REPORT of PROFESSOR DELAFIELD'S LECTURES ' • X < on the PRACTICE OF MEDICINE* VOLUME I A. D, MDCCCLXXXVI11 - PREFACE. - In presenting this book tn the students of the College of. Physicians and Surgeons, the editors wish to say that they have endeavored to give a faithful report of the lectures which have been given,during the past two. years in the department of the Practice of Medicine* In this respect,they think they have succeeded and that the following pages will be found to comprise all the subjects that have been treated of in that department. The value of such a set of notes, supplemented by the fresh matter gleaned by the student from the lecture.,we think will be apparent to all, To afford space for these additional notes, to be added by the' student while following the lecture, we have inserted at the end of each volume a number of blank pages considering this method preferable to leaving a wide margin for this purpose which would have lessened the compactness and portability of the bonk. This feature which we have considered of the greatest importance and to whichtthe rather peculiar shape of these volumes is due has not been lost sight ofo For a book tn be of use in the lecture room, it must be small enough to be easily carried in a satchel or in a coat pocket and^yet,this small size must net be attained by the sacrifice of the contained matter the legibility of the type. In regard to the typography,we have selec ted a larga, readlbla, type and have endeavored to make it as clear as the duplicating process will permit. Errors in spelling will occur and,while those who have never used a type writer may be surprised that there are so many, those who have will be surprised that the re are so few. Errors in sense have been carefully searched for and cor- rected when ever found but such as do exist must be ascribed to our omission for,while this book is published by the kind permission of Prof. Delafield,it is but just to say that he he s had no ha id either in the arrangement or revision and it is entirely the fault of the editors if errors exist. The?p regent volume will be found to contain the work of the first year and the next which is in preparation the remainder of the subjects treated of thus making a set of notes in every reap oat full* INWJmTION. inflammation may attack i^coidwtive tissue. 2-WCOUS SdERAl-ISSe 5-THE VISCERA. I-THE INFLAld-MTIONS OF CONNECTIVE TISSUE. Connective tissue is composed of a basement substance and. cells. During life,the basement substance is transparent and homogeneous: after death,it becomes coagulated and fibrillated. The cells in the substance- of connective tissue are branched dr have prolongations that look like wings. Others over the free sur- face form a single layer of flat polygonal nuclear cells,often called endothelial. The cells first mentioned are of considerable size and anastomose. Beside all these,there are in the basement substance itself little round culls identical v/ith the white cor- puseles of the blood. These little round cells are also found in the lymph tracts that pervade connective tissue. Connective tissue is also provided with blood vessels,lymphatic vessels,lymphatic spaces,and nerves varying in number and size. Ac regards inflammation, the most important constituents of eon** nective tissue are first,the culls and blood vessels: next, the lymphatics end basement substance. The part played by the nerves is unknown. Connective tissue is found everywhere in the body and constitutes a large part of the frame-work of the body.Therefore,it is a most • important tissue and the inflammations to which it is liable are very important indeed* They are the following: 1-Ce1lu1ar inf1ammation* 2-inflamination with the production of serum,fibrin,and pus- 3* Inf lamination with the production of serum, fibrin, pus, and new connective tissue. ^Inflammation with the production of granulation tissue* 5-Inflammation with the production of new connective tissue. 6 - Tub e 3? c u 1 a. r i nf 1 amma t i o n- 7-Syphilitic inflammation. ' 1-CELLULAR When connective tissue becomes the seat of a cellular inflammation, the product is new connective tissue cells.The basement substance and blood-vessels present but slight changes.The basement substance maybe split up by the new cells that are produced.This form of inflammation may run an acute or chronic course. ACUTE.-Aitor death,we find on the surface only a new production of cells in little groups- Deep in the connective tissue, the cells arc increased in numbem 2 and new polygonal cells are produced which,if they live,become branchod*If this form involve the peritoneum or pia mater,it is • apt to prove fatal in a few days. CHRONIC- It may last months and years but doos not change its char- actor. The cells produced form delicate threads which cover the surface of the membrane. This we see in pleurisy with adhesions. If cellular inflammation involve the peritoneum or the pia mater, it will probably cause death: if it involve the pleura, it need not destroy life and is apt to take on the chronic form. 2-INULM:MATI0N WITH TIE PRODUCTION 01? SEBUM,FIDHIN,AND PUS^ This is the most common of all the infdamnations that invade con- nective tissue. It is sometimes called inflammation with exudation o r, s imply,ac ute inf1aromat ion. The serum,fibrin,and pus nec d no t each be present in the same quantity*Indeed,one or two of them may be altogether absent. This form differs radically from the cellular. The culls take but little part in the inflammatovy process.Even- the basement substance is not affected..The blood vessels are the structures that undergo Ine cnange» ^hen blood circulates normally through healthy connective tissue, st passes with considerable rapidity. In the arteries,we notice a central column of red and a peripheral column of white eorpu-^0^* la the small veins,the white corpuscles arc*rather more numerous 3 than the red. In the capil laries,no particular division into col- umns is noticed. When the connective tissue becomes inflamed,a change takes place in the circulation and there is also a change in the size c-f the small arteries and veins.The small arteries and veins increase in size. The capiJlaries remain unchanged. In neither the arteries.veins, nor capillaries does the blood circulate as rej^idly. The current becomes slower and slower especially in the veins and capillaries and it may stop altogether in the veins. Then as the inflammation goes on,the capillaries become somewhat dilated. All these changes take place at the commencement and the inflammation may stop at this point. Then,we say that it has stopped at the stage of congestion. The parts may then return to their normal condition. If the inflammation go further,the dilatation continues,the blood continues to accumulate in the vessels,and the white corpuscles increase in number,especially in the small veins. The white cells continue to increase in number until they form a thick layer along the wall of the vessel. At the same time,they become much more numerous in the capillaries. Then,some of the constituents of the blood escape from the blood vessels and infiltrate the adjacent connective tissue. The plasma that escapes is called serum. The white cells begin to change their shape. They send out fine pro- longations which adhere to the wells of the vessel. Then,they find 4 their way into spaces between the cells that form the wall of the vessel and,finally,the white corpuscles pass through the wall of the vessel into the surrounding connective tissue*!t appears as a soft grayish matter on the surface of the membrane.lt may be in the form of'little granules,fibres, or as a homogeneous mass.The fibrin is form- ed outside the- blood-vessels by a combination of a substance con- tained in the white blood cells with a substance in the transuded plasma.. If the peritoneum be involved, its surface will be coated "^\t^ bus, and the cavity filled with serum. The present form varies much inx Intensity, in the mildest forms only serum is present, in the more 'severe pus and fibrin also.This form is subject to modifications vis. ;-l-Not only do the vessels become dilated ano contain move blood,but the current becomes slower and slower and may stop al together,if the stoppage last but a short time no harm is done,but,if it be perma- nent this part of the tissue must die.And so we have as a modifi- cation the death of larger or smaller portions of the connective tis- sue, if a considerable part die,it is very serious. -2-In this condition,as before,we find changes in the blood-vessels and exudation of serum,but,on account of excessive infiltration, soma of the vessels become compressed and' the circulation through *them is arrested.We also find bacteria,micrococci.The tissue dies but in very small areas.This death is called necrosis. It is 5 very serious. 3-Tbis differs from! the second modification only in degree. Abeesses are formed in the connective tissue. An abcess is a cavity that contains pus and fragments of the surrounding tissue. We have con- gestion and exudation but the inflammatory products are greatly increased in quantity and bacteria are added. Bacteria are necessary for the formation of an abcess. We get necrosis but the necrosed areas are numerous ano close together. The connective tissue is hard and swollen. The dead parts liquify and break down and form a cav- ity which contains the abcess. * 3-INFLAMMATION WITH THE PRODUCTION OF SERUM,FIBRIN,PUS.AND NEW CONNECTIVE TISSUE. This form of inflammation begins in the same manner as inflammation with exudation but the connective tissue no longer remains pas- sive. Early in the process,new connective tissue cells are pro- duced. Tn the early stages, all th'- inflammatory products are present at the same time. La ter, the serum, fibrin, and pm begin to disappear ano the cells increase ip number. Then, cs the inflammation continues, tiv *e rum, fibrin, and pus. entirely disappear. The cells continue to increase in number and form either granulation tissue or simply new connective tissue.If the patient recover,the connective 6 tissue is changed by the addition of new connective tissue. -4-INFLAMMATION WITH THE PRODUCTION' OF GRANULATION TISSUE.* Granulation tissue is derived from the connective tissue corpuscles or from the white corpuscles of the blood or from both. It is.developed in the course of both acute and chronic infla.ro* Orations after the destruction of tissue by necrosis,It builds up the destroyed tissue.Yet it may -be fox-med without the previous destruc" tion of tissue. Granule tion tirsvre is composed of a basemeat sub- "stance, cells and blood-vessels. The cells are very numerous, close ' together, and vary conside rably in size.Many of the cells resemble the white corpuscles,some are larger, others are large and flat like epithelium,others are branched.Between the cells is a little babe* Trent substance that contains blood-vesselc wi th very thin walls- 'On this account granulation tissue bleeds eerily. 'When granulation tissue is once formed.it nay remain as granulation tissue forever.More frequently,ita structure gradually changes. '"The cells decrease in number, the basement increases in quantity, ana the tissue resemble?^ norma.l connective tissue.lt is then called 1 cioat ricial tissue. 7 5-INFLAMMATION with the production of new connective tissue. This form of inflammation always runs a chronic course. The very first change is in the connective tissue* The connective tissue increases in size* This increase is simply due to the develop- ment of new connective tissue. There is no formation of granulation tissue?no previous formation of serum,fibrin>or pus. This form of inflammation attacks the peritoneum and the peritoneum gradually Meeomes thicker and. thicker. 6- TUBERCULAR INFLA^ATI ON. In this form of inf lamination, granulation tissue is produced but the tubercle bacillus is also present. The inflammatory products con- sist of a. basement substance and cells* At first, the basement sub- stance is not very plentiful and is delicate and soft-.as the inflam mation proceeds,it' increases in quantity and density. The basement substance is provided with round and oval nuclei. These nuclei are arranged so as to form a network which encloses rather large polyg- onal cells and giant cells which contain oval nuclei and have branches. The giant cells are not constant and may exist in sim- ple granulation tissue. Tubercular tissue contains but few blood vessels and,therefore, it has a tendency to degenerate and die. This tendency to degeneration is increased by changes which take place in the blood vessels surrounding. Their inner coats be- come inflamed,endarteritis. AL a result of this inflammation,the 8 lumen of the vessel is narrowed and the circulation through the part is impede d> ■ Tubercular tissue may bo arranged in one of two ways. In the first place it may be in the form of little globules*the so-called 5iu- bcroular granules* * Those, globules nay be scattered bn t, general ly, • they are pretty close together. This ar range meat is rather charac- teristic. In the- second plane,tubercular tissue may be arranged as ordinary granulation tissue. As a rulq, tubercular inflammation does not occur by itself. It is generally accompanied by one of the former kinds of inflamrvctioAU •If it .run-an. acute course and involve large arbas,thv patient is A 'apt to die an a direct result of the inflammatioru If it run a chronic course*it way nob cause death for a number of years and if it attack but small areas, it may never cause dur^h^Whcn a patient re covers from a tubercular inflammation, nearly the whole of the dis^ leased tissue is converted into a mass of granulation tissue* This granulation tissue may remain solid forever,but,more frequently,it softens and liquifies,the fluid products are absorbed,and a simple :loss' of tissue .results.. If the tubercular inflcw&ition be from th© first complicated with granulation tissue,the granulation tissue ,rny form cioatrieinl tissue and none uf the original tubercular tis-* ijuo will 'be left., . 9 7-SYPHILITIC INFLAMMATION. When a person has constitutional syphilis,the poison of the dis- ease can produce any of the former kinds of inflammation but none of thes so produced are regarded as belonging to the true syphil- itic type. True syphilitic inflammation of connective tissue is only a modification of one of the previous forms,namely,inflammation with the production of granulation tissue. In addition,it possesses a characteristic lesion,the gummy tumor. A new tissue is produced, that resembles granulation tissue but it differs from granulation tissue in the following particulars. The cells are nearly all small and are either round or oval,the blood vessels are not formed at all ox1 only in very small numbers, the ar- teries surrounding the new tissue are apt to become the seat of en- darteritis, and, therefore, this tissue is apt to degenerate and die. Syphilitic inflammation may run an acute or chronic course and any connective tissue in the body may be affected by it,for example,the periosteum,the fasciae,or the intermuscular septa. In all cases,the inflammation attacks but circumscribed areas. When the periosteum is attacked,it becomes swollen and a tumor is formed beneath it. If,at an early stage of its development,we re- move such a tumor,we find it composed externally of granulation tissue while,at the centre,degeneration has already begun. We tlso notice that the arteries around the tumor 10 A are inflamed, If instead of removing the tumor when it is small,we put the patient upon mi^ed treatment,we would find attthe end of a week that it had diminished in size and, finallygit would disappear* The disappearance of the tumor is due to degeneration and the sub- sequent absorption of the degenerated structures by the lymphatics* ■Should the patient not be treated,one of two things may happen* In the first place.the degenerated tissue may become cheesy and cicat.rioial tissue may be formed on the outside of the tumor* In the second plane,necrosis and suppuration may take place in the tumoraand an ahcess will be formed* This access will discharge and *leave an ulcer Lined with granulation tissue* These ulcers last a long time and are vary hard to cure* OF MUCOUS MTRmiNES * The structure of a mucous membrane is more complicate than that of connective tissue* A mucous membrane consists essentially of <troma, epithelium, and glands* The epithelial cells vary in shapes The stroma is always composed of connective tissue. The glands may have either a tubular or racemose form* In either ease^ their is the same, the secretion of mucus* . . When a mscous mesbrane is in. a healthy condition, the. epi th arc continually growing and de eg u umma ting.. The blood vessels in the stroma are quite numerous and contain ... moderate quantity of blood* This gives the mucous membrane a red color* The glands constantly 11 produce mucus,thin or thick,in great or small quantity. Mucous membranes may become the seat of five inflammations. These are, 1-Catarrhal,acute or chronic. 2-Purulent,generally acute. 3-Croupous. 4-Tubercular. 5-Syphilitic. 1-CATAiWAL INFLAMMATIONS. ACUTE. Acute catarrhal inflammation is the most common of all the inflam- mations that invade mucous membranes. At first,the membrane becomes congested and swollen and the blood vessels contain additional blood As the inflammation goes on,some little exudation of serum takes place and then,there is a change in the function of the glands. The secretion of mucus is arrested end the membrane becomes dry. This condition of dryness and congestion lasts for a longer or shorter period according to the si tuition of the inflammation. kla the larynx,it lasts from two to three days:elsewhere,but a few hours. As the inf lamination goes on, this dryness is succeeded by an increased production of mucus. This mucus may be thick, thin, or acrid,or it may be mixed, with serum. This increased production 12 of mucus continues throughout the tvhole inf 1 animation. Then the glands resume their normal function. The desquammation of the epith* elial cells goes on more rapidly. The supificial cells may des- ^quammate so rapidly that ulcers will be formed. If the surface of the mucous membrane be intensely inflamed,the white corpuscles may emigrate. Then we say that the discharge is muco-purulent. Some- times, the red corpuscles emigrate. This shows that the inflamma- tion is still more severe. Then the mucus will be streaked with blood. Some times,the vessels rupture and a considerable quantity of pure blood may be discharged. Some mucous membranes have lymphatics. When these membranes become inflamed,the lymphatic glands take part in the inflammation. They become swollen and degenerate and necrose at the'centre and this degeneration and necrosis mar/ involve the stroma and cells. Then, this degenerated mass is discharged, and ulcers are left which extend through the epithelium down to the stroma. Thus,we may have two kinds of ulcers in acute catarrhal inflammation. Such a catarrhal inflammation varies in intensity. The milder forms are very common.A mild form,however,can not as a rule be recog- nised after death. Im' the inflammation be more severe, the conges- tion and swelling will be more marked and the white corpuscles will infiltrate the stroma: if still more severe,pus and fibrin will be formed and. will make the mucus thicker. 13 -CHRONIC. - This ir also eommon.lt may follow the acute form or the inflammation may from the first be chronic. In the chronic form,bloodvessels are n-O't Minays found in the stroma but they' «may be present.If they be not present, the membrane will be pale. When the disease has lasted for a long time, the membrane becomes a sort of slate color. This is air to a deposit of pigment in the stroma. This pigment is derived from the bloo-d. It is only deposited in old cases. The secretion from the glands may be increased and the mucous thick- er or thinner than normal:on the other hand,the secretion may di- minish or stop altogether,ano the membrane will have a dry appear- ance. As the inflammation continues, we get structural changes.The epithe- lial, .cells may increase or diminish in number.This increase or diminution of the epithelial cells may affect the whole oi* only a part of the membrane. The stroma may become hypertrophied or atro- phied^Thi'S may also affect the whole nr a part of the membrane. If only apart be affected,little tumors will be formed which will project inward in the stroma.The mucous glands may be altered in structure.., they may be pressed and distorted by the hypertrophy of the stroma. This we often see in the stomach. The glands themselves may become hypertrophied. As a rule,this hypertrophy affects only circumscribed parts,involves the stroma,and forms little tumors. The ghands may become cysts by thel^*ducts being blocked up so that the mucus. 14 cannot escape. The lymphatic glands often remain unaffected but they may become the seat of a chronic inf lamination. Then, they will either swell or die and ulcers will be formed. The acute form of catarrhal inflammation has a tendency to get well by itself but the chronic form, especially if the inflammation have produced structural changes,does not tend to recovery and the mucous membrane may never return to its former condition. They are both apt to recui' even if cured. 2-PURULENT INFLAMMATION, This may be a variety of catarrhal,either acute or chronic. The same changes take place as in catarrhal inflammations but,in ad- dition^he white corpuscles emigrate and mix with the mucus in the form of pus. So, the mucus is more opaque,yellow, and. changed in con- sisteney. The terms purulent and suppurative differ. Really,there is no such "thing as a suppurative inf lamination of a mucous membrane. When sup- puration takes place,the stroma is inflamed and serum,fibrin, and pus are produced. So, i t is an inflammation of the stroma and should be classed with the inf laminations of connective tissue. 3 - CROUPOUS INFLAMMATI0 NL Fortunately, this is not as common as the other forms. It is so much 15 more serious, we have the same products as in catarrhal inflam- mations but the inflammatory and necrotic products combine. The blood vessels take the principal share as regards the inflam- matory part of the process. Congestion and exudation take place and the stroma is infiltrated with serum,fibrin,and,pus. Part of these inflammatory products finds its way to the surface and coag- ulates- The fibrin adheres to the epithelial layer, encloses pus cell# and forms a false membrane. So, the mucus membrane is of a red color swollen,and coated with a false membrane. The function of the glands is at once and for a considerable time arrested. This is due to the inflammatory changes and also to the fact that the false membrane stops up their ducts.This arrest of secretion continues until the inflammation subsides and the false membrane comes away. As an increase of mucus,helps to remove the false membrane,we are in the habit of giving jaborandi to increase the production of mucus. In edditJon to the inflammatory changes,there is also necrosis of the Inflamed tissue, in the milder o^ses,the neorosis only involves the- epithelial layer and contribute^ to the formation of the false membrane and, if the patient recover, the neerc ti e epithelium corner away and leaves the stroma bear. This Josb is,however, repaired* If to disease be more severe, the necrotic process involves the stroma as well as the epithelium and when the neo rosed areas come aray, 16 we have loss of tissue involving the stroma and ulcers are formed. If the patient recover,the ulcers will be filled up with granular tian tissue but the mucous membrane never returns to its former eon** dition for., over the ulcers, the epithelium will not be replaced. There may be a good deal of necrosis witnout the production of much serum*fibrin,and pus. If the patient die during the early stages of the disease,we find the false membrane and the stroma is infiltrated with serum, fie ria,and pus. A croupous inf 1 animation is always serious and may cause death in 'its earliest stages. It is frequently called liphtheritie inflam- mation. Some use the terms croupous and diphtheritic synonomously. Others use croupous to designate the milder forms and reserve diph- theritic for the more severe. 4-TUBERCULAR im?M<MATION. Tubercular inflammation presents itself under two forms. FIRST FORM-Just beneath the epithelium*the stroma is everywhere infiltrated with tubercular tissue and little aggregations of round and polygonal cells. At the same time,a mild form of catarrhal inflammation is set up with the production of some mucus. Things may remain in this state for some time ana,except by the aid of the microscope,it cannot be distinguished from a true catarrhal inflam- mation.As the inflammation continues,the little aggregations »f cells become larger and the tissue undergoes cheesy degeneration. 17 This necrosis extends to the stroma and epithelial cells and the tissue presents areas of dead membrane corresponding to the orig-. inal tubercular foci. Then,these necrotic portions slough away and ulcers are left consisting in part of tubercular tissue and in part of granulation tissue.When the inflammation reaches this stage,it is apt to become chronic* As the catarrhal inflammation goes on,it thickens the membrane between the ulcers and the mucous membrane has a ragged appearance.The ulcers may heal and be replaced by granulation and cicatricial tissue and the patient may recover. More frequently,they do not heal. "This form,we find in.the larynx,trachea,and small intestine. In the small intestine,the tubercular tissue is not formed in the stroma but in the solitary and agminate glands. The general pro- cess is however the same. SECOND PORM-We have the same catarrhal inflammation,and the same infiltration of tubercular tissue into the stroma but the tubercu- lar tissue is diffused,not in foci. We have the tendency to degeneration and necrosis appearing very early and involving both the stroma and cells. So,even early in the process,the membrane is yellow, swollen,coated with mucus,and in a state of cheesy degeneration. This degeneration extends to a con- siderable depth in the stroma. The membrane may remain in this condition for some time. • Then,the necrosed portions 18 slough away and. considerable areas are destroyed down to the stroma The loss of* tissue becomes deeper ani more diffused. This form, we find in the bronchi,pelvis of the kidney,ureters,uterus, and bladder. When it has once begun,it usually continues till death* Very seldom,does the tissue regenerate. 6-SYPHILITIC. If a person have constitutional syphilis,the mucous membrane may be the seat of either an acute or chronic catarrhal inflammation* In addition, there is a characteristic syphilitic lesion,the gummy tumor but the gummy tumor is now called a mucous patch, or condyloma/ So. the changes are very much the same as those we get in syphilitic inflammation of connective tissue. The stroma becomes infiltrated, with small round cells. However, this infiltration does not reach to any great depth but forms a little flat tumor on the surface. If properly treated, the mucous patch may disappear,. The cells de- generate and are taken up by th® lymphatics. If it be not properly , treated,the round cells and also the epithelium degenerate very rapidly* They slough away and'leave flat, ulcers formed of granula- tion tissue. 'These ulcers may heal but the epithelium will not be replaced and puckerings and deformities will- result. If they do not heal,they may extend very deeply. 19 3-INFLAMMATIONS OF THE VISCERA. The essential parts of every viscus • are the connective tissue stroma which forms the frame,characteristic cells,blood vessels, lymphatic vessels,and nerves situated in the stroma. The cells differ radically from connective tissue cells. Connective tissue cells live,produce new cells,undergo inf lamination, and form tumors. In addition to all this,the cells of the viscera perform some particular function. For example,the cells of the tubules of the kidney secrete urine. So,when the cells of a viscus are inflam- ed, the function of the viscus is disturbea.Simple congestion,may produce nearly the same result as inflammation for the cells are very sensitive. Congestion does not at once produce any structural change but the accumulation of blood in the vessels disturbs the function of the viscus. Congestion also alters the size and color of the viscus. The inflammations that attack the viscera are the foil o wi ng 4 1« P a re nc hyma t ou s. 2-Diffuse. 3-Interstitial 4-Tubercular. 5-Syphilitic. 20 -1-PARENCHYMATOUS.- The parenchyma of a viscus is that part which effects *its particular function.For example,by the parenchyma of the liver is meant the hepatic cells but not the stroma^by the parenchyma o the' lungs, is meant the air spaces composed of connective tissue. A parenchymatous inflammation may be either acute or chronic but in either case the changes in the cells are the same. The cell bo'dy is changed and swoolen,its composition is changed, it may be 'infiltrated with fat,or the cells may die and break down into an' amorphous mass of granular matter. Th the acute form,the inflammatory process often stops when the 'cells are swollen and somewhat opaque,and the cells may then rapid" ly return to their former condition.In other case:-,the cells may go on to the point of death and, when this happens,it makes a diffe??- ence as to the number of cells that go on to necrosis.If the inflam- mation he mild, only a moderate number of the cells may die. This may not be so serious.If however,the inflammation be more severe, many cells may die, the functions of ?.ne viscus will be seriously disturbed,and,may die. In such an acute inf lamination, we notice chief- ly the disturbances in the function of the viscus. If in c mild case,we examine the viscus after death,no change will • be noticed^but if the inflammation be more severe,the viscus will be Enlarged,its color will be changed,and a number cf cells will be found necrosed. 21 CHRONIC-The changes', go on slowly and gradually. If mild,it will last a long time and do little harm* if severest will last but a short time and do much more damage. A caronic inflammation is always serious and when viscus is the a t of a. chronic p a r e n c hy m a t ou s i nf 1 amm a t i g a, th e dis e a s e i s up t to last throughout the life of the patient. HNWTITUJj. The inflammatory process involves the stroma. The cells undergo only secondary changes. It presents itself under two formas, acute tv nd chronic. ACUTE-This exists under two distinct types. In the first,the blood vessels are dilated,the inflammatory prod- ucts transude, and the stroma is inf iltraced with rerum, fibrin, and pus. Some times, the patient will die at .his end these changes vill he found after death. If he recover,"he serunufibrin,and put are absorbed and the viscus returns to its former, condition. In the second form,there is the Same congestion and exudation hut we also have necrosis and abcess. In the first fornu the cells are not much changed but,in the second,the necrosis involves the cells as well as the stroma. The abcess may reach a very considerable size. In the liver,it may be several inches in diameter. It is apt to cause death unless the pus can be evacuated. 22 -CHRONIC.-In this form the inflammation involves the stroma as before.There is a production of new connective tissue cells and of basement substance.Sometimes the new cells are produced in great excess,and the stroma of the viseus is thickened by a tissue resem- bling granulation tissue.If the basement substance be produced in excess, the stroma will be thickened b?z new connective tissue. As a. rule,these two conditions do not succeed each other hut occur separ- ately. This chronic form regularly produces changes in the celJs. As the stroma increases in quantity,it presses upon the blood vessels and upon the cells and interferes with their nutrition, as a result, 'the cells atrophy,degenerate and become deformed. They become smal- ler, altered in shape,and infiltrated with fat and the function of the viscus is deranged. Such an inflammation is always serious,for, when it has once begun,it usually continues and may endanger the life of the patient* -3-DIFFUSE.- From the outset, bo th cells cind stroma are involved. It may run an "acute or chronic course. Acute-The changes in the cells are the same as in acute parenchy- matous infl animation and the changes in the stroma are the same as in the first form off acute interstitial. As a rule,abceases are ' net found. If it he sufficiently intense, the inf lamination nay cause die a th while it is still going on: if wild,the patient may get veil" 23 with a viscus just as good as before* Some times,however, when the patient recovers,the larger portion of the viscus will return to its former condition but some small parts never get well. The vis- ceral cells that have been destroyed are not reproduced and the infil tration of serum,fibrin,and pus is followed by the production of new connective tissue in small areas over the surface of the vis- cus. These areas often do no harm:but,at other times,al though the patient recovers temporarily, it soon becomes evident that the func- tion of the viscus is permanently deranged and a chronic form of the disease is established. CHRONIC-The changes in some of the cells are the same as in the milder forms of acute parenchymatous inf lamination/but there are other cells that undergo degenerative changes. They become infil- trated with fat or break down. The changes in the stroma are the same as those of interstitial. This chronic form is always bad. It very rarely stops altogether although it may go on very slowly. The stroma is effected, we m&y have miliary tubercles diffused through the stroma or tubercular and gx'anulation tissue in small areas which degenerate. If we have miliary tubercles,they are small and do not produce many changes. If we have large masses of tubercu- lar tissue,they press upon the cells of the viscus*They may look 4-TUBERCULAR. 24 almost like small tumors. 5-SYPHILITIO. The stroma is involved. The; inflammatory products may be of small size or of large size. If small,they are in tne form of rounded transparent nodules. These noaules are scattered through the stroma and are very plentiful. If large, they are in the form of gummy tumors. There tumors are of considerable size and press upon the cells of the viscus. There is apt to be an interstitial inflammation at the same time. DISEASES OP THE BRAIN AND ITS MEMBRANES. INFLAMMATION OP THE EXTERNAL LAYERS OP THE DURA MATER. This way follow an inflammation of the periosteum of the bones of the skull,an inflammation of the bones themselves,a fracture,an inflammation of the ear, or an inflammation of the orbit. It is not an idiopathic condition. It is often called pachymeningitis. The inflammation produces a collection of pus between the dura and the bone.As a rule,this accumulation of pus is not of large size ana its situation corresponds to that of the primary lesion. If it re- main confined to the external layers,it way an no harm and the pus 25 degenerates and is absorbed. Rut the inflammation may extend to the internal layers and the further it goes the more serious does it become. It may extend to the walls of the venous sinuses and cause coagulation and thrombosis. This spreading is very serious. It may extend in both directions. INFLAMMATION OF TRE INTERNAL LAYERS. ACUTE. This may be secondary to an inflammation of the external layers but it may come from other causes. The inflammatory products are pus, fibrin,and sometimes a little serum. The pus and fibrin, without greatly infiltrating the dura,collect upon its free surface and form a false membrane which varies in size. The more extensive the in- flammation, the worse is the ease. Such an inflammation almost invar- iably extends to the pia and may involve the walls of the sinuses. SYMPTOMS- It begins with rigors and a febrile movement. With the development of the fever,the pulse is at first rapid and strong, then slow and strong,then, at last,rapid and feeble. Cerebral symptoms are manifested. In some,there will be headache, severe and continuous fairly into the disease;in others,convulsions: in othere,delirium, mild or active will be the first symptom. There is always prostra- tion. Sometimes loss of appetite,vomiting,and constipation are present. L^ter the fever,headache,and convulsions continue. 26 TREA'PAENT-The treatment is the same as that of acute meningitis. CHRONIC. This is peculiar far it seems to come on without any cause. It is more common in adults than in children, in the lower than in the up- per classes,and among hard drinkers than among those of temperate habits. It is an idiopathic condition. The lesion is found on th* inner surface of the dura mater and eon- siets of a thin layer of connective tissue, cells,basement substance and blood vessels which are continuous with those beneath the dura mater. At first, this membrane is very thin and may escape detection but it becomes thicker. It is apt to begin over the convexity of one hemisphere and then it may extend and cover both sides of the brain. The new blood vessels have very thin walls and are very liable-to rupture. When they rupture, the blood is extravasated in the dura. These extravasations are not large but they are very numerous and the little clots make the membrane thicker. They may,however,be large and compress the external surface of the brain,. If many of the blood vessels rupture at once,we get the or~ binary- symptoms of apoplexy. This is rare. SYMPTOMS-In the early stages, there are scarcely any and many au- topsies reveal this condition which was unrecognized during life. If the inflammation continue and the membrane thicken,we get symp-^ toms. These symptoms are developed slowly. The patient is apt to complain of a dull headache which lasts throughout most of the 27 twenty-four hours. The intellectual faculties become impaired and the memory is lost. The patient sometimes exhibits an unsteadiness of gait. They often suffer from drowsiness during the day and remain for hours in an apathetic condition. Some times,they have attacks of loss of consciousness which may last for a few minutes or for hours. So they go on. The symptoms become more and more marked. There may be periods of improvement. The larger number die of some intercur- rent disease. This is the usual termination. Some times,however,they go on until they become insane. A dull stupid frame of mind results. In a few,sudden death takes place from extensive extravasation of blood upon the brain. TREATMENT-The disease is difficult to diagnose from chronic or syphilitic meningitis and there is no special treatment. SYPHILITIC IMPLhMUTION OF THE DURA MATER. This is the most common and the most important. The characteristic lesion is a circumscribed inflammation resulting in the formation of a gummy tumor. There may be one or many.. They may be large or small. They may be in the outer or inner layers or in both. The pa- tient is apt to have other syphilitic lesions which aid us in making the diagnosis. The tumors frequently appear directly beneath a gumma situated on the exterior of the head. In old cases,the cranial 28 bones become eroded. SxWrOMS^If the tumor be situated in the external layers,we get but ene symptom,headache,corresponding to the situation of the gumma, I£ 'the tumor involve the inner layers of the dura,we get symptoms due partly to the presence of the tumor and partly to its pressure upon the brain. Among the first class of symptoms,is headache which is severe and persistent and,when taken with other syphilitic symptoms,is very characteristic. The patient may have attacks of unconsciousness which may last a few minutes or hours.The patient becomes dull and listless and lies quietly in bed. Sometimes,he developes restlessness and delirium which may be mild or violent and often alternate, with stupor. Occasionally,there is vomiting. A febrile movement is not a marked symptom and has no close con* nection with this kind of inflammation. The foregoing symptoms are due to the presence of the tumor and are common to all kinds of syphilitie pachymeningitis. The symptoms due to pressure are the following. If the tumor be in the situation of the optic nerve,the nervous tissue will be destroyed and the patient will become blind. He may become deafi- in 'the same way. The tumor may press upon the motor tract and cause paralysis of the opposite side of the body. If the patient be not treated,the disease will prove fatal and 29 he will die either in coma or in convulsions. TREATMENT-The drugs we should use are the corrosive chloride of mercury and the iodide of potassium. The latter must be given in very large doses,one drachm three times a day. In those cases with marked headache,the corrosive chloride is used to control it and often promt results fallow the hypodermic injection of one-twentieth of a grain, twice or three times a day according to the severity of the headache. The favorable cases will respond to this plan of treatment in a very satisfactory manner. The great danger is 'in a relapse and, when this happens, the treatment must be repeated In bad cases,the symptoms continue and the patient dies much ema- ciated. THROMBOSIS OP THE SINUSES OF THE DURA MATER. This* may be caused by an inflammation of the dura mater. It may also be developed from changes in the blood in persons who have suffered from an exhausting disease. In children,a long-continued ' and severe diarrhoea is a frequent cause. If the diarrhoea be very severe, it is not necessary that it should last very long. The throw- basis may be secondary to a thrombus of the internal jugular which may be caused by an inflammation of the neck. 30 It may arise from an inf lamination of the ear, of the cranial bones, the face, or the neck.It may be developed without any cause and to this last class belong the most important cases. -PATHOLOGY.-When thrombosis takes place,one or more of the sinuses is" filled with coagulated blood.This coagulum is at first red,then as the patient continues to live,it becomes firmer and dryer and approaches more and more to a white color. In some eases it remains a firm, white plug. This obstruction is followed by an accumula- tion of blood in the veins emptying into the sinus.such an inflame mation may be followed by a venous congestion of the pia mater, or by an extravasation of blood which will damage the brain tissue. In other cases,, the thrombus undergoes changes due to bacteria. It softens,and is converted into fragments which are easily detach- ed.These fragments reach the lungs,and, as they have an infectious eharac ter,they set up inf1ammat i o n,and,by their prese ne e in the blood,they give symptoms similar to those of surgical pyaemia. -SYMPTOMS.-First, in children who have suffered from, an exhausting disease as diarrhoea.In these cases the thrombus does not break dawn and cerebral symptoms are added to those of the original dis- ease.We have alternations of restlessness and stupor.The pupils are contracted at the beginning of the disease and dilated at the end. Internal strabismus,tenderness of the back of the neck,muscu- lar contractions,convulsions,and coma are sometimes present. 31 A febrile movement is not necessary in this condition and the ab- sence of fever serves to distinguish it from acute meningitis* PROGNOSIS-The disease is regularly fatal. TREATMENT-The re is none* Try to make the patient comfortable. IN ADULTS. First,we have the history of the original disease,then,the cerebral symptoms'. The first symptoms are headache,impairment of the mental faculties,prostration,some disturbance of the stomach,and invol- untary contractions of the muscles of the eye,face,neck,or extrem- ities. The muscular contractions last throughout the disease. Then, come alternations of restlessness and stupor which go on to delir- ium or coma. The symptoms are slowly developed. Some patients have venous, congestion of parts of the face 01 of the fundus of- the eye and the eyes may be rendered more prominent by congestion. They may have nose-bleed.and they become comatose and die. -TREATMENT*.« Try to overcome the depression and make them comfortable. THE IDIOPATHIC CASES IN ADULTS. These are probably more common- than we might suppose. SYMPTOMS-The patient having been in good health'complains of head- ache or of neurangic pains following the course of the fifth nerve. These pains come and go* He feels out of sorts* The headache be- comes more continuous, and, if the disease began with neuralgic pains, the headache is added. The patient now feels pretty ill-,yet, there seems to be very little the matter with him.- In this condit- 32 ion he may remain fox* more than a month.Then,sooner or later,he begins to get stupid,goes to bed and stays there and as time goes on,you have more and more difficulty in arousing him. in some ca^es, there are vomiting and twichings of the voluntary mu^ole^.A week before the termination he is in stupor all the time and yet there is no fever.Now the stupor may alternate with restlessness and delirium.Then just before the termination,we get a fever-104 the pulse becomes more rapid,he becomes comatose,and dies. -PROGNOSIS.--! t seems to be a fatal disease- -DIFFERENTIAL DIAGNOSIS.-It may be mistaken for a tumor or an ab- ac ss of the brain. -TREATMENT.-None.Ammonia carbonate has been recommended.Theoretical- ly, we should render the circulation more rapid, we should use cardiac stimulants and vasa dilators,.heat, and friction of the skin.I have never seen these measures do any good,but,if you intend to treat at all,they are the best I know. 33 -INFLAMMATIONS f? THE PIA MATER.- -1-ACUTE MENINGITIS. - -2-C RONIC MENINGITIS.- -3-TUBERCULAR MENINGITIS. - -4-SYPHILITIC MENINGITIS.- -5-EPIDEMlC CEREBRAL SPINAL MENINGITIS. - 1-ACUTE MENINGITIS.- -PATHOLOGY.-The disease may exist under two anatomical forms. -First form.-There is a- very moderate degree of congestion of the pia mater which may escape observation.Examined after deathTyou would sometimes think that the pia was perfectly healthy even if you were on the lookout for the disease;but if you look at it with a microscope,you find a large number of cells which should not exist. Some of these are large polygonal cells,others are round and scat- tered over the convexity and the base of the brain.They may form little aggregations.So this is a cellular inf lamination. This form may be produced by any of the causes of meningitis.The membrane should always be examinee with a microscope. -Second form.-We have serum,fibrin,and pus in variable quantities. These inflammatory products do not as a rule collect on the surface but in the spongy tissue of the membrane,and they make the pia thicker. 34 Sometimes, they are most abundant at the convex!ty?sometimes,at the nase:ahd,if in the latter situation,the disease may extend to the pia mater of the cor4. If the disease be very severe,the pus will collect between the pia and the brain and the brain tis« sue will be involved. As a rule,in adults,the ventricles are found to be of moderate size and filled with a fair amount of serum. In children,the ventricles contain more serum which may distend them to such an extent that the sulci and convolutions may become flattened. This difference in the amount of serum that is found in the ventricles may account j£or the difference of the symptoms in children and in adults. ETIOLOGY-The disease may come without any cause. These idiopathic cases are more common in children than in adults. It may follow- suppurative inflammation of the middle ear, inf lamination of the cranial bones,or inflammation of the dura mater..It may complicate pneumonia,Bright*s disease.the exanthemata,typhus fever and typhoid fever. In epidemic cerebi -spinal meningitis it is the characteris- tic lesion. IDIOPATHIC CASES IN ADULTS. SYMPTOMS. The disease way be preceded by a prodromic period during which the patient suffers from headache,loss of apetite,sleeplessness, bad dreams and conges tian of the conjunctiva* He will have a 35 haggard look and he is apt to be apprehensive. In other cases, acute meningitis comes on suddenly with headache,delirium,pros- tration, fever, and convulsions. Convulsions may be the first symp- tom. The delirium may from the first be sudden and. violent. In whichever way it begin, af ter the disease is ushered in, we have the headache which is often localized and is usually severe. We also have periods of restlessness alternating with stupor. If the disease be not severe,the restlessness will not be overmarked: if severe,the restlessness may develop into a mild or violent de- lirium. The stupor may not be overmarked or it may be profound. The cases vary as to the relative t£me that is occupied by the restlessness and by the stupor. As a general rule,restlessness predominates during the early stages and stupor predominates during the later stages. This rule ha.^ its exceptions. There may be involuntary contractions of the muscles of the face or of other* muscles. On the face, the muscular contraction passes in a sort of wave and it seems as though the patient were making faces at you. In some cases,these muscular twitchings develop into convulsions and the patient may die in one of these convul- sions. These convulsions,however, are not constant. The skin of a part or of the whole of the body may become hyper- aesthetic. The patient will complain of the pressure of the bed clothes. 36 This hyperaesthesis belongs to the early and middle stages of the disease and is not constant. There may be a permanent contraction of the mu sr les of the back and of the back of the neck and the head ^ill be permanently extent doo.This is very common, the muscles cGnoe??ned become very tender* Th* ey;-s at first c-m unraturally sensitive tn light* This pho to- phobia gradually diminishes?and, at the close of the disease,the pati nts de not recognize light at all and may become blind. There may be internal strabismus. This and the blindness are very common-At first,the pupils are contracted,then?dilated. The ears may be affected.At first the -bearing is unnaturally ae-ute. Tn some this is quite a distressing symptom.Gone rally,this disap- pears later on and they may become quite deaf.These affections of hearing are not as common as those of sight. There may be loss of appetite and vomiting.In some eases vomiting is the first symptom^Gene rally,the vomiting does not amount to much but it way become so prominent a feature that there may be difficul- ty in feeding the prtierrU The tongue is at first coated.^.t the beginning, there is constipa- tion* then, d lav 1'hoea* The urine may contain albumen and casts. In adults,the fever is not propnpticnate to the severity of the disease.There is no regular time ^hen the temperature is highest nor does the height of the the temperature give any indication of 37 how the patient is doing. Some bad cases do not have a high tem^ perature At first, the pulse is full and rapid then, full and less rapid^ tien, towards the close if the patient is not doing well,more rapid aid feeble. This pulse is rather characteristic yet there may be a rapid pulse throughout. IN YOUNG CHILDREN. The symptoms are not as well marked as in adults. There is a febrile movement and, as a rule,a rapid pulse throughout. As cerebral symp- toms, we have convulsions,restlessness,and stupor. The periods of stupor are much longer than those of restlessness and,finally,the restlessness disappears and stupor alone is left. In some,a course is run which cannot be distinguished from tubercular meningitis. DURATION. The duration of acute meningitis varies. In some cases,it may prove fatal in thirty-six hours. In other cases,it may continue for weeks. The regular duration is from seven to fnurteed days. PROGNOSIS. The prognosis is serious but not hopeless. The patient may recover but the disease is always alarming. MENINGITIS SECONDARY TO ICRANIAL BONES, DURA MATER, The most common of these cases come from suppuration of the middle ear. The patient suffers from acute suppurative otitis. He has pain in the ear, rigors, fever,and prostration. These symptoms last a num- ber of hours or days until pus is formed in the middle ear. 38 This pru. will then perforate the membrana tympani, will escape from the external ear,and the symptoms will subside. In same cases, the inflammation will extend to the mastoid process and the rigors and prostration will continue. The fever may or may not continue. i By this extension of the suppurative otitis, an inf lamination of the ^pia mater near the temporal bone "dll be set up. This may extend to the rest of the pia,the patient will develop meningitis,and its reg- ular oyrptoms will be added. There i< apt to be a doubtful period during which you cannot tell whether the patient is going tn have meningitis or not. This is esy e ei?l ly the case in children, for, in children, the inflammation of the ear ma;/ be severe enough to produce restlessness and stu- por. In children, this doubtful period may last from one, two,or three days.Then if it be but an otitis, the symptoms '.Till entire!?/ sub» Bide.When the inf lemma Mon extends to the mastoid process,the pain is apt to persist,to be very severe,and to simulate cerebral symp« torn*§but,as the case goes on and nets no worse,it soon becomes evioerJ th/::t meningitis does not exist. «THF CfWLl?ATIMG WII^GITIS OP PNPAONIA, GET?S DISEASE, PYWA, dec. We see it most frequently with the pneumonia and Bright's disease. In these diseases, we may have cerebral symptoms without any menin- gitis but,when a true meningitis is developed,there is little 39 difficulty in making it nut. There are minor changes in the patient. The cerebral symptoms are more active. The periods of restlessness, delirium,and stupor are wore decided. We also have the involuntary contractions of the muscles of the face which we would not have in pneumonia. The pulse becomes mor-e rapid-, the patient looks sicker, and,as the disease progresses,the symptoms of meningitis become more and more marked. TREATMENT, If we see the patient early,we try to diminish the du- ■ ration and severity of the disease. This must be done at once. If he is strong,we may employ local bloon letting from the neck by means of cups and leeches. If this be done early,it is good treat- ment।if lat^it is of no use. Now comes the local appliestion of eoM This is of great value. The hnir should be cut ancTTags filled with pounded ice applied to the head day and night. This should be kept up as long as the inflam* mation seems to be acute. Instead of the ice bags,the rubber coil may be used and it is generally more agreeable tn the patient. Counterirritation is not so much used new as it formally was. It is very severe and not as good as the local application of cold. I Inunctions of iodofnx'm one drachm and vaselin one ounce have been I used. Good results have been reported but this method is new. As for drugs, iodide of potash and ergot have been used but I doubt 40 their valuer ' :: • The patient must be kept quiet and comfortable even during convalv esence.He must be kept upon a fluid diet.If the bowels be eonsti^ Pats^mild laxatives may be given. To control the headache,sleeplessness, and restlessness bromide of potash,chloral, or opium should be'used.The two former are prefer- able,Give from dr. |-to dr.l- of bromide of potash every three hours until the patient becomes stupid. If this do not succeed, use opium. This plan of treatment should never be departed from but should be persisted in even if the patient seem to do badly at first. -2-CHRONIC MENINGITIS.- The inflammatory process may be confined to the convexity or the i • base of the brain or may involve both.As a result the pia mater I is thickened.This is due,partly to an infiltration with serum*, fibrin, and pus, partly to a growth of new connective, tissue,and, partly to a thickening of the basement substance. T hh brain b e n e a th -may sho w an i n c r e a s e d numb er of eells.lt in ay become hard,or it may soften and break down. The ependyma of the ventricles may become enlarged and distended with serum. ' ETIOLOGY.-This inflammation requires months and years fox' i^ development,and the symptoms vary according to the stage at which 41 you see it.It belongs to adults past forty years.lt ©ay be second* ary to an inflammation of the cranial bones or of the dura mater. It may complicate Bright's disease.lt may be developed in poax* people who are alcoholic.We find it in persons suffering from*chron- ic endarteriitis or from a small thrombus.lt comes after an ex- travasation of blood,or it may come from no cause at all. The alcoholic eases are the most common and are apt to be found in hospital practice.Among the better classes,the cases with Bright's disease,and those with chronic endarteritis are the most common. -SYMPTOMS.-At first they are not well marked.In the eases with alcoholic habit and those with Bright's disease the first symptom is headache which is severe but not continuous. Then, the patient' becomes irritable and hysterical.Kis memory is not as good as it was.His stomach becomes deranged and he suffers from lose of ap- petite.His bowels are often constipated.His muscles get soft and flabby and he looks paler.In addition, we get the symptoms of Bright's disease or of chronic alcoholism.As they go on, the syirp- toms become more marked and general convulsions or attacks of loss of consciousness result.The speech and walk may become affected. They may die very suddenly. 42 Many die of some intercurrent disease. Others go on tn insanity and they may remain insane for' a considerable time* Others die in coma or in convulsions* CHRONIC MENINGITIS FOU^WING ENDARTETITIS. The patient has symptoms 'which depend partly upon the endarteritis 'and partly upon changes which it induces in other parts of the body* The history is somewhat like this. A st rang, hard-worked man goe on all right till he reaches his fiftieth or sixtieth year. Then, he notices that his work is becoming a burden,his appetite is fail- ing and he can not walk as far as he could. He now takes a holiday' and for a little time feels better but he still has a disinclin- ation for work* At this time,he developed some symptom not connected with the cerebral disturbance, This symptom is developed in some other part of the body and it may distract the attention of the physician. This secondary trouble may improve but still the patient is''no better. He becomes hysterical, hypochondriacal, peevish, restless-, cannot sleep at night and makes the lives of others a burden. Then he stays in the house, takes long naps, and becomes more apathetic. The end is apt to come from some intercurrent disease,generally a pneumonia which need be only slight. The arteries may burs Ver the patient may die como'tose. These cases are found among the better classes and the attention of the- physician is apt to-be diverted by the first intercurrent ailment. 43 TREATMENT. The patient must give up all work and his general health must be kept up. We may give iodide of potash but it is doubtful whether it do any good. The sleeplessness and restlessness are very difficult to treat. These symptoms bother the physician all the time., The bromides and hyoscyamus have no continuous effect. ft-TUBERCULAR MENINGITIS,OR ACUTE HYDROCEPHALUS. Tubercular meningitis may occur both in children and adults. IN CHILDREN. PATHOLOGY. As a rule, there are no changes in the dura mater,but some times,miliary tubercles are found in the inner layers. The brain is large and the convolutions and. sulci are flattened At first sight,the pia may present no changes but,miliary tubercles are scattered over its surface. They are apt to be most numerous at the bottom of the sulci at the base of the brain. In some cases* they will be evident enough. In other eases,the pia mater will be infiltrated with serum,fibrin, and pus. The ventricles are dilated and filled with serum. In the ependyma, are miliary tubercles. The surrounding brain tissue is soft. Occasionally,the inflammation extends to the pia mater of the cord. 44 As a rule,when miliary tubercles are found in the pia mater they are located as well in. the liver,lungs,and kidneys. When this is the ease, the eondition i& properly one of acute general tubeiv culosis. -ETIOLOGY.-Children of five years of &ge or less are especially liable to th- disease. In many we get the history of hereditary tuberculosis. This history is quite constant. In some,the meningitis may be preceded by a tubercular inflammation in some other pert of the body,particularly of the bronchial glctnds. As a rule,when a child has tubercular inflammation ana then deve- lops acute tuberculosis, he gives the symptoms of tubercular menin- gitis. The child may not have cerebral symptoms but this is the exception* So,th? disease may occur as a strictly localized tubercular inflam- mationiit may be preceded by another localized inflemmationjor it may occur as the predominating symptom of an acute tuberculosis* -SYMPTOMS.-These are divided into three stages which merge into one another. -First stage.-This lasts from two to five days. The symptoms are variable. The child's temper changes and he becomes peevish. His digestion is disturbed. There is constipation or vomiting. The child 'will stop while playing,as if ill and then go on again. He is restless and cries at night,and is unnaturally drowsy during the day. The tongue is white and coated. 45 ^Second stage.- The patient seems very much sicker,he stays in bed, and does not care to play. The expression of the f^ce is changed. The face is flushed,and he looks anxious. Then he begins to di 5- like the lights The pupils are sometimes contracted,. some times diluted. Sometimes there is internal strabismus, He gives the ap- pea Pence of one suffering pain. Then come altemotions of restless- ness and drowsiness. The drowsiness is marked by almost complete immobility. He lies quietly and appears to sleep but really he is not sleeping.The eases vai*y as to how much of the tim^ is occupied by the restlessness and how much by the drowsiness. The restless- ness may become delirium. The bowels ax^e constipated. The pulse is at first rapid then be- comes slow and irregular,and may lose a beat. Then the breathing becomes irregular. Sometimes this irregularity is only shown, by the increased effort of the child when he breathes. At other times,the child breathes very lightly.At other times, the breathing becomes so shallow that you can scarcely see it> then,it becomes very full: then,it becomes shallow again. This alternate shallow and full respiration is a characteristic symp- tom. Th<:3 urine is scanty and contains albumen and casts. It may he suppressed. There is always a fever which varies greatly in different children. In some,it reaches -104-105-|in others only 100. The fe- ver is always irregular,and the height, of the temperature is no guide to the severity of the disease. 46 Thira stage-The periods of restlessness are less marked and those of stupor are more decided, finally,the patient passes into com- plete stupor. Now, we have general convulsions,hemiplegia or paralysis of one arm or leg. The patient may perform curious automatic movements. He may pick at the bed clothes,lips,or nose or he may wove one arm slowly up and down. The^e is no photophobia. The pupils ere widely dilated and insensible to might. Internal strabismus and nystagmus are apt to be present. The temperature becomes higher and the pulse more rapid and feeble. If the mem- branes of the cord have been involved,the head may be drawn back. So the patient goes on. He may die in convulsions or in extreme emaciation and exhaustion. Towards the end,the urine is entirely suppressed,the pulse becomes awfully rapid,the skin becomes moist and the fever diminishes. DURATION. The typical cases last pretty regularly for three weeks. Sometimes, the first stage is absent and the disease is ushered in by convulsions followed by the remaining regular stages. These irregular cases are apt to be short and to simulate acute meningitis# PROGNOSIS. A cute tuberoulosis is always fatal. Yet,there are chil- dren who give all the "symptoms of tubercular meningitis and who do recover. This may be accounted for in two ways. In the first, piece,the patient may hwe had acute meningitis and not tubercular 47 meningitis. In the second place,he may have had tubercular meningi- tis as a strictly localized tubercular inflammation,with no other tubercular inflammation in any .part of the body. Thes- are the only eases that can recover. Those with acute tuberculosis must die. In all cases,there is the possibility that the patient is suffer- ing from acute meningitis. TREATMENT- The treatment is undertaken with the hope that the inflam- mation is localized or that we have been mistaken in the diagnosis. We treat for acute meningitis. Blood-letting and counter!rid. tatian are contraindicated. Cold applications are to be used when we are able to employ them. If we use the rubber coil,the water should be but moderately cold. The same drugs that we give in acute meningitis should be used. -IN ADULTS- PATHOLOGY- The pathology is the same as when the disease occurs in children with the exception that the ventricles are not as a rule involved. The disease is frequently secondary to a pulmonary phthisis which may be so slight as not. to attract the attention of* the physician. In adults>it is possible to have acute tuberculosis without cerebral symptoms. I* It is possible to have tubercular ^NtTE. ~ See acute general miliary tuberculosis. - 48 meningitis with no tubercles in other parts of the body* ETIOLOGY- The disease usually occurs between the ages of fifteen /' and twenty five, SYMPTOMS- When the disease is a part of acute tuberculosis,there may be no cerebral symptoms at all. Some of the patients have phthis- is first. In some the invasion is sudden,and severe;in others, mild. The symptom^ are nearly the same in either ease and differ only In intensity. We have a febrile movement which may or may not be preceded by rigors:then headache,vomitinghand prostration. If the invasion be mild,the prostration may not be sufficient to send the patient to bed,there may be no rigors and the headache and fever may not be severe. When the disease is fully developed,the prostration is well marked and the headache is severe and continuous.There are well marked alternations of restlessness and stupor. Delirium is often present. There are changes in the eyes,photophobia,conjunctivitis,and in- ternal strabismus. Later,the pupils are dilated and insensible to light. At first,the hearing is unnaturally acute;then,the patient becomes deaf. There may be hyperaesthesia and contractions of the volun- tary muscles. The urine is diminished and contains albumen and easts. 49 The fever is very irregular. In some cases,it is well-marked, IOS- 104 or higher throughout the disease. In oilier eases,it is only 99-101-102. These cases with a low temperature may be just as ill as those with a high temperature. The fever is also irregular in '• t he s ame p a t i e n t. In some cases,the ■pulse is like the pulse of acute meningitis^in others, it is rather rapid especially at the beginning and close of the disease and it may miss a beat* In some eases,the course is acute and severe and the patient dies in coma or- Convulsions at the end of one or two weeks. These cages are difficult to distinguish from*aeute meningitis. In other cases, the disease lasts for three or four weeks or for fifty or sixty days. In these long cases,the syupTomF are not as marked,the tem- perature is not as high,and there are periods of improvement. The patient becomes much emaciated and prostrated and dies in the ty- phoid state. These long cases sometimes resemble typhoid fever, especially if you see the patient in the stages of the disease and can get no good history* PROONOSIS-The prognosis is bad. and is only modified in the same way as in children. TREATMENT- The treatment is the same as in children 50 -4-bYPHILITIC MENINGITIS.- This may be either acute ar chronic. It is attended by the product- ion of gummy tumors and by a diffuse inflammation of the pia mater* The gummy tumors may be small and the accompanying inflammation extensive- The accompanying inflammation may run an acute course and,1put for the syphilitic history, the disease is an acute meningi- tis. In othexy eases, the tumors are small and the accompanying inflam- . mation is extensive but the accompanying inflammation runs a chronic course. It is then a chronic meningitis with the same modification as in the previous case. In other'cases, the tumors will be large , compress the brain and give the symptoms of a tumor of the brain. These symptoms will vary with the position of the tumor.. In making the diagnosis, we must be guided by the history. For epidemic cerebro-spinal meningi tis, see the infectious diseases. 51 -THE BRAIN- Lesions of the hrain are not very common and many of them are very obscure. The most common are the following. 1 -CEREBRAL HAEMORRHAGE. 2-OCCLUSION OF THE ARTERIES AND CHANGES SECONDARY. 3-CHRONIC INFLAMMATION OF THE ARTERIES AND CHANGES SECONDARY. 4-AHCESS OF THE BRAIN. 5-ANEURISM OF THE CEREBRAL ARTERIES. 6-TUMORS OF W BRAIN OR OF ITS MEMBRANES COMPRESSING THE BRAIN. Cerebral lesions may act as irritants or cause loss of function. Nearly all are attended by a fehrfle movement 'even when there is no inflammation. For aerebraTphy^iology and anatomy, text books mu^t he consulted. -1-CEREBRAL HAEMORRHAGE. - W® include under this title all extravasations of blood, within the orania1 aavity. -a- KETWEEN THE DURA AND THE SKULL.- Extravasations in this situation are the result of external injury -SYMPTOMS-The symptoms depend partly upon the presence of a cIoT" and the injury that produced the clot and,partly upon changes in the brain and its membranes whic result from thse injury and also result from subsequent changes, we have' first the. blow then,immed- iately or in the course of a few hours,the blood $s poured out and presses upon the brain. Such an injury is apt to produce laceration of the brain tissue on the opposite side of the head- This rule,that the laceration will be on the opposite side of the head has few exceptions. If the natient survive the injury., inflammation is apt to be set up in the pia mater and in the lacerated "brain tissue. The effect of • the blow is to produce unconsciousness but this may be delayed for several hours. The patient may get up and walk away immediately after the injury. The reasons for this are first,the severity of the blow and the hardness of the patient's head*secondly,the rapidity of the extravasation. If the extravasation take place at once,the patient will at once become unconscious. The clot may give rise to convulsions,paralysisor delirium. The cases vary as to the size of the clot and the way in which it acts. If it act as an irritant,we have delirium^if it cause loss of function,we have coma and paralysis. Laceration is usually followed by convulsions. Meningitis may be added- Whether meningitis be added or not,they - * always have a fever which comes on in twelve or twenty-four hours and lasts till death or convalescence. PROGNOSIS-The prognosis depends upon the severity of the injury. If the bones be fractured or if there be laceration,the prognosis will be bad. If there be only an extravasation,the prognosis will be better. The fatal cases usually terminate within two days but some go on for several weeks. 53 TREaTi'ENT- The treatment is partly surgical. If there be a fracture, it may be proper to trephine ami remove the clot. If this cannot be done,put the patient to beet,keep him quiet,give opium in moderate doses,await the development of acute meningitisyandtreat that. -b-BSTWEEM THE DURA AND PIA.- The extravasation takes place into the so-called cavity of the arachnoid. These clots way he situated over the convexity of one hemisphere,or they may extend over the convexity oi both hemispheres, or they may be situated at the base of the brain and run down the cord. According to their size,they exert more or less pressure upon the brain* -ETIOLOGY-These clots are found at all ages. Some are due to direct injury and it seems to require a less degree of injury to produce 'them than those between the aura and skull* G-enerally, there is no fracture accompanying them. They may result from chronic pachy- meningitis. They may follow changes in the walls of the cerebreil vessels which will cause these vessels to rupture. SYMPTOMS.. When the extravasation is the result of injury,there is no prodromic period of course* When it is the result of chronic pachymeningitis, the patient at first gives the symptoms of that disease. If it follow a diseased condition of the arteries,a pro- dromic period is common enough. The patient complains of heaviness, headache,and dizziness. His mind is sluggish and he may vomit. 54 These symptoms are due to the inflammation of the arteries and to changes induced in the brain tissue. When the clot is formed, the sgjjptoms vary according to its size and position* Thus,there may be loss of consciousness developed slowly or gradually,complete or partial,transitory or permanent. We may have delirium which may be mild or active. The function of "speech may be unaffected,impaired,or abolished. There is internal strabismus. The pupils may be dilated^contracted, or unevenly dilated. There may -be convulsive movements of the whole body or of special groups of muscles* These movements may come on when the clot is first formed or they may be deferred for a considerable time. * We may have paraplegia,hemiplegia,or complete paralysis below' the head,or we may have no paralysis at all. This depends on the size and position of the clot.As a rule,motor paralysis is not very common. As a rule,sensation is preserved but it may be impaired. If the unconsciousness be complete, thei*e may he stertorous breathing. The pulse will be rapid or slow according as the clot acts as an- irritant,or compresses the Vrain tissue. Fever is regularly developed within twelve or twenty-four hours. 55 -CLINICAL HI8TORY-The patients differ very much. One may go to bed in perfect health and be found dead the next morning* Another will fall while walking in the streets He will die in from five minutes to an hour after* At the autopsy a elot will he found pressing upon the medulla Another will suddenly develop a violent delirium* This will last a few hours* Then coma will follow accompanied by-a rise of tem- perature and the patient will die comatose within thirty-six hours. , In this ease,the clot will be found upon the convexity of the brains Another will suddenly become almost completely paralyzed. Then he will suddenly return to consciousness, his temperature will ris->, and he will die in a few days* The clot will be found on the convexity pressing upon the central convolutions. Another will suddenly be attacked with convulsions succeeded by celirium, coma,fever, and dilated pupils. He may live for weeks and the symptoms resemble those of acute meningitis* After death, the clot will be found spread cut over the convexity of one or hot h he mi sphe r e s • Still another will be seized, with convulsions succeeding one an- other in rapid succession and simulating those of uremic poisoning* The urine will be filled with albumen. After twenty-four or thirty- 56 six hours, the patient wil.1 die* The same lesion will be found as in the previous ease. So the eases differ very much- These eases of meningeal haemorrhage are not very common and,consequently,many errors of diagnosis results -PROGNOSIS- The prognosis depends upon the size and position of the elct^ if it be of moderate size, the patient may recover. The symptons will continue for days or months and then, the clot will gradua 11 y be ab s orbed. TREATMENT-There is hardly any. The condition, is mechanical Keep the patient quiet,make him comfortable, and await developments. -c-BETWEEN THE PIA AND THE BRAIN. These extravasations are not common except in connection with the two fore-going. when they do occur, they are most common at the base of the brain and are due to a diseased condition of the arteries -d-IN THE SUBSTANCE OP THE BRAN -CEREBRAL APOPLEXY-, These extravasations are the most common.The clot may be of almost any size from a pin's head up. This is important. 'When you see a ease,always try to estimate the size of the clot for the prog- nosis depends upon it* There may b^more than one extravasation but this is the exception,not the rule. If there be several,they may cell take place at the same time nr at different times. Their most common situation is in the corpus striatum and the adjacent parts of the optic thalamus. 57 tic we ver, there is hardly any part of the brain where they may not be- If they be in the neighborhood of the latere 1 ventricles,the bleed may break through their walls and escaping infiltrate the pia. Vihen small, they produce but little change in the brain tissue. The larger ones break it up- If the patient do not -die from the immediate effects of the clot,it will gradually diminish m size end- if small enough,it may disappear altogether and leave no changes behind it. If however it has been large enough to break up the brain tissue,even after its absorption, the brain- will be deformed. This little spot of deformed brain tissue will assume a reddish- brown color. Some of the patients have subsequent trouble from inflammation of the brain tissue. This is not of common occurrence and more frequently follows clots on the surface than thc.se in its substance. ETIOLOGY-A moderate number are caused by external injury.a greater number are due to a chronic inflammation of the cerebral arteries^ This inflammation changes the walls of the arteries,makes them thinner,and aneurismal pouches are formed which may rupture.The disposition tn rupture is rendered greater by changes in the heart and kidneys and in the arteries in other parts.c.f the body. There is no reason to believe that apoplexy is produced in any other than in these two ways. 58 Healthy cerebral arteries do not rupture by themselves. people past forty years are:especially liable to apoplexy. We may see such cases due to disease of the arteries in younger persons hut such cases are the exception. -SYMPTOMS-The symptoms are often preceded by a prodromic period which may last for a few days or for months. During this time, the patient becomes peevish,irritable,worries about things of little consequence and does not sleep at night. His memory and power of concentration are not as good. Sometimes,he is unnaturally drowsy during the day. He has attacks of partial loss of consciousness which may last for a few minutes or for half a day. He may have temporary loss of motor power,usually not complete and lasting for a few hours or part of a day. There may be loss of sensibility having the same peculiarities. There may be small extravasations ■in the retina which can be seen with the opthalmoscope. Now comes the rupture and the extravasation of blood. First, let us take the symptoms that depend, upon the size and po- sition of the clot^nd the rapidity of its formation. If the clot be large and involve the-corpus striatum,the patient will become comatose and completely hemiplegic1 and will develop stertorous breathing. In this condition,he will remain for a few hours or for several days. Then,a'fevev ■will be developed and death wi 11 59 •If the extravasation be situated in the perns varolii,corpora quad- rigemina,or medulla oblongata,the patient will develop profound coma which will last till 'death. If a large clot be situated outside the motor tract, it will be followed at once by coma,convulsions,or the development of an acute delirium. Ilie delirium will alternate with stupor. There will be no loss of motion. Death regularly follows. Tn regard tn the medulla,pons,and enrpora quadrigemina,I should have said that those parts of the brain are rarely the seat of extre vast ticns* The smaller clots give a greater variety of symptoms. If a small clot be formed in the corpora striati and if it he formed rapidly, the patient will at once fall to the ground but he may not at once pass into complete coma. There will be hemiplegia and,if the left corpus bo affected,there may be loss of speech at the same ime. If the clot m the corpus striatum be formed slowly, the patient will not at nnce become unconscious. He feels confused, ne may vomit,he is alarmed,yet he is able to stand up. Then as the extravasation becomes larger,he becomes unconscious and hemiplegia on the opposite Side of the body is developed. Whether the clot slowly,he will emerge from his ggm after _ ■ ^yt. Then, there will be a return of motor power which may take weeks or months fox- its completion 60 Tf the clot be spall and situated in the central convolution, tl ere will either be no loss of consciousness or the loss of conscious- ness will last but a short time. The accompanying hemiplegie will not be very complete. If the clot be smo.ll and situated in the centre of speech, there 'Till either be no loss of consciousness or it will be of short •juration. The patient will lose the power of speech. Small clots situated outside the speech and motog centres are only attended by temporary loss of consciousness and there is no motor paralysis. These are the least hurtful. . -GFKRRAL SYMPTOMS.-Immediately after the extravc sa tion, we often find both pupils dilated,but both may be contracted,or one may be dilated and the other contracted. Geneva 1.1^ the pulse is slow and full but, if the clot be small, this change will not be noticed. AS a rule,the temperature is at first lowered.97-96-95-: then,after a feyZhours.it rises to the normal;and,after twenty-four hours, ab-nve the. norma 1, in J -104. In fatal ct>ses,it reaches immediately before death J05-107-. -PROONOSTS.-Clots on the surface are most likely to be followed by meningitis. The prognosis is always serious. More than one-half the patients die within ten days of the formation of the clot. Those that dn not die immediately ar* liable to subsequent sub-acute 61 meningitis and to inflammation of the brain tissue. They are riled liable tn eystiti s, pneumonia, and b«d sores. It requires hut a slight pneumonia to kill them. a seenn-i attack of apoplexy is also tn he feerei. a third attack is commonly suppose-} to be fatal. Tf tb'^r Hn not njfrom ?inv of +.h-i<p oiroer?, thev exhibit C11 ^degrees of recovery according- to the position of the clot. 'The clots situated outside the motor tract give the best recoveries. If the clot b-> small yet situated in the cortical motor area,the chances of a fair recovery are fairly ^ood. The clots in the corpus striatum give but very imperfect r^cov^ry^for the intelligence is always apt to be affected. A patient with a small clot may recover without < return of motor power. In all cases that recover,the mind is apt to be affected. In cases in which the recovery is incomplete, the loss of mental power is more marked. ~TR^aTmt^nt.-If we see the patient ^arly, that is at the time of the extravasation nr within two hours after,put him to bed and keep him auiet. The only eases in which bleeding is justifiable are those in which the clot is formed slowly, a clot may take two hours to form. Diminish the force of the hearts action by cardiac depress scrs,yeratrum virine ano aconite or by nilators of the small arteries anc capillaries. 62 After th* elnt is formed, we simply await the outcome. If the patient continue to live, the paralyzed muscles must he treated by friction and electricity. We must look out for bed-sores. -2-OCCLUSION OF THE CEREBRAL ARTERIES. - Occlusion of the cerebral arteries is generally cue to plugs of fibrin derived from the valves of the heart, of pieces of the dis- integrated valves of the heart or nf the inner coat of the aorta. Chronic endocarditis attacks the mitral or aortic valves. The valves become thick,rough,and coated with fibrin. The fibrin breaks off. The same thing may take place in the arch of the aorta. The fragments are carried along and lodge in the cerebral arteries. Sometimes, thrombi are formed in. the cavity of the left ventricle without any changes in the valves and pieces of these thrombi-will become lodged in the cerebral arteries. Emboli formed in other parts of the body may also find their way into the cerebral arteries. Emboli often occur in the serebral arteries 'without our being able to find out where they oa-me 'from. So there may "be no murmur in the heart.. As a rule, emboli are not of large size and "in not lodge in the large branches. Their most frequent seat is the middle cerebral arteries. Most frequently, there' is but one embolus^less 63 there is mor^ than one. Least frequently, ?■ lot of fine broken* town grannhr matter blocks up nearly all the cerebral arteries at once. When a cerebral artery becomes occluded,the immediate result ij that the portion of brain that it supplies becomes anaemic.Less frequently,such an anaemic condition ones not result for venous congestion may be produced by a sort of regurgitation from the veins. In either case,th^ affeetr-o part of the brain undergoes no further change for a considerable time. Then, it becomes necrotic. When brain tissue becomes neerotie.it softens and is converted into a mass of granular matter. Tf the affected part of the brain be small, th^ granular matter will become smaller,.a cicatrix will be left, tad the patient will recover. If the embolus be situated near the pia mater, a localized or diffuse inf lammation of that membrane will be set up. When a person has suffered from a embolus in one of his cerebral arteries ana has recovered,he is liable to another attack even after weeks,months,and years. ! ^SYMPTOMS- We will first consider the symptoms that depend upon the siz^jposition.eno number of the arteries occluded. If all the arteries be occluded the patient will he killed ?Imo st instantly. This is rar*. If two or three of the arteries be occlude: at once,the patient c;t once becomes comatose. If the oeeluoen arteries be large^he will remain comatose for t few ;ays and then he yill die. 64 if one of the ri'* He cerebral arteries gt a branch that supplies the corpus striatum be c cclu-e-i, the symptoms will be the same c.s these nf apoplexy involving the corpus striatum. This is very serious. Death follows. Some instead' of developing coma will *ie- velr.p convulsions followed by coma. So far, it is very difficult to distinguish between embolus and cerebral apoplexy. A small plug may be loiged in a small branch that supplies a small part of the corpus striatum or in a small branch that goes to the ascending convolutions or to the centre of speech.In these eases, only a small part of the brain is affected and the patient may not lose consciousness at all nr,if he do,,the loss of consciousness will last but a short time. If the clot be in the small artery that goes to the corpus striatum, we will have hemiplegia on the opposite side of the body. The hemi- plegia is often incomplete. If it be in the small artery that goes t.G the ascending convolutions, we will have hemiplegia,of ten incom- plete and of short duration* The paralysis may involve arm alone. If in the artery that goes to the third left frontal convolution, th* patient will become aphasia. If the blood supply be cut off from the temporal convolution,the patient will develop word-deafness. If motor paraiysis be o^velop^d,convulsive movements will often teke place twelve or twenty-four hours afterwards. The convulsive movements will be succeeded by more gt less motor paralysis. 65 We will now consider the general symptoms depending upon the im- mediate occlusion of the arteries and the anaemia condition of the brain resulting from the occlusion. The lodgement of an em- bolus is often succeeded by a period, of confusion. Then about an hour afterward,one arm will either become paralyzed or will con- tract involuntarily and then lose its power of motion. The patient passes a restless night and,the next day,the paralysis of the arm continues. Then,it gradually diminishes until the motor* power is almost entirely regained. Then in two or three days,the paralysis returns and is worse than it was at first. The first paralysis is due to the anaemic condition of the brain,th£ secnnc, is due to necrosis. In the same way,the aphasia is first developed,then dis- appears, and then returns worse than it was at first. There is al- most always a febrile movement. After this,the progress differs in the different patients. In some,the intellect remains perfect. In others,it is either slightly or decidedly effected. The motor paralysis may last forever or,after a few months,motion may return. The same way with the aphasia. If the embolus op the necrotic changes be in the situation of the pia me ter,we will have meningitis and its ordinary symptoms. -PROGNOSIS-The occlusion of a small artery does not seem to be a serious affair and,indeed,the patient frequently recovers. Yet • be very careful about giving a favorable prognosis in these eases for even if the patient do well for two or three weeks,he is apt to turn out badlv. 66 He is fc.pt to develop an ( cute nr chronic meningitis t-nd may die from either. His mind is apt to be af feeted,especially if he is elderly. He will ant become a lunatic but he will not be able to attend tn his work as well as before and his mind will not be as ready. -DIFFERENTIAL DIAGNOSIS- Many oases cannot be distinguished from, apoplexy. This is of but little consequence for, when they ec.nnot be differentiated, one disease is as bad as the other. In other eases, we can sometimes distinguish between the two diseases. Embolism may occur in much younger persons than apoplexy. If the lesion be small,if there be no loss of consciousness at the time of the cttaok,it is more apt to be an embolus. The last-mentioned point is of a good oeal of value. If we believe the lesion tn he situated in the cortex, it is more apt to be an embolus. The more ineomple'te an" temporary the motor paralysis and loss of speech,the more apt is it tn he an embolus. If the lesion he situated on the left side of the body,it is more likely tn he an embolus. Remember that emboli may occur without any murmur in the heart and that 'murmurs are just as common with Apoplexy as 'with emboli* TREATMENT.-Look out for bed sores and get the patient out of doors <s sr<nn as possible. 67 -^-INFLAMMATION' OP THF CEREBRAL ARTERIES.- The inner and mid de coats of the arteries are the parts most frequently attacked. The number of arteries attacked varies and the acuteness and severity of the inflammation vary also. The most common forms c.f inflammation are the following. -1-There is a chronic inf lamination r.f the inner'coat end* to a less degree of the middle coat. In some places,they are thickened?in others,thinned. There is a variety as to the extent of this thick- ening and thinning. In some cases,the thickening is localized?in others,diffuseo. As a rule,the thickening does not diminish the calibre of the artery much but makes it rigid and~ noris-elastic. The thinning may also be circumscribed, nr diffused. This' form of inflammation runs a chronic course, when it has las- ted some time irregularities will be noticed here and there in the wall of the artery. Then,the thickened parts,formed of connective tissue may degenerate and be infiltrated. with fat or vith the salts of 1ime. If they become infiltrated with the salts of lime,cal- ciferous plates will be formed. When the inf lamination has laste-l a considerable time,the blood will no longer be able to circulate normally. In many cases,this is as far as the inflammation gets. Sometimes,the thinning will cause dilatations of the artery. This is the ordinary way in which aneurisms are formed. 68 -2-This fnrm is characterized by the production of new connective tissue cells and new connective tissue on the inner surface of the inner coat of the arteries and projecting' inward. The connective tissue cells have at first the ordinary appearance of the endo- thelial cells that line the wall of the artery but,as the connective tissue increases in quantity,the lumen of the artery is rendere I smaller and may be entirely occluded. This is very serious. This form is calleci obliterating endarteritis. -3-This form is characterized by a suppurative inflammation of the wall of the artery, The inflammation involves the outer vtll of the artery where the blood-vessels are tolerably numerous. As it goes on,this infiltration with pus extends to the middle coat. This is very serious for thj artery is liable to rupture. This is one r.f the ways in which aneurisms of the aorta are produced.That is ta say dissecting aneurisms. The cerebral arteries may be affacted in ail of the three ways mentioned. The first form is the most common and is often seen in the large arteries at the base of the brain. The second form is also common and involves the large- arteries at the base of the brain and their branches. The third form is least common,results in the rupture of the arte- ries,and is one of the ways in which cerebral apoplexy is produced. 69 -CTTOLOGY.-The disease is most common after the cine Gf forty >ears but it may occur ia young persons- Constitutional syphilis seens to be c predisposing e^use especially of the second form. Gout, vheumati sir, chronic alcoholism,and the atrophic form of Height's disease are causes. Persons who are liable to emihysema of the lungs are also liable tn this condition. FI non card! tis is a cause. In fact,people subject to Bright's discase,enoocardi tis,and emphysema generally develop en u rteri tis. It is a form r.f inf lamination which always manifests &. disposition to continue The slower the progress,the better for the patient, -SYMPTOMS." These vary with the size and condition of the ertery occluded and with the form of the inflammation. The first form usually lasts the longest without giving trouble rr symptoms unless the artery rupture gj? an aneurism be formed. The second form is more serious for the artery may become so occlud- ed that portions of the brain do not receive their proper supply or blond. The third form results in apoplexy ano ones notyas a rule,give symp- toms until then. When person suffers from the first or seeon-j l'nrm,he usually has temporary symptoms at first. The reasons for this are tht t th? lesions too small at first to produce any permanent effect 70 upon the circulation of blond &nd the symptoms are only the result of temporary causes acting upon the heart,for example,running to catch a ear. Any other external excitement may act in the same way* Headache and dizziness are commonly complained of. There may be partial or complete loss of speech and vision,loss of conscious- ness, convulsions,paralysis, contractions of the voluntary muscles, and localized anaesthesia. All of these temporary symptoms are not necessarily found together. They are generally accompanied by some slight prostration. These symptoms come on in attacks. When the patient has had one attack,he is almost certain to have another. Even aftex* his first attack,his mental condition is apt not to be as good as it was before. This is due to an extension of the lesion. His temper and self control are apt to suffer. Others become irritable and hyster- ical* The patient may go for a year without having another. The next attack is more severe and lasts longer. With these attacks, there is frequently a febrile movement* This fever depends simply upon the fact that there is a cerebral lesion and does not signify that there is any inflammation* The fever may reach 104-105. The attacks are often caused by indigestion and must not be mistaken for simple stomach disorder. Now,as time goes on,the patient may develops chronic meningitis or he may become comatose either rapidly or slowly. If the coma be 71 developed gradually,the patient will at first become drowsy and stupid*if rapidly,it is generally •omplete within two hours- The rule is that when they become tomato $ a, they die* Others develop hemiplegia or paraplegia slowly or rapidly. As a rule,as soon s as either is completely developed,they die. Others die of cerebral apoplexy. -PROGNOSIS*-The prognosis is always serious. The patient may live for ten years but he is never the man he was before. The prognosis varies with the severity and the number of attacks. In making the diagnosis,we are assisted by the knowledge of the existence of endarteritis of other arteries and the presence of the accompanying diseases* -TREATMENT,cannot hope to cure the disease but we can make it progress so slowly that the patient may live for a number of years. If he have syphilis or gout,we treat those diseases. If he have gout or rheumatism,we try to prevent their attacks. These two things are of a great deal of importance. A certain plan of life is neces- sary for those that suffer from bright's disease or emphysema. They should live out of doors* should not tire themselves* should not drink, smoke, or work hard,*and should avoid the sugars and starches for fear of indigestion. This is of vital importance. The contrac- tion of the smaller arteries is dangerous but can be remedied by inhalations of th" nitrite of amyl. After giving this drug,we may continue with bromide" of potash and chloroform in order to keep covn the arterial tension. 72 In closing, I wnrJd say the t this disease is very onmn, -4-ABCFSS HP THE BRAIM.- -PATHOLOGY. -Aboess of the brain presents itself under two ? natomi- Gr1 forms* -First form.- A smeller nr larger portion of the brain becomes softened and infiltrc.ted with pus but there is no abcess cavity. -Second form.-Presents the ordinary characters of an excess. The pus is apt to be thin and watery, a number of the pus cells are found in a state of fatty degeneration. An abcess may be found, in any part of the brain but it is most frequently situated in the temporal or parietal lobes. If it be situated near the pia mater,it will set up a meningitis. If it be situated near the lateral ventricles,the pus may perforate the ependyma and rupture into the ventricles. If near the venous sinuses^ thrombosis is apt to be established. "ETIOLOGY.-Abbess of the brain may follow injuries of the head or suppurative inflammation of the middle ear* As a rule,the head injury is not sufficiently severe to fracture the skull or to pro- duce apoplexy. The patient has usually recovered for some time from the blow, before the abcess is developed. Why this time should elapse between the receipt of the blo^ and the development of the aboers-s,we do not know but we see it so often that we cannot doubt external injury is an exciting cause. When it follows 73 suppurative inflammation of the middle ear, we do not know the exact steps of the process. An abcess may be developed without &ny appar ent cause. "SYMPTOMS. * These will vary according as to whether the suppuration be acute and cintinuous or not. The symptoms divide themselves into four classes. -1-As a rule,these acute abcesses run their course within one or two weeks but they may continue for a month or more. The same ac- tivity of suppuration and symptoms is present throughout, -2"This form begins as an acute suppuration and continues as such for one or two weeks. Then the acute symptoms subside. Put,the patient is not well. The abcess is in a latent condition and may not cause death. -?-At first,there is a period of acute symptoms^then, the latent period^then,the acute symptoms again come on. ~4-There is no acute period at first. The abcess remains latent for months and,then,the acute symptoms develop. This last variety is the most difficult tn recognize. : Thu general symptoms are those of active suppuration. Thera is pain m-ferm-d to the situation of the abcess or there may be general headache. There is a well marked febrile movement. We have alter- nations of restlessness and drowsiness which go on to delirium and coma. At first,th? pul^e is apt to be slow and irregular^at the close rapid and feeble. Convulsions are frequently present and th-- patient dies either in coma or convulsions. 74 The latent symptoms are not so veil marked. There is a feeling of dulness and prostration but the patient ig frequently not con- fined. to bed.There is apt to be more or less dull headache which may nr may not be localized. There are attacks of dizziness and perhaps attacks of vomiting. The patient may become anaemic. These symptoms tell yon very little. The local symptoms.rlf the abeess be situated away from the motor tract and if it do not involve any of the nervous centres nor any of the nerves that issue from the cranium,the only local symptom that we will have will be headache. We may have coma or convulsions. If it involve the motor tract,we will have hemiplegia nr convulsive movements. If it involve the speech centre,aphasia^if the sight centre,blindness. If it be situated near any of the cranial nerves, the functions of those nerves will be destroyed. -PROGNOSIS-The prognosis is bad. As a rule, the patient dies soonei* nr later. Still,if the abcess be small,if it pass into the latent state,and if it be situated near the motor tract,the patient may live till he dies of something else. -TREATMENT.-During the acute stages,the treatment is the same as tlu t of acute meningitis. During the latent period,keep up the patient's health. 75 -5 - TUMORS OF TME i$RAI NT. - We include under this heading those meningeal tumors that compress the brain. -PATHOLOGY- They present a variety of anatomical forms. The syphil- itic tumors have already been referred, to. There are fibrous tumors^ Sarcomata, tumors composed of connective tissue cells-, and, lastly, bony tumors,formed of flat cells and g-rowing both from the pia and from the brain. Whether the tumor be malignant or benign,makes but little difference. The malignant tumors kill quicker yet,ex- cept in the ease of a syphilitic tumor,we hardly try to distinguish between the two. -SYMPTOMS.-Some give no symptoms at all. The patient dies of some- thing else and the tumor is found at the autopsy. Others grow for a long time yet give no symptoms till a short time before death. These are very difficult to distinguish from abcess, apoplexy,or embolus for the symptoms are developed, so rapidly. Others give symptoms for weeks,months,and years.In these long oases, it is curious that the symptoms are not a rule continuous although the tumor is growing all the time. We will first consider the symptoms of tumors that keep clear of all important parts.The patient has headache,severe or slight. At any time,he may develop general convulsions,or he may become dull and stupid^eomatose or rest]ess.The mental faculties are affected. 76 The patient loses flesh and strength. He will lie in bed in a stu- pid condition. The pupils are generally dilated and there is ^ell- marked congestion of the fundus of the eye and of the op tie disc. In many cases,the diagnosis is easy especially after the patient has been confined tn bed. The patient is apt to die in coma or convulsions or in gr^at emaciation. If the tumor involve the nervous centres,we will get the special symptoms in addition. -TREATMENT.-There is no medical treatment. Doctor Weir has tre- phined and removed a lumber with very successful results. -Prognosis.-The patient may live for years but he will never get we 11. Z /y 770/7 -6-ANEURISM OF THE CEREBRAL ARTERIES.- Ca4'0-t&& These'aneurisms are commonly situated at the base of the brain and generally involve the basilar,middle cerebral, or cnrrc.n carotid artery. They are sacculated. When once formed,they regularly increase in size and,as a rule,rupture and cause deb th. -SYMPTOMS" They give the symptoms of a tumor of the base of the brain. The symptoms vary with the size of the aneurism and the structures pressed upon. We have headache, dizziness, deaf ne ss-^ain in the muscles of the face,hemiplegia,contractions of different groups of muscles,and the other symptoms of a tumor of the brain. The only special symptom is that in some cases the patient is con- scious of an unnatural pulsation in the cranial cavity. When they do have this pulsation,it is pretty characteristic. Yet,it may be caused by hypoehondria,hysteria,or disturbances of digestion. 77 -TREATMENT.-The treatment is mainly surgical. It consists in the ligature of the carotids. This is of doubtful efficacy for the patient has chronic endarteritis. We may give iodide of potas^iunu^- -LESIONS OF THE VENTRICLES OF THE BRAIN.- There is a variety of these lesions. -1-An acute inflammation of the lining membrane of the ventricles, particularly of the lateral ventricles. -2-The ventricles are enlarged and contain a quantity of cle^r serum but there are no changes in the ependyma. The origin of this Serum is unknown. This lesion is found both in adults <7nd children. It constitutes the disease known as chronic hydrocephalus. -^-First,there is a meningitis and the patient recovers. Hut the lesion in the ventricles continues. -4-A lesion nocuring in young adults and having the character of a sub-acute inflammation. There are changes in the ependyma and the ventricles are distended with turbid serum. -1-AWl'E INF1AMMATION OF THE EPENDYMA. - This is accompanied by the ordinary results of an inflammation of connective tissue with the production of serum, fibrin, and pus. The ependyma is thickened and covered with pus* and fibrin. 78 In the cavity of the ventricles th^re is pus mixed with fibrin* The lateral ventricles are most commonly affected. -^I'TOLOGV,M The cause is unkon^ni. The di^e^se is rar** and very fate 1. -SYMPTOMS.- Resemble those of acute meningitis with distension of th; ventriel-s. There is a febrile movement which is continuous throughout. This may or may not be preceded by a rigor. The pulse is the same as in acute meningitis. There is headache. There are alternations of restlessness and stupor going on to de- lirium and coma. Sometimes we have convulsions. There are the sam^ changes in the eyes as we have in acute memin- gltis. There is generally constipation. -DURATION. -Som^ cases run a very acute course lasting only one week, others lc st for several weeks or months. -T.WiT^ENT. - Same as for acute meningitis. -2- DISTENSION OP THE VENTRICLES WITH CLEAR SERUH^c.- -CHRONIC HYDROCEPHALUS.- -IN ADULTS.- Although not accompanied by ordinary inflammatory symptoms, the condition is,nevertheless, one of sub-ecute inf lamination. Th- 1<. terd • no fourth ventricles c re the ones most usually affect** ^d. 79 Some times,one lateral ventricle is more distended than the other. Generally the ependyma is not affected but it may present little thickened patches. If the serum be present in sufficient quantity, the external surface of the brain will appear flattened. -FTIOLOGY.-The causes of the disease are but little known. It oc- curs in all classes of life. When we find it in the better classes, we get a.' history of over mental work^when among the lower classes, of over physical work It may follow injuries of the head and chroni endarteritis. This lesion of the ventricles is comparatively com- mon. -SYMPTOMS.-The patient passes through two stages. First stage- This stage is the longer. During it,the patient is not confined to bed. He complains of headache which may or may not be continuous^noises in the ear$vertigo$ mental disturbances, such as loss of memory,dulness,listlessness,and sleeplessness. His speech may be affected. There may be disorders of digestion and temporary paralysis of one arm or leg. There is no fever. So he may go on for one,two,or three weeks. He gets continually worse. Then comes the second stage. -Second stage.-There is a sudden and abrupt change which may take place in one of two ways. In the first place,the patient may at once become completely comatose,remain so for a number of hours or days,and then die. From the suddenness and character of these symptoms, the disease is sometimes called11 serous apoplexy11, a very bad name. 80 ^Second ly h^ m< y suddenly develop an acute delirium which is apt ;n b- accompanied by blindness or internal strabismus. This delic- will last for two days and then -the patient will die in coma. ' ^^aWENT.-I do not know of any- The great difficulty is in mak- th- diagnosis in time to do any good. -IN CHILDREN*- ft, iS characterized by the same ,& S in adults but in ildren th?A lesion travels to a higher degree of developement, '■n"i brain looks like a sack of serum,and,in children in whom the Ul'cmelles and sutures are not closed, the bones are pushed ape rt the sutures and fontanelles widened. • fac« remains of the proper size. The larger number of eases to be developed in intra-uterine life.The eases vary in the nd bev°lopement ybieh takes place in intra-uterine life n... cfter birth. In some,which are developed during intra-uterine J-11 Q .1 1 head becomes so larg- that the child cannot be borne dive. ^'bers,he may be borne alive but he he s an unna tural appearance, p^nd badly, seems fretful, cries, or lies in an sort of stupor, nj5Ualiy dies at the ond of three or four days or* a few weeks* ed"e~ developed during intra-uterine life,at the time of inci \ bead is not enlarged. The child seems perfectly healthy <f?n'ains so for several months or fop a year or* so. 81 However,at some time,he begins to have trouble and the oases vary as to the rapidity with whioh whe symptoms are developed. In some of these oases,the quantity of serum is not very great, the distension of the brain is comparatively moderate,and the change in the size of the head is not very marked. In such cases,the in- telligence may remain fairly good. But,from time to time,the ohild suffers from fever,101-104-,loss of appetite,and occasional vom- iting. He loses flesh and strength,beoomes peevish and irritable and does not sleep at night. Such an attack es this may last a week and then subside. So these patients go on for a number of years. Although they do not die of hydrocephalus,they do not as a rule grow up. They die of some intercurrent disease and it takes very little to kill them. fther cases of this same class are much more severe. At birth, they appear healthy but,in a month or two,symptoms make their appearance. The serum is formed very rapidly and the enlargement of the cranium is well marked. The nutrition is always bad. The intellect is always poor. Some are idiotic and peevish and do not sleep well at night. Some have internal strabismus. Nystagmus may . be present. The pupils are usually dilated,the fundus of the eye congested,and the sight impaired. In some,the eyeballs are thrust forward and sometimes to such an extent that the lid may close behind the ball. There may be deafness. The child may have convul- sions from time to time. There may be short periods of improvement 82 Jose die feeble and emaciated,others- in convulsions,others of inter* current disease. Some live to grow up but they are idiots. -TREATMENT.-It was formerly advised to tap tpe serum but this does no good, keep up the general health and some of the milder cases may grow up. Beside these regular eases in young children,we also have a disease with the same name and with the sam^ lesions in older children, ten to fifteen years,and in young adults. These cases are not con- genital. The lesion is of a more inflammatory character. The serum may be turbid and the ependyma may be more thickened. Some of the cases are caused by meningitis especially the cerebro-spinal variety. After a time,the inflammation of the pia will subside but, instead of recovery taking place,other symptoms make their appearance. These symptoms are feebleness,irregular fever,restlessness and • delirium,convulsions or stupor. The patient will remain in bed for weeks getting weaker and weaker. Most die very much emaciated but some recover. Those that recover are ill for months. Other cases in young adults are caused by external injury or ap- pear to be idiopathie and are apt at first to be very obscure. The patient complains of headache,cannot learn his lessons as well as before,and mind and body become more feeble. He has disturban- ces of digestion and becomes anaemic but for a few days or a week he is not confined to bed. 83 When he is finally confined tn behave have < Iterations of rest- lessness and stupor, fever, t-nd headache. He gets worse and worse and dies in convulsions,or ruck emaciated* -DISEASES Oh1 THE SPINAL CORD.- -1-CONGESTION* - -2-MYELITIN- -^-ANTERIOR PtLIO-MYELITIS.- -4-aMYOTRO.PHIC LATERAL SCLEROSIS.- -5-LOCOMOTOR ATAXIA*- The spin&l cord acts as a channel of communicc tion, as n nervous centre,and exerts a special influence over the nutrition of the body. -1- CONGESTION, OR ACUTE HYPERaEM.IA* - We have no anatomical knowledge that this is the proper name for this disease but ve assume that it is from the clinical evidence. The post-mortem condition telle us nothing,for venous congestion might have been caused by the corpse lying ot its btek. 84 -ETIOLOGY.- Some of the patients have been exposed to cold and vet. Others Rive a history of over-sexual indulgence^others of eoncus- sion:, others of overwork, others of work in compressed air, as in diving bells*,and some give no history of cause at all. -SYMPTOMS.-The invasion is sudden as a rule. The patient in per- fect health may be attacked in the street. He may go to bed per- fectly veil and be attacked in the morning. The most constant and most characteristic symptom is loss of pow- er in the muscles of the legs. As a rule,this loss of power is not complete. The patient can move his legs somewhat especially when he is lying do vn. In most eases, the paralysis, remains in the legs but,in some,the bladder and rectum are also paralyzed. In some eases,the paralysis will even extend to the trunk and arms. Some have pain in the back. Others have tingling in the legs. In some,the paralyzed muscles will contract involuntarily from time to time. As a rule,there is no loss of sensation. When this condition is first established,the patient does not feel very ill. He may remain in this condition for a few days,for two or* three weeks, or for several months* The longer oases are, difficult to distinguish from hysterical paralysis. In men,the differential diagnosis is easier than in women. -PROGNOSIS--GOOD. The condition is only temporary. The time required for recovery varies. 85 -TREATMENT. - Bear in mind that the disease naturally terminates in recovery, Do not be too energetic.. You must try to shorten the duration of the disease. The patient must be kept absolutely <uiet in bed. Some say that they should not lie on their backs. Regulcte the diet. Do not starve them: give them easily digested solid food. The use of purgatives,not mild, cathartics,is very serviceable <md may effect a cure. This they do by diminishing the amount of blood in the cord. Use calomel and croton oil gtt^. j-gttL iij. Make applications to the skin of the back. Use dry cups or alternate heat c^nd cold. -2-MYELITIS. - -PATHOLOGY.- This is an inflammation of the substance of the cord. Both the white and the gray matter undergo changes. They swell and there is a change in the connective tissue stroma. There is a necrosis of the nervous elements of the cord and the cord is infiltrated with pus. The pus is only present in the more severe cases. The cord is congested. The connective tissue is swollen and assumes a gelatinous appearance. The nerve elements simply die. If the lesion involve but a. small part of the cord, there will be no change visible to the naked eye or to the touch. If the lesion be further advanced,as soon as you look at the cord,you vill notice 86 that it has softened and fallen in at certain places. If very far advanced,the cord will fall in two as you lift it out. Myelitis usually involves but a transverse segment of the cord and increases in size from the time of its development* This variety is called transverse myelitis. In other eases,nearly the whole length of the cord is involved. This variety we call disseminated myelitis. The disease may begin as a. transverse segment and then travel up the cord. This,we call ascending myelitis. as a rule,the disseminated form has the most active characters and,with it,we are most likely to have the pus cells. The trans- verse is the most common. -ETIOLOGY.- The causes of myelitis are but little known* The dis- ease is most frequently seen in middle-aged adults. In some oases, we get a history of over-sexual indulgence: in others,a history of exposure. Some of the patients have been alcoholics. However, in many, we can get no history. We group with myelitis a set of aisea-.-^ caused by injury. These are not truly myelitis. An injury may fracture a vertebra and the displaced bone may press upon the cord and cause necrosis. -SYMPTOMS- The symptoms vary with the character of the disease* DISSEMINATED MYELITIS- The disease is marked by an acute invasion 87 of constitutions 1 symptoms similar to* those of any acute inflam- mation, such as headache,vomiting,fever,and delirium and restless- ness alternating with stupor. These symptoms resemble those of acute meningitis. However,we are not left long in doubt for,at the seme time or shortly afterwards,the patiea* has loss of motion and sensation in different parts of the body. There will be paraly- sis of the bladder and rectum. The patient looks sericusly ill. The constitutional symptoms and paralysis continue. The paralysis gets no better and even worse. There may be some improvement in the constitutional symptoms but the patient dies in a very short time,two days.This form is not very common. -ASCENDING MYELITIS.-Here the invasion is acute hut there are no cnnstitutional symptoms. The paralysis is completely developed within twelve or twenty-four hours. These patients may live r a indefinite time. After developing the ecute paralytic symptoms, some,will remain stationary for two nr three weeks,and then will become worse. They notice that they cannot move the trunk as well as before and that the line of anesthesia is higher. This paraly- sis extends to the arms and neck. This is very dangerous. 88 There & re an marked constitutional symptoms hut, the patient gets weaker and. weaker day by day. His mind begins to wander* Then,he may develop a mild delirium and die exhausted. So ascending myelitis is a fatal disease. - TRANS WRS^ MYELITIS.-The paralysis comes on gradually. This if the ordinary history of the disease. In some,the first symptom is disturbances of sensation referred to the legs,prickling sen- sations. After these have lasted several weeks,there will he & gradual loss of muscular power. At first,the patient feels fatigued upon slight exertion and,as time goes on,he has less and less pow- er in the legs. There will also be loss of sensation. As a rule, the loss of sensation follows the loss of power. Reflexyaetion f increased. Usually,the loss of sensation and loss of motor power are not equally developed in both legs. Now,the patient has trouble with his bladder. At first,he does not urinate readily*then,the urine is totally retained. Sometimes, this is the first symptom. Then,there is great constipation. There are periods of intermission and • improvement, ^tut, no matter how slow the progress of the disease may he,it eventually goes on to complete paralysis and anaesthesia of the parts below the lesion. At first,the patient's health may remain fairly good. Most of the patients continue to live a number of years and die of some complicating disease, generally pneumonia. 89 The patient is very to develop cystitis. This should never be be allowed to happen. It is gener<-riy^c^need by dirty catheters <.nd the carelessness of assistants. In itself,cystitis is not dangerous but it very apt to lead to a supputative inf lamination of the kidney which is regularly fatal. The patient is very apt tn develop bed-sores for the nutrition of the parts below the lesion is diminished. These bed-sores have but little tendency to heal. They should never occur. -TREATMENT.-The disseminated form is fetal. Nurse the patient end keep him comfortable. Ju the ascending and transverse forms, there is time for treatment. The following plan, have been recommended. Fluid extract of ergot drem 1- t. i.d|belladonna in large coses*, iodide of potash in large orves;nitrate of silver in large doses continued for some time| chloride of gold and sodium^and counter irritation over the cox'd by means of iodine,cups,or blisters. As a rule,I think that this treatment is likely to prove ineffectual for necrosis is the pri- mary lesion. Of greater importance is it to nurse the patient and keep up his general health. Oy these means,death can be prevented. Look out for bed-sores-.Rub and knead the skin, change the position r-f the patient,and use u water bed. Empty the bladder regularly and keep the catheter clean. Use a strong solution of corrosive sub- 1 ima te c.s a disinfectant fo r the ca theter. 90 Rub the paralyzed parts every day; also, rib the whole body. There should be passive movement. If tkese means be adopted,the patient san be kept in perfect health and will be able to attend t^ ■busi- ness for a number of years. POLIO-mYELITIS.- The lesion is confined to the anterior horn of gray matter. The disease is also called acute nr chronic spinal paralysis when it occurs in adults and. infantile paralysis when it occurs in children. -IN CHILDREN. - -PATHOLOGY. - If the child die within a moderate length of time, the changes will be found to be of an inflammatory character. The part of the cord affected is congested and, to some extent infiltrated with pus. There is some swelling of the stroma and some degeneration and death of the nerve elements. The degenerative changes &re arrang- ed in foci on one or botJi sides. The lesion varies in extent. It is ( ften very slight; the amount of nervous tissue destroyed very small indeed: and the patient readily recovers, we find that other petients live for years with partial paralysis. In these cases, tie lesion is more extensive and leaves a cicatrix. -I TIOLDGY.-Children between the ages of cne-and-a~half and four years are especially liable to. this disease, ^oth sexes are affected with e^ual frequency. How much dentitif n has to do with it, we do not know. Exposure and concussion are causes. It is sometimes de- 91 veloped during the exanthemata. In tome eases there seems to he no cruse at all. It is more common in summer than in 'Vinter and ■i'■ net xn nncommon 6i •• e<■<:e -o ZXPTOMs. -/is a rule, the symptoms come on suddenly end acutely. There is fever,vomiting,drowsiness and stupor alternating with restlessness and delirium,and pain in the back and limbs. The se- verity of the constitutional symptoms is directly proportional to the extent of the lesion, as a rule,the child looks seriously ill. In some oases there is only a fever. Convulsions may be the first symptom. In some cases there are no constitutional symptoms at all. The child will go to bed in perfect health and in the morn- ing be paralyzed. The duration of the constitutional symptoms varies. The paralysis may be developed very rapidly but it may be developed slowly and take one or two hours. Most frequently a tingle leu is paralyzed. There may be paralysis of the bladder. There is no sensory paralysis. Sometimes all the muscles of the limb are not involved. 92 tycre frequentlv,the recovery is partial. Seme of the muscles will recover thoir power but ethers vill act. Per example, the flexor muscles of a limb may recover but its extensors may act recover.] Such cl partial recovery ia a child is a serious matter for it is' regularly followed by deformity. The foot or the leg will become twisted. Some show ar. improvement whatever: the muscles atrophy*, and, as a result, the bones do act grow ia proportion and one leg will be shorter and smaller than the other. -xTR^ATkWT. - Directed tr. the paralysis rather than tr the lesion. During the first days and weeks,keep the patient quiet|bu^as scon as improvement shows itself,assist it by passive me tion, rubbing, and kneading. This must be kept up until complete recovery takers place. Then,should any deformity be present,the child should be sent to an orthopedic surgeon for its correction. -IM ADULTS. - -PATHOLOGY.-The lesion is probably the same as in children but ye have sc few autopsies in adults that we rather infer from the symptoms what the lesion is. -SYMPTOMS.-The disease may run an acute rr chronic course but the distinction is rather arbitrary. The typical cases of the Wo divisions present veil marked differences but,be tween the two, th'-ra are many varieties. -ACUTP.-These resemble the eases in children- The patient suffers 93 from fever,colic,diarrhoea,headache,stupor,pains in the hack and limbs vhich may be dull nr sharp and are often very severe; and dis- turbances of sensation such as numbness and tingling. These eon- s+itutional symptoms come on suddenly,last for a fev hours or days, and then comes the paralysis. Not only do constitutional symptoms mark the commencement of the disease but they recur at intervals during its progress and are folloved by an extension of the par- alysis. -CHRONIC.-There is no fever. Often there is no particular day on vhioh you can say the disease began. The patient has disturbances of digestion,a feeling of fatigue in the limb,and disturbances of sensation such as numbness &e. Then,slovly,the paralytic symptoms are developed. The diagnosis it often not made out at the commencement of the disease. The .x- patients are frequently treated, for rheumatism and malaria and/ even after the motor paralysis is developed,the disease is often overlooked. The paralysis is developed singly or acutely accord- ing as the disease is acute or chronic. It is generally situated at first in the* legs and then extends to the arms but it may he the reverse.dome times the legs get veil and then the arms sre affected. As a rule,all the muscles are not paralyzed,but, gener- ally either all the flexors or all the extensors. 94 Often the muscles are not completely paralyzed* This distinguishes it from transverse myelitis- As a rule,the facial,rectal,and ves- ical muscles are not paralyzed* The bladder may be paralyzed but, generally, the retention of urine does not last for any length of time. The same is true of paralysis of the rectum which will cause retention or incontinence of faeces. In the chronic eases, it is sometimes years before the paralysis has reached its full degree of development. The muscles become soft and diminish in / size. This atrophy varies in rapidity and degree of development. When it is completely developed,the paralyzed muscles will no longer contract when stimulated, by either the galvanic or faradie current. The less the degree of development of the paralysis,the greater the degree of contractility that will be left. Reflex action follows no regular law-, it may remain normal,may be diminished,or may be exaggerated. The disturbances of sensation continue up to the complete development of the paralysis. There should be no loss of sensation and,as a rule,there is none. In Some eases,however, sensation is diminished. The intellect and general condition of the patient remain fairly gooi. There is no special disposition to the formation of bed sores. When these cases have begun,they regularly go through two stages. -First stage.-The patient is gradually'getting worse. This is the active stage and lasts for days,months,or years. 95 xSeetnd stage.*The patient, is in a quiescent condition getting neither better nor worse. There are no symptoms except the paralysis The length ef this stage varies. It usually lasts several weeks. Third stage.-This is the stage of improvement,marked by improved digestion and return of motor power. In the best cases,the patient finally becomes perfectly well. This stage is slow and takes months and years. Complete recovery is more common in adults than in children. In fact,adults generally recover entirely. Occasionally,there is only recovery of certain muscles but this partial recovery is not so serious as in children for deformities do not result. -PROGNOSIS.-Better than in children. ^TREATMENT.-The treatment varies with the stage. During the first stage,keep the patient very quiet and do not let him move the muscles. The disturbances of digestion may give much trouble. Mild counter irritation over the spine should be employed and should be kept up. . ' Use dry cups or sponges moistened with hot and cold water,or the ether spray. The counter-irritation should be inter- mittent so as to get the sudden effect of heat and cold. Give opium to relieve the pain. The treatment during this stage requires much patience but,remember,the disease is bound to stop. During the second stage,stop the counter-irritation,get the patient out of bed,and employ passive movement. 96 Attend to the nutrition. Knead the muscles and use either the gal- vanic or faradic current. As soon as the pains stop,discontinue the opium. This treatment must ...be kept up even after the patient has improved and until he is able to walk by himself. -4-AMY0-TROPHIC LATERAL SCLEROSIS.- -PATHOLOGY.-The lateral columns and anterior gray horns are affect- ed. The rim of the lateral columns is not involved. The lateral columns present a chronic interstitial inflammation which causes an increase of the stroma and degeneration and death of the nerve elements. The anterior gray cornua present changes in the nerve cells. The nerve cells degenerate and break down. These changes are very slowly developed and the patient gets worse from year io year. As a rule, the .^lesion commences in the cervical region, gradually travels dowh the cord,and then up to the medulla. So*at death,the change is found in the whole length of the cord. There is regularly developed an atrophy of some of the muscles. The muscles may be still further changed by an interstitial inflam- mation of the connective tissue that binds them together. -ETIOLOGY.-Nothing is known about it. -SYMPTOMS.- The invasion is very gradual. The first symptom appears ia the arms,frequently first in one then in the other. It consists in disturbances of sensation,numbness and shooting pains.' Then, 97 there is a peculiar tenderness of the muscles. This is due to the .inflammation of the connective tissue that binds them together. Now comes an atrophy of and a loss of power in the muscles. This is often observed in the hand before it is observed in the arm. The hand looks smaller. It is a. long time before the paralysis is complete. There are involuntary contractions of groups of fibres of different muscles,not of entire muscles. These contractions are easily excited by cold air or a cold sponge passed over the muscles. The patient may remain in this condition for a long time in otherwise perfect health.Then,the lesion travels down the cord and symptoms are developed in the legs. The main symptom in the legs is a loss of motor poorer. Sensation is preserved in both arms and legs and,when stimulated by the* current,the muscles will con- tract for a long time. After a long time,the muscles become contra cd and rigid. At first,this rigidity will be temporary but,as tim goes on,it becomes permanent. The muscles of the trunk become rigid also and,after a. time, the patient is perfectly stiff. This condition also lasts a long time. Then,the muscles of the tongue, larynx,and pharynx show the .game changes. Life is thus destroyed. ;by starvation. This is the regular full course of the disease. It may last five or six years.Of course,the patient may die of some intercurrent disease. ^TREATMENT.-When the disease has once begun, it continues in spite of everything. 98 -5- LOCOMOTOR ATAXIA.- This is one of the most common lesions of the cord* ^PATHOLOGY.-A change takes place in the posterior columns,the cdl- umns of Burdaeh. This change is a chronirT^nte^ tial inflammation which causes an increase in the connective tissue stroma and a degeneration and atrophy of the nervous elements. The lesion often remains in the posterior columns for a considerable time. Frequent- ly, it never involves any other part of the cord. Sometimes,however, it extends to the columns of Goll,posterior gray cornua,end poster- ior nerve roots,and it may involve the lateral columns and anterior gray cornua. The lower dorsal and upper lumbar regions are regular- ly first attacked. Then, the lesion extends, upwara end downward and may involve the whole length of the cord but,as a rule.the lesion is most pronounced where it first began. There are usually similar changes in the posterior nerve roots. The same lesion may be found in the second,third.fifth,and sixth pairs of cranial ne rve s. ■2d, In some rare cases,there is a secondary lesion of the bones. This is not an essential lesion.The tissue of the bones is changed. In the shaft, the lesion has the character of a Petrifying ostitis. The harder parts are softened and. the medullary "substance is in- creased in quantity. The same change takes place in the articular extremities but,here the joint becomes involved. 99 The eartilages become eroded^the synovial membrane is distended- and infiltrated with serum^and,finally^the joint is destroyed. ETIOLOGY.-Constitutional syphilis is the only known cause. Some s&y that it is the only cause. This is not so for a person may have locomotor ataxia without ever having had syphilis. The disease is more common in men than in women. -SYMPTOMS AND CLINICAL HISTORY.- The patient passes through three stages. - FIRST STAGE. - There are four symptoms.These are disturbances of'sensation,neural- gic pains,lessening of the reflexes,and affections of the oceular muscles. The first to make its appearance is the lessening of the reflexes. This we test by the patella reflex. Tlis is an early and important symptom. It is almost constant. Of course,it is possible to have diminution of the patella reflex, from some other disease of the cord or from no disease at all. The neuralgic pains are an early but not as constant a symptom as diminution of the patella reflex. When present,they may be shooting and excrutiating. One nerve alone may appear to be affected or the pain may attack a number of nerves and jump about from one to the other. From time to time,some circumscribed part of the arm or lag may be the seat of a severe pain. These pains come in paroxysms and. the cases vary as to the frequency of the paroxysms and as to their duration. They may last a couple of hours or only a., few seconds. 100 There may be-} pains in the interior of the body, in the larynx,stom- ach, bladder,and inte stine. When the pain is situated in the larynx,it is accompanied by other laryngeal symptoms which may take one of two forms. The patient may have a sudden cough like whooping cough,his face becomes red and swollen,and,at the end of the paroxysm,he takes a sudden in- spiration and gives a whoop.These attacks of coughing are frequently repeated,. When the symptoms take the second form, there is a spas- modic contraction of the muscles of the larynx. This produces dyso^ noea and the patient may almost suffocate. He may develop convul- sions or he may become unconscious but, throughout, there is no cough. These internal pains are called crises. In the stomach,there are pain end vomiting. The attempt at vomiting may continue even after the stomach is empty. These gastric crises may last for a number of days and may be mistaken for some stomach lesion. In the intestine,we have pain and diarrhoea. For vesical symptoms,we have pain and frequent micturition, the disturbances of sensation principally affect the skin,partie- ularly the skin of the legs. There may be hyperaesthesia er anaes- thesia or the patient may have the girdle fueling,that is he feels as though a cord were drawn, tightly around the'"waist or thorax. When anaesthesia involves the soles of the feet,it gives to the 101 patient the sensation of something between his feet and the ground- They often have a feeling of fatigue in the muscles of the legs. The muscles of the eye affected are the iri$?ciliary muscle.and external and internal recti. The affection of the iris and biliary . muscle consists in a diminution of their reflex contraction to the. ■stimulus of light. This is an early and characteristic symptom and should always be looked for. Of course,each eye should be tested separately. When the disease i^; further advanced,the pupil remains, permanently dilated and insensible to light. The recti muscles < are paralyzed. At first,this paralysis is usually neither complete nor permanent. The eyes look very natural but,if you place a prism in front of one eye and a candle at some distance from it,the pa~ tient will not see the two images one above the other. There will-.' be a lateral displacement. The patient may naturally have some degree of inequality of the recti muscles and this may prove a. . source of error. • .. • In some patients,there are additional symptoms. Some wiIT develop . blindness of one or both eyes. This is due to changes in the optic nerve similar to those in the cord. This comes on gradually and, finally-,one or both eyes may become perfectly blind. In. some, the ' reflex'muscles of the bladder will become affected-and there will • be retention of urine.The muscles of the .rectum may not respond 102 ttf the reflex stimulus of n faeces and there will be obstinate ^ruatipatioxu In the male., the sexual power will become gradually ert i ngu i shed. /f^ Syfr* Tie joints and bones may be affected. The joints are affected in the following order of frequency,first the knee,then the elbow, then the hip,and then the wrist. The affection of the joints pre- sents these characteristics. The joint becomes swollen. The swelling is due to distension of the synovial cavity with fluid. There is no heat,pain,nor tenderness. After lasting some time,this swelling will often rapidly disappear but the patient is liable to subse- quent attacks after which the swelling does not disappear. The cartilages become necrotic and eroded. The bones become the seat of a rarifying ostitis and the patient can no longer use the joint. If the shaft be affected,the solid tissue will be so much diminished in strength that the slightest injury may fracture the bone. The foregoing symptoms are not as regular d,nd characteristic as the four others. The duration of the first stage varies. In some,it will only last a few months^in others,for years, frequently,the patient never passes beyond the first stage. This is one of the hopeful features of the disease. The first stage is very common. Its severity varies in the different patients. The worse symptom is the neuralgic pains but all eases do not have them and,if they be absent,the other symptoms can be born^with little inconvenience. 103 la thie case , th- first stage is not 20 bad. If the patient do htye them it makes a difference how often they come on and how long they last. If they do not occur frequently and. be not severe,he i? not very badly off. The blindness,changes in the bladder,bones,&C*, ire very bad. -SECOND STaGE. - The symptoms of the first stage continue but there is also a loss of co-ordination of the movements of the voluntary muscles, especially the muscles of the leg. This is sometimes developed slowly,some times within a few hours. When suddenly developed,it is generally accompanied by fever and prostration,but these consti- tutional symptoms subside. When it is developed slowly,no change in the walk is at first noticed but, if you get the patient to per- form. some more difficult movements,the lack of co-ordination at oiee becomes apparent. Tell the patient to cross one leg over the other. The leg will go up and come down with a sort of jerk. As. the disease goes on,this lack of co-ordination becomes worse and worse until,as he walks, there is an exaggerated and b<5dly control- led action of the muscles. His movements are too violent. This symptom,when it has once begun,usually becomes more and more mark- ed until the patient can hardly walk at all. stil he can move the limbs. In many,however,it never reaches this extreme degree. The patient has to use a cane and that is all. He may remain in this condition for a long time without getting any worse. 104 The neuralgic pains may cease but there is no rule ebout this. Of course,all the symptoms of the first stage need not be present. As c rule,the mental faculties are not impaired during the first and second stages but,in some patients,they are affected during the second stage. The patient may suffer from loss of memory. He may become excited and exhilerated or he may become depressed in spirits. At one minute,the patient may feel very happy and feel sure of recovery and the next minute,he may make everybody miser- able with his depression. With all this, there is an inability to keep quiet. The patient does not sleep well and this sleeplessness may be very difficult to control. At last,the mental faculties become very much impaired. Whether or not this impairment of the mental faculties should be regarded as having anything to do with the disease,! do not know. As a rule,the second stage lasts a number of years and most patients never pass it. The patient usually di-s of some intercurrent disease. However,in some cases,the second stage comes on after a few months and the whole course of the disease may be very acute, a few go on to the third stage. - THIRD STAGE.- We have a new symptom,loss of motor power especially in the legs. The patient becomes paraplegic and the retina is completely paralyzed Life is not usually prolonged for any length of time. The patient 105 dies of some other disease and it takes very little to kill him. -PROGNOSIS.- It is doubtful whether tiny patient really recovers from locomotor ataxia,so the prognosis is bad on this tceount, but if the patient do not reach the second stage,the prognosis (is tolerably good. The disease oftdn comes to a stand still. The .patient may even improve and this improvement may last for some time. On this account,the prognosis is tolerably good, Me do not think as badly of the disease as we used to. -TREATMENT.- If we see the patient early,we may employ means direct- ed to the lesion in the cord. Two methods of treatment have been suggested. In the first place,a very large number have suffered from constitutional syphilis and we know that when this is the case the disease often yields to mixed treatment. Alternate corrosive sublimate and iodide of potash. This is good treatment whether the patient have syphilis or not. The second plan is the employment of constant counter-irritation over the spine by means of cups.blis- ters, ointments,heat or cold,iodine,etc.. These seem to me the most rational modes of treatment. In addition, we have to treat the pain's by the hypodermic injection of morphine. If the pains be frequently repeated,the patient should always be kept c^uiet during an attack. Look after the general health. If the patient cannot walk,employ kneading,passive motion,end electricity. 106 -INFLAMMATIONS OF THE PHARYNX. - Ws include,under this heading, the inflammstions of the uvula, ton- sils, soft palate,and posterior nares. The mucous membrane covering all is the same and an inflamma- tion of any one is apt to involve all the others. -1-ACUTE CaTARHJUL PHARYNGITIS.- This is the most common of these affections. -PATHOLOGY.-This is the same as for an acute catarrhal inflammation of any other mucous membrane. We have the s we Hi ng^° n ge $ t i n n, ar ee v t of the production of mucus,and then the increased production of cueus. All of these changes gradually subside and the membrane returns to its former condition. The cases vary as to the extent ard severity of the inflammation. If thin be very intense,the changes will be very decided. There are a few cases in which the mucus is produced in threat quantity and the posterior wc 11 of the pharynx may appear coated with it. This may be mistaken for a fclse membrane.This inflammation is very common especially in wet climates and in wet seasons of the year.lt is very common in Nev York. Some people seem to have a special predisposition to it and have it regularly every year. 107 -ETIOLOGY.-Exposure to cold and wet, disturbances of the stomach, ' ana the inhalation of irritating gases. -SYMPTOMS. - These are constitutional and local. The constitutional symptoms consist of rigors accompanied or fol- lowed by a febrile movement,paias in the back and limbs,and con- dicerable prostration. These precede the local symptoms,as a rule. The patient goes to bed and looks sick. The pulse is about 100, Rhe'temperature from 102- tn 104-. The next morning the patient complains of p< in in the throat*,and the throat is swollen,congest- ed,painful, and there is an increased production of mucus. The pain varies with the severity of the disease and with the char- acter of the patient. -DURATION.-Four to seven days. As a rule,the constitutional symp- toms subside two or three days before the local symptoms. In some cases,the disease continues for one,two,or even three weeks. -DIFFERENTIAL DIAGNOSIS.-When the mucus is produced in large quan- tity,you might suspect diphtheria but the mucus can be removed with a brush,whereas,a false membrane cannot-. -PROGNOSIS.-Good. The patient will get well without treatment. ;-TREATMENT.-This has for its object the diminution of the severity of the inflammation. Calomel and Dover's powder are of decided benefit. The tincture of aconite,and the extract or tincture of belladonna are also good. 108 I usually give aconite and belladonna together. You may give so- dium salicylate or salicin- grs.-v-to- grs*-x- every hour or two* These drugs do the most good during the early stages. Local appli- cations,if used,should be soothing. They are best applied in the form of a spray. You may use a weak solution of iodoform,or of 'opium, or simply warm water. When the first few days have passed use local astringents given by the spray. Alum,bo rax,and the sul- phate of iron are good for this purpose. This is all that it is necessary to do in regular cases. Do not use quinine. If the disease be protracted,continue the use of astringents but in stronger so- lutions, give sulphuric or hydro-chloric acid internally,and now you may use quinine. -ACUTE CATARRHAL TONSILLITIS.- -PATHOLOGY.-The tonsil consists of a layer of lymphatic glands crumpled up and covered by a layer of mucous membrane which dips down into recesses between the glands. These recesses are called the Crypts* of the tonsil* The glands rest below upon a sub-mucous layer and a muscular layer. The mucous membrane is really inflam- ed and not the tonsil to o.ny great degree. As the mucous membrane lining the crypts becomes inflamed,the tonsil becomes enlarged* The free surface presents little white dots due to the projection of the mucus filling the crypts. 109 This disease is commonly c< lied 11 ulcere ted sore throat "but, of course there is no ulceration. ^SYMPTOMS.-The Same as for the preceding except that you can see that the tonsils are inflamed. -DURATION.-The same,but it may last longed*. -TREATMENT.-The same. -ACUTE CROUPOUS INFLAMMATION OF THESE PARTS.- This occurs frequently as the characteristic lesion of diphtheria, also find, it without diphtheria,due to the same causes that excite the two preceding' diseases. If th' pharynx be attacked,the whole of it is swollen and congested, but soup parts will be more swollen than others and will be coated with a false membrane. If the tonsils be attacked,one or both of th^m will present the same condition. Th® constitutional symptoms are of the same kind as in the catarrh- al variety,but they are more severe.There is well marked fever and prostration.The severity of these constitutional symptoms serves to distinguish it from diphtheria for,in the latter disease,the 110 patient at first does not,as a rule,have a severe form of consti- tutional symptoms. As there is no diphtperia,there is no albumen in the urine. -DURATION.-Four to seven days. -DIFFERENTIAL DIAGNOSIS.-From diphtheria is not easy,and if diph- theria have prevailed in the neighborhood,the difficulty is in- creased. Sometimes,you cannot deci>e for a week and,in these cases, it is better to say that the patient has aMdiphthere tie sore throat1 which will be a correct diagnosis whichever the disease turns out to be. -TREATMENT.-Same as for the two preceding. This disease is characterized by the death and slaughing of con- siderable parts of the mucous membrane of the tonsil and the sub- stance of the tonsil. -ETIOLOGY.-It occurs as a complication in the exanthemata, an/ in epidemics. It may occur as an epidemic by itself. It is rare and has not been seen for years. It may be due to some special bacteria. It is a eonsti tutional disease. ♦ -SYMPTOMS.-Well marked., There are fever,prostration, restlessness, delirium,stupor,feeble heart action,and the patient soon Jies in a typhoid condition. -GANGRENOUS TONSILLITIS.- 111 -SUPPURATIVE TONSILLITIS.- The inflammation involves not only the mucous membrane but the connective tissue stroma as well. An abcess is formed. First,we have the congestion and swelling: then,the emigration of the white corpuscles and the exudation of serum-, and then, the necrosis of tissue. -ETIOLOGY^- The disease is very common. Some people seem to have a special predisposition towards it. They will have a number of attacks. It seems to run in families. Exposure to cold and wet is the exciting cause. -CONSTITUTIONAL SYMPTOMS.-These are the same as for an abcess in any other part of the body. They are rigors:fever,which varies in intensity-, headache: disturbance of the stomach:pains: and prostration. As a rule,they precede the local symptoms. LOCAL SYMPTOMS.- These are well marked. As a rule,but one tonsil is inflamed at a time. Generally, the inflammation of the stroma, is the first change but,often,the patient has a catarrhal tonsil- litis first. This modifies the prognosis of catarrhal tonsillitis? it may run on to suppuration. As soon as suppuration has begun, the tonsil increases rapidly in size and becomes very large. It will push the soft palate forward and can be appreciated on the outside of the neck. You will not be able to see the back of the pharynx. With the suppurative inf lamination, there is also a catarrhal .inflammation of the pharynx and tonsil 112 This produces a large quantity of mucus which troubles the patient very much. Sometimes he will have to spit all the time and the mucus will run out of the corners of his mouth. The swelling is attended with a good deal of pain.Swallowing is peinful and dif- ficult. As a rule, the breathing is not affected,but there are two excep- tions to this. In the first place,the inflammatioi may invade the upper part of the larynx ana,by causing oedema giottinis,produce dyspnoea. In the second place,both tonsils may become affected at the same time and,as they are much enlarged,only a very small chink m^y he left between them$now,if the uvula become inflamed it the same time,it may readily block up this chink and alarming dyspnoea will result. -DURATION.-If only one tonsil be inflamed,the disease usually lasts but for one week. The abcess then breaks by itself and gr^e&t re- lief is given. As a rule, the tonsil is largest just before it/ ruptures.Sometimes the disease runs its course in one tonsil unh when this is getting well,the other will be attacked. In some convalescence does not go on well.The abcess breaks,hut the acute suppuration is followed by a chronic suppuration ant the case nitty last for a number of Jays longer. 113 -PROGNOSIS.- As a rule the prognosis is perfectly good. The only danger is the obstruction to the breathing cited above. If we see the patient early,we may try to abort the disease. For this purpose,we may give calomel in large doses,grs.x-grs.xx re- peated at the end of twelve hours. With the calomel,a moderate amount of opium should be given If you fail,there is danger of salivating the patient. For the same purpose,we may give the tincture of aconite in small and repeated doses,m. j every fifteen minutes# The patient must be watched. Instead,you may give the salicylate of sndium,grs.x-grs.xx every hour. With this drug,you will do no harm. The application of decided and continuous cold to the side of the neck by means of rags wrung out in ice water or by the rubber coil is of service in aborting this disease. After the invasion,we roust remember that we have an abcess to treat. We must apply heat to the neck by means of poultices and, to the throat,by means of the vapor of hot water. The excessive quantity of mucus can be removed by astringent gargles and sprays. To relieve the pain and discomfort,give opium at night. When the abcess is fairly formed,do not be in too- much of a hurry to open it. If you open it too early,you relieve the patient for about an hour: then,the abcess forms again and the patient is just as badly off as he was before. In fact,he suffers more. If you intend 114 to open the abeess at all,always wait until you see a yellowish point projecting from beneath the soft palate. I believe in let- ting it break. If the patient suffer from dyspnoea due to the swel- ling of the uvula,make a free incision into it in order to reduce the swelling or cut off a piece. If the dyspnoea be due to oedema of the glottis,scarify the glottis. 115 -DISEASES OF THE LARYNX.- The larynx is capable of a. spasmodic contraction which may,more or less completely,close the chink of the glottis. This spasmodic contraction is called- -LARYNGISMJS STRIDULUS. - This disease is more common in children than in adults. In chil- dren there are two varieties. -First form.-There is a sudden and complete closure of the glottic which only lasts a few minutes,or rather,seconds. While it lasts, the child makes no effort to overcome it. Then the glottis sudden- ly opens. This form belongs especially to feeble and rickity chil- dren,and to the children of the poor. These children,during most of the time,exhibit no laryngeal symptoms at all,but,every once in a while,from some slight nervous impression,they stop breath- ing altogether and look as though they were dead. The skin becomes cold,there is more or less rigidity,there may be convulsions,and it looks more and more as if they were going to die. Then,after a short time, the child takes a deep,noisy,inspiration and. appears natural again.The rule is that these attacks are not fatal. Still, it is perfectly possible that a child may die in one. 116 -TREATMENT*-This is partly preventative. Improve the general health. 'Give iron,<uinina,and cod-liver oil. During an at taclr, introduce c tube# This is only necessary in prolonged eases. Any small tube., such as a catheter, either rubber or silver,will do. instant relief is given. The second form is more common. It belongs exclusively to children, and is often called11 spasmodic croup®. There is not a complete clo- sure of the glottis. The child does not stop breathing but fights against the dyspnoea. Expiration and inspiration are' both affec- ted. -ETIOLOGY.-It usually occurs in children under three years of age. All classes are equally liable to it. Indigestion is the most common cause. We know of no other. There is a predisposition to it in certain children,and it seems to run in families. -SYMPTOMS.-There are none until the time of the attack* The attacks usually occur in the night,and generally,about midnight or one A.M. The child will have well marked dyspnoea and looks as though he were going to die. The dyspnoea may last for several hours, as a result we have venous congestion,and this and the dyspnoea are the only symptoms. 117 These frighten the young practitioner very much but, no matter how ill the child may seem.as a rule,he does not die. In fact,I doubt if a child ever dies of this disease. -TREATMENT.-Give an emetic and a prompt emetic. You may give grs.iij- grs.v of the yellow subsulphate of mercury,apomorphine in small doses,ipecac although it is not very good,mustard and warm water, molasses and sweet oil,or you may tickle the pharynx with a feather. As a rule,as soon as the child vomits,he experiences great relief and,the next day,he is perfectly well. -INFLAMMATIONS OF THE LARYNX. - 1-ACUTE CATARRHAL LARYNGITIS., 2-CROUPOUS LARYNGITIS.- 1-ACUTE CATARRHAL LARYNGITIS. -PATHOLOGY- The lesion is just the same as in an acute catarrhal inflammation of any mucous membrane. We have the congestion,swel- ling, dryness, and excessive production of mucus. The structure of the larynx makes the swelling a matter of considerable importance for,as the mucous membrane swells,the chink of the glottis becomes narrowed. The dryness is also of importance for the mucous membrane of the larynx remains dry for a considerable time. The period of 118 dryness lasts from one to three days. When the excessive product* ion of mucus comes on,the congestion and swelling begin to subside* This is of practical importance. It is important to remember that acute catarrhal laryngitis rarely occurs by itself. There is gener- ally associated with it an inflammation of the trachea, bronchi^ pharynx,or tonsils. However,the laryngitis,itself is the most se- vere lesion. -ETIOLOGY.-Although it is not rare in adults,the disease is more common in children. It runs in families. Some seem to have a nat- ural predisposition towards it. In adults,it may occur as an idio- pathic condition. It may be caused by the inhalation of hot smoke or steem or by exposure to cold. It may accompany syphilis,phthisis, and the exanthemata. The whole group of infectious diseases may be complicated by it. It occurs with hay fever. In adults,the most common cases are'the idiopathic. - IN ADULTS.- There is often no fever and it is only present when the disease-' is very severe. Although there be no fever,the condition of the- patient is not good. There are loss of apetite,prostration,etc.1 Local symptoms are manifested by pain and cough and changes in the voice and breathing. The cough is at first dry and stridulous. The breathing is the breathing of laryngeal dyspnoea. While the 119 mucous membrane of the larynx remai.'S dry, the cr-ugh and breathing hive a"crr-upyDsound. When the excessive production of mucus takes place, they sound looser. The voice has the same harsh, stridulous character. It may be al- most lost. Generally speaking,when the voice is lost,it cenotes a bad case. The pain is referred directly to the larynx and varies in severit The dyspnoea is continuous but from time to time it gets worse. This is iue to an increased swelling of the mucous membrane. This increased swelling may subside within an hour am then the dysp- noea will bo no worse than it was before. As long as the patient struggles against the dyspnoea,there is no particular ranger but, sometimes,when it gets worse,he will stop breathing, as a rule, he then oies. This is the only real danger and,in the severer eases,you must always be on the look out for it. -TREATMENT.- The treatment consists in applications made tn the cutside and to the inside of the larynx^in the use of drugs,and in mechanically overcoming the obstruction to the breathing. The best local application that I know of is a i^rge sponge wrung nut in hot water. This is exceedingly efficacious. Internal eppl^ cations are best effected by the inhalation of steam. 120 Drugs.-We use drugs,in the first place,to exert an influence on the inf lamination: in the second place, to make the patient more com- fortable. With the first object,we give drugs which produce an increased secretion of mucus, tartar emetic gr. 1/WO frequently repeated,jaborandi,muriate of pilocarpine gr. 1/12-gr^ 1/10 fre- quently repeated,or ipecac although it is not very reliable. For the second objective* give opium in small doses. When the pase is severe,look out for death from apnoea. See the patient frequently and have a careful nurse. When the dyspnoea seems at all formidable,you must stay. When apnoea threatens, tracheotomy or intubation are the methods to be adopted. Intubation is tn be preferred. -IN CHILDREN.- The disease is much mare common in children and it is often called croup0. It occurs most frequently between the ages of one and five years. The predisposition in children and in families.is well marked.. Most of the cases are primary but it also complicates measles and All tl^e ?i.eases that it has been mentioned as compli- cating in adults. The lesion is exactly the same as in adults. -SYMPTOMS.-For local symptoms,we have dyspnoea,cough,and changes in the voice and in the breathing. The continuous laryngeal dysp- noea presents the same characters as in adults but,when it gets 121 worse,it resembles laryngismus stridulus. The exacerbations of the dyspnoea are due to a spasmodic contraction of the larynx. There is not the same ranger of death from apnoea the t there is in adult* for,however feebly the child may breathe,he never entirely ceases to do so. The other lrcal symptoms present the same characters as in adults. CONSTITUTIONAL SYMPTOMS.- Fever is the principal one. It is very but net absolutely constant. There is more or less prostration. Generally, the prostration -'o-s not amount to much and the sick appearance of the child is uue ta the fever. In some cases,the fever precedes the local symptoms but it may follow the local symp- toms or appear at the same time. The invasion is often sudden and the disease may begin with dyspnoea and laryngismus stridulus. At other times,the invasion will be gradual. The child will have a cold first nr the disease may begin with cough and a little dysp| noea in the morning and,at night,the symptoms will be decided, host cases run a pretty regular course r f three nights and the intervening lays and either begin in the afternoon or night. During the first night,the child is not very badly off. The fever may be absent. It is apt to be worst at three a.M. . During the first day,the child will seer pretty well and will con- tinue so until afternoon when the symptoms vill cope on again. The second night is apt to be the worst. All the symptoms are 122 decided. During the secant 4uy,the symptoms abate more or less and he is pretty well. During the third niRht he is again worse but not as badly off as on the second night. On the third day we have convalescence. This is the regular course of the disease and its course is very re;<ular. -PROGNOSIS.-The disease is not at all fatal. The child is often made very sick by the physician. He will get well if you will only give him a chance to do so. -TREATMENT.-Vapors.-,purging,poultices,an** local applications are all unnecessary. During the restless nights give opium to quiet the pstient. Give gr. l/loo of tarter emetic,frequently repeated,to he sten the production of mucus. If you can Ret good wine of anti- mony it is the best thing you can give,give from gtts.v-gtts.xx- every half,one,or two hours. If you have laryngismus stridulus give a rapid emetic. During the day,do not give any medicine. This is all that is necessary. In some cases,the disease is unusually protracted. They get better at the regular time but do not get entirely well. They still have a cough ant excessive production of mucus. In these cases give calomel,in one half grain deses,three or four times a day,small doses of quinine,belladonna and salicin,an* perhaps a little opium. Give an astringent gargle and keep them in the house. In some the "isease is followed by & mill or severe bronchitis or1 by a broncho- pneumonia. 123 -1- CROUPOUS LARYNGITIS.- The lesion has the regular character of a croupous inflammation of any mucous membrane.At first,there is congestion and swelling,after several hours,emigration of the white blood corpuscles,necrosis of the epithelial cells,the formation of fibrin,and a false mem- brane is formed in the regular way.Such a false membrane narrows the chink of the glottis even more than does a catarrhal inflamma- tion.As in catarrhal laryngitis,the mucous membrane of the pharynx and bronchi is also inflamed.If it involve the bronchi within the lungs,we will have a broncho-pneumonia.This last consideration renders the disease more serious. -ETIOLOGY.-Most of the cases occur as the characteristic lesion in diphtheria.These we are not considering.We also have it occuring without diphtheria. In adults it is rare except as following the inhalation of hot smoke or as accompanying the infectious diseases. In children,it may occur from the same causes but,in addition, it may follow exposure to cold or may be idiopathic.lt is difficult to tell the precise age at which children are liable to idiopathic croupous laryngitis for we get the disease mixed up with diphtheria 'but,apparently,it occurs most frequently at two years of age. It is most common among the poorer elasses^during the winter months, and in cold and wet weather. 124 -SYMPTOMS IN CHILDREN. - We may have the fever first, the laryngeal symptoms first, or both together,. Frequently, it comes on in the afternoon,evening,or night. It may come on suddenly or gradually. There is the same change in the voice and breathing as in catarr- hal laryngitis. When the disease has once begun,the child «ets steadily worse,the dyspnoea produces venous congestion, the heart becomes rapid and feeble,and the child looks sicker and sicker. It often happens that there are very short intervals of improve- ment. Now come cerebral symptoms,the result of the venous congest- ion. We have stupor and delirium and the child becomes unconscious and dies. If the inflammation involve the trachea or lungs,the child will die of a broncho-pneumonia. In most cases,the dyspnoea continues till death. Occasionally,the child does not struggle against the dyspnoea, and,unless you watch him carefully,you may be misled. There may be no apparent dyspnoea. The child may lie in bed very quietly and,yet,the respiratory movement may be very imperfectly performed. -DURATION.- The duration is from four to six days. There are rap- id eases lasting but twenty-four hours. -PROGNOSIS.-Rad. The younger the child,the worse it is. -TREATMENT.- The treatment is unsatisfactory. We really do not know of any drug that has a direct influence on a croupous inflam mat ion tf a mucous membrane. Feed and nurse the child. 125 Quiet the rettlessness with opium. For the laryngitis,we may make either hot or cold applications to the neck or we may make the patient breathe air saturated with moisture in order to hasten the desquammation of the false membrane. As to dru&s,we are very much at sea. We may give antimony but it is of little value,we may give mercury in small doses hut I think it must be confessed that neither give good results. I do not know of anything else. When the obstruction to respiration becomes alarming,we may perform tracheotomy or intubation. Tracheotomy does pretty well in the older children but I think intubation is to be preferred. Of course,in either case,you will only be success- ful when the inflammation does not involve the trachea or bronchi. 126 -INFLAMMATORY lesions of the pleura and lungs.- We have to consider in detail the different -PHYSICAL SIGNS.- These aid us in making a diagnosis and it should be borne in wind that,while they are a great help, too much reliance should, not. be placed upon them. -PERCUSSION.- Ry percussing the chest, we get six different kinds of notes. These are normal pulmonary resonance,dulness,flatness, tympanitie resonance,cracked-pot sound,and amphoric resonance. These differ in quality,intensity,pitch,and duration. It is ab- solutely necessary to be able to distinguish between these dif- ferent physical signs and,with practice it is easy to do so. By the quality,we mean the peculiar character that belongs to a particular sound and does not belong to any other. By pitch? mean whether it is high or low. Ry intensity,we mean its loudness. ,n..। ■ mm -i.iti. • 'i -i-i ■nun. - WBIWW**'''- By duration,we mean how long it lasts. Although a verbal description of these sounds must of necessity be very unsatisfactory,it is certainly necessary. 127 -Normal pulmonary resonance.- The quality is pulmonary. The pitch is low. The duration is considerable. The intensity varies. We expect to get this over* the healthy lung where the ether viscera do &ot intervene between the lunf< and the chest wall. •fulness.-The quality is dull,or altered pulmonary resonance. The pitch is higher than that of normal pulmonary resonance. This is important. The duration is shorter. This is also important. The intensity is not as great. Such dulness,we get in the normal chest wherever bone and muscle are superimposed,as ever the scapula* We also get it where the viscera are in contact with the lungs. The number of diseased conditions that may produce it is consid- erable. We get whenever the spleen,liver,or heart is enlarged. We get it with tumors of the lungs,with moderate consolidation of the lung,and with some cases of emphysema. Aneurisms of the thoracic aorta and abeesses of the pleura and mediastinum will produce dulness. -Flatness.-The quality is flat. The pitch is higher than that nf dulness. The duration is short. The intensity is not great. We get it over the liver and over the heart if the heart be very much enlarged. As a rule,very thick pleuritic adhesions and fluid in the pleural cavity give it. Tumors of the pleura give it. If the lung be completely consolidated and much enlarged,we may get flat- ness. Consolidation with a moderate degree of enlargement gives dulness. The sudden and complete occlusion of the bronchi will rive flatness* 128 -Tympanitic resonance.-The quality is tympanitic, - The type is found over the stomach and intestines. The pitch may be high or low. The duration is considerable. The intensity is very consid- erable. We do not get it over the .normal chest except when the. Dtomach lies behind the ribs. Air in the pleural cavity will give it. Large cavities in the lung will give it. We get it when the lung is altered in texture as,for example,when it is solidified/ A moderate number of cases of emphysema give it,particularly those with the "barrel chest0. Cracked-pot "sound.- This is a variety of tympanitic. It has a pe- culiar metallic quality like the chinking of metal. It is not very loud. It has no great duration. The pitch may be high or low. We get it over empty cavities and over compressed and con- solidated lung. Amphoric.-The quality is amphoric and resembles the tympanitic but it is easily distinguished from tympanitic resonance. The pit^h is low. The duration is considerable. The intensity is mod- erate. 'We get it over air in the pleural cavity. The respiratory murmur has to be divided into inspiration and ex- piration. When we listen to the normal chest, we find that inspir- ation is longer than expiration,of low pitch.,and distinctly au- dible. THE BREATHING. 129 -Normal pulmonary breathing.- Expiration is shorter,its pitch is lower,and its intensity is less than that of inspiration. In the diseased chest,we may get six pathological modifications of the breathing. These are bronchial,broncho-vesicular,cavernous, amphoric,sibilant,and sonorous breathing. Bronchial breathing.-The quality of.the expiration is bronchial* The pitch is higher than in normal pulmonary breathing. The inten- city varies. Expiration is longer and higher than in normal breath- ing. Sometimes, bronchial breathing is very loud but it need not necessarily be so. We get it regularly over compressed and con- solidated lung and over cavities and it is fairly characteristic o f the s e c ond i t i ons. When the trachea and larger bronchi are compressed,we get a breathing which very much resembles bronchial. It is often caused "by aneurisms of the aorta. The quality is a little different. The pitch is a little higher,expiration is a little longer,and it can readily be diagnosed from the ordinary bronchial breathing. Broncho-vesicular breathing.-This is a breathing which is not ex- actly bronchial and which is not exactly vesicular but which is something between the two. Expiration is longer and higher pitched than in normal breathing. We get it over the normal chest beneath the right clavicle and upper part of the inter-scapular resinm We get it over partly compressed and partly consolidated lung. 130 rCavemous,-The quality is cavernous. The pitch is low. Expiration is longer and lower pitched than inspiration.. We get it over eav>* ities and over compressed and consolidated lung. Amphoric breathing.-This is a variety of cavernous. The quality is amphoric. The pitch is low. Expiration is low and long. We get it over large cavities and when there is air in the pleural cavity and openings in the pleura. If the left lung be consolidated and you listen at its lower part,yeu may get amphor- ic breathing.This is due to the stomach being full of gas and pressing up the lung. This very often happens. -Sibilant.-The quality is sibilant. The pitch is high. The inten- sity is well marked.Expiration is long and high pitched. Sonorous.-The pitch is low. The intensity is considerable.. Expir- ation is prolonged. Both sibilant and sonorous breathing are due to a narrowing of the bronchi within the lungs. We get them with asthma and with acute and chronic bronchitis.They present well-marked characters and should not be mistaken for anything else. Rales are never heard over the healthy lung. They denote disease of the lung or pleura. The varieties of rales are crepitant,sub- crepitant,mucous or coarse,and gurgling. -RALES.- 131 Crepitant.- The crepitant rale is a fine,dry,orackling sound which is only heard at the end. of inspiration. It occurs in sort of puffs It is superficial in character. This is important to remember. It sounds as if it were in the chest wail just beneath your ear. We get it in dry pleurisy,pneumonia,and phthisis. In pneumonia and phthisis,it is probably produced in the pleura,not in the lung. -Sub-crepitant.- The sub-crepitant rale is fine but not as fine as the crepitant. It is more moist. It is heard both in inspir- ation and expiration. We get it in pleurisy,bronchitis,pneumonia, phthisis,and oedema of the lung. It may be produced in one of two ways. In the first place,it may be due to the rubbing of two rough- ened pleuritic surfaces together. In the second place,it can be produced in the lung itself where it may either be due to the presence of inflammatory products as in bronchitis,or to the pres- ence of serum as in oedema of the lung. -Mucous,or coarse.- The mucous rale is loud. Sometimes,it seems to be at a little distance. It may be produced when the pleura is roughened with fibrin. It may be produced in the lung when the larger and medium-sized bronchi are filled with inflammatory products. We get it in pneumonia,bronchitis and phthisis. -Gurgling.-The gurgling rales have a peculiar gurgling sound. They are due to small cavities in the lung. This cause is very constant. 132 They may be heard over compressed lung and are sometimes produced by pleuritic adhesions that have become infiltrated with serum. If you consider rales in this way,it is only necessary to bear in mind one friction sound.. This is a rubbing',grazing sound heard over the pleura in pleurisy and over the pericardium in pericar- ditis. When you suspect lung trouble, the changes in the voice as heard through the chest wall form voluble physical signs. You put your ear to the chest and tell the patient to count. This appears easy but it is really most difficult for it is hard to leave out of account the sound of his words as they pass into the air. Always use the double stethoscope. -Normal pulmonary voice.« It is feeble* The quality is pulmonary. The pitch is low. The thrill communicated to the chest wall is not tJ, all marked. In those parts of the chest where we get broncho- vesicular breathing,the normal voice is a little different. It is louder,higher,and its quality is not so distinctly pulmonary. The thrill is more marked. In diseased conditions,we may have eight modifications of the voi*e. These are increased vocal resonance,diminished vocal reson- ance ,suppressed vocal resonance,bronchophony,aegophony,cavernous, amphori c, and 'pec t o ri 1 lant. -THE VOICES - 133 -Increased vocal resonance.-It is louder and higher and the thrill is more marked than in the normal voice. We get it over compressed and consolidated lung and over cavities. Some times, we have it with emphysema . -Diminished vocal resonance.-It is weak. The thrill is diminished. We get it over small pleuritic effusions,over consolidated lung, and,sometimes,when the bronchi are obstructed. -Suppressed vocal resonance.- We get this when there is fluid in the pleural cavity. Some tumors give it and we also get it i i some cases of obstructed bronchi and consolidated lung. -Broneophony.-Thiv presents the same qualities as bronchial breath- ing. The pitch is high and the intensity and thrill are variable. -Aegophony.-This is a modification of the preceding and differs only in quality. It is important. Vvhen there is fluid in the pleural cavity,we hear it just at the level of the fluid. We also hear it over compressed lung. -Cavernous.-The quality is cavernous. We get it over cavities. -Amphoric.-We get this over cavities or when there is air in the pleural cavity. -Pectorillant.-We get this over cavities. We hear the actual words. It can be heard over compressed lung. 134 -INFLAMMATIONS OF TH* PLEURA.- -1-PLEURISY WITH THE PRODUCTION nF FIBRIN.- -2-PLFURISY WITH THE PRODUCTION OF FIBRIN AND SERUM.- -3-PLEURISY WITH THE PRODUCTION OF FIBRIN, SERUMS AND PUS.- -4-PLEURISY WITH THE PRODUCTION OF CONNECTIVE TISSUE.- -5 -TUBERCULAR PLEURISY. - -1-&-2- -WITH THE PRODUCTION OF FIBRIN AND OF FIBRIN AND SERUM. - -PATHOLOGY.-In anatomical characters,these t«ro are almost identical and,as they only differ by the presence of serum, they ivill be de- scribed together. The inflamed portion is congested. The endothelial cells fall off in patches, very soon comes the production of fibrin and,if serum be produced,it qrill appear at the same time. At first,both are formed in small quantities. At first,the fibrin gives a roughened appearance to the pleura. The serum does nnt infiltrate the i-ub- ctance of the pleura but goes to the bottom of the pleural cavity. The tissue of the pleura,therefor,does not suffer much change. 135 Then there is a growth of connective tissue cells ana an emigration of the white blood corpuscles. These pass to the layer of fibrin on the surface of the pleura and,when the disease is fairly ad- vanced,you can peel off this layer of fibrin,pus,and new connective tissue cells. The pleuua beneath presents very few changes- As the disease goes on,the layer covers both the costal and pulmonary pleurae and,these becoming fused together form ad- hesions. At first,these adhesions are formed of fibrin only. The pleurae may remain in this condition for a long time and the patient may die. If the disease run its full course,the serum and fibrin are taken up by the lymphatics and disappear. The pus cells are also taken up. A certain number of the connective tissue cells are taken up in the same way,but others remain. Those that remain continue to grow. A basement substance is formed between them. This basement substance is penetrated by blood-vessels and,when the patient recovers,the pleura is left thickened by connective tissue adhesions. The regular disposition of these forms of pleurisy to connective tissue adhesions is very important. When the patient recovers,layers of connective tissue are left on the surface of the pleura and adhesions are formed between its pulmonary and costal layers. 136 Th* recovery,therefor,is only partial,not entire. The adhesions remain and are always capable of giving trouble at a later period. The anatomical eharactex-. of these tvn forms ht? now been given and it will be necessary to consider their clinical features separately. -1-WITH the: PRODUCTION OF FIBRIN alone. - -DRY OR ACUTE PLEURISY.- The part of the pleura in which this disease begins,varies with the cause, as a rule,only a moderate area of the pleura is inflam- ed. Sometimes a space not more than two inches in diameter is attacked. It is possible,however,for the disease to involve all of one side of the chest. As a rule,the fibrin is not produced in very great quantity. It may,however,fill one half or two thirds of the pleural cavity and, thus, compress the lung. 'Fortunately, these eases are rare. -ETIOLOGY.-Exposure to cold-,punctured wounds of the chest,broken ribs,and inflammation of the lungs and peritoneum. The infectious diseases and Aright's disease are frequently complicated by it. host eases occur from exposure tn cold and as i complication of Bright's disease.In regard tn exposure to cold,some have a manifest disposition toward it and a slight exposure will bring it on. 137 ^PHYSICAL SIGN'S. -There is «. friction sound having the chc-rioter of a crepitant,sub-crepitant,or course ruleor simply of the rub- bing sounds produced by roughened surfaces. This is heared over the particular part which is inflamed and,as this portion is not large, you have to examine the whole chest very carefully. The friction sound is not present till the time nor is it present when the patient breathes quietly. Tn bring it out,make the patient cough or take two or three long breaths. If the inflamed portion be situated in the mediastinal or diaphragmatic pleurae,the friction sound will be too deep to be appreciated. In some eases,there will be dulness on percussion. It is not very marked. It is especially apt tn be present if the patient have had previous attacks. The presence of dulness is important to remember,for we get these same two signs in lobar pneumonia. -CLINICAL HI 8 TORY .r -Very mild cases.-These are very common. There are only two rational symptoms. These are pain and prostration or a feelins' of indis- position. The pain is usually referred to the inflamed portion of the pleura. This,however,is not invariable. The patient may locate the pain at a little distance from the seat oi inflammation. The prostration does not amount tn much. Those of the laboring classes go on working.Those of the upper classes continue to attend to business. Others give in and gn to bed. 138 The duration of the milder cases is usually one week or less. The disease may last for a month before the patient recovers. **More severe eases.-Beside pain and prostration we here have fever, headache,loss of appetite,and sometimes vomiting and pain in the back and limbs.There will often be a soft,dry cough without expec- toration. The attack will last for several days and then the con- stitutional symptoms will subside. The friction sound will last longer. The patient then recovers. These two sets of eases repre- sent the ordinary course of the disease and are very,very common. -Severe cases.--These resemble lobar pneumonia. The pain, fever, prostration,and headache are well marked and the patient looks sick. He is confined to bed for a week or two. The patient usually recovers but he may die. A fatal termination is extremely rare,as is also the occurence of these severe cases. -PROGNOSIS.-As a rule,perfectly good as fur as that attack is con- cerned. We must remember,however, that the patient gets well with a damaged pleura and,if he have a number of attacks, the pleura will be very much damaged. In many eases,this extensive damage will do no harm,the patient will feel that there is a difference between the two sides of the chest and that is all. In other case^, the patient will have trouble,he will develop a pleurisy with adhe- sions,an interstitial pneumonia,nr a bronchitis and he will become an invalid. 139 - TREATMENT. -No matter how mild the cane may be,put the patient to bed. In the mild eases,you do not have to do much more. Give a little opium and employ a little counter-irritation over the inflam- ed part of the pleura. As soon as the friction sound shall have disappeared,let the patient go out. In the more severe cases,put the patient to bed,give opium, to re- lieve the pain,aconite for the fever and calomel for the inflam- matory process. Counter-irritation is plainly indicated. If the patient is strong,use wet or dry cups or large blisters pretty thoroughly applied in order to produce an effusion of serum in the sub-cutaneous connective tissue. This is all that it is neces- sary to do till the friction sound disappears. -2-PLEURISY WITH THE PRODUCTION OF SERUM AND FIBRIN,- SUB-ACUTE PLEURISY,OR PLEURISY WITH EFFUSION. This disease is very common. The rule is that nearly the whole of the costal pleura and with it the other pleurae on one side of the chest become inflamed. Less frequently,both sides of the chest are affected. When this is the case, in ninety-nine cases out of every hundred, there is an accompanying pericarditis. In most cases, when the disease is fairly developed,there is serum in the pleural cavity and fibrin is found between the costal and pulmonary pleurae and upon the surface of the costal pleura. 140 There is always an appreciable amount nf serum which,in the erect pcsture,collects at the bottom of the pleural cavity and presses the lung upward and against the vertebral column. When the patient lies upon his back,the serum will collect at the back ^art of the pleural cavity and the lung will float forward. As a rule,there is enough serun present to appreciably change its position with the postuwdt of the patient. However, the pleural cavity may be com* ' pletely . • '"'filled with fluid and the lung will be complete- ly compressed. Then,the fluid will not change its position when you tilt the patient. It sometimes happens that the adhesions between the pleural layers divide the cavity into sacs. When this is the case,the fluid is said to be sacculated.This is comparative- ly rare. If the patient die in the middle of the disease,we find all these changes. If he recover,first the serum and then the / fibrin are entirely taken up by the lymphatics and the connective tissue adhesions alone are left.So the patient recovers with a damaged pleura and the pleura is much more damaged than in pleu- risy with effusion. -ETIOLOGY,-The causes are exactly the same as those of dry pleurisy. Most of the cases are due to exposure to cold or follow Bright's disease. * -PHYSICAL SIGNS.-These are the same in all cases although the ration- al symptoms may vary as will be hereafter stated. At the commencement of the disease when the pleura is roughened 141 and the serum is present in small quantity,you will get the frict- ion sound of dry pleurisy. As the serum increases in quantity,the friction sound will disappear but will return when the serum is being absorbed and the patient is getting well. When the chest is partly or completely filled with serum,we get signs due to the presence of fluii and to compression of the lung. 'Below the level of the fluid,we get flatness and absence, of voice ; and absence of breathing. At the level of the fluid,we get dulness and aegophony. Above the level of the fluid,the percussion note may remain nor- mal or be of an exaggerated high pitch or tympanitic. The breath- ing *may be pulmonary,exaggerated pulmonary,broncho-vesicular,or branchial according to the degree of compression of the lung. If the serum be present in considerably quantity,one side of the chest will be distended. If it be in still greater quantity,the intercostal spaces will be bulged out. This is r«re. The diaphragm may be pushed downward and the heart may be displaced according to the location of the fluid. 'When the fluid is situated at the bottom of the pleural cavity,it is better to examine the chest behind. There are exceptions to these regular physical signs and these exceptions are very common. Thus,below the fluid,the vocal fremitus may be present,there may be bronchial voice and bronchial breathing. 142 The bronchial voice may be present without the bronchial breathing* Absve the fluid,we may have cavernous breathing and gurgling rale Generally heard in the inter-clavicular region. If the fluid oc- cupy the posterior part of the thorax,we will get no special change over the anterior surface but behind we will get the signs. If the fluid be sacculated,it may be in an abnormal position and we may get the evidence of its presence in front with dulness be- low the clavicle. These sacculated eases are very difficult to diagnose. -RATIONAL SYMPTOMS AND CLINICAL HISTORY- We may divide the cases into two classes,those that are acute and those that are sub-acute. -Acute.-The acuteness is especially manifested in the invasion and during the first days of the disease. The invasion is the same as that of lobar pneumonia. I do not think that it is possible to distinguish between the two. The patient has rigors accompanied and followed by a febrile movement. The temperature runs up to 103,104,or 105. The pulse is full and regular,100-120. The patient has headache and pains in the back and limbs and over the affected portion of the pleura. There is a cough without expectoration. The breathing is frequent and shallow. The prostration is well marked. These acute symptoms may only last twenty-four hours or they may last over a week. Then they subside. The temperature fails rapidly to the normal,the pulse becomes less frequent,the other symptoms 143 subside and convalescence commences* Although the patient feels better,the products of inflammation still remain and it usually requires several weeks more for these to disappear. In fact,not infrequently,after the acute symptoms have subsidei,the products of inflammation remain for several months and the patient will exhibit sub-acute pleurisy. The pain is usually very severe. It is often referred to the inflamed portion of the pleura but as this inflamed part is very extensive,the part designated by the patient is apt to he varied. It may be referred to the upper ab- dominal region and may be mistaken for peritonitis. It may be refer! re4 to the lumbar region and may he mistaken for nephritic colic. If referred to the precordial region,it might be mistaken for pericarditis. These acute cases may terminate in one of three ways. The patient may die. This is rare. He may get well in a few weeks. He may develop sub-acute pleurisy. We have other1 acute cases in which the symptoms are not so well marked. The patient has some pain* fever, 101-102-, some shortness of breath-,and some prostration. Twenty-four hours after the invas- ion, the patient goes to bed but does not feel very sick. Now,the temperature is from. 99-102. The fever is usually higher in the afternoon. The patient may remain in this condition for a few weeks or for months. 144 "Sub-acute.-The invasion is very gradual. Indeed,it is often dif- ficult to tell when the disease began. The patient has some pain, not very severe in one side. He has slight dyspnoea and,sometimes, a dry cough.He loses flesh, and strength but he does not go to bed. He may continue at his work although his chest be two-thirds full of fluid. There may be no elevation of temperature or it may rise a little in the evening. The patient goes on for weeks and months getting worse and worse. The cases cited above exemplify the three ordinary courses of the disease. r If both sides of the chest be involved,the invasion is usually acute, there is regularly a pericarditis,the patient is seriously ill, and he usually dies- r-PROGNOSIS.-Most of the eases in which but one side of the chest is involved,do fairly well. Most recover but the recovery is often very slow. The serum may remain for a long time and may even re- turn after going away. In some eases,the disease will go on to the production of pus. Then,the patient will have empyema. A few die suddenly. This is comparatively uncommon. It is not easy to say why they die suddenly. After death,some show a congestion of the other lung: others a great displacement of the heart:but others show no changes to account for death. You must not take too favorable a view of pleurisy 'with effusion. There is always a good deal of 145 damage left. The extent of damage varies with the duration of the disease and the quantity of serum effused. In the worst eases, the lung that has been compressed by the fluid remains covered with adhesions and never returns to its proper size. As a result, the wall of the thorax falls in and a permanent deformity results. The healthy lung will become the seat of a compensating emphysema and,becoming larger,will contrast greatly in size with the lung that was compressed. The patient is always liable to pleurisy with adhesions,chronic bronchitis,and interstitial pneumonia but these are rare. When the disease has attacked the left side of the chest and. the heart has been pushed to the right,when the fluid, disap- pears, the heart often returns to its normal position but,sometimes, it remains on the right side. When the right side has been attack- ed<and the heart has been pushed to the left,when the serum has been absorbed,the right lung has become smaller,and the waal of the thorax has fallen in to fill up space,the heart may be per- manently pulled to the right side. -Differential diagnosis.-In many oases,the diagnosis is very easy but,in others,it is very difficult. You might mistake the disease for pneumonia,phthisis,or an abcess of the liver,or an intra- thoracic tumor. When in doubt,it is best to aspirate. This method of diagnosis is sure and can do no harm. Use a rather long and large needle. An ordinary hypodermic syringe will do. 146 -TREATMENT. - The treatment, varies with the stage -of the disease and with the character of the inflammatory process. In the early stages while the pleurisy is still aetive5use counter-irritation over the af- fected side,give opium to quiet the pain,and calomel to diminish the intensity of the inflammatory process. If the serum be present in sufficient quantity to cause dyspnoea,the only thing you can do is to aspirate? In the acute cases, the heart*s action may be- come so feeble as to require stimulants. Give alcohol and digital* is. Keep the patient in bed. When he has passed into the chronic condition,the inflammation is of a very low type and,if we can get rid of the serum,the pleurisy will get well by itself. If the pleural cavity be filly distended,it will be very dif- ficult to get rid of the fluid without operative measures. The lymphatics upon which we rely to abs»rb the fluid will he so com- pressed that they will not be able to take it up.Wait two days or a week and see if the fluid manifest any disposition to disap** pear.If it do not,you must aspirate. Remove a considerable quan- tity and,perhaps,the lymphatics will take up the rest. Aspirate from behind in the intercostal space below the inferior angle of the scapula. Never try to draw off all the fluid. Two or three aspirators full are sufficient. This,I think is very proper treat- ment but we must remember that it is accompanied by two dangers. In the first place,the patient may die twelve hours after aspiration. 147 I think this is largely dependant on the amount of fluid with - drawn but,even the withdrawal of a moderate amount of fluid has been followed by death. Many patients have died in this way but the cause of their death is unknown. The second danger is that the patient may develop empyema. The chance of this is lessened by keeping the aspirating needle clean. The danger is increased by frequent tapping. In spite of this,you sometimes have to tap very often. To If the chest be only moderately,say one-half full of fluid,get the patient out sf bed even if he have an even temperature of 100. Put him an ordinary diet even though he have an evening rise of temperature. If the appetite be poor,give tonics. In these eases in erner to get rid of the fluid,reduce the quantity of drink to a little less than a pint a day. If you do this,the patient will pass more than a pint of urine and the fluid will gradually dis- appear. This it will do in a comparatively short space of time. This plan of treatment often succeeds very nicely and will sur- prise you very much. Some patients are so anaemic that we have ^to use eounter-irritation,diuretics,and cathartics. To aspirate every patient is bad practice but,with the indications I have given,aspiration is good practice. 148 -PLEURISY WITH THE PRODUCTION OF SERUM,FIBRIN,AND PUS.- -EMPYEMA. - -PATHOLOGY.-Under this name, we include Wo forms of pleurisy. In both,pus is produced. They differ in the changes which are produced in the pleura,itself. This is very important. -First form.-The changes are exactly the same as those of pleu- risy with effusion with the exception that the serum, is mixed witfy pus. On the surface of the pleura, is a layer of pus and fibrin and,in the pleural cavity,there is serum mixed with pus. This form belongs especially to children and to young adults. -Second form,.-There is a layer of fibrin and pus on the surface of the pleura and in therpleural cavity, there is purulent serum,. Beneath the layer of fibrin, the pleura is infiltrated with cells.. The basement substance is split up by these ce&ls and the pleura ^resembles granulation tissue. Whichever form we have,the purulent serum may collect at the front or back of the pleural cavity or it may be sacculated. Sacculation is much more common in empyema than in pleurisy with effusion. In both forms,the lung is compressed. It may be pushed upward, downward,toward the vertebral column,or it may be held in differ- ent positions by adhesions. In the first form,we simply have this compression of the lung but, in the second form,the suppurative inflammation may extend to 149 th<? tissue of the lung itself,peefora tions may take place in the pulmonary pleura, the pus may enter the tissue of the lung and bronchi,and m<.;y he coughed up in considerable quantities. In the second form the pleura becomes much thickened and may be- come Coleified. In other cases,the inflammation may destroy the Parts of the pleura. An opening may be made through the walls of the chest and the pus may be discharged externally. In a small number of the second form,the pleura and the inflamma- tory products b- come gangrenous. The bacteria of putrefaction enter the pleural cavity and so set up death of tissue. Putrefac- tive gases will be evolved. -SYMPTOMS AMD CLINICAL HISTORY.-We will first consider those cases in which the disease is acute and occurs as a primary condition. A person having previously'been in good health,will be attacked with rigors,fever-10?-104-,prostration,pain in the back and limbs, vomiting,pain over the affected side,and decided difficulty in breathing. We listen at the chest and get a friction sound and evidences of fluid and compression of the lung. The symptoms may continue c ad the disease prove fatal in from one to three weeks^ having been acute throughout. In other cases thn disease will begin in an acute manner with the Simo symptoms c.s in the previous case, then the constitutional symp- toms will subside. 150 The temperature will fall,the prostration, will not be as marked, the patient will feel better,and,having passed into this condition of semi-recovery,may remain in it for weeks or years. The disease is then chronic. In these eases we may have either anatomical form. If the patient be young it is more apt to be of the first form,if an adult,of the second. In either case,the longer the disease continues,the more apt is it to be of the second form. If the disease begin as the first form,it may become the second. In other cases,the course of the disease is very different. The empyema is not a primary condition. The patient suffers at first from pleurisy with effusion but,instead of recovering or dying, the inflammation changes its character* Pus accumulates and there may be changes in the pleura itself. These are by far the most common cases. If the change in the character of the inflammation be sudden,there will be a sudden change in the patient* s condition. He will have rigors,will lose flesh and strength,will not eat as much as he did before,and will suddenly look much worse. If the change be gradual,you will hardly be able to tell on what particular day it began. The patient gets worse and worse,loses flesh and strength,the fever is e little higher each day,and there le sweating at night. 151 Whether the change be slowly oi' rapidly effected, the after condi- tion is apt to be chronic. The patient will rewain in this condi- tion for weeks or for years. The gangrenous cases begin as acute cases of empyema,or succeed an empyema following a pleurisy with effusion. The character of the inflammation is then changed by the bacteria,putrefaction is Quick- ly developed,the patient rapidly becomes worse,passes into the typhoid condition,and dies in a few days. These are the worst cases of empyema and,as far as I know,are always fatal. We shall now consider those cases that occur from external causey, such as perforating abcess of the thorax,abcess of the liver per- forating the diaphragm on the right side, other perfox'ating abdomi- nal abcesses,and abcesses or phthisical cavities perforating the pleura. In these cases, the symptoms win be acute. •-PHYSICAL SIGNS.- These are the same as those of pleurisy with effusion with the exception that the fluid is more apt to be sac- culated and,therefor,the disease is always more difficult to diag- nose. The course of the disease is sometimes acute but more often chronic. The patient is often not confined to bed although the pleural cavity my be one-quarter full of pus and the breathing done en- tirely by the other lung. 152 --PROGNOSIS.*-Bad.The gangrenous cases are the worst. The best cases are those that occur in young people in whom the pleura is not damaged. Of the acute cases,a certain number die quickly but,by far the greater number,become chronic and,if not treated,die. Recovery without treatment is possible in those cases in which the pleura is not involved but such recovery is rare* In those cases in which there is a communication between the bronchi and the pleural cavity,al though the patient coughs up some pus, he does not rid himself of much of it and,as a rule,he does not get better. When the pus is discharged externally,the perforation is usually situated in the lower part of the chest,between the axillary and mammary lines. Even when this takes place,the patient does not,as a rule,get better. The perforation does not exist all the time bu't frequently closer up. So, if the patients be left to themselves,they never,as-a rule,get better. The disease eventually proves fatal. Many patients die of phthisis,waxy degeneration of the liver,and kidney disorders. Some die of asthenia. 153 -DIFFERENTIAL DIAGNOSIS.-The diagnosis is often very easy but, in other eases,it is often very difficult. The disease is apt to be confounded with pneumonia,phthisis,and abcess of the liver. - From pneumonia.- The rational symptoms of the acute cases of empyema are,at first,the same as those of pneumonia, after fluid is produced,the diagnosis becomes easier. If any doubt exist,you may use the hypodermic needle but,remember,the fluid may be sac- culated, the adhesions may be very extensive,the pus may be very thick,and,consequently,you may get no fluid. If you fail to get any pus,do not give it up. Wait a, little while,and then try some- where else with a larger needle. You are warranted in trying a great many times. - From abcess of the liver.- An abcess of the right lobe of the liver will project up into the right pleural cavity and give the same physical signs as empyema. The rational symptoms may also be very much the same and the difficulties may be much increased by the patient having both conditions at once. The diagnosis is roly to be made out by <■ close observance of the rational symptoms. Sometimes we succeed, sometimes we fail,and, if we do fi.il,I do not think that we should feel very much ashamed of it. 154 - From chronic pulmonary phthisis.- I do not think that the two should ^ver be confounded# The way the mistake is made is this. We have an idea,when ^re look at the patient,, that he ought to have phthisis and,consequently,we do not make a careful examination. Sc -we fail through carelessness. I -have this mistake and think that it is very blamable. - TREATMENT.- - Acute eases.- First treat the general constitutional symptoms. When they have passed into the chronic condition,the indications for treatment vary with the anatomical form of the disease. If it be of the first form,you may be able to cure him by tonics and repeated aspirations. In judging of the anatomical form of the disease,we are guided principally by the age of the patient. If the patient be under fifteen years of age,the disease is apt to be of the first form. Even if he be old,if the pus it thin and his health good,the disease may be of. the first form. Get the patient out of bea and. out of the house if the weather be warm. For as- piration I prefer the troebar and canula. The first time you operate, do not remove more than a single aspirator-full. Wait a couple of days and then operate again and draw off more. Continue in this way at longer intervals and take off more and more each time. If the patient is to get well under this plan of treatment,he should do it within a month and it should never be continued lon- ger than this. 155 If this plan of treatment dn not succeed, the only thing to do is to make a permanent opening in the chest-wall. In the chronic second form of the disease,aspiration alone will not effect a cure. A permanent opening in the chest should he mtde. Let us imagine a case in which the left side is affected and you see the patient several months after the commencement of the disease. By this time,the patient may have begun to cough up pus. The heart will be pushed to the right, the diaphragm, downward, and the lung upward and the pus will occupy the lower part of the pleural cavity. It is better not to give an anaesthetic in these cases. Perform your operation under cocaine or the ether spray. It is better to have the patient sit up. First,with a hypodermic syringe,you make sure of the position of the pus. After waiting a day,you aspirate and draw off some of the pus. Then,a few days after this,you proceed to the operation. You choose for the site of the operation a point in the second intercostal space below the inferior angle of the scapula. First,use the hypodermic syringe for greeter surety and,having unscrewed the syringe,leave the needle in the thorax. Nfow make one plunge through the intercostal spa^e using the needle as a guide. Your incision should be two inches in length. Pass your finger into the wound and determine the po- sition of the lung and adhesions. 156 Then pass in a large steel sound and further determine the po- sition of the lung and the number of cavities. If you find that the cavity is not large,that it does not extend too far downward end forward,and if the empyema be not too old,one opening will dr. Pass in a drainage tube and cover it with an absorbent anti- septic dressing. In some eases, this is all that it will be neces- sary to do. The pus will be voided,the viscera will return to their proper places,and the patient will recover. However,if the cavity be large and the empyema old,it will be necessary to make a second opening. Make this second opening a little in front of the axil~X- lary line but not too near the heart. Pass a perforated drainage tube through the chest from the posterior opening through the an- terior. In this way,the fluid will more readily escape and you will be enabled to wash out the chest through a double opening. In ether cases,we have to resect 'a part of the ribs and allow the wall of the chest to fall in and fill up the cavity. I do not think th<. t more than, a portion nf two ribs should be excised. The re- sected portions should be at least four inches long. It often happens that one opening will relieve the patient up to a certain point and then he will cease tn improve. A second open- ing will then be made. The patient will continue to improve and then a^ain come tn a stand still, Then a part of the ribs will be removed. Whether one nr two openings be made nr whether a 157 a portion of the ribs be resected.the patient will always improve up to a certain point and,even if one opening alone be made,he may entirely recover. If,after you have made one opening,the pa- tient is no better at the end Tour weeks than he was at the end of one week,make another opening. If this be not followed by permanent recovery,resect a portion of the ribs. If you do not do this,the patient may die of phthisis or waxy degeneration of the viscera. -PLEURISY WITH THE PRODUCTION OF NEW CONNECTIVE TISSUE, - - PLEURISY WITH ADHESIONS.- Although this disease is comparatively common,it is not often described. - PATHOLOGY. -The lesion may involve one nr both sides of the chest. It is a chronic inflammation of the costal and pulmonary pleurae. The product is new connective tissue. Ther is no formation of serum, fibrin,or pus. The connective tissue cells,basement substance, and blood vessels are produced. The pleura is thickened,adhesions are formed,and the lung everywhere becomes adherent tn the wall of the chest. The disease is chronic from the outset. - ETIOLOGY. - It may follow a dry pleurisy,a pleurisy with effu- sion, or an empyema. The patient recovers from one of these diseases 158 then, some time afterward comes the chronic pleurisy with adhesions* It may begin as a primary inf lamination* ' In whatever way it begin-,at first it involves but a small portion of the pleura. Then,it extends on the side on which it began until it covers the whole of that side. The same thing happens on the other side until both lungs are adherent to the wall of the chest* When it has reached this stage,the lungs will be diminished in size:the heart will lie more in the median line than it should: and the liver,spleen,and kidneys may be smaller than they should be. The disease belongs to people beyond fifty years. - PHYSICAL SIGNS -We get some dulness on percussion over the af- fected parts. The breathing is diminished. Some times,you can scarcely hear it. Sometimes,we get sounds resembling sub-crepitant and coarse rales. These are due to pleuritic adhesions. We may get a friction sound. - RATIONAL SYMPTOMS AND CLINICAL HISTORY-At first, the symptoms are very trifling. It is not until a considerable amount of the pleura is involved that we really get symptoms. Then,the patient complains of a dull,intermittent pain,a certain amount of dyspnoea, ana a cough. At first,the dyspnoea is only manifested on exertion* The cough may be dry or,if chronic bronchitis be present at the same time,then may be expectoration. As the disease goes on,hese symptoms continue. The patient loses appetite and flesh and suffers from constant dyspnoea. The lungs bound down by adhesions,do not expand sufficiently. 159 The heart biomes more feeble. Now, these patients resemble ihose vr.th chronic miliary tuberculosis,chronic vehicular emphysema,QX- those with chronic bronchitis. The gradual emaciation is the m>st characteristic symptom. They slowly get worse and worse,month after month,year after year. - PROGNOSIS.-Most die of some intercurrent disease. Sometimes, they do go on to the termination of the disease and. this ter- mination is death. They die in great emaciation and exhaustion. - TREATMENT.- This is directed principally to the condition of the patient but,in addition,we may try to exert some influence on the disease. This may be done by counter-irritation which should be mild and should be kept up for some time. I hardly know whether this means be of any benifit or not. I always employ counter-irri- tation but,each time,I become more and more convinced of its in- efficiency. It will be found of more use to teach the patient a sort of pulmonary gymnastics. Twice or three times a day,let him exercise the lungs. At these times,let him take a series of full inspirations and expirations,or you may let him alternately breathe compressed anJ rarified air. These periods of pulmonary exercise should last about fifteen minutes. 160 - TUBERCULAR PLEURISY. - - PATHOLOGY.-By tubercular pleurisy,we do not mean every disease in which miliary tubercles are produced in the pleura. In many examples of general tuberculosis and phthisis, we find them in this situation. In these cases,however,the tubercles in the pleura are of minor importance. By tubercular pleurisy,we mean a localized tubercular inf lamination affecting the pleura alone. The patient has no accompanying phthisis or if he has the phthisis is slight. He has no tubercles in any other part of the body. When ct. person suffers from this disease,as tv rule only only one pleural cavity is affected and the disease may follow one of two types. The first type resembles a pleurisy with effusion. Serum and fibrin are present and,in addition,there are miliary tubercles in the pleura. The serum is apt to be bloody for some reason or other but ones not contain pus. In the second form, the pleural cavity will contain pus instead of serum, the pleura will be changed into granulation tissue,and the miliary tubercles will be present. The disease may,therefore, resemble u pleurisy with effusion or an empyema. - SYMPTOMS- If the disease take the type r.f a pleurisy with 161 effusion,you cannot at first distinguish between the two;but,as the case goes on, the patient does very badly with his supposed pleurisy with effusion. The fluid will not disappear and he gets much worse. Use the hypodermic syringe. If the fluid be clear, you will be no better off;if it be bloody,the patient probably has tubercular pleurisy. If in addition he has no injury of the thorax,the diagnosis is pretty certain. The patients do badly, it is regularly fatal,and you are not long left in doubt as to what the disease really is. It runs its course in from two weeks to four months. If the disease take the type of empyema,there seems to be no way of making the diagnosis. It simply looks like a bad case of empyema* - TREATMENT.-The treatment is unsatisfactory. The disease is not so very uncommon. - HYDRO-PNEUMO-THORAX.- This condition is characterized by the presence of both air and fluid in th^ pleural cavity. - ETIOLOGY.-Ry giving rise to putrifactive gases, the gangrenous for® of empyema may produce this condition. When perforation of the lung takes place in empyema, the air from the lung passes into the pleural cavity and the iisease is produced. If we operate in empyema,the condition of hydro-pneumo-thorax will be at once es- tablished. Penetrating wounds of the thorax,perforating abcesses, 162 ebeesses of the lung,and phthisical cavities may perforate the pleural cavity and establish this disease. - PHYSICAL SIGNS. - These are always the same. As a rule, the af- fected side will be the larger. It will be almost motionless during respiration. The heart will be pushed toward the unaffected side. Vocal fremitus will be absent. Below the level of the fluid,per- cussion gives flatness:above the level of the fluid,the percussion note varies,you may get exaggerated pulmonary resonance,tympanitic resonance,or flatness. If you get flatness,the percussion note will not give you the level of the fluid. Below the level of the fluid,auscultation gives absence of voice and absence of breathing: above the level of the fluid,absence of breathing or amphoric breathings When we get the amphoric breathing,it is very distinct. Beside all these,we have two physical signs which are more or less characteristic of this disease. These are Csuccussion" and the "metallic-tinkleu . .By "succussion" is meant the splashing sound which you hear when you place your ear to the patient's back and shake him. This you never get except when air and fluid are in the pleural cavity. By tme "metallic-tinkle11 is meant a sound re- sembling that produced by fluid dropping from a height into fluid below. How this is produced,! do not know. We get it in a certain number of the patients and never get it in any other kind of pleu- risy. 163 - RATIONAL SYMPTOMS:-These vary with the mode of its production* If it be secondary tn an empyema,they will not differ from the symptoms of that disease. If it be secondary to a perforating abcess of the lung or to a phthisical cavity,there will usually be symptomr at the time th. t perforation takes place. The patient complains of a sudden and severe pain in the affected, side. He feels, as though something had given way.And then sud- denly comes a very urgent dyspnoea. The patient has tn sit up in oroer tn breathe. The heart becomes rapid and feeble. There is decided prnatration which may amount to collapse. Some will die in a few hours. More frequently they do not die sn suddenly,the urgent dyspnoea, subsides to an extend,and the patient may live in this condition for a number of days or months. They will then have the symptoms of empyema added to those of phthisis nr abcess. - TREATMENT*-Ifthe disease be caused by perforating wounds, give stimulants at first. Afterward, the treatment is the same as that of empyema. 164 -DISEASES OP THE LUNG.- The important parts of the lung are the pulmonary pleura,bronchi, air passages,air vesicles,blood vessels,lymphatic vessels,and connective tissue. The pleura has been considered, We will now- turn to the bronchi. The walls of the bronchial tubes are composed of fibrous connective tissue re-enforced more or less by rings of cartilage. Inside is a layer of connective tissue of some thickness. This inner layer of connective tissue is rather loose,contains a good many cells and blood vessels,and the mucous glands are imbedded in it. Next, comes the mucous membrane. Most internally, is a layei* of epithel- ial cells. The tubes also contain muscular fibres. The very smal- lest tubes within the lungs contain no mucous glands. These tubes are thin,only composed of connective tissue,and lined by a single layer of connective tissue cells. - BRONCHITIS.- -1-ACUTE CATARRHAL BRONCHITIS.- -2-CHRONIC CATzARRHAL BRONCHITIS. -g-ACUTE CROUPtUS BRONCHITIS.- -4-CHRONIC CROUPOUS BRONCHITIS. - 165 -FTICLOGY O17 BRONCHITIS.-This is a disease,which,in its acute form,is roost common in younp children. Chronic bronchitis belongs especially to adult life. Penpie who are confined tn the house and those who have a poor constitution are particularly liable tn it. Some seem to have a natural predisposition to it. Climate is a factor in producing it. It is more common in the cold, and wet months. Particular regions m^y dispose to it. Elevate.; regions have the least bronchitis. Semetimes it is causei by the inhalation of some organism,what organism we Jo not know. It may be produced bythe inhalation of irritating gases and powders. It occurs as an epidemic,when it seems as though a number of people were exposed to the same cause. At other times,it will seem as though it were a general disease of which bronchitis were the characteristic lesion. It complicates certain of the infectious diseases. - 1 - ACUTE CATARRHAL BRONCHITIS - This disease ••iffers according as it occurs in young children,adults, or old persons. The essential character of the lesion is the same. - PATHOLOGY?-In most eases,the larynx escapes altogether but this is not invariable. The trachea is almost always involved. The larger bronchi are always involved. Here the inflammation will often stop but,in the more severe cases,the medium-sized tn* 166 smelliest bronchi may be involved.The rigid outer wall seems to take no part in the inflammatory process. The inner portion i.s affected. The mucous membrane becomes congested*swollen,and dry. The secret ti<n is,for a time,arrested. The large number of blood-vessels renders such a swelling of considerable importance for,if the layer of connective tissue be much swollen,the calibre of the tube will be much narrowed and respiration seriously interfered with^ Then comes the increased production of mucus. This mucus is coughed up. There may be an escape of red or white blood-corpuscles which will be coughed up also. As the mucus is produced the swelling subsides,but does not disappear altogether. In the smallest bronchi there is no mucous membrane and no mucous glands and the only evidence we get of the inflammation is the presence of pus. With such a bronchitis,there is no inflammation of the pleura,air- vesicles, or stroma of the lungs. However,in children we may have a change in the air-vesicles and air spaces due to the exclusion from them of the air. They collapse and the lung is saij to be in a condition of atelectasis. This condition belongs only to young children. - SYMPTOMS.- - In adults*-There are very mild, eases in which the inflammation is confined to the trachea and larger bronchi. The larynx may be involved to a slight degree. 167 As a rule, the patients have no fever. They dd net feel ill enough to go to bed. There are two things that trouble, the patients. These are bough and a feeling of oppression referred to the upper and middle parts of the chest. The cough may be dry in spite of the increased production of mucus. Others will expectorate a mod- erate amount of white mucus. These symptoms will last a couple of weeks; then,they will disappear. There will be no physical signa*,; In more severe eases,the lesion will be mo^e extensive. The medium-sized and some of the smaller bronchi will become inflamed. The patient has a troublesome cough which is at first dry then, later,there is expectoration. The mucus will often be streaked with blood. The patients have the .;me feeling of pain over the sternum and they may have it over the whole chest. Fever precedes and accompanies the cough and pain. With the fever,there are head- ache ,vomiting,loss of apetite,etc.,which vary in intensity with the height of the fever. Some of the patients will go about, others will stay in the house,others will go to bed and stay there. In this class of eases,we get physical signs which are generally heard over both lungs. They may be confined to the bronchi of one lung but this is the exception.They are sub-crepitant and coarse rales and sibilant and sonorous breathing. 168 There is an change in the percussion note. The rales are due tn the presence of mucus in the bronchi. The breathing is due tn a contraction of the walls of the bronchi. This- may be caused by the congestion of the sub-mucous connective tissue or to a contrac- tion of the muscles in their walls. Some patients will have an re symptom. This is spasmodic dyspnoea nr asthma. This is due to the same phenomena that cause the breathing. Some never have it. These symptoms last for y week or two. Most never look very ill but sometimes they look sufficiently sick tn be the cause of some anxie ty. -Severe cases*- These last for a long time. The patient has cough, expectoration-,and the physical signs mentioned, above. He loses flesh and strength and looks as though he were going tn have pul- monary phthisis. The disease may go on for months and he may reach a great degree of prostration. These eases are very difficult to diagnose. - TREATMENTr-The mild eases often require none at all. They are often not confined tn the house. However, sometimes the cough an'5 oppression are very annoying. You may give in pill form ipecac, belladonna,opium,and quinine, always combine them and give them in small Joses. The mineral acids are decidedly beneficial. You may give salicin and Dover's powder in capsules every three or four hours.All cough mixtures are objectionable for they dis- order the stomach. 169 The severer cases require mere treatment. The patient is often confined to bed. If you see the patient early and the bronchitis be severe,you may apply dry cups over the whole chest.You may use poultices. I do not like them. If you use them,they should be thin and light. For the fever,give the tincture of aconite root. Give diuretics. If the fever be <uite high,give antipyrin or antifebrin in small doses. For the bronchi tie,give the same drugs as in the mild cases. In some cases,the spasmodic dyspnoea becomes of considerable importance. In these,give iodide of potash,chloral hydrate,or the syrup of h^driodic acid. These drugs are often of service in relaxing the muscular spasm, At other times,a free flow of mucus will more readily relieve the asthma. Fer this purpose, give ipecac in larger doses,lobelia,jabnrandi,or grindelia robusta. For the immediate relief of the spasm, give nitrite of amyl. In the protracted cases,get the patient out of bed but keep him in the house if the weather be not warm. Give quinine in moderate doses,spirits of tarpentine, the mineral acids,and inhalations of oxygen. Some will run down in spite of all you can do. When this is the case,send the patient away immediately. It is not necessary to send him to a warm climate. Lakewood N. J. or Atlantic City will do. When there,make him stay out of doors as much as possible. A few days of life in the open air will often break it up. 170 The lesion is the same as in young adults but an attack of bronchitis is apt to be of more consequence in old people. They do not bear it 'veil. People over seventy years of age are apt to have structural changes in other parts of the body. They may have chronic endarteritis,emphysema,or the atrophic form of Bright's disease and,although these have never given trouble before,they make the bronchitis more serious. The prostration is more marked than in younger adults. They have an irregular fever which lasts throughout. The cough and expectoration trouble them greatly. There may be cerebral symptoms. The heart becomes more feeble. They have no appetite. They may become comatose. They do not bear the disease well. - PHYSICAL SIGNS. - These are often well-marked but,in some cases, they are localized. This makes it very troublesome to appreciate them and they may resemble the physical signs of lobar pneumonia. In some,there will be no rales at all. I do not know why this lo- calization is moie frequent in old people than in younger adults. As a rule these patients are more seriously ill than those that are younger. The disease is of longer duration. However,they do recover as a rule but they may frighten you very much. The patient may die but this is the exception. - TREATMENT.-Be more careful with drugs and give them in smaller doses but,otherwise,the treatment is the same as in younger persons. - IN OLD PERSONS. 171 - IN CHILDREN#- The disease is very eownn in children. In children, the bronchi form so large a part of the lung that the disease is more serous than in adults. The younger the child,the worse the disease. Th lesion is about the same as in adults with the exception <ha - in most cases,some of the smaller bronchi are involved. The seventy of the disease depends upon the size of the. bronchi that are at- tacked and the extent to which they are inflamed. The smaller the bronchi involved,the more dangerous is the disease. -• MILD CASES.- In these,there is no fever. The child hardly seems sick at all. He has but one symptom,a cough with a mucous expec- toration. He swallows the sputa. -Physical signs.- Coarse and sub-crepitant rales are present over both lungs. -Treatment.-Give them no drugs at all. Keep them warm and regulate the diet. Allow them no candy nor anything that will tend, to derange the stomach. If the cough prevent the child from sleeping at night,you may give him a little paregoric . -MORE SEVERE CASES.-A larger number of the bronchi are involved. The disease is often preceded by coryza,tonsillitis,pharyngitis, milder bronchitis,or a complicating measles or whooping cough. So,the invasion varies. If it follow any of the diseases that have been mentioned and are not infectious,the invasion is apt to be gradual. If it occur idiopathically,the invasion will be sudden and the disease is often ushered in by one or more attacks of general convulsions. - - 172 The temperature runs up tn 101-105, The heart becomes rapid and rather feeble. When the fever is once established,it is apt to be higher in the afternoon than in the morning and it may be said to be intermittent. The height of the temperature is a good guide tn the condition of the patient. The breathing is rapid throughout, If the disease be sufficiently severe, this rapid breathing will be more marked and it will become evident that the child is not aerating his lungs properly. The breathing may also be labored. The child will sit up to breathe. These disturbances of the respir- ation are a good guide to the severity of the bronchitis. In some cases,the stomach will become distended either with undigested food or with swallowed sputa and it will press up the diaphragm and so interfere with the breathing. The child is restless and may have stupor alternating with delirium. - PHYSICAL SIGNS.-We get coarse and sub-crepitant rales but they may not be heard until the second or third day or even later. The symptoms will continue a number of days. Most recover at the end of a few days or a week. Many of the patients are seriously ill and there is apt to be one period in the disease when they are apt to be more ill than at any other. The patien't may die. The cause of death'varies. He may die from the general bronchitis, because the bronchitis was. succeeded by a broncho-pneumonia, 173 because he vts very young,or because he was very sickly. When the disease occurs in young infants,one week to one month old,it gives but few symptoms and is usually fatal. The only symptoms are fever and rapid breathing. The prognosis of all the cases in children varies with the age of the child,the previous condition of the child, and the like- hood of the disease being followed by a broncho-pneumonia. Other- wise, the prognosis is good particularly in the middle and upper classes. - TREATMENT.- Remember that they are children and that it is easy tn de them harm. Children under five years of age are made worse by alcohol in any form. Cardiac stimulants are useless and may do harm. See that the room is large. Let the child stay in one room during the day and in another during the night. If the warmth of the room and clothing be properly attended to,the patient need not neces- sarily be confined to bed. If the invasion be severe,employ counter- irritation over the chest. Do not use dry cups or blisters. Croton oil and turpentine are very good for this purpose. Mustard plasters are very good also. Poultices are even more objectionable than in adults. If the fever be well marked,give aconite,antipyrin, or antifebrin in small dnses at regular intervals. If the child 174 be very restless and fretful, give opium in small doses. For the bronchitis, Prive ipecac combined with the opium. The ipecac should be given in such doses as will increase the production of mucus hut the doses should not be sufficiently large to make the child vomit. The character of the cough and the coarseness of the rales will guide you in its administration. If you have the dyspnoea due to distension of the stomach,give the yellow sub-sulphate of mercury as an emetic. On the bad day already alluded to,you will often give relief by the administration of calomel in one-half grain doses until the child shall have taken five or six grains. Then,he will either vomit or his bowels will move and the alarming symptoms will subside. As to the infants,there is no use in treating them. They are to small. -2-CHRONIC CATARRHAL BRONCHITIS.- Chronic bronchitis may follow one or more attacks of the acute form or the disease may from the first be chronic. It frequently accompanies chronic gout, emphysema, interstitial pneumonia., and chronic pulmonary phthisis. It may be caused by the inhalation of irritating gases. It may occur as an idiopathic condition. It is a disease of rather advanced adult life. It does sometimes occur in young people. 175 - PATHOLOGY. - There is a change in the mucous glands of the larger bronchi. They produce too much mucus and increase in size.4 After a time,the epithelium will destuammate. -SYMPTOMS.-There is a cough with an expectoration. The expector- ation varies in quantity and is composed of mucus nr of mucus mixed with pus. The mucus may be thick and tenaceous or it may be partly serous. Some simply cough up a little mucus upon rising: others raise a larger quantity throughout the day.When the quan- tity of micus expectorated is very great, there is always a sus- picion that dilatation of the bronchi has. taken place allowing of an accumulation of mucus. We may have a large quantity of mucus without this dilatation. In some cases, the mucus has a bad odor. This is due to decomposition and the patient is then said to suffer from "fetid bronchitis'1 . When the disease has lasted a long time and emphysema is also present,there will at first be dyspnoea on exertion and,later,constant dyspnoea. Some of the patients have a fever and the patient may sweat at night without there being any tuberculosis. If the disease be severe,the patient will lose flesh and strength. / - PHYSICAL SIGNS.- We get coarse and sub-crepitant rales which come and go with or without sibilant and sonorous breathing. The intensity of the rales is in proportion to the severity of the disease. 176 The enurse of the disease is very long and intermittent, The pa- tient is often free from it during the summer months. In some cases,the disease never advances beyond this point,The patient dies of some intercurrent disease. In other cases,the disease will not go away at all. When it has passed into its full development, chronic bronchitis does not as a rule prove fatal by itself. It is usually complicated by something else. It does not take much to kill the advanced cases. - TREATMENT.- The treatment is not easy nor is it satisfactory. The disease has a decided tendency to return after it has been relieved. This is true of all catarrhal inf laminations of mucous membranes. Regulate the patient's mode of life,his diet,and the place where he lives. The patient should live out of doors. The starches and sugars should be limited. Tobacco and alcphol should be avoided. He should be sent away. Whether the climate to which he is sent should be warm nr cold,will vary with the patient. He can generally find a climate in which the bronchitis will dis- appear as long as he remains there. If he cannot go away or can not find a suitable climate,we may give drugs. These drugs will re lieve the patient to a certain extent but they will not cure the disease. We may give the dilute mineral acids,m.xv-m.xx twice or three times a day. Quinine in moderate doses is of service tn 177 some. We may also give nux vomica,iodide of potash, syrup of liydri- odic acid,belladonna,or ipecac and opium in moderate doses. We may allow the patient to inLaie compressed air or compressed oxygen. - 3-ACUTE CROUPOUS BRONCHITIS.- This disease is act often seen except when it occurs with diph- theria or with lobar pneumonia. It may occur as a primary disease. When this is the case,the mucous membrane of the trachea and bron- chi will be congested and swollen and coated with a false membrane. The disease may follow a catarrhal bronchitis. - SYMPTOMS.-The patient suffers from rigors,fever,dyspnoea,great prostration,and a cough which is at first dry. Later,there is mucous expectoration and,if the patient live,he will cough up the false membrane. From the beginning, the dyspnoea is a marked, symp tom and it continues urgent and distressing throughout the disease. The dyspnoea is followed by venous congestion of the lips and face. As a result of the venous congestion,there will be eerebral symptoms. -PHYSICAL SIGNS.-Absence of breathing over one or both lungs or absence of breathing alternating with coarse rales. -PROGNOSIS.-The prognosis is bad. Fifty per cent of the patients die. They generally die in three or four days but they may live a week or a couple of weeks. If they recover,they are ill for a 178 long time. - TP.^ATM^NT.- The treatment is the same as that Af acute, catarrhal bronchitis but the measures are less likely to prove effective. - 4-CHRONIC CROUPOUS BRONCHITIS.- This name is given to a disease in which the patient coughs up casts of one or more bronchi. The lesions are not well made out. We get it mixed up with chronic bronchitis and phthisis. The course of the disease is very long. During most of the time, the patient gives symptoms of chronic bronchitis or he may have a little phthisis. At intervals,he will have severe coughing spells during which he will raise easts. These coughing spells will last several days*, then,he will go back to his chronic bronchitis. The casts look as though they were composed of fibrin but,under the microscope,they present a different appearance. The patients that cough up large casts are very anxious about themselves. They go about with their easts in a bottle and show them to their sympath- izing friends. Practically,they are no worse off than the other cases of chronic bronchitis. The disease is not fatal. It lasts a long time. -TREATMENT.-The treatment is the same as that of chronic catarrh- al bronchitis. 179 The lesions of the parenchyma of the lungs are called pneumonias alt? Gutd> in these diseases, the pleura and bronchi are regularly involved. We may make two classifications of .pneumonias, the ana* tomieal and the clinical. Of these,the clinical is the mare im- portant and is the one usually adopted. - ANATOMICAL CLASSIFICATION. - -1-INTRA-ALVEOLAR PNEUMONIA. - -2-INTERSTITIAL PNEUMONIA.- -5-BRONCHO-PNEUMONIA.- -4-TUBERCULAR PNEUMONIA. - -5-SYPHILITIC PNEUMONIA.- - CLINICAL CLASSIFICATION. - -1-LOBAR,OR CROUPOUS PNEUMONIA.- -2-SECONDARY,OR COMPLICATING PNEUMONIA- -3-THE PNEUMONIA OF HEART DISEASE. -4-BRONCHO-PNEUMONIA. - -5 -1NTERS TITIAL PNEUMONIA. - -6-SYPHILITIC PNEUMONIA. - -7-TUBERCULAR PNEUMONIAS.- The most important excepting broncho-pneumonia, is lobar pneumo- nia. Lobar pneumonia is very common. 180 - 1-LOBAR, PNEUMONIA. - - pathology - As a rule, the inflammatory process begins in one lone of one lung. Then,it extends rapidly and-,in a few hours, the whole lobe is in- volved. The right lung is the more frequently attacked and the lower lobes are those most apt to be affected. The disease often remains in one lung but it may extend so as to involve both and, though rarely,the inflammation may from the outset involve nearly the whole of both lungs. The inflammatory process invades the parenchyma,air vesicles,bronchi,and pleura but the inflamingtoiy products do not infiltrate the connective tissue. They collect in the cavities of the air spaces,air vesicles,and bronchi $ in the interstices of the connective tissue-,and on the surface of the pleura. They are for the most part fibrin and pus. The blood ves- sels are principally concerned in the inflammatory process. The disease is divided into four stages. These &re the stage of congas- tion,the stage of red hepatization,the stage of gray hepatization, and the stage of resolution. - THE STAGE OF CONGESTION.- This marks the beginning of the inflam- matory process. The lung is not consolidated:yet,it is harder than a healthy lung. The blood vessels are engorged. The air vesicles contain some fibrin and a few pus cells and epithelial cellsjbut they are not filled with them. The pleura is not involved. Hie 181 bronchi are usually inflamed, congested, and swollen. Tills stage varies as to its duration. In most eases,it lasts but a few hours. By the end of twelve hours,the second stage usually comes on. It may come on even sooner. The first stage may last for three days. - 2 - THE STAGE OF RED HEPATIZATION.-The lung is fairly consoli- dated. It is solid like the liver. The pulmonary pleura is coated by a thin layer of fibrin. The bronchi are swollen and sometimes coated by a thin layer of mucus. The smaller bronchi are filled with fibrin and pus. The cause of hepatization is that the air- vesicles are distended with the inflammatory products. In the air- spaces.,are coagulated fibrin,pus,and epithelial cells. Their rela- tive proportions vary. The walls of the bronchi and air-spaces are not changed at all. So there is no change in the parenchyma of the lung. The disease often»stops here. About wne-quarter of the fatal cases die during this stage. The lung may remain in this condition for ten or eleven days. - 3- THE STAGE OF GRAY HEPATIZATION.-The lung remains solid. Tl.e pleura remain coated with fibrin,and the air-vesicles filled wit! inflammatory products,but the color gradually changes from red to rray. This cbanr.e in color is partly due to the absorbsion of the coloring matter of the blood,and partly to a diminution of tbs blood supply of the lung. 182 The consistency of the lung changes after a short time. It becomes softer. This is due to a fatty and granular degeneration of the inflammatory products. One-half of the fatal cases die during the transition between the second and third stages,and one-quarter • die during the third stage* \ - 4" THE STAGE OH RESOLUTION;-This stage is marked by the degeneration,absoy^tdov,and expulsion of the inflammatory pro- ducts. They undergo fatty and granular degeneration. A certain amount of serum enters the cavities of the air-vesicles. They contain a semi-fluid material part of which is expectorated. The patient need not necessarily expectorate it.The larger part of the inflammatory products is taken up by the lymphatics. This pro- cess does not affect all partv of the lung at the same time. The lung will be partly solid and partly aerated at the same time. As resolution goes on the inflammatory products are gradually all removed. The lung finally returns to its former condition. This is a favorable feature of the disease. 'This the ordinary course of the pathological changes in lobar pneumonia but it is subject to six variations. - 1-The lung may remain in the condition of gray hepatization for a number of weeks. 183 - 2--There may be an excessive production of fibrin* This is very serious for the fibrin will distend the air-vesicles,and thus impede the circulation of the blood and prevent the lymphatics from taking up the products of Ve inflammation- This may c.u ■ the death of parts of the lung followed by their separation and i the formationof a zone of suppurative inflammation surrounding the dead lung tissue. . - 3-There may be an excessive production of pus.. As a rule., this does not mark a bad form of the disease but the pus-cells may infiltrate the walls of the air-vesicles and air-spaces.This is fa tai,but it is rare. - 5-The bronchitis which always accompanies it is often exaggera- ted as a catarrhal or a croupous bronchitis. If it take the catarrh- ol form,we have congestion of the bronchi and excessive production of mucus. If it take the croupous form, the bronchi 'Till be filled with the false membrane. - 6-In the regular pleurisy of lobar pneumonia,we should only have a thin layer of fibrin coating the lung and the plpura. In some eases,however,a large quantity of fibrin coversine surface of the pleura and there may be serumin the pleural cavity. 184 The pieural cavity may contain pus and we will then have an empyema. The empyema and pleurisy may make their appearance at the commence- went or near the end of the disease when they will continue after the pneumonia is cured. - ETIOLOGY.-- The disease is common both in warm and cold climates but,in New York,the colder the weather the more lobar pneumonia we have. It is more -common in cities than in the country and is less frequent in those persons who live out of doors than in those who live in the house. Many eases occur in New York during the month of May. Exposure to cold and wet cause it,as when,in winter,a person falls over-board.This will be followed in twenty-four hours by a lob'ar pneumonia. In other eases we get no history of exposure. Sometimes it seems to occur as an epidemic,whether as a general disease o'? as a local inflammation has not as yet been decided. I think that both ideas may be correct,the disease being sometimes due to exposure and,at other times to infection. It belongs to adult life. Children under five years of age,when they have an inflammation of the lungs,generally develop broncho-pneumonia,while between the ages of five and fifteen they may have either. Persons over twenty usually have lobar pneumonia. This is of considerable prac tical importance. 185 - PHYSICAL SIGHS.- As these vary with the development of the disease,it is necessary to remember' the four stages and, in any given ease,to try and find nut the stage in which the disease may be. - First stage-We often do not see the patient in this stage,par- ticularly if it be short* If you do, remember the condition of the lung,its softness,that only one lobe may be affected,and that there is no pleurisy. We get dulness and a few sub-crepitant rales over the portion of the lung that is inflamed. The dulness is so moderate that you cannot make it out except in favorable chests. - Second stages-Remember that there is solidity and dxy pleurisy^ We get dulness,but this dulness may not be well marked in many eases even with complete solidification. In other eases it will be very decided. In a few,we uet flatness when the lungs are"unusually distended and compressed t-gainst the wall of the chest. In a few cases,when the upper lobe is involved, we get either tympanitic or cracked-pot resonance beneath the clavicle. Increased vocal fremitus is generally present but not invariably so. Bronchial voice and. bronchial breathing are frequent- ly present. Remember that bronchial breathing need not be loud. 186 Bronchial breathing may be absent and bronchial voice present* A crepitant rale due to rubbing is present in a great many cases. It is not constant* ] - Third stages-The physical'signs are the same as in the second stage with the exception that the duiness is apt to be more marked and the bronchial voice and breathing are more constant* The crepi- tant rale is less constant*. - Fourth stage#-The. duiness diminishes but,yet,if it has been well marked,it will be pretty slow in going away* The' breathing is at first broncho-vesicular and' then normal. The rales crepitant, sub-crepitant,.and coarse* The rales then disappear and only a little duiness is left. In old persons,all the physical signh are uncertain or imperfect. They may all be absent. Even in adults,dn not depend too much on the physical signs in making the diagnosis* They are a great help and that is all* It is estimated that one-third of the eases have a prodromic period during which the patient suffers from irregular ehills,moderate fever,loss of appetite^aad oppression of the chest and breathing but he does not go to bed or even sta}^ in the house* - RATIONAL SYMPTOMS - 187 This period.may last from nne to four days and,when it does so, it seers to mean that the stage of congestion is unusually pro- longed. When the disease is fully developed,we have thirteen pretty characteristic symptoms. - symptoms. - - 1-In from eighty to ninety per-cent of the cases, the invasion is ushered in by one or more well-marked rigors occurring within the first twenty-four hours. These chills are often the first symptom and wy date the commencement of the disease from the initial chill. This symptom is important and very constant.. - 2- Accompanying and succeeding the chill,there is a rise of temperature which runs rapidly up to its maximum by the secon or third day. Then,it may remain at the same height or it may fall a little. It is usually somewhat lower in the morning and rises in the evening. The regular temperature varies from 1O1-1#4. It will be best if it do not go above 104. As a rule,the height of the temperature indicates the activity of the inflammatory process and the severity of the disease* However,this rule is not invar- iable. A fatal case may have a temperature of 101. or 100. A case may begin with a high ' temperature which may subsequently fall to ion and yet the patient may do badly. In rare cases, the disease has been known to occur with no fever. If successive parts of the lung be attacked,a further rise of temperature will mark each extension of the lesion. 188 At some time during the disease,we expect to have the temperature fall. In c. great many cases., this fall will be completed within a few hours^in others,it will take from two tn three days.This is called the period of defervescence. It may take place on any day of the disease from the second tn the eighteenth. but the seventh is the day on which it is most liable to occur. Next in frequency, comes the fifth:then the eighth:sixth:and ninth. These numbers are of considerable importance and,if you remember them.,you may be saved a good deal of trouble. Remember also that the day before defervescence takes place the patient often seems at his worst. - 5-In some cases,there will be profuse sweating between the second and third stages. It is not constant. I think that it is rather a good symptom. .- 4-Pain in lobar pneumonia seems to belong to the pleurisy. It is neither constant in existance nor in situation. It may be absent and,although it is usually referred to the affected part or below the nipple on the affected side,it may be referred some- where else. It has been referred to the hip. It is usually developed during the first twelve hours. A good deal of pain generally sig- nifies a bad case. This is especially true when the patient com- plains of it greatly. - 5-The pulse should be about one hundred and fairly full and strong. The first sound of the heart should be well marked. These 189 characters of the pulse and heart are very important. The day before defervescence,the pulse and heart are apt tn become sud- denly rapid and feeble and we must be on the look-out for death from he^pt failure. When this condition threatens,the patient's face will become dusky. This heart failure is often temporary but it is always possible for a patient who has had no very bad symptoms to die from this cause on the day before defervescence. From the outset,same patients do not have a regular heart and pulse. From the beginning', the pulse may be one hundred and twenty and feeble and the heart rapid and feeble. In lobar pneumonia, it is a good rule that if a patient have a pulse of one hundred and twenty he is apt to do badly. So,I think that the pulse is a better guide to the patient7s condition than the temperature. - 6-At first, the breathing is rapid and oppressed: then,rapid but not so much oppressed. The greater the area of lung inflamed, so much more rapid and difficult will the breathing become. - 7-Cough is a very regular symptom. It may be developed within twenty-four hours after the commencement of the disease or not until defervescence has taken place. There should be an expector- ation of rounded pellets of tenaceous mucus. At first,these pellets are red: then,yellow. The cough may he absent altogether. Titis is especially apt to be the case in eld persons of seventy years 190 or more. The patient may have a cough and no expectoration. The patient may bring up sputa like those of acute catarrhal bronchitis or, at the outset,he may cough up a dram or two of pure blood* When we have the characteristic sputa,the darker they are the worse is the disease. *-8-Tb.e face of tl.e patient is very characteristic* Tie cheeks are flushed and you can often make a "snap "diagnosis on the expres- Sion of the countenance* -~ ?- The tongue is White and coated but, in favorable cases,it. should remain moist* In bad eases,it should become dry and brown. - IS-Disorders of the stomach are manifested- Loss of appetite and vomiting are common during tb.e first twenty-four hours nf the disease. - 11-The urine is diminished and high-colored* It may contain some albumen and a few casts due to a complicating parenchymatous nephritis which is almost always present. As a rule,this nephritis does not develop to such a degree as to trouble the patient much. - 12- Cerebral symptoms are manifested. In the milder cases, we have only sleeplessness,discomfort,^nd headache. In the bad cases., and particularly in those which have been alcoholic,we have delirium, more or less active,and stupor which may go on to become uncon- sciousness. 191 - 13-The degree of prostration varies. As a rule,in from twelve to twenty-four hours, the patient goes to bed-. This rule is not invariable. We Lave very mild cases in which the patient does not go to bed at all and,when the whole of one lobe or even the whole of one lung is involved,the patient may not go to bed. These are called the"walking cases"and in them,the disease is apt to be fatal. - COMPLICATIONS.- - 1-The pleurisy may be. exaggerated. Serum, or even pus may accumu- late. When this is the case,the patient will frequently recover from the pneumonia and yet not be entirely well. Such a pleurisy may continue for weeks or months after the pneumonia has been cured. - 2-The bronchitis will often be exaggerated and the patient will cough up an excess of mucus. When this is the case in young persons, you often cannot distinguish it from acute phthisis. In old persons, you are more on the look-out fnr it. ■-3 - The pericarditis is apt to be over-looked,listen every day for the characteristic friction sound. Even then you may fail to get it . In some eases,the pericarditis makes itself manifest,the patient will then become worse and have pain over the heart. 192 - 4 - Acute meningit_is occurs in a moderate number of cases and is a very serious complication. Sometimes it will give its charac- teristic symptoms but,as a rule,the eases which develop it already have cerebral symptoms and the complication is liable to be over- looked. However, the delirium, and stupor are often so pronounced and the muscular twitchings so evident that it can readily be diagnosed. ■-5--Jaundice may be a complication. - CLINICAL HISTORY.- This is of great importance for the eases vary very much* - 1- Simple,straight-forward eases^- These give the appearance of simply suffering from an inflammation of the lunge The patient may have prodromae or not, chill, fever,pain,moderate prostration, charuc** teristi^ breathing,couhg and expectoration, some sleeplessness and restlessness,and. a typical temperature* The pulse is from -90-to 4 ~110~,the breathing frnm-25-to -40-,and the characteristic physical signs can be made out in from twenty-four to forty-eigh.t hours. T:.en,on the sixth nr seventh day comes defervescence., a few days later resolution takes place and convalescence begins, and, in a fe-v days more, the patient is welUEven in these simple cases, there are varying degrees of severity* Some look and are much sicker than nthe.^ Remember,on the day before defervescence the patient is apt to / become worse. 193 tie temperature higher, and the heart more rapid and feeble* This will last from six tn twelve hours and the patient may die from heart failure. ■-2-In these eases the physical signs are not developed until four or five days nr until over a week has elapsed. •-3-These eases will begin with aninflammation of the lower lobe of the right lung, then the upper lobe of the right lung or the lower lobe of the left will be attacked and the patient will become worse. •-4-Here,tt the very beginning, the whole of both lungs will be attacked. This is rare and certainly fatal. The dyspnoea will be marked,the temperature high,and death will take place within a very siiort time. - 5 - Defervescence takes place but the signs of consolidation continue and resolution may be delayed for three weeks. Then the patient may become perfectly well. - 6-These cases give the appearance of suffering from an infec- tious disease. They appear sicker than they should be. These cases give cerebral symptoms. The tongue is dry and brown, the temperature high, the heart feeble,and the prostration well marked. These unf w-r- able conditions con^inie-ytl.rnughout the disease. These are ven bad eases.The alcoholic patients are especially liable to this form of the disease. 194 When the patient recovers,the excessive cerebral disturbance often continues for a number of days after defervescence has taken place. Usually this is not an unfavorable termination for they generally disappear but.,in some,a permanent condition of insanity results. This is especially apt to be the case in old persons. - 7- The complies ting meningitis,perlcarditis,and pleurisy give their symptoms. - 8--In old persons,of seventy years or over,the physical signs, pain,cough,expectoration,and dyspnoea are frequently absent. Often the only symptoms are fever,prostration,and cerebral manifestations. Yet,there is something about the patient that is characteristic of the disease. -M^DES of death.- la simple cases. *1-From heart failure just before defervescence. ~2-From the great extent of lung involved. The cerebral cases die in the typhoid condition from the poison of the disease. A complicating meningitis,pericarditis,pleurisy,or Bright's disease already existing may cause death* 195 - DURATION. - In those eases that recover,the patient is well of the disease as' soon as resolution takes place. This should happen two or three days after defervescence. So,the disease is regularly of short 'duration. But, successive portions of the lung may become inflamed and resolution may be delayed. In these cases,the duration of the disease will be prolonged. flie'''fatal cases sometimes terminate within five or six hours. These tre apt to have a large part of both lungs involved from the outset but,in some of them,only a moderate amount of lung will be inflam- ed.. This is especially apt to be the case in old people for it takes but little to kill them. The "greater number of deaths take place on the seventh, eighth, and tenth days of'the disease,that is about the time of defervescence;' In old people,death is most frequent on the fifth, sixth, and sevent? days. There are fatal cases lasting two or three weeks. - PROGNOSIS.- The' prognosis depends upon the extent and character of the pneu- monia, the age of the patient,the complications,and the previous existence of the alcohol habit. The older the patient,the worse the prognosis. As to the character of the pneumonia, the simple^ cases are the best,the cerebral are the worst. The complications and the previous existence of the alcohol habit make the progno- sis more serious. - - 196 - TREATMENT. - - ABORTIVE TREATMENT. - This is only applicable to the simple cases and is only admissible within the first forty-eight hours. Two methods are adopted.. The first method consists in general blood-letting. It was more frequently employed in former times than at present. The patient was bled to faintness during the first forty-eight hours. The second, method consists in giving large doses of calomel. Twenty-five grains of calomel are placed on the tongue and washed down with water. This dose may be given three times a day. It will sometimes cut the disease short but,in some eases,it does not succeed and there is danger of salivating your patient. If you intend to try it,remember that it is only to be employed during the first forty-eight hours. I can neither advise you to try it nor dissuade you from doing so. As for myself,I do not fancy it but it is perfectly proper treatment. - REGULAR TREATMENT.- If you see the patient within the first twenty- four Lours,the treatment varies. In some cases,the patient will simply have a chill,vomiting,fever,and prostration and that is all. In other cases,the temperature will be already high,the breathing very much oppressed,the pulse very full,the heart very strong, and there will be great restlessness and apprehension. These are the two extremes and the treatment varies in the two conditions. 197 If the patient come under the first heading, let him alone*, he cc-uld not begin better. Put him to bed on fluid diet. If lie come under the second heading,you must do something. Employ counter-irritation pretty liberally over the chest. You need not be 'confined' to- the lung inflamed. Use either wet or dry cups,blis- ters,a large mustard plaster,or poultices. I think the best thing is a large mustard plaster covering the whole of the back and •' front of the chest and left on nearly to blistering. For the f^ver, antifehrin is very safe and reliable. Give gr.j-grs.v every four hours during the first twenty-four hours. If you cannot get it, you. may give calomel and opium in small and repeated doses, tine ture of aconite root,dr tincture of veratrum viride. In many cases, this will be all that is necessary. In simple cases,the symptoms subside after the first twenty-four hours and very little is needed* Do not allow the patient to talk and do not allow him. to see ady one. keep him on fluid diet and,if he be restless, or sleepless, give a little opium. When the fifth day arrives look out for heart failure no matter how well the patient may have been doing. See him every three or four hours day and night and have cardiac stim- ulants in the house. Have digitalis,convallaria,Caffeine,and alcohol in some shape or other. I think that convallaria and caf- feine combined with alcohol are more efficient than alcohol alone* The following is a very good combination. At each dose,give c-f th$ fluid, extract of digitalis- m.ij:fluid extract of convallaria m.xx: iodide of potash grs.v: whiskey dram j. water <• s.. Give this once every three or four hours according to the condition of the heart. Continue to give it for twenty-four or forty eight hours, that is till defervescence has taken place. This is the treatment of the simple cases. If the temperature be unusually high,continue the use of anti- febrin throughout or you may apply cold to the chest by means of the rubber coil. Do not use ice water in the coil. The object of the coil is not to act upon the inflammation but simply to reduce the temperature. If resolution be delayed after defervescence has taken place,keep the patient in bed, let him have solid food, and let him inhale oxyeren with some little effort so as to get as much as possible. If there be a complicating pericarditis,there will be no practical indications for treatment. Apply cups over the pericardium. If there be a complicating meningitis,make cold applications to the head. If there be a complicating pleurisy,you cannot do much while the pneumonia is going on. After the patient has.'re cove red from the pneumonia,treat the pleurisy as a distinct disease. If the acute catarrhal bronchitis be exaggerated,give iodide of potash,the mineral acids,turpentine,belladonna,or one of the prep arations of ipecac. 199 In the cerebral cases,the treatment is no longer as satisfactory. The temperature is high and has to be constantly diminished# The heart's action is poor throughout and. cardiac stimulants must con^ tinually be given. Give opium in small doses,alcohol in moderate doses,and convallaria and caffeine either alone or combined with digitalis. The drugs that-lower the temperatureTdo very well for the cerebral symptoms. Some do well with the bromides. With old people,we are not able to do very much. The temperature is frequently not high and we must be careful about lowering it. Cardiac stimulants are not well borne and,indeed,if we give them a little opium and let them alone,they do as well as if we treated them. - 2-THE SECONDARY, OR COMPLICATING PNEUMONIA OF ADULTS - This disease presents itself under two different anatomical forms. - 1 - This closely resembles a lobar pneumonia. Portions of one or more lobes become consolidated and pass through the four,regular stages. The inflammatory products are the same as those of lobar pneumonia and the only difference is that it is a secondary con- dition and does not involve as much of the lung. 200 - 2-This is a broncho-pneumonia. The inflammation involves the bronchi within and without the lungs. Not only is the mucous men- brane of the bronchi affected but the walls of the bronchi are infiltrated with cells and,the inflammation extending to the air- vesicles, their walls also become thickened and infiltrated with cells. - ETIOLOGY.- The disease is very common. It follows injuries of the brain and spinal cord and,when the brain is injured^Tt is surprising how rapidly the pneumonia will follow the cerebral le- sion. It will sometimes enme nn six hours after the brain has been injured. The reason for this is unknown. It follows surgical operations of all kinds. When,from any cause,the patient has been confined to bed for any time,he may develop this form of pneumonia. - SYMPTOMS.- Sometimes,the disease gives symptoms.They are chills, fever,rapid and difficult breathing,rapid heart,and the physical signs of either broncho-or lobar pneumonia. At other times,it gives no symptoms,the patient simply looks sicker than he was before. - PROG^IG. -Very bad. - TREATMENT.-As a rule,we do not treat it. We treat the original disease and are very happy if we can but diagnose the pneumonia. 201 - 3-THE PNEUMONIA OF HEART DISEASE.- -PATHOLOGY.-The disease is the result of lesions in the valves of the heart or of simple hypertrophy of the ventricles. Mitral stenosis is the most common cause. As a result of this lesion in the heart,the hlood escapes with difficulty into the left au- ricle and ventricle. At first,this is followed by a simple chronic congestion of the lungs and then,sooner or later ,by a chronic inflammation of the lung tissue. The walls of the air-vesicles are thickened and their cavities are filled with epithelium and pus. The lungs may become pigmented. Their color will vary from a red- dish brown to a blackish brown. The capillaries,by becoming in- creased in size,lengthened and tortuous,may add to the thickness of the air vesicles. - PHYSICAL SIGNS. - The physical signs are very obscure and,as both lungs are attacked,we cannot compare one side of the chest with the other. Dropsy makes the examination more difficult. You may only get dulness and a few rales and these are often absent. - RATIONAL SYMPTOMS.- The disease is developed very slowly and may not give symptoms for a long time. It may not be made out at all. The patient gives the symptoms of heart disease and seems to suffer from a bad attack. So,we rather infer from the history and the condition of the .patient that the disease exists.When a pa- tient has heart disease with exaggerated dyspnoea,and some cough 202 and expectoration,we may suspect a complicating pneumonia. When it is fully developed,a large part of both lungs become con- solidated and this is one of the ways in which death takes place from heart disease. - TREATMENT*-We treat the heart but,because we do not treat the pneumonia do not think it of no importance. Always be on the look- out for it. This disease is also known as capillary bronchitis, lobular pneu- monic'., and catarrhal pneumonia. Although very common,it is usually not as well described as lobar pneumonia. The name^broncho-pneumonia1 is 'h&d for it gives the idea that the disease is a combination of bronchitis and pneumonia. This is not the ease. It i^sa distinct inflammation of the lung. - PATHOLOGY*-There are two principal lesions. - 1-'There is an inflammation of the larger,medium-sized,and even the smallest bronchi. The inflammation usually affects the whole bronchial system of both lungs but not all parts equally. It is partly a simple catarrhal inflammation accompanied by all its changes hut,in addition,the bronchial walls are thickened abnormally and infiltrated with cells. In many eases, this is as far as the lesion of the. bronchi will go» - 4- BRONCHO-PNEUMONIA.- 203 In many eases,however,this infiltration of cells changes the con- sistency of the mills and they are no longer able tn withstand the pressure of the air. They will become dilated;in some eases,the ncrml tissue of the walls of the bronchi will disappear and there will be irregular cavities formed. --2-In the lung tissue itself, the inflammation involves the parts immediately surrounding the inflamed bronchi, not the air-vesicles to which the bronchus leads but those immediately surrounding. This inflammation of the air-vesicles is not uniformly distributed tn both lungs but is more marked in some parts than in others. The walls of the air-vesicles are thickened and their cavities filled with inflammatory products. The products of inflammation are generally fibrin,pus,and epithelium but,sometimes,we have'a tissue resembling connective tissue. In many cases, these twn sets of changes are the only ones to. be found in the lungs but,in more severe cases,the lung tissue between the zones of inflammation becomes attacked and the whole lung be- ' comes solidified. This diffuse pneumonia resembles a lobar pneumonia There is no change in the walls of the air-vesicles. Their cavities are simply filled with the inflammatory products. 204 In exceptional cases,there is a pleurisy with fibrin on the pulmon- ary and costal pleurae. In this disease,unlike lobar pneumonia,the patient recovers with a damaged lung. It lasts longer than lobar pneumonia,convalescence is more tedious^ and,in some patients, the acute inf lamination will be succeeded by a chronic one which may last for months or years end may convert the inflamed portion of the lung into dense fibrous tissue and there may be cavities resulting fromthe dilatation of the bronchi* The bronchial glands may he the seat of a simple or tubercular adenitis. -ETIOLOGY*-It is the regular pneumonia of young children. Persons between the ages of fifteen and twenty-five years may have either lobar or broncho-pneumonia. However, in persons over twenty lobar pneumonia, is the rule and broncho-pneumonia the exception. Measles,whooping-cough,diphtheria,and scarlet-fever are often com- plicated with it in children. It also complicates surgical operations and injuries to the brain and cord. It occurs,also,in patients wha,^r a long time-,have been confined tn their bed. In adults., it complicates some cases of constitutional syphilis and ~ emphysema but,in children it is generally idiopathic or complicating^ measles,whooping-coughjdiphtheria,or scarlet-fever. 205 - PHYSICAL SIGNS.- These are rather-'slow in developing. First we get the physical signs of the bronchitis and then those of con- solidation. About the third,fourth,or fifth day,we may get them. They vary with the condition of the lung. If there be no pleurisy there will be no crepitant rale. If pleurisy be present,you may get* one. If no consolidation be present,there will be no dulness,bron- chial voice nor breathing,but simply coarse and sub-crepitant rales, if present^there will be dulness,bronchial voice and breathing. Albumen is regularly found in the urine. -'RATIONAL SYMPTOMS.- When the disease occurs in very young chil- 'dren, about two weeks old, there are few syrup toms, rise of temperature, rapid breathing,dyspnoea,and a rapid pulse. It is always fatal in these cases. ~ Tn older children.- In many cases the invasion is rather gradual." At" first,he seems to have a cold'in the head,, then, stridulous cough 'ano'breathing,fever,and a rapid heart. In a few days,he goes to bedj seems sicker, and his temperature is higher. This gradual invasion is very common,and we often have difficulty in determining on what'' day the disease began. In other cases,the invasion is sudden and marked by one or more attacks of general convulsions* In other cates still,there will be no convulsions,but,a rise' of temperature an(s rap idx^ re a thing will mark the invasion. We do not expect the < initial chilir^s^n lobar pneumonia. 206 In typical cases,when the disease is fairly established,the fever continues. It may reach -IO5-IO6-or only -103-1^4-.The height, of the temperature is in direct proportion to the severity of the dis- ease. The heart is rapid and after a while, feeble. Remember that a quick pulse in a child is less harmful than in an adult. The breath- ing is rapid-40-60- and may be also labored.. The chil-' is restless and sleepless at night and may be delirious.. Remember that it takes very-little to make a child delirious at night. The face becomes flushed. There is usually a cough without expectoration for chil- dren may swallow their sputa. Sometimes there will be pain in the side or over the whole of the chest hut, generally., they cannot tell you much about it. At the beginning,there is often vomiting and this may continue for some time. As the inf lamination goes on, the symptoms all continue and,after a time,if the child is to recover, he begins to look better,the symptoms will subside mote or less, and by the end of a week or two., the constitutional symptoms will have disappeared. The physical signs will continue to be present for two or three weeks when,if he do perfectly well,they will dis- appear and the child will recover. - 2-In some of these perfectly regular eases,the inflammation will he so extensive and severe that the constitutional symptoms will continue. The child will look sicker an-» sicker,and he will usually die within one or two weeks. 207 - 3-In other cases, it will for some time he doubtful whether or not a chronic inflammation is to succeed the acute one. The child will begin to get better,the temperature will fall not quite to the normal,nor will the heart nor breathing be quite as they shuold be. This seems to me that the inflammation is in a sort of a hesit< tii?g condition. In many,it will finally subside but,in others,after some time,a chronic broncho-pneumonia will be developed. - 4-Other cases will begin a regular course,and will continue regular for some days then they will seem to get worse.This shows that a larger portion of the lung is inflamed. This may he repeated and the disease will be protracted. - 5.- Cerebral cases;-These are cases in which the cerebral symp- toms are strongly marked. They may be more marked than the pulmon- ary symptoms. They may be the first to announce themselves. When present,the patient has convulsions which are repeated for from twelve to thirty-six hours,stupor alternating with delirium,inters *nal strabismus,a high temperature,and a feeble heart. In some, they will only lust for twelve or thirty-six hours and you will suspect an acute meningitis. 208 In others, they will not be as marked but will last for more than a week without pulmonary symptoms. In these latter eases,you will ' suspect tubercular meningitis. Then,after a while,there will be pulmonary symptoms and physical signs. In these eases,it is very difficult to make the diagnosis. I do not know of any children's disease in which it is more so. If you are wise,you will wait sever- al days before giving a diagnosis.. Examine the lung every day and, as a rule,as soon as the physical signs are developed,the cerebral/^ symptoms abate. - 6-In other cases, there are no well marked symptoms. This is especially the case when the disease occurs with measles and whoop- ing cough and the diagnosis can only be made out at the autopsy. - 7-Some cases are succeeded by a chronic broncho-pneumonia. The child will begin to get well of the acute inflammation hut the physical signs will persist,he will have an irregular fever,his pulse is too rapid and he does not seem as though he were oonval* escing. The physical signs will disappear from the greater part of the lung but will remain in certain portions. This sort of thing may last many weeks and the child may appear to get well hut the physical signs will continue and,even after the child seems pern fectly well,you may get them over certain portions of the lung. This shows that the lung is damaged and that parts ®f i^ are changed into connective tissue. 209 - 8 - There are other cases in which not only do th;i physical signs con- tinue but a cough and some rales also,and a chronic bronchitis will be established which may last many years. Yet the patients may en- joy pretty fair health. - 9- Others will Jevelop an interstitial pneumonia and a chronic bronchitis. - 10«-Others will not get better at all. They will always have an irregular fever. They become more and more em^cifted and die at the end of some months in extreme emaciation. - Acute cases#-If the case ^e simple without marked cerebral symp- toms, the first thing to do is to see whether they need any treat- ment at all. If the breathing be not very rapid and not very much oppressed,if the temperature be not very highland if they sleep moderately we 11,put them tp bed. Ilf the breathing at the beginning be very oppressed and rapid, Juse counter-irritation. This may be done by means of poultices, mustard plasters,, croton oil,or by rubbing the chest with turpentine. This system of counter-irritation belongs only to the first days of the disease. If the temperature be very high,give anti-febrine,anti-pyrine,tinc- ture of aconite.,tincture of ve rat. rum viride,or small doses of calo- mel and opium. If the child be very restless and sleepless at night,give opium in very small doses at regular intervals. - TREATMENT.- 210 At) & rule^hne heart,s action does not require any treatment* A child? a vulse very easily becomes ranis' and is not naturally as full as the pulse of an adult. On this account,you must not think that there is any heart failure. They are not liable to heart fail- ure and I think it is hardly to be thought of or treated as a special condition. Alcohol in any shape does harm rather than good. Digitalis,convallaria,and caffeine are not to be used except when the broncho-pneumonia produces great depression and then,really, alcohol pure and simple is the best stimulant. In the cerebral cases,good results can be obtained from the use of the bromides or of opium. These drugs diminish the severity of the cerebral symptoms. Remember that the child has no meningi- tis. If the disease seem on the point of becoming chronic,give iron, quinine,cod liver oil,inhalations of oxygen,and,if possible,send, the patient away. You should not wait too long before you move them for the chronic pneumonia may become fairly established. I send them away even in winter and when they are confined to bed with an even temperature of 101-103. The disease is much less common in adults than in children. When it does occur, it may follow one of tvo types. The case may be very acute and begin dth rigors, fever,headache, - IN ADULTS. - 211 and pains in the back and chest. The temperature mounts up to 102- 105. The pulse becomes rapid and soon feeble. The breathing is rapid and imperfect and there are evidences of venous congestion. The cough is exasperating. At first, it is dry*, then, the patient expectorates a great quantity of more or less bloody m^us. He will sometimes expectorate pure blood. The urine will be diminished and it is apt to contain a good deal of albumen. The patient becomes more prostrated,the tongue becomes dry,he becomes unconscious or delirious,and passes into the typhoid condition. These acute cases are very bad. The patient dies in extreme dyspnoea and great ex- haustion at the end of two or three weeks. He may recover but the chances are very much against him. - PHYSICAL SIGNS.-We get coarse and sub-crepitant rales, sometimes crepitant. Sometimes,sibilant and sonorous breathing are present. The percussion note may remain unchanged or we may get exaggerated pulmonary resonance or d^ness. The physical signs are heard over both lungs. The reason that we do not as a rule get evidences of consolidation is that the cases are so acute. In the second class of cases,the patient begins as though he had a severe bronchitis. The temperature rises,the pulse becomes more rapid. The breathing becomes somewhat rapid and difficult and there are cough and expectoration. There is no venous congestion. We get physical signs,rales. 212 The patient goes to bed and does not look very sick but,when he gets to bed,he seems to stay there. He does not seem to get much worse hut still he does not seem to get better. He begins to lose flesh and strength and he does not care to eat. may get dulness at certain parts of the chest. This dulness shows consol- idation. He goes on in this manner week after week and you may think that he has acute phthisis. After several weeks, in favorable cases,the patient gradually recovers. If the ease be unfavorable, the patient simply gets a little worse and a little worse and in three or four months,he will die exhausted by the disease. In these coses,the diagnosis is almost impossible except at the autopsy# - The acute eases. - Early in the disease, employ pretty thorough and rapid counter-irritation . If the patient, he strong,use wet cups: if not,dry cups. This should be done twice on three times during the twenty-four hours. It is wise to begin a'^ the commence- ment of the disease with inhalations of oxygen and keep them up throughout the whole day. Give one-half ounce or even an ounce of whiskey every half hour. Give the other cardiac stimulants, digital - is, conva1laria, and caffeine. - The second class of cases.-These do not need cardiac stimulants nor inhalations of oxygen at first. Simply put them to bed and feed them. As the disease goes on,give alcohol in fair doses,car- diac stimulants in moderate doses,and inhalations of oxygen. treatment. 213 - INTERSTITIAL PNEWONIA. - The inf lamination produces changes in the walls of the air vesicles and in the connective tissue stroma of the lung. We find it in a moderate degree of development with chronic bronchitis,emphysema, and chronic phthisis,but,from time to time,we find it so fully developed that it is to be regarded as a distinct, disease. We reg- ularly find that only one lung is involved. The whole of this lung or only a single lobe may be attacked. The pulmonary pleura is thickened and joined to the costal pleura by bands of dense fibrous tissue. These bands extend from the pul- monary pleura into the lung* The lung will be harder,smaller,and denser than it should be. Only a moderate amount of air can enter the lung for,as the new tissue is produced,it contracts the air vesicles. There is a bronchitis and the bronchi are dilated. The other lung becomes hypertrophied. - ETIOLOGY. - It may follow a pleurisy or a chronic bronchitis. - CLINICAL HISTORY - We can sometimes get a history of the previous acute inflammation but we often see the patient after many years have elapsed and he has forgotten all about it* The disease is very chronic and the patient is often able to attend to his business. The history extends over many years. 214 There will be a rough,expectoration of mucus, and a certain amount c-f dyspnoea manifested on exertion.The patient complains of pain in the affected side. He is an invalid. He will he worse at one time than at another,he will expectorate and lose flesh,then, he will go on in his former condition. - PHYSICAL SIGNS.-The affected side will become retracted. The percussion note will become duller. Instead of dulness,we may get tympanitic or vesico-tympanitic resonance. The vocal fremitus is increased. We get sibilant breathing and coarse,gurgling,and sub-crepitant rales. If the bronchi be dilated,we may get bron- chial, cavernous, or amphoric breathing. The heart will be drawn to the affected side. So they go on getting a little worse. Sometimes,they die of emac- iation but this is rare. They usually die from some intercurrent inflammation of the healthy lung. -TREATMENT.- The treatment is unsatisfactory. It is much the same us the treatment of chronic phthisis. Give iron,quinine,and end liver oil. Treat the chronic bronchitis and send them away. In this way,they may be made to enjny comparatively good health but they will never get entirely well. 215 This is the result of constitutional syphilis.. It exists under several anatomical, forms# - I- It may begin as an inflammation of the connective tissue surrounding the larger bronchi and vessels at the root of the lung. Thence,it will gradually extend along the bronchi,blood vessels,and connective tissue septa and involve the walls of the £ir vesicles. The, roots of the lung and the connective tissue stroma are finally converted into fibrous tissue. - 2-This is the same as the'first but,in addition, there are %ummy tumors and obliterating endarteritis. - 3-This is a chronic inflammation-involving the walls of the smaller bronchi and the air vesicles surrounding them. It is s chronic bronchopneumonia. It is very slow in its course and the patient usually dies of some Intercurrent or complicating lesion. - 4-This form is more acute and has the character of either a lobar or bronchopneumonia, There is nothing specific about it 'except its cause. - SYPHILITIC PNEUMONIA.™ 216 - 5 - This is a peculiar inflammation that involves the walls of the trachea and larger bronchi. The lungs are not changed. The walls of the trachea and bronchi are thickened and infiltrated with cells. This cell infiltration will be greater at seme parts than at others and,where the cell infiltration is the greatest, there also will the walls be the most thickened. This will result in narrowing of the tube. In other places,the infiltrated cells will die and slough away. As a result of this sloughing,ulcers are formed that reach to a considerable depth. After a while,on account of the thickening and sloughing,great deformities of the trachea and bronchi will result. - SYMPTOMS.- It is attended by the regular symptoms of an inflam mation of the trachea and bronchi. The patient has a cough and expectorates mucus and blood. The breathing finally becomes more and more difficult and the dyspnoea is at last extreme. The patient dies in this extreme dyspnoea exhausted by the disease. As far as I c^n make out,these are the only syphilitic inflamma- tions of the lungs that there are. Syphilitic phthisis,for exam- ple,! do not believe exists. 217 - TUBERCULOUS INFLAMMATIONS OF THE LUNGS.- These are characterized by the presence of the tubercle bacillus. . - When any individual or any group of individuals?exposed to inflam- matory causes,is attacked by a tuberculous inflammation,we say that he is of a tubercular diathesis. This predisposition may 'be and often is inherited from generation to generation but it may also be acquired by a person who has no hereditary tendency. Any cause that continues for a long time and depreciates a per- son's health may create in him an acquired tuberculous diathesis, i/hen a person has this hereditary or acquired diathesis,it does not by any means follow that he will develop tuberculosis. There must be an exciting cause and this cause seems to act in one 'of two ways. Most commonly, with his hereditary or acquired diathesis, ne is exposed to the causes,say of a broncho-pneumonia but,instead ' cf getting a broncho-pneumonia,he gets a tuberculous inflammation of the lung which will in this case be localized. The second method is different and difficult to understand. At some time, often without an exciting cause,the patient will suddenly become ill and will seem to suffer from an infectious disease. 'He will be ill all over. In addition to the symptoms of an infect- ious disease,he will develop tubercular inflammations in many parts of the body. In this case,we say that the patient suffers from general miliary tuberculosis*. Why this is,we dn not 218 know. ^hen a person suffers from a tubercular inflammation of either form in any part of the body,the inflammatory products are mil- iary tubercles,diffuse tubercular tissue, the ordinary products of inf lamination, and the tubercle bacillus. The miliary tubercles ere composed of tubercular tissue nr of granulation tissue. Tu- bercular tissue has the structure nf granulation tissue somewhat modified. The other products present no special characters. 1 -ACUTE GENERAL MILIARY TUBERCULOSIS- as its name implies,this is not of necessity a tuberculous inflam- mation of the lungs,still, it is better tn introduce it here. It seems tn be an infectious disease of which the characteristic lesion is the miliary tubercle. It sometimes occurs in persons whose previous health has been perfectly good.In other cases,there will be a history nf a previous localized tubercular inflammation which generally has existed in the lungs nr branchial glands and may have preceded the general tuberculosis for months or years. -PATHOLOGY.-The miliary tubercles are fauna in the liver,lungs, spleen,peritoneum, serous membranes, <md possibly in other places. They are everywhere of small size and transparent or nearly trans- parent. The other inflammatory products may be plentiful or so scanty as to be scarcely recognizable tn the naked eye. 219 In the chest,the miliary tubercles are found in the pulmonary pleura and in the lung tissue. In the lung,they may he composed of tubercular tissue,granulation tissue np of amorphous granular matter and we find them in three situations.. They may be found in the cavity of tne air vesicles when they may infiltrate the walls of the air vesicles and cause some of the walls to degenerate and die. instead the cavities of the air vesicles may be filled with pus ana fibrin. he may find them infiltrating the stroma of the lungs. In the third place, the air vesicles may not be involved but the walls of the smaller bronchi may became thickened in particular parts with tubercular or with granulation tissue. - SYMPTOMS.- The symptoms are local and constitutional. The general symptoms depend upon the poison nf the disease*, the local,upon the situation of the miliary tubercles.The cases vary as to the predominance of one or the other set nf symptoms. In some cases,there are no local symptoms: in others,the local symptoms predominate and the patient seems tn suffer from a meningitis,pleurisy,or peritonitis. -i-Fever,but this fever is, perhaps, mo re irregular than in any other infectious disease. It varies in different patients as regards its height. One patient will run through a fatal attack of tu- berculosis with a temperature which will ant at any time be above 100. Another will have a temperature of 105-107-throughout the disease. - - - GENERAL SYMPTOMS. - 220 However, i~ these two eases, there will be an difference in the character of the disease nor in its intensity. The fever is var- iable in the same patient. Generally speaking,the higher the temperature throughout, the shorter the cas'e. It may run up and down. A patient with a low temperature may do worse than a patient with a high temperature. In making the diagnosis,you must be on the look-out for these cases with a low temperature,for,it is sometimes hard to believe that a patient 'with a temperature of 100 has a fatal disease. Many have the idea that a person with general tuberculosis must have a high temperature. This idea is erroneous. I insist upon this* - 2 - The pulse is usually rapid and,as a rule,becomes more rapid and feeble. If a tubercular meningitis reach a great degree of development,the pulse may be slow. - 3- The breathing may remain unaffected although the lungs be stuffed full of miliary tubercles. In other cases,it will be so rapid,labored,and inefficient that there may be venous congestion. This generally means that there is a considerable degree of inflam- mation of the lungs in addition toi the miliary tubercles. - 4-There may be sweating at night. - 5- The tongue becomes dry and brown: the patient loses appetite; and there may be vomiting,constipation,or diarrhoea. 221 - 6- The patient loses flesh and strength. Later,he developes delirium alternating with stupor and passes into the typhoid con- dition. - LOCAL SYMPTOMS. - - 1-As a rule,young children have tubercular meningitis. Adults may alsn have tubercular meningitis. - 2-In other cases,the pulmonary symptoms will be marked. There will be cough,expectoration,rapid and labored breathing,and, for physical signs,coarse,sub-erepitant,and crepitant rales which, with dulness on percussion,will generally be heard over both lungs. - 3-In other cases,the inflammation of the peritoneum will give the stamp to the disease. The patient will have pain in the ab- domen,marked nausea,vomiting,tympanities,tenderness over the ab- domen, the abdomen will be distended with fluid,and attention will be drawn to the peritoneum. The eases with local symptoms are the easiest to diagnose:the most difficult are those without local symptoms. A patient may have miliary tubercles throughout his entire body and,yet,you may get no peritoneal,pulmonary,or meningeal symptoms. The patient simply seems to be suffering from an infectious disease and resem- bles a patient with typhoid fever. Sometimes,after you have seen 222 a few such cases,you can pick them out,and yet,you can hardly say how you do it. Howevex', there are some eases that are too much for any physician and, in these cases, the only way you. will be able tn guess at the nature nf the disease is by a process of exclusion as the case gets worse. 'The duration nf the disease varies. Some eases last but a few days 'br a few weeks. However,most last longer,five nr six weeks. Some go on for several months. The long eases may not go to bed for a few weeks. " PROGNOSIS. - The prognosis is altogether bad. They never recover. - TREATMENT.- The treatment is not satisfactory nor is there any particular thing t© treat. There is no direct treatment far the disease. Nurse and feed the patient and relieve any uncom- fortable symptoms as they occur. - ACUTE PULMONARY PHTHISIS. This disease is often called "galloping consumption4 or acute catarrhal phthisis. The patient does not seem to suffer from an infectious disease but from a localized inflammation of the lunge But,it must be born in mind that this is not an ordinary inflam- mation but a tubercular inflammation of the lung conjoined with 223 other inflammations but the tubercular inflammation gives the stamp to the whole process. - PATHOLOGY. - The pathology resembles that of bronchopneumonia but differs from it in the foilowing respects. In bronchopneumonia,the bronchi may be the seat of a catarrhal inflammation or their walls may be infiltrated with cells* In acute phthisis,we have the same catarrhal inflammation but the cell infiltration instead, of being composed, of round cells is Composed of tubercular tissue. The infiltration of acute phthisis is much more likely to undergo cheesy degeneration than that of broncho-pneumonia. As a result of the cheesy degeneration,we have the formation of cavities,usually not of large size. The bronchi' are more frequently dilated in acute phthisis than in broncho- pneumonia. The peribronchi tie zones af inflammation may be just the same as in broncho-pneumonia but the walls of the air vesicles may be infiltrated with tubercular tissue and their cavities may be filled with it. The diffuse hepatization and the pleurisy are just the same as in broncho-pneumonia. There are two things that are peculiar to acute phthisis. The first of these is the presence of miliary tubercles scattered throughout the lungs. The second is that portions of the lung become necrotic and die but do not undergo suppuration nor pu- trifaction. - - 224 At first,they undergo coagulation neeresis and,then?cheesy de- generatisn. They may be only the size of a pin's head or they may be very large. When large,they are generally formed of an accumulation of small ones. There are two plausible explanations "of why portions of the lung should, die. The first is that their "death is due io an obliterating endarteritis which can generally be'demonstrated after death. The second is that it is due to the* '"presence of the special bacteria that cause the death of tissue.; Generally, the changes only involve one lung. Both lungs may be "involved but,-when this is the casQ,one part of the lungs will be more severely attacked than any other. In this,the disease 'resembles broncho-pneumonia. When one lung is involved, the upper lobe is generally most severely attacked. "ETIOLOGY. --A person who has the tuberculous diathesis is ex- posed to the ordinary causes of inflammation but the inflammation takes an the acute tuberculous character. CLINICAL HISTORY. 'The invasion may follow one of tws "types which differ in their degree of acuteness. " 1 - These eases are very acute indeed. The invasion is as acute- as that of labar-pneumonia. There are sudden rigors accompanied 'and followed by a fever,101-104 or higher,cough,repeated and large ;haemoptyses which may last for a few hours or several days. The 225 other symptoms usually continue but the haemorrhages generally stop. - 2-The invasion is more gradual. At first,the patient will not be sick enough to go to bed. He has a cough with some mucous ex- pectoration. He gets short-winded and loses appetite, flesh, and strength. There will be a little evening rise of temperature and it may be weeks before he will go tobed. The haemoptyses are • sometimes present and sometimes absent. When present,they present 'the same characters as in the first class of cases. When the disease is fairly established,the patient is pretty sick. The morning temperature is 101-102: the evening usually about 104 but it may be higher. The pulse becomes more rapid and feeble* There is apt to be sweating at night or in the early morning. The sweating will often be vehy profuse. The cough continues and 'it is apt to be very painful 'and very harassing . There is profuse expectoration. At first, the expectoration consists of mucus*, then, it is mued-purulent:and,finally,it contains fragments of the bronchi and dead lung tissue! The expectoration becomes more and more abundant as the disease goes on. The expectoration may at any time be mixed with more or less blood. The patient becomes 226 a good deal emaciated. The breathing becomes rapid and moi*e or less labored. The smaller the extent of lung involved,the better they breathe and vice versa. .The tongue may become dry and coated. - PHYSICAL SIGNS.- 'The physical signs resemble those of broncho-pneumonia and vary with thd anatomical condition of the lung. If there be a pleurisy^ we get crepitant and sub-crepitant rale if the lung be consoli- 'dated,dulness on percussion,bronchial voice and bronchial breath- ing. The bronchitis gives sub-crepitant rales-,and,as cavities are .produced in the bronchi,cavernous breathing. - DURATION*- The cases vary as to the acuteness of the disease after the in- vasion* In some cases-, with an active invasion, there will be no let up and they will die within one or two weeks# Others last longer and the symptoms are net as acute. They get worse and worse and it may be a number of months before they die. Still other cases,after an aexite invasion,gradually get .better. The'temperature falls,the cough becomes better,the physical signs begin to disappear^and the patient may get out, of the house and 227 attend to business. Yet,as a rule*, they do not get well. Parts of the lung are damaged and,after a time,a chronic inflammation will be developed in these damaged parts. This is what usually happens. - DIFFERENTIAL DIAGNOSIS. - - 1'-'Prom lobar'pneumonia*- It may be three weeks before you dan positively differentiate between the two. It is often impos- sible to' do so at first. - 2 -From broncho-pneumonia,especially from the sub-acute form that occasionally occurs in adults,--It may be impossible to dis- tinguish between the two. - 5- prom empyema. - PROGNOSIS'.- It is possible for a patient to recover from acute phthisis but, such recovery is very rare.It can only take place when there sire no areas of dead lung tissue and when the extent of tubercular inflammation is small in comparison to the extent of the general inflammation. So,as a rule,the prognosis is bsd* All the patients''do not run through the acute course but those who do' get better for a time generally develop chronic phthisis. - TREATMENT.- The treatment is not satisfactory. Put the patient "to bed,give a fluid diet,keep the temperature down with antifebrin, and check the cough with opiates. To relieve the dyspnoea,give inhalations of oxygen. As they emaciate,give cod liver oil. 228 - CHRONIC TUBERCULAR INFLAMMATIONS - These seem to have the character of local inflammations* They fol* low two main types which differ very much. ~ 1'-The main product of the'inflammation is miliary tubei'cles which are slowly and gradually produced* This we call chronic miliary tuberculosis of the lung. - 2-This form follows very much the type of acute phthisis./' In addition to the tubercular inflammation, we have a good deal of"another kind. The lung tissue becomes much changed by both the tubercular ana general inflammations* This we call chronic phthisis* ' '• in this disease t^e essential lesion is the production of miliary tubercles which are at first scattered singly or in groups through- out one lung, generally at its apex* Then,if the disease progress, ^he whole of the lung first affected will be studded with them* If it proceed still further,the inflammation will extend to the ilpper lobe of the other lung and,if'fully developed, the miliary tubercles' will stud the surfaces of both lungs* The tubercles are harder and larger than in acute tuberculosis ahd they are often changed into fibrous tissue or into cheesy Satter. - 1- CHRONIC MILIARY TUBERCULOSIS" 229 When once framed, they never disappear. This is the necessary and essential lesion and,in many cases,it will be the only lesion but we may have complications. These are the following. - 1 - We may have a bronchitis which may be catarrhal or may in- volve the walls of the bronchi. If it involve the walls of the bronchi, the bronchi will become dilated.' These dilatations arc apt to be sacculated and cavities will gradually be formed in A' the lung. This is a very common and very important lesion. - 2-The pleurae may become inf la-med. When this is the case, hew connective tissue will regularly be produced. The pulmonary pleura will be thickened and adhesions will be formed between it and the costal pleura. - 8-There may be a complicating interstitial pneumonia which will result, in the formation of a new tissue, sometimes connective tissue,sometimes granulation tissue. The air spaces will be pressed upon' by the new tissue and complete consolidation of the lung may result. .- 4--*«j>he lesions of vesicular emphysema may be added. The air spaces will become dilated. This may involve part of one lung, The; whole of both lungs,or the whole of one lung. These complications influence th£ physical signs and the clin- ical history. 230 There is another feature about the pathology. This is that,al though in many cases,the inflammation remains in the lungs:in others, the patient, will after a while develop tubercular inflammations of other parts and. it will seem as though he were infected by the disease.Thus,the larynx may become the seat of tubercular inflammation.Ulcers will be formed and the structure of the laryn- geal walls will be changed. This is often very important. In like manner,the intestines will be attacked:the agminate and solitary glands will be affected. This tubercular inflammation of the glands will bo followed by the formation of ulcers. This lesion of the small intestine has an important bearing upon the general nutrition of the patient:as soon as the glands are involved,he loses flesh more rapioly. We may have other extensions of the disease hut they are of lass importance. These two extensions and the compli- cating lesions in the lungs are of the greatest importance. It is equally important to remember that there may be no extensions. SYMPTOMS• Of course the invasion is slow and. gradual. The clinical symptoms are so slowly developed that many cases in the early stages of the disease have none at all. It is perfectly possible for a man to die of some other disease and,at the autopsy,to reveal miliary tubercles in his lungs. When the disease is developed,there are nine symptoms. 231 - 1 - as the disease goes on,some eases will Ifave haemorrhages from the bronchi. The patient may suffer from them for several d.t<y$j then, they may stop and the patient will feel just as well as he was before but,after he has once had them,he is apt to have them again with other symptoms. Some do not h^ve them. Some have thorn early,others late in the disease. - 2- After a time, the patient will have an irregular fever. Fever is not a constant symptom during the early stages. As a rule,it does not amount to much in any of. the patients. The evening rise of temperature may be followed by sweating at night. - 5-The patient loses flesh and strength. At first, this loss is trifling then,he loses more but,even after the disease is well advanced,the emaciation is often not progressive. The patient mey even begin to gain flesh and regain all he has lost and,then go down hill again. - 4-The character of the cough varies with the character of the lesion. Some have none. This is especially apt to be the case when the miliary tubercles are the only lesion. That the cough may be absent,! must ask you tn remember. If the patient have a cough,it may be due to the pleuritic adhesions,to the bronchitis, rr to the laryngitis. If due to the pleuritic adhesions,there will bo no expectoration. If it be due to the bronchitis,it will be accompanied by a mucous nr muco-purulent expectoration. 232 The expectoration will vary in quantity and character with the condition of the bronchi. If the bronchi be dilated,it will be plentiful,decidedly purulent,and may contain fragments of dead lung tissue- If the cough be due to the condition of the larynx, there will be a laryngeal cough either alone oi' associated with the other two. - 5*-Shortness of breath at first upon exertion then it becomes more and more marked. If the emphysema, be developed to a marked •degree, the dyspnoea will be more decided and there may be spas- modic dyspnoea. - 6-Most of the patients lose their appetite even before they become very sick. This often has a great deal tn do with their loss of flesh. - 7-The pulse and heart usually become rapid and remain so through- out the 'disease. This is generally more marked in women than in men. The pulse may vary but it is generally about nne hundred. - 8-If the larynx be involved,there will be pain in the larynx in addition to the cough. This pain will especially be manifested in swallowing for it is the upper part of the larynx that will be ulcerated. - 9 - The tubercular inflammation of the intestine gives two symp- toms. The first and most constant symptom is the rapid emaciation of the patient. The second and less constant is diarrhoea. 233 It is not necessary that a patient with tubercular inflammation rf the intestine should have diarrhoea. Some do not have it and because a patient has no diarrhoea,you must not assume that he cannot have a tubercular inflammation of the intestine. - PHYSICAL SIGNS.- These vary with the anatomical condition of the lung* There may be absolutely no physical signs* This is true of very many of the cases and it is very important that it should be remembered* 'When we have no physical signs,it means that the only lesion is the miliary tubere1es* If "the re be a pleurisy, we will get dulness^ sub-crepitant and coarse rales,and the intensity of the voice will either be diminished or increased. These signs will usually be heard beneath one clav- icle- If there be a bronchitis,we will get sub-crepitant and coarse rales,sibilant and sonorous breathing,and,if cavities have been formed, we will get gurgling rales- Over the cavities,we may get dulness,tympanitic,vesieo-tympanitic, nr cracked-pc.t resonance: cavernous and bronchial breathing: and bronchial voice or cavernous voice according to the size of the cavity. lx there be an interstitial pneumonia- and consolidation has t^ken place,we will usually get nothing more than dulness on percussion. If there be an emphysema,we will get exaggerated pulmonary breathing nr diminished pulmonary breathing: and dulness or the wooden per- 234 cus&ion note. - COURSE.- 'Trie course of the disease varies very much in the different pa- tients . *-I - In some the history will be as follows. First, the patient notices that he has a dry cough- then,he thinks that he is begin* ning to lose flesh and he weighs himself. He notices that his appetite is not what it was and that he is losing strength. He has uneasy feelings about the chest. These may simply be feelings of oppression or they may be acute pains. They will trouble some much,others little. He may spit up blood. Now,he goes to a phys- ician. The physician examines his chest. At this period of the disease,there will be no physical signs or,at the apex of the lung,there may be dulness,diminished breathing,and,perhaps,a few sub-crepitant rales. G-enex*ally, the dulness/is the only thing. The patient will go an in this way for a number of years,then, the symptoms will go away and he will return to his former con- dition of health. - 2-Others will have spitting of blood in greater ar less quan- tity. - 3-Others may have an irregular foyer and a rapid pulse. The fever will be highest in the afternoon or evening. They go on for years,at times bet ter,at other times worse. They may recover entirely with the lung a little damaged at the apex. This damage does no harm. 235 Others after having for a number of years recovered may have an- other attack. They may recover again but they are not likely to do as veil with subsequent attacks. - 5 - Others will begin in the same way as the first class of cases but they will not at any time get better. They go on for months c nd years but ci.re never well of all the symptoms. They are generally worse in the^wawSw and better ia the summer. The cough is apt to have an expectoration which will at first consist of mucus,then,of pus. If there be cavities in the bron- chi, the expectoration will be more profuse and it will contain fragments of necrotic lung tissue* The fever will become higher, the pulse will become more rapid,they will emaciate more rapidly, the physical signs will become more marked,and finally they will have tn remain inbed. If the only lesion be the miliary tubercles, the patient may go on to death without giving satisfactory phys- ical signs and the case will be very difficult io diagnose. When we have the accompanying lesions,they will give their symptoms. In many cases,there will be the laryngitis which will be accompan- ied by cough and pain.In most cases,the intestinal lesion will be developed:they will lose flesh more rapidly and die in extreme emaciation. These cases vary as to their duration and as to the degree of development of the physical signs. 236 As tn*the duration,many die in a couple of yearstothers may go on for an indefinite time,the disease remaining active all the while. The difference in the degree of development of the physical signs it very important in making the diagnosis. You may think that the diagnosis is easy but,when you have seen a case,you will realize how a man may die of this disease and yet no physician has made it out. Some are said to have chronic bronchitis:others,emphy- sema*, and others,cancer of the stomach. When they emaciate,they particularly resemble cancer of the stomach. Of course,if the physical signs are present,'there is no excuse for not making the diagnosis. If they are absent,you have to diagnose from the con- stitutional symptoms and the general appearance of the patient. Remember that there may be no physical signs. ■-6-In these eases,the laryngeal symptoms are present before tie pulmonary symptoms. This does not mean that the laryngeal lesion precedes the pulmonary lesion. It means that the pulmonary lesion is not extensive. They will often come to you and complain of the laryngeal cough and pain. As a rule,they do badly. The pulmonary lesion extends and they die. -•7--In a few cases,thelesion will be developed early while the pulmonary lesion will not be extensive. These cases also do badly and soon die. These are the most difficult cases 237 to diagnose for they may have no cough,pain,dyspnoea,or physical signs. There will be tuberculous ulcers in the intestine. They may or may not have diarrhoea. Some are impossible to diagnose. - MODES OF DEATH. - When chronic miliary tuberculosis proves fatal,the patients fre- quently die of exhaustion and emaciation. Sometimes,they will die early in the disease from a sudden oedema involving both lungs. This oedema is sometimes caused by exposure to cold. At other times,the patient will go on naturally until,suddenly,the breathing will become oppressed,there will be venous congestion,the temper- ature will rise,and \he will die in a few days. They may die from an intercurrent lobar pneumonia. They may develop a complicating Bright's disease and then they seem to die partly from the Bright's disease and partly from the pulmonary lesion. The treatment is the seme aS that of chronic phthisis and we will consider the two together. - TREATMENT.- - CHRONIC PULMONARY PHTHISIS.- The lesions are for the most part developed slowly. They are inflam- matory in character and they run a slow course but,from time to - PATHOLOGY. - 238 time, there may be attacks of acute inflammation, This is very important far it makes a difference in the pathology and history of the disease. The lesions are much the same as in acute phthisis: the principal difference is in the chronic character of the inflam- matory process. The bx^nche^pneumenia is present with its charae- terete tic changes. The bronchitis is more important in this disease than in ^eute phthisis fer it'may exceed all the other pulmonary symptoms. Surrounding the brenehi,we have the ^ones of hepatiza- * tian in which the air vesicles are thickened and obliterated and their cavities filled with inflammatory products. The lung between these zones is consolidated and the air vesicles filled with pus-, fibrin,and epithelial cells. There are,as in chronic miliary tu- berculosis,miliary tubercles,areas of necrotic tissue, the pleurisy, and the tubercular inflammation of the larynx and intestine. In some eases,the disease follows acute phthisis:in others,it is chronic from the outset. - PHYSICAL SIGNS.- The changes are of such a character as to give regular physical signs. In this important respect,chronic phthisis differs from chronic miliary tuberculosis. The physical signs ai*e due to consolidation,bronchitis,cavities, ' 'pleurisy,and,sometimes,to perforation of the lung. ->1-The consolidation gives dulness* If a large part of the lung 239 be consolidated,we will get flatness,tympanitic,or vesieo-tympan- itic resonance according to the extent of the consolidation. The breathing also varies with the extent of the consolidation. It may be bronchial,broncho-vesicular,diminished,or entirely absent* The consolidation also gives changes in the voice. The voice may be louder,higher,or bronchial.' The consolidation also gives increased vocal fremitus. - 2-The bronchitis gives sub-crepitant or coarse rales and,oe- casionally,sibilant and sonorous breathing. The pleurisy gives dulness which is sometimes well marked and friction sounds which are either creaking or rubbing in character or resemble crepitant or sub-crepitant rales. 3-The cavities give dulness, flatness, tympanitic, or cracked- pot resonance: bronchial, cavernous, or amphoric breathing: cc-arse and gurgling rales: and,if of large size., the so-called "metallic tinkle3. They do'not alter the voice. 4-If perforation of the lung take place,we have the condition of pneumo*thorax and get its characteristic physical signs. 240 - RATIONAL SYMPTOMS.- - 1-The patient may cough up blood which may have one of two sources. It may.come from the mucous membrane of the trachea and bronchi or from an eroded vessel in a cavity. It is absolutely necessary to remember that a person who coughs up blood need not' necessarily have phthisis. A man may have one large haemorrhage of a pint or more with no lung lesion whatever. This sometimes happens after severe muscular exertion especially in young men at college who go in for athletics. They may never have another* Great mental excitement may be followed by large haemorrhages. Women who do nut menstruate may have large haemorrhages from time to time without any pulmonary lesion. A person may have a single haemorrhage from no cause whatever. Persons with aneurism of the arch of the aorta may have a large and fatal haemorrhage. Some . persons,especially pregnant women and those who suffer from or- ganic heart disease may have several small haemorrhages due to a pharyngitis. We occasionally find persons,bo th men and women who for months and years will cough up small quantities of blood and,yet,they wi11 not have phihisis. When a person does have chronic phthisis,he is very apt to have haemorrhages. Two-thirds of the patients have them. Young persons, under fifteen years of age do not often spit- up blood. The cases vary as to the number and frequency of the haemorrhages. They 241 aiso vary as to the perioa of the disease at which tney occur* As before mentioned., the haemorrhages vary as to their source* This is important for if the haemorrhage come from the trachea or 'bronchi even if it be very extensive it is the rarest thing 'in the world for it to prove fatal. If it come from an eroded ves* sei in a cavity, it often proves fatal. The patient- may simply bleed to death or the blood that wells up in the trachea may be drawn into the bronchi and the patient may suffocate. The bleed** Ing comes without coughing and some patients hardly know whether 'they vomit' the blood or whethex' it comes from the lung. When the haemorrhage has ceaseci,the patient will continue to cough up elots Tor a number of days. Some patients will not have large haemorrhage: but will repeatedly cough up small quantities of blood. The bleed** ing 'from cavities comes late in the disease but it may occur in patients in whom the lung lesion is but of moderate extent^indeed no larger than your fist. In this affected portion of lung,there will'be a cavity and,running across this cavity there will be a pulmonary vessel of some size which will become eroded. This sort bf bleeding does not of necessity come from the patients that have given the most marked symptoms. The liability to suffocation is limited to those patients' that bleed from eroded vesselsTn cavities. This is difficult to understand. We would think that those who bleed from the bronchi would be equally liable to suffo- sati^n. - - 242 -- Cough is a very common but not a constant symptom. Some eases have hardly any. The cause of the cough varies* In some cases,it is due to the condition of the pharynx and is a throat cough,not a chest cougiu In other aases,it is due to the condition "of the larynx which may be the seat of a catarrhal or tubercular" inflammation. In'others, it is due to-a catarrhal or tubercular- inflammation involving the trachea and bronchi. In others, it is ' due to 'the pleuritic adhesions. The patients that cough very hard are apt io vomit and the vomiting interferes with their nu* trition. In some eases,the cough will be accompanied by expector* ■ 'atioh. Whether the*expectoration will be present or not,depends' upon the cause of the cough. If the cough be due to the condition' 'of the pharynx or to the pleuritic adhesions,there will be no "expectoration. If it be due id the condition of the larynx or " ''bronchi, there will be an expectoration which will consist, at first, "of mucus and, then, of mucus and; pus.' When cavities are formed, frag- '■ merits of dead lung tissue will be added to the expectoration. --3-• Dyspnoea,especially on exertion is very common. The degree 'of dyspnoea is partly proportionate to the extent of the lesion "'and partly to the character of the patient. The nervous patients 'will get more dyspnoea out of their lungs than those that are ''not nervous. The nervous patients may develop very marked dyspnoea 'on exertion even early in the disease. 243 - 4--Pain over the chest is not at all a constant symptom. Some have none at all,others have slight pain,others will complain of it very much. The pain may be referred tn the situation of the lesion or to the whole of that side of the chest in which the lesion is. •-5 - As a rule,the pulse is increased in rapidity. This is true of the great majority of the patients. The pulse remains rapid throughout the disease. It usually becomes rapid before any febrile movement although a patient may have a rapid pulse without any fever. ~'6 -Fever is a regular symptom and,in some patients, the first symptom will be an evening rise of temperature* In others, the fever will not be developed until a few months before death. In others,it will come and go. It seems to be due to the inflarma- tory changes in the bronchi and its height is proportionate to the severity of the bronchitis rather than to the extent of the lung lesion. A person may have the whole of one lobe of one lung con- solidated but,if there be no bronchitis-,he may have no fever. This is important.'When cavities are formed and,especially when they have necrotic walls and there is death and softening of tis- sue, then a febrile movement is constant and then,also,it is highest. The height of the temperature will vary from 102-104. 244 - 7- Disturbances of the stomach are very common- Some patients lose their appetite. In other cases,the cough will be followed by vomiting. In the long eases, a chronic catarrhal gastritis 'will be developed which will give its symptoms. These gastric 'disorders often become important considerations in the treatment. " - 8 '-Diarrhoea belongs to the later stages of the disease and it may be present with or without miliary ulcers in the intestine. When once developed,it is difficult to control and generally means that the case will soon terminate fatally. LThe laryngeal symptoms are cough,difficulty in speaking and swallowing, and loss of voice. - 10-As the disease goes on, the patient will lose flesh and 'strength but the emaciation is more marked in chronic miliary ■'tuberculosis than in ah®bhip'phthisis. The variety of cases is almost infinite - 1 - The patient has a cough which is at first, dry. He finds •'that he is losing a little flesh and strength. He suffers a little from dyspnoea on exertion. He suffers from intermittent pain or discomfort over the upper part of the chest. He has haemorrhages । either profuse or scanty. On examining the chest,you get dulness, 'prolonged expiration,a loud and high pitched voice,and a few sub 4 crepitant rales. He continues to lose flesh and strength and 'the - COURSE. - 245 symptoms progress. There will be a mucous expectoration. The haem- orrhages will be repeated. The physical signs will become more marked. Then comes the fever which is highest in the evening and falls in the early morning. There may be sweating when the fever falls. The patient has loss of appetite,vomiting,and diarrhoea. Now,we get the physical signs of cavities. The expectoration be- comes more profuse. The patient gets worse and worse and, finally., he dies because there is not enough lung left tn breath with. Sometimes,after death,a 'portion of the lung only four inches in diameter will remain aerated. -:2- These cases begin in the same way as the preceding but the lesion remains confined to a small part of the apex of one lung and,after a time,the active inflammation will stop. As this sub- sides, the symptoms gradually disappear and the patient returns to good health. He may never have any more trouble or,after a num- ber of years,he may have another attack. The second attack may either involve the same part of the lung as did the first or it may in- volve other parts. The patient may recover from this second attack and have another. - 3-These eases begin as acute phthisis. -4-The inflammatory changes involve a considerable part of the lung but,not to any extent,the mucous membrane Of the bronchi. The patient has little or no cough and,for many months,no other 246 symptoms them loss of flesh and. strength and. a rapid pulse. How,, ever, when you examine hhe chest,you get the physical signs of consolidation. After a time,he will begin tn get worse rapidly but,yet,there will be little or no cough. Now,if you examine the chest,you will get the signs of cavities of some little size. These, cavities are dilated bronchi,. After this5he does very badly and is soon confined to bed. - 5 - In these cases,the condition of the bronchi is very notic- able. The disease seems to follow the course of the bronchi of both lungs. The patient spits up mucus and,perhaps,blood. The bronchitis becomes worse and worse and the coarse and sub-crep- itant rales become more and more marked. The patient seems to run down pretty rapidly with the same signs of bronchitis but with few signs of consolidation. Some do badly but others will do «uite well. The bronchitis will disappear and they will do well for a time at least. Whether they ever recover or not,I do not know. When they are placed under unfavorable conditions,the disease is apt to reappear. -PROGNOSIS.- The prognosis is important,especially in the early stages of the disease. When the disease is far advanced,of course,the patient will die. In the early stages,when only a small part of the lung is involved,the prognosis depends upon the hereditary character 247 of the disease,upon the social position of the patient,and upon the character of the disease,itself. - 1-The hereditariness of the disease. If the patient belong to a tuberculous family,the prognosis will be worse than if he did not. If the hereditary predisposition be well marked,the prog- nosis will always be serious. - 2- The social position of the patient. In many cases,it is really a question of money whether the patient will live or die. This is one of the hard features of the disease. ■-3-The character of the disease. When the disease is developed rapidly,they do worst. Those cases in which the bronchitis is absent and in which the disposition to necrosis is not marked do better. - TREATMENT. - We include under this heading the treatment of chronic miliary tuberculosis. The treatment has two objects. The first is to ar- rest the inflammation if possible-, this is the more important. The second object is to relieve symptoms-, this is of considerable importance for the patient may suffer very much. - 1-To arrest the inflammation.- We must remember how the disease advances. In some cases,it does not proceed steadily but in a succession of attacks. It is on account of these attacks that the patient gets worse. 248 Each exposure will bring on the inflammation in other parts of the lung. In other cases,the patient will get worse by a gradual extension of the lesion. This extension is not due to exposure. The lesion simply keeps spreading. The most efficient method of treating patients with this disease is to place them in a proper climate but,in saying to what sort of a climate they should go and how long they should stay there,we must be guided by the man- ner in which the disease progresses. If the disease progress by successive attacks,the patient should go to a climate where bronchitis and pneumonia are unknown and he should stay there for the rest of his life for,no matter how long a time may have elapsed,he will be liable to another attack should he return. He should go to a dry climate where the land is elevated. Whether the climate should be warm or cold,depends on The patient. If the disease progress by $ gradual extension of the lesion,the patient should be sent to a place where his general health will continue the best but,when he shall have found this place,you should tell him to stay there a month or two then to go somewhere else and to spend two years in this sort of travelling. Then, he may return. 249 - 2- We treat the symptoms.- - a - The cough.-Try tn determine upon what it depends. If it be due to the condition of the pharynx,local applications will be the best treatment. Use medicated sprays that the patient can use himself. A two per-cent solution of cocaine combined with boracic acid,carbolic acid,sulphate of iron,or with a little opium makes the best local application. The two per-cent solution of cocaine alone is very good. You should treat the posterior nares as well. By this method of treatment,you do not destroy the patient's digestion. If the cough be due to the condition of the larynx, it should be treated in the same way,by means of sprays and powders. If it be due to the condition of the bronchi,you will have to give drugs internally. In selecting drugs for this purpose,have an eye to the digestion and give those drugs that will least impair it. Use the same drugs as in acute and chronic bronchitis and always give the^ in pills or in powders, or in capsules. If the cough be due to the pleura,make such applications to the skin of the chest as can be kept up for a long time without raising a blister. Spirits of turpentine:croton oil:and the tincture of iodine,al- though it is more severe.,are good for this purpose. If the cough be spasmodic-,give those drugs that we use for hysteria,assafoet* ida and valerian. Treat the general health and do not pay too much attention to the cough. 250 - b * The digesti®n. - The treatment of the digestion is of great importance. Many of the patients lose flesh and strength because they do not get enough fned and because they d© not digest their food. This treatment is of the greatest importance in the early stages of the disease. In some of the patients it is only neces- sary to avoid internal medication and the appetite will return ' In other eases,this is not enough and we have to feed them* We do better with the fats than with any other articles of food. Milk,cream,and cod liver oil are the fats to be used. If you give milk., the patient must take three or four quarts a day and, if he is to take this large quantity of milk,much,if not all,other food must be witheld. You may let the patient, have one square meal a day. If he do not take the milk readily,add to it bicarbonate' of soda or oxalate of cerium. I do not. think that peptonizing "the milk does any good. Sometimes,the patient will do better with cream and water.Those who cannot take the milk,should,if possible, ' take the pure cod liver oil:if they cannot take the pure oil,give one of the emulsions. Do not limit the patient to the tradition-^/// al three drams a day. Let him take as much as he can digest. Others who 'cannot take milk can be fed with beef preceded by a tumbler of very hot water. Others cannot, be fed in any of these ways. In. these eases,use the stomach tube* First wash out the stomach then,'without removing the tube,pour in milk or meat powders. 251 should be done three times & day. Others can.eat food either .with the aid nf an alkali in a bitter infusion before meals or an acid with the meals. Others will eat better if iron or quinine be given before meals. - 3-If the patient be constipated,give laxatives and if in* digestion be due to the liver,give choIagogues. -4-in gome patients,anaemia is developed early. The anaemia does not always show itself by the condition of the patient. The test is the systolic murmur in the second intercostal space.- NOTE. This is what Prof. Delafield said in 1887. In 1888,he stated that the connection of the murmur with anaemia was still under discussion and that it was a question of what value the murmur is in the diagnoses of anaemia and he said that there was no ques- tion that it was not to be considered as absolutely diagnostic of anaemia.-If anaemia be present,give iron and quinine. - 5 - When they spit blood in small quantity,do not treat the haemorrhages directly. If the haemorrhage be profuse and come from an eroded vessel in a cavity,you can do nothing. If a pro- fuse haemorrhage come from the mucous membrane of the trachea and bronchi,we can control it to a certain extent. We rely on three drugs,ergot,gallic acid,and ipecac. If you give ergot,give the fluid extract in dram doses every half,one,two,or three hours. It is very nauseating and many patients will not be able to take it. If you give gallic acid,give it in pill form or in solution with sulphuric acid. Give grs.v at a dose and repeat it frequently. If you give ipecac,give gr.j in pill every hour. - - 252 Some patients will nn be able to take it and will vomit. With each of these drugs,it is often benificial to give opium in small doses,, either combined with them or given hypodermically. - 6 - Sometimes.,the sweating requires treatment,, An efficient way to treat it is to sponge the patient with hot water at bed time* You may give drugs. The mineral acids: the extract of bella- donna: a tropine: and the preparations of zinc,particularly the zine oxide aie benificial. Antifebrin has already proved of service for this'purpose either when given alone or combined with atropine. Give it in three grain doses three times a day. - -When the laryngitis gives pain in swallowing,it must be treat- ed. Send the patient to a throat specialist. •' T ' - 3 -When diarrhoea sets in,it is apt to be troublesome. It comes late in the disease. You can sometimes control it with calomel-, 'iron, arsenic, acetate of lead,or bismuth each combined with small doses of opium but, in many cases-,you cannot control it at all- - S - In a moderate number of cases, the pain becomes a decided symptom. Fortunately,this is comparatively rare. There is only one thing to do and that is io give opium. - 10 - When the disease is far advanced and there are large cav- ities'" in the lung and especially if these cavities have necrotic ' walls,the question of treating them through the wall of the chest arises. This method of treatment has been alternately t.ried and 253 abandoned for many years. It comes into fashion and,then,goes out again. These cases are bad cases and,even if you cure the •avities,the phthisis goes on and the patient dies of that. How- ever,this idea of treating-the cavities is perfectly rational and', if done to relieve an immediate emergency, it is good treat- ment. If the cavity be large, it is apt to be situated near the anterior wall of the chest. Inject carbolic acid through the chest wall. Repeat the injection from time to time. There is no danger in doing this and it is of real service. But,you must not expect to cure the phthisis. You will cure the cavity and that is all. Another method of treatment is to let the patient breathe compreg- sed aim This also seems to be rational and is fairly applicable to those cases in which the phthisis takes the form of chronic miliary tuberculosis whether the bronchitis be absent or present. If the bronchitis be present,it is only an additional indication for this form of treatment. The theory is that the compressed air changes the rapidity of the circulation through the lungs* So, if the patient breathe compressed air during one part of the day and rarified air during the rest of the day,the circulatinn>%hrowgh the lungs will be rendered more active and this increased activity of the circulation will tend to stop the chronic inflammatory 254 process. It has been found to benfiit a moderate number of eases. - PULMONARY EMPHYSEMA. - 'This name is applied to a disease of the lung in which the air space s become dilated or in which the connecfive - tissue septa between the lobules become infiltrated. So,the disease is divided into two classes,the vesicular and interlobular. -- INTERLOBULAR. - The interlobular is not of much importance. It occurs with other and more important lung lesions,such as broncho-pneumonia in young children. In these cases,while parts of the lung show the ordinary lesions of broncho-pneumonia,the lobules in other parts will be infiltrated with air. - VESICULAR. - There are three varieties,the senile,compensating, and substan- five and each is different from the other. - Senile.- This is developed in old persons as a textural change,the result of old age. Both lungs are pretty uniform, ly affected. The lungs remain of normal size or they may become somewhat smaller. The air spaces and air vesicles are dilated but there are no inflammatory changes. In some eases,there is an additional chronic bronchitis but this has nothing whatever to do with the emphysema. 255 - Physical Signs. - These are the same as those of substantive emphysema. We get the signs of chronic bronchitis when it is present. There are no other symptoms and the patient is none the worse off than for any other senile change. It is hardly to be considered as a disease. It does no harm and requires no treat- ment. - COMPENSATING.- A change takes place in one lung or in part of one lung to make up for some destruction of lung tissue. For example,in empyema, ►pleurisy with effusion,and chronic phthisis the unaffected lung becomes larger. This is really an hypertrophy of the healthy lung. AH'its parts become larger and,of course, the air spaces with the rest. It does no haimi and the patient is all the better off for it. It gives physical signs but no rational symptoms. This is of real consequence. It is a morbid condition,it is very common,gives well-marked symptoms,and may prove fatal. It is en- tirely different from the- others. It is really a chronic inflam- mation, a chronic interstitial pneumonia which involves the air spaces,bronchi.,and the connective-tissue framework throughout the lung. It belongs to adult life and usually occurs in persons who have reached forty years. - SUBSTANTIVE.- 256 Sometimes, it occurs in persons who are younger. The hereditary predisposition is well marked. Some persons seem to have an ac- quired disposition for the disease. Persons suffering from any form of gout,but especially the chronic form are liable to emphy- sema. The modes of life that dispose to chronic endarteritis also dispose to emphysema. - PATHOLOGY. - Both lungs are changed. Often,there are old pleuritic adhesions* The surfaces of the lungs are puckered. This is due to bands of fibrous tissue that extend inward. from the surface. The lungs are larger than they should be. The bronchi are regularly the seat of a chronic catarrhal inflammation and their walls are somewhat '' thickened with new connective tissue. The walls of the larger blood vessels are thickened. The connective-tissue septa between the lobules will be irregularly thickened throughout the lung. The air passages and air vesicles are enlarged but vary in size" in the different cases. The air spaces are more dilated than the air vesicles and they are dilated before the air vesicles. The air spaces are-often dilated when the air vesicles are not dilated* The extent of dilaiaion of the air spaces is not in proportion to the severity of the disease. A patient may die with bu^ a moder- ate dilatation of the air spaces and may continue to live when they are very much dilated. So,the extent of dilatation does not 257 seem to be the important part of the lesion. Ilie epithelial cells of the walls of the air vesicles are larger and more numerous. Some of the cells will be thickened:others,thinned. This thick- ening and thinning take place irregularly. Little holes are formed in the walls of the air vesicles. At first,these holes are so small that they can only be seen with a high power. They are usually circular,sharply cut,and their edges do not show any structural changes.They are found both in dilated and undilated vesicles. How they are formed,we do not know. When once formed,they increase in size and may become quite large. The blood vessels can be read- ily injected after death. The walls of the larger vessels may be thickened and more'"rigid and, when the holes in the air vesicles are large,the capillaries will be displaced. But there is some obstruction to the passage of blood through the lungs during Ufa, for one of the symptoms of pulmonary emphysema is venous congestion and,in some cases,we get dilatation or dilatation and hypertrophy of the right ventricle. -Associated Lesions.- - 1-Mcst cases develop secondary lesions due to venous congestirn. The liver,spleen,kidney,and the mucous membrane of the stomach/ x py and intestine may each nr all be the seat of venous congestion. As in heart disease,the venous congestion may cause dropsy. In some patients,there will be a less of flesh and strength due to 258 congestion of the digestive organs. -2-The dilatation of the right ventricle or the dilatation and hypertrophy or dilatation of both ventricles belongs to the severer eases. - 3 - Chronic catarrhal bronchitis is the most common. -4-Chronic inflammation of the endocardium of the left side of the heart,particularly of the mitral valve. -5-Chronic inflammation ©f the aorta and all its branches. This is very common. -6- The atrophic form of chronic diffuse nephritis. This is very common. -7-A considerable number of the patients develop increased arter- ial tension. This we are accustomed tn associate with chronic diffuse nephritis but,in these cases,it is due to a chronic con- traction of the arterioles. This is of great importance as it is one of the most serious of the associated lesions. Fer a considerable time,the chest will remain of normal size. , This is important. In other eases,a curious prominence of the^ costal cartilages on each side of the Sternum will be developed. The sternum,itself may be protruded. This is very common and tolerably characteristic. In a moderate number of old and fart- advanced cases,the whole thorax becomes rounded. The patient is -PHYSICAL SIGNS.- 259 then said tn have the "barrel chest8of emphysema* The muscles of the chest may become hypertrophied by the dyspnoea and add to the apparent dilatation of the thorax- In the early stages,percussion may give normal pulmonary reson- ance* When the disease is further advanced,the most common per- cussion note has a wooden quality and a high pitch. When you first hear it,you may mistake it for dulness but upKn~omparison with dulness,the difference in quality becomes evident enough. This wooden percussion note is exceedingly characteristic of the disease. In other cases,we get an exaggerated resonance which may either be pulmonary oi* vesico-tympanitic in quality. If there be exten- sive pleuritic adhesions,you will get dulness at certain points. The breathing is usually changed early in the disease but it is changed in different ways.In some eases,it is only more feeble than it should be;in others,you will get prolonged expiration: and,in others,the expiration will be exaggerated. If there be no bronchitis,these will be all the changes in the breathing:if bronchitis be present,you will get the sub-crepitant and coarse 'rales and,sometimes,sibilant and sonorous breathing. In some cases, we get the sibilant and sonorous breathing when the patient suf- fers from asthmatic attacks. 260 RATIONAL SYMPTOMS. - -1-Tne most common is dyspnoea which may be of three kinds. These are dyspnoea on exertion,constant dyspnoea,and spasmodic dyspnoea* -a-Dyspnoea on exertion.-This is often the first kind of dyspnoea from which the patient suffers. It may be the only dyspnoea he ever has and it may be the only rational symptom. ~b-Constant dyspnoea.-After a time,this comes on in the more severe cases. The patient suffers from it even when asleep. Some are always fighting it,others are not troubled by it to any extent. and will make no effort to overcome it. When once established, it is L-erious whether they feel it or not. -e-Spasmodic dyspnoea, asthma. - From time to time, the patient wiL, have attacks of this in addition to the constant dyspnoea. -2- Another common symptom is bronchitis with its ordinary symp- toms. It has nothing to do with the emphysema. It is important" to remember that you may have emphysema without any bronchitis'. -3- In some cases,the condition of general venous congestion becomes established. The patient loses flesh,becomes anaemic, and developes dropsy. '■ " ' - . -4- At the same time as the venous congestion is established, there is liable to be still greater loss of flesh and a still greater disposition to dropsy. The patient will also become anaemic and develop cerebral symptoms.This is due to increased arterial ien* sion. . " 261 - 5- Complicating endocarditis,gout,etc.will give their symptoms. COURSE. A.11 the cases may be divided into three classes. These three classes differ very much. '--1--In these cases,the substantive emphysema is never anything more than an inconvenience. The patients are often large-, robust, strong,and florid. They may be athletes. They may enjoy good health to old age:then,when they exercise,they are short of breath. This is the only symptom they ever have. These patients form quite a large class, - 2-In these, the dyspnoea and bronchitis are very marked features^ The cases vary as to which comes first and as to which is the worse. They also differ in the kind of dyspnoea that they have. These are the most common of all the eases that are seen in hos- pital, dispensary, and clinical practice. Some only have the dysp- noea and bronchitis and do not-die of the bronchitis but others, after suffering for a certain length of time,will develop venous congestion and high,arterial tension and will die. - 3-These are the least common and,while they are of the great- est importance,they are frequently overlooked. The physical signs Iare the only pulmonary symptoms. After a time,they will gradual- ly develop venous congestion and high arterial tension followed by c erebra!* . symp toms, and death. 262 These three sets of eases differ so much that different physicians according to their experience have very different ideas of the disease. Some have only seen the first class of cases and think the disease very trivial. Others have only seen the second class and regard emphysema as it is exemplified by this class. Most physicians have little or no idea of the third class. So the third class of patients is frequently overlooked. In order to appre- ciate what the disease really is,you must remember these three classes. - TREATMENT. - We may almost exclude the first class of cases for these patients do-not as a rule apply for treatment. In the second and third classes,we have first to treat the condition of the lungs:In some cases,we can exert a direct influence upon the inflammation.This we do by regulating the patient's mode of life.The patient should live out of doors as much as possible. He must not use alcohol or tobacco in any shape. To a certain extent, the. starches and sugars should be avoided. In-other words,,' he should adopt the same mode of life as patients should who are suffering from chronic gout. For medicines,it may be neeessary to give the fats in the form of cod liver oil or cream. We may give iron. The patient may inhale compressed air and breathe it into rarified air in order to change the condition of the circula- tion in the lungs. 263 -2 ■-The constant dyspnoea*- This may be dependant on one of two conditions. In some cases,it is due Vo changes in the lungs and fop these,climate is of a great deal of importance. There is no good rule for the selection of a climate. The patient must find one fc.r himself. Many patients can find a country where they can live in comparative comfort. In other cases,it is dependant not so much upon changes in the lung as upon a permanent contraction of the arterioles of the lungs,the condition of high arterial tension. It can often be relieved by the drugs which cause dilatation of the arterioles. We have some drugs that do this very nicely. You may give iodide of potash grs.v-grs.xx t.i.d.,according to the susceptibility of the'patient and keep it up for some time. You may give nitro- glycerine, gr.1/100 once to four times a day according to the sus- ceptibility of the patient and keep this drug up for a consider- able time. You may give chloral hydrate,grs.v t.i.d* These are the three most efficient drugs. They will not remove the dyspnoea when it is caused by changes in the lung. •- 5-The asthmatic attacks.- The cause of these attacks differs so the treatment differs also. In some cases,it seems to depend upon a spasmodic contraction of the muscles in the walls of the bronchi. In these cases,,the inhalation of the fumes of strammo- nium and nitrate of potash,the inhalation of chloroform or ether* emetics which act promptly,belladonna,the compound spirits of ether,and opium are of service in relieving the attacks. 264 In other cases,the asthmatic attacks are caused by a sudden con- gestion of the bronchi. These eases never have asthma unless they develop bronchitis. In these cases,we do best if we employ means to diminish the congestion. We may give drugs that will rapidly cause an increased production of mucus from the mucous glands. For this purpose,we may give grindelia,lobelia,or jaborandi. Instead of this,we may employ counter-irritation over the chest. This is best effected by dry cups applied pretty thoroughly. In- stead of either of these means.,we may *ive drugs that increase the action of the heart,particularly the action of the right ventricle. For this purpose,you may give caffeine with conval- laria or you may combine these two drugs with small doses of dig- italis. In other cases,the asthmatic attacks seem to be due to increased arterial tension. In these cases,the contraction of the arteries is spasmodic,not continuous. During most of the time,the arteries are in their natural condition. We may give drugs that diminish the contraction of the arterioles. We may give nitrite of amyl by inhalation or,if the attack be prolonged,we may give chloral hydrate in fifteen or twenty grain doses,nitro-glycerine,or five or ten drops of Magendie's solution hypodermically according to the severity of the attack. For the long-continued eases,give iodide of potash. 265 Lastly., the asthmatic attacks may be largely due to the condition of the nose. There is a chronic naso-pharyngeal catarrh which thickens the mucous membrane of the nose and part of the mucous membrane of the posterior nares. In these cases.,use local appli- cations. When you treat an attack of spasmodic asthma,you should always try to find out the cause for one method of treatment will not do for all the cases. - 4-If -they suffer from bronchitis,employ the regular treatment according as the disease is acute or chronic. - 5'-The venous congestion and high arterial tension.-These are the most difficult symptoms to treat and,as a matter of fact,we can only palliate them. ''When a patient has developed these symp- toms, it usually means that the emphysema, will kill him if some thing else do not kill him first.He will have lost flesh and strength and there will be a tendency to dropsy and ^erebral symptoms.We may give drugs that increase the force of the heart,such as con- vallaria and caffeine combined with digitalis. We may give drugs ' that dilate the arterioles,nitro-glycerine and iodide of potash. In some cases-,we may give both sets of drugs at the same time. With cod liver oil and iron,we may relieve the anaemia:with cod liver oil,we can keep up the nutrition: and,by a change-of climate, their lives can be much prolonged. 266 The alternate contractions and dilatations of the heart are ac- companied by two sounds and two interva Is of silence. The first sound is syncronous with the apex beat,the ventricular contraction, and the closure of the cuspid valves. The first sound is the louder and longer arid it is heard over the whole heart but most distinct- ly at the apex* The first silence is short. The second sound is syncronous with the closure of the semi-lunar valves and it is most distinctly heard at the base of the heart. The second silence is longer than the firsts The main points to remember are the things that are syncronous- with the sounds of the heart. When we suspect any heart trouble.,we go through a certain routine of examination which should never be departed from. In the first place.,we determine the size of the heart. This is easily done. Percuss from above downward till you strike the up- per border. In the same manner,you find the position of the other borders. Then,determine the position of the apex with your finger. The right border is more difficult, to locate for the st.ernum is in the way. In many eases,you can determine the size of the heart - THE HEART.- 267 perfects well in this manner* In the mere difficult eases,,use the stethoscope while percussing. There are very few hearts the size of which cannot be determined i^ this manner. In the second place,we determine the force of the ventricular contraction. This we do by placing the hand or ear over the heart. At the same time,we notice the contrast between the force of the heart and the force of the pulse at the wrist. We determine the rythm of the heart,whether it is too rapid,too slow,or irregular. This is of great importance. We determine the character of the h^art sounds,whether or not they are as they should be. We may find that murmurs are present. These murmurs may be of several kinds. - I--The Pericardial Murmur.-This may be produced by fibrin, on the surface of the pericardium or by pericardial adhesions. It may be heard during the first sound,second sound,or second interval of silence. Sometimes,it is only systolic,diastolic,or presystolic but,at other times,.it may be heard during any two of the periods or during all three. It is not as syncronous with the heart sounds as the endocardial murmurs are. It has no point of maximum intensity.lt should be a superficial murmur and so it is in a great many cases butrsometimes,it sounds as far off as the endocardial murmurs. 268 Its intensity and point of maximum intensity are apt to vary in a few hours. When most characteristic,it resembles a pleuritic friction sound but it may be soft and blowing like the true heart murmurs. In these cases., the diagnosis is very difficult and-, ex- cept by other conditions, it may be impossible t<o distinguish be- tween the two. - 2 - Endocardial Murmurs. - These are produced in the heart. In a certain number of cases,they are produced at the mitral and aortic orifices:less frequently,at the pulmonary and tricuspid. They may be caused by roughening, stenosis,or insufficiency of the valves. If the aortic valve be stenosed or roughened,there will be a mur- mur with the first sound of the heart. It should be heard at the aortic valve:and should be transmitted upward along the course of the great vessels. If the aortic valve be insufficient,there will be a murmur with the second sound of the heart. The point of maximum intercity will be at the base of the heart or the sound may be transmitted all the way down the sternum. If the mitral valve be insufficient,there will be a murmur with the first sound of the hear^T The maximum intensity will be over the apex of the heart and the murmur will be transmitted to the. left,sometimes■as far as the back. 269 If the mitral valve be stenosed, there will be a presystolic mur- mur which will be heard during the period of second silence. The point of maximum intensity is at the apex. The murmur is very localized and is not transmitted. These are the most common murmurs. The right side of the heart is net frequently diseased and the diagnosis of its murmurs is very difficult. Stenosis or roughening of the pulmonary valves gives a systolic murmur over the base of the heart a little to the left. Insufficiency of the pulmonary valves gives a murmur with the second sound of the heart in the same position. , If the tri-cuspid valve be insufficient or stenosed,there will be either a systolic or presystolic murmur over the apex of the right ventricle. I think you will make fewer mistakes if you disregard the right side of the heart altogether. When I try to diagnose a pulmonary or a tri-cuspid murmur,I am much more frequently wrong than right. The left side of the heart is diseased in ninety-nine cases out of every hundred. ' Endocardial murmurs are also produced by change in the left ven- tricle. These changes are caused by endocarditis.. The endocardium^ corda tendinae,or papillary muscles become roughened. Thrombi may cause these murmurs or they may be due to congenital iendanous 270 wTds stretching across the cavity of the ventricle Any" one or all of these conditions may exist when the valves are perfectly normal, The murmurs that they produce are sys toile*.. Their pain/ of maximum intensity is at the apex* Hwy are localised. - There are other murmurs the true nature of which we do not under- stand* Some of them are called "anaemic murmurs"and they are heard in the perfectly healthy heart. Others are present when the pa- tient is'in perfect health. They are systolic and have two points of .maximum- intensity. The first point of maximum intensity is at' the apex, the second is in the second left intercostal space. When they occur in a perfectly healthy person, tEere is no satisfactory explanation of their cause. They have two peculiarities. In the first place, they are- circumscribed, some times not being transmitted more than half an inch. In the second place,they are heard better with the ear than with the stethoscope. Sometimes when heard with 'the ear, they cannot be heard 'with the stethoscope at all. In anaemic persons,they are very common and are almost always heard in the second intercostal space. In these cases,some believe that the murmur is due to insufficiency of the mitral valve caused by a weakened state of the papillary muscles. Others hold that the murmurs are due to accumulation of blood in the right auricle which,overlapping and even compressing the roots of the aorta and pulmonary artery,may produce stenosis and,thus,a murmur* 271 - INFLAMMATIONS OF THE PERICARDIUM. - - 1-PERICARDITIS WITH THE PRODUCTION OF FIBRIN.- - 2-PERICARDITIS WITH THE PRODUCTION OF FIBRIN AND SERUM. -. - 5-PERICARDITIS WITH THE PRODUCTION OF FIBRIN, SERUM, AND PUS.- - 4-TUBERCULAR -PERICARDITIS. - Pericarditis differs from pleurisy in the following respects. There is a tendency to the effusion of blood with the inflammatory products. There is much less of a tendency to the formation of permanent new connective tissue. If the pericarditis be not very severe nor long-continued,there will be no change in the heart nor in the connective tissue out- side of the parietal layer of the pericardium. If the inflammation be intense,there may be a degeneration nr an interstitial inflam- mation of the muscular fibres of the heart. Pericarditis generally begins at the base of the heart and travels downw&rd.When fibrin alone is produced,it varies greatly in quan- tity; In some cases,you will not be able to see it with the naked eye after death. In other cases,the pericardial sac will be dis- tended with it. Between these two extremes,there are all grades. If serum, be present,it will first accumulate in the lower part of the pericardial sac. 272 As more is produced, it begins to creep up on all sides and, often, the heart will rise in the fluid.The sac will be enlarged and it will be displaced either to the right or to the left. As the dis- ease goes on,especially if pus be present,the fluid will crowd the diaphragm downward,the lungs to one side,and you will get dul- ness beneath the upper part of the sternum. -ETIOLOGY.- Hericarditis is but seldom a primary condition. It almost always occurs as a complication to rheumatism*. It is a tolerably common complication of acute and chronic Bright's disease. It may complicate any of the infectious diseases. Inflam- mations of the lungs and pleura,especially lobar pneumonia and double pleurisy may be complicated by pericarditis. This complica- ting tendency is so common that when you find a patient has peri-* carditis,you ask him what other disease he has* This is one of the ways in which chronic Bright's disease is first recognized. - PHYS I GM SIGNS. - These vary with the character of the inf lamination. If fibrin alone be present,you will get a friction sound) the peri- cardial murmur. The systolic murmur is much the most common* If the fibrin be present in great quantity,the heart-will be : increased in size* This will be manifested by an increased area of cardiac Guineas. When the murmur is soft and blowing,we depend largely on the history^ 'Tell the patient to take a full breath,and then st©$ 273 breathing. You can sometimes bring it out in this way or by firm pressure with the stethoscope. When serum and pus are also present,the friction sound will be present at the commencement of the disease but,towards the close* it will gradually be absorbed. If the serum or pus be present in large quantities,the friction sound will disappear but we will get changes in the percussion note due to the pi^senee of fluid and depending upon its quantity, in some eases,we will get dul« nesssin others,flatness but the size of the heart may be the same in both cases. We. may get dulness as high as the upper border of the sternum. If the fluid be present in very large quantity, there may be a bulging of the precordial region. In some cases, we can see that the heart has been carried upward in the fluids This we determine by the position of the apex. The apex may he carried as high as the third intercostal space and it may be dis- placed. If we place the hand oyer the apex, we may get a thrill. You must remember that the patient may have endocarditis at the same time or he may have had it previously. In either case,you will also get the endocardial murmurs. - RATIONAL SYMPTOMS.- The rational symptoms are pain: rapid,feeble^and sometimes irreg- ular heart:rapid and sometimes oppressed breathing:difficulty in s wa 1 Lowing: f e ve r * and pro st ration. 274 These symptoms vary in intensity. They are least marked when fibrin alone is present-most marked,when there is fluid* If fibrin alone be present,we may only get some pain, fever, and a rapid and feeble heart action. Should the patient already have rheumatism, the heart symptoms are apt tn be overlooked. In these eases,we depend prin- cipally upon the physical signs in making the diagnosis. If fluid be present, the symptoms will be mere marked and will^onsist chiefly in an interference with the heart's action and with the , / breathing. The heart will be rapid, feeble, and often irregular^, 7^ Z • This will be followed by an accumulation of the blood in the veins and dropsy may result The breathing will be rapid and labored. This is partly due to an interference in the pulmonary tyii'culatinn and,partly, to the pressure of the enlarged pericardial sac upon the bronchi at the root of the lung,. The pressure on the oesoph- agus may interfere with the swallowing. When this happens, the prostration will be more marked. -TERMINATIONS.-Of those who recover,many get well within a week or within two or three weeks. Many recover with no permanent damage to the pericardium. At other times,adhesions will be left. A pericarditis with fibrin alone seldom proves fatal by itself. The patient generally dies of some of the complicating lesions.. When a person already suffers from one of the complications., a pericarditis with fibrin alone may suffice to kill him. If fluid 275 be present, the case will be much more serious* The patient will Suffer more,, the inflammation will last longer,and may prove fatal by itself. In other cases,instead of killing the patient,the inflammation will become sub-acute and the patient may live for weeks and months with fluid in the pericardium and then recover. When pus is present, the patients do badly. They do not die at once .but the inflammation becomes chronic and they die in several months* - TREATMENT.- When fibrin alone is present, the indications for txxjatment are not very marked* The disease is not dangerous and it is a question whether we can do anything. We may employ counter-irritation or cold over the pericardial region. This would certainly be rational treatment. If the pulse be rapid, feeble, and irregular, cardiac stimulants will be indicated. I think that it is good practice to combine those stimulants that affect the right side of the heart whith those that affect the left. For this purpose,combine digi- talis and caffeine. If the inflammation be more severe and if fluid be present employ counter-irrigation and cold and continue their use as long as the inflammation shall be acute. Cardiac stimulants will be plainly indicated. Use those mentioned above. 276 When the inflamination is sub-acute,we must try to get rid of the fluid. This we may do in one of two ways,we may puncture the sac or we may decrease! the amount of drink and increase the amount of urine. Sometimes the first measure should undoubtedly be resor- ted tc<,yet,I should advise you carefully to consider before em- ploying it. It is very easy to puncture the heart even when there is a great deal of fluid present. It is also easy to mistake a dilated heart for an enlarged pericardial sac. This last mistake is of considerable importance for death may follow it in a very short' time. So,you should be absolutely sure of your diagnosis and, if you aspirate, remember that the heart is higher than it sheuld be and direct your needle downwards. Puncture where the heart is uncovered by lung. For the second purpose,diminish the amount of drink and increase the amount of urine. Measure their respective quantities every day. If this be persistently carried out,the fluid will regularly diminish. ENDOCARDITIS. The endocardium is a connective-tissue membrane. The number of sells an< bloodvessels is not great and it may be compared to a tendon* The blood-vessels take but little share in the 277 process. The basement substance and cells are the parts af fee ted. So^w do not have any serum, fibrin and pus as a rule. The changes are either a simple swelling of the basement substance or an increase in number of the conneetiye-tissue cells. The increase in the connective-tissue cells may thicken the membrane or the cells may break down and leave ulcers. The fluid blood is always passing over the endocardium and,if the .blood is to circulate properly, there should be no thickening and 'conformation of ulcers. If either of these things happen, the constitution of the blood is changed and fibrin is deposited upon the roughened surface of the endocardium. The inflammations of the endocardium may be classed under three heads. - 1-ACUTE ENDOCARDITIS. - -2-MALIGNANT ENDOCARDITIS, - - 5-CHRONIC ENDOCARDITIS.- - 1-ACUTE ENDOCARDITIS.- The part of the endvea-ixiiu^ lamed, is the valves* The endocardium lining the ventricles may be inflamed but this is not frequently the ease. The aortic and mitral valves are regular* ly inflamed The valves - of^'he'*right side -of the heart are seldom 278 inflamed after birth but,in the foetus, they are sometimes inflamed.* An inflammation of the mitral or aortic valves may affect these valves in one ©f two ways. In the. first place., they may simply become thicker without any coagulation of blood upon their surfaces As the valves are apt to become a little shortened at the same time that- they are thickened,the effect of such thickening will be to prevent their complete closure. As a result, there will be a regurgitation of bloods In the second nlace., the valves will be- come swollen as before but,in addition there will be a new growth of cells. Ths endo-cardial cells will increase in number and size^ some of them will fall off,the valves will become more swollen, and their surfaces will lose ..their smoothness. Then, the growth of cells will continue until |ittle knobs are formed. At first, these knobs are of small size "but they exist in considerable num- bers* Now, the fibrin of the bla©& begins to be deposited in layers of varying size and thickness* /In 'home casea, the inflammation will stop when it has reached this point* In other cases, the knobs will increase in size and,as the fibrin accumulates,vegetations will be formed. Vegetations are long, soft processes that hang out from the valves. Now,parts of the valves will begin to degenerate and ulcers will be formed. In these way a, the valves become much changed,notched,and vegetated. । The second form,of course.,is much more serious than the first* 279 If the patient recover from the first form of the disease, the swelling of the valves will subside and his recovery may be per- fect. If a patient suffer from the second form,although he may get well,his valves will be permanently damaged and will either be stenosed or insufficient. Furthermore,the patient is liable to embelism,for the portions of coagulated fibrin readily become deta ched and may become lodged in any part of the body. - ETIOLOGY - Acute endocarditis is not often a primaiy disease. Most of the eases accompany rheumatism and scarlet-fever,particularly the farmer. There are eases which seem to occur without any exciting cause but these are rare. It may occur in persons whose hearts are already subject to disease. For instance,, the patient may already' have changes in the valves,either from a previous attack of &cute end©earditis or from a chronic endocarditis. -PHYSICAL SIGNS.- These depend upon the changes in the valves. If the valves be insufficient,we will get the characteristic murmur of mitral or aortic regurgitation. If the valves be not only insufficient but reughened,we will get the aortic systolic murmur. We do not often* get'a'pre-systolic mitral murmur but it is possible for the patient to have both valves involved,and then we will get both murmurs* 280 When the disease occurs with rheumatism,as a rule,it follows the ^inflammation of the joint,but,there are exceptional eases in which the disease is developed early in the rheumatism or it ma^ even precede it. A person may have endocarditis without having had rheumatism* If endocarditis complicate scarlet-fever,it will usually follow that disease. The most marked symptoms are due to disturbance, of the hearths action. There may be no fever, and the disease d*es not seem, to produce any great degree of prostration. The prostration seems to be due td the disturbances of the heart1 s .action. In some eases.,we have the symptoms of embolism,particularly if the emboli become lodged in the brain. The changes in the action of the heart seem to be developed in two ways# In the first place, the ventricles may contract too forcibly,/^ the heart will work harder than it should, the first sound will be exaggerated, and the impulse will be very distinct. The heart may also be tumultious and irregular and its eontrac*'- tions too rapid. As a result of all this., the circulation of the blood will noi properly eondue-ted and there will be .a tendency to vera2UJ5.-rw^^^ SYMPTOMS 281 In the lungs,there will be a congestion of the blood-vessels and^ an infiltration of serum and. even the commencement of a pneumonia* The lung will become unfit for breathing. Serum'will accumulate in the pleural cavity interfering more and more with the breath* ihg. In the brain, the effusion of serum may produce cerebral' sytop- toms*' There may be an infiltration of the peritoneum ar there may W congestion of the spleen, liver,or kidneys and the urine will be* esme scanty and may frequently contain albumen. Thre may also be congestion of the stomach and intestine which' will interfere with the digestion. The general venous congestion may produce dropsy of any part off the body but particularly of the feet and legs> The second way in which the changes in the heart's action are de- veloped is of an entirely different character. The heart simply becomes rapid and feeble,, like that of a patient far advanced In typhoid fever. As a rule., this does net produce venous congestion but it does produce syncope whqph may prove fatal. It also causes pain#cardiac dyspnoea,and marked prostration. The patient also b e comes anaemi c. So the rational symptoms do not depend upon the changes in the valves but upon the endocarditis. 282 The most favorable cases are those in which the valves are simply swollen. These may get well altogether. However,in most of the eases*, the valves are more or less damaged and the patient recovers with "them roughened and insufficient. It makes a good deal of difference as to how much damaged the valves are. If the damage be but moderate^ the patient may go^ bn with no further trouble or the heart may become slightly hyper* 'trophied. It is also important whether the Inflammation comes to a standstill or whether it is -succeeded by a chronic endocarditis*' 'The latter condition would continue to make the valves worse and worse from year to year* A patient may die as a direct result of the disease. - TERMINATIONS.- - TREATMENT.- *If the disease complicate acute articular rheumatism, the treatment of the rheumatism will,to a large extent,be the treatment of the heart. Give the salicylate of soda,oil of wintergreen,or salicin in considerable doses. We may also apply cups,blisters,or cold to the cardiac region. I prefer blistering pretty thoroughly by means of the nitric acid issue. 283 If the heart be exaggerated and tumultuous in its action, and if there be a tendency to venous congestion,give opium and chloral hydrate either separately or combined in small doses at regular intervals. If the venous congestion be decided, the opium and chlo- ral hydrate will not suffice. We must relieve it. Employ blood letting or apply leeches over the abdomen,thorax,and thighs and aPply poultices afterwards-. You may purge the patient or you may sweat him by means of the hot air bath. If the heart be rajpid and feeble,give alcohol and digitalis either alone or combined with convallaria and caffeine. - 2-MALIGNANT ENDOCARDITIS. - This disease is also known as ulcerative endocarditis and as diphtheritic endocarditis. - PATHOLOGYk--Any part of the endocardium may be inflamed but that covering the valves of the left side of the heart is most liable to be attacked. The greater part of the pathology is the same as that of one of the forms of acute endocarditis. There is a growth of connective-tissue cells in the substance and on the surface of the endocardium. Ulcers and vegetations are formed and the blood coagulates in the same way as in acute endocarditis but there is one point in which the pathology of the two diseases differs. - - 284 In malignant endocarditis.,we have the bacteria of suppuration. If we injure the valves of a healthy animal and,at the same time innoculate him with the bacteria of suppuration,he will have malig- nant endocarditis. If we innoculate without injuring the valves^ he will simply have pyaemia. So,,in order that a patient shall have malignant endocarditis,two conditions are necessary.. In the first place.,he must have an ordinary endocarditis.^ in the second place,,he mu$t be innoculated with the suppurative bacteria. The disease may attack either a healthy heart or one that has been previously subject to acute or chronic endocarditis. Embolism may be„a-complicating lesion and it is rather more common in this than in the acute form of endocarditis. The patient is liable to other complications such as acute menin- gitis., pericarditis., bronchitis pneumonia,pleurisy., rheumatism-, or in- f lamination of the parenchyma of the liver or kidney. Women in the puerperal condition are also predisposed to it,as are persons suffering from pneumonia and. rheumatism. However,in many cases.,we are not able to discover a cause. -- ETIOLOGY 285 - SYMPTOMS.- The eases differ as tn the preponderence of the general or local symptoms. Usually, the general sym^tops greatly predominate and the disease is apt to be overlooked for,in the first place, the local symptoms may be very slight and., ijji the second place, if the patient has already had valvular disease,you are apt only to recog- nize the old murmurs. The general symptoms are much the same as those of any infectious • disease. The patient suffers from fever, rigors,and vomiting. There may be diarrhoea.and the patient may pass blood. The pulse and breathing are rapid but usually not labored. Af ter a time, the pulse is apt to become feeble. The fever commences with the disease and continues throughout. It is apt to be high, 10 3-107 and rise's as the disease progresses. There may be sudden falls of temper- ature. These are only temporary and do not signify that the patient is any better* In some cases, there will be pupura haemorrhagic a as in typhus or yellow fever. The urine is often albumenous and scanty. There may be an inflammation of the joints as in pyaemia If the cerebral arteries be blocked up by emboli,we may get the characteristic symptoms depending upon the size.,position, and number of the arteries occluded. The patient passes more and more into the typhoid condition. The urine is retained,the faeces are passed involuntarily,and,unless he die of embolism,the patient will'die as a direct result of the disease. 286 The duration and severity of the disease vary. Some of the patients die in two,threeyor ten days- The first few days of the disease may not be so very severe; then, the patient will suddenly become worse end die within twelve or twenty-four hours- Other cases last three,four or five weeks and,in these,the symp- toms are not very severe at first and there may be periods of improvement:then,the symptoms will go on again. The disease is not at all uncommon. So far as I know-, the disease is always fatal. There seems to be no good reason why a patient with malignant endocarditis should not recover except that he never does. - PROGNOSIS.- The treatment is much the same as for any severe infectious dis- ease. Nurse the patient: keep him on fluid diet: and give cardiac stimulants. - TREATMENT.- 287 - CHRONIC ENDOCARDITISr- The inflammation may attack either the valves or any part of the endocardium lining the auricles or ventrieles^but that covering the valves of the left side -of the heart is most liable to be af- fected. The cases vary as to whether more than one of the valves is inflamed and also as te whether the rest of the endocardium be affected or not. ~- PATHOLOGY 5- The disease exists under two anatomical forms. - 1 - The valves become hardened-^thickened,and retracted* on account of their retrac tion, they may not close as they should or, on account of their st iff ne is,, they may 'become stenosed. The surfaces may re- main smooth oi' may become covered with smooth vegetations. These vegetations, however, give no cause for coagulation* When these con- ditions have lasted for some time., the salts of calcium may be de^ posited in the valves making them harder and more rigid. So this form leads to stenosis and insufficiency but not to coag- ulation. -* 2- This form is characterised by a marked growth of connec tive tissue cells resulting in the production of vegetations of consi* ' derable size and in the disintegration of the valve & and cardium. 288 The valves become rough, ulcerated, and irregular and,there is a tendency to coagulation on their surfaces. There may also be de- posits of calcium in the thickened valves. This form also leads to stenosis and insufficiency but it is much more serious than the first form is for the damage that is done is much greater. These cire the two ordinary courses of "valvular disease- of the heart. The valves are first affected,then,there is a change in the cavity of the heart which leads either to dilatation or hy- pertrophy or both of the auricles and ventricles. A disturbance of the heart's action may be added independant of the endocarditis- When this is the case., the patient is so much the worse off. Then,changes in the circulation of the blood due partly to the condition of the valves and,partly,to the distur- bances in the heart's action produce a number of symptoms-. When fibrin is deposited on the valves,there is danger of embolism# So,a "valvular® , or "organic1 lesion of the heart is the result of either acute or chronic endocarditis. -PHYSICAL SIGNS.- - 1- If the lesion is to lead to stenosis of the aortic valves, these valves will become stiffened. When the ventricle contracts and the valves should open,they are too stiff to do so and the aortic orifice will be permanently narrowed. 289 There may be similar changes in the aorta which will add to the stenosis. When a valve is stenosed it is -usually at the same time insufficient. As a rule/, the left ventricle becomes hypertrophied and dilated firsthand then the right. Yet-, they may remain of the normal size or gradually diminish in size until death. The aortic system of blood-vessels does not receive Enough blood. This leads to an accumulation of blood in the venous' system. The characteristic physical sign is a murmur with the first sound of the heart, often prolonged into the first silence-, transmitted up- ward to the right, and heard loudest over the sternum at its middle part atTEe^Tevel of the third costal cartilage.If it be very loud,it can be heard behind on the left side at the level of the second or third dorsal vertebra. Sometimes, it is heard loudest at the lower end of the sternum or, in the second right or left intercostal space. The last of these exceptions is the more im- portant /for it is in this position that we get the ^naemic^ mur- murs ana where we may get the murmur of pulmonary stenosis. In some of the cases, there will be no change in th©, charac tur of ... the heart's action nor in the pulse. This is very often the case particularly in the early stages but, as the disease goes en^we ; do as a rule get an irregularity in the heart and pulse. , 290 When the disease has reached its extreme degree of development, the frequency of the heart may not correspond with the frequency of the pulse. The pulse may be forty and the heart eighty. This means that some of the ventricular contractions cannot communi- cate a pulse through the stenosed valves. The course of aortic stenosis is apt tn be very slow indeed. In many eases-,a marked aortic stenosis will give but little trouble and the patient will continue at his work but,if the disease continue,at some time he will have symptoms. - 2™ AORTIC INSUFFICIENCY. - We may have this with or without stenosis. When it occurs separately, it means that there is no stenosis at all or a well-marked insufficiency with but little stenosis.The left ventricle almost always becomes dilated and hypertrophied. The ventricle cant robots and fills the aorta with blood but,when the valves should contract and fill the aortic orifice,they only partly do so and regurgitation of blood takes place from the aorta into the ventricle. So the cavities of the aorta and ventricle are always in communication and there is at* all times a continuous column of blood between the two. The aorta and its lax^ger branches are always too full of blood and, on this account, there is apt to be an unnatural pulsation of the arteries of the neck yet there is not as a rule any increase of arterial tension. 291 This distension of the arteries of the neck and an exaggerated apex beat are so constant that you can often diagnose the case by looking at the chest and neck. The characteristic physical sign is a murmur which is heard with the second sound of the heart. The point of maximum intensity is over the middle of the sternum at the level of the third costal cartilage but it may be heard loudest at the lower end of the sternum. This is so often the case that it can hardly be considered as an exception but there are two real exceptions to the point of maximum intensity. These are the fourth left intercostal space and the apex of the heart. As a rule, the heart is increased in rapidity even early in the disease but,for a considerable time-,it remains x^gular. As the heart becomes dilated,the increased action of the heart becomes more evident and we notice the increased force of the pulsation - of the larger arteries. All this often goes on far a long time without doing much harm and,even after the heart is considerably dilated,the patient will give but few symptoms. The prognosis is better than in any other valwlar disease. Some patients will have the regular symptoms. - 5-MITRAL STENOSIS. - This change in the mitral valve is found in all degrees of development but we find much wrse cases of mitral stenosis than we do of aortic stenosis. 292 The mitral orifice will often be of no greater diameter than a goose quill and yet the patient may live a long time. We- should get dilatation of the left auricle, then hypertrophy of the left auricle,then dilatation and hypertrophy of the right ventricle while the left ventricle is not changed in size. There are exceptions but,as a rule,we do not look for an enlarged heart. Disturbances in the circulation are developed early. There is a disposition to -emptying of the arteries and to venous congestion. The heart is apt to become irregular at a very eaTly stage and,generally speaking, it is the worst and most dangerous of all the valvular diseases of the heart. The characteristic physical sign is a ££e- -ystolic murmur which is? very circumscribed and heard at the apex of the heart. The only way in which this murmur varies is that it is often absent. If mitral insufficiency be present at the same time,you may get its murmur while that of mitral stenosis may be absent., - MITRAL INSUFFICIENCY* - The mitral valve does not elose as it should and there is regurgitation of blood into the left" auricle; The left ventricle is regularly dilated'and hypertrophied/ There is a great tendency' to aceumu 1 &tion 6f blood in the veins and to emptying of the arteries but this tendency is not as marked as in mitral stenosis. We get a systolic murmur at the apex of th® heart. Il is transmitted to the^left and is often heard behind x 293 on the left side of the vertebral column. This is a very constant murmur and it can be heard at almost any time but you must .remem- ber that we get systolic murmurs at the apex when' there is no cardiac lesion. The non-organic murmurs are more apt to be local- ized. The murmur of mitral insufficiency is heard as well or even better with the double stethoscope than with the ear: the non- organic murmurs are often heard better with the ear and may not be heard at all with, the stethoscope. In making the diagnosis, you should notice the dilatation and hypertrophy of the heart and also whether there be any irregularity in the heart's action, and,when you are doubtful,keep your opinion to yourself. Thes^ cases vary more than any of the others as to the amount ©f trouble that they give* A moderate insufficiency gives no trouble at all. Even when more severe,it is often well bom. Others will do badly at the beginning. This difference seems to depend partly upon the changes in the valves and,partly,upon the changes in the character of the heart's action. Generally speaking,the patient is apt to do well as long as the heart continues regular. The prognosis of mitral insufficiency is more uncertain than that of any of the other valvular lesions. - 5-If both the aortic and mitral valves be affected at the same time,you will get both sets of symptoms. The lesions of the pulmonary and tri-cuspid valves are s© rare by themselves that we will not consider them. 294 -ETIOLOGY.- The disease may occur in one of three ways. - 1 - The patient may have suffered from one or more attacks of acute endocarditis. 1$ these cases the rheumatism is the most con- stant cause of the endocarditis. These cases occur at all ages* - 2--These eases are not caused by rheumatism or if the patient has had rheumatism,it has nothing to do with the endocarditis. The disease is chronic from the outset. Why the patient should de- velop it we do not know but we do know that it occurs in this man- ner in persons who are liable to chronic Bright's disease,chronic endarteritis,and substantive emphysema. These cases usually occur in persons over forty years of age. Many have the gouty diathesis, many have suffered from constitutiolfeal syphilis,and many are al- coholics. Many give none of these cases. - 3-Cases of this class are rare. The valves are ruptured from external violence. This is followed by chronic endocarditis. Nt matter what valves be involved, the general symptoms-, in all casec re nearly the same* - 1 - The different murmurs*-The praotiea point about these mur- murs is that you must not attach too much importance to them* Always listen for them but do not think that they are the neces- s^ry and essential features of the disease. -GENERAL SYMPTOMS*- 295 We may have no murmurs with the two stenoses nor with a general enipoarditi&,nor does the presence of the murmur make the -liagno* sis-.. " •-2-- The size of the heart*-This you should always notice.The best thing that the heart can do is to remain normal in size. If it diminish, the patient,as rule, will be badly off^if it increase, try to determine whether it be hypertrophied or dilated. If it be dilated,it will be increased in size and the apex beat will be diffused and indistinct. As a rule,,if the heart be dilated, the first sound will be shorter and not as loud as it should be and the pulse will be feeble. Dilatation without hypertrophy is, generally speaking,bed. If the heart be simply hypertrophied,it will be enlarged, and the apex beat and first sound will be distinct. If the heart be both diluted and hypertrophied,it will be important to determine how- fur th'*se changes have gone. little dilatation and hypertrophy will be well borne,a great jdeal,badly borne. We must remember that we may have dilatation and hypertrophy without endocarditis. - 3-The action of the heart a.nd the character of the radial pulser- The heart should be perfectly regular and there should be a corres- ponding regularity in the pulse. This regularity will often be retained for a considerable time. 296 This is of great importance for,as long as this regularity is preserved,the patient suffers but little. As soon as the heart's action is changed,he will develop symptoms. The heart's action may become too rapid, too slow,too feeble,too forcible., intermittent, irregular, or tumult ous. The radial pulse will vary in character with the changes of the heart's action,but, in addition., it may be changed by the eon trac- tion of the small arteries. This introduces a new element of dis- turbance in the circulation and,as a result,we have high arterial tension. So the character of the circulation may be disturbed in three ways* Firstly the changes in the action of the hearty second, by c henges in the calibre of the arterioles^ third,,by a combination of the two. These conditions are of the greatest importance ani you should always try to make them out. There may be changes in the character of the heart's action ^nd in the tension of the arterioles without any endocarditis. For in- stance., the action of the heart is often disturbed in functional disease of that organ. We get increased arterial tension in a great variety of diseases. 297 - 4-Some have abnormal sense,tions about the heart. The patients vt.ry greatly in this respect. Many bcri eases do not have them at any time,others will have them early in the disease. The sensations- vary much in character, some will complain of <• sharp pain refer- red to the hec.rt and radiating to the left shoulder or arm,or backward to the spinal column. This sort of pain generally comes in attacks and is severe,sharp,£1.nd inteemittent. Others will simply feel the discomfort of its exaggerated pulsation. Others will complain of a constant dull pain. Others will have a feeling of oppression or a squeezing sensation as if the he^rt were displaced or turned over on itself. It is necessary to remember that any one of these sensations may be present in functional disease of the heart where there is no endocarditis. - 5- We have symptoms dependant on changes in the lungs which are secondary to the cardiac lesion. These are very common. In some, there will simply be a chronic bronchitis with its cough and ex- pectoration. In others,there will be bleeding from the bronchi in tmt 11 quantity or in considerable quantity. This bleeding is es- Apeciolly common with mitral stenosis. The patient may suffer from, dyspnoea which may be due to obstruc- tion to the circulation of the blood through the lungs, to congestion of the lungs,or to fluid in the pleural cavity. Some will develop the complicating pneumonia of heart disease. 298 - 6 - The stomach.- In many cases, there will be no v is turbine e of the stomach. In others, the most constant symptom will be a. severe and decided pain* Thit pain is apparently due to congestion of the stomach* Others will vomit, others will vomit blood in con- siderable quantity. Others will simply have a chronic gastritic. - 7-The small intestine.- There are no symptoms except changes in the patient's nutrition* He becomes anaemic which may be due to congestion of the small intestine. "8-The brain.-There is & variety of cerebral symptoms. These symptoms belong to the advanced and bad cases. Some will complain of faintness,especially on exertion. This faintness may either not amount to much or it may be so severe that the patient may fall to the ground*. The patient may die of syncope in one of these attacks* Others complain of headache and vertigo. Others will develop de- lirium alternating with stupor. Others will have general convul- sions, When these marked symptoms are developed,they generally mean that the patient has a. contraction of the arterioles and the symp- toms are dependant upon this contraction. With the cerebral symptoms-, there will often be a fever-1^1- 103- or even 108^-This fever is often supposed to mean that the patient has developed a complicating meningitis. This is not the case. The fever is simply due to the high arterial tension* 299 The cerebral symptoms may be caused by 'chronic endarteritis af- fecting the cerebral arteries or by an embolus derived from the diseased valves. In the latter case,the symptoms will vary with the size and position of the embolus. - 9 - Dropsy is developed in some patients,not in others. In some cases, it is the direct result of the lesion and the disturbances in the heart's action: in others, it is due to a complicating neph- ritis; and., in others, to the anaemic condition of the patient. -,in-Disturbances in the general nutrition,loss of flesh and strength and anaemia are found in a considerable number of the patients. They may be developed, early in the disease before any other marked symptoms. These changes in the nutrition are always important for,when present, they make the prognosis so much the worse. They seem to be principally due to venous congestion of the stomach,liver,and small intestine. - 11-The condition of the kidneys. - This is always of great importance. There are but few fatal cases which,after death,do not show changes in the kidneys. During the greater part of their lives7many cases will give no kidney symptoms at all. The kidney symptoms belong to the fatal eases and,as soon as they become established,the patient is very badly off. 300 The kidneys may either be the seat of a chronic congestion or of a chronic diffuse nephritis. If they be only congested,the patient will not be much the worse. When the congestion is established, the urine will be scanty,of normal specific gravity,and will con~ tain but few casts and but little albumen. If the kidneys be the seat of a chronic diffuse nephri ti&, the patient will be very badly off for the nephritis will add its symptoms to those of the endocarditis. The kidney symptoms will vaiy 'with the kin-5 of chronic diffuse nephritis which is developed. - 1 - A considerable number, especially at* the younger patients, have an acute attack first ^md,in these eases,the history is very straightforward. The patient has an attack of acute articular rheumatism from which he recovers,but he suffers from dyspnoea on exertion, then palpitation of the heartland then the heart becomes dilated,then hypertrophied, or it may be simply hypertrophied. Sonp go on all right. The disease seems income to a stand-still and*, cS the patient grows up, the increase in the size of the heart is ro longer apparent,and,when he shall have reached the age of forty years, the heart lesion does not interfere with his health. The patient will practically recover. - COURSE.- 301 In other patients of this same class, the disease goes on with intermissions but,each year, there will he exacerbations with symp- toms, They get worse and worse and die at any time below twenty- five and thirty years. Few go beyond this or,if they do, they will, be invalids. - 2-In these cases, there is no acute attack and the endocarditis is not due to rheumatism: it is idiopathic.. As a rule, there are no symptoms during the early stages. Sooner or later,however, they begin to come. Generally, the patient has only one or two symptoms at first. The cases vary as to what wi 11 be the first symptom. Some,having previously been in good health, first suffer from dysp- noea on exertion attended with some palpitation of the heart. When the dyspnoea is once developed, it is apt to remain forever either as a constant op intermittent symptom. In others, the first symptoms will be anaemia and loss of flesh. You have to be careful in these cases for there is nothing to call attention to the heart. Like the dyspnoea,when the anaemia is once developed,it is apt to remain as the prominent symptom. In other cases,the first symptom will be the bronchitis. The patient will simply complain of the cough and expectoration and the disease is apt to be overlooked. If you examine the chest,you will find that the bronchitis is not the primary disease but that it is dependant on chronic endocarditis. The bronchitis is also apt 302 to remain ann be the prominent symptom. In other eases,+h:e changes in the character of fa.e heart's action and the abnormal sensations about the heart will be the first symptoms. These are very easy to make out. In others, the stomach symptoms will come on first* These are not common and are apt to be overlooked. The patient will complain of the gastritis and will say nothing about his heart. In other cases,the dropsy will come on first;in others,the increas- ed arterial tension. The symptom first to present itself will always continue to be the most marked. - 3-In these cases, the disease is chronic from the outset but the symptoms only come on in attacks. Between the attacks,the patient's health is pretty good. These cases vary as to whether the succeeding attacks gradually become worse *ad worse or whether they remain of the same severity, This depends upon whether or not the disease comes to a stand-still. - 4-These cases begin in a chronic manner yet, for months or yearSygive no symptoms except,perhaps,a little shortness of breath or palpitation of the heart* Then,at some particular time,the patient may develop an acute pleurisy,pericarditis,or bronchitis none of which may be very severe yet he will at once give cardiac symptoms.In some eases,the sudden invasion of cardiac symptoms will come on without any cause at all. it is especially the 303 dyspnoea, that will be the prominent symptom. It is severe and distressing. The patient cannot lie down hut has to sit up and lean forward in order to breathe. Hour after hour, the dyspnoea will continue. There will be no let up. When this extreme dyspnoea has once appeared,it is apt to continue till death. These are the very worst cases. Some die in a few days? others last a few weeks. The short cases have no other symptoms: the longer may develop dropsy. The cause of all this is that the condition of increased arterial tension has been added to the old heart lesion. These are the cases in which the heart disease is likely to have complicated emphysema or Bright's disease. Up to this time,the emphysema and Fright's disease may have given no trouble. These cases are not et all uncommon and should, not be overlooked. In all cases,the inflammation way either* go on till death or it may come to a stand-still. If it stop at any time before the le- sion in the valves is far advanced>the prognosis will be good. If it continue,the patient will always do badly. He may go on slowly but he is sure to do badly sooner or later. As we have seen, the prognosis varies with the character of the disease. It also varies with the situation of the lesion. The following table has been given. - PROGNOSIS.- 304 The worst is tri-cuspid regurgitation: next,mitral regurgitation: next,mi t ral s tenosis• next, aorti o regurgi ta tian: next,pulmonavy stenosis: and,least dangerous, aortic stenosis. The condition of the ventricles is of great importance. If they be dilated,if they he very much dilated and hypertrophied,0r if they be diminished in size,the prognosis will he bad. The best cases are those in which the ventricles remain of normal size or become slightly hypertrophied. The character of the heart's action and of the arterial tension is of great importance. If cardiac lesions have already existed, you should always try to find out how rapidly they have been de- veloped. The prognosis is important for you see most of the cases in the early stages of the disease and they want a prognosis* - Modes of Death*- Some die in extreme dyspnoea: others die of exhaustion; others,with narked cerebrtil symptoms: t/i- others, from embolism, of the cerebral arteries. The patients that die a sudden death are few. Sudden deaths are most f requent in cases of marked stenosis. - TREATMENT. - -1-The Stationary Cases.-These cases give no symptoms except the physical signs. They require no medica-tion whatsoever. The only thing that the patient needs is some advice about his inode of life. 305 This advice is exceedingly simple. He should live out of doors, should, avoid tobacco and alcohol,and should diminish the stanches and sugars. He may take exercise and a good deal of exercise. )'any of the cases are a great deal better off for exercise. Of course,the patient should not lift heavy weights nor row reces. If possible,de not tell the patient that he has the disease. Tell his family. -2-The patients that do develop symptoms require treatment vary- ing with the particular form that the disease assumes. In some, the .symptoms seem to depend upon changes in. the heart's ectinn. These symptoms may assume one of two Terms. In the first place,the heart may be too feeble* This will be attended by at- tacks of syncape: loss ef flesh: and*later,dropsy. In these cases, give cardiac stimulants. Digitalis is the best and surest. Ilie best farm is the fluid extract. It does not make much difference which valve is affected nor whether' it he insufficient or sten- osed. In a few cases, conval la ria. and caffeine will do more good than digitalis. We must attend to the general nutrition of the patient. If he be anaemic^.give iron and initiations of oxygen* In the second placeythe heart's action my be too forcible. It is not always easy to tell whether or not the heart is ctmtraet- ing too forcibly. When the heart shakes the chest wall,of ourse it is easy enough to tell,yet,some feeble hearts make a good deal 306 rf fuss. This is important. If the heart be tumultuous but really feeble,give digitalis. If the heart's action, be really too for- cible,keep the patient quiet in the house. This will often be all that is necessary or you may employ counter-irritation by means of the nitric acid, issue kept up for a considerable time. This is the best treatment to adopt. With drugs,you must be very careful. Try to determine how much of the violent heart action ic due to increased arterial tension- If increased arterial tension be the cause,give nitrite of amyl,iodide of potassium, nitro-glyc er- ine,or opium. If these drugs do not answer and the non-medieinal treatment fail,you may give veratrum,viride,aconite,or belladon- na. Veratrum viride is very certain. I very rarely use any of these drugs. If I cannot get the heart to act as it should by other means,! let it alone. I think veratrum viride is a dangerous drug. Besides these plans of treatment directed to the central lesion, look to the gene ral health and relieve symptoms. The question of rest or exercise must be decided in each ease as,likewise,the advisability of giving oxygen,iron,and cod liver oil. If dropsy beconie a prominent symptom,it can be relieved by sweating,purging, diuretics, or by diminishing the amount of drink and incleasing the amount of urine. 307 .We may have dilatation or hypertrophy of one or tf both ventricles* independently of endocarditis. There are no lesions in the valves. There is a variety of these cases. •-1 - Dilatation or Hypertrophy or both Dilatation and Hypertrophy of One or of Both Ventricles*-These changes are apparently the result of long continued and excessive muscular exertion. The pet., ients are most apt to be soldiers, labore rs,or professional athelete* The soldiers have to take long marches and curry heavy weight*. I Lab ore rs., also, have to carry heavy weighty c-nd the tendency to ven- tricular dilatation will be still further increased if they are under-fed and,at the same time drink too much alcohol or beer. In gymnasts,the same thing holds true. - CHANGES IN THE VENTRICLES op THE HEART.- - SYMPTOMS.- la some, a simple enlargement of the heart and an exaggerated and. irregular heart action will be the first symptom. In others, there is dyspnoea on exertion. In either case, the patient simply goes on as if he had a feeble heart and that is all. They are con- sequently short of breath and are finally incapacitated for work. They lose flesh and strength and finally develop dropsy. - P.RngNOSIS^-Apt to be pretty bad. As a rule,no matter what you do they get no better. A patient may have this lesion in. a mild form without any great harm resulting. These cases are not included. 308 The prognosis is ant altogether hopeless* - TREATMENT. - Keep the patient quiet formas the disease was caused by his excessive exertion,you must try to counter-balance it. Keep him in bed. By the employment of massage,you can keep up his health. Give' great attention to the feeding and nutrition. For the heart, give digitalis and convallaria. As a rule.,begin the treatment without cardiac stimulants^ - 2 - Dilatation and Hypertrophy first of the Right Ventricle and,then,of the Left Ventricle.- This is due to pulmonary lesions, such as pulmonary emphysema,interstitial pneumonia,pleurisy with effusion,and some long eases of phthisis. It is also caused by deformities of the chest. There is an impediment to the passage of blood through the lungs and,as a result,the ventricles become dilated. - 3- Hypertrophy without Dilatation of the Left Ventricle.- These cases result from long-continued rapidity of the heart* We get the most common examples of this in exophthalmic goitre. Less frequently,it occurs in persons who suffer from palpitation of the heart. - 4- -We also get hypertrophy of the left ventricle with chronic Bright's disease^ aneurism of the aorta,and when the whole arterial system of vessels is narrowed. - 5 - Dilatation and Hypertrophy of the left Ventricle in Anaemic 309 tad PREGNANT Women. -These eases are curious. In the first place, there seems to be too much blood in the blood vessels* The blood may be impoverished but there is tno much of it all the same. The circulation is embarrassed. There is u call for more work on the part of the left ventricle and the left ventricle increases in size. These conditions are often temporary and the heart often ^returns to its proper dimensions. - 6- The Dilatation and, some times, Hypertrophy of the left Ven- tricle in some of the Infectious 0 seases. - This we see most frequently in scarlet and typhoid fevers. It is said that in some cases the heart reaches such a size as to cause death. I have never seen an example of this but I believe it to be true. In these cases, the increased size of the ventricles is due to changes in the muscular fibres of the heart and to obstruction of the small arteries and capillaries. -7- In these eases,it is difficult to discover any cause. Gen- erally./ooth ventricles an? dilated. The valves may either be in a normal condition or the dilatation may cause them to become insufficient. In some cases-, the structure of the heart will be perfectly normal: in others, there will be a fatty degeneration of the heart fibres or a growth of connective tissue cells between the muscular bundles. The lungs present the pneumonia of heart disease. Early in the disea.se,a congestion of all the viscera is 310 -^tablish^d. Th? re is dropsy in different part'd nf the body, -etiology. ~ The disease occurs in adults,either young or old. Some of the patients have previously been in perfectly good health! others have suffered from slight ailments. Some tell you that the disease followed muscular exertion but^even in these cases,the muscular exertion does not seem to be proportionate to the lesion. They seem to have rather a tendency to remember some muscular exertion in order to account for the disease. - Symptoms. ~ In whatever way the dilatation may have been devel- oped,^hen it has once commenced,it continues to get worse. The symptoms are dife to an irregular and feeble heart. The heart may be rapid and tumultuous. Usually, there are no murmurs but,at other times,you m«y get a mitral systolic murmur due to insufficiency. The insufficiency is due to the dilatation. If the disease contin- ue but a short time before death,severe dyspnoea,congestion of the viscera,with diminished urine which will perhaps contain albumen will be the only symptoms. The patient will suddenly become short winded and will go home and sit dow^. Then, within a few hours, he m^y become unconscious. Then,he vill become conscious ^nd will vomit. The vomiting will also stop after a time but the dyspnoea will continue. Then,the physician will find the pulse small, hard,and irregular: the heart, feeble and enlarged, ills remedies will be of no use. The dyspnoea and the rapidity and feebleness 311 of the heart may continue three weeks,then,the patient will die. There will have been no let up to the symptoms. Other'eases beein in the same way but the symptoms will not be as acute and the patient may last several months or a year. The dyspnoea never real- ly goes away but it is not as severe as in the former set of cases. In the latter, there will often be dropsy and the patient will emaciate. This class of ventricular disease is fortunately not common. When we do see these cases-, they are tolerably char- acteristic. - TREATMENT.-We do not seem to be able to do them any good at all. Even keeping the patient quiet does not seem to do him any good and,at last,ynu will get down to giving small doses of opium. - FATTY DEGENERATION OF THE HEART. - - PATHOLOGY. - Under this name are included two diseased conditions each of which is totally different from the other. - 1-There- is a deposit of fat between the pericardium and the heart. This is of no importance. - 2-The change is in the muscular fibres of the heart. The composition of the fibres is changed. At first, the fibres are infiltrated with fatty granules: then,with oily drops. The heart assumes a reddish-yellow color. It becomes softer and may have a greasy appearance. 312 While these changes in its ^11 are going on, the heart sometimes remains of normal size hut its bulk may either be increased or diminished. When the. size of the heart is increased,this increase is due to dilatation. -ETIOLOGY.-This disease may ant only occur in healthy hearts hut ivlso in those that have previously been the seat of disease. A person may have endocarditis with hypertrophy and then have the fatty degeneration added to the valvular lesion. Sometimes,it is a. secondary condition. The patient may first suffer from pernicious anaemia or from Addison's disease. It sometimes complicates the infectious diseases. It occurs in some patients who suffer from chronic phthisis or from ulcer of the stomach. However,when it is a secondary condition,it is not as likely to give marked symp- toms as when it is a primary disease. The primary cases are more common in males than in females,in the middle-aged and elderly, and. in persons of the gouty diathesis. It is also more common in the upper than in the lower classes. - PHYS IG aL SIGNS. - These a.re no t decided and simply depend upon a feeble and irregular heart. If the heart remain of normal size, percussion will tell you nothing. If the heart be increased in size,we can make out this enlargement. If it be diminished in size, it will be very difficult to make out this condition by percussion. The feebleness of the heart will show itself by the diminished 313 force of the apex beat and the indistinct and muffled chi; meter of the first sound. The irregularity you will detect by placing either your hand or ear over the heart. If the patient be anaemic, you may get the systolic murmur. These are all the physical signs. RATIONAL SYMPTOMS.- Some of the patients complain of pain. This pain may either be dull and constant or may come on in attacks and shoot into the left shoulder or arm. Some will suffer from syncope or vertigo after exertion. These symptoms are always alarming and may prove fatal. The patient may develop coma or convulsions which may either let up or may termini^te in death. Some have dyspnoea on exertion, others constant dyspnoea. In many of the1 patients, the general health is poor. Some will have attacks of angina pectoris which may prove fatal. As a rule,we have neither dropsy nor venous con- gestion in this disease. - COURSE.- - 1 - These give no eardiac symptoms and die of some other disease. - 2-The disease has apparently existed for some time,yet, the patient has no symptoms til|suddenly,he will have an attack of coma,angina pectoris, or syncope and will die from this first attack. He may die from rupture of the heart. These cases are pretty common. There is no pretense of making a diagnosis nor is there any necessity of making one. The patient generally dies 314 at night in bed,ar while taking a bath,er while sitting in a chair. Death is exceedingly sudden. - 5™ These give symptoms for months ox* years an< die in an attack of syncope, corca, rupture of the heart, nr simply f rom anaemia and emaciation. - TREATMENT. ~ It is only in the long-continued eases that the question of treat- ment comes up. Improve the general condition of the patient by massage. Regulate his mode of life. He should live out of doors and should not exert himself too much. Put him on a nutritious diet but do n^t allow him. too much fat. You may give cardiac stimulants. Give digitalis in small doses and keep it up for a long time. It must be confessed that treatment may not be veiy satisfactory. A number of the cases of rupture of the heart belong tn the disease that we have just discussed but there are other conditions that may cause the heart tn rupture. There may be a chronic endarter- itis nf the coronary artery which will result in obliteration nf some of its branches- This will be followed by degeneration of the muscular fibres in the adjacent part of the ventricle. - RUPTURE OP THE HEART.- 315 The fibres will become thinner and thinner and will at last rup- ture. -ETIOLOGY.-Fatty degeneration and endarteritis of the coronary artery are the two common causes of r.upture of the heart. The left ventricle is most frequently ruptured and,generally, the rup- ture takes place on the anterior wall,near the septum and near the apex. Less frequently, the right ventricle is ruptured, gen- erally,on its anterior wall. Least frequently,the right auricle ruptures. The rupture is never of large size and it may take place either rapidly or slowly. If the rupture take place rapidly,the blood will escape with a rush. If it take place slowly,the inner surface of the heart will rupture first and the blood will burnw through,and it may be a day or so before the rupture vill be com- plete. SYMPTOMS.- These vaiy with the rapidity of the rupture. If the rupture be sudden, the patient will at once pass into a state of collapse and will die in a few minutes.In some eases,death is almost instantaneous. Such rupture does not always take place after exertion. These eases of sudden rupture are the ;most common. If the rupture be gradual, the re will be a period of several hours or days during which the patient will give symptoms. He will have a sharp and decided pain about the heart. 316 Often,he will vomit. At first,there will be prostration and the surface will be cold. There will be difficulty in the breathing. The heart's action will be prolonged and feeble. These symptoms will continue till death. - NEUROSES OF THE HEART.- - 1- PALPITATION. - - 2-ANGINA PECTORIS. - -3- FALSE ANGINA PECTORIS.- - 4- EXOPHTHALMIC GOITRE. - These diseases give well-marked symptoms. They are dependant not on anatomical lesions but on some interference in the nervous system,particularly in the sympathetic. - 1 - PALPITATION OF THE HEART. - As a rale, there is no change in the stricture of the heart but, when the disease has lasted some time,the patient way develop an hypertrophy of the left ventricle or a dilatation of the right auricle but this has nothing to do with the disease. In most cases, there are no changes in the heart. Although we say the patient has palpitation M the heart,we do not really mean that the heart beats too forcibly. A certain numbex* do develop disturbances in 317 the heart's action, others have disturbances of sensation referred to the heart,and others both. The best marked eases are those with both sets of symptoms. In these, the heart will be too rapid, irregular, or tumultuous: and, in addition, the patient will have a constant pain,attacks of pain,or a feeling of squeezing or of dislocation referred to the heart. In other cases,the heart will be regular but the patient will have the abnormal sensations. Some complain of headache,vertigo.,or a feeling of fulness in the head. Some patients suffer frim attacks of syncope. Others have dyspnoea on exertion. Others suffer from insomnia. Some lose flesh and strength. On listening at the chest,you may get a murmur in the second left intercostal space. This murmur does not indicate any lesion. - COURSE. - - 1-The mild cases cannot be said to be ill. They attend to business but,on some days,they have the abnormal sensations. - 2 - The severe cases can do no work at all. They are weak, short of breath,not able to sleep,and they look as though they are ser- iously ill,and they are seriously ill. These are the two extremes but,between the two, there are all grades. I think you want to be careful not to think too little of palpi- tation of the heart. Some ca'.es are of no consequence; others are of great consequence. 318 - ETI^L^GY.- In some cases,we can discover a cause. It is some- times due to disturbances of the digestive organs,particularly of the stomach and liver. In other cases-,it depends on the pa- tient's mode of life. Thus,it is sometimes developed in persons who live in doors and take no exercise*, in others,it is due to excessive use of tobacco or tea*, in others, to anaemia. In other cases,we can find no cause. - TREATMENT. - In some cases,the condition is easy to relieveiin others,diffi- cult. The easiest cases to treat are those in which we can find a cause. If the patient suffer from disturbances of the stomach and liver,we treat these disturbances and,in most cases-, the car- diac symptoms will disappear in a moderate time without any special treatment* If the disease depend upon the in-door Life of the patient,the success of the treatment will depend upon how long the patient has been leading this unheal thy life. If the patient have lived in this way 'but for .a short time,send him out of doors and give him plenty of exercise. If the disease occur in old per- sons who have for a long time lived in this unheal thy manner, a change of the mode of life can only alleviate the disease,not cure it . If the disease depend upon the use of tobacco or tea, here, al so-, it will be a question of how long this habit has lasted. 319 If the patient be young, stopping their use will -improve his condition but it may take months to do so. If the patient be old,, although he give up tobacco and tea,the heart will continue irri- table for many years. When the disease is due to anaemia,give iron and oxygen. These cases generally improve readily. The most difficult eases to treat are those in which we can dis- cover no cause. In addition to the methods of treatment cited aboya, it may be neces- sary in all cases to give drugs for the patients are not contented to wait. Some do very well with small doses of digitalis,others with valerian, others with assafoe tida, and others exceedingly well with the bromides. In one or the other of these ways,we can regulate the action of the heart in the majority of eases,but,in the bad ones,al though you may do everything,they will ;®at improve. There are some rare and curious cases in which the patient seems to die of the disease. I have seen two such cases in neither of which was there any organic lesion. 320 - 2- ANGINA PECTORIS.- This name is used to designate a number of cases that resemble one another in clinical history but differ as regards the lesion end,perhaps as regards their cause. It is a disease characterized by pain,oppression,an abnormal action of the heart,and a fear of impending death. -PATHOLOGY.-When a patient dies of angina pectoris or,having had angina pectoris,dies of something else, the condition of the heart varies. In some cases,it will be perfectly normal: in others, there will be a fatty degeneration of the heart: in others, one of the lesions of chronic endocarditis: in others,a chronic inflammation of the aorta,particularly above the aortic valves:and,in a few, changes have been fo-und in the cardiac plexus of the sympathetic. So,there is no characteristic lesion. -ETIOLOGY.-The disease is especially common in persons of fifty years or more.,but it is not confined to them. We find it in young adults. it is much more frequent in males than in females. It is more common in the upper than in the lower classes.and, for this reason,we get but few autopsies.In hospital practice, the disease is rare. In some cases, the attacks do not apparently occur unless the patient has exerted himself in an unusual manner. 321 - SYMPTOMS.- The disease manifests itself by attacks,be tween which ,as a rule, the patient'S health is good so far as the disease is concerned. Between the attacks he may give the symptoms of the other lesions - An Attack*-The patient suffers from pain. Without pain^a person cannot have angina pectoris. The pain is severe.) it is referred to the heartland it may radiate in almost any direction. The patient may deceive you by saying that the pain is in the shoulder or in the abdomen. While in the attack,the patient will not tell you much about it:but,afterwards,although he knew that the pain was in the heart,he will tell you that it was in the shoulder. You must be on the look-out for this. The pain comes on suddenly. It may last a few minutes or an entire day. The severity ofthe pain varies slightly in the different cases. The patient also com- plains of a curious sense of oppression and of a feeling as of impending dissolution. These are the most constant symptoms. If you see a patient during an attack,examine the pulse and heart. In nearly all the cases the pulse is hard but,at the same time,it may be small and feeble. In some cases,the pulse will be very feeble and it may disappear altogether. 322 In other cases, the pulse will be irregular. The heart may either not be much changed or it may be feeble and irregular. In some cases., the breathing will not be particularly disturbed; in others, it will be labored.. When the breathing is labored, it seems to be due to. the feeling of oppression. In some cases.,we will get additional symptoms,such as violent and continued vomiting,eructations of gas,iiz%iness or loss of con- sciousness* The expression of the face is generally very anxious. The skin is usually cold and bathed, in perspiration. The face may be livid. An attack often comes on without any warning but, at other times,it will be preceded by abnormal sensations abuut the heart. Some patients know that certain muscular movements are apt to bring on an attack. In some cases, the attacks will be periodic. The cases vary as t.^ the number of attacks that they have. Some patients will have but one attack during thei g* lives; they will recover. Others will have a single attack which will prove fatal. Others go on suffering from attacks for many years and,during this time., the attacks may at first be frequent, then, farther and farther apart. In some cases., the attacks will stop altogether after a time. - PROGNOSIS.- The prognosis is exceedingly uncertain. When a person has had one attack of angina pectoris,it is very difficult to say what is 323 going tn happen next. The patient is much mor likely tn do badly than to dn well: much more likely tn die in an attack than to re- cover:but still,you cannot with certainty say that he will not recover. You might think that an examination of the heart would aid you in the prognosis but this is not so fox' we know that the eases without any cardiac lesion are just as likely to die as any others. I always tell the patient of all the cases I have seen that have recovered: but I always tell his friends of the eases that have died. - TREATMENT. - The treatmaent is directed towards the paroxysms. In most of the attacks,a contraction of the arterioles exists to a marked degree, and,if we can at once relieve this condition,we can at once and promptly relieve the paroxysm. This we can do with certainty in the following way. Give the patient m.v-m.x of Magendie's solution hypodermically. As soon as you ahave done this,let the patient inhale the nitrite of amyl. Repeat the inhalation till the worst is over: then,put him to bed:and, as by this time,he will behave begun to feel the affects of the morphine,he will go to sleep. This is the best method of treating most of the cases but, unfortunately,it will not do for all. In the cases that do not develop high arterial tension,it is of no use. In these,we can only give morphine. 324 Between the attacks, in order to prevent their recurrence., look to the general health in ever;/ way. - FALSE ANGINA PEGTORIS. The name is poor. In all probability, this disease has no connection with angina pectoris- Still,we have no better name- Under the title of false angina,we group together a certain number of cases of neuroses of the heart, which resemble each other to a certain extent and differ from the other neurotic diseases. They evidently do not depend upon organic lesions but are due to t*e nervous system- These cases are quite common. They are most frequently teen among the better classes and in persons between the ages of forty and sixty- - PATHOLOGY.-When a person dies in an attack,as he sometimes does., the condition of the heart varies. In some cases, there will be no lesion at all: in others the heart will be fatty or there will be old endocardial lesions: in others, there will be a chronic inflammation of the coronary artery. The patients do not develop high arterial tension. The disease resembles true angina in that the lesions have little to do with the symptoms. SWTOMS, The symptoms come on in attacks. These attacks may last longer'' 325 longer than those of true angina,a day or a day and a half. Between the attacks,the patient is all right. The pain which is so marked in true angina may be altogether absent. In some cases,it is present but it is never as severe as in true angina. This is one point of difference between the two diseases. V/hen present, the pain is referj^d to the heart and radiates as in • true angina. The fear of impending death is absent. The patient may feel alamed but he does not think that he is going tn die. During an attack, the heart may be feeble and irregular or tumultuous and irregular hut the pulse is feeble and,in reality, there is always a feeble heart action. The breathing may remain unchanged or it may become hurried and labored. There may be vomiting and pain in the stomach. There may be sudden syncope which will only cause some patients to sit down-, others will fall to the ground. Those that fall down may either preserve or lose consciousness or they may die. The attacks differ greatly in severity. Some patients will have many attacks but none of these attacks will be severe. The patient may be working and will suddenly become conscious of his heart. Then,a little later,he will notice that his heart is not working properly. He may or he may not have pain. He also has a feeling of weakness. Some patients will assume a particular position in order to make the attack pass off more rapidly. After lasting a few hours or days, the attack will pass off. 326 In other cases,the attack will be more severe. The sensation tbout the heart will be more decided and the weakness will be moi*e marked. The patient may fall down and may even lose consciousness. He miy vomit and there may be pain in the stomach. If you examine the heart during an attack,you will find it feeble. These more severe attacks are biways dangerous and the patient may die in one apparently from, heart failure. The attacks also vary as to their duration. In some cases,,an at- tack will only last a few minutes*, other attacks may last a day and a half. The longer attacks are difficult and,some times impos- sible to diagnose from palpitation of the heart. Curiously enough, the attacks sometimes seem to be periodic, When this is the case, they do not appear to be for they are not controlled by quinine. - PROGNOSIS. - The prognosis is always serious. Many patients suffer for years but do not die. Yet,you can never say that they mey nnt have a fatal attack. The prognosis is somewhat better than that of true angina. - TREATMENT.- The treatment is unsatisfactory. While the patient is in an attack,nitrite of amyl is of no use. If there be no pain, there will be no indication for the use of opium. The best that we can do is to give alcohol and ammonia. Give these drugs in considerable doses and give them quickly. Between the attacks, 327 The only treatment of any service is that directed to the general health,but this is of great use. Be sure to make the patient give up any bad habits he may have. This disease is characterized by an abnormally rapid heart action, by exophthalmos,and by an enlarged thyroid gland. - 4-EXOPTHALMIC GOITRE.- - PATHOLOGY r- We have very few autopsies. The disease is not fatal and,as the eases last a very long time;1 they are apt to pass out of observa- tion. It is only when the patient dies of something else., that we have a chance to examine the lesions. The exophthalmos often dis- appears after death. The hypertrophy of the left ventricle remains after death. The goitre remains,but it is not as marked as during life. The goitre'is due to an hypertrophy and enlargement of the blood-vessels of the thyroid body. Some changes in the sympathetic of the neck have been found but they are unsatisfactory to study. Very few know how to find them. StilL, some good authorities have found in the cervical ganglia a growth of new connective tissue and an atrophy of nerve fibres. Undoubtedly,we should get these changes. 328 - ETIOLOGY.- The disease is more common in young women than in young adults generally. When it occurs in women,it is often asso- ciated with anaemia. Mental excitement is sometimes an exciting cause. - SYMPTOMS.- Generally, the symptoms come on gradually but they may come on suddenly. In most cases, the first symptom, is increased rapidity in the heart's action. At first, the heart's action is not too forcible. The heart will beat eighty,ninety,ar even one-hundred &nd twenty times a minute. This rapid action of the heart will go on day and night,will continue during sleep,and will be exag- gerated by muscular exertion. When it is once developed,it lasts throughout the disease. After a time,the left ventricle will be- come hypertrophied. Even when the left ventricle has become hy- pertrophied, the action of the heart is not very strong. In some eases., this increased rapidity of the heart will be the only symp- tom: there will be no exophthalmos and there will be no goitre. In other cases,after weeks or months, the thyroid gland will be- come enlarged. As a rule, this enlargement is not very great but it is sufficiently evident. After a longer time,comes exophthal- mos.This may be developed to a marked degree, tn a slight degree, or it may be altogether absent. Some patients tell us that the goitre or the exophthalmos was the first symptom. In these cases, 329 it is always difficult to tell how much weight should be placed on what the patient says. Often the patient does not know that his heart is rapid. These are the three characteristic symptoms. When a patient suffers from this disease.,he is apt to complain a great deal about other things. As a rule<, the action of the heart does not trouble him much but some are annoyed by it. The general health is apt to suffer.Especially the women, lose flesh and strength. .Both men and women become hysterical. The patient may become very anxious. He often has digestive disturbances which add to his discomfort. The disease usually lasts for years with periods of improvement and exacerbations. - TREATMENT;- In some cases, good treatment is followed by re- "covery^in others, treatment can only alleviate^in others,it is of no avail. The best cases to treat are those that occur in young,anaemic women. For these., iron is all that is necessary. For many years, iron has been given as a specific for exophthalmic goitre. It is only of service in those cases that are anaemic. Iodine is of no service. We would like to change the character- of the hearths action but this is very difficult to do. 330 You may give every one of the cardiac stimulants empirically without regard to their specific actions and,yet,in many cases, they will have no effect* I have come down to digitalis in moderate doses and convaIlaria in large doses. tn some cases you can keep the heart down to ninety for a long time hy means of these drugs. This is the best you can do. How digitalis, acts in these cafees^I do no# know. I'give it empirically but I do hot'succeed in gettih^the^he^r^down to the normal. 'Another mode of treatment* the sympathetic nerve in the neck. This is? perfectly proper treatment and it has been followed by 'good results. It is of the greatest importance to improve the patients general health. Cure the digestive disturbances 'and make him eat good food. In this'way,you can sometimes effect a cure. 331 - ANEURISM OF THE AORTA.- Aneurisms are the result of two conditions. First, an inf lamination of the arterial wall and, second pressui'e from contained blood on tnese parts. There are three varieties?dissecting,fusiform,and sacculated. When you see a case treat it as an inflammation of the walls of ' the "artery. ^'A Dissecting Aneurism- The re is first a rupture of the inner coat'. In this case-, the inflammation is apt to be very intense* A'portion of the inner coat is infiltrated with cells. These cells' become necrotic,hence the liability to rupture. After the blood 'Jias found its way through the rent, it dissects between the coats'' io a considerable extent* The part of the aorta immediately above the valves is particularly liable to this kind of rupture. The blood passing between the middle and outer coats may extend as far as the thoracic aorta* The cases vary as to the size of the? rupture and as to the rapidity with which the blood burrows. If the rupture be small, the patient suffers from shock and some p?iin at the time'it takes place,then,after several days,he becomes Weaken and dies. ' - - 332 - Fusiform Aneurisms.- The inflammatory process is tslow,chronic, tolerably uniform, and involves a considerable part 6f the wall of the aorta. The whole arch or the entire aorta may be thus c-ilated. - Sacculated Aneurisms.- The inflammatory process involves but a circumscribed portion of the wall of the aorta. A small portion of the wall is rendered weaker. Some times, this weakened portion of the wull is no larger than a pin's head: at other times,it will be half an inch square. This weakened portion begins to give way, is pressed out,and a sac of considerable size is gradually formed. The opening retedns its original size. '.There may be one sacculated aneurism or there may be several. When once formed, they become larger and larger. When they have reached a considerable size, the blond often coagulates within them. These coagula may be large f r they may be small. Even a large coagulum will not prevent the sac from growing for,in the aorta, the blood pressure is so great# In the small arteries*, the coagula may prevent the sac from in- creasing in size. Of ten, sacculated and fusiform aneurisms will be present at the same time. The mechanical conditions in' the formation of ^n aneurism resemble those in dilatation of the bron* chi. - ETIOLOGY. -- The disease is more common in males than in females. It belongs to adult life and usually occurs in persons over thirty. 333 It occurs in those persons who are most likely to have chronic endarteritis. Syphilis, the gout;/ diathesis, substantive emphysema, and chronic diffuse nephritis by predisposing to endarteritis, predispose to aneurism. The arch is the part of the aorta most frequently affected. In classifying aneurisms of the arch,we distinguish between those situated just above the valves,those of the ascending part, those c-'f the transverse,and those of the descending part of the arch. Next in frequency to aneurisms of the arch of the aorta,come those of the abdominal aorta,in the neighborhood of the coeliac axis:next,those of thoracic ac-rta: and,next, those of the abdominal aorta below the coeliac axis. In considering their symptoms,we find that these are all due to a tumor. Until this tumor is formed, we have no symptoms. - PHYSICAL SIGNS.- Dulness,the feeling of a pulsating tumor,a th ri11,and,sometimes, a d cuble mu rmur. >-RATIONAL SYMPTOMS. - These depend upon pressure upon the heart, blood vessels, trachea, recurrent laryngeal nerves,and the vertex brae. When the disease has lasted some time,we may have symptoms due tn disturbance of the circulation. These resemble the dis- turbances that we get in lesions of the valves of the heart,ve- nous congestion and an anaemic condition of the arteries. Some patients have aneurisms sc small that they never give but 334 one symptom,sudden death from rupture. - 1 -ANEURISMS JUST ABOVE THE VALS&S. - Some are very small: others, very large.Whether small or large, they are generally given off from the anterior aspect of the aorta. If they continue small, they will remain within, the pericardial sac and,unless they rupture, they will give no symptoms. They often rupture and cause almost instantaneous death. The larger aneurisms may eventually rupture but many of them reach a very considerable size before they do. They first press the pericardium forward, become adherent to it,and finally reach the thoracic wall,generally a little to the right of the sternum. Thus, they do not trouble the thoracic viscera.. The physical signs will be well markbd. In some eases, the aneurism will pass to the left or it may extend backward. If it extend in the latter direction, there will be trouble from pressure. Most frequently,however, the aneurism presses upon the superior vena cava and causes venous congestion of the face, neck,and arms. The skin of the face will be congested and,if the patient bend forward,he will become dizzy and fall over. However, most of the aneurisms do not give trouble until they become large for most of them grow forward. They may rupture into the peri- cardium, the right ventricle,left ventricle,pulmonary vein,or right auricle but,most frequently,they do not rupture and the patient dies exhausted. 335 - 2- ANEURISMS OF THE ASCENDING PORTION.- These aneurisms are most frequently given off from the right an- terior aspect of the aorta. Yet, some are given off from the pos- terior aspect and others, from the left. They arise above the attachment of the pericardium. They usually reach a considerable size. When they are given off from, the right anterior aspect, they grow forward and present themselves as tumors immediately beneath or to the right of the sternum at the upper part of the chest. For a time,they give but little trouble:then,the patient complains of shortness off breath and pain and^^en the aneurism has reached a certain size,disturbances of the circulation and disturbances of nutrition result. Although, you would think that they would always press upon the superior vena cava, they often do not. If the aneurism be situated on the posterior aspect,it may press the heart downward and forward* it may press upon the trachea and cause difficulty in the breathing: or it may press upon the oesoph- agus. Aneurisms in this position give trouble sooner than the o the rs * The aneurism may rupture through the chest wall,into the peri- cardium, pulmonary artery, right auricle, superior vena cava, trachea, right bronchus, right lung, left lung,or into the right or left pleural cavity. 336 These aneurisms may be given off from the anterior wall,the pos- terior wall, or the upper part of the transverse portion of the arch of the aorta. There is not much difference in the frequency with which they are given off from the anterior and posterior walls. They give trouble very early. If the aneurism be given off frommthe anupper part,it will invade the orifices of the large arteries in this situation. There will be a difference in the pulsation of the arteries of the two halves of the body,for the aneurism generally involves but one of the large arterial branches. The aneurism grows upward and may extend above the s to mum. Those that arise from the posterior aspect are the very worst. Even when of small size,they press upon the trachea,oesophagus, and recurrent laryngeal nerves. Thu a, they give rational symptoms before they give physical signs.The patient often dies without giving physical signs^ ,The aneurism is too deep for us to appre- ciate any physical signs. The rational symptoms are developed, early and are characteristic. The pressure upon the inferior larv yngeal nerve gives cough and may give aphonia or paralysis of one vocal cord. The pressure upon the trachea gives at first a chronic catarrh: then ,the inflammation extends upward and downward. V/e get a laryngeal cough,expecto ration and dyspnoea. As it goes on,the dyspnoea becomes more decided. In some, 3-ANEURISMS OF THE TRANSVERSE PORTION.- 337 this dyspnoea will be the most prominent symptom. If you can fol- low the patient and see the dyspnoea get worse and worse, the cause can easily be determined;but,if you see the patient for the first time after the disease has existed some months,you may be deceived. The patient sometimes suffers from attacks of dysp- noea and these attacks look like spasmodic asthma^ The patient will sit up in bed in order to breathe and his face will become cyanobed. However, if it be an attack of spasmodic asthma,you will get rales and sibilant and sonorous breathing:if it be an aneurism,you will get tubular breathing. So far as I know, this tubular breathing is never produced except by something that nar- rows the trachea and bronchi. It does not resemble anything else. Vhen the dyspnoea is once established, the patient generally dies very .soon. The pressure on the oesophagus causes gradual diffi- culty in swallowing. The aneurism may rupture externally through the anterior wall of the chest, sometimes into the pericardium, or into the left pleura but, gene rally, it ruptures into the trachea or bronchi. The rupture may be small or large. If it be small, the blood will gradually leak into the trachea and will be coughed up for several days: if the rupture be large, the scene that will ensue will be very horrible. The patient will suddenly cough up large quantities of blood and he will generally die in a quarter or half an hour. When the rupture is small, the patient gradually * 338 bleed to death. If the aneurism rupture into the oesophagus, the patient may vomit a little blood.but most of it will pass down into the stomach and will completely fill and dist end the stomach. - 4- ANEURISMS OF THE DESCENDING PART OF THE ARCH.- They are most apt to be given off so as to press upon and erode the vertebral column. As they are deep, they give but few physical signs and the trouble that they give is due to pressure upon the left pleura and the vertebral column. The pressure upon the ver- tebral column gives very severe pain. This is apt to be the most marked symptom. If it press upon the left bronchus, the re will be cough and dyspnoea. The aneurism may rupture into the trachea. If it pass backward to the left,it will keep clear of the bronchus and vertebral column and,al though it press upon the lung,it*will give but little trouble. - ANEURISM OF THE THORACIC AORTA.- These aneurisms present much the same characters as those of the descending part of the arch. They may erode the vertebral column or press upon the left pleura. They may be large enough to pro- duce pulsation in the back, the axillary region,or the front of the chest. - ANEURISM OF TILE ABDOMINAL AORTA, - These-most commonly occur in the upper part of the abdominal aorta 339 near the coeliac axis. Less frequently,they may occur further clown at any point beneath the coeliac axis. They are generally given off from the anterior or posterior aspect. Those that erice from the posterior wall very soon press upon and erode the verte- bral column. They give rise to pain which is the most constant symptom. While of small size., they give no physical signs. J*o ratter how hard you press.,you cannot feel them. As they become larger, you can feel them,though with difficulty,by jamming your hands well back on both sides of the vertebral column. The pain never lets up. It is worse at some times than at others, as the aneurism increases in size,the pain becomes more intense and radiates down- ward into the groins and legs. It can scarcely be controlled by large doses of morphine.. If you can feel the tumor,your diagnosis will be certain but, of ten,you can not feel it. The aneurism fre- quently ruptures befoi*e it reaches a. large size. It may rupture behind the peritoneum or,if large,it may burst through the peri- toneum. If it 'be small and rupture behind the peritoneum, the blood will dissect up between the peritonuem tnd the verte- bral column and the patient may live for months;'then, the blood will finally burst through the peritoneum and the patient will die. When the aneurism arises from the anterior part of the aorta,it gives rise to the least pain and the pain when present i? referred to the anterior wall of the abdomen and radiates down into the inguinal region. - - 340 soon as the aneurism is at all large,it is easily recognized. They usually rupture into the abdominal cavity and cause death. When the aneurism is low down,the coagula that fill it may find their way into the iliacs and occlude them. If we consider all the aneurisms that occur in the thoracic cavity, we find that the ones most difficult to recognize are those that give no physical signs. Yet,the disease can often be made out by attention to the history and the rational symptoms. Those' aneurisms that come in contact with the walls of the chest do give physical signs. They may be confounded with tumors* A tumox* will give dull- ness but it will give no pulsation,murmur,or thrill. Some tumors may have pulsation communicated to them by the aorta but the char~ acter of such pulsation is entirely different. An aneurism may be confounded, with the dilatation of the aorta and large arteries which accompanies aortic insufficieney. This happens very often. In the abdominal cavity as well as in the tho rax, the deeply seated aneurisms are impossible to make out by physical signs. When they can be felt, they may be confounded with solid tumors or a too strongly pulsating aorta* The tumors most likely to he confounded with aneurism are some cancers of the pylorus. It is sometimes very difficult to distinguish between the two. They feel like aneurisms-, they pulsate, and, strangely enough, they may have a lateral pulsation. The mere dilatation of the aorta and the pulsation 341 in the epigastric region are very common with or without organic disease of the heart. These should never be mistaken for aneurism. - PROGNOSIS OF ANEURISMS OF TILE AORTA. - The prognosis is bad. Some of the aneurisms give trouble early. This they may do either by rupturing or by pressing upon important parts. If the patient do not die from either of these causes,he will develop venous co ngestion and arterial anaemia and rill die of exhaustion. The only treatment is medical and it is shorts The only drug that has any effect is iodide of potassium. Give grs.v-grs.xx t.i.d. . You judge of the size of the dose by the size of the tumor, the pain which the tumor gives,and the results that you get. Within two weeks,the tumor should be smaller, the pulsations should be weaker,and the patient should tell you that he feels less pein. If the smaller dose do no good,give the larger. One month will usually suffice to tell you whether or not the patient, is to improve. Tn many eases, the iodide of potassium will do no good. In the very large aneurisms it will be of no service. In the smaller aneurisms, it will do good. If at the end of a month the patient be no better, continue the iodide a number of weeks, then stop for a week,and then go on again. Give the iodide in this way through- out the patient's life. It will not cure the disease but he will - TREATMENT.- 342 be made more comfortable and the growth of the aneurism will be retarded. It may be retarded for a number of years. Treat the general health. Tell the patient to avoid all exertion- When the pain is very severe,the re is no alternative;you must give opium although you knov^ that the patient may acquire the opium habit. - LESIONS OF THE OESOPHAGUS.- These are few in number and most of them can be included under the headings of stenosis and dilatation. We will first consider stenosis. - STENOSIS OF THE OESOPHAGUS.- This may be caused in a variety of ways. -b It, may be congenital* This form, of stenosis may be so extreme that the patient may die in a few days. The child may grow up but he will have difficulty in swallowing and this difficulty will increase as he grows older* -2-A tumor of the thorax may cause stenosis of the oesophagus. -*^An aneurism of the transverse part of the arch of the aorta may cause stenosis of the oesophagus* -4-By a large goitre* -5-By tumors in the neck originating in the lymphatic glands* 343 When stenosis of the oesophagus is due to any of the above-mentioned causes,the only symptom is increasing difficulty in swallowing. At first, the patient will not be able ta swallow solid foo4: later, he will not be able to swallow liquid food. -7- Tumors of the pharynx may hang down into the oesophagus and cause stenosis. These come more under the domain of surgery. - 8-This is a much mox^e common cause. An acute inflammation of the inner surface of the oesophagus is set up, tissue is destroyed, and cicatrices result. Thus., the calibre of the tube is narrowed. This form of stenosis is caused by swallowing corrosive poisons. The treatment of stenosis resulting from any of these causes is more surgical than medical. It consists in dilatation,cutting, and gastrotomy. The cases that come under the care of the physician are those that are caused by new growths and by spasmodic stricture. These cases are not uncommon. - STENOSIS DUE TO OANOER.- - PATHOLOGY.-The new growth follows the type of a cancer of the skin or mucous membrane. It consists of epithelial cells enclosed in a connective-tissue framework. It begins in the deeper tissues, gradually increases in size,and begins to surround the oesophagus with a ring of cancerous growth. 344 This may happen at any part. Then,it may extend for a little dis- tance up and down, the oesophagus and may become one-and-a-half or two inches in breadth. It seldom becomes any broader than this. In some cases,the progress of the new growth is pretty decided and masses of it will project into the oesophagus. These masses often break down and ulcers will be formed. These ulcers are just as bad as the cancer. In many eases,the cancer will remain confined to the oesophagus hut it may extend to the lymphatic glands of the thorax, trachea and bronchi or it may infiltrate the vertebral column. Occasionally,there will be metastatic growths in other parts of the body. Sometimes,the same patient will have cancer of the oesophagus and cancer of the stomach. The disease is more common in males than in females.lt is more common in adult life than in young life. - SYMPTOMS. - - 1 -Difficulty in Swallowing.- As a rule,this is not developed suddenly but slowly and gradually. At first, the patient does not attach much importance to it and it only becomes evident when the patient swallows large pieces of food- Then,it becomes more marked and he has to cut his food into small pieces- He has to chew his food very carefully but,even at this stage,the patient is not apt to think much about it. The general health may remain good. - 2-Then, there is apt to be pain,usually referred to the upper 345 part of the sternum. The obstruction seems to be at this point no matter where it may really be situated. The pain is not conn stant and the patient may go through the whole disease with no pain at all. - 3 -In some eases,., after a while,there will be regurgitation of food. This may or may not be accompanied by vomiting. These are the three regular symptoms. - 4 - After a while, the patient will lose flesh and stx'ength. He will present the appearance of a person suffering from a malign nant growth. However, this cachexia is not as marked as in the other forms of cancer and it is hal'd to appreciate the serious character of the disease. During the first two or thi'ee months, there will be nothing about the patient's appearance to suggest a cancer but,after a time,, the patient will . become much ema* dated. Most die of starvation; a few, fx'om extension of the gi'owth. When it extends to the lungs,it may perforate the air passages and produce inflammation of the lungs. - TREATMENT.- At the present time, the treatment is limi ted to feeding the patient. As long as he can get fluid down, we feed him by the stomach: later, by the rectum. At first, these growths are entirely local and,if removed,are not likely to return and,as at first they are not large, they offer opportuni ties to the surgeon. I am suxprised that surgical treatment has not been tried. 346 ^STWOSiS 'D¥E'*TO SPAWDrc SWCTCRE? This is due to a spasmodic cantraction tf the muscular coat »f the oesophagus. It occurs in men and women,in young and old,and in varying degrees of severity and persistency. - 1 -Mild Cases*. -- On some particular day, the patient finds that he cannot swallow solid food and,often,he cannot swallow fluids. In some cases,an attack of choking will precede the attempt at swallowing. Toe spasm may be brought on by violent emotions or it may come from no cause. Such an attack will only last a few hours and,then, the patient will be able to swallow again. For the time being,he will have no further trouble but he is liable to subsequent attacks. - l~More Severe Cases.-As before, the symptoms come on sudden** ly but they do not entirely pass away. The patient will be able to swallow off and on during the day but he is never entirely well. These cases frequently last for years. - 3-Severe Cases.- The closure is almost complete. These are the o'rst cases. Starvation sometimes results. - - The treatment, varies with the severity of the disease. In the mild cases,it is only necessary to tell the patient not to try to swallow for a few hours* 347 If you wish to be more prompt, just pass a large sound down the oesophagus. This is all that is necessary and it is very effectual treatment. In the more prolonged cases-, the passage of a sound will not suf- fice. The best thing to do is to teach the patient to pass a stomach tube. For his breakfast,let him pour a pint of milk down the tube. He will often be able to eat his lunch and dinner. Then, let him start himself again in the morning. I have had no experience with those very bad cases that have died of starvation. I should think that you should always be able to pass the stomach tube. When I spoke of passing a sound,, I meant a large stomach tube,not a stiff instrument. It is best to use the largest size. If the stenosis be caused by a cancer,you may find the constriction at any part ox the oesophagus*if it be caused by spasm of the tube, the stricture will generally be found just above the stomach. When you begin to pass the tube,,you will often find that it caught at the junction of the pharynx and oesophagus. This is due to a spasmodic contraction of the muscles of the pharynx. Quiet this spasm by spraying the phaiynx with cocaine. If the stricture below be spasmodic,you will rarely fail to pass the tube. If you meet with any resistance,you may either make the tube stiffer with water or divert the patient's attention while you use gentle pressure. - -- 348 - DILATATIONS OF THE OESOPHAGUS. - These dilatations are of two kinds. These are*. - -1-A large dilatation involving a large extent of the oesophagus. -2-Small pouches. - 1- LARGE DILATATIONS. - Some of these are secondary to stenosis, The lower part of the oesophagus is narrowed and the upper part becomes dilated. These cases are not of importance. / Many cases are idiopathic. These are rare and curious. The change in the oesophagus seems to be inflammatory in character* The wall of the oesophagus becomes thickened in some places and thinned in others. As a result, the oesophagus becomes dilated. It may go on till the oesophagus becomes very large. Why this is,we do not know. Instead of swallowing more easily, the patient swallows with dif- ficulty. The food accumulates in the oesophagus and may remain there for some time . Some ruminate in order to swallow more easily others will simply regurgitate their food. The longer this goes on, the worse the patients get tiIL, finally, they die of starvation. - TREATMENT.- Feed the patient by the stomach tube. • - SMALL POUCHES* - These are of two kinds. These are: - *^1--These are given off from the posterior wall and upper part 349 of the oesophagus, jus t where it joins the pharynx. How these pouches are formed and whether they be due to congenital deformity or to unnatural stretching,we do not know* They occur in advanced life. At first, they are very small and the patient is hardly con^ scious of their existence* Then, they become larger and a part of the patient's food passes into them. Then,they increase in size more rapidly and make a place for themselves behind the oeseph- agus* They hang downward. The larger they get, the more food passes into them and,in the most severe eases,they will receive a large part of each meal. They may contain several pints. When once formed, they become worse. At first, the patient can empty them by changing his posture and using pressure but,later,he cannot do this. The pressure from the pouches gradually occludes the oesophagus and the patient dies of starvation, - TREATMENT.- In the eai*ly stages,you will be able to use the Vtomach tube but, later,you may not be able to do this. If the pouch be larg&, the tube will pass into it every time instead of going into the stomach. - 2 - These pouches are given off from the anterior wall and middle part of the oesophagus. They seem to result from changes originating in the bronchial glands. These glands become inflamed and adhere to the anterior wall of the oesophagus. They will set up a circumscribed inflammation of the oesophageal wall and will 350 exercise some little traction. In this way,little pouches will be formed. They seem to give no trouble unless they become inflamed. If they become inf lamed, they will rupture and food will pass into the thorax. When this happens, the patient will die from fatal inflammation of the thoracic viscera. - DISEASES OF THE STOMACH.- The stomach has two functions. In the first place-,it is a mucous membrane: in the second place,,it is a viscus. - GASTRIC DYSPEPSIA.- This term is generally employed to designate all derangements of the stomach. It should be limited to those derangements that in- volve the digestive process. However,it is almost impossible to limit it in this way and it is better to consider gastric dys- pepsia as a general term including a variety of stomach disorders. 351 There is a variety of causes. One.,common enough, is the character of the food that the patient eats. If he habitually eat food that is indigestible,or eat food in too great or too little quantity, or if he fill the stomach too rapidly,he may give symptoms of stomach derangement* The ways in which these causes act are various. In the first piaee., it is injurious to the stomach to be called upon year after year to digest too much food,and it is bad for the stomach to be in an habitual state of distension. In the second place, the stomach will be badly off if it do not receive sufficient food.Finally,if food remain too long in the stomach,it will de- compose and act as an irritant. In all these ways.,food may give rise to trouble but you must not think that it is the only or even the most frequent cause. One of the most serious errors that people with stomach troubles are liable to is the habit of starving themselves. They have an attack of dyspepsia:then, they try to remember the last thing that they eat and never eat it again* In this way,by excluding one article of diet after another,they eventually starve themselves. This is very common and you frequently have to compel the old cases to take food whether or not it give them pain, A patient cannot get well unless he eat sufficient food. - ETIOLOGY. - 352 Another cause of the disease is disturbances of the gastric juice. The glands of the stomach may produce too much,too little,or the secretion may be of poor quality. This condition may be produced by strong mental emotions and,if these emotions be continued for a considerable period of time,the secretion of the gastric juice may for a long time be interrupted. Any mode of life or outside condition impairing health may stop the secretion of the gastric juice. In some persons., senile changes may produce the same result. The secretion of the gastric juice may be arrested by any inflam- matory condition of the mucous coat of the stomach.However, it is important to remember that inflammatory conditions do not always produce this result. A person may have catarrhal gastritis and yet have perfectly healthy gastric juice. Any diseased condition of the mucous coat may give rise to gastric symptoms. By diseased conditions,! mean ulcers,inflammations, and new growths*. The condition of the muscular coat of the stomach may give gastric symptoms. The muscular coat may act irregularly and spasmodically, it may become thinned and weakened,or it may become thickened and strengthened^ So far as the stomach itself is concerned,,we find that there are a certain number of regular symptoms. All of these need not neces- sarily be present* - SYMPTOMS* - 353 - 1 - Changes in the appetite, - The appetite may either be increased or diminished or it may become perverted. - 2- Pain, - This is one of the most common symptoms. It is re- ferred to the epigastrium or left hypochondriac region. It be- gins in the stomach and may remain there or it may radiate back- ward to the left side,?upward to the heart,or downward to the ab- domen. The character and severity of the pain vary. In some cases, it is more of a feeling of oppression after eating and,aftez' the food has been digested,the pain will disappear. This is the most ' common sort of pain. In others, there will be a feeling of emptiness e-r "goneness11 about the stomach. This feeling is most apt to be • present when the stomach is empty and is relieved by food. The worst sort of pain is that which comes on in attacks. This kind is very severe,so severe that the patient cannot sleep nor attend to business. "3- A peculiar Sensation called'•Heart Rum".- This is different from other pains. It is a burning sensation and usually comes on in the morning. - 4-Nausea. - This is very common. It often occurs without vom- iting. It is apt to be present in the early morning. The patients complain of it a great deal. It is present every morning . - 5- Actual Vomiting.'-This is not very common but the patients sometimes suffer from'it. Some will vomit food: others, food that is partly digested and partly fe rmented: and others will vomit 354 a large quantity of fluid in which food may or may not be present. This fluid may amount to several pints. It consists of mucus,gas- tric juice,and serum. - 6-If there he stenosis of the pylorus or dilatation of the stomach, the food will accumulate and will be vomited in lai'ge quantities. - 7 - Some patients develop a peculiar, irritated, state of the stom- ach and the smallest particles of fond will excite vomiting. - 8-Regurgitation of a Soury Fluid from the Stomach. - This is called "water brash11 . It is apt to be associated with "heart burn*1 . Is is t^pt to occur in the morning, either before or after breakfast. It is particularly apt to be present with alcoholic gastritis although it is not confined to this disease. - 9 Flatulence.- By this term,is meant the distension of the stomach and intestines with gas. In some,it is due to fermentation of food: in others, to relaxation of the muscular coat; in others, it is a senile change? in others, it is due to nervous conditions and this, form is found in hysterical women and boys:but,in others/ it is difficult to determine the cause. The mild cases of flat- ulence are of but little consequence^the patient either belches the gas from the mouth or passes it from, the intestine. In some, however, the flatulence gives rise to pain and this pain may be 355 very severe. The patient will then complain very much of these symptoms. There are a few cases,, general ly hyste rical, in which the abdomen will be enormously distended and the patient will look as though she had an ovarian tumor or as thour/h she were in the last stages of pregnancy* In some,this condition will continue for months without letting up,but,in others,the gas will suddenly disappear and it is difficult to say what becomes of it. These are the local symptoms but you must remember that,after the disease has lasted some time-, the patient is apt to develop complicating symptoms. The patient may give symptoms in other parts of the alimentary canal,such as the liver and large and small intestine. These will add to his discomfort. The patient is liable to have pains in other parts of the body. Perhaps,the most constant of these pains is headache but the patient may have pains elsewhere* Thus,he may have pains over the heart and fancy that he has heart disease,or over the chest and fancy that he has some pulmonary trouble,or over the liver,cr if the patient is a woman,she may have pains over the ovaries and uterus. All these pains are like the headache,that is to say,complicating. When the disease has lasted a long time., the patient- will lose flesh and strength and will become anaemic. 356 This anaemia seems to be proportionate to the amount of food that the patient takes and. we find it most marked in those persons that diet and starve themselves. - TREATMENT. - The treatment is very difficult tn describe and I can only give you some general principles. We 'vdll consider the symptoms - 1 - The patient's appetite. - If it be increased,diminished, r-r perverted may require treatment. The first thing to do is to d e t e mine the cause. The change in the patient's appetite may be due to inflammatory conditions of the stomach. The t'^atment of these cases will be considered later. In other cases-, the reason that the patient loses his appetite is that the food is retained in the stomach for too long a time. In consequence of this,the stomach is full at meal times and the patient does not care tn eat. If at lunch time a person have his stomach two-thirds full of his breakfast,he will not care to eat his lunch. One way to treat these cases is to give them, small quantities of food at regular intervals. Another way is to continue- with the three regular meals but to give a sufficient quantity of simple food. By simple food,I mean meat,very little bread., fresh fruit,and nothing but water to drink. This form of treat - ment will often succeed veiy nicely. When the retention of food is of longer duration, this simple treatment will not suffice. 357 In these cases,you have to empty the stomach before each meal. If you use the stomach tube patiently for some time, the habit will disappear. In other cases-, the loss of appetite will he due to changes in the general health especially when these changes are associated with anaemia. In these eases,we leave the stomach alone o-nd treat the general health. In others., it is due to mental c o n d i ti o n s,sue h as o v e r-wo rk and eve r~wn r ry or th e d e p re s s e d c on - dition that results from working in an unhealthy atmosphere. In tlvse cases.,we do not treat the stomach,we treat the cause. Hysterical persons develop changes in the appetite and their ap»- petites are apt to become perverted. Here again,we treat the cause and not the stomach. In all these cases, I think that drugs to im^ prove the appetite are,as a rule.,had.They may afford temporary relief but they cannot effect a permanent cure. You should always treat the condition upon which the loss of appetite depends. - 2-The Pain. - This is nne of the most troublesome symptoms to treat. Jn the first place.,it is difficult to tell whether nr not the pain really belongs to the stomach. Pain in the upper part of the abdomen may be caused in a variety r.f ways. In the first pla° the pain may be due to the passage of a biliary calculus or to the presence of biliaiy calculi in the gall bladder. It is often very difficult to distinguish between this sort of pain and pain inLthe stomach. It may be difficult to distinguish between pain 358 in the Stomach and pains due to changes in the small and large intestine jin the kidneys,ure ters, even in the pleura,that caused by aneurisms Qf the abdominal aorta,or the pain in the earlier stages of caries ' of the spine. There are abdominal pains,par- ticularly in women,that we cannot locate at allows call them neuralgic for want of a better name. When you have made up your mind that the pain really belongs to the stomach,you must find out that it does not depend upon cancer,ulcer, or chronic catarrhal gastritis* In some cases,the presence of food in the stomach causes pain. This it may do in one of three ways. The most straight-foxward way is that the stomach may simply be intollerent of food or of any solid body. Thea,the pain will continue until the body is expelled, /mother way is the following. The patient can take food into the stomach and the food when first introduced causes no special inconvenience but,when the digestive process begins,the patient will have uneasy sensations. These sensations vary from feelings of oppression to actual pain. When the food passes into the intestine,the pain ceases. Pood may cause pain in a third way. The patient takes his food and digests it without any special inconvenience but thx^e,four,or five hours after eating,he will have pain and flatulence. The first way is usually associated with catarrhal gastritis. The second seems to be compatible with a healthy gastric juice,a healthy mucous coat, 359 & healthy mucous coat, and complete evacuation of the stomach. It is difficult* to give it any causeo Some of these patients will,otherwise be in perfectly geed health andean washing cut their stomachs four or five hours after a meal,you will get no food or mucus. In. the third set of cases, the p^ooess of stomach digestion is not perfectly perfanaed* In those cases in which the stomach is intelle rent,wash out the stomach with warm water at regular intervals. This is the only treatment that is of any use. At first,you have to keep the pa- tient on a milk diet but, as he gets better,you may gradually give him solid food. In this way, you can effect a certain cure. The second class of patients 1$ exceedingly difficult to treat. There seems to be no reason for starving the patients for they eat their food and are nourished by it® Do not put them on a fluid diet for the trouble will return when you go back to solid food. These are the patients that are apt to leave off en® article of diet after another yet,if you question them^you will find that all articles of food act alike. Give them theii' three regular meals aday pain or no pain. Washing out the stomach is of no use to relieve the pain. One vexy seductive method of treating the pain naturally presents itself. 360 This is to give the patient a couple of minims of Magendie's solution hypodemisally. Of course,this will make the pain disappear altogether but there is great danger that the patient will form the morphine habit and,hesides this, the relief is only temporary. We may give belladonna or opium internally. Rut,although opium is the best drug that we have for pain in the intestine,it is not so efficacious in relieving pain in the stomach.You may give conium in small doses,gr.j,or hyoscyamus in appreciable doses.You may give gelsemium. Pepsin is very good either given alone or with a mineral acid. Some patients do better with an alkali. Some patients,particularly the women are very difficult to treat. When the pain is due to the third cause, try to find out what food the patient can and cannot digest. The best way to do this is to try" the patient with different kinds of food. Wash out the stomach after each trial and,by observing the condition of the food that you last put into the stomach, you can determine the kind that the patient most readily digests. When you have found this out,feed the patient on those articles that were most readily digested. In this way, you will allow no undigested food to remain in the stomach. In women, simple anaemia may give rise to gastric symptoms. First, put them on a fluid diet,milk peptones or milk with an alkali, then treat the anaemia and, when you have caused this ta . disappear, 361 the pain will disappear also. Same people have true neuralgic pains referred to the stomach. These- pains come on in attacks at regular intexvals. During most Gf the tima, there is no stomach trouble at allo The pains may come on at any time and ?aay last for a few minutes er for hours,. The first thing you think of is that the patient may have lo- comotor ataxia. If he do not have locomotor ataxia,you will have to group him with these eases sf gastric dyspepsia* Look after the general health in every way and attend to evexy little detail in the mode of life. Some cases do better if you put them on a milk diets in ethex* case^this is not necessary. The use of drugs is largely empirical for we do net know why the patient should have these pains. Iron ben fits someswhy^I do not know. You may give arsenic in pretty fair de$e&?gr*l/oO-gra 1/40 of arsenious acid nr m.vj-moX of bowler7s solution. In some cases,you will do good with small doses of aconitine*in others, with gelsemium carried up to tolerenee. ~4~ 1 Heart burn3 associated with 3water brash®,as far as I know always signifies gastritis. We will discuss its treatment later. -„5 - alsa5seems to signify some kind of gastritis,exclu- ding the eases due to Bright3 s disease^ - 6-The actual vomiting &ay be dua^^artier!arly in those cases ' of irritable stomach, to acute $r ch panic gastritis. It ®ay be^duei 362 to simple congestion, tumors.,Cicero, the retention of food that follows stenosis of the pylorus,dilatation of the stomach,or it may simply be a habit. Put the patient on a fluid diet,wash out the stomach,and gradually return to solid food. In some cases-, the vomiting may be due to the condition of the large intestine. The large intestine may be loaded with feces. A patient may vomit every day from simple constipation. Give laxatives. Others vomit simply on account of changes in the general health. Anaemia and hysteria are frequently the cause of vomiting. Put the patient on fluid diet and treat the hysteria.and anaemia. Some women vomit on account of disease of the uterus,such as chronic inflammation of the neck and body. This is important. As soon as these conditions are cured, the vomiting will cease. Displacements of the uterus will cause vomiting. -Flatulence. - In some cases of flatulence., the stomach is at fault. The stomach does not digest its food properly. The undi- gested food acts as an irritant in the intestine and produces gas and causes spasm. We should feed the patient in such a way that no undigested food shall pass into' the intestine. The flat- ulence may be due to constipation:if so^this constipation must be relieved. Others seem to have flatulence out of all proportion to the stomach trouble And. constipation and the flatulence is 363 not relieved by curing either of these conditions. In these cases^ we my give drugs. These drugs may be divided into two classes. In the first placa?we may give drugs that increase the quantity of bile in order tn prevent the fermentation of food. Fnr this purpose*,you may give carbolic acid,corrosive sublimate,arsenic., or salicylate of soda in as large doses as possible without get- ting their poisonous effects. In some cases,these drugs do not succeed: in others*, they work very nicely. In the second place,we may give drugs to promote the contraction of the intestinal wall. This sometimes succeds very nicely. You may give strychnine in modernte doses or you may employ massage or electricity over the whole abdomen. The last two measures are often very satisfactory. Carminatives are very old fashioned but they will prove useful adjuncts to the foregoing modes of treatment. When the flatulence is due to hysteria,pay attention to the general condition,employ massage and electricity,and treat the hysteria. - 7--The headache.--We must make sure that it belongs to the stomach. If it be due to the stomach, it may be the result of acute or chronic catarrhal gastritis and the treatment will be directed to these two conditions. In other cases, the headache may simply depend upon disturbance of the function of the stomach and. not upon inflammation. 364 In order to relieve the headache,give caffeine,either alone in small and repeated doses,, or as ^roma-caffeine" ,ar in the form of strong tea and coffee. You may give guarana. These drugs are usually the most prompt in their action. - 8-The Dizziness.--It is difficult to determine how much of the dizziness belongs to the stomach and how much to the 13ven * It may be due to disease of either of these organs but it often seems that the principal part were due to the liver. This vertigo is apt to present itself in one of two ways. In the first piece-, it may only exist when the stomach is over-loaded. These eases may be very alarming. The patient may fall to the ground and may remain unconscious for half an hour then,often after spontaneous vomiting, the patient will again be perfectly well. In these cases-, it would appear as though the stomach were principally at fault. The second kind of vertigo is entirely different® It makes its appearance at any time whether the stomach be full or empty. It is unaccompanied by any feeling of nausea. In these cases,it would seem as though the liver were at fault. It is important to remember that there are persons who suffer from vertigo which is at first apparently due to the stomach or liver but,when the vertigo becomes more marked,it is associated with chronic endar- <eritis of the cerebral arteries. Dr. Alonzo Clarke was a good example of such patients. These cases are very puzzling and^whmx 365 you see an elderly person who has vertigo for the first time, look out for cerebral trouble* The first kind of vertigo is to be avoided by not over-loading the stomach and,when it exists^ it is to be treated by making the patient vomit. The second kind Gf vertigo is best treated by twenty dr-op doses of muriatic acid given with the food. This treatment should be kept up for a considerable time. - 2" ACUTE CATARRHAL GASTRITIS.- The pathology of this disease is the same as the pathology of' an acute catarrhal inflammation of any mucous membrane. While the inflammation is active, the mucous coat of the stomach is congested and swollen. It is probable that, at first, the function of the mucous glands is suspended* later, their activity is in- creased and too great a quantity of mucus is produced* The in- flammation frequently extends to the duodenum and common bile duet* With this disease,a person often has an attack of stomatitis nr pharyngitis. The disease does not usually last longer than a week and generally teminates in reeove^but it may be succeeded by a chronic gas- tritis* When a person has had one attack^ he is likely to hm-uww*- 366 De- not look upon the disease as acute indigestion but regard it as an acute inflammation. - ETIOLOGY.- Some persons have a special predisposition to this disease. It occurs with equal frequency in the two sexes and it is common to all ages from infancy to advanced life. It is more common in summer than in winter. Sometimes it is due to indiges- tible food which 'ferments in the stomach and acts as an irritant. In other cases,it is due to atmospheric conditions, such as extreme and prolonged heat. This is especially apt.tn be the cause of th$ disease when it occurs in children. Rapid changes in the temper- ature and exposure to cold and wet are causes of the disease. The abuse of alcohol is a cause., particularly if i.he alcohol be taken in excess at any one time. The ingestion of certain drugs will cause the disease but,frequently,we can determine no cause. The symptoms are pain, vomiting, fever?prestration,headache., and constipation. The mode of development of these symptoms varies with the age of the patient. SYMPTOMS. COURSE AND CLINICAL HISTORY. In these cases,improper food and extreme heat are especially apt to be the exciting causes. In regard to their severity, the attacks differ greatly. Of ten, the attack is very mild: but,at other times, - 1 - IN YOUNG INFANTS. - 367 it will be sn severe that you can not tell whether the child is going to live or not* The child ^y die. The most marked symp- toms are vomiting and fever. The vomiting is pretty constant. Some of the children will vomit evexything they take into the stomach. The fever is often marked, 103-104 and,with both the fever and the vomiting,the infant will be pretty ill. In some cases, the intestines will give trouble after a. few days and there will be diarrhoea. This diarrhoea is apparently not due to inflam- mation of the intestines. The most important part of the treatment is the feeding of the patient. Remember the natural coux'se of the inf lamination and remember that in a few days the infant is not likely to bo starved to death. If the infant is nursing and if there be nothing the matter with the milk, there will be no reason for changing his food. Let him nurse at longer intervals and do not let him take much at each time. Although he may vomit some of the milk, some of it will be retained. If the child is being brought up on the bottle-,it will be necessary to change his food. Give diluted cream, kumyss,or peptonized milk but do not give any of these preparations in large quantities and give them at as long intervals as possible. In order to relieve the thirst,wrap a piece of ice in muslin and give it to the child to suck. - TREATMENT. - 368 If the attack occur in the summer, the patient should be kept in as cool a place as possible. This is very important. If the attack be severe enough, the child should be sent away. The drugs that are necessary in the treatment are not very numerous* They are bicarbonate of soda,oxalate of cerium,and calomel. If you use calomel,give it alone or combined with a little soda in small doses so as to continue its use for a considerable time without affecting the bowels. If the child is being brought up on the bottle,you will do well to add bicarbonate of sodium or oxalate of cerium to the'milk. If you give opium to enable the child to sleep, give it in very small doses. - 2 - IN OLDER CHILDREN. - tn these older children, indigestible fond and heat ;o not so readily become causes and the disease is much less common in these' older children than it is in infants. Some of these children, between the ages of five and eight,will have attacks exactly like those that occur in infants. As a rule, they do not appear very sick yet,if the fever and vomiting continue far some days, you may be frightened and may think that something worse is coming. The child will be peevish,cross, and generally disagreeable. . he will have a headache and will complain of pain in the stomachs Now, children two or three years old always refer any^^in their may have to the epigastric region^bu^ in these older'childran, the 369 location of the pain is of rare importance. In some cases,the pain will not be very bad:but,in others-,it may be as bad as and may simulate the pain of peritonitis. The patient- suffers from nausea and, some times, he vomits. The vomiting is not so frequent nor is it as bad as in infants. There is constipation. Sometimes, there is fever. When the fever is present, it may be as high as 103 and,with these symptoms,you may suspect peritonitis. In the milder eases, the child is not sick enough to go to bed but he feels good for nothing. If the case be more severe.-, the child may go to bed and stay there and,after three or four days in bed, there may be marked emaciation. In many cases, these will be all the symptoms but,at other times, the inf lamination will extend to the duodenum and the child will end up with jaundice. The jaundice often marks the close of the disease. Regulate the food. Cream and water makery good diet. We give cream in order to get rid ef thYou may give casein, or peptonized milk. Same do well with milk to which a little b' arbonate sodium or exalate of cerium has been added. Some will bear meat fairly well. In these sases, you may give scraped raw meat. Some of the patients may be allowed to suck the juice of an -orange. Seme can eat hot-heuse grapes without vomiting. - TRFA^ffiNT. - 370 The medication is the same as in children except that opium be- comes a irug of greater importance. Given in larger doses, it is of decided value. It relieves the pain,quiets' the restlessness, an- acts upon the inf lamination. Sometimes, an adult will have an attack resemblino- those the t oc- cur in infants. The patient will suffer from fever,p<;in, consti* pation, vomiting, headache, and. a. moderate decree of prostration. He will behave in much the same way as an infant and jaundice will frequently follow the attack. In some cases,the fever will be hi^h and will continue for a week or tea 'ays. The temperature may ram/e between 101-102 and it may be difficult to tell whether or not the patient is oevel- rpinK typhoid fever or some other bed disease. In other cases, the vomiting will be a very decided symptom an5, with this excessive vomiting, there is *apt to he marked prostration. When you first see one of thepe patients,you will fear that he is about to pa.ss into The heart does become very rapid and feeble. You will be very much frightened hut,as a rule,if the patient be a richle~aued adult,he will not die. If,however, the patient be old an^' dehilitated,his condition may be dunremus. - 3- IN ADULTS. - 371 - TOWT. ~ Give food in small quantities at regular intervals. Give cream and water,kumyss,or peptonized milk. In regard to medication, there is one drug that is vastly superior to all others. This drug is opium. Opium is of great service, it checks the vomiting, olid, makes the patient move comfortable. It is- best given hypoder- mically. Give two or three minums of Magendie's solution every three or four hours and. keep this up for three or four days. This treatment is especially efficacious in the cases with per- sistent vomiting. We may also give oxalate of cerium,bi-carbonate of sodium,or calomel. If the bowels be constipated,you -will do most good with an enema. If the prostration be very narked, the use of stimulants will be indicated. Give alcohol in the form of wine or spirits. 3 - CHROMIC CATAWhklu GASTRITIS. H is perhaps more important in this condition* than in ^cute gastritis to remember that the disease is an inflammation* The examples of this disease ai'e so common, they present themselves in so many degrees of severity,and they are so apt to be asso- ciated with digestive disturbances, that we are apt only to con- sider the digestive disturbances and neglect the inf laudation. The best treatment is that which is directed towards the inflammation 372 In most Cases,even though the patient suffer for years,the ia- fltmmatory changes vill not have a ivanceo very far. The ru.Y.ns nemhrane it stktimes congested,tore timer not: the mucus fy y or ray not he increased in quantity. Genert 1 ly, the re is a thickening rf the miicous coat^ perhaps, a degeneration of the peptic follicles cells: and an infiltration of lymph cells between the follicles. These may be all the anatomical changes and they are not at all in proportion vith the severity of the disease. In this respect, chronic catarrhal gastritis resembles chronic bronchitis. As there a re no structural changes,the patient should be amenable to t re a tn^nt. In the very had cases,<e find rare decided changes. We find a great growth of connective tissue between the tubules an'1 between the mucous and muscular coats. This growth is accompanied by dov-eneratinn and atrophy r.f both kinds of follicles. As the disease ro^s on,the stomach vill no longer be able to ii^ett food und ciHestion has to proceed without the assistance of the stom?eh. In some cases,not only <111 there he a thickening of the connective- tissue coat,but the muscular coat <ill also become thickened aa> the <hnle <all of the stomach <111 become thick and virid.. - T'ATIPLGGY. - 373 This is most marked at the pylorus and stenosis of that orifice may result. On account of this stenosis,the stomach will become dilated. Tn other cases,the muscular coat will become weak and the stomach will become dilated. These far-advanced oases tre, however, the exception,not the rule. In nine-tenths of the cases, there are no structural changes. So,by chronic gastritis,we may mean that the patient suffers from h change in the function of the mucous glands with,perhaps, a degeneration of the epithelium of the peptic follicles: or, we may mean that the changes in the epithelium are more marked* we may mean that the structure of the mucous coat is so changed that the stomach cannot perform its function: or, lastly,we may moan that dilatation has taken place. The causes of this disease are numerous. They are the following. - 1 -Lesions of other parts of the body that produce a chronic venous congestion of the wall of the stomach. Under this heading, we class diseases of the heart, emphysema, phthisis, and cirrhosis of the liver. - 2-Bright7 s disease,chronic phthisis, rheumatism,and gout are very apt to be cramplisated with chronic catarrhal gastritis. - J?TIUL^Y. - 374 When a patient recovers from an infectious disease,he may give symptoms of gastritis. There is often an interval of several months between the termination of the infectious disease and the devel- opment of the gastritis. - 4--The disease often originates during pregnancy and continues after delivery. --5-The abuse of alcohol is a common cause.- - 6-The excessive use of tobacco. - 7 *- The habitual taking of drugs for no reason whatever. .- 3- The mode of life of the patient, the character of his food, and the manner in vhich he takes his food. - SYhlPTnMS. - The symptoms are not very numerous. The cases differ pore in regard to the severity of the symptoms than in regard to their variety and number. - Pain. - The mildest sort of pain is that vhieh accompanies gastric digestion* It commences shortly after food has been taken and continues foi' a couple of hours. In many cases,it cannot be called a pain: the patient sir-ply realize? that he has a- stomach. In other cases, there vill be a dull continuous pain* These tvo varieties are very common^yet,this sort of pain is not very se- vere. It does not keep the patient avake at night nor does it in- terfere ^ith his business. 375 Another kind of pain, fortunately less common, is due to an irri- table state of the mucous membrane of the stomach. This sort of pain not infrequently follows the first kind. After a time, it will become very severe indeed.lt keeps the patient awake* After the pain has lasted some time, spontaneous vomiting win take place or the patient will get the idea that if he could only vomit he would be all right and this is actually true. At first,the patient will eat only liquid food,will vomit when the pain comes on and will enjoy comparative ease;but,in the worst cases,even a complete fluid diet will not prevent the occurrence of the pain and the pain will not be relieved by vomiting. When the patient has reached this stage,his condition will be very deplorable. The pain will come on every day and he will look haggard and weary. He is apt to resort to opium and the opium habit will result. There is another sort of pain, "heart-bum8 . This is & burning sensation referred to the stomach. - 2- Nausea and Vomiting. - Neuser is very common but it is not a constant symptom. Most of the patients have it in the early morning before breakfast. Some hardly think of it as real nausea, they simply have no appetite .for breakfast but, if you question them closely,they will admit that they have had feelings of nausea. 376 Vomiting is not as constant as nausea and it belongs to the bad cases. Some simply vomit food. This sort of vomiting sometimes occurs after a meal hut the patient does not vomit in order to relieve the pain. In other eases, the vomiting is due to an irri- table state of the mucous membrane of sthe stomach. In these cases,the food first sets up pain and this pain is succeeded by vomiting'. At first,it will require a considerable amount of food to set up pain and vomiting but,later, they will be excited by the smallest particle of food. Some patients will vomit other substances than food. The gastritis is accompanied by the pro- duction of a brownish fluid. 'This fluid, is composed of serum, gastric juice,and mucus. It may he produced in considerable quan- tity and it will be vomited either alone or with the fond* This sort of vomiting belongs tn the bad cases.particularly to those cases in which dilatation of the attach has taken place. Some patients will vomit pure mucus* They may vomit half a pint of mucus every day and,if they have not taken food,the mucus will come up by itself* This is not very common* Some patients will vomit blood. This is due to a diffuse bleeding of the mucous membrane. This blood may be blackened and partly digested by the gastric juice oryif vomited when fresh,it will be red. In those 377 cases in which there is stenosis or in those with dilatation, without stenosis, there may be vomiting every few d^ys. The food will accumulate in the stom&uch until the stomach is distended and then the food will be vomited. - 3 - Imperfect performance of gastric digestion. - The food is taken into the stomach but the process of stomach digestion is not properly carried on. The cases vary greatly in regard to their ability to digest food. In the worst cases, there is no gastric digestion, at all: the food is either vomited or it passes undigested* into the int'-s tine. In the milder cases, gas trie di- gestion is partly but not thoroughly performed and part of the food passes undigested into the intestine. These milder cases are very common. - Addi ti onal Symptoms. - These i re constipation or diarrhoea,headache,and loss of flesh and strength -1-Constipation.-This is common but it is not a constant symptom. -2-Diarrhoea.-This is less constant than constipation. With dierrhoea and with constipation,there may be flatulence and intes- tinal pain. -5-Headache.-This is not constant and usually comes on in attacks. 378 -4- Loss of flesh and strength. - This is very common. In women, it is often accompanied by cessation of the menstrual flow. Some patients have curious disturbances of sensation referred to the mouth. The mouth may be always dry or they may complain of a bitter taste. You must not think that because a petient has chronic gastritis he will be exempt from other diseases.On the oontrary,he is es* peeially liable to disease of the liver, intestine,.and kidney and, of course,he may have any other disease. The uncomplicated cases are the' easiest to treat. BOURSE. ■-- The course is always very prolonged. The disease seems to have hut little tendency to get veil and,even after the patient has recovered, the disease is likely to return. The disease is apt to continue in an interrupted course for many years, This interrupted course forms the basis of the many cures that reported. As the disease goes on untreated,the intervals during which the symptoms are continuous will,each year,become mox'e prolonged. Tn many cases,however,the disease is never anything mo re than an Inconvenience. Many patients never go to a physician or,if they do, they do not continue his treatment. In others cases, the disease is more serious,the patient cannot put up with the symptoms, 379 and he may not be able to attend to hir work. The ou«*ep! with excessive pain are apt to do badly and are apt to acquire the opium habit. Some times,though rarely,a patient will die of the disease. The fatal cases are generally found among the poorer classes. - TRHATHWT. - One of the points that should be determined at the outset is how far the patient is likely to be benefited, by treatment. This depends upon the actual changes that have taken place in the mucous coat. If the gastric tubules have been destroyed, we cannot expect that treatment will do much good. These cases are incurable and all that we can do is to feed the patient as' well at we can and prolong his life. When we try to determine whether or not a patient belongs to this class,we must be guided by his age. In young and middle-aged persons,this condition is rare. It belongs to elderly persons of bad habits,who have abused the use of alcohol or tobacco or vho have been badly fed. If we think that the mucous membrane is entirely gone,we feed the patient upon starches and fats. The stomach does not have to digest this kind of fond. This is one plan. If we think that the stomach can do some work, we may give a small quantity of nitrogenous fc-od with pepsin and a mineral acid. 380 There are patients who,al though they do not suffer from this incurable form of the disease,yet,on account of their circumstan- ces, cannot carry out a beneficial plan of treatment. These cases we can only palliate, besides these cases,which we really do not tree t, there is a. large number who suffer from this disease and do not have any marked changes in the mucous membrane. These eases we can improve very much and we can make the symptoms disappear. When you treat these cases,do not think too much about the symp- toms and do not treat the symptoms directly. Treat the gastritis irrespective of the symptoms. In the treatment \ *of this disease, we are guided by the same principles that direct us in the treat- ment of a chronic catarrhal inflammation of any mucous membrane.? There are three methods upon which the treatment may be conducted. The first consists in regulating the patient's mode of life;this is the best of all. The second consists in the use of local ap- plications: this is of great service. The third method consists in the use of drugssthis is the least efficient of all. Now,when we come to a chronic catarrhal inflammation of the stomach,we have a fourth method of treatment: this is diet.. -1-Mode of life.- Find out whether or not the patient can afford to go to a climate that suits him and where he can live out of 381 doors. If he can,it is the best thing that he can do. Life for a single year in such a climate Till not suffice. It requires a number of years or a number of months out of each year for the patient is very liable to a relapse after he returns. ■- 2- Local applications.- We use the stomach tube. To be of ^ny use,this treatment should be kept up for a considerable time and,should relapses occur,the local applications should be re sorted to again. Tell the patient to drink two tumblers of milk between, seven and eight o'clock in the morning and at the end of three hours to come-and see you. previous to his visit,he should eat nothing more. You wash. out the stomach with a quart or two of warm water to which a little carbolic acid has been added. You will find that a certain amount of the casein will come up un* digested and,if the case be very bad,your tube will be clogged with casein. Then, tell the patient to beat a beefsteak within an hour after his stomach has been washed out. Let him tske part of a potato a.nd a glass of water with his beefsteak and, in the evening,let him have nothing but milk. If the stomach have di- gested the meat,you will find none of it when you next wash the stomach out. Do not trouble yourself about the pain that the meat may give. If you find no meat when you next wash out the stomach,ynu may let the patient have one square meal a day. 382 For a week,do not bother your^nlf about what the patient says. He may say that he is better op he may say that he is worse.. but you should pay no attention to hie remark?. At the end of a week,you may ask him how he feels*. In all probability, he will tell you that he feel*/ much better. The pain is he hardest symp- tom to get rid of,particularly if it have been very severe at first. Continue this treatment for a month then,if the patient do we 11,you may let him have two square meals a day.Keep this up for two or three weeks then,if he continue tn do well,you may let him have some fresh or cooked fruits. Never let him have canned fruits. If the fruits be well born,you may let him have some fresh vegetables and,by this time,he will pretty well fed. During all this time^you continue to wash out the stomach but, now,the patient should have learned to use the stomach tube himself. Ynu teach him to wash out his stomach before breakfast and let him have coffee,miIk,meat,bread and butter,and fruit for break- fast.. Now,it is better to get rid of the milk altogether. The next thing to do is to gradually let him discontinue, the use of the stomach tube. The patient is now cured and,for months or even for a whole year^he will have no further trouble but,unless he be extremely fortunate,he will have a relapse. Then,the treatment 383 must he commenced again but it need not be con tinned longer . ii: than three weeks. He may have another relapse and,perhaps, several but each succeeding relapse will be more easily managed and the p< tient will finally be cured- - 5- Drugs.- The usefulness of drugs is limited to the early stages of the disease when they may make the patient more eomfor- , table. You may give the salts of sodium,the salts of potash,mineral acids,bismuth,alcohol,iodoform,glyeevine,or hitter infusions but they only serve to alleviate the /symptoms in the early stages of the disease^ - 4-Piet--Under this heading, the re are several rules that should be laid down. In the first place,the patient should be well fed. In the second place,it is not at all necessary to cut those articles of food that are digested by the stomach. Indeed, the patients do meh better with these articles of food than without them. In the third place,the starches /which you might think would be good for the patient are not particularly beneficial. The patients do not bear them well- Fourthly,it is not necessary to give partly digested articles of food* They are not beneficial in these eases. In the fifth place,milk is well born by most of the patients and it is the best thing you can give. There are exceptions to this rule.- 384 Lastly,most of the patients can take some fresh fruits and some fresh vegitables. What these vegetables and fruits are,you must find nut in each-case. You must not expect tn cure by diet alone. It will frequently cause the patient to improve for a time,that is all* If you try to treat by diet alone,the best thing that you can give is milk. Often,all the symptoms -'Vill disappear while this diet is continued. Yet,you cannot keep a patient on a milk . diet for any length of time* If you do,he will have but little muscular or mental strength. However,you may keep up a milk diet fc-r several months but,as snon as you return to a mixed diet, the symptoms will also return. - 4-SUPPURATIVE, OR PHLEGMONOUS GASTRITIS.- - PATHOLOGY.- The inflammatory process begins in the connective-tissue coat and. it is in this eoat that the changes are principally developed. Pus infiltrates, mo re or less,the connective tissue,and,in ad- dition, there is necrosis. Sometimes,such a suppurative inflammation will only invade a small part and the pus will collect as in an abcess^This abcess may be as large as a man's fist although it is usually smaller. In other cases,the inflammation will in 385 vede all ar nearly all of the connective-tissue eoat. This eoat will then be from one-quarter to one-half an inch thick through ton throughout. The inflamination is apt to extend to the glandular coat and to the peritoneal coat* In the glandular coat,pus will be infiltrated between the tubules and the tubules will break down. If it extend to the peritoneal coat, that coat will be wc<7i/ with fibrin and pus and a general peritonitis may be set up* In the diffuse farm, the .pus may escape into the stomach. If the pus enter the stomach from an abcess,the patient may vomit the pus: if,however,it enter the stomach in the diffuse form of the disease, there will be but little perforation of the mucous coat or a number of small perforations and the patient will not vomit the pus. - ETIOLOGY.- It is a disease of adul't life and is more common in males than in females,other-vise,we know nothing about its cause. Fortunately,it is very rare. - SY'fPTOMS* - If the disease be of the circumscribed variety, the abcess will usually be situated near the pylorus. The patient will suffer from pain in the epigastrium, loss of appetite, vomiting, fever, and. considerable prostration. If the abcess be large,you will 386 be able to feel it in the epigastrium. If it rupture into the stomach,the patient may vomit the pus. The localised peritonitis will increase the pain* In some cases,the disease will be acute &nd«*rill terminate fatally in a few days. This is apt to be the ease if the peritonitis become general. In other cases,the patient will live for weeks,and months, will became more and more emaciated and will finally die exhausted. When the disease is of the diffuse form, its whole course is genearlly acute and short and it usually lasts a few days,a couple of weeks,or a little longer. In- these- cases,a general peritonitis is as a rule developed a fev days after the disease has commenced. The first symptom is regularly vomiting* At first,the patient vomits food,then,the attempt at vomiting continues after the stomach is empty. The re are pain and tenderness over the stomach. This pain and tenderness continue throughout the disease. Within an hour, the temperature will run up pretty high and,within twenty- four hours, there will be much prostration* Then,after a day or so, there will be pain over the whole abdomen. Thit pain is due to general peritonitis. The intestines will be distended with gas, the re will be constipation,the patient will emaciate,the face will become anxious,there will be cerebral symptoms,the 387 heart will become rapid and feeble,and the patient will die much in the same way as though he had acute general peritonitis. - TREA^IENT. - The treatment is unsatisfactory. Apparently, the best thing that we can do is to treat the oases as though they were eases of peritonitis. Give fluid diet. .If the stomach refuse food,nourish the patient by the rectum. Apply cold to the ubdo.men. Keep the patient almost narcotised with opium. As a rule,the inflammation it, fatal. - 5 -CHRONIC PERFORATING ULCER OF THE STOMACH.- - PATHOLOGY. - These ulcers may be either single or multiple. If multiple,they may all be developed at the same time or they may be developed one after the other. So, in the same stomach,we may find one ulcer cicatrized,another forming, and another fully developed. However,as a rule,there is but one ulcer. Their most frequent seat is at the pyloric extremity,on the posterior well,and near the lesser curvature. Of course,they may be developed in any part of the stomach. Most are small and vary from' half an inch to two inches in diameter. As exceptions to this rule,we sometimes find them not larger than a pin's head or they may be several inches in diameter. 388 Two may join together and form one of very large size* They are round or oval in shape and begin in the glandular eoat. The af- fected portion of the glandular eoat is destroyed and disappears and a rounds clean-cut hole is left. Th^ ulcer frequently stops here. In other eases,it Till invade the connective tissue coat and he re, also, a round hole will be formed a little smaller than that in the glandular coat. Here also, the ulcer may stop but it may extend to the muscular and peritoneal e-oats* So, the whole thickness of the stomach may be invaded* When these ulcers extend deeply,as they approach the peritoneal coat, a localized periton- itis may be set up and,as a result,the stomach may become adherent to the pancreas* So,the contents of the stomach may not escape into the abdominal cavity. In other eases,when the ulcer perfor- ates the stomach,the adhesion between the stomach and pancreas will not suffice to fill the gap. In consequence of this,the contents of the.astomaeh will escape in small quantities and will set up a localized peritonitis. This localized peritonitis vill result in the formation of adhesions in the upper part of the abdominal cavity which adhesions will shut in the pus. The localized peritonitis may extend and set up a general peritonitis. When the ulcer perforates the anterior1 wall of the stomach^no 389 adhesions will be formed and the whole contents of the stomach will escape into the abdominal cavity. The perforation will cause great shock and will be followed in a few hours by acute periton- itis. The floor of these ulcers is smooth. At their extreme edge, we find the wall of the stomach but,at the edge of the ulcer proper, there is nothing but a mass of amorphous granules. In the older cases, the edges and floors are farmee of pretty dense connective tissue. In other oases,the edges will be thickened and formed partly of granulation tissue or or' connective tissue. But, the floors and walls of these ulcers never look like the floors and walls of other ulcers. When a patient recovers,the ulcer cicatrizes. This is effected by the formation of connective tissue. When cicatrization takes place-, the ulcer 'will gradually diminish in size, the connective tissue will contract,and nothing but a cicatrix will be left. The exact way in which this healing process takes place,depends upon the size and depth • ...of the ulcer. Those that are small and not deep cicatrize as a whole without any special trouble or deformity and,with the exception of one small place,the stomach is practically as good as it was before* If.,however, the ulcer 390 he large and if it have penetrated deeply.,it may deform the stom« aeh a great deal when it cicatrizes. Far exar?ple,, if it be situated Some distance behind the pylorus, it will narrow that part of the stomach and,if near the pylorus, it will constrict that orifice* These deformities give much trouble* In some cases,when the pylorus is constricted,the rest of the stomach becomes dilated. In other cases,the entire stomach becomes contracted by the cicatrices^ These patients are left in a pretty bad condition. If the ulcer get through the glandular coat or if it involve the connective- tissue or muscular coats.,it may involve the blood vessels and haemorrhages will result. If the haemorrhage come from the glandular coatjit will be capillary in character but,if the ulcer pass deeper, a large artery or vein may become eroded. As a rule, the patient has a chronic catarrhal gastritis and it will often happen that, after the ulcer has cicatrized,the gastritis will continue and it may be very difficult to tell when the patient is cured. Vie will nnw consider the process of formation of these ulcers. First, there is an obstruction to the circulation in a particular part of the stomach. This may be due to embolism, thrombosis, or chronic endarteritis of the arteries or it may be due to throm- bosis of a vein* Then, this portion of the wall of the stomach 391 loses its vitality and changes into dead tissue.Now it no longer preserves its immunity eigainst the action of the gastric juice. It becomes softened and digested and there will be an erosion of the wall of the stomach but there is no inflammation. This the generally accepted explanation of the formation of these ulcers^ yet,at autopsies,you will have great difficulty in finding any obstruction to the circulation in the stomach* However, this is the best explanation that we have* -ETIOLOGY.- These ulcers are of common occurrence but they are of greater frequency in foreign countries than in ihnerica* In this country the disease is rather rare-,you may go for a num-* her of years and not see one* They are twice as common in women as in men* They occur at almost all stages of life.,yet,in young children, the disease is very rare. The larger ulcers occur between the ages of twenty and forty. The average age for their occur- rence in women is between twenty and thirty* Most authors lay great stress upon the age of the patient as a diagnostic point and they state that ulceh always occurs in young persons and cancer in old ones* This is undoubtedly a good rule but the ex- ceptions are numerous and it will not do to place too much con- fidence in it* 392 The rule is not of great practical importance in making the diagnosis. - REGULA SYMPTOMS. -- -. p-Pain. - This pain exists during a considerable part of the time. It is always increased by eating aad^as a, rule,by pressure. In same cases-, this will be the only kind of pain. It will be dull and not very severe. Other patients -'Till suffer fw severe sharp attacks of pain. The pain is usually referred to the ensiform Ocirtilage., just below it,or a little to its left* Some will locate the pain farther down or even in the back. In many cases,it is difficult tn tell how much of the pain is due tn the ulcer and how much to the gastritis. A patient may have ulcer of the stomach without pain but this is the exception. - 2- Vomiting. - Some patients will only vomit when they eat hut they need not always vomit after eating.Some can take liquid food without vomiting. Others ca.n take no food at all,not even a tea spoon of water without vomiting* Others will vomit even when they do not oat. About one-quarter of the patients vomit blood. When this takes place,the character of the vomiting varies Tith the rapidity with which the bleed is effused into the stomach. If only small quantity be gradually effused into the stomachy 393 it will be retained,be partly digested,and look like coffee grounds when it is vomited. If the blood be effused more rapidly,it will be vomited afresh. The patient may vomit a half pint or a pint of blood, or he may bleed to death. Occasionally,a patient will bleed to death without vomiting and,at the autopsy,the stomach will be found distended vith blood. Some of the blood may always pass into the intestine and be vo with the stools. - 5-The chronic gastritis is attended with more or less alter- ation in the gastric digestinn even if the patient can take food. As a rule, the bowels are constipated throughout the disease. In many cases,the patient will lose flesh and strength and will become anaemic. - COURSE.- - 1 - -Some have no symptoms at all although the ulcer runs its regular anatomical course and the condition is only revealed at the autopsy. - 2 - These go through the regular course and develop one symptom after another. Some lose flesh and strength. Some times, the symp* toms will go on month after month without intermission,then,they will all disappear.In others^ the disease will last several years hut,although the ulcer is present throughout, the symptoms will not be continuous. The symptoms will be present for several weeks then,they will stop for a week,then,they will come on again and the course of the disease rill be intermittent. In these cases, 394 it is difficult to tell whether the symptoms are due to one ulcer throughout or to several ulcers that have successively cicatrized and gotten well. At the autopsies,we may find either condition* - 3-These eases are marked by large haemorrhages- They usually vomit blood and pass some blood with the faeces. A patient may vomit blood in considerable quantity several times and yet get well. However, these eases are always alarming and the patient may die from haemorrhage. - 4-In these eases,perforation is the marked feature. If the perforation be large and if it take place rapidly, the patient will pass into collapse: then,in a few hours, there will be a general peritonitis which vill prove fatal in a few days. Some of these patients give a previous history of gastric ulcer but others give no symptoms till perforation takes place. These latter eases are very puzzling and,when you are culled to see one of them in collapse,you cannot always tell what is the matter with him until peritonitis sets in. If the perforation be small,there will be no sudden change in the patient* He '."ill gradually get worse, the pain will become more decided, and, when you examine the upper part of the abdomen,you will get a feeling of fulness. If the peritonitis remain confined to the upper part of the abdomen, 395 these will be all the symptoms that you will getiif it extend, you will get the symptoms of chronic peritonitis which, together with those of the localized peritonitis,may last for months before the patient dies. - PROGNOSIS- More than one-half the cases recover* entirely* so, the prognosis is fairly good. Of the fatal cases, some die from perforation, some from anaemia,and others from exhaustion. Of the eases that recover,most recover entirely,others are left with deformities of the stomach, and others continue to have a chronic eatarrhah gastritis. - TREATMENT. - - 1- The feeding of the patient. - The vomiting is apt tn inter- fere with the nutrition. If the patient do not vomit very often, we can often do well enough by feeding by the stomach. Give a fluid diet-,milk,beef juice,cream and water,or milk to which oxalate of cerium or bicarbonate of sodium has been added. If the vomiting be very frequent,if the patient cannot tolerate fluid fond,or if he has been vomiting pretty freely, introduce nothing into the stomach. Do not even give the patient water by the mouth except in the smallest quantities. You must nourish the patient by the rectum. You feed by the rectum at regular intervals of about four hours. 396 Once a is wise to wash out the rectum with warm Writer. Give peptonized milk or the yolks of eggs in emulsion with a little water. You may give some of the preparations of meat nr peptonoids of meat. In many cases,you will do best by alternating these different articles. The quantity to be given,'^ill vary with the patient. Some can take a pint ci peptonized vrilk and hear it well. Others cannot stani more than four,three,nr even two ounces. When you inject,use a soft rubber tube and carry it as far up the rectum as possible. If the -patient Jr. not tolerate the smaller enemata?give a little cocaine o.r opium, with them. In most cases, we are able to nourish the patient & considerable time by the rectum. This feeding of the patient io the most important part of the treatment and,in many eases.it is rill that is necessary. --2-In some eases,the pain is so.severe that ve have to control it. One way to do this is to administer drugs by the mouth. You may give iodoform or cocaine. Some patients will vomit these drugs. Others will not vomit them but the drags will give no relief. We may employ counter-irritation over the stomach by means of galvanic electricity or the nitric, acid issue. This will give some patients relief* others,none* If all these means fail,give morphine hypodermically. It is better not to use morphine^ if you 397 can possibly avoid it for the eases are apt to be prolonged and the patient may develop the opium hahit. - 3-When there are large haemorrhages, you might think that ergot and gallic acid would he of .service but,if you remem- ber that the haemorrhage comes not from the mucous membrane but from an eroded vessel,you will see that these drugs can be of no use-. While the patient bleeds,apply cold to the abdomen and give mo rphine hypodermi ca1ly. ~ 6-CANCER OP TILE STOMACH.- - PATHOLOGY.- Cancer r,f the stomach is,generally,a primary disease. Secondary cancer in this situation is very rare. There are three varieties of cancer that invade the stomach. These are common eancer,epithel- irmu,and colloid cancer. The first two run the same course,p resent the same gross appearance,and,for clinical purposes,it is not necessary to distinguish between the two. Both present themselves under three methods of growth. These are:- - 1 - This is the most common. The cancer begins in the deeper layers of the glandular coat-. At first.,it will be two or three 398 inches in diameter. All this portion of the wall of the stomach •'Till be thickened. The growth extends at the periphery and,at the same time,it becomes necrotic at the centre. The-sent re sloughs and forms an ulcer and,by the end of a few months, the cancer looks like an ulcer with thickened edges. This method of growth con- tinues as the cancer increases in size. The necrosis at the centre may lead to perforation. If the perforation be filled up by adhesions- adhesions,the cancer may extend to the adjacent parts and cavities will be formed in the pancreas and liver. There may also be per- itonitis. --2-* This method of growth is less common. The cancer begins in the way above described but, instead of growing laterally,it keeps growing into the cavity of the stomach. There is no necro- sis and the tumor becomes larger and larger. It may reach the size of a hen's egg. The base of the tumor will be larger than the size. - 3-The cancer begins in the same way in the deeper layers of the mucous coat but it extends laterally and gradually involves more and more of the wall of the stomach . The re is no necrosis nor is there any formation of a tumor. There is nothing but a flat infiltration. This is the least common method of growth 399 and,as no tumor is formed, it is the most difficult tn make nut during life. - Colloid Cancer.- This form of cancer generally invades a con- siderable part of the mil of the stomach- It infiltrates all the coats and the Thole wall of the stomach is very much thickened. The tumor is not circumscribed but involes a large area.* With cancer of the stomach, there is usually a chronic gastritis* The most frequent seat of cancer of the stomach is at the pyloric end, on the posterior wall and near the lesser curvature* If of moderate size,the tumor will remain confined to the pyloric end. If it extend,it may involve the whole of the lesser curvature or, even,the whole wall of the stomach. Less frequently,the cancer will be situated at the oesophageal extremity.. It may be situated anywhere. When the cancer is situated at the pyloric end, the position of the pylorus will often be changed. The pylorus will become heavier and it will have & tendency to sag down in the abdominal cavity. The pylorus is apt to become constricted and, as a result, the rest of the stomach will become dilated.. This dilatation of the stomach will still further alter the position cf the pylorus. So, the pylorus may be in almost any p^rt of the £b domina1 c avi ty. 400 Some times,the cancer will remain in the stomach hut,at other times, there will be metastatic growths in the lymphatic glands,in the liver,and in other parts-. The lymphatic glands near the pylorus are most frequently affected. They become cancerous and adhere to the pylorus,. Less frequently,the lymphatic glands of to ther parts,particularly those of the neck will become athe seat of metastatic nev growths. When the liver is affected,it is as a rule enlarged. It projects down into the abdominal cavity and we can feel nodules on its surface. Less frequently,the liver will be diminished in size or the nodules may be very small. Should this be the case-,we will not be able to feel the nodules. - ETIOLOGY The disease is equally common in the Wo sexes. Generally it occurs after middle life,he Ween the ages of forty and seventy. Less frequently, we find it in persons between the ages of thirty and forty- Occasionally, it occurs in young pe rsons, Wenty years of age* It is fairly common in all civilized countries. In New York City, cancer of the stomach is more common than ulcer. We know nothing of its real cause* There seems to be no decided hereditary tendency to ths disease and its real cause is unknown. 401 The symptoms of cancer of the stomach tv re much the same as those of ulcer. •-1- Pain. - This is more common than in ulcer. It is a good deal like the pain of ulcer. Some times, it 'vill be severe only after eating. The pain is partly due to the cancer,partly to the gastritis. But,al though pain is c, common symptom, it is not constant^ A patient may go through the uholn course of cancer of the stomach without pain. .- 2- Vomiting -This is a common tyrptom. The patient may vomit food,mucus,or browish or yello-i fluid. The severity of the vom- iting varies. Some patients only vomit at considerable intervals nr w?n they take solid food. Others vomit very frequently. I should say that as a rule vomiting is not ao bad in cancer of the stomach as in ulcer. Vomiting is not a constant symptom: some patients do not vomit at all. Vomiting of blond is more common in cancer of the stomach than in ulcer. (Jo vever, the bleeding is not as a rule considerable and the blood is oftw vomited ?xs the "coffee-ground fluid. - 4 - The patient may develop gastric indigestion, disturbances of the Iarge in te s ti ne,e ons t ipa ti nn,o r di a rrhoe a. - SYMPTOMS. - 402 - PHYSICAL SIGNS . -- The most certain symptom is the tumor. If the tumor he situated at the oesophageal end of the stomach, it will escape us al together and we shall have to diagnose without the aid of physical signs. If the tumor, al though situated at the pyloric extremity,be small or if it consist simply of a flat infiltration in this situation, we will not be able to appreciate it for it will be covered by the liver. Thex^ is one exception to this statement.The tumor may be so small that we may not be able to appreciate it when the patient is lying quietly in bed but if we cause him to take a full breath and so force down the diaphiagm, the tumor may pro- ject below the liver and may be felt. We should never forget to examine in this way when we suspect cancer. If the tumor be larger, the pylorus will be pushed down and the tumor may be felt. Most frequently,we feel the tumor in the epigastrium:less frequently, lower down. You must always feel as low as the umbilicus or even lower. The ease with which you will find the tumor will also vary according to whether the abdominal muscles be tense nr lax. In emaciated subjects-, the ribs will be prominent, the abdominal wall 7/111 slope backward away from the ribs,and the abdominal muscles will be hard. In these cases,make the patient take a full breath and r as, the tumor moves,you will be able to feel it. Occasionally 403 the ]vrrpha tic gland* n^ar the pyjoruy will become adherent to the vertebral column behind as well as to the stomach in front and the tumor will be fixed. These cases are very puzzling. The pylorus will receive pulsation from the aorta and,some times,it will seem to pulsate laterally and you may mistake the cancer for an aneurism of the aorta. In all such cases,ynu must pay at- tention to the history. If the patient has been ill only a few weeks or months,you would hardly expect the disease tn he a cancer* if,however, the disease Imve lasted a year nr two,you would ex- pect to find a malignant growth* When you examine a patient, al- ways remember tn make him take a full breath. In some patients, during the latter months of the disease, there may be a fever without any peritonitis. The patient will sometimes pass blood from the bowel. He may become jaundiced. The jaundice may be due to gastro-duodenitis,to pressure upon the common bile duet or to inflammation of the bile duct* At first,the general health is not much affected:but, Later, the patient developes the cancerous cachexia. - COURSE* - --1-These patients have an gastric sjrmptoms at all. They .begin tn run down,they lose flesh and strength,and they become anaemic. They do not vomit, they eat well,and. they have no pain. These cases are very puzzling. 404 As the disease goes an,you suspect a malignant growth somewhere but, where,you do not know unless you have been able to feel it* If you have been able to feel the tumor, the diagnosis will be easy enough in spite of the absence of gastric symptoms. - 2- These eases are also .apt to deceive you. They have given gastric symptoms for years and say that they are gradually getting 'irnrse. The reason for this is that the patients have first had chronic gastritis and,then,cancer of the stomach but they have sppreeiated no change except that they have gradually become worse. These eases are common* - 3 - . In any case,one or more af the regular symptoms may be and often are absent* Same patients continue with a good appetite; others never vomit although they hiay die others never vomit blood: others never have pain: others never give evidence of a tumor; and although nothing is easier than' to diagnose a typical ease of cancer of the stomach, the re a.re ' cases replete with difficulty* - PROGNOSIS. - The prognesis is bad* - DURATION.--The duration is usually not greater than two years* The patient usually dies within a year after you have made the diagnosis* The patient may live four years but this is the exception. - TREAT^fENT* - The medical treatment consists in feeding the patient and making 405 him move comfortable. The surgical treatment consists in excision of the new growth through the abdominal wall and has sometimes met with fair results- This treatment is indicated when the tumor is situated at the pylorus,when it is small,when there is no infiltration of the lymphatic glands,and when the patient is young- v/hen the ope cation is successful, the patient can recover for a time. The result of the operation depends upon the surgeon. For the operation to succeed it should not only he done v well but quickly- If much more than two hours be consumed in the op- eration, the rule is that the patient will die. I always favor the operation if I can get a surgeon to do it.. The trouble is that it is new and in New York there are very few surgeons who have had sufficient experience with it to want to perform it. If the operation cannot be done,feed the patient with solid food at first, then, give fluids hy the rectum. G-ive opium for the pain- • 406 - TH^ SVALL INTESTINE.- - 1- DISTURBANCES OF DIGESTION.™ A patient may have trouble from failure of intestinal digestion. Yet,it is difficult to pick out those cases in which the intestine alone is disturbed for, if the digestive function of the intestine is deranged,that of the liver and stomach is also apt to be dis-* turbed. Yet,there are cases in which the patient has no gastric symptoms- He has a pain referred to the middle of the abdomen, he loses flesh and strength,and he becomes anaemic. In former yea rs., I used tn be mo re decided about my d 1 agno yis in these ease v than I am at present. Now-a-days,I begin to doubt my ability to diagnose them. Now,it seems to me that most of these cases either belong to or are associated with disturbances of the liver. - 2 -DISTURBANCES OF THE ABSORPTIVE FUNCTION.- We have a number of examples that seem to be disturbances of the absorptive function of the small intestine. If,from any cause, a patient suffer from venous congestion for any length of time, he will be apt to lose flesh and strength and this would seem to be due to failure of the absorptive function of the small intestine* If a patient have changes in the mesenteric glands or ulcers in the small intestine^he may starve to death from this cause* 407 - INTESTINAL HOLIC.- mbi? name is given tn a spasmodic pain which is believed tn he due tn a spasmodic contraction of the muscular coat of the colon. These at tacks are very common. In a certain number of the eases, we can find a cause for the disease.lt may be caused by irritating food in the intestine-,by the accumulation of faecal mutter,or by habitual flatulence. It may come on after exposure to cold and wet. In other cases,we can find no cause. - SYMPTOMS. -- - 1-Pain. - This is always bad and,in many cases,it is exceed- ingly severe. It may be referred to any part of the abdomen. - 2-There may be noises due to displacement of gas in the colon This is caused by the muscular spasm. It often happens that each time the patient belches gus he will enjoy temporary relief. - 3-The abdominal wall will be retracted and the abdominal muscles will be tense. In some., the ^patients who have been flatulent,the abdomen will be distended. - 4-In some cases,there will be nausea and there may be vomiting. The patient ut first vomits the contents of the stomach and, then, mucus tinged with bile. 408 - 5-As a rule, the bowels do not move during an attack but often-, particularly in the milder eases, the pain disappears when the bowels do move. The milder eases simply look as if they were having a bad time: the severe eases will look haggard and anxious and will be bathed in perspiration. As a rule,the temperature is not changed but, in the prolonged cases,it may be elevated. The temperature may reach 101-102. The cases vary as to the severity and duration of the attack. The milder cases are not so bad: they constitute the well-known flbelly-ache " and only last & few hours,but there are much more severe attacks.: • The pain may be very severe, there may be nausea, vomiting, prostration, a rapid and feeble pulsa,and the patient may look very ill. If 'the attack only last a few hours, the patient will not be so badly off but one of these at- tacks may last a week and the patient may become alarmingly pros** trated. In these latter eases,if the patient have a cold skin and a week pulse,you may suspect stricture: if he have a rise Of temperatun,you may suspect peritonitis. These cases are par- ticularly alarming when they occur in persons over sixty years of age. Whether they ever really die., I do not know. I have seen eases that have alarmed me greatly. In the shorter cases, the 409 disease is tn be differentiated from biliary and renal cnlic. when you have jaundice with biliary colic,the differential diag- nosis is easy enough but,when there is no jaundice,the diagnosis may be impossible especially as the patient may at varying in- tervals have first one disease and then the other. Frequently, you can diagnose one condition from the other only by searching the faeces for the calculi. From renal colic, the diagnosis is easier for renal colic gives more characteristic symptoms. - TREATMENT. - In the treatment,there are tvn things to he considered. In the first place,if the patient have taken irritating food,it must be relieved by purgatives: in the second place, ve must relieve the muscular spasm.. - 1 - When the patient has taken indigestible food,the case is clear enough. Castor nil is the best purgative you can givp. Give it in full doses vith a little opium. If the patient cannot take it.,you <111 have tn give nther purgatives. - 2-The second purpose ve may accomplish in one of three ^rays. We may give drugs that vill cause contraction of other parts nf the intestine. For this purpose,you may give ca rminatives, car- bonate of ammonia,nil of aniseed, tincture of cardamon,or nil of pepermint. This treatment belongs only to the mild attacks 410 and it often answers well enough in these eases. In the second place,we may give drugs that will, substitute the regular contraction of the colon which accempanies the expulsien of faeces for the irregular muscular spasm. Castor oil is the best drug for this purpose. You may use any other laxative. In the third, place,you may give opium and belladonna in order to relax: the muscular spasm. In the more severe cases,carminatives are of no service and, indeed,in most cases, the laxative plan of treatment will be found the best. In the very severe case s-^ cantor oil will not act upon the bowels. In these.,use the opium and belladonna treatment. The ye drugs are best given hypodermically in the form of morphine and atropine. Give them in pretty fair and repeated doses. This disease is not as common as acute colic and it has been but little de sc ribed) ye tyre meet with it frequently enough. At first,the patient may have one or more attacks of acute colic, but he goes on having them year after year. The attacks may be repeated every month,every week,every few days,or even every day. - CHRONIC COLIC.- 411 They became more frequent and,in the worst eases, the patient tay never be free from pain. The patient suffers very much indeed f nd he may not be able to attend to his business. His general health begins to suffer and he loses flesh and strength. In addition,the patient often suffers from rem lies given to relieve the disease. The opium habit is apt to become established. Then, the general health suffers from the use of opium as well as from the pain. - TRMTdWT. - The treatment is entirely different from, that of acute colit. In the first place-,it is important to determine whether or not any or all of the attacks be due to the passage of biliary cal- culi. In many cases., there will be no calculi in the faeces and you will be able to exclude biliary soli*. In other cases,the calculi will be present after each attack:these cases do not come under this disease. In soma,the calculi will be present after seme attacks not after others: in these cases,we have a combination of both diseases. The diet should be very simple. In the worst cases,it should con- sist for a time exclusively of milk. In others,you may allow one square meal. As the cases get better,you may allow three meals. The meals should consist of meat,fresh fruits^and vege- tables. 412 - The Mode of Life. - The patient is often confined to bed but, as he gets better,he should take a good deal of exercise. He should have a regular action from the bowels every day* To secure this,you may give laxatives. Now for the actual treatment. There are two drugs which,given together are very efficient. These drugs are belladonna and ipecac. They should be given three times a day in pill form and in as large doses as the patient can tolerate. Give the bella- donna almost up to the point of poisoning. Patients differ greatly in regard to their susceptibility to belladonna. Some can stand a grain of the extract three times a day-, others can only stand one-twentyfifth of a, grain. Begin with small doses and push the drug until the patients mouth becomes dry. Do the same with the ipecac*, give the patient as much as he can take without vomiting. Begin with small doses and work up. When you have found the proper doses,keep the patient on them for some time after the pain -shall have disappeared. It is important to get rid of the opium as soon as possible.Until you do this, there will be no permanent improve- ment. fit first,diminish the opium and, then,withdraw it. 413 - DISORDERS OF DEFECATION.- Some people defecate once a day*others,twice a day: o the rs, every second,third, or even every fourth day. All this may be witnin the limits of health. The process of defecation may be disturbed in one of two ways, by constipation or by diarrhoea. - 1 - CONSTIPATION. - This may be due to a variety of causes and. in the treatment, the cause is almost always to be bam in mind. It is often caused by the patient not having any regular time for the performance of defecation. There should be a certain habit about defecation. This habit keeps up the natural anatomical action. Should it be neglected, the bowel does not act as it should. The bowel 'does not understand when to empty itself unless it be in the habit of doing so at a certain time* Veiy bad •onstipation tan be produced in this way. Constipation can be produced by disorders of the stomach al though nothing be the matter with the colon. Disturbances of the liveespecially disturbances of its bila - producing function^re oown causes of constipation. 414 Bad health is apt to be attended by constipation* Persons who do not eat enough vegetables and fru.it or who do not take enough fluid are apt to be constipated. Constipation may he due to the condition of the colon itself. The colon may lose its sensibility or the muscular coat may lose its contractility. This latter is especially apt to be the case if the colon be somewhat dilated. These are the most common causes. - TREATMENT.- There are two rules of treatment that apply to all cases irres- pective of their cause. In the first place,all oases should he treated, as much as pos- sible, without laxative^in the second place,, we should treat the cause,and regulate the diet and mode of life. When constipation is due to irregular habit,the patient should correct this. At seme time in the day, no matter when,he should defecate. Every day at this time.,he should go to the water closet and sit there whether he have a movement or not. He should not strain. He may take a newspaper to the closet if he wish but he must go. If the constipation be due to gastric indigestion or to chronic gastritis, treat the stomach. 415 Regulate the diet and give the drugs cited above. The eonstipa* tlon will frequently disappear under the treatment of washing nut the stomach. If the constipation be due to the bad health of the patient an$ the presence of anaemia,improve the general health in every way# These are the most difficult cases to treat but,as we improve the general health the constipation will disappear. If the constipation be due to the diet, change the diet. If the patient do not take enough water^make him take it* If it be due to the condition of the muscular coat of the stomach, treat it by massage and electricity,kept up for a considerable time. If the colon have lost its sensibility,we can do nothing. In all cases,at first,we have to give laxatives. You must not continue their use for any length of time. It is not easy to say which is the best drug for these cases,. Use that which seems the best for that particular patient. If the patient be young, if his constipation arise from irregular habit,too sedentary a mode of life,or improper diet,he will often do best with magnesium sulpha ta, either alone or combined with bi-tartrate of potassium,at first, give them together in dram doses, 416 then, gradually diminish the magnesium sulphate until ynu leave it nut altogether. Do the same with the bi-tartrate of potassium, then,give the patient only the tumbler of water. In other young Lubjects you will do better with the compound extract of colyeinth, either alone or with rhubarb,and diminish in the same way. If the patient be older but if his constipation he due to the same causes,give aloes and s tzyehnine,, either alone or combined with belladonna,and diminish as before. If the constipation be due to a diminished production of bile, give with the laxatives rhubarb,aloes.,Ipecac,podophyllum,calomel, magnesium sulphate, or the alkaline mineral waters* Their use is not to be continued for any length of time* You may give the soo a preparations. 417 - RETENTION, OR INACTION tF FAECES.- In these eases the accumulation of faeces is so great, that we tannot say that the patient is simply constipated. These cases are not so very uncommon and they are to be divided into four classes. •-1-These cases are very common. It is the faecal retention of old people.lt occurs in persons of sixty years. The faecal accumulation is in the lower pax*t of the rectum and this portion of the bowel may be distended with faecal matter. Some will tell you that they have been constipated for a considerable time and that the bowels have gradually ceased to act, others that their movements have been regular* but small,others will complain of diarrhoea and will have every day a discharge of loose faecal matter but,in all, the condition of the colon is the same.At first, this condition does not give rise to any great inconvenience but,after* a while,, the faecal matter becomes larger and harder. The Patient's efforts to cure himself by means of laxvtlves and injections are of no avalLj they may give rise to a tempo cary diarrhoea but that is all. The patient becomes mor? and more tons tip a ted, he may go to bed, or he may even die. So, in elderly persons,you must always be on your guard against this condition even although the patient comp Lain of a diarrhoea. 418 The existence of impaction of faeces is easily determined. Pass your finger into the rectum and you will find the mass immediately. - TRFATHWF.-- First remove the faecal matter,not by laxatives and injections, but with your finger or a blunt instrument. After ynu have removed as much as you can,give a large enema of ^rm water and tur- pentine. Then,you will be able to get nut some more. Alternately soften and dig away at the mass for & few days. When you have gotten away the greater part you may give laxatives. Give aloes and strychnine. You must be on the look-out for a return of the impacTIon. In some,the rectum will be so completely .filled with faecal masses that you can feel them through the anterior abdominal wall. -- 2„ These eases occur in rather young or in middle aged adults, especially in women. The impaction may be in any part of the colon. The faecal matter is not always very hard. Sometimes the stools will consist of small hard masses but generally, they are of the proper consistency. In some,you can distinctly feel the tumor but,in others,,you will not be able to feel it at <11 for the pe tient will f requently be f&t or s tout* 419 Sometimes, they give a st right-forward history of constipation and they may say that fo> two weeks they have not had a move- ment from the bowels. In these., the diagnosis is very easy. Yet,a patient may still have some sort of discharge from the bowel. This will make the diagnosis more difficult. In the first place,the patient will develop pain. This pain is apt to be severe and it may be referred to any part of the abdo- men. He may develop nausea,vomiting,and a well-marked febrile movement. He may go to bed and stay there,. The worst cases, those in which the fever and prostration are well marked are often difficult to diagnose at first. They look like eases of peritonitis, In some, there may be a little localized per- itonitis. This will account for the high temperature and pros- tration. - TREATMENT,- The faecal matter is apt to be so high up that you cannot reach it and you have to begin with purgatives. First,give calomel and,then,castor oil with a little opium. Then-,'give a full enema. This has to be repeated several times even if the bowels have moved pretty freely. Then,it should be gradually abandoned. The cases vary in the length of time they take to get well. The milder cases recover in two or three days,others will be in bed for a week or even for three weeks. 420 If the pain be very severe, the cold water coil over the abdomen ^ill give 'great comfort. In some cases you will have to give opium. - 3--These cases occur in young and middle aged adults and in elderly people. They are characterized by an absence of symptoms# They have a faecal mass in the colon?generally in the transverse part. The mass is composed of rather hard faeces and you can feel it through the abdominal wall yet the patient does not seem very sick. He may give a vague history of constipation and say that he is not feeling quite well. He may have felt the tumor in the abdomen and this may ha&e caused him to come to you. The tumor feels pretty hard and it does not feel like a new growth. These tumors are pretty freely movable. The only mistake that you are liable to make is that a patient may have a faecal accumulation in the colon below a new growth. These eases are difficult to moke out and you must be on your guard against this class of patients. - 'mEAT^NTr- The treatment it* much the same as for the second class but it need not be so energetic. Give smaller doses of laxatives, and extend, the treatment over a longer period of time. 421 - 4-This class is entirely different from all the others. The others are the ordinaxy cases,the fourth class is not very common. The patients are not apt to give a good history* They are apt to be hospital cases an they never seem to have any friends who can give an account of their case. It is really queer how little history you can get. The patient is sick. He goes to bed <uxd stays there.The ab- domen is distended but not with gas,fluid,or inflammatory products.and,as we work over it, it may seem as though the colon were firmer than the I'est of the abdomen. Yet,we get no distinct tumor. The patient generally has diarrhoea and this diarrhoea is apt to be marked. The patient loses flesh and strength and is apt to die in from one to three weeks. At the autopsy,the colon will be found distended from the anus to- the caput coli with a soft,pasty mass of faecal matter. This is all that will be found. These cases are exceedingly obscure and each new one is a surprise to the hospital when th e ai 11 o p sy re ve a 1 s th is co ntI i t i o n. •-TREATMENT.- If we could make the diagnosis in time,we would probably give laxatives and enemata but the patient is general- ly treated for diarrhoea and gets worse in consequence. 422 - DIARRHOEA. - When a person has a number of loose., pasty, evacuations during the twenty-four hours,we say that he has a diarrhoea. Such a condition may be due to a variety of causes. Most of these causes act upon the colon. A person may have diarrhoea with no lesion of the intestinal tract and with no other distur- bance of the general health. It may be temporary and may de- pend upon temporary causes. Thus,, it may be due to changes in the temperature,exposure to severe heat or cold,or to nervous influences,violent mental emotions,fear,anger,or anxiety. Some people are peculiarly affected in this way. There are certain fruits that are capable of producing diarrhoea in some persons,such fruits as melons, grapes, etc. This property of these fruits is apt to be especially marked if the fruits be unripe. If portions of undigested food pass from the stomach into the intestine,they may produ ce diarrhoea. This is par- ticularly apt to happen in young people. Water,especially when it contains large quantities of inorganic salts,may produce diarrhoea. Different people vary greatly in regard to their susceptibility to different kinds of water. Inflammatory changes in the colon, such as ulcers are frequently associated with diarrhoea. 423 persons who suffer from Bright*s disease or chronic pulmonary phthisis., of ten have a troublesome diarrhoea with or without ulcers in the intestine. - FUNCTIONAL DIARRHOEAS. - These are of short duration and depend either upon atmospheric conditions or upon the nervous system. As a rule,, they do not amount to much and subside in a few days by themselves. Keep the patient out of the sun,regulate his diet and give pare- goric or opium in snail doses. Under this heading,come the diarrhoeas caused by the ingestion of certain articles of food>fruits that act as purgatives, decomposed fruits,and undigested articles of food that irritate the intestine. In grown persons,these diarrhoeas are sometimes transitory but they may last several days and be accompanied by abdominal pain before each movement. Even in adults, such attacks may be tolerably severe if the weather be hot. Defe- cation may take place every two or three hours and the patient may become much prostrated. Such an attack may last a very long time. - TREATMENT.-Begin with a purgative and follow it with opium. The object of the purgative is to remove the irritating article of food and its use should never be ommitted. 424 Castor oil combined with a little opium makes the best pur- gative or you may give a full doseormagj^sitga sulphate. If the attack be severe,keep the patient quiet; if not severe, you may let him go about. Regulate the diet. Give him milk, meat,and toast. After you have purged the patient,give opium, either alone or combined with bismuth or the mineral acids. Ycu may combine the opium, with the vegetable astringents but the thing of real importance is the opium. Give it in. small doses at regular intervals and continue its use for several days. In many cases.,this will stop the diarrhoea but some patients will not get well in this satisfactory manner. They get rid of the actual diarrhoea and pain but they continue to have three or four loose,unnatvrally~enlored evacuations every day. They do not run down very much but,if this sort of thing continua,a certain extent of catarrhal inflammation of the colon will be established. Totprevent -hisTTFTsrnecessary to cure the diarrhoea as quickly as possible. However, many eases do not come back to you after you have stopped the active diarrhoea. They use patent medicines, If they do come back, attend to their node of life. The patient should not stay in the house but he should not go about too much in the summer nor should he fatigue himself. .If possibla,he should go away. 425 If milk agree, give it: if not,don't. Most of the patients bear eream and cod liver oil well. Give meat twice a day. Of the starehes, toast is the only thing that you should give or the patient may be allowed some fresh fruit and some fresh vege- tables. Continue the use of opium in small doses. Now,it is not sufficient to give the opium alone. You may give with it nuxx-m.xl of castor oil t.i.d. You may give ii with the dilute acids. In other cases,you will do better to combine the opium with the alkalies or with & little rhubarb or with & little bismuth. In one or other of these ways,you can generally get rid of the diarrhoea. When diarrhoea is caused by the use of a particular kind of water, stop the use of the water and the diarrhoea will also stop. It may be necessary to give a little opium. The diarrhoea of Bright's disease is often very troublesome, Particularly in dropsical patients. In some eases,it is of service to get rid of the dropsy; in other eases,it makes the patient very much worse. The re is no good tx*eatment< Opium will palliate. The diarrhoea of phthisis is also vexy troublesome. If the patient have ulcers in the intestine., the treatment will amount 426 to nothing: if the patient do not have ulcers in the int^rtina, you will frequently be able tn do a gand deal. The first thing to find nut is whether or not the patient be in the habit of swallowing his sputa. This is a frequent ctuse of the diarrhoea If he have this habit? wash out the stomach every day. We have also to find out whether the function of gastric digestion be properly performed and. whether or not any undigested arti- cles of food, pass into the intestine. In the latter ease&? exclude those articles of food that pass through. Those that are due to none of these causes are often much alleviated by the use of diugs. You may give opium with castor oil? rhubarb? etc. We can often cure such a diarrhoea in this"way. Diarrhoea may be caused by breaking a patient of the opium habit. Such a diarrhoea is often profuse and exhausting. Ipecac often succeeds in stopping it entirely. Give gr.1/4-gr.j in pills or capsules every two or three hours as '£he"case'"may seem to require. In some eases.,ipecac either will not do at all or it will make the patient vomit. In these? try the mineral acids,gtts.x-gtts*xx every three or four hours. In some, this will succeed:in others,it will not. If it will not succeed, you will have to diminish the opium more gradually. We now come to a diarrhoea which is partly functional and partly dependant upon a catarrhal inflammation of the colon. 427 It, Ie very common in cities and. it is difficult to estimate how much of the diarrhoea is functional and how much is de- pendant upon the inflammation. We run divide these cases into two classes,mild and severe. Both are pretty common. - Mild Oases.- The patient says th: t has general heal th is pretty good,he can eat all ordinary articles of food,he has no pain,¥ut he has one particular inconvenience. Every mom- ing,he will have two.? three., ar four loose movements from the bowels then,far the rest of the day^he will have no movements at all. Some patients will say that the first movement is of ordinary consistency then,when they get half way down town, they are compelled to go to stool again and will have a large, Inosa,watery passage and another when they go home. Others will wake up at five o'clock in the morning and have a loose move- ment, then, in two or three hours., they will have two or three more movements and, then, they will be all right for the rest of the day* So the disease bothers the patients very much. - TREATMENT. - Some cases can be easily managed: other's,not. The first thing that you will notice is that the patient does not have his diarrhoea when he goes awa^ from home but, when he returns., the diarrhoea comes back. 428 Sc^ynu can only get temporary benefit from change of climate. Al for diet,exclude those things that no one should eats the ordinary starches and sugars will do no harm. The same with the ordinary meats. You can always make the patient better for a time with opium, but this drug will do no permanent good. You may treat the disease as originating from one of two ceruses. In the first place,you may considex* that the dis- ease originates from a diminished production of bile-, in the second place^you may regard the cause as a low grade of catarrhal colitis. In addition,you should take into account the nervous element that always enters into these cases. You have to pay attention to this. If you think that colitis is the cause, you may give large enemata. These enema ta will also act upon the nenmus elementTTeUthe patient inject if possible a quart of cold water into the rectum. This should be done every morning before breakfast. The patient should retain the in- jection for about ten minutes and,then pass it. If you think that the liver is at fault, give cholagogues.If you think that the nervous element,plays a large part in the disturbance, give assafoetida in large doses, grs.xx-grs. lx* This is most excellent or you may give one of the preparations of zinc 429 valerian,particularly the valerianate of zine. For some reason or other,some do better with arsenic than with any other drug. In one oi* other of these ways,you will succeed in curing some patients in a short time: others,in a long time: o the I's, not at ell I. - SEVP'RE ^ASES.- These often begin as wild cases. After a while,the patient gets worse, the number of movements in the morning is increased, and the mere act of taking food may excite a movement from the bowels. When a patient reaches this st<ga,his general health begins to suffer and it becomes a ser- ious matter. These cases are always very hard to treat. The treatment is just the same as for the mild cases. The only difference is that it is much more likely to fail. Then, you have to fall back upon climate as a last resort. - DI.ARKHOEA IN YOUNG CHILDREN, - In young children,diarrhoea behaves in a different manner than in adults. Disturbances of the bowels are always matters of mere consequence In young children^ They are growing rapidly and,.as the alimentary canal forms so large a part of their 430 bodies that. they, riously affected by the disturbance. Childi'en sotetiS^s' develop diarrhoea as an aceompanymentt to dentition. Thebeffect of beat upon children is apt to b;e well marked for-beside the natural lassitude felt in hot weather,, the shin and mucous membranes undergo changes due to the heat.^ Children are much more sensative as regards their food than are adults. In childx*en brought up on good breast milk, this susceptibility to the influence of food is of no consequence for the milk of the mother generally agrees with the child; but, in children artificially fed,this susceptibility ih very marked indeed. If a child do not take an artificial food that agrees with him,he wi.ll instantly have trouble and one of the disturbances that he will be most likely to develop iydiarrhoea* In ehildren,as in adults, the Ingestion of unripe fruits or decayed vegetables will be very likely to produce a diarrhoea. Articles of food that are appropriate for adults may not be appropriate for children and such articles may cause diarrhoea. Any colitis will cause a diarrhoea* So there are many causes and no other disease is as common in children. It is more common in summer than in winter and among the poorer than among the upper classes. In large cities-, the death rate in summer is often appaling. 431 The invasion nifty be sudden and acute and accompanied by fever and vomiting. This may mean that there is an inflaixaation of the stomach and bowels but this gas tix)-enter!tis is not neces- Scjriiy of great severity. The disease may begin gradually. There will be no disturbance of the stomach nor will there be vomiting. The first thing noticed is that the faeces are white or green and become soft and pasty. The number cf movements is increased. The child may have five,, six, or even eight movements during the twenty four hours. The movements ^..re not usually watery but are pasty in consistency. In other cases,the first thing noticed is that the child pas- ses mucus mixed with blood: then,in a few daythe movements will have the same character as those mentioned above. In other eases,,portions of undigested food,but very little changed,will be found in the faeces. These are the ways in which the disease begins. In some cases,, in whichever way the disease begin,it will only last a few days or a week and, then, will gradually go away. In othex* cases.,it will gradually get worse.The child will ema- ciate, will develop an irregular fever or will have a tempera- ture below the normal,and in a few weeks or so he may die. 432 In others, the diarrhoea will go on for a considerable time, weeks or months. The child will lose flesh and strength,he will have & fever-, but he will not be sufficiently reduced tn die. He may finally recover# In other casethe disease will go on for weeks, the child will emaciate.,and will have a fever. Then, the diarrhoea will change its character* The passages will become more numerous. They will also become larger and laxger until the child will pass from half a pint to a pint of a white.,pasty mass. In these eases,it is always possible for the child tn recover but the loss of vitality may be so great that he will die. - TREATMENT.- We Till first consider the treatment of the early stages, say the first week. Whether the disease began acutely,gradually, or as a colitis,makes but little differences regulate the food.. If the child is nursing,it is not usually necessary to change the food. Hake him take his food less fI'equently. If the child is being bx'ought up on artificial food,his age and the number of teeth he has are mt tecs of importance in regulating the diet, if the child be young and if the development of the teeth be tardy.do out give him much to eat. barley water,eream and 433 water, kurnysa,peptonized milk,or rise water but,at this time,, you rather expecFTo~un.derf eed him. ~TH oIder children who have a number of teeth,you may give more food* You may give them the same things or scraped meat and dry rusk. The drugs that you should give during the first days depend on what the cause is likely to be and upon the way in which the disease began* If th& disease apparently.be due to improper or decomposing food,the first thing to do is to give a laxative* The best is castor oil. If the "disease began with evidences of colitis,with passages of mucus and bloodyyou should give castor oil* If,however,, the disease be an aceompanyment of dentition it will not always be proper to begin with a laxative, Give a very little opium combined with bismuth,ipecac,,o r sodium* If you do give a laxative,give a very little opium after the laxative has acted* Now,after the first few days have passed: - You should give opium but, with what you should combine the opium varies greatly in the different patients. It is difficult- to give any rule and I am scarcely able to tell you with what to combine the opium. 434 The following is a list of the drugs. A few drops of castor oil, not to ac t as a laxative• co rrosive sub ] ima te: calome 1, in snail doses not to act as a laxatives pMophyllum, in very small doses to change the character of the movements not to act d,s a laxative-, ipecacs bismuth; soda? or some of the antiseptics, salicylate of soda or naphthaline* Now,you will find that many of the children will get well without any special trouble, particularly those of the upper classes. But,some,particularly those of unhealthy parentage and belonging to the poorer classes will not improve but will get worse and will die in spite of all you can do, Their bad surround ings will have much to do with their deaths Others will get better* The movements will decrease in number but they will not return to their proper consistency and color and,although the child feels better,he does not gain strength. He will have., say? three or four loose movements a day. In these co Sos,, it is no longer proper tn underfeed the child. The child must have enough to eat* 'This is especially the case with children artificially fed* There are usually two kinds of food that they can digest in spite of the diarrhoea* These are fat in the form of cod- 435 liver oiL,olive ail? or cream but the cream must- contain no milksand meat,,given by preference in the farm of scraped meat. Besides these.you my continue the barley water etc. but you must not unddrfeed the child or you will get constant vomiting, emaciation and death. In these eases,you must not pay too much attention to the temperature*. The temperatux^ in the "rectum may be 100-101: do not mind ih In spi te of the diarrhoea I do not hesitate in children between the ages of two and three years tc give vegetables and fruits. Drugs: -Get rid of the opium very soon. Use without opium calomel bismuth, ipecac., soda,etc. A change of climate is of great value. Those patients who develop the large.white,pasty passages should be fed pi'etty liberally on meat. If the child be over two or three years of age,give him meat as often as two or three times a day. The ye a,re only three drugs: that I think are of any service. These are opium? the mineral acid a, and arsenic. If the diarrhoea have lasted some "Tine anT if ' life child be'very" much enfeebled,T prefer to give thorn all together. If the diarrhoea be of shorter duration and if the child be not much emaciated,begin with the mineral acids combined with opium. Muriatic acid has acted best in my cases. 436 Give gtts.x~gtts.xx t.i.d. withmim.iv~m.v of the deoderized tincture of opium according to the age of the child. If you give arsenic,give gtts.j«gtts.v of Fowlers solution aceor~ ding to the age of the child* As they improve., diminish the opium and continue the other drugs. A change of climate is of great service. - INFLAMMATORY AFFECTIONS OF THE SMALL INTESTINE. - Although these are not uncommon, there are few that require specia1 desgripti on. --1 - Acute Catarrhal Duodenitis. This will be considered with jaundice, - 2-The S tome h, Small Intestine., and Large Intestine may all be inflamed at the same time. This we call cholera morbus. *-3-In chronic disease of the kidneys, he a rt, and lungs, there may be a catarrhal inflammation of the small intestine but we have few evidences of its existence. - 4-There are cases of inflammation of the email intestine alone. These we will now consider. 437 - ACUTE CATARRHAL INFLAMMATION OF THE SMALL INTESTINE. - These eases are moderately common but they are not often des- cribed. The disease belongs especially to young adults. Some persons seem to have a special predisposition to the disease. In some ca«e^,we get a histoiy of exposure to cold,heat,or wet or of the ingestion of improper foods in other cases,we get no history of cause. - SYMPTOMS. - - 1--Pain.- This is referred to the central and lower parts of the abdomen. It is not colicky but steady,continuous,and severe like the pain of peritonitis or the pain of inflammation of the vermiform appendix. It is often associated with tender* ness and is made worse by pressure. - 2- Fever. - The temperature reaches 101-102-104* - 3-Prostration. - This is pretty marked. The patient goes to bed and looks seriously ill, - 4-P-Tn some cases,, we have vomiting: in others,not, - $_^s a rule, the bowels are constipated. The invasion is usually sudden. The patient is all at once attacked with all the symptoms and goes to bed. The severity of the disease and of the attack varies greatly. All the patients go to bed but they present different degrees of illness after 438 they get in bed. Sone are so ill that y<u suspect acute per- itonitis. In some eases, the course will terminate within a week.First,the fever-then, the pain will disappear: and the patient will be well. In other case ^although the temperature subside,, the pain will continues the patient will stay in bed: and the pain will last for a, week or two weeks. The first thing of importance is to make the diagnosis and, in order to do this,you must know of thb existence of the disease. --PROGNOSIS.-As a rule,the patients recover but there are a few in which the disease proves fetal and ,,after death,y^u find evidences of a catarrhal inflammation of the small intes- tine. -Differential Diagnosis.-The disease is to be distinguished from peritonitis and from inflammation of the vermiform ap- pendix. When the pain is general,you would suspect the former; when the petin is localized down in the right side,you would suspect the latter», - TREATMENT. - If you see the patient early.,keep him in bed on fluid diet and give calomel and opium in small doses* Of calomel,give gr.j in two or throe grains of Dover's powder.Repeat this 439 until the bowels act, then, stop* By this time, the first severity of the attack will have passed off. In some,n< further treat- ment will be necessary. If the pain continue and if the patient lose appetite and become prostrated,!t will no longer be proper to keep him on a milk diet. Give meat in moderate quan- tity. You may give beef juice c r sc raped meat* Vou may also give fruit. As for drugs, the- best results have been obtained from belladonna and ipecac.Do not continue the opium. The pain can be relieved much bettei' with belladonna in large doses. Of ipecac^give gr*l/4-gr. j. In a. few days, the pain will disap- pear and^as a rule,in a few days mo re, the patient will be perfectly well. - 'IHOLERA MORBUS-- Tbit disease ^sis an acute cauirnial inflegation of the larger part of the alimentary tract. It may be trifling or it may be of great severity. in the milder eases,we very seldom get a chance to make an autopsy, >vt the severer eas^s sometimes die. When a patient dies of this disease,we find the mucous membrane of the stonach,small intestine, and large intestine congested, swollen,and coated with mue-w, There is often some swelling of the solitary and agminate glands. 440 There may be some small swellings in the stomach and,sometimes, there are small abbesses in the glandular coat of the stomach and small intestine# The disease belongs to hot month&,especially August and , September. It may occur in perfectly healthy persons# It seems more likely to occur during rapid alterations of the temperature and during long spells of hot we a the r< Persons who are indis- creet in regard to their diet in hot weather are liable to the disease. Occasionally,during the cold weather, there will be epidemics of cholera morbus# The disease is then called winter cholera and we see it most frequently in cities. There seems to be a difference in different years as to the prevalence of the disease. - ETIOLOGY.- - SYMPTOMSe - It is important not to confound a true attack of cholera morbus with those o' is tu rbane e <• of the stomach and intestine so common in. hot weather and due to improper food. The^e latter are often called, cholera morbus but the really have nothing to do with this disease. The symptoms are apt to come on during the night. The patient 441 wakes up with a feeling of prostration and of pain and oppres- sion e«,bout the fbdomen. With this fooling of prostration, there are nausea and vomiting*The patient first vomits the contents of the stomach. Then,in a, short tim,the bowels move. At first, the patient has loose faecal passages; then,he peases a thin brown or white watery fluid in considerable quantity. All these symptons continue* The patient continues to vomit. In the bad eases, the vomiting find, purging will be very distressing. The patient may have cramps of the muscles of the legs and bowels. The prostration becomes more narked. The face is pale and distressed. To rv-ke up for the loss of fluid, there is con- stant thirst. WThe heart becomes rap id and feeble. The skin is cold and bathed in pervpiration. The eyes and cheeks fall in. The face may become dusky rind the patient nay look very badly indeed. The symptoms vary bnly in their severity and duration. The mild cases only last from, twelve to thirty-six hours and do not look very bad; the bad cases suffer more severely, the prostration is more marked, and the ease may last a number of days. A patient may die of this disease although we seldom see death take place except in old persons. As a rule7young persons 442 never die although they may appear dangerously ill. Keep the patient in bed as quiet as possible. Give opium. As a rule-,give it in small doses frequently repeated. As a rule, it is better to give it in the form of morphine,either by the mouth or hypodermically. This is the only drug - that is of any service. It may be necessary to give stimulants,especially if' the patient be old and greatly prostrated. Some times Some time a,you can give the stimulants by the mouth. Give them in small doses and as cold as possible. You may give them by the rectum and, al though the patient be purging all the time-, he may absorb some of the stimulant. In the worst eases,give hypodermic injections of whiskey with,perhaps-,a little digi- talis. This is all we can do. - TREATMENT* - - CHOLERA. INFANTUM. - In its clinical history,this diseo.se resembles cholera morbus but,after death,we do not find the same lesions. The evidences of an acute catarrhal inflammation are ^tbsent. The mucous mem- brane of the stomach is pale and sodden. The stomach contains 443 a whitish or brownish fluid. We find these same appearances in ths small and barge intestine. The solitary and agminate glands are somewhat swollen and a few ulcers may be ftound, yet,as a rule., the mucous membrane does not show evidences of i n f1ammati on. - ETIOLOGY.- The disease belongs to children under two years of age,children in their second summer. It is more common among children ar- tificially fed than among those brought up on breast milk. It is more common among the poor than among the upper classes and in hot than in cold weather.. During some summers, we seem to have more than during others. - SYMPTOMS. - It is sometimes impossible to distinguish this disease from other disturbances of the digestive tract. Children may suffer from other things during the summer months for instance, they may have diarrhoea and,yet,not have cholera infantum. It is common practice to apply the mime of ehole rev infantum to all bad or fatal eases of diarrhoea in children. I think that oho 1 e ra infan turn is a. d i s ea s e by i t s e 1 f. In some cases,, the invasion will be acute? in others,gradual, and the child will at first suffer from an ordinary diarrhoea. 444 The oases? generally begin with purging rather than with vomiting. The passages are at first faecal: then, alma st entix^ly fluid. At first, the vomiting consists of the contents of the stomach: then,of the white or brown fluid. The purging and vomiting c re apt to continue and, gene rally, the purging is the more marked. There may be no vomiting at all. There is marked pros- tration which increases hour after hour.The shrinking of the tissues and emaciation are very noticeable and,even at the end of twenty-four hours, they become more marked. The heart becomes rapid and feeble,often exceedingly so. There is constant thirst. The thirst is of more consequence in children than in adults for children are accustomed to take large quantities of fluid. In consequence of the thirst, the child cries and frets. He hardly sleeps at all. He will wake up, take water and vomit. As a rule,a febrile movement does not belong to this disease. The temperature usually falls-,but there may be a fever. On account of the vomiting and purging, the urine is diminished. In bhd cases,we will get marked cerebral symptoms. The rest- lessness will be marked and,as in meningitis,it may alternate with stupor. There may be coma and twitchings of the voluntary muscles. In bad ?ases,these symptoms will be identical with 445 those of acute meningitis. The duration of the disease varies greatly. Some eases last only twenty four hours^ o theru, seve ml days: o thers, for weeks: and the disease my pass into a sort of chronic condition. In the longe? cases., there may he temporary periods of improve- ment. The severity varies, Most of the patients seem pretty sick yet, some seem sicker than other's. The worst cases are short and severe. Some of these die from prostration in twenty-four hours. - PROGNOSIS. - The prognosis is always serious. Although the child not seem very sick at first,yet,even although he be placed under the best cnnditiona,he may die. The mortality varies with the severity of the at tack, with the previous con- dition of the child,with the height of the temperature.,and with the season of the year. The prognosis is worst in tenement house cases. At first,the treatment consists in feeding the child and,if he vomit, there may be much difficulty in doing this. If the •Mid is nursing,he may continue to do so but he must not take - TRMBMT. - 446 as much at a time. This rule applies to the beginning of the disease. If the child is being artificially fed,give eream and water, barley wate r,barley-wate r with egg albumen, kumysa, or peptonized milk. We my add to these things soda or the oxalate of cerium. If the child vomit,give these preparetions in small doses at regular intervals. Gf course, the child win vomit the greater part of these foods but he will absorb some* After two or three days,he will be able to keep down some of his food. Give the food. between the attacks of vomiting. If the ease be protracted,you my rub oil into the skin once or twice a da,y. It is best to keep the child in a large cool room from which the sunlight has been excluded. If possible,send the child away to a cooler place. Of course?you cannot transport the child any great distance* This matter of temperature is of great importance. We do not know of any drag that is of any service in this dis- ease. Still,you must try to alleviate the vomiting and purging. It is difficult to tell whether or not drugs given for this purpose do any good* For the vomiting,you may give bicarbonate of sodium? oxalate of cerium,prussic acid,chloroform, creosote, or carbolic acid?especially in the severer cases. For the 447 For the purging,you may give corrosive sublimate or calomel in small and repeated doses. We may give opium but this drug is not as valuable as in cholera morbus. Still,you may give it to quiet restlessness. There seems to be confusion in regard tn the nomenclature of this class of diseases. The most convenient way would be to call them all colitis but it is impossible to escape from the older name,dysentery. Yet, the name dysentery is used by differ- ent and by the same authors with different meanings. Some confine it to an inflammatory affection of the colon in which the patient has dysenteric passages. By a dysenteric passage, is meajnt a passage of small size,composed of mucus and blood-, and accompanied by pain. This classification would not include the inflammations of the upper part of the colon but only those of the rectum. Others use the two terms synonymously to designate au inflammation of any part of the large intestine# - INFLAMMATIONS OF THE COLON. - 448 Others use the term colitis to designate a local Inflammation and try keep the term, dysentery for those cases that have colitis as a symptom of a general infectious disease. I shall speak of the disease as colitis but I -wish you to understand that, at the same time,Iam describing dys^mtery. This disease presents itself under' several different forms. - 1 -Sporadic.- These arc the eases that most frequently occur in New York. They most frequently occur during the months of August, September, and October. This form of the diseei.se is sometimes caused by impure drinking water. Impure food and bad atmospheric conditions produce it. The patient seems to be suffering from a local inf lamination, not from an infectious disease. - 2-Xn some parts of the world, especially in tropical coun- tries and where malaria is prevalent, the disease is more com- mon than here. It is sometimes endemics at others,epidemic. The patient seems to be suffering from an Infectious disease. The symptoms are the w in the sporadic case# but they a. re mo re 3 vq r< ■ - J^arge bodies of m^n are congregated together, - COLITIS.- 449 as in armies,they are very apt to suffer from dysentery. In these cases,it often seems to be due to improper food:at other times,, to a malarious district? and, sometimes,it assumes the characters of an infectious disease. It is sometimes easy to distinguish between, the local inflammation and the infectious disease: at other times,it is very difficult tn do so* How- eve r.,these two,entlrely d'JSferent conditions do exist. In both, the characteristic lesion is the sama,an inflammation of the colon. - SPORADIC COLITIS.- It is this form of the disease with which we have most to do. It presents itself under three anatomical varieties. These are:- - 1 Catarrhal,acute or chronic* - 2 - Croupous,acute ox* chronic. - 3-Follicular,acute or chronic* - 1 - ACUTE CATARRHAL SPORADIC COLITIS.- - PATHOLOGY - The mucous membrane of the colon is congested,swollen,and coated with mucus^ In the milder canes, these 'Till be the only changes:in the more severe, the production of pus will be added. 450 This production, of pus is due to an emigration of the white blood cells from the vessels ami, in the worst eases.-, the inflame metion approaches a purulent character* In the worst case^ superficial ulcers will be formed by the desipaammation of the epithelial cells. Whether the disease be mild or severe, it nay be confined to the rectum,it involve the upper part of the eolon?or it may invade both these divisions. When the disease is limited to the upper part of the col-on,it is very apt to be overlooked for these eases are not nearly as common as those in which the r?ctum,.alone is involved. Still,we do have them in this climate* wa«When,the rectum,alone is involved* These are the mildest cases and they are exceedingly common^ - SymptomsThe disease is sometimes preceded by diarrhoea* some times, not e Whether this be the oase or not,when the dysentery is established,the mast constant and eharacteristie symptom is the dysenteric passages* The patient will have a consider* able number of them during the day* They are not faecal dis- eharge& but consist of mucus or of mucus aoc' bloocL The patient also has pain in the rectum and anus* This pain is due partly to the spaswdic contraction of the Sphincter and vdiieh 451 accompanies the disease. Soothe patient has a constant desire to go tn stool,and.,when at stool,he will pass a little mucus and blood with considerable pain* For a short time after defe- cation,he will feel better but,very sonn,he will have to go to stool a^in. In the milder eases, this will be the only symptom.. The patient will not be very sick and he need not lie confined to the house. If the attack be more severe-, there will be fever and prostration in addition to the dysenteric discharges. The patient will go to bed and stay there. These eases generally run their course within a week or a few days longer. In these mild eases, the only danger is that the inflammation may become chronic and the patient will then suffer from a chronic catarrhal colitis* -TREATMENT.-The treatment is very simple. It is necessary to keep the patient quiet. Whether he feel sick or not,put him to bed and keep him there. Practically, this is all that it is necessary to da,yet,you must do something to make the patient more comfortable. To do this-, give laxative^castor oil or magnesium sulphate. Give one good dose of either in order to empty the colon of faecal matter which the patient does not pass. The patient is really constipated. Put him on a restricted diet. 452 Give him milk?milk and beef tea, or gruels, To quiet the pain, give opium by the mouthy hypodermically, or by the rectum in. the form of suppositories, -b-When the rectum and a considerable pari of the colon are involved- The patient is wre seriously ill than in the former cases*. He has the same-; dysenteric passages but these passages are more frequent and more troublesome;'The inflammation is more intense* If pus be produced, it vill mingle vi th the epithelium as vill also the deaquammated epithelial cells. The patient is more pro stated. The pain in the rectum and colon is more severe. There may or may not be a fever or the tempo nature may be be lev the normal. The main thing is that the patient looks much sicker than in the former case* These cases a3so usually terminate in removevy. They may last one or two %ecks^ In these eases^there is the same danger that a chronic dysentery vj.ll succeed the acute attack* The acute attack may be so severe that the patient vill die. This is rather the The disease is especially apt to be fatal in thn^e cases in ^hich yu^ is produced. The fatal cases are not very common-in inhabitants of this part of the country 453 but belong rather to Southerners vho have come here yhile ill. The fatal cases frequently terminate very suddenly. - TREATMENT.- The treatment is just the same ay in the for- mer oases. If the pro st lotion be marked? give stimulants. Give the patient as much fluid food as he can digest. The greater number recover. -c-When the upper part of the colon is alone involved. This form of the disease differs in its characters as it oc- curs in adults and in children. «ln Adults,- One of the first things tlmt strikes you is that the patient does net have dysenteric passages nt all nor any pain in the rectum or ^mus. Instead of dysenteric passages?the patient has diarrhoeal movements. Some time x3 these movements are pasty and of a natural colors a t other times,?they are very fluid and frothy. He may have a considerable number of these discharges during the and many of the passages will be of considerable size.The patient has no pain in the anus at the time of the discharge but defecation may be preceded by colicky pains referred to the abdomen. 454 In more severe oases, the patient will pass blood mixed with faecal matter. He may pass a considerable quantity of pure blood. The disease resembles typhoid fever. The prostration is generally pretty well marked. The patient goes to bed. He is apt to have a fever. This fever is usually higher in the afternoon than in the morning. The morning temperature will be 99; the evening, 100-102. Some are only sick for a week: others, for several weeks. Most recover. Occasionally,howeve r, a patient will die. - TREATMENT.-Put the patient to bed and keep him there through- out the disease. Feed him on fluid diet and empty the colon. In addition,give opium. You give the opium tn relieve the pain and to make the passages less frequent. If the disease be not severe.,opium will be the only drug that it will be necessary to use: if the disease be more severe and continue longer, the opium will be of no use. It will not make the patient more comfortable. In the long and severe case??,give belladonna and ipecac in pretty fair doses. The larger number of these cases you are not likely to mi stake for anything else. -In Children. - The invasion is sometimes sudden. At first,the child seems to 455 have an ordinary diarrhoea* Usually,he does not pass mucus or bliod but he seems sicker than he should be with an ordinary diarrhoea. At other times, the child gradually loses appetite^ complains of nausea and uneasy feelings about the abdomen and, in a few days.The goes to bed and has diarrhoea. Every day, he will have four, five., or six loose faecal movements. He will have pain in the abdomen and he may suffer from, nausea and vomiting. He will have an irregular fever. The morning temper- ature will be 99,the evening,101-102. The pulse will become rapid. WThe child soon loses flesh and strength and looks pretty sick. These cases closely resemble typhoid fever and, for a week or even two weeks,it may be impossible to tell which disease the child has. The diagnosis will be cleared up when the child recovers for he will recover more rapidly than he would if he had had typhoid, fever. - TREATMENT.- The treatment is the same as in adults and con- sists in putting the patient to bed and giving a restricted diet,laxatives,opium,belladonna,and ipecac. 456 - 2- CROUPOUS COLITIS,OR CROUPOUS DYSENTERY.- - PATHOLOGY. -■ This form of the disease presents the ordinary characters of a croupous inflammation, The mucous membrane of the colon is at first congested and swollen. The fibrin and pus coagulate and form a false membrane. They also infiltrate the interstices of the mucous,muscular*and peritoneal coats. There is also necrosis of parts of the colon. This necrosis may be superfi- cial and involve only the outer portion of the glandular coat or it may extend deeply and invade the connective-tissue and muscular coats. As rule,these changes do not involve any extent of the mucous coat with the same degree of severity. We find the fibrin in small or large patches. The deposit of fibrin is apt to be discontinuous and,when the inflammation shall have run its full course ^ulcers will be left corresponding to the position of the patches* Less frequently,the deposit of fibrin Wil be continuous and will coat the entire surface of the colon and a la^ge extent of the mucous membrane will be des- troyed. In mild cases? the production of fibrin and pus and the necrotic changes do not take place to any great extent and,when the patient recovers, the fibrin? pus, and superficial portions of the epithelium come HW&y* Then,new epithelial 457 cells aw produced, and the colon returns to its natural con- dition. In more severe eases,when the fibrin and pus cone away., a slough of varying thickness,perhaps consisting of the whole thickness of the glandular coat of the colon,will come away also and. an ulcer of varying size, shape, and breadth will be left. After a time., the sides and bottom of this ulcer will be composed of granulation tissue and this granulation tissue will change into connective tissue, So., the patient recovers with a colon studded with cicatricial tissue, 'If the ulcers be small,he will recover with a damaged colon:but, if the ulcers be large,he will never really recover. This form of the disease belongs to the more severe sporadic Cc ses and to the epidemic cases of dysentery. It is much more severe than the catarrhal form of colitis. It may involve the rectum,alone^ the rectum and upper part of the colon^cr the upper part of the colon without involving the rectum. The first two differ only in the severity of their symptoms, 'Ilie gieater the extent of the colon involved, the more severe, the ease will be. / The invasion may be acute or the disease may be preceded by an ordinary diarrhoea. This diarrhoea may last for a few days* 458 When the disease is fairly established, the patient ha* dysen- teric passages. If a considerable part of the colon be involved, after a day or so, there will be in addition to the dysenteric passages,larger discharges of a brownish fluid containing faecal matten, fibrin,and small parts of the mucous membrane. The dysenteric passages are very frequent; they may take place every half hour or even every five or six minutes. The discharger of brownish fluid are not so frequent# The pain about the rectum is very intense. The bladder may take on sympathetic action The sphincter vesicae may become spasmodically contracted. This contraction of the sphincter together with some inflammation of the bladder that may exist may produce strangury. The pa- tient will have abdominal pains. These are sometimes colicky, some times, me rely feelings of discomfort. There are frequently loss of appetite,nausea and vomiting. These digestive distur- bances may continue throughout the disease. There may really be a gastritis or a gastro-duodenitis and the patient will become jaundiced. In some cases,the invasion will be marked by rigors. A febrile movement is present in some cases not in others. It has nothing to do with the severity of the colitis. Even in the worst cases, the temperature may be below the normal. 459 The fever may he absent. This is particularly apt to he the ease when the dysentery has the character of an infectious disease. At first, the heart is me re rapid but of fair strength: later,it becomes more rapid and feeble: and, in infectious ease&, the heart may be very rapid an-., feeble. The general appearance of the patient will vary witM the simple or infectious char- acter of the disease and with the severity of the attack. Ar a rule, the patient will look pretty sick but the milder t^ses do not at any time seem as though they were going to die. The mild cases usually get well although they may seem much prostrated. They usually recover within two or three weeks. If the colon as well as the rectum be involved-, the patient will look sicken his tongue will be d ry and coated:he will look anxious*he will lose flesh and strength*and,by the end of the fifth,.sixth,ov seventh day,if may be doubtful whether he is going to live or whether he is going to die. When the disease takes on the infectious character,the patient will have the regular symptoms but the prostration will be even more marked than in the severe sporadic cases. The patient will •i velop cerebral symptoms-,convulsions,and twitchings of the voluntary muscles. The pulse will disappear and he will pass into collapse. 460 - PROGNOSIS.- If only the rectum he involved,the patient should recover with but little damage left in this part of the colon. When the rectum and a considerable part of the colon are involved, the recovery of the patient will depend upon the extent and severity of the inflammation and whether or not it have an infectious character. If the disease have the infectious character, the patient may recover but the chances will be against him and the prognosis will be had. If a large extent of the colon be involved,the chances of complete recovery will depend upon how much of the mucous membrane is destroyed. If much be destroyed, the colon will be so damaged that the patient can never get entirely well but will have a chronic dysentery* If the ulcers be not too numerous, they may heal and the patient may make a very good recovery. If much of the colon be involved, the patient had much better die, fox', if he survive the acute disease, he will die of chronic dysentery. - TREATMENT.. - When the rectum alone or the rectum and part of the colon are involved,put the patient to bed and keep him on a restricted diet* At the commencement of the disease,give laxatives. 461 The laxatives you should give are castor oil and magnesium sulphate and. their administration has frequently to be repeated every third or fourth day. Give opium to relieve the pain and discomfort# If the rectum alone be involved, this may be all that it will be necessary to do. If, however, a larger part of the coUn be invaded,you must do something move. For these oases-, a large number of drugs have been proposed. Ipecac is the very best. Give it in very large doses. First,give your castor oil or magnesium sulphate; then, when these have acted, give m*v-m,x of Magendie* s solution hypodermically: then, grs.x-grs*xxx of ipecac in powders or* capsules* Then, the patient must lie down in bed and he must not eat or drink any thing for three hours in order to avoid vomiting the ipecac* The next day or the day after, repeat this treatment, This treat- ment is only likely to. succeed in the early stages of the disease before necrosis has taken place and,at that time,I think, that it is the best that you can adopt. You must make up your mind that these cases will nnt recover if left to themselves and, if the disease have not the infectious character and if it have not gone too far-, the cases that can recover do better with this treatment than with any other. 462 *1 -When the upper part of the colon is alone involved.- In these cases,, there will be no dysenteric discharges; no dis- charges of brownish fluid to any extent? no tenesmus;and no strangury. The patient will begin to feel unwell,he will lose apetite,he will sometimes vomit,and he will begin to wonder what is the matter with him. Then,he will have a little diarrhoea, the diarrhoeal discharges twill become more numerous,he may continue to vomit and he has a fever. The morning temperature will be 99-100; the evening,101-103. The patient's tongue will become coated,he will have a headache., and he will go to bed. The diarrhoea will continue and the patient may pass a certain amount of brownish fluid, in which floculi will be suspended. By the end,of the week,he becomes feeble and loses flesh and strength. He will go on in this way week alter week and,at the end of several weeks,he will die in the typhoid condition. Fortunately, these eases are rare. However, in New York, they are comparatively common. All that I have seen,have been fatal. - TRWHENT. - The treatment is the same as that of the other more severe forms of croupous dysentery but I have seen no good results from any method of treatment. These eases tire very difficult 463 to distinguish from, cases of typhoid fever and,up to the time of death,you may not be able to say which disease the patient has. After death,you will find ulcers of considerable size and considerable in number with the other evidences of the later changes of a croupous colitis. - PATHOLOGY. - The lymphatic glands embedded in the mucous coat, the solitary glands ace most affected. They become swollen, necrotic,and they slough and leave little circular ulcers. Usually,there is at the same time some inflammation of the mucous coat,sometimes catarrhal, sometimes croupous but the changes in the follicles are the essential lesions. The inflam* mation invades the greater part of the colon. The disease is particularly common in armies. In private practice,it is rather rare. -'SYMPTOMS.- The invasion may either be sudden or the disease may be preceded by a diarrhoea. The patient has a fever and he is at once prostrated. He begins to have movements from the b owe 1s♦ - 3 - FOLLICULAR COLITIS. - 464 These movements cure not the same in all the patients and their character varies with the character of the inflammation and with the particular part of the colon in which the accompanying inf laminations are developed. Some patients will have loose faecal movements: others, large movements composed principally of fluid*, others,will have the characteristic dysenteric dis- charges: and, in the same patient, the character of the discharge will vary at different times. The patient rapidly loses flesh and strength and, by the end of several weeks, the emaciation is extreme. - T&FATMENT. - In army practice.,it is very difficult. to do the patient any good. Give opium and feed the patient as well as possible. You may give ipecac,blsmuth,acids, camphor, ar acetate of lead with the opium. This treatment is only palliative and,apparently, the only satisfactory treatment for the bad eases is to send them home. Then, they do very well indeed. All the different fems that we have just considered, were the acute farms of dysentery. There is also a disease called chronic dysentexy^or chronic colitis* The chronic form of the disease 465 may follow an attack of the acute and-,indeed,it generally does. Yet, from the first, the disease nay have a chronic character. However it begin, it will follow one of the former anatomical types. - 1- CHRONIC CATARRHAL COLITIS.- If the disease has existed some time,we find after death changes in the whole thickness of the wall of the colon. The mucous membrane may be smooth, thickened-,nr eroded. The muscular and connective-tissue coa.ts and the connective tissue between the follicles will be infiltrated with cells. There will be a layer of mucus,more or less thick on the whole surface of the raucous membrane. The inflammation may only involve the rectum or it may invade a considerable part of the colon. 'The greet ter the extent involved,the worse will be the case. SYMPTOMS. The eases v&?y greatly in severity. The severity of the symp- toms will vary with the extent and severity of the colitis. In the milder eases, the general health does not suffer much. The patient will continue at work but,every day,he win have from four to six loose faecal movements or movements 466 composed of faecal matter mixed with fluid. T>e discharges may remain of the natural color or they may turn white or brown. The more severe ease? show more marked changes in the general health. They will lose flesh and strength and they may be confined to bed. Some will have loose movements composed partly of faecal matter: others will pass blood in considerable quan- tity: and others will either pass mucus mixed with faecal matter or they will alternate the mucus and faecal discharges. In these eases,unless the course of the disease be stopped,the patient will die in a number of years in extreme exhaustion. TRMW?. The treatment is not easy. It requires a good deal of patience and judgment. For months., no treatment 'Till effect a cure. A chronic catarrhal inflammation of any mucous membrane is al way? hard to get rid of. Remember the disease from which the patient suffers. You must not treat these eases as cases of diarrhoea. You must treat the chronic catarrhal inflammation. Climate is the best treatment. Find a climate in which the patient can get well without the use of drugs and,for most,such a climate can be found. 'The next best way in which to treat these cases,,is to regulate the diet and to make local applications 467 tn th? mucous membrane* Of course, the latter part r.f this treats m^nt i? only applicable tn thnwe case? in which the diQUa^e is confined to the rectum. The patient should either be put upon an exclusive milk diet or upon a diet consisting solely of milk and meat. Local applications can be made either in the form of fluids or suppositories. If you use fluids,you should use them in considerable quantity. Use the fountain syringe. Begin with a small quantity of fluid and,if possible work it up to two quarts. Give the injection slowly. Sometimes, tepid water will do very well. You may add carbolic acid,salicylate of sodium, sulphate of zinc, chloride of zinc, nitrate of silver, or sulphate of iron in small quantities to the water. This plan of treatment will answer for a great many. If you use suppositories,they should be introduced well up. Iodoform is the best drug to use alone in this way. You may combine with it bismuth opium,or tannic acid. The base of the suppository should be cocoa butter. If the disease invade the upper part of the rectum and if the patient cannot be sent away,enemata and suppositories are not of much use by themselves although they may assist in the treat- ment. Restrict the diet tn milk alone or to milk and meat. 468 In addition to this-, you must give drugs. There are hardly two consecutive eases that will be benefited by the same drugs* The object of these drugs is not tn stop the passages all at once but to make the passages gradually become less frequent and to make them return to their natural color. This is the way in which the patient should get well. You may give castor oil in small doses,m.xx-m. lx t. i.d. This drug is excellent. At first,combine it with two cr three drops of the tincture of opium. Biscath and opium make a good combination. You may give ipecac in small dnsea.gr. lXl-gr. j- All the mineral acids are of service. You may give the preparations of salicylic acid er you may give salicin in ten grain doses every two or three hours. You must take care that the patient do not become constipated. Vou should examine the movements every two or three days. If the patient da not pass enough faecal matter, you should give laxatives. You should gradually add fresh f ru i t s»s ta re he s, and ve ge tab les tn th e die t and * wi th pa ti ene e-, it is possible tn cure p- rsnaneatly a considerable number of the eases. But, there are some eases that are fairly hopeless* These are old cases in which the disease has lasted far years 469 c-nd in which great structural changes have taken place. - 2- CHRONIC CROUPOUS COLITIS.- This always follows the acute form of the disease. The ulcers of the acute form remain. The disease may nr may not be confined tn the rectum. These patients ace always worse nff than those with chronic catarrhal colitis and their symptoms are differ- ent. •-SYMPTOMS. - The patient with ulcers continues to have dysen- teric passages. In addition,he may pass Inose faecal matter, a brownish fluid,or mucus,in considerable quantity,or he may be constipated. Jie may pass a good deal of blood with the mucus. The gene ml health always suffers. The milder cases are invalids although they are not confined tn bed. The severity of the symptoms varies with the size and extent of the ulcers. If the ulcers be few in number and situated in the rectum, the ease will not be so bad^if the ulcers be numerous and high up, the patient 4'11 be very badly off. - TREATMENT.- The treatment is the same as that nf chronic catarrhal colitis 470 but the treatment by climate is not ar- satisfactory. The cas^s with ulcers it the rectum are sometimes amenable tn local treatment. However, some of these will not improve at all and the ulcers will not heal up. In these oase^you must put the patient under ether, dilate the sphinete ns expose the ulcers with a Sim^s speculum,and make pretty strong applications of nitric acid,chromic acid,nr nitrate of silver. In some eases, this treatment is very satisfactory. If the ulcers be situated higher up.? the patient will as a rule dn badly* We treat these cases by diet and drugs in the same way as we treat the cases ■ of chronic catarrhal colitis. Yet, as a rule, they get worse and, in fact,I am sceptical in regard io any treatment in these eases. - 3~CfH0Nin FOLIJCWm COLITIS, - In this form of the disease., we find ulcers. These ulcers do not heal but remain as open sores. Although these ulcer's are apt to be found in any part of the ooinn,yet,as a rule, they behave better than those of chronic croupous colitis. Although a patient may have suffered for months,his ease is not to be considered as hopeless and many of the bad cases do get well. 471 - TREATMENT. - The treatment by climate is excellent. Local treatment is of no use. Diet is good treatment. Give the milk or milk and meat diet. Drugs are of a great deal of use. Give the same drugs as in chronic catarrhal colitis. We have no exact knowledge about the lesions of this disease. The disease is not fatal and we only know it by its clinical symptoms. Yet, from the symptoms-, we should say that it must be a form of chronic catarrhal colitis. The disease belongs to middle life. It is more common in women than in men and it is seldom seen in children. It is not very common. In New York, one sees a case about once every two or three years. -MEMBRANOUS ENTERITIS.- - SY. fPTOUS. - Some patients have but nne attack: nthers,a number. The attacks may occur at long or at sheet intervals 472 From time tn time,the patient hay colicky pains in the abdomen cnd a feeling as though the abdomen re distended. Then,he has a number of large,loose, faecal passages. These passages are composed partly of faecal matter, partly of fluid,and partly of a peculiar formation -vith the follnving charac te ri sties, It is gelatinous and looks like very thick tenaceous mucus. In* steal of being passed in a shapeless mass,this substance comes avay in the form of bands and tubes' that look as if they had been moulded to the inne r •surface of the intestine. The quan- tity of this material is often considerable. The patient is apt tn put it in. a battle and present it tn his physician. This is the only essential symptom of the disease. As} the attacks do not occur very f requently, this symptom is apt to have but little effect upon the patient's health. The patient is apt to suffer from complications and these do seriously affect his health. Some have very severe gastric dyspepsias others hc^ve an alternating condition of constipation and dia rrhnea; o the r$, func tinnal di sc* rde rs n f the live r: and, among vn men, uterine and ovarian disorders are common* The patient is apt to become very anxious. This is often the fault of the physician. The physician should not pay so much attention to 473 the discharges. If you tell the patient that he has a Pare disease and that you <vant some of his offeta,his condition is apt to bee ome v e ry much rse. -PROGNOSIS.- The prognosis is good. The disease is amenable to treatment although the treatment may be very tedious. The disease is not fatal. - TREATMENT* - Pay attention to the associate!' conditions as '•veil as to the disease. Treat the complications and,above all things,treat the general health. When you have attended to the general health and the complications,there vill be but little left tn do. If you improve the general health,the disease vill often disap- pear vithnut further treatment. The best local treatment consists in injections of coolish vater. These enemata should be large, one or tvo pints. -GANGER OP THE COLON*- These cancers generally follow the colloid or epithelial form* The colloid cancer has its regular form. The epithelial cancer follows the type of the mucous membrane of the intestine and consists of tubules lined 'vith cylindrical epithelium* 474 They are generally found ih the rectum, three nr four inches above the anua,nr at the caput co 11,yet, they may be in any part of the enlnn* They begin at some point and generally, grow so as to surround that part of the wall of the gut which will became thickened. Often this is the only change. At other times-, the cancer will project inwards and will form no stricture. It may project inwards at one part and slough away at another and, thus form no stricture. It may perforate the wall of the colon and a local or general peritonitis will result. It belongs to persons past thirty years. It is not as common as cancer of the stomach. The symptoms vary with the exact situation of the growth# -In the Rectum.- If the cancer be situated in the rectum, two or three inches above the anus,it will give no symptoms at all when it first begins# When the symptoms are developed, they are at first developed gradually: af te r vu rd, mo re rapidly. In some nf these cases, the first marked symptom will be con- stipation. There will be no constitutional disturbance hut the act of defecation will be attended with constantly increasing - SYMPTOMS. - 475 difficulty.Then, the patient notices that the stools are rounds small, nr ribban shaped. This is due to the stricture. Then, the patient becomes anaemic and may have pain in the rectum. So, he goes on for a number of months: then,he gets worse rapidly end will die in much the same way as though he had cancer of the stomach. In others., diarrhoea will be the first symptom. This diarrhoea will resemble that of chronic catarrhal colitis. The patient will first pass faecal matter,then,blood and mucus. He will have pain about the rectum.Later, the re will be an almost constant discharge of brownish fluid due to paralysis of the sphincter.The patient will die exhausted.In these,the cancer has ulcerated.You must be careful about these patients not calling your attention tn their local symptoms. Some will say they have piles.Others will complain of the anaemia and will want tn know what is the matter with them. Of ten,it is only by the closest questioning that you can get a history of the local symptoms. If yoi put your finger into the rectum,you can generally feel the cancer. When the cancer is at the caput coll, the invasion is slow.Some first have a gradual failing of health and strength.Then,they may have flatulence,occasional nausea and vom- iting, alternating diarrhoea and constipation. In some, there will be retention and impaction of faeces.This belongs to cancers rather above the caput coll. Southey go on for months getting gradually worse and worse. In the early stages, the cancer cannot be felt and it. is not until late that you can. The patient may die without your having been able to feel it. 476 In some,the first symptom will be pain before the changes in the general health. This pain is different from colicky pains as a rule. It is seve re,sharp,lancinating,and comes on in attacks which may last several minutes or hours. At first,these attacks come on at considerable intervals. Then,they become so frequent that they occur every day or several times a day. Then follow the other symptoms and,in these cases also,it may be difficult to feel the tumor. -Midway between the Caput Cali and Rectum.- The retention of faecal matter will become a more prominent symptom. The stricture will cause a tumor to be formed. As at first, the general health does not suffer,you will hardly be able to tell whether a cancer exist or not . - TREATMENT. - As far as medical means are concerned, the treatment is only palliative. Feed the patient and make him as comfortable as possible. The peal treatment is surgical and depends upon the exact si&e and position of the new growth. - The End of Volume 1 - 477 - INWCr- Abeess of the Brain 73 Amyo-troph. Lat.Seler 97 Aneurism of the Aorta..... 332 Aneurism of Abdom. Ao pta... 339 Aneurisms of the Arch 336 Aneurism of Thrnracic.. S39 Aneurism of Cereb. Arter.. 77 Angina Pectoris Palse.. 325 Angina lectoris True 321 Acrtic Insufficiency 291 Arrtic Stenosis..... 289 Apoplexy Cerebral. 57 Auscultation....... 129 Brain,Abeess of .....73 Brain,Tumor of 76 Bronchitis Cat* Aeut 166 Bronchitis Cat. Chron 175 Bronchitis Croup. Acute...178 Bronchitis Croup. Chron. ..179 Broncho-Pneumonia 203 Cancer of the Colon. 474 Cancer of the Stomach...... 399 Cholera Infantum. ....443 Cholera Morbus. ......440 Colic-, Chronic. .411 Colie,Intestinal 403 Colitis Spr ead. Cat. Aeut. 450 Colitis Spo rad. Cat. Chrnn. .436 Colitis Sporad. Croup. Aeut457 Colitis Spor. Croup. Chron. 470 Colitis Spor. Follie.Aeut. .464 Colitis Spor. Collie. Chron471 Coion,Ca leer of 474 Constipation. 414 Diarrhoea . .423 Diarrhoea of Phthisis 426 .Du ra Ha ter, Diseases of 25 Dyspepsia,Gastric 351 Embolism, He reb ral 63 478 Emphysema, Pulmonary. 25.5 Emphysema,Compensating..♦♦256 Emphysema, Senile^...... <255 Emphysema,Substantive*...>256 Empyema .. 149 Fndarteritis,Cereb ral...... 68 Endocarditis,Acute........ 278 Endocarditis,Chronic.... • .288 Endocarditis,Malignant. * ♦ • 284 Enteritis ♦ .438 En te ri t i s, Memb rannus .472 Ependyma,Inflammation of... 78 Exophthalmic-Goitre....... 328 Gas tri tis, Cat. Acute...... 363 Gastritis,Chronic........ • 372 Gastri tis Suppurative..... 385 Haemorrhage,Ce rebral....... 52 Haemo rrhage, Pulmnna ry..... 241 Heart,Patty Degeneration..312 Heart,Palpi tation of.# ♦ . *.. 317 Heart,Physical Diagnosis ..267 Heart,Rupture of........... 315 Hyd rocephalus,Acute.........44 Hydrocephalus, Ch mnic 79 Hyd m-Pneumo-Tho rax 162 Impaction of Faeces........413 Inflammation. 1 Inflammation of Con.Tissue*..1 Inflam, nf Mucous Membrane.. 11 Inflam, of Viscera. ..20 Laryngitis,Cat.Acute....... 118 Laryngitis,Cmupous........ 124 Laryngismus Stridulous..... 116 Locomotor Ataxia... 99' Lung,Physical Diagnosis of.127 He ni agi ti s Acu te 34 Me ningi tis Ch tonic 41 479 Ve ningitis,Syphi1i t i e...... 51 keningi tis. Tube rcular..... *44 Eitral Insufficiency*..***293 Mi tral Stenosis........... 292 Pyelitis* . 36 Oe sophagus,Dilatatinn gf.. -M9 Oesophagus,Steaogis nf*...3-43 Paehymeningi ti s Ex he ma.... 25 Pachymeningi tis Int. Aeut,.. 26 Pachymeningitis Int.Chran..27 Pachymeningi tis Syphi1..... 28 Pereus sina. 127 Perieardi tis.............*272 Pharyngitis Cat. Acute.... 107 Ph thisi s, Pulmn nary Aeu te.. 223 Phthisis,Pulmonary Chronic238 Pia Ma te r, I nf lama tia ns .. * 34 Pleurisy,Acute nr Dry....*137 Pleurisy, Sub -a cute 140 Pleurisy vith Adhesions***158 Pie u ri sy, Tub e re u 1 a r 161 PneurcniayBroncho..... 203 Pneumonia, I ate eg ti tial*.... 214 Pneumonia,Lobar............ 181 Pneumonia of Heart Disease*202 Pneumonia, Secondary........ 200 Pneumonia, Syphili tie....... 216 Polio-Hyeli tis, Anterio r..... 9b Pulmonary .Emphysema........ 255 Quinsy Sore Threat......... 112 Ra 1 eS* ♦ 131 Spinal Cord, Conges tion of<#.84 S tnmaeh,Cancer of*.......... 398 S tomaah, Pe rforating Ulee r.. 388 Tonsillitis,Cat. Acu t.... *. 109 Tonsillitis, C mupnus....... 110 Tnnsilli tis, Gangrenous..... Ill Tonsillitis, Suppurative.... 112 480 Tuberculosis,Gen.Mil.Aeut.219 Valvular Diseases of Heart. 277 Tubereulnsis,Mil.Chron.... 229 Voices in Lung Disease..... 133 Thrombosis of the Sinuses of Dura Mater. 30 - ERRATA- Page 59,last line,read *death will result11 . Page Saline 7, for "worse in summe r% read "worse in winter11. Page 331,line 9^ insert!i tn galvanize"before0 the sympathetic ne nre» 4 Page 570?sixth line from bottom, for"easeiaa, read 8kumyss". Page 3885line 7,for "peritoneum infiltrated4, read "peritoneum covered *. 481