to be fulfilled in accordance Avith general principles, and the strength of the patient is to be maintained by a highly nutritious dietary. VI. DISEASES OF THE ESOPHAGUS. ESOPHAGITIS. ACUTE ESOPHAGITIS. Definition.—An acute inflammation affecting either the mucous membrane or submucous tissues of the esophagus, or both. Pathology.—The ordinary morbid changes of an acute esophagitis DISEASES OF THE ESOPHAGUS. 723 are those of a simple catarrhal inflammation of the mucosa. It is rather characteristic of the condition that there is no increased secretion, a sponginess and rapid desquamation of the epithelium taking place in- stead, and causing a granular appearance of the membrane. Occasion- ally the mucous glands are SAvollen, and may break doAvn, Avith the for- mation of small follicular ulcers. Catarrhal erosions may also be seen here and there. A croupous or diphtheritic exudate is seldom found in the lower portion of the esophagus, and small-pox pustules are rarely, if ever, seen. A diffuse or circumscribed purulent inflammation of the submucosa may dissect up the mucous membrane so as to consid- erably diminish the esophageal caliber; pus is usually discharged into the tube. In severe cases of poisoning (corrosive esophagitis) sloughing may extend into the muscular layer, and may produce a foul, dark, hem- orrhagic mass. A fibrinous cast of the gullet has been ATomited up by an hysteric Avoman (Birch-Hirschfeld). Etiology.—The causes of acute esophagitis, other than traumatic, are rare. Under the latter are included the mechanical, thermal, and chemical irritants, such as the presence of foreign bodies and the swal- loAving of hot liquids, corrosive poisons, "concentrated lye," mineral acids, and arsenic. The condition may also be the result of the folloAv- ing: (a) an extension of catarrhal inflammation of the pharynx; (b) specific infectious fevers, as typhoid, typhus, and pneumonitis; (c) diph- theria (pseudo-membranous esophagitis) by the extension of pharyngeal diphtheria; (d) small-pox, giving rise to a pustular inflammation of the gullet; (e) local disease, as carcinoma of the esophagus, glandular or vertebral abscess, or laryngeal perichondritis (Striimpell). Symptoms.—Pain during deglutition may be referred to the region of the esophagus, and a steady, dull pain may exist beneath the sternum. Dysphagia and regurgitation of food may be caused by spasm in severe cases. Mucus, blood, and pus may be discharged later. Th*e absence or mildness of pain is not a true indication of the gravity and extent of esophageal inflammation. Sequelae.—Simple catarrhal or follicular ulcers may appear, and the necrotic form of the disease may be folloAved by suppurating ulcers, which, if healing takes place, may cause cicatricial stenosis. Diagnosis.—This may be based upon the localization of pain, especially during deglutition; upon the pain occasioned by the passage of the esophageal sound; and upon the mucus, blood, or pus adherent to its bulb on Avithdrawal, provided carcinoma at the cardiac orifice of the stomach can be excluded. The expulsion of a pseudo-membrane (diphtheritic) from the gullet should be differentiated from esophago- mycosis (thrush), especially in children. The diagnosis of the particu- lar form of esophagitis will depend upon the facts elicited relating to the etiology. The prognosis is good in mild cases, and should be guarded in those associated with grave disease. Death may occur in either the purulent or necrotic form. Treatment.—This is entirely symptomatic, and in severe cases is of little value. A soft, bland diet, preferably of milk, may be borne in ordinary instances; if not, rectal alimentation should be resorted to. For the mild cases SAvallowing of bits of ice, and later of warm demul- 724 DISEASES OF THE DIGESTIVE SYSTEM. cent drinks, should be recommended. In cases of marked pain and esophageal spasm relief may be afforded by a hypodermic injection of morphin and atropin. CHRONIC ESOPHAGITIS. Chronic catarrh of the gullet may result from continued irritation by the causes of the acute form, and also from passive congestion due to hepatic cirrhosis, chronic cardiac or renal disease. The last-named con- ditions may also cause varicose esophageal veins, and fatal hemorrhage may result therefrom. The increased mucous secretion may cause eruc- tations and nausea. Postmortem evidence of esophagitis, either acute or chronic, is found with extreme rarity. ULCER OF THE ESOPHAGUS. This is a consequence of a simple or follicular catarrh of the gullet or of gangrene. " Catarrhal erosions " and follicular ulcers may occur in numbers, and necrotic ulcers may occur in bedridden persons opposite the cricoid cartilage. The extensive purulent ulceration following the separation of necrotic sloughs may heal and cause contraction and marked stenosis of the tube. Ulcers simulating those occurring in the stomach (ulceres ex digestione) may sometimes be found at the lower end of the esophagus. Postmortem digestion, hoAvever, must not be mis- taken for peptic ulceration. There may be pain or localized points of tenderness on the passage of the esophageal bougie, with some pus and blood on the bulb after its withdraAval. Rest from SAvallowing should be secured as far as possible. The sipping of hot milk may be sooth- ing, and the slow swallowing of mild boric-acid and sodium-bicarbonate solutions, or of glycozone, may be tried with benefit. CARCINOMA OP THE ESOPHAGUS. This is the most frequent affection of the tube, and, as it is the com- monest cause of stenosis, it is important from a diagnostic, standpoint. Pathology.—Carcinoma of the esophagus is primary and of an epi- theliomatous nature, the mucous membrane here being composed of pave- ment-cells. The new growth affects the mucosa first, and then, increasing in size and causing ulceration, it may involve the entire circumference of the tube like a ring-like mass. This may either be hard, dense, and fibrous, or soft and jelly-like. The esophageal lumen is markedly dimin- ished as a rule, although disintegrating ulceration or "flat" carcinoma may encroach upon the caliber but very little. There may be a diffuse dilatation of the esophagus above the groAvth, as well as an hypertrophy of the circular muscular fibers. The cancerous tumor is found most commonly in the middle and lower thirds of the esophagus. CARCINOMA OF THE ESOPHAGUS. 725 Etiology.—The predisposing causes of esophageal carcinoma are age and sex, males past forty years of age being the usual subjects of this neoplasm. The exciting causes are of uncertain origin. It has been alleged that various forms of protracted irritation of the mucous mem- brane may cause the development of carcinoma; and especially has this point been maintained in connection Avith the frequent occurrence of carcinoma of the gullet in topers. It is also believed by some that as gastric carcinoma may develop from the scars of old ulcers, a like con- dition in the esophagus may act as a nucleus for a carcinomatous groAvth in that structure also. Symptoms.—Dysphagia is the earliest symptom of esophageal car- cinoma Avith beginning stenosis of the tube. This gradually and steadily increases, so that liquids alone can be SAvallowed, and later regurgitation even of liquid foods takes place. There may be considerable pain in some cases. The ejecta may contain cancerous fragments, blood, and mucus. The dysphagic symptoms may subside spontaneously, owing to the disinte- gration and ulceration of the growth, or the dysphagia may be so slight as to be masked by the prominent symptoms of hepatic or pulmonary carcinoma and gangrene secondary to a very flat esophageal carcinoma. Or, Avithout secondary manifestations of such a groAvth, the esophageal symptoms may rarely be latent. The cervical glands may be enlarged. The most important general symptom of esophageal carcinoma, as of this malignant growth elseAvhere, is the progressive emaciation, which increases with the stenosis and obstruction to the entrance of nourish- ment into the stomach. Though seemingly anemic, the patient's blood may contain an excessive number of corpuscles in a given bulk. This is due to inspissation from failure to absorb water and food into the body. Course, Duration, and Termination.—The disease is chronic, becoming progressively worse, and is often beset with grave complica- tions (vide infra). It seldom lasts longer than one and a half years, and the duration of medullary carcinoma of the gullet is usually much shorter. A fatal ending is inevitable, by inanition and exhaustion, or as the result of metastasis and secondary complications. Complications.—These follow extension of the cancerous groAvth to neighboring parts. Thus, involvement of the larynx, trachea, and bronchi has been noted. The cancerous ulcer may also perforate the pleura, the pericardium, or the aorta or its branches, and cause fatal hemorrhage. The vertebrae have been eroded, and compression of the cord, with resulting paraplegia, may take place. Paralysis of the vocal cords may be the effect of pressure by the groAvth upon the recurrent laryngeal nerve; most frequently pulmonary gangrene is due to perforation of the lung or to the inspiration of can- cerous and decomposing particles that have been regurgitated. Diagnosis.—As the dysphagia is a symptom of paramount im- portance in the diagnosis of esophageal carcinoma, all other causes of the symptoms must be excluded. Thus, enlarged tonsils, pharyngeal tumors, pressure from without by cervical intrathoracic tumors, as aneur- ysm, or by displacement of the sternal end of the clavicle, and the presence of foreign bodies or cicatricial strictures of the gullet,—all fig- ure in the production of difficult deglutition. The history of the case, 726 DISEASES OF THE DIGESTIVE SYSTEM. the age of the patient, the progressive emaciation (cancerous cachexia), and the obstinately increasing dysphagia va ill enable us to exclude the other affections named. In using the esophageal bougie for diagnostic purposes great care should be exercised, as an aneurysm may thus be ruptured or a deeply ulcerated carcinoma perforated. The Avithdrawal of cancerous tissue upon the bulb will decide the case. The esophago- scope may be useful in certain cases, but requires great care and special skill. The prognosis is hopeless, and the supervention of grave compli- cations or pulmonary gangrene renders the chances of an early demise very probable. Treatment.—This is essentially symptomatic and sustentative. If feeding by the mouth is difficult on account of the extreme stenosis, although permitting the passage of an esophageal tube, the latter may be used for the passage of liquid nourishment. Rectal feeding may later become imperative. The mechanical treatment of the cancerous stricture by the passage of the graduated esophageal bougie is seldom of any avail, although temporary improvement may perhaps be obtained. Soft, disintegrating, and ulcerating carcinoma should thus be treated, though Avith the absence of any force Avhatsoever, lest perforation take place. The performance of esophagostomy may prolong life in some cases. RUPTURE OP THE ESOPHAGUS. The first recorded case of this rare condition occurred under the ob- servation of Boerhaave in 1724 in the person of the Baron Wassemar. Pathology.—Softening, together with a great friability, of the esophageal Avails may be found, this probably being the effect produced by the solvent action of the gastric juice upon the mucous membrane at a time when the local circulation is disturbed and the vitality of the tissues thus lessened. The postmortem evidence of this accident consists of a longitudinal (as a rule) tear about 5 cm. (2 inches) in length, and situated in the loAver half of the esophagus. Food and air may be found to have es- caped into the left pleural cavity, and unless death occur at an early date signs of secondary purulent inflammation Avill probably be noticed. Postmortem digestion of the esophagus is more common (Osier). The perforation is often quite large, and is located in the posterior wall of the tube. Etiology.—Softening of the walls of the gullet (esophago-malacia) is suggested by Zenker as a condition that always precedes spontane- ous rupture, so called. The exciting cause is believed to be violent and persistent vomiting after a particularly heavy meal or during acute alcoholism. Symptoms.—These come on suddenly or soon after a full meal, and commence with nausea and very severe vomiting, accompanied by great pain and rapid and extreme collapse of the Avhole body, due to the shock. A cutaneous emphysema of the neck and chest is manifested soon after the rupture. NEUROSES OF THE ESOPHAGUS. 727 The diagnosis, if made at all, must rest upon the clinical history. Death usually takes place in a few hours, or days at the most, and the prognosis is necessarily hopeless. The treatment is equally so in the present status of surgery. Pain, if excruciating, should be dulled by the hypodermic administration of morphin. NEUROSES OF THE ESOPHAGUS. MUSCULAR SPASM. [Esophagismus.) Definition.—A spasmodic contraction of the muscular layer of the esophagus. Etiology.—It is almost always a secondary affection, met with not infrequently in hysteria, hydrophobia, and rarely in chorea and epilepsy. I have seen one instance of the idiopathic form of the disease in a female possessing a highly neurotic constitution. In this case the esophageal bougie could be passed only with a great deal of difficulty during the spasm: when this relaxed, the bougie glided into the stomach without meeting with any noticeable resistance. It has usually been observed in aged males, and especially in those suffering from hypochondriasis. It may be due to reflex causes, originating, for example, in the uterus; thus, in some cases, it occurs only during the pregnant state. Symptoms.—The chief subjective characteristic is dysphagia. Al- though liquids can be swallowed, solids, as a rule, cannot. Post-sternal pain is sometimes noticed, and choking signs are quite common. In the hysteric variety emotional disturbances are found among the prodromata, and most probably bear a causal relation. Diagnosis.—The etiologic factors must be carefully weighed in connection Avith the symptoms and the valuable testimony gained by the use of the sound. The bougie on reaching the constriction is rather tightly gripped, though gentle pressure soon causes it to relax. After the subjective symptoms and spasm are over the sound passes without the slightest difficulty, providing a point of the greatest diagnostic import. The elderly hypochondriac is, as before stated, liable to develop a similar condition, which must not be confounded with true cancerous stricture. The prognosis is good. The treatment is directed to the disease on which the condition is found to depend, and this must receive careful attention. The sound should be used as previously indicated under the discussion of Esopha- geal Stricture. Its passage has often been followed by speedy and per- manent cures. PARALYSIS OF THE ESOPHAGUS.1 In extensive bulbar paralysis, Avhen adjacent parts are involved, Ave may infer the existence of esophageal implication, though there be no 1 For remarks on the treatment of this complaint the reader is referred to section on Nervous Diseases. 728 DISEASES OF THE DIGESTIVE SYSTEM. objective evidence to adduce in confirmation. Doubtless the esophagus rarely shares in post-diphtheritic paralysis also. Dysphagia is the lead- ing symptom. An invaluable peculiarity belonging to diphtheritic paralysis is the fact that solids are more readily swalloAved than liquids. DILATATION OP THE ESOPHAGUS. Pathology and Etiology.—Diffuse dilatation of the esophagus is usually secondary to stricture at or near the cardiac orifice. In accord- ance with the common law of compensation, the first effect of the stenosis is to engender hypertrophy of the muscular layer above it with a view of overcoming the resistance caused by the obstruction. The wall of the esophagus becomes thickened, and the tube is generally somewhat nar- roAved, above the seat of the stenosis; but finally, as a result of degen- erative changes, the muscular coat weakens, the esophagus dilates, and food accumulates above the stricture—a condition that, once begun, progresses. Congenital dilatation, in Avhich the whole extent of the tube partici- pates, has also been met with, though such a condition is rare indeed. It sometimes results from fatty degeneration of the muscular wall, and a predisposition to the complaint may be acquired as the result of injury or prior inflammation. Symptoms.—The essential symptom is chronic dysphagia. When dilatation folloAvs stenosis the patient often locates the point at which the food lodges in the esophagus. Most of the ingesta are regurgitated several hours after eating, and this process is often attended by more or less severe strangling. The esophageal sound comes upon the stricture, and is either gripped firmly or totally resisted; in the latter event the bulb can be moved about above this point with abnormal freedom. In the rare cases of spindle-shaped dilatation without stenosis the sound usually detects no obstacle on its way into the stomach. A sac is occasionally formed, however, as the result of localized bulging of the paralyzed wall, in Avhich food may collect or the exploring sound may catch, thus lead- ing to erroneous inferences. Dysphagia is present, though it pre- sents peculiarities, in that the food may either pass down very sloAvly until it reaches the stomach, or it may find its way down for some dis- tance and then lodge in the shallow pouch, as above described. In the latter event the food may be gulped up from time to time. If the sound can be easily introduced into the stomach, we may safely eliminate stricture as the cause of the dilatation. The prognosis is good as long as sufficient food can be gotten into the stomach for the support of life. Treatment.—The chief object in the treatment of this condition is to keep the patient well nourished. If sufficient food cannot be swal- lowed, a Symond's tube should be inserted and nourishment given through it; and when this mode of feeding is no longer feasible, the physician has to choose between gastrostomy and rectal feeding. There can be no doubt that by means of nutrient enemata nutrition may be ESOPHAGEAL DIVERTICULUM. 729 fairly well maintained for a considerable period of time, but not indef- initely, as these cases would seem to demand. In the hands of a com- petent surgeon, on the other hand, gastrostomy is often fruitful of brilliant results. Galvanism has been recommended on high authority, but I cannot speak from personal experience in its use. Local lesions, when present, must be dealt with in accordance Avith the rules govern- ing the treatment of the several causal conditions. ESOPHAGEAL DIVERTICULUM. {Pharyngocele.) Definition.—A circumscribed sac in the Avail of the esophagus. Pathology and Etiology.—Two varieties are met Avith, which Zenker has termed pressure and traction diverticula; the latter are rare. Diverticula that occur at or near the inferior constrictor, and more par- ticularly the larger ones, are congenital in origin. When acquired they are the result of a localized lesion in the muscular coat, through which the mucous membrane bulges like a hernia. This is owing to repeated slight pressure occasioned by the passage of food. When once such a process is started, various factors tend to continually enlarge the pouch. Chief among these are the morsels of food that find lodgement and naturally tend to augment the size of the diverticulum by dragging it doAvnAvard. The sac may finally attain, a diameter of not less than 4 inches (10 cm.). Its situation is nearly always on the posterior Avail at the pharyngo-esophageal junction, and its form is usually saccular or pear-shaped. Most instances have been met Avith in males after middle life. The cause of the Aveakened area at which the diverticulum occurs is to be found sometimes in injury, but more frequently in an antecedent inflammation. Histologic changes are observed only in the mucous and submucous layers, these anatomic elements together forming the pouch. Traction diverticula are produced by the fringe of tissues that often becomes adherent to the upper aspect of the esophagus, and from their mode of occurrence they will obviously be more or less funnel-shaped. Their dimensions are small. They are more common in children than in adults, for the reason that in the former, more frequently than in the latter, do the bronchial glands suppurate, with subsequent cicatrization. This circumstance affords an explanation of the fact that traction diver- ticula are usually seated on the anterior Avail of the esophagus, near the bifurcation of the trachea. Clinical History.— Traction diverticula do not, as a rule, give rise to clinical symptoms. Exceptionally, hoAvever, as the result of the mechanical irritation caused by bits of food that are retained in these funnels, ulceration may occur and be followed by perforation of their apices. In this manner the main bronchi are often perforated (causing pneumonia and pulmonary gangrene), also the pleura (causing empyema), and, more rarely, the pericardium (causing suppurative pericarditis). Pressure diverticula when small cannot be recognized, owing to the 730 DISEASES OF THE DIGESTIVE SYSTEM. absence of signs and symptoms. When they attain considerable size, however, they are often attended Avith severe symptoms. The earliest clinical manifestation is difficulty in SAvallowing; some of the food enters the sac, and, if alloAved to remain, undergoes putrefactive decomposition, causing fetor of the breath. From time to time, and especially on at- tempting to swallow, the partly or wholly filled condition of the pouch excites nausea and vomiting, associated with prolonged strangling; this results in the ejection of a portion of the accumulated contents. After such an attack the patient is unable, temporarily, to SAvallow food, and in consequence of the limited amount of food taken signs of inanition soon appear; this may finally become extreme, and is sometimes the immediate cause of death. The appearance of a pear-shaped swelling in the side of the neck has been observed. As the tumor enlarges it displaces the larynx and presses upon the enlarged vessels—more rarely upon the superior laryngeal nerve, giving rise to dyspnea and distressing fits of coughing. Diagnosis.—A leading point in the differentiation of this affection is the enlargement of the sac after meals (not all the food passing into the stomach), and its disappearance after being emptied. Another valuable discriminating sign is the effect of compression by the hand in causing the contents (" air and sodden food ") to flow back into the mouth. In those instances in Avhich the tumor is absent, Avhile the symptoms point to the disease under consideration, we may demonstrate its existence by the use of the esophageal sound. If the sound passes into the sac, its descent will soon be arrested. If, however, the instru- ment fails to enter the mouth of the pouch, it readily glides into the stomach. An elbowed sound, bent at an obtuse angle near the tip, is especially useful in such cases. It may be inserted in different direc- tions, so as to avoid entrance into the sac. Prognosis.—The outlook is unfavorable in the absence of operative treatment, though modern surgery gives promise of curing a certain proportion of cases. Wheeler has operated successfully in one instance at least. The physician may prolong life by directing attention to the nutrition of the patient, but he cannot hope to promote a cure. If the patient cannot SAvallow an adequate amount of nourishment, he may be successfully fed for an indefinite period through a tube, which he him- self should be allowed to pass. When sufficient food cannot be intro- duced by this method to maintain the poAvers of the patient, rectal feed- ing should be instituted. If excision of the diverticulum be deemed impracticable by the surgeon, then the establishment of a gastric fistula is worthy of extended trial in cases in which the above-mentioned modes of feeding have failed. STRICTURE OF THE ESOPHAGUS. Etiology.—A stricture of the esophagus may be due either to (a) Congenital narrowing (exceedingly rare); (b) Squamous epithelioma, usually producing an annular constriction; (c) Rarely to polypi pro- truding from the mucosa, which almost occlude the lumen of the tube; STRICTURE OF THE ESOPHAGUS. 731 (d) Rarely to specific inflammation, as syphilis and tuberculosis; (e) Simple stricture generally results from the ingestion of corrosive fluids, Avhich cause extensive sloughing of the mucosa, folloAved by cicatricial contraction. Clinical History.—The symptoms vary with the special cause and Avith the degree of stenosis. The first and most prominent indication of narrowing of the gullet is a very sloAvly increasing dysphagia. The patient for a long time complains of a sense of pressure at a certain sub- sternal point on swallowing solid food, or, more rarely, an apparently healthy person will suddenly experience painful pressure in attempting to SAvallow a larger quantity of food than usual. By and by even fluids cause dysphagia, and the patient observes that the time required for the food to reach the stomach is lengthened. The impediment to the act of swalloAving is not due alone to mechanical stenosis, but partly to the weakness of the muscular coat, sometimes OAving to its partial destruc- tion, and in exceptional cases partly to spasmodic contraction. When due to carcinoma, difficult deglutition is, as a rule, the only symptom complained of. When occasioned by corrosive fluids or traumatism, pain is prominent from the onset. Above the seat of stricture the esophagus is often dilated and con- tains accumulations of the ingesta. The latter, together with consider- able mucus, are regurgitated three or four hours after meals, and we may be certain that the materials thus ejected do not come from the stomach if they are alkaline in reaction. The leading clinical features are the gradually increasing debility and emaciation, finally reaching an extreme degree. Diagnosis.—HoAvever characteristic the symptoms may be, the bougie should invariably be passed before pronouncing a positive diag- nosis. By this means we ascertain the degree and the seat of the stric- ture. To begin Avith, a medium-sized gum-elastic bougie (No. 16 Eng- lish scale) should be employed, after warming it and lubricating Avith glycerin. Its use should be preceded by a cocain-spray to prevent spasm. The patient should occupy a Ioav seat, with his head supported by an assistant from in front of the operator. The head should be only slightly thrown backAvard. The forefinger of the left hand should then be passed back over the tongue until it touches the epiglottis, and the bougie inserted along it Avith the right hand, thus avoiding the error of passing it into the naso-pharynx or the larynx. When the bougie reaches the cricoid cartilage it is sometimes gripped pretty firmly even in a healthy person—a fact that is ahvays to be remembered. No force should be applied. The instrument may pass the constriction with a jerk, or it may not only be gripped, but distinctly arrested, when a smaller bougie should be tried. By moving the instrument upward gently Ave may detect sometimes several strictures lying one above an- other. To locate the obstacle, the distance from the teeth to the point of stricture is measured on the instrument, and the results compared with the normal measurements, Avhich are as follows: from the teeth to the cricoid cartilage, 7 inches (17.7 cm.); to the left bronchus, 11 inches, (27.8 cm.); and to the opening into the diaphragm, 15 inches (37.9 cm.). Auscultation of the esophagus has been practised, but the clinical indications afforded are of little practical value. The stethoscope is 732 DISEASES OF THE DIGESTIVE SYSTEM. placed to the left of the spine, and the patient takes a mouthful of water, when, if a stricture be present, a splashing, cooing sound will be heard at the seat of the stricture instead of the normal esophageal bruit. Differential Diagnosis.—It is important to determine not only the ex- istence of a stricture, but also the diseased underlying process, since Avithout this knowledge rational methods of treatment cannot be in- stituted. First and foremost, Ave must exclude those affections that simulate simple and malignant stricture, in certain of which the in- troduction of the sound would be attended with grave dangers. Com- pression of the esophagus by enlarged or accessory thyroids, aortic aneurysms, vertebral abscess, enlarged lymphatic glands, and occasion- ally pericardial effusions, may produce dysphagia, and on passing the bougie resistance is offered at the seat of the external pressure. As a rule, the extent of the stenosis is moderate. If the narrowing be due to aneurysm—" (a) rhythmic movement is sometimes communicated to the free end of the sound introduced as far as the stenosis." Careful physical examination will often reveal the presence of an aneurysm or other pressing tumor, and should never be neglected. A passage of the sound in cases of aneurysm has even caused rupture of the sac and death, (b) Spasm of the esophagus or paralysis (the latter rarely) may closely resemble true stenosis. These neurotic forms are almost exclu- sively met with in young hysteric females; on the other hand, malig- nant strictures are found almost solely in males over forty years; while in simple stricture there is usually a definite history and certain etiologic factors. To discriminate between simple and malignant stricture is not diffi- cult, as a rule. When a clear history of gumma, of tuberculous disease, or of injury (from corrosive liquids) is obtainable, the presence of a simple stricture may be safely inferred after eliminating the affections previously mentioned. In the absence of etiologic data pointing to the simple form, cases occurring in the male after forty years of age may be looked upon as malignant. Prognosis.—In forming a prognostic opinion the chief factor to be considered is the nature of the stricture. Practically, so long as the stenosis is dilatable, the prognosis is not unfavorable provided sufficient nourishment can be taken ; moreover, not a few cases of simple stricture. are curable. The majority, hoAvever, come to a fatal termination finally, death resulting from exhaustion. Treatment.—The chief object of the treatment is to gradually and methodically dilate the stricture in a mechanical manner. The flexible English bougie above mentioned is the best for the purpose, commencing with one of good size; conical ivory bougies, having a flexible whalebone handle, may also be used, though, being quite hard, they are apt to inflict injuries unless used cautiously. It is sometimes necessary, on account of the tightness of the stricture, to begin with a catgut sound. The method of introducing these instruments has already been given. They should be used once daily, and often can be passed successfully by the patient himself. At intervals of three or four days trials of bougies of larger size should be made. I have seen truly remarkable results from this treatment when carried forward systemati- cally in cases due to cicatricial contraction, the patients increasing in DISEASES OF THE STOMACH. 733 bodily weight and strength. In annular constrictions of a malignant type, however, the same plan of treatment is productive of temporary benefit only. The diet deserves most careful attention. When the stenosis is so pronounced as to prohibit sufficient food being SAvalloAved, a Symonds tube should be passed into the stomach, and through it liquid food is introduced. Concentrated forms of nourishment, as raw eggs, bovinin, and the various infants' foods, may also prove useful, and may be ad- ministered Avith milk. So long as an adequate amount of food (semi- solid or liquid) can be easily introduced into the stomach, the amount given should be sufficient to fully meet all the demands of perfect nutrition. When the passage of the bougie is no longer possible relief may be secured in one of two ways: (1) rectal feeding; (2) gastrostomy, if the seat of the stricture be near the stomach, and esophagostomy if at the upper portion of the gullet. I have recently witnessed favorable re- sults from gastrostomy in a case of simple stricture operated upon by Laplace. It is important that the patient should thoroughly masticate the food before introducing it into the stomach. Before resorting to operative procedures, however, careful trial should be made of rectal feeding, since life may be prolonged for an indefinite period by this means. Various forms of nutritious enemata and other points regard- ing rectal alimentation will be found in the Treatment of Gastric Ulcer. VII. DISEASES OF THE STOMACH. METHODS OF DIAGNOSIS. EXAMINATION OF THE GASTRIC FUNCTIONS. Secretory Function.—When food enters the stomach the glands im- mediately begin to secrete their various juices, and continue to do so until the food has passed into the duodenum. During the later stages of gastric digestion the activity of the secretory function of the stomach diminishes, and to obtain accurate knowledge of any pathologic condition of the organ, examinations of the gastric contents must be made under conditions as nearly like the physiologic as possible. Reliable results cannot, therefore, be obtained from an examination of ordinary vomita, but the contents of the stomach must be procured at a definite period after a so-called test-meal (vide infra). Numerous test-meals have been offered to the profession, but those that I have found most satisfactory are " the test-breakfast of Ewald and Boas" and "the test-dinner of Leube-Riegel." The former being simpler and easier of preparation than the latter, it is the oftenest used. The Ewald-Boas test-breakfast consists of one or tAvo rolls (50-70 gm.) and one cup of tea or Avater (300-400 c.c). I constantly advise the use of one roll and a glass of water. About an hour after this meal has been taken the contents of the stomach are to be withdraAvn, and at such a time HC1 should be the only acid present. 734 DISEASES OF THE DIGESTIVE SYSTEM. The Leube-Riegel test-dinner consists of a large plate of soup (300- 400 c.c), a large piece of beefsteak (150-200 gm.), and some potatoes (about 50 gm.) or a roll—practically, a large plate of soup, a piece of meat (preferably beefsteak), and a roll of bread. The examination is to be made about three and a half to four hours after the meal. To obtain the contents of the stomach we should use a soft, flexible- rubber tube Avith an end-opening, or, better still, with several additional openings on the sides, and it should be marked at a point 23.5 to 25.5 inches (58-64 cm.) from the end introduced, this helping the examiner to determine whether it has entered the fundus. The tube is moistened Avith wrater and the end carried back to the pharynx; the patient is now asked to swalloAv, and the tube is gently pushed doAvn the esophagus, these acts being repeated until the tube reaches the stomach. An ordi- nary Politzer bag is noAv attached to the tube (E\vald), or a Boas aspi- rator (Avhich consists of a rubber bulb having a soft-rubber tube at one extremity with clamps). If the Politzer bag be employed, it is com- pressed and allowed to re-expand, the contents being thus Avithdrawn into the bag. There are cases in Avhich it is safer to empty the stomach by siphonage. This is readily accomplished by using a long tube and exerting gentle pressure on the abdomen to start the current. The method I have most frequently used is that of "expression," as folloAvs: The patient is asked to take a deep inspiration, and then to contract his abdominal muscles as in the act of having a stool: in this way the contents are quickly expelled through the stomach-tube above described. These should be first examined microscopically to detect any residue from previous meals, such as meat and the like, and the quantity obtained should be 20 to 40 c.c. After filtering the gastric contents thus obtained they are variously tested. Among qualitative tests the folloAving are important: To determine the reaction, ordinary litmus-paper is used; if acid, the blue turns red. The presence of free acids is determined—(a) By Congo-red, a solu- tion of Avhich is turned blue by the addition of liquids containing free acids. The use of Congo-paper (prepared by dipping ordinary filter- paper in Congo-red solution) is the easiest method. (b) Tropeolin O. O.—Alcoholic solutions of tropeolin are turned by the addition of liquids containing free acids to a brownish-red, deep red, or deep mahogany-broAvn, according to the amount of acids present. Tropeolin-paper (filter-paper immersed for some time in an alcoholic so- lution) may be used, but must not be kept too long. Free HCl.— Giinzburg's test—phloroglucin gr. xxx (2.0), vanillin gr. xv (1.0), absolute alcohol sj (30 c.c). To two or three drops of this reagent add an equal number of the gastric filtrate in a porcelain dish, and sloAvly evaporate to dryness over a flame; and if free HCl is present, a rose-red tint appears along the edges. BloAving at the edge Avill hasten the reaction. The great delicacy of this test is conclusively shown by its availability Avhen HCl is present in the proportion of 1 to 20,000. There are no recognized interfering conditions. Boas' Resorcin Test.—Resublimed resorcin 5 parts, Avhite sugar 3 parts, and diluted alcohol 100 parts. The method of procedure is the same as in Giinzburg's test, and a purple-red color appears. More EXAMINATION OF THE STOMACH 735 caution is required in evaporating, but this method Avill also detect the presence of free HCl in the proportion of about 1: 20,000. Lactic Acid.— Uffelmanns test. The reagent should ahvays be freshly made, as follows: To 10 or 15 c.c. of a 2 per cent, aqueous solution of carbolic acid add 1 or 2 drops of neutral ferric chlorid, Avhen an amethyst-blue color Avill appear. To 1 or 2 c.c. of the mixture add a few drops of the filtrate, and if lactic acid is present it changes to a canary-yelloAv color. Certain substances that are often found in the stomach, as alcohol, sugar, and various salts, especially the phos- phates, may give a coloration simulating that of lactic acid. These sources of error may be overcome by shaking 5 or 10 c.c. of the fil- trate Avith double the quantity of ether, and, after allowing the ether to separate and pouring it off', more is added, the Avhole shaken, and the Avashing is repeated. The ether is then decanted and evaporated almost to dryness in a Avater-bath. To the residue about 1 c.c. of Avater is added, and to this an equal quantity of the Uffelmann reagent from a pipette; if a canary-yelloAV noAv appears, positive proof of the presence of lactic acid is afforded. Boas and others have experimentally shown to their OAvn satisfaction that the presence of lactic acid in the gastric contents during the first stage of digestion (formerly believed to be physiologic) has pathologic significance. Boas also found that ordinary bread contains lactic acid, and hence he has abandoned the usual test- meal, so far as the determination of this acid is concerned, and adopted a thin gruel made by adding to a quart of Avater flavored with salt half an ounce of oatmeal-flour. Boas states that no lactic acid is present in the filtrate several hours after this test-meal, except in cases of carci- noma of the stomach. The use of this test-meal for usual clinical purposes is noAv generally held to be superfluous. Lactic acid in the stomach-contents occurs Avith fermentation-stagnation from either ob- struction or deficient motility. A more reliable test for lactic acid than the foregoing is that of Boas, as folloAvs: Digest the filtrate several times Avith ether to remove the fatty acids; add a feAV drops of phosphoric acid and boil. Transfer the mixture to a distillate flask; add H2S04 and Mg02; heat, and lactic acid will be distilled over. This can be conducted into a strongly alka- line solution of iodin and potassium iodid. The presence of lactic acid is then shoAvn by the production of iodoform, which can be recognized by its odor and by the precipitate that is formed. Fatty or Volatile Acids.—Heat to boiling a few c.c. of the filtrate in a test-tube, over the mouth of wliich place a strip of moistened blue litmus-paper; the presence of fatty acids will change the paper to red. Acetic Acid.—In large quantities this acid is detected by its odor, and in smaller quantities its presence is determined by neutralizing with sodium carbonate the watery residue of the ethereal extract, and adding neutral ferric chlorid, Avhen a blood-red color will be struck. Quantitative estimation of certain constituents is desirable. Total Acidity.—To 10 c.c. of the filtrate add 1 or 2 drops of a 1 per cent, alcoholic solution of phenophthalein, and as many cubic centimeters of a decinormal solution of sodium hydrate are added slowly from a buret until the reddish color that appears fails to disappear on snaking. The number of cubic centimeters of the decinormal solution normally required 736 DISEASES OF THE DIGESTIVE SYSTEM. ranges from 4 to 6 ; hence, if these be multiplied by 10, Ave have 40 to 60 as the percentage of acidity. Under pathologic conditions these num- bers may be either higher or lower. This total represents both free and combined acids. If no organic acids be present, the above figures will represent the percentage of HCl. The latter is also reckoned thus: If it required 5 c.c. of the decinormal solution of sodium hydrate to be added to 10 c.c. of the filtrate to get the red color (alkalinity) with the phenophthalein, we say the acidity is 50, and multiplied by 0-003,016 — 0.1823 per cent, of hydrochloric acid. It should be stated that the normal range of percentage is from 0.14 to 0.24. Estimation of Free HCl.—Mintz's method: To 10 c.c. of the filtrate add a decinormal solution of sodium hydrate from a buret until no re- action is given with Giinzburg's reagent. The number of c.c. of the decinormal solution used, multiplied by 10 and then by 0.003,646, gives the percentage of free hydrochloric acid. Estimation of Lactic Acid.—If the volatile acids are present, they should be removed by boiling. Take the total acidity of 10 c.c. of the filtrate; then to a second 10 c.c. add 25 to 30 c.c. of ether; shake well, allow the ether and filtrate to separate, remove the ether, and again add 25 to 30 c.c. of ether ; shake, and repeat the process. Next obtain the acidity of the watery solution, and the difference between this and the total acidity, multiplied by 10X0.09, will give approxi- mately the amount of lactic acid. In the gastric digestion of the albuminoids (proteolysis) the proteids are converted into peptone. Although commenced in the stomach, this function is dependent in greater part upon the action of the pancreatic ferment in the small intestines. Among the substances earliest engen- dered by this process are the albumoses (propeptone), whose separation may be thus effected: Add a small quantity of a saturated solution of sodium chlorid to an equal amount of gastric filtrate, and if it becomes cloudy propeptone is present, the degree of the cloudiness indicating the amount present. If the mixture does not become turbid, add a few drops of acetic acid, when it will become so in the presence of this sub- stance, however slight the quantity. If heated, the solution becomes clear, and if allowed to cool, the propeptone precipitates and may be obtained by filtration. In a later stage of the process of albumin-digestion peptone is pro- duced and its detection is easy. To a small quantity of the filtrate (the propeptone having been removed) add enough sodium or potassium hy- drate to render the solution alkaline; then add a few drops of a 1 per cent, solution of cupric sulphate, and, if peptone be present, a purplish color is presented. The Test for Pepsin.—In a test-tube containing 5 c.c. of filtrate add a small piece of egg-albumin, and keep at a temperature of about 100° F.; if present, the albumin disappears in from two to six hours. If hydrochloric acid is absent from the filtrate, it is necessary to add a few drops of the dilute acid. It should be pointed out that laboratory attempts to estimate the rate of albumin-digestion are unreliable. Rennet Ferment.—To 5 or 10 c.c. of raw milk add a feAV drops of the gastric filtrate, and keep it at a temperature of about 100° F.; if rennet EXAMINATION OF THE STOMACH. 737 is present, coagulation into a single cake occurs in from a few minutes to an hour or more. Rennet Zymogen (which is converted into rennet ferment in the pres- ence of an acid).—To 5 c.c. of gastric filtrate add enough sodium car- bonate or sodium hydrate to make it slightly alkaline ; then add calcium chlorid (1-2 c.c. of a 2 per cent, solution); then mix Avith an equal quan- tity of milk, and, if zymogen is present, coagulation occurs as in the case of rennet ferment. Both rennet ferment and rennet zymogen may be assumed to be present when HCl has previously been found. Starchy Derivatives.—To a small quantity of gastric filtrate add 1 or 2 drops of Lugol's solution; the presence of dextrin gives a blue reaction—erythrodextrin purple, achrobdextrin, grape-sugar, and malt- ose (intermediate substances)—showing a yellowish color. If there is a mixture of these starchy derivatives, as when the digestion of starches proceeds naturally, the first feAV drops of Lugol's solution may produce no color-reaction, or it may be taken up by the dextrose or maltose, while the addition of more of Lugol's solution will give a purple (if erythro- dextrin be present) or a blue color, due to starch. Indeed, if a minute quantity of the solution strikes a blue or purple tinge, conversion of starch into maltose has been abnormally tardy. I believe this is oftenest due to hyperacidity, though it may also more rarely be due to a defective ptyaline-supply.1 The Tests for the Motor Function.—More important than the secret- ory is the motor function of the stomach. There are three recognized tests: The oldest method is that of Leube. It consists in washing out the stomach from six to seven hours after a large meal, preferably consisting of beef-soup (13 oz.), beefsteak (6| oz.), bread (IJ oz.), and water (6J oz.), or from tAvo to two and a half hours after EAvald's test-breakfast. Normally, the stomach should be empty Avithin these periods of time, so that if a residue remains it denotes a lack in the motor force. Salol Test of Ewald and Sievers.—Salol being composed of phenol and salicylic acid, it is not acted upon in an acid medium; therefore, ^vhen introduced into the stomach it remains a stable compound, and is only broken up in the intestine by the action of the pancreatic juice. The salicylic acid is absorbed into the blood and eliminated through the urine, in which it can be detected by adding a few drops of neutral ferric chlorid, a violet color appearing. The patient is given 15 grains (1 gm.) of salol in two thin gelatin capsules; the bladder is emp- tied, and the patient told to urinate every half hour for tAvo hours. Normally, it requires from three-fourths to an hour for the salicyluric acid to appear in the urine, but when the motor function of the stomach is much impaired it may require t\vo or more hours. In order to detect the earliest traces of the eliminated salicyluric acid, Ewald and Einhorn have suggested moistening a piece of filter-paper with the urine, and then alloAving a drop of neutral ferric chlorid solution to come in con- tact with it, the edges of the drop shoAving a violet color in the presence of the slightest traces. The varying reaction of the intestinal contents 1 The tests for the estimation of the combined acids, of some of the fatty acids, and of many of the products of proteolysis are complicated and unnecessary in an ordinary clini- cal examination. 47 738 DISEASES OF THE DIGESTIVE SYSTEM. renders the salol test very unreliable. Sometimes in healthy individuals the decomposition of the salol is retarded, and to overcome this objection Huber has suggested the determination of the precise time when the salicyluric acid no longer appears in the urine. He found that normally it required from twenty-four to thirty hours. If, then, the reaction out- lasts this period, it shoAvs peristalsis or the motor function to be unduly tardy. Leube's test is much more reliable. Klemperer s Oil-test.—The stomach is thoroughly washed, and 31 ounces (100 c.c.) of olive oil are poured into it through the tube. Two hours later the remaining oil is withdrawn by aspiration. As the stom- ach-wall does not absorb oil, the difference between the original amount and that Avithdrawn shows the condition of the motility. Klemperer states that at this time the residue should not exceed 20 to 40 c.c. This test is also unreliable. To Test the Absorptive Power.—The method described by Penzoldt has been almost universally adopted: A capsule containing grains \\ (0.1), of potassium iodid is given to the patient, care being taken that the capsule is first carefully Aviped. The iodid is absorbed from the stomach and appears in the saliva, which is to be examined for the pres- ence of iodin. For this purpose strips of starch-paper (filter-paper moistened in a solution of starch and dried) are used; they are moist- ened with the saliva of the patient, and the moistened areas treated with a drop of fuming nitric acid. As soon as the iodin enters the saliva, the characteristic reaction for starch is struck—a blue color. Normally, this reaction occurs in from ten to fifteen minutes ; under abnormal con- ditions it may be delayed for half an hour or more. Rarely it fails to occur. This test cannot be strongly depended upon. PHYSICAL OR EXTERNAL EXAMINATION. This implies the Avell-known physical signs—inspection, palpation, percussion, succussion or splashing, and auscultation. Inspection.—(a) General.—This may give an idea of the nature of the illness as well as its severity by noting Avhether the patient appears to belong to a neurotic group, the general health often being good, or Avhether the patient is emaciated, or has with the latter the cachexia of a malignant groAvth. In diseases of the "stomach attention should be di- rected to the mouth, and especially to the teeth, because the latter are often of causal importance in many gastric ailments. Dental affections often prevent the possibility of curing the various chronic diseases of the stomach. (b) Local Inspection.—In patients with thin and relaxed abdominal walls the contour of the stomach can be plainly noted; especially is this the case in very large, dilated stomachs or in those that have been dis- placed. The examiner is greatly aided by inflating the stomach with air or gas. The former is to be preferred, for the reason that the supply is easily regulated; he is enabled to watch the different steps of the dis- tention, and after the examination is completed the air is allowed to escape through the tube. For this purpose an ordinary stomach-tube is most convenient, and its passage is to be effected in the same way as in removing the gastric contents. A double bulb-attachment is connected EXAMINATION OF THE STOMACH. 739 with the external end of the tube, by means of which air is readily forced into the stomach (Runeberg's method). Frerichs' method is sometimes used. It consists in administering 3j (4.0) of tartaric acid, dissolved in half a glassful of water, and im- mediately afterward 3j (4.0) of sodium bicarbonate, dissolved in the same amount of Avater. Effervescence noAv occurs, with a progressive visible distention of the organ. The chief objection to this method is the fact that either too much or too little distention is obtained. The inflated stomach presents a circumscribed protuberance, usually in the epigastric, and also in the umbilical region if the organ is dis- located or dilated. The air may find its way into the intestine, produ- cing a visible change in the contour of the abdomen. Tumors and other abdominal enlargements may also be recognized, and an idea obtained as to which organ is involved, after making due alloAvances for displacement, as in gastroptosis and pyloric carcinoma. Exaggerated peristaltic waves may also be noticeable in the upper portion of the abdomen, usually Avhen associated with the stomach, and in the loAver portion if it is in the small intestine. Peristalsis is increased from various causes—inflation of the stomach, external tapping, neuroses, pyloric obstruction, and the like. The value of the gastroscope in inspecting the interior of the stom- ach is, I think, doubtful. Gastro-diaphany (illumination of the stomach) is sometimes useful in showing the fundus extending to a loAver level (at the navel) than is indicated by percussion. The Rontgen rays (skiag- raphy) already enable us to detect non-penetrable foreign bodies in the stomach, and bid fair to distinguish aneurysms, gall-stones, and the like in the interior of the body. Palpation.—This elicits at times more trustworthy information than inspection. The patient should be in the recumbent position, the lower limbs partially flexed on the abdomen and the head low. The examiner should stand at the right side of the patient and use the right hand, which should be Avarm. With the palmar surface doAvn gentle pressure should be made Avith the fingers and the ulnar side of the hand. If the abdominal Avail is tense, it is best to distract the attention of the patient from the examination by talking to him. In this manner Ave can corroborate the inspection as to the size, shape, and position of the stomach, and can detect morbid groAvths and determine their consistency and movability. Caution must be exercised to differentiate between normal and abnormal conditions, and opportunities should not be ne- glected by the physician to equip himself in delicacy of palpation by practice upon a normal abdomen. Deep palpation elicits the degree of sensitiveness, tenderness, or pain, whether circumscribed as in ulcer or diffuse as in generalized inflammatory states (enterocolitis, peritonitis). In some instances relief from pain may be noted on pressure with the broad hand in neuroses. Variations in the degree of tension and of resistance are found and prove valuable aids. With Boas's algesimeter Ave are enabled to detect the amount of pressure necessary to be exerted over a given area to cause pain, by reading the number of kilograms from a scale. In some instances this is a serviceable instrument, but in ulcer, when palpation must be done 740 DISEASES OF THE DIGESTIVE SYSTEM. with the greatest gentleness, it would not be a very safe procedure as compared with the soft hand—nature's own instrument. Percussion.—The patient is placed in the recumbent position; the examiner uses his fingers and endeavors to discriminate the slightest differences in the note, and percusses lightly. If the stomach is empty or partially filled with gas, it gives a lower tympanitic sound than the colon, which is also often filled Avith gas. To ascertain the size and position of the stomach by percussion the process should begin at the symphysis pubis and follow the median line upward. The upper border of the stomach is at the ensiform cartilage, the loAver about tAvo fingers' breadth (3 cm.) above the umbilicus; hence, if the latter is below the umbilicus and the upper border in the normal position, it denotes an enlarged stomach. If the upper margin is some distance below the ensiform, displacement of the organ is indicated. It is Avell to trace the limits of resonance of the stomach and of any areas of dulness met with, so that their size and position may be graph- ically represented. The differences in the percussion-note over the stomach and colon may be greatly exaggerated by inflating the former. Runeberg's method is to be preferred. By employing light percussion the limits of the stomach can now be easily and accurately defined, unless the transverse colon be at the same time greatly distended with gas. In such instances Dehio's modification of Piorry's method is to be resorted to. It consists in giving about 1 liter (1 quart) of Avater in fractional doses while the patient is standing; one-quarter of the liter is swallowed and percussion practised, when a dull note will be obtained over the most dependent portion of the stomach. A second quantity of equal amount is given and a re-examination made, and so on, the object being to ascertain to what point the loAver border sinks on the addition of more fluid. Boas holds that this method tests effectively the tone of the stomach, and that a marked descent of the lower border after each addition of water is indubitable evidence that there exists weakness or atony of its walls. If a neoplasm originates posterior to the stomach or colon, inflation of the latter may cause the previous circumscribed dulness to disappear. By striking the abdomen in the epigastric region splashing-sounds may be produced. This sign is of diagnostic value in dilatation of the stomach, though its absence does not contradict the presence of the dilatation. Again, if the splashing-sound is obtained in a fasting stom- ach, it may give a clue to some abnormal condition. In many instances, however, the stomach may contain large quantities of fluid and no splashing-sound be obtained. Caution should be exercised lest the splashing-sound sometimes produced in the transverse colon be mistaken for that originating in the stomach ; in the former the sound is usually associated with diarrhea, while in the latter constipation usually obtains. Auscultation.—Various sounds are heard, none of which are pathog- nomonic of any diseased condition. Succussion-sounds are produced by shaking the patient, and, if the stomach is dilated and contains fluid, the sounds may be audible some distance from the patient. The patient can sometimes engender similar sounds by voluntary contraction of the abdominal muscles. Various murmurs are heard in the act of deglutition—one Avhen the food passes MALPOSITION OF THE STOMACH. 741 from the pharynx into the esophagus; Ewald has described two, both heard at the cardiac extremity of the stomach; the first is a hissing murmur, the second a splashing or sprinkling. The heart-sounds are heard over an inflated stomach, and have a clear, metallic quality. Sizzling sounds are audible when fermentation occurs; also after giv- ing a Seidlitz powder. MALPOSITION OF THE STOMACH. The stomach may occupy a truly vertical position.in consequence of the persistence of the normal infantile condition or of improper cloth- ing, as long-continued pressure from corsets and the like. Unless an angular condition of the duodenum, causing obstruction to the outfknv of the gastric contents, folloAved by dilatation of the stomach, be en- gendered, the malposition is of little or no clinical significance. Trans- position of the stomach, with the organ occupying the right hypochon- drium, is rarely met with in association with transposition of other viscera. GASTROPTOSIS. Definition.—DoAvmvard displacement of the stomach. The lesser curvature of the organ lies about midway between the ensiform cartilage and the umbilicus, and the greater curvature near the symphysis pubis. Etiology.—So far as our present knoAvledge extends, the conditions and circumstances contributing mostly to the origin and development of gastroptosis are—(a) Age and sex. Meinert of Dresden found among girls of fourteen years gastroptosis in 80 per cent., and among the women Avho presented themselves at his private clinic in 90 per cent. According to my own observation, gastroptosis is not as frequent among American girls and women as among the Germans. " Dislocation occurs in about 5 per cent, of the male population of Dresden." (b) Improper clothing, particularly tight lacing, (c) Dislocation of the right kidney. This operates potently, and prolapse of other abdominal organs may occasionally constitute the chief point of departure, (d) Repeated pregnancies, inducing a relaxed state of the abdominal Avail, (e) Mus- cular strain and local injury, by diminishing the tonicity of the gastro- hepatic omentum. (/) Abnormalities of the chest-formation (kyphosis); great meteorism, and enlargement of the abdominal organs, especially of the spleen and liver. Certain chronic diseases may be active—e. g. chlorosis, tuberculosis. Symptoms.—Malposition of the stomach may exist without symp- toms, but in most instances it produces functional disturbances of clin- ical importance. The latter are due, first, to the difficulty that the stomach experiences in emptying its contents. Soon functional dis- orders arise in consequence of gastric atony, and later there is apt to be a greatly diminished gastric secretion, associated with a nervous dys- peptic condition. Especially to be emphasized is the fact that the stom- ach may be of natural or of diminished size (as the primary result of the compression of the corsets—Fleiner), or it may be dilated—a not 742 DISEASES OF THE DIGESTIVE SYSTEM. uncommon event that often colors the clinical picture in a peculiar man- ner. Constipation due to defective peristalsis, and colicky pains due to spasm of the intestinal muscles, are important features. Physical examination of the inflated stomach1 permits the accurate demonstration of gastroptosis. The percussion-note now indicates the position of the organ. It is to be borne in mind that the cardiac end remains fixed at the twelfth dorsal vertebra, while the pylorus moves dowmvard and to the left: this will explain Avhy the epigastrium is free of gastric tympany. Succussion splashing-sounds may be heard if atony, with retained gastric contents, obtains. The differentiation of gastrop- tosis from dilatation of the stomach is also accomplished by the method of inflation, since this makes plain the course and position of the lesser curvature and of the pylorus. The prognosis is not bad, being much the same as in nervous dys- pepsia ; it is modified in some cases by the presence of special causal agencies, and in others by the occurrence of certain complications, as dilatation of the stomach. The treatment has relation to the removal of all causes that favor the condition and to the associated functional disturbances. Nervines and nutrients are especially to be employed. DILATATION OF THE STOMACH. The condition is to be subdivided, clinically, into acute and chronic forms. The normal capacity of the stomach varies within rather Avide limits, though the maximum normal capacity, according to Ewald, does not exceed 1600 c.c. (1.5 quarts); enlargements above this capacity may then be said to fall under the heading of dilatation. Pathology and Etiology.—The chief factor in the production of chronic dilatation is pyloric stenosis. This is usually due (a) to such diseases of the stomach as carcinoma, ulcer (occasionally), hypertrophic thickening of the pylorus, or the thickening and induration consequent on the action of corrosive poisons; (b) to the external compression aris- ing from carcinoma of the liver, pancreas, or gall-bladder, from the omental lymph-glands, and not infrequently from a displaced right kidney, or from large gall-stones; (c) congenital pyloric stenosis and adhesions about the pylorus may also act as causes of dilatation. Obviously, in all such instances increased force is necessary to pro- pel the food from the stomach into the duodenum, thus leading gradually to a hypertrophy of the muscular fibers; this is noted in an especial degree in the immediate vicinity of the pylorus. So long as this hyper- trophied state of the muscular layer compensates for the obstructive lesion no pathologic dilatation can occur. Just as soon, however, as the muscles prove to be inadequate on account of secondary degenera- tive changes, accumulation of the undigested food in the stomach en- sues. This tendency for the contents of the stomach to accumulate is 1 Inflation may be accomplished by the use of effervescent mixtures or by the intro- duction of atmospheric air {vide ante). DILATATION OF THE STOMACH. 743 very much augmented by the increasing weakness of the muscle on the one hand and the increasing degree of stenosis on the other. A further step in the anatomic alteration is the development of a chronic gastric catarrh in consequence of the chemical and mechanical effect of the un- digested food, the latter inevitably undergoing fermentative aud putre- factive changes from prolonged retention. The degree of dilatation is, to some extent, augmented by the generation of excessive amounts of gases under these abnormal conditions, as well as by the great weight of the accumulated gastric contents. When produced in this manner the stomach attains enormous dimensions, and one instance has been re- corded in which it Avas capable of containing 90 pounds of fluid (Loomis). Dilatation is usually general, though there may be mere diverticula cor- responding to the seats of ulcers or to erosions of the walls. Dilatation may also occur independently of pyloric stenosis, though this class of cases is not so large as the preceding, nor does the condi- tion attain so pronounced a degree. In this variety of dilatation there is atony of the muscular coats, due to various and dissimilar causes : (a) repeated over-strain of the muscular layer, due to over-filling of the organ with food and drink, is a comparatively frequent cause, and one met with in diabetics and in those Avho habitually drink large quantities of beer; (b) chronic gastric catarrh frequently Aveakens the muscle, and more especially when associated Avith an over-indulgence in food and drink; (c) fatty and other forms of degeneration or nutritional disturb- ances associated with certain constitutional diseases (particularly carci- noma, anemia, and tuberculosis); (d) congenital weakness of the mus- cular coat; (e) impaired innervation, leading to imperfect peristalsis and consequent dilatation ; (/) omental hernias (Bamberger) that drag down the stomach ; (g) fibrous bands, by binding the stomach to other organs, will occasionally cause slight dilatation. Acute dilatation has for its chief causes—(a) specific fevers, pro- ducing parenchymatous degeneration of the muscular coats ; (b) the acute paralytic distention of Fagge, Avho ascribed the condition prima- rily to chronic catarrhal inflammation ; ( DATE z ■A /' / 1 r I"' I La \ "■ X *| A , / s, i/\ p -\- \/ \ \- V \ - /-■ \ — 1 '"" J__ .__L. A ~ — V \ A A ^ J '\ / \ __i_ V ' A t \, L s v s/ V y Ktr. A .|p. t-,,t- .1 >ER/i TUF EJ 812 13 14 15 16 17 18 19 20 21 22 23 24 25 Fig. 58.—Temperature-chart of a case of appendicitis. M. M---, aged thirty-five years; motor- man. Laparotomy, by Prof. E. Laplace, disclosed catarrhal appendicitis with adhesions. An elevation of temperature, however trivial, is most significant, pointing as it does to inflammation as the cause of the local symptoms. The pulse-rate is somewhat higher than the elevation of temperature would lead one to expect, and in bad cases the pulse is usually much quickened. Sometimes, however, it remains at 80 to 90 per minute, and may be full and soft, even though the patient be practically moribund. Fixed tenderness is practically constant on pressure over a limited area, midAvay on a line betAveen the anterior superior iliac spine and the umbilicus (McBurney's point), and is a most valuable sign. The seat of the tenderness may rarely be found at other points, depend- ing upon the location of the appendix. I have twice observed it in the lumbar, once in the right hypochondriac region, and once below the usual point, in the right iliac fossa. It has also been found in the umbilical and left iliac regions, in the pelvis, and in the groin. In several instances, although I have found it elsewhere in the early stage, it has shifted to McBurney's point later. On the other hand, it may move from the usual position in cases that are allowed to drag on. When the sensitive area is at McBurney's point, as is the rule, the gentlest pressure often suffices to elicit exquisite tenderness, but when it is situated elseAvhere firmer pressure Avith the finger-tips is usually required. Deep pressure always reveals localized tenderness at some point in the abdomen if the case Is one of appendicitis. Palpation also detects an abnormal tenseness of the right rectus abdominis muscle. On or about the second day a circumscribed induration manifests itself, folloAved soon by a fulness and swelling tending to obliterate the depres- APPENDICITIS. 817 sions above and in front of the anterior iliac spine. The position of the indurated area varies according to the location of the appendix, but is usually found at or in the vicinity of McBurney's point. Sometimes a resistant mass of the shape and size of an enlarged appendix is palpable. In such cases peritoneal exudation has not as yet occurred to any great extent. In some cases the induration is diffuse at first, but assumes the usual circumscribed form later; it may, moreover, be so deeply seated as not to be appreciable. The degree of tenseness of the two recti mus- cles—right and left—should be compared, though an absence of tension of the right rectus does not, I feel certain, eliminate the possibility of appendicitis. The results of percussion furnish no certain guide. As a rule, the note on light percussion differs from that on the opposite side; on deep percussion a dull tympany or a circumscribed area of dul- ness can be outlined. This deadness may be due in great part to the presence of fecal matter in the adjacent coils of intestine. While at the start the abdomen may be flattened or even retracted, tympanitic dis- tention afterward appears, particularly in the cecal region, giving rise to exaggerated tympany on percussion. Less characteristic, though still of diagnostic Avorth, are certain other symptoms. At the beginning vomiting usually occurs, unless there be diarrhea, and is attended by more or less nausea; it may con- tinue throughout the course of the attack. In most cases, hoAvever, after a few fits of vomiting the symptom disappears, though it may recur if errors in diet be committed or if peritonitis supervene. During the attack constipation is the rule, though diarrhea, Avhich sometimes precedes appendicitis, may also occur at a late stage as a septic symp- tom. There is anorexia, and the tongue is coated. The decubitus is dorsal, with the right leg flexed. Frequent micturition (early) and re- tention of urine (later) are not uncommon, the urine having a deep color-tint, and sometimes containing albumin. The case may folloAv a mild course, terminating in resolution Avith recovery; or it may be of a severe type and develop perforation, with the formation of abscess or diffuse peritonitis. As graphically stated by Fitz, it is impossible to obtain statistical evidence on a large scale of the relative frequency of these alternatives, and hence the frequency of treatment of appendicitis by abdominal section. From all available data, hoAvever, it would appear that in more than one-half of the cases the course is light and favorable. If not operated upon early, the fever may continue for three to five days, and then subside, with simultaneous abatement of the severe local and general symptoms and Avith the establishment of convalescence. The same amelioration of the symptoms may be brought about by early free purgation, either as the result of salines or, rarely, spontaneously. In these instances resolution takes place even after invasion of the peri- toneum. Small abscesses may be absorbed, and usually in cases ter- minating in resolution perforation has not occurred. Infection of the peritoneal membrane directly through the appendix is not uncommon. In severe attacks perforation may occur, with the development of localized peritoneal abscess or generalized peritonitis (vide Pathology), and it must be remembered that cases that begin gradually may also show a tendency toward perforation. When this event occurs early in 52 818 DISEASES OF THE DIGESTIVE SYSTEM. the course of a severe attack or after a protracted mild appendicitis, the symptoms of local or general peritonitis are superadded. If early, the symptoms pointing to peritonitis are intense; the abdomen sAvells quickly, and is exquisitely tender, though the physical signs of a tumor are ab- sent. The temperature often falls, and the characteristic vomiting and circulatory collapse appear. Often the generalization of the peritonitis is marked by less violent symptoms. Starting from the seat of circum- scribed inflammation, the pain and tenderness propagate themselves noticeably from day to day until every portion of the peritoneum has been invaded. Besides progressive augmentation in the local features, including the pain, there is a gradual failure in cardiac poAver, as shown by the condition of the pulse ; vomiting also returns, and at last becomes fecal. Death results from asthenia, and sometimes suddenly Avhen un- anticipated. If perforation occurs later, sufficient time has been allowed usually for the inflammation to become circumscribed, in which case the localized abscess is generally intra-peritoneal; it may, however, rarely be extra-peritoneal. The local symptoms intensify, the pain becomes excruciating, and the spot of tenderness may rapidly extend itself in all directions, particularly doAvnward. Vomiting sets in, and may become troublesome, and constipation is absolute, not even gas escaping from the rectum. Retention of urine is common. Physical Signs.—Inspection shows distention of the belly, the affected area being especially prominent, Avith an obliteration of the natural de- pression in the right iliac region. Palpation discoA^ers induration and great tension that soon yield to pressure (doughy), and edema of the skin. If the abscess is superficially seated, fluctuation may be appre- ciated on bimanual palpation. Deep-seated tumors are not uncommon, hoAvever, and then fluctuation is detected with difficulty or not at all. An examination per rectum, with a vievv to determining whether the abscess has gained the pelvis, is highly important. Counter-pressure above Avith the free hand aids materially. In doubtful cases bimanual pelvic examination should not be neglected. Percussion reveals dulness if the abscess be superficial. A tympanitic note, however, is often elici- ted, due either to an intervening coil of intestine or to the gas contained in the sac of the abscess. If active peritonitis and septicemia do not develop, the constitutional as well as the local symptoms may abate, and the patient leave his bed, carrying Avith him, however, the abscess. The latter may point some- where in the right loAver quadrant of the abdomen or in the lumbar region. There is also a strong tendency toward spontaneous rupture into the rectum, bladder, vagina, or cecum. Often, preceding the dis- charge of pus into these organs, the latter display marked irritability, particularly the rectum and bladder. There is ahvays the danger that the contents of the abscess may find their way into the general perito- neal cavity. The symptoms of hepatic abscess may develop at an ad- vanced stage. The pus may traverse the abdomen in the upward direc- tion until it touches the diaphragm, when the symptoms of subphrenic abscess may be manifested. Extension through the diaphragm may noAV occur, causing pleurisy or pericarditis, and a pleuro-fecal fistula may thus be established. The general symptoms undergo a modification, due to the suppurative APPENDICITIS. 819 process. Rigors or a decided chilliness may occur. Diarrhea often succeeds to previous constipation, and drenching sweats to a dry skin. Improvement and even spontaneous cure may ensue if spontaneous rup- ture into one of the outlets of the body should occur. The fever (Fig. M E M E M E M E M E M E M E M E M E M E M E M E M '- M E M E M E M E BOWEl <1 " " - ~ - - - - ~ " " - ~ OAU-Y AMOUNT . F. 105° 104° 103 102 101 100 9'/ 9S' 9?' DATE z ^ -3 ^!- - < -£ t£ 05 -o — - -Uj -O -I — — ~ ~CO A \ '\ \ , \ A £ / 1 P — P V / | X ^ t J It \ ^ t \ A t V, A 4 \ 'I Li \ 1 q \ / I / A 1 / / I \ / 1/ \ A J y V / sj l/ / 1 w -ii 1 V 1 , I 1/ / ! \ V V V u 1 1 1 1 — CORNING A N Ni 'TE MPE IN Lr t v c I25 26 27 23 29 30 31 11 2 3 4 5 6 7 8 9 10 c. Hl° Fig. 59.—Temperature-chart of a case of appendicitis. R. C---, aged nineteen years ; carriage- builder. A peritoneal abscess was found, while the appendix was becoming gangrenous. 59) may be either remittent or intermittent, and if the localized inflam- matory process be active, the usual pronounced features of septicemia are predominant in the clinical picture. The latter specially grave con- dition often drifts into an extreme typhoid state with a hopeless course. Diagnosis.—Typical cases of appendicitis are readily diagnosti- cated. Their recognition rests upon a feAV cardinal symptoms—viz. the acute development of severe pain in the right iliac fossa, coming on in a person previously healthy and usually under forty years of age ; appendicular tenderness, unilateral induration, fever, vomiting, and con- stipation, or, more rarely, diarrhea. Atypical cases, however, may offer great difficulty, at least at an early stage in primary attacks. Often the pain is, for a time, referred to a circumscribed area far removed from the usual site of the appendix, and rarely it continues Avithout a change of situation throughout the attack. In the latter case the local lesions may occupy the usual, though oftener they have an unusual, position. Thus, Avhen the pain is referred " due east," or to the left iliac fossa, with 820 DISEASES OF THE DIGESTIVE SYSTEM. bilateral induration, the appendix will be found in the pelvis (Deaver). In such instances a rectal and a bimanual vaginal examination are im- perative. It should be an unvarying rule in all cases of severe abdom- inal pain to palpate Avith the finger-tip every square inch of the abdomen if necessary, to find the localized tenderness Avhen it is not found at McBurney's point. The degree of tenderness sustains a close relation- ship to the severity of the local inflammation as long as the condition remains strictly localized, but this relationship is lost Avhen generaliza- tion occurs. With the appearance of a circumscribed induration and of the intense local tenderness and pain it is reasonably sure that per- foration either has occurred or is impending. Perforation, however, may occur without local induration, and even after subsidence of the acute pain and excessive tenderness. Gangrenous appendicitis is most deceptive. The very acute symptoms, including the fever, may disap- pear, and unless the physician be upon his guard the patient Avill be considered convalescent and be allowed to go about. Rupture of the abscess now occurs unexpectedly into the peritoneal cavity, intestines, or some other direction, or a large-sized abscess develops Avith the usual signs and symptoms. Differential Diagnosis.— Typhlitis, and especially the Massing of Feces in the Cecum.—These are truly rare conditions. According to McBurney, 99 per cent, of all typhlitic abscesses are of appendicular origin, and of 400 autopsies by Einhorn 91 per cent, had this origin. Ball and others have performed laparotomy for ulcerative cecitis, but this condition cannot be recognized during life. Stercoral typhlitis is discriminated from true appendicitis by the precedent constipation, which may become absolute, by the dragging character of the pain, the late-appearing fever, and chiefly by the physical signs, Avhich indicate the presence of a superficial, sausage-shaped tumor that is often doughy and extends vertically from a point near the right costal border "south- Avard " through the ileo-cecal region. Percussion elicits dulness over the seat of the tumor. The localized tenderness and circumscribed resist- ance of acute appendicitis are Avanting, and a thorough emptying of the large intestine usually cures stercoral typhlitis.1 Renal Colic.—The absence of fever and of a localized spot of ten- derness and induration, and the presence of hematuria are points that distinguish this affection. Indigestion.—Digestive disturbances, and particularly pain and vom- iting, accompany appendicitis. When they occur independently of ap- pendicitis, however, they can be relieved, and the appendicular region remains free from fixed pain, tenderness, or tumor. Acute Inflammation of the Gall-bladder, with Distention.—This gives rise to a superficial, mobile, pear-shaped tumor, with or without jaun- dice—features not met Avith in appendicitis. Osier, hoAvever, mentions a case of the sort in which the diagnosis Avas undetermined until lapa- rotomy was performed. Perinephric Abscess.—Without a clear history of chronic renal dis- ease or of nephrolithiasis the differentiation cannot be made except by exploratory incision. 1 It is highly probable that the term "stercoral typhlitis" is synonymous with chronic appendicitis with retained feces in the cecum. APPENDICITIS. 821 Carcinoma of the Large Intestine.—This discriminates itself by its peculiar and more chronic history. Acute Peritonitis, due to Ovarian or Tubal Disease.—To eliminate these conditions the results of a careful bimanual pelvic examination and a clear antecedent history are demanded in many instances. Right ovaritis, OAving to the presence of pain, tenderness in the right iliac fossa, and fever, often closely simulates appendicitis. In the former tenderness is less pronounced, and the organs of utero-gestation manifest certain disturbances of function. A pelvic examination will noAv com- plete the discrimination. Extra-uterine Pregnancy.—In this condition the menstrual history furnishes important information. There is, in addition, profound col- lapse, due to hemorrhage, Avhen rupture of the adhesions occurs. Ele- vation of temperature is absent. The localized tenderness and in- creased resistance are loAver in the pelvis than in appendicitis. Acute Tuberculous Peritonitis.—As in appendicitis, so in tuberculous peritonitis, pain, tenderness, and fever are present, but in the latter the onset is more gradual, and the signs of tumor and increased resistance in the right iliac fossa are absent. Movable dulness may be present in the tuberculous affection, and not in appendicitis until the peritonitis has become generalized. The lungs are generally implicated in tuberculous peritonitis. Acute Intestinal Obstruction.—When this is due to intussusception there may be signs of a tumor, but not at McBurney's point; the ten- derness over the site of the mass is less intense, while the frequent bloody discharges that are seen in this condition, accompanied by tenes- mus, do not characterize appendicitis. When obstruction is caused by strangulation stercoraceous vomiting is apt to occur, and is absent in appendicitis. Pain, local tenderness, and, not uncommonly, signs of a tumor appear, but elsewhere than at McBurney's point. Some of these instances, hoAvever, remain obscure till the diagnosis is set at rest by the surgeon's knife. Hip-joint Disease.—In both hip-joint disease and appendicitis the dorsal decubitus with flexed leg is noted. If the patient be anesthet- ized, however, full extension of the leg and a normal condition of the hip-joint are easily demonstrable in appendicitis. Typhoid Fever.—Mild cases of appendicitis with accompanying diar- rhea bear a close superficial resemblance to typhoid fever. In the latter affection, however, the onset is more gradual and the fever-type more continuous than in appendicitis. In typhoid the stools are someAvhat peculiar, the spleen is SAvollen, there is dulness of intellect, bronchitis and the characteristic eruption attend,—all features that are absent in appendicitis. The diazo-reaction, if present, would strengthen the diag- nosis of typhoid, and a response to Widal's test would be conclusive. In appendicitis the local features, and in typhoid the general, are pre- dominant. Dietl's Crises.—In a case of movable kidney Avhich I saw recently all the symptoms pointed to appendicitis. An operation was about to be performed when a sudden subsidence in the abdominal swelling and local induration occurred. The kidney was subsequently detected in an abnormal location (vide Mobility of the Kidney). 822 DISEASES OF THE DIGESTIVE SYSTEM. CHRONIC APPENDICITIS. {Relapsing Appendicitis.) Relapses occur in nearly one-half the total number of persons Avho have suffered from a primary attack of appendicitis. In most of these cases there is constantly present a slight local discomfort during the in- terval ; in a small percentage, hoAvever, there is an entire freedom from uneasiness. The local symptoms in those having had an antecedent peritonitis are more pronounced than in the first attack, but after a number of recurrences the symptoms are likely to be less severe with each subsequent attack. The most constant symptom betAveen attacks is a subacute form of pain that is liable to manifest acute exacerbations with slight fever. Physical fatigue, a strain, and errors in diet causing gastro-intestinal disorder are very likely to induce a relapsing appendi- citis. Chronic appendicitis strongly favors the retention of fecal mat- ter in the cecum, thus forming so-called stercoral typhlitis. This asso- ciation was formerly mistaken for primary typhlitis. The characteristics on which the diagnosis is based during the attack are similar to those detailed under Acute Appendicitis; the course is, hoAvever, someAvhat more condensed than that of the acute form. In the intervals between the attacks the appendix can be readily ap- preciated on palpation, the method employed by Edebohls being prefer- able : "The patient lies upon his back Avith the examiner at his side; the latter places his right hand upon the patient's abdomen over the right rectus muscle, opposite the anterior superior spine of the ilium, and presses the left hand upon the fight, so that no force is used by the right hand and the tactile sense of its fingers is left undisturbed. The hands are draAvn slowly outward, allowing the contents of the abdo- men to slip from underneath them. The coils of intestine can be felt as they escape from under the hand as it presses against the posterior abdominal wall."1 In this Avay the appendix may be felt as an elon- gated tumor of the size and shape of the little finger. If there be only a slight exudation present, the appendix often appears to be immediately beneath the abdominal Avail. It may, hoAvever, be, deep-seated, even though the exudation with adhesions be absent. Both pain and tender- ness are pronounced, and particularly if pus be present. The results of chronic appendicitis upon the general health and nu- trition of the patient are quite noticeable, and tend to augment as time passes, if the attacks be frequent or the intervals betAveen them grow shorter. The chief symptoms are those of a nervous type; emaciation and debility are also observed. The associated nervous symptoms are those of neurasthenia. These patients often become introspective and exceedingly irritable, the mental condition being accounted for, to a great extent, by the consciousness that there is ever the danger of a fresh attack with serious possibilities. Differential Diagnosis.—Carcinoma of the Cecum.—Thrs presents many points of similarity to chronic appendicitis. I have under my care at present a lady aged sixty years suffering from chronic appendicitis, Avhose case had been diagnosticated as carcinoma of the cecum, and for a considerable time my own vieAv coincided Avith that of my predecessor. 1 B. Farquhar Curtis: Twentieth Century Practice of Medicine, vol. viii. REC URRENT A PPENDICITIS. 823 The occurrence from time to time, hoAvever, of relapses, during Avhich the feces Avere massed in the cecum and fever arose, soon indicated the correct diagnosis. Besides the absence of periodic attacks of fever, the general features—loss of flesh and strength, anemia—are more steadily and rapidly progressive in carcinoma of the cecum. The historv of the mode of onset also aids in the distinction. Pain, tenderness, and a re- sistant tumor are common to both affections. Hypochondriasis and Hysteria.—Hypochondriasis and hysteria may lead to the manifestation of morbid feelings simulating those of appendi- citis. Such cases may shoAv merely a greatly exaggerated uneasiness, or such an increase of sensibility as to cause the patient to complain of pain in the right iliac fossa. In addition, there may be localized ten- derness. I recently witnessed the removal of the normal appendix from an hysteric female in Avhose family tAvo genuine cases of appendicitis had occurred not long previously. Hypochondriasis and hysteria dis- tinguish themselves by the antecedent history and by the absence of a tumor-mass and of increased resistance ; there is also an absence of localized tenderness if the patient's attention be AvithdraAvn. In such subjects oxaluria is not infrequent, and it is possible that irritation of the right ureter by the passage of crystals of calcic oxalate, as men- tioned by Cabot, may explain the localizing of the discomfort (Wood and Fitz1). I recently saAv a ease of this sort in a neurasthenic med- ical student. RECURRENT APPENDICITIS. When successive attacks occur in the same individual at intervals varying from several months to a year or more, each new attack is spoken of as a recurrent appendicitis. Severe attacks may succeed light ones, or, conversely, mild recurrent may folloAv severe preceding attacks. I recall several cases in Avhich rudimentary appendicitis (indi- cated merely by colicky pain) occurred, and lasted from a fe\v hours to a day or tAvo. Often the illness is too trivial to lead the patient to con- sult a doctor. An absolute diagnosis demands, besides the subjective symptom, pain, the presence of localized tenderness (with or Avithout induration), and elevation of the temperature. In several subjects of recurrent appendicitis formerly under my care the last attack occurred three or four years ago. That each new attack may be the last is always to be remembered. Prognosis.—In forming the prognosis in a given case of appendi- citis the same rules may be followed as in the case of acute infectious diseases, since to the latter category this affection probably belongs. To estimate the severity of the type of infection, however, is not a simple matter. Unlike many of the acute infectious diseases, the height of the temperature and, to a lesser degree, the rate of the pulse are un- reliable guides in appendicitis. Broadly speaking, hoAvever, in the severer forms the local process exhibits a strong tendency to spread ; the temperature and pulse are relatively high, and tend to rise with the progress of the affection. These are the cases that suppurate or result in perforative peritonitis (often rapidly spreading) and in pericecal abscesses. They are among the gravest of knoAvn conditions. Of this 1 The Practice of Medicine, p. 886. 821 DISEASES OF THE DIGESTIVE SYSTEM. fatal group -of cases not less than 68 per cent, die before the eighth dav. The development of fulminant peritonitis or of a peritoneal abscess after perforation is attended by a falling temperature, though subsequently the latter may mount high or become markedly irregular. On the other hand, in the mild types that are included in the name catarrhal appendicitis recovery is the unvarying rule. These lighter cases often lead to adhesive peritonitis—a circumstance that strength- ens the vieAv that they are of an infectious nature. The temperature is only moderately elevated as a rule, and the pulse-rate correspond- ingly quickened. Both pulse and temperature indicate marked im- provement on the third or fourth day, while the pain and localized tenderness disappear. In this connection the deceptiveness of gan- grenous cases must be recollected (vide supra, Diagnosis). The com- plications that are most likely to arise and other points of prognos- tic significance have been fully stated in the Clinical History. The general mortality of appendicitis is about 14 per cent. (Fitz). Im- proved methods, chiefly surgical, of dealing Avith the disease have, however, greatly reduced its death-rate. The prognosis in chronic appendicitis is most uncertain; after the patient has survived several attacks it is on the whole more favorable. Treatment of Appendicitis.—Whether imminent danger of per- foration exists or not, the physician who is called to a case of appendi- citis should request the services of a competent surgeon. Few surgeons subscribe to the doctrine that all cases require operation, but, since it may become necessary to operate at any hour of the affection, the latter should help to settle the important question, " When is operative inter- ference demanded in the individual case ?" The physician who does not pursue the course above recommended falls short of his duty, both toward the patient and toAvard the surgeon on whose skill he relies to safely re- move the source of danger. It may be that a surgeon's fears are some- times groundless, but I am convinced that there is much truth in the state- ment that physicians too often invoke the aid of the surgeon when the patient is beyond hope of recovery. Surely, in a disease that so often baffles both physician and surgeon, suddenly developing, as it sometimes does, a fatal virulence without previous unfavorable symptoms, they should stand guard together from the moment the case is diagnosticated or appendicitis is strongly suspected. With rare exceptions, I think surgical interference should be recom- mended. The indication for immediate operation is undoubted in all cases of acute appendicitis, whether marked by sudden and severe or mild invasion-symptoms, if seen at the beginning of the attack. Obvi- ously, the conditions are less favorable for operation after a case has progressed to the beginning of abscess-formation—i. e. from the third to the fifth day of the illness. It is at this period that the peritoneal in- flammation tends to circumscribe itself by the formation of adhesions. which are, hoAvever, not yet strong. Hence, as Richardson has graph- ically stated, it is " too late for an early operation, and too early for a safe late operation," since there is great risk of infecting the general peri- toneal cavity. Whether it is Avise to alloAV the appendix to remain after adhesions have been formed in some cases, and to merely drain, cleanse, APPENDICITIS. 825 and pack the cavity, cannot be discussed here. The very mild attacks that develop in the course of chronic appendicitis after numerous previ- ous and improperly treated seizures need not excite alarm. Under such circumstances operation should be undertaken between attacks, Avhen the mortality is practically nil. On the other hand, in cases that have been alloAved to drag on until general peritonitis has set in, Avith threat- ened or actual collapse, the operative treatment might as Avell be aban- doned. Finally, the most ardent advocate of immediate operative treat- ment is sometimes compelled to rest satisfied with medical measures. Such cases are those in Avhich there are associated chronic affections (advanced diabetes, Bright's disease), not to speak of those in which the patient refuses to submit to an operation. General Management.—The patient should be kept in bed in a quiet, Avell-ventilated apartment, and in no affection is the value of absolute rest in the treatment of inflammation greater than in appendicitis. The diet should be liquid and nutritious, consisting chiefly of pancreatized milk and concentrated broths. All articles of food that tend to undergo fermentative changes, and all carbonated drinks, should be prohibited, since they increase meteorism. The patient should be under- rather than over-fed. At the start, and particularly if a sausage-shaped tumor be present, intestinal irrigation, oft-repeated Avith a view to removing the fecal matter, must be carried forward assiduously. Saline laxatives (Rochelle salts, 3ij—8.0—every hour or two, preceded by a dose of castor oil or a few fractional doses of calomel) are to be administered until the evidence of their action upon the bowels has been definitely noted. There almost never exists a contraindication to the use of saline aperients at the onset of the attack, and they constitute the best known means of obviating, as well as limiting, the spread of peritonitis by de- pleting the portal system and emptying the boAvels. If commenced early, they may be continued throughout in doses sufficient to produce two or more daily evacuations. In the event of a development of evidences of peritonitis Avith pus-formation, salines should be pushed vigorously, unless an operation can be promptly performed. I am aware that many authors advocate withholding purgatives when indications of suppuration appear, but I have yet to see a case in which perforation has followed an active saline treatment. I avoid the use of high enemata in progressi\Te cases, since they are more apt than salines to induce rupture of the sac. As regards the use of opium professional opinion is not united, though a general tendency toward the limitation of its use to the mini- mum amount necessary to alleviate pain is happily noticeable; unless demanded by excessive suffering it had better be omitted altogether. W hen necessary, it is best administered hypodermically in the form of morphin (gr. -fa-%—0.0054-0.0081). The greatest objection to the use of opium is its effect in veiling the symptoms that assist the physician in forming a judgment as to the peculiarities in the case. Local Measures.—The suspended ice-bag is an excellent means of combating the pain, and often obviates the necessity of an internal use of opium. Instead of the ice-bag, cloths Avet in cold water may be applied and changed every few minutes. In the early stage a fe\v leeches may be beneficial in their effect upon the local inflammation. Blisters, however, are rarely advisable, and are particularly objection- 826 DISEASES OF THE DIGESTIVE SYSTEM. able should the patient afterward be submitted to an operation. Mild forms of counter-irritants (mustard-paste) are preferable, though these also render the skin and underlying tissues hard and leathery. Management of Convalescence.—The patient should not be allowed to leave his bed for several days after the disappearance of all symp- toms ; even the mildest forms of exercise should not be undertaken for at least one Aveek subsequent to getting out of bed. During convales- cence the diet must be carefully guarded, and the bowels, at all hazards, kept in a soluble condition. It is questionable whether drugs will aid in the absorption of the exudate or assist in resolution. Gentle and per- sistent counter-irritation Avith preparations of iodin Avill be found useful. INTESTINAL OBSTRUCTION. [Ileus.) Definition.—An acute or chronic, complete or partial, occlusion of the intestinal canal. Pathology and Etiology.—The causes of intestinal obstruction may be divided, at once most simply and practically, into the (1) acute and (2) chronic forms. In the former variety the narrowing or closure develops very suddenly or rapidly, and usually in the small bowel; in the latter, the large bowel is commonly affected by pathologic conditions that develop slowly and gradually and narrow its lumen; the latter conditions usually occur in persons of advanced years. Acute.—(a) Strangulation.—In the order of frequency, this is first among the causes of acute intestinal obstruction. It is produced most often by bands of adhesion, the result of a former recent or remote peri- tonitis, and is most commonly situated in the right iliac fossa. Incar- ceration of the bowel from flexions and adhesions not rarely follows upon abdominal section for the treatment of pelvic disease in women. The usually free end of Meckel's diverticulum is sometimes attached to the abdominal wall, and may thus cause constriction of a loop of bowel. This diverticulum is the remains of the fetal omphalo-mesen- teric duct, and arises from the ileum about half a meter (1.64 ft.) from the ileo-cecal valve. A similar constricting band is formed by a cord representing one or more of the obliterated omphalo-mesenteric vessels. The adhesive attachment of the free end of the appendix vermiformis may also form an opening through Avhich the bowel may be caught. Internal strangulation (hernia) may be the result of forcing a portion of bowel through a slit in the omentum or mesentery, or into peritoneal diverticula and openings, such as the duodeno-jejunal fossa (Freitz's retro-peritoneal hernia) or the foramen of WinsloAv. Diaphragmatic hernise are not of extreme rarity, and may be either of congenital or traumatic origin. Most cases of intestinal strangulation occur in males during early adult life. (b) Intussusception.—Invagination is the descending" telescoping of one section of the boAvel into another," probably caused by a circum- scribed, irregular peristalsis of the intestine. The effect of the latter state in producing invagination may be either a thrusting forward of INTESTINAL OBSTRUCTION. 827 the receiving portion by a contraction of the longitudinal muscular coat ^Xothnagel), or a thrusting inAvard and doAvnAvard of the portion imme- diately above by means of an increased or spasmodic peristaltic action. Thus, a cylindric or sausage-shaped tumor results, varying from a half inch to over a foot (1.3-30 cm.) in length. The layers met Avith in intussusception are the outer or receiving, called the intussuscipiens, the middle or returning layer, and the inner, called the intussusceptum. The seat of invagination is most commonly at the ileo-cecal valve, though it is often found in either the ileum or colon alone. Sometimes the in- tussusception occurs and is detected in the rectum. A lateral or partial invagination, more or less chronic, may also occur, due to the attachment of a tumor Avithin the boAvel. The intussuscepted portion of intestine is usually the seat of perito- neal adhesions and considerable tumefaction, so that in pronounced cases the parts are so firmly agglutinated that reduction is Avellnigh impossi- ble. The engorgement may pass into an intense local inflammation, with final necrosis and sloughing, and even the discharge per rectum of the invaginated portion : or a fatal termination may be ushered in by perforation of the bowel. Intussusception occurs most frequently by far in children prior to ten years of age, in Avhom also the disease is more acute than in adults. Males are more subject to invagination than are females. Invagination is asserted to be an occasional consequence of the ope- ration of circular enterorrhaphy and of lateral anastomosis by plates (Robinson).1 (c) Volvulus.—Twists of the intestine are met Avith most commonly at the sigmoid flexure of the colon. An unusually long or relaxed mes- entery predisposes to the condition, so that the axis of tAvisting may either consist of the mesentery itself or frequently of the bowel. Xot rarely the pedicle of the volvulus contains both a tAvist and a sharp bend in the bowel, causing complete acute strangulation. The latter condition may be pronounced in such cases, or at least be hastened, by the accumu- lation of the intestinal gas and of masses of feces, or by bowel-adhesions to an adjacent stump of omentum (Nieberding). The passive reactive pressure of the coils of intestine and of the abdominal Avails tends also to further confine the enormously dilated and twisted loop of bowel to its abdominal state. Knots mav be formed by the association of loops of the ileum Avith each other or about the pedicle of a tAvisted cecum. Here, again, males betAveen forty and sixty years of age have been observed to be especially the subjects of volvulus. Chronic.—(a) Fecal Impaction.—Intestinal Concretions.—Accumula- tion of feces (coprostasis) is a common cause of intestinal obstruction, the impaction taking place usually in the cecum or sigmoid flexure. Though not infrequent in children, fecal obstruction is more common in adults (particularly in females), in the hysteric, the demented, and the hypochondriac. Congenital dilatation of the colon may predispose to coprostasis, and an acquired dilatation, Avhich in some cases becomes enormous, is often the result of paresis of a portion of bowel caused by over-distention for a long period of time. The retained fecal masses may become hard, but for some time permit the passage of soft or liquid 1 Med. Record, Aug. 13, 1892. 828 DISEASES OF THE DIGESTIVE SYSTEM. material through the interstices of the accumulation, until finally either complete obstruction takes place or the condition is relieved. So severe may the obstruction prove in some cases as to result in inflammation, ulceration, and even perforation of the boAvel. Among other causes of obstruction due to abnormal contents mav be mentioned enteroliths. These are intestinal concretions formed of various nuclei, as gall-stones, hardened feces, phosphates of lime and magnesia, various foreign substances, and organic derivatives. Balls of tangled ascarides may mass sufficiently to cause obstruction. Gall-stones not infrequently become impacted in the duodeno-jejunal or ileo-cecal regions after ulceration through the duct, except in the case of very small stones, which enlarge subsequently by accretion. Foreign bodies, as pins, buttons^ coins, fruit-stones, may also cause obstruction of the bowel. It is stated that even insoluble mineral medicines, as bismuth or magnesia, have caused obstruction by accu- mulation in the intestines. (b) Tumors.—Tumors cause a form of chronic obstruction that may at any time develop suddenly into the acute type. They may do so either as—(1) new groivths in the wall of the intestine itself, or by (2) com- pression and traction from without. Again, the intestinal neoplasms may be malignant or benign in nature. Carcinoma of the bowel is at once the most frequent and important of these. It may be either cir- cumscribed and annular, causing a gradual narroAving of the bowel- lumen, or a diffused infiltration of the intestinal wall, commencing either in the mucosa or in its glands (cylindric epithelioma). Its most common seat of growth is the large boAvel, about the sigmoid flexure. The mesenteric and retroperitoneal glands are usually secondarily affected. Ulceration of the boAvel and catarrhal inflammation of the mucous membrane above the carcinoma may coexist late in life. Sarcoma usually attacks the small bowel, starting beneath the mucosa, and is of the recurrent variety. Regional infection of the mesenteric and retroperitoneal glands (Lobstein s cancer) is also a usual consequence of sarcoma. It may occur in children or in young adults. Benign tumors may be polypoid, adenomatous, fibromatous, and lipomatous. Intestinal obstruction due to compression or traction may be caused by tumors (omental) or by adhesions of the pelvic viscera. (c) Cicatricial strictures cause chronic intestinal obstruction, as after the healing of various ulcers, the cicatrices of Avhich slowly contract. Cicatricial stenosis of the colon is commonly due to the cicatrization of dysenteric ulcers. In the rectum the stenosis is usually a result of a syphilitic lesion. Tuberculous and, very rarely, typhoid ulceration may be followed by stricture of the small intestine. (d) Congenital stricture is rare, and is more purely surgical than the preceding cases. It is often an occlusion or an imperforate condition of the anus (atresia ani), and is only mentionable in this connection. (e) Paresis of Peristalsis.—This condition—called also adynamic ob- struction—while it is a functional affection, is held to be either a cir- cumscribed or diffuse paresis of the intestinal muscular coat. It is caused by some such inflammatory disturbance as enteritis or peritonitis, or even by the manipulations employed in prolonged abdominal sections. In such cases the obstruction is due to an accumulation of feces and INTESTINA L OBSTRITCT1 ON. 829 erases in the paretic portion of the boAvel, causing marked tympanites, vomiting, and constipation. Special Pathology.—The pathologic changes that accompany nearly every form of intestinal obstruction are briefly stated as folloAvs: Accumulative dilatation—with hypertrophy in chronic cases—of the intestine above the seat of disorder, and an emptiness, narrowing, and even atrophy below the obstruction. The affected Avails of the boAvel are inflamed, and there is a surrounding acute or chronic peritonitis. Catarrhal and sometimes diphtheritic inflammation of the mucosa may develop. Gangrene, ulceration, and perforation of the bowel, Avith resulting generalized peritonitis, may also ensue. Symptoms.—Acute Obstruction.—There is suddenly developed ab- dominal pain that may follow some abrupt or severe exertion. Early vomiting and absolute constipation are also conspicuous and important svmptoms. If the obstruction is high in the small bowrel, distressing hiccough and eructations may precede the vomiting. Except for the possible discharge of the intestinal contents beloAv the seat of obstruc- tion, the constipation is usually complete and obstinate. Accompanying the latter condition there is tympanites, which is most marked in ob- struction of the colon. Intermittent and colicky at first (partial obstruction—Treves), the pain soon becomes agonizing and constant. Vomiting, also, alternating Avith painful retching, is more constant and severe after several hours. The material at first ejected is gastric and mucous; it then becomes bilious, and finally is characteristically ster- coraceous, due, most probabl}*, to the putrid decomposition of stagnated contents above the obstruction. The constitutional symptoms develop early, are intensely threatening to life, and cause rapid and profound depression and collapse. The pinched and pallid features, cool and moist skin, Hippocratic expression, rapid and feeble pulse, the usually subnormal temperature, shallow and accelerated breathing, marked thirst, scanty urine, great anxiety and prostration,—all indicate the gravity and danger of the condition. The physical examination Avill discover a swollen, extremely tender, and tympanitic belly. Exaggerated peristalsis of the intestine above the obstruction may be visible on the surface of the abdomen. Bor- borygmi, gurgling, and splashing may be heard on auscultation. Chronic Obstruction.—The symptoms are more dependent upon the special causes operating than in acute obstruction. The fact that early in the case only partial obliteration of the intestinal lumen may be rightly inferred in many of the chronic forms of obstruction has given rise to the discriminating term of intestinal constriction. In gen- eral, the clinical history is one of increasing and intractable constipa- tion, sometimes alternating Avith diarrhea, due to catarrhal inflammation of the mucosa above the obstruction. Paroxysms of colicky pain and, later, augmenting tympanites, vomiting, and prostration, attend. These symptoms may merge suddenly into those of the acute form of obstruction. The boAvel-movements in chronic obstruction are irregular, infrequent, slight, and sometimes accompanied by pain and tenesmus. The stools consist often of small, hard, ribbon-like, or scybalous masses, and may contain blood and mucus. When the stenosis is in the small intestine, the constipation is less apt to occur on account of the fluidity of the 830 DISEASES OF THE DIGESTIVE SYSTEM. contents. Sometimes, and particularly in old people, the rectum be- comes distended with hardened accumulations of feces; there is in such cases a constant feeling of fulness and a harassing desire to defecate, but the attempts thereat are ineffectual. The pain of fecal impaction may be due either to colitis or to peritonitis, and may be referred to the regions of the cecum or sigmoid flexure. In malignant and in cicatricial stenosis there are a prolonged and variable history of constipation, occasional vomiting, localized pain, meteorism, and, in cancerous cases, the development of the characteris- tic cachexia and the progressive emaciation. Physical Examination.—Inspection shows the abdomen to be dis- tended from meteorism, the movements, and contour even, of the coils of intestine in active peristalsis above the seat of stricture being evi- dent. A tumor or .the throbbing aorta (excited, perhaps, by pressure of the distended bowel or growth) may be palpated. Tympany and borborygmous noises may also be noted. Diagnosis.—Locality of the Obstruction.—Given the symptoms of a sudden, severe, and exacerbating pain in the abdomen ; of marked, and later feculent, vomiting; of absolute constipation and of tympanites and profound, early, systemic depression,—a diagnosis of acute intestinal obstruction may be easily made. The determination of the seat of trouble, however, is often very difficult. First may be mentioned the differential diagnosis betAveen obstruction occurring in the small and in the large intestine. It may be noted of the former that vomiting occurs early, is scanty, and later feculent, Avhile in the latter there is less vom- iting and the vomitus is seldom feculent. Again, in obstruction of the small gut the distention is both less marked and higher situated, Avhile in that of the large gut tympanites is often quite marked, is more cen- tral, is associated Avith tenesmus, and sometimes with mucus and blood. If the cause of obstruction be a tumor or stricture, the locality may be successfully palpated or the lower limit of the active coils of hypertro- phied intestine may be defined. In stenosis of the duodenum or jejunum, OAving to the stagnation and decomposition of albuminous substances, the products of Avhich (indol and phenol) are absorbed and partly excreted by the urine, use may be made of the discovery of increased amounts of indican in the urine for diagnostic purposes. On the other hand, in stenosis of the large intestine the urinary test may be negative, since the albuminous elements of the intestinal contents are absorbed before they reach the stenosed portion of boAvel, Avhere stagnation and putrefaction can take place. Examination per rectum Avith the finger or Avith the rectal tube, by means of liquid distention or gaseous inflation of the colon, may enable us to determine the seat of obstruction in certain cases. The detection of a deeply-seated incarcerated hernia (in the abdominal fossae and pouches. diaphragm, or obturator foramen) is often made only postmortem. Nature of the Obstruction.—This is even more difficult of discovery than the preceding. The folloAving causes of obstruction Avith their differentiation may be referred to in attempting a diagnosis : Strangu- lation often affords a previous history of peritonitis or abdominal sec- tion or of recurrent attacks of abdominal pain, occurring mostly in young adults. Early fecaloid vomiting is common. INTESTINAL OBSTRUCTION 831 Intussusception usually gives a negative previous history. The sud- denness of the attack, Avithout appreciable cause, occurring in a child, and associated Avith colicky pain, tenesmus, and the' presence of mucus and bloody stools, and of an elongated cylindric tumor in the right iliac or umbilical regions, however, render this condition easy of diag- nosis in some instances. It is to be noted that absolute constipation and meteorism here are unusual. The intussusception may be felt in the rectum. In volvulus it may be helpful to elicit a history of former constipa- tion and flatulence, with evidences of atony of the boAvel, in persons of advanced years, along Avith marked abdominal tympany, tenderness over a distended coil, Avhich may perhaps be outlined (Wahl), a rigid abdomen, and sometimes dyspnea from great gaseous distention. The history in cases of fecal obstruction is nearly ahvays one of obstinate, habitual constipation, and occurs especially in females and neurotic subjects. The onset is gradual; pain is less acute; and tym- pany and fecal vomiting are less prominent and late in appearance. Fecal masses in the colon and rectum may be palpated, and even in- dented, particularly, in the cecal and sigmoid flexures. Dulness is present on percussion, Avith slight tenderness over the tumor. Obstruction due to large enteroliths or foreign bodies may be only surmised; especially is this true Avhen symptom's of appendicitis arise. Biliary calculi may give a history of previous attacks of hepatic colic and jaundice. In the chronic obstructive form of stricture of the boAvel due to cica- trices or neoplasmata the history of dysentery, tuberculosis, sarcoma, or carcinoma should be considered. The detection of an irregular tumor and the cancerous cachexia point to malignancy. In obstruction caused by intestinal paresis there is generally a history of a previous enteritis, peritonitis, or celiotomy. The abdomen is smooth, though tympanitic throughout, and there is no perceptible peristalsis. Not rarely it will be of therapeutic as well as of diagnostic import- ance to ascertain whether an attack of acute obstruction is primary, or Avhether it is the terminal exacerbation of a chronic condition, such as carcinoma of the bowel. Here a study of the past history of the patient, as Avell of the present signs of a probable nature, will afford considerable aid. Differential Diagnosis.—Acute intestinal obstruction must be discrim- inated from acute generalized peritonitis. Acute Generalized Peritonitis. Acute Intestinal Obstruction. Etiology. There is a history of causal conditions or There is a history of previous chronic diseases (ulcer, appendicitis, pelvic in- obstruction or hernia. (The age of fection). the patient if it be intussusception.) Symptoms. An early and considerable rise of temper- No early rise (except in volvulus), but ature ; later variable or may be absent. later with advent of peritonitis. Pain more continuous and diffuse. Pain in short paroxysms and localized. ^ omiting is characteristic, but not ster- Vomiting becomes characteristically ster- coraceous. coraceous. Collapse occurs later. Earlier onset of collapse. Slight increase of indican in the urine. Excessi\re indicanuria, particularly when the small intestine is obstructed. 832 DISEASES OF THE DIGESTIVE SYSTEM. Physical Signs. Distention of the abdomen is usually Less marked (sometimes partial), unless general and marked. the obstruction be situated in the lower segment. Visible peristaltic waves absent. Present and pronounced when the seat of obstruction is low. Tenderness general. Tenderness localized. Signs of effusion appear. Less common, due to secondary perito- nitis. Auscultation negative. Loud gurgling and splashing sounds au- dible on auscultation. Prognosis almost hopeless. Not so if operated upon early. It must also be differentiated from acute enteritis, in Avhich (particu- larly when due to toxic minerals) there is more apt to be diarrhea with considerable mucus and blood, an elevated temperature, intense gastric pain, associated Avith traces of the poison in the vomitus, as Avell as with its effects on the oral mucous membrane, and an absence of marked tympanites and fecal vomiting. There are also localized pain, tender- ness, and tumor, or there may be collapse. The various forms of abdominal colic, as enteralgia, hepatalgia, and nephralgia, should not be mistaken for acute intestinal obstruction after considering the history of the cases, the character and locality of the pain, and the absence of such symptoms as obstinate constipation, fecal A'omiting, early collapse, intense local pain and tenderness. Course, Complications, and Prognosis.—A case of acute ob- struction usually terminates within from two to seven days. The chronic form may last weeks, and even months, with progressive emaciation and anemia, until the superaddition of more or less acute symptoms, lasting from ten to fourteen days. As a rule, the prognosis is wholly unfavor- able, and especially in the acute cases. The chronic forms, due to fecal or other impaction, often recover with the discharge of the disturbing intestinal contents. Life may be prolonged by surgical interference in certain cases if they are taken in their inception. Complications that may occur, as secondary peritonitis, gangrene, perforation, septico-pyemia, and enteritis, are all grave, and only tend to hasten the dissolution. Treatment.—Whilst the treatment of intestinal obstruction is sooner or later essentially surgical, attention to the medical aspect is frequently of prime importance. The first indications for therapeutic interference in acute obstruction are presented by the pain and the incessant vomiting. The former is to be met by hypodermic injections of morphin, which at the same time tend to arrest the excessive peri- stalsis. For the vomiting no other measures are comparable to gastric lavage and starvation. It is well in most cases to Avithhold food for some hours to prevent retching and aggravation of the condition. The lavage is strongly advised by Kussmaul, Avho claims that both the tension above the seat of stricture and the inordinate peristalsis are thus greatly diminished and, exceptionally, cured. It may be repeated eArery six hours. A diagnosis of intestinal obstruction having been made with- out having learned the cause or character of the obstruction, cathartics should absolutely not be given. If it has been determined that fecal impaction is the trouble, it is still prudent to avoid purgatives until the CARCINOMA OF THE INTESTINE. 833 main mass has been moved, as in many cases there are both paresis and inflammation at the seat of impaction, so that this class of agents would thus be useless, if not harmful. High rectal injections, copious, steady, and regularly repeated, are to be practised, using for this purpose pre- ferably "a warm saline solution of olive oil" (particularly if scybala be present) administered Avhile the patient is in an inverted position by means of a fountain syringe, so that the Aoav is readily controllable. The abdomen should be methodically kneaded (a valuable adjunct in the procedure) and the patient at times Avell shaken. This method of treatment, by hydrostatic pressure, can and must be carried forward without undue violence, and if it be unsuccessful, the intestines are to be inflated from a large india-rubber bag Avith air or hydrogen gas (Senn), of Avhich two to three gallons may be cautiously introduced. Thorough manipulation of the abdomen from beloAv upAvard, particularly if it be a case of intussusception, may be combined. In the latter con- dition inflation, early and perseveringly applied, cures the majority of instances. In cases of intussusception or strangulation of the bowels these efforts should be continued for tAventy-four hours, Avhen, if the condition is not relieved, immediate operation is to be encouraged and advised. Although the statistics of Fitz shoAv the mortality in cases Avithout operation to be loAver (69 per cent.) than with operation (83 per cent.), I am convinced from personal observation that the less favor- able results from abdominal section would not obtain if it Avere per- formed in due time. To relieve the excruciating tympanites the plunging of a fine trocar and cannula into the intensely distended bowel, as in case of vohulus, may be required. In chronic obstruction the treatment of the underlying or etiologic conditions and various complications is to be conducted on general prin- ciples. Additionally, the patient's dietary is to be arranged Avith care, and the bowels moved with unfailing regularity, by the use of unirri- tating laxatives and enemata. During the periods of threatening com- plete occlusion, Avith pain, the methods advocated above for acute ob- struction are appropriate. If total obstruction persist despite medical treatment, surgical treatment—enterectomy, enterotomy, or other opera- tion, as the circumstances of individual cases may dictate—is required. The after-treatment consists in keeping the bowels active and regular by habit, diet, and an aperient pill if needed. Massage and electricity to the abdomen are found useful at this time. CARCINOMA OP THE INTESTINE. (Carcinoma Intestinalis.) Carcinoma of the intestine is perhaps the commonest cause of chronic intestinal obstruction. The stenosis is usually partial, and is due both to compression and to direct invasion of the lumen of the bowel by the growth. Primary intestinal carcinoma is rare in comparison Avith the occurrence of gastric carcinoma. 53 834 DISEASES OF THE DIGESTIVE SYSTEM. Pathology.—When carcinoma attacks the intestine it is usually in the form of a cylindric-celled epithelioma, although it mav assume the various forms as found in carcinoma of the stomach—namely, scirrhous, medullary, and colloid. The growth may be annular or semipolypoid, or it may occur as a diffuse nodular infiltration of the bowel-walls. Ulcera- tion of the surface of the carcinoma may take place, and the glandular structures of the abdominal cavity sometimes reveal metastatic growths. The most frequent seat of intestinal carcinoma is the rectum, and next in order of frequency are the sigmoid flexure, the transverse and descend- ing colon, the papilla duodenalis, the ascending colon, and the lower and middle portions of the ileum. The bowel is dilated above the constric- tion, and is usually filled with an accumulation of fecal matter. The muscular coat is hypertrophied. Below the narrowing the intestine may be small and atrophied. Etiology.—Heredity and advanced age are of chief importance as predisposing causes. Whether or not antecedent intestinal ulceration may afford a probable nidus for carcinomatous growths is scarcely be- yond conjecture. Symptoms.—A description of the course of rectal carcinoma be- longs more properly to surgical works. The chief symptoms a^e pro- gressively increasing distress and radiating pain in the rectum; these occur, at first, during defecation only, but later almost constantly. There may be diarrhea alternating with constipation, and the feces often con- tain blood and mucus. Gradual bodily wasting and increasing mental anxiety are associated. Paralysis of the anal sphincter and consequent incontinence may ensue. The symptoms of carcinoma of the bowel above the rectum are often vague, and vary according to the portion involved by the neoplasm. With or Avithout an appreciable tumor in the abdomen the clinical his- tory is usually that of chronic obstipation of the intestines. There are irregular attacks of sharp, colicky pains, especially a few hours after eating, distressing defecation, obstinate constipation, perhaps alternating Avith diarrhea, sometimes vomiting, which may be feculent, and not rarely slight meteorism. The special symptoms of carcinoma of the papilla of Vater are vomiting, jaundice, and colic. The progressive emaciation and debility of the patient are marked. In advanced cases of stenosis the feces are passed in small, compressed lumps resembling sheep's dung. Physical Examination.—Inspection of the abdomen may show the presence of a tumor produced by the carcinomatous growth along the line of the sigmoid flexure or colon ; peristalsis may be seen above the site of the carcinoma, communicating its movements to the abdominal walls. Palpation may be resorted to in order to confirm the above, and the growth is then frequently found to be nodulated. Percussion may give either dulness or a muffled tympany over the tumor and for some distance above, on account of accumulated masses of feces. This area of impaired intestinal tympany may be sharply defined by a clear tym- panitic note elicited over the empty bowel beloAv the growth. Diagnosis.—This may rest, in some cases, upon heredity, the age, the evidences of the cancerous cachexia, sharp, radiating abdominal pains, bloody stools, and the detection of a more or less firm and nod- ular tumor. CARCINOMA OF THE INTESTINE. 835 Differential Diagnosis.—(a) Carcinoma of the boAvel above the rectum needs to be discriminated from other abdominal tumors. The presence of the following may render the diagnosis of carcinoma during life Avell- nidi impossible: sarcomata, fibromata, myomata, adenomata, and cys- tomata, all of Avhich may produce symptoms of obstruction like those due to carcinomatous growths. The cancerous cachexia may be simu- lated by other conditions. The advanced age of the patient and the distressingly rapid and downward progress of the disease will, hoAvever, point toAvard malignancy. Fecal tumors, enteroliths, and foreign bodies may need to be excluded also. Fecal masses have been mistaken for carcinoma, and Avhen it is recollected that such may exist above and overshadoAv the presence of carcinoma of the intestine, the difficulty in differentiating the two is quite obvious. (b) The portion of the bowel involved by the neoplastic growth is also difficult of definite diagnosis, except Avhen it occurs in the rectum, Avhen the digital and visual examination of the parts, supplemented, it may be, by microscopy, are sufficient. The locality of the tumor as detected by palpation, associated Avith special symptoms, is of value in arriving at a diagnosis of the diseased portion of boAvel. Thus, a hard, nodular mass felt in the lower epigastric or upper umbilical region, and increas- ing gastric dilatation, Avith marked and persistent jaundice, Avould indi- cate probable carcinoma of the duodenum, with complete or partial closure of the common bile-duct. It is apparent, hoAvever, that carci- noma of the pylorus, of the left lobe of the liver, or of the omentum or mesenteric glands, or a thickened cecum might all be easily confounded Avith carcinoma of the bowel at various adjacent parts of its course. The injection of fluid into the bowel may be resorted to in locating the probable situation of the growth. Thus, if obstruction from carcinoma exists in the sigmoid flexure, liquid will be arrested there and the rec- tum distended, Avhile, if the stenosis be high up in the large or small intestine, the colon will be found comparatively emptied of feces and will be distended Avith the injected liquid. The history of the case and a careful exclusion of factors not common to carcinoma, presumably in the locality under observation, together with repeated physical ex- aminations, must all be brought to bear in arriving at a diagnosis. Course and Complications.—Carcinoma of the intestine some- times runs a rapid course, and, symptomatically at least, lasts but a few months or even Aveeks; in the scirrhous variety, hoAvever, the disease may last tAvo or three years. • Intestinal carcinoma may perforate the boAvel and cause fatal puru- lent peritonitis, and carcinoma of the rectum may perforate and inArade the vagina and bladder, causing purulent vaginitis and cystitis. Or, OAving to extreme distention by fecal accumulation between a cancerous stricture of the sigmoid flexure, for instance, and the resistant ileo-cecal valve, rupture of the colon, folloAved by a terminal peritonitis, may result. Extension of the groAvth into surrounding tissues, with ulceration, may lead to cellulitis, phlebitis, and pyemia. The prognosis is almost hopeless. Treatment.—This, from a strictly medical standpoint, is simply palliative. The diet should be highly nourishing and easily assimilable, but Avhen the symptoms of acute obstruction supervene the administra- 836 DISEASES OF THE DIGESTIVE SYSTEM. tion of food by the mouth is contraindicated. Attention to the state of the bowels by the use of enemata, or of the aloin, strychnin, and bella- donna pill is necessary in most cases. Opium or cannabis indica for the pain, and stimulants for the depression, may also be serviceable. Lavage of the stomach gives decided relief when decomposing mat- ters tend to cause regurgitation on account of the damming back of accumulated food-detritus. Carcinoma of the boAvel may be treated surgically by colotomy, ex- cision, lateral anastomosis of the boAvel, enterostomy, and, if the groAvth be situated in the rectum, by extirpation by means of sacral resection (Kraske's operation). HABITUAL CONSTIPATION. (Costiveness.) Definition.—Chronic fecal retention, habitual infrequency, irregu- larity, difficulty, or insufficiency of the evacuations of the boAvels. Although constipation is a symptom, and although habitual consti- pation is frequently a symptom of chronic disease, the causal elements of the latter may be so indefinite and obscure that the former takes on all the individual importance of a functional affection. I describe habit- ual constipation, therefore, as a disease suigeneris ("idiopathic"). Etiology.—In the majority of cases habitual constipation is the direct effect of a lack of expulsive or peristaltic poAver, and also of a deficiency of the hepatic and intestinal secretions. Two sets of causes operate to bring about these conditions of abnormal defecation: General Causes.—(a) Temperament: it has been observed often that people of a nervous and "bilious " or motive temperament, of the dark type—brunets with a predominating nervo-muscular susceptibility— are much troubled with inherent constipation. Anemic brunets—per- sons having pale skin and dark hair combined—are particularly so affected, although alternating periods of diarrhea may supervene, owing to the hydremic state of the blood. "Torpid liver" and "sluggish bowels " are commonly held to be synonymous Avith these physical cha- racteristics, (b) Habit: a sedentary life conduces to secretive inactivity. Thus, a lazy life, in which the calls of nature are irregularly attended to or habitually neglected, leads to frequent over-distention of the rectum and paresis, a common cause of chronic constipation. Again, the femi- nine false modesty (so called) that prompts a postponement and suppres- sion of the desire to defecate in public places, as well as the habitual, hurried performance of the act in illy-kept, uncomfortable, and unsani- tary closets,—all these tend to obtund the sensibility of the bowel to fecal masses in the rectum. The accumulation of these fecal masses causes paralytic over-distention, their hardening into scybala, and diffi- culty of expulsion, (c) General bodily weakness, and diseases, as neur- asthenia, hysteria, anemic brain- and spinal-cord affections (causing inhibitory disturbances of the intestinal nerve-supply), acute fevers, hepatic disorders, especially the presence of jaundice, and the habitual HABITUAL CONSTIPATION. 837 dependence upon and use of purgatives, (d) Diet: the constant use of concentrated articles of food, as.meats, in Avhich little residual mat- ter is left to stimulate the bowel to peristalsis. On the other hand, a very coarse diet may leave such an excess of residue as to cause fecal impaction, (e) Abundant and prolonged diuresis and diaphoresis, by causing loss of fluids, also may induce chronic constipation. Local Causes.—(a) Atony of the abdominal muscles from obesity or, in females, as a result of many pregnancies, (b) Atony of the large bowel (the sigmoid flexure in particular) from chronic colitis, (c) Pres- sure by tumors, (d) The presence of intestinal stenosis from external or internal constriction, (e) Congenital stricture or giant growth of the colon, Avith coprostasis (as in Formad's case) (Functional Neuroses of the Intestines, vide p. 844). Symptoms.—In cases in which there is no adequate cause for habit- ual constipation other than a constitutional and perhaps an inherent pe- culiarity there may be the appearance of perfect health. Nothing is complained of save the fact that an evacuation of the bowels occurs too infrequently. It should be borne in mind here, hoAvever, that the term "constipation " is, individually speaking, almost wholly a relative one— i. e. one person may enjoy good health Avith but one evacuation every other day, another Avith two passages per diem, while still another must have one stool a day, cceteris paribus, to feel perfectly well. The last is usually considered an average normal state Avith most people. Persons such as are instanced above, in apparently good health, but observing that they have to defecate less often than many others, sometimes groAV anxious, Avorried, and even hypochondriac, until assured that they are not truly constipated if enjoying perfect physical ease. Symptoms of habitual constipation may be direct or reflex. Direct or local troubles are seen in the feeling of fulness, Aveight, and pressure in the perineum and abdomen. Flatulence, colicky pains, and alterna- ting diarrhea occur not infrequently. The hurried and inattentive per- formance of defecation gives rise to the so-called "cumulative constipa- tion," in Avhich the accumulated feces are but partially evacuated with the movement, and the rectum consequently is not emptied. A sense of fulness then remains, and complete relief is not felt in these cases. Reflex and general symptoms are malaise, languor, hebetude, irrita- bility of temper, headache, facial flushing, palpitation, cold extremities, anorexia, vertiginous attacks, paresthesia, menstrual distress in women, sleeplessness, and bad dreams. Pressure on the sacral and visceral nerves may cause neuralgias. The tongue is coated. Palpation of the abdomen often shoAvs the presence of doughy-like fecal tumors at the cecum or at the hepatic, splenic, and sigmoid flexures, or of bologna- like masses at intervening places. In marked cases attacks of nausea and vomiting, with diarrhea, may ensue; fever may also be present, and typhoid fever even may be simulated (Meigs). Complications and Sequelae.—Hemorrhoids, ulcerative colitis, perforation, and enteritis may be associated Avith chronic constipation. Not rarely do Ave have as results dilatation of the colon or sacculation, with the presence, in old people mainly, of enteroliths (calcified scyb- ala) ; also intestinal obstruction and typhlitis, or cerebral hemorrhage or hernia from violent straining efforts. 838 DISEASES OF THE DIGESTIVE SYSTEM. Diagnosis.—Bearing in mind the relativity of constipation in dif- ferent individuals, the diagnosis is read at sight. The detection of the causes is not difficult, though sometimes tedious. Hypochondriasis or melancholia should be carefully placed either as precedent to or conse- quent upon chronic constipation, the nervous condition often acting to produce the latter, and vice versd. The prognosis is usually favorable, but should be guarded. Treatment.—Hygienic.—Causative factors must, of course, be re- moved, modified, or lessened. Systematic regularity as to time and frequency and sufficiency of movements of the boAvels should be en- joined upon and practised by the patient. Exercise is of signal value, and particularly horseback riding or gymnastic motions that bring the ab- dominal muscles into play. Attention to the calls of nature should be esteemed a duty, and proper time and heed must ahvays be given to the completeness of defecation. Young girls especially should be in- structed in this regard. The wholesale swallowing of cathartics is to be vigorously combated. The dietetic regimen, if properly looked after, often avails much in relieving this affection, and foods calculated to be easily digestible, but leaving a moderate residue after digestion, are to be recommended. Such are bread made of unbolted flour, plenty of vegetables and fruits, butter, and such laxative articles as figs or honey. A glass of cold Avater taken regularly at bed-time and in the morning before breakfast is efficacious and a point of common knowledge. Remedial.—The methods and means offered for the cure of chronic constipation number legion. From the little aperient pill or "peristaltic persuader " to the cannon-ball rolled externally along the course of the large boAvel is made up such a list of drugs and measures as to leave un- tenable any plea of lack of resource that may be advanced. Drugs occupy a subordinate part in the treatment of habitual constipation. Indeed, their use should be restricted mainly to those periods Avhen the boAvels become unusually obstinate and when a more or less free movement is urgently needed. That the constant use of laxative and purgative drugs tends to a confirmation of the condition, and its ulti- mate resistance to the action of cathartics Avhen circumstances will have required their use, is familiarly knoAvn. I have found of value, especially in lithemic and dyspeptic subjects, the laxative bitter Avaters. as Hunyadi Janos, Kissingen, Friedrichshall, and Carlsbad. Drugs employed to unload a filled bowel may at times be used spar- ingly and in the smallest adequate quantities; the mildest forms should be selected. Since the constipation is only temporarily relieved by catharsis, the frequent use of strong purgatives in large doses only tends to render the bowel accustomed to their use; it then gradually becomes irresponsive to the most drastic drugs. Among those laxatives and cathartics most commonly used may be mentioned aloes, rhubarb, Rochelle and Epsom salts, compound licorice poAvder, castor oil, jalap, senna, mercury, colocynth, and podophyllin. Important adjuncts in combination with one or more of the above are the extract of nux vomica (or strychnin) and the extracts of belladonna, hyoscyamus, and physostigma. The much-used aloes, strychnin, and belladonna pill can be used for a considerable length of time in the hope HA BIT UAL CONSTIPA TION. 839 of stimulating a normal intestinal and sphincteric activity, and thus in- ducing even a cure in some cases. The formula may be made up as follows: B/. Aloin., gr. iij—v (0.194-0.324); Strychninae sulphat., gr. l-l (0.0216-0.0324); Extr. belladonnas, gr. ij—ijss (0.129-0162). M. et div. in pil. No. xx. Sig. One pill at bedtime. Sulphur in confection, along Avith the official pill of aloes and iron, has been recommended for the habitual constipation of anemia. In senile atony of the bowel, with much flatulence, a laxative pill having in combination asafetida or capsicum is often beneficial. The subjoined formulae are also rationally and empirically service- able in chronic constipation : B/. Ext. cascar. sagrad., sss (2.0); Ext. nucis vomicae, gr. iv (0.259); Ext. physostigmat., gr. iij (0.194); Ext. belladonna?, gr. ij (0.129). M. et ft. in pil. No. xx. Sig. One at night, or night and morning. (Aloes, gr. j (0.0618), or podophyllin, gr. ij-iij (0.129-0.194), may be substituted for cascara in the foregoing formula.) Or, B/. Ext. colocynth. comp., gr. xxx-xl (1.94-2.59); Ext. hyoscyami, gr. x-xx (0.648-1.29); Ext. nucis vomic, gr. iv (0.259); Ext. gentianse, gr. xx (1.29). M. et ft. in pil. No. xx. Sig. As above. The mechanical means of relieving habitual constipation, as by enemata, are injurious if long continued, by reason of their irritating effect on the rectal and colonic mucous membrane, as well as on account of their tendency to become incompetent. At times, when the stomach is weak or irritable, a loaded bowel may be relieved by an ordinary enema of soap and water or by one containing ^ to 1 ounce (16.0- 32.0) of castor oil, with 1 or 2 drams (4.0-8.0) of oil of turpentine if there be some flatulence. Glycerin enemata, containing from \ to 2 ounces (16.0-64.0) of the agent, may be used. Suppositories of soap, molasses candy, or glycerin are included in the armamentarium. Mas- sage also claims an important part in the relief of habitual constipation. It acts by stimulating the peristalsis and the abdominal muscles, and should be employed at set times in the day preceding a desired evacu- ation of the bowels. The hand of the masseur, or that of the trained patient even, when systematically used in this way, may be effectual when all other means have failed. The regular rolling of a metal ball along the course of the greater gut may be mentioned for its novelty as well as for its undoubted efficacy. The application of the faradic cur- rent to the abdominal Avails or galvanization of the lumbo-abdominal 840 DISEASES OF THE DIGESTIVE SYSTEM. circuit deserves proper trial in many cases. Hydro-therapeutic meas- ures, or cold sponging and baths, are nearly ahvays useful adjuncts in the treatment of this often stubborn affection. DILATATION OP THE COLON. [Ectasia of the Colon.) This is usually a chronic condition, though not rarely it is acute. It may also be general, but in the majority of cases it is confined to the colon, and particularly to the sigmoid flexure. The postmortem findings are those of hypertrophic dilatation of the boAvel, and rarely (as in a case of Bolleston and Haywrard') ulcerative and catarrhal lesions of the in- testinal mucosa are noted. The sigmoid flexure is prone to become di- lated in subjects in whom it is congenitally elongated. Mya2 believes that the condition is due to a faulty development and not to fetal dis- ease. The most distinctive features are constipation, which generally dates from infancy, and great abdominal distention. In the case of Rolleston and Hayward peristaltic waves were visible upon the surface. The condition may fluctuate, constipation alternating with regular daily movements, and the distention changing to a normal softness of the ab- dominal parietes in some instances. I have recently seen a case of this kind in a male aged twenty-seven, in Avhom the affection had commenced in infancy. In the treatment of the constipation resulting from congeni- tal ectasia of the colon, Wage of the intestine Avith a very long tube is superior to laxatives or purgatives. NEUROSES OF THE INTESTINE. As in the case of the stomach, these embrace derangements of (a) secretion, (b) sensation, and (c) motion. (a) SECRETORY DISTURBANCES. Unquestionably the intestinal secretion may, through a purely ner- vous influence, be augmented. This manifests itself most frequently in the primary morbid secretion of mucus (mucous colic) and in membranous enteritis. Moreover, the fact that an actual catarrh of the intestinal mucosa may supervene as a secondary event is undeniable. MEMBRANOUS ENTERITIS. {Enteritis Membranacea.) Definition.—A peculiar pathologic condition, chiefly of the large intestine, attended by a morbid secretion of mucus. Pathology.—In the truly primary form there are no morbid lesions 1 British Medical Journal, May 30, 1896. 2 Lo Sperimentale, 1894, fasc. iii. p. 215. NEUROSES OF THE INTESTINE. 841 discoverable in the mucosa. Osier states that the membrane is due to a derangement of the functions of the mucous glands the nature of which is unknoAvn. My OAvn view is that this is a secretory neurosis, and that the catarrhal process may develop as a secondary event. Etiology.—Sex has a decided influence; according to W. A. Ed- wards, not less than 80 per cent, of all cases occurring in adults are noted in women. Hysteric females and those of a highly neurotic con- stitution are the most frequent victims of the disease, Avhich is rare in children. Symptoms.—I have found the condition to be invariably associ- ated Avith a decidedly constipated habit—a fact that may, in part, ex- plain its occurrence, since time is thus allowed for the formation of the membrane. The most important clinical feature is the passage, at vary- ing intervals, of long, ribbon-like threads of mucus or of more or less perfect casts of the gut, the act being attended Avith tenesmus and severe colicky pains. The composition of the stools has been thoroughly in- vestigated by M. Rothmann and 0. Rothmann and C. Ruge. They " consist of a uniformly turbid ground-substance, which, on the addition of acetic acid, becomes opaque and striped. It is interspersed with a cellular detritus, consisting partly of strongly refractile granules and partly of cellular elements, desquamated epithelial cells, round cells, and peculiar glossy flakes. There are also found cholesterin-crystals, needles of fatty acids, triple phosphates, remnants of undigested food, pigment- granules, many bacteria, and occasional red and Avhite corpuscles." The individual paroxysms vary in duration from one to ten days or more. In one case observed by me the attacks lasted about two days, recurring regularly at the end of every three months. Ordinarily the recurrence is after a shorter interval. Diagnosis.—It is important to make a microscopic examination of the pieces of membrane. If, when thus examined, mucus, cylindric- celled epithelium, a feAV round cells, and the other elements already mentioned are found present, the diagnosis of mucous enteritis is un- doubted. It is to be recollected, however, that membranes are not passed with every attack. Course and Prognosis.—The disease pursues a very chronic course and lasts for many years. The bodily nutrition suffers consider- ably if the attacks are frequent and severe, though, as a rule, this does not occur until a late stage in the affection. The risk to life, it is need- less to say, is slight. [b) SENSORY DISTURBANCES. It may be noted here that the sensory nerves of the intestines, as well as the inhibitory and vaso-motor dilators, are traceable to the splanchnics. Increased sensibility of the sensory nerves produces— ENTERALGIA. {Neuralgia of the Intestine.) Etiology.—This is commonly met with in hysteric, neurasthenic, and anemic subjects. It occurs as a reflex neurosis, as in the case of 842 DISEASES OF THE DIGESTIVE SYSTEM. cold, gout, and irritative lesions of the pelvic organs (kidneys, liver). Enteralgia is symptomatic of many local affections and conditions that induce direct irritation of the sensory nerve-filaments of the in- testine ; among these are inflammation of the mucosa, foreign bodies, gall-stones, abnormal distention with gas, and enteroliths. Under these circumstances the condition is associated with increased activity of the motor nerves or heightened contraction of the muscularis, forming true intestinal colic. In lead colic it is probable that the lead acts directly upon the nerves or their ganglionic cells. I have repeatedly observed the action of certain exciting causes, and particularly of nervous shocks. Symptoms.—Enteralgia may develop very suddenly, but oftener it sets in less abruptly, and is then attended with eructations of gas, ex- pulsion of flatus, and the like. In the fully-developed attack the pain may attain to great violence, causing the patient to " bend double " or even faint, and its character is variously described as boring, tearing, or cutting. The pain may be confined to a circumscribed spot or may be diffuse. The attacks are sometimes brief, or they may be character- ized by a sudden subsidence. At other times they last for days or per- haps weeks, and then subside gradually. Recurrences are common, but the intervals between the attacks vary extremely in duration. Hypogastric neuralgia is a term applied to neuralgia affecting the sensory nerves lying in the most dependent segments of the intestine. Here the nerve-fibers entering into the hemorrhoidal plexus are involved. It is caused chiefly by tabes, by hemorrhoids, and by the neurotic state so common to females. This form of neuralgia has its seat in the hypo- gastric region, and is accompanied by a distressing sensation of pressure in the rectum and bladder, and by an irresistible desire to go to stool; pains also radiate to the sacrum, thighs, and perineum. Diagnosis.—The various organic diseases and conditions mentioned under Etiology, in the course of which colic is a common symptom, must be separated from the true neurotic enteralgia. The former are distin- guished from the latter by a group of symptoms peculiar to themselves (fever, aggravation of the pain upon pressure, vomiting, constipation, or diarrhea), and by the usual definite causes furnished by the history. Renal and hepatic colic bear a superficial similarity to enteralgia. The former conditions, however, are distinguished first by the seat and direction of the pain, and secondly by the appearance of jaundice in hepatic colic and of hematuria in renal colic. Rheumatism of the abdominal muscles is easily eliminated, since it is generally combined with rheumatism in other parts of the body; the pain is also greatly increased upon throAving the muscles into contraction, as in stooping or rising; finally, it vanishes in response to the action of the salicylates. DIMINISHED INTESTINAL SENSIBILITY. This implies diminished peristalsis or constipation. A greater or less degree of anesthesia of the bowel attends, with a loss of desire to go to stool and an accumulation of feces in the rectum. This is a usual concomitant in many diseases of the brain and cord, with which paraly- sis is associated. Motor innervation may remain intact, and Avhen atony NEUROSES OF THE INTESTINE. 843 of the intestine is absent spontaneous movements of the bowels occur; when atony is present, however, to a marked degree (motor paralysis), the feces must be artificially removed. (c) DISTURBANCES OF MOTILITY. When the contractility of the muscularis is increased from purely nervous causes the result is— NERVOUS DIARRHEA. This condition presents no morbid lesions. The increased contrac- tility results from an exaggerated irritability of the motor nerves of the bowels. It may also result from morbid processes in the central nervous system and in other organs of the body; in short, the condition may be a reflex one. Examples of this sort are caused by tabes, by gastric disturbances, as after certain foods and drinks, by dentition, and the like. Most cases, however, are encountered in persons having an abnormally irrita- ble nervous organization—i. e. the neurasthenic and hysteric classes. In such the effect of mental excitement, of fright, and similar psychic influences is to induce diarrheal evacuations. Symptoms.—The stools vary in number from two or three to twenty-four or more daily. In rare instances they are soft—not truly diarrheal—and formed, yet they may be quite frequent. Blood and mucus, pus, and other morphologic elements are absent from the de- jections. It is characteristic of nervous diarrhea that the stools follow one another in rapid succession, usually during the morning hours, and then discontinue for the greater part of the day. The bodily nutrition is often well preserved. In the diagnosis organic affections of the bowel are to be carefully eliminated. ENTEROSPASM. {Spasm of the Intestine) By this term is meant a concurrent spasm of both the longitudinal and circular muscular fibers, usually inducing spasmodic constipation, and sometimes total, though temporary, occlusion of the bowel. Its causes are similar to those of nervous diarrhea, and the condition is clinically related to enteralgia. Neither pain nor constipation, hoA\r- ever, is a constant feature. The stools may assume the form of a rib- bon or of large rounded masses (sheep's dung), but they are not pathog- nomonic. They may also be covered with mucus. EAvald distinguishes between an idiopathic and a secondary or symptomatic spasm, the lat- ter being a concomitant of basilar meningitis and of chronic lead- poisoning. Another variety affects the rectum (proctospasm), and is generally secondary to some other rectal affection, as fissure of the anus; it may, however, occur as a neurosis in the hysteric and nervous class of subjects. The diagnosis of true functional enterospasm can only be made after all organic causes that may produce spasm of the bowel have been excluded. 844 DISEASES OF THE DIGESTIVE SYSTEM. CONSTIPATION. This is a common condition as a functional neurosis. It is due to an abnormality of function of the intestinal nerves that leads to a weak- ened peristaltic action, and is met with in hysteria, neurasthenia, and in those suffering from the various forms of psychoses. Central nervous affections often manifest atony of the intestine as a symptom; hence this form is not a disease sui generis. Cases of this class do not respond to any variety of cathartics, Avhether they act upon the small or large intestine (Ewald). Paralysis of the external sphincters is a common concomitant in a great variety of local (catarrhal) and central nervous diseases. Under these circumstances the act of defecation may be purely reflex, OAving to loss of control of the voluntary muscles ; or it may be voluntary, ex- cept when the person affected is not upon his guard, or during mental excitement, micturition, sneezing, and like influences, the latter condi- tion being a mere Aveakness. Treatment of Intestinal Neuroses.—A suitable change of en- vironment, including an appropriate arrangement of the dietary, is of primary importance, and is uniformly applicable in this class of sufferers. Further, the treatment of special cases has peculiar reference to the character of the nervous derangement. After making an accurate diag- nosis a search for the factors of the greatest etiologic importance should be made, and these must then be vigorously assailed. In the secretory neuroses an associated membranous enteritis must be corrected, the digestion must be improved if faulty, and the obstinate constipation overcome. For the latter symptom enemata containing ox- gall, either alone or in combination with salines, are especially service- able. Kussmaul and Fleiner have obtained the best results from reg- ular large oil-enemata administered once or twice daily. During the painful attacks simple enemata, repeated every couple of hours, will sometimes bring speedy relief by facilitating the removal of the scybala, and Avill assist nature's efforts at separating the adherent membranes. Pain must be relieved by morphin. In the sensory disturbances in which the activity of the sensory nerves is increased (enteralgia and hypogastric neuralgia) the treatment may be considered under two headings : first, the relief of the neuralgic pains ; and secondly, the correction of the causes or conditions on which the enteralgia depends. If the pain be severe, opium or morphin may be required. Especially good as an antispasmodic is codein, which may suffice in all save the severer cases. The object should be to give the minimum amount of the opiate that will meet the necessities of the case, with a view to obviating a resultant constipation. In hypogastric neuralgia I have found suppositories containing opium to be little short of magical in their effects. In cases in which there is constipation due to diminished sensibility, with a loss of motor innervation (atony of the bowel), the feces must be artificially removed unless the underlying condition can be successfully overcome. It is especially important that the environment—physical and psychic—be so regulated as to bring about an improvement in the gen- DISEASES OF THE LIVER. 815 eral condition of the patient. It may become necessary to employ tonic preparations of strychnin, iron, or arsenic. The treatment of nervous diarrhea involves the same principles, so far as the indication presented by the peculiar nervous organization is concerned, as in the sensory and secretory neuroses. It is especially important to prevent the operation of the direct causes—fright, mental excitement. Astringents and intestinal antiseptics are not called for, unless the bodily nutrition be affected thereby. Enterospasm is to be met by the same remedies that are used to control enteralgia. IX. DISEASES OF THE LIVER. ANOMALIES IN SHAPE AND POSITION. Altered Shape.—Occasionally malformations of the liver are met with that materially alter the shape of the organ, either primarily Avhen the result of disease, or secondarily from pressure of adjacent structures. Of the latter class the most important cause is tight-lacing, met Avith almost exclusively in Avomen and producing the so-called " corset liver." The loAver part of the right lobe of the liver is usually the part affected ; the hepatic parenchyma is atrophied, OAving to continued compression, and shoAvs deep grooves that correspond to the position of the loAver ribs. The connective-tissue capsule and the peritoneal coat are both thickened at this point, the smaller blood-vessels often being entirely obliterated. In marked cases the right loAver lobe may become con- verted into a dense fibrous band, with only a vestige of the former liver- structure remaining. Among other acquired causes of anomalies in the shape of the liver may be mentioned deformities of the vertebrae and ribs, or tumors of the ribs or adjacent structures (the pylorus, omen- tum) pressing against the liver. Diagnosis.—Rarely, clinical symptoms are present. "A constant sensation of pressure and pulling is felt in the hepatic region, and sometimes, as a result of venous stasis, there is a temporary but decided swelling of the isolated portion, and, possibly, violent pain and indica- tions of irritation of the peritoneum, such as vomiting and an approach to collapse. Jaundice is rare in consequence of this deformity " (Striim- pell). The danger of this condition lies in a possible mistaking it for an abdominal tumor (Pepper), amyloid disease, passive congestion, or new growths of the organ (Striimpell). Primary alterations in the shape of the organ may be due to active or passive congestion, hereditary syphilis, hypertrophic or atrophic cir- rhosis, acute yelloAv atrophy, carcinoma, abscess, or hydatid cyst. The accompanying symptoms Avould, of course, be those of the disease caus- ing the deformity. Anomalies of position are not infrequently met with, the organ being displaced upAvard, dowmvard, or laterally. The most common cause of lateral displacement is found in an abnormal lengthening of the suspen- sory ligament. The organ may occupy the epigastric region or be dis- 846 DISEASES OF THE DIGESTIVE SYSTEM. placed into the lower part of the abdominal cavity, but a change in the posture of the patient or external pressure is often sufficient to replace the liver in its normal position. The symptoms (if present at all) con- sist of a dragging sensation, often amounting to pain that may be severe and referred to the right shoulder. On physical examination palpation may reveal a fissure between the right and left lobes, together with a movable tumor presenting the size and normal outlines of the liver, which by manipulation may be returned to the right hypochondriac region. Percussion gives tympany over the normal area of liver-dulness, which changes to flatness Avhen the organ is pressed or falls into its natural position. Displacement upward may result from gastric or intestinal distention, marked ascites, or an abdominal tumor; while doAvmvard displacement may be due to a mediastinal tumor, an emphysematous lung, or a pleural effusion. Diagnosis.—Among the conditions likely to be confounded with movable liver may be mentioned carcinoma of the omentum or of the pylorus, dermoid cysts, tumors of the ovary and uterus, hydro- or pyo- nephrosis, tumors of the kidney, and chronic proliferative peritonitis. By a careful study of the symptomatology, and in the absence of the normal physical signs over the hepatic area, the differential diagnosis can usually be firmly established, although marked fatty degeneration or atrophic cirrhosis may coexist with any of the above conditions and cause marked diminution in the area of hepatic dulness. The treatment of movable liver is merely palliative, and consists in the application of a suitable bandage for preventing the displacement. JAUNDICE. {Icterus.) Definition.—A condition in which the tissues and secretions are stained Avith bile-pigments. Jaundice is not a disease, but a symptom. The various theories of the origin of so-called hematogenous jaundice have been, I take it, successfully overthrown by the investigations of Stadelmann, Hunter, and others. All forms are due to obstruction either in the larger or smaller ducts (hepatogenous). Hepatogenous or obstructive jaundice is more commonly seen in— (1) Inflammatory swelling of the duodenum or of the lining membrane of the duct, which is by far the most common factor in its causation, and demands separate consideration (vide infra, Catarrhal Jaundice); (2) Foreign bodies within the ducts, as gall-stones or parasites; (3) Stric- ture or obliteration of the duct; (4) Tumors within the duct or ob- structing its orifice; (5) Pressure on the duct from without, as by a tumor of the liver, stomach, pancreas, or omentum; also by fecal ac- cumulations, displaced organs, a pregnant uterus, enlarged glands in the fissure of the liver, and, more rarely, by abdominal aneurysm; (6) Low- ered blood-pressure in the vessels of the liver favoring resorption of bile, as in simple icterus of the neAv-born (Frerichs). CATARRHAL JAUNDICE. 847 CATARRHAL JAUNDICE. {Hepatogenous Jaundice; Icterus Catarrhalis; Duodeno-cholangitis; Inflammation of the Common Bile-duct.) Definition.—A condition characterized by a discoloration of the tis- sues from retention and absorption of bile and resulting from a catarrhal inflammation of the lining membrane of the ducts, more especially the larger, and of the duodenum. Pathology.—On examining a liver and gall-bladder in situ in a case of catarrhal jaundice the former is usually found enlarged, lighter in color than normally, and of a distinct icteroid tint. In well-marked cases the smaller ducts are distended throughout the hepatic parenchyma, and on making a longitudinal section drops of bile can be collected on the edge of the section-knife. The gall-bladder is found distended Avith bile, and on firm pressure a tough plug of mucus is usually expelled from the common duct into the duodenum, after Avhich bile Aoavs into the intestine freely. The mucous membrane lining the ductus communis is swollen and inflamed, and the catarrhal process may extend to the cystic, and in some cases to the hepatic, duct. As a rule, that portion of the common duct lying in the intestinal wall is more frequently and more deeply involved. If the disease becomes chronic, a formation of connective tissue occurs, owing to the irritation caused by the retained secretion, and atrophy of the livrer-cells, with biliary cirrhosis, may result. Suppuration is exceed- ingly rare in this affection. Etiology.—As simple catarrhal jaundice results in a majority of cases from extension of inflammation due to gastro-duodenal catarrh, the chief predisposing causes may be mentioned as follows: (a) Exposure to cold and wet; (b) The use of improper foods, under Avhich heading may also be comprised faulty cooking, improper mastication, irregular meals; (c) The excessive or prolonged use of such irritants as tea, coffee, or alcohol; (d) Prolonged anxiety and mental or physical overwork; (e) Certain acute diseases, as pneumonia, relapsing fever, typhoid fever, and malaria; (/) Portal obstruction, occurring in chronic heart- or kidney-disease; (g) More rarely it has occurred in epidemic form. Symptoms.—(a) Icterus, or tinting of the body-surface, is often the first symptom noticed in this condition, appearing usually on the forehead and neck and gradually spreading over the entire body. The conjunctivae also early become discolored, and the general hue, though variable, is generally a bright lemon-yellow. In chronic ca- tarrhal jaundice the color is apt to change to a bronzed or deep- green tint. (b) Secretions and Excretions.—The urine and swTeat are often found to contain bile-pigment, the patient's linen frequently being discolored. In extreme cases the urine may be dark-green in color, Avhile in those of average severity it is of a lighter or deeper greenish-yellow hue. The shaken specimen foams, and the froth has a yellow color-tint. Often the presence of bile is detected before any noticeable coloring of the conjunctivae occurs. In cases of intense or long-standing jaundice albumin and tube-casts may be present, and the latter may 848 DISEASES OF THE DIGESTIVE SYSTEM. be bile-stained.1 Hyaline casts are often found in cases of moderate intensity. The boAvels are constipated, and the stools are pale-drab or slate- colored ; they are usually very fetid. Diarrhea, however, may be pres- ent, owing to the production of irritating substances and decomposition. The tears, saliva, and milk are rarely stained Avith bile-pigment. The expectoration also is rarely tinted, unless pneumonia or some form of pulmonary infiltration coexists. (c) Circulation.—The pulse, although not appreciably altered in vol- ume or tension, is usually sIoav (often 30 or even 20 beats per minute), though this is not an unfavorable symptom. {d) The temperature is usually normal, although slight elevations may occur (100°-101° F.—37.7°-38.3° C). (e) G astro-hep otic Symptoms.—Among the first symptoms noticed in catarrhal jaundice may be those of dyspepsia—viz. anorexia, a sense of fulness after eating with flatulence, acid eructations, nausea and vomiting, accompanied by a dull, heavy pain over the hepatic area, with some tenderness on pressure. These often develop insidiously, and may be present several days before the appearance of the jaundice. More rarely they occur suddenly with a severe rigor or chill, violent head- ache, and vomiting—e. g. in the epidemic form. (/) Cutaneous Phenomena.—Pruritus or itching often becomes a troublesome symptom, being more common, however, in the chronic forms. Lichen, urticaria, furuncles, and SAveatings (diffused and local- ized) may develop, the latter being often limited to the skin covering the abdomen and the palms of the hands. A peculiar disease of the skin called xanthelasma or bita higoidea may also occur. It consists of bright-yellow spots, slightly elevated, appearing on the eyelids, and rarely on other parts of the body. In the more severe forms spots of ecchymosis, and in some instances profuse hemorrhages, may occur into the skin and mucous membranes. These are usually associated with other symptoms of a grave type. (g) Nervous Symptoms.—Headache and vertigo are common; irri- tability of temper, despondency, and Avakefulness or mental dulness almost equally so. With the oncoming of darkness vision may grow indistinct (hemeralopia) or it may attain unnatural clearness (nyc- talopia). Rarely, objects look yellow (xanthopsia). The nervous phe- nomena observed in catarrhal jaundice are attributable to the effects of the bile-acids. In certain cases, however, associated with destruc- tion of the hepatic substance, as in acute yellow atrophy, carcinoma, cirrhosis, and fatty degeneration, grave cerebral symptoms (acute delirium, convulsions, and coma) may develop suddenly and prove fatal. This class of symptoms has been named acholia, cholemia, or cholesteremia (the latter owing to the mistaken supposition that cho- lesterin is the poisonous product). The true nature of the toxic agent in the blood is unknoAvn. In some fatal terminations of this charac- 1 Tests for Bile.—Gmelin's test, or the play of colors, consists in bringing a few drops of urine in contact with the same quantity of commercial nitric acid on a plain white slab, whereupon various shades of yellow, green, red, and violet are produced. Rosenbach's test is made by filtering the suspected urine and touching the filter-paper with a drop of nitric acid. If bile be present, a green circle will form at the point of contact. (See also Choluria, p. 944.) CATARRHAL JAUNDICE. 849 ter death Avas due directly to a renal complication rather than to the primary affection. The physical signs in a case of simple catarrhal jaundice show on palpation and percussion an increase in the hepatic area, the loAver bor- der of the liver projecting in some instances several fingers' breadths beloAv the ribs. Rarely, the distended gall-bladder projects below the loAver lobe of the liver, as when there is complete obstruction near or at the duodenum, and then it can be distinctly palpated. Diagnosis.—The etiology (errors in hygiene and diet), a history of previously existing gastro-intestinal catarrh, the age of the patient (young adult life), and the appearance of the jaundice unaccompanied by pain or general emaciation, together Avith an absence of symptoms pointing to cirrhosis, carcinoma, or acute yelloAv atrophy, form a cha- racteristic grouping of clinical indications. Duration and Prognosis.—The duration of catarrhal jaundice varies from two to eight Aveeks. If the symptoms continue longer than two months, grave doubts may be entertained as to the case being one of simple jaundice. The prognosis is guardedly favorable. A rise of tem- perature usually indicates mischief (Pepper), while hemorrhages of the skin and mucous membranes always influence the prognosis unfavorably. Treatment.—The diet and hygiene are the first considerations in the treatment. Systematic bathing (Turkish or Russian baths, under super- vision), regulated hours of sleep, and moderate exercise in the open air, all exert a beneficial effect. Rich, highly seasoned foods, rich pastries, fats, and sweets, are to be interdicted ; starchy foods, lean meats, bread, soups (containing no fat), and green vegetables may, however, be used in moderation. Skimmed-milk, butter-milk, and alkaline drinks (Vichy and Saratoga mineral waters) may be used freely, while sour wines, lem- onades, and tamarind-water are allowable. The free use of pure water often does good by increasing the flow of bile and by dislodging plugs of mucus that may obstruct the duodenum and the common duct. Gerhardt and Kraus have recommended the faradic current, applied over the region of the gall-bladder ; manipulation has also been tried with a view to removing the obstruction in the common duct. Neither of these methods has met with success. The first therapeutic indication is to keep the bowels freely soluble by the use of saline aperients, as Hunyadi water or Carlsbad salts (^ to 1 teaspoonful in hot water before meals). The latter remedies tend to lessen the catarrhal inflammation by depleting the mucous membranes. In obstinate constipation calomel, rhubarb, the extract of colocynth, or castor oil may be employed. Prevost and Binet believe that calomel is in part converted in the economy into mercuric chlorid, which stimu- lates the biliary secretion. Conspicuous among other remedies may be mentioned the alkalies, sodium bicarbonate, salicylate, and phosphate, Avhich tend to increase the flow of bile and render it less thick ; hydrochloric acid (Avhich, accord- ing to Ewald, by aiding digestion prevents the formation and consequent absorption of toxic substances), in combination with the bitter tonics— gentian, quassia, and nux vomica; ammonium chlorid, which sometimes proves beneficial; and silver nitrate (gr. l-l—0.008-0.016, three times daily). 54 850 DISEASES OF THE DIGESTIVE SYSTEM. Injections of cold water (60°-70° F.—15.5°-21.1° C), daily, in quantities of 1 or 2 quarts (1-2 liters), are highly recommended as promoting the secretion of bile ; while lavage, practised daily and over a protracted period of time (one to two months), has proved highly bene- ficial, especially when gastro-duodenal catarrh has existed. This treat- ment was advocated by Krull, but has given negative results in the hands of Osier and Burney Yeo. Itching.—This troublesome symptom may often be relieved by the ex- ternal application of a solution of borax or sodium bicarbonate (,sss-Oj— 16.0-512.0), or of menthol and alcohol (gr. x-sj — 0.648-32.0). Inter- nally, large doses of the bromids (gr. xx-xxx—1.20-1.94, at bedtime) or the continued use of pilocarpin (gr. ^ to \—0.00-3 to 0.008, two or three times a day), as recommended by Witkowski, are worthy of a trial. Flatulence may often be relieved by preventing fermentation. To this end it is important to regulate the diet, avoiding starches and sugars as far as possible. Ox-gall and sodium chlorate (gr. v—0.324—of the latter three times a day) are sometimes useful in checking the formation of gas. Charcoal tablets, bismuth subnitrate or salicylate, and beta- naphtol are also useful in checking fermentation. Diarrhea.—Occasionally attacks of diarrhea alternate with constipa- tion in catarrhal jaundice, and when present demand treatment. As they are usually due to fermentation, salol and creasote (Tfl.ss—0.033), combined with the bismuth salts (subgallate, subnitrate, subcarbonate, or salicylate), are usually efficacious ; they are administered before meals. Headache is caused by the circulation in the blood of some toxic prin- ciple, due to the absorption of bile ; it is often persistent and annoying, although rarely acute in character. Temporary relief may sometimes be obtained as the result of free sweating induced by means of the hot bath or hot pack. Of drugs, caffein citrate, acetanilid, camphor monobromate, and phenacetin, either singly or in combination, may be recommended. In the other forms of hepatogenous jaundice permanent relief can only be afforded by removing the obstruction in the biliary channels, and thus permitting the normal outflow of bile. When the obstruction is due to mechanical causes (biliary calculi, tumors pressing on the duct) the treatment is chiefly surgical, and con- sists in their removal (vide Cholelithiasis). OTHER FORMS OP JAUNDICE. Modern experiments, as I have said (vide p. 846), tend to show that the so-called hematogenous jaundice is ahvays hepatogenous—i. e. the blood-dyscrasia probably exerts a toxic influence on the liver-cells; and there may at the same time be a more rapid blood-destruction in the liver (Neumeyer, Stadelmann, et al.). Among the more common causes of jaundice not purely catarrhal in origin are the following: (a) Certain fevers, as yelloAv fever, relapsing fever, (b) Grave forms of anemia, as pernicious anemia and chlorosis, (c) Certain poisons, as in pyemia, septicemia, shock, snake-bite, chloroform- and ether-poisoning; also in poisoning by phosphorus, arsenic, mercury, and other minerals. The pathology of these forms of jaundice differs essentially in the BILIARY CALCULI. 851 individual cases according to the cause, and will be considered under the different diseases mentioned in the etiology. Symptoms.—In the ordinary forms the symptoms are less marked than in the catarrhal variety. The skin presents in many instances only a slight lemon-yelloAv tint. The normal pigments of the urine are usually increased in amount, Avhile bile-pigments may be entirely absent. Finally, the stools are not characteristic, as in the catarrhal form, and may be even dark in color. This occurs in cases in which the extra- hepatic bile-ducts are only partially obstructed or the cause is solely intra-hepatic. In the severe forms of this variety of jaundice, as in that produced by acute yelloAv atrophy of the liver, symptoms of cholemia (described under the Symptoms of Catarrhal Jaundice) are apt to develop. The prognosis and treatment depend entirely upon the cause. BILIARY CALCULI. (Gall-stones ; Cholelithiasis.) Definition.—Concretions formed in the gall-bladder, due to an altered physiologic function or pathologic change; they vary in their composition and consist for the most part of bile-elements, and often set up characteristic disturbances (cholelithiasis). IJtiology.—As a result of biliary retention increased consistency and a concentration of bile occurs, and certain constituents that Avere before held in solution are thrown dowTn. Among the most common predisposing causes may be mentioned the folloAving: (a) Female sex, especially between the ages of forty and sixty. Durand-Fardel's sta- tistics (1868) shoAv that out of 230 cases, 112 Avere Avomen and 88 men. Senac's statistics, out of a total of 311 individuals give 227 women (Dujardin-Beaumetz). (b) Irregular meals and an excessive diet of starches and fats, combined Avith a sedentary life, are strong predispos- ing factors, (c) According to Harley, gall-stones and biliary concre- tions of all kinds are frequently hereditary. Among other, and perhaps minor, causes may be mentioned constipation, tight-lacing, pregnancy, chronic obstruction to the flow of bile (as from tumors pressing from without on the ducts, or catarrh of the ducts), and, more rarely, the rachitic and lithic-acid diathesis. Composition and Appearance.—Water comprises from 2 to 5 per cent, of the composition of gall-stones, the chief solid constituent being cholesterin, and the remainder being composed of bile-pigment and salts (lime, potash, soda, and perhaps traces of iron and copper). Pigment-lime may be, though rarely, the main constituent. In size they vary from the smallest particle of sand to that of a goose-egg. Harley records a case in Avhich a pyriform cholesterin-calculus was discovered in the feces; in a dry state it weighed 400 grains (26.0) and measured 21 inches (5.6 cm.) in length and 1^ inches (2.7 cm.) in diameter. Fagge reports a calculus weighing, in a dry state, 462 grains 852 DISEASES OF THE DIGESTIVE SYSTEM. (30.0). The color varies from Avhite or light-yellow to that of a dark- green (as in pigment-lime calculi), and may present any variation betAveen these two extremes. The nucleus often consists of cholesterin, the outer layer being usually the harder, and made up, for the most part, of lime-salts. The center of the nucleus generally consists of desquamated epithelium or dried mucus, and on cross-section concentric laminae are usually developed. The cholesterin gall-stones cut like Avax, are white, and the cut section presents a crystalline appearance. Other forms are apt to be brittle. The surfaces may be smooth, stri- ated, or hollowed out, solitary calculi being usually round or ovoid, while multiple stones often present smooth facets, due to the massing together of the calculi (Dujardin-Beaumetz). They are usually olive- shaped, but may be pyramidal, cylindric, lenticular, pisiform, cubic, finger-shaped, or olivary. Their seat is usually the gall-bladder, but they may be found anyAvhere along the biliary passages. Symptoms.—There may be no subjective symptoms of biliary cal- culi unless the stone becomes impacted in the hepatic, cystic, or com- mon duct. Thus, Naunyn states that "the gall-bladder will tolerate large numbers for an indefinite period of time, postmortem examinations shoAving that they are present in 25 per cent, of all women over sixty years of age;" and I quite agree with him in his estimate. The passage of a calculus through the duct will give rise to hepatic colic, Avhereas a permanent blocking of the duct will cause symptoms of chronic obstruc- tion, followed in many cases by those of ulceration and perforation, Avith the establishment of a biliary fistula. Hepatic Colic.—When a gall-stone becomes impacted in a bile-duct the patient experiences agonizing pain (tearing, cutting, or lancinating in character) in the right hypochondriac region, radiating to the right shoulder, and accompanied often by profuse sweating, vomiting, and a feeble running pulse. The most common seat of the pain is tAvo to three inches to the right of the median line and about an equal distance beloAv the ensiform cartilage. Less frequently it is in the region of the gall-bladder. This happens in cases in Avhich the gall-stone is impacted in the cystic duct, and may be in greater part due to distention of the gall-bladder. In some instances the pain is so severe as to produce syncope. Hepatic colic, however, may occur independently of the passage of biliary calculi, as from inflammation of the gall-bladder. On the other hand, large calculi have been found in the dejecta Avithout having excited hepatic colic. I recently saw an instance of this kind in which the gall-stone was of the size of an English walnut. A rigor or chill often precedes the attack, which is usually accompanied by mod- erate fever, the temperature reaching 101°-102° F. (38.3°-38.8° C). If the stone passes through the duct Avithout becoming impacted, jaun- dice and pain may either be only slight or entirely absent. When, how- ever, occlusion of the common duct occurs, the jaundice becomes intense. This symptom, however, may be present, though less marked, before the gall-stones reach the ductus communis. Jaundice occurs in about 50 per cent, of the cases (Fitz), and it sets in from eight to twenty-four hours after the onset of the attack of pain. Physical examination reveals on inspection a slight prominence in the hepatic area, and on palpation the edge of the liver- can often be distinctly felt below the costal margin— BILIARY CALCULI. 853 at times as Ioav as the umbilical level. The enlarged liver is sensitive on pressure, and particularly the gall-bladder, Avhich can be palpated in not a few cases. If the latter viscus contains many calculi, crepitation may be noticeable to the palpating fingers, and a friction-sound may be distinguished on auscultation. The SAvollen organ, after the cessation of the colic, subsides with truly remarkable rapidity. Recurrences of the painful attacks after varying intervals of time are common. Finally, the gall-stone is expelled and the colic ceases to return. Multiple stones, hoAvever, may be passed. Rupture of the duct, followed by fatal peritonitis, has been knoAvn to occur. Attacks of biliary colic are of variable duration, lasting from a feAV hours to a feAV days, and in some instances one or more weeks. Sudden cessation of the pain is usually followed by rapid disappearance of the jaundice (Avhen present) and the discovery of the stone in the feces. Examination of the urine after the paroxysm reveals bile and an abundance of uric acid and urates. The pulse often becomes slowed. The prognosis of biliary calculi as regards life is good, but as re- gards recovery only guardedly favorable. Attacks of biliary colic usually terminate favorably, although cardiac distress with palpitation may occur and form a serious complication. Fatal syncope has also been known to occur, and fatal intussusception has followed the impaction of gall- stones in -the region of the ileo-cecal valve. If evidences of an infec- tious inflammation arise, the outlook is then more serious. Diagnosis.—The diagnosis of gall-stones is sometimes extremely difficult on account of the obscure clinical symptoms and the entire ab- sence of physical signs. When, however, the calculus becomes impacted in the duct, symptoms of biliary colic usually appear, characterized by intense pain in the epigastrium and right hypochondriac region, radiat- ing to the back and right shoulder. There is also fever, vomiting, and in one-half the instances jaundice and the finding of the stone in the dejecta. Differential Diagnosis.— Gastralgia usually occurs in individuals with neurotic tendencies, and is characterized by severe paroxysmal pains in the epigastrium, extending to the back and base of the chest. It occurs often when the stomach is empty and is relieved by eating. Firm press- ure over the epigastrium often alleviates the pain temporarily, and the absence of fever, jaundice, stones in the dejecta, and the negative urinal- ysis, together with the history of former attacks, wTould tend to differenti- ate it from hepatic colic. Renal Colic.—The pain in this condition, Avhich is often as acute as that of biliary colic, starts in the flank of the affected side and is trans- mitted down the ureter. The testicle and inner side of the thigh are very painful, the former being often retracted. Micturition is frequent and sometimes painful, and the urine is scanty in amount and often mixed with blood. Intense pain may also be felt in the back and abdomen, although it is usually localized in the affected side. This grouping of symptoms is wholly unlike that characterizing biliary colic. Intestinal Colic.—In this variety the pain is of a boring or twisting character, usually centering about the umbilicus. It is relieved by firm pressure. Abdominal distention is often present, and relief comes with the passing of flatus. Usually there is a history of an indiscretion in 851 DISEASES OF THE DIGESTIVE SYSTEM. diet. When due to lead-poisoning, the history, the blue line on the gums, and the presence of wrist-drop Avould tend to confirm the diagnosis. Reflex colic, due to uterine or ovarian disease, may also occur. The recurrence of the attacks, together with other symptoms pointing to dis- ease of these organs and the exclusion of all other causes, would tend to establish the identity of the condition. In all forms of colic, if the pain be very severe symptoms of shock may develop, indicated by vomiting, cold, clammy skin, pale and pinched features, and a rapid running pulse. CHRONIC OBSTRUCTION OF THE DUCTS BY GALL-STONES. The obstruction may exist in the ductus choledochus, in the cystic duct, or in both. 1. Obstruction of the Common Duct.—Pathology.—The result of the irritation produced by the presence of the stone is a catarrhal pro- cess (cholangitis) that may either remain chronic or terminate in suppu- ration (suppurative cholangitis). In a case of simple obstruction the gall- bladder is often moderately enlarged, though rarely extending below the lower border of the liver. The common duct is greatly distended, the stone being usually located near its termination ; it is distinctly felt just beneath the mucous membrane of the descending duodenum. Occasion- ally two or more calculi are present, completely obliterating the canal. The hepatic duct and its branches are greatly dilated, and often contain thin, colorless mucus, the membrane lining the ducts being smooth and clear. The liver in these cases is firmer in consistency than normal, showing some increase in the connective-tissue elements, though cirrhotic changes are rare. Moderate enlargement of the organ usually exists, but progressive atrophy may occur. When suppuration has occurred the mucous membrane is greatly SAvollen and reddened, and in some instances shows erosions or ulceration. The process often extends through the hepatic and cystic ducts into the liver and gall-bladder, giving rise to localized abscesses in the former and to empyema of the latter. In some instances the gall-bladder has been perforated and abscesses have formed between the liver and stomach. Diverticula are sometimes found post- mortem, containing biliary calculi. Symptoms.—Chronic obstruction by gall-stones, with coexisting ca- tarrhal inflammation, is characterized by a distinctive group of symp- toms, among the most prominent of Avhich are— Jaundice.—This may be constant and very intense, or intermittent and slight, depending upon the amount of obstruction present. In some cases it disappears entirely for several months, and then recurs with vary- ing intensity (ball-valve action of the stone). Itching is, as a rule, a most distressing feature. Pain, occurring in paroxysmal attacks and referred to the region of the liver. This is accompanied by fever that may reach a high degree (102°-103° F.—38.8°-39.1° C), also by chills and sweating, resem- bling somewhat the paroxysms of malaria. Painful points in the right side posteriorly may be annoying ; these are either constant or par- oxysmal. The chills are often intense, and may present a quotidian, tertian, or CHRONIC OBSTRUCTION OF THE DUCTS BY GALL-STONES. 855 quartan form. The temperature of the intervals is normal. The peculiar exacerbations of temperature were first described by Charcot, and to them has been given the name of Charcot's intermittent fever. Many theories have been advanced as to its cause, and Murchison Avrites: "These paroxysms may be more or less periodic, and may extend over several months, without necessarily indicating pyemic hepatitis, the pa- tient ultimately recovering." He further states that they are probably due to simple irritation by a stone, and are analogous to febrile paroxysms produced in passing a catheter along the urethra. Charcot believes the etiologic factor to be a septic poison, bacterial in origin and the result of chemical changes in the bile. Various micro-organisms have been de- tected in the bile in such cases (bacterium coli commune, streptococcus pyogenes, et al). Gastric Disturbances.—These may be so severe during the paroxysm as to excite alarm. Intense pain is complained of in the epigastrium, accompanied often by persistent nausea and vomiting, which, however, usually subsides at the close of the paroxysm, while the jaundice at this time deepens. The attack may persist for years without progressive fail- ure of health. When, hoAvever, suppurative cholangitis occurs the prognosis becomes grave and recovery is unknown. The paroxysms occur more frequently, the fever merging into a remittent rather than an intermittent type. Grave constitutional symptoms, indicating septico-pyemia, are present, the duration is shorter, and the case rapidly tends to a fatal issue. The attacks of colicky pain occur and the jaundice, but the latter symptom is less intense than in the catarrhal form. Hepatic enlargement, on the other hand, is more marked than in the latter variety. 2. Obstruction of the Cystic Duct.—This almost invariably causes distention of the gall-bladder (dropsy of the gall-bladder), which may be felt distinctly below the lower edge of the liver as a pyriform, fluctuating tumor. If obstruction of the cystic duct alone occurs, jaun- dice may be entirely absent, the bile in the distended tissues being re- placed by a thin, mucoid fluid. This is more apt to exist as the obstruc- tion becomes more chronic. In some instances the distention is so great as to reach below the umbilicus, and the dilated viscus has even been mistaken for an ovarian tumor. Osier records a case in which 18 oz. (556.0) of fluid were removed from the gall-bladder. The contents are neutral or alkaline in reaction, albumin being often present in abun- dance. Catarrhal inflammation of the gall-bladder is often associated, causing pain and sensitiveness in the region of the organ. The pain may be severe and simulate biliary colic or appendicitis. The examiner can feel an elastic, gourd-shaped tumor closely connected with the liver, movable in respiration in the vertical, and also, under the influence of the palpating fingers, in the lateral, direction. If the obstruction persist for a length of time, calcification or atrophy of the bladder are common sequelae. In the former calcareous plates may be deposited in the mucosa, or the wall may be the seat of calca- reous infiltration, converting the viscus into a hard, stone-like body that is gritty on section. When atrophy occurs the organ shrinks into a small fibroid mass the size of a cherry, Avhich on section is often found to con- tain a stone. Complete obliteration of the cavity may occur. 856 DISEASES OF THE DIGESTIVE SYSTEM. Among rarer sequelae of chronic obstruction may be mentioned—(a) Empyema of the Gall-bladder.—When this takes place the organ be- comes greatly distended, and has been known to contain as much as a pint of purulent material. The symptoms of suppurativa cholecystitis simulate those of purulent cholangitis, and are often preceded by those of catarrh of the gall-bladder and ducts. Perforation may occur, giving rise to circumscribed periportal abscesses or to generalized peritonitis. (b) Acute Phlegmonous Cystitis.—This is of very rare occurrence, cha- racterized clinically by pain and tenderness in the hepatic region, rigors and high fever, and intense prostration. It often proves fatal as the result of peritonitis from perforation. More Remote Effects of Gall-stones.—These will be spoken of under three headings: 1. Stricture of the duct, resulting from ulceration and cicatrization produced by the passage of a stone. 2. Intestinal obstruction, due to impaction of gall-stones. 3. Biliary fistulae resulting from perforations. 1. Stricture of the Duct.—Obliteration of the common duct may re- sult from the passage of .a gall-stone, giving rise to ulceration and cica- trization, or the stone may become impacted and lead to adhesions and permanent closure of the duct below it (Murchison). When due to ulceration the seat of the stricture is usually Ioav down in the common duct.1 Symptoms.—The symptoms are those of chronic obstructive jaundice (Osier). In many cases there will be an antecedent history of the passage of gall-stones. In all cases in which the symptoms of gall-stones are folloAved by permanent jaundice without pain it may be suspected either that the calculus has become firmly impacted or that it has produced organic stricture or closure of the duct. 2. Intestinal Obstruction from Impaction of Gall-stones.—The ileum is commonly the seat of obstruction by gall-stones, that may give rise to intussusception or cause ulceration and gangrene of the boAvel with per- foration and fatal peritonitis. The latter event, however, occurs more frequently when the biliary concretions are situated in the cecum. Rarely they are found in the appendix, causing, as other foreign bodies, inflam- matory changes, followed by ulceration and in many cases by perforation and death. Cases of impaction in the rectum of several biliary calculi have been recorded. I have recently seen a case with Dr. R. Bruce Burns. Symptoms.—If the impaction occurs in the small intestine, the abdo- men becomes tympanitic and tender on pressure. The contents of the stomach are first vomited, followed by bile and stercoraceous matter. Obstinate constipation persists, and symptoms of peritonitis develop and continue until either the impaction disappears or death ensues. Ileus, the result of biliary concretions, is common in females of advanced age. The history of previous acute attacks would tend to confirm the diagnosis. The pain is intense and vomiting severe and persistent. The duration of the last attack is often short, terminating fatally in a few hours. 1 In vol. ix. pp. 22 and 130, Pathologic Transactions, two cases are recorded in which the strictures were exactly similar to those of the urethra, one being situated in the hepatic duct of the left lobe and the other in the common duct. TREATMENT IN CHOLELITHIASIS. 857 3. Perforation may occur with the establishment of fistulous com- munications between the gall-bladder and stomach, intestinal canal, blad- der, vagina, lungs, abdominal parietes, or portal vein. Fistulae between the gall-bladder and stomach are rare, though cases are recorded by Oppolzer, Frerichs, Cruveilhier, Murchison, and others. Cruveilhier states that vomited gall-stones necessarily reach the stomach through fistulous tracts, as the passage from the duodenum through the pyloric orifice would be impossible. Fistulae into the duodenum are of much more common occurrence, ulceration taking place usually in the fundus of the gall-bladder and in the descending or third portion of the duodenum: 39 cases are recorded of fistulous communication with the colon (Osier). I have reported a fortieth case,1 which prior to reaching a fatal issue had developed wide- spread septico-pyemic lesions. In 6 of 9 cases reported by Murchison carcinoma of the gall-bladder was present. Fistulae into the urinary passages may occur, 2 authenticated cases being reported. The distended gall-bladder may come in contact with the urinary viscus, or the stone may perforate into the pelvis of the kidney and pass through the ureter into the bladder. Fistulous openings through the abdominal parietes are the most com- mon of all fistulae, the place of exit of the biliary concretions being usually in the region of the gall-bladder or at the umbilicus, to which (according to Murchison) it may be directed by the suspensory ligament of the liver. As many as 600 stones have been removed from the gall- bladder in this manner. They vary greatly in size, being often as large as a goose-egg. Advanced life and female sex are said to be predis- posing causes. Murchison records 5, and Courvoisier's statistics show 184 cases, in 78 of which recovery took place. Fistulae into the pleura, bronchi, and vagina have been recorded, but are extremely rare. Courvoisier records 24 cases of fistulae into the lungs, only 7 of which terminated in recovery. Fauconneau, Dufoesne, Frerichs, Bristowe, and Murchison mention cases of fistulae into the portal vein, with the presence of biliary concretions in the latter. Treatment.—The indications for treatment in cholelithiasis are (a) to remove the cause; (b) to relieve the paroxysms of hepatic colic; and (c) to adopt palliative or radical measures for the removal of the gall- stones. Preventive Treatment.—In this, as in the treatment of jaundice, diet and hygiene play an important part. The former should be as simple as possible, consisting largely of skimmed-milk, lean meat, eggs, fruit, and green vegetables. Fatty foods, sugars, starches, and pastries are to be strongly interdicted. All foods should be thoroughly masticated, so as to digest easily, and meals should be taken at regular intervals. Syste- matic exercise in the open air is of signal value, as it stimulates the flow of bile. Punkhauer strongly recommends horseback-riding, believing this to be efficient in removing obstructions in the common duct. Among the drugs mostly used in the treatment of this condition I would advise the following: Sodium sulphate, combined with the extract of taraxacum (Harley); ox-gall (Dubney), in 5- to 10-gr. (0.324-0.648) 1 Clinical Lecture, International Clinics, vol. ii. third series, p. 27. 858 DISEASES OF THE DIGESTIVE SYSTEM. doses, three times daily (to relieve flatulency and stimulate the biliary secretion); sodium salicylate (gr. x to xv—0.648 to 0.972, three times daily); and sodium chlorate (gr. iv to vj—0.259 to 0.388) three times a day (Schiff). The bowels should be kept freely soluble, constipation being carefully avoided. In my own experience a dram (4.0) of sodium phosphate or of Rochelle salts in concentrated solution in the morning on rising has yielded excellent results. Other laxatives whose use is to be advised and encouraged are cascara sagrada, podophyllin, and rhubarb. Treatment of the Paroxysm of Biliary Colic.—At the very onset of an attack of hepatic colic the prompt exhibition of morphin or of codein may greatly mitigate an attack. The former may be given hypodermi- cally in |- to 4^-gr. (0.008-0.016) doses every hour until relief follows; the latter is exhibited by the mouth in doses of 1 gr. (0.0648) every hour. Inhalations of chloroform, with morphin hypodermically, the former being continued until the latter has taken effect, may be regarded as the typical treatment during an attack. Hot baths and hot applications (with counter-irritation) over the liver are valuable aids in the treatment of hepatic colic, being given at a tem- perature of 98° to 100° F. (36.6° to 37.7° C), and continued for twenty minutes if endurable, so as to effect relaxation. If cardiac depression results and the pulse becomes weak, the baths should be discontinued. Hot flaxseed-poultices, cloths wrung out of hot water, hot hop-bags, or turpentine stupes may be applied over the hepatic region until the attack subsides. Ice-poultices have been advised by Buchetan. If shock or syncope should develop, the body-temperature must be maintained by hot bottles or bricks placed in contact with the surface of the body, together with strychnin (gr. -^—0.0021), atropin (gr. yi^-— 0.00042), and brandy (1 dram—4.0) hypodermically. Nausea and vomiting may be reduced by 15-drop doses of spirits of chloroform every half hour; also by brandy and soda-water or cham- pagne. In mild cases sodium salicylate (gr. viij-xv—0.518-0.972 in twenty- four hours), recommended by Prevost and Binet, or codein (gr. j), with phenacetin (gr. x), every few hours gives relief. The free use of olive oil or glycerin in hepatic colic has been followed by a beneficial effect (Rosenberg, Goodhart). The former is given in quantities of 4 to 6 oz, (128.0-192.0) by the mouth every three or four hours, nausea being pre- vented by concealing the taste with lemon-juice ; the latter, recommended by Ferrand, is given in doses ranging from 1 to 2 tablespoonfuls, repeated in the same length of time. Both remedies are supposed to do good by increasing the flow of bile, thus forcing the stone outward toward the bowel. Treatment for Removal of Gall-stones.—The palliative treatment consists in the administration of agents that tend to increase the Aoav of bile. The free use of pure water by the mouth, together with copious rectal injections daily of cold water, has been found effective. It may be rendered alkaline by sodium bicarbonate or borate in a 3 per cent. solution. A course of alkaline treatment at some of the more noted mineral springs (Bedford, Vichy, Carlsbad) is often attended with good re- CARCINOMA OF THE BILE-DUCTS. 859 suits. Perhaps the three best cholagogues that may be mentioned are sodium phosphate, sodium cholate, and ox-gall; all of these aid the biliary flow. Olive oil and glycerin (2 tablespoonfuls of the former to 1 of the latter) three or four times daily also increase the secretion of bile. Cholagogues are quoted by some authorities to be contraindicated when intermittent hepatic fever and tenderness are present on pressure over the liver, but the fact is to be remembered that both symptoms may occur without ulceration having taken place. Agents to dissolve the stone have been tried at various times, among them being Durande's method (turpentine and ether), but, so far, all such methods of treatment have been unsuccessful. Of the various surgical measures for the removal of gall-stones the fol- lowing are the chief: (a) Removal of the stone from the common duct (choledochotomy); (b) Removal of the stone from the cystic duct (cho- lecystotomy); (c) Establishing a fistulous opening betAveen the gall-blad- der and the bowel (cholecystenterostomy); (d) Extirpation of the gall- bladder (cholecystectomy), the latter operation giving a mortality of 17 per cent., according to Murphy's statistics. CARCINOMA OP THE BILE-DUCTS. The biliary passages may be the seat of carcinoma, which may occur primarily and exist over a long period of time without being recognized. Pathology.—The gall-bladder, as the result of obstruction of the duct, is often greatly distended, measuring as much as 7 inches (17.7 cm.) in length (in a case reported by Harley) from the entrance of the duct to the fundus, and being filled with a cloudy liquid, somewhat resembling barley-water, that contains flakes of epithelium, granular matter, and particles of inspissated bile. The reaction is usually alka- line, the specific gravity varying from 1010 to 1015. The mucous mem- brane lining the interior may present a red, granular appearance. If the growth be near the duodenal orifice, the common and cystic ducts are often greatly distended, and the dilatation may extend into the hepatic ducts and their branches. The liver may be enlarged, and in some in- stances presents the secondary nodules that are characteristic of the disease. Etiology.—The causes of carcinoma of the bile-ducts are the same here as elsewhere, and among these the mechanical or inflammatory theory of Yirchow must be accepted. Tight-lacing and mechanical irritation by gall-stones are followed in many instances by cancerous degeneration; Osier states that " biliary calculi are present in at least seven-eighths of all cases." Among other factors, heredity and age (after forty) play an important part. Although carcinoma of the liver undoubtedly occurs more frequently in males, Musser found that out of 100 cases of carci- noma of the ducts 75 Avere females; in the same number of cases col- lected by Courvoisier 83 occurred in males. 860 DISEASES OF THE DIGESTIVE SYSTEM. Symptoms.—The signs and symptoms, according to Harley, present nothing characteristic to distinguish them from other causes of obstruction in the ducts. On palpation in the early stages the gall-bladder is found moderately enlarged, but later it rapidly undergoes diminution in size. Jaundice becomes very intense, and remains permanent. Throughout the course of the disease all the symptoms referable to chronic obstruction of the duct by gall-stones (paroxysmal pain, gastric disturbance, rise of temperature, Charcot's fever) may develop. Examination of the urine and feces reveals the presence of bile-pigment in the former and its entire absence or a greatly diminished amount in the latter. Ascites not rarely occurs during the later stages, with the involvement of surrounding organs by contiguity, as well as with the appearance of secondary nodules in the liver and the development of cachexia. Diagnosis.—Carcinoma of the biliary ducts cannot always be detected by physical examination. Distinct evidence of chronic obstruction of the duct, as persistent and intense jaundice (which occurs in three-fourths of the cases), the development of cachexia and the absence of cancerous in- volvement of other organs, however, will tend to characterize it. Often a hard tumor-mass is present in the region of the gall-bladder, and it should be recollected that this is oftener a seat of the primary affection than the liver. An assured diagnosis of carcinoma of the gall-bladder, however, is often impossible. Prognosis.—The prognosis of carcinoma of the bile-ducts is, like that of other organs, absolutely fatal, though the course of the disease is not so rapid as that of carcinoma elsewhere until secondary involvement of the liver occurs. Treatment.—The treatment is merely palliative. Operative meas- ures are rarely justifiable, since the disease is rarely recognized before the liver becomes involved. As seven-eighths of the cases follow obstruc- tion of the duct by gall-stones, the preventive treatment of the latter should be carefully observed whenever symptoms of disordered liver-func- tion manifest themselves. The treatment of the pain, anemia, and emaciation will be described in the discussion of Carcinoma of the Liver (vide p. 896). STENOSIS OP THE BILE-DUCTS. Stenosis, or narrowing of the duct, may result from any of the follow- ing causes: (a) Round-worms in the duct; (b) Foreign bodies, as seeds; (c) Ulceration and cicatrization following the passage of gall-stones; (d) Pressure from without, as from tumors (carcinoma chiefly) of the head of the pancreas and pylorus ; (e) Abdominal tumors; (/) Aneurysm of the abdominal aorta or of the celiac axis; (g) Secondary enlargement of the lymphatics of the liver; (h) More rarely in man than in the lower animals distoma hepaticum or liver-flukes and echinococci; (i) Adhesions due to chronic peritonitis. Pathology.—If the stenosis is of recent origin, the liver is enlarged STENOSIS OF THE BILE-DUCTS. 861 and shows more or less congestion, with some increase of the connective- tissue elements. The substance is firmer than normal, the color varying from an olive-green to a deep bronze. The biliary passages are dilated, and in some instances filled with bile. " It is not uncommon to find the ducts larger than the middle finger, and many instances are on record where the dilatation has been even greater than this " (Murchison). If, hoAvever, the obstruction be of long standing, the presence of the dilated ducts and the increase of connective tissue cause secondary atrophy of the hepatic cells, Avith a diminution in the size of the organ. Symptoms.—The symptoms vary greatly according to the cause of the stenosis, but in the main they are those of chronic obstruction of the duct—viz. paroxysmal pain in the region of the liver, referred to the right shoulder; jaundice of varying intensity, but gradually deepening after each attack ; and gastric disturbance, with ague-like paroxysms (fever and sweating), the latter being most frequently met with in occlu- sion from gall-stones. Diagnosis.—The pathognomonic symptoms determining the nature of the stenosis are very often wanting, and the diagnosis is rendered cor- respondingly difficult. " Great and progressive enlargement of the liver, with jaundice and moderate continued fever, is more commonly met with in cancer " (Osier). When the condition is due to lumbricoid worms, reflex symptoms usually appear in the intestinal canal, as pruritus of the nose and anus, grinding of the teeth during sleep, and convulsions. In carcinoma of the head of the pancreas or the pylorus pressing on the ducts the growth may be detected by palpation, together with a rec- ognition of other more or less characteristic features (vide infra, p. 908), and the rapid course of the disease. Abdominal aneurysm may give rise to obstruction of the duct without being evidenced by physical signs. Usually, however, when the saccula- tion presses against the bile-duct, the throbbing in the epigastrium, the tumor (which can often be grasped), and the expansile pulsation on pal- pation will tend to establish the cause of the obstruction. When due to cancerous nodules in the liver there is usually a history of primary carcinoma of the stomach, mammary gland, rectum, or of one of the pelvic viscera. Osier records a case in which jaundice (thought to have been catarrhal in origin) developed seven weeks previously. On careful examination " a small nodule was detected at the umbilicus, which on removal proved to be scirrhus." When the stenosis is due to ulceration following the passage of gall- stones, the history of biliary colic and of the presence of calculi in the dejecta, and the paroxysmal pain with jaundice and intermittent fever, will serve to establish the cause. If the fever be of the continued type and the liver uniformly enlarged, with the development of jaundice, the case is probably one of hypertro- phic cirrhosis; Avhereas if the enlargement be progressive and nodules can be detected on palpation in addition to the appearance of cachexia, carcinoma is undoubtedly present. Physical signs aid but little in the diagnosis, as obstruction of the common duct is usually unattended by any great enlargement of the gall- bladder. 862 DISEASES OF THE DIGESTIVE SYSTEM. In many cases only by remembering the various causes and eliminating them carefully, one by one, can the diagnosis be positively made. Prognosis.—It may be said of the prognosis, as of the symptoms, that both vary according to the cause of the stenosis. Generally speak- ing, the prognosis is rather grave, since many of the causal conditions are fatal. If the obstruction is due to cicatricial contraction, the prog- nosis is guardedly favorable as to life, but hopeless as to recovery. If the obstruction is permanent, the prognosis is absolutely hopeless. Treatment.—The treatment of occlusion of the bile-ducts varies according as it is due to cicatricial contraction following ulceration or to foreign bodies (seeds or lumbricoid worms), or to gall-stones or tumors pressing upon or involving the ducts or adjacent organs (pancreas, pylorus). If the stenosis folloAvs ulceration in the duct, and is sufficient to cause almost complete occlusion with biliary retention, the operation of cholecystenterostomy may become necessary in order to prevent dila- tation of the gall-bladder with resorption of bile. Foreign bodies in the duct may be removed by free purging, aided by the liberal use of alkaline mineral waters. In critical cases the operation of cholecystotomy has been practised. Gall-stones form the most frequent cause of stenosis, and the treat- ment, both for the prevention and removal of calculi, has already been described in the discussion of Biliary Calculi (vide p. 857). ICTERUS NEONATORUM. Definition.—Jaundice occurring in the new-born. This may be either pathologic or physiologic—a slight tinting of the skin occurring quite commonly in the new-born. Pathology.—The morbid anatomy of the pathologic form varies with the cause of the jaundice. The secretion of bile, like the secretion of urine, begins long before birth, and Zweifel has found bile-pigment and bile-acids in the contents of the intestines of a three-months' fetus. Hence children may be born laboring under an attack of well-marked jaundice. In well-marked cases of pathologic jaundice the skin presents a deep greenish-yellow hue, the conjunctivae being markedly discolored and the mucous membrane of the lips pale and anemic. The internal tissues (intestines, liver) are also stained with bile-pigment. Etiology.—Of the physiologic forms, the following are the main causes: 1. The ductus venosus may remain patulous, alloAving some of the portal blood, containing bile, to flow into the systemic circulation (Quincke). 2. Diminished pressure in the portal vessels from ligation of the umbilical vein causes increased tension in the hepatic capillaries and absorption of bile. Pathologic Icterus.—The causes are the following: (a) Congenital stricture or absence of the duct; (b) Syphilitic disease of the liver; (c) Septic processes set up by infection through the umbilical vein. Symptoms.—In physiologic jaundice the skin is tinted greenish- VASCULAR (CIRCULATORY) AFFECTIONS OF THE LIVER. 863 yellow, resembling somewhat that of chlorosis. The mucous membranes are pale and the conjunctivae pearly-white. The pulse is feeble and some- times rapid. Auscultation over the base of the heart often reveals a soft systolic murmur transmitted to the vessels of the neck and associated with a venous hum. According to Murchison, false or physiologic jaundice differs from the true or pathologic form in that—1. The conjunctivae are of a natural color; 2. The urine is free from bile-pigment; 3. The yel- low color gradually fades from the skin after a few days; 4. The child is quite Avell and the bowels are acting properly. In pathologic jaundice the skin and conjunctivae are more or less in- tensely icteroid, the urine is loaded with bile-pigment, while the feces are of the pipe-clay variety. Hemorrhage from the cord may occur and de- struction of life may be rapidly accomplished, or the condition may last for some weeks without serious impairment of the general health, with final recovery. Treatment.—In the milder cases calomel in minute doses, combined with lactopeptin and sodium bicarbonate, can be recommended. In ma- lignant cases treatment is of no avail. VASCULAR (CIRCULATORY) AFFECTIONS OF THE LIVER. ANEMIA. The physical symptoms of this condition are absolutely nil, and its existence only discoverable postmortem. Its most common causes are those of general anemia, fatty and amyloid degeneration. HYPEREMIA. Definition.—An excess of blood in the liver. This may be of two varieties: (a) active and (b) passive, the latter being the more common. ACUTE HYPEREMIA. {Active Congestion.) Definition.—An excess of arterial blood in the liver. Etiology.—Among the common causes are rich living, sedentary habits, alcoholism, traumatism, acute infectious diseases (typhus, typhoid), and pernicious malaria. The condition may also be vicarious, due to a sudden cessation of menstruation or of hemorrhage in other parts of the body. A physiologic condition is the temporary hyperemia that occurs during the ingestion of a full meal. Symptoms.—There are no symptoms characteristic of this condition; those present in the different cases are varied and referable to disturb- ances of other viscera, as in coexisting cardiac hypertrophy or gastro-in- testinal catarrh. Often, however, there is a sense of fulness and distress in the right hypochondrium after eating, with tenderness on palpation over the lower margin of the organ. Prognosis and Course.—It is impossible to make any definite state- ment as to the course and prognosis of active hyperemia, these depending 864 DISEASES OF THE DIGESTIVE SYSTEM. wholly upon the cause of the affection. When due to errors of diet and hygiene the condition is easily remedied; the prognosis of hyperemia accompanying hepatic cirrhosis, however, is decidedly grave. PASSIVE HYPEREMIA. {Passive Congestion.) Definition.—An increase of venous blood in the liver. Pathology.—The organ is enlarged in size and changed to a deep- red color, its substance being firmer than normal. The center of the lobule (the area of the hepatic vein) becomes deeply pigmented, the pe- riphery (occupied by the portal vein) being lighter in color, sometimes owing to fatty infiltration. Because of its mottled appearance this has received the name of the "nutmeg liver." In long-standing passive congestion there is an increase of connective tissue, due to a proliferation of round-cells, causing atrophy of the parenchyma. The blood in the central capillaries becomes altered, the capillaries themselves are distended, and brown pigment is deposited about the center of the lobules. The organ becomes very much darker in color, and to this condition the name "cyanotic induration" or "cardiac liver" has been given. Later, contraction of the connective tissue occurs, causing a diminution in the size of the organ, and forming the so-called "atrophic nutmeg liver." Etiology.—The causes that lead to passive hyperemia are both local and general. Among local causes may be mentioned the following: 1. Pressure over the portal area from without, as from a tumor or cyst. 2. Disease of the walls of the veins, as in syphilitic phlebitis. 3. Coagulation of the blood in the veins (thrombosis). Among the general causes are— 1. Chronic valvular disease affecting the right side. Passive hyper- emia is also common in mitral disease. 2. Pulmonary emphysema and cirrhosis of the lung. 3. Intrathoracic tumors, which by their mechanical action cause an increased pressure in the efferent branches of the hepatic veins. Symptoms.—Often the patient experiences a sensation of fulness and weight in the region of the liver that amounts in some instances to actual pain. Jaundice is usually present, but varies in intensity, and is due to obstruction of the smaller ducts by the distention of the hepatic venules. Hematemesis is not rare, and symptoms of gastro-intestinal disturbance are usually present. In marked cases the stools are clay- colored, showing the absence of bile ; the urine is loaded Avith bile-pig- ment; and jaundice deepens with the development of ascites or anasarca from portal obstruction. On palpation the organ is tender and increased in size, extending in some instances fully a hand's breadth beloAv the costal margin. In marked cases the whole organ pulsates, owing to the regurgitation of blood into the hepatic veins. This symptom is best elicited by placing one hand on the ensiform cartilage, while the other presses against the liver below the right loAver border of the ribs. Diagnosis.—The diagnosis of passive congestion, per se, is often very difficult, but when secondary to heart- and lung-diseases it is ren- dered more plain. DISEASES OF THE PORTAL VEIN. 865 The prognosis and treatment depend wholly upon the causal factors. DISEASES OF THE PORTAL VEIN. THROMBOSIS AND EMBOLISM. Thrombi are rare occurrences in the portal vein. Among the causes that lead to their occurrence, hoAvever, may be mentioned—(a) Trauma- tism ; (b) cirrhosis; (c) carcinoma of the liver, involving the portal area; (d) pressure from without, as in proliferative peritonitis involving the gastro-hepatic omentum, abscesses, enlarged glands, or impacted calculi pressing on the veins; (e) obstruction of the blood-current, as by foreign bodies or by a roughened venous wall; (/) slowing of the circulation due to splenic diseases, such as marasmus. Pathology.—In the early stages the clot presents a grayish-red or yelloAvish appearance, and on loosening it is found to adhere more or less closely to the inner coat of the vein. Later it becomes a mass of small white fibrin tightly adherent to the sides of the blood-vessel, which itself undergoes fibroid change, giving rise to the so-called adhesive pylephle- bitis. Organized thrombi are rarely found, except in the smaller branches of the portal area. If the thrombus obstruct the vessel, collateral circu- lation may be established for years, as in a case recorded by Osier. Septic softening, however, is a very common result, and most frequent of all is pylephlebitis. If a parietal or channelled thrombus be formed, partial or complete circulation may be re-established and recovery take place. Hem- orrhagic infarction may take place, but is very rare. Symptoms.—Symptoms may be almost lacking in portal obstruction, or the condition may simulate cirrhosis of the liver. In ordinary cases the symptoms are very slight, the hepatic circulation, as shown by Cohn- heim and Litton, being " sufficient for the nourishment of the liver and secretion of the bile" (Henry). If the occlusion be complete, edema followed by the rapid development of ascites may occur. In such cases loss of strength is persistent and progressive, and death may result from exhaustion. Hemorrhages due to venous stasis may occur from the nose, stomach, and intestines. Jaundice and diarrhea occur frequently, the former being the result of obstruction to the biliary passages from the same causes that produce the thrombosis or the diminished pressure in the portal area. On palpation the liver is found slightly enlarged and tender on pressure, and projecting below the lower margin of the ribs; the spleen is also enlarged. Percussion also reveals enlargement over the splenic area. If ascites is present, percus- sion will reveal dulness in the flanks, changing with the position of the patient; and on gently tapping one side of the belly-Avail, Avith the hand on the opposite side, a Avave of fluctuation will be felt. Diagnosis.—The diagnosis of portal thrombosis is often extremely difficult. "A suggestive symptom, hoAvever, is sudden onset of the most intense engorgement of the branches of the portal system " (Osier). Sequelce.—If the emboli are septic in origin, an abscess, with all its accompanying symptoms, Avill be the result. Hemorrhagic infarction 55 866 DISEASES OF THE DIGESTIVE SYSTEM. may occur, but is very rare, since a free anastomosis exists between the lobular plexuses and the hepatic artery. " Pylethrombosis may be regarded as probable if no other possible cause of the portal obstruction seems likely, and if Ave are able to discover a cause for thrombosis, like a former attack of circumscribed peritonitis " (Striimpell). The prognosis is always unfavorable, although certain cases have been demonstrated by autopsy to have improved temporarily. Course and Duration.—Nothing definite can be stated in regard to the course and duration of this affection, since these depend entirely upon the cause. Treatment.—The symptoms resulting from portal congestion, due to thrombi in the portal vein, are those described under Cirrhosis of the Liver, and the treatment is identical with that of interstitial hepatitis. In rare instances septic emboli give rise to abscesses that are usually multiple; when these occur the treatment is purely symptomatic. SUPPURATIVE PYLEPHLEBITIS. Definition.—A purulent inflammation of the portal vein or its branches. Pathology.—If noted in the early stages, the coats of the portal vein are distended and thickened, and the connective tissue surrounding the portal area is infiltrated and the seat of minute ecchymoses. The inflammation usually originates in the smaller veins of the portal system or in the hepatic branches of the vein itself; the main trunk is attacked least often. Numerous thrombi are found obstructing the vein and its branches, which finally undergo suppuration. From these, emboli enter the circulation and are carried to all parts of the liver, forming meta- static abscesses. In advanced cases the Avhole organ (especially the pe- ripheral parts) becomes infiltrated with pockets of pus, that communicate with the portal vein or its branches, and extend in some instances into the mesenteric or gastric veins. A single large abscess may be present, but multiple abscesses are the rule. The contents may be very fetid and bile-stained, or, as in many instances, they may be composed of thick, creamy laudable pus. From this focus of suppuration embolic abscesses may extend to the lungs, brain, kidneys, and joints. The macroscopic appearance, with the organ in situ, is sometimes practically normal. The liver may present a uniform enlargement, the surface being of normal color and the capsule non-adherent. More com- monly, however, the cortex presents a mottled appearance, and numerous yellowish-Avhite spots are seen beneath the capsule. Etiology.—The most frequent source of purulent pylephlebitis is perityphlitic abscess. Rarely the disease arises idiopathically. Among other causes are the following : (a) A secondary (becoming a general) pyemia, (b) Ulceration of the intestines, occurring in dysentery and, more rarely, in typhoid fever, (c) Gastric ulcer, (d) .Pelvic ab- scess ; abscess of the spleen, (e) Specific infection through the umbili- cus, occurring in the neAv-born. Symptoms.—The symptoms vary according as to Avhether the case remains one of suppurative pylephlebitis or terminates in hepatic ab- SUPPURATIVE PYLEPHLEBITIS. 867 scess. If the condition is part of a general pyemia, the symptoms refer- able to the liver may be almost negative. The liver is usually enlarged, and tender on pressure, the enlargement being most marked Avhen an he- patic abscess exists. Though pain is present, in many cases it is not a marked feature; it is frequently referred to the epigastrium, and may radiate laterally or doAvmvard. Percussion in the left axillary line shows splenic enlargement, and the organ can in some instances be felt beloAv the costal margin, constituting the " acute splenic tumor" of septico- pyemia. The fever is of an irregular septic type, the elevation in temperature is accompanied by rigors or chills and followed by profuse sweating. Other febrile symptoms, as headache, anorexia, and scanty, high-colored urine, are present. Jaundice of varying intensity is present, although usually it is not pronounced, the complexion being merely doughy or muddy. Diarrhea is not an infrequent symptom of this condition, and the dejecta sometimes contain blood as a result of the venous engorge- ment. Nausea and vomiting are often marked. As the case advances the pulse becomes rapid and small, and a low form of delirium develops; this is folloAved by stupor, coma, and death. Duration and Prognosis.—The duration of suppurative pylephle- bitis is usually from one to three or four weeks or longer. The prognosis is absolutely fatal. Diagnosis.—The diagnosis of suppurative pylephlebitis is sometimes extremely difficult, unless the case is complicated by hepatic abscess, as enlargement of the liver is not constant in the former condition. The etiology, septic temperature, enlargement of the spleen, jaundice, and pain in the region of the liver would all, hoAvever, point to this affection. The differential diagnosis of hepatic abscess will be spoken of later. Treatment.—Unfortunately, the treatment of suppurative pylephle- bitis can only be palliative. Surgical measures are rarely curative, unless the abscess is single and localized and shows signs of pointing. Free stimulation should be begun early, and should be persisted in throughout the course of the disease. Xausea and vomiting may often be relieved or controlled by pellets of cracked ice, brandy, and soda-Avater or champagne. One-drop doses of wine of ipecac every half hour until relieved, or the antiemetics, as cre- asote (TTL|—0.033—every half hour combined Avith bismuth subnitrate gr. Ar—0.324) or cerium oxalate (gr. \—0.016—every two hours), often check the gastric irritability. The^am in suppurative pylephlebitis is often acute, and demands the free use of morphin, either hypodermically or by the mouth. If much nausea exists, suppositories containing the extract of opium may be given at intervals. As the disease is almost invariably fatal, opium or its alka- loids may be given liberally. Fever may be controlled by repeated cold spongings or by the cold pack (68° F.—20° C), aided by large doses of quinin and salol. As the pyrexia is pyemic in character, hoAvever, drugs have little or no effect in reducing the temperature. Delirium, Avhich, with the rise of temperature, usually becomes aggra- vated toward evening, can best be subdued by applying an ice-cap to the head; this may also be reinforced by motor and sensory depressants, 868 DISEASES OF THE DIGESTIVE SYSTEM. as chloral hydrate and the bromids. In well-marked cases hypodermic injections of hyoscin hydrobromate (gr. Tfo—0.0006—every two hours until relieved) may be necessary. STENOSIS. Obstruction of the portal vein may be due, as before mentioned, to (a) thrombosis; (b) cicatricial contraction from cirrhosis or syphilis of the liver; and (c) tumors pressing on the portal area. The first cause is the more common, chiefly because mechanical obstruction, by causing a stasis of the blood-current, induces the formation of a thrombus. The symptoms of portal stenosis may be nil; if the stenosis occurs slowly, the hepatic artery furnishes sufficient blood to carry on the func- tions of the liver, the compensatory circulation being established by means of the systemic vessels. If due to thrombosis, the symptoms of portal engorgement appear suddenly with the development of edema and ascites. The liver is rarely enlarged in this condition. Prognosis.—This depends wholly upon the cause of the affection. Thrombi in the portal vein often give rise to a suppurative pylephlebitis, terminating in hepatic abscess; tumors are rarely accessible; whereas fibroid conditions of the liver causing cicatricial contraction are incurable. As a rule, the prognosis may be said to be guardedly unfavorable. AFFECTIONS OF THE HEPATIC BLOOD-VESSELS. Osler records a case of stenosis of the hepatic veins that was asso- ciated with fibroid obliteration of the inferior vena cava, with a greatly enlarged and cirrhotic liver. Among other affections of the hepatic veins are (a) Emboli, orig- inating from a thrombus in the right auricle, and (b) Dilatation, from stasis of the blood-current flowing to the right heart, due to enlarge- ment of the latter. Affections of the hepatic arteries are exceedingly rare, but may occur in one of the folloAving forms: (a) Aneurysm.—Only 10 or 12 cases of aneurysm have been reported, (b) Hypertrophy and Dilatation.—These may occur in connection with general hepatic cirrhosis, the cicatricial bands obstructing the lumen of the artery, and causing thickening in some places, and ampullae, or sac-like dilatations, in others, (e) Sclerosis. —This may form a part of a general arterio-sclerosis, though it occurs oftener in connection with cirrhosis or syphilitic hepatitis. ATROPHY AND HYPERTROPHY OF THE LIVER. (a) Atrophy.—Simple atrophy of the liver may result from pressure (corset-liver), syphilis, advanced cirrhosis, senility, and from the toxic HEPATIC INFILTRATIONS AND DEGENERATIONS. 869 action of phosphorus, arsenic, or chloroform—all factors that induce rapid fatty degeneration with cell-destruction. (b) Hypertrophy is of two kinds—(1) true and (2) false. (1) True hypertrophy may be subdivided into simple and numerical (hyperplasia), the latter referring to an increase in the number of the parenchymatous cells, and not, necessarily, implying an increase in the size of the organ. The tAvo causes of simple hypertrophy are active and passive conges- tion. Among the causes of numerical hypertrophy may be mentioned the following: Leukemia, hypertrophic cirrhosis, atrophic cirrhosis (hyper- plasia), syphilis, diabetes, and malaria. (2) Pseudo- or false hypertrophy occurs in amyloid and fatty infiltra- tion, carcinoma, and abscess, and consists in an increase in the tissues least concerned in the function of the organ. HEPATIC INFILTRATIONS AND DEGENERATIONS. AMYLOID INFILTRATION. {Waxy, Lardaceous, Bacony, or Albuminoid Infiltration; Amyloid Disease.) Definition.—A deposit in the hepatic connective tissues of a peculiar substance having some of the reactions of, and resembling, starch. A physiologic example of amyloid infiltration may be found in the corpora amylacea? of the prostate gland, in which there is a concentric arrange- ment somewhat resembling a starch-granule. Pathology.—The organ is larger than normally and of firmer con- sistence. The edges are rounded and not well defined, and the surface is of a light color, presenting in some instances a mottled appearance. On section the surface presents a grayish-brown, glistening appearance, which when scraped fails to exude oil-droplets, as in the fatty liver. On microscopic examination the connective-tissue trabeculae and the intima and media of the capillary walls (the starting-points) are chiefly affected, the lumen of the latter being lessened; this decreases the blood- supply to the liver, and often directly induces fatty degeneration. The hepatic cells may be atrophied and show evidences of fatty change. Amyloid material is structureless, and appears in small cloudy masses under the microscope. Chemically, it contains small amounts of potassium and phosphorus and an excess of sodium and chlorin. Etiology.—Amyloid infiltration may occur primarily in the liver, but it is often a part of a general infiltration, affecting especially the spleen (sago spleen) and kidneys. It is also found in some syphilitic scars and in certain tumors and old thrombi. Dickinson believes that the deposition of amyloid material is due to a decrease in the alkalinity of the fluid of the body, the pus (in cases of long suppuration) having removed a large quantity of the natural potas- sium salts. In malarial cachexia, however, such losses could not have occurred. " Amyloid infiltration is not uncommon in scrofulous, tuberculous, and rickety children " (Harley). It is a frequent sequel to long-standing 870 DISEASES OF THE DIGESTIVE SYSTEM. and exhausting suppurating and cachectic affections, as necrosis of the bones, hip-joint disease, and pyelitis; especially is this the case Avhen they occur in an hereditary tuberculous or syphilitic constitution (Har- ley). Amyloid disease may also complicate chronic malaria. Tests and Characteristics of Amyloid Material.—Although of animal origin, amyloid matter is closely related to a vegetable albuminoid starch. It is, however, sIoav to decompose, and is not acted on by weak acids and alkalies, whereas strong alkalies dissolve it. Iodin gives a blue color upon the addition of sulphuric acid. Lugol's solution (the aqueous solu- tion of iodin and potassium iodid) gives a brown tint to amyloid liver- substance and stains ordinary hepatic tissues a yellowT color. Gentian- violet gives a reddish or pinkish hue to amyloid substance, while normal tissue is stained blue. The following is taken from Harley's Comparative Table of Amyloid Tests : Starch. Amvloid. Cholesterix. Water. Dissolves on ing. boil- Dissolves on boil-ing. Unchanged. Ether. Insoluble. Insoluble. Dissolves. Heat. Dries up. Dries up. Melts. Sulphuric acid. Chars. Swells up, reddish-brown. Becomes green, blue, etc. Iodin. Becomes blue. Blue color with H2-S04, which is de-stroyed by excess. Remains un-changed. Sulphate of indigo. Amyloid tissue soaked in it be-comes a brilliant blue, while with ordinary liver-tis-sues the blue fades to a pale green. Symptoms.—When amyloid disease occurs in children the subjects are poorly developed and puny, the complexion is, as a rule, muddy or salloAv, and the abdomen usually prominent. Occasionally the skin is exceedingly transparent. Various gastro-intestinal symptoms are present, prominent among which are marked constipation and a capricious appe- tite. Mental phenomena, as impairment of memory and inability to con- centrate, are not unusual in this disease. The physical signs show an increase in the area of hepatic dulness; the edges of the organ extend below the costal margin and have a rounded outline. Sometimes, hoAV- ever, the edge, even in a very great enlargement, is sharp and large. Wilks speaks of an amyloid liver weighing 14 lbs.—6.35 kgms. (Osier). In rare instances the liver is reduced in size. Pain about the hepatic region is a rare symptom. The spleen is usually enlarged from coexist- ent amyloid infiltration. The urine often contains albumin (globulin is nearly always present) and waxy tube-casts ; it is of high specific gravity, is usually scanty, and dark colored. Diagnosis.—The foregoing symptoms and physical signs, in con- junction with an ordinarily clear etiology, are sufficient to establish the diagnosis. Treatment.—As amyloid disease is almost invariably a secondary FATTY INFILTRATION OF THE LIVER. 871 condition, the treatment must be directed to the removal of the primary cause, whether syphilis, tuberculosis, or rickets. The diet should consist of nitrogenous or animal substances, with a minimum amount of fatty or farinaceous foods. French rolls and bran- or gluten-bread are allowable, together with lean meat and green vegetables. Stimulants are to be strictly avoided. Moderate exercise, Avith the judicious use of Turkish (hot-air) and Russian (hot-vapor) baths, is also of great value. Many drugs are mentioned in the treatment of this disease, among the more important being the ammonium salts (the chlorid, gr. v to x— 0.324 to 0.648—three or four times a day), and other alkalies, together with tonics and laxatives. When syphilis has been clearly established as an etiologic factor of the disease, the tincture of iodin in 10-to 15-minim (0.666-0.999) doses, well diluted, has been recommended to be given three or four times daily. Cod-liver oil as a nutritive has been tried with good effect. Of tonics, the dilute mineral acids, given in moderate doses over a long period of time, have probably achieved the best results. FATTY INFILTRATION. Definition.—A deposit of fat in the hepatic tissues due to the in- gestion of fats and albuminates. Pathology.—The infiltration occurs often in localized areas, and may be so intense that the organ Avhen cut presents a shiny, oily ap- pearance. The liver is often evenly enlarged, and may weigh twelve to fifteen pounds. The edges are rounded and the substance less firm than normally. Portions of the liver-substance float in water, being of low specific gravity. The color is light-yelloAV or grayish. On micro- scopic examination the protoplasm of the cell is seen to be pushed to one side by the fat-droplets, Avhich tend to coalesce. When the fat is removed the cells resume their normal outline and appearance. Etiology.—(a) Fatty infiltration may form part of a general obesity or it may folloAv excessive over-eating or sedentary habits, (b) It often occurs in Avasting diseases, as carcinoma, syphilis, chronic malaria, and tuberculosis, and it often accompanies fatty degeneration. Symptoms.—The subjective symptoms of fatty infiltration may be entirely Avanting, since the function of the liver is not impaired to any extent. When they are present progressive anemia and debility are noted, and are accompanied by nervous irritability and insomnia. In marked cases the cardiac rhythm is disturbed, causing a feeble and irregular impulse. The physical signs are usually Avell defined, and the area of hepatic dulness is uniformly increased, extending in some instances as low as the umbilicus. The enlargement, hoAvever, is not as great as in amyloid disease. Diagnosis.—Fatty infiltration of the liver, Avhen well developed, is not apt to be mistaken for any other affection of this organ. The occurrence of general obesity, together with an entire absence of symp- toms of obstruction to the portal vessels or bile-ducts or of other evi- dences of fatty degeneration (particularly feeble heart-sounds), will help to distinguish it from this latter condition. The etiologic factors above mentioned will also aid in the differentiation. 872 DISEASES OF THE DIGESTIVE SYSTEM. Prognosis.—This is decidedly favorable, as the function of the liver in many instances is not impaired in the slightest degree. Treatment.—As the disease is of gradual development and long duration, a modification of the diet constitutes the first essential of the treatment. That prescribed under the Treatment of Amyloid Liver is admirably suited to this affection. Saccharine and farinaceous articles of food (potatoes, oatmeal, and SAveetmeats) must be escheAved. Wheat- bread must be partaken of sparingly, and in its place gluten- and bran-bread or crusts of French rolls should be used. Fish, lean meats, fresh vegetables, and fruits are also alloAvable. Alcoholic beverages must be interdicted. Graduated daily exercise and Turkish or Russian baths, judiciously used, are important factors in the treatment. Medicinally, the salts of the alkalies are highly recommended: sodium sulphate (in dram—4.0— doses, taken on an empty stomach) and ammonium carbonate (gr. xv to xxx—1.0 to 2.0—in twenty-four hours). FATTY DEGENERATION OF THE LIVER. Definition.—A conversion of the albuminates of the cells into fat; it is characterized anatomically by a destruction of the liver-substance, with atrophy of the organ, and clinically by biliary, gastro-intestinal, cardiac, and renal symptoms. Pathology.—On examining a liver that is the seat of marked fatty degeneration the organ is found smaller than normally, and the sub- stance is light yellow in color, soft, pliable, and easily torn. On section the relation betAveen the interlobular connective tissue and the acini is lost, the latter being replaced by fat-cells and oil-droplets. Scattered areas of pigmentation may be observed throughout the organ. Microscopically, the cells lose their shape and become globular; the nuclei tend to coalesce, and finally disappear, together with the cell-wall, giving rise to compound globule-cells, which do not tend to coalesce and are stained black by osmic acid. Crystals, granular debris, Lener s spheres, cholesterin, tyrosin, and phosphatic crystals are also found in this form of granular change. Etiology.—The following are among the recognized causes of the affection: (a) The excessive use of beer or alcoholic liquors, (b) It may be a sequence of amyloid disease, and hence result from any of the causes of the latter, (c) Diminution of the oxygen-supply to the tissues, occurring in phosphorus-, chloroform-, or arsenic-poisoning and in certain wasting diseases (carcinoma, phthisis, and chronic dysentery), (d) It may occur as a complication in the grave anemias and in acute infectious diseases ; also as a part of the pathology of acute yellow atrophy of the liver. Symptoms.—I feel convinced that partial or mild cases of fatty de- generation of the liver present no morbid symptoms of diagnostic import. Pain, jaundice, and ascites may occur separately or conjointly, but form the exception rather than the rule. The severe forms are characterized PERIHEPATITIS 873 by the symptoms seen in phosphorus-poisoning and acute yellow atrophy, to the discussion of which the reader is referred. Complications.—The disease may be complicated with fatty change in the kidneys. Under these circumstances the urine is diminished in amount, of low specific gravity, and contains an abundance of albumin, fatty or oily casts, and crystals of cholesterin, leucin, and tyrosin. In marked cases there is a very feeble and irregular cardiac impulse, accom- panied by attacks of vertigo and syncope, the latter symptom indicating beginning degeneration of the cardiac muscle. Edema of the lower ex- tremities and anasarca may occur as complications of this condition. The physical signs elicited by palpation and percussion show increas- ing diminution in the size of the liver as the disease advances. Diagnosis.—The chief diagnostic points of fatty degeneration may be summated thus: (a) A history of alcoholism, of poisoning by drugs (arsenic, phosphorus, or chloroform), or of an acute infectious disease (acute yellow atrophy); (b) Grave general symptoms, as albuminuria, edema, ascites, cardiac failure, terminating often in acholia or cholemia ; (c) Progressive diminution in the size of the organ. When these occur conjointly the diagnosis is established beyond a doubt. Prognosis.—The prognosis is entirely dependent upon the cause. If due to an excessive use of stimulants, the process, if recognized early, may be arrested ; if associated with acute yellow atrophy or other infec- tious disease, the prognosis is absolutely hopeless. Treatment.—The indications for treatment may be divided into the dietetic, hygienic, and medicinal. The same precautions regarding diet should be observed as in fatty infiltration. An open-air existence, short of injurious exposure, aided by hot salt-water, Turkish, or Russian baths, under restriction, is sure to improve the general condition of the patient. The medicinal treatment varies according to the cause of the disease. If due to grave anemia, iron (tinct. ferri chlorid. or syrup, ferri. iodid.) may be given in ascending doses. Poisoning by drugs that produce fatty degeneration of the liver is to be combated by their respective antidotes. Gastro-intestinal disturbances, if coexistent, demand appropriate treat- ment. For the latter Frerichs recommends highly the salts of the alka- lies (sodium sulphate in dram—4.0—doses taken on an empty stomach and ammonium carbonate). Ascites and cardiac asthenia, when occurring as complications, must be met by suitable measures. PERIHEPATITIS. ACUTE. PERIHEPATITIS. [Pyo-pneumothorax Subphrenicus.) Definition.—An inflammation, either suppurative or fibrinous, of the peritoneal covering of the liver and the corresponding portion of the diaphragm. Pathology.—The morbid changes may consist in a purely plastic inflammation, the serous layers being thickened, opaque, and covered with a fibrinous exudate leading to adhesion. In the majority of cases, 871 DISEASES OF THE DIGESTIVE SYSTEM. however, the inflammatory product is chiefly purulent, and is ribboned by fibrous bands so as to form circumscribed areas, filled Avith pus, lyino- between the liver and the diaphragm; this constitutes the subphrenic abscess. The latter is found more commonly to the right than to the left of the suspensory ligament. It may contain much pus (1 quart—1 liter—or even more), Avhich in most cases is mixed with air or gas de- rived from the gastro-intestinal canal. Rarely, bilirubin-crystals arc found, betraying the presence of bile. If the latter be present in large amount, the pus assumes an ocher-yellow hue. Etiology.—The fibrinous variety may result from the direct exten- sion of one or other of the acute forms of inflammation of the liver (ab- scess, hydatid cyst), from a pleurisy spreading along the lymphatics in the diaphragm, or from traumatism—particularly a blow. The suppura- tive form (pyo-pneumothorax subphrenicus, Leyden) may be caused in the same manner as the former, but far oftener—in more than one-half of the instances—it follows perforation of a gastric ulcer, and at times follows perforation by a duodenal or colonic ulcer. Appendicitis and penetrating wounds are not infrequent causes. Perihepatitis is a grave complicating event in carcinoma (of the stomach, esophagus, and intes- tines), lobar pneumonia, and purulent pleuritis. Symptoms.—Those of the acute fibrinous variety are scanty, and often are either altogether missing or are too vague to admit of correct interpretation. The coappearance, however, of severe pain, increased on deep breathing, and tenderness over a circumscribed area either in the right hypochondrium or the epigastrium, after the action of some knoAvn cause or the occurrence of one of the causal affections, is a symp- tom of great clinical import. A friction-sound may at times be heard below the seventh rib in the mammiilary and the ninth rib in the axil- lary line, or over the epigastrium, as in two cases in my own practice. It is of short duration, and is limited usually to the end of inspira- tion. It must be recollected that plastic pleurisy may be an associated condition. In suppurative perihepatitis the symptoms are sometimes screened by those characterizing the special causative complaint, but in my experi- ence, in cases due to perforation—the most common cause—the onset is rapid and severe, and is marked by acute pain referred to a circumscribed spot in the hepatic region, great tenderness, rapid, embarrassed, and painful respiration (owing to implication of the diaphragm), by vomiting (often bilious, though at times hemorrhagic) or nausea, and by faint jaundice in some cases. Shortly the general features of circumscribed peritoneal abscess also appear—rigors, irregular fever, sweats, and pro- gressive prostration and emaciation. Physical Signs.—Inspection discloses, bulging of the right hypo- chondrium and often of the epigastrium. The same regions are immo- bile, but this is best appreciated by palpation. The anterior edge of the liver is felt even as Ioav as the umbilical level. Percussion reveals a variable increase of hepatic dulness upAvard, sometimes touching the fourth rib. The upper level of the fluid is movable on changing the po- sition of the patient, and this is particularly striking if air or gas is con- tained in the abscess ; the presence of the latter also causes a zone of tympanitic resonance above the dull area, while overlying the latter CHRONIC PERIHEPATITIS. 875 there is the semi-tympanitic area of the retracted lung. Auscultation reveals an absence of breath-sounds and of the vocal resonance over the dull and tympanitic areas, Avhile the respiratory sounds over the dis- placed lung are broncho-vesicular. Diagnosis.—Acute suppurative perihepatitis often remains unrecog- nized during life. It may be confounded with empyema of the right side, but the tAvo conditions have different modes of development. Perihepatitis is preceded and accompanied by abdominal symptoms; empyema mani- fests thoracic symptoms—e. g. cough and pleuritic pain. At a later stage the exaggerated respiratory murmur above the dull area, the slighter cardiac displacement toAvard the left, and the greater hepatic displacement doAvnAvard in suppurative perihepatitis aid in the differen- tiation. The introduction of the trocar in the seventh or eighth inter- costal space in the mid-axillary line may also be helpful, especially if the exudate be found to contain bile-pigment. Pfuhl's sign—the more ready escape of the fluid during inspiration on aspiration of abscesses below the diaphragm—may not be without value. The points narrated above may likeAvise serve to separate pyo-pneumothorax from suppurative perihepatitis (see also Pneumothorax, p. 565). Course and Prognosis.—In the milder or fibrinous variety the outlook is favorable and the course is brief. On the other hand, the suppurative type due to perforation, if not early brought under proper surgical treatment, often terminates unfavorably by gradual asthenia. Rarely the pus is resorbed, or it may find an outlet through the lungs, abdominal walls, or other avenue, folloAved by slow recovery. The treatment is the same as for localized peritonitis. The first evidence of the presence of pus is the signal for appropriate surgical interference—evacuation and drainage. CHRONIC PERIHEPATITIS. {Zuckergussleber.) This affection is a chronic inflammation of the perihepatic fibrous membrane, which becomes opaque and thickened. Contraction of this capsule ensues, Avith compression of the liver and atrophy to even one-half the size of the normal organ (as in a case reported by Rumpfl), and par- tial or total occlusion of the vessel and bile-ducts. Perhaps these changes are most marked in cases that folloAv acute suppurative perihepatitis. Genuine instances shoAV no hyperplasia of the interstitial connective tis- sue; hence the condition is closely related pathologically to " Glissonian cirrhosis" (vide p. 886). The main causes of chronic perihepatitis are great and protracted local pressure, as from a corset, and certain occupations. It may rep- resent a portion of a more general chronic inflammation of the serosse. Finally, I am of the belief that syphilis is the leading single cause, and have discovered no other factor present in two cases that yielded to antisyphilitic treatment. The diagnosis is generally problematic. Of special clinical Avorth are the etiology, pain in the right hypochondriac region—particularly in cases due to syphilis—absence of the signs of stasis of the gastro- intestinal tract, and the very protracted course. 1 Deutsch. Arch.f. klin. Med., March 13, 1895. 876 DISEASES OF THE DIGESTIVE SYSTEM. The treatment is purely palliative, apart from the effort to remove the special cause, whether this be syphilis, occupation, or other influ- ential factor. ABSCESS OF THE LIVER. [Hepatic Abscess; Suppurative Hepatitis.) Definition.—A circumscribed collection of pus in the hepatic parenchyma. Pathology.—If examined in situ, a liver that is the seat of ab- scess-formation is usually found to be symmetrically enlarged, and on careful palpation one or more areas of fluctuation (either deep or super- ficial, according to the location of the abscess) may be detected. If single, its position is usually in the right lobe near the convexity of the organ (70 per cent, of cases). The tissue surrounding the abscess-wall is usually deeply injected, the Avail itself in acute cases being poorly defined, but grayish in color, irregular and shreddy, and composed of necrotic liver-cells, pus-corpuscles, and often amebfe. In chronic cases it becomes greatly thickened and often cartilaginous in appearance. Microscopically, the hepatic cells are filtered in shape and deAroid of nuclei; they undergo rapid degeneration. A round-celled infiltration occurs about the blood-vessels, their walls being filled Avith small emboli containing innumerable staphylococci and streptococci. As the sup- purative process continues liquefaction-necrosis occurs, resulting in complete destruction of the hepatic parenchyma. The amount of fluid contained in a liver-abscess may exceed 2 or 3 quarts (2-3 liters), and its color varies from grayish-Avhite to a creamy, reddish-brown. The collection in some instances resembles healthy pus. I have spoken of the methods of infection and of some of the different varieties of hepatic abscess in the discussion of Dysentery (see p. 96). Various odors are described, depending largely on the extent of bac- terial invasion and the degree of necrosis. In this connection it may be said that in amebic dysentery, with abscess of the liver as a compli- cation, the abscess is often single (involving more often the right lobe), Avhereas other forms due to septic infection give rise to multiple abscesses. In the latter instances the surface of the organ presents many small yellow areas beneath the capsule, varying from 5 to 15 mm. (^—f inches) in diameter. Usually, in such cases infection has taken place through the portal circulation, and on section the appearances of a suppurative pyle- phlebitis present themselves. If thrombi have formed in the portal tributaries, localized necrotic areas are the result, but more often the invasion affects the whole portal system, the liver being riddled with abscesses. If the abscess is secondary to obstruction by gall-stones or inspissated bile, the ducts are greatly distended and the gall-bladder is filled with pus mixed with bile. Etiology.—Idiopathic abscess of the liver is rare even in tropical climates. The affection, even vvhen excited by mechanical causes, as traumatism or obstruction by gall-stones, is invariably septic in cha- ABSCESS OF THE LIVER. 877 racter, and the infecting material reaches the interior through the hepatic vessels or the biliary passages. Septic emboli enter the liver by means of the vascular system through the hepatic artery or portal vein, the latter being the more common channel of transmission. Gastric ulcers, or the ulceration occurring in dysentery, typhoid fever, typhilitis (?), or appendicitis, may be folloAved by a purulent portal pylephlebitis, resulting in abscess-formation. In gen- eral pyemic processes or in bone-suppurations of long standing the germs enter the venous circulation, traverse the intralobular pulmonary plex- uses, and enter the liver through the hepatic artery. Suppurating wounds of the head are not uncommonly folloAved by abscess of the liver. Because of obstruction of the common duct by gall-stones, either from pressure-necrosis or owing to the decomposition of accumulated bile, germs may enter the liver and cause abscess-formation through the medium of the bile-ducts. In such cases gastro-hepatic. disturbances usually make their appearance before the symptoms of abscess develop. The most common method of infection, however, is through the portal vein. Among other causes may be mentioned foreign bodies travelling up the ducts, as parasites, round-Avorms, liver-flukes; also, more rarely, suppuro-perforation by mechanical irritants (needles, fish-bones, and the like), and suppuration occurring in the course of an hydatid cyst. Symptoms.—In a typical case of hepatic abscess the most promi- nent symptoms are—hectic temperature, pain, tenderness, and enlarge- ment of the organ, and often slight jaundice, although it must not be forgotten that any or all of these may be absent during the development of an abscess. The multiple abscesses occurring in pyemic conditions, which are frequently diagnosed when in view upon the postmortem table, form an instance of this. To facilitate the subject I shall consider the more important symp- toms seriatim : Pain is circumscribed to the hepatic region, and radi- ates to the right shoulder in conjunction Avith the other symptoms and physical signs; it is very characteristic, although not pathognomonic of hepatic abscess. In the earlier stages this symptom is not pronounced unless the abscess or abscesses lie superficially. It is usually of a dull, boring character, differing in severity with the patient's position; it is usually aggravated by pressure over the costal margin and by lying on the left side, this tending to drag the liver by its own weight from its normal position. Luschka explains the radiation of pain to the right shoulder by stating that filaments of the phrenic nerves that distribute themselves in the suspensory ligament and Glisson's capsule are irri- tated. The phrenic arises from the third, fourth, and fifth cervical nerves, and, as the fourth supplies sensation to the right shoulder, the impression is thus transmitted through the central nervous system. In acute cases accompanied by rapid destruction of the hepatic tis- sues the temperature usually rises rapidly, reaching 103° or 104° F. (39.4°-40° C.) in the course of from twenty-four to thirty-six hours. Its course, however, is irregular and intermittent, and it may be hectic in character; just as often it resembles a tertian or quartan intermittent or a remittent temperature. Rigors or decided chills frequently accompany the rise of temperature, and during the decline profuse SAveatings may take place, thus simulating to a certain extent the symptoms of malarial 878 DISEASES OF THE DIGESTIVE SYSTEM. fever. In chronic abscess of the liver pyrexia may be entirely absent. Less commonly the temperature may remain continuously high, with slight morning and evening exacerbations and remissions. The pulse is usually rapid in proportion to the temperature. The physical signs in a case of hepatic abscess are always present to a greater or less degree, and are often pathognomonic. Inspection may reveal nothing during the entire course of the dis- ease, although in cases accompanied by intense congestion in Avhich the abscess involves the anterior surface of the right lobe, bulging of the ribs on that side will occur, Avith a marked prominence in the hypo- chondriac region extending three or more finger-breadths below the costal margin. Palpation confirms inspection and reveals tenderness on pressure below the costal margin in the mammary line. The liver, if projecting below the edge of the ribs, is usually enlarged uniformly, unless the abscess involves the surface of the margin. As the upper right lobe is more often involved, especially in a large single abscess, the increase in size is in an upAvard direction, thus rendering palpation negative. In rare instances the abscess gives rise to fluctuation on palpation, and if the peritoneum be inflamed and adherent a friction fremitus may be detected. Percussion.—The area of hepatic dulness may be increased uni- formly, but it is usually most marked upAvard and to the right, in some instances reaching at the anterior axillary line to the fifth rib, and pos- teriorly to the level of the angle of the scapula. The increase of per- cussion dulness upAvard and to the right may also differentiate abscess from other affections of the liver, in wliich the enlargement usually extends in a dowmvard direction. Other Symptoms.—The skin is pale and shows slight icterus, the conjunctivae being often bile-stained; intense jaundice, however, is rare. Progressive loss of flesh and strength, with gastro-intestinal dis- turbance (fulness in the epigastrium, flatulence, water-brash, nausea, and occasional vomiting), are common symptoms at the onset. The bowels are variable, and constipation usually alternates Avith diarrhea, the stools in some cases containing the ameba coli. Ascites may develop from pressure on the inferior vena caArse, but these cases are rare. The spleen may undergo active hyperplasia in acute abscess-formation. Pul- monary symptoms are not uncommonly present; they are due to com- pression of the base of the lung by the abscess pressing upon the dia- phragm. In fatal cases certain nervous symptoms (muttering delirium, cephalalgia, and subsultus tendinum) make their appearance, and are fol- loAved by stupor and coma. Complications and Sequelae.—The abscess may perforate into the pleural cavity (pyothorax), bronchi, lungs, intestinal tract, stomach, pericardium, peritoneal cavity, or externally through the abdominal Avail, giving rise to various symptoms. If rupture occurs into the intestinal tract, sudden diarrhea, Avith the discharge of large quantities of pus, takes place; there is then an amelioration of the pain, fever. and other symptoms. If the rupture is into the lung, the physical signs Avill reveal the sudden development of Aveak, tubular breathing over the base, Avith increased tactile fremitus and percussion-dulness, together ABSCESS OF THE LIVER. 879 with the occurrence of profuse expectoration. In cases spoken of by Budd and Osier the sputum Avas of a reddish-broAvn color, resembling anchovy sauce, while Reese and Lafleur found the ameba coli in the bronchial discharge. Rupture in the abdominal cavity gives rise to the rapid development of a purulent peritonitis that is often fatal. Rarely, the abscess is emptied into the pericardium, giving rise to fatal acute pericarditis. Septic emboli have been known to lodge in the circle of Willis, producing fatal brain-abscess. Diagnosis.—The clinical symptoms of hepatic abscess are of diag- nostic importance only Avhen taken in the aggregate, since the pain, fever, enlargement, and even hectic symptoms, occur singly in other conditions unaccompanied by suppuration. The chief points in the establishment of the diagnosis of the affection may be summed up as follows: Residence in tropical countries, the previous existence of typhoid or dysenteric ulceration (or other gastro-intestinal inflamma- tion), enlargement of the liver, with pain and tenderness on pressure, and in some instances fluctuation on palpation. Lastly, aspiration may succeed in revealing pus-corpuscles, hepatic cells, staphylococci and streptococci, the ameba, and bile-pigment, Avhich when found are path- ognomonic ; if the abscess be secondary to an echinococcus cyst, the presence of hooklets will be detected. Differential Diagnosis.—Hepatic abscess may be misdiagnosed for empyema, malarial fever, and hepatic calculi. Empyema.—The mode of onset and the physical signs peculiar to this condition, if studied carefully, are entirely different from those of abscess. In empyema there may be the history of a perforating Avound of the chest, the rupture of a bronchiectatic or tuberculous cavity, or the pre-existence of a sero-fibrinous pleurisy; Avhereas hepatic abscess may be preceded by an attack of amebic dysentery or intestinal ulcera- tion, or it may folio av the impaction of biliary calculi. In both there may be the occurrence of a hectic temperature, Avith chills and sweating; but in empyema cough and dyspnea are prominent, and, if the pleural cavity communicates Avith a bronchus, profuse muco-purulent expectora- tion containing pus-cells, staphylococci, streptococci, and in many cases elastic tissue and tubercle bacilli. Rarely, an abscess of the liver pene- trates the diaphragm, and, entering the bronchi, is expectorated. The recognition of hepatic abscess under these circumstances is to be based mainly upon clear evidence of the affection prior to the occurrence of perforation and copious purulent expectoration. The detection of the amoeba coli in the sputum alone Avould set the diagnosis at rest. The contents of hepatic abscess obtained by aspiration consist of the micro- organisms of suppuration, and in addition broken-down liver-cells, bile- pigment, and in some cases the amoeba coli. Inspection in empyema reveals bulging of the intercostal spaces on that side, while percussion gives absolute flatness over the base of the chest, rising posteriorly and changing Avith the change from a dorsal to a sitting position. Above the area of flatness Ave find either a normal pulmonary note or hyper- resonance. In abscess of the liver the lung is very slightly displaced upAvard, being often bound to the diaphragm by adhesions, and the line of percussion-dulness in the right hypochondriac region does not change with the decubitus of the patient. 880 DISEASES OF THE DIGESTIVE SYSTEM. Hepatic Abscess. Malaria. History of traumatism, dysentery, intes- History of previous attacks. Residence tinal ulceration, or residence in tropi- in warm, damp climates among the cal countries. lowlands. Hectic character of the temperature— Regularly recurrent rise of the tempera- high every evening and low every ture (intermittent or remittent, quotid- morning; irregular chills, followed by ian, tertian, quartan, or septinarian), fevers and sweatings. and the rise occurring during the chill, followed by profuse sweating; chills more often in morning. An irregular, fluctuating tumor or multi- The spleen is enlarged; also there is a pie nodules in the liver ; no splenic en- yellow-brown coloration of the skin, largement; rapid emaciation, with or more or less marked; and, in long- without jaundice, but no cachexia. standing cases, the occurrence of ca- chexia. Blood shows simple anemia and leuko- The presence of the hematozoa of Laveran cytosis, and in marked cases disinte- and free pigment in the blood. gration of red blood-cells, but an ab- sence of micro-organisms. Abscess-contents consist of the staphylo- Absent. cocci, streptococci, pus-cells, and, in some instances, amebae. Impacted Calculi.—In this condition attacks of hepatic colic are often first noticed, followed by jaundice, and, if impaction be not absolute, by the occurrence of stones in the feces. In abscess the pain is not parox- ysmal, but dull and boring in character, increasing in severity as the disease progresses. In chronic impaction occasional attacks of fever (not hectic in character), jaundice, dull pain over the hepatic area, dis- tention of the gall-bladder (Avhich in some instances can be palpated), and clay-colored feces, constitute the principal symptoms. In abscess of the liver jaundice is comparatively rare, the temperature is often hectic in character, and, unless the abscess rupture into the gastro-in- testinal tract, the stools contain nothing abnormal. In some instances biliary abscesses may follow impacted calculi, or perforation may occur into the peritoneal cavity, with rapid development of peritonitis, which may prove fatal. Among other conditions that are liable to be mistaken for hepatic ab- scess may be mentioned carcinoma, hypertrophic cirrhosis, and hydatid cyst, the differential diagnosis of which will be spoken of under these diseases. Prognosis.—The prognosis of hepatic abscess is very unfavorable, the disease generally progressing to a rapidly fatal termination. Prompt evacuation of the abscess Avhen its location can be detected may be suc- cessfully performed. The mortality ranges from 50 to 60 per cent. In rare cases the walls of the abscess become calcified and the disease re- mains latent. The single large abscess that most often folloAvs dysentery offers the best opportunity for surgical measures. Treatment.—Barring operation, the treatment of abscess of the liver is purely symptomatic, being in many instances identical with that of septico-pyemia. The temperature often responds to repeated spong- ings with cool Avater (65° F.—18.3° C). For the pain mustard-poul- tices, the turpentine stupe, or hot fomentations over the hepatic area, in conjunction with full internal doses of opium, prove beneficial. Full and free stimulation and the free exhibition of quinin as soon as the ACUTE YELLOW ATROPHY. 881 condition is detected both support the system and control, in a measure, the pyemic process. If the abscess be single and localized, prompt evacuation should be resorted to. ACUTE YELLOW ATROPHY. {Malignant Jaundice; Icterus Gravis.) Definition.—An acute and probably infectious disease, character- ized by a rapid destruction of the parenchyma of the liver and by a diminution in the size of the organ; also by jaundice, hemorrhage, and grave cerebral phenomena. Pathology.—Macroscopically, in a case of acute yellow atrophy the liver is seen to be much reduced in size, Aveighing but 15 or 20 ounces (480.0-640.0), instead of its normal weight (50 oz.—1.6 kgms.). The capsule is shrivelled and the Avhole organ is of a pulpy consistence, and changed in appearance from a mahogany-broAvn to a light-yelloAv color, due to rapid fatty degeneration. On section the cut surface often pre- sents areas of red and yelloAv discoloration, the so-called "red atrophy " and "yellow atrophy," the former being a later stage of the latter. The red appearance is due to an excess of blood in the capillaries, with free pigment that has been liberated by destruction of the red blood-cells. Microscopic examination reveals a Avidespread destruction of the hepatic cells. The nuclei have disappeared, and the cell-wall contains a num- ber of fat-globules of various sizes containing free pigment. In ad- vanced cases, accompanied by total disintegration of the cells, fat-drop- lets, granular debris, cholesterin-plates, leucin spheres, tyrosin needles (first discovered by Frerichs, both in the cells and in the blood-vessels), and crystals of bilirubin may be found. The common duct is patulous and the gall-bladder is usually empty. In well-marked cases both the heart and kidneys shoAv evidences of fatty degeneration, the kidneys often showing ecchymotic areas. The spleen is greatly enlarged from active congestion, giving rise to the so- called " acute splenic tumor." The splenic substance is soft and easily torn, and on section the organ often drips blood. The skin and mucous membranes may be the seat of numerous ecchymoses, and dropsy of the pericardial and other serous cavities is frequently noted. The blood is dark and fluid, and under the microscope is seen to contain disintegrated red corpuscles, Avith crystals of leucin and tyrosin. Etiology.—The causes of acute yelloAv atrophy are both primary and secondary. Primary or idiopathic acute yelloAv atrophy is a rare and an invariably fatal condition. Among the secondary predisposing causes may be mentioned age (fifteen to thirty-five years), female sex, pregnancy, syphilis, and certain acute fevers (puerperal fever, typhoid, septicemia, malaria). Acute phosphorus-poisoning is almost invariably folloAved by acute yellow atrophy. The disease rarely accompanies cirrhosis of the liver, and may follow a debauch. In some instances an endemic form is assumed, but the exciting cause is thus far unknoAvn. Although certain investigators claim to have discovered micrococci in the hepatic vessels, 56 882 DISEASES OF THE DIGESTIVE SYSTEM. they have not yet been able to prove them to be the pathogenic genua of the disease. Symptoms.—The clinical history in a case of acute yellow atrophy varies considerably in the early stages of the disease, the graver symp- toms of the later stage alone being pathognomonic. The attack is usually ushered in by headache, malaise, anorexia, nausea and vomiting, moderate fever, and after a variable length of time (usually a few days) jaundice appears. Physical examination at this time shows the area of hepatic dulness to be normal or only slightly increased. After a period varying from a few days to two or three weeks grave nervous and cerebral symp- toms present themselves, as restlessness and violent headache, followed by delirium, which often becomes maniacal. Convulsions then appear, and are succeeded by stupor and coma, the latter occurring usually within forty-eight hours from the onset of the period of cerebral excitement. Often coarse tremors are noticed in the voluntary muscles, and with the onset of the second stage the jaundice usually deepens. The temperature often remains normal until just before death, Avhen it may rise one or two degrees. The pulse is much diminished both in volume and tension, and is rapid in proportion to the temperature. The tongue at the onset is covered with a light coating, most marked on the dorsum and around the tip and edges. Later, it changes to a thick yel- low color and becomes dry and fissured, like that of typhoid fever. Vomiting appears usually during the premonitory stage and often be- comes intense ; the vomit consists at first simply of the gastric contents, which later in the disease become mixed with blood (hematemesis). Hem- orrhages also frequently occur into the skin (ecchymoses) and from the mucous membranes, giving rise to epistaxis, hematuria, melena, hemop- tysis, and menorrhagia. These are supposed to be the result of a diape- desis of corpuscles due to the altered blood-pressure and to a diminished poAver of resistance in the muscular coats of the arterioles caused by degeneration. The urine in acute yellow atrophy is often scanty in amount, high col- ored, and shows an increase in specific gravity (1028-1032). The urea is greatly diminished, but bile-pigments and albumin, tube-casts, leucin, and tyrosin are found both on chemical and microscopic examination. The latter can be easily demonstrated by allowing a drop of the urine to evaporate on a cover-glass and examining under the microscope. Striim- pell regards the diminution in the quantity of urea, with the appearance of leucin and tyrosin, as a significant fact in vieAv of the theory supported by Meissner and von Schroder, who claim that urea is manufactured by the liver. Among other products found in the urine worthy of mention are creatinin and sarcolactic acid, Avhich, hoAvever, have no clinical importance. The patient is usually constipated, and the stools are clay-colored in appearance, being devoid of bile-pigment. When hemorrhage from the bowels occurs the dejecta are dark-colored, owing to the presence of al- tered blood. The physical signs reveal tenderness over the hepatic region, often amounting to actual pain, though this is rarely severe or lancinating. During the second stage, in extreme cases, the edges of the organ cannot be palpated under the costal margin. Percussion, moreover, shows a THE LIVER IN PHOSPHORUS-POISONING. 883 great diminution in the size of the liver, the area of dulness in a case recorded by Harley extending over but 1 inch (2.5 cm.) in the mammary line and 1^ inches (3.1 cm.), measured perpendicularly, in the mid-axil- lary line. The left lobe is often the first to shoAv physical signs of atrophy, per- cussion giving tympany instead of flatness in the upper epigastric region. As the atrophy continues the tympany extends below the seventh rib from above and advances upward from the costal margin, leaving but a small circumscribed area of hepatic dulness. The atrophy is usually progress- ive until death occurs, although favorable cases have been recorded in which the liver increased in size perceptibly during recovery (Harley, p. 260). When occurring in pregnant females the affection is likely to be complicated by abortion or miscarriage. Diagnosis.—The symptoms of acute yelloAv atrophy of the liver, and especially those occurring during the second stage of the disease, are usually so characteristic as to leave little doubt concerning the diagnosis. The occurrence of gradually increasing jaundice, grave delirium, hem- orrhages into the skin and mucous membranes, and the presence of an immense amount of bile, Avith leucin and tyrosin, in the urine, all com- bine to form a typical clinical picture. In hypertrophic cirrhosis the onset is more gradual. There is gener- ally a previous history of alcoholism, and the condition is often accom- panied by jaundice, Aromiting, hemorrhages (from passive congestion), and delirium. Examination of the urine, however, fails to reveal leucin and tyrosin, fever is rarely present, and the physical signs often shoAv an enormous increase in the area of hepatic dulness. The differential diagnosis betAveen this disease and phosphorus- poisoning is given under the latter condition (vide infra). The prognosis is almost invariably fatal, since every case of true yellow atrophy is associated with a destruction of liver-cells that is accompanied by acute toxemia. Treatment.—As yet no specific treatment has been discovered, all remedies used being directed to the relief of symptomatic indications. The gastro-intestinal system should be relieved at the onset by divided doses of calomel. For the vomiting cracked ice, Avith 1-minim (0,066) doses of the wine of ipecac repeated every half hour or divided doses of opium, may be given. Marked nervous phenomena with delirium I have seen controlled by cool baths and the ice-cap, together Avith cam- phor, chloral, or other antispasmodics used internally. Free stimulation should be begun early and persisted in throughout the course of the disease. THE LIVER IN PHOSPHORUS-POISONING. Folloaving the ingestion of a dose of phosphorus varying from gr. -|- to gr. 1 (0.008-0.0648) symptoms of poisoning manifest themselves (Taylor, Wormley) as folloAvs: After a period of time varying from three to tAvelve hours a sense of wretchedness, nausea, abdominal pain (not intense), and often vomiting, 884 DISEASES OF THE DIGESTIVE SYSTEM. occur. The vomit consists of the gastric contents, Avith bile, and during the first few hours it may contain phosphorus, Avhich gives it a luminous appearance in the dark. After the second or third day the vomiting usually cease's with the appearance of jaundice, which may become intense as the process con- tinues. Later in the course of the case emesis recommences, the vomita consisting of altered blood, giving rise to the so-called "black vomit." At this stage nervous symptoms usually manifest themselves (headache, insomnia, vertigo, and delirium, with convulsions and coma in fatal cases), death closing the scene usually in from thirty-six to forty- eight hours. The bowels are constipated, although attacks of diarrhea may super- vene, the evacuations being in some instances phosphorescent. Fever is irregular and usually is not marked, the temperature SAving- ing from 99° to 101° F. (37.2°-38.3° C). In fatal cases the temper- ature may become subnormal just before death. The urine is scanty, of high specific gravity, and contains bile, bile- acids, albumin, sarcolactic acid, and in rare cases leucin and tyrosin (Wood). Renal epithelium and free fat-globules have also been found. When occurring in pregnant Avomen abortion or miscarriage invariably follows. • Physical examination reveals a liver uniformly enlarged and tender on pressure. In protracted cases atrophy of the organ may rarely occur. Pathology.—On opening the abdominal cavity in a case of phos- phorus-poisoning the liver is seen to extend below the costal margin, its surface being lighter in color than normal and mottled in appearance, and its substance softer in consistence and friable. The cut section presents marked evidences of fatty degeneration, the acini being lighter in color than the interlobular tissue. Portions of the hepatic parenchyma are deeply bile-stained, and on scraping the cut surface bile- and fat-globules will be found on the edge of the knife. The gall-bladder may be either full or empty. Microscopically, disin- tegrated liver-cells, fat-globules, granular debris, biliary coloring-matter, leucin-spheres, cholesterin-plates, and tyrosin-needles are noted. The gastric mucosa is found thickened, opaque, and yellow-white in appearance, due, as pointed out by Virchow, to a universal gastro-adeni- tis, and not to the local action of the poison. Ulcerative or erosive gastritis is very rare in phosphorus-poisoning. The kidneys may show beginning atrophy, the epithelium in the cortices undergoing granular and fatty degeneration, with final destruc- tion of the cells. The blood is dark, fluid, and not easily coagulable. Concato found that during life the Avhite corpuscles are increased in number, and that the red are changed in shape and smaller than normal (Wood). Pete- chiae and ecchymoses frequently appear in all parts of the body, and occur oftenest in the mediastinum and serous membranes. Bollinger records a fatal case in which a hemorrhagic effusion was discovered between the membranes and the spinal cord. Diagnosis.—The diagnosis of acute phosphorus-poisoning is always extremely difficult and often impossible. The disease with Avhich it is CIRRHOSIS OF THE LIVER. 885 most apt to become confounded is acute yellotv atrophy of the liver. The differential points may be summated as folloAvs: Acute Phosphorus-poisoning. Acute Yellow Atrophy. There is a history of accidental ingestion There is often an endemic history. of poison (friction-match heads, rat- poison). The onset is sudden ; violent nausea, A slow onset—malaise, slight fever, with vomiting, and pain over the region of nausea and vomiting ; jaundice is a be- the liver. Jaundice appears on the ginning symptom. second or third day. Nervous symptoms appear late in the Nervous symptoms may appear early, disease—always preceded by jaundice. often before the occurrence of jaundice. The vomit and stools are phosphorescent. Black vomit occurs early and persists Black vomit precedes death. throughout. Temporary arrest of symptoms between Progressive march of symptoms with no the occurrence of jaundice and black remission. vomit. Sarcolactic acid is present in the urine, Leucin and tyrosin are common in the and rarely leucin and tyrosin. urine. Prognosis and Duration.—The prognosis in phosphorus-poison- ing is bad, as small a dose as gr. -1- (0.008) of white phosphorus having caused death (Wormley). The duration is usually from one to six days, although the symptoms have been known to persist for twelve days be- fore death. In violent cases the end may come within twenty-four hours. Treatment.—The initial plan of treatment is by causing emesis to free the system of the poison that still remains undigested. For this purpose copper sulphate (gr. x—0.648) in divided doses (gr. ij or iij— 0.129 or 0.194—every five minutes) should be given until free vomiting occurs. As copper sulphate is a chemical antidote, forming Avith phos- phorus black copper phosphid, it should be continued in less frequently repeated doses (gr. ij—0.129—every half hour) and guarded by morphin to prevent vomiting. If emetics by the mouth fail to afford relief, apo- morphin muriate (gr. \—0.0129), hypodermically, may be resorted to. The free evacuation of the stomach should be folloAved by the adminis- tration of the French oil of turpentine. Wood recommends that 1 part be given to every 100th part of the poison ingested. Ordinary turpen- tine is useless, but combined Avith mucilage of acacia 2 fluidrams (8.0) of French oil of turpentine may be given every fifteen minutes until 1 ounce (32.0) has been taken. Alkalies (magnesia) have been given, but are practically valueless. Free purgation should be effected if possible by Rochelle salts or mag- nesium citrate. Demulcent oils are never alloAvable, as they dissolve the phosphorus and hold it in solution. After absorption of the poison and degeneration of the tissues have taken place all knoAvn remedies are futile. CIRRHOSIS OF THE LIVER. {Sclerosis of the Liver; Nutmeg Liver; Gin-drinker1s Liver; Interstitial Hepatitis.) Definition.—A chronic disease of the liver, characterized by an excess of connective tissue, with atrophy of the liver-cells. It presents various biliary, gastro-intestinal, circulatory, and cerebral symptoms. 886 DISEASES OF THE DIGESTIVE SYSTEM. Pathology.—There are two leading forms, pathologically: (//) the atrophic and (b) the hypertrophic. In the atrophic form thecapsule is thickened, though the organ is greatly reduced in size and altered in shape. Foxwell's recent studies, hoAvever, show that, as a matter of fact, the alcoholic (indurative) liver is more frequently enlarged than decreased in size. This accords with my experience also. Strands of grayish-Avhite interstitial tissue may be seen surrounding yellowish areas of hepatic structure that are elevated above the surface and look not un- like hob-nails ; hence the term "hob-nailed liver." The substance is much firmer than normally, resists the cutting knife, and a cut-section presents a granular appearance. Microscopically, the connective tissue is most abundant about the acini; the liver-cells surrounding the hepatic veins are atrophied from pressure and undergo fatty degeneration. Sieveking in a microscopic examination of 20 well-marked cases of atrophic cirrhosis, chiefly alco- holic, found that the proliferated connective tissue infiltrated the liver- substance in an irregular manner. In some parts the newly-developed connective tissue Avas inter-acinous, and in others intra-acinous; only Avhen the connective tissue encircled separate cells or^mall groups of cells did atrophy occur. He therefore regards the proliferation of con- nective tissue as a primary change, and the atrophy as secondary. On the other hand, Weigert and his disciples contend that atrophy is often the primary change, and connective-tissue production the secondary— filling the gap, so to speak. The biliary canaliculi are apparently in- creased in number, consisting for the most part of rows of liver-cells that are caught in the ne\vly-formed connective tissue. As the cirrhotic pro- cess continues the minute portal veins are pressed upon, causing obstruc- tion to the portal circulation, with the development of ascites. This form of cirrhosis was first described by Laennec. Hypertrophic.—On examining the liver in situ during hypertrophic cirrhosis the organ is found enlarged (sometimes enormously), the lower border projecting several fingers' breadths below the ribs. The margin of the organ is well defined, the substance firmer than normal, and it cuts Avith difficulty. The organ is lighter in color than in health, and pre- sents a yellow or mottled-green appearance. On treating a section Avith compound iodin solution (Lugol's) the color changes to that of a deep mahogany-red. The acini are darker in hue than the interstitial tissue. Microscopically, the peripheral portions of the acini are first seen to be the seat of a round-cell infiltration, with the formation of embryonal tissue; later, the interlobular connective tissue undergoes hyperplasia, causing obstruction of the biliary ducts Avith retention of bile and sub- sequent atrophy of the liver-cells. Two other varieties may here be mentioned: (1) That characterized by marked fatty degeneration of the hepatic parenchyma and resembling fatty liver, except in the excessive amount of newly-formed connective tissue. The organ either maintains its normal size or is enlarged; its consistence is increased and section is difficult. It presents both macro- and microscopically the appearance seen in fatty infiltration. (2) Capsular or Glissonian cirrhosis, or perihepatitis, in which the CIRRHOSIS OF THE LIVER. 887 organ is surrounded by a dense white fibrinous membrane which con- tracts, reducing the size of the liver and altering its shape (vide Chronic Perihepatitis, p. 875). Associated with this form of the disease sclerotic kidneys, arterio- sclerosis, chronic gastritis, and fatty degeneration of the heart are often found at autopsy. Etiology.—Among the more important factors in the causation of all forms of cirrhosis are: Male Sex and Middle Life.—:The disease is most common in men about the age of forty, although cases have been knoAvn to occur in children. D'Espine records a case of hypertrophic cirrhosis in a child of six and a half years; Jacoby, a case in a child of four years; Gilbert and Fournier report 7 cases of biliary cirrhosis in children, the majority of Avhich, in addition to the usual symptoms, showed enlargement of the spleen. In children the affection is usually either of syphilitic origin or follows the infectious fevers, notably scarlet fever (vide also Syphilis, p. 334). Alcoholism is said to be responsible for at least 50 per cent, of all cases, and Freyhan found this causal factor operative in nearly all of his cases. Clinical history tends to prove that the stronger the alco- holic beverage and the larger the quantity consumed the more quickly cirrhosis occurs. Spicy foods are, according to some, classed as predis- posing agents. Tiraboschi records a case that had long been induced by the use of spicy foods and by over-eating. In many cases ptomains, the products of mal-assimilation through faulty digestion, are supposed to be the exciting cause. Certain chronic diseases (syphilis, rickets, diabetes, gout, malaria, carcinoma, tuberculosis) that favor the formation of connective tissue are apt to be complicated by cirrhosis. Hanot and Roix state that these cases are preceded by protracted gastro-intestinal derangement, and that the sclerotic process extends to the acini, but does not affect the biliary passages. Passive congestion, secondary to chronic cardiac lesions or to obstruc- tive lung-disease, not infrequently gives rise to hepatic cirrhosis. Here venous stasis produces a chronic inflammation Avith the formation of con- nective tissue. Primary inflammation or chronic obstruction of the bile-ducts is not infrequently followed by cirrhosis of the liver. Symptoms.—Atrophic Cirrhosis.—The symptoms of this variety of cirrhosis may present nothing characteristic as long as the sclerotic pro- cess does not interfere with the bile-passages or the portal circulation. Among the prodromal symptoms, a gradual loss of flesh, anorexia, con- stipation, a coated tongue, slight jaundice, dyspepsia, and occasionally hematemesis, are to be mentioned. As the obstruction becomes more marked, the mucous membrane of the gastro-intestinal tract becomes more and more swollen and con- gested, and gives rise to augmenting nausea and vomiting (most marked in the morning), and hemorrhages from the stomach (hematemesis) and intestines (melena), which may be frequent and profuse, but are rarely fatal. Severe hemorrhages may also occur from enlarged, varicose esophageal veins. Owing to the establishment of a compensatory circulation the super- 888 DISEASES OF THE DIGESTIVE SYSTEM. ficial epigastric and internal mammary veins enlarge, forming about the umbilicus the so-called " caput medusa." Hemorrhoids also are not uncommon, and are due to passive conges- tion of the inferior hemorrhoidal veins. As the disease progresses the general emaciation becomes more marked. The face assumes a pinched expression, the tip of the nose having a purple tint from distended veins; the eyes are sunken, the cheeks hollow, and the skin presents a sallow tint. Failure of the compensatory circulation gives rise to edema and ascites, and the latter causes in many instances hydroperitoneum, leading to enormous distention of the abdomen. Later in the disease toxemic symptoms may develop, due to some poisonous product in the blood, the exact nature of Avhich is unknown; these are violent head- ache, folloAved by wild, noisy delirium, convulsions, stupor, and coma. They not uncommonly occur Avithout jaundice, and have been mistaken for uremia. Fever is usually absent throughout the course of the disease, but may rarely be present, and reach 100°-102° F. (37.7°-38.8° C). Examination of the urine shoAvs it to be of increased specific gravity, loaded with urates, and containing bile. In a small proportion of cases it is slightly albuminous, and contains casts, though out of 28 urinal- yses in cases of cirrhosis Henry discovered the presence of albumin in but one. The amount of urea is constantly diminished, owing to the disturbance of the urea-forming function of the liver. An excess of indoxyl sulphate in the urine is a frequent occurrence. The physical examination in a typical case of atrophic cirrhosis re- veals a distention of the abdomen ; there may be also an extreme enlarge- ment of the superficial veins over the surface of the body, and an icteroid tint of the skin. Palpation of the liver and spleen may be greatly interfered Avith by the large amount of peritoneal fluid present. On Avithdrawal of the latter, however, the spleen is found greatly enlarged and extending in some instances to the epigastric region. The liver may shoAv slight enlargement in the beginning of the dis- ease, but it soon atrophies, and in emaciated subjects with lax abdominal Avails its finely granular or nodular edge can be felt above the margin of the ribs. Percussion shoAvs its vertical diameter, which normally extends from the sixth interspace to the costal margin, and averages about 4 inches (10 cm.), diminished, especially toward the median line. Posterior dul- ness begins lower than normally. Hypertrophic Cirrhosis.—In this variety of the disease there is usu- ally a distinct history of alcoholism. The liver often shows moderate enlargement before subjective symptoms are noticed, and the latter may be practically absent until late in the course of the disease ; they then resemble in a marked degree those of acute yelloAv atrophy, with a rap- idly fatal termination. Nausea, vomiting, epigastric distress, and ten- derness over the hepatic area are often the first symptoms observed. Jaundice is more common than in the atrophic form, often appearing early and persisting throughout the course of the disease ; it may be in- tense. These symptoms may persist for months or even years: as the obstruction increases, hoAvever, the portal circulation becomes engorged, CIRRHOSIS OF THE LIVER. 889 and gives rise to hemorrhoids, and in some cases to hematemesis, epis- taxis, and melena due to passive congestion. Splenic enlargement occurs in this variety of cirrhosis, but ascites is rare. The urine in the hypertrophic form may shoAv an increase in the amount of urates, and albumin and tube-casts may be present if the kid- neys are involved. The presence of leucin and tyrosin is not constant. Late in the disease the increase in the size of the liver becomes more apparent, because of the general emaciation of the subject. Jaundice deepens, the venous stasis becomes more marked over the surface of the body, and sometimes petechia develop in the skin. Delirium, convul- sions, stupor, and coma are not uncommon symptoms of the later stages of the disease. The temperature ranges usually from 102° to 104° F. (38.8°-40° C), although fever may sometimes be absent throughout the course of the case. Physical examination shows a moderate and, in some cases, a uniform enlargement of the organ ; the loAver border is felt distinctly outlined beloAv the costal margin, its edge being rounded and in some instances finely granular. The substance is firmer than normally, the increase in density being due to the neAvly-formed connective tissue. On making deep pressure tenderness may be elicited. Percussion shoAvs an increased area of hepatic dulness, most marked anteriorly toAvard the median line and extending beloAv the costal mar- gin. The fatty or Glissonian cirrhosis, Avhen well marked, presents the same symptoms as the atrophic variety. Among the more common com- plications are chronic interstitial nephritis, cardiac hypertrophy, hemor- rhages from the mucous membranes, chronic pachymeningitis, and tu- berculous peritonitis, the latter being not infrequently associated Avith cirrhosis. Diagnosis.—At the very onset the diagnosis is rendered obscure, and often impossible, by the absence of characteristic symptoms. A history of alcoholism, however, or of long-standing diseases that favor the growth of connective tissue (gout, syphilis, chronic rheumatism), together with the development of ascites, edema, and progressive en- largement of the liver (in the hypertrophic form), and the negative signs elicited by careful examination of the heart, lungs, and kidneys, make the diagnosis of cirrhosis reasonably positive. Among the more important affections to be differentiated from this disease are the following: carcinoma of the liver, abscess, hydatid cyst, and chronic peritonitis with effusion. Cirrhosis. Carcinoma of the Liver. History of alcoholism or of long-standing Hereditary history. diseases. Occurs in middle adult life (twenty-five Usually occurs after forty years of age. to fifty years). Occurs as a primary affection. Often occurs as a secondary growth. Jaundice is slight or intense, according Anemia is present, and also the develop- to the variety ; there is no cachexia. ment of a typical cachexia. Tenderness is marked. The case runs a There is more pain, with rapid emacia- slow course, usually lasting many tion. The case terminates usually years. within one year. Enlargement is regular in the hypertro- The liver is irregularly enlarged, and phic form ; there are no umbilications. contains umbilicated nodules. (See Fig. 60.) 890 DISEASES OF THE DIGESTIVE SYSTEM. Cirrhosis. History of alcoholism or chronic disease. Occurs idiopathically. Fever, jaundice, and ascites may be pres- ent singly or together. Anemia and emaciation slowly progres- sive. Enlargement or atrophy of the liver ac- cording to variety of cirrhosis. No fluctuation or thrill. Aspiration is negative. Hydatid Cyst. History of ingestion of the embryo of tenia echinococcus with improper food. Simultaneous occurrence in colonies or in others in the vicinity. No fever, pain, jaundice, or ascites. Emaciation not marked. On palpation an irregular, fluctuating tumor is felt over the hepatic area, giving an " hydatid thrill." Aspiration gives a clear, serous fluid, rich in chlorids, and containing hooklets. Fig. 60.—Showing approximate enlargement of the liver corresponding to the different dis- eases described in the text (after Rindfleisch): I, position of the diaphragm to the maximum enlargement (carcinoma); II, II, normal situation of the diaphragm; II, III, relative dulness; IV, border of the liver in cirrhosis; V, border in health; VI, lower border of the fatty liver; VII, of the amyloid liver; VIII, of carcinoma, leukemia, and adenoma. Cirrhosis. History of irritants (alcohol) or chronic processes (tuberculosis or gout), form- ing a growth of connective tissue. Usually a slow course. There is tender- ness, but no pain. Hectic symptoms absent. Moderate fever appears late in the disease. Runs a slow course, lasting months or years. Abscess of the Liver. History of dysentery, traumatism, or pyemia. Acute course, severe pain. Hectic symptoms appear early (fever, chills, and sweating). Runs an acute course, lasting a few weeks. CIRRHOSIS OF THE LIVER. 891 Cirrhosis {continued). Abscess of the Liver [continued). Slow enlargement, often regular, or Rapid development of a fluctuating slightly nodulated. No fluctuation. tumor in the hepatic area. Aspiration is negative. The aspirating needle reveals the pres- ence of pus. Prognosis.—Atrophic Cirrhosis.—The prognosis of this form of cirrhosis is decidedly unfavorable, the function of the liver-cells having been impaired or destroyed by contraction of the neAAly-formed connec- tive tissue. In rare cases the symptoms abate, OAving to the establish- ment of a compensatory circulation, and may remain in abeyance for months or years. The duration varies usually from a few weeks to five or six months after the symptoms of portal obstruction appear. Hypertrophic Cirrhosis.—Because of the frequently definite history of alcoholism in this variety the prognosis may be said to be more favor- able than in the atrophic form if the disease be recognized in its early stages and the source of irritation removed. Even after the occurrence of jaundice, hematemesis, and toxic symptoms, under appropriate treat- ment patients have been known to enjoy comparative health for years. Treatment.—The prophylactic treatment, if the disease be early recognized, consists in improving the general health of the patient and in removing, if possible, the cause of the affection. Rest, graduated exercise, systematic bathing, and regular hours for eating and sleeping should be inaugurated and strictly adhered to. Alcohol, strong coffee, spices, and gastro-intestinal irritants of every nature must be inter- dicted. The diet should be simple and easily digestible. An exclusive milk diet has been highly recommended (Semmola). The medicinal treatment is largely symptomatic, no remedy having been discovered to prevent the formation of, or remove, the newly-formed connective tissue. The chief object is to deplete the portal system and prevent, if possible, the occurrence of ascites. The bowels should be kept freely open by the use of saline purgatives (concentrated solution of Epsom salts), elaterium, or compound jalap poAvder. The skin is to be kept active by means of Turkish or Russian baths (under supervision), and in extreme cases by the steam bath or hot pack, employed just short of the point of exhaustion. The kidneys should also be kept active by the hydragogue diuretics (as potassium acetate), squills, digitalis in the form of the infusion, or Niemeyer's pill. Jendrassik recommends calomel as an efficient diuretic (gr. iij—0.194—t. i. d. until diuresis begins). Klemperer and others have also recently recommended urea as an efficient diuretic, and from 20 to 30 grains (1.29-1.94) may be given in solution. Urea acts best after paracentesis. If the case be syphilitic in origin, potassium iodid should be exhibited in ascending doses. Ascites, when it appears, calls for free and thorough diuresis, diapho- resis, and catharsis, and if not relieved in the course of a fe\v days tap- ping should be resorted to. Cases are recorded in Avhich, after early tapping Avith free depletion, the course of the disease has been appa- rently checked for months or even years. The operation of paracentesis abdominis, if performed under strict antiseptic precautions, is free from danger. The bladder having been emp- tied, a spot over the linea alba about 3 inches (7.5 cm.) above the sym- 892 DISEASES OF THE DIGESTIVE SYSTEM. physis pubis is anesthetized (preferably with a compress of cracked ice and salt), and a trocar is quickly thrust through the abdominal wall for a distance of about 1 inch (2.5 cm.). The distance is determined by the fore-finger, which is placed at the desired distance from the point of the cannula before its insertion. The patient must be in a sitting or semi-reclining position, so as to allow the ascitic fluid to collect by grav- ity in the lower part of the abdominal cavity. A tube having been attached to the cannula to convey the liquid to a receptacle, the trocar is withdrawn, the fluid allowed to run out, the cannula removed, and the Avound closed by antiseptic gauze or a pledget of cotton. Turlington's balsam is then smeared over the site of puncture, and the abdominal binder, Avhich has been previously applied, is tightened. The operation should not be repeated until orthopnea begins to develop, as absorption may occur after the first tapping. Complications, as cardiac hypertrophy, tuberculous peritonitis, or chronic meningitis, demand appropriate treatment; this is described in full in the discussion of the respective diseases. CARCINOMA OF THE LIVER. Definition.—A malignant groAvth of the liver, occurring usually after the age of forty, and characterized by pain, progressive emaciation, cachexia, and the appearance of a nodular mass in the hepatic paren- chyma. It may be primary or secondary, though the former variety is very rare as compared Avith the latter. Pathology.—Histologically, the cells are not distinctive, being iden- tical Avith those of carcinoma elsewhere; they are epithelial in charac- ter, having a small vesicular nucleus and much protoplasm. They are altered greatly by pressure, and vary in shape, being hexagonal, poly- hedral, or amorphous. Large giant-cells and spots of pigment knoAvn as " broAvnish granules " are not uncommonly found in the cancerous mass. The so-called colloid cancers are nearly always mucoid, and the cells have undergone a mucoid change; the stroma of connective tis- sue surrounding the cancer-nests in some instances undergoes hyaline or myxomatous degeneration. In other instances the interstitial tra- beculse completely surround the epithelial nests, Avhich are separated by a basement membrane; to this variety the name of adeno-carcinoma has been given. AVhen examined microscopically, medullary cancer, either in a large mass (primary) or in secondary nodules scattered throughout the organ, is the most common variety found in the liver. On examining a liver that is the seat of carcinoma, one of tAvo conditions usually presents itself: First, the organ may be apparently normal Avith the exception of one lobe (usually the right), which contains a dense whitish growth of firm consistence, being distinct and sharply defined from the surrounding liver-tissue. On section the tumor is often of uniform density, bluish- white in appearance, and exudes a milk-Avhite fluid known as '' cancer- juice," Avhich, Avhen examined microscopically, is found to contain large, nucleated, and irregularly-shaped cells containing free granular matter. The center of the tumor may have undergone liquefaction-necrosis, Avith the formation of a cyst, or it may be the seat of an abscess. A arious CARCINOMA OF THE LIVER. 893 smaller nodules may be scattered throughout the organ by metastasis from the primary growth. The second and most common condition is that found on examining a liver which is the seat of secondary carcinoma, the primary lesion being situated in the mammary glands, pylorus, or the cervix uteri. Numerous nodules are scattered throughout, and can usually be seen projecting beneath the capsule, those superficially situ- ated having received the name of " Farre's tubercles." In the center of these nodules characteristic pits or umbilications are often present, caused sometimes by contraction of the interstitial trabecular and some- times by a central softening. On section they are usually grayish-Avhite in color and of firm consistence, although cysts, hemorrhages, pus-cav- ities, or areas of hyaline and fatty degeneration are often found. The cells are identical Avith those of the primary growth, and are composed for the most part of cylindric epithelium. In rare instances carcinoma occurs simultaneously Avith cirrhosis in the same liver, the organ presenting an uneven, nodular appearance, and being slightly increased in size and of firmer consistence than normal. When examined in situ the external appearance does not differ materi- ally from that of cirrhotic liver, but on section the whole organ is found to be infiltrated with various-sized cancer-nodules surrounded by bands of cicatricial tissue. In some cases the excess of connective tissue and the amount of contraction are extreme, and the size and Aveight are reduced below the normal. Etiology.—Among the more important predisposing factors may be mentioned— (a) Age.—The disease seldom occurs before thirty-five or forty years of age, although cases have been knoAvn to occur in children. Descroi- zilles reports the case of a child eleven years old who died Avith a tumor in the right hypochondriac and iliac region, the autopsy revealing a liver studded Avith cancerous nodules, the nature of which Avas demonstrated microscopically; the small intestine was also the seat of cancerous infiltration. (6) Sex.—Men are more often the victims of carcinoma of the liver than women. When occurring in the latter it is often secondary to car- cinoma of the uterus or mammary gland. (c) Heredity is said to be the cause of hepatic carcinoma in at least 20 per cent, of all cases, and is one of the strongest arguments in sup- port of the diathetic theory of the disease. (d) Mechanical Obstruction.—Primary carcinoma of the gall-bladder and bile-ducts not infrequently follows chronic obstruction by gall- stones. Symptoms.—There may either be almost no symptoms of carci- noma involving the liver, or its manifestations may be intense and varied according to the extent and location of the growth or growths. Associ- ated gastric symptoms, Avhich increase as the disease advances, usually attend. A more or less marked cachexia may be the first noticeable feature. The chief symptoms may be considered in detail, as follows: (a) Jaundice.—Discoloration of the skin and tissues is often by no means intense, and may be entirely absent. Harley states that true icterus Avas present in only 6 out of 100 cases seen by him, though few observers agree with him in his extreme view as to the rarity of this 894 DISEASES OF THE DIGESTIVE SYSTEM. symptom. The reason given for its lack of intensity is that in the great majority of cases the growth is situated in the right lobe of the liver, and neither compresses the bile-ducts nor destroys the secretory cells of the liver. (b) Pain is usually present to a marked degree, though it also mav be entirely wanting. It is dull and boring in character, and localized generally in the right hypochondriac region. In some instances (as in the case of impacted biliary calculi) it may radiate to the right shoulder and the scapular region. It usually appears as the hepatic enlargement progresses, although cases of enormous-sized cancerous tumors of the liver have been known to occur Avithout pain. The character and loca- tion of the pain are of diagnostic importance, and will be spoken of under the differential diagnosis. (c) Ascites.—When the cancerous growth compresses the portal ves- sels, and also in cases of cirrhosis Avith carcinoma, obstruction to the portal circulation occurs, and results in the development of ascites. This may cause distention of the abdominal cavity to such an extent as to occlude the physical signs of hepatic enlargement. The cancerous growth may invade the peritoneum and cause an effusion. This symp- tom, hoAvever, is not frequent, at least tAvo-thirds of all cases terminating without the appearance of ascites. (d) Fever is usually absent until the later stages of the disease. It may then appear and rise to hyperpyrexia (105° F.—40.5° C), but it is usually moderate in degree, irregular, and intermittent in type. (e) Cachexia.—In every case of carcinoma, at some stage of the dis- ease, cachexia develops; when pronounced, it is almost pathognomonic. (/) Cerebral Symptoms.—These may be absent throughout. In the advanced stages, hoAvever, the deleterious products in the blood, due to the perverted functions of the liver and the toxemic condition of the patient, often produce such striking symptoms as violent headache, mental hebetube, or delirium (less frequently) Avhich may be maniacal in character. These symptoms resemble those of cholemia (vide Hepatic Cirrhosis, p. 885). The patient may die in sudden coma. Physical Signs.—Inspection often reveals enlargement of the super- ficial veins over the abdomen, and a prominence in the upper epigastric and hepatic regions, varying with the degree of enlargement, may also be seen. In the nodular form and late in the disease, when emaciation has become extreme, elevations that are movable with respiration can be noticed beneath the skin. On palpation the organ can be distinctly felt projecting beloAv the costal margin and extending in some instances to a point beloAv the level of the umbilicus. During deep inspiration the liver can be felt to move doAvnAvard, and during expiration upward, the organ being under the influence of the diaphragmatic excursions. In emaciated subjects the cancer-nodules are readily appreciable, and in some instances the central pits or depressions are palpable, forming a pathognomonic sign. Cancerous infiltration of the anterior margin is most easily felt, and in any enormous enlargement of the organ I have frequently detected them on the posterior surface as well. Rarely the liver is found to be uniformly large. Palpation may also show splenic enlargement, due to passive congestion. CARCINOMA OF THE LIVER. 895 Percussion shoAvs flatness, extending in many cases in both an up- ward and a downward direction. In primary carcinoma (usually found in the right lobe) the area of hepatic dulness is increased irregularly doAvnAvard and generally to the right. On the other hand, in second- ary groAvths (usually massive) the nodules are oftener distributed equally throughout the liver. In such cases the area of dulness may extend across the epigastrium to the left hypochondriac region, the heart and other viscera being now displaced. Posteriorly, dulness may extend upAvard on a level Avith the fourth rib, and anteriorly doAvmvard to the iliac fossa. The organ may noAv Aveigh from 15 to 20 lbs. (6.5-9 kgms.), while the weight of cancerous livers in ordinary cases varies between 3 and 6 lbs. (1.3-2.6 kgms.). Diagnosis.—In forming a positive diagnosis the family tendency, the history of primary carcinoma elsewhere in the body, the age of the patient, the localization of the pain in the right hypochondrium, the cachexia, and the progressive enlargement of the liver, with the charac- teristic umbilicated nodules, are the most reliable points. The appear- ance of jaundice or ascites, or both, is confirmatory. Differential Diagnosis.—Among affections of other organs that are likely to be mistaken for carcinoma of the liver may be mentioned— (1) carcinoma of the pylorus ; and (2) carcinoma of the colon and omen- tum. The chief diseases of the liver itself apt to be diagnosed as car- cinoma are—(a) abscess, (b) syphilis, (c) benign growths (adenomata, angiomata), (d) hydatid cysts, and (e) hypertrophic cirrhosis. (1) Carcinoma of the Pylorus.—In carcinoma of the pylorus the phys- ical examination frequently shows a hard nodular tumor that is most plainly outlined in the epigastric region. In a typical case, on deep inspi- ration, the tumor is pressed dowmvard by the liver, but is not pulled up- Avard by forced expiration, as in hepatic carcinoma. In many instances, hoAvever, adhesions bind the stomach firmly to the under surface of the liver, which may be the seat of secondary involvement. The absence of early nausea and vomiting and the presence of jaundice, as Avell as the negative results from an examination of the gastric contents, would tend to eliminate pyloric carcinoma. (2) Carcinoma of the Colon and Omentum.—Secondary carcinoma of the intestine affects most frequently the sigmoid flexure. The symptoms of intestinal obstruction arise, constipation being followed by attacks of serous diarrhea due to irritation, and later by the presence of blood in the stools. In carcinoma of the liver, on the other hand, the bile-ducts may be obstructed, causing clay-colored stools, but otherwise the dejecta are normal; the seat of the nodular enlargement and pain is located in the right hypochondrium. Jaundice and ascites are absent in carcinoma of the colon. The tumor, if palpable, in the latter condition is more movable and is less under the influence of the diaphragm. It does not give an absolutely flat percussion-note, as does hepatic carcinoma. Car- cinoma of the omentum is usually secondary. The absence of small mov- able tumors in the umbilical, lumbar, or hypogastric regions, ranging in size from that of a pea to a walnut, aids in the elimination of carcinoma of the omentum. As the latter affection advances the abdomen be- comes distended and painful to the touch, the bowels are obstinately constipated, and the physical signs reveal the presence of an effusion 896 DISEASES OF THE DIGESTIVE SYSTEM. Avhich, Avhen aspirated, is generally serous, but sometimes bloody. Mi- croscopic examination may possibly reveal the presence of cancer-cells, though their recognition is difficult. The liver, unless primarily in- volved, is not enlarged, and cachexia does not usually appear until late in the course of the disease. From hepatic abscess the points of differentiation are— Carcinoma of the Liver. Hepatic Abscess. Is often hereditary. There is a history There is a history of traumatism or of in- of a primary growth. testinal ulceration, as in dysentery. Occurs usually after the age of forty. Occurs at any age. Jaundice is rare. Jaundice is sometimes present. Fever is absent or slight. Hectic temperature, chills, and sweating. Cachexia is present and almost pathog- Anemia may be present, but never ca- nomonic. chexia. Pain is dull and boring in character, and Pain is sharp, lancinating, and paroxys- more constant. mal. A nodular, umbilicated tumor or tumors A fluctuating tumor may sometimes be may be detected. detected below the costal margin. The enlargement is dowmvard. The enlargement usually upward. The duration is a few months to one year. The duration is usually a few weeks. Microscopic examination reveals disinte- The microscope reveals pus, liver-cells, grated liver-cells, cancer-nests, and in staphylococci and streptococci, and in some cases the micro-organisms of sup- some cases the ameba coli. puration. Benign Growths (Adenomata, Angiomata).—Occasionally growths are detected in the liver, and may occur at any age; Avhen these are present at or about the age of forty, they may be mistaken for carci- noma. The absence, hoAvever, of a primary growth in some one of the other viscera, together with the duration of the groAvth and the absence of cancerous cachexia, would tend to differentiate them from cancerous involvement. An examination of the blood may be of service, leuko- cytes being more common in carcinoma. The diagnosis between hepatic carcinoma and hypertrophic cirrho- sis, hydatid cyst of the liver and syphilis, has been spoken of in the dis- cussion of the latter diseases. The prognosis is invariably fatal, the disease terminating rapidly in from a few months to a year. The most rapid course is run by sec- ondary carcinoma of the organ. Treatment.—The treatment is purely symptomatic. An easily digested, nutritious diet should be given, together with active stimulation to support the system. The pain may be relieved by the free use of morphin, given by the mouth, rectum, or hypodermically. For the nausea and vomiting that are apt to supervene the carbonated waters, cracked ice with champagne, or repeated doses of creasote (beechwood), dilute hydrocyanic acid, or wine of ipecac (2 minims—0.133—every hour until relieved) may be given. If violent delirium should occur during the later stages of the disease, cold compresses to the forehead or vertex, and bromids and chloral hydrate given in rectal enemata, may prove efficient. OTHER NEW GROWTHS IN THE LIVER. (a) Angioma, Adenoma, and Cyst. Occasionally, benign growths occur in the liver, and often with an DISEASES OF THE SPLEEN. 897 absence of symptoms unless their increase in size gives rise to mechan- ical obstruction. One of the most common of these is angioma, which is often found in the livefs of old people. Angiomata consist of tortu- ous and dilated capillaries in the hepatic connective tissue; they rarely attain to a size larger than a crab-apple, and usually cause no symp- toms. Although most common in adults, they have been known to occur in children. Adenomata and cystomata may also occur in the liver. They are both benign growths. The former is of the tubular variety, consisting of connective-tissue nests lined Avith cylindric epithelial cells. Yon Berg- man removed a portion of a tuberous adenoma of the liver with perfect recovery and non-recurrence of the groAvth. (b) Sarcoma. Of the many varieties of sarcomata, those occurring most commonly in the liver are the small and large round-celled and the melanotic vari- ety, the latter often being secondary to sarcoma of the choroid coat of the eye. These grow rapidly, causing a widespread destruction of the liver-structure, Avith a change in the size and shape of the organ that is often demonstrable by palpation. E. R. Axtell reports a case in which at the postmortem the upper two-thirds of the liver revealed an entire absence of hepatic structure, and consisted of three tumor-masses which, on microscopic examination, were found to be small round-celled sar- comata. On section the tumor is seen to be of firmer consistence than the surrounding liver-tissue, and presents a dark, grayish-white, striated appearance. If the groAvth be of the pigmented variety, patches of a deep black or of different shades of pigment may be scattered through- out the mass. Metastasis is rapid and widespread, as is shown by the fact that other organs are invariably found involved at the time of the groAvth and development of the sarcoma in the liver. Codd of Birming- ham describes a case of melano-sarcoma of the liver in which growths were also found in the heart, pancreas, right kidney, and right lung, and Holsti reports a similar case in Avhich the omentum, peritoneum, and myocardium were involved. The symptoms are those of mechanical obstruction, and consist of gastro-intestinal disturbances due to passive congestion, edema, and ascites. Anemia and emaciation may become marked late in the disease, but cachexia does not develop. The diagnosis can often be made from the primary growth (melano- sarcoma of the skin or sarcomata of the lymphatic glands) and from the rapid development of the tumor. The prognosis is, of course, absolutely fatal, and the treatment merely palliative. X. DISEASES OF THE SPLEEN. Diseases of the spleen are mostly secondary to other diseases, the consideration of Avhich embraces an appropriate description of the as- sociated splenic disorders. The intimate relation between the spleen 57 898 DISEASES OF THE DIGESTIVE SYSTEM. and blood accounts for the frequency with Avhich this organ is involved in many of the blood-diseases. DISLOCATION OF THE SPLEEN. {Floating Spleen.) Ktiology.—This may be due to the increased Aveight of an enlarged spleen, to tight-lacing, relaxation of the ligaments, and traumatism; sometimes the cause is unknown. Symptoms.—The symptoms are vague and are the result of pressure by the wandering and mobile spleen. By physical examination Ave dis- cover with the touch the spleen as a mobile tumor pendant from the left hypochondrium; the tumor is superficial, blunt-edged, and notched on its anterior border, and may be replaced by the hand nearly in its nor- mal position. On percussion over the splenic area the normal dulness is found to be absent. In the diagnosis it is important to distinguish betAveen floating spleen and simple enlargement, as Avell as betAveen the former and mov- able kidney. The prognosis is guarded as to cure, though favorable as to life. The treatment must be mechanically supportive, consisting of pads and bands. Splenectomy for dislocated spleen has been successful in a majority of the cases in Avhich it has been performed. SPLENIC HYPEREMIA. Acute or active hyperemia may be found as the result of the acute infectious diseases, giving rise to the acute splenic tumor, or as the result of amenorrhea, or of injuries and inflammation (circumscribed hyper- emia). The organ is uniformly enlarged (except in the last-named cases), and is darker in color and softer in consistence ; the capsule also is tense. This condition merges insensibly into acute splenitis. Chronic or passive hyperemia is due to some mechanical obstruction of the portal circulation caused by tumors, cardiac, hepatic, and pulmo- nary disease, and pylephlebitis. The spleen is enlarged, firm, dark-red in color, and the capsule is somewhat thickened. The symptoms are vague, and may consist of simply a sense of Aveight, fulness, and pressure, and some tenderness in the left hypochondrium. In cases of extravasation of blood and rupture of the spleen the symp- toms of intestinal perforation, hemorrhage, and collapse may supervene. On physical examination the edge of the spleen may be palpated be- low the margin of the ribs. The percussion-dulness is increased in area, especially doAvnward and forAvard, and may encroach upon the slightly-curved umbilico-axillary "resonant line." The detection of acute or chronic splenic hyperemia, as manifested in enlargement of the organ, is often of invaluable aid in the diagnosis of the causative disease. The prognosis and treatment are embraced in those of the disease causing the congestion. SPLENITIS. 899 SPLENITIS. Definition.—This term comprises acute and chronic (hypertrophic) proliferative splenitis and suppurative inflammation. Pathology.—Next to the kidneys, the spleen is the favorite seat of metastatic inflammation and embolic infarction. Splenitis, due to a benign embolus originating in the left side of the heart or from the aorta above the splenic arteries, is usually circumscribed to a zone of scro-hemorrhagic infiltration about the resultant infarct. The latter is hemorrhagic at first, and later becomes particolored or mixed, and is of a yelloAv color, OAving to partial fatty degeneration; still later it may become whitish and remain as a wedge-shaped (the base being periph- eral), cheesy (necrotic softening), or even calcareous mass or as a fibrous cicatrix. Infection of the infarcts by pus-micrococci leads to the devel- opment of small abscesses, and the trabeculse surrounding the latter may give Avay until several abscesses or one large pus-sac may be formed. Perisplenitis generally follows, and sometimes Avith adhesions attached to adjacent hollow organs, as the stomach and colon, through which the perforating abscess may discharge its purulent contents. An unfor- tunate termination is the bursting of the abscess into the peritoneal cavity; a more fortunate ending results in an external opening. In acute splenic tumor there is an active congestion, with round-cell infil- tration and some proliferation of the splenic cells. The spleen is mod- erately enlarged, dark, soft, pulpy, and friable. In cases of intense vascular engorgement, as in the acute splenic tumor of severe typhoid fever, intermittent fever, and epilepsy (during the paroxysm), hemorrhagic extravasation may occur, and there may finally be even a rupture of the capsule and a passage of the blood into the peritoneal cavity. In chronic splenic tumor there is a persistent hyperplasia of the splenic cells, and frequently also of the trabecular cells, minus the acute engorgement. Cirrhosis of the spleen (chronic interstitial splenitis) differs characteristically from that of other organs (as the liver and kidneys) in that there is enlargement instead of con- traction. Added to the increase in the size of the spleen, there are in both forms of chronic splenitis thickening of the capsule, patches often of old perisplenitis, and a slaty color of the tissues, Avith more or less pigmentation. Etiology.—The disease probably never starts primarily in the spleen itself. Aeute proliferative or hyperplastic splenitis (acute splenic tumor) is seen as the result of the acute infectious diseases (typhoid, typhus, relapsing, and malarial fevers). Chronic proliferative splenitis occurs as the so-called chronic splenic tumor in connection Avith chronic malarial infection, splenic anemia, chronic passive congestion of the spleen, and leukocythemia. The leukemic spleen represents a some- what different form of chronic proliferative splenitis from the ordinary forms. Acute suppurative splenitis, or abscess, is usually secondary to infectious (pyogenic) emboli, as in ulcerative endocarditis and pyemia. Again, as the result of simple valvulitis or aortic thrombosis, not infre- quently embolic infarction of the spleen may be found, Avhich may soften and break down in abscess-formation from subsequent infection. Abscess 900 DISEASES OF THE DIGESTIVE SYSTEM. of the spleen may also folloAv traumatism or the perforation of a gastric ulcer and the extension of adjacent suppurative processes. Symptoms.—These are indefinite or absent in most cases. Usually there is no pain or tenderness unless perisplenitis exists. Considerable enlargement of the spleen may be attended with a sense of Aveight, ten- sion, or distress in the left hypochondrium, and perhaps by slight dys- pnea. Any suppurative fever present will most probably be disassociated from the idea of abscess of the spleen, provided the local signs of pus be absent. Sudden pain appearing in the gastric region, followed by the vomiting of pus and blood, in the course of an infectious disease, Avith splenic enlargement, may be due to the rupture of an abscess of the spleen. Ascites may also be present. The physical examination may reveal some bulging on inspection, and a fluctuating tumor may be palpated. The enlargement may be sufficient to enable the examiner to feel the notch in the spleen, and also the anterior and lower borders, reaching even to the umbilicus and to a level with the pelvic brim. The percussion-dulness is correspond- ingly increased.. Diagnosis.—This may be made from a consideration of the physi- cal signs in conjunction with a study of the primary disease. In cases in which pus is suspected an exploratory puncture may clear the diag- nosis. The splenic inflammation is rather an aid to diagnosis than a condition essentially needful of recognition in itself, by reason of its almost invariably secondary nature. Acute suppurative splenitis might be mistaken for gastric or pancre- atic disease, but the previous history in the former, as contrasted Avith that of the latter affection, conjoined with the local symptoms that are more or less characteristic of the organ involved, will generally furnish an accurate means of differentiation. The huge enlargements of chronic splenitis may be confounded with hepatic, renal, omental, or ovarian growths. Here a careful, discrimina- ting observation of the constitutional state and of the physical signs is requisite for a diagnosis; even then it is often puzzling and difficult to attain. Care must be taken that splenic enlargement be not assumed when a large pleural effusion on the left side is causing the depressed lower border of the organ to be felt. Finally, fecal accumulation in the splenic flexure of the colon may be mistaken for moderate enlarge- ment of the spleen. The former gives an irregular, doughy tumor, tympanites, vomiting, and a history of constipation alternating some- times with diarrhea; there is no increase in the splenic area of dulness. Prognosis.—This will depend upon the primary systemic condition in most cases. Abscess of the spleen is always a very grave complica- tion, the main danger consisting of rupture and fatal peritonitis. Even in acute splenic tumor of a violent type there may be a hemorrhagic ex- travasation so severe as to burst the capsule. Chronic splenitides are not in themselves grave disorders. Treatment.—This is to be directed mainly at the causative condi- tion. Quinin and arsenic are often useful in the malarial form, and the chalybeates, iodids, and ergot have been recommended for the various chronic splenic enlargements. Abscess must be treated by splenotomy and drainage. Splenectomy may be useful in certain cases of simple RUPTURE OF THE SPLEEN. 901 hypertrophy, but records shoAv only about 20 per cent, of recoveries from the operation. The state of the patient must be Avell considered. Splenectomy is probably never justifiable in leukemic enlargement. AMYLOID DEGENERATION OF THE SPLEEN. {Sago Spleen.) This occurs as a part of the cachectic condition attending amyloid or Avaxy degeneration of other organs (liver and kidneys). The con- dition develops in the course of cases of prolonged and Avasting dis- charges (phthisis, empyema, suppurative ostitis, syphilis, chronic peri- tonitis, chronic entero-colitis). The spleen is, as a rule, greatly enlarged, putty-like, and rotund. The capsule is tense and glistening. There are two forms of Avaxy degeneration—namely, the so-called "sago" spleen and the diffuse waxy or lardaceous spleen. In the former the Mal- pighian bodies are chiefly affected and appear on section like sago- granules ; in the latter the whole splenic pulp, and even the trabeculse, are more or less degenerated, and on section the spleen appears pale, smooth, and homogeneous. This may be but a late stage of the "sago" spleen. The symptoms are those of general cachexia, and the diagnosis rests upon the detection of an enlargement of the organ associated with evi- dences of amyloid disease in other organs. The prognosis is unfavorable, and the treatment does not differ from that indicated for the underlying and causative disease. MORBID GROWTHS OF THE SPLEEN. The principal morbid growths of the spleen are the granulomata, as tubercles and syphilitic gummata; also secondary carcinoma, sarcoma, and hydatid and other cysts. These affections of the spleen are all of rare occurrence, and are not readily, if at all, discoverable during life. They are of no clinical or therapeutic interest apart from the general or primary disease. It may be stated that carcinoma of the spleen is always secondary ; it may be diagnosticated by a physical examination, shoAving the organ to be en- larged, with the unmistakable signs of the primary carcinoma, as of the stomach. Secondary sarcoma is more common, and is recognized by an irregular enlargement and the presence of a primary tumor. Syphilitic gummata of the spleen are often associated with amyloid degeneration and enlargement. RUPTURE OF THE SPLEEN. This may occur as the result of an intense hyperemic engorgement, both in splenitis from the rupture of an abscess and from traumatism. In the acute splenic tumor of typhoid fever, in malaria, and during an epileptic paroxysm, rupture of the capsule has been known to occur on 902 DISEASES OF THE DIGESTIVE SYSTEM. account of the extravasation of blood. The symptoms are usually mis- taken for those of intestinal perforation with internal hemorrhage. The treatment is palliative. XI. DISEASES OF THE PANCREAS. ACUTE PANCREATITIS. Investigations of late years have rendered it probable that this disease is not so rare an occurrence as Avas formerly presumed, when it was not so readily recognized, owing partly to insufficient clinical and pathologic data, and partly to an indifference as to its existence. HEMORRHAGIC PANCREATITIS. Pathology.—The pancreas is enlarged, usually firm, and someAvhat chocolate-colored. Irregular areas show the circumscribed as well as the diffused form of hemorrhagic infiltration of the interstitial fat-tissue, with thrombosis of the pancreatic veins in some cases (Day). There is also a cellular or fibrino-cellular exudation between the lobules of the glands. The adjacent tissues may also be found to be hemorrhagic, as the mesentery, mesocolon, omentum, and perinephric tissues. The gall- bladder may contain biliary concretions. The gastro-intestinal mucosa may be hyperemic, ecchymotic, or in a slightly catarrhal state. Evi- dences of a localized peritonitis (peripancreatitis) are not frequent, though they should be looked for. Disseminated fat-necrosis is quite commonly associated Avith hem- orrhagic pancreatitis. Small areas of a peculiar substance, ranging from the size of a miliary tubercle to that of a pea or even larger, are found scattered in the fatty interlobular pancreatic tissue, in the omen- tum, mesentery, and sometimes in the abdominal panniculus or fat. They are opaque-Avhite, and slightly firmer (tallow-like) than the sur- rounding fatty tissue. They contain fatty acids in combination with lime or lime-salts. Bacteria are sometimes found in and near the patches of necrosis, but the precise relation that this more or less inflammatory degeneration bears to pancreatic disease has yet to be determined. Mention should be made here of the fact that as the result of the in- fectious fevers Ave find the pancreas shoAving diffuse, parenchymatous, and granular degenerative changes. Chiari has also recently pointed out the fact that postmortem digestion is very frequent in the pancreas. Etiology.—Most of the cases reported have occurred in men, and in persons past fifty years of age. An especial predisposition to the disease seems to be the result of cases of severe and obstinate dyspepsia (gastro-duodenal), alcoholism, gall-stones (Fitz), and traumatism. Hem- orrhage into the pancreas of either traumatic or unknown origin may lead to subsequent pancreatic inflammation. A prolonged course of mercury has seemed to have a causal influence; the condition has also followed glycosuria. It is seen occasionally postmortem in cases of acute tuberculosis, of the specific fevers, and of septico-pyemia. Symptoms.—The onset is sudden and violent. It is character- HEMORRHAGIC PANCREATITIS. 903 ized by excruciating, deep-seated pain, usually in the epigastrium or between the xiphoid and umbilicus. There are also nausea and severe retching and vomiting, constipation, and speedy collapse, ending fatally within a fe\v days (second to the fourth—Fitz). Fever is generally slight, though it may be absent. Dyspnea and a rapid, feeble pulse, with jactitation and marked anxiousness or an afebrile delirium, may perhaps be present. In some cases there may be diarrhea, Avith thin and watery stools containing free fat. Instances may be repeated in which, owing to the coincident presence of gall-stones, there may be jaundice and colicky pains over the right hypochondrium. The jaun- dice, however, may sometimes be due to a considerable swelling of the head of the pancreas, Avhich presses upon the common bile-duct. Tym- panites occurs in a majority of the cases. Hiccough and albuminuria have also been noted. The pain in this disease, as well as the profound collapse, may be due either to a circumscribed peritonitis or to pressure upon the solar plexus. Diagnosis.—This is at all times difficult, since many or all of the symptoms enumerated may be present in other affections. A careful inquiry into the previous history is important. The sudden develop- ment of an intense, deep-seated pain in the epigastrium, folioAved by vomiting, collapse, abdominal distention, with circumscribed resistance in the epigastrium, and the presence of constipation and slight fever, should point strongly to hemorrhagic pancreatitis. The detection of free fat in the dejections, and the discovery of scattered points of tenderness, Avhen they occur, are also of corroborative significance. Differential Diagnosis.—The temperature is apt to be higher and the pain and tenderness less localized and more constant in peritonitis. Fecal vomiting would indicate obstruction of the bowel. Here also we may determine the patency ot the bowTel by injection or inflation. Intestinal obstruction is of comparatively rare occurrence in the epigastrium, where the pain and distention of acute pancreatitis are localized; there are likely to be present more marked and general tympany and a circum- scribed distention of the intestinal coils. In perforating gastric or duodenal ulcer there is a history of pain after eating, hemorrhages from the digestive tract, and of anemia or chlorosis occurring more commonly in the young female. Corrosive poisons may be excluded by the history of the case and by an examination of the mouth and vomitus. Hepatic colic may also be excluded; the pain in this condition is intermittent, and referred more to the right side than in pancreatitis. There are also an early collapse and an absence of jaundice in the pancreatitis, as a rule. Acute gastro-duodenitis is characterized by fever, by a history of injudicious eating, followed by mild inflammatory symptoms within a few hours, and by an absence of the sudden prostration and collapse so com- mon to hemorrhagic inflammation of the pancreas. Prognosis.—Acute hemorrhagic pancreatitis in most cases ends in death. It is but fair to state, however, that in view of the ease with which the disease may be overlooked it is quite possible that certain cases of a less severe type may often recover; in these the recovery has been said to follow an entirely different affection. Osier reports a case diag- nosticated as one of intestinal obstruction in which abdominal section was 904 DISEASES OF THE DIGESTIVE SYSTEM. performed. There was no obstruction found, but disease of the pancreas and fat-necrosis were definitely noted, and recovery followed the section. Treatment.—This must needs be merely palliative and symptomatic. The treatment as for shock by the use of external heat and of warm saline solutions (by injection), hypodermics of morphin, atropin, strych- nin, and of diffusible stimulants may probably be of some avail. SUPPURATIVE PANCREATITIS. Pathology.—The suppuration may be diffuse, with numerous small abscesses, or a single abscess may exist in the head or body of the pan- creas, which may be considerably enlarged and the glandular structure extensively destroyed. The abscess may communicate with peripancreatic areas of suppuration, or it may evacuate either into various organs (stom- ach, duodenum, peritoneal cavity) or externally. Pylephlebitis and hepatic abscess or pyemia may follow. A disseminated fat-necrosis is not found so frequently as in hemorrhagic pancreatitis. Etiology.—Most of the cases collected have occurred in adult males prior to fifty years of age. Intemperance, debauchery, gluttony, and various dietetic errors enter into the previous history of suppurative inflammation of the gland. Symptoms.—These may be acute, subacute, or chronic. Acute cases occur less frequently than the latter, there being a marked tendency of the disease to chronicity. Acute suppurative pancreatitis usually begins suddenly, with severe epigastric pain, vomiting, hiccough, chills, and an irregular pyemic temperature,✓progressive tympanites (at times limited to the left half of the abdomen), and perhaps acute splenic enlargement. Constipation may be folloAved later by diarrhea, and slight jaundice may appear. Prostration is generally great, and death may set in within one week from the onset. Not seldom, however, the course is prolonged to three or four weeks, the symptoms persisting Avith progressive emaciation and final exhaustion. Rupture of the circumscribed peritoneal abscess, evidenced by copious dejections in which the sloughing pancreas has been found, and rapid diminution in the size of the abdomen, may take place. Again, the onset may be less severe, and yet the case progresses steadily downward with little pain, slight suppurative fever, anorexia, anemia, and gradually increasing debility, lasting for months or even a year, and ending in anasarca and death. A pancreatic swelling is rarely palpable. Diagnosis.—A limitation of the pain and tympany to the epigas- trium, irregular fever, and the constitutional indications of suppuration are probably all that can be relied upon in arriving at a diagnosis. In fact, the diagnosis is hardly made antemortem. The differentiation from circumscribed peritonitis, perforative gastric or duodenal ulcer, and acute obstruction of the bowel is the same as in the case of hemorrhagic pancreatitis (vide ante). The prognosis is fatal and the treatment palliative. GANGRENOUS PANCREATITIS. Pathology.—The pancreas may be found in various stages of necro- sis, depending upon the duration of the disease. It may be a dark-brown, CHRONIC PANCREATITIS. 905 flabby, soft, friable, shreddy, and putrid mass, with areas of hemorrhagic infiltration and yellow softening, and surrounded by a dirty-greenish, thin, purulent, and ichorous fluid. In cases lasting for from three to seven weeks the gland may be found completely sequestrated, lying in the omental cavity as a small, thin, brownish-black, shreddy, and foul-smell- incr detritus, soaked in a dark-colored, ichorous, and purulent fluid. The peri- and para-pancreatic tissues are usually involved with acute peritonitis. Splenic thrombo-phlebitis is commonly associated, and, as in the hemor- rhagic, so in the gangrenous pancreatitis, disseminated fat-necrosis is fre- quently seen. The sloughed pancreas may be discharged into the intestine. Btiology.—Males and females seem to be equally liable to this variety of pancreatitis, and persons past thirty years of age are most commonly affected. Hemorrhagic pancreatitis is the most frequent ante- cedent of the gangrenous form. The disease may result also from perfor- ative inflammation of the gastro-intestinal or biliary tract, or from the simple extension of a catarrhal inflammation of those tracts into the pancreatic duct (Fitz). Symptoms.—These are essentially the same as those of hemorrhagic pancreatitis. The course may last longer, however, so that death may not occur until the second or fourth week, preceded by symptoms of collapse. CHRONIC PANCREATITIS. Pathology.—The pancreas is indurated from an increased develop- ment of interstitial fibrous tissue. The secreting glandular substance may be nearly obliterated, or at least considerably changed, and, owing to occluding pressure upon the duct of Wirsung, small pancreatic cysts may be formed. Interstitial hemorrhages and peripancreatic adhesions may be present. In chronic suppurative pancreatitis there may either be several small circumscribed abscesses or one large pyogenic cyst. The pus is often found to have undergone cheesy changes or calcareous infil- tration. Btiology.—Chronic pancreatitis may be due either to one or to sev- eral attacks of the acute disease. Chronic inflammation of the pancreatic duct—often secondary to gastro-duodenal catarrh—is the most frequent cause. Persistent inflammations of contiguous structures, frequent irri- tation from biliary calculi, and the causes of cirrhotic changes in other organs (chronic alcoholism, syphilis) probably also lead to this disease. The condition may be limited to a part of the organ. Symptoms and Diagnosis.—The symptoms are hardly indicative of the disease. For a long time the symptoms of chronic gastric catarrh, frequently attended by diarrhea, may compose the clinical picture. Later there may be paroxysms of deep epigastric pain, and slight fever, with great anxiety and faintness, occurring at irregular intervals. Some ascites and occasional jaundice, due to pressure, may be observed. The detection of free fat in the dejections (without jaundice), and the occur- rence of glycosuria and lipuria, would be of distinct diagnostic value. 906 DISEASES OF THE DIGESTIVE SYSTEM. The presence of glycosuria in this variety of pancreatitis probably indi- cates an extreme degree of destruction of this gland (Fitz). A cachectic, emaciated appearance may be associated. Circumscribed resistance on palpation in the pancreatic area has been noted. Evidences of hepatic cirrhosis or of chronic renal and arterial disease may be present, and are likely to overshadow the pancreatic lesions. The prognosis is grave. It is to be recollected, however, that the greater portion of the gland may become functionless, as the result of progressive fibrous change, without much impairment of the general health or the production of permanent (fatal) glycosuria. Treatment.—The major treatment is dietetic. Fats and starches, since they demand the pancreatic ferment for their conversion, are to be interdicted, or, if permitted, are to be, so far as may be, artificially di- gested by the administration of tablets of pancreatin and soda (gr. at-x— 0.324-0.648) fifteen or twenty minutes after meals. Malt diastase, com- bined with alkalies, should also be tried. Becher has found that car- bonated waters stimulate pancreatic secretion in dogs, and hence their use may be advised. According to the result of Abelmann's experiments, minced pancreas promotes the digestion of fats. PANCREATIC HEMORRHAGE. {Pancreatic Apoplexy.) It is only in recent years that this fatal affection has been clearly iso- lated and defined, and mainly through the observations of Zenker, Draper, and especially Fitz. Profuse hemorrhages within and around the pancreas are seen postmortem. Pathology.—The pancreas may or may not be enlarged; it may also be soft and friable. The hemorrhage is apt to occur into circumscribed areas of the gland, the interstitial and subperitoneal tissues both usually being the seat of hemorrhagic infiltration of a dark-purple color. Con- siderable blood may be found in the omentum, transverse mesocolon, in the retroperitoneal fat-tissue, and surrounding the kidney even. Fatty infiltration and degeneration of portions of the pancreas may occasionally coexist. Miliary aneurysms have not been found, but hemorrhages into the adjacent mucous surfaces have been detected in some cases. Etiology.—Slight hemorrhages into the pancreas may be found that are secondary to excessive chronic passive congestion or to hemophilic or purpuric cases, and they may be met with in acute infective diseases. These have, hoAvever, no clinical import. The precise cause or causes of marked hemorrhage into the pancreas are not known. Most cases have occurred in adults past forty years of age in whom the previous health was unusually good. Traumatism, or some obscure local vascular weak- ness, superinduced by alcoholic habits or a rich diet in an atheromatous person; or, possibly, some corrosive action of the panceratic secretion in certain destitute states, may operate as causes. Symptoms.—The patient may have been in apparently robust health when the attack comes on with sudden and startling gravity. The most prominent early symptom is intense pain, located in the epigastric region CARCINOMA OF THE PANCREAS. 907 or in the lower chest, together with a sense of constriction. Nausea and vomiting may be associated, and the latter is usually obstinate and gives only temporary relief. Tympanites may also occur. There are early and constant general evidences of internal bleeding—an anxious countenance, restlessness, depression, yawning, pallor, cold sweat, a loAvered surface- temperature, and a small, rapid, and weak pulse. Prostration and syn- cope follow, and death ends the case in from half an hour to twenty-four hours. According to Zenker, death is caused by reflex paralysis of the heart, due either to some coincident vascular affection, or to pressure, perhaps upon the solar plexus and semilunar ganglion (pancreatic apo- plexy). The diagnosis is rarely made; but given the suddenly-developed signs of a concealed internal hemorrhage, with pain referred distinctly to the epigastrium, and vomiting and rapid collapse, a probable diagnosis may be made. Treatment.—This consists in relieving the pain by opiates and in overcoming the collapsed condition by free stimulation. CARCINOMA OF THE PANCREAS. Pathology.—Primary carcinoma is the more frequent variety. It is of the scirrhous form in most cases, and usually involves the head of the gland, which may attain to the size of a child's head. Not rarely the adjacent organs are found affected, either by direct or metastatic exten- sion of the disease or by the pressure of the growth; the liver, perito- neum, stomach, portal vessels, bile-ducts, ureters, and aorta may thus be involved. The pancreatic duct may be occluded, so as to form retention- cysts. Adjacent organs are often adherent to the cancerous pancreas. Etiology.—Men past forty years of age are most liable to carci- noma of the pancreas, though it has been met with even in the new-born. Mirallie* has collected 113 cases of primary carcinoma of this viscus (Fitz). Symptoms.—These are scarcely ever sufficient to indicate the dis- ease with any certainty. There are usually a stubborn dyspepsia, a progressive loss of flesh and strength, anemia, and a dull, or sometimes neuralgic, epigastric pain. Nocturnal paroxysms of pain are common, and are often accompanied by signs of collapse. In some cases vomiting and diarrhea are present. The stools may be light in color, greasy, and may contain blood. There may also be found an abundance of undigested muscular fibers in the stools in the absence of diarrhea; this is an incon- testable proof of faulty pancreatic digestion. Among the pressure-effects due to carcinomatous enlargement of the head of the pancreas there may, not rarely, be jaundice (due to pressure upon the common duct), which persists and " is associated with an enlargement of the liver and gall- bladder." Ascites may appear from pressure on the portal vein. Chyl-, ous ascites, from pressure upon the thoracic duct, has been observed in 2 cases. The inferior vena cava may be compressed, causing dropsy of the lower half of the body ; also the duodenum, followed by gastrectasis or by signs of intestinal obstruction. Fitz points out that carcinoma of the tail 908 DISEASES OF THE DIGESTIVE SYSTEM. of the pancreas may be a cause of hydronephrosis of the left kidney from pressure upon the ureter. Marasmus and the cachexia groAv from bad to worse, and emaciation may become so extreme as to permit of a satisfac- tory palpation of the tumor, which occupies a position near the median line above the umbilicus. Very often, however, the growth is too deep- seated to be felt, being palpable in about one-third of the cases only. Glycosuria may be associated. Diagnosis.—Carcinoma of the pancreas is probably present in a given case in which there are rapid and progressive emaciation, deep- seated epigastric pain, muscular fibers in the stools, without diarrhea, but with late jaundice and enlargement of the gall-bladder, and the detection of a deeply-situated, fixed, and firm tumor in the region of the gland. The quantity of indican in the urine is diminished. Aortic abdominal aneurysm may be mistaken for carcinoma of the pancreas because of the transmission of the aortic pulsation to the tumor. But in aneurysm the impulse is expansile instead of to and fro, and the contact is neither so sharp nor so sudden; moreover, the cancerous cachexia is absent in aneurysm, and the history of the case may be clearly indicative. It is sometimes difficult to differentiate a malignant tumor of the pan- creas from carcinoma of the pylorus, of the stomach, or of the transverse colon or omentum; the following points will help in the differentiation of the former two : Carcinoma of the Pancreas. Carcinoma of the Pylorus. The tumor is deep-seated and fixed : later The tumor is more freely movable, and it becomes slightly movable. It is not is usually associated with dilatation of associated with gastric dilatation. the stomach. Symptoms of chronic dyspepsia manifest There are more marked gastric symptoms. themselves. The vomitus is bilious ; does not contain " There is coffee-ground" vomitus. It is blood ; often is that of gastrectasis. seldom bilious. HCl is present, while there is an absence HCl is absent from the gastric contents; of lactic acid. lactic acid is present. The stools contain undigested muscle- Usually the bowels are constipated, with fibers. There is an absence of pan- occasional diarrhea. The stools are creatic secretions. The urine may con- black after a hemorrhage. The urine tain sugar. does not contain sugar. There is usually jaundice ; sometimes Usually there is no jaundice or ascites. ascites is present. Inflation of the stomach shows the absence Inflation shoAvs the presence of a pyloric of a pyloric growth. tumor. The course is more acute. Death may The course is more chronic, and second- occur within a few weeks or months. ary growths appear in the liver. Neoplastic growths of the transverse colon are also more often super- ficial, and are movable and definable with the palpating fingers. There are symptoms of intestinal obstruction here, and inflation of the colon will show the relation of the tumor to the gut. In carcinoma of the colon the urine generally contains an increased amount of indican. Obstructive jaundice due to gall-stones may be mistaken for pancre- atic carcinoma; but in the latter affection the jaundice develops more gradually, may be less marked, and is permanent, while that of chole- lithiasis is transient. In hepatic colic the onset is sudden and the pain PANCREATIC CYST. 909 is severe and colicky, or is reflected to the right and posteriorly, with equally sudden relief. A discussion of the prognosis and treatment of carcinoma of the pancreas is obviously unnecessary. PANCREATIC CYST. Pathology.—Pancreatic cysts may be single or multiple, and large or small. When large they develop chiefly to the left of the median line. Sometimes a cystic pancreas may have the appearance of a bunch of grapes, or a single cyst may be so large as to simulate an ovarian cys- toma, and may contain as much as several quarts of fluid. The contents may at first consist simply of retained pancreatic juice, and usually the liquid is dark-gray or dark-brown, alkaline, and hemorrhagic or albumin- ous. The specific gravity is from 1010 to 1024. Atrophy of the pan- creas may ensue. Examined microscopically, the contents reveal leuko- cytes, red blood-corpuscles, oil-drops, fatty degeneration of the epithelium, and crystals of fatty acids and cholesterin. Etiology.—Cysts of the pancreas may be due to occlusion of the pancreatic duct or its branches by compression from within or without the gland. They may also be due to tumors, to impaction of biliary or pancreatic calculi, to cirrhosis or angular displacements of the gland, or to the obstructive swelling from extension of catarrh of the bowel (Krecke). Many cases have been traced distinctly to traumatism. Lloyd suggests that the cysts that follow local injury are in reality instances of encysted peritonitis involving the lesser omentum or that portion of the latter covering the pancreas. Cysts of the pancreas usually occur in adults, though rarely they may be congenital. Sex is without influence. Symptoms.—The symptoms are those of pressure, and in part are the result of an absence of the pancreatic secretion. Pain may be ab- sent, or it may occur as colicky paroxysms, referred either to the epigas- trium, the left hypochondrium, or even the left shoulder. Jaundice and ascites are present in large tumors. Vomiting, constipation, or fatty diarrhea, with undigested muscular fibers in the dejecta, or clay-colored, pasty, and offensive stools, may be present. Albumin and sugar may be found in the urine. Emaciation is not infrequent. Intestinal hemor- rhage may occur and recur. A late and constant symptom is a feeling of pressure in the epigastrium. On physical examination a smooth, elastic, lobulated tumor is discov- ered in the region of the pancreas if the growth is moderate in size. Sometimes a very large cyst develops in a remarkably short space of time—i. e. in a few weeks. When very large in size fluctuation is easily elicited. It may be slightly movable in the grasp and during inspiration. It usually presents between the stomach and transverse colon an area of dulness, and unless the tumor be of large size it is surrounded by tym- panitic resonance of deeper timber above than below. Auscultation may reveal a murmur caused by compression of the aorta. When the cyst attains enormous dimensions the usual mechanical pressure-effects are produced. Diagnosis.—The diagnosis rests on the typical physical signs—the 910 DISEASES OF THE DIGESTIVE SYSTEM. discovery on palpation of a smooth, elastic, lobulated, or rounded tumor that is slightly movable, and on percussion of a dull area that is not con- tinuous above Avith the spleen- and liver-dulness. Resort has been had to filling the stomach with air and the colon with water (after purging), and thus proving by palpation the deep-seated situation (behind the stomach) of the tumor. The supposed cyst may be aspirated, and if pancreatic fluid be obtained, it will digest albumins and emulsify fats. This test is not wholly reliable, however. A pancreatic cyst may be mistaken for an ovarian cyst, for renal tumors (cysts), dropsy of the gall- bladder, and retroperitoneal sarcoma (Lobstein's cancer). The differ- entiation is extremely difficult, and must be made by a comprehensive and careful study of all the points in the case. The prognosis is good under proper treatment, which would seem to be incision and drainage. PANCREATIC CALCULI. Pathology.—These are grayish-white, rounded concretions, consist- ing of calcium carbonate or phosphate, with a nucleus of inspissated mucus in most instances. The calculi may be fine as dust or as large as an almond. Among their remote pathologic effects are fistulous com- munications with the colon, peritoneal cavity, and stomach. Atrophy of the organ is frequently, and carcinoma rarely, associated. Etiology.—Pancreatic calculi presuppose a catarrhal condition of the pancreatic duct, with retention of secretion, anomalies of the pancre- atic secretion, or the presence of cysts or some other form of obstruction of the pancreatic duct. The Symptoms are developed when, during the passage of the stones along the duct to the duodenum, the latter excite inflammation. In con- sequence, paroxysms of pain occur (pancreatic colic) that are usually attributed to gall-stones, and Ave are often unable to differentiate the two conditions. The radiation of pain along the loAver left costal border to the back rather than to the right side, and possibly the detection of free fat in the stools, or glycosuria, may aid markedly in the diagnosis. Jaundice is usually absent in pancreatic colic. Moreover, the finding of characteristic calculi in the stools is entirely confirmatory. Soon or late emaciation may become marked in calculi of the pancreas. The prognosis is mainly dependent upon the associated lesions and upon certain sequelae—pancreatic cysts and chronic pancreatitis. The indications for treatment do not differ materially from those of hepatic colic. XII. DISEASES OF THE PERITONEUM. ACUTE PERITONITIS. Definition.—An acute inflammation of the peritoneum. The con- dition may be primary or secondary. Clinically, two varieties—general and circumscribed—are recognized, while, pathologically, the disease is classified according to the nature of the exudate. DISEASES OF THE PERITONEUM. 911 Anatomic and Physiologic Peculiarities.—The surface area of the peritoneum is quite extensive, being almost equal to that of the skin. Fluids of all sorts are rapidly absorbed by the peritoneum, and thus, if they be poisonous, constitutional infection is speedily propagated. Pathology.—Upon opening the abdomen in acute general peritonitis vascular injection both of the serous covering of the intestine and of the parietal layer is observed. Even in the most recent cases the coils of intestine may be feebly glued together by lymph, Avhile in those of longer duration the adhesions are quite firm. As in the analogous inflammation . of the pleurae or pericardium, we distinguish the folloAving forms patho- logically : (a) A plastic or fibrinous, in Avhich there may be also a small amount of serum present, (b) Sero-fibrinous (comparatively infrequent), chiefly characterized by an abundance of sero-fibrinous fluid. Addition- ally, the coagulated fibrin forms a covering for the parietal and visceral layers of the peritoneum, (c) Purulent (most frequent). The amount of inflammatory exudate varies greatly, and is frequently enormous, ex- ceeding 30 liters (quarts). Not rarely putrefactive decomposition of the pus occurs, especially in perforative and puerperal peritonitis, giving rise to a thin fluid that is grayish-green in color, is sometimes distinctly sani- ous, and emits a gangrenous odor. Offensive gases are present with rela- tive frequency. These may come from the intestinal canal, following the track of perforations, or they may be due to decomposition of the puru- lent exudate, (d) Hemorrhagic. This form is common in cases that are of a cancerous or tuberculous nature, though it also occurs in acute gen- eral peritonitis of traumatic origin. Tuberculous peritonitis is considered separately. In severe types of the disease the intestines are the seat of morbid changes. Their Avails are often thickened on account of inflamma- tory edema, while at the same time their muscular coat is also Aveakened —even to absolute paralysis—allowing of a greater or less degree of tympanitic distention of the bowel. The different pathologic varieties above described may be limited to definite portions of the peritoneal sac, when they are termed " encapsu- lated " or localized acute peritonitis (vide supra). In localized purulent peritonitis, further extension of the process is arrested by the rapid forma- tion of circumscribed adhesions due to the exudation of lymph; there are also undoubted instances of circumscribed, aplastic peritoneal ab- scesses. The milder forms of limited plastic and sero-fibrinous perito- nitis pursue a slower course than the purulent variety, and as commonly lead to the development of firm adhesions (adhesive peritonitis). Since the histologic changes in acute peritonitis do not differ from those ob- served in other inflammations of serous membranes, the reader is referred to the section on Pleurisy for their consideration. Etiology.—The irritants causing acute peritonitis may be—(a) Or- ganized inflammatory agents (organic irritants). These may be specific and non-specific. Among the non-specific agents are the pyogenic bac- teria. Grawitz has shown that the latter can only cause peritonitis under certain conditions; they excite the disease when injected into the perito- neal cavity or when poured out from the diseased or injured membrane more rapidly than the peritoneal tissue can dispose of them ; also when the epithelial layer has from any cause been removed. Absorption may be interfered with, while the pyogenic micrococci continue to enter from the 912 DISEASES OF THE DIGESTIVE SYSTEM. bowel or other viscera in great numbers. Unfortunately, the clinical practitioner often meets with cases of peritonitis in which these pyogenic organisms are the only positive agents. These essential conditions obtain Avhen the membrane is wounded by the perforation of gastric and intestinal ulcers, and also in perforation of the gall-bladder, in rupture of the liver, kidneys, and spleen, when the latter are the seat of abscesses, and, with uncommon frequency, in appendicitides Avith purulent inflammation in the ovaries, and in the Fallopian tubes. " There are instances in which peritonitis has followed rupture of an apparently normal Graafian follicle " (Osier). It has been experimentally shown that non-specific organisms that are non-pyogenic are incapable of causing peritonitis unless the serosa is injured. Death may result from the injection into the peritoneal sac of putrid liquid if the dose be large enough, but it is practically the same whether the fluid is injected into the blood-stream at once or allowed to find its way into the peritoneal cavity, and the result follows nearly as quickly in the one case as in the other " (Moullin). The rapid absorption of liquid substances gives full opportunity for the phagocytic action of the white blood-corpuscles. Among specific organic irritants the tubercle bacillus deserves especial mention, though, as before intimated, a discus- sion of its characteristics is not in place here. The streptococcus pyog- enes is probably responsible not only for many cases of puerperal perito- nitis, but also for many of the post-operative variety. More frequently than the streptococcus, however, has the staphylococcus pyogenes aureus (or albus) been found in such instances. The bacterium coli commune (always present in the intestinal tract) is most frequently the leading factor in peritonitis of intestinal origin, and, I believe, also in that form following operations upon the appendix. Occasionally other organisms, as the pneumococcus, the bacillus of Fried- lander, or the bacillus pyocyaneus, have been found. Osier saw a case In which the ameba coli was found in the thin, fibrous peritoneal effusion. Patients have been known to die of septicemia after operations on the abdomen (secondary infection), without any detectable evidence of peri- tonitis. (b) Chemical Irritants.—These are rather numerous and varied, though all produce their effect in one of two ways. First and most frequently, the irritant acts upon the membrane, exciting an exudation of lymph. In this instance constitutional intoxication is secondary. Secondly, the chemical irritant may be quickly absorbed and produce systemic intoxica- tion immediately. (c) Mechanical irritants, as, for example, a hernia, which may produce a localized peritonitis. (d) Peritonitis may be due to a direct extension of inflammation from the intestinal tract or other adjacent organs. In the majority of instances this variety is protective in character and results in local adhesions. I have seen a few undoubted instances of peritonitis secondary to pleurisy in which the irritants presumably found their way from the pleura to the peritoneum along the course of the lymphatics in the diaphragm. (e) The disease very rarely occurs idiopathic ally: somewhat more fre- quently it appears as a rheumatic condition, and then it is usually attrib- uted to exposure to cold or wet. These so-called idiopathic cases are probably instances of cryptpgenetic infection. As in other inflamma- ACUTE PERITONITIS. 913 tions of serous membranes, so peritonitis may be secondary to chronic Bright's disease. In such cases the special irritants reach the membrane either from the intestinal canal or through the general circulation. Clinical History.—The symptoms are both of a local and a general nature. In sthenic cases of perforative peritonitis they occur simul- taneously with great severity and suddenness. On the other hand, in asthenic cases, such as occur frequently in those already afflicted Avith some serious disease that is apt to result in perforation (for example, typhoid fever), both the local and constitutional symptoms are more or less masked by the disturbances due to the primary affection. Again, circumscribed abscesses of the peritoneum often lead to diffuse suppura- tive peritonitis, and the change may take place so insidiously as to defy detection. These anomalies from the typical onset and course of the disease are by no means exceptional, and should ever be distinctly borne in mind by the physician. Local Symptoms.—Among these, pain is the chief. At the commence- ment its seat of greatest intensity corresponds, in most instances, Avith the seat of origin. Hence the character of the causal disease is often betrayed by the location of the chief pain. For instance, if this ap- pears in the region of the stomach and is referred to the back or shoul- ders, Ave would think of gastric ulcer; if in the ileo-cecal region, of ap- pendicular disease; and so on. It follows that quite commonly the severest pain is in the lower half of the abdomen. It is almost constant, increases in severity, and finally becomes general and excruciating ; it is also much increased by deep respirations, by pressure, and by bodily movements. It remits, but does not intermit, though it may be slight in asthenic cases. Here the patient is excessively weak, while his sen- sibilities are greatly blunted. Gastro-intestinal symptoms are prominent, more particularly vomiting, which occurs early and is apt to recur Avith relative frequency. It may follow the taking of food, though, in my OAvn experience, it has more frequently taken place spontaneously ; the vomitus then consists of a Avatery liquid greenish in color and contain- ing mucus. In rare instances the matter vomited is a dark-broAvn liquid. Vomiting may sometimes be absent, however, owing to the presence of marked asthenia or coma. Eructations are common, and constipation is usually present. On the other hand, there may either be diarrhea throughout the disease or this symptom may often precede the constipation. Constipation is due chiefly to a Aveakened condi- tion of the muscular coat of the intestine, while the diarrhea is to be ascribed to an increased peristalsis due to intestinal catarrh. The apex of the heart is elevated ; the tongue at first is furred and moist, and later it is dry, brown, and often fissured. Constitutional Symptoms.—At the onset the patient in asthenic cases is seized with a rigor that may be repeated. The shock sustained by the nervous system in acute peritonitis is most intense: the temper- ature rises immediately, though it does not, as a rule, attain to a high point, and it frequently presents a curve more or less characteristic of suppuration. The rectal temperature is often relatively high; the respirations are shallow and much accelerated, ranging from thirty to forty per minute. We have, as factors to account for this increased frequency, (a) a crowding upward of the diaphragm, (b) the greatly en- 58 914 DISEASES OF THE DIGESTIVE SYSTEM. feebled heart, and (c) the pain occasioned by throwing the diaphragm into action. The heart early becomes excessively Aveak, and, as would be expected, the pulse is rapid, small, and soft. The pulse toAvard the close becomes exceedingly frequent (130 to 150 beats per minute) and is almost imperceptible; during the early stages the pulse ranges from 100 to 130. Other evidences of more or less marked circulatory col- lapse soon manifest themselves. The patient wears an anxious facial expression, the eyes are sunken, the features pinched and cool, the lips cyanotic, and the extremities are likeAvise cold and someAvhat livid. The patient invariably assumes the supine position, with the lower extrem- ities draAvn up, so as to lessen the tension of the abdominal muscles, and thus to secure the greatest possible comfort. The urine is scanty, high- colored, and contains indican. There may be a retention of urine. though more often, perhaps, micturition is more frequent than in normal health. Marked nenrous symptoms do not appear; indeed, the mind usually remains quite clear to the close. Moderate delirium, hoAvever, Avhich sometimes gives Avay to mild stupor, is met with occasionally. In connection with these facts it should be pointed out that in the asthenic form of acute peritonitis the constitutional features differ from those above described. The temperature is usually subnormal (except in the rectum), the pulse is exceedingly feeble and running, and the signs of collapse are Avell marked from the onset. Physical Signs.—Inspection reveals the gradually increasing abdom- inal distention, that frequently becomes excessive if the intestinal walls are more or less completely paralyzed. Often the amount of effusion soon becomes large, when the abdomen appears Avidened. The degree of distention bears a definite relation to the severity of the inflammatory process, and is in inverse ratio to the development of the abdominal muscles. Thus, Avhen the latter are poorly developed or greatly relaxed the expansion is enormous. On the other hand, Avhen they are strong the muscles are apt to be quite tense, permitting of a relatively slight enlargement; the- abdomen may even sIioav a small concavity, in Avhich case the Avails are of a board-like hardness. The cardiac apex-beat is displaced upward and outward, occupying the fourth interspace. Palpation elicits extreme tenderness, more particularly in the vicinity of the umbilicus. In not a few instances of acute peritonitis have I been able to detect a distinct friction-rub. Percussion gives everywhere an exaggerated tympanitic note. There is often an absence of liver- dulness in the mammary line, and rarely also it is absent in the mid- axillary line. In pneumo-peritoneum, resulting from perforation of the gut or stomach, we often meet Avith an absence of liver-dulness, especially when a large purulent effusion coexists. It is to be remembered, how- ever, that a great diminution in, or even the total effacement of, the dull area may be caused by coils of intestine forcing their way up between the anterior surface of the organ and the inner surface of the abdominal Avail. OAving to the fact that the diaphragm is pushed up, both the upper and loAver lines of hepatic dulness, Avhen present, are correspond- ingly higher than normal. To the left we find the lower level of cardiac dulness as high as the fifth rib, the heart being pushed upAvard in ad- vance of the diaphragm. Splenic dulness is quite often obliterated. By means of percussion, sooner or later, fluid effusions are usually LOCALIZED OR PARTIAL PERITONITIS. 915 detectable in asthenic cases. On the other hand, there may be in mark- edly asthenic cases a very slight amount of liquid exudation, that is often too small to admit of detection. When the effusion is considerable in quantity there is dulness on percussion over the most dependent parts; Avhen tympanitic distention is excessive, hoAvever, even a copious effusion may be so effectually hidden as to elude discovery in this Avay. I have already reported one such instance.1 On account of the painful character of the illness the patient's position cannot, in the majority of instances, be changed. When, hoAvever, the decubitus can be altered the line of dulness will be found to be movable, but the degree of mo- bility varies exceedingly, depending upon the extent of the peritoneal adhesions present. The effused material is partly contained in pouches, giving rise to areas of circumscribed dulness, and these must not be mistaken for the lesions of a localized peritonitis. Course and Prognosis.—Asthenic forms of peritonitis are perhaps invariably fatal. Though the local symptoms and signs are not marked, the characteristic evidences of collapse appear almost immediately and grow in intensity to the end. The duration in sthenic cases rarely ex- ceeds one or two days; in asthenic cases it is longer, lasting from four or five to six or eight days. Death sometimes occurs quite suddenly, owing to cardiac exhaustion or paralysis. Although most instances are dynamic in the early stages, acute diffuse peritonitis assumes a markedly adynamic form in the later stages, the cases terminating in fatal collapse. The clinical peculiarities and the course of an individual case are greatly influenced by the etiology. Acute generalized peritonitis arising from perforative appendicitis, from perforation of a gastric ulcer, or from external injuries is usually of a severe type and proves quickly fatal. Prompt operative interference, hoAvever, is powerful in saving life in a small percentage of the latter class. When the disease is traceable to rheumatism or exposure recovery may take place. A case occurred in my own practice in Avhich acute sero-fibrinous peritonitis with consider- able effusion Avas associated with acute articular rheumatism and organic lesions of the aortic segments ; the patient recovered. Acute generalized peritonitis may not infrequently merge into a chronic condition; this, hoAvever, Avill receive separate consideration in its proper place. LOCALIZED OR PARTIAL PERITONITIS. ( Circumscribed Peritonitis.) This is a localized form of inflammation of the peritoneum that is coextensive only Avith the serous covering of single organs, and involves a limited portion of the membrane. Hence, to the various forms of cir- cumscribed peritonitis such terms as perihepatitis, perisplenitis, peri- nephritis are applied. The condition is found in its most important form in appendicitis, but the points that are characteristic of localiza- tion in this disease have been mentioned elseAvhere (vide Appendicitis, p. 817). Local peritonitis may also be caused by a carcinomatous groAvth. Pyo-pneumothorax subphrenicus is the term applied to a circum- scribed peritoneal abscess containing air, situated between the liver and 1 International Medical Clinics, vol. iii. second series, p. 82. 916 DISEASES OF THE DIGESTIVE SYSTEM. diaphragm. The condition is described under the heading Acute Peri- hepatitis (p. 873). Local pelvic peritonitis (perimetritis) is the most frequent variety, and is secondary, as a rule, to inflammation about the uterus, Fallopian tubes, and ovaries. Its consideration, however, must be left to special works on gynecology. Symptoms.—The local clinical features do not differ from those described under the diffuse form, but their area of distribution is more or less strictly limited to definite regions. By eliciting the physical signs with care fluid collections are sometimes demonstrable. The constitutional symptoms are likewise similar in character, though less marked than those belonging to the diffuse variety. There may be rigors, and pyemic symptoms appear, together with the temperature- curve peculiar to this condition. The danger of involvement of the general peritoneal cavity as the result either of rupture or of an exten- sion of septic inflammation is a constant menace. When the peritonitis remains localized these cases may pursue a subacute or even a chronic course, though in most instances the constitutional disturbance becomes grave at last. Diagnosis.—In attempting to diagnosticate acute generalized peri- tonitis it is of great importance for the clinician to keep in remembrance the sthenic and asthenic forms of the affection. The character and gravity of the symptoms, both general and local, are such as to render the diagnosis of the sthenic form entirely easy. Especially valuable features are the constant pain, the marked tympany, the excessive ten- derness under pressure, and the vomiting at intervals of a greenish fluid material. Of equal importance are the serious general disturbance previously depicted, and in particular the cool, sharpened features and the ever-increasing weakness and rapidity of the pulse. These clinical manifestations clearly foreshadow cardiac exhaustion or fatal collapse. When the cases are not seen until the advanced stage has arrived, how- ever, the diagnosis presents many difficulties. Nothing is noAv more important than the consideration of the history from the time of onset, also of the previous history, with a view to determining the point of origin and the probable cause of the disease (usually some such primary disease as appendicitis or gastric ulcer). The smaller number of cases belonging to the adynamic type are from the start extremely difficult of diagnosis. Here a history of the causal factor, the presence of moderate tenderness, and augmented ten- sion of the abdomen, Avith profound collapse, Avould point strongly to this condition. It must, however, be confessed that a positive opinion is often unwarranted, owing to the absence of such clinical indications as have been before mentioned. Differential Diagnosis.—Hysteric peritonitis (so called) simulates in every leading particular the genuine form so closely as to make the dis- tinction an insurmountable difficulty, unless there be present other hys- teric manifestations. In my experience the tenderness has been out of proportion to the gravity of the constitutional disturbance. The patient often complains bitterly before the abdomen has been touched; on the other hand, Avhen his attention has been otherwise engaged firm and prolonged pressure can be made. LOCALIZED OR PARTIAL PERITONITIS. 917 Acute generalized peritonitis occasionally supervenes on typhoid fever. In such cases it is caused either by perforation of the intestine or by a direct extension of inflammation from a deep typhoid ulcer. If con- sciousness be retained, sudden severe pain, tenderness followed by ex- cessive tympany, and signs of collapse Avill establish the diagnosis. Peritonitis, hoAvever, develops more often in those grave cases of typhoid that are attended Avith coma, marked meteorism, and profound adynamia, and under such conditions it often remains unrecognized (vide Typhoid Fever, p. 35). In acute enteric catarrh the meteorism and sensitiveness under press- ure are usually less pronounced; the disease also lacks the marked con- stitutional symptoms of acute peritonitis. The pain is colicky, is cha- racterized by exacerbations, and even intermits in entero-colitis, Avhile it is constant in peritonitis. The pain in acute enteric catarrh is often folloAved by diarrheal stools. Intestinal colic is distinguished from peritonitis by the flatulence, the borborygmi, and the Avandering pain in the absence of all other phe- nomena. Rheumatism of the abdominal muscles excites pain, Avhich, however, is superficially located (the disease being an affection of the muscular layer), and is frequently associated with rheumatism in other parts of the body. There may also be a clear history of previous rheumatic attacks. Tubal pregnancy (after rupture) has also been confounded with acute peritonitis, but its differential diagnosis is fully discussed and must be looked for in special works on gynecology and obstetrics. Rupture of an abdominal aneurysm and embolism of the superior mesenteric artery are also conditions that give rise to peritonitic symp- toms—meteorism, recurrent vomiting, and collapse—all appearing Avith explosive violence. Acute generalized peritonitis in its symptomatology bears a close resemblance to acute intestinal obstruction, and the discriminating points have already been tabulated (vide p. 831). Prognosis.—General suppurative peritonitis is almost invariably fatal. Under the present improved methods of dealing with the affec- tion, hoAvever, it may be confidently expected that the mortality-rate will be lessened in the near future. Perforative and puerperal periton- itis offer the most unfavorable prognosis, Avhile that form due to extension of inflammation promises the most favorable outcome. In localized forms of the disease timely operative interference has saved many lives. Death may be caused either by the primary shock or by cardiac exhaustion. Sequelce.—If recovery should take place, the inevitable result is the formation of adhesions and fibrous bands, the contraction of which may cause constriction of the boAvels, bile-ducts, and other structures. Treatment.—Hygienic and Dietetic.—The patient should be placed in the position that will give him most comfort, and should be kept ab- solutely undisturbed. The sick-room should be of good size and Avell ventilated; the temperature should be kept at from 65° to 70° F. (18.3°-21.1° C). The diet demands careful attention. Pancreatized milk in accurate dosage (3iv—vj—128.0-192.0—every tAvo hours) should be administered, and if the stomach will not bear the introduction of 918 DISEASES OF THE DIGESTIVE SYSTEM. nourishment, recourse should be had to rectal alimentation. < )ther pre- digested liquid food-stuffs, as meat-juices, may also be allowed. Medicinal.—Formerly the opium method of treatment, first insti- tuted by the late Alonzo Clarke, Avas the one folioAved by the bulk of the profession. His plan was to administer -1- gr. (0.0324) of mor- phin or its equivalent (gr. ij—0.129) of opium, and repeat the dose every tAvo hours until the respirations Avere loAvered to ten or twelve per minute. The pupils were then observed to be contracted, the pulse from 76 to 80, the pain relieved, and peristalsis arrested. This latter effect was obtained, even though in the case of some patients larger doses of opium than here indicated Avere necessary; in others smaller doses sufficed. The bowels were absolutely let alone. It is explained that in favorable cases the bowels moved spontaneously at the end of one week, and that the patient then entered upon convalescence. This method of treatment is at present adhered to only by the ultra-conserv- ative element of the profession. Among those authors who recommend opium as the most efficient measure in the treatment of this disease many still advise against the immoderate dosage previously so generally administered, but employ just enough to keep the patient well under the influence of the drug. The leading mode of treatment to-day consists in the use of saline purgatives, exhibited in divided doses in concentrated solution (3J-ij— 1.0-8.0—-every tAvo or three hours) until several copious serous dis- charges occur daily ; this effect is to be maintained until the local con- dition shows decided improvement. Purgatives do good Avhen given in this manner by causing a rapid exosmosis of serum from the blood-ves- sels of the intestines, by removing the collateral edema, and by indi- rectly relieving the congestion of the peritoneum, thus promoting a rapid absorption through the latter membrane. By increasing the peri- staltic movement they also diminish the danger of peritoneal adhesions. The remedies to be selected will depend upon two primary considera- tions : first, the etiology of the individual case (Avhether a communica- tion has or has not been established between the peritoneal cavity and the boAvel), or an intra-peritoneal abscess or abscess-cavity in one of the abdominal viscera; and secondly, the type of the case, Avhether sthenic or asthenic. If perforation is known to have taken place or the occur- rence of this accident is strongly suspected, a prompt laparotomy, fol- loAved by the free use of salines, is the proper treatment. After the primce vicv have been looked after by the surgeon, salines, for the reasons before stated, are to be used Avith a free hand. For a like reason they are most serviceable in peritonitis due to extension of the inflammation, and also in the puerperal form. If the patient be robust, with a full, tense pulse, we may begin the treatment by the use of mercury, the best preparation being calomel, exhibited in fractional doses (gr. ss— 0.0324—every hour) until its purgative action is obtained ; this is to be folloAved by the salines. The object of the calomel treatment is to de- fibrinate the exudation as Avell as the blood of the patient. Indications demanding the opium treatment do not often present themselves. \\ hen, hoAvever, the vital forces are profoundly depressed, as shoAvn by the symptoms of collapse, and there is not even a reasonable suspicion of perforation, then opium should be tried, but not in the heroic doses CHRONIC PERITONITIS. 919 formerly advocated. Enough only should be given to obtain the physi- ologic effect of the drug in a moderate degree. Again, if the evidences of perforation into the general peritoneal cavity are complete and com- petent surgical skill is not at hand, large doses of morphin are imper- ative, with a view to relieving pain, keeping the patient at absolute rest, and sustaining the heart against the exhausting effect of shock. The bowels should now be relieved by simple large enemata. Local Treatment.—At the onset, if the patient be strong, from twenty to thirty leeches are to be applied to the abdomen. In cases in Avhich meteoric distention is not great I have also made repeated trial of the folloAving ointment with gratifying results : B/. Ung. ichthyol., gj (32.0); Ung. belladonnas, §ss (16.0); Ung. hydrarg., q. s. ad gij (64.0).—M. Sig. Apply t. i. d. In order to relieve the tympany turpentine stupes are serviceable. I have also had moderately good results from the use of the long rectal tube (soft esophageal) in treating the same symptom. Injections con- taining turpentine should be tried, as in the folloAving combination : B/. Turpentine, 3ij ( 8.0); Ox-gall, 3ij ( 8.0); Milk of asafetida, giv (128.0); Warm Avater, 3yj (192.0). Puncturing the abdomen Avith a hypodermic needle in order to re- lieve tympany, as recommended by Loomis, may also be resorted to, though I have had no personal experience with this measure. Pain.—No matter what general plan of treatment is pursued, the pain must be relieved by opium in some form. Thirst is to be relieved by chipped ice, over Avhich a little brandy may be sprinkled. The vomiting is best treated by carbonated Avater exhibited in small quan- tities, or by iced champagne similarly administered. One-drop doses of creasote are also of value. CHRONIC PERITONITIS. Definition.—Chronic inflammation of the peritoneum. Pathology and Etiology.—The anatomic characters presented by different cases are greatly varied, though for convenience of study they may be considered under two divisions (as in the acute form): 1. Local; 2. General. The latter may be (a) Adhesive, when the peritoneal layers are inseparable and indistinguishable, Avith an obvious thicken- ing, and the intestinal coils are everyAvhere seen to be grown together. The cause is usually a previous acute attack, and, doubtless Avith great relative frequency, the condition is produced by the acute progressive form (Mikulicz), which is localized at the start. Rheumatism is also an occasional factor, and a mild variety of adhesive peritonitis, confined, as 920 DISEASES OF THE DIGESTIVE SYSTEM. a rule, to small circumscribed areas, may be engendered by the trocar used for tapping in ascites. (b) Proliferative Peritonitis.—" The essential anatomic feature is great thickening of the peritoneal layers, usually Avithout much adhesion " (Osier). It has been found to be associated with cirrhosis of the stom- ach, liver, and other abdominal organs. The amount of liquid effusion, varying in composition from serum to pus, is usually moderate, and it may, owing to adhesions, be loculated. The omentum is sometimes rolled up in the form of a massive cord, with its long axis in the trans- verse direction. In an autopsied case of chronic peritonitis apparently secondary to hepatic cirrhosis I observed in the thickened membrane numerous small hard nodules that were at the time regarded as being tuberculous in nature. It is to be pointed out, hoAvever, that a number of cases of pseudo-tuberculosis have been recently reported. In several of these an operative incision was followed by recovery, and this was put down as a cure of tuberculous peritonitis till the microscope shoAved the nodules to be fibrous. Among etiologic factors chronic alcoholism stands first. In one case that I saw, acute followed by chronic rheumatism seemed to be the only assignable cause. The condition is sometimes secondary to chronic nephritis. (c) Cancerous Peritonitis.—Quite often in connection with cancerous growths in the peritoneum a well-marked peritonitis is evident. There may be a liquid exudation, Avhich is apt to be bloody and chylous. (d) Chronic Tuberculous Peritonitis.—This is the most important vari- ety. The inflammatory lesions are quite pronounced, as a rule, and lead to marked thickening of the layers—changes that are to the naked eye identical in appearance with those noted under the preceding forms, but which on histologic examination show the presence of tubercles and caseous degeneration. The amount of liquid effusion varies Avithin Avide limits, and is usually blood-stained. The frequent association of hepatic cirrhosis Avith tuberculous peritonitis should be remarked. From tuber- culous peritonitis, tuberculosis of the peritoneum is also to be distin- guished clinically; the latter may be acute or chronic, and the lesions consist in the deposit of various sized tubercles without much collateral inflammation. Acute and chronic tuberculosis of the peritoneum have received due consideration in their appropriate place (p. 309). (e) " Chronic Hemorrhagic Peritonitis."—This term should be limited in its application to that form first described by VirchoAv, in Avhich the peritoneum is at intervals partly covered by a membrane of new con- nective tissue that alternates, as it were, Avith layers of hemorrhagic extravasation. A similar condition results from the frequent use of the trocar for ascites. Chronic Localized Peritonitis.—This is of frequent occurrence, and is confined most commonly to the serous covering of the spleen, liver, and certain portions of the boAvel, particularly of the appendix. The condi- tion results in the formation of firm adhesions, with matting of the in- testinal coils and fibrous bands. It is usually the sequel of localized acute peritonitis occurring in connection with inflammatory diseases of the different abdominal organs. Symptoms of the General Forms.—Whether chronic peritonitis folloAvs the acute form or not, it always develops insidiously. Most cases CHRONIC PERITONITIS. 921 remain quite obscure, and not a feAV are totally devoid of clinical mani- festations. When the latter are present, however, the patient complains of disturbances of the alimentary tract, and especially of constipation. On the other hand, diarrhea is observed in tuberculous peritonitis from associated intestinal ulceration. Rarely pressure on the common duct or portal vein gives rise to obstructive jaundice or ascites, as the case may be. I saAv an instance recently in Avhich compression of the veins leading to the lower extremities caused unilateral edema. Subjective abdominal sensations, as uneasiness, oppression, heat, and pain (often colicky in character) are experienced. Sometimes pain is entirely absent. General symptoms appear, though they are feebly marked as a rule. An irregular fever, hectic in type, is occasionally observed. Later, in- creasing general Aveakness and emaciation become rather prominent clinical features. Some of these phenomena, however, may be due to associated affections. When the peritonitis is tuberculous we frequently see clinical evidence of the causal disease in other parts of the economy (vide Tuberculous Peritonitis, p. 309). Physical Signs.—Inspection usually shows the belly to be slightly, though unequally, enlarged. As in acute peritonitis, so here, we find the belly flat, or even concave occasionally, with great tension of its Avails. Fluctuation is sometimes obtainable over limited areas only, since the fluid is not free, but encapsulated. The coiled-up and shrunken omentum may be palpable as a sausage-shaped mass, and thick bands of adhesion may also not rarely be felt, in different places, as hard, un- even masses simulating neoplasmata. The percussion-dulness varies con- siderably with the amount of effusion, its arrangement, the degree of peritoneal thickening, as well as with the character and locality of the fibrous bands. It folioavs that in some cases irregular areas of tym- panitic percussion-resonance and of dulness are to be found side by side scattered over the abdomen. Obviously, too, changing the patient's posture would not give movable dulness, OAving to sacculation of the fluid. A marked sense of resistance is experienced on percussion over the dull area. Friction-fremitus can sometimes be elicited, and less fre- quently friction-sounds also during forced breathing. Symptoms of Chronic Iyocal Peritonitis.—This condition is often entirely latent. When not so, the most characteristic indication is constant pain, distinctly colicky in nature and often quite intense. The physical signs are negative, as a rule. Very rarely a resistant, ill- defined mass, corresponding with the seat of greatest pain, can be felt. A fibrous band may be so arranged as to form a snare through which a knuckle of bowel may pass, with resulting strangulation. Fitz's analy- sis of 295 cases showed 63 to be caused in this Avay. Diagnosis.—That form of chronic peritonitis (serous or granular) most frequently seen in females at the commencement of puberty is hard to discriminate from tuberculous peritonitis, since the latter may be more or less latent. Tuberculous peritonitis is attended with fever, more pain and tenderness, and there is a more rapid accumulation of the exudate. Again, the general features, debility and loss of flesh, progress more rapidly than in granular peritonitis. The detection of conclusive evidence of the disease in persons closely related, or on phys- 922 DISEASES OF THE DIGESTIVE SYSTEM. ical examination of associated pulmonary or pleural lesions, would ren- der the diagnosis of tuberculous peritonitis almost certain. In obscure cases the guinea-pig should be inoculated Avith the exudate (see Pleu- risy, p. 539). Course and Prognosis.—The milder varieties of simple chronic peritonitis may, though very rarely, reach a favorable issue. In cases belonging to this category the disease takes a chronic course, and leads gradually to a condition of extreme debility, even if it does not, as is usually the case, materially shorten life. Tuberculous peritonitis has, until recently, been regarded as being almost uniformly fatal at the end of several months. Cures that must be attributed to the surgeon's Avork, however, are at present by no means uncommon. Rarely spontaneous cures also occur, particularly among children, in whom the disease is less serious than in adults. Treatment.—The patient should be enabled to enjoy the benefit of good sanitary surroundings. Close attention is to be paid to the diet, the coarser vegetables and sweets being prohibited, since they increase the pain by exciting the production of gas. A change of air has im- proved the condition in several instances occurring in my own practice. The usual constipation may be relieved by simple enemata or by the use internally of the fluid extract of cascara sagrada. Tonics and alter- atives, the latter with a vieAv to promoting the absorption of the exudate, may also be employed, and I would recommend especially for this pur- pose the double iodids, as in the formula given in the discussion of Pleurisy (vide p. 554). In the early stages some degree of relief, or even a curative effect, may be secured by local means, as the application of equal parts of belladonna and iodin ointments until mild counter- irritation is produced. Ichthyol ointment is also serviceable. After all, however, little is to be gained from therapeutic measures, and it is to surgery that we must look for fresh triumphs in the treatment of this truly distressing complaint. Cases of chronic localized peritonitis with adhesions have been operated upon successfully by W. E. Ashton, H. A. Kelly, and others. Instances of chronic generalized peritonitis, whether tuberculous or not, in Avhich the fluid effusion reaccumulates rapidly after repeated tappings, also furnish adequate indications for operative procedures. ASCITES. {Hydrops Peritoncei; Dropsy of the Peritoneum.) Definition.—An accumulation of serum in the peritoneal cavity, resulting from stasis in the branches of the portal vein. Pathology.—The quantity of liquid contained in the peritoneal cavity is quite variable, though it often amounts to several gallons. It is clear and transparent, or slightly opalescent, especially on standing, and the specific gravity ranges from 1010 to 1014. In color it often has a faint lemon-yellow tint; it may, hoAvever, be either, distinctly yelloAv, brownish (in cirrhosis), bile-stained (as Avhen jaundice is present), or slightly blood-stained. In reaction it is usually alkaline; very rarely it is either acid or neutral. ASCITES. 923 The ascitic fluid usually contains much albumin, resembling in this respect blood-serum, as would be expected from its source. The per- centage of albumin may be approximately ascertained by noting the specific gravity of the fluid by the urinometer. Thus, in true ascites the specific gravity ranges from 1010 to 1014, and the variation in the percentage of albumin is from 1 to 2. In effusions due to peritonitis the percentage of albumin ranges higher (2.5-6 per cent.); hence the specific gravity ranges correspondingly higher (1015-1024). The standing specimen may shoAv to the unaided eye a minute coagulum of fibrin. In the loAvest layer of the fluid the microscope discloses leu- kocytes, red blood-corpuscles (in abundance when ascites is due to gen- eral venous stasis), fat-cells, endothelium, and cholesterin-crystals. In ascites the microscopic appearances of the peritoneum are usually normal, while in instances of peritonitis the membrane, including the subperito- neal fibrous tissue, is opaque and slightly thickened. In the so-called chylous ascites the fluid resembles milk, owing to the presence of molecular fat. This condition may be associated with a collection of milky fluid in the left pleural sac Avhen there is thrombosis of the subclavian vein at the point at which the thoracic duct enters. The term ascites adiposus is applied to a milky fluid in the peritoneal sac Avhich shows the presence of large and small fat-globules to the ex- clusion of other morphologic elements. In true ascites of long standing the abdominal, and to a lesser degree the thoracic organs, become atrophied from the great and prolonged pres- sure exerted by the dropsical fluid. The heart is often considerably elevated. Etiology.—Among the chief causal factors are those that hinder or arrest the return of venous blood from the peritoneal membrane, as the following: (a) Pressure upon the branches of the portal vein within the liver, due to contraction of surrounding tissues, as in hepatic cirrhosis, syphilis of the liver, and cancerous infiltration, (b) Numerous conditions in the course of which pressure may be made upon the portal vein external to the liver, as enlargement of the glands in the fissure, carcinoma, hydatids, or abscesses connected Avith the liver. Tumors of any adjacent organs (e. g. pancreas) may produce it, and rarely also secondary contraction in perihepatitis, (c) Thrombosis of the portal vein. (d) Pressure upon the inferior vena cava after it receives the hepatic trunk (Roberts), or upon the latter itself, or the lymphatics, (e) The portal circulation is also impeded in chronic pulmonary affections (cir- rhosis and emphysema) and organic heart-diseases. (/) A neAv growth in the peritoneum may compress the smaller veins lying in the membrane or the root of the mesentery, (g) Diminished resistance of the Avails of the portal vessels due to chronic affections that diminish the albumin- ous constituents of the blood and impair the nutrition of the peritoneum, as Bright's disease, carcinoma, syphilis, chronic malaria. (A) Chylous ascites is caused either by a leakage of the lacteals (due to ulceration, injuries, or the presence of filariae) or by the obstruction of the thoracic duct (due to thrombosis, cicatrices, compression), (i) Adipose ascites has for its direct cause fatty cellular degeneration, such as is found in carcinoma, tuberculous, and other forms of chronic peritonitis. Leyden has recently (1897) described an ameboid organism observed in the ascitic fluid in 2 cases. 924 DISEASES OF THE DIGESTIVE SYSTEM. Symptoms.—Slight peritoneal dropsy gives rise neither to symp- toms nor to abnormal physical signs. When the sac contains 1 quart (1 liter) of fluid or over, hoAvever, the first subjective symptoms that are due to the mechanical effect of the fluid appear. They are a sense of Aveight and fulness Avith slight uneasiness. As the proportion of trans- uded serum becomes gradually increased these symptoms become more pronounced. There may in addition be a dragging pain in the loins, gastro-intestinal disturbance (meteorism, constipation), and dyspnea (oAving to the resistance opposed to the descent of the diaphragm, resulting in compression of the lungs). The latter symptom is much increased upon exertion or on assuming the recumbent posture. Since the heart is displaced upward, an embarrassment of its action (rapidity and irregularity) would be expected. Syncope is not infrequent for similar reasons. Frequent micturition from pressure upon the bladder is common, and the kidneys, owing to compression of the renal vessels, secrete an albuminous urine, which is greatly lessened in amount. Physical Signs.—After the serum has collected in considerable amount the physical signs afford characteristic evidence of the condition. From inspection we learn many valuable points : (a) The belly is uniformly prominent (the degree depending upon the amount of serum present), giving a rounded form. Changing the posture of the patient shifts the point of greatest pouching, (b) The skin is seen to be tense, smooth, and shining, and sometimes shows linese albicantes ; the umbilicus com- monly bulges forward; less frequently it is obliterated, and the surface- veins are often enlarged, (c) The thorax appears small, except at the base, Avhere it is distended, and the ensiform cartilage is sometimes abruptly curled up. (d) The respirations are hurried and are of the thoracic type, the abdominal movements being slight or entirely Avant- ing. As soon as the belly-walls become moderately tense fluctuation is readily obtainable. It is to be elicited by placing the palm of the left hand vertically upon one side of the abdomen, and then, Avith the fin- ger-tips of the right hand, tapping lightly the opposite side; impulses thus sent through the fluid will be distinctly felt by the hand in contact Avith the abdomen. When the dropsical fluid is small in quantity the physical signs should be practised with the patient in the erect posture during the examination. Percussion gives dulness, even to flatness, over all of that portion of the abdominal cavity occupied by the fluid. The upper level of dulness is not represented by straight transverse lines, but presents a concavity that is pointed toward the head. The dulness is extremely movable, shifting as the patient's position is changed. When the decubitus is supine the flanks and the lower por- tion of the abdomen give dulness on percussion, whilst over the anterior portion there is normal tympany. Again, if the patient be made to lie on either side, the opposite or uppermost flank will be found clear, the ascitic fluid ahvays gravitating to the most dependent portion of the sac. Encapsulation of the fluid does not take place unless the case is complicated Avith peritoneal adhesions. In mapping out the limits of dulness, if the layer of liquid be thin the pleximeter finger should not be pressed too firmly upon the surface, othenvise the liquid Avill be dis- placed and a clear note elicited. Moreover, to obtain reliable results under these circumstances the gentlest percussion only is allowable. A ASCITES. 925 verv large quantity of fluid even may occupy the abdominal cavity, and yet emit no dulness, owing to extreme tympanitic distention of the in- testines, as occurred in a case reported by myself.1 When the colon is thoroughly emptied tympanitic resonance may be elicited over the cecum and descending colon, despite the presence of considerable ascitic fluid. In the cardiac region there is often percussion-resonance as high as the fourth rib, and occasionally a murmur may be heard at the base. Diagnosis.—In order to arrive at a positive diagnosis a clear his- tory of one or the other of the known causative conditions is requisite, joined Avith distinct evidence of the presence of fluid—viz. fluctuation and movable dulness. Differential Diagnosis.—Ascites is most apt to be mistaken for an ovarian cyst. The accompanying table presents the chief differenti- ating points: Ascites. Ovarian Cyst. Clinical History. General health is bad prior to the ap- General health is good before the devel- pearance of the enlargement. opment of the tumor ; failure of health afterward. History of disease of liver, lungs, heart, Frequent history of dysmenorrhea, neg- kidneys, or other organ. ative as to organic affections. Swelling begins below and gradually ex- Swelling is unilateral at first, gradually tends higher ; more noticeable when becoming more central. sitting than in the standing posture. Physical Signs. Enlargement is symmetric, the abdomen Enlargement is asymmetric or irregular, being rounded and most prominent unless the tumor be very large, when about the umbilicus ; in the supine it may fill the entire abdomen. The posture the abdomen flattens, with lat- greatest circumference is below the eral bulging ; the umbilicus is often umbilicus, which never bulges, pouched and thin. Fluctuation is general from side to side Fluctuation is circumscribed, correspond- and in a vertical direction. ing to the limits of the tumor. No aortic pulsation felt. Aortic pulsation is sometimes evident. Vaginal examination often shows the Vaginal examination shows the uterus to uterus to be movable. A pouch may be displaced. A cyst may be felt and project into the vagina, but no cyst is outlined in the pelvis. detectable. When standing, the upper line of dul- When standing, the upper line of dulness ness is concave. is uniform or convex. In the supine position the flanks are In the supine position dulness is still in especially dull, with tympany in front. front and the flanks are resonant. Dulness is movable according as the po- The area of dulness is not varied by sition is altered. change of posture. Character of the Fluid. Ascitic fluid has a specific gravity of Ovarian fluid has a specific gravity of 1010-1014, and is usually clear. It is 1018-1054. It is of a thick, turbid of a pale straw-color. character, and the color is variable. It should be recollected that large cysts may spring from other ab- dominal organs than the ovaries, as the pancreas and liver ; the elimi- nation of these latter conditions, however, does not, as a rule, offer marked difficulty. Ascites must be distinguished in practice from the 1 International Medical Clinics, vol. iii. second series, p. 88. 926 DISEASES OF THE DIGESTIVE SYSTEM. exudation due to chronic peritonitis, and the points of differentiation have been arranged thus : Ascites. Chronic Peritonitis. A previous history of organic disease of There is a previous history of acute peri- the liver, heart, kidneys, or other organ tonitis, tuberculosis, or inflammatory is obtainable. diseases of the female pelvic organs; sometimes a history of injury. No pain is experienced. Pain is a prominent symptom. The abdomen is symmetrically enlarged. Abdomen is irregularly prominent, and rarely flat. Fluctuation is general in the transverse Fluctuation is often limited to circum- or vertical directions. scribed areas due to loculation of fluid. Palpation detects no hard masses of ir- Palpation often detects resistant, uneven regular prominence. prominences. Dulness is always movable upon altering Dulness often not changeable on varying the position of the patient. the position, owing to adhesions. The fluid consists of serum with few mor- The fluid is either sero-fibrinous, sero- phologic elements. It is limpid, with purulent, or milky in nature. It is a specific gravity of 1010-1014, and is often viscid, and its specific gravity is pale straw-yellow in color, often with 1018-1024. The color varies. a greenish tinge. Over-filling of the bladder has also been confounded Avith ascites, and this organ has been tapped under the mistaken notion that the condition was one of dropsy of the peritoneum. If, however, the precaution be taken to catheterize the patient before tapping for supposed ascites, the error cannot, as it should not, occur. Prognosis.—The duration of ascites may be for many months or even years. In most instances the prognosis is unfavorable, though modified by the character of the causal condition in individual cases. The immediate cause of death may be either syncope, asphyxia, pul- monary atelectasis from compression of the bases of the lungs by the diaphragm, or it may be the causal disease. Treatment.—Dietetic.—The diet should be largely nitrogenous, light, nutritious, and given at frequent intervals with a view to main- taining the normal proportion of albuminous material in the blood. Medicinal.—By means of therapeutic measures Ave should aim to accomplish two things: First, the improvement or cure of the original disease; and secondly, to relieve the chief symptoms by removing the ascitic fluid on which they depend. Though the causative affection is usually chronic and incurable, every effort should be made to remove or mitigate its pernicious activity in accordance with the principles laid do\vn in appropriate portions of this Avork. Of medicines used to re- move the transudation, hydragogue cathartics are most potent for good, and particularly Avhen the ascites is due to cardiac or renal disease. Calomel and jalap in combination, or salines in full doses, administered after the Matthew Hay method, should be tried. Diuretics are also recommended, and English authors greatly praise copaiba and its resin as being among the best. The bitartrate and other salts of potash, either alone or in combination Avith juniper and digitalis, are of signal value. Equally important Avith the exhibition of the above remedies is the use of tonics to promote the general nutrition of the patient. I have reported one instance, occurring at the Philadelphia Hospital, in which a cure was effected perhaps solely as the result of the exhibition of NEW GROWTHS IN THE PERITONEUM. 927 measures intended to assist the nutritive processes. In ascites due to cirrhosis of the liver recourse should be had to paracentesis abdominis, not as a last resort only, but "as a systematic method of treatment" (Roberts). A single tapping may be sufficient, though rarely is this the case. No valid objection, hoAvever, can be urged against a repetition of the measure from time to time, and at least until the collateral circu- lation is established. A favorable result is obtained relatively often, and especially Avhen, at the same time, the general nutrition receives careful attention. In cases in Avhich the transuded serum has rapidly re-formed after its removal by tapping, Southey's tubes, by means of which permanent drainage is secured, have been used with good result. NEW GROWTHS IN THE PERITONEUM. The most frequent and important of the neAv groAvths of the perito- neum are (a) carcinoma and (b) tuberculous deposit and tuberculous peritonitis, the latter tAvo haAlng been already considered. CARCINOMA OP THE PERITONEUM. There occur the usual varieties—scirrhous, encephaloid, and colloid —the latter most frequently involving the omentum. Primary carci- noma of the peritoneum is rare. Primary endothelioma, hoAvever, is occasionally met Avith. It resembles true carcinoma in macroscopic as Avell as in microscopic appearances, though it is in reality to be ranked Avith the sarcomata on account of its origin. Carcinoma of the perito- neum is almost always secondary to carcinoma of the stomach, liver, or pelvic organs. The peritoneum may either be the seat of numerous small round miliary tumors, or, less frequently, of larger and distinctly nodular masses, the most extensive development being presented by the colloid A'ariety. Cancerous peritonitis is commonly found to be an asso- ciated condition, and the retro-peritoneal lymph-glands not infrequently show cancerous development. Etiology.—More cases occur in the female sex than in the male. Age has also a potent influence, most cases appearing late in life. Symptoms.—When primary, carcinoma of the peritoneum is ob- scure during the early part of its course. Local pain and discomfort are complained of, and clinical evidences of the cancerous cachexia develop early, but these symptoms are not at first striking enough to be entirely characteristic. Later, hoAvever, the nodules can often be plainly felt (unless the liquid effusion be too marked), and the ascites, loss of flesh, weakness, and anemia are noAv sufficiently developed for diagnosis. In the colloid variety ascites is often absent, the abdominal cavity being the seat of a large, semi-solid, non-fluctuating mass. The secondary form usually folioavs carcinoma of the stomach or the ovaries, and the cachexia will have been developed before the peritoneum is secondarily involved in consequence of the presence of the primary growth. Hence, any symptoms referable to the general abdominal cav- 928 DISEASES OF THE DIGESTIVE SYSTEM. ity are strongly suspicious. Among other constitutional symptoms, apart from those already mentioned, is fever (rarely absent), Avhich may be due in small measure to the anemia, though in a greater measure to the associated peritonitis. Physical Signs.—The abdomen protrudes if effusion be present or if the carcinoma be of the colloid form, though this cannot be set down as a uniform rule. Even Avhen the tumor is large, dropsy of the peri- toneum sometimes makes its detection impossible. On practising palpa- tion after tapping, however, the nodules can be easily made out, either extending from side to side or being more or less localized and not adherent to underlying structures. Differential Diagnosis.—It will be remembered that an oblong tumor lying in a transverse position beloAv the stomach is met with in certain forms of chronic peritonitis. This offers the same physical signs that are presented by cases of peritoneal carcinoma, unless the tumor- masses in the latter affection be of considerable size. Carcinoma, Iioav- ever, is most apt to occur in persons past middle life, Avhile nodular tuberculous peritonitis appears almost exclusively in children and young adults. Evidences of tuberculous disease elsewhere, past or present, and particularly suppuration about the umbilicus, Avould point to tuber- culous peritonitis. Moreover, in all forms of abdominal carcinoma the inguinal glands are apt to be indurated and enlarged. Proliferative peritonitis usually gives a history of chronic alcoholism. The differen- tiation of hydatid cysts of the peritoneum from carcinoma depends upon the history of the case, the presence of hydatid fremitus, the finding of the hooklets in the fluid, the less rapid growth of the tumor, and the lessened amount of pain, fever, and cachexia in the latter disease. Carcinoma of the intestine may simulate somewhat the disease under consideration, but the signs of increasing stenosis, as evidenced by the colicky pain, the discharge of blood and pus Avith the stools, and the ribbon-like character of the feces, will serve to separate the condi- tions. Retro-peritoneal tumors (sarcomata) are discriminated Avith the greatest difficulty. Tumors of the peritoneum, however, whether of the omentum or mesentery, are movable, Avhile those behind the peritoneum are immovably fixed. Omental tumors lie in front of the intestines (as can be shoAvn by inflation of the bowel); mesenteric new growths some- times have a coil of intestine in front of them. On the other hand, retro-peritoneal tumors are always crossed by loops of intestine. Peri- toneal tumors (particularly the omental) folloAv the movements of respi- ration, while the retro-peritoneal remain immobile. The latter always cross to some extent the central long axis of the body, while the former may be confined to one or the other side. The prognosis is always unfavorable. Treatment can accomplish nothing beyond a more or less com- plete relief from the distressing symptoms. PART VII. DISEASES OF THE URINARY SYSTEM. I. DISEASES OF THE KIDNEY. MOBILITY OF THE KIDNEY. [Movable Kidney; Floating Kidney; Wandering Kidney; Ren Mobilis; Nephroptosis.) Definition.—A distinction is made between two common varieties of mobile kidney, according to the degree of displacement, as follows: (1) Movable kidney, the upper end of which can be felt during deep inspiration, and Avhich can be pushed down in the retro-peritoneal space to the level of the umbilicus; (2) Floating kidney, which is freely mov- able beloAv or beyond this point—i. e. possessing a larger arc of mobility. In the so-called palpable kidney the lower edge of the organ can barely be felt on deep pressure. Etiology.—Although an anomalous position of the kidney is usu- ally acquired, it may be congenital; in such cases the condition may be due to relaxation of the perinephric (peritoneal) tissues, the kidney thus having a mesonephron and floating freely about in the abdominal cavity. An abnormally long renal artery may also predispose to the develop- ment of a movable kidney. Emaciation Avith a marked wasting of the fatty capsule in Avhich the kidney is imbedded is a frequent underlying cause of movable kidney. Women are oftener affected than men, and relaxations from multiple pregnancies, tight-lacing and girdling, and traumatism (falls, heavy lifting, and the like) have frequently caused displacement and mobility of the kidney. Heavy tumors of the organ, the pressure of adjacent tumors (as of the liver), and the traction of hernias may likewise cause the condition. In enteroptosis, or Glenard's disease, in which there is a downward displacement of all the viscera, mobility of the kidney is often asso- ciated. Although either kidney, or even both kidneys, may be abnor- mally mobile, the right one is usually affected, probably owing to its anatomic position and to its relation Avith the liver above. Sometimes a floating kidney becomes fixed by peritoneal adhesions in an abnormal position, as in the right iliac fossa; an instance of this occurred in a seaman, under my care, admitted to the Medico-Chirurgical Hospital 59 929 930 DISEASES OF THE URINARY SYSTEM. of Philadelphia. In this case the dislocation of the kidney was appa- rently caused Avhile on shipboard by a prolonged and intense straining at stool after taking a large dose of castor oil. Symptoms.—Movable kidney may exist without any symptoms whatever. It may be discovered accidentally by physical examination, and not infrequently it is found postmortem in a similar manner, no history of trouble having been elicited during life. The symptoms of movable kidney are local, reflex, and general, the local and reflex symptoms being the most prominent in the average case. The reflex symptoms, though usually abdominal, may become general. The local symptoms are most marked in extreme mobility of the kidney (floating kidney), while in moderate mobility the reflex symptoms usually predominate over the local. Most frequently there is a troublesome dragging pain, or a sense of weight or pressure in the loins or abdomen, especially after long Avalking or standing or hard labor; this may, at times, be referred to the sacral region. Sometimes the pain may be quite sharp and colicky in nature. Pain in the kidney itself is seldom complained of, and then only in those comparatively rare conditions in Avhich congestion is produced by pres- sure or traction upon the renal veins, obstruction of the ureter, or the like. The patient himself sometimes recognizes the kidney as a tumor, tender and distressing, as in a case under my own care. Reflex gastro-intestinal disturbances are common. Indigestion is usually complained of, and occasionally nausea and vomiting are noted. Dilatation of the stomach may possibly be caused by a dislocated kidney pressing upon the duodenum, but the association of the two conditions is probably coincident rather than causative. Pressure-jaundice is also an unusual concomitant of the floating kidney. Cardiac palpitation, constipation, flatulence, and edema of the lower extremities (from pres- sure on the inferior vena cava) may attend, and disturbances of the pelvic viscera have also been noted occasionally (dysmenorrhea, abortion, and irritable bladder). Some cases of displaced kidney are characterized by sudden and severe attacks of nephralgic or gastralgic pain, chills, fever, nausea and vomiting, and general collapse. These attacks are often periodic, occurring sometimes at the menstrual period, and are knoAvn as " Dietl's crises" or "incarceration symptoms." They may be excited, also, by a too free indulgence in eating and drinking, as in a case reported by Osier. It is most probable, as Dietl himself sug- gested, that these cases are due to a tAvisting or bending of the renal vessels or of the ureter, or, perhaps, to circumscribed inflammation of the mobile kidney. An acute hydronephrosis may thus develop, with diminished diuresis. The urine is concentrated, and may contain uric acid or oxalates in excess. After three or four days, as the attack subsides, micturition becomes free, the swollen and sensitive kidney becoming movable once more. When produced by movable kidney the attacks of hydronephrosis may occur intermittently (vide Hydro- nephrosis). Floating kidney associated Avith Gle*nard's disease (enteroptosis, splanchnoptosis), in which the transverse colon, pancreas, stomach, intestines, and other viscera are prolapsed, OAving to looseness and weakness of the visceral attachments, gives rise to symptoms similar to MOBILITY OF THE KIDNEY. 931 those stated above, only Avith the addition of greater discomfort and nutritive and nervous disturbances. The general symptoms of movable kidney are those of tl nervousness " neurasthenia, or hysteria. Mental anxiety, leading to melancholia, some- times follows the discovery by the patient of a movable abdominal tumor, which is persistently believed to be a " cancer." Cephalalgia, backache, mental irritability, paresthesias, neuralgias, nervous dyspepsia, and vari- ous hysteric manifestations may arise and prove a perpetual annoyance. In those less frequent instances in which men are affected Avith mobile kidney hypochondriasis may develop. The physical signs of movable or floating kidney are highly import- ant and diagnostic. Palpatioi, especially bimanual, as by Israel's method of counter-pressure (the left hand being placed over the lumbar region, the right next the skin in front, manipulating the abdomen from above doAvnward), may detect a firm, movable tumor of renal size and shape in either flank (usually the right) just beloAv the ribs (movable kidney), or in the inguinal or umbilical regions (floating kidney). Though comparatively easy to outline, the tumor is nevertheless hard to grasp; it is often, however, readily pushed into place. Deep breath- ing may affect a palpable or movable kidney, but has no effect upon one that freely Avanders about the abdomen (floating kidney). Pulsation of the renal artery may be felt in the last-named cases. Inspection and percussion of the lumbar region in movable kidney are uncertain, and therefore unreliable. Visible depression here is rarer than a visible tumor anteriorly ; the latter, however, is not common, although it is occasionally noted in cases of marked wandering of the kidney, as to the inguinal region. I have noted increased tympany over the affected side in several cases as compared with the same area on the opposite side. A diagnosis is possible only after a careful and thorough physical examination. When this is made, an abnormally mobile kidney is usually discovered Avithout difficulty. The size and shape of the organ, its right-sided position, and its mobility, associated Avith a train of local, reflex, or general nervous disturbances, especially in a thin, emaciated woman, are quite distinctive. A standing (preferably bending forAvard with the hand resting on a table) or knee-elbow posture is sometimes more favorable than the recumbent position for determining a movable kidney, and a lax abdomen greatly facilitates the physical exploration. Floating kidney is of course more easily diagnosticated than the movable type, and partly because of the fact that in instances of the latter, tumors of the gall-bladder especially, and Avandering spleen must first be excluded. The absence of a Avell-defined splenic notch, the presence of pulsation of the renal artery, and an unchanged area of splenic dulness will assist in the diagnosis; in addition there is the fact that Avandering spleen is a comparatively rare affection. Tumors of the gall-bladder, as Henry Morris has shown, are fre- quently mistaken for movable kidney, and occasionally the opposite error is made; sometimes, indeed, both conditions may exist. They are both common to women; the right kidney is much more often movable than the left; they both may present as tumors in the right hypochon- driac and umbilical regions ; they are more or less movable, firm, smooth, 932 DISEASES OF THE URINARY'SYSTEM. slightly tender, round or oval in shape, with variable percussion-signs, and dyspeptic symptoms; and either may give rise to paroxysms of severe colic, or to jaundice. Jaundice, however, is probably rare in movable kidney, Avhile emaciation and general nervous disorders are more com- mon ; the floating tumor is also less easily palpated than the cholecystic, and may vary in size (hydronephrosis), the diminution being accompanied by a marked increase in the flow of urine. If the gall-bladder be filled with calculi, the consistence is firmer than that of the kidney, and fre- mitus may be felt. Moreover, the movements of the gall-bladder are usually lateral within a short arc of a circle, the center of which is a point beneath the edge of the right lobe of the liver; while those of floating or movable kidney may be either vertical, oblique, or lateral in arcs of a much larger radius. Again, tumors of the gall-bladder descend with inspiration, as is not the case with wandering' kidney. In some cases it may be necessary to distinguish between the attacks of pain knoAvn as " Dietl's crises " and renal, hepatic, or intestinal colic, acute intestinal obstruction, and appendicitis; the symptoms peculiar to these conditions must then be considered in forming a diagnosis. Tumors of the ovaries and bowel are rarely confounded Avith Avander- ing kidney. Prognosis.—In uncomplicated cases life is never endangered, and a cure may be effected in a large majority of cases in which suitable com- bined medical and surgical treatment is pursued. The general nervous symptoms are usually very obstinate, but after relief is afforded from the local and reflex symptoms, Avhether by tentative or operative means, they subside or cease altogether. Treatment.—Since emaciation and loss of perirenal fat is a fre- quent cause of wandering kidney, it is often advisable to resort to meas- ures that will tend to increase the weight and fat of the body. The "rest-cure," with its forced feeding, may be all that is necessary in highly nervous subjects having but a slightly movable kidney. In all cases more or less prolonged intervals of rest (lying down) throughout the day aid markedly in ameliorating the symptoms. Other hygienic measures, as the avoidance of over-exertion, extreme bodily movements, straining—as at stool—and so forth, should also be enjoined. Trusses, kidney-pads, and bandages, I have recently been convinced, avail nothing. A transverse, oval, and concave abdominal shield, how- ever, if placed between the umbilicus and the symphysis, and sustained from the sacral region by a pad connecting the shield with springs (or by an inelastic material passing over the hips, as recommended by Schatz) will give comfort, support, and ease. In severe cases of renal displacement, in which recurring attacks of hydronephrosis, strangula- tion-crises, profound nervous and mental disturbances, or other grave renal complications occur, some such surgical procedure as nephrorraphy may be necessary. This often proves an effectual cure, although occa- sionally the anchorage may be torn loose by a sudden or severe physical effort. Total extirpation of the kidney (nephrectomy) is justifiable only in the gravest cases and after other means have failed. The hypodermic injection of morphin and atropin and the external application of heat are indicated in the crises of Dietl. PASSIVE HYPEREMIA OF THE KIDNEY. 933 CIRCULATORY DISORDERS OF THE KIDNEYS. ACTIVE HYPEREMIA. {Acute or. Active Congestion.) Definition.—An acute, temporary engorgement of the vessels of the kidneys, Avith little or no exudation. Pathology.—The kidney is SAvollen, deep-red in color, and en- gorged with blood, Avhich Aoavs freely on section. Microscopically, in severe congestion there may be seen cloudy SAvelling of the cortical epithelium. Etiology.—Acute renal congestion is due mainly to the action of irritants present in the circulation, as in the acute infectious (especially the eruptive) fevers. The stimulating diuretics and certain poisonous drugs, as copaiba, squills, cantharides, potassium chlorate, and car- bolic acid, also sudden contraction of the peripheral blood-vessels by exposure to cold while the body is overheated, act as causes. When prolonged the congestion passes into an acute nephritis. It may be caused in one kidney as a result of the nephrectomy of its folloAv. Cer- tain ill-defined centric and peripheral nervous influences and neuroses are held by some to cause an active hyperemia of the kidneys through a vasomotor paralysis of the renal arteries. Symptoms.—There may be a dull pain in the lumbar region, Avith a slight elevation of the temperature and pulse-rate. The urine either is scanty, or, as in cantharides-poisoning, it may be altogether sup- pressed. It is dark, the specific gravity is increased, and it contains some free blood, a trace of albumin, and a feAV hyaline tube-casts. Diagnosis.—The absence of a marked quantity of albumin, of the numerous and various casts, of dropsy, and of uremic symptoms distin- guishes active hyperemia from acute nephritis. The prognosis is quite favorable upon the removal of the cause. It must be borne in mind that a frequent repetition of the attacks may lead to a nephritis. Treatment.—Absolute rest and a liquid diet should be ordered. Cupping over the loins or the use of hot fomentations should be prac- tised. The free use of Avater and other diluents or mucilaginous drinks should be encouraged. Saline laxatives to freely open the boAvels, and the use of hot air or a hot pack to promote SAveating, are important aids in relieving the congested kidneys. PASSIVE HYPEREMIA. {Chronic or Passive Congestion.) Definition.—A chronic venous engorgement of the renal vessels, generally secondary to diseases of certain other viscera. Pathology.—There is in the later stages a characteristic condition of the kidneys called " cyanotic induration." Earlier in the case the organs are enlarged, firm, and of a dark, bluish-red color. The capsule is usually non-adherent. On section the medullary substance is seen to be darker red than the cortex and coarsely fibrous in appearance. Micro- 934 DISEASES OF THE URINARY SYSTEM. scopic examination shows the capillaries (both glomerular and medullary) someAvhat dilated and the walls thickened. The epithelium may either be unchanged or a little cloudy and swollen, or, later, even fatty ; the interstitial tissue may be slightly increased, especially beneath the cap- sule of the kidney. Etiology.—Most commonly the renal congestion is a part of a gen- eral venous engorgement due to chronic cardiac, pulmonary, or hepatic disease. It is found in mitral valvular disease with ruptured compen- sation of the heart; in pulmonary emphysema, fibroid phthisis, and chronic adhesive pleurisy ; and in cirrhosis of the liver. The u cardiac kidnej " is the commonest variety. Less frequent causes of congested kidneys are tumors, the pregnant uterus, and ascites, all of Avhich bring about the condition through pressure upon the renal veins. Only rarely may passive renal congestion be due to thrombosis of the ascending vena cava or of the renal veins. Symptoms.—These are accompanied by those due to the primary diseases that are manifested in the general venous congestion, as edema of the lower extremities. There may be a sensation of Aveight in the loins. The urine is diminished in quantity, of a higher specific grav- ity, and darker in color ; it contains a little albumin, some blood-cor- puscles, and a feAV hyaline casts and epithelial cells, depending upon the chronicity and intensity of the congestion. Urates may be deposited in the standing urine. Diagnosis.—From nephritis passive renal congestion may be differ- entiated by the comparative absence of albumin, casts, dropsy, and uremia, and by the undiminished quantity of urea. Prognosis.—This depends upon the primary cause. Chronic con- gestion may pass into chronic nephritis. Treatment.—Rest and a light and easily assimilable diet, together with cardiac tonics and diuretics, are indicated. The infusion of dig- italis serves a good purpose by increasing the quantity of urine and clearing it of albumin. Basham's mixture is a useful adjuvant. EMBOLIC INFARCTIONS. Anemic and hemorrhagic infarctions of the kidney are of pathologic rather than of clinical significance. Cicatrices may result from these infarctions, giving rise to the "embolic contracted kidney." Very rarely the sudden appearance of a slight amount of blood in the urine, associated with cardiac disease and possibly Avith a sudden seA'ere pain over the loin, may point to hemorrhagic infarction. SPECIAL PATHOLOGIC STATES OF THE URINE. HEMATURIA. Definition.—The presence of blood in the urine. Etiology.—(1) Local or renal causes of hematuria include conges- tion, acute inflammation of the kidneys, and acute exacerbations of chronic nephritis, embolic hemorrhagic infarction, renal calculi and HEMATURIA. 935 pyelitis, tuberculosis, traumatism, and parasites (the filaria sanguinis hominis and distoma haematobium (Bilharz). (2) Affections of the Urinary Tract.—In the ureter, calculi or lacera- tions due to traumatism, as in protracted and complicated abdominal sections; in the bladder, calculi, malignant tumors, acute cystitis, ulce- ration and rupture of varicose veins at the vesical neck; and in the urethra, gonorrhea, calculi, parasites, and traumatism,—may all cause hematuria. (3) General Diseases.—Acute specific fevers and certain blood-dys- crasiae (purpura, scurvy, hemophilia, malaria, and leukemia) may produce hematuria. Malarial hematuria in mild form is not an uncommon feature of paludism in the Middle States of this country, and may occur after the manner of intermittent malarial paroxysms. That due to the renal congestion of chronic heart-, lung-, or liver-disease is not a marked con- dition, and has not been of frequent occurrence in my experience. Senator describes an interesting and unusual form of hematuria that is sometimes seen in young persons whose health may be quite fair, the blood often appearing paroxysmally and without apparent cause ("renal hemophilia"). Hematuria may be also a manifestation of vicarious menstruation. Endemic hematuria, so called, is that variety found in some of the tropical regions where the distoma haematobium (a trematode Avorm) abounds. Diagnosis.—This has for its object the discovery (1) of blood in the urine, and (2) of the source of the hemorrhage. Bloody urine varies in color according to the quantity of blood present, to its condi- tion (coagulability), disposition, and the length of time present in the urine. A light reddish tinge may indicate a slight quantity of blood. A dark coagulum may be at the bottom as a sediment, Avith small clots floating above in a deep-red, turbid layer, above which, again, the urine may shoAv but the slightest tint of red. Or the urine may have a smoky- red or chocolate-hued appearance. Microscopically, the blood-corpuscles are readily discovered, establishing the diagnosis from hemoglobinuria, in Avhich condition they are absent. When red corpuscles are associated with tube-casts, renal hemorrhage may be positively diagnosed. In ammoniacal urine or in urine of low specific gravity the corpuscles are very pale and shadoAvy (dissolved hemoglobin). After remaining in ordinarily acid and diluted urine they lose their disk-like shape and swell into spheres of a smaller diameter. Urine containing blood ahvays shows the presence of albumin. Chemically, the blood-pigment may be detected by Heller's test, which consists in adding liquor potassse, boiling the urine, and observ- ing the flakes of precipitating phosphates, which become reddish-yellow or broAvn from the hematin-crystals as they fall. The guaiacum test is also used. The spectroscope is sometimes employed to discover the bands produced by the blood coloring-matter. The source of the blood in hematuria is of great diagnostic and therapeutic importance. In renal hemorrhage the blood is thoroughly mixed with the urine, giving a uniformly red or brown color, as in hemorrhagic nephritis. Blood-casts and leukocytes may also be found. The disease causing hematuria may be traced sometimes by a study of the 936 DISEASES OF THE URINARY SYSTEM. urine; thus, in cases of valvular cardiac disease the sudden appearance of hematuria would indicate infarction of the kidney. The discoverv of a few red blood-corpuscles in a concentrated urine Avould point to renal congestion. In profuse renal hemorrhages clots representing moulds of the renal pelves and of the ureters may be discharged. Blood from the ureters is usually moulded in clots in the shape of curved cylinders, and appears like small dark Avorms in the urine. Casts from the ureters are often secondary to hemorrhages; in such cases the hematuria may alternate with the passage of clear urine, OAving to temporary hemorrhages or to the blocking of the ureter on the dis- eased side. (See also Fibrinuria.) Cystic hemorrhages may be quite copious. The blood and urine are not intimately mixed, and large clots settle on standing. The first por- tions of urine discharged may not be bloody, while the last portion may consist of pure blood; again, on washing out the bladder blood-tinged urine comes away, Avhile this is not the case if the hemorrhage comes from the higher portions of the urinary passage. Finally, urethral blood is discharged in advance of the urine, and either comes away freely or may be "milked out" independently of urination. The endoscope has been used successfully to determine the source of the hemorrhage. It is especially useful in women. It is also possible with this instrument to determine Avhich kidney is affected. HEMOGLOBINURIA. Definition.—The presence of blood-pigments, especially methemo- globin, in the urine. Etiology.—The direct cause of hemoglobinuria is a condition of the blood in which, as a result of the dissolution of the red corpuscles, the hemoglobin is set free and is excreted by the kidneys. (1) The causes of the hemolysis are principally toxic, and include the following: (a) Poisons (carbolic and pyrogallic acids, potassium chlo- rate, naphtol, phosphorus, arseniuretted hydrogen, and carbon dioxid). (b) The ingestion of poisonous fungi or of tainted edible mushrooms (Helvetia cesculenta). (c) The poisons of certain infectious diseases (scarlatina, typhus and typhoid fevers, yelloAv fever, syphilis, scurvy, purpura), (d) Extensive burns, the absorption of hemorrhagic effusions, and the transfusion of animal blood, (e) Rarely it may be due to ex- posure to cold and to violent physical exertion. (/) Finally, there is the so-called epidemic hemoglobinuria (Winckel's disease) that occurs in the new-born. (2) Paroxysmal hemoglobinuria, a rare and interesting variety, may occur without any apparent cause in persons enjoying otherwise good health. It appears thus distinctly as an independent disease. Some of these cases, however, have been attributed to a peculiar susceptibility to cold (generally or locally applied) and to marked exertion; especially is this the case in adult white males. It is held by some to be a manifestation of Raynaud's disease, and by others to be the result of syphilis. (3) It appears as a symptom of malaria (which acts like the other infec- ALBUMINURIA. 937 tious diseases) in the southern part of this country, where the pernicious varieties of malarial toxemia are most common. This is termed malig- nant malarial hemoglobinuria. In Africa it is called black-water fever. Symptoms.—These are generally the symptoms of the condition that accompanies hemoglobinuria. In paroxysmal hemoglobinuria the attacks are usually sudden, brief in duration, and sometimes intermit- tent, especially when of malarial origin. Jaundice may be an associ- ated symptom. The hemoglobinuria seldom lasts for more than two days, though very grave cases take on the aspect of a pernicious mala- rial attack. There may be lumbar pains, chills and fever, and gastric disturbances. Urticaria and purpura have also been noted, as has anemia in cases in Avhich frequent attacks have taken place. Diagnosis.—This is made by an examination of the urine. Macro- scopically, it is of a red-brown color, slightly turbid, with a reddish- brown or brownish-black sediment. The reaction is usually acid, and the specific gravity slightly loAvered. The microscopic features that distinguish hemoglobinuria from hematuria are variable. In the former condition few or no red corpuscles are present, and the few that may be seen are usually colorless (" shadows ") or fragmentary. Small flakes or granules of disintegrated hemoglobin are found, and are broAvnish-black in color. There may be also broAvn-tinged casts and epithelium. Chemically, the urine is found to contain albumin, for the discovery of which Heller's and the "guaiac" tests for blood-pigment may be tried. The former has been described in the preceding discussion of Hematuria. The guaiac test consists in overlaying with urine a mixture of the tincture of guaiac and hydrogen peroxid or the oil of turpentine (equal parts). When the blood-coloring matter is present, an indigo-blue ring is formed above a Avhite resinous deposit. When shaken a lighter blue color develops throughout the contents. By means of the spectroscope the three absorption-bands of methemoglobin may be seen (red, green, and yellow). The blood-serum in hemo- globinuria may be somewhat red-tinged on account of the dissolved hemoglobin. The hemoglobinuria is further marked by the aplasticity of the red corpuscles, by their pallor, by poikilocytosis, and by the presence of the irregular flakes of hemoglobin. The prognosis of hemoglobinuria depends upon the cause. It is favorable in the ordinary paroxysmal form. Malignant malarial hemo- globinuria, however, is often fatal. The treatment consists primarily in rest in bed. The application of dry cold to the loins is useful, and the hypodermic injection of ergotin is to be recommended for trial. Internally, such hemostatics as the extract of hamamelis virginica, the extract of hydrastis canadensis, gallic acid, lead acetate, ergot, and opium may be used. Hemoglobinuria is rather intractable. During the paroxysms ex- ternal warmth is needed, along with hot drinks to encourage perspira- tion. In malarial cases quinin, and in syphilitic the iodids, should be administered. ALBUMINURIA. Definition.—The presence of albumin in the urine. Pathology and Etiology.—The immediate cause is the escape of 938 DISEASES OF THE URINARY SYSTEM. the normal blood-constituents, serum-albumin and serum-globulin, from the vessels into the renal tubules. This transudation of albumin indi- cates either a transient and slight or a permanent and grave nutritional disturbance of either the epithelium lining the glomeruli or of that of the contained tufts of capillaries, or, possibly, of the membrana propria or the epithelium of the uriniferous tubules. These changes induce and offer an abnormal perviousness to the albumin of the blood. The principal causes of albuminuria are—(1) Those associated with definite lesions of the kidney ; nephritis, acute and chronic ; renal con- gestions, active and passive (the latter being secondary to chronic liver-, heart-, and lung-disease, pregnancy, or tumors) ; and certain toxemias. Among the last-named are included scarlet fever (scarlatinal nephritis) and gout. Other causes are—amyloid and fatty degeneration of the kidney, suppurative nephritis, and renal tumors (cystic kidney). Albuminuria occurs also in conditions in Avhich (2) the renal lesions are either slight or undemonstrable: (a) Thus, it is present in blood- changes, as in chronic lead-, mercury-, and arsenic-poisoning, scurvy, purpura, syphilis, leukemia, or extreme anemia, and in cases in Avhich urobilin or bile-pigment and sugar (glucose) circulate in the blood. Again, slight albuminuria may be present in pregnancy (kidney of pregnancy), in saccharin diabetes, and after etherization. In certain affections of the nervous system albumin is found in small quantity, as after an epileptic paroxysm, in tetanus, injuries to the head, apoplexy, and exophthalmic goiter. (b) The so-called accidental or spurious albuminuria is due to the presence of pus or blood; in such cases the condition is not a true renal albuminuria, since it is commonly associated with cystitis, pyelitis, urethritis, or is the result of hemorrhage from the pelvis of the kidney, from the ureters, bladder, or urethra. (c) Febrile albuminuria is of rather frequent occurrence in diseases accompanied by pyrexia, especially Avhen long continued. Among these are typhoid fever, small-pox, yellow fever, diphtheria, and even follic- ular tonsillitis and pneumonitis. The renal changes in these cases are, I believe, merely a transitory cloudy swelling in the glomeruli, which, together with the albuminuria, rarely lasts longer than the fever. (d) Other forms of albuminuria have been styled physiologic or func- tional, dietetic, intermittent, and cyclic ; in these no definite lesions of the kidney are found, and are denied by some to exist. Recent observ- ers are inclined to believe that trivial, non-progressive renal changes occur in these cases. Slight albuminuria certainly does occur in some cases after a heavy meal rich in albumin, after marked and prolonged muscular exertion, intense emotion, and cold bathing. (e) Cyclic albuminuria has come to be of greater interest and import- ance in later years, particularly as it bears upon the prognosis and upon life-insurance risks. In this variety there is a periodic appearance and absence of albumin in the urine. The albuminuric paroxysms are very variable, recurring usually after meals or on exertion, but generally being absent during rest at night or early in the morning. The albu- min is present in but small quantity, and only rarely are casts (hyaline) found. The urinary features are otherwise normal, and the accompany- ing signs and symptoms common to nephritis are absent. Cyclic albu- ALBUMINURIA. 939 minuria is most common in adolescent anemic males, of poor nutrition, neuralgic, often neurotic, and even hysteric. Under careful manage- ment these cases ordinarily recover. There is, however* a class of cases in which the albuminuria is persistent, though but a mere trace of albu- min may be detected, and neither can tube-casts be found nor are symp- toms complained of. As a rule, however, an insidious degeneration of kidney-structure may manifest itself many years later, an urgent con- dition sometimes developing. Diagnosis.—This rests upon the discovery of albumin by means of any one or more of the reliable tests shortly to be described. Since albuminuria is no more synonymous Avith nephritis than is glycosuria or polyuria Avith diabetes mellitus, it becomes important and necessary, both for prognostic and therapeutic reasons, to differentiate between the so-called functional albuminuria, the cyclic variety, and those associated with coarse and definite anatomic lesions of the kidney. Differential Diagnosis.—Inquiry and careful inference concerning the etiology of a given case must be made. Renal albuminuria is persistent and of considerable quantity, except in chronic interstitial nephritis. Tube-casts are usually present. Functional albuminuria is slight and inconstant. Tube-casts are either absent or exceedingly few in num- ber in the latter. Again, in the former variety general symptoms, as dropsy, cardiac hypertrophy, anemia, and uremic prodromes, are pres- ent. It is true that slight edema is sometimes found in cyclic albumi- nuria, but this is probably due to the marked anemia that is so often seen. In this variety of the mild albuminurias also there may be at times a considerable quantity of albumin, due to the presence of pus or blood, the microscopic elements of which, Avhen found, of course settle the question as to the origin of the albuminuria. When the quantity of albumin is disproportionately large in spurious albuminuria, a suspicion of coexisting renal albuminuria should be aroused (Striimpell). Tests for Albumin.—Two samples of urine, one of the morning before any food is taken, and one of the evening before the patient retires, should be examined. Care should be taken that there be no contamina- tion of the urine with the menstrual, leukorrheal, or urethral discharges. The smallest quantity can be detected only by its coagulum rendering the urine turbid; hence any turbidity present before the given test is made should be removed by filtration, unless this turbidity be due to urates, Avhen a little warming of the tube will render the urine clear. (1) Boiling Test.—This is the commonest and I think the most reli- able practical test for albumin. The tube is filled about two-thirds full of urine. If alkaline or neutral in reaction, a drop of acetic or nitric acid is added; an excess of acid must be carefully avoided, lest the albumin (if present) be converted into a non-coagulable form. The tube, held aslant, is then applied to the flame, and slowly revolved with the fingers, so that the upper portion of the column of urine is brought to the boiling-point. A comparison of this with the lower portion of the urine is made. Any turbidity is due to albumin or phosphates. If albumin, adding a few drops of nitric acid will increase and thicken the coagulum; if phosphate, the opaqueness Avill be cleared at once. (2) Heller's Nitric-acid Test.—This is easily performed, and is both delicate and satisfactory. About 1 c.cm. of nitric acid is poured into a 940 DISEASES OF THE URINARY SYSTEM. tube, and some urine is allowed to flow slowly from a pipet and settle upon the acid. The presence of albumin is indicated by a Avhite ring at the point of contact of the two liquids. Uric acid, urates, and certain urinary coloring-matters form a pink or deep-red ring or zone; this forms, as a rule, above the juncture of the acid and urine. Hemialbu- mose also gives a white zone, but does not respond to the boiling test as does serum-albumin. (3) Johnson s Picric-acid Test.—To filtered urine in a test-tube are slowly added a few drops of a saturated watery solution of picric acid. Immediate turbidity indicates albumin. Some authorities prefer that a dram or two (4.0-8.0) of the yellow fluid be placed gently on the surface of the urine, Avhen, if albumin is present, a Avhite zone at once is appa- rent, together Avith a haziness that spreads doAvnward Avith the diffusion of the liquids. Heating emphasizes the evidence of the test, which is extremely sensitive. (4) Roberts' nitric-magnesium test is also very delicate. It consists in using the following mixture, just as in Heller's test: one volume of concentrated nitric acid, added to five volumes of a saturated solution of magnesium sulphate. (5) Trichloracetic-acid Test.—This will discover minute traces of albumin, but has the disadvantage that it responds to nucleo-albumin as well as to serum-albumin. A feAV crystals may be dropped into the urine, or a saturated solution may be used after the tk contact method," when, if albumin be present, a white coagulum forms. This and the Geisler test-papers (Vierordt) constitute portable and handy tests. (6) The acetic-acid and potassium-ferrocyanid test is also valuable and minutely sensitive. The urine is first made decidedly acid Avith acetic acid. A feAV drops of a freshly prepared solution of potassium ferrocyanid are then added, and if either albumin or hemialbumose be present, it will be precipitated. (7) Quantitative Test—Esbach's Albuminometer.—This consists in using a graduated test-tube, into which definite amounts of urine and a reagent composed of 10 parts of picric acid, 20 of citric acid, and enough water to make 1000 parts are carefully mixed by reversing several times the stoppered tube. After allowing this to stand about twenty-four hours, the height of the precipitated albumin is read off on an etched scale, which will indicate approximately the parts per thousand. Not less than 0.5 parts per thousand can be estimated correctly, however. Should there be a hematuria, if the percentage of albumin by Esbach's method, divided into the number of red cells per cubic centimeter of urine, is less than 30,000, it suggests a purely hematuric albuminuria; if greater, it suggests an independent albuminuria (Goldberg). Prognosis.—Etiologic considerations bear heavily in this matter. Functional abuminuria is of favorable import, as a rule. The febrile, hemic, cyclic, and paroxysmal varieties usually clear up with convales- cence and with advancing years (in the latter case). The persistence of albumin in these cases, hoAvever, even in slight amounts or at vari- able periods, should cause suspicion, since there must be some glome- rular renal change to account for the disorder, the tendency of Avhich is to progress steadily and insidiously. Especially is this true when there is associated a gradually increasing arterial tension. The presence of INDICANURIA. 941 tube-casts is conclusive of structural change in the kidneys, marked by degenerations and by exudative and productive inflammation, either acute or chronic. PEPTONURIA AND ALBUMOSURIA. True peptone (Kiihne) has never been demonstrated in the urine. The so-called peptones discovered by Devoto's and other methods are really albumoses, and the term albumosuria should be substituted for pep- tonuria. These albumoses (proto-, deutero-, hemi-) are found in acute suppurations or when resolution of inflammatory effusions is going on, as in lobar pneumonia. They may be found also in acute rheumatism, scorbutus, and in certain forms of metallic and ptomain or bacterial poisoning. Albumosuria may be suspected when, after negative results with the boiling and nitric-acid tests, cold acetic acid produces a cloudi- ness. This suspicion may be confirmed by the biuret test, as follows: Any albumin that is present must first be coagulated and removed. Then, after placing some Fehling's solution in a test-tube, an equal quantity of urine is allowed to come in contact Avith it, when, if albu- moses be in the latter, a rose-pink zone or halo appears at or near the point of contact. Hemialbumose is formed in the urine in osteomalacia, in chronic suppurations, and in sarcomatous disease of the spinal cord, though the clinical or diagnostic significance of the substance has not been fully determined as yet. INDICANURIA. Definition.—The presence of a pathologic quantity of indican in the urine. Indican occurs in the urine in health in very small quantities as a colorless compound, and is, chemically speaking, indoxyl-potassium sulphate. Pathology and Etiology.—Indican is increased abnormally in the urine by any disorder Avhereby large quantities of albuminous mat- ters are decomposed. Thus, it occurs in intestinal obstruction, especi- ally when the caliber of the small bowel is diminished from any cause so as to produce a stagnation of the contents and a consequent decom- position from bacterial action. Under such circumstances indol and phenol are formed. The former, being absorbed and oxidized into in- doxyl, finally appears in the urine in combination with potassium sul- phate. Acute peritonitis, obstinate and chronic constipation, wasting diseases, and cachectic conditions in Avhich there is a considerable de- struction of albuminoids (as in Addison's disease, neoplasmata, cholera Asiatica, and empyema) usually have an associated indicanuria. An increase of the aromatic sulphates in general, or an increase in pro- portion to the fixed sulphates, is especially significant of intestinal pu- trefactive processes. Since the pancreatic secretion peptonizes the pro- teids from which arise leucin and tyrosin, and these in turn are decom- posed into skatol, indol, and phenol, it is stated (Piseuti) that any ob- struction preventing the Aoav of the pancreatic juice into the bowel 942 DISEASES OF THE URINARY SYSTEM. would be reflected in a diminished quantity of indican in the urine. On the other hand, any epigastric tumor suspected of pressing upon the small intestines Avould be accompanied Avith indicanuria. Diagnosis.—This depends upon the demonstration of indican by adding strong oxidizing agents, which decompose this product and set the indigo or pigment free. At times sufficient oxidation of the indican has taken place in the urine before any chemical test is applied, so that a bluish tinge is given thereto. This may be seen in urine that has been standing for some time, the sediment giving a bluish reflection, or there may be a blue-turbid film on the surface. In the urine of indican- uria, moreover, where putrefaction is marked, a pronounced blue-black color may be present. Tests.—Jaffe's well-knoAvn test consists in mixing equal volumes of urine and hydrochloric acid, and then adding, drop by drop, a concen- trated solution of chlorinated lime, shaking the tube after each ad- dition. A strong indigo-blue color appears if there is much indican. A good modified test is the use of fuming nitro-hydrochloric acid and urine (equal parts) and a saturated solution of chlorinated potash, used as in the above method. A blue-black cloud or ring appears below the surface. If a few drops of chloroform are then added and the mix- ture is agitated slightly, a blue color settles at the bottom, OAving to the chloroform carrying with it the oxidized indican. PYURIA. Definition.—The presence of pus in the urine. Etiology.—Pyuria is due to (1) suppurative inflammation along some portion of the genito-urinary tract, or (2) to the rupture of adjacent ab- scesses into the tract. According to the source of the pus the urinary manifestations differ in a more or less characteristic manner. Pyelitis and Pyelo-nephritis.—Pus from the pelvis of the kidney may be due to calculous, tuberculous, or other irritation. It is associated at times Avith the "railed" or transitional epithelium usually seen early in the case. In pyelo-nephritis casts may indicate renal involvement, although it should be borne in mind that in abscess of the kidney pus may be discharged continuously Avithout the appearance of any casts in the urine Avhatsoever. One such case came to necropsy under the ob- servation of H. S. Anders, in Avhich small uratic calculi Avere dis- charged now and then for several years. Later, several larger stones were removed from the bladder by Willard by suprapubic cystotomy, in the hope that by drainage and irrigation of the bladder the marked pyuria might subside or cease. The abdominal opening healed in a few months, and, whilst bladder-symptoms were absent after removal of the calculi, pyuria persisted. Death having occurred suddenly from coro- nary-artery disease and interstitial myocarditis, it was found postmortem that a large abscess occupied the loAver third of the left kidney, which was filled with small, dark, and irregularly-shaped calculi. A thick pyogenic membrane surrounded the purulent and calculous contents. No casts were found at any time during life, though repeated exami- nations Avere made, and, remarkable as it seems, renal symptoms Avere altogether absent. CHYLURIA. 943 The pyuria is sometimes intermittent, one ureter becoming tempor- arily occluded (on the side of the disease), the clear, normal urine from the healthy kidney passing until the ureteral obstruction is relieved, Avhen pus again appears. Purulent urine from the kidney is usually acid in reaction, except Avhen the pyelo-nephritis is secondary to cystitis, when it is mbre apt to be alkaline and to contain a decided quantity of mucus. Cystitis.—Pyuria in this affection is fetid in most cases. Bladder- symptoms are marked. The urine is alkaline, and a stringy, tenacious muco-pus comes Avith the last portions. Triple phosphates are often found. The pus and urine are not so intimately mixed as in pyelonephritis. Urethritis.—The pus is in small quantities, is passed in advance of the urine, and can be "milked out" from the male urethra. There is usually a history of gonorrheal infection, and the gonococcus may be demonstrated in most cases. Rupture of contiguous abscesses into the urinary tract is accompanied usually with a sudden discharge of a large quantity of pus in the urine, preceded by symptoms of abscess elsewhere, as in the pelvis or right iliac fossa (suppurative appendicitis) or perinephritic abscess. The pyuria disappears as abruptly as it came on, or lasts but a feAv days, lessening gradually until there is a complete cessation. The strongylus gigas in the pelvis of the kidney causes pyuria as Avell as hematuria. Diagnosis.—Pus gives a greenish-yelloAv or yelloAvish-Avhite tinge to the urine and sediment, the latter very often becoming very tenacious or jelly-like from the presence of mucus. It may resemble a phosphatic precipitate, as in cystitis; the latter, hoAvever, is white, lighter, more gran- ular, and not so thick or tenacious. Microscopically, a positive diagnosis is made by the discovery of pus-corpuscles (or leukocytes) with their granular protoplasm, Avhich has the faculty of clearing up and shoAving one or more nuclei upon the addition of acetic acid. The corpuscles are either more or less swollen and clear, or opaque, granular, or even nucleated, according to their number, the length of time in the urine, and the degree of alkalinity or acidity of the latter. The greater the change in the urine, the more marked the change in the corpuscles. A few phosphatic crystals may be seen, and epithelium more or less cha- racteristic of the seat of suppuration is present. Chemically, there is slight albuminuria, a marked amount of albumin usually indicating renal disease. Nephritis may be diagnosed in con- nection with pyuria by the discovery of casts. On the addition of liquor potassse to urine containing pus the latter is converted into a clear gelatinoid substance; mucus, on the other hand, becomes thin and flocculent. Mucus may also be distinguished from pus by its failure to react to cold nitric acid, whilst the albumin of purulent fluid coagulates. CHYLURIA. Definition.—The presence of chyle in the urine. Etiology.—This interesting condition may be either parasitic or non-parasitic in origin. The former type is more common in the tropics, and is caused by an engorgement and rupture of the bladder or renal lymph-vessels, due to obstruction of the larger branches of the thoracic duct or in the duct itself, by the filaria sanguinis hominis (vide Filaria- 944 DISEASES OF THE URINARY SYSTEM. sis). The latter form, the pathology of which is not definitely known, is occasionally found in temperate regions. It is held to follow injuries to the lymphatic ducts, and may be associated with pregnancy. Diagnosis.—The urine is increased in quantity, and has a milky turbidity (galaeturia) due to the emulsified fat. After standing for a time a light coagulum settles to the bottom and a creamy pellicle of fat rises to the surface. The sediment contains also the fibrin of the chyle. Some- times as much as 2 or 3 per cent, of fat is present (lipuria); this may be tested by agitating a portion of the urine with ether, whereupon the turbidity disappears. Owing to the serum-albumin in the chyle, the various tests for that substance Avould show traces of its presence in chyluria. Hematuria may be associated with chyluria, especially in parasitic cases, in which case the blood comes from ruptured veins and tinges the urine accordingly. Microscopically, chyle-containing urine resembles milk in its millions of fine granules and fat-droplets. Prognosis.—Chyluria is intermittent in its appearance, correspond- ing to the times of rupture of the vesical lymphatics, and may last for years. The prognosis of non-parasitic chyluria is good as to life, but unfavorable as to cure. CHOLURIA. Definition.—The presence of bile-pigment in the urine. Etiology.—Choluria may be caused by any disease, local or general, in which jaundice is a symptom. Diagnosis.—Bile-stained urine has a color varying from a green- rsh-yellow to a broAvnish-green or brown-black, resembling porter. When shaken its foam assumes a characteristic yellow or green ish-yelloAv color. White filter-paper dipped in the urine is stained yellow. Tests.—The chloroform test consists in adding this substance to the urine and allowing it to settle to the bottom of the tube. If bile or pigment be present, the gravitated chloroform will be colored yellow. Gmelin's test is most commonly employed, though it is not the most delicate. A few drops of urine and nitric acid are allowed to run together on a white porcelain plate; if bile-pigment (bilirubin) be con- tained in the urine, a play of colors ensues, the green predominating, fol- lowed by the blue, violet, and red, each shade representing a new form of pigment. The first color noticed (green) corresponds to the biliver- din or normal bile-pigment of herbaceous animals. This oxidation of bilirubin into biliverdin is better accomplished by nitric acid containing a little nitrous acid. Hence, the test may be improved by adding enough fuming nitric to ordinary nitric acid to form a yellow trace of the nitrous acid. This may be placed in a test-tube or wine-glass, and some of the urine added gently from a pipet. Bile-pigment will be indicated by successive rings of green, blue, violet, and red from above dowmvard; this occurs, however, only when the bile-pigment is present in consider- able quantities. Rosenbach's test is a modification of Gmelin's, and is more distinct. The urine is first filtered, and a drop or two of the nitric-nitrous acid is then poured upon the filter-paper, when the characteristic colored rings will appear if bile be present. According to Penzoldt, the Gmelin- Rosenbach test is made more distinct by acidulating the filtrate with UROBILINURIA—GLYCOSURIA. 945 acetic acid and pouring a thin layer into a white shallow dish. The acetic acid assumes a greenish-yelloAV, and later a green, or even a blue- green, shade if bile be in the urine. This reaction is quickened or in- tensified by the application of heat to the liquids. In the Marechal-Rosin test a mixture of one part of the tincture of iodin and ten parts of alcohol is spread in a deep layer over the suspected urine in a test-tube or glass. A grass-green ring forms at the point of contact in choluria. Bile-acids.—These are principally the glycocholic and taurocholic acids. Traces are found in normal urine, and their clinical significance or diagnostic importance, as far as is knoAvn, is practically nil. When testing for bile-acids the Stranburger modification of Petten- kofer's method may be used, as folloAvs: " After isolation cane-sugar is added to the extract, which is then filtered. A drop or two of strong sulphuric acid is spread on the dried filter; a violet or purple color appears" (Musser). Other constituents of the urine in choluria of long standing are slight quantities of albumin and icteric or yelloAv bile-stained hyaline or finely-granular casts. A point in differential diagnosis should be noted in connection with the fact that certain drugs, as rhubarb and santonin, when given intern- ally, may produce a discoloration of the urine similar to that caused by the presence of bile. On agitation, however, there will be no yellow foam and no reaction to the tests for bile, while the addition of liquor potassse causes a red color. UROBILINURIA. Definition.—The presence of pathologic quantities of urobilin in the urine. Urobilin is the principal coloring-matter of the urine, and hence is present in normal urine in small quantity. It is derived from hematoidin or bilirubin as a product of the reduction of these substances in the tissues and blood-vessels. When present in large quantities urobilin gives to the urine a red- brown color. This is seen in fevers, varying in depth of shade accord- ing to the degree of pyrexia; also in diseases of the liver, after hemor- rhagic effusions (due to resorption), in the hemorrhagic diathesis, and in progressive pernicious anemia. When deposited in the tissues it gives rise to a form of jaundice— in which there is a brownish discoloration of the skin—called urobilin- icterus. Diagnosis.—The presence of urobilin is best detected by a spectro- scopic examination. A marked absorption-band between Frauenhofer's lines (f and b), fading off from the green into the blue, is characteristic. Chemically, the addition of a few drops of a watery solution of zinc chlorid to the urine will cause the peculiar red-green fluorescence of urobilin to appear. GLYCOSURIA. Definition.—The presence of sugar (glucose) in the urine. Nor- mally, a trace of sugar is present in the blood (glykemia), but it may be doubted Avhether any is excreted in the urine in health, except after 60 946 DISEASES OF THE URINARY SYSTEM. the ingestion of an excess of food rich in saccharine or starchy sub- stances. Uric acid may give the same reactions as glucose in the urine. Etiology.—The causes of glycosuria may be enumerated as follows: (1) Diabetes mellitus—the most common. (2) Certain diseases, like gout (intermittent glycosuria), cholera, typhoid, typhus, and scarlet fevers, whooping-cough, diphtheria, malaria (paroxysmal glycosuria), tetanus, phthisis, hepatic cirrhosis, and organic nervous diseases, espe- cially those affecting the medulla and involving the floor of the fourth ventricle. Glycosuria may also result from psychic causes, as excessive mental exertion, extreme emotional activity (grief, Avorry, and shock), from injuries, as cerebral concussion and hemorrhage, and fracture of the skull, from apoplexy, cerebro-spinal meningitis, and after epileptic parox- ysms. (3) Pregnancy. (4) Certain toxic agents cause a transient gly- cosuria, among these being carbon monoxid, morphin, hydrocyanic acid, amyl nitrite, curare, chloral, alcohol, mercury, arsenic, turpentine, phlo- ridzin, and various coal-tar derivatives, as salicylic acid and salol. This source of glycosuria has been experimentally demonstrated in dogs bv Paul Gibier of the NeAv York Pasteur Institute. (5) Obesity may cause a temporary glycosuria (lipogenic). (6) Pancreatic disease (chronic in- terstitial pancreatitis and, less commonly, pancreatic calculi, carcinoma, and cysts). (7) Glycosuria may occur in exophthalmic goiter, and, ac- cording to Lyman, may be present for a short time in (8) diabetes insip- idus. (9) Heredity probably plays a part in predisposing to glycosuria in certain cases, particularly in the permanent affection. (10) Dietetic glycosuria may at times be noted. Diagnosis.—The daily quantity of the urine of typical glycosuria— i. e. Avhen masking saccharine diabetes—is greatly increased (60 fluid- ounces—2 liters—and over per diem); it is of high specific gravity (1025 and over), of a clear, pale-yellow color, a "ripe-fruit" odor, a SAveetish taste, and an acid reaction that is intensified on standing, OAving to the fermentation of the sugar. Albuminuria is not infrequently associated Avith glycosuria, and the albumin should be removed before testing de- cisively for sugar. Again, since urine of high color, heavy density, and marked acidity often contains uric acid, and since this substance, as already pointed out, responds to the sugar tests, care must be exercised lest a false conclusion be drawn. Tests.—The most important of these depend mainly upon the pe- culiar property of glucose in reducing the blue oxid of copper to the orange or red suboxid. It must be remembered that other metallic sub- stances are similarly decomposed. (1) Fehling's Test.—I1 wo solutions are used, equal parts being mixed to form the Fehling's solution, as folloAvs : Solution I. contains 34.61 gm. of cupric sulphate, dissolved in enough Avater to make 500 c.cm. Solution II.: 173 gm. of Rochelle salt are dissolved in 480 c.cm. of sodium hydroxid (sp. gr. 1.11); this is then diluted with water up to 500 c.c. Application: Dilute 1 c.c. of Fehling's solution (about 10 drops of each of the above solutions) Avith about 1 dram (4 c.c.) of Avater in a test-tube, and heat to the boiling-point. If the clear blue color re- mains, the solution is ready for use ; should it change color, however, the solution is unfit for use and should be discarded. The suspected GLYCOSURIA. 947 urine is added, drop by drop, heating occasionally, Avhen, if glucose be present, the blue color will be discharged by a yelloAv turbidity, Avhich increases until finally a deep-yellow or orange red precipitate falls. Bluish-Avhite flakes and a greenish discoloration of the mixture simply indicate cupric hydroxid, and not glucose. This test serves for the detection of .001 per cent, of glucose (Wormley). (2) Trommer's Test.—To about 5 c.c. of urine in the tube add one-third or one-half its volume of potassium or sodium hydroxid, and then, drop by drop, add a 10 per cent, solution of cupric sul- phate. If a bluish-white precipitate falls, either filter or agitate the liquid until it assumes a slight and uniform turbidity ; then heat, and, if sugar be present, a yelloAv or red deposit of cuprous oxid falls: .01 per cent, of glucose may be detected in this Avay. Besides uric acid, there are certain other substances Avhich Avhen present in urine make the copper tests fallacious by reducing the cupric to cuprous oxid. Among these are mucin, lactose, pyrocatechin, hydrochinon, bile-pigments, glycosuric acid, the products of elimina- tion after the ingestion of chloral (urochloric acid), and benzoic and salicylic acids. (3) Bbttger's Bismuth Test.—This may be performed as a counter to the copper tests. Albumin, hoAvever, interferes Avith the test on account of the contained sulphur, Avhich forms a black bismuth sulphid : hence, if present, it must first be removed. This may be done by acidulating the urine Avith acetic or nitric acid, boiling, and then filtering. Bott- ger's test is then made by adding to the non-albuminous urine or to the filtrate from one-half to an equal quantity of liquor potassae and a feAV grains of bismuth subnitrate. Boil for several minutes, and if glucose be present black metallic bismuth will be precipitated. (4) Nylander's reagent may be employed. This consists of 2 parts of basic bismuth nitrate and 4 parts of sodium tartrate to 100 parts of an 8 per cent, solution of caustic soda. One part of the reagent is boiled Avith 10 parts of the urine for a feAV minutes, Avhen a change from the original to a broAvn or black color will indicate the presence of glu- cose. This test is quite distinct, but has the fallacy that is common to all the bismuth tests, of forming a black precipitate with the sulphur compounds. (5) Fermentation Test.—Though not ahvays convenient to apply, this is, nevertheless, a most reliable test. It depends upon the action of yeast in breaking up glucose into alcohol and carbonic-acid gas (carbon dioxid). It is performed easily by adding a small piece of compressed yeast to the urine in a test-tube, inverting the latter in a dish of the same, and standing aside for twelve to twenty-four hours, the temper- ature being kept at about 80° to 100° F. (26.6°-37.7° C). The evo- lution of gas resulting from the fermentation of the sugar takes place, Avith a consequent reduction of the specific gravity of the urine. The yeast may be tested simultaneously for its purity and strength by pla- cing one portion in a test-tube containing about two-thirds mercury and filling with normal urine, and a similar portion in a second tube Avith mercury and a thin, watery solution of sugar or glucose; the fermenta- tion test of the suspected urine may be made at the same time, and all three tubes inverted over a dish of mercury. Obviously, the first 918 DISEASES OF THE URINARY SYSTEM. tube should not show the presence of carbon dioxid if the yeast was free from sugar ; but the second tube should show this gas to be present or the yeast was inert. Other tests, such as Moore's liquor-potassce-and-boiling test, Johnson's picric-acid test, and the phenyl-hydrazin test, are more intricate and in no way more reliable. The quantitative estimation of sugar may be made with Fehling's solution in tAvo parts, as recommended above for the qualitative test. This method is based upon the fact that the cupric oxid of 1 c.c. of Fehling's solution will be reduced by not less than 0.005 gm. of glucose. Place 1 c.c. of the solution in a test-tube and dilute Avith 1 c.c. of Avater (5 c.c. dil. sol.). Heat to the boiling-point, and add 1 c.c. of urine, and heat the liquid again. If reduction has taken place, 0.005 gm.—0.5 per cent, or more—glucose is present; if no reduction has occurred, less than 0.5 per cent, is present. If 2 c.c. urine are used before the color of the Fehling solution is discharged, there will be 0.25 per cent, glucose. If J c.c. is used, 1 per cent, is present. If Y^c.c. urine is all that is required (about 2 drops), then 5.0 per cent, of glucose is present. Roberts' differential-density method depends upon a loss in the specific gravity of the urine, due to the fermentation of glucose. Ac- cording to Roberts, each degree in specific gravity lost is equivalent to 1 grain of glucose in 1 imperial fluidounce (437.5 gr.) of urine, or one degree represents 0.23 per cent, glucose. (See works on Urinalysis.) Circumpolarization.—Finally, sugar may be determined by the sac- charimeter or polariscope. Glucose polarizes light to the right. The percentage may be calculated by reading the vernier scale indicating the degree of reflection, and multiplying the number read by the factor of the apparatus used, after making any required corrections. ACETONURIA, DIACETONURIA, AND OXYBUTYRIA. Acetonuna, diacetonuria, and oxybutyria are so closely allied with glycosuria, and especially with diabetic coma (acetonemia), that they may be considered together. In the first-named condition the urine contains acetone; in the second, diacetic or aceto-acetic acid; and in the last, oxybutyric acid. Diacetic and oxybutyric acids are products of the decomposition of acetone, and hence the importance previously ascribed to the latter, Avhen detected in the urine of diabetics, has given place to the two former, the oxidation of which yield acetone. Acetonnria may exist to a minute degree in health, the acetone being a product of the normal metamorphosis of albumin. It may be present also in—(1) diabetes ; (2) carcinoma; (3) febrile conditions ; (4j inanition; (5) psychoses; and (6) auto-intoxication. Urine that con- tains acetone in pathologic quantities has a fruity (apple-like) odor or one resembling that of chloroform. Tests.—(1) Gerhardt's original test consisted in the addition of a few drops of the tincture of the chlorid of iron, which produced a Burgundy- red color with acetone, or rather Avith the aceto-acetic acid. (2) Nitro-prussid Test.—To a fluidounce (32.0) of the urine add a dram or two (4.0-8.0) of a solution of sodium nitro-prussid (gr. v. to §j LITHURIA. 949 —0.324 to 32.0) and a feAV drops of strong aqua ammonise. On stand- ing a rose-violet color appears. According to Legal, proportionately smaller quantities of urine and the reagent may be used, and strong liquor potassae. A bright-red color develops, and fades rapidly, but upon adding acetic acid this changes to purple or violet-red (Vierordt). This is a better test. (3) Perhaps the most accurate and, at the same time, satisfactory test for acetone is the folloAving : Distil the urine with a little phosphoric acid, and add to the distillate a feAV drops of sodium hydroxid and of Lugol's solution. If acetone be present, yellow crystals of iodoform Avill form, Avith the characteristic odor. Diacetonnria and oxybutyria never occur normally. They are often associated with acetonuria in diabetes, and sometimes in fever, or occur as an independent disease (V. Jaksch). Moreover, it is believed that diacetic and oxybutyric acids are the causes of diabetic coma, and not acetone, as was held formerly. Stadelmann affirms that of like value Avith the recognition of oxybutyric acid in diabetes is the deter- mination of a marked and increasing amount of ammonia in the urine (1 gram—gr. xv—and more per diem), as indicating the imminence of diabetic coma. Diacetonuria is found to occur in certain acute diseases of children, accompanied Avith convulsions. Tests.—The presence of diacetic acid is demonstrated by the chlorid- of-iron reaction, as in the case of acetone, except that the urine is boiled previously. This is done to avoid fallacy, since in unboiled urine acetic, formic, and oxybutyric acids may strike a Burgundy-red also; in urine that has been previously boiled these do not react, while the diacetic acid does, if present. Diacetic acid is usually present simultaneously with acetone. If a portion of the urine is mixed Avith sulphuric acid and extracted with ether, diacetic acid may be inferred to be present if the extract shoAvs a chlorid-of-iron reaction that fades within twenty- four hours (V. Jaksch). LITHURIA. Definition.—A persistent excess of uric (lithic) acid and urates (lithates) in the urine. Normal urine contains about 0.4 part of uric acid to 1000 parts of urine (about gr. x—0.648—per diem), or it exists in the proportion of about 1 to 45 of urea, the principal solid constituent. The evidence of recent experimentation is in favor of the vieAv that uric acid is derived Avholly or almost wholly from a metabolic solution of leukocytes and nuclear substances generally, and that uric-acid formation is not to be regarded as an "unfinished product" in the old sense. Etiology.—The causes of lithuria, as seen in certain conditions in which this metabolic change occurs, may be put doAvn to be chiefly as folloAvs: (1) Lithemia (uricemia; uric- or lithic-acid or gouty diathesis); (2) gout and rheumatism; (3) fever; (4) leukemia and pernicious an- emia; (5) pulmonary affections in which the interchange of gases is in- terfered with ; (6) a highly nitrogenous diet. Certain other conditions of the urine may diminish its poAver of dissolving the uric acid shortly after A'oidance, and may cause a deposit that should not be mistaken for 950 DISEASES OF THE URINARY SYSTEM. an excess. Such are—(a) temporary increase in the quantity of uric acid from an over-indulgence in nitrogenous food; (b) temporary high acidity; (c) deficiency in mineral salts. Diagnosis.—The urine has a high specific gravity, a deep red-yel- low color, and a marked acid reaction, although, rarely, uric acid is formed in neutral or alkaline urine (Yierordt). On standing the uric acid is deposited in yellowish-red or " Cayenne pepper " grains, com- posed of microscopic uric-acid crystals. Chemically pure uric acid is colorless, but that deposited from urine has ahvays this yelloAvish-red appearance both to the naked eye and under the microscope. Exami- nation Avith the latter shoAvs a great variety of rhombic prisms—" Avhet- stone-shaped," "crosses," "lozenges," and other many-shaped and sized crystals—single and in agglomerations. Test.—The murexid reaction may be obtained by evaporating a little urine in a watch-glass or porcelain dish, adding a feAV drops of strong nitric acid, and heating to dryness again; this is alloAved to cool, and a drop of liquor ammoniae added, Avhen a beautiful purple shade of murexid will appear if uric acid be present. Urates.—These are increased in pathologic conditions that give rise to uric acid in excess, and are usually present Avith the latter in some quantity. It is not rare, hoAvever, in healthy individuals for a deposit of urates to occur in concentrated urine exposed to a cool atmosphere. Urates appear also in the scanty urine due to the profuse perspiration and diarrhea of renal congestion, in fever, from renal calculi, and after a meal rich in albuminous elements. Urates occur principally as acid sodium urate, calcium urate, and ammonium urate. They appear macroscopically as a flesh-colored or "brick-dust " (lateritious) sediment; this is usually abundant and very finely granular in appearance, Avhile the urine above is cloudy. It is quite characteristic that upon heating such urine it becomes clear, the urates being completely dissolved. Microscopically, the sodium and calcium salts of uric acid occur as needle- or dumb-bell-like crystals or as fine, dark, amorphous granules. Ammonium urate is found in alka- line urine, often Avith triple phosphates Avhen some putrescence has en- sued. It is seen in dark-brown or green spiculated spherules; these are sometimes called "hedge-hog" or "thorn-apple" crystals. On the addition of a drop of hydrochloric acid under the cover-glass uric-acid crystals may be seen to develop. OXALURIA. Definition.—A persistent excess of calcium oxalate in the urine. A feAV crystals may occur in normal urine that has been standing for a long time. Transient oxaluria may folloAv the ingestion of sub-acid fruits, as pears, or of vegetables containing oxalates, as rhubarb, tomatoes, sorrel, and caulifloAver. Oxaluria has been described by some English physicians as an inde- pendent disease or special diathesis in Avhich marked dyspepsia and hypochondriasis or neurasthenia are associated. The condition is better explained, probably, as one of a disturbed metabolism—particularly of PHOSPHATURIA. 951 the fats and carbohydrates—in Avhich the oxaluria and the nervous symptoms are manifestations analogous to the lithuria and the irregular gouty symptoms of lithemia. Oxalates and lithates are not infrequently found together in the urine of those subject to the gouty habit. Oxa- luria is also present in Avasting diseases, as in tuberculosis, diabetes mellitus, and in the cancerous cachexia; it may appear in catarrhal jaun- dice, spermatorrhea, also Avith the "mulberry calculi," and in general paresis of the insane. Diagnosis.—Oxalate-of-lime crystals appear in the urine in tAvo forms—most commonly as minute, regular, highly-refracting octahedra, or, more rarely, as hour-glass- and dumb-bell-shaped crystals. The octahedral crystals have two crossed axes, giving a star or enve- lope-like appearance. Oxalates sometimes give a glittering and scintil- lating effect to floating mucus in urine that has undergone fermentation. PHOSPHATURIA. Definition.—A persistent excess of phosphates in the urine. Phosphoric-acid salts may be precipitated in normal urine that has become temporarily alkaline. These acid sodium and potassium phos- phates in normal acid urine are derived from the alkaline phosphates (neutral sodium and potassium phosphates) of the blood. In normal urine 1.2 parts alkaline phosphates per 1000 and 0.8 part earthy phos- phates are appreciable. Conditions that produce an alkaline fermentation of the urine cause a deposit either of amorphous earthy phosphates or of crystalline phos- phates. They are also found in the decomposing urine of chronic cys- titis, of phosphatic vesical calculi, of paralysis, and in undue retention of urine. In this alkalinity, due to the ammoniacal fermentation of urea, ammonium carbonate reacts with the phosphates of magnesium to form the triple ammonio-magnesia phosphatic crystals, the commonest variety of phosphaturia. Here the phosphates are deposited before or immediately after the urine is passed, giving a milky appearance to the last portion. Deposits of phosphates, and especially of triple phos- phates, by no means, hoAvever, indicate an actual phosphaturia. This must be determined by chemical analysis. Amorphous carbonate of lime in small quantity may be present also if the urine is strongly alkaline and ammoniacal (Beale). The calcium phosphates are generally more abundant than the magnesian, and may be found in cases of ner- vous or atonic dyspepsia, neurasthenia, melancholia, and other debili- tated conditions. Whether or not a marked precipitate of phosphates means an excess to the detriment of nervous tissue alone has not been determined precisely as yet. Obviously, hoAvever, a certain portion of phosphates is supplied by food and the rest of the body, OAving to defec- tive assimilation and metabolism. A quantitative estimation of the daily output of phosphates shoAvs a decided increase in the quantity in Avasting diseases, as tuberculosis, leukemia, chronic articular rheumatism, and acute yelloAv atrophy of the liver. The phosphoric acid is not increased, however. The so-called "phosphatic diabetes" is characterized by polyuria, excessive phospha- turia, thirst, emaciation, and nervous disturbances (Tessier). 952 DISEASES OF THE URINARY SYSTEM. Diagnosis.—Phosphatic urine has usually a stale, ammoniacal odor, a whitish turbidity, and a copious light-colored granular sediment falls on standing. Microscopically, the calcium phosphate crystals ap- pear singly as " knife-blade," " arrow-head," or " slender wedge-shape," or in stellate clusters. Acetic acid dissolves them. The ammonio-mag- nesian phosphate crystals are transparent rhombic or triangular prisms, large and small—" coffin-lid-shaped." These also are soluble in acetic acid ; oxalate-of-lime crystals are not so. On heating phosphatic urine an increased cloudiness is produced that simulates albumin, but on acidifying, as Avith a drop of nitric acid, this is cleared up at once. LEUCINURIA AND TYROSINURIA. Definition.—The presence of leucin and tyrosin in the urine. These are strictly pathologic substances, and are usually found together. They are products of the decomposition of albumin, intermediary to the formation of urea, and are most apt to be found in the urine, along Avith biliary matters, in certain hepatic conditions. Etiology.—The principal causes of leucinuria and tyrosinuria are acute yelloAv atrophy of the liver, acute phosphorus-poisoning (in both of Avhich fatty degeneration of the liver is pathologically conspicuous), specific infectious diseases, as typhoid fever, small-pox, and yellow fever, and pernicious anemia. Diagnosis.—Of the two substances, leucin is the more soluble, and hence is rarely found in the urinary sediment. Tyrosin, on the other hand, may be discovered sometimes as a fine greenish-yelloAv deposit. Bile-pigment may be found not infrequently in urine containing leucin and tyrosin. A trace of albumin also may be present, while the urea is, as a rule, markedly diminished. Leucin and tyrosin may be de- tected by evaporating a few drops of urine on a glass slide and examin- ing microscopically. Leucin appears in the form of slightly glistening, greenish-yellow spheres that may show radiating lines and concentric rings. Tyrosin is recognized by the slender tufts of fine, needle-like crystals arranged in star- or cross-like fashion. If the residuum after evaporation be heated with a drop of nitric acid, slowly evaporated to dryness, and then touched with a drop of sodium hydroxid, the leucin, if present, will assume a yellowish-brown hue. Tyrosin becomes red in color Avhen boiled Avith Millon's reagent of mercurous nitrate, or it is demonstrated by a violet color Avhen carefully warmed Avith a little sulphuric acid, and then treated with a drop of the solution of phenic chlorid. CYSTINURIA. Definition.—The presence of an excess of cystin in the urine. Cystin in minute quantity may be found sometimes in normal urine. It contains sulphur. The causes of cystinuria have not been well made out, though hereditary influences seem to have an important bearing on the etiology ; in what manner they act, however, is not knoAvn. On account of the insolubility of cystin any marked quantity would be deposited in UREA IN URINE. 953 the urine. Cystin calculi sometimes result, though cystinuria may ex- ist without the presence of a cystin calculus. Brieger points out a probable significance in the discovery of the associated presence of ptomains with cystinuria. Thus, in certain infec- tious diseases, as intestinal mycosis, a ptomain-cystinic product is sup- posed to be formed, then to be absorbed, and finally decomposed in the urine, thus setting free the cystin. Cystitis may be caused by the action of the ptomains. Diagnosis.—The sediment is light, and not very unlike that of the amorphous urates. It is not dissolved by heat, however, though soluble in ammonia. Under the microscope cystin occurs in the form of thin, transparent, hexagonal crystals. Care should be exercised in forming a diagnosis of cystinuria that a contamination Avith iodoform be excluded, since the microscopic appearance of that substance is similar to that of cystin. On account of the sulphur contained in cystin, a test may be employed by Avhich hydrogen sulphid is liberated, as by boiling the sus- pected urine Avith a solution of lead oxid and sodium hydroxid, black lead sulphid resulting from the reaction if cystin be present. VARIOUS OTHER CONDITIONS. Urea.—This occurs in solution in the normal urine as a product of the perfect decomposition of the nitrogenous elements of food and tis- sues. In 1000 parts of urine about 20 parts are constituted of urea (2 per cent., equivalent to about gr. 450—30.0—daily). The quantity of urea is increased in the urine after the ingestion of a considerable quan- tity of proteid food ; sometimes after exertion; in acute inflammation and in fevers—either relatively or absolutely, as in pneumonitis; in diabetes and other morbid conditions in Avhich metabolism is accom- panied by an increase in the tissue-waste. In febrile states its excretion increases or diminishes Avith the exacerbations and remissions of tem- perature respectively. Urea is pathologically diminished in quantity in all forms of nephri- tis, and markedly so in uremia; in organic liver-diseases, as acute yellow atrophy; in cachectic and anemic states; and in dropsy, inanition, and allied conditions. The quantitative estimation of urea may be made according to one or more of several methods: Fowler's hypochlorite test (Avith Labarraque's solution) is perhaps the most practical for ordinary clinical purposes ; the hypobromite and Liebig's methods, both requiring special apparatus, are better adapted for the laboratory.1 Fowler's method is based upon the loss of specific gravity upon the liberation of the nitrogen of the urea. The mean specific gravity of a mixture of 1 part of urine and 7 parts of the solution of sodium hypochlorite is taken while quiescent, and is then subtracted from the specific gravity of the mixture taken after agitation several times during about tAvo hours. The difference which is due to the liberation of the nitrogen (as is shown by the effer- vescence), multiplied by the factor 0.77, gives the approximate percent- age of urea in the urine. This test, however, has a considerable range of error. 1 See works on Urinalysis. 954 DISEASES OF THE URINARY SYSTEM. Urine evaporated to a syrupy consistence and then treated with nitric acid shoAvs crystalline quadratic plates of urea nitrate. Chlorids.—About 10 parts of the chlorids of sodium and potassium in 1000 parts of urine are excreted daily. They are increased in the urine after muscular exertion, during the resorption of mechanical or inflammatory transudations and exudations, and in intermittent fevers, OAving to the destruction of the red corpuscles. Pathologic diminution in the quantity of chlorids occurs in fevers, in the nephritides, in cachectic conditions, and especially in such diseases as pneumonitis, pleuritis, and rheumatism. In the last-named class the chlorids diminish as exudation continues, and may even totally disap- pear from the urine in extensive pneumonic consolidations, to reappear again with the resorption of the exudate. Test.—The chlorids may be detected, after first removing any albu- min that may be present, by acidulating Avith a feAV drops of nitric acid (to keep the phosphates in solution), and by then adding, drop by drop, a strong solution of argentic nitrate. According to the abundance of the resultant Avhite, curdy precipitate of argentic chlorid a rough esti- mate may be made of the total quantity of chlorids in the urine. Lipuria is a term applied to the presence of fat in the urine. It may result from the steady use of cod-liver oil or of fatty food, or it may be found in pyonephrosis (Ebstein); in phosphorus-poisoning; in pro- longed suppuration; in the lipemia of diabetes mellitus; in the " large Avhite kidney" with fatty degeneration of chronic Bright's disease; in beer-drinkers; and in chyluria. Fatty urine becomes clear upon agitat- ing after the addition of ether. Lipaciduria, or urine containing volatile fatty acids (acetic, butyric, and propionic), is as yet Avithout diagnostic significance. Melanuria, or urine containing the pigment melanin, is found in cases of melanotic sarcoma. The urine is dark, either just after being voided or after some exposure and oxidation. Hematoporphyrinuria ( Urospectrin).—This term implies the presence of hematoporphyrin (iron-free hematin) in the urine. It occurs after long-continued use (even in small doses—Miiller) of certain coal-tar products, particularly sulfonal and trional. Among the symptoms in poisoning from these substances is a cherry-colored or dark blue-red urine, the abnormal appearance of the latter being due to the presence of hematoporphyrin resulting from the destruction of the red blood-cor- puscles. The urine is ahvays quite acid. According to Garod, hemato- porphyrin is a scanty though constant ingredient of normal urine. He extracts it by adding 100 c.cm. of urine to 20 c.cm. of a 10 per cent, solu- tion of sodium hydroxid. This precipitates the phosphates, which are Avashed Avith Avater and redissolved Avith rectified spirits. After acidula- tion with hydrochloric acid the solution shoAvs spectroscopically bands of acid hematoporphyrin. The treatment consists in the prompt Avith- drawal of these drugs and the free administration of alkalies. Pneumatinuria, or gas-formation in the bladder, rarely occurs. Heyse' records a case of myelitis in Avhich this condition Avas present. Fibrinuria.—In certain conditions of the genito-urinary tract, partic- 1 Zeit.f. klin. Med., 1894, xxiv. p. 130, quoted in The American Year-Book of Medicine and Surgery for 1896. THE NEPHRITIDES. 955 ularly pyelitis and ureteritis, fibrinous (and mucous) casts are found in the urine. Fibrinuria may folloAv nephro-lithiasis, as in a case recorded by v. Jaksch. Bacterinuria.—There are probably fe\v specimens of urine that do not contain bacteria. Engel has found a great variety of organisms in the nephritides, one of Avhich (a micrococcus of characteristic groAvth and properties) was present in 17 out of 31 cases, hence regarded by him as the specific cause of some of the cases in this category of diseases. This organism was found in mild types of nephritis, and Engel believes it to be responsible for many instances of the sort beginning as mild forms of "bacterial albuminuria." Lactosuria.—Lactose is found in the urine of some puerperae. Inosituria.—Inosite occurs in the urine in diabetes insipidus. Alkaptonuria.—Alkaptone is an obscure substance (so called by Bredeker) that is sometimes found in the urine of phthisical cases, or at times in that of patients Avithout any apparent local or general dis- ease. On exposure the urine darkens in color; also upon the addition of liquor potassae. It gives the sugar-reaction Avith Fehling's solution (Osier). Urine as affected by the administration of various drugs—as carbolic acid, salol, antipyrin, and potassium iodid—responds to certain chemical tests, for the study of Avhich the reader is referred to works on urinal- ysis and clinical diagnosis. THE NEPHRITIDES. Before considering the several varieties of nephritis, and especially the clinical history peculiar to each variety, it may be Avell to first de- scribe certain general manifestations of renal disease—Avhether degen- erative, exudative, or productive lesions are predominant—that are more or less common to all. Reference to these symptoms under the different forms of nephritis will, it is hoped, thus make possible a clearer appre- hension of their significance and value, as Avell as render unnecessary any further elaboration. One of these pathologic conditions has already been described—viz. (1) Albuminuria. It remains, then, to speak of (2) the Morphologic constituents of the urine in nephritis, (3) Edema (anasarca, dropsy), and (4) Uremia. THE MORPHOLOGIC CONSTITUENTS OF THE URINE IN RENAL DISEASE : CASTS, EPITHELIUM, ETC. 1. Tube-casts.—These are undoubtedly the most important morpho- logic elements in the urine of a nephritic. Albuminuria is coincident- ally present, and the occurrence together of these tAvo pathologic con- stituents furnishes indisputable evidence of renal disease. According to the nature and quantity of the casts also may be determined the cha- racter and variety of the affection of the kidneys in most instances. Casts, as their name implies, are simply cylindric bodies moulded in 956 DISEASES OF THE URINARY SYSTE3I. the renal tubules, and composed essentially of the coagulable substances in the serum exuded from the blood-vessels. The coagula of the tubules are mostly albuminous. Other morphologic elements may be mixed with casts, such as epithelium, red blood-cells, pus-cells, and the granu- lar matter and fat-droplets due to degeneration of the renal epithelium. Singly, the casts are invisible to the naked eye, but in acute nephritis they may be so abundant as to form a cloudy sediment near the bottom of the urine-containing glass. (a) Microscopically, the unmixed or hyaline cast—the commonest— appears either long or short and narrow or broad, of a clear, transparent, homogeneous substance, delicate in outline, and often shoAving ends with a cheesy—or wax-like—fracture. They may be straight or slightly curved and tortuous, Avith fine short transverse lines here and there at the borders of the cast. Rarely, a cast may be found equal to a milli- meter in length. The so-called narroiv casts are about equal in Avidth to the diameter of a leukocyte, while the medium or broad casts are from three to four times this size. They will take either the carmin or gentian-violet stain. Hyaline casts are usually associated with other varieties of casts in nephritis, though in fevers, congestion of the kid- neys, chronic interstitial nephritis, and in amyloid kidney they may occur unassociated with other forms of casts (Yierordt). (b) Granular casts are nothing more than hyaline casts with fine or coarse granules superadded. The granules represent minute, opaque particles of urates, albumin, fat, cellular debris, and even bacteria (bacterial casts). It should be remembered, however, that granular casts may be simulated by casts of coagulated albumin covered with particles of hematoidin, especially in acute nephritis. The hematoidin can be recognized, hoAvever, by the brown-yelloAv coloration. (c) Epithelial casts are hyaline casts covered with renal epithelium, or composed entirely of an epithelial conglomeration, indicating an acute desquamative nephritis. The opaque, spheric renal cells should not be confounded with swollen leukocytes. Again, the epithelial cells themselves may show evidence of granular or fatty change. (d) Blood-casts consist of coagula of red corpuscles shaped in the renal tubules, or they may be composed of soft hyaline (mucous) casts, having red blood-cells imbedded in them. These are present in renal hemorrhage and in acute hemorrhagic nephritis. (e) Waxy casts are similar in appearance to hyaline casts, though better defined, broader as a rule, and of an opaque, slightly yelloAvish tint. They often show broken ends. It has been suggested that they may be the products of a metamorphosis of hyaline casts because of their occurrence in various forms of nephritis, and since they do not merely indicate amyloid disease of the kidney as was formerly held. They may, hoAvever, sometimes show the amyloid reaction Avith iodin and potassium iodid, and are ahvays suggestive of serious renal disease. (/) Fatty casts are such as have left upon and in them fat-droplets or granules, Avhich, if abundant, are indicative of fatty degeneration of the kidney. Cells shoAving granulation from fatty change may be seen simultaneously. Rolled casts (made by sliding a cover-glass over a specimen of urine) of urates, cells, and debris should not be mistaken by beginners for DROPSY OF RENAL DISEASE. 957 genuine tube-casts. The same may be said of mucous cylindroids and foreign substances. Nephritis may exist Avhen the casts are ahvays to be found, varying in numbers only, while albuminuria may be incon- stant or intermittent. 2. Epithelium.—Renal cells are found in the urine of those forms of nephritis that are characterized by a catarrhal or desquamative and exudative process in the tubules. Epithelial cells from the kidney are polygonal or spheric in contour, with an indistinct cell-Avail; they have a large oval nucleus, and are either abundantly granular or show a fatty change. These cells are about the size of the white corpuscle. 3. Leukocytes.—Only Avhen attached to casts can it be positively affirmed that leukocytes are of renal origin (Striimpell). 4. Red Blood-corpuscles (vide Hematuria, p. 934).—In acute hem- orrhagic nephritis and in severe renal congestion free red blood-cor- puscles are generally to be found. 5. Fat-globules and granular, fatty-degenerated cells are seen espe- cially in the subacute and chronic forms of nephritis with fatty degen- eration of the proliferated epithelium, or in the fatty stage of large white kidney. DROPSY OP RENAL DISEASE. Since, as in other conditions, renal dropsy or edema is an abnormal accumulation of Avatery fluid transuded from the blood-vessels into the cellular tissues and lymph-spaces, the question arises, " What is the rationale of its development in nephritis?" On the ground that the renal secretion consists principally of Avater, and that in most forms of nephritis the urine is diminished, it Avas formerly held that the dropsy was due to the saturation of the tissues Avith the Avater that Avas not excreted by the kidneys. This theory is not fully tenable, hoAvever, for there are some cases of edema unaccompanied by any diminution in the daily quantity of urine; on the other hand, certain instances of renal disease in Avhich there is a state of almost anuria show no evidence of dropsy Avhatever. Indeed, it has been suggested (Striimpell) that edema is the cause rather than the result of a diminished elimination of water by the kidneys, this view corresponding in part Avith Cohnheim's assertion that the increased transudation is due to changes in or injury to the endothelium, increasing the perviousness of the blood-vessels. The failure of any one theory as advanced above to explain the etiology and pathology of edema has justified the proposal of another and un- doubtedly a more plausible one by Landerer—viz. that the relaxation of the tissues (Avhich may be caused by the increased transudation of stasis, or by hyponutrition from hydremia), and their consequent loss of elas- ticity, prevent that forcing of the lymph into circulation that exists in the normal state, and as a result a Avatery infiltration of the tissues is permitted. The loss of elasticity or power of resistance in edematous tissues is quite apparent under the skin, and affords a positive means of diagnosis in the pitting produced by the pressing finger. The dropsy of the nephritides may be either slight or marked, local or general (anasarca), and sudden or slow in onset. It is purely renal in origin perhaps only in acute Bright's disease or in the earlier stages of chronic Bright's disease. In all forms of chronic nephritis the dropsy 958 DISEASES OF THE URINARY SYSTEM. may be due, in part, to the venous stasis of cardiac incompetencv. In chronic interstitial nephritis, especially, edema is slight, and usually is the result of Aveakness and dilatation of the heart, increasing pari passu with the latter. I desire to mention here those rare cases of dropsy that simulate Bright's disease in Avhich no satisfactory causative lesion is apparent or discoverable, and also those cases, rarer still perhaps, that have a peculiar family or congenital origin. The recognition of edema is made possible both by inspection and palpation. Renal dropsy is manifested first by puffiness of the skin of the face, and especially of the eyelids. At other places Avhere there is loose subcutaneous cellular tissue, and in particular Avhere the parts are dependent, dropsy is most apt to be seen early, as under the malleoli of the ankles, the dorsum of the foot, and the scrotum. Later, the limbs and the lower part of the back become SAvollen, and even the whole body is involved in severe cases. The skin has a peculiar waxy pallor and a glossy appearance. When evident vascular or cardiac changes exist, so as to permit of increased dropsy from engorgement, as in cirrhotic kidney, a cyanotic or muddy color of the skin may prevail. Dropsy is most constant and most persistently decided in the> large white kidney of subacute or chronic nephritis; it is most uncommon and irregular in chronic interstitial nephritis (red granular and contracted kidney). The familiar pitting on pressure over edematous tissues is a true indication of fluid under the skin. There is also a doughy or putty- like consistence. In very marked cases of dropsy the deeper parts, such as the muscles, become affected. The serous cavities also in general anasarca show evidences of effusion, and thus give rise to hydro-thorax, hydro-peritoneum, and hydro-pericardium. Less frequently there may be edema of the larynx, uvula, conjunctiva, and other mucous membranes. Edema of the brain, either local or general, may be the cause of grave uremic symptoms in chronic nephritis, or of unilateral convulsions or paralysis and apoplectic seizures. The dropsical liquid is chemically similar to a diluted blood-serum. A minute quantity of albumin and urea is present. UREMIA. Definition.—Uremia is the term applied to a group of manifestations, mainly nervous and either acute or chronic, resulting from a toxemia due to the retention in the body of certain products of urinary or renal origin. Strictly speaking, uremia means simply blood containing excrementitious urinary substances. Although most common in Bright's disease, uremia may arise also in other diseases, as in gout (gouty kidney), scarlet fever (scarlatinal nephri- tis), typhus fever, yelloAv fever, and cholera, in Avhich the kidneys and blood may be seriously affected. Kidneys which, on account of marked structural changes, fail to eliminate the normal quantity of urates and solid constituents are directly or indirectly responsible for an association of the morbid conditions knoAvn as uremia. Our present knoAvledge of the pathology and etiology of uremia, as of renal edema, is based solely upon theoretic vieAVS. The theory that attributes uremic symptoms to the retention of the excretory prod- UREMIA. 959 ucts appears to have the strongest proofs to support it; but the positive nature of these substances, or which is the most toxic, or Avhether several are concerned in the causation or not, remains to be determined. Since the urea and uric acid have been found in increased quantities in the blood of uremic patients, and since these products are diminished in the urine of nephritis, they also Avere at first supposed to be the cause. Am- monium carbonate, it was alleged by Frerichs, operated in the same man- ner after it accumulated in the blood in sufficient quantity as a result of the decomposition of the urea by a ferment. Not only some of the solid urinary constituents accumulate in the blood in uremia, but the water also is only partly eliminated, and its presence in the blood renders the latter hydremic and of lower specific gravity. It is true, hoAvever, that, notwithstanding the fact that most cases of uremia may be traced to a marked simultaneous diminution in the quantity of urine passed, there remain still certain instances of renal disease in which uremic symptoms appear Avithout any perceptible dimi- nution of the urinary secretion. Again, and even more frequent perhaps, are those perplexing cases of anuria noAv and then reported in Avhich no uremic symptoms appear. In the latter instances it is probable that the elimination of products normally excreted by the kidneys may be accom- plished through other channels, as by the skin and bowels ; in the for- mer it is still likely that the solid urinary constituents are retained, even Avith an undiminished quantity of water excreted. Traube's theory of the cause of uremia, particularly of the nervous or cerebral manifestations, was that it is an acute edema of the brain—local or general—Avith cerebral anemia. This Avould seem to explain certain cases of nephritis, as already mentioned, in Avhich a fair amount of urine and solid constituents are passed ; also cases of anuria due to urethral ob- struction in Avhich no uremic symptoms appear ; and certain cerebral disturbances. But Avith our present knoAvledge of the chemico-pathology and of the clinical cause of the uremia of nephritis in all its forms there is, I think, no doubt that most cases are caused by the toxemia produced by the retention of the mass of excrementitious substances that is due to an abatement of the renal functions. Delafield, however, attributes the sudden violent motor symptoms of acute uremia to a contraction of the arteries from some unknown cause other than blood-contamination. The symptoms of uremia may be either acute or chronic in onset, severity, and course. In acute uremia the severest nervous symptoms come on suddenly; they last but a comparatively short time, and termi- nate fatally, with convulsions and coma, dyspnea, feeble cardiac action and pulse, fever, and pulmonary edema. These acute symptoms, hoAvever, are not infrequently preceded by mild uremic prodromes, as headache, somno- lence, nausea, malaise, slight dyspnea, and uneasiness. Chronic uremia is characterized by the absence of the marked symp- toms referred to above, the milder manifestations alone appearing and lasting over a considerable length of time. Here the general prostration, the feeble cardiac and arterial states, the occasional stupor and delirium, transient dimness of vision, anorexia and nausea, irregularly hurried breathings, and muscular twitchings, indicate the grave condition of the patient. To gain a more thorough knowledge of this interesting and 960 DISEASES OF THE URINARY SYSTEM. serious complication of renal disease a divisional study of the symptom- atology is necessary. Cerebral Symptoms.—These vary from a slight headache, tremors, and the restlessness of anxiety to the most violent maniacal delirium and con- vulsions ; from somnolence and mental stupor to profound coma ; and from the slightest visual disturbances to complete amaurosis. The onset of a noisy delirium, and less commonly of a marked mania, is often quite abrupt, and may be the first manifestation of Bright's disease in an in- dividual. Delusional insanity (folie Brightique) is seen in some cases. Melancholia and the delusion of persecution, with suicidal and homicidal tendencies, may thus occur. The most characteristic symptom of uremia, however, is the convulsion (uremic eclampsia). Uremic convulsions are epileptiform in type, although they may be either unilateral or local—of the Jacksonian form of epilepsy. They are supposed to be due to a local or general edema of the brain, and are probably allied to the apoplexia serosa of early Avriters (Osier). The convulsions of uremia may come on suddenly or may be preceded by headache, vertigo, dropsy, nausea, and vomiting. As in the epileptiform convulsion, after the early tonic rigidity there may follow at short intervals the clonic spasm, Avith cyanosis, fever, and contracted arteries, and the intervening periods of unconsciousness, shallow or noisy respiration, and slow, hard pulse. Coma may come on gradually as Avell as during the convulsive attacks. It may be preceded by headache, apathy, and insomnia, and continue progressively to deepen for a long time. A typhoid state not infre- quently accompanies uremic coma. The temperature is usually low- ered, and moderate dilatation or contraction of the pupils may be evidenced. Uremic Amaurosis.—Blindness may follow uremic convulsions, or, rarely, it may come on without motor disturbances. It is of purely centric origin (the cortex of the occipital lobe), and its duration is short, lasting but a few days in most instances. Uremic deafness, Avhich is probably also of centric origin, is a less common manifestation. Other nervous phenomena, as hemiplegia, monoplegia (from cerebral or spinal congestion or edema), contractures, aphasia, pruritus, paresthesiae, and cramps in the calf-muscles are not so frequent in occurrence. Circulatory Disturbances.—The pulse is moderately slow, tense, and full in uremia, but Avith the onset of acute and severe symptoms, as con- vulsions, it usually becomes accelerated, small, and feeble. The heart's action is labored and feeble. Respiratory Symptoms.—Renal dyspnea, Avhich is sometimes called " uremic "or " renal asthma," is a marked, rather constant, and often an early symptom of uremia. The respirations are deep and often stertorous in coma, or they may be irregular, accelerated, and shallow, sometimes assuming the Cheyne-Stokes type. Dyspneic attacks are especially apt to occur at night. In chronic uremia slight dyspnea may be continuous for a long time. Again, alternating paroxysmal exacerbations may arise. The uremic dyspnea is probably due in most cases to the toxemia affecting the respiratory nervous centers. It may, however, be the result of cardiac weakness or of dropsy or pulmonary edema. Gastro-intestinal Symptoms.—Uremic stomatitis is generally seen. The breath is foul, the tongue, lips, and gums are red, swollen, and pain- UREMIA. 961 ful, and the saliva is increased. Uremic vomiting is also usually of cen- tric origin, though it may be provoked by the irritation of the gastric mucosa, caused by the vicarious elimination of the urea and the decom- position of the latter into irritating ammonium carbonate. The vomiting may come on suddenly and be persistent. Uncontrollable hiccough and sometimes uremic diarrhea may be associated. The irritant action of the ammonium carbonate on the intestinal mucous membrane may produce a catarrhal or diphtheritic inflammation. Uremic diarrhea may also exist apart from any marked gastric disturbances. General Symptoms.—The skin of the face is usually pale in uremic coma. Urea may be excreted by the sweat-glands, and may be seen as minute glistening crystals in some of the cutaneous furroAvs after the evaporation of a free SAveat. The skin is often harsh and dry, as in chronic interstitial nephritis. Uremic pruritus is probably the result of the peripheral irritation of the cutaneous nerves by crystals of urea. The temperature is generally loAvered, but uremic fever frequently accompanies the convulsions or they may be preceded by "uremic chills." In some cases the temperature rises to 105°-107° F. (40.5°-41.6° C.) just before death, Avhilst in other cases, characterized by a profound and lasting coma that deepens into collapse, the temperature may be so low as 91° or 93° F. (32.7°-33.8° C). There is not infrequently an ammoniacal odor about a uremic patient. The urine is diminished in quantity, is generally highly albuminous, and deficient in urea. A previous dropsy is sometimes markedly reduced upon the appearance of acute uremic symptoms. Duration and Prognosis.—Acute uremia is manifested by coma and convulsions, seldom lasting more than a feAV days. Chronic uremia, in Avhich milder nervous symptoms, nausea and vomiting, and dyspnea are more prominent, may persist, however, for many weeks. While a grave condition, uremia, even in its most acute and violent forms, is not at once necessarily fatal, for under proper treatment—as by venesection, for instance, followed by judicious hygienic measures—life may be con- siderably prolonged. Sooner or later, however, barring a possible death from some intercurrent affection, the kidney-lesions are of such a nature as to preclude the likelihood of anything but a fatal result. Diagnosis.—Uremia may be recognized by the history, the marked arterial tension, and the accentuated second sound of the heart; also by the albuminuria (the urine has to be withdraAvn), the temperature, and the odor of the breath. The presence of dropsy in some cases is a valu- able indication of the nephritic origin of uremic manifestations. Differential Diagnosis.—Uremic unconsciousness coming on suddenly, as in chronic interstitial nephritis, may simulate alcoholism, cerebral hemorrhage (apoplexy), cerebral tumor, or meningitis. The points of dissimilarity between the first tAvo conditions and uremia are here tabu- lated (after Herrick): Cerebral Hemorrhage. Alcoholic Narcosis. Uremia. Pupils unequal or dilated. Pupils contracted or di- Pupils generally dilated; lated ; eyes injected. albuminuric retinitis. Stertorous, puffy breath- No stertorous breathing. Sharp, hissing stertor. ing, and flapping cheek. No odor. Odor of alcohol. No odor, unless urinous. 61 962 DISEASES OF THE URINARY SYSTEM. Cerebral Hemorrhage. Paralysis ; hemiplegia. Unconsciousness absolute. Pulse slow and strong or irregular ; arteries often atheromatous. Coma sudden and deep. Convulsions late ; may be unilateral. Urine generally negative. Apoplectic habit; heart may show hypertrophy. Alcoholic Narcosis. No paralysis, usually. May be aroused. Pulse frequent and feeble. Coma gradual. No convulsions. Urine generally negative. Red face and nose, heart often weak, dilated, my- ocarditic. Uremia. No paralysis. May or may not be aroused. Pulse at first strong, later weak and rapid ; tension strong; arterio-scle- rosis. Coma gradual or sudden. Preceded by general con- vulsions, headache, etc. Urine albuminous. Edema and pallor ; heart hypertrophied. In meningitis the mode of onset, the rigidity of the neck, incoherence or mild delirium, photophobia, and pronounced fever point to the distinction. Uremic coma must also be differentiated from opium-poisoning and diabetic coma. Chronic uremia must not be confounded with the asthenic state of typhoid fever and acute miliary tuberculosis. In opium-poisoning the pupils are contracted and do not respond to light. Again, in opium- poisoning the respirations are slow, deep, and full, and the patient may ansAver rationally when aroused. In uremic coma, it will be remembered, consciousness is abolished. In diabetic coma the history must be learned, the harsh, dry skin and emaciation noted, and especially are the ethereal odor and the Burgundy-red reaction of the urine (acetone) with the tincture of the chlorid of iron to be observed; sugar is also present. The prognosis is grave, but guarded; it is even favorable in many cases, so far as immediate results are concerned. Treatment.—This will be detailed in the discussion of the various forms of nephritis. Suffice it to say that the supreme indication is the prompt elimination of the poisons in the blood. When diaphoresis and catharsis fail either in promptness or efficiency, venesection should be em- ployed ; the latter measure is also probably the most reliable in urgent cases of uremic convulsions or coma. Bozzoli recommends the subcutaneous injection of sterilized serum because of the gratifying results secured in a number of cases of uremia. AMYLOID KIDNEY. Definition.—Amyloid (waxy or lardaceous) degeneration of the kid- neys ; it is usually coexistent with a similar degeneration of other viscera. Pathology.—Macroscopically, the amyloid kidney appears pale, greenish or yellowish-white, and uniformly enlarged, and the surface is smooth, glistening, and often mottled, owing to the prominence of the stellate veins. It has a doughy consistence. On section a homo- geneous, anemic, or " bacon-like " surface presents itself, particularly in the cortical region. The cortex is wider than normal; the pyramids may be red in color and slightly infiltrated ; and the glomeruli may show an infiltration by the glistening, translucent amyloid (albuminoid) mate- AMYLOID KIDNEY. 963 rial. On the application of Lugol's solution of iodin to the amyloid areas a mahogany-broAvn color is produced. Brushing over the amyloid substance with a solution of iodin, and then with dilute sulphuric acid, gives a blue or violet tint. Similarly used, a 1 per cent, solution of methyl-violet strikes a red color. The capsule of the kidney is not adherent. Microscopically, the amyloid change is generally found in the early stages to affect the walls of the capillaries of the Malpighian tufts. The walls are swollen with the homogeneous material and the vessel-lumen is diminished or obliterated. The straight uriniferous tubules are also infil- trated later perhaps, the deposit occurring primarily in the membranae propriae. A diffuse nephritis is nearly ahvays an associated condition, the so-called pure amyloid kidney, Avith normal renal tissue other than that above mentioned, being relatively infrequent. Fatty degeneration of the epithelium, glomerulites or waxy glomeruli, and a thickening of Bowman's capsule are common in markedly amyloid kidneys. In ad- vanced cases most of the secretory structure becomes atrophied. Amy- loid infiltration of the smaller granular kidney is less common than of the large white kidney, with intense parenchymatous changes. Hypertrophy of the heart is not always present in amyloid disease of the kidneys. Amyloid infiltration of other organs, however, as of the liver and spleen, is usually associated with waxy kidneys. Etiology.—The causes of amyloid kidney are those of the amyloid change affecting (either simultaneously or nearly so) other organs, as the spleen, liver, and intestines. Commonly, amyloid disease is marked also in the other solid organs named above ; it is secondary to wasting diseases, cachexiae, and the like. Perhaps the most frequent cause of the waxy kidney is tuberculosis, espe- cially of the lungs ("chronic ulcerative phthisis "): tuberculosis of the intestines also is often associated and aggravates the amyloid infiltration. Next in order are the prolonged suppurations, particularly of the bones, as in osteitis of the vertebrae and hips (usually tuberculous). Chronic empyema, intestinal ulcers, vesico-vaginal fistulae, and other purulent affections, chronic in nature also, have the same etiologic effect. Amyloid kidney is often present in syphilis, especially in the tertiary stage, when ulceration of the mucous surfaces and of the bones is present. Rarely, gout, malaria, and chronic valvular endocarditis with insufficiency seem to produce amyloid disease. Symptoms.—These vary greatly according to the extent to which the amyloid degeneration has encroached upon the normal kidney-struc- ture, and may be overshadowed partially or completely by those of the dominant causal affection. The urine is pale yellow, clear, and variable in quantity, and the amount passed in twenty-four hours is sometimes normal or may be slightly diminished. More frequently, perhaps, it is increased, and espe- cially in marked or advanced cases. The specific gravity is apt to be low (1015-1005), and there is seldom any sediment. Serum-albumin and globulin may both be present in the urine, but a highly significant condition, and one that is seemingly diagnostic, is the high proportion of globulin as compared with the serum-albumin (Sal- kowski, Senator). Tube-casts may be found, but their presence may be 964 DISEASES OF THE URINARY SYSTEM. only temporary ; they are usually wide hyaline or fatty and granular, and are few in number. The amyloid reaction may be elicited with the hyaline casts; sometimes symptoms referable to the kidney are rare in comparison Avith those of the nephritides. Dropsy is not invariably pres- ent, and when present is but moderate in degree and generally in the legs only. It is proportionately prominent with the increase in the anemia, circulatory depression, and wasting of flesh and strength. These latter manifestations, constituting a cachectic appearance, are quite commonly observed in amyloid kidney. The associated enlargement and the firm, sharp outlines of the liver and spleen are of diagnostic significance. Marked diarrhea may be due to coexisting amyloid infiltration of the intestines or to tuberculous intes- tinal ulcers, and is often seen in advanced cases. Diagnosis.—This can seldom be made upon the urinary manifesta- tions alone. Important and often necessary adjuncts are the histories of causation and of the associated symptoms and physical signs. Thus, there will be evidenced in most cases tuberculosis, chronic bone-suppura- tions, or syphilis, while coexisting hepatic and splenic enlargements, wast- ing, and cachexia are usually present. In any of the diseased conditions mentioned amyloid kidney may be diagnosticated with reasonable cer- tainty upon the development of an increased quantity of pale clear urine of low specific gravity and containing a large amount of albumin, or even with slight albuminuria. From parenchymatous nephritis amyloid kidney is to be differentiated by the history, by the more marked and generally distributed dropsy, and by the albuminuric retinitis that characterize the former. In chronic interstitial nephritis there are less marked albuminuria and dropsy, and there are present arterio-sclerosis, cardiac hypertrophy, and a pronounced tendency toward uremic symptoms. Prognosis.—This varies with the cause. Incipient bone-disease or tuberculosis, with only slight evidences of amyloid change in the kidneys, may be controlled. As a rule, however, the structural alterations are so far advanced, and the constitutional powers of resistance so much ener- vated, before the amyloid infiltration can be distinctly apprehended that in the majority of instances the prognosis is entirely unfavorable. In decided cases death ensues in from several weeks to as many months. Treatment.—This also depends upon the causal affection. Hygienic and dietetic measures are always useful, however, with a vieAV to improving the general nutrition. The iodid of iron has been recommended as an alterative, and easily assimilable and palatable fats and tonics may also be tried. Tuberculous cases require creasote or allied preparations ; syph- ilitics require mercurials and iodids; while malarial subjects do best under the systematic use of arsenic, iron, and quinin. NEPHROLITHIASIS. {Renal Calculi; Pyelitis Calculosa; Renal Colic; Gravel.) Definition.—A condition characterized by the formation of fine or coarse concretions in the kidney-substance or in the renal pelvis by the precipitation of certain of the solid urinary constituents. NEPHR OLITHIA SIS. 965 Varieties.—According to their size, renal concretions are variously termed—(1) Renal sand, of which the particles are fine and pulverized; (2) Renal gravel, consisting of coarse grains or even of pea-sized concre- tions ; (3) Renal stone, or calculus, Avhen larger masses than the preceding exist, either more or less rounded or as stony casts or moulds of the pelvis of the kidney, its infundibula, and calyces (dendritic or coral calculi). According to their composition, the chemical varieties of renal concre- tions are—(1) Uric-acid calculi, the most frequent in occurrence. Urates are often associated in the calculus Avith uric acid, thus producing strati- fication. These concretions may occur as sand, gravel, or large stones; they are usually quite hard, reddish-brown or black in color, and have a smooth though irregularly-shaped surface. The fracture is crystalline, and in the larger calculi often shows the alternating layers of uric acid and urates. Pure uratic stones may occur in children. (2) Calcium-oxalate concretions occur more rarely in the kidney. They constitute the so-called "mulberry calculi," from a fancied resemblance to the mulberry, owing to their dark-brown or black color and very irreg- ular and nodulated or prickly appearance. They are also quite dense; lamination, however, is not common, although they are sometimes formed about a uric-acid nucleus. (3) Phosphatic calculi of the kidney are still less common than the oxalate, but they are more common in the bladder. They may consist of calcic phosphate or ammonio-magnesic phosphate, and may possibly be associated Avith calcic carbonate. Phosphatic salts are most often depos- ited secondarily about uric-acid or oxalate calculi in the alkaline urine of a cystitis set up by the irritation of the true renal stones. Phosphatic calculi are grayish-white in color and are comparatively soft. (4) Renal stones composed of cystin, xanthin, carbonate of lime, fatty or saponaceous matters (urostealith), indigo, and fibrin, though of extreme rarity, have been occasionally reported. Cystin calculi have a pale-yellow color and a Avaxy luster. Pathology.—The anatomic changes of the kidney vary with the degree and persistence of the irritation, the size of the calculi, and their passage or retention. Sometimes numerous granular and pea-sized con- cretions are found in the renal pelvis, Avith desquamated epithelium and a turbid urine. Interesting cases are those in which a dendritic stone occupies a great portion of the atrophied kidney-substance, as well as the entire pelvis of the organ. In one of my own patients the left kidney was, apparently, nearly twice the normal size, owing to the presence of a large coral-calculus (uric acid and urates), connected by an isthmus with a rounded stone in the inferior portion quite as large as a large Avalnut. The pelvis of the right kidney also contained a dendritic calculus. Secondary Lesions.—Perhaps the most usual result of renal concre- tions is a pyelitis : this may be simple catarrhal, diphtheritic, or purulent, with or Avithout hemorrhages, depending upon the intensity of the mechan- ical irritation. A pyelo-nephritis may follow in severe cases, as may even a general suppuration (pyonephrosis) or perinephric abscess and perfora- tions. Renal pus-cavities are sometimes found postmortem containing numerous small stones. Hydronephrosis is another important pathologic sequel, in which the cause is to be attributed to the blocking of the ureter by an erstAvhile passing stone or by the closing of the aperture of 966 DISEASES OF THE URINARY SYSTEM. a ureter from within the pelvis. Pressure-necrosis and perforation may thus be induced. Owing to the prolonged pressure of a dendritic calculus, there is commonly a distinct and marked atrophy of the renal parenchyma, resulting in chronic diffuse nephritis with little or no exudation. Etiology.—The definite causation and the exact manner of formation of renal concretions are still unestablished. We may rnfer not a little, however, with some good reason, since the predisposing causes are rather distinct. Thus, in children and in advanced life the occurrence of calculi is most common, the uratic variety being most frequent in the former and the uric acid in the latter. Men are subject to nephrolithiasis more often than are women. The uric- or lithic-acid state (lithemia), gout, and the various influences that induce these conditions, as an excessive meat (proteid) diet or a sedentary life, seem to predispose to stone. Heredity, I believe, plays a prominent part in many cases. Broadly speaking, any habit of the system that encourages the pre- cipitation of insoluble abnormal ingredients or of normal ingredients in excess, owing to chemical changes in the urine, tends to the formation of calculi. It should, however, be provisionally stated that the primary cause of calculus-formation is the presence of some solid substance in the urinary tract that affords a nucleus about which the successive layers of crystals may deposit and adhere, such as bits of mucus, epithelial shreds, parasitic ova, bacteria, blood-clots, and tube-casts. It is generally believed that the requisite conditions for the formation of an uric-acid renal calculus are—a highly-acid urine, an excess of uric acid, and a low percentage of salines. Symptoms.—These may be slight, progressive, and chronic, or they may be intensely acute and comparatively short in duration, though sub- ject to repetition—i. e. renal colic. It is not unusual for patients to pass uric-acid sand and gravel for years without much complaint. A sudden blocking of a ureter, however, or a slowly-passing stone of dis- tending dimensions produces great agony at times. A smooth, snugly- fitting dendritic calculus in the pelvis may not cause any symptoms for years until the destruction of tissue by its weight and mechanical irritation ensues ; there is then a progressive failure of health, a constantly increas- ing pain in the back, occasional hematuria, tenderness on pressure over the diseased kidney, both anteriorly (deep) and posteriorly, and finally uremia and death. The characteristic symptoms of stone in the kidney appear as an attack of renal colic. This happens when a calculus in its passage down the ureter acts as a mechanical irritant, or when it is caught and stopped in the passage. The large "gravel" or pea-sized and more or less rough stones usually cause the attack, which comes on, as a rule, quite suddenly, although it may be preceded by a chill and some general uneasiness or by slight pain in the region of the kidney. It may be excited by a sud- den muscular effort. The pain is tearing in character, and rapidly reaches an agonizing maximum of severity, starting from the lumbar re- gion and extending down along the ureter into the groin, and often into the testicle and inner side of the thigh. The paroxysm may appear in the form of a diffuse abdominal and lumbar pain in some instances. There is local tenderness on pressure, and nausea and repeated vomitings are frequent. The patient is often collapsed, and perspiration, a rapid, small, NEPHROLITHIASIS. 967 and feeble pulse, trembling, anxiety, bodily tAvistings about, convulsions even, and syncope may ensue. There may be moderate fever. The urine is scanty or may be suppressed for a time, and is often bloody. Frequent and painful attempts at urination are made, Avith the passage of but a fe\v drops at a time, OAving perhaps, in part at least, to a reflex spasm of the vesical sphincter (vesical tenesmus). The presence of pus and of pelvic epithelium in the urine indicates a pyelitis. When a large quantity of clear urine is passed, as sometimes happens, it may be looked upon as having come from a healthy kidney. The paroxysm of renal colic ends when the impacted stone passes out of the ureter. This may occur within a few hours or it may take several days; in instances of the latter type the attacks of renal colic may be intermittent. Recovery is not always complete immediately upon the evacuation of the stone. The previously retracted testicle may be painful and swollen for a little while, and there are apt to be an aching and a soreness over the affected kidney and ureter. In certain severe cases of mechanical irritation the symptoms of pye- litis, pyelo-nephritis with abscess, or hydronephrosis may be superadded. Anuria and uremia result from simultaneous obstructive suppression of the urine upon both sides. Nephrolithiasis as a chronic affection may exist for many years, with recurring paroxysms of renal colic. Between the latter the patient may be entirely comfortable, save perhaps an occasional burning in the urethra on micturition, owing to a highly-concentrated, acid urine or to the pass- age of minute uric-acid granules. There are apt to be pain and tenderness over the kidney containing a large imbedded stone. A smoky-hued urine, due to slight hematuria, is also sometimes present in long-standing cases of renal calculus, particularly after exertion. A renal intermittent fever, simulating malarial paroxysms, may occur in nephrolithiasis, and is analogous to the hepatic intermittent fever of cholelithiasis. Pyelitis—simple or purulent—with late involvement of the kidney- parenchyma (pyelo-nephritis) is a frequent concomitant of chronic nephro- lithiasis. The presence of pus in the urine is constant, with an absence of renal epithelium in cases of an abscess-cavity of the kidney. In ordi- nary pyelitis the pyuria is often intermittent. The general health of patients Avith nephrolithiasis is, as a rule, re- markably good. Anorexia is not only seldom present, but such persons are habitually free and good livers. Persistent headaches with nausea, however, should warn one of uremia. Splenic and hepatic enlargement may be found with prolonged suppurative pyelo-nephritis, indicating amyloid disease. Diagnosis.—This resolves itself into a study of the diagnostic cha- racters of (a) the attacks of renal colic, (b) of the underlying systemic condition in general, and (c) the renal condition in particular that renders these attacks possible. The latter can be discovered only by a careful and continuous study of the clinical history and urinary manifestations as outlined in previous paragraphs. Nephrolithiasis may be positively diagnosed in a case in which, after sudden, agonizing, colicky pain, referred to either lumbar region and 968 DISEASES OF THE URINARY SYSTEM. radiating down the ureteral course to the testicle, a concretion is found to have passed with the urine. It is therefore necessary in a suspected case of renal colic to pour the urine through a fine sieve as soon as passed. Differential Diagnosis.—Renal colic must not be taken for biliary or intestinal colic. The antecedent history is of great value in arriving at a diagnosis. In biliary colic there may be jaundice, and pain referred to the upper rather than to the lower abdominal zone, both of Avhich symp- toms are absent in renal colic ; while in the latter the disturbance of mic- turition and the character of the urine, especially the hematuria, are characteristic. In intestinal colic the griping pain is usually most intense in the um- bilical region, is often relieved by pressure, and is associated with tym- panites and constipation; it has usually a dietetic origin, while the renal and urinary symptoms are absent. The exclusion of lumbodynia and lumbo-abdominal neuralgia is not so difficult. The differentiation of the varieties of calculi from the symptoms is not positive. It has been sug- gested, however, that the oxalate stones usually cause the sharpest pains and the hematuria. Prognosis.—This should always be guarded, owing to the possible dangers and complications that frequently attend nephrolithiasis in all of its forms. Thus the passage of gravel without marked symptoms tends to persist or recur—in both events an unfavorable tendency, since subsequent formations are apt to be larger and cause serious symptoms. An attack of renal colic may itself be fatal. Large latent calculi (den- dritic), of long standing, are nearly always incurable, and in most in- stances lead to such grave complications as pyelo-nephritis, pyo- and hydronephrosis, perinephric abscess, and uremia. Treatment.—Paroxysms of renal colic call for prompt relief. This is best afforded by hypodermic injections of morphin and atropin, coupled with hot baths or fomentations applied to the loins. The free use of hot drinks, as lemonade, soda, or plain Avater, is also helpful in promoting the passage of the stone. Cases of excessive suffering re- quire the inhalation of chloroform. The treatment of the nephrolithiasis without or between attacks of renal colic is most important. First to be considered are the hygienic and dietetic measures, for in mild and uncomplicated cases much can be done to prevent the aggravation of the disorder, and at least the forma- tion of larger concretions may be delayed. When the tendency is to uric-acid gravel (the commonest variety), the patient should live a reg- ular, calm, steady, and temperate life. Exercise should be so managed that it may be taken rather moderately in the open air, and with a view to preventing additional weight in persons of fair nutrition and to pro- moting a reduction of weight in the obese. In short, the exercise should be sufficient to thoroughly use up all nitrogenous food, so that the formation and elimination of urea may be increased to normal and the quantity of uric acid diminished. Hence I would strongly advise a clinical study of the percentage of urea in the urine {vide p. 953). Over-indulgence in food, particularly in red meats (liver, sweetbread, and similar nuclear food), should be prohibited, owing to the ready for- mation of uric acid from the latter. Alcohol should be taken seldom, or, better, not at all. On the other hand, since the urine is apt to be NEPHR OLITHIASIS. 969 scanty and highly acid, the patient should be encouraged to drink freely of plain and alkaline waters, artificial and natural. The value of various pure spring-waters as diluents is undoubted, the Buffalo, Londonderry, and Otterburn Lithia, the Saratoga, Bedford, and Poland waters, all being distinguished for their purity. More marked and more generally useful for their alkalinity are the Carlsbad, Vichy, and carbon- ated waters. In cases characterized by occasional hematuria the Rock- bridge alum-water may be tried. Plain soda-water and lemonade may be used as adjuvants. The medicinal treatment of nephrolithiasis is aimed to secure a sol- vent and disintegrating action upon the stones ; it is symptomatic. It is extremely doubtful whether stones once formed in the pelvis of the kid- ney and remaining there are ever dissolved, though certain drugs would seem to have had an eroding effect in some instances, and they are to be recommended as useful in preventing the formation of new deposits. Lithium citrate or carbonate in 5-grain (0.321) doses in tablet form, three or four times daily, has been generally employed for the purpose. Sodium phosphate and the vegetable salts of potash, as the citrate, acetate, and tartrate, are useful. Much water, especially the carbonated, should be drunk, along with doses of the above, in order to facilitate the solvent action, and in this way relieve, in a measure, the local distress and pain. Recently piperazin has been brought forward as an uric-acid-calculus solvent by some clinicians, and that it has an action such as is claimed for it has been proved beyond a doubt in certain cases. Whilst it de- serves a further trial in nephrolithiasis, it is too much, however, to ex- pect to look for positive and successful results in every case. It is pre- scribed usually in 5-grain (0.324) tablets three or four times daily, with much water. Recently, Von Noorden has recommended calcium carbonate (gr. x- xv—0.648-0.972—or more thrice daily). The theory is that the calcium unites with the acid phosphates in the intestines, and thus reduces the deuterophosphates in the urine, leaving the protophosphates to dissolve the uric acid. He reports excellent clinical results. The reaction of the urine must be tested at stated intervals and kept faintly acid. Should the urine become alkaline, the alkaline treatment must be suspended for a Avhile, or a secondary deposit of phosphates about the uric-acid stone may be induced. Nagging lumbar pains may be re- lieved by occasional doses of such analgesics as phenacetin, belladonna, hyoscyamus, codein, and indirectly by the sweet spirits of niter, buchu, and uva ursi. Renal hemorrhage may be controlled effectually by the use of the fluid extract of ergot, or by alum in 10- or 15-grain (0.648 or 0.972) doses, or by gallic acid in 20- or 30-grain (1.29-1.91) doses. Efforts to acidify the urine are indicated when the calculus happens to be composed of phosphates or of calcium carbonate. This is more difficult of accomplishment than when it is necessary to reduce the acidity. Saccharin in 2- or 3-grain (0.129-0.194), and benzoic and boric acids in 5- to 15-grain (0.324-0.972) doses, in capsules, seem to be most useful for this purpose. The question of surgical interference must be decided in not a few cases ; thus, it may be briefly stated that in protracted and obstinate cases of calculous renal disorder, with persistent local pain, a gradually 970 DISEASES OF THE URINARY SYSTEM. decreasing capacity for work, and evidences of severe pyelitis, pyelo- nephritis, or, worse, of perinephric abscess, the surgeon must operate. In the simplest cases a nephrotomy or nephro-lithotomy may be performed and the stone removed. Where the renal structure is much damaged it may be necessary to do a nephrectomy. To avoid the increased perils of the latter operation, however, it were better that a nephrotomy Avere done as early as consistent with the diagnosis of incarcerated pelvic stone and the condition of the patient. ACUTE NEPHRITIS. {Acute BrigMs Disease; Acute Diffuse Nephritis; Acute Parenchymatous Nephritis; Exudative, Catarrhal, Tubal, Desquamative, and Glomerulo-nephritis of Acute Course.) Definition.—An acute inflammation of the kidneys, more or less diffuse in nature. It may be either of a mild, severe, or grave cha- racter. Delafield describes three varieties of acute renal inflammation under the common synonym of acute Bright's disease, as follows : (1) acute degeneration of the kidneys, (2) acute exudative nephritis, and (3) acute productive nephritis. This division is of etiologic and pathologic import- ance and interest, rather than of clinical necessity or practical value. Pathology. —The anatomic changes in, and the appearances of, the kidneys vary considerably in different cases according to the degree of involvement. From the very mild to the gravest cases of nephritis there is an intermediate series of continuously more marked pathologic changes in the renal tissues. These depend greatly on the amount of poisonous material circulating in the kidneys and eliminated by them, as Avell as upon the intensity and duration of its noxious action. In the mildest cases the microscopic appearances of the kidneys may present nothing distinctly abnormal. As a rule, however, the organs are slightly enlarged, SAvollen, and somewhat softened. These conditions are more evident when the interstitial exudation is abundant and Avhen in- flammatory edema is evident. The kidneys may be reddened and con- gested and appear bloody on section, or they may be pale and mottled. In examples of the former, hemorrhages may be formed beneath the cap- sule (acute hemorrhagic nephritis), though it is more common to see red patches of hyperemia alternating with opaque, whitish portions on both the outer and cut-surfaces of the kidneys. The cortex especially is swollen, turbid, and pale, or slightly congested in the mildest cases, and is deeply mottled (red and pale glomeruli) or hyperemic in severe in- stances. The pyramids usually shoAV an intense redness. The surfaces are smooth and the capsule non-adherent. Microscopically, alterations may be discovered that are not visible to the naked eye in the very mild cases referred to. above. There is simply a cloudy SAvelling or a granular (parenchymatous) degeneration of the epithelium of the Malpighian tufts, Bowman's capsule, and of the cortical uriniferous tubules. This is not true acute nephritis, however, in the absence of exudative changes in the interstitial tissue. The acute paren- ACUTE NEPHRITIS. 971 chymatous degeneration may be almost exclusively limited to the glome- ruli, as in some cases of scarlatina, and hence the term glomerulo-nephri- tis. The cells are SAvollen, opaque, and irregular in shape, while the cell-contents are granular (albuminoid or fatty) and the muscles are either swollen or absent. A further advance in the process is seen in the death of the cells that is due either to coagulation-necrosis or disintegration, desquamation of the cells, and hyaline degeneration of masses of them in the tubules. Acute degenerative changes are frequently found in the acute infectious diseases or when inorganic poisons have been introduced into the body. In phosphorus-poisoning actual fatty degeneration of the epithelium may be found, this either proceeding from the cloudy swelling or developing independently. A rapid necrosis of cells is also met with in severe cases. True acute nephritis is not only characterized by changes of the renal epithelium (the parenchyma), but the inflammatory exudate (serum, leu- kocytes, and erythrocytes) is found between the tubules. The kidneys shoAV different stages of the process in different portions. In some places there is only a slight cellular infiltration of the intertubular tissues; in others, besides the desquamation of necrotic epithelial cells and the pres- ence of hyaline casts in the tubules, the interstitial tissue is swollen by the coagulated sero-fibrinous exudate, abundant leukocytes, and some red blood-corpuscles. It should be stated that the inflammatory exudate col- lects also in the Malpighian bodies and tubules. The epithelium lining the latter, especially the convoluted portion, is often flattened, and the tubules themselves may be dilated and choked Avith degenerated cells, or, more frequently in the straight tubules, with hyaline casts. The Avhite blood-cells that are found infiltrating the stroma of the kidney are not usually equally diffused, but are collected in foci in the cortex. The glomerular epithelium of the capsule, and especially that covering the outside of the capillaries of the tufts, is SAvollen and opaque, and the outlines of the individual capillaries are lost. In most cases of diffuse exudative nephritis new epithelium appears, and a restoration of the glomerular function takes place. In the productive variety of acute diffuse nephritis, however, according to Delafield, certain lesions are more permanent in character from the first in the glomeruli and stroma, and hence the increased gravity of the disease. The additional changes that are here superadded to the usual exudative condition are—(a) a groAvth of the cells lining the capsules to such a degree as to form a mass that compresses the tuft, " and leading finally to obliteration of the vessels and fibroid glomeruli; " (b) a groAvth of the connective tissue parallel to. and surrounding, one or more arteries having thickened walls, and form- ing more or less numerous and regular strips or wedges in the cortex. In the more intensely acute cases the new tissue between the tubules is largely cellular; in those of a subacute type it is relatively dense and fibrous. Anasarca and pleural, pericardial, and peritoneal dropsy are also found in those dying of acute Bright's disease. Cerebral edema, meningitis, and lobar pneumonia are to be mentioned as complicating conditions that are sometimes seen postmortem. Etiology.—Acute nephritis may occur at any time of life, though it more often makes its appearance before than after middle life. Males are 972 DISEASES OF THE URINARY SYSTEM. more susceptible than females, and particularly when engaged in occupa- tions requiring exposure to cold and wet. The habitual use of alcoholics also is generally a predisposing cause of acute Bright's disease. The principal exciting causes of acute diffuse nephritis are the follow- ing : (1) Those acting on the skin, as cold and dampness, extensive burns, and chronic skin-diseases. In many cases it is difficult to estimate Avhether the influence of alcoholic intemperance predominates or the exposure in- cident to it. Thus, acute intoxication from beer-drinking itself may cause an attack of acute nephritis, but it is likely that in most instances the direct exciting cause is cold acting upon the individual in his ex- posed and maudlin condition. The disease may also be attributed at times to exposure to cold and wet irrespective of alcoholic indulgence. It may be presumed with reason that in such cases there is some inherent or acquired weakness or a susceptibility of the kidneys, rendering them the weak links in th& visceral or systemic chain. (2) Biologic Toxic Agents.—These embrace the poisons of the acute infectious diseases, though in the majority of cases scarlet fever is the primary affection. Nephritis may supervene during the height of scarla- tina, but more often it occurs in the second or third week of convales- cence. Other infectious fevers may also cause acute nephritis (small- pox, typhus, typhoid, relapsing fever, cholera, diphtheria, yellow fever, measles, chicken-pox, erysipelas, septico-pyemia, acute lobar pneumonia, cerebro-spinal meningitis, dysentery, acute articular rheumatism, and tuberculosis: syphilis is rarely a cause). Acute infectious nephritis may also occur as a primary disorder, and the brunt of the affection may fall either upon the kidney, rather than upon any other part, or upon the organism as a whole, as in the fevers. Mannaberg, among others, has described such cases, and demonstrated streptococci in the urine. (3) Chemical Toxic Agents.—Among the principal irritants of this class are turpentine, cantharides, carbolic and salicylic acids, iodoform, the mineral acids, potassium chlorate, and such inorganic poisons as phos- phorus, lead, arsenic, and mercury. The excessive ingestion of highly- acid, spiced, or adulterated foods (as from salicylic acid and lead chromate) may in certain individuals cause acute renal inflammation. (4) Pregnancy.—Here the nephritis (gravidarum) comes on in prim- iparae, usually in the last months of pregnancy. It is probably caused by renal engorgement due to mechanical pressure, as well as to nutritive dis- turbances in the kidney, owing to the altered blood-condition. (5) Finally, latent and insidious chronic nephritis may be the cause of an onset of a manifest acute nephritis. Symptoms.—The onset varies with the cause of the nephritis, though generally it is rather sudden. Chilliness, nausea and vomiting, pain in the back, and, Avithin twenty-four hours, dropsy, are seen in some cases. Children may be seized with convulsions (uremic), and adults are not less liable to them in severe attacks. Fever may be present, although it is neither constant nor high. The characteristic symptom is the early appearance of edematous puffiness of the eyelids and face, with pallor of the skin. Soon (and sometimes at first, even) a swelling is noticed about the ankles and legs, and in marked cases the Avhole body becomes drop- sical, so that pitting on pressure may be observed pretty much all over the bodily surface. In such instances the scrotum and penis or the ACUTE NEPHRITIS 973 labia may become enormously distended, the skin having almost a trans- lucent appearance. Local symptoms, as pain and tenderness in the lumbar region, are often Avanting and are never marked. There may-be a desire to mictu- rate often, accompanied by slight burning and vesical tenesmus, due to the concentrated urine. In very severe dropsy the tense, dry skin, as of the limbs, may be sensitive or even painful to the pressing finger. Movements of the body are often difficult, painful, and distressing in marked anasarca. Intense headache and backache may precede the on- set of uremia. In mild cases the renal condition may be overlooked unless a urinary examination is made. Prostration may be unnoticed, and the patient feel nothing more than a general malaise. The characteristics of the urine in acute nephritis are all-important. The total quantity passed in twenty-four hours is diminished, and may be very scanty, sometimes amounting to not more than from 5 to 25 ounces (150-740 c.c). Suppression occurs in some cases of toxic origin, Avhen an acute degeneration or necrosis of the renal epithelium takes place, and in the most severe exudative inflammation's. The specific gravity is in- creased to 1025 or more early in the case ; later it may be as low as 1010 or 1015. The color is darker than normally, and is usually smoky-red or reddish-brown, according to the amount of blood passed. If the ab- normal morphologic constituents are present in great quantity, a more or less abundant flocculent sediment appears on standing. Microscopically, some red blood-corpuscles and renal epithelium are found, along Avith the characteristic hyaline, blood, and epithelial tube- casts. Chemically the urine is acid, and on boiling a thick, curdy pre- cipitate of albumin forms. The percentage of the latter by weight varies from l to 1 per cent. The urea is diminished. Other symptoms may develop during the course of acute Bright's dis- ease. If great general edema is present, physical signs of hydrothorax, ascites, and hydropericardium may be elicited. The first-mentioned con- dition is bilateral and causes dyspnea ; the second increases the dyspnea by pressing the diaphragm upAvard; and the last impairs the heart's action. Striimpell describes a form of pneumonia—a " stiff inflammatory edema"—midway between lobar pneumonia and broncho-pneumonia, that sometimes develops in severe cases of acute nephritis. Edema of the conjunctivae, soft palate, and larynx may also occur. The pulse is often hard and tense, and, though slow at first, it may become accelerated later. Cardiac hypertrophy of a slight degree may be detected. The aortic second sound is accentuated. Epistaxis is an occasional symptom, and subconjunctival hemorrhages are sometimes seen as a result of uremic convulsions that may not have been witnessed. A very constant symptom is the dry, anemic skin. Uremic manifestations may ensue at any time during the course of the disease. They appear early in the most severe cases, with intense headache and backache, vom- iting, and convulsions. The clinical course in other cases differs somewhat from the above, which may be considered as the common form resulting from exposure. Acute nephritis occurring as a complication of the infectious fevers, except scarlatina, may be characterized by the very slight degree, or even by 974 DISEASES OF THE URINARY SYSTEM. the absence, of dropsy. Albuminuria, hematuria, anemia, and uremia supervene in the graver affections. In scarlatinal nephritis, hoAvever, ana- sarca is common, and slight edema at least is quite constant. In mild affec- tions simply a little -albumin and a few hyaline casts reveal the paren- chymatous degeneration. In cases of degenerative nephritis due to min- eral poisoning the subsidence of the acute toxic symptoms may be fol- lowed by the typhoid condition, marked by prostration, muscular twitch- ings, stupor, coma, and death. In the so-called nephro-typhoid condition, Avhere typhoid fever begins Avith pronounced symptoms of acute nephritis, hematuria may be marked. The nephritis of pregnancy is usually grad- ual in its onset. The albumin increases in amount from month to month, and reaches a high percentage during the eighth and ninth months. Some hyaline casts are found, but otherwise there are few morphologic elements, and erythrocytes rarely appear in the urine. Danger of eclampsia is constant until the child is delivered, but recovery is rapid after the birth of the child in uncomplicated cases. That variety of acute (productive) nephritis in Avhich there is a tend- ency to the formation of patches or wedges of fibrous tissue is charac- terized by higher fever, by cerebral and circulatory disturbances of a typhoid nature, and by anemia, dropsy, and a highly albuminous urine, even though blood may be absent and casts may be few. The dropsy is most apparent in the legs. Dyspnea, vomiting, diarrhea, and a progres- sive and rapid loss of flesh and strength ensue until convulsions or coma end in death. Milder cases, lasting from tAvo to four Aveeks, apparently get well, albumin and casts persisting, hoAvever, until, after an interval of weeks or months, another and similar attack occurs. In short, the first acute attack is liable to chronic repetition until a fatal one takes place. Diagnosis.—The condition cannot be overlooked when the urine is carefully examined both chemically and microscopically. The dreaded eclampsia gravidarum can, however, be recognized only by repeated urinary examination, especially during the last months of pregnancy. Acute Bright's disease should be suspected, and the urine examined in every case shoAving pallor of the skin and puffy eyelids, whether general prostration of the health is apparent or not. The characteristic symp- toms of acute exudative nephritis, as commonly seen Avhen the condition is due to cold or occurs in scarlet fever, are the following: headache, restlessness, muscular tAvitching, nausea and vomiting, a tense pulse, moderate fever, dropsy, and anemia. Tube-casts and albuminuria are constant. It should be borne in mind that slight albuminuria occurring in the course of pregnancy or during any of the fevers, without easts, is not a true nephritis, although the latter may be a more or less remote consequence of the glandular degeneration of the renal epithelium asso- ciated with the febrile albuminuria. In addition to the presence of albu- min and hyaline and cell-casts, however, a diminished quantity of sooty- looking urine and the discovery of red and Avhite blood-corpuscles will render the diagnosis positive. The history of the case and the causal factors are also to be taken into consideration. Prognosis.—The duration of ordinary exudative nephritis folloAV- ing exposure to cold and Avet varies from a feAV days to three, four, or six weeks. The albuminuria steadily decreases, and Avith the casts finally disappears, Avhile the daily quantity of lighter urine increases, ACUTE NEPHRITIS. 975 as does the daily excretion of urea. The prognosis depends much upon the primary disease or causative condition, and also upon the intensity and character of the renal inflammation. Scarlatinal nephritis is less likely to be recovered from than nephritis due to exposure to cold after alcoholic excesses. The acute parenchymatous degeneration that accom- panies typhoid fever, diphtheria, and other infectious fevers, as well as pregnancy, is usually a mild affection and recovery takes place easily. But in acute yelloAv atrophy, yelloAv fever, cholera, and in severe phos- phorus- or mercurial poisoning death may occur from the intense and Avidespread necrosis of renal epithelium. In favorable cases of ordinary exudative nephritis the dropsy and albuminuria gradually diminish, while the color of the skin and the quantity of urine and urea increase, so that in the course of from three to four or six Aveeks recovery is established. After the disappearance of the dropsy the albumin may persist for some time, and then slowly disappear; but rarely, in unfavor- able cases, even when dropsy has disappeared, albuminuria may continue and the affection become a chronic parenchymatous nephritis. Serious and often dangerous symptoms of acute nephritis are—severe general edema, dropsical effusions into the serous sacs (as hydrothorax), uremia (especially when beginning Avith cerebral manifestations, as coma or convulsions), and finally inflammation of the internal organs, as pleu- ritis, pneumonitis, pericarditis, peritonitis, and meningitis. In the ab- sence of uremia recovery in cases of marked general dropsy is quite common. Suppression of urine, hoAvever, lasting more than twenty-four or forty-eight hours, is usually a fatal symptom. The prognosis is un- favorable also in cases in which the nephritis has a productive character. Life may, on the other hand, be prolonged for several years. Treatment.—I shall not include here the management of the pri- mary affection of which the nephritis may be either a complication or consequence. Since the renal function is diminished by the congestion and inflam- mation, the first object in the treatment is to relieve these conditions and thus restore the excretory function. The single or combined use of diaphoretics and cathartics is practised, therefore, not that the skin and boAvels should be made to perform the Avork normally done by the kidneys, but in order to restore the functional equilibrium by the anti- phlogistic effect produced. Absolute rest in a Avarm bed and in a warm room is of primary im- portance. Woollen undenvear and blankets should be provided, so as to promote a constant free action of the SAveat-glands. These hygienic measures should be carried out both in the mild and in the severer cases. Bland liquid foods only should be alloAved in the diet, and the patient should be encouraged to drink freely of Avater (plain, distilled, or car- bonated), lemonade, skimmed milk, or buttermilk; these are especially valuable when hot. Later, thin meat-broths may be allowed, although a strict milk diet is better. Local bloodletting, as by leeches or cupping over the loins, I seldom employ; in rare cases, however, when much pain is complained of, it may be useful, although hot fomentations may be more so. Diminution of the edema and the elimination of urea and other urinary constituents that may be retained in acute nephritis are best obtained by exciting a 976 DISEASES OF THE URINARY SYSTEM. profuse perspiration. This vicarious action of the skin, as before stated, also relieves the congestion of the kidneys. The hot-air or hot-water bath and the hot Avet-pack are also used to accomplish these results, and in most cases the last-named method suffices. It is easily applied by Avringing a blanket out of hot water, wrapping the patient in it, and then Avith a dry blanket, and finally a rubber-cloth cover, surrounding all. This furnishes a steam-bath in which the patient may remain until copious sweating has lasted an hour or so, according to the condition, Children suffering from scarlatinal nephritis may be treated thus, or quite readily also by immersion in hot water, for twenty, thirty, or forty minutes; the skin should then be lightly dried, and the child Avrapped in warm sheets or blankets and warmly covered in bed. Hot vapor or air may be generated alongside the bed, and transferred under the raised or cradled bed-clothes by means of a tin funnel and pipe. The SAveating will be aided by the drinking of hot lemonade or soda-Avater or of Avater containing spirit of Mindererus. Should the skin fail to respond to these measures, as in uremia, perspiration may be started by a hypo- dermic injection of pilocarpin (gr. ^ to \—0 008 to 0.0108), after Avhich it will continue to pour out on the application of heat. The heart and pulse should be watched after the injection of pilocarpin, as serious col- lapse sometimes attends its use. The SAveatings should be repeated until the dropsy disappears and as often as the patient's strength will permit. A useful adjunct to the above is the administration of hydragogues, as the saline cathartics, elaterium, and compound jalap poAvder. Elaterium extract (gr. |—^—0.0108-0.0162) is prompt in action, and magnesium or sodium sulphate ($j—4.0), given in hot concentrated solution every hour, or a calomel purge, may be recommended. It may be necessary to aid in relieving the tension and distress of extreme edema by multi- ple punctures or by the use of a small trocar and cannula, with a drain- age-tube (Southey) attached to the latter after the trocar is withdrawn. Aspiration must be performed if either hydro-thorax, hydro-pericardium, or ascites assumes serious proportions. Half-ounce (16.0) doses of the spirit of Mindererus (liq. ammon. acetat.) in water may be added to the diaphoretic treatment; this, combined Avith aconite, aids in controlling the fever that may be present and in preventing the vaso-constriction that is often premonitory of uremic symptoms. Uremic convulsions that do not soon yield to prompt diaphoresis and catharsis should be treated by venesection. As much as a pint or two (.5-1 liter) of blood may be Avithdrawn and life saved thereby. Some- times chloroform-inhalations are needed to subdue the very violent con- vulsive seizures, as in eclampsia. Their return may be prevented by rectal injections of potassium bromid and chloral, consisting of 1 dram (4.0) of the former and l dram (2.0) of the latter. Nausea and vomiting may be controlled by the use of cracked ice, minute doses of cocain, dilute hydrocyanic or hydrochloric acid, bis- muth, and by the addition of soda- or lime-Avater to the milk. Contraction of the arteries with increased tension and beginning muscular tAvitchings call for the use of nitroglycerin, chloral hydrate, or, possibly, morphin. Diuretics other than the simple diluent drinks mentioned have very little use in the therapy of acute diffuse nephritis, at least early in the CHRONIC NEPHRITIS. 977 disease. Later, as adjuvants to the diuretic properties of Avater, potas- sium bitartrate or acetate, sodium benzoate, and stimulants to aid cardiac depression at the same time, or caffein citrate and the infusion of digi- talis, may be given Avell diluted. During convalescence care must be exercised that the patient does not catch cold. The diet must not be increased to solids too sud- denly nor too rapidly, and particularly in the matter of meats. Light Avatery vegetables, fruits, and cereals may be gradually added to the diet-list, although milk should be mainly used. Ferruginous tonics are indicated for the anemia, and Basham's mixture is an admirable preparation at this stage. A change of locality to a Avarmer, drier, and more equable climate, and careful habits of dress, diet, and exercise, are necessary in cases of recovery from the very serious forms of nephritis, in Avhich the renal parenchyma is shown by the persistence of slight albuminuria at inter- vals to have been somewhat damaged. CHRONIC NEPHRITIS (EXUDATIVE). {Chronic Bright's Disease; Chronic Parenchymatous Nephritis; Chronic Diffuse Nephritis with Exudation; Chronic Tubal and Chronic Desquamative Nephri- tis; Chronic Glomerulo-nephritis; Large White Kidney; Secondary or Fatty and Contracted Kidney.) Definition.—A chronic diffuse inflammation of the kidneys, at- tended Avith epithelial degeneration, exudation from the blood-vessels, and permanent connective-tissue changes in the stroma. According to Delafield, this is the chronic productive (or diffuse) nephritis with exu- dation—one of tAvo varieties of chronic Bright's disease. Pathology.—Although there are several types of pathologic kidney in this disease, and many individual cases in Avhich anatomic differences are noted, the changes of structure are essentially the same, and the variations depend upon the causation and duration of the nephritis. The first type of kidney to be mentioned is the large white kidney (Avithout Avaxy degeneration). It is either enlarged or normal in size, and pale or yelloAvish in color. The surface is smooth, and the capsule is easily stripped off. On section the cortex is broader than normally, yelloAvish-white throughout, or it may present opaque yelloAvish or whit- ish areas with mottlings of red. The pyramids are congested in some cases. Microscopically, the following changes are commonly observed: the renal epithelium is SAvollen, hyaline, granular, or fatty, and more or less disintegrated or flattened; the glomeruli are enlarged from the groAvth of the capsule-cells and of the cells covering the capillaries, and in some cases, owing to the connective-tissue thickening of the capsule, the tuft of capillaries is found to be atrophied. The interstitial tissue shoAvs some thickening of the arterial Avails and a moderate groAvth of connective tissue in patches around the glomeruli and tubules ; the latter contain hyaline and granular casts. The small white kidney, or secondary contracted kidney, in most in- 62 978 DISEASES OF THE URINARY SYSTEM. stances is probably a later stage of the preceding, in which the degen- eration of epithelium is more advanced and the groAvth of connective tissue and resultant cicatricial contraction are prominent features. The kidneys are about normal in size (shrinkage of the large Avhite kidnev), the surface is slightly granulated, and the capsule is proportionately ad- herent. While this kidney is usually grayish or yellowish in color (pale, granular kidney), there may be some mottling due to red spots. The consistence is firmer than that of the large Avhite kidney. The cut- surface shoAvs yellowish-Avhite foci of the fatty degenerated epithelium in the someAvhat narroAved cortex, and hence the term that is sometimes used of "small, granular, fatty kidney." Under the microscope Ave find extensive degeneration and disintegration of the epithelium of the glomeruli and convoluted tubules, with atrophy of the parenchyma, and a corresponding increase of the interstitial connective tissue. Waxy degeneration may be associated. Another variety is the large red or variegated kidney of chronic hem- orrhagic nephritis. The organs are usually enlarged, SAvollen, red, and congested-looking or mottled, and frequently " bumpy" or slightly bossellated. The capsule is slightly adherent to the depressions betA\-een the bosses. Red spots, due to small hemorrhages, may be noticed on both the outer and cut-surfaces of the kidney. The section shoAvs also congested portions and gray or yelloAv spots corresponding to the anemic and fatty degenerated portions. Small cortical hemorrhagic areas or striations, brownish-red in color, are distinctive of the kidney. The microscopic appearances are those of the large Avhite kidney plus those of acute nephritis—viz. granular and fatty degeneration, proliferation of epithelium, thickened glomeruli-capsules, atrophied capillary tufts, and a groAvth of interstitial fibrous tissue in some places. In others there are inflammatory edema and cellular infiltration of the intertubular tissue, and dilated tufts of capillaries Avith surrounding cellular hyper- plasia. This variety of chronic nephritis is frequently found in inebriates. Ktiology.—The disease may folloAv either the acute diffuse nephri- tis, as of scarlet fever or pregnancy, or simple chronic congestion and chronic degeneration of the kidneys. More often it arises insidiously, in a subacute manner and Avithout any previous acute manifestation. Males are more frequently subject to this form of chronic Bright's disease than females. Children affected with the disease have usually had scarlatinal nephritis. Young adults are more commonly affected, however, with the usual variety, developing subacutely. Drinkers of beer and other malt and alcoholic intoxicants seem to be liable to the disease. It is not improbable that some toxic or infectious agency, acting sloAvly and persistently, may in the insidious cases be the cause of the nephritis, although manifestations elsewhere may be absent. I have observed it in certain individuals living in malarial regions. Persons Avorking under exposure to cold and wet, or those living in humid and Ioav, marshy localities, are more liable to this renal malady than those Avho are better protected from climatic vicissitudes. Tuberculosis, syphilis, and chronic suppuration may give rise to this so-called " parenchymatous " form of chronic Bright's disease, and it is usually combined with amyloid disease (Avaxy degeneration). Symptoms.—There may be a persistence, in a lesser degree, of the CHRONIC NEPHRITIS. 979 svmptoms of an acute parenchymatous nephritis, particularly the anemia, dropsy, and the albuminuria, until the affection becomes chronic. In most cases, however, the disease develops sloAvly and gradually, in a subacute manner, though the earlier symptoms seldom indicate any renal derangement. There may be simply a general impairment of health and strength, loss of appetite, nausea, and attacks of indigestion, headache, dulness, and perhaps some pallor. Soon there is puffiness of the eyelids or SAvelling of the feet or ankles, or both, and the com- plexion takes on a blanched appearance. The edema gradually extends up the legs, and is often Avorse as the day groAvs, Avhile on rising in the morning it may be found to have disappeared during the night's rest and recumbency. The quantity of urine is diminished in the majority of cases, though in the later stages it may be nearly or quite normal, and even slightly increased in long-standing instances of pale contracted kidney or when absorption of the dropsy is taking place. Superadded acute nephritis may cause a very scanty or a suppressed secretion of urine. The specific gravity is, of course, increased in scanty urine, and vice versa. Albumimtria is often quite marked. The amount of albumin may be from one-fourth to three-fourths of the volume of the urine, or from 1 to 3 per cent, by Aveight, so that the daily loss of albumin may be considerable. The urea is much diminished. The color of the urine is turbid, sometimes smoky-yelloAv, and urates, casts, red and white blood-cells, epithelial cells, granular debris, and fatty granular cells are found in the usually abundant sediment. The tube-casts are of different varieties, but narroAv or broad hyaline, fatty granular, and epithelial casts are commonly observed. The edema is prominent and persistent. It gradually extends all over the body, so that pitting can be obtained on the limbs, chest, abdo- men, and back. The loose subcutaneous tissues, as of the penis, scrotum, and eyelids, are particularly distended. In chronic hemorrhagic nephri- tis, only, the edema may be absent or very slight. The pasty, pallid complexion and anasarca are most characteristic of chronic exudative nephritis, especially with large Avhite kidney. The dropsy may be mod- erate and about stationary for several months; then, despite all treat- ment, it becomes insidiously Avorse, death ensuing in a month or tAvo. Dropsy of the serous sacs, Avith its attendant distressing symptoms, may be present in serious cases, and edema of the larynx and lungs may come on suddenly and cause death. Dyspnea may be toxic and nervous, as well as mechanical or cardiac in origin. Cardiac dyspnea, due to failure of the heart's action as seen in many cases, is usually worse on lying doAvn. It may be provoked by vaso-constriction, and is then a danger-signal of uremia. Catarrhal bronchitis may be associated with cough and expectoration. The heart is often affected with moderate hypertrophy of the left ventricle, and later by dilatation and a\ eakness of both ventricles. The aortic second sound is accentuated and the pulse-tension increased. Uremic symptoms are frequently manifested, except the convulsions which are common to chronic nephritis without exudation. Headache, vertigo, sleeplessness, nausea and vomiting, diarrhea, and stupor, coma, or delirium, may develop and precede a fatal termination. Albuminuric neuro-retinitis, as evidenced by dimness of vision and 980 DISEASES OF THE URINARY SYSTEM. field-defects, occurs in quite a number of cases. The skin of the legs becomes subject to a red eczematous eruption in some cases of great dropsical distention. In the absence of complicating inflammations, such as pericarditis, endocarditis, pneumonitis, and ulcerative colitis, Avhich are rare, the temperature is practically normal. The course of chronic exudative nephritis may either continue from bad to Avorse, until death ends all in a year or two, or anemia, dropsy, and albuminuria may attack one who for years previous has had apparent good health, after a first attack the second proving fatal within a few months. Again, some patients, having a little pallor, slightly diminished urine of high specific gravity, Avith albumin, may complain of nothing for years, until decided attacks, lasting for several months, may occur at intervals, during which the dropsy, dyspnea, etc. may be absent, although some albuminuria persists. The average duration of the disease varies from one and a half to three years. Diagnosis.—The diagnosis of the disease itself is not difficult, but of the stage or the variety of kidney it is almost impossible to tell cor- rectly in some instances. The urinary examination, coupled with the symptoms of dropsy and anemia, is sufficiently diagnostic of chronic diffuse nephritis (with exudation). In cases of large white kidney the urine passed is less in quantity and of higher specific gravity than in the small, pale, and contracted kidney. Edema is usually greater in the former also, while in the latter cardio-vascular changes are more marked, as shown by the physical signs and the hard pulse. The transition of the disease from the earlier to the later stage may be thus noted. The existence of hemorrhagic kidney may be inferred from the chronic congestion of the kidney and alcohol- ism and the presence of marked red blood-corpuscles and blood-casts in the urine. The duration of the latter form of chronic nephritis may be someAvhat longer (eight months to tAvo years) than that of the large white kidney (six to eighteen months), but it is shorter than the second- ary, contracted kidney, which lasts from one and a half to three or even five years. The casts in the latter may also be narrower and more darkly granular than in the large white kidney. Chronic parenchymatous is distinguished from chronic interstitial nephritis by the following points of difference: Chronic Parenchymatous Nephritis. Occurs in early or middle life. There is a previous history of an acute attack of scarlet fever, or perhaps of acute alcoholism. The onset is gradual or markedly mani- fest. Dropsy is a constant symptom. Vascular changes and cerebral symptoms are comparatively uncommon. Marked albuminuria, with tube-casts. Urine but little increased in quantity, often diminished; specific gravity is increased or slightly diminished. Anemia occurs earlier and is more dis- tinct. Chronic Interstitial Nephritis. Occurs later in life. A previous history of gout, chronic lead- poisonini;-, syphilis, excessive eating and drinking (spirits), nerve-strain; otherwise often negative. The onset is very slow, insidious, and in- definite. Dropsy is rare. Arterio-sclerosis, cardiac hypertrophy, and cerebral symptoms are common. Very slight albuminuria and few casts. Urine of very low specific gravity, and excessive in quantity. Anemia slowly progressive and less marked. CHRONIC NEPHRITIS. 981 Chronic Parenchymatous Nephritis. Chronic Interstitial Nephritis. Uremic symptoms are generally less se- Uremic symptoms are, generally severe vere—amaurosis, vomiting, diarrhea, —coma and convulsions, great dyspnea. headache. Runs a shorter course—from two to six Has a more chronic course—seven to or seven years. thirty years. Prognosis.—This is invariably bad as to cure, though life may be prolonged in certain cases. In severe cases death may take place in from three months to a year, either from uremia, dropsy, cardiac dilatation, or complications. Cases of a year's duration almost never recover, and, a fortiori, those in Avhich advanced secondary contraction of the kidney may be inferred are incurable, and may soon terminate fatally. Com- plete recoveries from the disease, particularly in children that have had scarlet fever, may occur but rarely. The prognosis depends greatly on the quantity of urine passed in the tAventy-four hours, and upon the amount and persistency of the albumin, as well as upon the degree of cardio-vascular and retinal changes. It should be remembered that acute attacks may supervene, and that relapses may occur in apparently favor- able cases. Treatment.—The indications for treatment are similar to those in acute nephritis. The dropsy and uremia must be treated symptomatically, and the diet is of importance. Skimmed milk and buttermilk should be depended on as much as possible Avhen dropsy is pronounced. When dropsy is slight, more solid food, white meats, vegetables, and fruits, and an out-door life, should be recommended. Residence in a warm, dry climate may aid in prolonging life. Wool- lens should be Avorn next to the skin, and prolonged, sudden, and severe exercise should be forbidden. The infusion of digitalis may be needed in cardiac Aveakness, or nitro- glycerin for contracted and tense arteries with a tendency to uremic twitchings. Unirritating diuretics and Basham's mixture for the anemia are useful. Strontium lactate in doses of from 15 to 20 grains (0.972- 1.29), three times daily, I have found useful in some cases. CHRONIC NEPHRITIS (NON-EXUDATIVE). {Chronic Interstitial Nephritis; Chronic Bright\s Disease; Primary, or Genuine, Contracted Kidney; Cirrhotic Kidney; Red Granular Kidney; Renal Arterio- sclerosis ; Chronic Productive {Diffuse) Nephritis without Exudation {Delafield) ; Gouty Kidney.) Definition.—A chronic diffuse inflammation of the kidneys, attended with a groAvth of connective tissue in the stroma, degeneration and atrophy of the renal parenchyma, and marked change in the cardio- vascular system. Pathology.—In genuine primary contraction of the kidneys there is a reduction in size and Aveight about equal in both organs. They may be only one-half or one-third the size of normal kidneys, and the two kidneys together may not Aveigh over two ounces. They are often 982 DISEASES OF THE URINARY SYSTEM. found imbedded in thick adipose tissue, the capsule being thick, opaque, and very adherent, so that on stripping it off it brings aAvay portions of the renal cortex. The outer surface of the kidney is red, irregularly granular, or finely nodular, and occasional small cysts are sometimes present. The consistence is firm, dense, and resistant to the knife. Ex- amination of the cut-surface shoAvs a thin atrophied cortex, and dark, reddish streaks alternating with pale portions. The pyramids are also diminished, and darker than the cortex. In the gouty contracted kidney the pyramids show fine striations of sodium urate or of uric acid, or crys- tals representing uric-acid infarctions. Microscopically, the essential changes are an increased production of connective tissue, especially in the cortical substance, and a more or less proportionate degeneration and atrophy of the renal parenchyma, the destruction of which is due to the circulation of noxious agents, but which is replaced by cicatricial fibrous tissue (Weigert). The new tissue is not uniformly distributed in the cortex, but occurs in irregular masses around the shrunken glomeruli or between the tubules. The distribution of connective tissue in the pyramids is more diffuse. Many of the glomeruli are quite small and fibrous in advanced cases, while in the earlier cases the cells of the tufts and capsules are SAvollen and multiplied, and a small-celled infiltration is seen around the glom- eruli and tubules. Later this infiltration of cells becomes fibrillated and ends in thickening. Glomerular atrophy is due partly to the changes in and groAvth of the capillary and intra-capillary cells, as well as of those around the tufts; partly also to capsular thickening and hyaline or waxy degeneration; and partly to the thickening and occlusion of arterioles. The tubules show marked changes. Some are included in masses of connective tissue, so that there is compression-atrophy and even total oblit- eration of the lumen. In other instances the intertubular connective tissue constricts the tubules in certain places, so that the lumen is else- where increased. This dilatation is especially prominent in the granules seen on the outer surface of the kidney, and, owing to the damming back of urine in some of the tubules thus obstructed, little cysts are visible to the naked eye here and there. The epithelium lining these tubules shoAvs granular, fatty, or waxy degeneration, and may be either flattened, cuboid, or swollen. The tubes may contain granular or fatty debris and tube-casts. An important change in most cases is the groAvth of fibrous tissue in the walls of the arteries, causing sclerosis. This affects the intima (end- arteritis), the media, and adventitia, all of which are thickened by the hyperplasia of connective-tissue elements. The arteries and capillaries are thus mostly occluded by the obliterating endarteritis or by their con- version into masses of connective tissue. Waxy or hyaline degeneration is seen also (vide Arterio-sclerosis). These arterio-capillary changes may in some cases be the primary condition that leads to granular and con- tracted kidneys, and may represent the renal effects of a general arterio- sclerosis or fibrosis. An almost constant accompaniment of chronic, non-exudative, produc- tive nephritis is cardiac hypertrophy. The degree of the latter depends upon the extent of the renal, and also of the general arterial, degener- CHRONIC NEPHRITIS. 983 ation and sclerosis. The whole heart may become so large that the term cor bovinum has been fittingly applied to it. In moderate enlarge- ments the left ventricle only is hypertrophied. Complicating lesions of chronic Bright's disease that may be men- tioned are cerebral hemorrhage, cirrhosis of the liver, pulmonary em- physema, chronic endocarditis, chronic endarteritis, pericarditis, bron- chitis, and gastric catarrh. Etiology.—The cause of the very slow primary, diffuse degenera- tion, atrophy, and fibroid contraction of the kidneys is sometimes quite obscure, (a) In some cases it Avould seem to be " only an anticipation of the gradual changes Avhich take place in the organ in extreme old age" (Osier)—the "senile kidney." (b) Heredity undoubtedly plays a part in the causation of certain cases, even to the third or fourth gene- ration, (c) Age and Sex.—The disease is more common in males than in females, and it usually begins near middle life; it is seldom manifested symptomatically until about fifty or sixty years of age, and is therefore an affection of advanced life, (d) Individuals having a special tendency to sclerotic degeneration of the arteries, from Avhatever injurious influ- ence, whether chemico-toxic or parasitic, are more liable to chronic in- terstitial nephritis, although the prolonged irritation of such deleterious agents may give rise to the disease in those whose cellular nutrition is usually not defective. Thus, the folloAving causes have been attributed to the disease : alcoholism, uric acid, and lead, giving rise to chronic poisoning. Chronic syphilis and chronic malaria probably also are caus- ative factors, (e) Habitual overeating and drinking, owing to the imper- fect metabolism of the substances ingested, causes a constant excretion of irritating products by the kidney, and no doubt frequently causes granular atrophy and sclerosis of the organ. The continuous and even moderate use of alcohol for many years, especially of spirituous liquors, is a Avidespread cause of the disease. It is equally likely that the ex- cessive use of red meats in the diet leads to the production of the uric acid that induces the renal disorder (uricemia-lithemia) by deranging the function of the liver (Murchison). (/) Allied to the above is gout, which causes chronic Bright's disease—in England perhaps more than in this country, where lithemia and nervous dyspepsia are more common. (g) According to Striimpell, severe acute articular rheumatism is some- times followed by contracted kidney, (h) Chronic Bright's disease Avith renal sclerosis is favored in origin and development by the anxieties, worries, and high nervous tension connected Avith modern business ac- tivity and "social functions," the latter particularly acting their part among elderly ladies. Associated with these are usually over-indul- gence in rich foods and wines and sedentary habits, (i) The cold, moist climate of New England and the Middle States Avould seem, ac- cording to Purdy, to predispose to contracted kidney. A chronic pro- ductive nephritis without exudation, though not the true " contracted and red granular " kidney, may be caused by hydronephrosis, chronic pyelitis, and chronic congestion of the kidney, as from heart-disease. Symptoms.—These may be latent for years, Avhile the morbid pro- ductive changes in the kidneys are sloAvly effected. The first symptoms may not appear until late in life, although the kidneys may be in an advanced stage of degeneration. Or some complicating or intercurrent 981 DISEASES OF THE URINARY SYSTEM. affection may set in, as pneumonia or pericarditis, and cause the de- velopment of grave or fatal renal symptoms. More commonly, how- ever, there is an attack of uremia, Avith headache, stupor, or convulsions, dyspnea, nausea and vomiting, and a tense pulse. This attack may be recovered from. Then there is an interval of variable duration, during Avhich the health is more or less impaired, and lassitude, drowsiness, disordered digestion, headache, failing vision, dyspnea, and frequent micturition are complained of. This is folloAved by another uremic attack, severer than the first, or perhaps fatal; if not fatal, the general health is still more reduced, and confinement to the house or bed is necessary, until the vital forces can no longer compensate for the destruc- tion of the renal parenchyma. Spasmodic dyspnea (uremic-cardiac) is sometimes the first manifesta- tion of contracted kidney. The gradual onset of .periods of uncon- trollable drowsiness during the day is often marked. An attack of hemiplegia may also be the first indication of renal disease. Sometimes progressive loss of flesh and strength, with a dry, harsh, Avrinkled skin, may be from the beginning the only clinical features of the affection until death results from sheer feebleness and emaciation. The complex- ity and variability of the symptoms make it best to describe them under the heads of the various systems: Urinary System.—The daily quantity of urine is usually increased so much that patients are troubled with a desire to urinate frequently, not only during the day, but two or three times during the night. This complaint may be aggravated by the hyperacidity of the urine and the irritability of the prostate (especially in advanced age) that are so often associated with cases of renal cirrhosis. The urine voided during the twenty-four hours may measure several quarts (2 to 4 liters) in well- marked cases of the disease. Early in the attack, when the incipient degeneration and destruction of the parenchymatous cells is taking place, the quantity of urine may be slightly decreased ; but as the " blood-floAV to the parts that remain must, cceteris paribus, be as great as it would have been to the Avhole of the organs if they had been in- tact," excessive pressure is brought to bear within the capillaries by the compensating hypertrophy of the heart, and the secretion of the urine, especially of the Avatery elements, becomes more active. The polyuria may give rise to a suspicion of diabetes. The urine is clear and pale- yellow in color, the specific gravity being seldom above 1010 or 1012, and it may be as low as 1002 or 1005. Albumin is found only in traces or it may be absent altogether (glomerular atrophy), especially in urine voided in the early morning. The urea is diminished, as in all forms of Bright's disease, and there is little or no sediment. A very careful microscopic examination may reveal a few, usually narrow, hya- line or granular easts, perhaps some leukocytes, and rarely a few ery- throcytes. In the later stages of the disease or upon the supervention of an uremic exacerbation or of a complicating inflammation the urine may be decreased, the albumin increased, and numerous casts be discovered in a more apparent urinary sediment. Hematuria is rare. Circulatory System.—The physical signs of cardiac hypertrophy (of the left ventricle in particular) are present. Symptoms referable to the heart are absent, unless dilatation and feebleness, sudden arterial con- CHRONIC NEPHRITIS. 985 traction, cardiac complications, or endocarditis occur. Inspection and palpation of the hypertrophied heart shoAV an apex-beat displaced doAvn- ward and to the left, and an increased, heaving, and rather circumscribed apical impulse. These signs may be less evident both in cases of coex- isting emphysema and later when dilatation may eclipse the hypertrophy. The left border of the deep cardiac dulness extends outside the nipple- line in the fifth or sixth interspace. The first sound of the heart is loud, and may be duplicated. A distinctive auscultatory sign is the accentuation of the aortic second sound, indicating increased vascular tension ; it may have a metallic quality in some cases. A mitral sys- tolic murmur may also develop, OAving to relative insufficiency. The pulse is increased in tension, and is hard, incompressible, and persistent, the duration of each pulse-wave being increased (pulsus tar- dus). The radial artery itself—and this is true of most of the palpable arteries—feels hard, thickened, and often tortuous, on account of the arterio-sclerosis. As soon as compensation of the heart fails, symptoms of breathlessness (especially on exertion), palpitation, and the like appear, and sometimes in paroxysmal attacks (" cardiac asthma"). The resultant stasis gives rise to transudation into the lungs (bron- chorrhea-pulmonary edema), and later to edema of the extremities. Respiratory System.—Epistaxis may be a serious symptom. Sudden edema of the larynx may also occur, and is ahvays grave. Transuda- tions into the pleural sac (hydrothorax), as well as into the lungs (vide supra), may precede death. Dyspnea, Avhich is either cardiac or uremic, is usually worse at night, and a true orthopnea, together Avith Cheyne-Stokes breathing, may be observed toAvard the end of the pa- tient's life and in association with uremic stupor and coma. Nervous System.—Symptoms referable to the nervous system are very important, since they are usually indicative of grave uremia. Cephal- algia is frequent, and neuralgic pains throughout the body, and insom- nia, may be complained of. Later great drowsiness is often a premo- nition of uremic coma. Convulsions may be preceded by muscular twitchings, which should attract attention to the imminent danger of the former. Cerebral apoplexy with hemiplegia may be the first symptom of contracted kidney. It is especially apt to occur in cases of marked hardening and Aveakening of the arteries. There may be an hemorrhagic pachymeningitis, as Avell as a hemorrhage into the brain-substance. The hemiplegia may persist until death, or it may disappear in a short time, and be folloAved by subsequent attacks at in- tends. Formication, numbness, and pallor of one or more fingers (the so-called "dead finger") I believe with Dieulafoy to be sometimes the earliest symptoms of chronic Bright's disease. Of the special senses, nephritic retinitis is often the earliest evidence of chronic Bright's disease. The patient may or may not have had slight dimness of vision (mistiness) prior to the ophthalmoscopic exami- nation. The loss of vision affects both eyes, and is usually partial (am- blyopia). Sudden and complete blindness may come on in grave cases —uremic amaurosis—the condition being due to a neuro-retinitis. The optic papilla is SAvollen, and surrounded by retinal hemorrhages or by white dots and streaks (" feather-splashes "). Tinnitus aurium, deafness, and vertigo are not uncommon. 986 DISEASES OF THE URINARY SYSTEM. Digestive System.—Anorexia, nausea, and annoying dyspepsia are often complained of. Severe vomiting may usher in an uremic attack. Catarrhal gastritis may exist for some time, the tongue being coated and the breath heavy and urinous. Uremic diarrhea may also occur. The Skin.—Edema is usually absent in renal sclerosis; Avhen it does occur, hoAvever (as in the ankles and limbs), it is due to dilatation and failure of the heart. The skin is dry, and minute lustrous scales of urea may be seen around some of the pores. A certain degree of pallor is noticed, and often the skin has a cyanotic tinge. Pruritus and trouble- some eczema are frequently present, and muscular cramps, occurring especially in the calves of the legs and at night, may also be associated. The general nutrition gradually fails, so that in advanced cases the debility and emaciation are extreme. It is important to bear in mind the fact that uremia may come on at any time during the course of the disease, and that it may be the first symptomatic manifestation ; also that it may either be sudden and severe in its onset (acute uremia) or mild, insidious, and gradual (chronic uremia). Moderate fever may attend an uremic attack, or the tempera- ture may be normal; in chronic uremia, Avith prostration, coma, delir- ium, and feeble pulse, it may be even subnormal. Among the complications that may occur in the red, granular, and contracted kidney are the folloAving: pneumonia, either lobar or lobu- lar ; pleuritis, pericarditis, laryngitis, bronchitis, gastritis, enteritis, peritonitis, meningitis, endocarditis, emphysema, phthisis, and hepatic cirrhosis. Diagnosis.—This depends in great part upon the physical, chemi- cal, and histologic examination of the urine. Both the morning and evening urine should be examined repeatedly for albumin and casts, since one examination—and especially that of the morning urine—may give negative results, owing both to the scarcity of these two pathologic elements and to the fact that albumin may be altogether absent in some instances. The mere discovery of a trace of albumin or of a few casts is not ahvays positive evidence of chronic Bright's disease, as both may exist in other conditions. But the age, habits, and symp- toms of the patient must be studied in connection Avith frequent urinary examinations; and a persistent slight albuminuria, with casts, and the passage daily of large quantities of clear, pale urine of low specific gravity, afford sufficient grounds for making the diagnosis. Contracted kidney should be suspected in all cases in which, during middle life, either one or more of the folloAving symptoms and signs may be noticed: frequent headache, congestive disorders, repeated epistaxis, vertigo, dimness of vision, impaired strength, dyspneic attacks, gastro- intestinal dyspepsia, noises in the ear, itching of the skin, cramps in the calves, muscular twitchings, growing mental dulness, increasing pulse- tension, and a rigidity and tortuosity of the temporal and radial arteries. Sudden coma, convulsions, amaurosis, apoplexy, vomiting, or dyspnea in persons in the middle period of life, Avith or without a history of polyu- ria, should create the suspicion of chronic Bright's disease. It will be found in such cases that there has been a diminution in the urinary Aoav before the attack. Persons of lithemic, gouty, rheumatic, or alcoholic habits, or in Avhom lead-toxemia is discoverable, with evidences of car- CHRONIC NEPHRITIS. 987 diac hypertrophy, an accentuated aortic second sound, and a hard pulse, are often readily diagnosed as subjects of contracted kidney when a fur- ther examination of the urine is made. The diagnosis may be very difficult, however, in cases in which the first examination of the patient is made during a sudden uremic or apo- plectic attack. Catheterization should be done if necessary, and the detection of albuminuria will then clear the diagnosis. In order to differentiate betAveen primary renal affection with second- ary cardiac hypertrophy and primary heart-disease with a secondary con- gested kidney occurring late in the case, the general features, course, symptoms, and signs must be carefully and judiciously balanced. Prom- inent cardio-vascular changes would indicate an arterio-sclerotic kidney, rather than the primary granular and contracted kidney of toxic origin, though even here the diagnosis is often as difficult as it is unnecessary from a therapeutic standpoint. Prognosis.—The duration of chronic interstitial nephritis varies. In uncomplicated cases it may last for five, ten, twyenty, or possibly thirty years. Complications or intercurrent affections may, however, shorten the duration very much, or the existence of the condition may be un- known, as frequently happens, Avhen the postmortem examination shoAvs the characteristic kidneys in one Avho during life had no symptoms indi- cating renal disease, and whose death Avas caused by some intercurrent disease. Chronic Bright's disease with contracted kidneys destroys life sooner or later unless the patient dies from some intercurrent disease. The gradual destruction of the renal parenchyma and its replacement by scar-tissue cause irreparable damage to the organs. On the other hand, the fact that the process is usually a slow one and its duration long is compatible Avith the preservation of life for many years, and Avith comparative comfort, even, in many instances. The prognosis in a given case depends very much upon the general constitutional condition, the cardio-vascular state, and the presence or absence of uremia and inflam- matory complications. Cardiac dilatation and insufficiency indicate a not far distant end. Convulsive and apoplectic seizures are often fatal, and hemorrhages, persistent vomiting, and diarrhea, retinitis nephritica, coma, and delirium render the prognosis as to further systemic toler- ance of the degenerated kidneys exceedingly grave. Treatment.—An early recognition of the disease and the steadfast practice of careful hygienic measures will prevent, to a considerable degree, the advance of the cirrhotic changes. Noxious substances enter- ing into the etiology of the affection must be avoided and removed as far as possible. The formation of uric acid must be reduced by dietetic management, alcoholics must be interdicted, and lead—when the cause of the condition—must be kept from further poisoning the system by a change of occupation. By diminishing these irritants the heart and blood-vessels are also conserved—a point of vital importance. The hygienic treatment must embrace a regulation of all the habits of body and modes of life. The patient must be treated, and not his malady, since that is incurable. A dietary that is suitable for each in- dividual case must be made out, and on general principles. Saundby's rule is a good guide: " Eat very sparingly of butcher's meat; avoid malt liquors, spirits, and strong wines." An exclusive milk diet may 988 DISEASES OF THE URINARY SYSTEM. be necessary for short periods when gastric irritation is present, but in such a chronic disease undue Aveakness Avould result from a restriction to milk alone. I would therefore recommend a light nourishing diet, including lean meat once daily in favorable cases. Vege- tables, greens, fruits, and light, Avell-cooked farinaceous articles may also be partaken of, and tea, coffee, and cocoa may be drunk. The use of natural mineral Avaters aids in the renal circulation and keeps the kidneys flushed. In general a mixed diet will be of advantage; the nitrogenous and carbohydrate elements (sugars and starches) are used in limited amounts, while pure fats and fruits (raAv or cooked) are to be recommended. Stout persons and those leading sedentary lives should have less food than those taking exercise, and gastric disorder requires the elimination of all but soft, bland foods, or a liquid diet until diges- tion is restored. Extremes of bodily, mental, and emotional activity should be avoided, and physical exercise should be moderate, regular, and taken in the open air, provided the latter be Avarm and dry. Men- tal labor should never be excessive, nor should the patient be subjected to the vicissitudes of worry, anxiety, or competitive tension. Venereal excitement and indulgence of any kind tending to unbalance the self- control or disturb the equanimity, cheerfulness, and contentment should be strictly forbidden and guarded against. A change of residence to a warm, mild, and dry climate is often of service in prolonging life. The variability and humidity of temperate climates, particularly during the Avinter months, aggravate this disease, while a sea-voyage or a sojourn at some southern European resort may be very beneficial to one who can afford it. The indications for medicinal treatment are principally as follows: The bowels should be kept free by the aid of laxatives or laxative alka- line mineral waters. Papoid, peptenzyme, and other digestants, with bitter tonics, are useful in some cases in Avhich a furred tongue and indi- gestion are troublesome. Acids or alkalies, according to special indica- tions, may also be used simultaneously. An increased vascular tension (vaso-constriction), such as to place a serious strain upon the heart; the other extreme, of a very Ioav tension that induces dropsy ; and compli- cations, usually uremic (convulsions, dyspnea, headache), also call for therapeutic assistance. High tension is to be met by the cautious use of nitroglycerin in gradually ascending doses, beginning with 1 minim (0.066) three or four times daily, until all danger of rupture of the ves- sels seems to be past. Headache, vertigo, and the so-called renal asth- ma (dyspnea) are also often relieved by this drug. Loav tension, with signs of cardiac dilatation, scanty albuminous urine, and edema, requires heart-tonics and stimulants, in conjunction with purgatives. Digitalis (preferably in infusion) has good effects, especially when combined Avith strychnin nitrate or Avith caffein citrate. Calomel and the salines should be given for the dropsy. Uremic symptoms should be treated as in acute Bright's disease by causing profuse sweating and free catharsis, and in some cases by phle- botomy. Inhalation of amyl nitrite or chloroform, or, what is often a useful and necessary measure, the hypodermic injection of morphin (gr. |—0.0108), may be tried in convulsions, severe headache, or dyspnea. Contracted kidney of a probable malarial or syphilitic origin may be PYELITIS. 989 benefited someAvhat by the use of arsenic and the iodids respectively; but no drugs can possibly restore the destroyed renal parenchyma or transform connective-tissue cells into secreting kidney-cells. PYELITIS. {Pyelo-nephritis; Pyonephrosis.) Definition.—Inflammation of the pelvis of the kidney. The com- pound terms above (in italics) represent an inflammation of the kidney- structure as a result of, and combined Avith, pyelitis. Pathology.—In the mildest varieties of pyelitis (the catarrhal) the morbid changes consist simply of a reddened, swollen, and turbid mucous membrane, covered with an exudation of viscid muco-pus and desqua- mated epithelium. Ecchymoses are sometimes seen. The urine in the pelvis of the kidney is also turbid from the admixed pus-corpuscles and pelvic epithelium. In calculous pyelitis, owing to prolonged and severe irritation, purulent inflammation and ulceration prevail, and the kidney- structure is also involved by extension (pyelo-nephritis). Renal ab- scesses are thus formed, and small dark calculi are frequently found mingled with the pus in quite a number of small abscess-cavities; or perhaps, as noted before (vide Nephrolithiasis), one large abscess-cavity may replace the destroyed renal parenchyma (pyonephrosis). A diphtheritic inflammation, Avith the formation of a false membrane and sloughing of the pelvis, sometimes folloAvs the severe infections of the specific fevers. Marked hemorrhagic areas may be seen also. In tuberculous pyelitis there is usually an association of nephritis with areas of tuberculous softening and ulceration, and later pyonephrosis. In very chronic and sluggish cases the pyelitis may be followed by an infiltration of the kidney-structure Avith cheesy or putty-like masses that may become the seat of calcification. Persistent obstruction leading to pyelitis is associated Avith dilatation of the pelvis from retention of urine or of pus (pyonephrosis). This in turn, from prolonged pressure, causes the marked atrophy of the secret- ing structure of the kidney that is seen in such cases. There is also an increase in the interstitial tissue and secondary contraction. The so-called surgical kidney is found when an acute bilateral pye- litis, folloAving a severe cystitis, has excited an acute suppurative in- flammation of the kidney. Acute suppurative or interstitial inflamma- tion of the kidney due to metastatic or miliary abscesses is considered under the heading Pyemia (vide p. 199). Etiology.—Pyelitis rarely is primary or independent in origin, as after exposure to cold and Avet. The secondary causes of pyelitis are as folloAvs: (1) renal calculi (the most frequent); (2) extension upAvard of urethritis, cystitis, or ureteritis; (3) retention of decomposed urine in the pelvis of the kidney ; (1) renal affections, as tubercle, carcino- ma, and acute nephritis; (5) specific fevers; (6) foreign bodies, other than stone in the pelvis ; (7) irritating diuretics. To point out briefly certain additional facts bearing upon the above in the order named, it 990 DISEASES OF THE URINARY SYSTEM. should be mentioned that calculous pyelitis may result from the irrita- tion of the constant presence and passage of small stones (" gravel "), or even of uric-acid "sand," as well as from the large dendritic concre- tions that send offshoots into the calyces. Extensions of inflammation to the pelvis from lowTer portions of the urinary tract may occur in pro- tracted cases of such affections as gonorrheal urethritis aud puerperal and calculous cystitis. Obstructive pyelitis sometimes follows the im- paction of renal calculi or of other foreign bodies in the ureter when there is pre-existing inflammation of the tract, or when, as usually hap- pens, there is chemical irritation from the decomposition of the accumu- lated urine. There may be obstruction in the bladder and urethra, as from enlarged prostatic tumors, stricture, phimosis, and paralysis of the sphincter vesicae, or as in paraplegia. Under the consideration of tuber- culosis and carcinoma of the kidney is included the involvement of the pelvis by these conditions. Infectious pyelitis may also result from small-pox, diphtheria, typhus and typhoid fevers, and scarlatina, and it depends upon the irritating effect of certain substances eliminated by the kidneys. It is usually associated with more or less nephritis (pyelo- nephritis). Parasites, such as the echinococcus (hydatids), distoma, strongylus, and filaria, may give rise to pyelitis. Cantharides, cubebs, copaiba, turpentine, and diabetic urine even, may in rare instances also excite a pyelitis. Symptoms.—These are frequently overshadoAved by those of the primary condition that causes the pyelitis: they are varied also for the same reason. The clinical manifestations of a simple catarrhal pyelitis are slight pain and tenderness in the region of the affected kidney or kidneys, mild fever, with a turbid urine of acid reaction, shoAving a few pus-cells, a little mucus, rarely some red blood-corpuscles, and a trace of albumin. In the severer varieties, as in calculous pyelitis, especially when there are attacks of renal colic, the urine frequently shoAvs to the naked eye the presence of blood and a marked amount of pus, some mucus, and the transitional caudate epithelial cells from the middle layers of the mucosa. The presence of the latter, hoAvever, is not constant, hence its absence does not exclude the existence of a pyelitis, since some of the most destructive forms of the affection, as the acute or chronic suppurative or the pyelo-nephritic, may be unaccompanied by the presence of the pelvic epithelium in the urine. This holds still more true in the case of true pyonephrosis, in which the kidney usually becomes one large abscess. In severe pyelitis the pain is often acute, coursing doAvn the ureters. The fever is moderate, and there are present the common symptoms de- scribed under Nephrolithiasis (vide p. 966). The fever in purulent pyelitis (pyonephrosis) and pyelo-nephritis takes on a hectic or typhoid type. Paroxysms of rigors or chills, fol- lowed by a rapid rise in temperature and ending in perspiration, may be observed, or there may be marked prostration and feebleness of cir- culation, delirium, and stupor. The temperature-curve runs an irregu- lar course, with marked remissions, in cases of a pyemic nature. In obstructive pyelitis the urine sometimes Aoavs freely and nor- mally for a Avhile, until the developing pain over the inflamed kidney PYELITIS. 991 ends in relief by the expulsion of the obstacle and the passage of puru- lent urine. This alternation of normal with pyoid urine is indicative of a unilateral pyelitis. Ammoniacal urine is met Avith in cysto-pyelitis. Albuminuria is de- cidedly shown according to the degree of pyuria. In chronic suppurative pyelitis or pyelo-nephritis the pyuria is vari- able both in quantity and constancy. Intermittent pyuria may be due to the temporary blocking of the ureter by a stone (vide Obstructive Pyelitis). The pus is seldom mixed with epithelium in chronic purulent pyelitis. The associated intermittent fever may be like that of tubercu- lous pyelitis, and marked prostration, anemia, and emaciation are con- comitants. Evidences of amyloid change may be revealed in long-stand- ing, chronic cases. The term ammoniemia has been applied to that complexus of nervous symptoms that is supposed to arise from the decomposition and absorption of urinary substances. These symptoms may be similar to the manifesta- tions of diabetic coma. Distinct enlargement and fluctuation of the diseased kidney may be determined in some cases of pyonephrosis. This may also be inter- mittent, being detectable while there is obstruction to the flow of pus, and vice versa. According to A. H. Smith, at the menstrual periods pyelitis may be subject to marked exacerbations, simulating renal colic. In chronic pyelitis with atrophy of the kidney the onset of uremia may terminate the case. Granular kidney alone may have been simulated by the passage of an increased quantity of urine of proportionately low specific gravity. Diagnosis.—This embraces the discrimination from other affections, and the possible detection of the variety—etiologically considered—of the pyelitis. It is most important to pay attention to the clinical history of any case with a view to the discovery of the cause; also the urinary con- dition must be carefully studied. In the very nature of this affection it is often impossible to exclude other affections of the urinary tract, as nephritis, cystitis, and urethritis. Any severe inflammation of the tract in which the lower portion is known to be affected is generally associated with pyelitis or pyelo-nephritis, from the well-knoAvn tendency to exten- sion by continuity. Epithelium from the pelvis of the kidney cannot be distinguished from transitional bladder-cells; but, given the indications of a pyelitis, its cal- culous cause is at once made clear upon the passage of the characteristic uratic or oxalatic concretions. It may happen that the urine from one kidney is prevented from flowing by the impaction of a stone in the ureter. The urine may now flow clear from the other and vicariously acting kidney until, the stone having given way, it suddenly increases in quantity and changes in character, owing to the return of the mor- phologic elements of the pyelitis (corpuscles, desquamated epithelium, crystals, and debris). In women catheterization of the ureters and renal pelves, as described and practised by Pawlik and Kelly, is a most certain method of deter- mining in doubtful cases from which side the purulent urine arises. Pal- pation of the ureters through the lateral and anterior fornix of the vagina 992 DISEASES OF THE URINARY SYSTEM. will sometimes reveal thickening and tenderness in cysto-pyelitis, and ureteral distention sometimes may be felt in pyelitis calculosa. Vierordt mentions having seen in some cases of pyelo-nephritis pecu- liar hyaline casts " split like a pair of trousers." Casts and albumin are usually present Avhen the kidney-structure is involved by extension of the pyelitis, while marked pain in the region of the kidney indicates predom- inant pyelitis, though it does not exclude the possibility of coexisting nephritis. Marked vesical irritability points to associated cystitis, but in intense pyelitis with much pus and an acid urine vesical tenesmus may also be troublesome. Tuberculous can be discriminated from calculous pyelitis, possibly, only by the detection of the tubercle bacilli in the pus. The presence of a fluctuating tumor in the lumbar region is significant enough of pus, but it may be difficult to determine whether it is due to pyonephrosis or perinephric abscesses, although pyuria and the previous history of pyelitis, as well as the more circumscribed and less edematous character of the swelling of the former, are important distinguishing points. The hemorrhagic pyelitis of Senator, Delafield, and others, described as occurring in milder forms, and particularly in girls of neurotic types, may be distinguished by the intermittent hematuria and the occasional lumbar pain, lasting but a feAV days or a week, and followed uniformly by recovery. Digestive disturbances may be prominent in these cases. Much difficulty is sometimes experienced in diagnosticating pyelitis when coexistent with cystitis—pyelo-cystitis. These infections will not be confounded, however, Avhen it is recollected that their histories differ, acid pus being usually present in the former, and evidences of ammoniacal decomposition in the latter (with alkalinity). There is also pain in one lumbar region in the former, and in the bladder in the latter. Prognosis.—Renal complications ahvays make the pyelitis a serious affection. Catarrhal cases recover. Calculous pyelitis tends toAvard chronicity. Pyelo-nephritis and pyonephrosis are apt to end fatally from exhaustion or uremia. Perforation and the discharge of pus into the peri- toneal cavity, pleural sac, intestine, and bronchi even, may precede death. The gravity of all cases of pyelitis depends upon the causes and upon the tendency to consecutive suppuration. Treatment.—This varies according to the cause: the latter needs to be removed, its effects counteracted, and its return avoided. The treatment of calculous pyelitis is essentially the treatment of nephro- lithiasis. Primary inflammation of the loAver portions of the urinary tract must be combated; causes of retention of decomposed urine, as an urethral stricture or enlarged prostate, must be diminished; infectious fevers must be judiciously handled and irritating diuretics Avithheld. Local measures are of value in all forms of pyelitis. Hot-Avater bags, fomentations, poultices, and dry cupping are often of great service. Internally, the use of diluents is to be recommended, especially the alkaline mineral Avaters, flaxseed tea, barley-water, skimmed and butter- milk, and lemonade. Potassium citrate, uva ursi, buchu, and pareira brava are some- times selected for their soothing properties. But, practically, none of the remedies named nor any other drug is of any avail Avhen suppu- ration is once established. Irrigation by means of Kelly's ureteral HYDRONEPHROSIS. 993 catheter may be practised with good results in females. In chronic pyelitis salol and the oils of turpentine, sandahvood, juniper, copaiba, and erigeron have been used for their stimulating and alterative effects upon the mucous membrane. Surgical intervention is necessary in severe purulent pyelitis, pyelo-nephritis, and pyonephrosis. HYDRONEPHROSIS. Definition.—An obstructive accumulation of urinary fluid in the pelvis and calyces of the kidney; it may cause dilatation, pyelitis, or inflammation and atrophy of the renal structure. Pathology.—Hydronephrosis is usually unilateral The pathologic changes consist of a dilatation of the pelvis of the kidney, associated with a degree of atrophy of the renal tissue depending upon the degree and persistence of the pressure. The accumulated fluid causes flatten- ing and atrophy of the papillae, and gradually of the tubules and glom- eruli, as the dilatation and distention increase, until in extreme cases remnants only of the renal structure remain in the Avails of the hydro- nephrotic cyst. The mucous membrane lining the pelvis and calyces first becomes thinned, and later thickened, by the growth of connective tissue, thus forming the dense sac-Avail. There is also a growth of con- nective tissue in the renal parenchyma, medullary and cortical, a chronic nephritis Avith degeneration and atrophy of the renal cells being set up. A nephrydrotic cyst may be very large, containing as much as several gallons of liquid. Sometimes in medium-sized sacs the external appear- ance of the Avails may be lobulated; the interior, hoAvever, usually shows only partial septa projecting from the wall into the cavity of the sac. The smaller sacs partially enclosed by the membranous septa probably represent the dilated calyces. According to the seat of obstruction one or both ureters may also be dilated. If one kidney is affected, its fellow is often hypertrophied. The fluid contained in the sac varies in composition, but usually is a clear, thin, yelloAvish, watery urine. The specific gravity is Ioav, and the reaction is often slightly alkaline. Traces of albumin, urea, uric acid, and salts are found. Turbidity may be present, owing to admix- ture with pus, blood, or epithelium, but only in instances in Avhich pre- vious inflammatory conditions, as a calculous pyelitis, or subsequent complications of like nature have existed. Etiology.—Hydronephrosis—or, better, nephrydrosis—is in most instances secondarily produced by diseases—congenital or acquired— that cause occlusion of the ureter. It is, therefore, rather an associated abnormal condition than a distinct disease in itself. Probably from 20 to 35 per cent, of cases are congenital (Roberts). In these cases the causal condition is one of stricture, due to obstruction caused by a de- fective development or malformation in the urinary passage of one or both sides, usually the latter. Thus, there may be a valve-like formation or a very acute insertion of the ureter into the kidney. The dilatation has occasionally become so great in the fetus as to cause considerable mechanical difficulty during labor. 63 994 DISEASES OF THE URINARY SYSTEM. Among adults, women are more often subject to hydronephrosis than men, and especially women who have borne children. The condition may be bilateral, as from a stricture low down and due to gonorrheal urethritis, but more often it is unilateral. The causes of these acquired cases are as follows: (1) Impacted calculi in the ureter or renal pelvis. (2) Disease of the ureteral Avails, as inflammatory thickening and cica- tricial stenosis from ulcers. (3) Flexion and tAvisting of the ureter, as from movable kidney. (1) Pressure upon the ureter from Avithout, as by tumors and constricting bands (pelvic adhesions). The gravid and retrodisplaced uterus, uterine and ovarian neoplasms, and similar con- ditions causing compression or traction and obliteration of the lumen of the ureter, are found in this class. (5) Diseases and tumors of the bladder that involve the ureteral orifices, particularly carcinoma, or that cause retention, as prostatic enlargement. (6) Urethral stricture. Symptoms.—These depend somewhat upon the cause and extent of the hydronephrosis. Marked bilateral disease, Avhen congenital, may render the fetus inviable. The unilateral variety may be overlooked for years, and no symptoms may point to the trouble until a tumor can be made out by inspection and palpation, or until the ureter of the re- maining kidney may become obstructed and symptoms of uremia super- vene. The latter are more apt to come on, and earlier too, in double hydronephrosis. Locally, the patient may complain of frequent and severe pains that shoot about the affected loin and doAvnward toAvard the thigh. Sensa- tions of Aveight and a dragging discomfort are common. Anorexia, nausea and vomiting, eructations, and irregularity of bowel-action are associated sometimes. In large hydronephrotic cysts a continuous dull, aching pain only may be felt, or, as is not infrequently the case, the tumor may be absolutely painless. Obstinate constipation may result from compression of the colon, or in moderate enlargements diarrhea may occur from the pressure-irritation. Usually a SAvelling is detected in the region of the affected kidney. It gradually increases in size, and in marked enlargements distinct bulging may be visible in the hypochondriac and lumbar regions. Pal- pation reveals a rounded, firm, yet someAvhat elastic and sometimes fluc- tuating tumor. There may be slight tenderness. Dulness on percussion is found over the mass, except Avhere the colon overlies it, when tym- pany is elicited; this is a characteristic sign of kidney-tumors. Mod- erate enlargements generally do not descend during inspiration. There may, hoAvever, be exceptions to this rule. The intermittent form of hydronephrosis (Landau) is interesting from the variations that occur in the size of the tumors. A marked diminu- tion is coincident with a more or less sudden increase in the quantity of urine passed, and, on the other hand, as the tumor gradually enlarges the flow of urine decreases. These cases are in most instances due to movable kidney. Colicky pains often usher in the periods of greatest distention preceding the sudden increase in the Aoav of clear urine. This variety of the affection occurs most frequently in women that have borne children. The general symptoms scarcely amount to more than a certain loss of flesh incident to the associated worry and anxiety. The filling of the nephrydrotic cyst, the distention, and the pain and HYDR ONEPHR OS IS. 995 discharge, Avith subsidence of the tumor, recur Avith variable frequency. According to Osier: " Among the circumstances liable to cause them are sudden and violent exercise, the jarring and jolting of riding and driving, any fatigue, mental emotions, and errors in diet." The tumor may continue to develop in size for several days after the pain has dis- appeared. The latter may last from several hours to a day. During the intervals, and after the urine has increased in quantity, gradually or quickly, the patient feels tolerably comfortable, and this sometimes for Aveeks or months. For obvious reasons the tumor is rather mobile in intermittent hydronephrosis. The occurrence of chills, fever, and sweats, nausea and vomiting, abdominal distention, and rapid pulse usually indicates suppuration, and pyonephrosis may be the consequence. The urine Avill then be cloudy and reveal pus, following both discharge and aspiration. A loAvered specific gravity and the presence of albumin v\ ill be noted Avhen a chronic nephritis has been set up. Increased arterial tension and symp- toms of acute febrile or chronic afebrile uremia may be added. Hydronephrosis paraplegica is a form of the disease in Avhich para- plegia develops as a complication. The course of nephrydrosis is usually chronic, with variations and exacerbations depending upon the cause of the affection. Diagnosis.—This is obviously very difficult in cases in Avhich the accumulation of liquid is small. Characteristic signs are the gradual development of a tumor in either flank, as described above, Avith dimi- nution in the urinary flow, folloAved by a more or less sudden free dis- charge and the subsidence of the tumor, Avith recurrences (as in the in- termittent variety). When these do not occur and the tumor continu- ously enlarges, aspiration may be practised to determine Avhether the mass is solid or liquid ; the nature of the latter may also thus be ascer- tained, Avhether urinary or not. Ureteral catheterization will determine which is the dry side. The history of the case and the detection of some causative occlusion will point to the diagnosis. Differential Diagnosis.—The nephrydrotic sac must be distinguished by exclusion from an ovarian cyst, cystic kidney, and tumors of the spleen, liver, and gall-bladder. Very large cysts may be mistaken for ascites. Assurance of the presence of the colon over the tumor is diagnostic, and a chemical examination of the fluid obtained by the use of the ex- ploring needle will suffice in most cases. It should be remembered, hoAvever, that a slight amount of urea is sometimes found in ovarian cystic fluid. The presence of pus-cells in abundance in the aspirated fluid, with symptoms of suppuration, is significant of pyonephrosis. Prognosis.—This is generally unfavorable, though in unilateral hydronephrosis evidences of compensation on the part of the unaffected kidney should render the case guardedly favorable, particularly if the cause be a movable kidney. The bilateral affection is ahvays grave, OAving to the danger of uremia. Infection of the cyst Avith pus-organ- isms is usually a fatal complication. Recovery may ensue in rare in- stances in Avhich a spontaneous discharge of the liquid takes place. Rup- ture of the sac is unlikely. Treatment.—The removal of the cause is seldom feasible. Symp- 996 DISEASES OF THE URINARY SYSTEM. tomatic treatment only is required in mild cases, though sometimes gen- tle massage over the sac, properly directed and cautiously applied (to avoid rupture), may cause a reduction in the size of the tumor. Most often surgical measures only are of use. These embrace puncture and aspiration, incision (nephrotomy) and drainage, nephrorrhaphy, ne- phrectomy, and the formation of a renal fistula. These procedures, how- ever, are undertaken only when successive reaccumulations of the fluid follow those measures first mentioned. PERINEPHRIC ABSCESS. {Perinephritis.) Definition.—Suppurative inflammation of the connective tissue surrounding the kidney. Pathology.—The suppuration attacks either the lax adipose tissue or the fatty capsule in which the kidney is imbedded and the adjacent retroperitoneal tissue. The starting-point of suppuration is usually be- hind the kidney. There may be several small abscesses at first, but more often a single large abscess is found. The walls may be soft and shreddy, or in more chronic cases thickened and fibrous. A bulging externally over the affected lumbar region is not infrequent, particularly in large and extensive accumulations of pus. The latter has a tendency at a given point to burrow into the surrounding tissues, and especially downward toward the iliac fossa, pointing in the groin near Poupart's ligament. It may extend backward and open upon the skin-surface. Sometimes the pus perforates the diaphragm and discharges through the pleural cavity and lungs, or the colon, vagina, bladder, or peritoneum may be perforated. The pus is occasionally quite offensive, and may be ichorous from an admixture of infiltrated urine. Perirenal abscess due to calculous pyonephrosis may contain calculi that have ulcerated through pelvic or renal walls. Thickening of the juxtaposed peri- toneum is often found. In certain cases of perinephritis, which usually gave no symptoms during life, the postmortem examination has revealed fibrous adhesions and a firm and thickened and fatty capsule, stripped with difficulty from the true capsule of the kidney. Etiology.—Perirenal abscesses, when not traumatic in origin, de- velop most frequently as a result of purulent pyelo-nephritis or pyo- nephrosis. Hence they are usually secondary. Other primary condi- tions that may cause perirenal suppuration are the following : extension of inflammation from the ureter or pelvis of the kidney; from a pelvic abscess ; from appendiceal or hepatic abscesses ; and from spinal caries (psoas abscess) and empyema. Sometimes tuberculous processes in the kidney and suppurating new growths, as carcinoma and cysts (includ- ing the echinococcus), are complicated by perirenal abscess. More rarely such severe infectious diseases as typhus fever, small-pox, and pyemia lead to purulent perinephritis. Finally, there are cases for which no cause is discoverable. CYSTIC KIDNEY. 997 Symptoms.—Subjectively, there is noted a dull, throbbing pain over the affected region that is increased by motion; sometimes, Avhen the abscess is large and presses on the large nerve-trunks, the pains may become shooting in character and be felt in the leg on the same side. Numbness may also be felt. Pain and tenderness on palpation are com- mon. The patient is prostrated, weak, and often quite emaciated, and flexure of the thigh on the affected side is frequent. The characteristic fever of suppuration is present in the deeply remitting or intermitting type, Avith alternating chills and debilitating SAveats. Pus is found in the urine only when the kidney is involved. Sooner or later evidences of a tumor are seen; the areas can be palpated, and a gradual bulging in the lumbar area, increasing slowly, with smoothness and glistening of the skin and pitting (edema), may be observed. Fluctuation is fre- quently apparent in advanced cases, and in favorable cases signs of "pointing" appear. Diagnosis.—Should the abscess tend to burrow dowmvard, the condition may be somewhat obscure on account of the absence of dis- tinct local symptoms. Indeed, involvement of the psoas may give rise to symptoms of coxitis, as pain referred to the knee-joint. The diag- nosis is usually easy, and Avhen in doubt as to whether the tumor is an abscess or an hydronephrosis or solid mass, the exploring needle should be used. Differential Diagnosis.—An important point in differentiating peri- nephric abscess from suppurative pyelitis or pyelo-nephritis alone is the fact that in the latter the quantity of urine is usually diminished, whilst in the former there is less apt to be any interference with the renal secretion. Again, whilst in the latter the urine usually contains blood and pus, in the former the urine is free from blood, though not necessarily from pus, and casts are also absent here. Prognosis.—This is guardedly favorable if the abscess points ex- ternally in the lumbar area. Of course rupture into the peritoneal cavity, bladder, bowel, and groin is ahvays a serious occurrence. The treatment is essentially surgical, and consists in free incision and drainage. CYSTIC KIDNEY. {Renal Cyst.) Pathology.—Congenital cystic kidneys are in reality collections of cysts, varying in size from a pea to a marble, and separated from each other by septa of compressed renal or fibrous tissue. Either one, or fre- quently both, kidneys may be affected with what is sometimes termed congenital cystic degeneration of the kidneys. There is considerable en- largement of the organs, and during intra-uterine life they may attain a size so enormous as to render parturition extremely difficult and danger- ous. The fetus is usually non-viable, though in mild cases the affection may be tolerated for some years after birth. The cystic fluid may be either clear or turbid, a reddish-yellow or a dark-brown in color, acid 998 DISEASES OF THE URINARY SYSTEM. in reaction, and holds in solution urinary salts, blood, cholesterin, and sometimes uric acid and urea. A single layer of flattened epithelial cells lines the cyst-walls. The cysts themselves seem to be dilatations of the renal tubules and of BoAvman's capsules, due, in some instances, to an obliteration of the tubules of the papillae or to stenosis of some portion of the urinary tract. The cystic kidneys usually met Avith in adult life (acquired) are of several varieties: (1) One or perhaps a few cysts may be present, larger usually than those in the congenital cystic kidney, Avhich seem to cause no interference Avith the normal renal functions. Sometimes a reddish- brown colloid material is contained in these cysts. (2) Small and often quite minute cysts frequently accompany the chronic nephritic kidney that is small, contracted, and cirrhotic. These result from dilated tubules and capsules when the former are narrowed by the hyperplasia of fibrous tissue. (3) Cystic kidneys in adults may have the pathologic characteristics of the congenital variety—a mere conglomeration of cysts containing a clear or colored serum or a cloudy, dark, thick, and colloid liquid. This condition is sometimes associated with similar cystic disease of the liver and spleen. It may be a late manifestation of mild congenital disease. The kidneys have been found converted into cysts in cases in Avhich the presence of calculi (uric acid) in the tubules has probably started the the cystic degeneration. (4) Solitary cystic adenoma occurs rarely. It is in the form of a globular tumor projecting from the surface (usually the anterior) of the kidney. It may be as large as an orange, and may be enclosed in a dis- tinct capsule. On section the mass is found to be composed of various- sized cysts separated by septa of fibrous tissue lined with cuboid or columnar epithelium. The remainder of the kidney appears to be quite healthy. Etiology.—Cystic disease of the kidneys is either congenital or acquired. The former is probably commoner than the latter condition, and may persist for a Avhile in extra-uterine life, Avhile the acquired variety may be of unknoAvn origin or secondary to chronic interstitial nephritis or to urinary calculi in the renal tubules. The direct cause of intra-uterine renal cysts is not definitely knoAvn, but they are probably developmental rather than pathologic, since other defects of embryonic growth are frequently associated Avith the disease. Symptoms.—These may be absent in adults until the sudden de- velopment of uremia. Ordinarily, the clinical picture is similar to that of chronic interstitial nephritis. There is an increase in the quantity of urine, Avhich is of low specific gravity. Slight albuminuria may be present. On palpation a large, rounded, and sponge-like mass may be felt in either hypochondrium or on both sides. Cardiac hypertrophy and increased arterial tension, as in chronic cirrhosis, are also fre- quently met with in cystic degeneration of the kidneys. The diagnosis can only be made upon the presence of the above symptoms and the discovery of the clear physical signs of the tumor. It should be pointed out that a possible complication of perinephric abscess, due to rupture of one or more of the cysts (as has occurred—Osier), Avould of course render a diagnosis Avellnigh impossible. NEW GROWTHS OF THE KIDNEY. 999 Prognosis.—Bilateral cystic disease of the kidney must eventually prove fatal, owing to the sudden onset of uremia or cardiac failure. Solitary cysts give a tolerably favorable outlook under proper surgical interference. Treatment.—The unilocular cysts just referred to above may be removed, capsule and all, and the kidney sutured. Bilateral disease cannot be operated upon for obvious reasons; unilateral cystic degen- eration may be treated by nephrectomy, Avith narrow chances of success. NEW GROWTHS OF THE KIDNEY. The most common tumors of the kidney are those belonging to the class of adenomata (benign) and those that are either sarcomatous or car- cinomatous (malignant). Adenomata may be congenital or acquired. They grow in the cortex of the kidney in the form of small nodular masses, Avhich in some cases may increase to a considerable size before any symptoms are pro- duced. A cystic growth may be combined Avith adenoma (cystic ade- noma), and lymphadenoma is also occasionally seen as a secondary growth. Other benign tumors that may affect the kidney are angioma, fibroma, and lipoma. Very large vascular adenomata may become malignant. Sarcoma and carcinoma may be either primary or secondary. Sarcoma is frequently congenital in origin, and may have an admixture of striped muscular tissue. The presence of the latter in the kidney points to developmental disturbances during embryonic life as the cause of a variety of tumor knoAvn as rhabdomyoma. Alveolar sarcoma is also met with. Renal carcinoma is probably of less frequent occurrence than sar- coma ; it may, however, be found in children as Avell as in aged persons, the two extremes of life. Carcinoma of the kidney is usually of the soft medullary or encephaloid variety, and as a primary affection it Avas thought to be of comparatively frequent occurrence, especially in early life. There is at least some doubt, hoAvever, connected with the sup- posed carcinomata of children. Both sexes are subject to the disease. Secondary carcinoma of the kidney, although probably more frequent than the primary form, is seldom of clinical importance. Renal carci- noma may occur as a diffuse infiltration or in nodular masses, one kid- ney usually being affected in primary carcinoma. The tumor sometimes reaches an enormous size, and instances are recorded in which nearly the Avhole abdomen has been filled, and in Avhich the growth weighed as much as 31 lbs. (14 kgms., Roberts). Rhabdomyomata do not, as a rule, attain a very large size, though sarcomata may grow quite large. Softening and hemorrhage Avithin these malignant growths may occur. The pelvis of the kidney may be invaded, and metastatic areas may form in the liver or the lungs, though this occurs in the case of primary renal carcinoma less readily than from carcinoma in other organs. Me- tastatic groAvths arise most likely through involvement of the renal vein. 1000 DISEASES OF THE URINARY SYSTEM. The renal parenchyma is either partially or wholly destroyed, the pyr- amids being attacked later than the cortex. Symptoms.—Lumbar pain on the affected side is often an early symptom, and may persist throughout the course of the disease. It may be paroxysmal, and be felt extending doAvn the thigh, or it may be dull, dragging, and limited in character. Pain is not, however, a con- stant symptom in a certain proportion of the cases. Hematuria may occur early or late, and often appears before any tumor is palpable. The blood may be in a fluid state or in clots, the latter not seldom taking the form of pelvic or urethral casts, the passage of which may give rise to colicky pains. Casts of the ureter sometimes resemble lumbricoid worms. The hemorrhage may be excessive and cause marked weakness and a symptomatic anemia, superadded to the cancerous anemia that is usually present; on the other hand, it may be so slight as to be discoverable only microscopically. It recurs at irreg- ular intervals of days or weeks. Large clots may accumulate in the bladder and cause vesical irritability. The urine from the healthy kid- ney may be quite normal, and may be secured for observation by ureteral catheterization. Cancer-cells or tissue-fragments of the neoplasm very rarely appear in the urine, at least so as to be distinctly recognizable as such. Anorexia, nausea and vomiting, progressive loss of flesh and strength, increasing pallor, and the concomitant symptoms of the can- cerous cachexia are seen to develop. Physical Signs.—These may not be sufficient to reveal the presence of the tumor for some time after the above symptoms have been observed. The appearance of a palpable tumor in either flank is a definite aid to diagnosis. It is felt between the ribs and pelvis latero-anteriorly, and at first, when small and on the right side, it may be movable. Both sarcoma and carcinoma of the kidney may assume enormous sizes. The tumor feels dense and hard (except rapidly-growing tumors, as encepha- loid), either smooth or lobulated, and, when not too large, may retain the natural position and form of the kidney. The growth extends downward and inward, and in the very large malignant renal tumors of childhood the abdomen shows considerable enlargement, along with an abnormal pulsation and a prominence of the veins. Usually the tumor does not move with respiration. Percussion gives dulness over the mass, although in small and moderately large tumors the overlying colon may cause a tympanitic note to be heard. Neighboring organs, as the liver and spleen, may be found by palpation and percussion to be displaced by the renal tumor. Diagnosis.—The presence of a tumor, Avhen not too large and dis- tinctly occupying the lumbar and lower lateral abdominal region, to- gether Avith hematuria, pain of a local nature, and progressive failure of nutrition, may be looked upon as diagnostic of a malignant type of renal tumor. The relation of the colon to the tumor and immovability of the latter during respiration are also diagnostic. When the tumor is very large and adhesions have formed, as in cancerous kidney, it may be mistaken for other conditions. Differential Diagnosis.—Affections such as hydronephrosis, pyone- phrosis, cystic kidney, hydatids, ovarian, splenic, and hepatic tumors, and (particularly in children) retroperitoneal sarcoma must be differentiated DISEASES OF THE BLADDER. 1001 from renal growths. Careful bimanual palpation will aid in the diagno- sis, but the exclusion of other lumbar enlargements must be made by close attention to the history and to the development and course of the symptoms. Hematuria alone, in aged persons, is suggestive of carcinoma when no tangible cause for the presence of the blood is at hand. Hepatic and splenic tumors are usually movable during deep breathing, whilst renal tumors are not so. In cases of hepatic groAvths also the area of dulness extends higher, whilst in renal growths on the right side a tym- panitic area generally lies betAveen the liver and the tumor. The cha- racteristic notch and edge of the spleen, and the absence of the overlying colon-tympany, are points that distinguish splenic enlargements from those of the left kidney. Pelvic growths (ovarian and uterine) enlarge from below upward, and are readily detected by vaginal examination. In children Lbbstein's cancer (retroperitoneal sarcoma), if very large, is easily mistaken for a renal tumor, except that it is usually more cen- trally situated and more firmly fixed. Prognosis and Treatment.—The termination in cases of renal carci- noma is inevitably fatal, and children succumb more quickly than adults. The disease may last from a feAV months to sometimes a year or two. If the kidney be removed while the growth is still small, the prog- nosis is fairly good; but if large or if metastatic tumors have formed, the prognosis is always bad. The treatment, aside from early surgical measures, is entirely symptomatic and supportive, and obviously it is unsuccessful. Renal colic, excessive hematuria, and a gradually lowered vitality may be met by the use of palliatives, tonics, and by a nutritious and easily digestible diet. Nuclein may be tried hypodermically or by the mouth. II. DISEASES OF THE BLADDER. CYSTITIS. Definition.—Inflammation of the mucous membrane of the bladder. It may be either acute or chronic, the latter being clinically the much more frequent condition. ACUTE CYSTITIS. Pathology.—Cystoscopic examination performed according to Paw- lik's or Kelly's method, hereafter to be described, reveals an intensely hyperemic condition of the vesical mucosa, Avhich is puffy, edematous, and of a bright-red color; this may be more intense at points, especi- ally in the vicinity of the trigone. The membrane is bathed in a thick, tenacious muco-pus, and here and there may be noted denuded areas, and the exfoliated epithelium often hanging in shreds from the bladder- wall ; overlying these denuded patches hemorrhagic effusions may be observed. In the severer grades of the disease the intense general hy- peremia causes a disappearance of the blood-vessels that are to be seen in the normal condition. Occasionally small patches of ulceration, due to abscess-formation (phlegmonous cystitis), may be observed, and in 1002 DISEASES OF THE URINARY SYSTEM. rare and fatal instances the entire bladder-wall is involved in a necrotic process. Etiology.—Cases of acute cystitis may be grouped according to their origin into four main classes, as follows : (1) Catarrhal.—Like other mucosae, the vesical epithelium is very re- sponsive to systemic circulatory disturbances. Thus, sudden exposure to extremes of cold or heat or violent atmospheric changes, thereby abruptly suppressing the action of the skin, may be potent influences in the etiology of the disease. An intense acute catarrhal inflammation may folloAv retention of the urine in the bladder, with or without its subsequent decomposition; it may also be the result of pressure from an enlarged prostate or other tumor, and may follow cystocele, urethral stricture, or paresis of the bladder-wall. In simple over-distention of the bladder, with the accumulation of a gallon (4 liters) or more of urine, the so-called acute exfoliative cystitis may result, in which the entire mucous membrane of the bladder may be shed, and the patient shortly manifest all the symptoms of grave uremic intoxication. The prolonged retention of urine is followed by decomposition of the fluid, and this by its irritant action always excites a cystitis that soon assumes the chronic type. (2) Septic.—This may result either from the direct introduction of pus-producing germs into the bladder or from the systemic transmission of these micro-organisms to the organ. This is known as the bacterial origin of cystitis, Under the first class may be mentioned the passage of a dirty catheter or sound; this is the great cause of cystitis in puerperal women, and in men who are the subjects of minor grades of urethral stricture, and Avho have been subjected to gradual dilatation by means of bougies. Gonorrheal cystitis is also to be included under this heading. There is a condition known as febrile cystitis, which consti- tutes the second class of septic cases. This comprises the vesical in- flammation that is present in the various febrile conditions, and which is probably a direct result of the presence in the urine of the causal bacilli or their toxins (Fitz). Thus, in all of the infectious diseases and fevers (typhoid and the other exanthemata, rheumatism, diphtheria, tuberculosis) there is noted a cystitis of varying degrees of severity that can be accounted for only by the local irritant action of the spe- cific germ of the associated disease. The so-called gouty cystitis, which is often present in lithemic individuals, and which is due to the irri- tating and concentrated urine, may also be here included. (3) Toxic.—Certain drugs when introduced into the system manifest an intense antipathy for the vesical mucosa, and promptly excite a severe grade of acute cystitis. Prominent among these may be mentioned cantharides and other irritants of the urinary tract—cubebs, copaiba, and sinapis. > (4) Traumatic and Irritant.—Traumatic inflammation of the bladder follows the improper and careless use of the catheter, sound, or other instrument; the presence in the bladder of calculi or other foreign bodies ; and the pressure of the fetus in parturition, or of large masses of impacted feces. Irritation with consecutive inflammation may result from the extension of an inflammatory process from sur- rounding structures either by continuity or contiguity of tissue. Thus, ACUTE CYSTITIS. 1003 a cystitis may follow a urethritis—gonorrheal or otherwise ; it may re- sult from an extension dowmvard of a ureteritis, or it may be conse- quent upon a vaginitis, a malignant neoplasm of an adjacent viscus, a salpingitis, pelvic peritonitis, or pelvic abscess in the immediate vicinity of the bladder, as in the vesico-uterine pouch, the inflammation extend- inc by an involvement of contiguous tissue. Symptoms.—The symptoms of acute cystitis are very manifest. Pain, vesical irritability, vesical and rectal tenesmus, frequency of mic- turition, fever, and urinary changes are all pronounced. Prominent among these is pain, which may be most intense and is the earliest and most persistent manifestation of the disease. Its seat is the suprapubic region, whence it may radiate to the sacral region, the perineum, the end of the penis, or the upper portion of the thighs ; it is most con- stant, but is worst just before micturition, by Avhich it may be alleviated. It is considerably relieved by the recumbent posture, and is aggravated by pressure over the bladder. As the inflammatory process diminishes the pain gradually disappears, and the entire attack may subside in a few days or a Aveek. With the pain, and probably ranking second in severity, is the rec- tal and vesical tenesmus, or strangury. There is an almost constant de- sire to urinate, the patient sitting upon the urinal, it may be, for hours. The urine may be opaque or highly-colored. It is often bloody (in very acute cases the vesical contents may consist of a small quantity of pure blood only), is of a specific gravity varying from 1005 to 1030 (in the febrile cases), and contains pus-corpuscles in abundance, mucous flakes in large quantities, shreds of disintegrated and exfoliated epithelium (blad- der) ; also numerous micro-organisms (streptococci, staphylococci, gono- cocci, proteus vulgaris, bacilli of tuberculosis, and very commonly the bacillus coli communis). Its reaction may be either acid or alkaline ; if alkaline, it contains ammonium urate, amorphous phosphates, and triple phosphates (crystalline) as a rule. More or less albumin will be noted, and on standing a dense sediment forms in the bottom of the flask, composed of all the foregoing substances, as shown by chemical and microscopic examination. The total quantity of urine voided in the twenty-four hours may be normal in amount or even slightly in ex- cess of the normal. On the other hand, if exfoliation of the mucous membrane takes place, there may occur partial or even total suppression of the urine. Fever, Avith or without an initial rigor, persists through- out the attack, but is not of a severe type, save in the septic and ma- lignant (diphtheritic) forms of the disease, when it may reach 103°-105° F. (39.4°-40.5° C). Abscesses may form, and betray themselves by localized pain, ten- derness, and, in some cases, by a circumscribed induration. These may rupture into the bladder, followed by the free escape of pus from the urethra and by relief (temporary as a rule) from urgent symptoms, or they may spread to the peritoneum and induce peritonitis, which, if not promptly treated by surgical measures, may prove fatal by gradual asthenia. In the variety associated with extreme exfoliation of the vesical mucosa grave uremic manifestations follow. These include all the features of the typhoid state (dry, black tongue; mild delirium; ner- 1004 DISEASES OF THE URINARY SYSTEM. vous and muscular twitching; headache; gastric disturbances; and coma). There is also some degree of malaise and anorexia. It must not be forgotten that acute cystitis may represent an acute exacerbation in the chronic form, and at times may assume a severe type of the disease. Diagnosis.—Cystitis should be readily recognized from the history of the case and the frequency of the two almost pathognomonic symp- toms—suprapubic pain and vesical tenesmus. An examination of the urine will reveal the characteristic clinical features. Cystitis may be confounded with acute nephritis or pyelo-nephritis, but a careful study of the clinical manifestations and, if need be, the catheterization of the ureters after vesical irrigation, will reveal the true condition. The presence of tube-casts in the urine would indicate renal involvement. The percentage of albumin is usually much larger in nephritis than in irritability of the bladder. The differentiation between cystitis and vesical irritability will be noted under the latter condition. The prognosis of the milder grades of cystitis is good; the septic and malignant (diphtheritic) cases offer a much graver outlook. Exten- sion of the process upward toward the kidneys is always serious. Treatment.—The treatment of acute cystitis includes prophylactic, hygienic, and medicinal measures. Prophylactic.—Most important is the prevention of the disease, and this includes, in addition to the usual care of the body, the observance of thorough asepsis whenever it becomes obligatory to introduce an instrument (catheter, sound) into the bladder. Hygienic.—The cause of the disease, if evident (calculus, external pressure), should be sought and removed. The patient should at once be placed absolutely at rest in the recumbent posture. The value of this injunction will be most clearly understood when it is stated that in the erect position the intra-vesical pressure is three times that in the dorsal position. The simple observance of this law will do much toward relieving the sufferings of the patient. The diet must be regulated, and all irritating, highly seasoned articles of food must be interdicted. Alcohol in any form is prohibited. If it can be enforced, during the early stages of the disease an absolute milk diet will be most bene- ficial. The patient should be instructed to drink freely of water and other diluent drinks, whereby an internal irrigation of the bladder may be secured and much of the irritating substance removed. The free action of the skin may be secured by friction and warm bathing. Medicinal.—The drugs to be employed are the saline laxatives and the various mild diuretics and urinary alterants. The reaction of the urine will indicate the variety of alterant to be employed. If it be acid, alkaline waters are serviceable, as the soda-preparations, Vichy, or the potassium salts. In alkaline conditions of the urine probably the most valuable drugs are benzoic and boracic acid and salol. Benzoic acid is best administered in the form of ammonium benzoate, which may be given in 10-grain (0.648) doses thrice daily in the compound infusion of buchu. Hot applications and hot local bathing (sitz-baths) will do much to relieve the pain and tenesmus; if these be severe, a rectal sup- pository of opium and belladonna or an enema of chloral hydrate will generally give prompt relief. Tincture of cannabis indica, administered CHRONIC CYSTITIS. 1005 internally, may ansAver if opium be contraindicated. Under such a course as the preceding a cure may be expected within eight cr ten days. CHRONIC CYSTITIS. Pathology.—The vesical mucosa is not so hyperemic as in the acute variety, but is of a peculiar muddy or grayish-blue (slate) color, dotted here and there with patches of erosion or of actual ulceration. The muco-pus that bathes its surface is not so apt to be hemorrhagic as in the acute form of the disease, although slight hemorrhages may and do occur. Owing to the slow course and long duration of the disease there folloAvs an immense thickening of the bladder-Avail from hyperplasia of its constituents, conjoined Avith more or less edema of the tissues. The result is a contraction of the Avail Avith a proportionate diminution in the vesical capacity. The mucosa may become, as it Avere, polypoid in spots, and there may follow obliteration or partial obstruction of the ureteral orifices, Avith consequent dilatation of the ureters and renal pelves from a damming back of the secretion. The urinary changes are about as in the acute form, save that the reaction is always alkaline and the amount of mucus and pus is proportionately greater. Etiology.—Chronic inflammation of the bladder may be the result of a neglected or oft-repeated acute attack. It may occur from the persistent action of an exciting cause, as the presence of some irritating substance (calculus) in the bladder, or of some excitant external to that viscus, as a localized inflammation or a displaced uterus. Again, the inflammation of the bladder may be chronic from the beginning; espe- cially is this true of the tuberculous variety and of that due to neoplas- mata of the organ. The symptoms and diagnosis differ but slightly from those of acute cystitis. It may, however, be pointed out that the pain and tenes- mus are less intense. Oppositely, the amount of albumin in the urine is comparatively large. The same remark applies to the quantity of mucus and pus (vide Pathology); indeed, the last-named ingredient often forms a thick gelatinous mass in the standing urine that tends to adhere to the receptacle. Chronic cystitis is accompanied by debility and emaciation, which, however, are of slow development. The prognosis is always serious, and the course of the disease is at the best protracted. Treatment.—Very generally, the treatment set down for the acute disease will not answer in the chronic form. Undoubtedly, there will follow more or less amelioration of the symptoms, but the tendency is toward a prolonged chronicity. In such cases, after the removal of the ascertainable causes so far as practicable, we are compelled to resort to local treatment of the bladder. This includes—(1) Vesical irrigation; (2) Topical applications; (3) Permanent drainage of the bladder. Vesical irrigation is secured by means of an aseptic soft-rubber catheter which is connected with a graduated glass funnel: a siphonage is produced by the alternate elevation and depression of the funnel, which contains the irrigating fluid. The latter may consist of plain sterilized (boiled) water, sterile normal salt-solution (40-60 gr. to the pint—2.59-4.0 per ^ liter), or a weak solution of mercuric chlorid (1: 1006 DISEASES OF THE URINARY SYSTEM. 50,000-100,000). The irrigation should be done slowly, and not more than twice or thrice daily in severe cases, and much less frequently in ordinary cases, according to the exigencies of the condition. Vesical medication may be secured by means of the funnel after irri- gation, the medicating substances being dissolved in a pint of water and allowed to flow slowly in and out of the bladder. The drugs that may be used in this manner are silver nitrate or zinc sulphate (1-5 gr. to the ounce—0.0648-0.324 to 32.0) or a saturated solution of boric acid. If the salts of zinc or silver are used, not more than an ounce of the solu- tion should be allowed to enter the bladder, and much less than this amount will generally suffice. In cases in which there exist patches of ulceration the application must be made directly to these areas through the endoscope or cystoscope (PaAvlik, Kelly). In Avomen this may be readily done by placing the patient in the exaggerated lithotomy or knee-chest posture, dilating the urethra, and introducing the cystoscope, through which a reflected light is thrown upon the distended bladder- Avall. Stronger solutions may now be employed, as silver nitrate, 20- 30 gr. (1.29-1.94) to the ounce. This application should be followed by a slight irrigation of the bladder. When this local medication fails to effect a cure, permanent drainage of the bladder must be secured—in the male by a suprapubic or perineal incision, and in the female by the establishment of a vesico-vaginal fis- tula. This places the bladder absolutely at rest, and gives the inflamed mucosa a chance to heal under proper medication. As to internal remedies, various agents that possess a local stimulating effect upon the genito-urinary tract are advised by most authors, but I think little is to be gained from their employment as compared with the results achievable from topical treatment. Most efficacious among inter- nal remedies are—oil of sandalwood, terebene, buchu (fluid extract), and the oil of copaiba. If disinfection of the bladder in loco is not practi- cable, antiseptics should be given internally, combined with those stated above. Salol and potassium chlorate are excellent for this purpose. NEOPLASMS OF THE BLADDER. Primary new-growths of the bladder are exceedingly rare, occur- ring, however, with greater frequency in males in about the proportion of 3 to 1; they may be either benign or malignant. On the other hand, secondary neoplasmata, particularly carcinomata, are relatively common. The most frequent variety of new-growth encountered is carcinoma, par- ticularly the so-called villous or papillomatous carcinoma, Williams* find- ing in 20 women affected with bladder-tumor, carcinoma in 16. Other growths are sarcomatous, fibromatous, and papillomatous in nature. The symptoms are the same for all varieties, and include, first and most commonly, hemorrhage (which is both persistent and free), together with pain, frequency of micturition, and occasionally the discharge of detached fragments of the growth. In carcinomatous cases of advanced 1 Brit. Med. Journ., 1889. NEUROSES OF THE BLADDER. 1007 standing cachexia will be marked. Examination by means of the cysto- scope will reveal the nature of the complaint. In the case of secondary growths the primary tumor may often be detected. The prognosis, of course, will depend upon the nature of the growth. The treatment is purely surgical, and comprises enucleation of the tumor either by means of the snare, or after a vesical section. VESICAL HEMORRHAGE. (Vesical Hemorrhoids.) Hemorrhage of the bladder has been mentioned as a symptom of various affections, both general and local, among the former being leu- kemia and malarial hematuria, and among the latter nephrolithiasis and tuberculosis and carcinoma of the bladder. It is also a prominent mani- festation in stone in the bladder, and not infrequently appears in preg- nancy (late). Independently of the operation of all of the above-men- tioned etiologic factors, hemorrhage has been known to occur from the bladder, and recent precise methods of exploring the viscus (endoscopic examination) have shown it to be due to a hemorrhoidal state of the ves- sels. The hemorrhage may be profuse, and, rarely, even fatal in its effects. The diagnosis is based in part upon the absence of the more obvi- ous causes of hematuria and the presence of free bleedings, but chiefly upon the result of a careful cystoscopic exploration of the bladder. The prognosis, so far as my experience extends, is eminently favor- able, though a few fatal cases have been reported. Treatment.—This is mainly local. The bladder may be irrigated with an astringent solution (1 per cent, tannic acid, \ per cent, alum), and this may be alternated with an antiseptic solution (3 per cent, boric acid, 1 per cent, salicylic acid). I have recently observed a case in which recovery followed the internal admission of the extract, hamamelis fluid. (3J-4.0), t. i. d. NEUROSES OF THE BLADDER. IRRITABILITY OF THE BLADDER. Definition.—By this term is meant a condition of the bladder in which there exists an hyperesthesia of the organ, especially of the neck— that portion surrounding the urethral and ureteral orifices (vesical trigone) —without the presence of any tangible cause therefcjr. This must be dis- tinguished from the irritability that is associated with true organic dis- ease of the bladder itself, as in the presence of calculi, tumors, or fissure of the neck, or with disease of the surrounding structures. 1008 DISEASES OF THE URINARY SYSTEM. Pathology.—There are no pathologic features to be noted. A cysto- scopic examination of the bladder may reveal a slight increase in the vas- cularity of the mucous membrane, but the condition, in most instances at least, must be regarded as a true neurosis. The condition of irritable bladder in women, which has previously been held to be a purely func- tional derangement, is now regarded by Dacheux and Zuckerkandl as a localized hyperemia, especially at the bas fond, and less often at the beginning of the urethra.1 Utiology.—While in many instances no well-defined causal relations can be determined, it is very generally true that the patients who are the subjects of vesical irritability are individuals of a neurotic temperament, very often manifesting strong hysteric tendencies. They present the cha- racteristic features of this unfortunate group. They are generally illy- nourished, fretful, irritable, peevish, suffering almost constantly from vague neuralgic attacks in different portions of the body (cephalalgia, tic douloureux, lumbo-sacral pain), and in a chronic condition of physical prostration. Frequently they eventually develop a true hypochondriasis or melancholia. In others there may be found a history of extreme men- tal and physical tire, overwork, business anxiety, over-indulgence in ven- ery, menstrual irregularity, dysmenorrhea, ovarian or uterine disorders, long-continued gastro-intestinal disturbance (dyspepsia), improper hy- gienic surroundings, improper regimen, indulgence in late hours, and a general lack of will-poAver. It must, however, be remembered that sub- jects of chronic malarial intoxication very often manifest all the symp- toms of vesical irritability, marked, it may be, by a feature of more or less periodicity. This has been termed by some malarial fever of the urethra and bladder. Lithemic individuals also are very prone to develop a pro- nounced vesical irritability, the affection in them probably resulting from the local action of the highly concentrated and irritating urine. The con- dition must commonly, however, be regarded as belonging essentially to the large group of neuroses. In a certain percentage of cases the bladder-trouble is a reflex mani- festation of some disease of an adjacent organ, as the urethra, ureter, va- gina, rectum, anus, or the internal organs of generation. These are not, however, to be looked upon as cases of true neurotic vesical irritability. Symptoms.—The symptoms of irritable bladder are mainly extreme painfulness and frequency of micturition, associated with marked vesical and rectal tenesmus. The dysuria is not always or altogether relieved by micturition; indeed, the pain may be just as severe, or even worse after, than before, the voiding of the urine. Especially is this true when there coexists a more or less spasmodic muscular action of the bladder-walls, the hypersensitive mucosa then being squeezed, and the patient suffering at times to such ah extent as to be thrown almost into a state of collapse. There is usually a sense of weight or pressure in the pubic region, which is largely relieved when the patient assumes the recumbent posture. Uri- nation is often performed spasmodically, or there may be a spasm of the urethra and neck of the bladder resulting in an utter inability to perform the act. The urine may be normal in appearance and amount. Very often it is increased in quantity (hysteric polyuria), and at times the op- posite may be true and more or less suppression be noted. In lithemic 1 The American Year-Book of Medicine and Surgery, 1897, p. 576. NEUROSES OF THE BLADDER. 1009 cases the urinary characteristics already mentioned under that condition will be present (vide p. 401). Diagnosis.—-Very frequently Avill simple vesical irritability be con- founded with true cystitis. The points of differentiation, however, are as follows: Irritable Bladder. Cystitis. The patient is of a neurotic tempera- May occur in any individual, irrespective ment, and generally gives no history of temperament. It frequently follows of organic bladder-disease nor of ope- catherization, sounding, or other trau- rations upon the bladder. matism. Pain is severe, and often worse after mic- The pain is usually much relieved by turition. micturition. The constitutional symptoms are those of The constitutional symptoms are not nervous depression. marked, save in grave cases. Never results fatally. May result fatally. The urine does not present any marked There are always present marked and alteration in its physical or chemical characteristic alterations in the physi- qualities. It may shoAV hyperacidity, cal and chemical qualities of the urine. or extreme concentration, or dilution. The appearance of the mucosa is negative Cystoscopic exploration reveals the angry in true neurosis. and diseased mucosa, and may show the cause (calculus, tumor). The duration is always protracted. The duration of acute attacks may be short. Prognosis.—Good as regards life; doubtful as regards the ultimate cure of the patient. Treatment.—Since the condition is largely one of neurotic origin, the attention of the physician must be directed mainly toward a bet- terment of the state of the nervous system. Absolute rest, physical and mental, must be insisted upon, and the patient must be subjected to a course of strict moral suasion whenever this may be deemed necessary. Any cause of reflex irritation must be removed, and a careful search should be instituted for some such condition as cervical stenosis, uterine displacements, anal fissure, hemorrhoids, stricture of the rectum, vaginitis, urethritis, tuberculous infection of Skene's glands of the urethra, chronic gastro-intestinal catarrh, and the like. The habits of the patient must be inquired into, and late hours, the eating of improper and unwholesome articles of food, masturbation, or the reading of sensational and trashy literature corrected. In many instances the pronounced neurasthenic condition demands a course, more or less protracted, of the Weir-Mitchell rest-treatment (vide Neurasthenia, p. 1177). The urine should be care- fully examined for lithemic and other pathologic features, and by an ap- propriate course of treatment it should be rendered as bland and unirri- tating as possible. Large draughts of diluent drinks may be of benefit, and if these be combined with the prolonged administration of nerve- sedatives and antispasmodics, a marked amelioration of the patient's con- dition may be secured. In cases associated with spasmodic muscular con- traction it may become necessary to employ an occasional suppository of opium and belladonna, or an enema of chloral hydrate. Change of air and scene, regulation of the diet, the institution of a proper course of gymnastics, mental and physical, and the observance of a happy and cheerful atmosphere will generally do much to improve the patient's con- 64 1010 DISEASES OF THE URINARY SYSTEM. dition. The administration of tonics (strychnin, iron) and the prevention of constipation are very essential. Especially must it be remembered that in all these cases of simple vesical irritability physical exploration of the bladder is absolutely contraindicated. The patient's mind must be directed away from the bladder in order to secure good results. NEUROSES OP MICTURITION. 1. Incontinence of Urine (Enuresis).—An inability to retain the urine. This may arise from a number of causes. Frequently it is the result of some lesion of the spinal cord involving the sphincteric cen- ter of the bladder; this is known as paralytic incontinence, and is to be recognized by a constant dribbling, alternating with spurts of urine when voluntary or involuntary muscular action is brought into play, as in the act of coughing, sneezing, or bending forward of the body. It may be the result of a general bodily weakness or after prostrating diseases (typhoid, late stages of pulmonary tuberculosis). Again, it may result from some local condition in the bladder or urethra. Here may be mentioned paralysis of the urethra from over-dilatation or from traumatism, or that due to pressure of the fetal head in a prolonged labor; imperfect vesical innervation; over-distention of the bladder, producing a paresis of its walls; or from some temporary obstruction at the urethra or base of the bladder, such as a tumor or a sharply retroflexed uterus. It may be a result of over-distention of the bladder, with partial paral- ysis of the sphincter, the bladder remaining overfilled, while there is a constant escape of a few drops of urine (incontinence of retention). It may follow some local causes of irritation, as the presence of vesical cal- culi, pressure from an anteflexed uterus upon the fundus of the bladder, cystitis, and parasites. The condition known as spasmodic incontinence is that due to an over-action of the compressor muscle of the bladder, as a consequence of which there is a diminution of the vesical capacity, the urine being forcibly and involuntarily ejected at irregular intervals. Finally, nocturnal enuresis is that variety which is so common in young, delicate, and often neurotic children: this is usually noticed in the early hours of sleep, and is often the result of some local irritation acting upon a hypersensitive organism, such as the presence of ascarides, an elongated prepuce, contraction of the urethral meatus, or masturbation. Nocturnal incontinence may be a manifestation of nocturnal epilepsy or of incipient cerebral or spinal disease (Fitz). The constant escape of urine in the paretic cases is apt to result in extensive excoriation of the parts. The treatment varies according to the cause. The enuresis of chil- dren, if left alone, will eventually cure itself as the age and strength of the patient increases, though obvious exciting causes, if present, should be removed if not impracticable. Good hygiene, systematic evacuation of the bladder, plenty of out-of-door exercise, a change to the seashore or mountains, an abundance of suitable and strengthening food with a mini- mum of water, and the administration of tonics (iron, cod-liver oil, and strychnin), will generally effect a cure. Excellent results often follow the administration of minute doses of atropin or tincture of belladonna. A favorite formula of my own in cases possessing a hypersensitive nervous organization has long been as follows : NEUROSES OF MICTURITION 1011 B/. Tr. belladonnas, 3ss-j ( 2.0-4.0); Sodii brom., 31J ( 8.0); Ac. hydrobrom. dil., 3ijss ( 10.0); Ext. ergotae fl., 31J ( 8.0); Glycerini, 3j ( 4.0); Elix. simplicis, q. s. ad %iv (128.0). M. et Sig. 3j (4.0) three or four times a day for a child of five years. In very delicate or feeble children suffering from enuresis I substitute a motor tonic and stimulant (tr. nucis vom.) for the bromids or nerve- sedatives. Spasmodic action of the vesical compressor may be relieved by the cautious use of the motor depressants, while its converse, paresis, de- mands the exhibition of full doses of strychnin or tincture of nux vomica. The judicious and careful use of the catheter, followed by the adminis- tration of strychnin, will promptly effect a cure in the incontinence of retention. Any local cause of vesical irritation must be removed. Gal- vanism in the paretic cases, applied both to the bladder and to the urethra, may be of service, and in the female Sanger suggests massage of the urethra. Should excoriation occur, bland ointments, as of zinc oxid and lanolin, should be used. 2. Retention.—Nervous retention of the urine is occasionally encountered in hysteric and highly neurotic individuals. Its most common manifesta- tion is an inability to urinate in the presence of others. It is also occa- sionally noted after childbirth, Avhen it may be due to nervous reaction, to edema and tortuosity of the urethra, or to a temporary inability of the bladder-Avails to contract upon their contents, thereby permitting a longer retention of the vesical contents, and even favoring over-disten- tion of the organ. If the urine be allowed to remain for too long a period in the bladder, fermentative changes follow and a secondary cys- titis will result. Under these circumstances an exfoliation of a portion or even of the entire bladder-epithelium may be noted. The treatment consists in the administration of strychnin and other nerve-tonics, in building up the general constitution, and in affording a change of air and recreation. In that variety following childbirth the patient should be urged to make voluntary efforts at micturition, and these may be seconded by the firm application of an abdominal binder and compress. The sound of running water, as when pouring water from a pitcher into the basin, often causes a contraction of the bladder and excites the flow of urine. It may become necessary, the foregoing meth- ods failing, to resort to catheterization, the usual antiseptic precautions being observed. PART VII DISEASES OF THE NERVOUS SYSTEM. While the following is only an outline of the anatomy and physi- ology of the nervous system, a certain amount of knowledge of the sub- ject is essential to a thorough appreciation of the lesions thereof. Embryologically, the earliest trace of the nervous system appears as the so-called medullary furrow on the dorsal surface of the embryo. This rapidly deepens into a groove, and is soon converted into the me- dullary canal by the closing over and union of the dorsal edges. At first its ectodermal lining is composed of cells of similar character. Soon, however, a differentiation takes place, forming a layer of radially disposed columnar cells lying next to the medullary canal, while more ex- ternally, small round-cells are to be seen situated between the columnar Outer border {layer). White substance (longitudinal fibers) Germ-cells Central canal Inner border [layer Spongioblasts Neuroblasts Anterior roots Fig. 61.—Transverse section through the spinal cord of a vertebrate embryo; X 550 (after AV. His.). cells (see Fig. 61). The former are called spongioblasts, and give rise to the neuroglia or " spider " cells ; the latter, the neuroblasts or germ-cells, as they have been termed, give rise to the nerve-cells and fibers. The spinal ganglia arise from an accumulation of ectodermic cells 1012 DISEASES OF THE NERVOUS SYSTEM. 1013 (the neural crests) lying on either side of the posterior part of the medul- lary canal (see Fig. 62). With the groAvth of the cerebro-spinal axis the spider cells become more or less irregularly scattered through both white and gray matter, serving, in part at least, as sustentacular tissue. It is quite possible also that they may functionate in some other manner. From their ecto- dermal origin and close relationship with the neurogenetic tract, also from their peculiarly branched form, they cannot be regarded as mere con- nective tissue. The rest of the supporting framework of the nervous system is composed of connective-tissue trabecular derived from the pia. In the gray matter the ground reticulum consists of collaterals, terminal axons, and nerve-fibers. Many of the nerve-fibers become invested with a medullary sheath or the white substance of SchAvann, a derivative of the mesoblast; the time at which this occurs varies in different fibers, but is constant for each group. This fact was taken advantage of by Flechsig, who perceived that he could thereby study the course of the fibers. It has been ob- served that the white matter appears first in those tracts that are imme- diate prolongations of peripheral nerves, and later in those connected with the brain-centers. Thus has been described the development of both the cells and fibers, the predominance of one or other of which in a certain area constitutes the gray or white matter respectively. Nervous tissue is, therefore, seen to consist of nerve-cells and fibers with a supporting framework of neuroglia and connective-tissue trabeculse. The nerve-cell consists of a cell-body, protoplasmic processes (den- drites) with their lateral buds or spines, and the axis-cylinder or axon 1014 DISEASES OF THE NERVOUS SYSTEM. with its collaterals. To this composite body Waldeyer has given the name neuron. The cell-body consists of a more or less granular protoplasmic mass having a nucleus and a nucleolus. The cytoplasm is prolonged into one or, more commonly, several, processes, from which fact has arisen the custom of describing these cells as unipolar, bipolar, or multipolar (vide Fig. 63). The protoplasmic processes probably form the path of afferent nerve- impulses, while the axon is the efferent path; hence the terms proposed by Cajal—viz. centripetal or cellulipetal for the former, and centrifugal or cellulifugal for the latter. The axis-cylinder processes are delicate filaments that form the nerve- fibers and terminate either in arborizations or special structures, and give off collateral branches at regular intervals in their course that end in Fig. 64.—Section of spinal cord (after Dana), showing complete subdivision of white columns into— iDPy, direct pyramidal tract. AFC, anterior funda- mental column. Lateral columns. f Column of Goll. Posterior columns. \ Column of Burdach. 1 RZ, rim-zone, or Lissauer's I column. LFC, lateral fundamental column. LL, lateral limiting layer. CPyT, crossed pyramidal tract. CT, direct cerebellar tract. ALT, antero-lateral ascending tract. f ARZ, anterior root-zone. 1 MRZ, middle root-zone. I OZ, oval zone. I PRZ, posterior root-zone. arborizations. The ganglion-cells tend to collect in certain centers of the cerebro-spinal axis, as in the horns of the cord, Clarke's column, and the basal ganglia and cortex of the brain. They vary in size, and have a direct relation with the length of their axis-cylinder processes; hence we find the largest in the anterior horns of the cord and the paracentral lobule. The neurons are never found in actual contact in any part of their distribution, but are merely contiguous. When the axis-cylinders and the collaterals terminate in relation to other ganglion-cells they expand to form a latticework arrangement or arborization about the dendrites of another neuron. A nervous impulse originates in a cell-body, passes out through the neuraxon, and is then distributed to another neuron or series of neurons by means of the tufts of the collaterals or the terminal arborization of the axon in relation with the dendrites. DISEASES OF THE NERVOUS SYSTEM. 1015 In 1852, Waller discovered that section of a nerve is followed by degeneration in the direction in Avhich impulses are conveyed; hence the term " Wallerian degeneration." The columns or tracts that have been mapped out in the cord may be seen in the accompanying diagram (Fig. 64). In the antero-lateral por- tion are found the anterior or uncrossed pyramidal column, the antero- lateral column of GoAvers, the cerebellar column, and the crossed pyram- idal column. In the posterior region are the columns of Goll and Bur- dach. The rest of the Avhite matter forms the so-called ground-bundles. In the area comprising the anterior and lateral columns both ascend- ing and descending fibers are found. The columns that transmit ascending impulses are—1. The direct lateral cerebellar column. 2. The antero-lateral ascending column of Gowers. 3. The antero-lateral ground-bundle or fundamental column. 4. The columns of Goll and Burdach. Descending impulses are trans- mitted chiefly by the direct and crossed pyramidal tracts and the antero- lateral descending tract. The direct lateral cerebellar tract of Flechsig takes origin in the cells of the column of Clarke, and first appears in the lower dorsal region, and passes through the restiform body to the cere- bellum. Gowers' tract, or the antero-lateral ascending column, is first seen in the lumbar cord, and arises from some of the cells of the pos- terior horn. It then crosses to the other side of the cord through the posterior commissure and terminates in the region of the lateral nucleus. The antero-lateral ground-bundle, or fundamental column, is made up of commissural fibers that connect different levels of the cord; also of fibers that pass through the anterior commissure from the gray matter of the opposite half of the cord; and of obliquely-coursing fibers derived from the anterior root. The direct and crossed pyramidal columns constitute the great motor path by which fibers descend from the cortex and end in the motor nuclei of the cranial and spinal nerves—in the latter case in the multipolar gan- glion-cells of the anterior horns. Their origin is in the motor region of the cerebral cortex—i. e. the ascending frontal and parietal regions, the paracentral lobule, and the posterior part of the inferior frontal convolu- tion ; they then approach one another, as do fibers from all parts of the cerebral cortex (known collectively as the corona radiata), to enter the internal capsule. This may be described as a wedge, bounded in front and to the inner side by the caudate nucleus and the optic thalamus, and on the outer side by the lenticular nucleus. All of the fibers of the corona radiata do not pass through the internal capsule, some being lost in the gray matter of the basal ganglia, while others take origin in the ganglia. The angle of the internal capsule is known as the genu or knee, the part anterior to it as the anterior limb, and the posterior portion as the posterior limb. Through the anterior limb pass the fibers from the frontal region ; in the region of the genu are the fibers for the muscles of the face and tongue ; and in the pos- terior limb, the motor fibers to the extremities, also the sensory or teg- mental fibers, and at its posterior end the fibers of the optic radiation. The crusta consists of fibers that pass through the pons and enter the medulla, constituting its pyramidal tracts. 1016 DISEASES OF THE NERVOUS SYSTEM. The tegmental fibers are continuous through the longitudinal fibers of the pons with those derived from the formatio reticularis of the medulla. This is formed by fibers from the superior cerebellar peduncles, the olivarv body, and the posterior and lateral columns of the cord, which are rein- forced in their upAvard course by fibers derived from the quadrigeminal and geniculate bodies. Tracing the pyramidal fibers through the medulla, they will be found to divide into two unequal portions at its lower part. The larger decussates at this point (the region of the first and second cervical nerves), constitut- ing the decussation of the pyramids; it then crosses to the posterior part of the lateral column of the opposite side, in which it runs as the crossed pyramidal tract. In their course these fibers give off collaterals at right angles to them- selves. These pass into the gray matter, and terminate in arborizations about the root-cells of the anterior horn of the same side. The main axes end in the same manner. As these main fibers with their collaterals pass into the gray matter at various levels of the cord, the tract becomes more and more attenuated, and terminates finally in the lumbar enlargement of the cord in the neighborhood of the third or fourth sacral nerve. The smaller division of the medullary pyramids passes directly into the anterior region of the cord Avithout decussating, and is known as the direct pyramidal tract, or the column of Tiirck. In its course it gives off collaterals at right angles. These pass through the anterior commissure at different levels of the cord, and end in relation with cells of the anterior horn of the oppo- site side. The main fibers terminate precisely in the same manner. Thus it will be observed that the fibers of the column of Tiirck de- cussate in the anterior commissure of the cord; like the tract previously described, it becomes gradually smaller from above downward, and ends in the lower part of the dorsal cord. The axis-cylinders of the multi- polar ganglion-cells of the anterior horns pass out through the anterior roots of the same side and terminate in end-plates of muscles. Dejerine, Oppenheim, MonakoAv, and other neurologists believe that each motor cortex sends fibers to both sides of the body, and that the decussation of the pyramids is not a complete one, a small number of the fibers running in the lateral pyramidal tract on the same side as the lesion. This is borne out clinically by the slight paresis and the plus knee-jerk on -the same side, neither of which, hoAvever, approaches in degree the palsy and increased knee-jerk on the side opposite to the lesion. Pathologic confirmation of this vieAV has been obtained by several observers, who have found degeneration in both latero-pyramidal col- umns in cases of a unilateral lesion in the motor cortex. Motor-fibers from the nuclei of cranial nerves after decussating join Avith motor-fibers of the internal capsule. The exact course of these fibers, hoAvever, has not been demonstrated anatomically. Since many of the muscles supplied by the cranial nerves functionate bilater- ally—e. g. the eye-muscles and the muscles of mastication.—the suppo- sition is that in addition to fibers from its oavii nucleus each motor cranial nerve receives fibers from the corresponding nucleus of the opposite side. It Avas Broadbent Avho first pointed out that parts that functionate bilat- erally are supplied from both sides of the brain. The ganglion cells of the anterior cornua, about which the fibers of Fig. 66. Fig. 60.—x, Peripheral sensory tract; b, 51,62,63, cells in the short fibers, through the intercalation of which sensory impulses are conducted to the brain; c, continuation of the paths for sensory impulses leading to the cortex. Fig. (>('>.—1, Motor centers forthe lower extremities; l1, motor centers for the upper extremities ; 2, motor centers for the nerves of the face; 3, 4, 5, lateral pyramidal tract (red); 6,7,8, anterior pyramidal tract (green); py, pyramids (red); col (red and green), collateral fibers leading to gray substance. The Roman numerals < III, IV, etc.) indicate the nuclei, and correspond with the numbers of the cerebral nerves ; the letters (g, h, etc.) represent the points of decussation and the names of the individual nerves. DISEASES OF THE NERVOUS SYSTEM. 1017 the pyramidal columns terminate, have been more carefully studied than those of any other part of the body. Throughout the protoplasm there are scattered a number of small irregular bodies, arranged more or less concentrically, and bending, in the form of spindles, into the protoplasmic processes, that stain intensely Avith the basic aniline dyes. These ahvays shoAvthe earliest changes in degenerative processes in the cell, becoming paler, irregular, or more diffuse, and it has been supposed that they represent, to a certain ex- tent, the nutritive elements. The course of the fibers of the posterior column is as follows : The ganglion-cells on the posterior roots give rise to tAvo fibers, fused for a short distance from the cell, but soon bifurca- ting. The longer of the two, the centrifugal fiber, extends to the surface and terminates in pointed or bulbous endings in the epi- dermis, or in special sensory nerve-endings in tactile cells, tactile corpuscles, or end-bulbs. The centripetal fibers or axons penetrate the cord, and divide in the white matter into ascending and descending fibers. The for- mer may be either long or short. The short fibers are vertical at first, but finally bend into the gray matter, and end in relation with certain cells of the anterior cornua, forming perhaps a part of the reflex arc. Their collat- erals end in a similar manner. The long fibers extend up the cord to the medulla, ending in the usual manner in the gray nuclei of the columns of Goll and Burdach; these are known as the nucleus gracilis and nucleus cuneatus, respectively. They also give off col- laterals in their course. The descending fibers, on the other hand, are all short, and probably constitute the so-called comma tract of Schultze. Since fibers continue to enter the cord at different levels, those that have entered beloAv are pushed more and more toAvard the median line. It will thus be seen that the column of Goll is made up almost entirely of long fibers, and that the column of Burdach also contains long fibers, although it is probable that the short ones predominate. The long fibers are concerned in muscular coordination and equilibrium. It is likely that the fibers of pain and temperature sense, although entering by the posterior roots, do not pass up through the posterior columns, but rather through the gray substance of the spinal cord. Sacral Fig. 67.—Diagram showing the groupings and plex- uses of the spinal nerves (redrawn after Baker). 1018 DISEASES OF THE NERVOUS SYSTEM. The lateral group of fibers of the posterior roots is smaller than that just described. The most external of them, constituting the Spitzka- Lissauer column, are situated near the substance of Rolando. They spring from the posterior roots, run a short distance up the cord, and then enter the posterior horn. The others terminate in relation with the cells of the column of Clarke. All these fibers give off collaterals; they are concerned in visceral and cutaneous sensibility. It will be remembered that the motor tracts have two decussation- areas—one in the lower part of the medulla, the other through the anterior commissure at various levels of the cord. The sensory fibers also cross at an upper and a lower level, the former (about to be de- scribed) being through the lemniscus, and the latter, as previously narrated, through the posterior commissure. The axons of the cells of the nucleus gracilis and nucleus cuneatus pass into the lemniscus, decus- sate with similar fibers from the opposite side, are joined by the sensory cranial nerves of the opposite side, give off collaterals in their course, and terminate finally in cells of the basal ganglia or in the cells of the cortex of the parietal, temporal, and occipital regions (vide Figs. 65, 66). In the crus they occupy the lower part already described as the teg- mentum, and in the internal capsule they are situated in the posterior limb, behind the motor fibers for the extremities, and between it and the fibers of the optic radiation. Since the post-natal growth of the vertebrae is more rapid than that of the cord, it follows that the spinal nerves assume a more and more oblique position, until finally the spinal segments, each of which con- sists of an anterior and posterior nerve-bundle with a transverse plane of white substance, lie considerably above the vertebrae after which they are named (see Fig. 67). The following table (Starr, modified by Mills and Dana from the experimental and clinical studies of Thorburn and others) shows the localization of function (not organs) in the different segments of the cord: Localization of the Functions of the Segments of the Spinal Cord. Segment. First cervical. Second and third cervical. Fourth cervical. Fifth cervical. Muscles. Rectus laterales. Rectus capitis. Anticus and posticus. Sterno-hyoid. Sterno-thyroid. Sterno-mastoid. Trapezius. Scaleni and neck. Omo-hyoid. Diaphragm. Diaphragm. Deltoid. Biceps. Coraco-brachialis. Supinator longus. Rhomboid. Supra- and infra-spi- natus. Deltoid. Biceps. Coraco-brachialis. Brachialis anticus. Supinator longus. Supinator brevis. Deep muscles of shoul- der-blade. Rhomboid. Teres minor. Pectoralis (clavicular part). Serratus magnus. Reflex and Centers. Hypochondrium (?). Sud- den inspiration pro- duced by sudden pres- sure beneath the lower border of the ribs. Pupillary (fourth cervi- cal to second dorsal). Dilatation of the pupil produced by irritation of the neck. Scapular (fifth cervical to first dorsal). Irrita- tion of skin over the scapula produces con- traction of the scap- ular muscles. Supinator longus. Tap- ping the tendon of the supinator longus pro- duces flexion of fore- arm. Sensation. Back of head to vertex and neck. (Occipitalis major, occipitalis mi- nor, auricularis mag- nus, superficialis colli, and supraclavicular.) Neck. Shoulder, anterior sur- face. Outer arm. (Supracla- vicular, circumflex, externa] musculo-cu- taneous, cutaneous.) Back of shoulder and arm. Outer side of arm and forearm to the wrist. (Supraclavicular, cir- cumflex, external cu- taneous, internal cu- taneous, posterior spi- nal branches.) DISEASES OF THE NERVOUS SYSTEM. 1019 Segment. Sixth cervical. Seventh cervical. Eighth cervical. First dorsal. Second dorsal. Second to twelfth dorsal. Muscles. Deltoid. Biceps. Brachialis anticus. Subscapular. Pectoralis (clavicular part). Serratus magnus. Triceps. Pronators. Rhomboid. Latissimus dorsi. Triceps (long head). Extensors of wrist and fingers. Pronators of wrist. Flexors of wrist. Subscapular. Pectoralis (costal part). Serratus magnus. Latissimus dorsi. Teres major. Triceps (long head). Flexors of wrist and fingers. Intrinsic hand-muscles. Extensors of thumb. Intrinsic hand-muscles. Thenar and hypothenar muscles. Reflex and Centers. Triceps (fifth to sixth cervical). Tapping el- bow tendon produces extension of forearm. Posterior wrist (sixth to eighth cervical). Tap- ping tendons causes extension of the hand. Anterior wrist (seventh to eighth cervical). Tap- ping anterior tendons causes flexion of wrist. Palmar (seventh cervical to first dorsal). Strok- ing the palm causes closure of the fingers. Muscles of back and ab- domen. Erectores spinse. First lumbar. None. Second lumbar. Vastus internus. Third lumbar. Fourth lumbar. Fifth lumbar. First and second sacral. Third, fourth,and fifth sacral. Sartorius; adductors of thigh. Flexors of thigh. Extensors of knee. Abductors of thigh. Outward rotators. Flexors of knee. Flexors of ankle. Peronei. Extensors of toes. Calf-muscles. Glutei. Peronei. Extensors of ankle. Small muscles of foot. Perineal. Muscles of bladder, rec- tum, and external genitals. • Epigastric (fourth to sev- enth dorsal). Tickling mammary region causes retraction of the epigastrium. Abdominal (seventh to eleventh dorsal). Stroking side of ab- domen causes retrac- tion of belly. Vaso-motor centers. Sec- ond dorsal to second lumbar. Cremasteric (first to third lumbar). Stroking in- ner thigh causes re- traction of scrotum. Patellar. Striking pa- tellar tendon causes extension of the leg. Gluteal (fourth to fifth lumbar). Stroking buttock causes dimp- ling in fold of buttock. Achilles tendon. Over- extension causes rapid flexion of ankle, called ankle-clonus. Plantar (fifth lumbar to second sacral). Tick- ling sole of foot causes flexion of toes and retraction of leg. Genital center. Vesical center. Anal center. Sensation. Outer side and front of forearm. Back of hand, radial distribution. (Chiefly external cu- taneous, internal cu- taneous, radial.) Radial distribution in the hand. Median distribution in the palm, thumb, in- dex, and one half of the middle finger. (External cutane- ous, internal cutane- ous, radial, median, posterior spinal branches.) Ulnar area of hand, back, and palm, in- ner border of forearm. (Internal cutaneous, ulnar.) Chiefly inner side of forearm and arm to near the axilla. (Chiefly internal cutaneous and nerve of Wrisberg or 1 e s s- er internal cutane- ous.) Inner side of arm near to and in the axilla. (Intercosto-humeral.) Skin of the chest and ab- domen, in bands run- ning around and downward, corre- sponding to spinal nerves. Upper gluteal region. (Intercostals and dor- sal posterior nerves.) Skin over groin and front of scrotum. (Ilio- hypogastric, ilio-in- guinal.) Outer side • and upper front of thigh. Lum- bar region. (Genito- crural, external cuta- neous.) Front and outer side of thigh. Inner side of leg and foot. Inner side of thigh, leg, and foot. (Internal cutaneous, long sa- phenous, obturator.) Back of thigh and outer side of leg and ankle ; sole ; dorsum of foot. (External popliteal, external saphenous, musculo- cutaneous, plantar.) Back of buttock and thigh, side of leg and ankle: sole; dorsum of foot. Circumanal region, anus, rectum, penis, urethra, vagina, per- ineum. (Small sciatic, pudic, inferior hemorrhoidal, inferior pudendal.) 1020 DISEASES OF THE NERVOUS SYSTEM. To the foregoing table, which illustrates spinal localization, should be added another, shelving Avhat functions reside in the pons and medulla, as follows: Nuclei. III. IV. Sphincter iris. Ciliary muscles. Levator palpebrae superioris. Rectus internus (in convergence). Rectus superior. Rectus inferior. Obliquus inferior. Obliquus superior. (Upper facial group.) f (Associated movement of levator palpebrae.) { Muscles of lower jaw. {Rectus externus. Rectus inter, of opposite side in lateral movements. VII.—Facial muscles. , /T n . , \ IX. { Muscles of pharynx. XII. { (^owf fa^ SrouP-) X. I Muscles of esophagus. 1 Muscles of tongue. XJ j Mugcleg of ^^ Cerebrum.—The cortex of the cerebrum is composed of the follow- ing layers; considerable variation, however, exists in the structure of the cortex in different parts of the brain : (1) Neurogliar layer. (2) Molecular layer, composed of— a. Horizontal fibers of Kblliker and Exner ; b. Polygonal cells ; c. Fusiform cells ; d. Triangular cells. (3) Small pyramidal cell-layer. (1) Large pyramidal cell-layer, or layer of psychic cells of Cajal. (5) Polymorphous layer. (6) Fusiform cell-layer. The white matter of the cerebral hemispheres is made up of medul- lated nerve-fibers that arrange themselves in the folloAving groups: (1) Projection-fibers. (2) Association-fibers. (a) Connecting various parts of the same hemisphere : Short or arcuate fibers; Long association-fibers. (b) Connecting opposite hemispheres : Commissural fibers. (3) Terminal fibers. The projection-fibers have been divided into the cortico-afferent and the cortico-efferent, the former being chiefly sensory and the latter chiefly motor. The pyramidal fibers have already been described, and these constitute the main part of the cortico-afferent group. They take origin in the psychic cells of Cajal, and possibly from the small pyra- midal and polymorphic cells also ; they then pass as part of the corona radiata through the internal capsule, the foot of the crus cerebri, the pyramids of the medulla, and the anterior and lateral columns of the cord. In their course collaterals are given off, some of Avhich pass through the corpus callosum to be distributed in the cortex of the oppo- DISEASES OF THE NERVOUS SYSTE3I. 1021 site hemisphere. Others traverse the anterior commissure. Both these sets of collaterals are really commissural fibers. Some of the collat- erals terminate in relation with cells of the basal ganglia. The course of these efferent fibers has been ascertained almost solely through researches along pathologic lines. It is manifestly more diffi- cult to trace the afferent fibers, as their presiding cells are more distant. The ascending fibers of the antero-lateral columns of the cord termi- nate in the gray masses known as the nucleus magno-cellularis diffusus of Kblliker. The association-fibers connecting parts of the same hemisphere are both short and long, the short or arcuate fibers connecting adjacent convolutions, Avhile the long ones bring into relation more distant parts of the cortex. The long fibers course in definite groups to Avhich special names have been given, such as the uncinate fasciculus, superior and inferior longi- tudinal fasciculi, perpendicular fasciculus, cingulum fornix, fimbria, and bundle of Vicq d'Azyr. The association-fibers connecting the cerebral hemispheres are knoAvn as commissural fibers. They are the fibers of the corpus callosum and of the anterior commissure. Their exact origin and termination have never been ascertained, but it is believed that they unite symmetric cortical areas and consist of both axons and collaterals. It is supposed that they spring chiefly from the small pyramidal cells of the cortex, and that after crossing the commissural bridge they divide and spread out in a fan-shaped arrangement over wide areas. The anterior commissure connects the opposite temporal and occipital regions and olfactory lobes; other parts of the cortex are related through the corpus cal- losum. The terminal fibers are cortico-afferent fibers. These various fibers are the pathways for the conduction of nervous impulses to those regions of the cortex that preside over sensory, special sense, psychic, and motor functions. Mills says: " Too much stress is laid upon motor and sensory cells. The great function of all cells is trophic. Cells in sensory nerves do not feel, nor do they originate, sensation ; neither do motor cells spon- taneously generate motion. They are simply bodies placed in the great sensori-motor mantle to administer to the nutritive functions of the fibers which convey sensory and motor impressions." These motor cor- tical centers are not sharply delimited, but overlie one another (vide Fig. 68). An area exists in each center, stimulation of Avhich produces more marked results than stimulation of any other part of the same center. From this point the response to stimulation becomes progressively less as the periphery of the area is approached, until a spot is reached where tAvo sets of results are manifest, due to the overlapping of adjoining areas. Many observers discredit the idea that distinct motor centers exist, and believe that muscle and tactile sense-areas coincide in part or Avholly with the motor region. This is probably true, and has the endorsement of such men as Hitzig, Fritsch, and Horsley, Avho claim that tactile and muscular sense are represented to a slight degree in the motor region. Owing to extensive sensory compensation, however, very 1022 DISEASES OF THE NERVOUS SYSTEM. little disturbance of a sensory nature is manifest in lesions involving the motor cortex. Some dulness in the paralyzed extremities is present. Perhaps the best confirmation of this view is had in those cases of epi- leptiform convulsions that are preceded by a sensory aura. Others be- lieve the motor zone to be distinct, but do not regard it as being spon- taneously motor. Ferrier believes that the motor zone, though anatom- ically separate, is both functionally and organically connected with the Fig. 68.—Diagram of the cortical centers and areas of representation on the lateral aspect of the hemicerebrum (Mills). sensory. He further believes that association-fibers carry impulses from the sensory to the motor regions. Some observers have experimentally severed these connective fibers, with resulting paralysis, though electric stimulation of the motor cor- tex showed both it and the projection-tracts to be intact. Sensory Cortical Area.—OAving to the extensive compensation of sen- sory fibers, by means of which each side of the brain sends fibers to both sides of the body, it is impossible to map out the center Avith precision. It is generally believed, for reasons already stated, that the central convolutions (motor area) contain muscular and tactile sensory functions. These are also spread out over the parietal lobe, and it is possible, in- deed probable, that the sensory zone extends to the mesial surface of the hemisphere, as does the motor area. That this is the chief sensory center, as claimed by some observers, is, however, very questionable. From the cuneus, fibers pass to the pulvinar, forming an optic radia- tion of the Gratiolet. From the pulvinar they apparently pass to the external geniculate bodies, and thence to the anterior corpus quadrigemi- num. The optic tracts arise by two roots that curve round the crusta on either side and unite immediately in front of the tuber cinereum. Fibers from the two tracts pass to the homologous sides of both retinae; DISEASES OF THE NERVOUS SYSTEM. 1023 therefore the lesions posterior to the chiasm give rise to blindness of half of the retina on the same side. Visual Centers.—The exact center for ordinary vision is in the cor- tex of the occipital lobe of the inner surface in the region of the calca- rine fissure. A higher center exists, probably located in the angular gyrus, and a lesion of which produces mind-blindness: this is a condi- tion in which vision is not lost, but the seen objects are not recognized by the individual. Ferrier says that a lesion in this region sometimes gives rise to crossed amblyopia. The eye opposite to the lesions is chiefly affected, though vision is also restricted in the eye on the same side of the lesion (visual tract). Olfactory Center.—This is located in the anterior part of the uncinate convolution, on the inner surface of the temporal lobe. It is possible, too, that fibers pass from this region through the anterior commissure to the cortex of the opposite hemisphere. Auditory Center.—A lesion in the posterior part of the first temporal convolution produces a deafness in the opposite ear that is transient in cha- racter, OAving to compensation. Bilateral lesions produce complete deaf- ness. Mind-deafness, or an inability to understand spoken words, has resulted from a lesion in the first temporal conA^olution of the left side. Speech Center.—The articulate speech center is located in the poste- rior part of the left third or inferior frontal convolution, and in the ad- jacent part of the ascending frontal in right-handed people (but on the right side in left-handed persons). It is not known exactly Avhat part the island of Reil plays in articu- late speech. Word-blindness results from a lesion in the angular gyrus. Word-deafness results from a lesion in the posterior part of the first left temporal convolution. Taste Center.—The area of cortical representation is unknoAvn. By some it is located in the gyrus hippocampus. Psychic Centers.—It is possible that the frontal lobes, anterior to the precentral fissure, contain the psychic centers. Such extensive compensation probably exists that no ordinary lesion produces mental aberration, but these centers are probably represented by the whole cortex. The Cerebellum.—The cerebellum, like the cerebrum, consists of a cortical layer of gray substance, within Avhich is the medulla or white matter. The latter in turn encloses some gray nuclei. The cortex is made up of two layers: (1) The outer or molecular layer, and (2) The inner or granular layer. At the junction of these is found a layer of large cells, the cells of Purkinje, and from the upper part of the latter spring two or more mul- tibranching protoplasmic processes. The medulla contains both cortico- afferent and cortico-efferent fibers. Part of the afferent paths divide after entering the medulla, and the branches end in relation with the tufts of Purkinje's cells. Cajal has called these the scandent or climb- ing fibers. The afferent fibers to the granule-cells of the inner layer have irregular protoplasmic thickenings upon them, and suggested to Cajal the name of " mossy fibers." He looked upon them as the termina- tions of the cerebellar tracts of the cord. The efferent fibers run to the cerebrum, pons, medulla, and basal ganglia. The function of the cerebellum is that of coordination. Fibers pass 1024 DISEASES OF THE NERVOUS SYSTEM. from its cortex to that of the cerebrum, and vice versa. The impressions derived from the cerebrum are believed to be inhibitory. Peripheral impressions reach the cerebellum through the direct cere- bellar tracts of the lateral columns of the cord, and also from fibers de- rived from cells in the nuclei of the columns of Goll and Burdach. Motor impulses run from the cerebellar cortex to the motor region of the cerebral cortex by way either of the superior or middle peduncle, also by way of the inferior peduncle (restiform body) to the multipolar ganglion-cells of the anterior horns. GENERAL AND TOPICAL DIAGNOSIS. Nervous diseases are usually spoken of either as being functional or organic; but, as our methods of research become more refined and our technic more perfect, the breach betAveen these two groups is being gradually but perceptibly lessened. Granting this, they all really become organic diseases, though some in Avhich neither macroscopic nor microscopic change has ever been discovered are called functional for the sake of convenience. Organic nervous diseases may be produced by tAvo types of lesions: 1. Lrritative, causing an increase of function, continuous or inter- mittent. 2. Destructive, resulting in paralysis of motion or sensation, or both. Irritative lesions are prone to become destructive in course of time. They may be operative in the upper segment, which includes the brain and fibers leading to or from it as far as the ganglion-cells of the cord; or in the lower segment, including the multipolar ganglion-cells of the anterior horn, together Avith the peripheral motor and sensory nerves. When a complete pathway is involved a systemic disease is said to be produced. When tAvo or more paths or neuron complexes are simul- taneously involved combined systemic disease results. Brain-lesions may be (a) focal or (b) diffuse. Cord-lesions are either (a) transverse, (b) focal, or (c) insular (a series of foci). Cord-lesions result in ascending or descending degeneration, the de- structive process travelling, as a rule, in the direction in which impulses are normally transmitted. In the fillet degeneration may extend up or down. The theory has been advanced that the vulnerability of the tracts of the spinal axis is in direct proportion to the degree of their functional activity; hence the reflex (sensory and pyramidal) tracts are more likely to degenerate under nutritional disturbances or toxic processes than other parts. It has been supposed that the tardy myelination of the pyra- midal tracts predisposes to various nervous maladies, and particularly to those of a convulsive type. The folioAving may be accepted as a general rule: the motor-nervous system is the last to develop, the first to lose, and the last to regain, its function; while the sensory nervous system is the first to develop, the last to lose, and the first to regain, its function. In making a diagnosis it is, therefore, of the utmost importance to try to determine the locality and extent of the morbid process, and to ascertain whether the lesion is a focal or systemic one. The symptomatology of GENERAL DIAGNOSIS. 1025 systemic diseases is pretty constant, and, except in their very incipiency, they are usually not difficult of diagnosis. The symptoms of focal dis- eases, on the other hand, vary, of necessity, according to the location of the focus. They are often difficult and at times impossible to diag- nose. Especially is this true of lesions occurring in the frontal lobes of the cerebrum, in the basal ganglia, and in the cerebellum. Since the study of the motor centers and tracts has been pursued Avith so much more success than that of the sensory system, positive or negative motor phenomena occurring in the course of nervous diseases furnish us with much more valuable information than do sensory mani- festations. Further, motor symptoms are objective, and'consequently appeal to us in a much greater degree than the sensory symptoms, which are purely subjective, and the elicitation of Avhich depends so much upon the mental capability of the patient. Irritative motor-lesions produce, according to the degree of irritation, either fibrillary muscular twitchings or mild or severe convulsions, tonic or clonic in character. Destructive motor-lesions, according to their extent, produce mere muscular weakness, paresis, or actual paralysis of a single muscle, groups of muscles, or of the entire musculature of one or more limbs. Irritative sensory lesions give rise to neuralgia, hyperesthesia, or hyperalgesia. Destructive sensory lesions cause a more or less complete absence of sensation, as analgesia, anesthesia, or loss of temperature-sense. Upper-segment or Upper-system Diseases.—A lesion occurring in the motor pathway anywhere between the cortex and the multipolar cells of the anterior horns (but not including the latter) gives rise to the folloAving symptom-complex: Loss of motion, both automatic and vo- litional, and chiefly on the side of the body opposite to the lesion, though, if carefully sought for, some paresis will be found'on the same side as the lesion, due to the fact that each motor cortex supplies both sides of the body, though most of the fibers cross to the opposite side. The paralysis is spastic in type, flaccidity never being present. The muscles resist passive movements, showing that their tone is increased. This is relative, and is due to the removal of cerebral inhibition, which allows the lower centers free play. They also tend to undergo shorten- ing, and contractures result. Reflexes are increased chiefly on the side opposite the lesion, but also on the same side, the increase being the result of the removal of cerebral influences. The bilateral character is due to the manner of crossing of the fibers, a unilateral cortical lesion giving rise to bilateral degeneration in the cord. Owing to inactivity, the muscles of the paralyzed members undergo a more or less marked atrophy, though there are no degenerative changes, since the neuron bodies are intact. For the same reason the response to electric stimulation is not interfered with. An irritative lesion of this upper system, particularly when operative in or upon the cortical region, gives rise to tonic or clonic convulsive movements. When the lesion is localized to a single center, focal or so- called Jacksonian epilepsy results. The cortex is wonderfully tolerant, when the lesion is of gradual onset and the parts accommodate them- 65 1026 DISEASES OF THE NERVOUS SYSTEM. selves to the sloAvly increasing pressure. HoAvever, a local irritative le- sion may at first cause Avidespread symptoms, due, as Xothnagel pointed out, to pressure, vascular disturbances, or irritative inhibition. Lower-segment or Lower-system Diseases.—This includes the periph- eral neuron system. Since there is no crossing of the fibers, the lesion and resulting paralysis are on the same side of the body. The paraly- sis, however, is of the flaccid, flail-like variety, hypotonus being present. The muscles offer no resistance Avhatever to passive movement, contrac- tures do not occur, and reflexes are lost. Extreme degrees of Avasting occur in this type of paralysis, OAving partly to disuse, but chiefly to the fact that the neuron body, the nutritional or trophic center for the fiber, is injured. Pathologic changes therefore take place in the muscles themselves, and form a true degenerative atrophy. The protoplasm first becomes granular, and then fatty; it then breaks down and is absorbed. Its place is taken by the connective tissue, Avhich is both relatively and absolutely increased, so that in the course of time fibrous masses alone remain. Electric changes also occur. The muscles first cease to respond to the faradic current, and soon respond in an abnormal manner to the galvanic. Instead of short, sharp contractions, they react in a slow, wavy manner, ACC being stronger than KCC. Irritative lesions of this system cause fibrillary muscular contractions and periph- eral convulsions, of which laryngismus stridulus is a type. I. DISEASES OF THE PERIPHERAL NERVES. ACUTE ASCENDING PARALYSIS. {Landry's Paralysis.) Definition.—An acute paralysis, beginning in the legs and ascend- ing by Avay of the trunk and upper extremities, and ultimately involving the medullary centers. It usually runs a short course, and, as a rule, terminates in death. Pathology.—Although in many cases neither gross nor microscopic lesions have been found, either in the cells, peripheral fibers, or muscles, it is believed to be either an acute myelitis or an acute polyneuritis, the weight of opinion seeming to favor the latter view. Ross arrived at the latter conclusion after an analysis of 93 cases. Nauwerck, Barth, and Centanni hold the same belief, and the latter has discovered a bacillus in the lymph-spaces of peripheral nerves. Remlinger1 has reported a case occurring in a young man in Avhom paraplegia developed acutely, and eleven days later death resulted from bulbar involvement. Postmortem the cord was found congested in the region of the anterior horns. Microscopic examination revealed the presence of inflammation and streptococci in the cervical cord. The organisms occupied the tissue between the multipolar cells of the anterior horns. These latter in many instances were severed from their processes. Pure cultures of 1 Gazette hebdomidaire de Medecine et de Chirurgie, Xo. 27, 1896. ACUTE ASCENDING PARALYSIS. 1027 streptococci were obtained from the cord at various levels, but they were non-pathogenic for the rabbit. R. and F. Schultze and Sinkler have also reported cases in Avhich the only postmortem lesion was mye- litis, yet, as stated, the majority of observers believe it to be a neuritis. That it is primarily due to some toxemia, hoAvever, as originally claimed by Westphal, cannot be gainsaid. The prodromes, when present, are suggestive, and the enlargement of the spleen, Avhich is a constant con- comitant, and more rarely the lymphatic enlargement and albuminuria are all confirmatory. That the poison should have a selective tendency, since the nervous involvement is chiefly or solely motor, is not unique. We meet Avith toxic paralysis of the motor muscles of the eye, also with lead-palsy. Etiology.—No definite cause is knoAvn. It has followed cold and exposure, traumatism, and the infectious fevers, including influenza. Remlinger's case, quoted above, folloAved malaria. It occurs in males chiefly between tAventy and forty years. Symptoms.—In the most acute cases there are practically no pro- dromal symptoms other than malaise and possibly chilly sensations. Weakness, followed in a feAv hours or a day or two by paralysis, de- velops in the lower 'extremities. One may be involved a few hours earlier than the other. It spreads toAvard, and soon involves, the trunk also, and in quick succession the arms. The third and usually fatal stage is reached when bulbar symptoms develop. Very rarely the upper extremities may be first attacked. Death may occur in forty- eight hours. The paralysis is a flaccid one ; the muscles can be passively moved without offering any resistance. Wasting sets in, but no electric changes. In less acute cases a decided febrile stage precedes the onset of paralysis, chills, fever, malaise, and possibly formication or even sharp pain. In any case the later symptoms are pre-eminently or solely motor. Sensory symptoms when present are very slight. Sensation may be delayed, and the reflexes are generally absent; accordingly, there is edema or SAveating. The bladder and rectum are not implicated, nor do bed-sores develop. As stated, Avhen the bulb is attacked death gen- erally follows, due to cardiac or respiratory failure or to interference with deglutition. There are no cerebral symptoms. Course.—Death may occur in from forty-eight hours to a feAv weeks. A feAv cases of recovery have been reported, however, in some of which paralysis had been Avidespread, even reaching the bulb, judging from the labored respiration. When improvement takes place, it does so in the reverse order to the onset, so that the part last affected is the first to recover. It is much slower than the invasion. Diagnosis.—The rapid onset of a paralysis that usually ascends, the relaxation of the muscles, slight wasting, if any, and the absence of electric changes and of sensory symptoms, Avith or without fever, serve to make the diagnosis, and to distinguish Landry's disease from polio- myelitis, neuritis, and spinal hemorrhage. For the differential diagnosis betAveen Landry's paralysis and acute myelitis, see page 1072. Prognosis.—Ahvays grave, particularly if bulbar symptoms occur, and especially if they appear early. The treatment is essentially the same as that for any acute disease of the cord or nerves—i. e. rest, freedom from all excitement or worry, 1028 DISEASES OF THE NERVOUS SYSTEM. moderate purgation and diaphoresis; ergot, belladonna, and iodids in- ternally. Should the patient survive, electricity and massage should be administered. NEURITIS. Definition.—An inflammation of a nerve or of its fibrous envelope. Pathology.—A true neuritis is almost always an inflammation of the nerve-sheath or of the septa between the fasciculi, and usually begins as a perineuritis. The so-called parenchymatous neuritis is really a degen- erative process ; it is prone to follow neuritis, the result of excessive or prolonged irritation or from pressure by the products of inflammation. The sheath becomes hyperemic and the seat of a round-cell infiltration. The affected nerve becomes red and swollen. We may have a, perineuritis or an interstitial neuritis. Again, these may be focal or diffuse (disseminated), involving limited patches or con- tinuous areas of a nerve. Finally, many nerves may be simultaneously affected, constituting a multiple neuritis. In the parenchymatous form the ordinary signs of inflammation are absent. The nuclei of the sheath increase in size and number, and the protoplasm about them increases in amount. The white substance of Schwann becomes segmented, breaks up into droplets, then becomes granular and fatty, and is finally ab- sorbed. The axis-cylinder becomes discontinuous at the site of disorgan- ization of the myelin. Ultimately, there may be seen scattered promis- cuously among the more or less healthy fibers the withered nerve-sheaths, containing many nuclei, some granular debris, and pigment. Occasion- ally fatty aggregations occur along the nerve. Leyden has termed this condition lipomatous neuritis, but it is not worthy of a special name, as it is only a stage in the ordinary degenerative process. Parenchymatous degeneration is similar to the secondary or Wallerian degeneration previously mentioned. It is the chief lesion in multiple neuritis, though in this disease changes have also been found in the mul- tipolar ganglion-cells of the anterior horns. Utiology.—(a) Focal neuritis may be due to—(1) Exposure or cold (the so-called rheumatic neuritis). (2) Extension of inflammation from neighboring parts. (3) Traumatism—wounds, compression, excessive stretching resulting from fractures or dislocation. (4) Microbic and autogenetic poisons. (b) Multiple neuritis may be due to—(1) Poisons of extrinsic origin —alcohol, carbon bisulfid, lead, arsenic, mercury, ether. (2) Poisons resulting from the infectious fevers (typhoid, diphtheria, variola, typhus, leprosy, beri-beri, measles, syphilis, tuberculosis, septicemia, malaria, in- fluenza). (3) Cachexias, anemia, carcinoma. (4) Auto-intoxication. (5) Cases arise in which no definite cause can be ascertained; these are the so-called idiopathic or spontaneous cases. Symptoms.—(a) Focal Neuritis.—In localized neuritis the symptoms vary according to the function of the nerve involved. In the case of a sensory nerve there will be pain, usually of a boring or shooting charac- ter, along its course and distribution. There will be also tenderness on pressure along the nerve, and especially at its points of emergence from NEURITIS. 1029 bony canals. Weir Mitchell believes this to be due to irritation of the nervi nervorum. The skin is generally hyperesthetic (though tactile sensation is often lowered), reddened, sometimes edematous, and local sweatings may occur. In the more chronic cases trophic symptoms eventually arise, as glossiness of the skin and an impaired growth of the nails. When a motor nerve bears the brunt of the attack, mus- cular tAvitchings will be observed in the area supplied by the affected nerve. This is soon folloAved by more or less impairment of motion, even amounting to paralysis; sometimes contractures occur, and ulti- mately wasting of the muscles, and even reactions of degeneration, take place. When both motor and sensory nerves are simultaneously in- volved the symptoms Avill necessarily partake of a mixed character. The constitutional symptoms are, as a rule, of little moment. (b) Multiple neuritis is an involvement of the peripheral nerves in various parts of the body, affected simultaneously or in quick succession, and due to endogenous or exogenous poisons. Lettsom's paper, pub- lished in 1789, embodied the first description of the disease. Among cases due to poisons of extrinsic origin is alcoholic neuritis. In 1822, James Jackson of Boston clearly gave its clinical history, though Dumestfil in 1864 was the first to publish the result of an autopsy upon a case. Other pioneers Avere Leyden, Buzzard, and Ross. This is the most common type of multiple neuritis, and occurs oftener among women than men. It results from spirit-drinking in moderate amounts and continued over a long time. The onset is generally sIoav, being preceded by gastric catarrh, insomnia, tingling of the extremities, a rapid, Aveak heart, and a tendency to SAveating on exertion. Some mus- cular twitching and paresis may exist contemporaneously, but the loss of power soon becomes more marked—first in the loAver and then in the upper extremities, the extensors being chiefly affected. Wrist-drop and foot-drop follow. Occasionally paraplegia and, more rarely still, a loss of control of the bladder and rectum take place. Fever is rarely pres- ent. Sensory symptoms may vary from the tingling or numbness already noted to burning or boring pains of great severity. The skin is hyperesthetic at first, at all events. Later, paresthesia develops, Avith anesthesia and a more or less decided loss of muscular sense. The mus- cles are tender when touched. The cutaneous reflexes are preserved unless the anesthesia is marked. The knee-jerks are generally lost, though exceptionally they may be in- creased. In the less severe cases a certain amount of incoordination may be present. When this is the case the absence of the knee-jerk, the loss of muscular sense, ataxia, and the pains in the extremities sim- ulate locomotor ataxia, and the term pseudo-tabes has been applied to the condition. Vaso-motor and trophic symptoms appear, and in some cases the special senses are involved (impairment of vision, amblyopia, limitation of the color-field). The cerebral symptoms are important. They may be so slight as to consist merely of loss of memory, irri- tability, perhaps an hallucination or illusion (particularly after night- fall, and especially if the patient has had insomnia), or they may be of the type and degree seen in general paralysis. The duration of an attack varies from a feAv Aveeks to a year or so. Arsenic neuritis differs from the above in that the head-symptoms 1030 DISEASES OF THE NERVOUS SYSTEM. are generally absent. The onset may be much more abrupt and the course is usually shorter. Carbon bisulfid neuritis occurs chiefly in workers in rubber-factories. There are noted intense frontal headache, giddiness, marked excitability, muscular cramps, and possibly convulsions. Saturnine neuritis is con- fined to motor nerves, and especially to those of the upper extremities. Very rarely some disturbance of sensibility may result. Lesions of the anterior cornua are more likely to occur in saturnine multiple neuritis than in any of the other varieties. Head-symptoms are not common, but optic neuritis and convulsions may occur. Cases due to an attack of some infectious disease may be local or multiple, and generally present the same symptoms as neuritis due to any other cause. (1) Malarial Neuritis.—According to Romberg, malaria gives rise at times to "intermittent paraplegia." The legs of the patient suddenly become paralyzed, with or without alteration of sensation or loss of control of the sphincter. That the cause is probably malarial is shown by the fact that the condition is periodic, each attack subsiding with a critical sweat, and finally yielding to quinin. (2) Recurring Multiple Neuritis.—A few cases have been reported in which attacks of more or less widespread paralysis, due to neuritis, have recurred. (3) Endemic neuritis, or beri-beri, is a tropical disease, characterized by Aveakness, Avasting of the muscles, paralysis, anasarca, anemia, numbness, pain, areas of anesthesia, and diminution or loss of tendon-reflexes. There are two forms, the acute and chronic. Its eti- ology is obscure, though it is apt to supervene upon any condition that impoverishes the physical or nervous vitality. Intestinal parasites have been said to cause it. Ogata of Tokio has described a specific bacillus; Pekelharing and Winkler, however, claim that it is due to a micrococcus. Whatever its cause, the researches of these latter observers, together with those of Baelz and Sheube in Japan, prove it to be a peripheral multiple neuritis. The symptoms of the acute form are fever, anemia, general edema, effusion into the serous cavities, dyspnea, precordial pain, vomiting, and peripheral paralysis. Death often results, even in a few days, from emboli or thrombi in the pulmonary or systemic circu- lation. In the chronic form the symptoms are less pronounced. The face is apt to be puffy, and palpitation and serious cardiac dilatation may occur. The gait is tottering, the muscles are somewhat wasted, the tendon-reflexes are lost, and paresthesia develops. The cases associated with the cachectic states may be general, though usually they are local and of the interstitial variety of neuritis. The cases due to auto-intoxication are usually associated with fever, and at first simulate rheumatism or some infectious disease. Soon, however, the tingling, pain, palsy, loss of the knee-jerks, and anesthe- sia reveal the neuritis. Death may result from cardiac or respiratory paralysis. When life is spared the convalescence is exceedingly slow. Spontaneous or the so-called idiopathic neuritis does not differ from the general type of the disease, except that no cause can be discovered to account for it. Diagnosis.—This does not present any difficulty, as a rule. The spontaneous cases, in the early stages, may simulate acute spinal paraly- sis or acute ascending paralysis. The fever, palsy, electric change, and NEURITIS. 1031 the loss of knee-jerks are common to both, but in acute spinal paralysis there are never any sensory symptoms. The palsy in idiopathic cases rapidly spreads, but soon subsides again. In other forms of peripheral neuritis the onset is not only apt to be less abrupt, but some sensory symptoms are almost invariably present; the distribution of the palsy is more symmetric bilaterally, and after it has reached its acme no improvement takes place for a few weeks or months. In ascending paralysis there are no sensory symptoms, the knee-jerks are preserved, there is neither muscular atrophy nor electric change, and the order in which the paralysis supervenes differs from that of peripheral neuritis. Cases of pseudo-tabes are sometimes confounded with locomotor ataxia. The main points of differentiation are included in the following table: Pseudo-tabes. Locomotor Ataxia. The course is shorter, and often results The course is progressive from bad to in recovery. worse, and chronic in nature. Pain is never of the fulgurant type. Fulgurant pains often are present. Pain- crises are almost diagnostic. There is tenderness over the nerve-trunks. There is no tenderness over the nerves. Sensory disturbances are more marked Sensory disturbances are less marked. (tingling and numbness). Argyll-Robertson pupil is absent. Argyll-Robertson pupil is present. There is a " foot-drop," with the typical No " foot-drop." The toes are raised, and "steppage" gait. the foot is brought down flatly, with the heel first. Paralysis is often present. There is no actual loss of power. Prognosis.—Peripheral neuritis may terminate in one of the fol- lowing ways, according to Drs. Gibson and Fleming1: 1. In complete recovery; 2. With damaged peripheral nerves; 3. With injury to the central nervous system, such as to cause symptoms of ataxia, spastic paraplegia, or disseminated sclerosis; 4. In death, from failure of the organic centers, especially that of respiration. The prognosis is gen- erally good, though in the acute variety (from any cause) it should be guarded, and occasionally is grave. Exposure and chill, alcohol, diph- theria, and beri-beri give rise to the most serious types, and often cause death by failure of the heart or respiration or by coagula in the vessels. Mild cases may entirely recover in a few weeks, while severe ones often require a year or two. Treatment.—First ascertain the cause, and, if possible, remove it. It may be unwise in alcoholic cases to suddenly stop the alcohol, but each case must be judged on its merits. Rest is very important, and all sources of worry should be stopped. Locally, anodynes may be em- ployed and the part wrapped in cotton wool. In febrile cases, especially in the earlier stages, the salicylates are valuable. The general health should be toned up by strychnin and tonics, and by nourishing but eas- ily digestible food. Further medication will depend upon the etiology, quinin being demanded in malarial, and mercury or the iodids in syphi- litic cases. As soon as the acute symptoms have subsided massage and passive movements should be begun, galvanism applied to the muscles, and warm-water or sulphur baths administered. Contractures must be carefully guarded against. 1 Edinburgh Hospital Reports, vol. iii. 1032 DISEASES OF THE NERVOUS SYSTEM. NEUROMATA. Neuromata, or tumors of nerves, have been described as (a) true and (b) false. (a) True neuromata consist of medullated or non-medullated nerve- fibers (the myelinic and amyelinic varieties—Virchow), and rarely of ganglion-cells also. (b) False neuromata contain no nerve-elements. The growth is situ-* ated on the nerve-trunk itself, and consists of either fibrous, myxoma- tous, gliomatous, or sarcomatous tissue. Neuromata have also been classified according to their situation as (1) Stump neuromata, or bulbous nerves; (2) Subcutaneous neuromata, or tubercula dolorosa; (3) Nerve-trunk neuromata; (4) Plexiform neuromata. (1) Stump neuromata develop on stumps or on the ends of divided nerves as the result of traumatism. They may consist of fibrous tissue, but are usually myelinic. (2) Subcutaneous tumors, or tubercula dolorosa, are painful, as the latter name implies, and are apt to be multiple. In individuals so afflicted nerve-trunk neuromata may coexist. (3) Nerve-trunk neuromata are usually multiple. In one case quoted by Gowers as many as 3020 were found. They may be true or false. In the former case the nerve-fibers are less apt to be interfered with than in the heterologous growth. (4) Plexiform neuromata consist of beaded and tortuous, interlacing neural cords. They are usually congenital. Utiology.—Neuromata may be due to traumatism. When multiple, however, they are usually hereditary, occurring in families of a neurotic or strumous diathesis. They are most commonly found in men. Symptoms.—There may be none. When present their character necessarily depends on the nature of the nerve involved and whether the lesion is an irritative or destructive one. More or less pain, numbness or tingling, paraesthesia, and palsy are among the most common symp- toms. Various reflex manifestations have been described, and epilepti- form convulsions have been attributed to their presence. Treatment.—Apart from anodynes, operative measures are alone of value, except Avhen the tumors are the result of syphilis, as occasion- ally happens; in such cases specific treatment must be employed. It must not be forgotten, however, that stump neuromata may occur in those hereditarily predisposed, in which case, as Bowlby has pointed out, their removal will almost surely be followed by a return. NEURALGIA. Definition.—Neuralgia (nerve-pain) is the result of some irritation directly or indirectly applied to a nerve. While this is true of all pain, yet the special nerve-pain under consideration presents the following characteristics: 1st. In its distribution it follows the course of a nerve- NEURALGIA. 1033 trunk or its branches. 2d. It shows a tendency to shift from place to place. 3d. The presence of painful points (points douloureux). 4th. Intermission and remission of pain. The pain of neuralgia varies both as to character and intensity. It may be merely a mild ache, or, on the other hand, it may give rise to the most excruciating agony ; it may be of a throbbing, boring, tear- ing, shooting, or burning character, or it may come on in shock-like paroxysms. Any nerve in the body may be affected. Quite often one can find no definite cause of the neuralgia, and as Ave are not certain as to its ultimate pathology, it may be due to some slight inflammation of the nerve, or to hyperemia, ischemia, exudation, and the like. Among the predisposing causes are—(1) Age, the condition being most common in those between thirty-five and fifty years, and less so above that age. It is least common in children. (2) Sex. On the whole, neuralgia is most common in women, though the severer grades are found quite as frequently in men. Sciatica is more common in men, while trigeminal neuralgia occurs more frequently in Avomen. (3) Heredity. Neuralgia is very prone to occur in a family in which hysteria, epilepsy, or other neurosis or psychosis is present. (4) The general physical condition. In persons reduced by illness or by mental or physical exertion, and in anemia, neuralgia is common. (5) Occupation. Painters and workers among metallic dust are specially predisposed. The exciting causes are—(1) Exposure to cold and wet. (2) Me- chanical, chemical, or thermal irritation, including compression. (3) Traumatism. (4) Neuromata. (5) Infectious diseases. (6) Rheuma- tism and gout. (7) Endogenous or exogenous poisons. We are hardly justified to-day in speaking of idiopathic neuralgia. Such cases probably result from some endogenous or exogenous poison, an auto-intoxication, or malaria, rheumatism, syphilis, some metallic poison, or alcohol or tobacco. Finally, a form exists which we speak of in no certain manner as " reflex neuralgia," and which is said to re- sult from disease of the sexual or other organs often remote from the painful nerves. General Symptomatology.—Neuralgia may be of sudden or slow on- set, with or without prodromata. When the latter exist they consist of a sense of uneasiness, perverted sensations, chrlliness, and stinging or slight burning pains. The pain may be of the character previously de- scribed, either strictly localized or radiating to neighboring nerves, and may be aggravated by drafts, movements, or mental perturbation. On pressure certain tender or painful spots will be found, especially where the nerves emerge from deeper parts and become superficial. The affected part is usually hyperesthetic; occasionally, however, it is anes- thetic, and may continue so for some time after an attack. Reflex muscular contraction may be present in proportion to the in- tensity of sensory irritation. Vaso-motor symptoms manifest them- selves in the flushing or blanching of the affected part and in increased secretions, as sweating. Trophic disturbances may result in temporary or permanent changes. To the former belong the herpetic and urticarial eruptions, while the latter 1034 DISEASES OF THE NERVOUS SYSTEM. groups include change of color in, loss of, or overgroAvth of the hair, various changes in the skin (as pigmentation and morphea, and even ulceration, though in the latter instance there is probably a more pro- found pathologic change than that which we regard as the cause of neur- algia). Unless the attacks are severe or prolonged, however, the general system seldom suffers. Neuralgia may be divided into the following groups : neuralgia of the head, neck, trunk, upper and lower extremities ; neuralgia of the genitals and rectal region ; and visceral neuralgias. NEURALGIA OF THE HEAD. Trigeminal neuralgia (Tic douloureux) may manifest itself in any one or all of the branches of the fifth nerve. Neuralgia of the First Branch (Ophthalmic Neuralgia).—The chief points of pain in this variety are the supra-orbital foramen (the exit of the nerve), the nose, the eyeball, and parts around the eye. Supra-maxillary neuralgia (involving the second branch of the fifth, the supra-maxillary nerve). The tender points here are the infra-orbital foramen (the exit of the nerve), the cheek, side and cavities of the nose, the upper lip and gums, and the zygoma. The infra-maxillary division, the third branch of the fifth. The men- tal foramen is the point of greatest tenderness ; other spots, however, are the temporal region, and along the tongue and loAver lip. NEURALGIA OF THE NECK AND TRUNK. The cervical branches of the dorsal and lumbar nerves are involved in this group. 1. Cervico-occipital neuralgia, occurring in the occipital and posterior parietal region, is apt to be quite severe, but when not due to spondylitis (the result of caries) or neoplasms the prognosis is fair. It is sometimes the result of direct pressure, as in carrying heavy loads on the neck and shoulders. The painful spot is found between the mastoid process and upper cervical vertebrae. Falling of the hair may also occur. This is much more apt to take place, however, when the occipitalis minor is in- volved, as it is said that the latter is generally a syphilitic neuralgia. 2. Phrenic neuralgia has been described, but is a rare condition. The pain is in the lower anterior thoracic region, at the points of inser- tion of the diaphragm. 3. Intercostal Neuralgia.—The middle intercostal nerves are most liable to be affected, and generally on the left side. The posterior dorsal branches are seldom involved. When specially severe and persistent, intercostal neuralgia may be a symptom of disease of the cord or its membranes, aneurysm of the aorta, neoplasms, or disease of the vertebras or ribs. Traumatism and cold also give rise to it. This form of neuralgia is most common in women, the painful spots being at the extremity and at the middle of the ribs. The pain is of a sharp, lancinating cha- racter and radiates along the nerve. It is intensified by all movements of the chest; hence the affected side is more or less fixed. Herpes may develop, but in such cases it is probable that a true neuritis exists. NEURALGIA OF THE EXTREMITIES. 1035 4. Mastodynia is really a variety of intercostal neuralgia, and occurs almost solely among women. It is very painful, and gives rise to the development of tender "lumps" in the breast, simulating malignant disease. The paroxysms are often accompanied by vomiting. 5. Lumbo-abdominal neuralgia is not a common form. The pain is chiefly in the lumbar region, though the hypogastrium, genitals, and buttocks may also be involved. NEURALGIA OF THE EXTREMITIES. Cervico-brachial neuralgia occurs in the distribution of the four lower cervical nerves. When the condition is bilateral we should look for disease of the cord or membranes, for ne\v groAvths, or for disease of the vertebrae. When unilateral, any of the causes already enumerated may be operative. The radial and ulnar nerves are more frequently affected than the median. The pain is most apt to be distributed along the whole course of the nerve, but painful points are found in the following sit- uations—in the axilla; over the brachial plexus; on the shoulder, Avhere the cutaneous branches of the circumflex nerve emerge through the deltoid muscle; about the middle of the outer surface of the upper arm; over the ulnar nerve; in the sulcus betAveen the olecranon and epitrochlea; also near the wrist and at the bend of the elboAv over the musculo-spiral nerve. Femoral or crural neuralgia is a somewhat rare type that attacks the anterior surface of the thigh, the knee-joint, and the inner surface of the leg and foot. Obturator neuralgia is distributed along the inner side of the thigh doAvn to, and including, the knee-joint. This form is common in women subject to ovarian diseases. Sciatica stands next to trigeminal neuralgia in the order of fre- quency, and is by far more common in men than women. In addition to the ordinary causes of neuralgia—exposure, compression, trauma- tism—the condition may be an early symptom of tabes or it may be due to constipation or hemorrhoids. The painful points are in the gluteal region and the popliteal space or malleolar region, though ten- derness may be elicited along the whole course of the nerve. The pain is sharp and shooting, or more often of a tearing variety. Fine or coarse tremors or spasms may be present, together with some disturbance of sensation and loss of poAver. Herpes occasionally develops along the course of the nerve. This form of neuralgia is quite common, and is generally easy to recognize, but it may be simulated by hip-joint disease, psoas abscess, or lumbago. Sciatica may also be caused by neuritis, the result of exposure or compression by pelvic growths, or by the fetal head during labor. In such cases there is, as a rule, slight fever, and the tenderness on pres- sure and the degree of pain are infinitely more severe than neuralgia. In severe cases the patient is bed-ridden, but in milder attacks he can be about; Avalking greatly increases the pain, however. It is slightly mitigated by relieving the tension on the nerve, by bending the knee, and walking on the toes. It is an obstinate condition, and relapses are common. 1036 DISEASES OF THE NERVOUS SYSTEM. The diagnosis is generally not difficult. The distribution of the pain, the location of tender points, and the character of the gait suffice to pre- vent error, as a rule. A rectal or vaginal examination should be made to determine whether it is a primary disease or secondary to some pel- vic condition, for clearly, if the cause can be removed, the prognosis will be good. Neuralgia of the Genitalia and Rectum.—These varieties are not met Avith frequently. The former is sometimes a symptom of stone, prostatic disease, or stricture, and in women ovarian and uterine neu- ralgias are generally hysteric manifestations. Coccydynia, unless of traumatic origin, is almost solely found in Avomen. The pain in the region of the coccyx is excruciating at times, and may even call for operation. Visceral Neuralgia.—As implied by the name, these forms are neuralgias resident in the various viscera. They most frequently attack the stomach or bowel, and are recognized as colic. Other viscera may also be involved (liver, kidney). Treatment of Neuralgia.—The first requisite in the treatment of neuralgia is to ascertain whether it is due to local or general causes. That of the former class may be caused by a cicatrix, neuroma, aneur- ysm, neoplasm, or by caries or traumatism; and the treatment must necessarily be directed toAvard the removal of the cause when possible. When the fault is a general one, the neuralgia may occur either as the immediate result of the systemic disease or remotely, as the result of the altered blood-state (anemia). This is particularly well illustrated by an attack of malaria, in which it is palpable that success can only be obtained by attention to the underlying cause. It is sometimes necessary to use an analgesic, of which morphin is certainly the best. Its thera- peutic value is most decided when the drug "is given hypodermically, and if injected directly over the track of the painful nerve (e.g. supraorbital branch of the fifth), it not only affords immediate relief, but also obviates recurrences of the painful paroxysms in many instances. It is, however, scarcely necessary to urge the exercise of caution, for the morphin-habit is readily formed in these cases. The folloAving may also be used; anti- pyrin, phenacetin, codein, veratrum viride, aconite, also counter-irritants and vesicants, including the galvanic current. The general tone of the system must be attended to, bad habits prohibited, the state of the bowels regulated, and the eyes examined and corrected for errors of refraction. Rest is a valuable adjunct to any form of treatment. In neuralgia of the upper extremities and in sciatica I have often obtained good results from putting the limb in splints. Sciatica is often very intractable. If it fails to yield to the salicyl- ates; counter-irritation, leeches, and the rest-treatment of Weir Mitchell may be used, or nerve-stretching, either by flexing the thigh upon the abdomen or, as a last resort, by cutting down upon the nerve itself. Other nerves are sometimes subjected to this method of treatment also, but less frequently than the sciatic. Absolute rest in bed, Avith the limb kept perfectly still by means of sand-bags or a long splint, always gives relief, and in some cases seems to cure. Alternating hot and cold douches also give great relief in some instances. Deep injections of DISEASES OF THE CRANIAL NERVES. 1037 thein, ether, or chloroform are sometimes used, and even distilled water may give relief when injected into the nerve. The use of guaiacol ( absolutely reliable means of diagnosing meningitis of any form (except the well-advanced diseases) before Quincke, in 1890, introduced his method of lumbar puncture. This is comparatively simple of applica- tion, and has become a well-recognized measure. The tubercle bacillus and streptococcus pyogenes, also the pneumococcus and micrococcus meningitidis, have frequently been found in the fluid withdrawn. Prognosis.—In Avell-marked cases, in Avhich no doubt exists as to the diagnosis, the prognosis is always grave. The milder forms—the cortical cases, for instance—generally recover, but of the basal type very few survive, and those that do often retain evidences of the previous trouble in the shape of cranial-nerve involvement (strabismus, ptosis, facial palsy). That even tuberculous cases may recover is proved, hoAvever, by that of West, and even more strikingly by those of Baumann and Senlie, who found the tubercle bacillus in the cerebro-spinal fluid. The case recov- ered, but died some months later from an intercurrent affection; the diagnosis gained additional confirmation from the postmortem, findings. Treatment.—This has been previously considered. It is only neces- sary to add that Ave are able to do no more in this form than in the tuberculous. We have no specific, and all that can be done is to meet the symptomatic indications. In certain cases—e. g. those secondary to middle-ear disease—operation may seem justifiable. When in doubt the physician should not delay action until too late, but should call in a surgeon while some benefit may still be hoped for. DISTURBANCES OF CIRCULATION OP THE BRAIN. HYPEREMIA. Definition.—An abnormal increase in the amount of blood in the cerebral capillaries. The condition is not in any way associated Avith the primary phenomena of inflammation. What has already been mentioned in the case of hyperemia of the cord is equally true in this case—viz. that Avhile congestion undoubtedly may take place, there is nothing symptomatically pathognomonic in the 70 1106 DISEASES OF THE NERVOUS SYSTEM. fact, and hence we do not recognize it as a definite clinical entity. " Congestion of the brain " is rather a " diagnostic haven " and satisfies the patient, Avhile at the same time, provided the assumption is not made on too superficial evidence, it harms no one. Two forms of hyperemia have been described: 1. Active hyperemia is met Avith in men more frequently than in women, and results from over-action of the heart and Avidespread ob- struction to the circulation, as when the surface capillaries contract, or there is arterial dilatation, due to excessive mental activity from anv cause or to drugs—alcohol, amyl nitrite, nitroglycerin. 2. Passive congestion is met with in cases of obstruction of the cere- bral sinuses and veins, and is due to pressure on the superior cava or the innominate or jugular veins by tumors or aneurysms; also in suffo- cation and strangling, in cases of excessive strain, and in tricuspid in- sufficiency. Pathology.—There are no marked changes in the brain in these cases. In the active form the gray matter will appear someAvhat darker than normal, and a macroscopic section of the Avhite matter shows the puncta vasculosa to be increased. It often leaves no trace postmortem. In passive congestion the veins and sinuses are engorged and more or less edema may be present. The symptoms are described under two headings—1, those of irri- tation, and 2, of depression. Among the former are headache, vertigo, irritability, rapid pulse, restlessness, insomnia, and special nervous phe- nomena, as flashes of light, hyperacusis, and even convulsive movements. The latter is manifested by the obtunding of the senses; in fact, the antithesis of the other. The cerebral symptoms met Avith in febrile processes are probably due either to faulty metabolism or to some toxin, and should not be regarded as the result of hyperemia. Treatment.—The recumbent posture is of great importance. Leeching, Avet-cupping, and venesection are sometimes employed. Cold applications to the head, bromids internally, and attention to the bowels will be of assistance. Freedom from annoyance and Avorry of all kinds is necessary. ANEMIA. Definition.—A condition in Avhich an insufficient amount of blood circulates in the cerebral capillaries. It is due to exhausting discharges (diarrhea), an abnormally sIoav pulse or Aveak heart, to hemorrhage, obstructive endarteritis of the ves- sels supplying the brain, and to syncopal attacks and dilatation of the intestinal vessels, owing to the too rapid AvithdraAval of ascitic fluid. Pathology.—The gray matter is quite pale ; the puncta vasculosa are diminished, and sometimes cannot be seen; the cerebro-spinal fluid is frequently increased. Symptoms.—The most exaggerated type is met Avith after a pro- nounced hemorrhage. There are pallor, Aveakness, vertigo, headache, flashes of light, subjective noises, rapid respiration, cool skin, possibly profuse SAveating, and in extreme cases coma, convulsions, and death. We are more familiar Avith the ordinary fainting-attack. When cerebral anemia is brought about more sloAvly " irritable weakness " results. The EMBOLISM AND THROMBOSIS. 1107 patient is either somnolent, dull, and apathetic, or he may be a Alctim of insomnia. Headache, vertigo, tinnitus aurium, muscce volitantes, and lowered muscular power are present. The patient becomes irritable on the slightest provocation. Marshall Hall has described a group of symp- toms as " hydrocephaloid " from their resemblance to hydrocephalus; they occur especially in young children after diarrhea. There are pal- lor, hebetude, contracted pupils, and depressed fontanels. The som- nolence may deepen into a coma that often becomes more profound until death results. The treatment varies Avith the cause. The recumbent posture is always indicated, and in some cases it is necessary to depress the head, administer stimulants, and even transfuse or inject a normal saline solu- tion. A light and easily assimilable diet should be given during con- valescence. EDEMA OF THE BRAIN. Definition.—An infiltration of serum into the subarachnoid space and a greater or less increase of ventricular fluid, Avith or without infil- tration into the brain-substance. Pathology.—The fluid is chiefly in the meshes and beneath the membrane. The ventricular fluid is increased in amount; the brain- substance is pale, and in some cases infiltrated and softened. Micro- scopically, lacunae may be seen in the cerebral tissue, the perivascular spaces are dilated, and some slight degree of nerve-cell degeneration is often present. Etiology.—Edema is met with in Bright's disease, in senile cere- bral atrophy, and as a result of active or passive hyperemia. Symptoms.—In general the symptoms are those of anemia, though nothing definite is knoAvn of them. Since the condition is ahvays sec- ondary, it may be that symptoms directly referable to the edema are masked by the primary condition. Cases of apoplexy are seen occasion- ally, in Avhich the only postmortem finding is an effusion of fluid into the pia and ventricles. This has been termed " serous apoplexy." The treatment is that of the primary condition. EMBOLISM AND THROMBOSIS. (Cerebral Softening.) Embolism.—Definition and Etiology.—The obstruction of arteries or capillaries by material brought to the spot from some other part by the blood-current. The material, generally fibrin, usually comes from the heart, and is either a vegetation of a recent endocarditis or, more commonly, of chronic valvular disease; it may possibly be a fragment of the valve plus the fibrin in ulcerative endocarditis. In the latter case the plug is generally septic, giving rise to suppurative processes. An embolus may be Avashed from the auricular recesses, from an aneur- ysm of the aorta or carotid, or from atheromatous patches; rarely from the pulmonary veins. In puerperal women, and in certain febrile processes (diphtheria and pneumonia) the coagulability of the blood is increased. Heart-clots 1108 DISEASES OF THE NERVOUS SYSTEM. form, and fragments may be washed into the cerebral vessels. OAving to the direction of the vessels the embolus most frequently enters the left carotid, Avhence it usually passes to the left middle cerebral. Al- most any cerebral artery may be obstructed, but the cerebellar very rarely. Embolism occurs most frequently betAveen the tenth and forti- eth years of life. The middle cerebrals are most frequently involved, and next in order the internal carotid and anterior cerebrals. Pathology.—That region of the brain that is cut off from its blood- supply by the embolus undergoes softening. The cortical changes are less marked than those of the central ganglia, since in the former case more or less anastomosis exists, with none in the latter. When the em- bolus is septic one or more metastatic abscesses result. The degree of softening varies in different cases Avithin wide limits. There may be nothing more than a slight diminution in the consistence, the affected area being someAvhat paler than normal, or absolute dissolution may occur, the myelin breaking up into granules, while the tissue becomes infil- trated with serum, and the vessels undergo hyaline or more often fatty change. The color of the part varies with the amount of blood. In recent cases it is red. As the hemoglobin is absorbed a yelloAv color appears, and soon predominates. Red and yellow softening are found chiefly in the cortex. The so-called Avhite softening is met Avith particu- larly in the white matter. A variety of red softening in Avhich numer- ous small hemorrhages exist has been termed capillary apoplexy, while plaques jaunes is the term given by the French to a form of yellow soft- ening often seen in the cortex of old people. The ultimate changes de- pend in a great measure upon the extent of the lesion. If this is small, the granular de'bris is absorbed, and the proliferation of connective tis- sue results in the formation of a scar. On the other hand, if large the solid elements are removed, and the cavity that remains contains more or less fluid (a cyst). In many instances fibers, trabecular, and even vessels that have escaped destruction, pass through the cyst. Thrombosis.—Definition.—Obstruction of a vessel due to clotting in situ. This may occur (a) in the arteries or (b) in the veins and sinuses. In the Arteries.—Etiology.—Thrombosis results from disease of the vessel-Avail, atheroma, endarteritis, or syphilitic arteritis, extension from surrounding diseased areas, traumatism, in aneurysms, in depraved blood-states, and at the seat of lodgement of an embolus. Thrombosis of a cerebral vessel may rarely follow ligation of the carotid. In gen- eral we may say thrombosis results from (1) changes in the vessel-wall, (2) retardation of the blood-current, and (3) hypercoagulability of the blood. It occurs most frequently in the middle cerebral, basilar, in- ternal carotid, and vertebral arteries. Pathology.—The changes in the brain-tissue are precisely those de- scribed under Embolism. Within the vessel a clot is found adherent to the vessel-Avail, and extending from the nearest large branch on the proximal side to the contracted branches on the distal side. If of recent and rapid formation, it is ahvays of a red color. The sloAver the formation the paler the color. Such clots are often laminated. The ultimate changes are contraction and atroplnT, or, more rarely, calcifica- tion, or even softening and removal, the vessel again becoming patulous. EMBOLISM AND THROMBOSIS. 1109 In the Veins and Sinuses.—Etiology.—Thrombosis may be (1) primary, due to general causes, or (2) the result of local changes. Primary thrombosis is less common than the secondary variety. It is met with in marasmic children (one of the causes of infantile hemiplegia—Gowers), in Avhich the clot is called marantic throm- bosis, cachexia, phthisis, carcinoma, and in blood-dyscrasiae (anemia, chlorosis). Secondary thrombosis usually results from an extension of neigh- boring forms of inflammation, caries of the bone, middle-ear disease, or meningitis. It may also be due to fracture of the skull or compression of a sinus by a tumor. Pathology.—In primary thrombosis the most common seat is the su- perior longitudinal sinus. From this it spreads into the veins of both sides, and frequently also into the lateral sinuses of one or both sides. In secondary thrombosis the sinus nearest the local disease suffers. The veins emptying into the sinus involved become distended, often rupture, and in consequence the brain-tissue and pia become infiltrated. When the veins of Galen are blocked serum escapes into the ventricles. Red, yelloAv, and white softening is met Avith as a final result of the ex- travasation. Secondary thrombi are usually septic. Primary throm- bosis is probably due in many cases to an excess of carbonic acid in the blood. Chlorotic blood is probably charged with it. The com- parative infrequency, hoAvever, of clotting in the cerebral sinuses is due to the fact, recently shown, that they contain very little carbonic acid. Symptoms.—FolloAving Embolism or Thrombosis of Arteries.—The symptoms necessarily depend upon the position and extent of the lesion. Often it is discovered postmortem, not having been suspected during life. We meet with many such cases occurring in late adult life. Then, too, extensive lesions may occur in those portions of the brain that never yield any localizing symptoms—the frontal region, for instance. Apart from the etiologic differences, the clinical pictures of embolism and thrombosis differ as folloAvs: In the former the onset is sudden, without premonitory signs, and is in many cases accompanied by loss of consciousness. In addition to symptoms arising directly through implication of the particular part involved, there are those of shock. In the less severe cases consciousness soon returns and the apoplectic symptoms pass off. When more severe, coma supervenes and may prove fatal. When hyperemia occurs in or about the motor region the irrita- tion may give rise to convulsions. In other cases delirium is a promi- nent feature ; hence three varieties of softening are described by some writers—the apoplectic, convulsive, and delirious, from the prevailing feature. Thrombosis may commence abruptly, but as a rule the onset is slow, the patient meanwhile complaining of vague pains, numbness, tingling, headache, and vertigo. It is observed that a gradually in- creasing impairment of the mind is going on, and that motor weakness, slight at first, increases until the function is lost. The special symp- toms are, as stated, dependent upon the location of the obstruction. If this is in the middle cerebral artery, the most common seat, there will be hemiplegia, OAving to destruction of the internal capsule. The trunk may 1110 DISEASES OF THE NERVOUS SYSTEM. be spared and one of its branches stopped. The latter run to the third frontal, ascending parietal, supramarginal, angular, or temporal gyri. Thus, then, Ave can account for the aphasia so often met Avith in these cases by the plugging of the branch that supplies the third frontal con- volution of the left side. If both middle cerebrals are plugged, symp- toms develop that are indistinguishable from hemorrhage into the ven- tricles. This condition is generally fatal. Thrombotic obstruction of the anterior and posterior cerebral arteries rarely causes symptoms, owing to compensatory circulation. " Hebetude and dulness of intellect may occur " (Osier), with obstruction of the anterior cerebral. Hemianopsia may arise from a lesion of the posterior cerebral, since it supplies the cuneus. The left cerebral is more often involved than the right. In either case bulbar symptoms develop. Cerebellar softening is rare. When it does occur it is usually in the region supplied by the posterior cerebral artery. Not long ago Drs. Vincent Dickinson and S. Russell Wells reported an extremely inter- esting case occurring in the person of an infant. Clinically, it pre- sented nothing suggestive as to the presence of a gross brain-lesion. Postmortem, there Avas found a probable embolism of the basilar artery at its bifurcation, and secondary thromboses obstructed the posterior cerebral and superior cerebellar arteries, giving rise to softening in the superior part of the cerebellum and in the pons. The chief point lies in the possibility of the clot having come from the umbilical cord vid the ductus venosus and foramen ovale. Following Thrombosis in Veins and Sinuses.—The symptoms are vari- able. Those directly due to the vascular disturbance are severe head- ache, optic neuritis, delirium, or convulsions, and, later, great depres- sion. Hemiplegia may result. When the superior longitudinal sinus is affected epistaxis is common, while in lateral sinus-involvement post- auricular edema is common. In secondary cases, moreover, Ave have to reckon Avith the cause. Since this is so often septic, septicemic symptoms are the rule. Cases have been reported by Church, Owen, Wilks, Bristowe, Lee Dickenson, Sir Dyce DuckAvorth, and others. Sinus-thrombosis is not always fatal. In exaggerated cases of chlorosis optic neuritis and severe headache are highly suggestive. Sir Dyce Duckworth has reported a case that he saw with the late Matthews Duncan of a woman aged thirty-five, ill for three Aveeks Avith a " Avhite leg," following confinement. She had headache, optic neuritis, and slight convulsive attacks. Thrombosis of the cerebral sinuses was the diagnosis, and this was verified postmortem. Treatment.—Of Embolism and Thrombosis of Arteries.—Very little can be done in brain-softening. In the early stages, however, Avhile it is absolutely impossible to repair the tissue already damaged, an effort should be made to prevent the spread of the process. Rest in bed with the head slightly elevated should be insisted on. When shock is present it must be met by gentle stimulation, ammonium carbonate, and even by alcohol and digitalis in some cases; hot-water bottles may be applied to the body. Venesection is contraindicated. The boAvels should be made to move gently and purgation should be avoided. Later, as stated, symptoms of irritation often appear. In such cases the bro- mids should be given, and also a diaphoretic mixture, or ice should be VASCULAR DEGENERATION. 1111 placed to the head. In any case in which syphilis, rheumatism, gout, chorea, or other malady capable of causing or adding to the trouble ex- ists, the original disease should be treated promptly and thoroughly. In the mean time efforts should be made to improve the patient's general tone by the strict observance of hygienic and dietetic rules. Of Thrombosis of Ileitis and Sinuses.—Treatment in these cases de- pends largely on the cause. In the primary form it is that of the sys- temic disease. Good, Avholesome, and easily assimilable food should be given, together with a tonic treatment. In secondary thrombosis care- ful search should be made for pent-up inflammatory products, Avhich should be liberated at the earliest possible moment. The emunctories must act freely. Counter-irritation, applied to the neck, is of question- able value, but internally quinin, iron, and strychnin, and, if stimulation is necessary, ammonia and alcohol, will all be useful. VASCULAR DEGENERATION. Arterial.—The cerebral arteries undergo a more or less decided de- generative change in the majority of people past middle life (Bichat said seven-tenths). It is met Avith much earlier, however, as a result of disease. Bright's disease, rheumatism, gout, alcoholism—in fact, any irritation of the vessel-Avail, Avhether autogenous, the result of faulty metabolism, or Avhether introduced from Avithout, as alcohol—is capable of bringing about a change of the inner seat of the vessel, to which Virchow gave the name " endarteritis deformans." The circle of Willis and its branches are the most frequent seats. Various stages may be met Avith in different vessels or even in the same vessel—viz. hyaline degeneration, fatty degeneration, liquefaction-necrosis, atheromatous ulcers, and calcification. Syphilitic arteritis is not a true degenerative process. It is rather a proliferative process in Avhich both intima and adventitia are involved. Venous.—The veins are less liable to disease than arteries, possibly because they are more yielding, yet the same pathologic changes may be met Avith in them. They are more commonly damaged by extension of inflammation from neighboring tissues or by pressure. Aneurysm.—Dilatation of a vessel results from any of the causes above mentioned. The aneurysms may be very small—miliary—or often as large as a filbert-nut, and rarely as large as a hen's egg. They occur more commonly in males than in females. The middle cerebrals and basilar are most frequently attacked, and next come the internal carotid, the vertebral, and the anterior and posterior cerebrals. Symptoms of Aneurysm.—There may be none, but in any case they are due to pressure exerted by the mass, and are therefore comparable to tumors of the brain. In many cases the first evidence of any trouble is an apoplectic attack, and it is scarcely necessary to add that this is usually fatal. In other cases headache, vertigo, and optic neuritis are present, and more rarely a subjective murmur. Still more rarely an objective murmur may exist. 1112 DISEASES OF THE NERVOUS SYSTEM. INFLAMMATION OF THE BRAIN. (Encephalitis.) Definition.—Encephalitis, strictly speaking, is an inflammation of the brain-substance, and does not include inflammation of the meninges, though in many instances the tAvo conditions coexist as the result of a common cause, or one may precede and give rise to the other. Encepha- litis is met with in two forms—(a) Focal, and (b) Diffuse. FOCAL ENCEPHALITIS. (Abscess.) Pathology.—In very acute cases no time is given for encapsulation ; when of longer duration, however, the abscess is Avell circumscribed, having a Avell-defined wall, within which there are cell-detritus, pus, and sometimes more or less altered blood. It may be offensive. About it the brain-substance is generally softened and edematous. The abscess is generally single, except in pyemic cases, and varies greatly in size in different instances. Etiology.—Abscess of the brain is a more or less circumscribed process, due to (1) Injury.—In the majority of cases of abscess following head-injuries either a compound fracture of the skull exists, with or with- out hernia cerebri (fungus cerebri), or a punctured wound has been made. Less commonly it may folloAv a simple fracture, and rarely it is said to occur Avhen neither a fracture nor even an abrasion of the scalp has been produced. Meningitis is an almost invariable concomitant. (2) Exten- sion from some neighboring inflammatory focus, as from orbital, nasal, or aural disease, in which the bones have usually become affected. (3) Pyemia, in which case the abscesses are apt to be small and multiple. It is also met with occasionally in gangrene of the lung, bronchiectasis, ulcerative endocarditis, suppurative hepatitis, or bone-disease, and rarely in chronic septic processes. (4) Congenital Heart-disease.—Little is known of this condition. Within the past two or three years Northrup, Packard, Sir Dyce Duckworth, and Osier have reported such cases. (5) Obstruction of an artery, vein, or sinus, whether of spontaneous origin or the result of ligature, may give rise to abscess. Generally, hoAvever, the cerebral change is that of softening, and not of true suppuration. (6) Intracranial tumors. (7) Infectious fevers. Symptoms.—These at first are generally vague, but in traumatic cases, and more especially in those in which a compound fracture of the skull has resulted, the course may be most acute, and fever, headache, delirium, and possibly vomiting may be seen quite early. These are fol- lowed by other evidences of irritation, soon by compression with convul- sions, and then by coma and death. In the more chronic cases the symp- toms depend upon the size and location of the abscess and whether or not a vent exists. In such cases an intermission in the symptoms is occa- sionally met with, due to filling and emptying of the sac. Apart from the headache, pyrexia (not ahvays present), twitching, and droAvsiness, that occur in the course of these cases, more or less hemiparesis commonly exists, except in abscess of the frontal lobes. The latter are spoken of as "silent regions." An abscess may be "latent," hoAvever, in almost CEREBRAL HEMORRHAGE. 1113 any region, these latent abscesses being typified in certain cases of con- genital heart-disease. I do not think they were suspected during life in any of the cases reported thus far, and therefore optic neuritis has not been looked for; in other cases this latter symptom is commonly present. Diagnosis.—In the acute cases folioAving injury little difficulty pre- sents as a rule, though even in this group a latent period may exist. With such a history, however, the onset of headache, fever, delirium, and convulsive movements is decidedly suspicious, and, should optic neuritis also exist, practically no doubt can remain. When dural or nasal disease exists the head-symptoms should be carefully studied, since they are prone to develop in ear-disease soon after a cessation in the dis- charge. Brain-tumor usually runs a more chronic course, and is seldom accompanied by fever, at least not until its final stage. It may be im- possible to differentiate cerebral abscess from meningitis, and the two conditions often coexist, as already stated. The prognosis is ahvays grave. Treatment.—When an abscess is suspected immediate operation is indicated. The most acute cases, however, may be treated symptomati- cally unless focal symptoms develop. Rest in a darkened room will be necessary, with ice to the head, leeching or more free bleeding, and in- ternally calomel and bromids. It must be remembered, however, that in a great many cases no localizing symptoms appear, and, since we knoAv that most abscesses occur either in the temporo-sphenoid lobe or in the cerebellum, when we have reason to suspect the presence of one, these regions should be explored. DIFFUSE ENCEPHALITIS. A good deal of doubt exists in the minds of some as to whether diffuse encephalitis ever exists except as a result of traumatism. Certain it is that it is less common and much less is known about it than of inflam- mation of the cord. We meet Avith it especially in the frontal regions in certain cases of general paralysis of the insane. The changes often escape the unaided eye. Microscopically, the vessels will be found injected and the perivascular spaces distended with leukocytes; these latter escape into the surrounding tissue, which becomes softened and edematous. Symptoms.—It is manifestly impossible to give a definite symp- tomatology in the present state of our knowledge. Excepting the trau- matic cases the symptoms are, as a rule, chiefly psychic. CEREBRAL HEMORRHAGE. (Cerebral Apoplexy.) Definition.—Hemorrhage into the brain-substance; though bleeding into the meninges, which rarely co-exists, is generally embraced in the definition. Pathology and Etiology.—In intracerebral hemorrhage the blood will be found to have infiltrated the brain-substance, and, if extensive, it 1114 DISEASES OF THE NERVOUS SYSTEM. may have penetrated into the ventricle. In such cases the white matter is torn asunder, leaving a ragged space that is more or less filled with recent clot and fragmentary gray matter; if the ventricles have been entered, blood may escape from the lowest into the subarachnoid space. In less severe cases the territory involved is less extensive, and the blood may occupy a single space or several small spaces, forming mere separations of the nerve- fibers. Other changes take place according to the duration of the case. The blood changes color and gradually grows lighter, Avhile reactive in- flammation about the lesion results in the formation of a wall. The cyst —for such it has become through fatty degeneration of its contents—may remain as such, or when the lesion is a small one connective tissue may form within and a scar result. The larger arteries are generally atherom- atous, and an aneurysm is occasionally met with; many miliary aneur- ysms may be seen in the course of the smaller vessels. It is very seldom that the actual source of the hemorrhage can be discovered. Secondary degeneration follows a lesion occurring in the motor region (the cortex or internal capsule), so that sclerotic changes can be traced from the cortex through the corona radiata, internal capsule, crura, pons, and medulla to the termination of the fibers in the cord. Cerebral hemorrhage is generally of arterial or capillary origin. It is rarely venous, and in the latter case is due almost always either to trau- matism or to rupture. Spontaneous rupture generally results from exten- sion of some neighboring focus of disease to the vessel-wall. Andral states that varicose veins occur in the pia and that they occa- sionally rupture. Capillary hemorrhage may follow the plugging of a large vein, and of the larger vessels any one or more may be involved, but it has been observed that hemorrhage tends to take place at par- ticular places. In more than one-half of all cases the lenticulo-striate artery (Charcot's artery of cerebral hemorrhage) gives way, and damages the lenticular nucleus and internal capsule. Other regions in the order in which hemorrhage occurs are as follows: centrum ovale, cortex, pons, peduncle, cerebellum, optic thalamus, and the posterior and anterior parts of the hemispheres. Hemorrhage into the cerebrum occurs twenty times more often than hemorrhage into the cerebellum; it may take place into the brain-substance, into the ventricles, or into the meninges, the latter form having already been considered. Arentricular hemor- rhage in a great number of cases is caused by a more or less extensive laceration of brain-matter, thus permitting the blood to escape into the ventricles. Not only the lateral ventricles, but the third and fourth also, may contain blood. Symptoms.—Generally the patient is seized without any warning, but in other cases headache, depression, possibly choreiform movements, and more or less paresthesia, precede an attack. The loss of conscious- ness is usually the first manifestation, though for a feAv moments before, motor weakness, with or without spasmodic movements, may exist. In very slight attacks consciousness may be preserved throughout. The cause of the unconsciousness is still an open question. Niemeyer re- garded it as due to pressure acting either directly upon the convolutions or by limiting the blood-supply. This view is scarcely tenable, how- ever, for unconsciousness occurs even when the hemorrhage is too small to exert pressure, and, moreover, the hemorrhage and loss of conscious- CEREBRAL HEMORRHAGE. 1115 ness are usually simultaneous. The symptoms are in direct proportion to the extent and position of the hemorrhage. The patient falls, the face is usually congested, one side often expressionless, and the cheek flaps during respiration. Breathing is stertorous and, in grave cases, of the Cheyne-Stokes type; 'the pulse is generally feeble for a feAv mo- ments, but soon becomes full and bounding in character. The pupils vary, and may either be contracted or dilated. There is frequently a relaxation of the sphincters, and on raising the limbs it will be found that those of one side offer absolutely no resistance. The temperature is slightly lowered at first, but after a feAv hours rises to, or just above, normal. In grave cases it w ill either remain Ioav or will mount up to 106° F. (41.1° C) or even higher, such cases usually being fatal. Con- jugate deviation of the head and eyes takes place in some cases, the deviation being toward the lesion and a\vay from the paralyzed side. In pontine hemorrhage the opposite to this occurs. As a rule the symp- toms that we group under the term apoplexy—viz. loss of consciousness, motor povver, and sensation, Avith or Avithout relaxation of the sphincters —pass off in twrelve to tAventy-four hours. In fatal cases the coma deepens, but death rarely ensues under twelve hours. In hemorrhage into the medulla or ventricles it may rarely be more rapid. In from twenty-four to forty-eight hours after the onset febrile reac- tion sets in, Avith irritative symptoms due to the inflammatory changes occurring about the original lesion. There are fever, often delirium, twitchings or spasmodic movements of a more pronounced type, and sometimes rigidity in the affected limbs. Trophic changes in the form of vesicles, or even sloughing, may occur. Death may take place dur- ing this stage. Cases are generally fatal also in which a second " stroke " follows closely upon the first, indicating a fresh hemorrhage. After the reactionary period a stationary period follows ; sooner or later control of the damaged members is then gradually, but not perfectly, regained. The degree of recovery is dependent upon the resumption of function of slightly damaged tissue or upon the compensatory activity of the other side of the brain. In well-marked cases the move- ments of the affected side are subsequently ataxic. In certain cases the structural damage has been too great, and permanent paralysis remains, Avith rigidity, Avasting, and secondary contractures. Ingravescent Apoplexy.—In certain cases the onset is slow, conscious- ness being lost gradually. Coma deepens and the case, as a rule, termi- nates fatally. Simple Apoplexy.—A condition in which no recognizable lesion is found postmortem. Many of the cases that were originally described by Abercrombie may have been due to uremia or embolism, though these do not explain all. The condition may be the result of a toxic en- cephalopathy. Serous Apoplexy.—The cases present clinical evidences of apoplexy, but the only postmortem finding is an excess of serum, and this is in no way responsible for the apoplexy. These cases probably belong in the same category as those just mentioned, but occur in old persons whose brains have atrophied. Hemiplegia.—When this is complete one side of the face and the arm and leg of one side, generally the same, are all involved. The facial 1116 DISEASES OF THE NERVOUS SYSTEM. palsy is not complete, the frontalis and orbicularis oculi escaping. The tongue Avhen protruded deviates towrard the paralyzed side. As a rule the arm is affected to a greater extent than the leg, and, indeed, in some cases the face and arm may alone be paralyzed. The trunk-mus- cles ahvays escape, possibly owing, as Broadbent suggested, to the func- tional unison of the spinal nuclei of the two sides that preside over them, and, since they habitually act together, he supposed that they might be stimulated from either hemisphere. There is no Avasting of the affected muscles as a rule, nor are there electric changes, except during the irritative period, when the response to stimulation is heightened. Occasionally marked atrophy occurs, and is due in some cases, as Charcot has shown, to changes in the cells of the anterior horns. In others no such change is found, and we are forced to regard the Avasting as cerebral. Sensation is of course absent during the period of unconsciousness. Subsequent sensory disturbances are not constant for all cases. Spots of anesthesia often exist for a brief period, and hemianesthesia is rare. A lesion in or about the posterior part of the posterior limb of the in- ternal capsule is specially prone to give rise to disturbances of sensation. The special senses may be temporarily perverted or in abeyance, but rarely do permanent disturbances occur. More or less mental deteriora- tion may be permanent, hoAvever. The deep reflexes are increased on the paralyzed side, and the superficial reflexes are absent. Crossed Hemiplegia.—When a lesion occurs in the lower part of the pons the fibers of the facial nerve that are involved have already decus- sated ; hence facial palsy occurs on the same side as the lesion. The fibers coming from the cortex are implicated before their decussation, so that paralysis of the limbs occurs on the side opposite to the lesion. Lesion of the crus may lead to oculo-motor palsy of the same side, and palsy of the face, arm, and leg of the opposite side. Course and Terminations.—As previously intimated, the course depends on the position and extent of the lesion. In the most extensive cases death rarely takes place under several hours. Hemorrhage into the medulla may prove fatal more quickly. In the slightest cases, per- fect recovery may take place in a few days or weeks. Generally, hoAv- ever, when little or no improvement occurs in tAvo or three months, per- manent changes result. The facial muscles soon recover, and next the leg, while at first the patient is able merely to move the toes. Daily improvement then follows until he can support his Aveight; dragging of the foot, however, is marked at first, and rarely disappears absolutely. In the mean time a less pronounced change for the better has been taking place in the arm. This member very rarely recovers, however, to the same extent as the leg, and secondary contractures develop in time, the arm and hand becoming flexed. The hand is usually bluish and cold, and swells if kept in a dependent position. More or less ataxia is con- stant, and rheumatoid pains are apt to occur during this stage. Other late manifestations that are only occasionally met with are athetosis, arthropathies, post-hemiplegic chorea, and tremors. Diagnosis.—Apoplexy is to be distinguished from other conditions capable of causing unconsciousness, such as cardiac syncope, epilepsy, alcoholic or opium-poisoning, insolation, or uremia. If some previous CEREBRAL HEMORRHAGE. 1117 history can be obtained, the difficulty of the diagnosis is lessened, though it may still be great. In syncopal attacks the pulse is very feeble and the face is pale, respiration being shallow and often sus- pended. The sphincters are hardly ever relaxed; the reflexes are usu- ally preserved, and the skin is often moist. In epilepsy there is a his- tory of previous attacks, or, failing to obtain this, one can usually learn that a convulsion has immediately preceded the coma. With alcoholism the case is more difficult. The odor of alcohol on the breath is of no value, as spirits may have been given by a bystander; moreover, hem- orrhage is common in alcoholics (vide table of differential diagnosis, p. 961). In opium-poisoning the coma comes on gradually, and when not too profound the patient can be aroused Avhen shaken or shouted at. The respirations, Avhich are very slow and deep at other times, become somewhat quicker and shallower when he is aroused. In insolation the temperature suffices as a rule, though, as stated, high temperature may occur in apoplexy. The presence of albumin is not conclusive evidence of uremic poisoning unless the centrifuge and the microscope reveal the presence of casts or other indications of renal change; even then the case may be one of apoplexy in a subject of nephritis. In the case of diabetic coma the presence of sugar in the urine serves to make the diagnosis. When we meet with a comatose case in which there is abso- lutely no resistance when the limbs of one side are raised, while those of the other still exhibit some tonicity, particularly if the deep reflexes are exaggerated on the flaccid side, the probability is that it is an apoplectic attack. It is generally not possible to tell whether the condition is due to hemorrhage, embolism, or thrombosis, though the tabulated points of distinction (after Leube, vide infra) will afford material aid : Emboli. Early adult life. Previous development of atheroma, car- diac disease following acute rheuma- tism, sepsis, chronic valvular disease, fatty heart, general cardiac weakness, aneurysm. Detection of emboli in other organs. During the attack there is an absence of congestion of the face; the pulse is normal; in cardiac affections it is ac- celerated and irregular. Temperature normal, but shortly after the attack it begins to rise, without making an unfavorable prognosis. The attack, as a rule, is short, but if there is a protracted embolic infarction, the duration is long 5 but the circulation may adjust itself. Remote effects are infrequent. Hemi- plegia is i-ight-sided, with aphasia. Hemorrhage. Late adult life ; in early life very rare. Atheroma with cardiac hypertrophy. History that the patient up to the time of attack was well; also the finding of casts in urine and other symptoms of chronic nephritis. During the attack there are noted flushes (reddish) of the face, pulsating carotids, and slow pulse. Temperature during the attack is sub- normal, but just previous to death there is an antemortem rise. The duration is, as a rule, longer. Coma of long duration (about two days) gives a very unfavorable prognosis. Remote effects quite frequent; alteration in the urine—albuminuria, polyuria. 1118 DISEASES OF THE NERVOUS SYSTEM. Ophthalmoscopic Examination. At times the ophthalmoscope reveals The retinal arteries may show various either a recent or an old embolus in the stages of atheromatous degeneration ; arteria centralis retinae. as a result there may be a hemorrhagic retinitis or there may be a thrombus of the central vein of the retinae. In a few instances, in which the hemorrhage occurred in the ventricle, the pupils were contracted. It is not an uncommon occurrence to have patients brought to a hos- pital dazed and smelling of liquor. These should always be carefully watched, for mistakes readily occur, and many such cases have been condemned to a prison-cell when they were really suffering from fracture of the skull. Prognosis.—Sufficient has already been said on this point. Treatment.—The patient should be kept as quiet as possible and in the recumbent position, Avith the head somewhat elevated. The clothing about the neck should be loosened to prevent constriction. An ice-bag may be put to the head and hot bricks or a hot-A\ater bottle to the feet, Avhile sinapisms may be placed on the back of the neck or on other parts of the body. If the pulse is strong, full, and incom- pressible, and the face is congested—venesection is probably justifiable, particularly if the age and condition of the vessels support the idea that hemorrhage is taking place. It must not be done without consid- eration, however, since it Avould be useless in embolism and thrombosis. The bowels should be made to move freely ; a cathartic may be exhibited by the mouth (croton oil, gtt. j or ij), and at the same time an enema may be given. When consciousness returns an endeavor should be made to keep up the tone of the affected muscles by massage, and after two or three weeks have elapsed by faradization. It is questionable if the iodids or any other drugs have an influence over the subsequent changes. APHASIA. Definition.—Impairment or total suppression of the power of speech, due to cerebral disease. This is a complex subject, and cannot be more than touched upon here; but the chief disturbances will be briefly mentioned, omitting any further description of the form due to disease of the bulb (anarthria), since it has already been dealt with in speaking of Bulbar Palsy (vide p. 1091). The majority of cases of aphasia are met with in connection with hemiplegia. They are apt to be more marked in the beginning, owing to the general obtunding of the psychic processes that is induced by the shock. Speech is the expression of thought in words, and is the result of external stimulation in which the impulse awakens in the mind a recollection of similar impulses that have preceded it—e. g. the sight of a dog, sound of a bell, or certain odors (vide Fig. 72). Bastian, however, believes that it is not necessary to postulate the existence of a separate center for conceptions or ideas. He believes that a better knoAvledge of APHASIA. 1119 the functional activity of the auditory and visual word-centers obviates it, and gives the following three ways in which the perceptive center may be called into activity: (1) By voluntary recall of past impressions, as in an act of recollection ; (2) by association—that is, by impulses communi- cated from another center during some act of perception or during some thought-process; and (3) by means of external impressions. Two principal forms of aphasia exist: (1) Motor, and (2) Sensory. I shall consider these forms of aphasia separately, although before doing so it seems necessary to indicate by means of the accompanying schematic diagram (Fig. 73) the different paths on which the individual acts for the J Aeal—Sugar, 77 grains (4.9); coffee, 4 ounces (128.0); milk, 1 ounce (32.0); occasionally bread, 1 ounce (32.0). Evening Meal.—Caviare, \ ounce (10.6); one or two soft-boiled eggs; beefsteak, foAvl, or game, 5 ounces (160.0); salad, 1 ounce (32.0); cheese, 1 dram (4.0); bread, rye or bran, \ ounce (16.0); fruit or water, 4 to 5 ounces (120.0-148.0). The mechanical treatment of corpulence, by exercise, is to be used in conjunction with the dietetic. The form of the exercise, and also the time and frequency, must be adjudged for each case. When cardiac dilatation and myocardial degeneration (fatty) are the cause of symp- toms of precordial distress, dyspnea (however slight), and palpitation, resort may be had to Oertel's system of graduated walking on the level 1 Twentieth Cent. Pract. of Med., vol. ii. pp. 698, 699. 2 Loc. cit. 1226 THE INTOXICATIONS; OBESITY; HEAT-STROKE or climbing along " health paths" (vide Fatty Overgrowth, p. 657). Or, the well-knoAvn Nauheim or Schott treatment may be used. Great care must be exercised in prescribing the mechanical treatment in obese persons who have atheromatous vessels. The medicinal treatment is neither satisfactory nor successful. The juice of the phytolacca berry may reduce the weight, but it usually does so at the expense of bodily strength. Recently, the use of thyroid extract has come into favor, and this, judiciously given, promises good results Leichtenstern, Wendelstadt, EAvald, and others have reported success in a number of cases, especially in those exhibiting the anemic, flabby, " myxedematoid " form of obes- ity. The loss of weight was from 2 to 3 pounds (1-1.5 kgms.) in one week, and as high as 20 pounds in two to four weeks. In two of my own cases belonging to this category the use of thyroid extract (desiccated) in small doses (gr. j—0.0648, t. i. d.) caused a progressive loss of weight at the rate of 4 and 6 pounds per week respectively, without injury to the general health. Thyroidin, the active principle of the thyroid gland, as shown by Baumann and Ross, gives results that are perhaps as good as those of thyroid-feeding. JeozykoAvski treated 10 cases of corpu- lence by thyroidin in doses from 5 to 8 grains (0.324-0.518) per diem. In 1 case more than 40 pounds (18.1 kgms.) were lost in two months, and in another 30 pounds (13.6 kgms.) in three months. Symptoms of thyroidism are the signal for a reduction in the dosage of thyroid ex- tract (vide Myxedema, r^ 463). HEAT-STROKE. (Sunstroke; Insolation; Thermic Fever; Heat-exhaustion; Heat-prostration.) Definition.—A diseased condition the effect of exposure to exces- sive heat. Pathology.—Rigor mortis is marked and comes on early. The high temperature of the cadaver accelerates the putrefactive changes, which also appear early. There is considerable venous engorgement of the brain and of the cerebral and spinal membranes; also of the lungs, spleen, and conjunctiva. The blood is fluid and dark, and the corpus- cles are crenated and do not tend to form rouleaux. Ecchymoses and extravasations of blood are found in the skin, the serous membranes, and the cavities, around the superior (cervical) sympathetic ganglia and the vagus and phrenic nerves. Parenchymatous changes in the liver and kidneys may be found. Rigid contraction of the left ventricle is a notable feature, while the right ventricle is usually dilated Avith blood. Van Gieson's recent report of the cellular pathology of the cerebro-spinal system in 3 cases of sunstroke in New York shows an acute parenchym- atous degeneration of the neurons of the whole neural axis similar to that of, and,'Van Gieson thinks, here actually due to, " a species of auto- intoxication." He found the chromophilic plaques in the cortical cere- bral and cerebellar (Purkinje's) cells and also in the cells of the anterior horns of the spinal cord, diminished in number, changed in shape and HEAT-STROKE. 1227 position, sometimes finally broken up, and even entirely absent. The nuclei stain more deeply than normally. Etiology.—Anything that lessens bodily resistance to external high heat predisposes to heat-stroke. Thus, privation, unsanitary surround- ings, fatigue of body or mind, emotional excitement, worry, and exces- sive fretfulness, overeating, indulgence in alcoholics (especially), and previous attacks of sunstroke, are all conducive to heat-stroke on expos- ure to high temperature. Males are affected more often than females. Sunstroke occurs in persons (on land) Avorking hard under the direct rays of the sun, in an atmosphere that is very hot and humid, still, and sultry. Soldiers on the march and heavily accoutered, masons, brick- layers, hod-carriers, roofers, drivers, farmers, and other out-door labor- ers are particularly subject to insolation. Heat-stroke and thermic fever are terms more appropriately applied to those similarly affected in midsummer while Avorking in places not exposed to the sun, but yet close, confined, and excessively hot, such as glass-works, foundries, ocean steamers, stoke-holes, boiler-rooms, steam laundries, sugar-refineries, kitchens, and the like. Heat-exhaustion (prostratio thermic a) is caused under similar condi- tions as the preceding, but manifests dissimilar, and sometimes almost opposite, effects. The majority of the cases of sunstroke occur between 2 and 5 p. m., although heat-stroke and heat-exhaustion may occur at night as late as 10 or 11 P. M., as among bakers, night engineers, and hotel cooks. It seems to be the consensus of opinion that the direct cause of the symptoms of sunstroke, heat-stroke, or heat-prostration is the action of the excessive heat upon the heat-centers, or upon the vasomotor center or nerves (H. C. Wood), the former of Avhich, if paralyzed, produces "thermic" or " heat-fever," while the latter, if paralyzed, produces heat-exhaustion. It should be stated, hoAvever, that Lambert and Van Gieson,1 after a clinical and pathologic study of 805 cases of sunstroke occurring in New York City during 1896, hold to the not improbable view that the immediate basis of sunstroke is autotoxic, Avith heat only as a contrib- uting cause. Symptoms.—Two forms of heat- or sunstroke are usually met with: (1) The asphyxial or apoplectic form ; (2) the hyperpyrexia! form. Flint believes that the majority of the cases of sunstroke are combinations of apoplexy and exhaustion. Vallin puts all cases of insolation into two classes: the first, sthenic or asphyxial, corresponding to our hyperpy- rexial or congestive variety; the second, asthenic or syncopal, corre- sponding to our heat-exhaustion. Mixed forms may occur quite fre- quently, the most prominent symptoms being referable to the organs suffering the most, as the cerebro-spinal system, heart, lungs. Heat-apoplexy (asphyxial sunstroke) is probably the least frequent form. There may be sudden premonitions, or dizziness, chromatopsia, throbbing headache, cessation of sweating, or dyspnea. Sometimes the patient, while at work in the sun, suddenly falls unconscious, a feAv convulsions may occur, and in this state he may die with symptoms of cardiac failure. More often, insensibility is not so profound as complete 1 Med. News, July 24, 1897. 1228 THE INTOXICATIONS; OBESITY; HEAT-STROKE. coma, there is much restlessness, epigastric " cramp" may be complained of, also a sense of thoracic oppression, and occasionally there are nausea and vomiting. The headache may be intense, the face is flushed, the pulse is rapid and full, the temporal and carotid arteries are bounding, the breathing may be labored and stertorous, the pupils are contracted (except in grave cases), and urination is often frequent. The skin is hot and dry, and may show petechiae. The tongue is coated with a whitish fur. A Avild delirium has been observed in some cases. The temperature may be subnormal, and is not higher than 102° F. (38.8° C.) in many instances. In others, a mild degree of thermic fever may be associated Avith the apoplectic condition, the ther- mometer registering 104°-106° F. (40°-41.1° C). In fatal cases the coma becomes deeper and deeper, the pulse more rapid and feeble, and Cheyne-Stokes respi- ration may precede the termina- tion. A " mousey " odor about the body has been noted. In favorable cases the temperature falls to normal by lysis in three or four days, consciousness being rapidly regained at the same time. The hyperpyrexia! variety comprises the numerous cases of marked sunstroke that re- semble the preceding type, Avith the addition of an intensely high temperature (thermic fever). The patient may suddenly become comatose and die in an asphyxi- ated condition, with a tempera- ture as high as 110°-115° F. (43.3°-46.1° C.) or even higher. Sometimes prodromes, as an- orexia, progressively increasing physical weakness, cramp-like abdominal pains, irritability and restlessness, vertigo, colored and blurred vision, lack of SAveating, a " bursting " headache, and an irritable bladder may exist for several days. A subconscious (automatic) state, in Avhich the patient may be unaware of his surroundings, although walking or even working, may be noted for hours before he is stricken down. The onset is marked by hyperpyrexia; the skin is hot, burning, dry, sometimes flushed and red, and sometimes cyanotic and clammy; the eyes are suffused or " staring and filling," with pin-point pupils. There is a full, rapid, and non- !- r. — tr £ 107° -106° -105° -- - \ ,u z \ _£ _£ 1 JL 4 J _I Li S S- QT < «T < 7 «i DATE 8 9 10 Fig. 75.—Chart of a case of sunstroke. J. D., aged forty years; steam-fitter. Recovery. HEAT-STROKE. 1229 compressible pulse, and coma may be present. Clonic spasms may alternate Avith either muscular rigidity or flaccidity. Delirium, moan- ing, jactitation, and explosive expiratory sounds may occur. There is frequently incontinence of both feces and urine. The temperature is very high in most of the cases, varying from 105° to 112° F. (40.5- 44.4° C.).1 The pulse-rate varies Avith the temperature, from 90 to 160 beats per minute. The respirations are also increased to 24-50 per minute. Many of the alarming symptoms, including the high fever (vide accompanying chart, Fig. 75), unconsciousness, cyanosis, dyspnea, and conATulsions, may greatly subside during and after the use of the cold bath. Secondary exacerbations occur for a few days before con- valescence is established in the favorable cases (vide chart, Fig. 76). DATE 10 ___________________________11__________________________ AUGUST Fig. 76—Chart of a case of sunstroke. C. B., aged twenty-nine years. Recovery. Some patients never rally, and die in a state of asphyxia. Retention of urine (suppression) is observed at times, and particularly in those accustomed to the use of alcohol. Leukocytosis is noted, besides the crenation of the erythrocytes (degeneration of the red cells). Fatal complications of sunstroke are pneumonia, meningitis, uremia, and cardio-respiratory paralysis. Heat-prostration or heat-exhaustion may come on gradually or sud- denly, with prodromal symptoms (dizziness, faintness, headache, nausea, J Lambert (toe. cit.), reports a case in the N. Y. Hosp. of 117.8° F. (47.6° C). 1230 THE INTOXICATIONS; OBESITY; HEAT-STROKE. thirst, drowsiness, yaAvning, epigastric or lumbar pains, numbness and tingling of the hands and feet). These are followed by coldness, clam- miness, and pallor of the surface, marked muscular Aveakness and pros- tration, a small, febrile, rapid pulse, sighing.breathing, syncope, and col- lapse in the graver cases. The temperature at first is subnormal (95° to 97° F.—35° to 36.1° C), though mild thermic fever of from 100° to 102.5° F. (37.7°-39.1° C.) may be present. Consciousness is rarely completely absent and is regained early. Recovery usually takes place within one or two days, and in milder cases, under prompt and appro- priate treatment the patient may be ready to go about in a feAV hours. In a few cases of extreme prostration in wreakly persons death may ensue from cardiac failure. The sequelae of heat-stroke are quite interesting and peculiar in some instances. Osier relates the case of a patient who " Avas subse- quently so sensitive to temperatures in the neighborhood of 75° F. (23.8° C.) (italics mine) that at such times he lived comfortably only in the cellar, and finally sought refuge in Alaska." Chromatopsia, severe headaches, irritability and ugliness of temper, or delirium may occur in some patients as soon as warm weather sets in, and may be due occasionally to chronic meningitis (Wood). Diagnosis.—Bearing in mind the characteristic differences that are outlined above between sunstroke (including the asphyxial and hyper- pyrexial forms) and heat-exhaustion, the diagnosis is not difficult. The history and circumstances attending the seizure are also important in making the diagnosis. From other affections, as acute alcoholism, men- ingitis, uremia, and cerebral apoplexy, the differentiation is readily made by noting the previous history, mode of attack, presence or absence of thermic fever, state of consciousness, urine, skin, pupils, pulse, respira- tion, and nervo-muscular apparatus. Prognosis.—This is usually favorable in cases of heat-prostration. It is less so in sunstroke, but in all cases it depends on the severity of the stroke, the previous health and habits of the patient, the complica- tions, and the promptness and facility of the treatment. The mortality- rate during a prolonged period of excessively hot and humid weather may be very high, ranging from 15 to 50 per cent. In New York City, during the week ending August 15, 1896, out of a total number of 1810 deaths, 648 were reported as due to sunstroke (Lambert).1 Treatment.—Prophylaxis.—This is highly imperative in hot, sultry weather, particularly in cities, in which persons must work in the sun or in poorly-ventilated and highly-heated, closed places. Workmen should be taught and warned privately and publicly, as through the medium of the press and Health Board circulars, to take extra pre- cautions during hot Aveather, to Avork and sleep in as well-ventilated rooms as possible, and to secure artificial ventilation, if necessary. They should live regular and temperate lives, avoiding alcohol and heavy eating; oat-meal water should be drunk, light-weight and light- colored clothing should be worn, and the direct rays of the sun should be avoided as much as possible. The condition of the skin should be Avatched and care taken that sweating continues freely. Shelter or rest should be sought at once if sweating stops. Cool wet cloths or green 1 Doc. cit. HEAT-STROKE. 1231 leaves should be Avorn inside a light straw hat, and sometimes it may be necessary for employers to shorten the hours of labor during the hot- test part of the day. Treatment of the Attack.—Cases of ordinary heat-prostration seldom require much treatment beyond the removal of the patient to the shade of a comparatively cool place, loosening all constricting clothing, spray- ing Avith cool water, the use of ammonia- or amyl-nitrite-inhalations, and of the aromatic spirits of ammonia or spiritus glonoini by the mouth. If the temperature is subnormal and collapse threatens, a hot bath is advisable. Strychnin and digitalis may be used for a day or tAvo to combat the nervo-muscular weakness. Heat-stroke, especially the hyperpyrexial cases, must be promptly treated by the application of the ice-bath (ice floating in a tub of Avater), temperature about 40° F. (4.4° C), or by rubbing, by the cold pack, or by the needle-spray with iced water. In the asphyxial cases venesection is frequently indicated. Exter- nal stimulation should be applied to the precordium by mustard and to the feet by hot bottles, and hypodermic injections of nitroglycerin, strychnin, atropin, brandy, camphor, or ether are useful. Ice should be rubbed over the head constantly. Care should, however, be taken to see that the temperature is not reduced too far. A temperature of about 102° F. (38.8° C.) should be the signal for cessation of the ice- bath, and for the removal of the patient to a cot, where he is to be rubbed dry and allowed to rest until an exacerbation of fever indicates the reapplication of the cooling measures. Ice-water enemata, with or with- out brandy, are often useful adjuvants. The needle-spray of cold water is an excellent nervous stimulant as well as antipyretic. It is given while the patient lies on a Kibbee or netting cot, or on a cot covered with a rubber sheet so arranged as to drain into a pail or trough. In- ternal antipyretics are seldom well absorbed, and their depressant action is so well known as to discourage their use in place of hydrotherapy. Hutchinson, Coplin, and Bevan recommend highly the use of morphin to control the convulsions of heat-stroke. Artificial respiration in the asphyxial cases, kept up until other measures and stimulants have time to act, may be the means of saving life. After the reduction of the hyperpyrexia the patient should be lightly covered on a cot placed in a cool place. An ice-cap should be applied to his head, and small pieces of cracked ice may be given to allay gas- tric irritability, with calomel to open the bowels if necessary. Albumin- water, skimmed milk, buttermilk, unfermented grape-juice, junket, and the like may be given for several days preparatory to the ingestion of heavier food. If, as sometimes happens, free diaphoresis does not come on after the reduction of most of the fever and the stimulating treatment, a hot bath may be given, and perhaps aided by the hypodermic injec- tion of pilocarpin in urgent cases. Sequelce must be treated on general principles. The increased susceptibility to repeated attacks of insolation (after the first attack) makes it necessary to avoid exposure to heat ever after, and if possible, to seek a cooler climate during the hot months. PART XI. ANIMAL PARASITIC DISEASES. PSOROSPERMIASIS. Psorosperms belong to the lowest form of protozoa. They are also knoAvn as sporozoa, and, because of their parasitic relation to cells, as cytozoa. The amoeba coli of amebic dysentery belongs to the protozoa. Blood parasites (hematozoa), as the plasmodium malaria, are likewise closely related to the sporozoa. Various coccidia may occur in man to produce the disease indicated by this heading. The coccidium oviforme of the rabbit is the commonest variety, being found also in rats and mice. It escapes from the livers of the latter animals and passes into the dejecta; it produces an hepatic disease in Avhich there are numerous Avhitish nodules studding the liver. These range in size from a pinhead to a split pea, and on section dis- close a bile-duct, the dilated portion of Avhich forms the nodule. The ovoid coccidia are found in the epithelial cells of the Avails of these biliary expansions. The coccidium perforans and coccidium bigeminum are found in the cells of the intestinal villi instead of in the liver of the hosts mentioned above. Among veterinarians a common form of sickle-shaped organism is knoAvn that is found within an ovoid body in the sarcolemma of the pig's muscle—(i. e. the so-called Rainey's tube). In man, hepatic disease similar to that found in the rabbit is pro- duced by the coccidium oviforme. The tumors formed by the coccidia may be palpable, and the liver may be quite tender. Some chilliness and fever, malaise, and stupor passing into coma have been observed. Death Avas caused on the fourteenth day in a case admitted to St. Thomas's Hospital (Osier). The necropsy showed whitish neoplasms in the peritoneum, omentum, and kidneys. In the intestinal variety of internal psorospermiasis nausea and vomiting, diarrhea, and the typhoid state may be manifested. Involve- ment of the kidneys has caused hematuria and frequency of urination. External or cutaneous psorospermiasis, one form of which was for- merly called keratosis follicularis, is characterized by lesions at first of a hard, crusty, papular type, later becoming confluent, and situated on the face, lumbo-abdominal, and inguinal regions. These papillomatous groAvths contain numerous parasitic sporozoa. In carcinoma, epithelioma, and l'aget's disease of the nipple coc- cidia are readily found in and between the pathologic epithelial cells, .1232 DISTOMIASIS. 1233 but Avhether they have an etiologic bearing upon these malignant affec- tions is still a matter of uncertainty. Prophylaxis consists in cleanliness and care in preparing such food vegetables as spinach, lettuce, cabbage, and other greens that may pos- sibly be contaminated by the excreta of the lower animals liable to psorosperm-infection. The treatment of psorospermiasis is symptom- atic, though rectal injections of a solution of quinin (1: 5000 to 1:1000) may be tried. DISTOMIASIS. (Trematodiasis.) Various forms of trematodes, including the distomata, may become parasitic in man. Distoma Hepaticum (Liver-fluke).—Among the more common va- rieties of trematodes or flukes, is the distoma hepaticum or liver-fluke, a parasite found in animals (horse, goat, ass, sheep, rabbit) and acci- dentally ingested by man. It is almost 30 millimeters (1.1 inches) in length, and inhabits the biliary passages of the animal, and from them is discharged into the intestinal tract and evacuated with the feces. Under certain conditions of temperature and moisture, a ciliated embryo escapes from the egg, and is ingested by a gasteropod or snail (limncea truncatula), in Avhich it undergoes development into a sporocyst, that in turn gives origin to radios or parent nurses. These give birth to daughter-radiae or cercarice, which leave the gasteropod or snail and attach themselves to aquatic plants, where they are in turn eaten by animals. Symptoms.—When present in sufficient numbers in the bile-passages the liver becomes greatly enlarged, with the occurrence of jaundice and ascites that may prove fatal. Other symptoms may also be present; thus pain was prominent in 41 out of 100 cases reported by Kurimato in Japan, and heart-murmurs were present in 42 of those cases. Late in the disease the liver may become nodulated and terminate in atrophy. On inspection in well-marked cases, a peculiar barrel-shaped bulging is sometimes seen, extending over the hepatic area, with tense abdom- inal walls over the enlarged liver. This is a pathognomonic symptom of hepatic distoma. An endemic form occurring in Japan has been de- scribed; it is characterized by marked emaciation, diarrhea, hepatic enlargement, and often by ascites. The prognosis of distoma hepaticum is absolutely fatal and the treat- ment is merely palliative. Among other trematodes may be mentioned (a) distoma lanceolatum (found also in cattle); (b) distoma crassum, which is larger in size than the preceding; (c) distoma sibiricum; (d) distoma pulmonale (D. Rin- qeri); (e) distoma spatulatum (endemicum); (f) amphistomum hominis ; (g) distoma hematobium (Bilharz). Two of these deserve extra, though brief, mention. 78 1234 ANIMAL PARASITIC DISEASES. Distoma Pulmonale (D. Ringeri) (Bronchial-fluke ; Parasitic He- moptysis).—This parasite is very common in Japan. It finds lodgement primarily in the lung, and its ova sometimes form emboli in the brain, liver, and other tissues, and may also be found in the form of little cysts throughout the body. The symptoms are a cough, a reddish-broAvn bloody sputum, and the presence of the flukes in the expectoration. The latter are club-shaped, and are about 8-10 mm. (^ in.) long. Distoma Hematobium (Bilharzia hematobia; Blood-flukes).— This hematode is a narrow Avorm Avith anterior abdominal sucking-disks. The male is shorter and thicker than the female; the former being 4-15 mm. (|—f in.) long; the latter, about 20 mm. (f- in.). It prevails mostly in Egypt, Cape Colony, and other parts of Africa, and its en- trance into the human body is now believed to be through the skin of those who bathe frequently in the African rivers, in many of which it abounds. It is not unlikely that, as formerly held, infection may also occur in many cases from drinking the impure water of the rivers. The parasites or their ova are found in the bladder, the pelvis of the kidney, and the veins (especially the portal and mesenteric). The symptoms are hematuria, Avith some pain during urination. Pus, and some of the ova of the parasites, may also be found in the urine. No serious systemic disturbances occur in bilharziosis. Prophylaxis as regards drinking and bathing in African waters should be exercised. Fouquet affirms the value of the extract of male-fern internally in this form of distomiasis. NEMATODES. Helminthologists include in this class the cylindric worms, certain varieties of which are among the most common entozoa that infest the human body and inhabit the intestines. ASCARIASIS. Ascaris lyUmbricoides (Round-worm).—Natural History.—This species resembles the common earth-Avorm, and is the most frequent in occurrence of all the parasites. It usually appears in children be- tween the ages of three and ten years. The round-worm inhabits the upper portion of the small intestine, and occurs singly or in numbers. Its body is round, fusiform, and marked with fine transverse striae. It has a yellowish or reddish-broAvn color, and measures in the female from 7 to 14 inches in length (17.5-35 cm.), and from 4 to 8 inches in the male (about 20 cm.), its thickness being about that of an ordinary goose-quill. The cephalic extremity of the Avorm has three oval papillae, furnished with fine teeth; the caudal extremity is straight in the female and curved in the male. Lumbricoid worms develop from ova, which are about .05 to .06 mm. long, elliptic, dark-reddish in color, and have a thick, resisting envelope. There may be sixty million of them in a single female worm, and they sometimes occur in the feces in vast numbers. The development ASCARIASIS. 1235 of the embryo and worm external to the body is not accurately knoAvn. The eggs obtain entrance into the human intestine most probably through drinking-water, and it has been held that abundant mucus, and the pre- dominating starchy and saccharine diet of which children so often par- take, offer a favorable nidus for the development of the ingested asca- ridian eggs. The round-Avorm sometimes, though rarely, migrates from the small intestine. It has been vomited up, and it has also craAvled into the pha- rynx, mouth, and nares, and has been AvithdraAvn thence by the patient's fingers. It has even passed into the larynx and trachea, causing fatal asphyxia or pulmonary gangrene. The Eustachian tube and biliary ducts may be invaded Avith such serious symptoms as perforation of the mem- branum tympani and hepatic abscess. The ascarides have also been found in the peritoneal cavity, postmortem, Avith intestinal perforation, due, most likely, to other causes. They may penetrate the pancreatic duct and enter fistulae connected with the intestine. Symptoms may be absent, and yet the Avorms be found repeatedly in the stools. Existing symptoms are indefinite, and point simply to an irritative condition of the boAvel. Serious symptoms may, however, result from the migration of the Avorm, as into the biliary passages, Eustachian tube, or larynx. Fever is not a necessary concomitant. Lumbricoid Avorms may give rise to any or all of the following symp- toms : colicky pains, nausea, vomiting, indigestion, diarrhea (sometimes), restlessness, irritability, anorexia, itching of and picking at the nose, disturbed sleep with grinding of the teeth, salivation, and nervous tAvitchings. The child's abdomen and face may be swollen. Very ner- vous children may manifest epileptiform convulsions, choreic movements, dilated pupils, vertigo, cephalalgia, mental disturbances, and even con- tractures. Complications.—The deArelopment of jaundice will indicate obstruc- tion of the bile-duct, in cases in which the Avorms have been found in the feces. So also, suffocative symptoms coming on, especially at night, in a child with Avorms, may be due to a migrating lumbricoid. Perineal abscesses and inflamed herniae that have perforated externally some- times discharge the ascaris lumbricoides. Diagnosis.—This is positively determined only by discovering the worm or ova in the stools. In doubtful cases, judged symptomatically, the administration of a suitable purgative and inspection of the resultant passages will enable the physician to arrive at a diagnosis. The prognosis is good, unless serious complications arise (vide supra), when the case should be guarded accordingly. Treatment.—Prophylaxis.— The water used for drinking-purposes should be obtained from the purest sources. That from small streams, shallow wells, and the like is most likely to contain the ova of the lum- bricoides, and should be avoided. The use of filtered water should be encouraged. . . Before giving an anthelmintic, it should be borne in mind that no good result can be certainly obtained unless the gastro-intestinal tract be nearly deprived of food for from twelve to thirty-six hours, so that the toxic action of the drug used may be exerted directly upon the un- protected worm. 1236 ANIMAL PARASITIC DISEASES. Santonin is at once the most efficient and the most easily administered remedy. It may be given in doses of gr. \ to 1 (0.0162-0.0648) of the crystals to a child, or from gr. ij to iv (0.1296-0.2592) to an adult, in the form of a troche, before breakfast. A little milk or other light nourishment may be alloAved, the troches being continued once or twice daily for two or three days. This treatment is to be folloAved by a brisk purge, preferably gr. j to iij (0.0648-0.1914) of calomel. I have sometimes combined small doses of calomel Avith the santonin in a troche, and with good effect. Xanthopsia or yelloAv vision, spasms, and even convulsions, and saffron-colored urine may follow the use of san- tonin in cases of idiosyncrasy or overdose of the drug. Oil of worm- seed (chenopodium) in doses of five to ten drops, in emulsion, capsules, or on sugar, may also be used with benefit. Another favorite remedy with some is the unofficial fluid extract of spigelia and senna, to be given in from 1- to 3-dram (4.0-12.0) doses. Finally, the fluid extract of spi- gelia alone (1 to 2 drams—4.0-8.0), followed by a brisk purge, may bring away dead Avorms. Oxyuris Vermicularis (Seat-, Pin-, Thread-, or Maw-worm).— Natural History.—The ascaris vermicularis, as this worm is also called, inhabits the colon and especially the rectum. It is a small worm, as several of the commonly-used terms signify, and frequently it occurs in great numbers, sometimes agglutinated with mucus into feculent balls. It is most common in children, though found not rarely at any period of life. The female oxyuris is Avhitish in color and about ten or twelve millimeters (one-half inch) long, the male being about three or four millimeters (about one-sixth of an inch) in length. Oxyures develop from ova in about two weeks after the ingestion of the latter. The eggs are irregularly ovoid, about j^ in. (0.05 mm.) in length, and tena- cious of life. By the time the embryos have reached the cecum, they are sexually mature, and Avhen the female arrives in the rectum, im- mense numbers of eggs are deposited that mature into great numbers of worms, the latter being discharged with the feces. Sometimes the worms craAvl out of the anus. Infection Avith the ova may take place through water and food (green, uncooked vegetables and fruit) that have come in contact with the hands of infected persons. Scratching the anus will permit of the reception of oxyuris eggs under the finger-nails (Zenker and Heller), and in careless, ignorant, and uncleanly persons the possibility of such an auto- or re-infection should be recognized and avoided. Symptoms.—Pruritus ani (itching of the anus), sometimes burning pain, and tenesmus, with restlessness and disturbed sleep, are the com- monest symptoms of the presence of this parasite. The itching is always worse at night, and may be paroxysmal. An herpetic or eczem- atous eruption around the anus should arouse suspicion, particularly in children, of the presence of the oxyuris in the rectum, and it ac- counts for the intense itching (Flint). Anorexia and anemia, rectal irritability, and " nervousness " may be associated. It is believed that the migration of the worms into the vagina of girls may set up pruritus and leukorrhea, and that habits of masturbation may be induced in both girls and boys by the sexual irritation caused by the worm. Inspection of the stools will reveal, in positive cases, the whitish, thread-like parasites. ASCARIASIS. 1237 Diagnosis.—The pruritus, indicating rectal trouble, will direct the physician's attention to the anus, Avhere the oxyures may be seen; if not found, their discovery in the feces or the discovery of the eggs by microscopic examination will suffice. The prognosis is good, and proper treatment is always effective. Treatment.—The exhibition of anthelmintics and purgatives, such as recommended for destroying and removing the lumbricoid worm, may be effective against seat-Avorms also, but mainly in reaching those lodged in the bowel above the rectum. Attacking the oxyures directly, however, by means of enemata is the most useful and rational treatment. The rectum should be well emptied of feces, so that the worms may be exposed to the action of the medicament injected, and for this pur- pose enemata of cold water, either simple or with salt or soap, may be resorted to. Injections containing the decoction of quassia (1 or 2 ounces—32.0 to 64.0—of the poAvder or chips to the pint—half liter— of water) are nearly always curative. Other useful remedies are carbolic acid, turpentine, tannin, vinegar, camphor, potassium sulphid, and the oil of eucalyptus. The injections should be repeated once or twice daily for at least ten days. It sometimes happens that killing the worms as directed above affords only temporary relief. The reason for this is obviously to be found in the fact that the oxyuris breeds in the cecum, and that only groAvn forms descend, reaching the rectum. Rectal irritation may be allayed by injections of laudanum and starch-water (gtt. iij-v to the ounce—32.0). Anal itching is often amenable to carbolized vaselin, applied at bed-time, or to belladonna ointment, or the folloAving, Avhich has been highly recommended: B/. Hydrarg. chloridi mitis, Bij (2.592); Petrolati, §ss (16.0). M. et ft. ung. Sig.—Apply at bedtime. Asearis Alata.—This is another name for the ascaris mystax, a species of worm found in the intestines of the dog and cat, and occa- sionally in man. It is a slender worm, with a closely-rolled spiral tail and a wing-like projection on either side of the head. The female is about 6-7 centimeters (2.7 inches), the male about 4 centimeters (1.75 in.) in length. Scarcely ten instances, however, have been recorded in Avhich this parasite has occurred in man. Trichocephalus Dispar (Ascaris trichiura).—Natural History.— This worm measures about four or five centimeters (2 inches) in length, and is characterized by the very slender, hair-like appearance of the anterior two-thirds of its body, in contrast to the thick posterior por- tion, which is more or less straight and blunt-pointed in the female, but rolled into a spiral in the male. Its particular habitat seems to be the cecum, though sometimes it is also found in the colon. It may exist in great numbers. Europeans appear to be infected Avith the parasite more commonly than Americans. The trichocephalus has been found postmortem in many subjects dying with various diseases, as typhoid fever (Flint), meningitis (Barth), profound anemia (Osier), and ben-ben. Propagation is effected by the microscopic eggs, which are ovoid, hard nodular, brownish, and about 0.05 mm. (-gfo in.) in length. 1238 ANIMAL PARASITIC DISEASES. Symptoms.—It is not certain that the parasite causes any symptoms, nor even that it aggravates those of an associated disease (vide supra). When occurring in great numbers the possibility of fecal accumulation may be mentioned. The diagnosis may be made by microscopy. The ova may be de- tected in the feces. The prognosis and treatment are not called for. ANKYLOSTOMIASIS. Ankylostomum Duodenale (Dochmius duodenalis).—Natural History.—This parasite belongs to the family of strongylidce of the nematoid worms. It was discovered in Milan, in 1838, by Dubini. The length of the female is from 8 to 18 mm. (^ inch), and of the male from 6 to 10 mm. (^ inch). Its body is thread-like, with a conical- shaped head, and a large, bell-shaped mouth surrounded by a horny capsule, and possessing four hook-like teeth, ventrally situated, and two smaller, vertical teeth on the dorsal side, by Avhich the worm fixes itself to the mucous membrane. A bulbous-like SAvelling exists at the tail end of the male worm. It inhabits the jejunum and duodenum. The eggs are found in muddy water, and there liberate the embryos. These de- velop into larvae, which, when taken into the human bowel through drinking-water develop into mature Avorms. Since the ankylostoma do not multiply within the intestine, " the number there present corresponds to the number of embryos Avhich have been swallowed " (Flint). Pathology.—The ankylostomum is nourished by the blood it sucks from the intestinal vessels. It is found postmortem, sometimes, in the mucous or even submucous coat, rolled up in a little blood-cavity. Ec- chymoses, containing a central opening through Avhich blood can ooze, are the usual result of the Avorm's action. Chronic catarrhal enteritis is usually associated. Hypertrophic dilatation of the heart is seen quite frequently, and the blood is notably deficient in corpuscular richness. Symptoms.—The chief symptom of the condition is anemia (second- ary). When the number of ankylostoma embryos introduced into the intestine is large, the anemia may develop acutely; Avhen but a few are introduced, the AvithdraAval of blood is more gradual, and chronic anemia develops. I think, however, it may be safely affirmed that the anemia is not Avholly due to blood-sucking. In some cases the impoverishment of the blood has been so profound as to simulate closely a pernicious anemia. This parasite has been found to be the cause of the disease knoAvn as " Egyptian chlorosis," first described by Griesinger. Ankylostomiasis is not uncommon in tropical countries (Italy, Brazil). In Italy it has been termed tunnel or mountain anemia; in Belgium it is known as brickmaker's anemia ; again, it occurs among workers in coal-mines— miner's cachexia. In this country it is rare, though alleged to have been seen in the Southern States. The importation of infected Italian, Hungarian, and Polish laborers may, at some future time, cause the propagation of the ankylostoma parasite in the United States. The anemia of ankylostomiasis is progressive, and it is noteworthy that no ocganic cause for it can be discovered. There may be in addition, TRICHINIASIS. 1239 slight gastro-intestinal disorder (anorexia, colicky pains, nausea and vomiting, and constipation alternating with diarrhea). In cases marked by an acute development of anemia considerable general Aveakness, dyspnea and sometimes dropsy may ensue. The areas of the apical cardiac impulse and of cardiac dulness are increased doAvmvard and laterally. Various murmurs—hemic—may be heard, and the pulmonic sound may be accentuated (vide Pernicious Anemia, p. 429). Diagnosis.—This is made by finding the eggs or mature Avorms in the feces. The former are oval-shaped, about 0.05 mm. (jfa inch) in length, and have a much thinner shell than the ova of the round-Avorm. They do not segment except Avithin the intestine. In any case of pro- nounced anemia in which the cause is obscure the patient's dejections should be carefully examined for the ankylostoma parasite or its eggs. A diagnosis is thus easily made. Duration.—The disease may last for months or for several years. Prognosis.—If left untreated, the affection may end fatally. Intense anemia, obstinate diarrhea, and profound nutritive disturbances consti- tute symptoms of grave import. Properly treated, the prognosis is quite favorable. A spontaneous cure may occur in some cases, by either the complete evacuation or death of the strongylus Avorm. Treatment.—Prophylactic.—Workmen in mines, tunnels, brick-yards, and in tropical localities especially, should be warned not to drink the water close at hand without previous boiling and then cooling to a wholesome and palatable degree. Medicinal.—Anthelmintics to kill the ankylostoma and purgatives to remove it from the intestine are indicated as for other intestinal parasites. The oleoresin of male fern in h to 1-dram (2.0-1.0) doses, santonin, and thymol are very useful for the first named object. A preparation called doliarina is much used in Brazil, and is composed of the juice of the ficus doliaria, iron and aromatics (Flint). Ordinary cathartics or enemata may be needed to bring aAvay the dead parasites, after Avhich the general state of the patient should be improved by the use of highly nourishing food, iron, and tonics. TRICHINIASIS. (Trichinosis.) The parasite that gives rise to this affection is the trichina spiralis. Natural History.—The mature male worm is 0.8 to 1.5 mm. (^ in.) long and the female 2 to 4 mm. (^~i in.). The head is pointed and unarmed, and the neck is long and more slender than the body, which has a round blunt end. The worm is viviparous. It inhabits the intes- tines of such animals as the rat, dog, cat, hog, and man. The embryo or muscle trichina is about 0.6 to 1 mm. {^ in.) long, and lies coiled up in a spiral form within an ovoid capsule in the sarcolemma- sheath of muscle-fiber. The life-history begins with the larval state of the trichina? encysted in the muscles. When this flesh is eaten by another animal or by man. the larvae are liberated during the digestive process. Parsing into the intestines, they reach the adult stage in from two to four days being then sexually mature, and in five to seven days more they produce hundreds of living embryos. 1240 ANIMAL PARASITIC DISEASES. The intestinal trichinae become fully grown, and then usually die in from four to five weeks. The female trichina may bring forth several broods of embryos during her life-period in the intestine. The living embryos leave the intestine at once, and invade the muscles through various channels—principally along the connective-tissue routes—so that the symptoms of muscular irritation develop in from seven to ten days after eating the trichinous meat. The embryos attain to maturity (larval form) in about two weeks after entering the muscular tissues. Their presence causes a mechanical irritation that results in the formation of a fibrous capsule in from four to six weeks. Usually but a single worm is found within one capsule, though occasionally three and four are seen. Leuckart found numbers of embryos free in the abdominal cavity of in- fected animals; they have also been found in the mesentery. The en- capsulated trichinae may live many years in the muscles, and cases have been reported in which infection from trichinous meat occurred twenty or even thirty years before the living trichinae were found (Huber). With increasing age the capsules become thicker and may be the seat finally of calcareous infiltration. Pathology.—The diaphragm is most thickly infested with the larval trichina?. Next in order are such trunk-muscles as the intercostals and abdominals, then the muscles of the neck, including the larynx, head, eyes, and extremities. Up to the seventh week of the disease the intes- tinal trichinae may be very numerous, as many as a dozen being found in a drop of intestinal mucus. There may be some intestinal inflammation (catarrh) and the mesenteric glands may also be swollen and appear like those of typhoid fever. In cases that proved fatal during the second month, Cohnheim noted an abundance of fat in the liver, a granular state of the renal epithelium and of the heart-muscle, broncho-pneumonic areas (occasionally), and hypostatic pneumonia (frequently). Microscopically, the muscles show "the changes characteristic of acute myositis" (Fitz) after the fifth week. The trichinous cysts in the muscles may be seen Avith the naked eye as small, grayish-white, opaque, " oat-shaped " specks, longitudinally disposed in the meat-fibers. Sources of the Trichina.—The trichina was first found in pork— the usual source of trichiniasis in man—by the late Joseph Leidy. It should be noted that some individuals may be dangerously infested with trichinae and yet give no symptomatic evidence of the presence of the parasite. Recent investigations show that the live trichinae may be found in the fatty as well as the fleshy portion of pork. The pig is infested by eating trichinous rats, trichinous pork, or possibly human or porcine ex- crement containing the embryos of propagating intestinal trichinae. The rat may be the original host of the parasites, or it may itself become in- fected by older rodents eating their fellows, or by eating trichinous pork or human or porcine excrement voided during the stage of intestinal infection. As to the frequency of the infection of hogs, it may be said that about 2 per cent, were found to be trichinous, according to Salmon's report (1884), of nearly three hundred thousand examinations of American pork. Other examinations, hoAvever, show a variation of infection of from .05 to 6 per cent, of hogs. In Prussia, according to Eulenberg's statistics, the ratio is decidedly less varying—from 1 to 2160 hogs (1876) to 1 to TRICHINIASIS. 1241 1817 (1889). According to Osier, " the dissecting-room and postmortem statistics show that from one-half to two per cent, of all bodies contain trichinae." Of course, man, as a rule, becomes infected by eating raw or partially cooked pork containing living muscle-trichinae (larvae). The habit of indulging in raw ham and sausages, so common among the Germans of Prussia (particularly during pic-nics) and in some parts of the United States where German immigrants have settled in large numbers, explains the comparative frequency of this parasitic disease in such localities. Trichiniasis has occurred in epidemic form in North Germany, France, Spain, Russia, the Scandinavian countries, and in several of the north- western United States. Symptoms.—The fact that the postmortem examination often reveals the presence of muscle-trichinae, Avhereas no history of trichiniasis or of any disease resembling it has been obtainable, shows that one may eat trichinous pork containing a small number of larvae without the develop- ment of any symptoms. It is to be recollected that to the migration of the parasites the principal symptoms of trichinosis are due. In wTell-marked cases of infection gastro-intestinal disturbances appear on the second or third day after the ingestion of the infected meat. Vom- iting, diarrhea, and colicky pains in the abdomen may be present. The diarrhea sometimes takes on the characteristics of a choleraic attack or may be followed by obstinate constipation. Extreme "muscular weariness" and bodily fatigue often occur for several days before the embryonic parasites can have begun to wander into the muscles. On about the tenth to the fifteenth day, when migra- tion usually commences, chills, followed by a temperature of 101.5° to 104° (38.6° to 40° C.) and marked myositis, come on. The muscles are stiff, tense, painful on pressure and motion, and someAvhat swollen. The flexors of the extremities are particularly sore and often firmly contracted, causing the knees and elbows to be acutely bent. Mastication, deglu- tition, and phonation may be difficult and painful because of the involve- ment of the muscles of the jaws, pharynx, and larynx. Intense and distressing dyspnea is frequent on account of the involvement of the dia- phragm and intestinal'muscles. The temperature shows marked remis- sions in most cases, and may even be subnormal. The fever lasts from three to seven weeks. The pulse varies with the temperature. Edema is characteristic in nearly all of the cases. It appears on about the seventh day after the infection, and begins in the face, usually beino- noted first in the eyelids, and extending thence to the extremities and trunk during the height of the muscular symptoms. It may last for several days, then disappear for several days or a week, and reappear Ascites even has been observed. Edema of the larynx and bronchial catarrh the latter rarely leading to broncho-pneumonia, may also super- vene and add to the gravity of the dyspnea. Profuse sweating may last for several weeks. Miliaria, urticaria, acne, furunculosis, herpes, and pruritus may occur as skin-manifestations. Insomnia, headache, a tempo- rary loss of the tendon-reflexes, and dilatation of the pupils (Rupprecht) have been noted among the nervous symptoms. Prolonged cases show a marked degree of emaciation and anemia. Complications, as a typhoid state, hypostatic pneumonia, and pleurisy 1242 ANIMAL PARASITIC DISEASES. may appear. Albumin, with casts, and occasionally red and white cor- puscles are found in the urine. Recovery is effected in mild cases within two weeks; in the severe cases of infection from six weeks to several months may be occupied before convalescence begins. Diagnosis.—The following symptoms are regarded as pathogno- monic : sudden swelling of the face, coming on after the patient has suffered for several days from muscular soreness; loss of appetite, fever, and profuse sweats (Bohler); painful, tender, and "rubber-like" hard- ness of the muscles, with difficulty in movement; semiflexed extremities; gastro-intestinal catarrh, with a red, dry, coated tongue; dyspnea, diar- rhea, and edema of the extremities following the subsidence of that first noticed in the face. Friedreich also emphasizes the hoarseness due to invasion of the laryngeal muscles. Meat- and sausage-poisoning may be distinguished from trichiniasis by the more rapid course of the former, and by the dry throat and skin, jaundice, visual disturbances, more marked gastro-enteritis, and the ab- sence of edema and muscular symptoms. Direct examination of the passages and of the muscles may be resorted to. The discovery of the parasites in the pork a portion of which has been eaten by the sick of course establishes the diagnosis. A low-power microscope should be used to examine the intestinal mucus for the trichinae. Light purgation should precede this endeavor. Harpooning such muscles as the biceps for the purpose of removing some muscle-fiber, or directly incising a small portion under Schleich's method of infiltration-anes- thesia, may permit of a positive diagnosis in some cases. Acute rheumatism, cholera, typhoid fever, and acute polymyositis (pseudo-trichiniasis) may at times resemble trichiniasis. Epidemics of the parasitic disease are more readily diagnosed than an isolated case. Prognosis.—This depends upon the number of parasites ingested with the infected meat or sausage, and upon the number of embryos gen- erated in the intestines by the matured worms. Marked early diarrhea is favorable. The prognosis should be guarded, hoAvever, in all cases, as the mortality-rate may range from 5 to 35 per cent. Death, too, often occurs as late as from the fourth to the sixth week. Treatment.—Prophylaxis is of supreme importance, both as to the infection of the hog and the danger of eating infected pork. Care should be exercised in the feeding of swine, and the destruction of rats should be made as complete as possible in and about the styes. Pig-excrement should be removed and burned, and feeding with milk, bran, grain, and vegetables should be forced upon all keepers of swine. Rigid inspection of the meat-supply, as is done in Germany, should be carried out by sanitary officers employed by the government. It is held to be an impracticable measure where immense quantities of meat are handled daily to examine microscopically simply a minute fragment of pork taken from each hog slaughtered. Decidedly the safest and most'efficient Avay to prevent trichinosis is to thoroughly salt, smoke, and cook the pork that is to be used. Roasting should be particularly well done, in order that the heat may effectively reach the central portions of the meat. Putrefaction does not kill the parasites. The treatment of those who have eaten trichinous meat should be by FILARIASIS. 1243 a prompt evacuation of the bowel, especially within the first twenty-four hours, as after the embryo young have been brought forth and have passed into the muscles no known treatment is successful in attacking them. Calomel is one of the best drugs, and active purgation usually follows its use in large doses, succeeded by salines; rhubarb, senna sul- phur, aloin, and large doses of oil or glycerin may also be tried. In combination with the purgatives some anthelmintic (male fern, santonin, thymol) should be used. The encysted or larval parasites are not acces- sible to treatment, although picric acid has been recommended. The symptoms to be met are the great muscular pains, insomnia, and weak- ness, which is often severe in protracted cases. Prolonged hot baths, anodyne embrocations, with hypodermics occasionally, may prove useful for the first; bromids, chloralamid, and the like for the second symptom ; and a concentrated liquid diet, strychnin, peptonoids, and the like for the last. Massage, electricity, and stimulating applications, as chloroform liniment, may be required during convalescence and for some time there- after to combat the muscular weakness, soreness, and stiffness. FILARIASIS. (Filaria Sanguinis Hominis.) There are several varieties of filariae that may be found in human blood. The two principal ones are the filaria sanguinis hominis nocturna and filaria sanguinis hominis diurna. The first is a white, opaline, thread-like worm, tapering toward the ends, which latter, however, are blunt. The male is 83 mm. (3.2 inches) long; the female 155 mm. (6.1 inches). The second worm is known only in embryonic form, and is distinguished by granulations in the axis of the body. Manson found them in the blood of Congo negroes, but only during the daytime. On the other hand, the nocturnal filaria is found only at night, or, if the host be either by habit, necessity, or choice, a day-sleeper, during this time, showing, then, that there is some condition of the body during quietude that is conducive to the appearance of the filaria in the blood (blood and chyle flow, Granville). This " filarial periodicity " is a curious and strik- ing characteristic of these parasites. The embryos are produced by the female in great numbers, and are so small that they readily pass through the capillaries. According to Man- son, who, in 1877, found the larvae of filaria sanguinis hominis in the stomach of a female mosquito, it is probable that after filling itself with the blood of an infested man during sleep, the mosquito seeks stagnant water, dies, and the larvae are set free. In this way it may happen that man takes in the embryos through the drinking-water. They find a permanent seat in the lymphatics of the human host, mature, and bring forth young, which may again infest the blood by passing through the lymph-ducts into the thoracic duct and general circulation. The geographic distribution of the filaria is limited mainly to the tropics and sub-tropics. Filariasis is most common in Brazil, the West Indies Mexico, the Southern States, Southern China, India, Egypt, a part of Australia, and the southern Pacific islands, where it is quite The symptoms of filariasis are in abeyance until some obstruction 1244 ANIMAL PARASITIC DISEASES. of the lymph-channels is caused by the parasite. There are several con- ditions or endemic diseases produced. Elephantiasis arabum. is believed by Manson to be the effect of these parasites in a certain proportion of cases at least. In specimens of night-blood from 88 Cochin Chinese he Fig. 77.—The movement of a single filaria during a series Fig. 78.—Filaria alive in the of four successive instantaneous exposures. The length of blood. Instantaneous photomi- each exposure was one-fifth of a second, the entire series crograph. Four hundred diam- occupying less than five seconds. The magnification is to eters magnification. Four milli- eight hundred diameters, with a Zeiss one-twelfth homoge- meters Zeiss apochromatic (F. P. neous immersion lens (F. P. Henry). Henry). found filariae in 21; 14 specimens came from patients with elephantiasis, and only 1 showed filariae. This latter fact, he explains, is to be expected, since, in order to give rise to elephantiasis (due to an infarction of the lymphatic glands connected with the diseased areas), the adult filariae must lie on the distal side of the glands, which makes it impossible for the young filariae to pass into the general circulation. " Therefore the person least likely, in a filarial district, to have filariae in his blood is one who is the subject of elephantiasis."1 Hematochyluria and Chyluria.—The patient passes a white, opaque, milky urine, occasionally bloody, with a clotty sediment. This may be intermittent, and normal urine may be passed for many Aveeks before chyluria or hematochyluria reappears. There may be at the same time a slight degree of polyuria. Under the microscope, fat granules and white and red corpuscles are seen. The lively, wriggling embryo filarial may also be discovered in the urine, as well as in the blood at night. There is a dilatation of the lymph-vessels in the kidneys alongside of the tubules, and in the abdominal lymph-plexuses. Sometimes a little vesical irritation and straining during urination may be caused by the endeavor to pass chylous blood-clots. The thoracic duct above the diaphragm has been found impervious (Stephen Mackenzie). 1 British Med. Jour., June 2, 1894. DRACONTIASIS 1215 Lymph-scrotum and lymph-vulva have been caused by the filariae. The parts are greatly swollen, thickened, and contain distended lymphatics filled with a turbid and either milk-Avhite, salmon-colored, or blood-red coagulable liquid that is discharged upon puncturing the varices. The filaria is not ahvays found in the exuded lymph. The inguinal and femoral regions are often enlarged and doughy. An erysipelatous inflam- mation of the parts is not infrequent in these cases, and may be ushered in by a chill and high fever, lasting a day or two, and ending with a pro- fuse sweat. The filariae have also been found in a case of ascites (Winckel), in one of hemoptysis (Yamane, Japan), and, by the same observer, they were found in the feces (chylous diarrhea). Treatment.—Prophylaxis in regard to the drinking-water is essen- tial in order to avoid filariasis. Filtering, boiling, and storing the water in mosquito-proof receptacles is sufficient. Thymol in from 1- to 5-grain (0.0648-0.324) doses, given for from tAvo to eight weeks, has caused the disappearance of the larval filariae in several cases. Methylene-blue appears also to have produced a cure in a case of chyluria reported by Flint, although Laveran and Henry believe that it is of little value. The latter states that he has " given this drug in larger doses than were used in the case reported by Flint, and for a much longer period, with- out the slightest effect upon the parasite."1 The adult filaria seems to be beyond the reach of any knoAvn medication that will not prove dangerous, either directly or indirectly, to its human host. DRACONTIASIS. (Guinea-worm Disease.) The parasite is the filaria or dracunculus medinensis or persarum, common in the tropics of Asia, Africa, and America. It is only recently that the male guinea-worm has been found. It is usually solitary, and measures from 50 to 100 cm. (20 to 40 in.) in length and about 2 mm. (^ in.) in diameter. It is cylindric, whitish, with blunt papillated head, and a sharp, curved tail. The body is nearly filled by the uterus, which contains innumerable embryos. The live young dracunculus escapes from the intestines of an infested man, ox, horse, dog, or jackal, enters the body of a cyclops or small cray-fish, and there becomes a fully-devel- oped larva. It is then taken into the stomach and intestines of man through the contaminated drinking-water. The female enters the intes- tines by way of the mesentery, and the male worm, after fulfilling its sexual functions there, probably dies, while the female brings forth its young, which pass into the connective tissues of its human host. The worm has an inexplicable affinity for the subcutaneous and intermuscular tissues of the feet and legs, where it attains full development. Symptoms.__Wherever the parasite is situated, it may often be felt coiled up under the skin, which at that point becomes red, sore, and fluc- tuating like an abscess. When opened, either surgically or naturally by the worm, the head appears through the aperture. The favorite spot for perforation is the dorsum of the foot, though sometimes it extrudes from 1 Med. News, May 2, 1896. 1246 ANIMAL PARASITIC DISEASES. the legs, occasionally from the thighs, and very rarely from the thorax and abdomen. Treatment.—Prophylaxis in regard to the drinking-Avater and as to bathing where the intermediary host of the dracunculus—the cyclops— has its habitat is essential for safety. The active treatment embraces the surgical measures necessary to re- move the worm entire and to promote the healing of the irritated tissues. The burrow should be opened, and the worm gradually coiled around a quill or a smooth, cylindric piece of wood until it can be withdraAvn with- out being torn and allowing any embryos to escape into the tissues. Roth claims that after incision the application of compresses of carbolic acid (1 to 15) over the wound causes the worm to be removed in two or three days. Native Indian physicians commend highly the local application of the leaves of the " amarpattee " plant. Asafetida and sulphur have been recommended internally, but without any definite result. OTHER PILARIS. Among other filariae that have been found in man are the following: The filaria immitis, which causes hematuria and has been found in the por- tal vein, whilst the ova were discovered in the ureteral and vesical walls; filaria labialis, found in a lip pustule; filaria lentis, found in a cataract; filaria trachealis and bronchialis, seen in the trachea, bronchioles, and lungs ; filaria hominis oris, observed by Leidy in the mouth of a child; filaria loa, noticed in the tropics among negroes, its habitat being beneath the conjunctiva. OTHER AND UNCOMMON NEMATODES. Eustrongylus Gigas.—This parasite is exceedingly rare in man, but has been found in many of the carnivora and in some herbivora. It is supposed that fish act as the intermediate host for the larvae. The worm is enormous in size, the female being from 25 to 100 cm. (10 to 40 in.) in length and from 5 to 12 mm. (£ to \ in.) long. It is a red, cylindric parasite with blunt-pointed ends. Its most common seat is the kidney, which it may destroy, causing hematuria and, perhaps, the presence of the eustrongylus ova. Strongylus paradoxus has been found in the respiratory organs of the pig and in the dejecta of a pork-dealer. Anguillula stercoralis or intestinalis occurs in the stools of certain tropical endemic diarrheas. The parasites are oviparous, and the eggs may be taken through the drinking-water. They have been found in the biliary and pancreatic ducts, as well as in various parts of the intestines. Boiling the water as a prophylactic measure and the administration of thymol or male-fern are to be recommended. Echinorhyncus gigas belongs to the Acanthocephala (thorn-headed worms) and infests the intestines of the pig. The larval host is the cockchafer or floral beetle grub. In the only case reported, that of a boy (Lambl), a small echinorhyncus was found in the intestines. Echinorhyncus moniliformis occurs in rats, and one case, that of a Sicilian, has been reported by Calandruccio, in which the ova were found ECHINOCOCCUS DISEASE. 1247 in the feces. The larval host is probably the Blaps micronata. The ethereal extract of male-fern causes the expulsion of the parasite. CESTODES. ECHINOCOCCUS DISEASE. (Hydatid or Bladder-worm Disease.) The taenia echinococcus is also called tcenia nana by Van Beneden, but should not be confounded with the tenia nana of v. Siebold, a brief de- scription of Avhich follows this article. It is the smallest tape-worm of our domestic animals, and lives betAveen the villi in the small intestine, especially in the larger breeds of dogs, as the mastiff and Newfoundland. It has a length of from 4 to 9 mm. (\ to ^ in.), and consists of only three or four sections, the last one of which is mature. The rostellum project- ing from the small head has thirty or forty hooklets arranged in a double row. Hundreds and sometimes thousands of eggs are contained in the mature segment. The intermediary hosts for the larvae are rarely man, the horse, and the sheep, and more often the hog and ox. !Life History.—The ova, embryos, or the proglottides even, of the adult tenia are voided by the dog, and in various ways, to be pointed out later, are ingested by man. The dog first becomes infected by eating the bladders or echinococcus cysts of some animal that harbors the larval form of the tenia, and the matured teniae appear in from eight to ten weeks. The liberated six-hooked embryos burrow through the intestinal wall or enter the portal vein; they then pass into the solid viscera, as the liver, into the peritoneal cavity, the muscles, lungs, brain, etc. There they develop into the larval form and cause the formation of hydatid or echinococcus cysts. During the latter process the hooklets disappear. In the development of echinococcus cysts, about four weeks after the ingestion of the bladder-worm eggs, small nodules appear, about 1 mm. (-1- in.) in size. In about five months the cyst-walls consist of two layers, an external layer and an inner, granular, parenchymatous layer (or endocyst), containing a clear liquid. As the reaction to the irritation caused by the parasite and its cyst increases, a fibrous investment forms around them. At this time, also, small daughter-cysts, or vesicular buds, form the minor granular layer of the mother-cyst, and contain the heads of the larva?. They are soon set free, and may themselves give rise to other or granddaughter-cysts in a similar way. These really become the breeding capsules of little cellular outgrowths that form the scolices or heads of future teniic. They show the four sucking disks and a circle of hooklets. Each scolex, when taken into the intestine of the dog, de- velops into an adult bladder-worm or taenia echinococcus. This endogenous mode of cystic growth is common in man (E. hydatidosus); but in some of the lower animals, and rarely in man, the daughter- and grand- daughter-cysts may develop between the two layers of the primary or mother-cyst and then extrude (exogenous variety; E. granulosus). A third variety is the multilocular echinococcus (E. alveolans, Buhl), 1248 ANIMAL PARASITIC DISEASES. affecting principally the liver. A large, hard tumor is seen that on sec- tion shows a firm connective-tissue framework surrounding alveoli that average a small pea in size. These alveoli contain small echinococcus cysts with thick, laminated walls. They may contain scolices or hooklets, and sometimes they are quite sterile. The echinococci may be situated in the lymph-channels and bile-ducts (Zenker). The pure hydatid fluid is colorless, odorless, limpid, neutral in reaction, and has a specific gravity of 1005 to 1012. About 96 to 98 per cent, is water, and sodium chlorid, carbonate, and sulphate, traces of sugar (dextrose), and uric acid are found among the constituents. Among the changes that an echinococcus cyst may undergo the com- monest is that of the death of the echinococci, as from diminished nour- ishment due to intense proliferation of daughter- and granddaughter- cysts. The contents become thickened, putty-like, or granular, and even calcified. Remnants of these obsolete cysts, such as the chitinous sub- stance of the old and outer wall-layer and hooklets, may be found. Traumatism or chemical irritation may also cause the death of the echinococcus and obliteration of the cysts. Sometimes rupture of the cyst occurs, with serious consequences to the patient; on the perito- neum daughter-cysts or free scolices may be disseminated and grow. Or perforation into the respiratory, digestive, or urinary tracts and dis- charge of daughter-cysts and hydatid fluid may take place. Lastly, sup- puration and the formation of large hepatic abscesses may ensue, eithei- spontaneously or on account of septic instruments used for tapping the cysts. Utiology.—Carelessness in the feeding and the keeping of dogs is the primary source of hydatid disease, and the preparing of food where dogs are allowed to roam about, to be petted, and so on, accounts for the majority of cases. Females are more often affected than males, and chil- dren and young adults seem to be oftener affected than those older m years. As regards the geographic distribution, echinococcus disease prevails most extensively in Iceland, Avhere man and dog live closely together. In Australia, alsor many persons are affected. It is not so common in Europe, Asia, or Africa, and in America it is rare. Organs Affected.—The tenia echinococcus has an undoubted predi- lection for the liver. Next in order of frequency are the lungs, intes- tines, perhaps the urinary organs, brain, and spinal cord. The spleen, bones, muscles, the heart, and blood-vessels are involved with uncertain frequency. Symptoms.—Hydatids of the Liver.—Unless the cystic tumors com- press the portal area or the biliary passages, or invade the neighboring viscera, subjective symptoms may be entirely wanting. Not infrequently echinococcus sacs, partly calcified, have been found postmortem, not having produced any symptoms during life. Gradual but progressive loss of flesh and strength with the presence of a fluctuating tumor may be the only symptoms present until late in the disease. If the cysts attain a large size, a sensation of dragging, and of pain even, is often present; as a rule, however, pain is absent throughout the course of the disease. If the tumor displaces the diaphragm upward and compresses the lung, cough and dyspnea result. In some cases the sac has ruptured ECHINOCOCCUS DISEASE. 1249 into the bronchi, and given rise to cough and to expectoration of the fluid and vesicles. If the portal veins and bile-duct are compressed, splenic enlargement from passive congestion, ascites, and jaundice will occur, these symptoms being more common Avhen the cysts are multilocular. Rupture may occur into the intestines (colon), into the pleura or pericardium, causing pyothorax or pyo-pericardium, or into the inferior vena cava, causing fatal pulmonary embolism. Fever is usually absent throughout, unless the contents of the sac become converted into an abscess; then rigors or chills, fever (hectic in type), and sweatings occur, with jaundice (more or less intense) and rapid emaciation. Not infrequently the cyst-wall becomes partly calcified and the con- tents are reabsorbed, with an entire absence of symptoms, the patient dying in after years of some intercurrent disease. When rupture occurs, unless the contents be evacuated through the respiratory or alimentary tract or externally, symptoms of collapse develop and are followed by death. The physical signs give on inspection fulness or bulging in the right hypochondriac region, especially if the cyst be single, of large size, and situated anteriorly. Palpation confirms inspection and shows a fluctuating mass or masses. A trembling impulse is felt sometimes on deep palpation, aided by light percussion over the opposite side of the cyst, constituting the so-called " hydatid thrill." This sign cannot always be elicited, but when present is pathognomonic of the disease. The remainder of the liver shows uni- form enlargement. The spleen is often palpably increased in size from passive congestion. Percussion reveals, in addition to the hydatid fremitus, an increased area of dulness to the left or posteriorly, depending on the location and extent of the growths. If the left lobe be involved, the line of flatness may extend across the sternum to the left hypochondriac region. If the cysts are multiple and on the anteroinferior surface, the stomach may be displaced toward the left and dulness may extend across the epigastrium; if posteriorly, the pleural cavity may be encroached upon, causing an increased area of flatness upward in the postero-axillary line. Frerichs claims the line of dulness posteriorly in hydatid disease to be a curved one, whose convexity is upward. Auscultation gives, according to Santoni and others, a short sharp booming sound when the tumor is percussed, that may be likened to one produced by striking a membrane stretched over a metallic frame. Diagnosis.__In the entire absence of subjective symptoms and of characteristic physical signs, the diagnosis is impossible. If, however, the cyst be of sufficient size to give fluctuation and the liver be irregu- larly enlarged, Avith an absence of fever, pain, and marked emaciation, the disease may be strongly suspected. The only certain demonstration of the condition is the discovery of the characteristic hooklets in the as- pirated or discharging contents of the cyst. Among the conditions that may be misdiagnosed for hydatid disease are—(a) Dilatation of the gall- bladder (b) hydronephrosis, (c) right-sided pleurisy with effusion, (d) syphilis'of the liver, (e) carcinoma, (/) abscess, and (g) cirrhosis. 79 1250 ANIMAL PARASITIC DISEASES. Hydatid Cyst. Previous history negative, except the com- panionship of dogs. Pain and jaundice usually absent. Enlargement in any direction, depending upon the location of the cysts. Hydatid thrill may be present. Less so. Dilatation of the Gall-bladder. A previous history of having passed biliary calculi is often present. Attacks of biliary colic followed by jaun- dice either are present or enter into the previous history. Enlargement is always in one direction— downward and posteriorly. " Hydatid fremitus " never present. The tumor is somewhat movable. Hydatid Cyst. The history is negative (vide supra). Urinalysis is negative. The tumor is most prominent over the hepatic area, and is associated with enlargement of the liver. The duration is indefinite and uremia rare. Hydatid Cyst. The onset is slow; pain and fever are absent. The presence of a fluctuating mass in the hepatic area, not changing with the po- sition of the patient. Hydatid fremitus is present, but no bulging of the inter- costal spaces. Aspiration reveals a clear yellow liquid of low specific gravity, containing no albumin, but chlorids and hooklets. The disease invariably runs a chronic course. Hydronephrosis. There is a history of renal calculi or of vesical inflammation. Urinalysis reveals evidences of renal disease. The tumor is most prominent in the flank and iliac fossa. If extending to the right hypochondriac region, it does not move with the liver. The duration is short; a termination in uremia is common. Pleurisy with Effusion. The onset is sudden, and violent pain is present, with fever and dyspnea. The presence of effusion, beginning at the base of the chest and gradually extending upward—changing with the position of the patient and accompanied by bulging of the intercostal spaces. Aspiration gives a cloudy, turbid liquid, containing albumin and flakes of lymph with high specific gravity. The disease generally runs an acute course. For a differential diagnosis from (d), (e), (f), and (g) I would refer the reader to the discussion of the several diseases (vide Diseases of the Liver). Echinococcus of the Respiratory Organs.—The lung has been the seat of the larvae quite frequently, and instances have been noted especially in North Germany and Australia. The right loAver lobe has been the seat of predilection, though sometimes the pleura is the primary source of trouble. There are pain in the chest, cough, dypsnea, perhaps arching of the overhanging thoracic region, signs of a pleural effusion, a tym- panitic note above the prominence, hemoptysis, and the pathognomonic expectoration of hydatid disease. The general condition may not be seri- ously affected. Perforation into the pleural sac by pulmonary echino- cocci may be followed by empyema, and, later, by perforation of the chest wall. The heart may be dislocated. Compression of the lung may pro- duce gangrene. The diagnosis, in the absence of the characteristic sputum, is to be made from phthisis and a pleural effusion. Their location at the base of the chest may serve to differentiate hydatid cysts from phthisis, as well as the absence of marked emaciation. The characteristic curved upper ECHINOCOCCUS DISEASE. 1251 boundary of dulness in pleural effusion and the change of the boundary upon changing the patient's position will serve to distinguish this affec- tion. Puncture of any bulging area will determine the character of the liquid. Pleural echinococci sometimes cause great compression of the lung and a barrelling of the chest on one or both sides. The pain may be quite sharp, and the respiratory murmur either distant or altogether absent. Echinococcus of the Mediastinum.—Hare has collected 6 cases of hydatid disease among 520 cases of mediastinal tumors. Echinococcus of the Heart.—Since most of the cases have shown in- volvement principally of the right side of the heart, the instances of sud- den death that have been reported may be readily understood. Echinococcus of the brain and spinal cord should not be confounded with cystic degeneration of the choroid plexuses. The symptoms of cere- bral hydatids are those of tumor, peristent and intense cephalalgia, vom- iting, psychical disturbances, convulsions, amblyopia, and "choked disk," and sometimes paralysis. Hydatid disease may develop inside the dura mater, or it may penetrate from without and destroy the vertebra before they compress the cord to a great degree. The symptoms are those of a compression myelitis. Echinococcus of the Spleen.—About 40 cases of involvement of the spleen have been described. The organ may become greatly enlarged and be mistaken for that due to malaria, leukemia, etc. The hydatid thrill may be detected. Echinococcus of the Kidneys.—More than 100 cases have been ob- served, mostly in Germany and France. The cyst may be as large as in hydronephrosis. Many of the cysts are of the exogenous form of growth. As a rule, one kidney only is affected, and generally the left one. Ab- dominal and thoracic compression symptoms may be caused, and bulging is often present in the lumbar region in marked cases. This may be punctured as an aid in the diagnosis. Rupture into the pelvis of the kidney and the discharge of the smaller cysts may give rise to renalcolic and to the discharge of the cysts with the urine. More rarely, rupture of a suppurating cyst may take place in the loin. Echinococcus of the peritoneum is rare as a primary condition. Echinococci have also been located in the bladder, prostate, testicle, ovary, uterus, great omentum, mesentery, arteries, lymphatics, thyroid gland, muscles, bones, joints, parotid gland, orbit, and mamma. A multilocular echinococcus cyst may give rise to a very large, fluc- tuating, bossellated tumor beloAv the liver; this may simulate colloid cancer, either of the liver or the gall-bladder. Icterus, marked and obstinate, with or Avithout ascites, an enlarged spleen, and a long course without decided loss of flesh, are indicative of this form of hydatid. Fatal hemorrhage may supervene. A peculiar complication of echinococcus cysts is the occasional development of urticaria. It has been noted especially shortly after the puncture of a cyst, and this is someAvhat diagnostic when it appears. The prognosis is generally grave both as to life and cure, although some cases of hydatid disease of the liver have lasted for more than ten years. The character of the changes in the cysts and their mode of termi- nation influence the prognosis. Thus, the occurrence of suppuration 1252 ANIMAL PARASITIC DISEASES. is to be dreaded. Spontaneous cures have been noted in a feAv in- stances. Treatment.—As in most of the other parasitic diseases, prevention is more or less effectual, and a cure is difficult or impossible. Infection of the dog should be avoided by preventing its gaining access to possible sources of hydatid disease, as the raw flesh of animals, especially in the form of meat-scraps around slaughter-houses. In order that human beings may not be affected, dogs should not be carelessly handled or alloAved to be where they may come in contact Avith food and drink in any way, Avhether meat or eggs, vegetables, fruits, or cereals. Cleanli- ness in keeping dogs and in the proper preparation of food are essential in regions Avhere hydatid disease is prevalent. Medicines cannot reach the parasites in man, situated as they are in larval form encysted in the various tissues and organs of the body. Whenever the cyst becomes large, accessible, and the cause of trouble- some symptoms, surgical measures may be resorted to. Among these are, simple tapping, tapping Avith aspiration, and Avith the subsequent injection of various substances (as iodin and zinc-chlorid electrolysis), and incision Avith drainage. Excision of the liver cysts has been practised by Raggi, Pozzi, Tansini, and others, but its practical value is still undetermined. T^lNIJE OR TAPE-WORMS. Natural History.—Tape-worms are found in the intestine of man, and are the matured or completely developed larvas or cysticerci from the muscles and solid viscera of animals. Different varieties of cysticerci develop from tbe ova of the respective varieties of teniae. These tape- worm eggs, after having passed out of the bowel, may be taken into the systems of various animals by various modes, entering the circulation, it may be, and becoming fixed Avithin the solid tissues, especially the muscles. In about two or three months pea-sized cysts develop, and from the cyst-Avails there gradually forms a new tenia-head, called a scolex, or nurse. The Avorm-cysts, popularly termed "measles," con-' stitute the cysticerci. Remaining in the tissues, they die and become calcified in from three to six years (Striimpell). But, if taken into the stomach by the eating of raw or partially-cooked meat, a tape-Avorm de- velops from the scolex. The maturation of the segments of the tape- Avorm-commences several months after the fixation of the scolex in the intestine. In the natural life-cycle of a tape-Avorm the usual order of lodgement may be reversed. Thus man instead of a loAver animal may become the host of the tenia eggs, Avhich in turn may find their way into the solid viscera and muscles to develop into cysticerci. Again, this same order may in some way be brought about by "auto-infection." The tape-worm, as its name indicates, has a ribbon-like form; although it has a number of segments and joints, giving it a link-belt appearance. When matured, these segments, or proglottides, develop male and female generative organs. Varieties.—Taenia Solium (Pork Tape-ivorm).—This Avorm is seen much less frequently here than in Europe. It develops in the small intestine after the ingestion of raw or underdone "measly" pork. This worm does not necessarily exist singly, as its name would indicate, TAPE-WORMS. 1253 although such is usually the case. It ranges from 2 to 4 meters (6 to 13 feet) in length. The head is rounded, pin-head in size, and is succeeded by a thread-like neck and by gradually shortening and Aviden- ing segments. Four suckers and a projecting circle of twenty-six long and short hooklets arm the head of the tenia. There may be as many as 800 segments. The mature ones become detached continuously, and are passed Avith the feces, several, as a rule, occurring together, and not singly, as in the case of taenia saginata. They are about 1 centimeter (| in.) in length and from 6 to 8 millimeters (l-l in.) in breadth, and about 1 meter (39.36 in.) from the head they are "approximately quad- rilateral " in shape. These proglottides are bisexual. The female mat- rix occupies the middle of each proglottis, and is provided with from eight to fourteen irregular, tree-like branches on each side. The male generative organs are small vesicles in the anterior portion of the seg- ment. The sexual opening is situated on one side, near the middle. The ovarian or uterine apparatus of a mature segment contains myriads of thick-shelled eggs, each one of which has an embryo with six hooklets. Taenia Mediocanellata (Saginata).—The beef tape-worm is some- times called the "unarmed tape-Avorm," since the head possesses suck- ing disks, but no hooklets. It is more common in this country and even in some of the European nations, as England. Longer than the tenia solium, being 1 to 6 meters (12 to 20 feet) in length, its segments are also thicker and larger, measuring from 16 to 18 mm. (-| in.) long, and from 8 to 10 mm. (^ in.) broad. The head of the Avorm as well as the ripe ovum is also slightly larger and proportionately thicker. The ova- rian branches are more numerous (eighteen to thirty in number) and di- Alde more dichotomously than those of tenia solium. Proglottides are also found in the stools, where they sometimes exhibit a craAvling motion that has caused them to be mistaken for individual parasites. Cysti- cercus saginata has never been observed in man. Bothriocephalus latus (Fish tape-worm, Tccnia lata) occurs most com- monly in Russia, Switzerland, Holland, and the German Baltic prov- inces. It is the longest cestode, measuring from 6 to 10 meters (20 to 30 feet). The head is club-shaped, unarmed, and has two lateral longi- tudinal grooves as suckers. The segments may be distinguished from those of the preceding varieties named by their marked breadth and shortness, also by the centrally situated, tortuous ovarian rosette, and the sexual orifice near the center of the abdominal surface of each pro- glottis. The ova are larger than those of the pork and beef tape-worms, though thinner-shelled and with a sort of lid at one end. They develop only in fresh Avater. From them is formed an embryo Avith vibrating cilia and six hooklets. Pike and other fish sAvalloAv these embryos, which develop into cysticerci in the muscles, peritoneum, and solid vis- cera. The eating of measly fish, raw or partially cooked, thus favors the development of this tape-worm in the human intestine. Symptoms.—Contrary to what has been supposed in days gone by, there are no absolutely diagnostic symptoms of the presence of tape-worm that can be relied upon. Indeed, the existence of a tape-worm in the bowel may not be suspected even because of the total absence of indica- tive, subjective sensations. On the other hand, teniae may cause consid- erable local distress and impairment of the general health. Because of 1254 ANIMAL PARASITIC DISEASES. this fact a knowledge of the existence of tape-worm in certain neurotic subjects leads to an inordinate description of symptoms that exist mainly in the workings of a morbid imagination. Alimentary symptoms of tape-worm may be as follows: anorexia alter- nating with a voracious appetite, constipation alternating Avith diarrhea, colicky pains in the abdomen, indigestion, nausea, and vomiting, and sometimes salivation. Greneral symptoms of the teniae may-be added, as lassitude, inappe- tence, mental uneasiness, worry and irritability, depression of spirits, some physical prostration, and even emaciation. Various reflex symptoms, such as pruritus of the nose and anus, vertigo, migrain, tinnitus aurium, palpitation, visual disturbances (even temporary amaurosis), dilatation of the pupils, choreic movements, and epileptiform convulsions have been attributed to these parasites. But, on careful inquiry, adequate causes for some of these symptoms may be found in other associated morbid conditions. Diagnosis.—This is always to be made by the discovery of tenia segments or ova in the underclothing or stools. The doubtful presence of suspected tape-worm may be cleared by the administration of a suitable purgative, which will usually suffice to bring away portions of the worm in the dejections. I would here add a special warning lest mucous casts or shreds or vegetable structures (as of onion) be mistaken for tape-worm. The diagnosis of the variety of the tape-worm may also be made by a careful scrutiny of the segments. Those of the tenia saginata are larger and fatter than, and their generative apparatus is unlike that, of tenia solium (vide supra). Hypochondriasis can be excluded by repeated examinations of the stools, especially after the exhibition of cathartics, and by the uniform failure to detect portions of tape-worm or tenia eggs. The prognosis is favorable. Indeed, teniae may exist at all ages and for years without any danger to the patient. Treatment.—Prophylaxis.—The way to avoid acquiring a tape- worm is to use none but well-cooked meats; this applies to beef and pork in particular. The use of pure drinking-Avater is of no little im- portance also. The proglottides of the tenia should ahvays be burned, and not throAvn where they may be taken into the bodies of other ani- mals, as the cow or hog, and then be allowed to propagate. Govern- mental inspection of the meat-supply in abattoirs should be rigidly carried out in all parts of the country. Curative.—Before administering the chosen anthelmintic, the patient needs to undergo a "preparatory treatment." This has for its object the starvation of the parasite, so as to Aveaken, if possible, its hold upon the intestinal mucosa. This is specially necessary in the case of tenia solium, in which the cephalic hooklets are obstinately and firmly fixed to the membrane, and since a cure cannot be said to have been effected unless the head be dislodged with the dejecta. For about two days prior to giving the remedy the patient should be restricted in diet to milk, light soups, a little white bread, and the like. Meanwhile, the bowels should* be purged gently once or twice, after a simple enema, to clear away accumulated fecal masses that might prevent the easy discharge of the worm. TAPE-WORMS. 1255 In the evening preceding the day on which the drug is to be exhibited, a saline cathartic should be given to empty the boAvel of fecal matter as completely as possible. The folloAving morning no breakfast should be allowed, and before noon the selected anthelmintic should then be ad- ministered. Some authors assert that if the worm does not come away in a feAv hours, and an intense sense of pressure is felt in the abdomen, a brisk purge is indicated. To make assurance doubly sure, and if the patient be not too weak, it might be well to order a cathartic as routine practice, within a few hours at the latest. There are several very efficacious anthelmintic drugs to choose from. Prominent among them is male fern. Given to an adult in doses of J to 1 dram (2.0-4.0) of the ethereal extract, and followed in several hours by a calomel and a saline purge, it usually succeeds in bringing away the tenia. Another valuable remedy is pelletierin, the active principle of pomegranate, dose J to 2 grains (0.0324-0.1296) in capsules; or, a de- coction of the pomegranate bark may be used, in combination with male fern, as in the Leipsic formula (Striimpell): B/. Granati radicis corticis, giv-v (128.0-160.0); Aquae, Oij (1 liter). Mix and macerate for twenty-four hours, and boil until reduced to f gv (148.0). Add : Oleoresinae aspidii, 3j (4.0). Sig. To be taken in three or four doses, at short intervals. Pepo in emulsion or in a sugary paste (about two ounces—64.0—and deprived of the envelopes) is at once a useful and harmless remedy. Another effective vermifuge is kousso (Brayera anthelmintica). An infusion of half an ounce (16.0) of the floAvers to one pint of water and mucilage of acacia is made, a Avineglassful of which may be taken every half hour. The Germans recommend sometimes the agreeable, though more expensive, Rosenthal's "kousso tablets." Enough of these to make 15 grains (0.972) may be taken within one hour, with cafS noir or lemonade. Koussin (the active principle) in doses of 30 to 40 grains (1.94-2.592) has also been recommended, but should not be given to pregnant women, as abortion may be produced. Among other remedies of value as vermifuges may be mentioned kamala (1 to 3 drams—4.0- 12.0__of the powder and hairs, in Avine or water), oil of turpentine (£ to 2 ounces__16.0-64.0—in emulsion or milk), and thymol. The combined use of such drastics as croton oil renders the action of the anthelmintic drug more certain at times. Although the head of the tenia may not be detected in the stools along with the body of the worm (and such is usually the case), a cure usually follows nevertheless, since, on account of its smallness, it may easily escape notice, and also from the fact that the head often dies and thus loses its hold upon the membrane, being carried away with the feces. On the other hand, if after the lapse of several months from the removal of a tape-worm, segments again appear in the stools, it may be inferred that the head was not dislodged or that another worm has developed. In cases where the tenia seems to redevelop with remarkable frequency and 1256 ANIMAL PARASITIC DISEASES. obstinacy it may happen that the head and neck are well protected beneath one of the valvulae conniventes. After the removal of the tape-worm—a weakening procedure, as a rule—the condition calls for supportive measures. The diet should not be too heavy for a time, but nutritious and easily digestible. T^iNIA NANA. This is the smallest tape-worm in man (v. Siebold). It varies from 8 to 20 mm. (^--f in.) in length and from 0.5 to 0.7 mm. (^ in.) in width. The head has four suckers, a rostellum, and hooklets. The seg- ments are yellowish, short, and broad. It is believed by some observers that, occurring in children, as it commonly does, this parasite is the cause of epileptiform convulsions and enuresis nocturna. Thousands of ova may be found within a cubic centimeter of fecal matter. TAENIA CUCUMERINA. (Elliptica; Canina.) A small reddish tape-worm found frequently in the intestines of the dog. It is 10 to 40 cm. (4-16 in.) in length. The larvae or cysticerci develop in the louse or flea of the dog or cat. The parasite is more com- mon in children than in adults, owing to the intimate relation of the former with the last-named pet animals. TAENIA PLAVOPTJNCTATA. (Tcenia Diminuta; Tcenia Leptocephala.) Taenia diminuta is a very small cestode, 20 to 60 mm. (f-2^- in.) in length, with a small club-shaped head and nearly a thousand segments. The cysticerci inhabit such insects as the asopia famialis (caterpillar and cocoon); the anisolabis annuli (belonging to the orthoptera); and the coleoptera axis spinosa and scaurus striatus. Man has been infected a number of times, probably by taking food containing these infested insects. Tcenia Madagascariensis and Tcenia serrata are other forms rarely found in man. PARASITIC ARACHNIDA. Pentastoma Tenioides.—This parasite in its adult form is an inhabitant of the nasal fossae of the dog or horse, though it may also occur in man both in this and in the larval form. The ova are ejected during sneezing, and are then ingested by man. The larvae are found in the liver, lungs, and kidneys. Sarcoptes (Acarus Scabiei).—This insect produces the skin affection known as "the itch," or scabies, an affection more common in Europe than in America, where it constitutes only about 4 or 5 per cent, of all OTHER PARASITIC INSECTS. 1257 cases of skin disease. It is most prevalent among the poor and the un- clean. The female is visible to the naked eye, and is about 0.5 mm. (to in-) in length; the male is about 0.25 mm. (y^ in.). Both are nearly as broad as they are long. The parasite penetrates the skin and lives in a burrow or cuniculus that it makes for itself. The female lives in the end of the burrow, which may contain a number of ova, and appears as a minute, brownish-black, dotted, sinuous line, situated chiefly in the cutaneous folds, where the skin is mostly delicate, as between the fingers. Secondary skin lesions, due to scratching, are common. Sulphur ointment, well rubbed in after hot bathing, is usually quite efficacious. Sarcoptes scabiei hominis is a variety of the preceding that infests other animals (cat, dog, cow, horse, wolf, goat, camel, etc.). Occasionally it may gain an entrance into man's skin, but dies simultaneously in the human host, although many invasions may occur. Leptus Autumnalis (Harvest Bug).—The most common of several va- rieties is a mite of a reddish color, having six legs armed with claws and sharp mandibles. It arises among low bushes and thus appears about the ankles and legs. It partially penetrates the skin, boring only far enough Avith its short, thick head to procure nourishment. Artificial dermatitis may be produced by the irritation of scratching. Mercury, sulphur, and naphthol ointments suffice to destroy the parasite. Demodex Foliculorum (Comedo Mite).—This minute parasite may be expressed from swollen sebaceous follicles of the nose, cheek, and other parts of the face. It has a Avorm-like body with very short legs, and is only about 0.2 to 0.4 mm. {£$ in.) in length. It is not known to produce acne, as was formerly supposed. OTHER PARASITIC INSECTS. PEDICULOSIS. (Phthiriasis.) Lice or pediculi live on and attack the skin. Three forms are found on man : pediculus capitis, pediculus corporis, and pediculus pubis. The pediculus capitis is whitish or grayish in color, about 1 mm. (^ in.) long (male), and has six legs under the front part of the body. The oviparous female is nearly twice as long as the male, and lays from fifty to eighty eggs on the hairs Avithin a week. These ova, or "nits," ma- ture in from three to eight days. Itching is the most prominent symp- tom, and an eczematous eruption above and behind the ears and in the neck is often associated. "Plica polonica " was a phrase once used to designate the matted condition of the hair in extremely dirty, crusty, and long-neglected cases of head-lice. Pediculus Vestimentorum (Corporis).—This louse inhabits more often the clothing than the body itself. It is larger than the head louse, and, like the latter moves slowly. The nits are found Avith difficulty on the 1258 ANIMAL PARASITIC DISEASES. fibers of the underclothing. It sucks blood through a proboscis inserted into the sweat pores, and after withdrawing leaves a minute hemorrhagic speck. Irritation of the skin is produced, and in old cases, as in filthy tramps (the great unwashed class), the skin becomes scaly and quite pig- mented (vagabond's disease). The efforts at scratching are almost frantic, and after a cure is effected parallel white lines, the remains of scratch- marks, followed by atrophic changes, may be visible, as in a case that I reported.1 Pediculus or Phthiriasis Pubis (Crab-louse).—This parasite is not limited to the pubis, but attacks also the hairy region in the axilla, on the chest, and may even reach the beard and eyebrows. It clings firmly to one or two hairs close to the skin. Its six legs with strong claws are placed closely together at the anterior part of the ovoid body. Treatment.—The hair should be cut short Avhere the head-lice and nits are abundant. Saturating the hair and scalp with kerosene oil for tAventy-four hours usually kills the parasites. Body-lice may be destroyed by scalding the underclothing and hot-ironing carefully about the seams. A hot soap-and-water bath is sufficient for the body, and sedative and antiseptic ointments may be useful adjuvants. Mercurial and beta- naphthol unguents usually suffice in treating for pediculus pubis. Prof. J. V. Shoemaker2 affirms that naphthol is a remedy that seems to meet the indications presented by the three forms of the disease; he prepares it as follows : B/. Beta-naphtol, 3j (4.0); Cologne water, giv-vi (120.0-178.0).—M. Cimex Lectularius or Bed-bug.—This too well-known parasite is flat, brownish-red in color, and from 2 to 5 mm. (1V--5- in.) in length. It in- fests beds and public vehicles, emitting a disagreeable odor. It is a blood-sucker, and causes considerable itching, local irritation, and urti- caria even in some persons, while others are unmindful of their attacks. Sulphur fumigation and mercuric chlorid applications to the harboring places of the bed-bugs are effectual destructive agents. Saturated sodium bicarbonate solution will relieve the burning and itching. Pulex Irritans (Common Flea).—This "ubiquitous" parasite is from 2 to 4 mm. (iV~"-g- m-) ^n length, black or (when filled Avith blood) broAvn- ish-red in color, having six legs, the hind ones of which are relatively very large and powerful, enabling it to jump many times its own height. A flea's bite causes a sharp sting, and leaves a slightly raised red spot. Treatment is the same as for the preceding insect. Pulex Penetrans (" Jigger ").—This parasite, also called " sand-flea, "• is indigenous to the West Indies, South America, and the Southern States. The impregnated female penetrates the skin, and especially that of the feet, for purposes of ovulation. As the distention with the eggs occurs, swelling, pain, and even ulceration may appear. The sand-flea is a small, egg-shaped insect, about half the size of an ordinary flea, brownish in color, and exceedingly resistant to crushing force. Prophy- laxis in regard to foot-wear is necessary. Essential and antiseptic oils may also be put on the feet or stockings. 1 International Clinics, vol. iii. third series, p. 76. 2 A Practical Treatise on Diseases of the Skin, p. 849. fc OTHER PARASITIC INSECTS. 1259 Ixodes (Wood-tick).—There are several varieties of tick- or wood- louse that may attack the human skin, among Avhich ixodes albipictus is supposed to be the most common. Ixodes ricinus and ixodes bovis are found on horses and cattle. They are blood-suckers, adhering to the skin very firmly, and wheals may be produced by them. A drop of tur- pentine, or of some such essential oil as anise or rosemary, will cause them to loosen their hold. Dermanyssus Avium et Gallinae.—These bird- and fowl-insects are small and grayish-white in color, and may attack the human skin and cause eczematous eruptions, owing to the scratching induced by the irritation. Culicidae (Mosquitoes and Ghtats).—The blood-sucking mosquito (culex auxifer), so well known, may also transfer to human beings the filaria sanguinis hominis and perhaps the plasmodium malaria?. The gnat (culex pipiens) is very troublesome during certain seasons, particularly along Avater-courses and in wooded districts. Its bite is quick, sharp, and stinging. The hirudo (leech) is a parasite that sometimes attaches itself to bathers. In the tropics it has been known to cause severe bites and inflammation. The bites and stings of bees, wasps, spiders, and ants have been known to cause considerable inflammation, edema, and blood-poisoning. CEstridae (Bot-flies).—These may become parasitic in man in the larval form. Species of the hydoxerma and dermatobia, that infest the skin of the horse, ox, goat, etc., have also been observed among the Central and South American Indians. They burrow beneath the skin of the abdomen, scrotum, and other regions. Muscidae (Common Flies).—Common flies affect the skin of man by depositing eggs in Avounds. The ova hatch within twenty-four hours sometimes, and the dipterous larvae may swarm to make the so-called "living " wound or sore (myiasis vulnerum). The larvre or maggots do not penetrate the tissues, however. The principal flies that infest wounds are the flesh-fly {sarcophila carnaria), the blow-fly (calliphora vomitoria), the screAV-worm fly (compsomyia macellaria), and the ordinary house-fly (musca domestica). Internal myiasis may also be caused by swallowing the ova of these flies. The larvae may thus be vomited or defecated. Epidemic urticaria is often caused by the migration of the caterpillar (cuethocampa). Among other parasites that attack man and inhabit par- ticular regions are the following: The simulium reptans, or creeping gnat of Sweden ; the seroot-fly (zimb)' of Abyssinia ; the ixodes carapato, a virulent bed-bug in Brazil; the hcematopota pluvialis (Clegg) of the West Highlands. INDEX. Abscess, atheromatous, 676 hepatic, 876 of brain, 1112 of liver, ^76 complications and sequelae, 878 diagnosis, 879 etiology, 876 pathology, 876 physical signs, 878 prognosis and treatment, 881 symptoms, 877 of lungs, 532 etiology, 532 pathology, 532 prognosis, 233 symptoms and diagnosis, 433 treatment, 533 of spinal cord, 1077 perinephritic, 996 retropharyngeal, 722 Acarus scabiei, 1256 Acetonuria, 948 Acidity of gastric contents, 734 Acid, lactic, in gastric contents, 735 Acromegaly, 1178 Acroparesthesia, 1191 Actinomycosis, 350 bacteriology, 351 course and prognosis, 352 cutaneous, 352 intestinal, 351 method of detecting actinomyces, 352 modes of infection, 351 oral, 351 pulmonary, 351 Acute articular rheumatism, 202 ascending paralysis, 1026 cause, 1027 definition, 1026 diagnosis, 1027 etiology, 1027 pathology, 1026 prognosis and treatment, 1027 reflexes in, 1027 symptoms, 1027 Bright's disease, 970 catarrhal gastritis, 747 laryngitis, 471 chorea, 1142 cystitis, 1001 delirium, 1133 fatty degeneration of the new-born, 418 febrile jaundice, 368. (See Weil's Dis- ease.) gastro-intestinal catarrh, 798 myelitis, 1070 nephritis, 970 pancreatitis, 902 perihepatitis, 873 phthisis, 282 Acute rhinitis, 465 spinal meningitis, 1065 suppurative gastritis, 751 yellow atrophy, 881 Addison's disease, 450 blood in, 452 definition, 450 diagnosis, 453 etiology, 451 extract of suprarenal capsules in treatment, 454 pathogenesis, 451 pathology, 450 prognosis, 453 skin in, 452 symptoms, 453 treatment, 453 urine in, 453 Adenia, 444. (See Pseudo-leukemia.) Afebrile typhoid, 32 Ainhum, 1190 Albumin, tests for, 939 Albuminuria, 937 causes, 938 functional, 939 Alcoholism, 1204 chronic, 1206 Alimentary or lipogenic glycosuria, 382 tract, tuberculosis of, 304 Allorrhythmia, 667 Amblyopia, toxic, 1039 Amoeba coli. (See Dysentery.) dysenterise, 99 Amyloid degeneration of heart, 657 kidney, definition, 962 diagnosis, 964 etiology, 963 pathology, 962 prognosis and treatment, 964 symptoms, 963 urine in, 963 Anemia, 419 blood in simple, 420 definition, 419 diagnosis, 417 etiology, 416 idiopathic, 426 infantum pseudo-leukffimica, 448 pathology, 449 symptoms, 449 of simple, 419 primary or essential, 420 prognosis, 417 progressive pernicious, 426 secondary, 433 simple or benign, 420 symptoms, 416 treatment, 417 Aneurysm, 680 arterio-venous, 692 axial, 680 1261 1262 INDEX. Aneurysm, cardiac, 658 congenital, 692 definition, 680 differential diagnosis, 687 false, 680 fusiform, 680 miliary, 680 of abdominal aorta, 690 of celiac axis, 691 of hepatic artery, 691 of pulmonary artery, 691 of splenic artery, 691 of the heart, 658 of thoracic aorta, 681 peripheral arteries in, 685 physical signs, 684 symptoms, 681 pathology and etiology, 680 peripheral, 680 prognosis, 688 pulse in, 685 sacculated, 680 sphygmographic tracing in, 685 tracheal tugging in, 686 treatment, 688 varieties, 680 Angina ludovici, 707 maligna, 179 pectoris, 669 diagnosis from pseudo-angina, 670 etiology, 670 pathology, 670 prognosis and treatment, 671 symptoms, 670 vasomotoria, 670 Angioneurotic edema, 485 Anhydremia, 419. (See Anemia.) Animal parasitic diseases, 1233 Ankylostomum duodenale, 1238 Anorexia, 785 Anterior poliomyelitis, definition, 1074 etiology, 1075 prognosis and treatment, 1075 reflexes in, 1075 symptoms, 1075 Anthracosis, 533. (See Pneumonokoniosis.) Anthrax, 352 bacillus, 353 diagnosis, 355 edema, 354 external, 354 immunity in, 353 internal, 354 manner of infection, 353 morbid anatomy, 353 prognosis, 355 treatment, 355 Aortic incompetency or insufficiency, 597 regurgitation, 597 blood-count in, 600 Corrigan or water-hammer pulse in, 601 murmur in, 602 pulse-tracing in, 602 Quincke's capillary pulse in, 601. stenosis, 603 murmur in, 605 Aphasia, 1118 motor, 1119 sensory, 1119 Aphthongi'a, 1060 Aphthous fever, 373. (See Foot-and-Munth Disease.) Aphthous stomatitis, 694 definition, 694 diagnosis, 695 prognosis and treatment, 695 symptoms, 695 Apoplexy, cerebral, 1113 ingravescent, 1115 serous, 1115 Appendicitis, 810 anatomical aspect, 811 bacteriology, 815 chronic, 822 clinical history, 815 consequences of perforation, 813 definition, 810 diagnosis, 819 from acute intestinal obstruction, 821 from acute tubercular peritonitis, 821 from extra-uterine pregnancy, 821 from indigestion, 820 from perinephritic abscess, 820 from renal colic, 820 from typhoid fever, 821 local measures in treatment, 825 pathology of catarrhal, 811 of interstitial, 812 of ulcerative, 812 physical signs, 818 recurrent or relapsing, 823 surgical aspect in treatment of, 824 temperature chart, 819 treatment, 825 Apraxia, 1120 Arsenicism, 1215 Arterial sclerosis, 676 clinical history, 678 definition, 676 diagnosis, 679 etiology, 677 pathology, 676 prognosis and treatment, 680 Arteries, aneurysm of, 680 atheroma of, 676. (See Arterial Sclerosis.) diseases of, 675 Arthritic muscular atrophy, 1199 Arthritis deformans, 387 acute form, 391 causes, 388 diagnosis, 391 pathology, 388 symptoms of chronic form, 389 treatment, 391 varieties, 390 gonorrheal, 213 Arthropathies in locomotor ataxia, 1081 Ascaris alata, 1237 lumbricoides, 1234 Ascites, 922 adiposus, 923 character of fluid in, 925 definition, 922 diagnosis from chronic peritonitis, 926 from ovarian cyst, 925 etiologv, 923 fluid in, 923 pathology, 922 physical signs, 924 prognosis, 926 symptoms, 924 treatment, 926 Asiatic cholera, 108 Astasia-abasia, 1181 Asthma, 491 INDEX. 1263 Asthma, bronchial, 491 cardiac, 655 clinical history, 492 course and prognosis, 494 Curschmann's spirals in, 493 definition, 491 diagnosis, 494 duration of attack, 493 etiology, 491 hay-, 469 pathology, 491 reflex causes of bronchial, 491 renal, 960 treatment, 494 Ataxic paraplegia, 1086 Atelectasis, pulmonary, 519 Atheroma, 776 Athetosis, 1148 Atrophy, acute yellow, 881 definition, 881 diagnosis, 883 etiology, 881 liver in, 881 pathology, 881 physical signs, 882 prognosis, 883 symptoms and physical signs, 882 treatment, 883 urine in, 882 Autumnal catarrh, 469 Bacillus, comma, 110 of anthrax, 353 of diphtheria, 181 diagnostic value of, 187 manner of staining, 181 of Eberth. (See Typhoid Fever.) of glanders, 348 of influenza, 158 of leprosy, 346 of syphilis, 327 of tetanus, 360 of the plague, 169 of tuberculosis, 263 distribution of, 264 of typhus, 68 Bacterium coli commune, 110 of cerebro-spinal meningitis, 124 Barrel-shaped chest of emphysema, 528 Basedow's disease, 457. (See Exophthalmic Goiter.) Baths in scarlet fever, 243 in typhoid fever, 55 Beaded ribs in rickets. 405 Bed-bug, 1258 Bed-sores in typhoid fever, 65 Beef tape-worm, 1252 Bell's palsy, 1049 Beri-beri, 1030. (See Endemic Neuritis.) Bile-ducts, carcinoma of, 859 stenosis of, 860 Black death, 169. (See Bubonic Plague.) vomit, 120 Bladder, diseases of, 1001 hemorrhage of, 1007 neoplasms of. 1006 neuroses of, 1007 Bleeders' disease, 415. (See Hemophilia.) Blood, diseases of, 416 in anemia infantum pseudo-leuksemica, 449 in chlorosis, 424 Blood in leukemia, 440 in progressive pernicious anemia, 430 in pseudo-leukemia, 447 in purpura, 414 in scurvy, 408 in secondary anemia, 433 in simple anemia, 419 in typhoid, 22, 40 Bothriocephalus latus, 1253 Brachycardia, 665 associated with a neurosis, 666 diagnosis, 669 etiology, 668 pathology and etiology, 665 physical signs, 669 prognosis, 669 symptoms, 668 treatment, 669 Brain, abscess of, 1112 and meninges, diseases of, 1101 anemia of, 1106 disturbances of circulation of, 1105 edema of, 1107 emboli and thrombosis of, 1107 hyperemia of, 1105 inflammation of, 1112 sclerosis of, 1129 softening of, 1107-1110 tuberculosis of, 315 vascular degeneration of, 1111 Break-bone fever, 167. (See Dengue.) Breast-pang, 669 Bronchial asthma, 491 diagnosis, 491 pathology and etiology, 490 physical signs, 490 prognosis and treatment, 491 symptoms, 490 stenosis, 491 Bronchiectasis, 487 diagnosis from tuberculosis, 489 etiology, 488 histology, 488 physical signs, 489 prognosis, 489 symptoms, 488 treatment, 489 Bronchitis, acute, 479 capillary, 512 catarrhal, 478 physical signs, 482 chronic, 483 clinical varieties, 484 diagnosis from pulmonary tuberculosis, 484 from pneumonia, 481 fibrinous, 496 plastic, 496 prognosis, 486 treatment, 486 Bronchocele, 455. (See Goiter.) Broncho-pneumonia, 512 atelectasis in, 512 blood in, 513 cerebral type, 515 definition, 512 diagnosis from lobar pneumonia, 516 duration, 515 etiology, 513 general, 516 morbid anatomy, 513 pathology, 512 physical signs, 514 1261 INDEX. Broncho-pneumouia, prognosis, 517 sputa in, 514 treatment, 518 tubercular, 516 Bronchorrhea, 484 Brown atrophy of heart, 657 Brown-Sequard's spinal paralysis, 1077 Bruit de diable, 423 Bubonic plague, 169 Buhl's disease, 418. (See Acute Fatty Degen- eration of the New-born.) Bulbar paralysis, 1091 Cachexia, in cancer of stomach, 772 malarial, 90 pachydermique, 461. (See Myxedema.) saturnine, 1213 syphilitic, 332 Caisson disease, 1182 Calculi, biliary, 851. (See Cholelithiasis.) pancreatic, 910 renal, 964. (See Nephrolithiasis.) Camp-fever, 67. (See Typhus Fever.) Capillary bronchitis, 512. (See Broncho- pneumonia.) Carcinoma of esophagus, 724 of intestines, 833 of liver, 892 of lungs, 536 of pancreas, 907 of stomach, 769 Cardiac aneurysm, 658 dilatation, 643 diseases, 583 hypertrophy, 636 murmurs, hemic, in acute chorea, 1142 in chlorosis, 423 in pernicious anemia, 429 in aortic regurgitation, 597 in aortic stenosis, 603 in mitral regurgitation, 605 in mitral stenosis, 611 in pulmonary regurgitation, 619 in pulmonary stenosis, 620 in tricuspid regurgitation, 615 in tricuspid stenosis, 618 thrombosis, 634 Cardialgia, 783 Catarrhal bronchitis, 478 laryngitis, acute, 471 chronic, 473 Celiac disease, 802 Cephalodynia, 365. (See Muscular Rheumatism.) Cerebral hemorrhage, 1113 palsies of childhood, 1131 Cerebro-spinal fever or meningitis, 123 meningitis, abortive form, 128 complications, 128 cutaneous symptoms, 127 differential diagnosis, 129 duration and prognosis, 130 fulminant or apoplectic form, 129 history, 123 immunity in, 130 incubation, 125 intermittent form, 128 local remedies in, 131 micro-organism of, 124 mild or rudimentary form, 128 modes of conveyance, 125 mortality, 130 nervous symptoms, 126 pathology, 123 Cerebro-spinal meningitis, predisposing causes, 125 sequelae, 130 symptoms, 125 treatment, 130 typhoid form, 128 Cestodes, 'l247 Chalicosis, 533. (See Pneumonokoniosis.) Chicken-pox, 231. (See Varicella.) Chills and fever, 78. (See Malaria.) Chloroma, 450 Chlorosis, 421 blood in, 424 complexion in, 422 heart-murmurs in, 423 malaise in, 422 pica in, 422 rubra, 422 Choked disk, 1039 Cholelithiasis, 851 acute obstruction in, 852 chronic obstruction in, 854 composition and appearance of biliary calculi, 851 definition, 851 differential diagnosis, 853 etiology, 851 prognosis, 853 rupture of the duct from, 853 symptoms, 852 Cholera Asiatica, 108 algid stage, 113 bacillus of, 110 causes, 110 clinical types, 114 complications, 114 contagiousness, 111 diet in, 115 differential diagnosis, 114 enteroclysis in treatment, 117 epidemic, 108 mortality of, 114 history, 108 hypodermoclysis in treatment, 116 immunity in, 112 incubation period, 112 intravenous injections in treatment, 117 lavage in treatment, 116 modes of infection, 111 preventive inoculations in, 115 prognosis, 114 prophylaxis in, 115 serous diarrhea in, 112 sicca, 112 stage of reaction, 113 symptoms, 112 temperature in, 113 treatment of attack, 116 urine in, 113 visceral lesions, 108 infantum, 798, 800 morbus, 804 nostras, 804 Choluria, 944 Chorea, acute, 1142 chronic. 1145 electrica, 1147 fibrillary, 1148 major, 1153 rhythmic, 1146 Choreiform disorders, 1146 Chronic arsenical poisoning, 1216 INDEX. 1265 Chronic cystitis, 1105 hydrocephalus, 1126 interstitial nephritis, 981 laryngitis, 473 lead-poisoning, 1213 mercurial poisoning, 1217 myelitis, 1073 parenchymatous nephritis, 977 pericarditis, 582 tuberculosis, 286 Chyluria, 943 Cimex lectularius, or bed-bug, 1258 Cirrhosis, atrophic, 8S7 Glissonian, 886 hypertrophic, 888 of liver, 885 of lung, 510 Colic, renal, 964 Colitis, 794 simple ulcerative, 809 Collapse of the lungs, 519. (See Pulmonary Atelectasis.) Colon, dilatation of, 840 Comma bacillus, 110. (See Cholera.) Congestion of lungs, 498 Constipation, 836-844 hygienic treatment, 838 Convulsions, infantile, 1158 Cow-pox, 229. (See Vaccinia.) Cranial nerves, diseases of, 1037 Croup, diphtheritic, 179 membranous, 185. (See Laryngeal Diph- theria.) Croupous or fibrinous pneumonia, 132. (See Lobar Pneumonia.) Culicidae, 1259 Cvstic kidney, 997 Cvstitis, 1001 catarrhal, 1002 chronic, 1005 septic, 1002 toxic, 1002 traumatic, 1002 Degenerations of the heart, 654 amyloid, 657 brown atrophy, 657 calcareous, 657 fatty, 654 fatty overgrowth, 656 hyaline, 657 Delirium, acute, 1133 tremens, 1207 Dementia, alcoholic, 1207 Demodex folliculorum, 1257 Dengue, causes, 167 complications, 168 symptoms, 167 treatment, 168 Dermanyssus avium et gallinae, 1259 Diabetes insipidus, 385 treatment, 387 mellitus, 374 acetone in, 378 acute, 377 blood in, 376 causes, 377 chronic, 377 coma in, 379 cutaneous symptoms, 379 diagnosis, 382 diet in, 383 hygienic treatment, 384 Diabetes mellitus, infantile, 381 medicinal treatment, 384 microbic theory of, 375 mortality, 382 nervous symptoms, 379 pancreatic, 381 pathogenesis, 374 pathology, 375 Pavy's view of, 375 prognosis, 382 special etiology, 377 sugar in, 378 symptoms, 378 test for acetones, 378 treatment, 383 uric acid and urea in, 378 urine in. 378 Diabetic coma, 379 Diarrhea alba, 802 nervous, 843 of children, 798 Dilatation of heart, 643 of stomach, 742 Diphtheria, 179 albuminuria in, 186 antitoxin treatment, 192 bacillus, 181 blood in, 180 causes of death in, 189 complications, 186 diagnosis, 187 external applications in, 192 hygienic treatment, 190 immunity in, 183 incubation of, 183 intubation in, 192 laryngeal, 185 local treatment, 191 malignant, 184 modes of infection, 182 mortality, 188 nasal, 185 paralysis in, 186 pathology, 179 of pseudo-membrane, 179 pharyngeal, 183 predisposing factors, 183 prognosis, 188 prophylaxis against, 189 pseudo-diphtheria, bacillus of, 151 sequelae, 186 serum-therapy in, 192 skin-rashes in, 186 tonsillar, 183 toxins, 182 tracheotomy in, 192 treatment, 189 use of cultures in diagnosis of, 187 Diphtheritic dysentery, 102 Disease, Addison's, 450 caisson, 1182 celiac, 802 of the coronary arteries, 653 Diseases, combined forms of cardiac, 620 of arteries, 675 of auditory nerve, 1050 of bladder, 1001 of brain and its meninges, 1101 of bronchial plexus, 1061 of cervical plexus, 1061 of circulatory system, 573 of cranial nerves, 1037 of dura mater, 1101 80 1266 INDEX. Diseases of esophagus, 722 of fifth nerve, 1046 of glosso-pharyngeal nerve, 1053 of hypoglossal nerve, 1059 of intestines, 786 methods of diagnosis, 786 of kidneys, 929 of liver, 845 of lumbar and sacral plexuses, 1063 of mediastinum, 569 of meninges, 1064 of motor nerves of eyeball, 1042 of muscles, 1193 of nervous system, 1012 of pancreas, 902 of peripheral nerves, 1026 of peritoneum, 910 of pharynx, 718 of pia mater, 1104 of pneumogastric nerve, 1053 of portal vein, 865 of salivary glands, 707 of seventh nerve, 1048 of spinal accessory nerve, 1057 of spinal nerves, 1061 of spleen, 897 of stomach, 733 methods of diagnosis, 733 of the blood, 419 of the bronchi, 478 of the ductless glands, 450 of the heart, 586 of the larynx, 471 of the lungs, 499 of the nose, 465 of the pleura, 539 of the respiratory system, 465 of the suprarenal capsules, 450 of the thyroid gland, 454 of the tonsiis, 709 of the urinary system, 929 of unknown pathology, 1135 Distomiasis, 1234 Dorsodynia, 365. (See Muscular Rheumatism.) Dracontiasis, 1245 Ductless glands, diseases of, 418 Duodenal ulcer, 806 Duodenitis, 793 Dura mater, diseases of, 1101 Dysentery, 96 ameba coli in, 99 amebic or tropical form, 99 catarrhal form, 98 causes, 97 chronic catarrhal, 106 intestinal irrigation in, 107 complications, 101 dietetic treatment, 107 diphtheritic, prophylactic treatment of, 104 sequelae, 104 hepatic abscess in, 100 history of, 97 intestinal ulceration in, 100 Dyspepsia, atonic, 783 chronic catarrhal, 752 nervous, 777 Dystrophia musculorum progressiva, 1197 Ear, care of, in scarlet fever, 244 complications of, in scarlet fever, 239 condition of, in syphilis, 332 Ebstein's method in obesity, 1224 Eburnation of cartilages, 'i^ Echinococcus disease, 1247 endogenous, 1247 exogenous, 1247 fluid, 1248 multilocular, 1247 Echinorhyncus gigas, 1246 moniliformis, 1246 Echokinesis, 1152 Echolalia, 1152 Eclampsia infantilis, 1158 Ectopia cordis, 673 Edema, angio-neurotic, 1183 of brain, 1107 of larynx, 478 of lungs, 500 Ehrlich's reaction in typhoid fever, 43 Elastic tissue in tubercular sputum, 292 Electrical reaction in facial palsy, 1049 Electrolysis in aneurysm, 688 Elephantiasis, 1244 arabum, 1244 Emaciation in acute tuberculosis, 276 in anorexia nervosa, 1169 in carcinoma of esophagus, 725 of stomach, 772 in chronic tuberculosis, 299 Embolism in aneurysm, 681 in chorea, 1142 in typhoid fever, 39 of cerebral arteries, diagnosis of, 1117 Embrocardia, 668 Emphysema, 522 compensating, 523 complications, 528 cough in, 525 diagnosis from pneumothorax, 527 dyspnea in, 525 hypertrophic 523 cyanosis in, 525 etiology, 524 hereditary character of, 525 pathology, 524 physical signs, 526 interlobular, 522 nature of, 523 senile, 529 vesicular, 522 Emprosthotonos in tetanus, 361 Empyema, 556 diagnosis from pleurisy with effusion, 558 differential diagnosis, 558 method of James in treatment, 559 micro-organisms in, 556 necessitatis, 558, 687 of pericardium, 581. (See Purulent Peri- carditis.) paracentesis in, 559 peptonuria in, 557 pulsating, 558 rupture of air-cells in, 557 Encephalitis, chronic diffuse, 1113 focal, 1112 optic neuritis in, 1113 Encephalopathy,lead, 1213 Endocarditis, 586 cerebral variety of ulcerative, 592 chronic interstitial, 594 diagnosis of ulcerative from typhoid fever, 493 etiology of simple acute, 587 of ulcerative or malignant, 591 INDEX. 1267 Endocarditis, malignant or infectious form 590 micro-organisms in etiology of, 588 recurrent malignant, 592 simple acute, 486 syphilitic. 339 tuberculous, 289 ulcerative, 590 mural, 590 valvular, 590 varieties, 586 Enteralgia, 841 Enteric fever, 17. (See Typhoid Fever.) Enteritis, catarrhal, 790 croupous or diphtheritic, 803 membranous, 840 phlegmonous, 803 ulcerative. 809 Enteroclysis, 116 Enteroliths as a cause of appendicitis, 814 Enteroptosis. 789 Enterospasm, 843 Enuresis, 1010 Environment in phthisis, 318 in tuberculosis, 266 Ephemeral fever 370. (See Febricula.) Epidemic catarrhal fever, 158. (See Influenza.) hemoglobinuria, 418 stomatitis, 373. (See Foot-and-Mouth Dis- ease. ) Epilepsy, 1136 diagnosis from hysteria, 1139 etiology, 1136 grand or haut mal, 1137 in plumbism, 1215 Jacksonian, 11 :>s in brain-tumor, 1124 nocturnal, 1138 paroxysmal period, 1136 pathology, 1136 petit mal, 1137 post-epileptic phenomena, 1138 prognosis, 1139 symptoms, 1137 treatment, 1139 Epistaxis, 470 in hemophilia, 416 in scorbutus, 409 in typhoid fever, 27 Erysipelas, 170 bacteriology, 171 causes, 171 complications and varieties, 174 diagnosis from acute eczema, 175 from chronic erythematous eczema, 175 from eczema nodosum, 175 from erythema, 175 from urticaria, 175 duration, 175 facial, 173 gangraenosum, 173 incubation, 172 local treatment, 177 method of conveyance, 172 migrans, 173 mortality, 176 " nephro-." 174 occurring in typhoid fever, 44 pathology, 170 phlegmonous, 174 " pneumo-," 174 prognosis, 175 Erysipelas pustulosum, 173 relapsing, 174 sequelae, 175 symptoms, 172 treatment, 176 vesiculosum, 17,1 Erythromelalgia, 1190 Esophagismus, 727 Esophagitis, acute, 722 chronic, 724 Esophagus, carcinoma of, 724 dilatation of, 728 diseases of, 722 diverticulum of, 729 neuroses of, 727 paralysis of, 727 rupture of, 726 stricture of, 730 ulcer of, 724 Estridae, 1259 Exophthalmic goiter, 457 acute, 458 cardiac, physical signs in, 458 chronic, 458 etiology, 458 muscular tremors in, 459 treatment, 460 Eyes in cerebro-spinal meningitis, 127 in hemiplegia, 1116 in intracranial growths, 1124, 1125 in syphilis, 332 oculo-motor paralysis of, in brain-tumor, 1125 Face in apoplexy, 1114 in Bell's palsy, 1049 in bulbo-paralysis, 1091 in disease of seventh nerve, 1048 in epilepsy, 1136 in hemiplegia, 1115 in progressive muscular dystrophy, 1198 in syphilis, 332 in torticollis, 1058 progressive hemiatrophy of, 1186 Facial expression in chronic tonsillitis, 716 in paralysis agitans, 1154 nerve, 1048 spasm or paralysis, 1047 Facies in cholera, il3 in jaundice, 848 leontina in leprosy, 345 Fallopian tubes, tuberculosis of, 314 False croup, 475. (See Spasmodic Laryn- gitis.) Farcy, 348. (See Glanders.) Fat-embolism in diabetes, 376 Fat-necrosis, 912 Fatty degeneration in acute yellow atrophy, 881 in cirrhosis of liver, 886 in idiopathic anemia, 427 of heart, 650 of kidneys, 986. 982 in diabetes, 376 in phosphorus-poisoning, 884 of liver, 872 in phosphorus-poisoning, 884 infiltration of liver, 87i overgrowths of heart, differential diag- nosis, 652 Febricula, 370 Febris flava, 118. (See Yellow Fever.) recurrens, 72. (See Relapsing Fever.) 1268 INDEX. Fecal concretions as a cause of appendicitis, 814 impaction, 827 vomiting, 829 Fehling's test for sugar, 946 Fermentation test for sugar, 947 Fetal heart-rhythm, 668 Fetus, endocarditis in, 597 Fever and ague, 78. (See Malaria.) cerebro-spinal, 123 dengue, 167 gastric, 748 hysteric, 1170 in abscess of liver, 877 in acute pneumonic phthisis, 283 in appendicitis, 815 in cholera, 114 in chronic obstruction of bile-passages, 854 in chronic tuberculosis, 290 in general miliary tuberculosis, 276 in Hodgkin's disease, 446 in influenza, 158 in intermittent fever, 85 in meningitic tuberculosis, 279 in multiple neuritis, 1030 in pneumonia, 514 in pyelitis, 990 in pyemia, 200 in pylephlebitis, suppurative, 867 in relapsing fever, 74 in remittent fever, 89 in scarlet fever, 236 in secondary syphilis, 329 in septicemia, 197 in small-pox, 223 in sun-stroke, 1228 in tuberculosis of lymph-glands, 274 in typhoid fever, 28 jail-, 68. (See Typhus Fever.) lung, 132 malarial, 78 Malta, 369 Mediterranean, 369 miliary, 372 mountain-, 66 pernicious malarial, 88 relapsing, 72 ship-, 67. (See Typhus Fever.) splenic, 352 spotted, 123 typhoid, 17 typhus, 67 yellow, 118 Fibrinous bronchitis, 496 pleurisy, 542 Fibroid induration of lung, 510 of pancreas in diabetes, 375 Fifth nerve, diseases of, 1046 paralysis of, 1047 trophic changes in paralysis of, 1047 Filaria bronchialis, 1246 hominis oris, 1246 immitis, 1246 labialis oris, 1246 lentis, 1246 loa, 1246 sanguinis hominis, 1244 distribution of, 1244 tracheajis, 1246 Filariasis, 1244 Fire, St. Anthony's, 170. (See Erysipelas.) Flatulence in hysteria, 1169 I Flint's murmur in heart disease, 603 Floating kidney, 927, 929 Florid phthisis, 282. (See Acute Phthisis.) Fluke, blood-, 1234 bronchial, 1234 liver-, 1233 varieties of, 1233 Folie brightique, 960 Follicular stomatitis, 694 Food-infection and ptomain-poisoning, 1219 Foot-and-mouth disease, 373 Foot-drop, 1029 Foreign bodies in intestinal obstruction, 828 Fourth nerve, 1044 paralysis of, 1044 Fremitus, hydatid, 1249 tactile, in chronic tuberculosis, 296 . in pneumonia, 516 French measles, 248. (See Rubella.) Friction-rub in acute peritonitis, 914 Friction-sound in pleurisy, 541 in sero-fibrinous pericarditis, 578 Friedreich's disease, 1083 sign in adherent pericardium, 583 Frontal convolution, speech-center in, 1023 Gait, ataxic, 1008, 1031 in differential diagnosis of locomotor ataxia, 1081 in peripheral neuritis, 1030 in pseudo-hvpertrophic muscular paraly- sis, 1196 in pseudo-tabes, 1031 in spastic paraplegia, 1085, 1086 Gall-bladder, distention or dropsy of, 855 empyema of, 856 fistulous communications of, 857 phlegmonous inflammation of, 856 Galloping consumption, 282. (See Acute Phthisis.) Gallop-rhythm in fatty degeneration of heart, 655 Gall-stones, 851. (See Calculi, Biliary.) remote effects of, 856 treatment for removal of, 858 Galvano-puncture in aneurysm, 689 Ganglion, basal tumors in or about, llr3» Gangrene, expectoration in, 531 in diabetes, 379 in ergotism, 1220 in lobar pneumonia, 149 in Baynaud's disease, 1185 in typhoid fever, 40 in typhus fever, 71 of lungs, 529 Gangrenous stomatitis, 701 Gastralgia, 783 Gastrectasis, 742 Gastric contents, examination of, 734 crisis, 1080 fever, 747 juice, hyperacidity of, 780 subacid ity, 781 ulcer, 761 clinical forms, 765 diagnosis from gastralgia, 766 differential diagnosis, 766 hematemesis in, 764 Gastritis. (See Stomach.) acute catarrhal, 747 suppurative, 751 chronic catarrhal. 752 INDEX. 1269 Gastritis, diphtheritic, 751 toxic, 750 Gastrodynia, 783 Gastro-enteritis, 798 Gastroptosis, 741. (See Malposition of Stom- ach.) Gastroxynsis, 781 Gelbfieber. (See Yellow Fever.) General lymphadenoma, 444. (See Pseudo- leukemia.) miliary tuberculosis. 275 paresis, 1129 of insane, 1129 diagnosis from cerebral syphilis, 1131 stage of mania in. 1130 tic, 1152. (See Tic.) Genito-urinary system, tuberculosis of, 312 German measles, 248. (See Rubella.) Giant cells in tuberculosis. 261 Gigantoblasts in progressive pernicious anemia, 430 Gin-drinkers' liver, 885. (See Cirrhosis.) Glanders, 348 acute, 348 bacillus mallei, 348 chronic, 349 diagnosis, 349 immunity in, 348 lesions of, 348 modes of infection, 348 period of incubation, 348 prognosis and treatment, 350 Glioma of brain, 1123 Globus hystericus, 1166 Glomerulo-nephritis, 970 Glossitis, 704 desiccans, 706 Glosso-labio-laryngeal paralysis, 1091 Glosso-pharyngeal nerve, 1053 diseases of, 1053 Glossy skin in arthritis deformans, 390 Glottis, edema of, in small-pox, 221 in typhoid fever, 38 Glycosuria, 945 alimentary, 382 salts for, 946 Gmelin's test for bile, 944 Goiter, 455 exophthalmic, 457 physical cardiac signs of exophthalmic, 458 simple, 455 symptoms of exophthalmic, 458 thymus gland in treatment of simple, 457 treatment of exophthalmic, 460 Gonorrheal arthritis, 213 endocarditis in, 214 pathology of, 213 Gout, 392 causes, 394 dietetic treatment, 399 differential diagnosis, 398 irregular, 396 morbid anatomy, 393 nervous manifestations in, 397 pathogenesis, 392 prophylactic treatment, 398 retrocedent, 395 rheumatic, 387 symptoms of acute, 39a of chronic, 396 treatment, 398 Gout, urine in, 397 Graefe's sign, 459 Grain-poisoning, 1218 Grand mal, 1136 Granular kidney, 981 Graves's disease, 457. (See Exophthalmic Goiter.) Green sickness, 421. (See Chlorosis.) Grippe, la, 158 Ground-soil, Pettenkofer's theory of, 24 Guaiacum test for blood, 935 Gummata in acquired syphilis, 330 in congenital syphilis, 332 of arteries, 335, 339 of brain and spinal cord, 333 of heart, 338 of liver, 335 of lung, 337 of pharynx, 336 of rectum, 337 of testicles, 340 of tongue, 336 structure of, 327 Gums, blue line in lead-poisoning, 1213 Gustatory nerve, 1047 Habit-chorea, 716 Habit-spasm, 1149 Hair in typhoid fever, 33 Hallucinations in hysteria, 1167 Handwriting in general paresis, 1130 Harrison's groove in rickets, 405 Hay-asthma, 469. (See Autumnal Catarrh.) Hay-fever, 469. (See Autumnal Catarrh.) Headache in intracranial growths, 1123 in syphilis, 334 in typhoid fever, 41 in uremia, 959 sick, 1140. (See Migrai7ie.) Heart, amyloid degeneration of, 657 aneurysm of, 658 arrhythmia of, 667 brown atrophy of, 657 calcareous degeneration of, 657 canter-rhythm in dilatation of, 646 congenital affections of, 672 degenerations of, 654 dilatation of, 643 displacement of. in pleurisy, 546 fatty, 654 floating, 661 hyaline degeneration of, 657 hypertrophy of, 636 in pneumothorax, 565 irregular, l>(>7 minor affections of, 660 misplacement of, 661 new growths of, 660 organic murmurs of, 597. (See Cardiac Murmurs.) palpitation of, 661 parasites of, 660 rapid, 663 rupture of, 659 shape of, in hypertrophy, 636 slow, 665 thrombosis of, 634 tuberculosis of, 315 Heart-failure in diphtheria, 187 in typhoid fever, treatment, 154 Heat-apoplexy, 1228 Heat-exhaustion, 1226 Heat-stroke, 1226 1270 INDEX. Heat-stroke, temperature in, 1229 treatment, 1230 Heberden's nodules, 390. (See Arthritis De- formans.) Heller's test, 939 Hematemesis, 776 diagnosis from hemoptysis, 777 in acute yellow atrophy, 882 in cirrhosis of liver, 887 in hysteria, 1169. in leukocythemia, 440 Hematobium distoma, 1234 Hematomyelia, 1069 Hematorrachis, 1069 Hematozoa of malaria, 81 Hematuria, 934 in acute cystitis, 1003 in acute nephritis, 973 in acute yellow atrophy, 882 in blood-flukes, 1234 in chronic tuberculosis, 300 in chyluria, 944 in malaria, 88, 91 in nephrolithiasis, 967 in renal calculus, 967 in scorbutus, 409 in tuberculosis of kidney, 313 Hemeralopia, 1039 Hemiauopia in brain-tumors, 1125 Hemic murmur in chlorosis, 429 Hemicrania, 1140. (See Migraine.) Hemiplegia, 1115 anesthesia in, 1116 atrophy in, 1116 crossed, 1116 diagnosis, 1116 in brain-tumors, 1125 in chronic nephritis, 985 in hysteria, 1168 of childhood, 1131 reflexes in, 1116 spastica cerebral is, 1132 Hemoglobin in anemia, 424 Hemoglobinuria, 936 diagnosis, 937 etiology, 936 in Baynaud's disease, 1185 paroxysmal, 936 treatment, 937 . Hemolysis, causes of, 936 in toxic hemoglobinuria, 936 Hemopericardium, 585 Hemophilia, 415 Hemoptysis, 502 etiology, 503 in acute pneumonic phthisis, 29 in emphysema, 528 in gangrene of lung, 531 in hysteria, 1170 in mitral incompetency, 607 in mitral stenosis, 512 in onset of phthisis, 290 in scorbutus, 409 in tuberculosis, 293 parasitic, 1234 pathology, 503 symptoms, 504 treatment, 506 vicarious, 504 Hemorrhage, broncho-pulmonary, 502 cerebral, 1113 extra-meningeal, 1067 in acute yellow atrophy, 882 Hemorrhage in anemia, 429 in cirrhosis of liver, 887 in hemophilia, 416 in infantile scorbutus, 411 in intussusception, 831 in leukocythemia, 440 in malaria, 90 in purpura, 413 in scarlet fever, 840 in scorbutus, 409 in tuberculosis of kidney, 313 in typhoid fever, 34 in yellow fever, 118 into spinal cord, 1069 into spinal meninges, 1067 intra-meningeal, 1067 pulmonary, 293 retinal, in chronic nephritis, 985 vesical, 1007 Hemorrhagic diathesis, 415 diseases of the new-born, 418 nephritis, 978 in variola, 221 pleurisy, 550 purpura, 412 scarlet fever, 238 Hemorrhoids in cirrhosis of liver, 888 Hepatic abscess, 876 blood-vessels, diseases of, 868 colic, 852 infiltrations and degenerations, 869 Hepatitis, diffuse syphilitic, 334 interstitial, 885 suppurative, 876 Hepatization, gray, 133 red, 132 white, of fetus, 338 Hepatogenous jaundice, 850 Hereditary ataxia, 1083 muscular paralysis, 1200 Heredity in tuberculosis, 268, 269 Herpes in cerebro-spinal meningitis, 127 in febricula, 37i in malaria, 86 in neuralgia, 1034 in pneumonia, 143 Hirudo, 1259 Hodgkin's disease, 444. (See Pseudo-leuke- mia.) Huntingdon's chorea, 1145 Hutchinson's teeth, 332 triad, 332 Hyaline casts in urine, 973, 979, 984 Hydatid disease, 1247 thrill, 1249 Hydrarthrosis, 214 Hydrocephalus, chronic, 1126 Hydrochloric acid, test for, in gastric juice, 734 Hydroniyelia, 1095 Hydronephrosis, 993 intermittent, 994 Hydropericardium, 584 in nephritis, 973 Hydrophobia, 356 diagnosis, 358 incubation, 357 morbid anatomy, 356 paralytic stage, 357 Pasteur's treatment bv attenuated virus, 359 preventive inoculation in, 358 prodromal symptoms, 357 INDEX. 1271 Hydrophobia, stage of excitement, 357 temperature in, 357 virus of, 356 Hydrops articulorum intermittens, 1184 peritonaei, 922 Hydrothorax, 567 in nephritis, 973 Hyperorexia, 786 Hyperpyrexia in heat-stroke, 1229 in hysteria, 1170 in rheumatic fever, 207 in scarlet fever, 238 in tetanus, 361 Hypertrophy of the heart, 636 Hypnotism in hysteria, 1172 Hypochondria in neurasthenia, 1175 Hypoglossal nerve, 1059 paralysis of, 1060 spasm of, 1060 Hypostatic congestion in typhoid fever, 38 of lung, 499 Hysteria, 1163 anesthesia in, 1169 ataxia in, 1168 cataleptic form of, 1167 contractures in, 1168 convulsions in, 1166 dyspnea in, 1169 fever in, 1170 gymnastic form of, 1167 latent or interconvulsant stage of, 1168 nervous system in, 1168 paralysis in, 1168 prodromal stage of, 1165 pseudo-angina in, 1170 psychic symptoms, 1169 stage of delirium, 1167 tachycardia in, 1170 traumatic, 1165 urinary symptoms, 1170 Hystero-epilepsy, 1166 Icterus, 846. (See Jaundice.) neonatorum, 862 Idioglossia, 1120 Idiopathic anemia, 426. (See Progressive Per- nicious Anemia.) Ileo-colitis, 799 Ileus, 826. (See Intestinal Obstruction.) Imbecility in cerebral palsies of childhood, 1132 Imitation in chorea, 1152 Incontinence of urine in locomotor ataxia, 1080 Indicanuria, 941 Infantile convulsions, 1158 Infarction, intestinal, 806 Infectious diseases, 17 Influenza, 158 antagonism of, 160 bacillus of, 15!) broncho-pneumonia in, 162 causes, 159 clinical types, 161 complications, 161 diagnosis, 163 . ... 1C, from cerebro-spinal meningitis, IM from pneumonia, 163 from typhoid fever, 163 duration, 164 heart-failure in, 162 history, 158 immunity in, 160 Influenza, lobar pneumonia in, 161 manner of invasion, 159 modes of conveyance, 159 mortality, 164 nervous system in, 162 pathology, 159 pleurisy in, 162 prognosis, 164 prophylaxis in, 161 sequelae, 164 symptoms, 160 treatment, 165 Injection of salines in cholera, 116 Inoculation, preventive, in hydrophobia, 1058 in small-pox, 229 protective, in yellow fever, 122 tuberculosis produced by, 267 Inoculations, prophylactic, in typhoid fever, 50 Insular sclerosis, 1088 Intermittent fever, 83 Intestinal catarrh, 790 hemorrhage in typhoid fever, 34 infarction, 806 obstruction, 826 perforation in typhoid fever, 34, 35 tumors, 828 ulcers, 806 Intestine, carcinoma of, 833 diminished sensibility of, 842 neuralgia of, 841 neuroses of, 840 spasm of, 843 Intestines, diseases of, 786 Intoxications, 1204 Intracranial growths, 1122 Intussusception, 826 Invagination, «26 Iridoplegia, 1044 Iritis in syphilis, 332 Irregular heart- and pulse-beat, 667 Ixodes, 1259 Jacksonian epilepsy, 1136 Jail-fever, 67. (See Typhus Fever.) Japan, bronchial fluke in, 1234 endemic neuritis in, 1030 Jaundice, 846 acute febrile, 368 catarrhal, 847 forms of, 850 hepatogenous, 487, 846 in acute yellow atrophy, 881 in atrophic cirrhosis of liver, 887 in biliary calculi, 852 in carcinoma of liver, 893 in epidemic form, 847 in hypertrophic cirrhosis of liver, 888 in impacted calculi, 880 in pneumonia, 147 in the new-born, 846 in Weil's disease, 368 in yellow fever, 121 malignant, 881 xanthelasma in, 848 Joints in gout, 392-396 in rheumatism, 203 in small-pox, 221 in syphilis, 339 Jumpers, 1153 Keratitis in inherited syphilis, 332 in small-pox, 222 1272 INDEX. Keratosis follicularis, 1232 Kidney, amyloid, 962 carcinoma and sarcoma of, 999 circulatory disorders of, 933 cirrhosis of, 981 congenital cystic, 997 contracted, 981 cyanotic induration of, 933 cystic, 997 diseases of, 929 echinococcus of, 1251 floating, 929, 930 gouty,981 granular, 981 lardaceous, 962 large white, 977 movable, 932 new growths of, 999 removal of, in carcinoma, 1001 rhabdomyoma, 999 syphilis of, 339 tuberculosis of, 312 wandering, 929 waxy, 962 Kidneys, active hyperemia of, 933 embolic infarctions of, 934 in diphtheria, 181 mobility of, 929 passive hyperemia of, 933 stone in, 964 Kindhusten, 251. (See Whooping-cough.) Knee-jerk, loss of, in ataxia, 1078 in diphtheria, 186 in diseases of lumbar plexus, 1063 Lactic acid, test for, 736 Lagophthalmus, 1043 La grippe, 158. (See Influenza.) Landry's paralysis, 1026 Lardaceous degeneration of kidney, 962 infiltration of liver, 869 Larvae of flies, 1259 Laryngeal crises, 1054,1080 nerves, 1054 Laryngismus stridulus, 475. (See Spasmodic Laryngitis.) Laryngitis, acute catarrhal, 471 chronic, 473 membranous, 473-476 spasmodic, 475 Larynx, adductor paralysis of, 1055 anesthesia of, 1056 diseases of, 471, 1054 edema of, 472-478 hyperesthesia of, 1056 nerves of, 1053, 1054 paralysis of, 1054 complete, 1055 of abductors, 1055 spasm of, 1054 tumors of, 477 unilateral abductor paralysis of, 1055 Latah, 1153 Lateral sclerosis, amyotrophic, 1092 primary, 1084, 1085 Lateritious sediment, 950 Lathyrismus, 1221 Lathyrus cicera, 1221 clymenum, 1221 sativus, 1221 Lavage in chronic gastric catarrh, 760 in dilatation of stomach, 746 in gastric ulcer, 768 Lead arthralgia, 1214 colic, 1214 encephalopathy, 1214 in urine, test for, 1214 palsy or paralysis, 1214 Lead-poisoning, 1212 blue line on gums, 1213 cerebral symptoms, 1214 cramps of, 1214 Lead-workers, gout in, 394 Lepra alba, 346 cells, 345 Leprosy, 345 anesthetic form, 346 bacillus of, 346 diagnosis, 347 etiology, 346 history, 345 modes of infection, 346 pathology, 345 prognosis, 347 treatment, 347 trophic alterations in, 347 tubercular form, 346 Leptomeningitis, 1065, 1104 acute, 1065 as a sequel to acute febrile diseases, 1104 chronic, 1066 non-tubercular form, 1104 tache cerebrale in, 1104 tubercular form, 1066, 1104 Leptus autumnalis, 1257 Lesions of cauda equina and conus termi- nalis, 1101 Leucin, 952 in leukemia, 437 in urine, test for, 952 Leucinuria, 952 Leukemia, 437. (See Leukocythemia.) blood in, 441 bone-marrow in, 438 complications of, 443 etiology, 439 liver in, 438 lymphatic, 437-442 glands in, 441 microbic origin of, 439 pathology of, 437 spleen in, 441 splenic-myelogenous, 437 symptoms, 440 Leukemic blood, abnormal substances in, 437 peritonitis, 440 Leukoplakia oris, 706 Leukocythemia, 437 pseudo-, 444 pseudo-anaemia infantum, 448 spleno-medullary, 1000 Leukocytosis, 436 pathological, 436 physiological, 436 Leyden's crystals, 493. (See Asthma.) Lichen in jaundice, 848 Lienteric diarrhea, 795 Lingual psoriasis, 706 Lips, tuberculosis of, 304 Lipuria, 954 Lithemia, 400 Lithic-acid diathesis, 949 Lithuria, 949 Liver, abscess of, 876 active congestion of, 863 acute yellow atrophy of, 881 INDEX. 1273 Liver, affections of blood-vessels of, 868 altered shape of, 845 amyloid infiltration of, 869 anemia of, 863 anomalies in shape and position of, 845 atrophy of, 869 carcinoma of, 892 circulatory affections of, 863 cirrhosis of, 885 atrophic, 861 hypertrophic, 861 diagram of, in cirrhosis, 890 diseases of, 845 dulness of, in acute peritonitis, 914 fatty degeneration of, 872 infiltration of, 871 gummata of, 335 hydatids of, 1248 hyperemia of, 863 hypertrophy of, 869 in phosphorus-poisoning, 883 new growths of, 896 perihepatitis, 873 psorospermiasis in, 1232 syphilis of, 334 toxic symptoms in acute yellow atrophy of, 882 tuberculosis of, 311 waxy, 869 Lobar pneumonia, 132. (See Pneumonia.) Localization, cerebral, 1024 spinal, 1018 Lockjaw, 359. (See Tetanus.) Locomotor ataxia, 1078 Argyll-Robertson pupil in, 1080 course, 1087 diagnosis from ataxic paraplegia, 1081 from cerebellar disease, 1082 from peripheral neuritis, 1081 etiology, 1079 gait in, 1080 gastric crises in, 1080 pathology, 1078 polyesthesia in, 1080 prognosis, 1082 symptoms, 1079 treatment, 1082 trophic changes in, 1080 Long thoracic nerve, 1061 Ludwig's angina, 707 Lumbago, 364. (See Muscular Rheumatism.) Lumbar puncture, 1066, 1105 Lumpy-jaw, 350. (See Actinomycosis.) Lung, actinomycosis of, 351 carcinoma of, 536 echinococcus of, 1250 gangrene of, circumscribed, 530 diffuse, 529 embolic, 529 hemorrhagic infarction of, 503 hydatid cyst of, 538 neoplasms of cobalt miners, 538 sarcoma of, 537 splenization of, 500 Lung-fever, 132 Lungs, abscess of, 532 embolic, 532 symptoms of, 533 active hyperemia of, 498 apoplexy of, 508 brown induration of, 499 cirrhosis of, 510 Lungs, congestion of, 498 edema of, 500 embolism of, 508 emphysema of, 522 fibroid induration of, 510 gangrene of, 529 etiology, 530 pathology, 529 symptoms, 531 hemorrhage of, 502 hemorrhagic infarct of, 508 new growths of, 536 passive hyperemia of, 499 syphilis of, 337 tuberculosis of. 277 Lymphadenitis, 569 tuberculous, 569 Lymphadenoma, general, 444 Lymphatics, distended, 1245 Lymph-glands, suppuration of, 569 tuberculosis of, 271 Lymphoma, multiple malignant, 444 Lympho-sarconia, malignant, 444 Lymph-scrotum, 1245 Lymph-vaccine, 230 Lymph-vulva, 1245 Lyssophobia, 358 Macrocytes, 424 Macrocytosis, 419 Maidismus, 1220 "Main en griffe" in diseases of muscles, 1194 Malacia, 786 Malarial cachexia, 90 fever, 78 ameba causing estivo-autumnal fever, 82 causing quartan fever, 82 causing tertian intermittent fever, 81 chart in, 80 ciliae or flagella in, 83 complications, 91 cutaneous symptoms, 86 diagnosis, 92 etiology, 79 hematozoa of, 81 hematuria and hemoglobinuria in, 91 hot stage of intermittent, 84 immunity in, 83 incubation in, 83 intermittent, 83 temperature chart in, 84 life-cycle of parasite, 83 localities of, 78 masked intermittent, 90 mild form, 86 mode of infection in, 83 occurring with typhoid fever, 43 parasite of, 81 paroxysms in intermittent, 83 pathology of, 78 pernicious intermittent form, 86 algid form, 87 comatose form, 88 congestive chills in, 87 hematuric form, 88 Plasmodium of, 81 prognosis, 93 prophylaxis in pernicious intermit- tent, 95 quartan, 85 quotidian, 85 1271 INDEX. Malarial fever, remittent form, 88 seasons favoring, 80 spleen in, 79-86 splenic enlargement in^ 86 sub-varieties, 78 sweating stage of intermittent, 85 telluric couditions, 79 tertian, 85 treatment of intermittent form, 94 urine in, 86 Malignant edema, 354 lympho-sarcoma, 444. (See Pseudo-leu- kemia.) pustule, 352. (See Anthrax.) Malta fever, 369 Mammary glands in hysteria, 1168 tuberculosis of, 315 Mania-a-potu, 1206 Mania, acute delirious, 1133 Bell's, 1133 melancholic stage of, in general paresis, 1130 typho-, 1133 Marriage in hemophilia, 417 in syphilis, 342 Marrow of bones in leukocythemia, 437 in pernicious anemia, 427 in small-pox, 216 Masticatory spasm, 1047 AlcBurney's point, 815 Measles. 245 bacteriology of, 245 catarrhal stage, 246 causes, 245 complications, 246 contagiousness of, 245 desquamation in, 246 diagnosis, 247 from German, 250 epidemics of, 245 eruption of, 246 German, 249 immunity in, 245 incubation of, 246 mortality, 247 pathology, 245 symptoms, 246 temperature in, 246 treatment, 218 of German, 290 Meat in animal parasitic disease, 1254 tuberculous infection by, 267 Meat-poisoning, 1219, 1242 Meckel's diverticulum, 826 Median nerve, diseases of, 1062 Mediastinal hemorrhage, 572 Mediastinum, abscess of, 570 carcinoma of, 570 diseases of, 569 dysphagia in diseases of, 571 inflammation in, 569 sarcoma of, 570 tumors of, 570 Mediterranean fever, 369 Medulla, tumors of, 1125 Megalocytosis, 419. (See Anemia.) Megalogastria, 745 Melano-sarcoma of liver, 897 Melanotic carcinoma, diagnosis in Addison's disease, 453 Melanuria, 954 Melasma suprarenale, 453 Melena in typhoid fever, 31 Meniere's disease, 1052 Meningeal apoplexy, 1067 Meninges, diseases of, 1064 Meningitis, acute spinal, 1065 cerebro-spinal, 128 in encephalitis, 1112 in erysipelas, 174 in gout, 397 in hydrocephalus, 1128 tuberculous, 278 Meningo-encephalitis, tuberculous, 315 Mercurial tremor, 1217 Mercurialism, 1216, 1217 stomatitis and salivation in, 1217 Meiycism, 782 Mesenteric artery, occlusion of, 806 glands in typhoid fever, 19 tuberculosis of, 273 Mesenterica, tabes, 273, 310 Mesentery, hemorrhage into, 902 Mesocolon, hemorrhage into, 902 Metallic rales, 565 tinkling, 297, 565 Metastatic abscesses, 199 Meteorism in typhoid fever, 64 Micrococci in measles, 245 Micrococcus in dengue, 167 melitensis in Malta fever, 369 Microcytes, 424 Microcytosis, 419 Micro-organisms in chorea, 1142 in rheumatic fever, 203 Middle cerebral artery, embolism and throm- bosis of, 1108 ear, disease of, in measles, 247 in scarlet fever, 239 Migraine, 1140 ophthalmique, 1043 Miliary abscesses in typhoid fever, 20 fever, 372 tubercles, 288 in typhoid fever, 38 tuberculosis, general, 275 Milk in scarlet fever, 235 in tuberculosis, 266 in typhoid fever, 26 poisoning by, 1218 Milk-curds, 700 Milk-sickness, 371 Mimic spasm, 1150 Mind-blindness, 1042 Mind-deafness, 1120 Miner's cachexia, 1238 lung, 533 neoplasms of lung, 538 nystagmus, 1043 Mitchell, Weir, rest-cure in hysteria, 1171 Mitral incompetency, 605 regurgitation or insufficiency, 605 diagnosis from functional mur- murs, 610 mechanism of, 606 murmur in, 608 stenosis, 611 chlorosis and, 611 chorea and, 611 murmur in, 614 pathology and etiology, 611 physical signs in, 613 presystolic murmur in, 614 rheumatism in, 611 sphygmogram of, 613 symptoms, 612 INDEX. 1275 Moist rales, 297 Monoplegia facialis, 1049 hysteric, 1168 Morbus Addisonii, 453 coxae senilis, 390. (See Arthritis De- formans.) maculosus neonatorum, 418 Morphea, 1189 Morphinism, 1211 Mortality in cerebro-spinal meningitis, 130 in pneumonia, 152 in small-pox, 225 in typhus fever, 72 in whooping-cough, 255 in yellow fever, i21 Morvan's disease, 1095, 1096 Mosquitoes, 1259 relation of, to filaria disease, 1243 Motor cells, degeneration of, 1092 centers, 1021, 1022 impulses, course of, 1924 nerves of eye-ball, diseases of, 1042 oculi, lesions of, 1043 paralysis of, 1043 spasm of, 1043 phenomena in neurasthenia, 1174 system, lesions of, 1025 tracts, decussation areas of, 1018 Mountain anemia, 1238 fever, 66 Mouth, diseases of, 602 Mouth-breathing, 715 Movable kidney, 929 diagnosis, 931 dilatation of stomach in, 930 symptoms, 930 treatment, 932 Movement, limitation of, in eye-muscles, 1045 Muco-pus, occlusion of bronchioles, 481 Mucous membranes, lesions of, in syphilis, 337 Mulberry calculi, 965 Multiple malignant lymphoma, 444. (See Pseudo-leukemia.) neuritis. 1029 sclerosis, 1088 Mumps, 258. (See Parotitis.) Murmur, Flint's, 603 in aneurysm, 685 in congenital heart disease, 674 in endocarditis, 588 in rachitis, 405 in subclavian artery in phthisis, 295 in valvular disease, 602, 605, 608, 614, 617, 619, 620 Murmurs, hemic, 423-429 myocardial, 649 Musca domestica, 1259 Muscaria amanita, 1221 Muscidae, 1259 , Muscle, diseases of, 1193 Muscle-trichinae, 1241 Muscles, electric reaction of, Erb's sign, 1156 of eye, paralysis of, 1045 Muscular atrophy, 1200 arthritic, 1199 neural progressive, 1194 progressive, 1092 facio-scapulo-humeral type, 1198 infantile type, 1198 spinal, 1193 pseudohypertrophic, 1195 contractures, hysteric, 1168 Muscular cramp in dilatation of stomach, 744 hypertrophy, 1200 paralysis, hereditary, 1199 rheumatism, 363 sense in Brown-Sequard's spinal paral- ysis, 1077 wasting, hysteric, 1168 weariness in trichiniasis, 1239 Muscularis progressiva, dystrophia, 1198 Musculo-spiral nerve, paralysis of, 1062 Mushroom-poisoning, 1221 Music-faculty, loss of, in aphasia, 1120 Musical murmur, 609 Mussel-poisoning, 1219 Myalgia, 363. (See Muscular Rheumatism.) cervicalis, 364 lunibalis, 364 Mycosa stomatitis, 699 Mycosis, intestinal, 354 Mycotic diarrhoea, 798 Mydriasis, 1044 Myelin droplets of Virchow, 480 Myelitis, acute, 1070 chronic, 1073 diagnosis, 1072 diaphragmatic breathing in, 1071 diffuse, 1070 disseminated, 1071 girdle-feeling in, 1072 reflexes in, 1072-1074 transverse, 1070 Myelocytes, 441 Myelogenic leukemia, 437 Myiasis, internal, 1259 vulnerum, 1259 Myocarditis, 648 acute, 648 circumscribed, 648 diffuse interstitial, 648 parenchymatous, 648 angina pectoris in, 651 cardiac arrhythmia in, 651 chronic or fibrous, 649 in rheumatism, 203, 206 in syphilis, 339 segmentaire, 21 Myocardium, diseases of, 648 lesion of, due to disease of the coronary artery, 653 Myosis, 1043 spinal, 1044 Myositis, infectious, 1193 progressive ossifying, 1194 Myotatic irritability' 1093 Myotonia congenita, 1200 Myotonic contraction, 1201 Mytilotoxin, 1219 Myxedema, 461 associated with cretinism, 464 operative, 464 pathogenesis, 461 treatment of, by thyroid-feeding, 463 true, 461 varieties, 461 Myxoma in intracranial growths, 1123 Nails in typhoid fever, 33 Nasal catarrh, acute, 465 chronic, 466 diphtheria, 185 Necrosis, anemic, 653 in tubercle, 262 Necrotic tonsillitis, 712 1276 INDEX. Nematodes, 1235 uncommon, 1246 Neoplasms of bladder, 1006 Nephrectomy, 932 Nephritides, the, 955 Nephritis, acute parenchymatous, 970 cardiac hypertrophy in chronic inter- stitial, 985 chronic interstitial, 981 parenchymatous, 977 complicating the infectious fevers, 973 complications, 986 definition, 970 diagnosis, 974 diet in treatment, 975 dropsy in, 957 edema in, 972 etiology, 971 glomeruli in, 971 hemorrhagic, 970 hvgiene and diet in treatment of acute, 975 interstitial changes in acute, 971 large white kidney in chronic, 977 lymphomatous, of Wagner, 43 of pregnancy, 974 pale, granular kidney of chronic, 978 pathology, 970 prognosis, 974 suppurative, 989 symptoms, 972 treatment, 975 tube-casts in, 955, 973 tubular changes in acute, 970 in chronic interstitial, 982 uremia in, 958, 973 urine in, 973, 979, 984 Nephrolithiasis, 964 Nephroptosis, 929 Nephrorrhaphy, 932 Nephro-typhoid, 42 Nerves, auditory, 1050 brachial plexus, 1061 cervical plexus, 1061 fifth, 1046 fourth, 1044 glosso-pharyngeal, 1053 hypoglossal, 1059 lumbar and sacral plexuses, 1063 of eyeball (motor), diseases of, 1042 peripheral, diseases of, 1026 pneumogastric, 1053 seventh, 1048 sixth, 1045 spinal accessory, 1057 diseases of, 1061 third, 1043 Nervous dyspepsia, 777 system, diseases of, 1012 function of cerebellum, 1023 of cerebrum, 1020 of spinal cord, 1012 general and topical, diagnosis of. 1024 histology of, 1012 lesions of, 1024 localization of functions of segments of spinal cord, 1018 tumors of, 1032 Nettlerash. (See Urticaria.) Neural progressive muscular atrophy, 1193, 1194 Neuralgia, 1032 Neuralgia, cervico-brachial, 1035 cervico-occipital, 1034 femoral or crural, 1035 infra-maxillary, 1034 intercostal, 1034 lumbo-abdominal, 1035 mastodynia, 1035 obturator, 1035 of genitalia and rectum, 1036 of the head, 1034 ophthalmic, 1034 phrenic, 1034 supra-maxillary, 1034 visceral, 1036 Neurasthenia, 1173 diagnosis from hysteria, 1176 etiology, 1173 lithemic, 1175 motor phenomena, 1174 psychic symptoms in, 1175 , rest-cure in, 1177 sensory disturbances in, 1174 symptomatic, 1174 Neuritis, 1028 alcoholic, 1029 arsenical, 1029 diffuse, 1028 endemic, 1030 focal, 1028 in diphtheria, 186 interstitial, 1028 lipomatous, 1028 malarial, 1030 multiple, 1029 reflexes in, 1029 recurring multiple, 1030 rheumatic, 1028 spontaneous or idiopathic, 1030 Neuroglial- tissue, 1123 Neuromata, 1032 Neurons, 1013 Neuroses, occupation-, 1161 of bladder, 1007 of intestine, 840 disturbances of motility, 843 secretory disturbances, 840 sensory disturbances, 841 of micturition, 1010 of stomach, 777. (See Stomach.) of the heart, 661 Neurosis, spastic vaso-motor, of the extrem- ities, 1194 Neutrophiles, 441, 442 Night-blindness, 1039 in scurvy, 409 Night-sweats in phthisis, 299 Nipple, Paget's disease of, 1232 Nits, 1257 Nodosities, Heberden's, 390 Noma, 701. (See Gangrenous Stomatitis.) pudendae, 702 Normoblasts, 430 , Nose, diseases of, 465 Nose-bleed, 470. (See Epistaxis.) in typhoid fever, 27 Nutmeg liver, 885. (See Cirrhosis of Liver.) i Nyctalopia, 1039 Nystagmus, bilateral, 1084 in insular sclerosis, 1089 paralytic, 1045 Obesity, 1222 treatment, 1225 INDEX. 1277 Obesity, treatment, Oertel's 1225 Obstruction, intestinal, 826 acute, and varieties, 826 chronic, and varieties, 827 Occupation-neuroses, 1161 Oculo-motor palsy, 1043 Oligemia, 419. (See Anemia.) Oligochromemia, 419. (See Anemia.) Oligocythemia, 419. See Anemia.) Omentum, new growths in, 927, 928 tuberculosis of, 309 Omodynia, 365. (See Muscular Rheumatism.) Onomatomania, 1152 Onychia in arthritis deformans, 390 syphilitic, 331 Ophthalmic migraine of Charcot, 1043 Ophthalmoplegia, 1046 Opium-inebriety, 1210. (See Morphinism.) Opiumism, 1210 Opium-poisoning, differential diagnosis from uremia. 962 Oppolzer's sign, 576 Optic atrophy, 1040 nerve, and tract, diseases of, 1038 neuritis, 1040 in abscess of brain, 1113 in Bright's disease, 979 in tuberculous meningitis, 281 in tumor, 1124 Optic-nerve atrophy in locomotor ataxia, 10-M) Orchitis in parotitis, 259 interstitial, in syphilis, 340 in tuberculosis, 3i3 in typhoid fever, 43 Oriental plague, 169 Osteitis deformans, 11-M) Osteo-arthropathy, hypertrophic pulmonary, of Marie, il80 Osteo-myelitis, acute, diagnosis from rheu- matism, 209 Otitis media in scarlatina, 239 Ovaries, tuberculosis of, 314 Oxaluria, 950 Oxyuris vermicularis, 1237 Oysters, poisoning by, 1219 typhoid bacilli conveyed by, 26 Ozena, bacillus mucosis as a cause of, 467 Pachymeningitis, 1064 externa and interna, 1101 hemorrhagica, extra-dural, 1102 Palate, paralysis of, in diphtheria, 186 tuberculosis of, 305 Palpitation of heart, 661 Palsies, cerebral, of childhood, 1131 Palsy, lead, 1030 Paludism. (See Malarial Fever.) Pancreas, calculi of, 910 carcinoma of, 907 cyst of, 909 diseases of, 902 hemorrhage of, 906 lesions of, in diabetes, 375 Pancreatic cyst, 909 Pancreatitis, acute, 902 chronic, 905 fat-necrosis in, 902 gangrenous, 904 hemorrhagic, 902 suppurative, 904 ; Paralysis, acute ascending (Landry s 1026 Paralysis after diphtheria, 186 agitans, 1154 alcoholic, 1029 Bell's, 1049 bulbar, acute, 1091 chronic, 1091 crossed, 1116 crutch-, 1062 diver's, 1182 general, of insane, 1129 hysteric, 1168 in cerebro-spinal meningitis, 127 infantile, 1131 in lateral sclerosis, 1085 in locomotor ataxia, 1080 in progressive muscular atrophy, 1194 of brachial plexus, 1061 of circumflex nerve, 1062 of diaphragm, 1061 of facial nerve, 1049 of fifth nerve, 1047 of fourth nerve, 1044 of hypoglossal nerve, 1059 of larynx, 1054 of median nerve, 1062 of musculo-spiral nerve, 1062 of oculo-motor nerve, 1043 of olfactory nerve, 1037 of recurrent laryngeal nerve, 1054 of sixth nerve, 1045 of third nerve, 1043 of ulnar nerve, 1063 of vocal cords, 1054 periodic, 1162 pseudo-hypertrophic muscular, 1125 radial, 1063 sleep-, 1062 Paralytic thorax, 293 Paramyoclonus multiplex, 1146 Paraphasia, 1222 Paraplegia, ataxic, 1086 congenital, 1086 from ergotism, 1220 from tumors of the cord, 1098 hysteric, 1168 in tabes, 1080 intermittent, 1088 pellagra, 122i reflex, 1088 spastic, 1086 syphilitic, 334 Parasites, animal, diseases due to, 1232 of heart, 660 Parasitic arachnida, 1256 gastritis, 748 Parkinson's disease, 1153 Parosmia, 1037 Parotitis, 259 complications and sequelae, 259 contagiousness of, 258 duration, 259 epidemic, 258 etiology of, 258 facial paralysis in, 260 immunity in, 259 in lobar pneumonia, 147 in typhoid fever, 37 pathology, 258 symptomatic, 708 symptoms, 259 treatment, 260 i, Paroxysmal hemoglobinuria, 936 Parrot's ulcers, 699 1278 INDEX. Pediculosis, 1257 Pediculus capitis, 1257 corporis, 1257 pubis, 1258 Peliomata typhosa (taches bleuatres), 33 Peliosis rheumatica, 413. (See Arthritic Pur- pura.) Pemphigus neonatorum, 331 Pentastoma taenioides, 1256 Peptones in the urine, tests for, 941 Perforation of bowel in dysentery, 101 in typhoid fever, 35 Pericarditis, 573 acute plastic or fibrinous, 573 adhesive, 582 chronic, 582 diagnosis from acute pleurisy, 580 from cardiac dilatation, 580 hemorrhagic, 582 hyperpyrexia in, 579 in rheumatism, 206 pulsus paradoxus in sero-fibrinous, 577 purulent, 581 sero-fibrinous, 576 tuberculo-mediastinal, 575 varieties of, 573 Pericardium, diseases of, 573 dropsy of, 563 tuberculosis of, 308 Perichondritis, laryngeal, in typhoid fever, 38 Perihepatitis, acute, 873 chronic, 875 Periuephritic abscess, 996 Peripancreatitis, 902 Perisplenitis, 899 Peristaltic unrest, 782,1169 Peritoneum, carcinoma of, 927 diseases of, 910 new growths in, 927 tuberculosis of, 309 Peritonitis, acute, 910 adhesive, 920 cancerous, 920 chronic, 919 hemorrhagic, 920 tuberculous, 920 circumscribed, 915 hysteric, 916 in typhoid fever, 35 leukemic. 440 localized or "partial, 915 proliferative, 920 saline treatment of, 919 symptoms of general, 913 Perityphlitis, 811 Perlicher, 701 Pernicious anaemia, 426 malaria, 86 Pertussis, 251. (See Whooping-aough.) Petit mal, 1137 Peyer's patches in typhoid fever, 17 Phagocytosis in erysipelas, 170 in tuberculosis, 262 Pharyngitis, acute, 718 chronic, 720 herpetic, 718 membranous, 719 Pharyngocele, 729. (See Esophageal Divertic- ulum.) Pharynx, acute infectious phlegmon of, 721 diseases of, 718 inflammatory edema of, 722 j Pharynx, tuberculosis of, 305 Phosphaturia, 951 Photphorus-poisoning, liver in, 883 Phrenic nerve, diseases of, 106i Phthiriasis, 1257 Phthisis, acute broncho-pneumonic, in chil- dren, 285 acute pneumonic, 282 chronic ulcerative, 285 course of acute pneumonic, 284 diagn >sis of acute pneumonic, 284 fibroi 1, 302 pathology of acute pneumonic, 282 stone-cutter's, 534 subacute cases, 284 symptoms of acute pneumonic, 283 Pia mate:. diseases of, 1104 Pic:;, 422 Pigeon-breast in rickets, 405 Pigmentation of skin, 453. (See Addison's Disease.) Pin-worms, 1236 Pituitary body in acromegalia, 1178 Pityriasis versicolor, 301 Plague, bacillus of, 169 bubonij, 16J duration and prognosis, 170 treatment, 170 Plasmodium malariae. (See Malaria.) Pleura, diseases of, 539 new growths in, 568 Pleurisy, 539 acute plastic, 539 aspiration in, 555 Baccelli's sign in, 557 bacteriology of, 539 ; chronic, 560 ! diagnosis from lobar pneumonia, 551 j diaphragmatic, 549 diet in, 554 I egophony in, 547 encysted, 549 hemorrhagic, 550 ! in scarlet fever, 239 i interlobar, 549 pulsating, 658 diagnosis from aneurysm, 687 purulent, 556. (See Empyema.) sero-fibrinous, 542 Skoda's resonance in, 547 tuberculous, 548 varieties of acute sero-fibrinous, 548 with effusion, 542. (See Sero-fibrinous Pleurisy.) Pleurodynia, 364. (See Muscular Rheumatism.) Plica polonica, 1257 Plumbism, 1213 prevention of, 1215 Pneumatinuria, 954 Pneumogastric nerve, branches of, 1054-1056 diseases of, 1053 Pneumonia, abortive treatment of, 155 abscess of the lung in, 133 bacteriology in, 134 blood in, 142 catarrhal, 512 causes, 135 cerebral symptoms, 142 chronic interstitial, 149, 510 circulatory symptoms, 140 complications of, 145 crisis in, 140 cutaneous symptoms of, 143 INDEX. 1279 Pneumonia, delayed resolution in, 149 diagnosis, 149 from, acute pneumonic phthisis, 150 from meningitis. 152 from typhoid fever, 152 diet in, 154 differential diagnosis, 150 duration, 149 endocarditis in, 146 epidemic, 148 epidemics, influence in, 136 gangrene of the lung in, 134 gray hepatization in, 133 heart-clots in, 146 hydrotherapy in, 155 hypostatic, 500 immunity from, 137 in children, 148 in diabetes, 381 inhalation-, 514 in influenza, 163 in the aged, 148 jaundice in, 147 latent, 148 lobar, 132 local measures in, 157 meningitis in, 147 micro-organism of, 134 migratory, 148 mode of infection, 135 modes of death, 153 mortality of, 152 neuritis in, 147 pathology, 132 pericarditis in, 146 physical signs, 143 pleurisy in, 145 preventive inoculations in, 137 prodromal symptoms, 138 prognosis, 152 purulent infiltration of the lung in, 133 red hepatization in, 132 relapses in, 149 resolution in, 133 secondary, 157 special symptoms, 139 sputum in, 139 stage of engorgement in, 132 symptoms, 138 syphilitic, 337 temperature-chart of lobar, 141 terminations, 140 treatment, 154 typhoid, 147 urine in, 143 venesection in, 155 Pneumonokoniosis, 533 Pneumopericardium, 585 Pneumorrhagia, 508 Pneumothorax, 562 bell-tympany in, 565 diagnosis from large pleural cavity, 567 from large pulmonary cavity, 566 dyspnea in, 563 etiology, 562 Hippocratic succussion in, 565 metallic tinkling in, 565 Pneumotoxin, 138 Pneumotyphoid, 38 Podagra, 392. (See Gout.) Poikilocytosis, 419. (See Anemia.) Poisoning by milk and meat 1218 1219 Polioencephalitis of Strumpell, 1131 Poliomyelitis, acute, 1076 anterior, 1074 chronic, 1076 subacute, 1076 Polysarcia adiposa, 1221. (See Obesity.) Polyuria, 385. (See Diabetes Insipidus.) Pons, tumors of, 1125 Porencephalia of Hesche, 1123 Portal vein, stenosis of, 868 suppurative pylephlebitis, 866 thrombosis and embolism of, 866 Post-epileptic phenomena. 1138 Post-hemiplegic chorea, 1148 Post-typhoid elevations of temperature, 32 Pott's disease, 1096 Presystolic murmur, 603, 614 Priapism in leukemia, 440 Proctitis, 795 Progressive hemiatrophy of the face, 1186 muscular atrophy, 1092 ossifying myositis, 1194 pernicious anemia, 426 arsenic and bone-marrow in treatment of, 432 blood in, 430 diagnosis, 430 lesions of, 427 spinal muscular atrophy, 1194 Prostate, tuberculosis of, 313 Protozoa, 1232. (See Psorospermiasis.) Pseudo-angina pectoris, 671 Pseudo-apoplectic attacks in fatty heart, 655 Pseudo-bulbar paralysis, 1092 Pseudo-cyesis, 1168 Pseudo-diphtheria, 179 Pseudo-hydrophobia, 358 Pseudo-hypertrophic muscular paralysis, 1196 Pseudo-leukemia, 444 blood in, 445 spleen in, 445 varieties, 445 Psorospermiasis, 1233 Ptosis, 1044 Ptyalism, 707 Pulex irritans, 1258 penetrans, 1258 Pulmonary apoplexy, 508 atelectasis, 579 diagnosis from pleuritic effusion, 521 physical signs, 520 edema, 501 embolism, 508 hemorrhage, 502 etiology, 503 treatment, 506 varieties not due to phthisis, 505 incompetency, 619 regurgitation, 619 stenosis, 620 Pulse, capillary, Quincke's, 601 Corri gan's, 601 Pulse-tracings, 602. 604, 613 Pulsus alternans, 667 paradoxus, 577 quadrigeminus, 668 trigeminus, 668 Puncture, lumbar, 1066, 1105 Pupil, Argyll-Eobertson, 1080 Purpura, 412 arthritic, 413 fulminans, 414 haemorrhagica, 414 1280 INDEX. Purpura, Henoch's, 414 idiopathic, 412 pemphigoid, 413 prognosis, 415 secondary, 412 simplex, 412 treatment, 415 Pustule, malignant, 352. (See Anthrax.) Pyelitis, 989 catarrhal, 990 hemorrhagic, 992 obstructive, 990 pathology, 989 pyuria in, 991 Pyelonephritis, 989. (See Pyelitis.) Pyemia, 199 abscesses in, 199 bacteriology, 199 diagnosis from septicemia, 202 pathology, 199 paths of infection of the body in, 200 spontaneous, 200 temperature in, 201 treatment, 202 ulcerative endocarditis in, 201 Pylephlebitis in appendicitis, 813 in dysentery, 102 Pyonephrosis, 989 Pyo-pneumothorax, 562. (See Pneumothorax.) subphrenicus, 873. (See Acute Perihepa- titis.) Pyuria, 942, 991 in cystitis, 1003 Quartan parasites, 82 Quinine as a specific in malaria, 93 hydrobromate hypodermically in ma- laria, 94 Quinsy, 711. (See Tonsillitis.) Quotidian intermittent fever, 82 Babies, 356. (See Hydrophobia.) preventive inoculation in, 358 Rachitic rosary, 405 Rachitis, 402 Radial paralysis, 1062. (See Musculo-spiral Paralysis.) Rag-pickers', disease, 355 Railroad spine, 1165 Rainey's tube, 1232 Ray-fungus, 350. (See Actinomyces.) Raynaud's disease, 1184 clinical grades, 1185 diagnosis of, from diabetes, 1186 hysteric, 1185 paroxysmal hemoglobinuria in, 1185 Reaction of degeneration in anterior polio- myelitis, 1075 in chronic myelitis, 1074 in neuritis, 1029 in progressive muscular atrophy, 1094. (See Myelopathic.) Recrudescence of fever in typhoid fever, 32 Rectum, syphilis of, 337 tuberculosis of, 306 Recurrent laryngeal nerve, paralysis of, 1055 Recurring multiple neuritis, 1030 Red softening of brain, 1108 Reduplication of heart-sounds, 668 Reichmann's disease, 781 Relapse in typhoid fever, 50 Relapsing fever, 72 causes, 73 Relapsing fever, clinical varieties, 76 history, 72 pathology, 73 spirillum of, 73 Remittent fever, 88 Ren mobilis, 929 "• Renal cplic, 964 tuberculosis, 312 Respiratory system, diseases of, 465 Rest-cure in hysteria, 1177 Retina, diseases of, 1038 Retinitis, albuminuric, 1038 leukemic, 440 pigmentary, 1038 syphilitic,'1038 Retroperitoneal sarcomata, 928 Retropharyngeal abscess, 722 Rhabdomyoma of kidney, 999 Rhagades, 331 Rheumatic fever, 202 gout, 387. (See Arthritis Deformans.) myositis, 365 nodules, subcutaneous, 207 peliosis, 411 Rheumatism, acute articular, 202 bacteriology, 203 blood in, 203 chronic articular, 366 complications, 206 diagnosis, 209 differential, 209 duration, 205 endocarditis and pericarditis in, 206 gonorrheal, 209 immunity in, 204 in children, 209 joints in, 205 local measures in, 213 monarticular, 205 muscular, 363 treatment, 365 pathology, 203 subacute, 213 symptoms, 204 temperature in, 207 treatment, 211 Rheumatoid arthritis, 387. (See Arthritis Deformans.) Rhinitis, acute, 464 atrophica, 466 chronic, 466 hypertrophica, 466 simplex, 465 syphilitica, 331 Ribs, resection of, in empyema, 559 Rice-water stools, 112 Rickets, 402. (See Rachitis.) etiology, 403 " fat-rickets," 406 Harrison's groove in, 405 prophylaxis, 406 Rock-fever, 369. (See Malta Fever.) Romberg's sign, 1080 Root-nerve symptoms in compression-para- plegia, 1096 "Rose-cold," 469 Rose-spots, 32 Rotheln, 248. (See Rubella.) Round worms, 1234 Rubella, 248 Rubeola notha, 248. (See Rubella.) Rumination, 782 Rupture of heart, 659 INDEX. 1281 Saccharomyces albicans, 699 Sacral plexus, diseases of, 1063 Salaam convulsions in hysteria, 1179 Salad, chicken, poisoning by, 1219 Saline injections, intravenous, in diabetic coma, 385 subcutaneous, in cholera, 117 Salivary glands, diseases of, 707 Salivation, 703 in bulbar paralysis, 1091 Saltatoric spasm, 1153. (See Spasm.) Sand-flea, 1258 Sanitaria, home, 322 Sapremia, 195. (See Septicxmia.) Saranac sanitarium, 322 Sarcina ventriculi, 743 Sarcoma, mediastinal, 570 melanotic, 897 of bladder, 1006 of brain, 1123 of kidney. 999 of liver, 897 of lung, 537 of pleura, 568 Sarcoptes scabiei hominis, 1257 Sardonic grin, 361 Saturnine encephalopathy, 1215 neuritis, 1030 Saturnism, 1212 Sausage-poisoning, 1219 Scarlatina, 234. (See Scarlet Fever.) Scarlet fever, 234 anginose form, 238 arthritis synovitis, rheumatism in, 239 atactic form, 238 causes, 235 complications, 239 desquamation in, 239 diagnosis, 241 eruption in, 236 "goose-skin" in, 236 hemorrhagic, 238 immunity in, 236 incubation period, 236 infection in, 235 invasion of, 236 lesions in, 234 malignant, 238 microorganisms in, 234 mild form, 238 modes of conveyance in, 235 nephritis in, 239 otitis in, 239 prognosis, 242 prophylaxis against nephritis, 244 pulse in, 237 pyemia in, 239 sine eruptione, 238 temperature in, 237 tongue in, 237 tonsils in, 236 treatment, 242 urine in, 237 Schlammfieber, 368 Schonlein's disease. (See Rheumatic peli- osis. ) "Schweinfurth's" green, 1215 Sciatic nerve, 1063 Sciatica, 1035 Scleroderma diffusum, 1188 Sclerosis, amyotrophic lateral, 1092 arterial, 676 Sclerosis caused by ergotism"—"ergot tabes," 1220 caused by syphilis, 333. (See also Loco- motor Ataxia.) combined system, 1087 lateral, 1084 multiple or disseminated, 1088 of brain, 1129 of pulmonary artery, 677 of veins, 677 posterior, 1078 Sclerotic changes in chronic gastritis, 753 Scolices of echinococcus, 1247 Scorbutus, 407 diagnosis, 410 dietetic treatment, 410 infantile, 411 Scrivener's palsy, 1161. (See Writers' cramp.) Scrofula, 271. (See Tuberculosis of Lymph- glands. ) Scrotal appendicitis, 813 Scurvy, 407. (See Scorbutus.) Seasonal relations of erysipelas, 171 of malaria, 80 of pneumonia, 136 of rheumatism, 204 Secondary fever-curve in small-pox, 220 spastic paralysis, 1086 Senile chorea, 1145 emphysema, 529 " Sepsis intestinalis," 196 Septicemia, 195 bacteriology, 195 coagulation-necrosis in, 195 diagnosis from sapremia, 198 modes of infection aud introduction of the poison into the system, 196 pathology, 195 ptomains in, 195 symptoms, 197 treatment, 198 true, 198 Serous membranes, tuberculosis of, 307 Sewer-gas, relation of, to typhoid fever 26 Shaking palsy, 1153. (See Paralysis Agitans.) Shell-fish, poisoning by, 1219 Ship fever. (See Typhus Fever.) Sick headache, 1140. (See Migraine.) Siderosis, 535. (See Pneumonokoniosis.) Simple continued fever, 370. (See Febricula.) Sinus-thrombosis, 1109 in chlorosis, 423, 1109 secondary to ear-disease, 1109 Sixth nerve, paralysis of, 1045 Skoda's resonance in lobar pneumonia, 144 in sero-fibrinous effusion, 547 Skull in external hydrocephalus, 1126 in internal hydrocephalus, 1127 in rickets, 403 natiform, in congenital syphilis, 331 Small-pox, 215 abortive form, 223 bacteriology, 217 causes, 217 complications, 219 confluent form, 222 contagion of, 217 diagnosis, 223 eruption of, 219 hemorrhagic form, 222 immunity in, 217 incubation of, 218 81 1282 INDEX. Small-pox, initial rashes in, 218 mortality and prognosis, 225 prophylaxis in, 225 secondary lesions in, 216 special modes of treatment, 228 symptoms, 219 treatment, 225 Snake-virus, purpura caused by, 412 Snuffles, 331 Soil, influence of, in cholera, 110 in malaria, 79 in tuberculosis, 270 in typhoid fever, 24 Southern California in tuberculosis, 321 Southern Georgia, 321, 322 Southern Italy and France, 322 Spasm, habit-, 1149 in ergotism, 1220 in hydrophobia, 357 in hysteria, 1166, 1168 mimic, 1150 of the intestine, 843 retro-colic, 1058 saltatoric, 1153 tonic, in tetanus, 360 Spasmodic laryngitis, 475 Spasms of paralysis, 1047 Spastic paraplegia, 1084 congenital, 1086 family tendency in, 1085 Speech, 1118. (See Aphasia.) in general paralysis of insane, 1130 in hereditary ataxia, 1083 loss of, in bulbar paralysis, 1091 scanning, in multiple sclerosis, 1089 Spina bifida in lesions of cauda equina, 1101 Spinal accessory nerve, paralysis of, 1059 compression, 1097 cord, abscess of, 1077 compression of, 1096 diseases of, 1064 disturbance of circulation in, 1068 hemorrhage into, 1069 localization of functions of, 1018 syphilis of, 334 tuberculosis of, 315 tumors of, 1097 unilateral lesion of, 1077 membranes, hemorrhage into, 1067 meningitis, acute, 1065 nerves, diseases of, 1061 neurasthenia, 1175 Spirals, Curschmann's, 493 Spirillum of relapsing fever, 73 Splanchnoptosis, 790 Splashing sounds in dilatation of stomach, 744 Spleen, amyloid degeneration of, 901 diseases of, 897 dislocation of, 898 echinococcus of, 1251 floating, 898 hyperemia of, 898 in anthrax, 354 in cirrhosis of liver, 888 in malaria, 79, 90 in pseudo-leukemia, 447 in rickets, 406 in typhoid fever, 20, 28 in typhus fever, 69 morbid growths of, 901 rupture of, 901 sago, 901 | Splenic fever, 352. (See Anthrax.) Splenitis, 898 Spondylitis deformans, 390. (See Arthritis Deformans.) Sporadic cretinism, 461. (See Myxedema.) Spotted fever, 123. (See Cerebro-spinal Men- ingitis.) Sputa, ameba coli in, 102, 879 in abscess of lung, 533 in acute bronchitis, 480 in asthma, 493 in bronchiectasis, 488 in cancer of lung, 536 in chronic bronchitis, 484 in chronic pulmonary tuberculosis, 290 in edema of lung, 501 in fetid bronchitis, 484 in gangrene of lung, 531 in lobar pneumonia, 139 St. Anthony's fire. (See Erysipelas.) St. Vitus's dance, 1142. (See Chorea.) Status eclampticus, 1159 epilepticus, 1138 Stellwag's sign, 459 Stenocardia, 669. (See Angina Pectoris.) Stenosis, bronchial, 491 of aortic orifice, 603 of mitral orifice, 611 pulmonary, 620 tricuspid, 618 Stomach, auscultation of, 740 carcinoma of, 769 chemical examination of contents, 734 dilatation of, 742 diminished peristalsis of, 782 diseases of, 733 hemorrhage of, 776 hyperacidity of, 780 hyperesthesia of. 785 increased peristalsis of, 782 inflammatory diseases of, 747 malposition of, 741 neuroses of, 777 of motility of, 782 of secretion of, 780 of sensation of, 783 palpation of, 739 percussion of, 740 physical or external examination of, 738 test for absorptive power of, 738 test-meals used in diagnosis, 734 tests for the motor function of, 737 ulcer of, 761 Stomatitis, 693 aphthous, 694 gangrenous, 701 La Perleche, 701 membranous, 696 mercurial, 703- parasitic, 699 ulcerative, 697 Strabismus, 1045 Strangulation of bowel, 826 " Strawberry tongue " in scarlet fever, 237 Stricture of esophagus, 730 Strictures and tumors of bowel, 828 cicatricial, of bowel, 828 congenital, of bowel, 828 Strongyloides intestinalis, 1246 Strumitis, 454. (See Thyroiditis.) Styrians. arsenical habit in, 1216 Subphrenic abscess, 566. (See Acute Peri- hepatitis.) INDEX. 1283 Succussion, Hippocratic, 565, 566 Sudoral form of typhoid fever, 33 Sugar in the urine, 374. (See Diabetes Mel- litus.) Sun-stroke, 1226. (See Heat-stroke.) Suppurative pneumonitis, 532. (See Abscess of Lungs.) pylephlebitis, 866 Surgical kidney, 989 Swamp-fever. (See Malaria.) Sweating sickness, 372. (See Miliary Fever.) Sydenham's chorea, 1142. (See Acute Chorea.) Symptom-complex of Brown-Sequard, 1099 Syncope, local, in Raynaud's disease, 1185 Synovitis, gonorrheal, 213 Syphilis, 326 amyloid degeneration in, 330 bacteriology of, 327 brain-tumor in, 334 Colles' law in, 328 differential diagnosis of, 341 eruption of, 329 general diagnosis, 340 gummata in, 330 haemorrhagica neonatorum, 418 hereditary, 328 Hutchinson teeth in, 332 hypodermic treatment, 343 incubation of, 329 inunctions in, 343 late symptoms of hereditary, 333 malignant, 330 modes of infection, 328 morbid anatomy, 327 of alimentary tract, 336 of arteries, 339 of brain and cord, 333 of circulatory system, 338 of joints, 339 of kidneys, 339 of liver, 334 of lungs, 337 of spleen, 338 of testicles, 340 of the arteries, 339 primary sore of, 329 stage, 329 secondary stage, 329 tertiary stage, 330 treatment of acquired, 343 of hereditary, 342 visceral, 333 Syphilitic cachexia, 329 fever, 329 paralysis, 334. (See Dementia Paralytica.) Syringomyelia, 1094 hydromyelia in, 1095 Taenia mediocanellata, 1253 nana, 1256 solium, 1252 Taeniae or tape-worms, 1252 Teeth, Hutchinson's, 332 Temperature-sense, loss of, in syringomyelia, 1095 Tertian intermittent fever, ameba causing, 82 Testes, syphilis of, 340 tuberculosis of, 313 Tetanus, 359 acute, 360 antitoxin of, 363 bacillus of, 360 cephalic, 361 chronic, 361 diagnosis, 361 duration, 362 idiopathic, 360 immunity in, 360 incubation, 360 modes of infection, 360 morbid anatomy, 359 mortality, 362 traumatic, 360 treatment, 363 Tetany, 1155 Thermic fever, 1227 Third nerve, diseases of, 1043 paralysis of, 1043 relapsing and recurring paralysis of, 1043 Thomsen's disease, 1201 Thoracic aorta, aneurysm of, 681 dropsy, 567. (See Hydrothorax.) duct, rupture of tuberculous focus into, 275 Thorax in emphysema, 526 in pulmonary tuberculosis, 283 in rachitis, 405 Thread-worm, 1236 Throat, acute infectious phlegmon of, 721 Thrombi in veins in typhoid fever, 39 Thrombosis, cardiac, 634 Thrush, 699. (See Parasitic Stomatitis.) Thymus gland, diseases of, 572 Thyroid extract, use of, 460, 463, 464, 1153 gland, diseases of, 454 in cretinism, 464 in exophthalmic goiter, 457 in goiter, 455 in myxedema, 461 Thyroidin, 461 Thyroiditis, 454 Thyro-proteid, 461 Tic convulsif, 1150 douloureux, 1034 general, 1152 Tobacco as a cause of arrhythmia, 668 of tremor, 1155 Tongue, acute inflammation of, 704 atrophy of, 1060 chronic inflammation of, 705 diseases of, 704 fissure of, 706 in bulbar paralysis, 1092 paralysis of, 1060 spasm of, 1060 ulcers of, in syphilis, 329 Tonsillitis, acute catarrhal, 710 acute parenchymatous, 711 chronic, 715 follicular, 710 Tabes, diabetic, 380 dorsal is, 1078. (See Locomotor Ataxia.) mesenterica, 310 Tache bleuatres, 33 Tachycardia, 663 neurotic, 664 symptomatic, 664 Tactile fremitus in emphysema, 527 in passive hyperemia, 499 in pleural effusion, 546 in pneumothorax, 564 in pulmonary tuberculosis, 294 Taenia cucumerina, 1256 echinococcus, j24J flavopunctata, 1256 1284 INDEX. Tonsillitis, necrotic, 712 Tonsils, diseases of, 709 Toothache in actinomycosis, 351 Tophi in gout, 393 Torticollis, 364. (See Muscular Rheumatism.) Tracheo-bronchitis, 478 Traube's semilunar space, 547 Tremor, hereditary, 1155 hysteric, 1155 in exophthalmic goiter, 459 in multiple sclerosis, 1155 in paralysis agitans, 1154 senile, 1155 simple, 1155 smokers', 1155 toxic, 1155 Trichina spiralis, 1239 sources of infection with, 1240 Trichinosis, 1239 diagnosis, 1242 symptoms, 1241 treatment, 1242 Trichocephalus dispar, 1238 Tricuspid incompetency or regurgitation, 615 regurgitation, murmur in, 617 venous congestion in, 617 stenosis, 618 Trigeminus, 1046. (See Fifth Nerve.) Trismus, 359. (See Tetanus.) Trousseau's sign in tetany, 1156 Tuberculosis, 260 acute, 274 cerebral or meningeal form, 278 general miliary form, 275 pulmonary form, 277 typhoid form, 275 amyloid degeneration in, 289 antiseptic treatment of, 319 associated diseases and complications, 316 associated inflammatory processes in, 263 bacillus of, 263 biology of bacillus, 264 cavities in chronic, 287 changes occurring in a tubercle, 262 chemical products elaborated by bacillus, 264 chronic, 285 climatic treatment of, 321 clinical types of tuberculous meningitis, 281 contagious theory of, 266 diagnosis of acute, 276 of chronic, 301 diet in, 323 differential diagnosis, 302 direct hereditary transmission, 268 disseminated, 288 distribution of the bacilli in, 264 of tubercular lesions in, 261 dyspnea in,293 elastic fibers in, 292 elementary tubercle, 261 etiology, 263 of chronic, 285 Flick's studies in, 266 general pathology of tubercular lesions, 261 general prognosis, 316 general symptoms, 297 general tuberculous adenitis, 274 geographical distribution of, 260 hemoptysis in chronic, 293 Tuberculosis, histology of tuberculous men- ingitis, 280 historic note of, 261 infection by inoculation, 267 by swallowing, 266 inhalation of the bacilli, 265 inoculations in, 264 interstitial pneumonia in, 288 intestinal, 305 isolation in, 318 local causes, 270 symptoms of chronic, 290 mensuration in, 294 method of staining bacilli, 291 modes of infection, 265 morbid anatomy of chronic, 285 night-sweats in, 299 of alimentary tract, 305 of arteries and veins, 316 of brain, 315 of bronchial glands, 273 of endocardium, 289 of Fallopian tubes, ovaries, and uterus, 314 of genito-urinary system, 312 of heart, 315 of intestinal tract, 289 of kidneys, 312 of larynx, 289 of lip, 304 of liver, 311 of lymph-glands, 271 of mammary glands, 315 of mesenteric glands, 273 of pericardium, 308 of peritoneum, 309 of pleura, 288 of serous membranes, 307 of spinal cord, 315 onset of chronic, 289 pathology of tuberculous meningitis, 278 physical signs in stage of consolidation, 293 of cavity, 296 predisposing causes, 268 prognosis of tuberculous meningitis, 282 prophylaxis, 317 sources of the bacilli, 264 special remedies in, 324 special symptoms of chronic, 299 sputum in, 290 stages in development of tubercle, 261 symptoms of tuberculous meningitis, 280 temperature in chronic, 298 treatment, 319 of leading symptoms, 324 tuberculin in, 320 Tumors, intracranial, 1122 of larynx, 477 of nerves, 1032. (See Neuromata.) of spinal cord, 1097 Tunnel-anemia, 1238 Tussis convulsiva, 251. (See Whooping-cough.) Twists and knots in the bowels, 827 Tylosis linguae, 706. (See Lingual Psoriasis.) Tympanites in acute peritonitis, 914 in appendicitis, 8i8 in intestinal obstruction, 829, 830 in typhoid fever, 34 Typhoid fever, 17 abnormal course of fever, 31 bacteriology of, 22 INDEX. 1285 Typhoid fever, bed sores in, 33 blood-changes in, 40 chart showing effect of cold baths in, 59 clinical history, 27 varieties, 44 complicated by infectious diseases, 43 constipation in, 33 contraindications to cold baths in, 59 delirium in, 41 diabetes in, 43 diagnosis, 46 diarrhea in, 34 diazo-reaction in, 43 diet in, 54 differential diagnosis, 47 disinfection in, 52 Ehrlich's reaction in, 43 epistaxis in, 38 etiology, 22 fastigium or second stage, 28 gastric symptoms in, 36 guaiacol in treatment of, 60 headache in, 62 history, 17 hydrotherapy of, 55 hypostatic congestion of lungs in, 38 in children, 45 incubation of, 27 insanity in, 42 insomnia in, 62 internal antipyretics in, 60 intestinal antiseptics in, 61 hemorrhages in, 34 in the aged, 46 isolation of patients, 53 liver in, 20 lobar pneumonia in, 38 lobular pneumonia in, 37 lungs in, 21 management of convalescence in, 65 methods of conveyance of the poison into the human body, 25 modes of infection, 25 mouth and tonsils in, 37 muscular system in, 22, 43 nephritis in, 42 nervous symptoms in, 41 neuralgia in, 42 osseous system in, 43 pathology, 18 perforation in, 35 pericarditis in, 38 period of Wunderlich, 29 peritonitis in, 35 Peyer's patches in, 18 pleuro-typhoid, 45 post-typhoid elevations of tempera- ture in, 32 predisposing causes, 24 prognosis, 48 . prophylactic inoculations in, 53 prophylaxis in, 51 pseudo-membranous inflammation in, 44 pulse in, 39 pyelitis in, 43 recurrence of, 51 relapses in, 50 rose-colored spots in, 32 serum-therapy in, 46, 61 skin-rashes in, 33 Typhoid fever, spleen in, 36 stage of decline, 28 of development, 27 stimulants in, 54 stools in, 34 substitutes for the cold bath in, 59 subsultus tendinuni in, 41 sweating in, 33 temperature-charts in, 30 thrombosis in, 39 tonsillo-typhoid, 36 treatment, 51 of bed-sores, 65 of hemorrhages, 64 of individual symptoms, 62 of lobar pneumonia. (See Sec- ondary Pneumonia.) of tympanites, 64 tympanites in, 34 typho-toxin of, 23 urine in, 42 walking form, 44 Widal's reaction in, 46, 47, 821 Typhus fever, 67 causes, 68 contagiousness of, 68 course and duration, 71 diagnosis, 71 eruption in, 69 history, 67 pathology, 67 symptoms, 68, 71 temperature in, 70 treatment, 72 laevissimus, 44. (See Typhoid Fever.) Ulcer, duodenal, 806 follicular, 809 gastric, 761 intestinal, 806 in typhoid fever, 18 of bowel in dysentery, 98, 100, 103, 106 of esophagus, 724 solitary, 810 stercoral, 809 Ulcerative endocarditis. (See Endocarditis.) stomatitis, 697 Ulcero-membranous tonsillitis, 709 Ulcers, aphthous, 695 Ulnar nerve, diseases of, 21, 1063 Uremia, 958 acute, 959 Chronic, 959 diagnosis from cerebellar hemorrhage and alcoholic narcosis, 961 in chronic nephritis, 984 pathology and etiology, 958 symptoms, 959 Ureter, blocking of, 965 tuberculosis of, 313 Urethritis in lithemia, 401 Uric-acid calculi, 965 diathesis, 400. (See Lithemia.) Urinary system, diseases of, 929 Urine, acetone, diacetic and oxybutyric acids in, 948 albumen in, 937 alkaptone in, 955 bacteria in, 955 bile-pigment in, 944 blood in, 934 chlorides in, 954 chyle in, 943 1286 INDEX. Urine, cystin in, 952 fat in, 954 fibrinous casts in, 955 gas-formation in, 954 glucose in, 945 hematoporphyrin in, 954 hemoglobin in, 936 in acute cystitis, 1003 in Bright's disease, 973, 979, 984 in chronic parenchymatous nephritis, 979 in diabetes insipidus, 386 in diabetes mellitus, 378 in diphtheria, 186 in jaundice, 847 in pneumonia, 143 in scarlet fever, 240 in typhoid fever, 42 incontinence of, 1010 indican in, 941 inosite in, 955 lactose in, 955 leucin and tyrosin in, 952 oxalates in excess in, 950 peptone and albumose in, 941 phosphates in excess in, 951 pus in, 942 retention of, 1011 special pathologic states of, 934 suppression of, in acute intestinal ob- struction, 829 in acute nephritis, 973 urea in, 953 uric acid in excess in, 949 urobilin in, 945 Urobilinuria, 945 Urticaria epidemica, 1259 giant, 1184 in acute articular rheumatism, 207 in chronic gastritis, 756 in pneumonia, 143 in typhoid fever. 33 Uterus, tuberculosis of, 314 Uvula, edema of, in diphtheria, 184 Vaccination, 229 complications, 231 danger of conveying syphilis when hu- manized virus is used, 230 history, 229 lymph used in, 230 operation, 230 period of life for, 231 site, 230 symptoms, 231 time for revaccination, 231 Vaccine virus, 230 Vaccinia, 229 "Vagabond's disease," 453 Valvular (cardiac) diseases, complications of, 621 duration, 622 prophylaxis in, 624 treatment, 625 venesection in, 629 disease of the heart, chronic, 594 tuberculosis, 316 Varicella, 231 cause, 231 diagnosis, 233 from variola, 224 eruption in, 232 gangraenosa, 232 immunity in, 232 Varicella, incubation, 232 treatment, 233 with sero-purulent vesicles, 232 Variola, 215. (See Small-pox.) Varioloid, 223 Vasomotor and trophic disorders, 1183 disturbance in chronic pleurisy, 561 in exophthalmic goiter, 457 in migraine, 1140 in myelitis, 1072 in neuralgia, 1033 in tumors of the spinal cord, 1099 Veal pie, poisoning by, 1219 Veins, arterio-venous aneurysm, 692 cerebral, thrombosis in, 1110 diastolic collapse of, 583 Vena cava inferior, compression of, by an- eurysm, 682 Venesection in chronic valvular disease, 629 in emphysema, 529 in pneumonia, 155 Venous cerebral hemorrhage, 1114 pulse in aortic incompetency, 601 in neurasthenia, 1175 in tuberculosis, 299 Ventricles of brain, enlargement of, 1127 tapping of, 1129 Ventricular hemorrhage, 1114 Vertebrae, injuries and caries of, 1096 Vertigo, auditory, 1052. (See Meniere's Dis- ease. ) gastric, 756 in arterio-sclerosis, 679 in cerebellar disease, 1123 Vesical catarrh in typhoid fever, 43 hemorrhage, 1007 irrigation. 1005 medication, 1006 Vesiculae seminales, tuberculosis of, 313 Voice, change of, in mouth-breathers, 716. (See Speech.) A'olitional tremor, 1089 Volvulus, 827 Vomica, 287. (See Cavities in Chronic Tuber- culosis.) Vomit, black, 121 coffee-ground, 771 stercoraceous, 829 Wall-paper a source of arsenical poison- ing, 1215 War of the Rebellion, statistics of dysen- tery in, 97 Washing out the stomach, method of, 734 Water, infection by, in cholera, 111 in dysentery, 100 in typhoid fever, 25 Water-hammer pulse, 60 Weber, syndrome of, 281 Weil's disease, 368 Weir Mitchell's disease, 1190 Werlhoff's disease, 414 Wernick's "aphasia of conduction," 1120 Wet pack, 60 " White flux" of India, 802 White softening, cerebral, 1109 Whooping-cough, 251 catarrhal stage, 254 complications and sequelae, 255 contagiousness, 251 diagnosis, 256 etiology, 251 incubation, 254 INDEX. 1287 Whooping-cough, mortality, 255 nature and bacteriology, 203 paroxysmal stage, 254 pathology, 251 prognosis, 255 symptoms, 254 treatment, 257 Winckel's disease, 418. (See Epidemic Hemo- globinuria.) Wringed scapulae, 294, 526 Wintrich's sign, 297 Wood-tick, 1259 AArool-sorters' disease, 352. (See Anthrax.) AATord-blindness, 1121 AAford-deafness, 1120 Wormian bones, 1127 Worms, 1234. (See Nematoda.) Wound-diphtheria, 185 Wrist-drop, 1062 in plumbism, 1214 Writers' cramp, 1161 Wry-neck, 1057. (See Torticollis.) Wunderlich, "ambiguous period" of, 29 Xanthelasma, 848 Xanthin, 965 Xanthopsia, 848, 1236 Xerostoma, 708 Yellow Fever, 118 bacteriology, 119 blood in, 119 causes, 119 duration, 121 epidemics of, 118 grave symptoms in, 121 hemorrhages in, 120 history, 118 incubation, 119 invasion stage, 120 mortality, 121 pathology, prophylaxis in, 122 protective inoculation in, 122 remission stage, 120 secondary fever or collapse in, 12Q temperature in, 119 treatment, 122 varieties, 121 vomit in, 120 softening, cerebral, 1108 vision, 1236 Yeo's diet list, 1225 CATALOGUE OF THE MEDICAL PUBLICATIONS OF W* B* SAUNDERS, No. 925 WALNUT STREET, PHILADELPHIA. Arranged Alphabetically and Classified under Subjects. TpHE books advertised in this Catalogue as being sold by subscription are usually to be obtained from traveling solicitors, but they will be sent direct from the office of pub- lication (charges of shipment prepaid) upon receipt of the prices given. All the other books advertised are commonly for sale by booksellers in all parts of the United States; but any book will be sent by the publisher to any address, carriage prepaid, on receipt of the published price. Money may be sent at the risk of the publisher in either of the following ways: A post-office money order, an express money order, a bank check, and in a registered letter. Money sent in any other way is at the risk of the sender. See pages 30, 31, for a List of Contents classified according to subjects. LATEST PUBLICATIONS. Amer.Text-Book of Genito-Urinary and Skin Diseases. Page 3. Macdonald's Surgical Diagnosis, just Ready. See page 16. Anders* Practice of Medicine. See page 6. Moore's Orthopedic Surgery, just Ready. See page n. Penrose's Diseases of Women. See page 18. Mallory and Wright's Pathological Technique. See page 16. Van Valzah and Nisbet's Diseases of the Stomach. See page 28. American Year-Book of Medicine and Surgery. See page 6. Senn's Genito-Urinary Tuberculosis. See page 25. Sutton and Giles' Diseases of Women. See page 28. Stoney's Nursing—Revised Edition. See page 27. Garrigues' Diseases of Women—Revised Edition. See page ». Keen's Surgical Complications of Typhoid Fever. See page is. Gould and Pyle's Curiosities of Medicine. See page u. De Schweinitz' Diseases of the Eye—Revised Edition. Page jo. Chapin's Compendium of Insanity. Just Ready. See page 8. Church and Peterson's Nervous and Mental Diseases. Page 9» SPECIAL ANNOUNCEMENT. Mr. Saunders is pleased to announce that arrangements have been completed for the publication of an English edition of the world-famous Lehmann medicinische Handatlanten. For scientific accuracy, pictorial beauty, compactness, and cheapness these books surpass any similar volumes ever published. Each volume contains from 50 to 100 Colored Plates, besides numerous other illustrations in the text. These colored plates have been executed by the most skilful German lithographers, in some cases twenty or more impressions being required to obtain the desired result. There is a full and appropriate description of each plate (printed, for convenience, opposite the plate), together with a condensed outline of the subject to which the book is devoted. The same careful and competent editorial supervision will be secured in the English edition as in the originals. The translations will be directed and edited by the leading American specialists in the different subjects. The great advantage of natural pictorial representation is indisputable. For lasting and practical knowledge, one accurate illustration is better than several pages of dry description. These Atlases offer a ready and satisfactory substitute for clinical observation, avail- able only to the residents of large medical centers; and with such persons the requisite variety is seen only after long years of routine hospital service. By reason of their projected universal translation and reproduction, affording inter- national distribution, the publishers have been enabled to secure for these Atlases the best artistic and professional talent, to produce them in the most elegant style, and yet to offer them at a price heretofore unapproached in cheapness. The success of the under- taking is demonstrated by the fact that volumes have already appeared in German, English, French, Italian, Russian, Spanish, Danish, Swedish, and Hungarian. While appreciating the value of such colored plates, the profession has heretofore been practically debarred from purchasing similar works because of their extremely high price, made necessary by the limited sale and the enormous expense of production. The very low price of these Atlases will place them within the reach of even the novice in practice. The following volumes are in active preparation and will be issued at an early date: Atlas of Internal Medicine and Clinical Diagnosis. By Dr. Chr. Jakob, of Erlangen. Edited by Augustus A. Eshner, M.D., Professor of Clinical Medicine in the Philadelphia Polyclinic; Attending Physician to the Philadelphia Hospital. 68 colored plates, and 64 illustrations in the text. Atlas Of Legal Medicine. By Dr. E. R. von Hofmann, of Vienna. Edited by Frederick Peterson, M.D., Clinical Professor of Mental Diseases, Woman's Medical College, New York; Chief of Clinic, Nervous Dept., College of Physicians and Surgeons, New York. With 120 colored figures on 56 plates, and 193 beautiful half-tone illustrations. Atlas of Operative Surgery. By Dr. O. Zuckerkandl, of Vienna. Edited by J. Chalmers DaCosta, M.D., Clinical Professor of Surgery, Jefferson Medical College, Philadelphia ; Surgeon to the Philadelphia Hospital. With 24 colored plates, and 217 illustrations in the text. Atlas Of Laryngology. By Dr. L. GrUnwald, of Munich. With 107 colored figures on 44 plates; 25 black-and-white illustrations. Atlas of External Diseases of the Eye. By Dr. O. Haab, of Zurich. Edited by G. E. de Schweinitz, M.D., Professor of Ophthalmology, Jefferson Medical College, Philadelphia. With 100 colored illustrations. Atlas of Venereal Diseases. By. Dr. Karl Kopp, of Munich. Edited by L. Bolton Bangs, M.D., late Professor of Genito-Urinary and Venereal Diseases, New York Post-Graduate Medical School and Hospital. With 63 colored illustrations. Atlas of Skin Diseases. By Dr. Karl Kopp, of Munich. With 90 colored and 17 black-and-white illustrations. Medical Publications of W. B. Saunders. 3 AN AMERICAN TEXT-BOOK OF APPLIED THERAPEUTICS. Edited by James C. Wilson, M.D., Professor of the Practice of Medicine and of Clinical Medicine in the Jefferson Medical College, Philadelphia. One handsome imperial octavo volume of 1326 pages. Illustrated. Cloth, $7.00 net; Sheep or Half Morocco, $8.00 net. Sold by Subscription. "As a work either for study or reference it will be of great value to the practitioner, as it is virtually an exposition of such clinical therapeutics as experience has taught to be'of the most value. Taking it all in all, no recent publication on therapeutics can be compared with this one in practical value to the working physician."—Chicago Clinical Review. "The whole field of medicine has been well covered. The work is thoroughly prac- tical, and while it is intended for practitioners and students, it is a better book for the general practitioner than for the student. The young practitioner especially will find it extremely suggestive and helpful."—The Indian Lancet. AN AMERICAN TEXT=BOOK OF THE DISEASES OF CHILDREN. Edited by Louis Starr, M.D., Physician to the Children's Hospital, Philadelphia, etc.; assisted by Thompson S. Westcott, M.D., Attend- ing Physician to the Dispensary for Diseases of Children, Hospital of the University of Pennsylvania. In one handsome imperial octavo volume of 1190 pages, profusely illustrated. Cloth, $7.00 net; Sheep or Half Morocco, $8.00 net. Sold by Subscription. "This is far and away the best text-book on children's diseases ever published in the English language, and is certainly the one which is best adapted to American readers. We congratulate the editor upon the result of his work, and heartily commend it to the attention of every student and practitioner."—American Journal of the Medical Sciences. "A condensation between the lids of a single volume of an amount of information upon childhood and its diseases which will be eagerly sought after by the profession."—New York Medical Times. AN AMERICAN TEXT-BOOK OF DISEASES OF THE EYE, EAR, NOSE, AND THROAT. Edited by G. E. de Schweinitz, M.D., Professor of Ophthalmology in the Jefferson Medical College, Philadelphia; and B. Alexander Randall, M.D., Professor of Diseases of the Ear in the University of Pennsylvania and in the Philadelphia Polyclinic. In Preparation. AN AMERICAN TEXT=BOOK OF GENITO-URINARY AND SKIN DISEASES. Edited by L. Bolton Bangs, M.D., Late Professor of Genito-Urinary and Venereal Diseases, New York Post-Graduate Medical School and Hospital; and William A. Hardaway, M.D., Professor of Diseases of the Skin, Missouri Medical College. In Press. Ready soon. This latest addition to the series of "American Text-Books" it is confidently believed will meet the requirements of both students and practitioners, giving, as it does, a comprehensive and detailed presentation of the Diseases of the Genito-Urinary Organs, of the Venereal Diseases, and of the Affections of the Skin. Having secured the collaboration of well-known authorities in the branches represented in the dertaking the Editors have not restricted the Contributors in regard to the particular views set f th but have offered every facility for the free expression of their individual opinions. The work will therefore be found to be original, yet homogeneous and fully representative of the several depart- ments of medical science with which it is concerned. Hlustrated Catalogue of the "American Text-Books" sent free upon application. 4 Medical Publications of W. B. Saunders. AN AMERICAN TEXT=BOOK OF GYNECOLOGY, MEDICAL AND SURGICAL. Edited by J. M. 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Its descriptions of conditions, its recommen- dations for treatment, and above all the necessary technique of different operations, are clearly and admirably presented.....It is well up to the most advanced views of the day, and embodies all the essential points of advanced American gynecology. It is destined to make and hold a place in gynecological literature which will be peculiarly its own."— Medical Record, New York. AN AMERICAN TEXT-BOOK OF LEGAL MEDICINE AND TOXI- COLOGY. Edited by Frederick Peterson, M.D., Clinical Professor of Mental Diseases in the Woman's Medical College, New York ; Chief of Clinic, Nervous Department, College of Physicians and Surgeons, New York ; and Walter S. Haines, M.D., Professor of Chemistry, Pharmacy, and Toxicology in Rush Medical College, Chicago. In Preparation. AN AMERICAN TEXT-BOOK OF OBSTETRICS. Edited by Richard C. Norris, M.D.; Art Editor, Robert L. 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"The obstetrician and the general practitioner will find this book not only a pleasant and interesting volume, but the most valuable of its kind, both on account of the wide experience of the several authors and because of the attractiveness and accuracy of its illustrations. . . . As an authority, as a book of reference, as a ' working book' for the student or practitioner, we commend it because we believe there is no better."—American Journal of the Medical Sciences. AN AMERICAN TEXT=BOOK OF PATHOLOGY. Edited by John Guiteras, M.D., Professor of General Pathology and of Morbid Anatomy in the University of Pennsylvania; and David Riesman, M.D., Demonstrator of Pathological Histology in the University of Pennsylvania. In Preparation. Illustrated Catalogue of the "American Text-Books" sent free upon application. Medical Publications of W. B. Saunders. 5 AN AMERICAN TEXT-BOOK OF PHYSIOLOGY. Edited by William H. Howell, Ph. 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" If this text-book is a fair reflex of the present position of American surgery, we must admit it is of a very high order of merit, and that English surgeons will have to look very carefully to their laurels if they are to preserve a position in the van of surgical practice."— London Lancet. "This book marks an epoch in American book-making. All in all, the book is dis- tinctly the most satisfactory work on modern surgery with which we are familiar. It is thorough, complete, and condensed."—Boston Medical and Surgical Journal. AN AMERICAN TEXT-BOOK OF THE THEORY AND PRACTICE OF MEDICINE. Edited by William Pepper, M.D., LL.D., Professor of the Theory and Practice of Medicine and of Clinical Medicine in the University of Pennsylvania. Two handsome imperial octavo volumes of about 1000 pages each. Illustrated. Prices per volume : Cloth, $5.00 net; Sheep or Half Morocco, $6.00 net. Sold by Subscription. " I am quite sure it will commend itself both to practitioners and students of medicine, and become one of our most popular text-books."—Alfred Loomis, M.D., LL.D., Pro- fessor of Pathology and Practice of Medicine, University of the City of New York. " We reviewed the first volume of this work, and said: ' It is undoubtedly one of the best text-books on the practice of medicine which we possess.' A consideration of the second and last volume leads us to modify that verdict and to say that the completed work is in our opinion the best of its kind it has ever been our fortune to see."—New York Medical Journal. " American physicians can look with pride upon the work of Dr. Pepper and his corps f ciates It brings our knowledge down to the present hour, and has been written from an eminently practical standpoint."— Medical Record, New York. Til trated Catalogue of the "American Text-Books'' sent free upon application. 6 Medical Publications of W. B. Saunders. AN AMERICAN YEAR-BOOK OF MEDICINE AND SURGERY. A Yearly Digest of Scientific Progress and Authoritative Opinion in all branches of Medicine and Surgery, drawn from journals, monographs, and text-books of the leading American and Foreign authors and investigators. Collected and arranged, with critical editorial com- ments, by eminent American specialists and teachers, under the general editorial charge of George M. Gould, M.D. One handsome imperial octavo volume of about 1200 pages. Uniform in style, size, and general make-up with the "American Text-Book" Series. Cloth, $6.50 net; Half Morocco, $7.50 net. Sold by Subscription. " It is difficult to know which to admire most—the research and industry of the distin- guished band of experts whom Dr. Gould has enlisted in the service of the Vear-Book, or the wealth and abundance of the contributions to every department of science that have been deemed worthy of analysis. . . . It is much more than a mere compilation of abstracts, for, as each section is entrusted to experienced and able contributors, the reader has the advantage of certain critical commentaries and expositions . . . proceeding from writers fully qualified to perform these tasks. . . . It is emphatically a book which should find a place in every medical library, and is in several respects more useful than the famous * Jahrbiicher' of Germany."—London Lancet. ANDERS' PRACTICE OF MEDICINE. A Text=Book of the Practice of Medicine. By James M. Anders, M.D., Ph.D., LL.D., Professor of the Practice of Medicine and of Clinical Medicine, Medico-Chirurgical College, Philadelphia. In one handsome octavo volume of 1287 pages, fully illustrated. Cloth, $5.50 net; Sheep or Half Morocco, $6.50 net. " We know of no recent author who has as effectively succeeded in bringing the new facts and ideas together, weaving them with the substantial realities of the old, in better form. The concise character of the text, the clearness with which its ideas are expressed, the ingenious arrangement of its data, the completeness of its detail, the order of sequence of its topics, and the whole general appearance of the volume tell of careful, conscientious work done by him. His tables for aiding in differential diagnosis, his association of clinical symp- toms with the morbid lesions that accompany them, his tested therapeutic formulae, his appro- priate illustrations, his bacteriology, and his modern orthography have made of it a fully up- to-date, handy text-book for the general practitioner."—American Medico-Stirgical Bulletin. ASHTON'S OBSTETRICS. Third Edition, Revised. Essentials of Obstetrics. By W. Easterly Ashton, M.D., Pro- fessor of Gynecology in the Medico-Chirurgical College, Philadelphia. Crown octavo, 252 pages; 75 illustrations. Cloth, $1.00; interleaved for notes, $1.25. [See Saunders' Question-Compends, page 21.] " Embodies the whole subject in a nut-shell. We cordially recommend it to our read- ers."—Chicago Medical limes. BALL'S BACTERIOLOGY. Third Edition, Revised. Essentials of Bacteriology ; a Concise and Systematic Introduction to the Study of Micro-organisms. By M. V. Ball, M.D., Bacteriol- ogist to St. Agnes' Hospital, Philadelphia, etc. Crown octavo, 218 pages; 82 illustrations, some in colors, and 5 plates. Cloth, $1.00; interleaved for notes, $1.25. [See Saunders' Question-Compends, page 21.] " The student or practitioner can readily obtain a knowledge of the subject from a perusal of this book. The illustrations are clear and satisfactory."—Medical Record, New York. Medical Publications of W. B. Saunders. 7 BASTIN'S BOTANY. Laboratory Exercises in Botany. By Edson S. Bastin, M.A., late Professor of Materia Medica and Botany, Philadelphia College of Pharmacy. Octavo volume of 536 pages, with 87 plates. Cloth, $2.50. "It is unquestionably the best text-book on the subject that has yet appeared. The work is eminently a practical one. We regard the issuance of this book as an important event in the history of pharmaceutical teaching in this country, and predict for it an unquali- fied success."—Alumni Report to the Philadelphia College of Pharmacy. '' There is no work like it in the pharmaceutical or botanical literature of this country, and we predict for it a wide circulation."—American Journal of Pharmacy. BECK'S SURGICAL ASEPSIS. A Manual of Surgical Asepsis. By Carl Beck, M.D., Surgeon to St. Mark's Hospital and the New York German Poliklinik, etc. 306 pages; 65 text-illustrations, and 12 full-page plates. Cloth, $1.25 net. " An excellent exposition of the ' very latest' in the treatment of wounds as practised by leading German and American surgeons."—Birtninghatn (Eng.) Medical Review. " This little volume can be recommended to any who are desirous of learning the details of asepsis in surgery, for it will serve as a trustworthy guide."—London Lancet. BOISLINIERE'S OBSTETRIC ACCIDENTS, EMERGENCIES, AND OPERATIONS. Obstetric Accidents, Emergencies, and Operations. By L. Ch. Boisliniere, M.D., late Emeritus Professor of Obstetrics, St. Louis Medical College. 381 pages, handsomely illustrated. Cloth, $2.00 net. " It is clearly and concisely written, and is evidently the work of a teacher and practi- tioner of large experience."—British Medical Journal. " A manual so useful to the student or the general practitioner has not been brought to our notice in a long time. The field embraced in the title is covered in a terse, interesting way."— Yale Medical Journal. BROCKWAY'S MEDICAL PHYSICS. Second Edition, Revised. Essentials of Medical Physics. By Fred J. Brockway, M.D., Assistant Demonstrator of Anatomy in the College of Physicians and Surgeons, New York. Crown octavo, 330 pages ; 155 fine illustrations. Cloth, $ 1.00 net; interleaved for notes, $1.25 net. [See Saunders' Question-Compends, page 21.] " The student who is well versed in these pages will certainly prove qualified to com- prehend with ease and pleasure the great majority of questions involving physical principles likely to be met with in his medical studies."—American Practitioner and News. "We know of no manual that affords the medical student a better or more concise exposition of physics, and the book may be commended as a most satisfactory presentation of those essentials that are requisite in a course in medicine."—New York Medical Journal. " It contains all that one need know on the subject, is well written, and is copiously illustrated."— Medical Record, New York. BURR ON NERVOUS DISEASES. A Manual of Nervous Diseases. By Charles W. Burr, M.D., Clinical Professor of Nervous Diseases, Medico-Chirurgical College, Philadelphia; Pathologist to the Orthopedic Hospital and Infirmary for Nervous Diseases; Visiting Physician to St. Joseph's Hospital, etc. In Preparation. 8 Medical Publications of W. B. Saunders. BUTLER'S MATERIA MEDICA, THERAPEUTICS, AND PHAR- MACOLOGY. A Text-Book of Materia Medica, Therapeutics, and Pharma- cology. By George F. Butler, Ph.G., M.D., Professor of Materia Medica and of Clinical Medicine in the College of Physicians and Surgeons, Chicago; Professor of Materia Medica and Therapeutics, Northwestern University, Woman's Medical School, etc. Octavo, 858 pages, illustrated. Cloth, $4.00 net; Sheep, $5.00 net. A clear, concise, and practical text-book, adapted for permanent reference no less than for the requirements of the class-room. The arrangement (embodying the synthetic classifi- cation of drugs based upon therapeutic affinities) is believed to be at once the most philo- sophical and rational, as well as that best calculated to engage the interest of those to whom the academic study of the subject is wont to offer no little perplexity. Special attention has been given to the Pharmaceutical section, which is exceptionally lucid and complete. CASSELBERRY ON THE NOSE AND THROAT. Diseases of the Nose and Throat. By W. E. Casselberry, Pro- fessor of Laryngology and Rhinology in the Northwestern University Medical School, Chicago. In Preparation. CERNA ON THE NEWER REMEDIES. Second Edition, Revised. Notes on the Newer Remedies, their Therapeutic Applications and Modes of Administration. By David Cerna, M.D., Ph.D., formerly Demonstrator of and Lecturer on Experimental Therapeutics in the University of Pennsylvania; Demonstrator of Physiology in the Medical Department of the University of Texas. Rewritten and greatly enlarged. Post-octavo, 253 pages. Cloth, $1.25. "These ' Notes ' will be found very useful to practitioners who take an interest in the many newer remedies of the present day."—Edinburgh Medical Journal. " The appearance of this new edition of Dr. Cerna's very valuable work shows that it is properly appreciated. The book ought to be in the possession of every practising physi- cian."—New York Medical Journal. CHAPIN ON INSANITY. A Compendium of Insanity. By John B. Chapin, M.D., LL.D., Physician-in-Chief, Pennsylvania Hospital for the Insane; late Physi- cian-Superintendent of the Willard State Hospital, New York; Hon- orary Member of the Medico-Psychological Society of Great Britain, of the Society of Mental Medicine of Belgium, etc. In Preparation. The author has given, in a condensed and concise form, a compendium of Diseases of the Mind, for the convenient use and aid of physicians and students. The work will also prove valuable to members of the legal profession and to those who, in their relations to the insane and to those supposed to be insane, often desire to acquire some practical knowledge of insanity presented in a form that may be understood by the non-professional reader. CHAPMAN'S MEDICAL JURISPRUDENCE AND TOXICOLOGY. Second Edition, Revised. Medical Jurisprudence and Toxicology. By Henry C. Chapman, M.D., Professor of Institutes of Medicine and Medical Jurisprudence in the Jefferson Medical College of Philadelphia. 254 pages, with 55 illustrations and 3 full-page plates in colors. Cloth, $1.50 net. "The best book of its class for the undergraduate that we know ol."—New York Medical Times. Medical Publications of W. B. Saunders. 9 CHURCH AND PETERSON'S NERVOUS AND MENTAL DISEASES. Nervous and Mental Diseases. By Archibald Church, M.D., Professor of Mental Diseases and Medical Jurisprudence in the North- western University Medical School, Chicago; and Frederick Peter- son, M.D., Clinical Professor of Mental Diseases in the Woman's Medical College, New York; Chief of Clinic, Nervous Department, College of Physicians and Surgeons, New York. In Preparation. CLARKSON'S HISTOLOGY. A Text=Book of Histology, Descriptive and Practical. By Arthur Clarkson, M.B., CM. Edin., formerly Demonstrator of Physiology in the Owen's College, Manchester; late Demonstrator of Physiology in Yorkshire College, Leeds. Large octavo, 554 pages; 22 engravings in the text, and 174 beautifully colored original illustra- tions. Cloth, strongly bound, $6.00 net. " The work must be considered a valuable addition to the list of available textbooks, and is to be highly recommended."—New York Medical Journal. '' This is one of the best works for students we have ever noticed. We predict that the book will attain a well-deserved popularity among our students."—Chicago Medical Recorder. "The volume is a most valuable addition to the armamentarium of the teacher."— Brooklyn Medical Journal. CLIMATOLOGY. Transactions of the Eighth Annual Meeting of the American Climatological Association, held in Washington, September 22-25, 1891. Forming a handsome octavo volume of 276 pages, uniform with remainder of series. (A limited quantity only.) Cloth, $1.50. COHEN AND ESHNER'S DIAGNOSIS. Essentials of Diagnosis. By Solomon Solis-Cohen, M.D., Pro- fessor of Clinical Medicine and Applied Therapeutics in the Philadel- phia Polyclinic; and Augustus A. Eshner, M.D., Instructor in Clinical Medicine, Jefferson Medical College, Philadelphia. Post-octavo, 382 pages; 55 illustrations. Cloth, $1.50 net. [See Saunders' Question-Compends, page 21.] " We can heartily commend the book to all those who contemplate purchasing a 'com- pend.' It is modern and complete, and will give more satisfaction than many other works which are perhaps too prolix as well as behind the times."—Medical Review, St. Louis. CORWIN'S PHYSICAL DIAGNOSIS. Essentials of Physical Diagnosis of the Thorax. By Arthur M. Corwin A.M., M.D., Demonstrator of Physical Diagnosis in Rush Medical College, Chicago; Attending Physician to Central Free Dis- pensary, Department of Rhinology, Laryngology, and Diseases of the Chest Chicago. 200 pages, illustrated. Cloth, flexible covers, $1.25 net. " It is excellent. The student who shall use it as his guide to the careful study of nhvsical exploration upon normal and abnormal subjects can scarcely fail to acquire a good working knowledge of the subject."—Philadelphia Polyclinic. "A most excellent little work. It brightens the memory of the differential diagnostic and it arranges orderly and in sequence the various objective phenomena to logical S1f t-' n of a careful diagnosis."—Journal of Nervous and Mental Diseases. 10 Medical Publications of W. B. Saunders. CRAGIN'S GYN/ECOLOGY. Fourth Edition, Revised. Essentials of Gynaecology. By Edwin B. Cragin, M.D., Attend- ing Gynaecologist, Roosevelt Hospital, Out-Patients' Department, New York, etc. Crown octavo, 200 pages; 62 fine illustrations. Cloth, $1.00; interleaved for notes, $1.25. [See Saunders' Question-Compends, page 21.] "A handy volume, and a distinct improvement on students' compends in general. No author who was not himself a practical gynecologist could have consulted the student's needs so thoroughly as Dr. Cragin has done."—Medical Record, New York. CROOKSHANK'S BACTERIOLOGY. A Text=Book of Bacteriology. By Edgar M. Crookshank, M.B., Professor of Comparative Pathology and Bacteriology, King's College, London. Octavo volume of 700 pages, with 273 engravings and 22 original colored plates. Cloth, $6.50 net; Half Morocco, $7.50 net. " To the student who wishes to obtain a good resume of what has been done in bacteri- ology, or who wishes an accurate account of the various methods of research, the book may be recommended with confidence that he will find there what he requires."—London Lancet. Da COSTA'S SURGERY. A Manual of Surgery, General and Operative. By John Chalmers DaCosta, M.D., Clinical Professor of Surgery, Jefferson Medical College, Philadelphia; Surgeon to the Philadelphia Hospital, etc. Handsome volume of 810 pages; 188 illustrations in the text, and 13 full-page plates in colors. Cloth, $2.50 net. "We know of no small work on surgery in the English language which so well fulfils the requirements of the modern student."—Medico-Chirurgical Journal, Bristol, England. DE SCHWEINITZ ON DISEASES OF THE EYE. Second Edition, Revised. Diseases of the Eye. A Handbook of Ophthalmic Practice. By G. E. de Schweinitz, M.D., Professor of Ophthalmology in the Jefferson Medical College, Philadelphia, etc. Handsome royal octavo volume of 679 pages, with 256 fine illustrations and 2 chromo-litho- graphic plates. Cloth, $4.00 net; Sheep or Half Morocco, $5.00 net. " A clearly written, comprehensive manual. One which we can commend to students as a reliable text-book, written with an evident knowledge of the wants of those entering upon the study of this special branch of medical science."—British Medical Journal. " A work that will meet the requirements not only of the specialist, but of the general practitioner in a rare degree. I am satisfied that unusual success awaits it."—William Pepper, M.D., Professor of the Theory and Practice of Medicine and Clinical Medicine, University of Pennsylvania.' DORLAND'S OBSTETRICS. A Manual of Obstetrics. By W. A. Newman Dorland, M.D., Assistant Demonstrator of Obstetrics, University of Pennsylvania; Instructor in Gynecology in the Philadelphia Polyclinic. 760 pages; 163 illustrations in the text, and 6 full-page plates. Cloth, $2.50 net. "By far the best book on this subject that has ever come to our notice."—American Medical Review. " It has rarely been our duty to review a book which has given us more pleasure in its perusal and more satisfaction in its criticism. It is a veritable encyclopedia of knowledge, a gold mine of practical, concise thoughts."—American Medico-Surgical Bulletin. Medical Publications of W. B. Saunders. 11 FROTHINGHAMS GUIDE FOR THE BACTERIOLOGIST. Laboratory Guide for the Bacteriologist. By Langdon Froth- ingham, M.D.V., Assistant in Bacteriology and Veterinary Science, Sheffield Scientific School, Yale University. Illustrated. Cloth, 75 cts. " It is a convenient and useful little work, and will more than repay the outlay neces- sary for its purchase in the saving of time which would otherwise be consumed in looking up the various points of technique so clearly and concisely laid down in its pages."—Ameri- can Medico-Surgical Bulletin. GARRIGUES' DISEASES OF WOMEN. Second Edition, Revised. Diseases of Women. By Henry J. Garrigues, A.M., M.D., Pro- fessor of Gynecology and Obstetrics in the New York School of Clinical Medicine; Gynecologist to St. Mark's Hospital and to the German Dispensary, New York City, etc. Handsome octavo volume of 728 pages, illustrated by 335 engravings and colored plates. Cloth, $4.00 net; Sheep or Half Morocco, $5.00 net. " One of the best text-books for students and practitioners which has been published in the English language ; it is condensed, clear, and comprehensive. The profound learning and great clinical experience of the distinguished author find expression in this book in a most attractive and instructive form. Young practitioners to whom experienced consultants may not be available will find in this book invaluable counsel and help."—Thad. A. Reamy, M.D., LL.D., Professor of Clinical Gynecology, Medical College of Ohio. GLEASON'S DISEASES OF THE EAR. Second Edition, Revised. Essentials of Diseases of the Ear. By E. B. Gleason, SB., M.D., Clinical Professor of Otology, Medico-Chirurgical College, Philadelphia ; Surgeon-in-Charge of the Nose, Throat, and Ear Depart- ment of the Northern Dispensary, Philadelphia. 208 pages, with 114 illustrations. Cloth, $1.00; interleaved for notes, $1.25. [See Saunders' Question-Compends, page 21.] " It is just the book to put into the hands of a student, and cannot fail to give him a useful introduction to ear-affections ; while the style of question and answer which is adopted throughout the book is, we believe, the best method of impressing facts permanently on the mind."—Liz'erpool Medico- Chirurgical Journal. GOULD AND PYLE'S CURIOSITIES OF MEDICINE. Anomalies and Curiosities of Medicine. By George M. Gould, M.D., and Walter L. Pyle, M.D. An encyclopedic collection of rare and extraordinary cases and of the most striking instances of abnormality in all branches of Medicine and Surgery, derived from an exhaustive research of medical literature from its origin to the present day, abstracted, classified, annotated, and indexed. Handsome im- perial octavo volume of 968 pages, with 295 engravings in the text, and 12 full-page plates. Cloth, $6.00 net; Half Morocco, $7.00 net. Sold by Subscription. " One of the most valuable contributions ever made to medical literature. It is, so far as we know absolutely unique, and every page is as fascinating as a novel. Not alone for the medical profession has this volume value: it will serve as a book of reference for all who are interested in general scientific, sociologic, or medico-legal topics. "—Brooklyn Medical Journal. "This is certainly a most remarkable and interesting volume. It stands alone among A' 1 literature an anomaly on anomalies, in that there is nothing like it elsewhere in mej'Cai literature! It is a book full of revelations from its first to its last page, and cannot ^ ''T est and sometimes almost horrify its readers."—American Medico-Surgical Bulletin. 12 Medical Publications of W. B. Saunders. GRIFFIN'S MATERIA MEDICA AND THERAPEUTICS. Manual of Materia Medica and Therapeutics. By Henry A. Griffin, A.B., M.D., Assistant Physician to the Roosevelt Hospital, Out-Patient Department, New York City. In Preparation. GRIFFITH ON THE BABY. The Care of the Baby. By J. P. Crozer Griffith, M.D., Clini- cal Professor of Diseases of Children, University of Pennsylvania; Physician to the Children's Hospital, Philadelphia, etc. 121110, 392 pages, with 67 illustrations in the text, and 5 plates. Cloth, $1.50. " The best book for the use of the young mother with which we are acquainted. . . . There are very few general practitioners who could not read the book through with advan- tage. ''—Archives of Pediatrics. "The whole book is characterized by rare good sense, and is evidently written by a master hand. It can be read with benefit not only by mothers but by medical students and by any practitioners who have not had large opportunities for observing children."—Ameri- can Journal of Obstetrics. GRIFFITH'S WEIGHT CHART. Infant's Weight Chart. Designed by J. P. Crozer Griffith, M. D., Clinical Professor of Diseases of Children in the University of Penn- sylvania, etc. 25 charts in each pad. Per pad, 50 cents net. A convenient blank for keeping a record of the child's weight during the first two years of life. Printed on each chart is a curve representing the average weight of a healthy infant, so that any deviation from the normal can readily be detected. GROSS, SAMUEL D., AUTOBIOGRAPHY OF. Autobiography of Samuel D. Gross, M.D., Emeritus Professor of Surgery in the Jefferson Medical College, Philadelphia, with Remi- niscences of His Times and Contemporaries. Edited by his Sons, Samuel W. Gross, M.D., LL.D., late Professor of Principles of Sur- gery and of Clinical Surgery in the Jefferson Medical College, and A. Haller Gross, A.M., of the Philadelphia Bar. Preceded by a Memoir of Dr. Gross, by the late Austin Flint, M.D., LL.D. In two handsome volumes, each containing over 400 pages, demy octavo, extra cloth, gilt tops, with fine Frontispiece engraved on steel. Price per volume, $2.50 net. "Dr. Gross was perhaps the most eminent exponent of medical science that America has yet produced. His Autobiography, related as it is with a fulness and completeness seldom to be found in such works, is an interesting and valuable book. He comments on many things, especially, of course, on medical men and medical practice, in a very interest- ing way."—The Spectator, London, England. HAMPTON'S NURSING. Nursing: Its Principles and Practice. By Isabel Adams Hamp- ton, Graduate of the New York Training School for Nurses attached to Bellevue Hospital; Superintendent of Nurses, and Principal of the Training School for Nurses, Johns Hopkins Hospital, Baltimore, Md. i2ino, 484 pages, profusely illustrated. Cloth, $2.00 net. " Seldom have we perused a book upon the subject that has given us so much pleasure as the one before us. W7e would strongly urge upon the members of our own profession the need of a book like this, for it will enable each of us to become a training school in him- self."—Ontario Medical Journal. Medical Publications of W. B. Saunders. 13 HARE'S PHYSIOLOGY. Fourth Edition, Revised. Essentials of Physiology. By H. A. Hare, M.D., Professor of Therapeutics and Materia Medica in the Jefferson Medical College of Philadelphia; Physician to the Jefferson Medical College Hospital. Containing a series of handsome illustrations from the celebrated "Icones Nervorum Capitis" of Arnold. Crown octavo, 239 pages. Cloth, $1.00 net; interleaved for notes, $1.25 net. [See Saunders' Question-Compends, page 21.] "The best condensation of physiological knowledge we have yet seen."__Medical Record, New York. HART'S DIET IN SICKNESS AND IN HEALTH. Diet in Sickness and in Health. By Mrs. Ernest Hart, formerly Student of the Faculty of Medicine of Paris and of the London School of Medicine for Women; with an Introduction by Sir Henry Thompson, F.R.C.S., M.D., London. 220 pages; illustrated. Cloth, " We recommend it cordially to the attention of all practitioners ; both to them and to their patients it may be of the greatest service."—A"e7u York Medical Journal. HAYNES' ANATOMY. A Manual of Anatomy. By Irving S. Haynes, M.D., Adjunct Professor of Anatomy and Demonstrator of Anatomy, Medical Depart- ment of the New York University, etc. 680 pages, illustrated with 42 diagrams in the text, and 134 full-page half-tone illustrations from original photographs of the author's dissections. Cloth, $2.50 net. " This book is the work of a practical instructor—one who knows by experience the requirements of the average student, and is able to meet these requirements in a very satis- factory way. The book is one that can be commended."—Medical Record, New York. HEISLERS EMBRYOLOGY. A Text=Book of Embryology. By John C. Heisler, M.D., Pro- fessor of Anatomy in the Medico-Chirurgical College, Philadelphia. In Preparation. HIRST'S OBSTETRICS. A Text=Book of Obstetrics. By Barton Cooke Hirst, M.D., Professor of Obstetrics in the University of Pennsylvania. In Prepa- ration. HYDE AND MONTGOMERY ON SYPHILIS AND THE VENEREAL DISEASES. Syphilis and the Venereal Diseases. By James Nevins Hyde, M D. Professor of Skin and Venereal Diseases, and Frank H. Mont- gomery, M.D., Lecturer on Dermatology and Genito-Urinary Diseases in Rush'Medical College, Chicago, 111. 618 pages, profusely illustrated. Cloth, $2.50 net. " We can commend this manual to the student as a help to him in his study of venereal diseases.' '—Liverpool Medico- Chirurgical Journal. "The best student's manual which has appeared on the subject."—St. Louis Medical and Surgical Journal. 14 Medical Publications of W. B. Saunders. JACKSON AND GLEASON'S DISEASES OF THE EYE, NOSE, AND THROAT. Second Edition, Revised. Essentials of Refraction and Diseases of the Eye. By Edward Jackson, A.M., M.D., Professor of Diseases of the Eye in the Phila- delphia Polyclinic and College for Graduates in Medicine; and— Essentials of Diseases of the Nose and Throat. By E. Bald- win Gleason, M.D., Surgeon-in-Charge of the Nose, Throat, and Ear Department of the Northern Dispensary of Philadelphia. Two volumes in one. Crown octavo, 290 pages; 124 illustrations. Cloth, $1.00; interleaved for notes, $1.25. [See Saunders' Question-Compends, page 21.] "Of great value to the beginner in these branches. The authors are both capable men, and know what a student most needs."—Medical Record, New York. KEATING'S DICTIONARY. Second Edition, Revised. A New Pronouncing Dictionary of Medicine, with Phonetic Pronunciation, Accentuation, Etymology, etc. By John M. Keating, M.D., LL.D., Fellow of the College of Physicians of Phila- delphia ; Vice-President of the American Pediatric Society; Editor "Cyclopaedia of the Diseases of Children," etc.; and Henry Hamilton, Author of "A New Translation of Virgil's ^Eneid into English Rhyme," etc.; with the collaboration of J. Chalmers Da- Costa, M.D., and Frederick A. Packard, M.D. With an Appendix containing Tables of Bacilli, Micrococci, Leucoma'ines, Ptomaines; Drugs and Materials used in Antiseptic Surgery; Poisons and their Antidotes; Weights and Measures; Thermometric Scales; New Official and Unofficial Drugs, etc. One volume of over 800 pages. Prices, with Denison's Patent Ready-Reference Index: Cloth, $5.00 net; Sheep or Half Morocco, $6.00 net; Half Russia, $6.50 net. Without Patent Index: Cloth, $4.00 net; Sheep or Half Morocco, $5.00 net. "lam much pleased with Keating's Dictionary, and shall take pleasure in recommend- ing it to my classes."—Henry M. Lyman, M.D., Professor of the Principles and Practice of Medicine, Rush Medical College, Chicago, III. " I am convinced that it will be a very valuable adjunct to my study-table, convenient in size and sufficiently full for ordinary use."—C. A. Lindsley, M.D., Professor of the Theory and Practice of Medicine, Medical Dept. Yale University. KEATING'S LIFE INSURANCE. How to Examine for Life Insurance. By John M. Keating, M. D., Fellow of the College of Physicians and Surgeons of Philadelphia; Vice-President of the American Psediatric Society; Ex-President of the Association of Life Insurance Medical Directors. Royal octavo, 211 pages; with two large half-tone illustrations, and a plate prepared by Dr. McClellan from special dissections; also, numerous other illustrations. Cloth, $2.00 net. " This is by far the most useful book which has yet appeared on insurance examination, a subject of growing interest and importance. Not the least valuable portion of the volume is Part II, which consists of instructions issued to their examining physicians by twenty-four representative companies of this country. If for these alone, the book should be at the right hand of every physician interested in this special branch of medical science."—The Medical News. Medical Publications of W. B. Saunders. 15 KEEN ON THE SURGERY OF TYPHOID FEVER. The Surgical Complications and Sequels of Typhoid Fever. By Wm. W. Keen, M.D., LL.D., Professor of the Principles of Sur- gery and of Clinical Surgery, Jefferson Medical College, Philadelphia; Corresponding Member of the Societe de Chirurgie, Paris; Honorary Member of the Societe Beige de Chirurgie, etc. Octavo volume of about 400 pages. Cloth, $3.00 net. jYcdrly Ready. This monograph is the only one in any language covering the entire subject of the Surgical Complications and Sequels of Typhoid Fever. It will prove to be of importance and interest not only to the general surgeon and physician, but also to many specialists—laryn - gologists, gynecologists, pathologists, and bacteriologists. KEEN'S OPERATION BLANK. Second Edition, Revised Form. An Operation Blank, with Lists of Instruments, etc. Required in Various Operations. Prepared by W. W. Keen, M.D., LL.D., Professor of the Principles of Surgery in Jefferson Medical College, Philadelphia. Price per pad, containing blanks for fifty operations, 50 cents net. KYLE ON'THE NOSE AND THROAT. Diseases of the Nose and Throat. By D. Braden Kyle, M.D., Chief Laryngologist to St. Agnes' Hospital, Philadelphia; Bacteri- ologist to the Orthopaedic Hospital and Infirmary for Nervous Diseases ; Instructor in Clinical Microscopy and Assistant Demonstrator of Pathology in the Jefferson Medical College, etc. In Preparation. LAINE'S TEMPERATURE CHART. Temperature Chart. Prepared by D. T. Laine, M.D. Size 8 x 13^ inches. A conveniently arranged Chart for recording Temperature, with columns for daily amounts of Urinary and Fecal Excretions, Food, Remarks, etc. On the back of each chart is given in full the method of Brand in the treatment of Typhoid Fever. Price, per pad of 25 charts, 50 cents net. " To the busy practitioner this chart will be found of great value in fever cases, and especially for cases of typhoid."—Indian Lancet, Calcutta. LOCKWOOD'S PRACTICE OF MEDICINE. A Manual of the Practice of Medicine. By George Roe Lock- wood M.D., Professor of Practice in the Woman's Medical College of the New York Infirmary, etc. 935 pages, with 75 illustrations in the text, and 22 full-page plates. Cloth, $2.50 net. " Gives in a most concise manner the points essential to treatment usually enumerated in the most elaborate works."— Massachusetts Medical Journal. LONG'S SYLLABUS OF GYNECOLOGY. A Syllabus of Gynecology, arranged in Conformity with " An American Text=Book of Gynecology." By J. W. Long, M.D., Professor of Diseases of Women and Children, Medical College of Virginia, etc. Cloth, interleaved, $1.00 net. » The book is certainly an admirable resume of what every gynecological student and ' " er should know, and will prove of value not only to those who have the ' American practition ^ Qynecol0gy,' but to others as well."—Brooklyn Medical Journal. 16 Medical Publications of W. B. Saunders. MACDONALD'S SURGICAL DIAGNOSIS AND TREATMENT. Surgical Diagnosis and Treatment. By J. W. Macdonald, M.D. Edin., L.R.C.S., Edin., Professor of the Practice of Surgery and of Clinical Surgery in Hamline University; Visiting Surgeon to St. Barnabas' Hospital, Minneapolis, etc. Handsome octavo volume of 800 pages, profusely illustrated. Cloth, $5.00 net; Half Morocco, $6.00 net. " The rapid advances made in the art of surgery have caused the literature of the science to grow apace. Systems of surgery in many volumes, and text-books of large dimensions, are now deemed necessary to cover the field. The practical part of the surgeon's work is, however, almost limited to two questions which he must answer every time his professional advice or help is sought. The first question is, ' What is the disease or injury ?' The second question is, ' What is the proper treatment ? ' "While I would not for a moment underestimate the importance of a profound study of the principles of surgery, of surgical pathology, or of bacteriology, the present work will be confined to a solution of the two questions just mentioned, with the view of putting into the hands of students and practitioners a single volume containing the most practical part of practical surgery."—From the Author's Preface. MALLORY AND WRIGHT'S PATHOLOGICAL TECHNIQUE. Pathological Technique. By Frank B. Mallory, A!M., M.D., Assistant Professor of Pathology, Harvard University Medical School; and James H. Wright, A.M., M.D., Instructor in Pathology, Harvard University Medical School. Octavo volume of 396 pages, handsomely illustrated. Cloth, $2.50 net. " I have been looking forward to the publication of this book, and I am glad to say that I find it to be a most useful laboratory and post-mortem guide, full of practical information, and well up to date."—William H. Welch, Professor of Pathology, Johns Hopkins Uni- versity, Baltimore, Md. MARTIN'S MINOR SURGERY, BANDAGING, AND VENEREAL DISEASES. Second Edition, Revised. Essentials of Minor Surgery, Bandaging, and Venereal Diseases. By Edward Martin, A.M., M.D., Clinical Professor of Genito-Urinary Diseases, University of Pennsylvania, etc. Crown octavo, 166 pages, with 78 illustrations. Cloth, $1.00; interleaved for notes, #1.25. [See Saunders' Question-Compends, page 21.] "A very practical and systematic study of the subjects, and shows the author's famil- iarity with the needs of students."—Therapeutic Gazette. MARTIN'S SURGERY. Sixth Edition, Revised. Essentials of Surgery. Containing also Venereal Diseases, Surgi- cal Landmarks, Minor and Operative Surgery, and a complete de- scription, with illustrations, of the Handkerchief and Roller Bandages. By Edward Martin, A.M., M.D., Clinical Professor of Genito- Urinary Diseases, University of Pennsylvania, etc. Crown octavo, 338 pages, illustrated. With an Appendix containing full directions for the preparation of the materials used in Antiseptic Surgery, etc. Cloth, $1.00; interleaved for notes, $1.25. [See Saunders' Question-Compends, page 21.] " Contains all necessary essentials of modern surgery in a comparatively small space. Its style is interesting, and its illustrations are admirable."—Medical and Surgical Reporter. Medical Publications of W. B. Saunders. 17 MCFARLAND'S PATHOGENIC BACTERIA. Text=Book upon the Pathogenic Bacteria. Specially written for Students of Medicine. By Joseph McFarland, M.D., Pro- fessor of Pathology and Bacteriology in the Medico-Chirurgical College of Philadelphia, etc. Octavo volume of 359 pages, finely illustrated. Cloth, $2.50 net. " Dr. McFarland has treated the subject in a systematic manner, and has succeeded in presenting in a concise and readable form the essentials of bacteriology up to date. Alto- gether, the book is a satisfactory one, and I shall take pleasure in recommending it to the students of Trinity College."—H. B. Anderson, M.D., Professor of Pathology and Bac- teriology, Trinity Medical College, Toronto. MEIGS ON FEEDING IN INFANCY. Feeding in Early Infancy. By Arthur V. Meigs, M.D. Bound in limp cloth, flush edges, 25 cents net. '"This pamphlet is worth many times over its price to the physician. The author's experiments and conclusions are original, and have been the means of doing much eood "__ Medical Bulletin. & g ' MOORE'S ORTHOPEDIC SURGERY. A Manual of Orthopedic Surgery. By James E. Moore, M.D., Professor of Orthopedics and Adjunct Professor of Clinical Surgery, University of Minnesota, College of Medicine and Surgery. Octavo volume of 356 pages, handsomely illustrated. Cloth, $2.50 net. A practical book based upon the author's experience, in which special stress is laid upon early diagnosis, and treatment such as can be carried out by the general practitioner. The teachings of the author are in accordance with his belief that true conservatism is to be found in the middle course between the surgeon who operates too frequently and the orthopedist who seldom operates. MORRIS'S MATERIA MEDICA AND THERAPEUTICS. Fourth Edition, Revised. Essentials of Materia Medica, Therapeutics, and Prescription" Writing. By Henry Morris, M.D., late Demonstrator of Thera- peutics, Jefferson Medical College, Philadelphia; Fellow of the College of Physicians, Philadelphia, etc. Crown octavo, 250 pages. Cloth, $1.00; interleaved for notes, $1.25. [See Saunders' Question-Compends, page 21.] "This work,.already excellent in the old edition, has been largely improved by revi- sion."—American Practitioner and News. MORRIS, WOLFF, AND POWELL'S PRACTICE OF MEDICINE. Third Edition, Revised. Essentials of the Practice of Medicine. By Henry Morris, M. D., late Demonstrator of Therapeutics, Jefferson Medical College, Phila- delphia ; with an Appendix on the Clinical and Microscopic Examina- tion of Urine, by Lawrence Wolff, M.D., Demonstrator of Chemistry, Jefferson Medical College, Philadelphia. Enlarged by some 300 essen- tial formulae collected and arranged by William M. Powell, M.D. Post-octavo, 488 pages. Cloth, $2.00. [See Saunders' Question-Compends, page 21.] « The teaching is sound, the presentation graphic ; matter full as can be desired, and le attractive."—American Practitioner and News. 2 18 Medical Publications of W. B. Saunders. MORTEN'S NURSES DICTIONARY. Nurse's Dictionary of Medical Terms and Nursing Treat- ment. Containing Definitions of the Principal Medical and Nursing Terms and Abbreviations; of the Instruments, Drugs, Diseases, Acci- dents, Treatments, Operations, Foods, Appliances, etc. encountered in the ward or in the sick-room. By Honnor Morten, author of "How to Become a Nurse," etc. i6mo, 140 pages. Cloth, $1.00. " A handy, compact little volume, containing a large amount of general information, all of which is arranged in dictionary or encyclopedic form, thus facilitating quick reference. It is certainly of value to those for whose use it is published."—Chicago Clinical Review. NANCREDE'S ANATOMY. Fifth Edition. Essentials of Anatomy, including the Anatomy of the Viscera. By Charles B. Nancrede, M.D., Professor of Surgery and of Clini- cal Surgery in the University of Michigan, Ann Arbor. Crown octavo, 388 pages; 180 illustrations. With an Appendix containing over 60 illustrations of the osteology of the human body. Based upon Gray's Anatomy. Cloth, $1.00; interleaved for notes, $1.25. [See Saunders' Question-Compends, page 21.] " For self-quizzing and keeping fresh in mind the knowledge of anatomy gained at school, it would not be easy to speak of it in terms too favorable."—American Practitioner. NANCREDE'S ANATOMY AND DISSECTION. Fourth Edition. Essentials of Anatomy and Manual of Practical Dissection. By Charles B. Nancrede, M.D., Professor of Surgery and of Clinical Surgery, University of Michigan, Ann Arbor. Post-octavo; 500 pages, with full-page lithographic plates in colors, and nearly 200 illustrations. Extra Cloth (or Oilcloth for the dissection-room), $2.00 net. " It may in many respects be considered an epitome of Gray's popular work on general anatomy, at the same time having some distinguishing characteristics of its own to commend it. The plates are of more than ordinary excellence, and are of especial value to students in their work in the dissecting room."—Journal of the American Medical Association. NORRIS'S SYLLABUS OF OBSTETRICS. Third Edition, Revised. Syllabus of Obstetrical Lectures in the Medical Department of the University of Pennsylvania. By Richard C. Norris, A.M., M.D., Demonstrator of Obstetrics, University of Pennsylvania. Crown octavo, 222 pages. Cloth, interleaved for notes, $2.00 net. " This work is so far superior to others on the same subject that we take pleasure in calling attention briefly to its excellent features. It covers the subject thoroughly, and will prove invaluable both to the student and the practitioner."—Aledical Record, New York. PENROSE'S DISEASES OF WOMEN. A Text=Book of Diseases of Women. By Charles B. Penrose, M.D., Ph.D., Professor of Gynecology in the University of Pennsyl- vania; Surgeon to the Gynecean Hospital, Philadelphia. Octavo volume of 529 pages, handsomely illustrated. Cloth, $3.50 net. " The book is to be commended without reserve, not only to the student but to the general practitioner who wishes to have the latest and best modes of treatment explained with absolute clearness."—Therapeutic Gazette. " Taking it all in all, this is in our opinion one of the best works upon this subject that has appeared, and Mr. Saunders may feel justly proud of having the work issued from his press.'' —Matthews' Quarterly Journal. Medical Publications of W. B. Saunders. 19 POWELL'S DISEASES OF CHILDREN. Second Edition. Essentials of Diseases of Children. By William M. Powell, M.D., Attending Physician to the Mercer House for Invalid Women at Atlantic City, N. J. ; late Physician to the Clinic for the Diseases of Children in the Hospital of the University of Pennsylvania. Crown octavo, 222 pages. Cloth, $1.00; interleaved for notes, $1.25. [See Saunders' Question- Compends, page 21.] "Contains the gist of all the best works in the department to which it relates."— American Practitioner and A'nvs. PRINGLE'S SKIN DISEASES AND SYPHILITIC AFFECTIONS. Pictorial Atlas of Skin Diseases and Syphilitic Affections (American Edition). Translation from the French. Edited by J. J. Pringle, M.B., F.R.C.P., Assistant Physician to the Middlesex Hospital, London. Photo-lithochromes from the famous models in the Museum of the Saint-Louis Hospital, Paris, with explanatory wood- cuts and text. Complete in 12 Parts. Price per Part, $3.00. " I strongly recommend this Atlas. The plates are exceedingly well executed, and will be of great value to all studying dermatology."—Stephen Mackenzie, M.D. (London Hospital). "The introduction of explanatory wood-cuts in the text is a novel and most important feature which greatly furthers the easier understanding of the excellent plates, than which nothing, we venture to say, has been seen better in point of correctness, beauty, and general merit."—New York Medical Journal. PYE'S BANDAGING. Elementary Bandaging and Surgical Dressing. With Direc- tions concerning the Immediate Treatment of Cases of Emergency. For the use of Dressers and Nurses. By Walter Pye, F.R.C.S., late Surgeon to St. Mary's Hospital, London. Small 121110, with over 80 illustrations. Cloth, flexible covers, 75 cents net. "The directions are clear and the illustrations are good."—London Lancet. "The author writes well, the diagrams are clear, and the book itself is small and port- able, although the paper and type are good."—British Medical Journal. RAYMOND'S PHYSIOLOGY. A Manual of Physiology. By Joseph H. Raymond, A.M., M.D., Professor of Physiology and Hygiene and Lecturer on Gynecology in the Long Island College Hospital; Director of Physiology in the Hoagland Laboratory, etc. 382 pages, with 102 illustrations in the text, and 4 full-page colored plates. Cloth, $1.25 net. " Extremely well gotten up, and the illustrations have been selected with care. The text is fully abreast with modern physiology. "-British Medical Journal. RONTGEN RAYS. Archives of the Rontgen Ray (Formerly Archives of Clinical Skiagraphy). Edited by Sydney Rowland, M.A., M.R.C.S., and W S Hedley, M.D., M.RC.S. A series of collotype illustrations, vith descriptive text, illustrating the applications of the new photo- graphy to Medicine and Surgery. Price per Part, $1.00. Now ready: Vol L, Parts I. to IV.; Vol. II., Part I. Joiwfex: Qatfidm QrnifmU SAUNDERS' Arranged in Question and Answer Form, V^ U .CO 1 1L/1N npHE MOST COMPLETE AND BEST C^r\^7rTyc\TT\C ILLUSTRATED series of V^LJlVlr^lNlJo COMPENDS EVER ISSUED. Now the Standard Authorities in Medical Literature .... with Students and Practitioners in every City of the United States and Canada. ^ OVER \ 65,000 COPIES SOLD. ^ THE REASON WHY. They are the advance guard of "Student's Helps"—that DO help. They are the leaders in their special line, well and authoritatively written by able men, who, as teachers in the large colleges, know exactly what is wanted by a student preparing for his examinations. The judgment exercised in the selection of authors is fully demonstrated by their professional standing. Chosen from the ranks of Demonstrators, Quiz-masters, and Assistants, most of them have become Professors and Lecturers in their respective colleges. Each book is of convenient size (5 x 7 inches), containing on an average 250 pages, profusely illustrated, and elegantly printed in clear, readable type, on fine paper. The entire series, numbering twenty-three volumes, has been kept thoroughly revised and enlarged when necessary, many of the books being in their fifth and sixth editions. TO SUM UP. Although there are numerous other Quizzes, Manuals, Aids, etc. in the market, none of them approach the " Blue Series of Question Compends;" and the claim is made for the following points of excellence : I. Professional distinction and reputation of authors. 2. Conciseness, clearness, and soundness of treatment. 3. Quality of illustrations, paper, printing, and binding. Any of these Compends will be mailed on receipt of price (see next page for List). oaunders' Question-Compend Series* Price, Cloth, $1.00 per copy, except when otherwise noted. "Where the work of preparing students' manuals is to end we cannot say but the baunders Series, in our opinion, bears off the palm at present."— New York Medical Record. 1. ESSENTIALS OF PHYSIOLOGY. By H. A. Hare, M.D. Fourth edition revised and enlarged. ($1.00 net.) 2. ESSENTIALS OF SURGERY. By Edward Martin, M.D. Sixth edition, revised, with an Appendix on Antiseptic Surgery. 3. ESSENTIALS OF ANATOMY. By Charles B. Nancrede, M.D. Fifth edition, with an Appendix. 4. ESSENTIALS OF MEDICAL CHEMISTRY, ORGANIC AND INORGANIC. By Lawrence Wolff, M.D. Fourth edition, revised, with an Appendix. 5. ESSENTIALS OF OBSTETRICS. By W. Easterly Ashton, M.D. Fourth edition, revised and enlarged. 6. ESSENTIALS OF PATHOLOGY AND MORBID ANATOMY. By C. E. Armand Semple, M.D. 7. ESSENTIALS OF MATERIA MEDICA, THERAPEUTICS, AND PRE- SCRIPTI0N=WR1TING. By Henry Morris, M.D. Fourth edition, revised. 8, 9. ESSENTIALS OF PRACTICE OF MEDICINE. By Henry Morris, M.D. An Appendix on Urine Examination. By Lawrence Wolff, M.D. Third edition, enlarged by some 300 Essential Formulae, selected from eminent authorities, by Wm. M. Powell, M.D. (Double number, $2.00.) 10. ESSENTIALS OF GYN/ECOLOGY. By Edwin B. Cragin, M.D. Fourth edition, revised. 11. ESSENTIALS OF DISEASES OF THE SKIN. By Henry W. Stelwagon, M.D. Third edition, revised and enlarged. ($1.00 net.) 12. ESSENTIALS OF MINOR SURGERY, BANDAGING, AND VENEREAL DISEASES. By Edward Martin, M.D. Second ed., revised and enlarged. 13. ESSENTIALS OF LEGAL MEDICINE, TOXICOLOGY, AND HYGIENE. By C E. Armand Semple, M.D. 14. ESSENTIALS OF DISEASES OF THE EYE, NOSE, AND THROAT. By Edward Jackson, M.D., and E. B. Gleason, M.D. Second ed., revised. 15. ESSENTIALS OF DISEASES OF CHILDREN. By William M. Powell, M. D. Second edition. 16. ESSENTIALS OF EXAMINATION OF URINE. By Lawrence Wolff, M.D. Colored " Vogel Scale." (75 cents.) 17. ESSENTIALS OF DIAGNOSIS. By S. Solis Cohen, M.D., and A. A. Eshner, M.D. (£1.50 net.) 18. ESSENTIALS OF PRACTICE OF PHARMACY. By Lucius E. Sayre. Second edition, revised and enlarged. 20. ESSENTIALS OF BACTERIOLOGY. By M. V. Ball, M.D. Third edition, revised. 21 ESSENTIALS OF NERVOUS DISEASES AND INSANITY. By John C. SHAW, M.D. Third edition, revised. 22 ESSENTIALS OF MEDICAL PHYSICS. By Fred J. Brockway, M.D. Second edition, revised. (#1.00 net.) OX FSSENTIALS OF MEDICAL ELECTRICITY. By David D. Stewart, M.D., and EdwardS. Lawrance, M.D. 14 ESSENTIALS OF DISEASES OF THE EAR. By E. B. Gleason, M.D. Second edition, revised and greatly enlarged. Pamphlet containing specimen pages, etc. sent free upon application. PRACTICAL. EXHAUSTIVE, AUTHORITATIVE. SAUNDERS' New Series of Manuals FOR STUDENTS AND PRACTITIONERS. 0 I 'HAT there exists a need for thoroughly reliable hand-books on the leading branches of Medicine and Surgery is a fact amply demonstrated by the favor with which the SAUNDERS NEW SERIES OF MANUALS have been received by medical students and practitioners and by the Medical Press. These manuals are not merely condensations from present literature, but are ably written by well-known authors and practitioners, most of them being teachers in representative American colleges. Each volume is concisely and author- itatively written and exhaustive in detail, without being encumbered with the introduction of "cases/' which so largely expand the ordinary text-book. These manuals will therefore form an admirable collection of advanced lectures, useful alike to the medical student and the prac- titioner : to the latter, too busy to search through page after page of elaborate treatises for what he wants to know, they will prove of ines- timable value; to the former they will afford safe guides to the essen- tial points of study. The SAUNDERS NEW SERIES OF MANUALS are con- ceded to be superior to any similar books now on the market. No other manuals afford so much information in such a concise and avail- able form. A liberal expenditure has enabled the publisher to render the mechanical portion of the work worthy of the high literary stand- ard attained by these books. Saunders' New Series of Manuals* VOLUMES PUBLISHED. PHYSIOLOGY. By Joseph Howard Raymond, A.M., M.D., Professor of Physiology and Hygiene and Lecturer on Gynecology in the Long Island College Hospital; Director of Physiology in the Hoagland Laboratory, etc. Illustrated. Cloth, $1.25 net. SURGERY, General and Operative. By John Chalmers DaCosta, M.D., Clini- cal Professor of Surgery, Jefferson Medical College, Philadelphia; Surgeon to the Philadelphia Hospital, etc. 188 illustrations and 13 plates. (Double number.) Cloth, $2.50 net. DOSE=BOOK AND MANUAL OF PRESCRIPTION=WRITING. By E. Q. Thornton, M.D., Demonstrator of Therapeutics, Jefferson Medical College, Phila- delphia. Illustrated. Cloth, $1-25 net. SURGICAL ASEPSIS. By Carl Beck, M.D., Surgeon to St. Mark's Hospital and to the New York German Poliklinik, etc. Illustrated. Cloth, #1.25 net. MEDICAL JURISPRUDENCE. By Henry C. Chapman, M.D. Professor of Insti- tutes of Medicine and Medical Jurisprudence in the Jefferson Medical College of Phila- delphia. Illustrated. Cloth, $1.50 net. SYPHILIS AND THE VENEREAL DISEASES. By James Nevins Hyde, M.D., Professor of Skin and Venereal Diseases, and Frank H. Montgomery, M.D., Lecturer on Dermatology and Genito-Urinary Diseases in Rush Medical College, Chicago. Profusely illustrated. (Double number.) Cloth, #2.50 net. PRACTICE OF MEDICINE. By George Roe Lockwood, M.D., Professor of Practice in the Woman's Medical College of the New York Infirmary; Instructor in Physical Diagnosis in the Medical Department of Columbia College, etc. Illustrated. (Double number.) Cloth, #2.50 net. MANUAL OF ANATOMY. By Irving S. Haynes, M.D., Adjunct Professor of Anatomy and Demonstrator of Anatomy, Medical Department of the New York University, etc. Beautifully illustrated. (Double Number.) Cloth, $2.50 net. MANUAL OF OBSTETRICS. By W. A. Newman Dorland, M.D., Assistant Demonstrator of Obstetrics, University of Pennsylvania; Chief of Gynecological Dis- pensary, Pennsylvania Hospital, etc. Profusely illustrated. (Double number.) Cloth, #2.50 net. DISEASES OF WOMEN. By J. Bland Sutton, F.R.C.S., Assistant Surgeon to Middlesex Hospital and Surgeon to Chelsea Hospital, London; and Arthur E. Giles, M.D., B.Sc. Lond., F.R.C.S. Edin., Assistant Surgeon to Chelsea Hospital, London Handsomely illustrated. (Double number.) Cloth, #2.50 net. VOLUMES IN PREPARATION. NOSE AND THROAT. By D. Braden Kyle, M.D., Chief Laryngologist to the St. Acmes Hospital Philadelphia ; Bacteriologist to the Orthopaedic Hospital and Infirmary for Nervous Diseases ; Instructor in Clinical Microscopy and Assistant Demonstrator of Pathology in the Jefferson Medical College, etc. Mcrwrnic niSFASES By Charles W. Burr, M.D., Clinical Professor of Nervous TWwes Medico-Chirurgical College, Philadelphia; Pathologist to the Orthopaedic Hospital' and Infirmary for Nervous Diseases; Visiting Physician to the St. Joseph Hospital, etc. 11 be published in the same series, at short intervals, carefully-prepared works variousrseubjects by prominent specialists. on Pamphlet containing specimen pages, etc sent free upon application. 24 Medical Publications of W. B. Saunders. SAUNDBY'S RENAL AND URINARY DISEASES. Lectures on Renal and Urinary Diseases. By Robert Saundby, M.D. Edin., Fellow of the Royal College of Physicians, London, and of the Royal Medico-Chirurgical Society; Physician to the General Hospital; Consulting Physician to the Eye Hospital and to the Hos- pital for Diseases of Women; Professor of Medicine in Mason College, Birmingham, etc. Octavo volume of 434 pages, with numerous illus- trations and 4 colored plates. Cloth, $2.50 net. " The volume makes a favorable impression at once. The style is clear and succinct. We cannot find any part of the subject in which the views expressed are not carefully thought out and fortified by evidence drawn from the most recent sources. The book may be cordially recommended."—British Medical Journal. SAUNDERS' POCKET MEDICAL FORMULARY. Fourth Edition, Revised. By William M. Powell, M.D., Attending Physician to the Mercer House for Invalid Women at Atlantic City, N. J. Containing 1750 formulae selected from the best-known authorities. With an Appen- dix containing Posological Table, Formulae and Doses for Hypo- dermic Medication, Poisons and their Antidotes, Diameters of the Female Pelvis and Foetal Head, Obstetrical Table, Diet List for Various Diseases, Materials and Drugs used in Antiseptic Surgery, Treatment of Asphyxia from Drowning, Surgical Remembrancer, Tables of Incompatibles, Eruptive Fevers, Weights and Measures, etc. Hand- somely bound in flexible morocco, with side index, wallet, and flap. $M5 net- " This little book, that can be conveniently carried in the pocket, contains an immense amount of material. It is very useful, and, as the name of the author of each prescription is given, is unusually reliable."—Medical Record, New York. SAUNDERS' POCKET MEDICAL LEXICON. Fourth Edition, Revised. A Dictionary of Terms and Words used in Medicine and Surgery. By John M. Keating, M.D., Fellow of the College of Physicians of Philadelphia; Editor of the "Cyclopaedia of Diseases of Children," etc.; Author of the "New Pronouncing Dictionary of Medicine;" and Henry Hamilton, Author of "A New Translation of Virgil's ^Eneid into English Verse;" Co-Author of the "New Pronouncing Dictionary of Medicine." 321110, 280 pages. Cloth, 75 cents; Leather Tucks, $1.00. " Remarkably accurate in terminology, accentuation, and definition."—Journal of the American Medical Association. SAYRE'S PHARMACY. Second Edition, Revised. Essentials of the Practice of Pharmacy. By Lucius E. Sayre, M.D., Professor of Pharmacy and Materia Medica in the University of Kansas. Crown octavo, 200 pages. Cloth, $1.00; interleaved for notes, $1.25. [See Saunders' Question-Compends, page 21.] "The topics are treated in a simple, practical manner, and the work forms a very useful student's manual."—Boston Medical and Surgical Journal. Medical Publications of W. B. Saunders. 25 SEMPLE'S LEGAL MEDICINE, TOXICOLOGY, AND HYGIENE. Essentials of Legal Medicine, Toxicology, and Hygiene. By C. E. Armand Semple, B. A., M. B. Cantab., M. R. C. P. Lond., Physician to the Northeastern Hospital for Children, Hackney, etc! Crown octavo, 212 pages; 130 illustrations. Cloth, $1.00; interleaved for notes, $1.25. [See Saunders' Question-Compends, page 21.] " No general practitioner or student can afford to be without this valuable work. The subjects are dealt with by a masterly hand."—London Hospital Gazette. SEMPLE'S PATHOLOGY AND MORBID ANATOMY. Essentials of Pathology and Morbid Anatomy. By C. E. Armand Semple, B.A., M.B. Cantab., M.R.C.P. Lond., Physician to the Northeastern Hospital for Children, Hackney, etc. Crown octavo, 174 pages; illustrated. Cloth, $1.00; interleaved for notes, $1.25. [See Saunders' Question-Compends, page 21.] " Should take its place among the standard volumes on the bookshelf of both student and practitioner."—London Hospital Gazette. SENN'S GENITO-URINARY TUBERCULOSIS. Tuberculosis of the Genito-Urinary Organs, Male and Female. By Nicholas Senn, M.D., Ph.D., LL.D., Professor of the Practice of Surgery and of Clinical Surgery, Rush Medical College, Chicago. Handsome octavo volume of 320 pages, illustrated. Cloth, $3.00 net. " An important book upon an important subject, and written by a man of mature judg- ment and wide experience. The author has given us an instructive book upon one of the most important subjects of the day."—Clinical Reporter. " A work which adds another to the many obligations the profession owes the talented author."—Chicago Medical Recorder. SENN'S SYLLABUS OF SURGERY. A Syllabus of Lectures on the Practice of Surgery, arranged in conformity with ««An American Text=Book of Surgery." By Nicholas Senn, M.D., Ph.D., Professor of the Practice of Surgery and of Clinical Surgery in Rush Medical College, Chicago. Cloth, $2.00. " This syllabus will be found of service by the teacher as well as the student, the work being superbly done. There is no praise too high for it. No surgeon should be without it."—New York Medical Times. SENN'S TUMORS. Pathology and Surgical Treatment of Tumors. By N. Senn, M D PhD. LL.D., Professor of Surgery and of Clinical Surgery, Rush'Medical College; Professor of Surgery, Chicago Polyclinic; Attending Surgeon to Presbyterian Hospital; Surgeon-in-Chief, St. Toseph's Hospital, Chicago. Octavo volume of 710 pages, with 515 engravings, including full-page colored plates. Cloth, $6.00 net; Half Morocco, #7-°° net < Th ost exhaustive of any recent book in English on this subject. It is well illus- a H will doubtless remain as the principal monograph on the subject in our language trated, an ^he book is handsomely illustrated and printed, and the author has given a for sorn y ja^. contribution to surgery."—Journal of the American Medical Association. 26 Medical Publications of W. B. Saunders. SHAW'S NERVOUS DISEASES AND INSANITY. Third Edition, Revised. Essentials of Nervous Diseases and Insanity. By John C. Shaw, M.D., Clinical Professor of Diseases of the Mind and Nervous System, Long Island College Hospital Medical School; Consulting Neurologist to St. Catherine's Hospital and to the Long Island College Hospital. Crown octavo, 186 pages; 48 original illustrations. Cloth, $1.00; interleaved for notes, $1.25. [See Saunders' Question-Compends, page 21.] "Clearly and intelligently written."—Boston Medical and Surgical Journal. "There is a mass of valuable material crowded into this small compass."—American Medico-Surgical Bulletin. STARR'S DIETS FOR INFANTS AND CHILDREN. Diets for Infants and Children in Health and in Disease. By Louis Starr, M.D., Editor of "An American Text-Book of the Diseases of Children." 230 blanks (pocket-book size), perforated and neatly bound in flexible morocco. $1.25 net. The first series of blanks are prepared for the first seven months of infant life ; each blank indicates the ingredients, but not the quantities, of the food, the latter directions being left for the physician. After the seventh month, modifications being less necessary, the diet lists are printed in full. Formulae for the preparation of diluents and foods are appended. STELWAGON'S DISEASES OF THE SKIN. Third Edition, Revised. Essentials of Diseases of the Skin. By Henry W. Stelwagon, M.D., Clinical Professor of Dermatology in the Jefferson Medical College, Philadelphia; Dermatologist to the Philadelphia Hospital; Physician to the Skin Department of the Howard Hospital, etc. Crown octavo, 270 pages; 86 illustrations. Cloth, $1.00 net; inter- leaved for notes, #1.25 net. [See Saunders' Question-Compends, page 21.] " The best student's manual on skin diseases we have yet seen."—Times and Register. STENGEL'S PATHOLOGY. A Manual of Pathology. By Alfred Stengel, M.D., Physician to the Philadelphia Hospital; Professor of Clinical Medicine in the Woman's Medical College ; Physician to the Children's Hospital; late Pathologist to the German Hospital, Philadelphia, etc. In Preparation. STEVENS' MATERIA MEDICA AND THERAPEUTICS. Second Edition, Revised. A Manual of Materia Medica and Therapeutics. By A. A. Stevens, A.M., M.D., Lecturer on Terminology and Instructor in Physical Diagnosis in the University of Pennsylvania; Demonstrator of Pathology in the Woman's Medical College of Philadelphia. Post- octavo, 445 pages. Cloth, $2.25. "The author has faithfully presented modern therapeutics in a comprehensive work, and, while intended particularly for the use of students, it will be found a reliable guide and sufficiently comprehensive for the physician in practice."—University Medical Magazine. Medical Publications of W. B. Saunders. 27 STEVENS' PRACTICE OF MEDICINE. Fourth Edition, Revised. A Manual of the Practice of Medicine. By A. A. Stevens, A.M., M.D., Lecturer on Terminology and Instructor in Physical Diagnosis in the University of Pennsylvania; Demonstrator of Pathology in the Woman's Medical College of Philadelphia. Specially intended for students preparing for graduation and hospital examinations. Post- octavo, 511 pages; illustrated. Cloth, $2.50. "The frequency with which new editions of this manual are demanded bespeaks its popularity. It is an excellent condensation of the essentials of medical practice for the student, and may be found also an excellent reminder for the busy physician."—Buffalo Medical Journal. STEWART'S PHYSIOLOGY. A Manual of Physiology, with Practical Exercises. For Students and Practitioners. By G. N. Stewart, M.A., M.D., D.Sc, lately Examiner in Physiology, University of Aberdeen, and of the New Museums, Cambridge University; Professor of Physiology in the Western Reserve University, Cleveland, Ohio. Octavo volume of 800 pages; 278 illustrations in the text, and 5 colored plates. Cloth, S3.50 net. " It will make its way by sheer force of merit, and amply deserves to do so. It is one of the very best English text-books on the subject."—London Lancet. "Of the many text-books of physiology published, we do not know of one that so nearly comes up to the ideal as does Prof. Stewart's volume."—British Medical Journal. STEWART AND LAWRANCE'S MEDICAL ELECTRICITY. Essentials of Medical Electricity. By D. D. Stewart, M.D., Demonstrator of Diseases of the Nervous System and Chief of the Neurological Clinic in the Jefferson Medical College; and E. S. Lawrance, M.D., Chief of the Electrical Clinic and Assistant Demon- strator of Diseases of the Nervous System in the Jefferson Medical College, etc. Crown octavo, 158 pages; 65 illustrations. Cloth, #1.00; interleaved for notes, $1.25. [See Saunders' Question-Compends, page 21.] " Throughout the whole brief space at their command the authors show a discriminating knowledge of their subject."—Medical News. STONEY'S NURSING. Second Edition, Revised. Practical Points in Nursing. For Nurses in Private Practice. Bv Fmily A M Stoney, Graduate of the Training-School for Nurses, Tawrence Mass.; late Superintendent of the Training-School for Mnr.es Carnev Hospital, South Boston, Mass. 456 pages, illustrated with 73 engravings in the text, and 8 colored and half-tone plates. Cloth, $1.75 net. u i,c intpnded for non-professional readers which can be so cordially A " ^^ZaV^T^tn this oJ"-Therapeutic Gazette. endorsea Dy a. wrjtten, eminently practical volume, which covers the entire range of " This is a wei ~ -sa'e(j from hospital nursing, and instructs the nurse how best to private nursing as ^ '^ °ncies which may arise, and how to prepare everything ordinarily meet the various em » patient."—American Journal of Obstetrics and Diseases of needed in f^^ W inen an ^ ^^ ^g physician can place in the hands of his private nurses with the suranceof benefit. "-Ohio Medical Journal. 28 Medical Publications of W. B. Saunders. SUTTON AND GILES' DISEASES OF WOMEN. Diseases of Women. By J. Bland Sutton, F.R.C.S., Assistant Surgeon to Middlesex Hospital, and Surgeon to Chelsea Hospital, London; and Arthur E. Giles, M.D., B.Sc. Lond., F.R.C.S. Edin., Assistant Surgeon to Chelsea Hospital, London. 436 pages, hand- somely illustrated. Cloth, #2.50 net. "The book is very well prepared, and is certain to be well received by the medical public.''—British Medical Journal. "The text has been carefully prepared. Nothing essential has been omitted, and its teachings are those recommended by the leading authorities of the day.''—Journal of the American Medical Association. THOMAS'S DIET LISTS AND SICK=ROOM DIETARY. Diet Lists and Sick=Room Dietary. By Jerome B. Thomas, M.D., Visiting Physician to the Home for Friendless Women and Children and to the Newsboys' Home ; Assistant Visiting Physician to the Kings County Hospital. Cloth, $1.50. Send for sample sheet. " The idea is good, and the lists are copious."—London Lancet. "Its practical usefulness places it among the requirements of every practitioner."— Chicago Medical Recorder. THORNTON'S DOSE=BOOK AND PRESCRIPTION-WRITING. Dose-Book and Manual of Prescription-Writing. By E. Q. Thornton, M.D., Demonstrator of Therapeutics, Jefferson Medical College, Philadelphia. 334 pages, illustrated. Cloth, $1.25 net. " Full of practical suggestions; will take its place in the front rank of works of this sort."—Medical Record, New York. VAN VALZAH AND NISBET'S DISEASES OF THE STOMACH. Diseases of the Stomach. By William W. Van Valzah, M.D., Professor of General Medicine and Diseases of the Digestive System and the Blood, New York Polyclinic; and J. Douglas Nisbet, M.D., Adjunct Professor of General Medicine and Diseases of the Digestive System and the Blood, New York Polyclinic. Octavo volume of about 600 pages. Cloth, $3.50 net. Nearly Ready. VIERORDT'S MEDICAL DIAGNOSIS. Third Edition, Revised. Medical Diagnosis. By Dr. Oswald Vierordt, Professor of Medi- cine at the University of Heidelberg. Translated, with additions, from the second enlarged German edition, with the author's permission, by Francis H. Stuart, A.M., M.D. Handsome royal octavo volume of 700 pages; 178 fine wood-cuts in text, many of them in colors. Cloth, $4.00 net; Sheep or Half Morocco, $5.00 net; Half Russia, $5.50 net. " A treasury of practical information which will be found of daily use to every busy practitioner who will consult it."—C. A. LiNDSLEY, M.D., Professor of the Theory and Practice of Medicine, Yale University. " Rarely is a book published with which a reviewer can find so little fault as with the volume before us. Each particular item in the consideration of an organ or apparatus, which is necessary to determine a diagnosis of any disease of that organ, is mentioned; nothing seems forgotten. The chapters on diseases of the circulatory and digestive apparatus and nervous system are especially full and valuable. The reviewer would repeat that the book is one of the best—probably the best—which has fallen into his hands."—University Medical Magazine. Medical Publications of W. B. Saunders. 29 WARREN'S SURGICAL PATHOLOGY AND THERAPEUTICS. Surgical Pathology and Therapeutics. By John Collins Warren, M.D., LL.D., Professor of Surgery, Medical Department Harvard University; Surgeon to the Massachusetts General Hospital, etc. Handsome octavo volume of 832 pages; 136 relief and lithographic illustrations, 33 of which are printed in colors, and all of which were drawn by William J. Kaula from original specimens. Cloth, $6.00 net; Half Morocco, $7.00 net. "There is the work of Dr. Warren, which I think is the most creditable book on Surgical Pathology, and the most beautiful medical illustration of the bookmaker's art that has ever been issued from the American press."—Dr. Roswell Park, in the Harvard Graduate Magazine. " The handsomest specimen of bookmaking that has ever been issued from the American medical press."—American Journal of the Medical Sciences. "A most striking and very excellent feature of this book is its illustrations. Without exception, from the point of accuracy and artistic merit, they are the best ever seen in a work of this kind. Many of those representing microscopic pictures are so perfect in their coloring and detail as almost to give the beholder the impression that he is looking down the barrel of a microscope at a well-mounted section."—Annals of Surgery. WEST'S NURSING. An American Text-Book of Nursing. By American Teachers. Edited by Roberta M. West, late Superintendent of Nurses in the Hospital of the University of Pennsylvania. In Preparation. WOLFF ON EXAMINATION OF URINE. Essentials of Examination of Urine. By Lawrence Wolff, M. D., Demonstrator of Chemistry, Jefferson Medical College, Philadelphia, etc. Colored (Vogel) urine scale and numerous illustrations. Crown octavo. Cloth, 75 cents. [See Saunders' Question- Compends, page 21.] " A very good work of its kind—very well suited to its purpose."—Times and Register. WOLFF'S MEDICAL CHEMISTRY. Fourth Edition, Revised. Essentials of Medical Chemistry, Organic and Inorganic. Containing also Questions on Medical Physics, Chemical Physiology, Analytical Processes, Urinalysis, and Toxicology. By Lawrence Wolff, M.D., Demonstrator of Chemistry, Jefferson Medical College, Philadelphia, etc. Crown octavo, 218 pages. Cloth, $1.00; inter- leaved for notes, $1.25. [See Saunders' Question-Compends, page 21.] "The scope of this work is certainly equal to that of the best course of lectures on Medical Chemistry. "—Pharmaceutical Era. CLASSIFIED LIST OF THE Medical Publications W. B. SAUNDERS, 925 Walnut Street, Philadelphia. ANATOMY, EMBRYOLOGY, HISTOLOGY. Clarkson—A Text-Book of Histology, 9 Haynes—A Manual of Anatomy, . . . 13 Heisler—A Text-Book of Embryology, 13 Nancrede—Essentials of Anatomy, . . 18 Nancrede—Essentials of Anatomy and Manual of Practical Dissection, ... 18 Semple—Essentials of Pathology and Morbid Anatomy.........25 BACTERIOLOGY. Ball—Essentials of Bacteriology, ... 6 Crookshank—A Text-Book of Bacteri- ology, .............10 Frothingham—Laboratory Guide, . . II Mallory and Wright — Pathological Technique,..........16 McFarland—Pathogenic Bacteria, . . 17 CHARTS, DIET-LISTS, ETC. Griffith—Infant's Weight Chart, ... 12 Hart—Diet in Sickness and in Health, . 13 Keen—Operation Blank,......15 Laine—Temperature Chart,.....15 Meigs—Feeding in Early Infancy, . . 17 Starr—Diets for Infants and Children, . 26 Thomas—Diet-Lists and Sick-Room Dietary..............28 CHEMISTRY AND PHYSICS. Brockway—Essentials of Medical Phys- ics, ..............7 Wolff—Essentials of Medical Chemistry, 29 CHILDREN. An American Text-Book of Diseases of Children, . . .......3 Griffith—Care of the Baby,.....12 Griffith—Infant's Weight Chart, ... 12 Meigs—Feeding in Early Infancy, . . 17 Powell—Essentials of Dis. of Children, 19 Starr—Diets for Infants and Children, . 26 DIAGNOSIS. Cohen and Eshner —Essentials of Di- agnosis, Corwin—Physical Diagnosis, Macdonald—Surgical Diagnosis Treatment, ........ Vierordt—Medical Diagnosis, . DICTIONARIES. Keating—Pronouncing Dictionary Morten—Nurse's Dictionary, Saunders' Pocket Medical Lexicon, nd 16 28 14 18 24 EYE, EAR, NOSE, AND THROAT. An American Text-Book of Diseases of the Eye, Ear, Nose, and Throat, . 3 Casselberry—Dis. of Nose and Throat, 8 De Schweinitz —Diseases of the Eye, 10 Gleason—Essentials of Dis. of the Ear, II Jackson and Gleason—Essentials of Diseases of the Eye, Nose, and Throat, 14 Kyle—Diseases of the Nose and Throat, 15 GENITOURINARY. An American Text-Book of Genito- Urinary and Skin Diseases......■ 3 Hyde and Montgomery—Syphilis and the Venereal Diseases,.......13 Martin—Essentials of Minor Surgery, Bandaging, and Venereal Diseases, . 16 Saundby—Renal and Urinary Diseases, 24 Senn—Genito-Urinary Tuberculosis, . 25 GYNECOLOGY. American Text-Book of Gynecology, 4 Cragin—Essentials of Gynecology, . . 10 Garrigues—Diseases of Women, ... 11 Long—Syllabus of Gynecology, ... 15 Penrose—Diseases of Women, .... 18 Sutton and Giles—Diseases of Women, 28 MATERIA MEDICA, PHARMACOL- OGY, AND THERAPEUTICS. An American Text-Book of Applied Therapeutics,..........3 Butler—Text-Book of Materia Medica, Therapeutics and Pharmacology, ... 8 Cerna—Notes on the Newer Remedies, 8 Griffin—Materia Med. and Therapeutics, 12 Morris—Essentials of Materia Medica and Therapeutics, . . .....17 Saunders' Pocket Medical Formulary, 24 Sayre—Essentials of Pharmacy, ... 24 Stevens—Essentials of Materia Medica and Therapeutics,.........26 Thornton—Dose-Book and Manual of Prescription-Writing........28 Warren—Surgical Pathology and Ther- apeutics, ............29 MEDICAL JURISPRUDENCE AND TOXICOLOGY.. An American Text-Book of Legal Medicine and Toxicology,.....^ Chapman—Medical Jurisprudence and Toxicology,..........8 Semple—Essentials of Legal Medicine, Toxicology, and Hygiene......25 Medical Publications of W. B. Saunders. 31 NERVOUS AND MENTAL DISEASES, ETC. Burr—Nerv'aus Diseases,...... 7 Chapin—Compendium of Insanity, . . 8 Church and Peterson—Nervous and Mental Diseases,......... 9 Shaw—Essentials of Nervous Diseases and Insanity,...........26 NURSING. An American Text-Book of Nursing, 29 Griffith—The Care of the Baby, ... 12 Hampton—Nursing,.......12 Hart—Diet in Sickness and in Health, 13 Meigs—Feeding in Early Infancy, . . 17 Morten—Nurse's Dictionary, . . . . iS Stoney—Practical Points in Nursing, . 27 OBSTETRICS. An American Text-Book of Obstetrics, 4 Ashton—Essentials of Obstetrics, ... 6 Boisliniere—Obstetric Accidents, Emer- gencies, and Operations,...... 7 Dorland—Manual of Obstetrics, . . . 10 Hirst—Text-Book of Obstetrics, ... 13 Norris—Syllabus of Obstetrics, .... 18 PATHOLOGY. An American Text-Book of Pathology, 4 Mallory and Wright — Pathological Technique,...........16 Semple—Essentials of Pathology and Morbid Anatomy, . . ......25 Senn—Pathology and Surgical Treat- ment of Tumors, .......25 Stengel—Manual of Pathology, ... 26 Warren—Surgical Pathology and Thera- peutics, .............29 PHYSIOLOGY. An American Text-Book of Physi- ology, .............. 5 Hare—Essentials of Physiology, . . . 13 Raymond—Manual of Physiology, . . 19 Stewart—Manual of Physiology, ... 27 PRACTICE OF MEDICINE. An American Text-Book of the The- ory and Practice of Medicine, . • • • S An American Year-Book of Medicine ^ and Surgery, • • • • - • '. " 'c Anders—Text-Book of the Pract.ce of ^ Medicine,......, ■ " ' ." " r Lockwood—Manual of the Pract.ce of Medicine, ... ■ r ^./pra;tice - 0f Morris—Essentials of the Medicine, . - ■ . • __ A;chiv'es' of Rowland and Heaiey ^ the R°en'f "^f • the ' Practice' of Stevens—Manual 01 .....^ J[e licine,..... SKIN AND VENEREAL. An American Text-Book of Gen.to- AUr£Tryand Skin Diseases,.....3 Hyde and Montgomery—Syphilis and the Venereal Diseases,.......13 Martin—Essentials of Minor Surgery, Bandaging, and Venereal Diseases, . 16 Pringle—Pictorial Atlas of Skin Dis- eases and Syphilitic Affections, ... 19 Stelwagon—Essentials of Diseases of the Skin,............26 SURGERY. An American Text-Book of Surgery, 5 An American Year-Book of Medicine and Surgery,...........6 Beck—Manual of Surgical Asepsis, . . 7 DaCosta—Manual of Surgery, .... 10 Keen—Operation Blank,......15 Keen—The Surgical Complications and Sequels of Typhoid Fever,.....15 Macdonald—Surgical Diagnosis and Treatment,...........16 Martin—Essentials of Minor Surgery, Bandaging, and Venereal Diseases, . 16 Martin—Essentials of Surgery, .... 16 Moore—Orthopedic Surgery,.....17 Pye—Elementary Bandaging and Surgi- cal Dressing, .... ......19 Rowland and Hedley—Archives of the Roentgen Ray,........19 Senn—Genito-Urinary Tuberculosis, . 25 Senn - Syllabus of Surgery,.....25 Senn—Pathology and Surgical Treat- ment of Tumors......... . 25 ■Warren—Surgical Pathology and Ther- apeutics, ............29 URINE AND URINARY DISEASES. Saundby—Renal and Urinary Diseases, 24 ! Wolff—Essentials of Examination of Urine,.............29 MISCELLANEOUS. Bastin—Laboratory Exercises in Bot- any, .............7 Gould and Pyle—Anomalies and Curi- osities of Medicine,........II Gross—Autobiography of Samuel D. Gross,.............12 Keating—How to Examine for Life Insurance,............14 Keen—Surgical Complications and Se- quels of Typhoid Fever.......15 Rowland and Hedley—Archives of the Roentgen Ray,........19 Saunders' New Series of Manuals, 22, 23 Saunders' Pocket Medical Formulary, . 24 Saunders' Question-Compends, . . 20, 21 Senn—Pathology and Surgical Treat- ment of Tumors,..... . 25 Stewart and Lawrance—Essentials of Medical Electricity,........27 Thornton—Dose-Book and Manual of Prescription-Writing, ....... 28 Van Valzah and Nisbet—Diseases of the Stomach,...........28 In Preparation for Early Publication. AN AMERICAN TEXT-BOOK OF DISEASES OF THE EYE, EAR, NOSE, AND THROAT. Edited by G. E. de Schweinitz, M.D., Professor of Ophthalmology in the Jeffer- son Medical College, Philadelphia; and B. Alexander Randall, M.D., Professor of Diseases of the Ear in the University of Pennsylvania and in the Philadelphia Polyclinic. AN AMERICAN TEXTBOOK OF PATHOLOGY. Edited by John Guiteras, M.D., Professor of General Pathology and of Morbid Anatomy in the University of Pennsylvania; and David RiesMAN, M.D., Demon- strator of Pathological Histology in the University of Pennsylvania. PETERSON AND HAINES' LEGAL MEDICINE AND TOXICOLOGY. An American Text-Book of Legal Medicine and Toxicology. Edited by Frederick Peterson, M.D., Clinical Professor of Mental Diseases in the Woman's Medical College, New York; Chief of Clinic, Nervous Department, College of Physicians and Surgeons, New York; and Walter S. Haines, M.D., Professor of Chemistry, Pharmacy, and Toxicology in Rush Medical College, Chicago. STENGEL'S PATHOLOGY. A Manual of Pathology. By Alfred Stengel, M.D., Physician to the Phila- delphia Hospital; Professor of Clinical Medicine in the Woman's Medical Col- lege ; Physician to the Children's Hospital; late Pathologist to the German Hospital, Philadelphia, etc. CHURCH AND PETERSON'S NERVOUS AND MENTAL DISEASES. Nervous and Mental Diseases. By Archibald Church, M.D., Professor of Mental Diseases and Medical Jurisprudence in the Northwestern University Medical School, Chicago; and Frederick Peterson, M.D., Clinical Professor of Mental Diseases in the Woman's Medical College, New York ; Chief of Clinic, Nervous Department, College of Physicians and Surgeons, New York. HEISLER'S EMBRYOLOGY. A Text=Book of Embryology. By John C. Heisler, M.D., Professor of Anatomy in the Medico-Chirurgical College, Philadelphia. KYLE ON THE NOSE AND THROAT. Diseases of the Nose and Throat. By D. Braden Kyle, M.D., Chief Laryngologist to St. Agnes' Hospital; Bacteriologist to the Orthopedic Hospital and Infirmary for Nervous Diseases; Instructor in Clinical Microscopy and Assistant Demonstrator of Pathology, Jefferson Medical College, Philadelphia. HIRST'S OBSTETRICS. A Text-Book of Obstetrics. By Barton Cooke Hirst, M.D., Professor of Obstetrics in the University of Pennsylvania. WEST'S NURSING. An American Text-Book of Nursing. By American Teachers. Edited by Roberta M. West, Late Superintendent of Nurses in the Hospital of the University of Pennsylvania. ( \ NATIONAL LIBRARY OF MEDICINE NLfl DGlObbflfl M ^^^B NLM001066884