- REPORT - 
of 
- PROFESSOR DELAFIELD'S LECTURES - 
on the 
PRACTICE OF M E D I C I N E* 
- VOLUME II.- 
i 
- A. D. fWCL/CXXVI 11 AS THE CONDITION OF THIS VOLUME 
WOULD NOT PERMIT SEWING, IT WAS 
TREATED WITH A STRONG, DURABLE 
ADHESIVE ESPECIALLY APPLIED TO 
ASSURE HARD WEAR AND USE. - E k ic A TA-.- 
Page 71, Twelfth Une. For"pleura# read •pleural cavity1. 
Page 9 3. Second lino. For'bilibry colic • v&u?. "iirpac Ud calculus1. 
Page 176. Sixth line. Poi,8until a fur; Gays before death'reac 
until co^th which will follow in a fuw aayj 
Ptge 190. Seaono line. For"in any way ^odifiou1rcaa8to any great 
degree modified8. 
Page 217. Firtt line. For8 about the disease8road8about the 
length of the period of incubation*. 
Page, । 4r75. Ninth line. Inserfln other casey we can find 
no cause*. 
Page 556. Lat: t line. For"yellow1 rvac sgraya. THE LlVm. 
When we suspect liver disease^the first thing we do is to 
determine the exact size and position of the liver. This,we 
palpation and percussion. 
^hen you detewihe the size^let the patient lie on his back. 
percuss from above downward and,in the healthy liver,/ 
^en you to the fourth or fifth rib, the percussion note 
becomes dull and,when ym get to the sixth rib,the note be- 
somes flat, These two points give the upper border of the ; 
liver in front. Then percusD at the side. He re, percussion 
•ver the upper border gives flatness for the lung doe* not 
Intervene. In the axillary line,we get this flatness at the 
level c>f the seventh rib. When the liver is heal thy,you cannot 
a rule determine the position of the upper border behind 
percussion.for the lung comes right down and you will not 
2-t flatness but,in enlarged and diseased livers,you may get 
^latnesg. 
*^e lower border of the liver is more difficult to determine. 
1- the liver be diminished in size,it will retract behind the 
if it be enlarged,it will descend below the ribs. You 
cut the position of the lower border by palpation.Put 
1 your haai on the abdemen and press gently and intermittently* 
Tell th1 patient to take a full breath* This will cause the 
liver it mere and,as it mevesfyau will be able ta feel the 
lover border. The thickness of the abdominal walls and the 
condition of the right rectus will make the examination easTer 
q i* more difficult. The edge of the rectus often feels like th<v 
liver. It is very difficult to determine the position of the 
lower border af the liver and I advise you to be very careful 
how you say that the liver is enlarged* You must be sure that 
you feel it first. 
The liver has a stroma of connective tissue,peculiar polygonal, 
nucleated cells called the hepatic cells,and an extensive 
system tf blood vesyels^particularly an extensive venous system. 
This system of venous blood vessels is very important. The 
relation of the portal vein to the liver makes any disease of 
the liver important to all the other abdominal viscera for . 
the blood coming from them must find a free inlet to the gen*' 
e?al circulation. The bile must escape readily. These are the 
parts that may become diseased. 
2 The true function of the liver 13 really hut little known 
and our ignorance in this respect troubles ue at every turn 
when we come to treat liver diseases. We know that the liver 
produces bile and that this bile passes into the Intestine. 
This bile seems to assist in the digestion of the fats and 
Peptones: It stimulates the peristalsis of th2 intestine*it 
Prevents the fermentation of food:it aids defecation:and a 
i^rge part of it is reabsorbed. When the bile-preducing function 
the liver is deranged,the principal way in which it gives 
trouble is by embarasaing the digestion of the fats and peptones, 
^7 causing flatulence,and by causing constipation. Probably, 
^ore harm than this Is done for the reabsorption of the bile 
is important and,when this 1$ prevented, the general health 
buffers* 
The liver has another function. This is to cause changes in 
blood. Unless these changes'ba properly effec ted, the health 
^111 suffer. .This is about all we know about the liver. 
3 FUNCTIONAL DERANGEMENTS OF THE LIVER. 
Functional derangements .of the liver may he due to structural/ 
changes. These changes may be present in but slight degree 
or they may he absent. In patients with but slight structural 
changes,these derangements are very common- Some times,these 
derangements ar? accompanied by derangements of the stomach 
and intestines: at other times, they are not. In order to treat 
these patients properly,we should have more knowledge of the 
function nf th? liver. These eases are divided into two classes. 
-First Class of Patients,- 
These patients suffer from disturbance of the bile-producing 
function of the liver. Enough bile is not produced. The di- 
gestion of fats and peptones is interfered with. To a certain 
extent,the patient is starved* 
-Symptoms*-V^ny of the patients become emaciated*In others, 
the muscles become flabby. There is often an Inability to di- 
gest fats. These patients cannot take milk or cream or,if they 
do,they have pain,or vomit it,or pass it undigested. This form 
cf the disease 13 found bn th in adults and children. The non- 
digestion of fats Is sometimes absolute. There is often the 
greatest difficulty in feeding them. The disease is common in 
4 ^Idren, even very ytung children. Canstipatlon,often obstinate 
troublesome 1$ produced as is also flatulence which is 
?e to fermentation of food. The flatulence is often aeeompan- 
by pain. The severity of this pain varies. It is sometimes 
^y a feeling of oppx^ssinn: at other times, the patient comes 
i° you on account of the pain. The pain may be referred to any 
t of the abdominal cavity. The faeces are apt to be hard 
light colored* The tongue is apt to be coated and the patient 
complain of a bitter taste in his mouth. The patient is apt 
u ^-ook anaemic and hie complexion is apt to be muddy. In some 
1?s, there will be a disposition to the formation of pimples 
f^ce. The patient suffers from loss of appetite,headache, 
। ^normal sensations of heat and cold which alternate and 
j $ and go. The heart'saction is frequently disturbed: the 
^nt will suffer from palpitation. The urine vill contain 
Recess of the oxalate and phosphate nf lime and, oeca-.-ionally, 
quantities of albumen. 
$ vary as tn the number of .symptoms that they give. 
in G only one or two; others,all* 
worst cases, the re is apt to bo added a nervous condition, 
y^$hondriasis* This often becomes the most marked feature 
5 rf the disease and the limit between it and true rooLanoholla 
Ie aften very fine. The wnon become hysterical 
-'Treatment, -Try to re-establish the bile-producing funotien of 
th* liver. This is often very difficult to do and the w to do 
it varies vith the severity of the case. 
"The Mild cases.-These are most common In middle-aged adults. 
They lose flesh,do not feel like vo rking, their howls are con- 
stipated and their appetites are bad. All this is enough to 
make the patient very uncomfortable. The treatment is sometimes 
exceedingly satisfactory. Hut off the fate and diminish the 
utarehes. See that the patient taken enough exercise. As for 
drugs,there la none so efficient as magnesium sulphate,dram 
1/Mmr j in cold vater before breakfast* Gradually diminish 
the magnesium sulphate and,finally,give only the glass of cold 
rater before breakfast. 
-Hore Severe Cases- These are more difficult tn treat. The 
magnesium uulphate may be of no service. When it fails,you have 
to try one or other of the cholagogues,podophyllum,aloes, rheubarb, 
ipecac,sod turn sulphate,sodium phosphate,mu viatic acid,or calomel. 
Oft "n, you have to try first one, then, another. The appetite is 
apt tn be cap vicious.but you roust try to give a sufficient 
quantity of fond. The patient must take sufficient exercise 
but the had cases are so feablo that they cannot do so* * these eases,you have to try massage and passive motion, 
have to manage the mental and moral disturbances. Your 
^cess in treating these conditions <ill depend largely upon 
amount of moral contrtl vhich you have over your patient. 
- Second Class nf Patients.- 
J these cases,the symptoms seem to be due to the fact that 
blood that passes through the liver does not undergo its 
^per chemical changes. These patients do not suffer in their 
r^itinn; they do not lose flesh and strength. They are often 
and robust but,although they look 'Te 11, they often suffer 
'^tly. They have cerebral symptoms, suffer from vertigo and 
of memory and have abnormal sensations in their heads. They 
think that there is something the matter with their 
F$$>thjy vlll stumble or one leg *<7111 give ^ay from under them 
i they are diking. They often think their brains are too 
and fear apoplexy* The patients <ho give this symptom 
aften said, tn have •congestion of the base of the brain' 
an < i 
tney are generally rather pleased when told so. 
have the same feelings of heat and cold and the headache 
£ I mentioned when speaking of the first olassof patients 
■n°ugh the headache ie generally not as severe as in the 
7 the former cases. There is often diarrhoea. This diarrhoea 
( most frequently takes place tn the morning and,than,the patient 
; will often have nn movements for the reyt of the day. 
The urine :ls apt tn be diminished and high colored. It may 
, contain small quantities of sugar and albumen. The quantity of 
' uric acid is increased,. 
! The patient is apt tn have a disposition tn gout and people 
who inherit the gouty disposition are predisposed to this disease- 
- Treatment.-Medication is of nn use. Regulate the patient's 
mode of life. He must give up alcohol and tobacco and he must 
be put upon a diet that excludes the starches and cigars as 
much as possible. The patient must take very decided exercise. 
He should walk four or five miles a day and he must walk them 
rapidly nr he may take up boxingyfencing,ov some other f o 4n of • 
gymnastics. The natural alkaline mineral waters are of benefit. 
The patient should go for a few weeks tn the sp ringed rink the 
waters and take exercise. JAUNDICE. 
We use this term to designate the adoring of different parts 
nf the body by the pigment nf the bile. Dating heal th, we see 
the bile pigment only in the faeces but, when a person becomes 
Jaundiced,we find it in a number of places. Usually,it makes 
itu appearance first in the urine. The urine looks darker 
and we recognize the presence of the bile pigments by the 
hsuul tests Next, the conjunctiva and,then,the skin become 
bellow or brawn. The sv»?at may have the same yellow color, 
^ter death,we find nearly all of the internal viscera colored 
Tile faeces which in health contain bile,in jaundice,do not and 
^^ey become white or clay-colored. 
n$n a person becomes decidedly jaundiced,we get certain regular 
^aptnms. These an? constipation and flatulence: the digestion of 
is interfered with: the skin itches: the temperature is apt 
0 fall below the normal: the pulse becomes slow?there is a dis- 
PnQitlen tn the extravasation of blood in the mucous membranes: 
j 8 (uno times, there are cerebral symptoms,mentai dulness and 
delirium, com, and stupor. If the case be pmtracted, the patient 
It fl(fsh and strength and will become emaciated. The sever* 
of these symptoms depends upon the severity and duration 
9 nf the jaundice. We are still in ignorance as tn the cause of those 
symptoms but we believe them tn be due either tn the presence nf 
bile in the blnr.d nr tn some disturbance in the re^ahsnrptlnn nf 
the bile. Cases nf jaundice are divided into tvo classes,those that 
are obstructive and those that are ann-nbst ruetive. 
- OBSTRUCTIVE JAUNDICE.-The jaundice is due tn a mechanical imped- 
iment tn the escape nf bile into the intestine,ooeluslon nr narrow- 
ing nf the bile ducts. In these cases,it is believed that the bile 
,nr at least the bile pigment,is directly absorbed into the blnnd 
by the veins and that it circulates in the blnnd. This condition 
may be caused in a variety nf ways. The bile duets may be obstruct- 
ed by biliary calculi,Inspissated bile, thi ckened mucus,rnal-fo r- 
matinn nf the bile duets,ulcer nr inflammation of the duodenum, 
inflammatinn nf the bile ducts, any tumor nf the bile duct nr of 
the doudenum near the bile duct,by tumnrs in the abdominal cavity, 
or by inflammation nf the capsule of the liver. 
In order to have obstructive jaundice,it is not necessary that the 
obstruction be complete and,in some eases,it is astonishing hnw 
insignificant this obstruction may be. Often,after death,a moderate 
amount nf pressure will suffice tn force the bile into the intes- 
tine. 
10 Evidently,the bile does not exert much pressure during life. These 
are the most important eases. 
- 2 - NON-OBSTRUCT IVE JAUNDICE.-In these cases, the jaundice 
is not apt to be of great clinical importance and its symptomsis 
is are either not at all developed or they are only developed to a 
slight degree. We often find this form of jaundice with the infect- 
ious diseases,yellow fever, typhus fever, typhoid fever,and malarial 
fever and wi^h severe inflammations, ay lobar pneumonia.The jaundice 
^oes not add tn the severity of the disease but it is more apt 
to occur in the severe cases. The bites of some poisonous snakes 
^re followed by jaundice. Some patients become jaundiced after 
°hlnrnfnrm narcosis,concussion of the brain,and violent mental 
^motions. .. . 
eases of nnn-obstruetlve jaundice are explained as follows, 
know that in health the bile enters the intestine and that a 
°®rtain amount of it is here re *>ub sorbed into the blond. This is 
u normal prneessbbut,it is held that in health this bile does not 
as bile tn the blond but undergoes various changes and 
transformations. Now, when a person suffers from non-obstractive 
^unlice, the bile that is re-absorbed dnes not undergo these 
Changes but remains as bile in the bl«nd or,at least,as bile-pigment 
11 One of the most common forms of obstructive jaundice is called: 
SIMPLE JAUNDICE, 
In these eases* the obstruction is in the common bile duet and is 
eaused by an acute catarrhal inflammation of the mucous membrane 
nf the .iuct. This inflammation is attended by swelling nf the muenus 
membrane and by an increased production of mucus and these changes 
suffice tn interfere with the passage of bile^ According tn the 
severity nf the inflammation,this interference 'fill he more nr 
less complete. In the more severe cases, the obstruction is com** 
plete. In a considerable number nf the cases,the inflammation will 
remain confined tn the enmmnn bile ductbutbut,in others, there vi.ll 
be u similar catarrhal inflanmatinn of the stomach or of the duod- 
enum nr nf bnth. The^e additional inflanmations will modify the 
symptoms* 
SYMPTOMS* 
There ar? certain symptoms that are common tn all cases* These 
are malaise and ce reb ral symptoms,headache, s tupo r, 4 no wsdnees dui^-OR 
the day,and vertigo* The tongue Is enated. There are nausea and 
vomiting. Tie faeces are not as yellow as they should be or they 
may be white. The urine contains the bile pigment* Peyer is devsl~ 
oped in the more severe cases. Pain is often present . I* 1$ 
referred tn the gall bladder nr epigastrium. The degree of pigmen- 
tation of the skin and conjunctiva will vary with the severity ox 
12 the jaundicn. The jaundice way precede the constitutional sywptnmrF 
or the constitutional symptoms may precede the jaundice. The 
Constitutional symptoms may.cnme nn a week before the jaundice 
niakcs its appearance. They may both cnme together. When the jaun- 
dice is fully developei,the skin itches. The pulse may be some- 
That singer and fuller than it should be. 
If there be nn inflammation of the stromach or duodenum, the cases 
Till be mildest. There -7111 be no vomiting nr fever. The patient 
Till mt be confined to bed, the cerebral symptoms Till not be 
developed to a great degree.tand the jaundice will be the nne marked 
symptnm. The patient will feel dull but will go on with his or- 
dinary work. The faeces will be clay colored. 
When the inflammation of the duodenum is added,the patient is 
father worse off. He gives the symptoms nf jaundice but, in al- 
i 1itinnrpain is apt to be present. The pain is refer Nd tn the epi- 
gastrium nr gall bladder. 
^n the inf lamination of the duodenum and the inflammation of 
।the stomach an) added,all the symptoms will be well developed. 
Smiting is present and it is often marked and distressing. The 
^ver is marked. The prostration may confine the patient to bed 
may make you very anxious. The patient will ln$e flesh and 
13 und strength. He will deve, , wiiTium alternating with ^upor. 
The tonhue tongue will be dry and prill be coated brown. If h- 
patient already have a fatty or cirrhotic liver, such an attack 
of jaundice ivill be apt to be very serious and may prove fatal- 
If the liver be healthy,the patient should recover. 
- TREATMENT. - 
In the mil lest cases of simple jaundice,those in which the bile 
duct alone is inflamed,the patient often does not apply for treat- 
ment. He does not think it worth while and he gets well 'without 
treatment. Should the patient apply for treatment,it is not nenes- 
sary tn confine him tn the house nr to regulate the diet to any 
extent. Should the bowels be constipated,give & mild laxative/ 
and that is all. 
When the inflammation is accompanied by inflammation of the duoi- 
enum:-These patients feel more indisposed and have pain. It is 
best tn keep them in the house unless the weather be very warm. 
Keep the bowels open. If they will not take solid fond,give milk 
with bicarbonate of soda nr lime water. In order to relieve the 
pain,we may apply bliste ra,plaste rs,or some of the other forms 
of counter-! r ri tatinn to the region of the liver. In some cases, 
this means rill not control the pain and, then,you may give small 
hypodermics nf morphine*. 
Jaual13'' 18 accompanied by gastm-iuodenitiss - The 
vomiting is more serious and may be very tmublesnme. 
14 The best way tn check it is tn feed the patient vlth very small 
quantities nf fond at e time.The best food tn give in this -vay 
is milk. Give frnm a dram tn a half ounce at a time and give 
some alkali with it. In addition,you may apply counter-irri tution 
tn the vhnle region of the stomach. In some cases,in spite of c.n 
you can do,the vomiting 'Till continue for the first few days: then, 
these measures will either take effect or the inflammation ^11 
subside <ani the vomiting rill cease* In orier to relieve the 
constipation,while the vomiting continues,you must use enemata. 
ilf the cerebral symptoms he marked,give the bromides or opium 
and,if the patient vomit,you rill have tn give them by the rectum. 
If the heart become feeble,you. may have to give stimulants. Keep 
the patient quiet in bed. 
If the patent have a fatty liver,he is apt to -lie and the treat- 
ment is n.ot apt tn be of much use. When there 1$ nn previous Jis* 
case of the liver,nn matter how badly the patient may look,he 
a rule,get veil but the patients vary very much in the 
^Pllity ivith which wthey recover. You must not lose patience, 
patient should get »?ell in a week but he may very* veil gn on 
*nr three nr four we^ks. When the patient goes on for three nr 
f^ur weeks,it means that the inflammation haw become sub-aoute - 
15 or chronic. This is no reason for changing the plan of treatment. 
Go on quietly In the same vay,neither more severely nor lose severe- 
ly.When the inflammation continues and sho-v? a lisposition to 
become chronic, the best thing to -lo is tn send the patient ^-vay* 
16 BILIARY CALCULI. 
In health, the bile Is a fluid but portions of it may become less 
fluid op,even,entirely solid. When the bile becomes less fluid, 
it means that its solid constituents have became mixed with ten* 
aoenus mucus,have became thickst,and have farmed a pasty substance 
called inspissated bile. This substance is pasty, red ar green, 
nd, when dried,it becomes a powder. It is composer t>f pigment 
"''ith a\little chelesterin,salts,and mucus.When the solid pnr^ 
tlons,especially the cholesterlna, become separated from the bile/ 
they form solid bodies which most frequently collect in the gall 
^^dder, sometimes in the bile ducts,and are called biliary cal* 
^uli^ They may be small nr large,many or fem,hard or soft./ 
have now tn consider the various ways in which biliary calculi 
inspissated bile may be formed. 
is said that normal bile is neutral or slightly alkaline and, 
it become acid, the cholesterin will be precipitated. 
* 13 alsn said that the liver sometimes produces more cholester* 
than the bile can hold in solution. 
1 other times,the biliary calculi are formed bytthe bile remain- 
too long in the gall bladder and the cholesterine becoming 
^^oipiUted. 
other times,a chronic catarrhal inflammation of the gall blad» 
/Tlll be set up. This will be accompanied by an increased pra^ 
ctlon nf mucus and this mucus will form inspissated bile. 
17 In infants and children,biliary calculi are rare but,after the 
age of twenty, they are' common enough* They are mere common in 
women than in men,among the better classes than among the la- 
boring classes,and among those people who live sedentary and 
luxurious lives* They are often associated with constipation. 
It is believed that the eating of too- much fat and starch pre- 
disposes to biliary calculi. It is also believed that people 
who live in malarious districts are predisposed to biliary cal- 
culi. 
The biliary calculi or the inspissated bile may remain for a 
long time or for a shert time in the gall bladder,in the hepatic 
ducts.,in the cystic duct,in the common bile duct,or in the small 
duets in the liver, and., some times-, after they have reached the 
intestine-, they remain within the intestine. 
- 1 - BILIARY CALCULI IN THE' GALI, BLADDER.- 
The symptoms of the presence of biliary calculi or inspissated 
bile in the gall bladder will vary according to their position 
and also as to whether they be stationary or movable* 
Frequently, the calculi in the gall bladder will remain, stationary 
and will n»t move around*. When this is the caser, there tire often 
no symptoms at all and^yet, at the autopsy, the gall bladder 
may be filled with calculi. This is important and you must re- 
member it in the treatment. 
In other cases., they will remain in the gall bladder but they 
will not remain quietly. This is especially apt to be the case 
when they are small. From time to timezone will move to the 
opening of the cystic duet and will jusfy engage its orifice. 
i a It will remain in this situation for minutes or for hours: then, 
it will slip back. This may be repeated a number of times at vary- 
ing intervals. The one symptom is pain, refe rred to the gall bladder, 
epigastrium,or liver generally. The pain lasts till the calculus 
'-'lips back and while it lasts,it is very severe. 
■'hile the patient is suf fe ring, our object is tn relieve the pain. 
Hag may be done in one of two ways. In the first place, we may 
give morphine hypodermically nr,in the second place, we may try 
hasten the slipping back of the calculus and the best way to do 
this is tn make the patient vomit. The vomiting often suffices 
make the calculus slip back. When the attack is ove r, we try 
to prevent the formation of more calculi. We will discuss the 
'-thods in vhich to prevent the formation of more calculi,later. 
cuius nr a 'lumber of calculi may remain in the gall bladder 
set up inflammation, and cause dilatation of the pall bladder* 
e inflammation may be either catarrhal or suppurative. 
the inflammation be catarrhal in its nature.the gall bladder 
be distended by the increased production of mucus, will often 
^^jeet below the ribs,will be the seat of pain,and the patient's 
k^eral health may suffer to a moderate degree. 
19 If the inflammation be suppurative in charac tex^ the pus will 
accumulate in the gall bladder. The gall bladder will be distended, 
will project below the ribs and will be the seat of pain. In 
addi tion, there will be a febrile movement, sweating, loss of flesh 
and strength, and prostration* The patient will be very ill* 
His condition may be rendered worse by an extension of the inflame 
mation to the outer surface of the gall bladder. This will set 
up a localized peritonitis,adhesions will be formed between the 
outer surface of the gall bladder and tine surrounding viscera., 
and you will .not be able to feel the gall bladder as a circum- 
scribed elastic tumor* You will feel a substance that gives the 
feeling of a localized peritonitis» 11 will simply be a large 
swelling* 
TREATMENT, 
The tre^itment varies with the severity of the inf lama tinn and, 
yet? sooner or later^we are as a rule obliged to resort to sur- 
gical treatment* If the inflammation do not lave a decided ef- 
fect upon the health of the patient>you may put him to bed, 
apply eold^and see if the inflammation will not subside. It may 
20 rto bo and. the patient will bo well for a time but he is liable 
to have a return of the inflammation- The only radical treatment 
Consists in cutting down on the gall bladder,brining it for- 
^rd,opening it,and removing the calculi- The gall bladder will 
become obliterated but this does not seem to do any harm. 
*2-WHEN A CALCULUS PASSES INTO THE CYSTIC DUCT AND BECOMES 
IMPACTED.- 
Sometime a, when this happens., the only result is dilatation of the 
€&11 bladder. This dilatation seems to take place in one of two 
p^ys, In the first place., the calculus may act as a valve and 
^111 allow bile to enter the gall bladder but will not allow 
to escape. In the second place., there may be a production of 
^ln mucus or serum from the inner wall of the gall baldder. 
SYMPTOMS. 
patient will not hav* jaundice or constitutional symptoms 
^t}at the time of the impaction,he will suffer from pain,biliary 
colie< Tm*. pain may last for hours or days, When the calculus 
^top$j moving around, the pain will cease. In many cases, the 
faction will not take place until the patient has suffered 
severed attacks of biliary colic. The impaction of 
21 a calculus In the cystic duet is one of the ways in which attacks 
of biliary colic are cured for, when the duet is stopped up by 
a ealoulu^nt more calculi can pasts' through iU 
The patient will exhibit a tvmox' in the abdominal cavity. This 
turner will be the enlarged gall bladder,. After thi^ tJie patient 
may have no further trouble* 
In other casei^affairs do Knot proceed as smoothly. The calculus 
is impact ed7 tine gall bladder becomes di la ted, but the gall bladder 
continues to increase in size. In addition to this., there is . 
constantly going on a catarrhal Inflammation of the mucous mem-/ 
brane of the gall bladder. The gall bladder may become of such 
siz<e as to fill the whole right side of the abdominal cavity. 
The general health will suffer. This will be due partly to the 
'tumor and,partly to the inflammation. Th'5 patient is often troubled 
with nausea and vomiting. There 'Mil he an irregular fever which 
is often accompanied by sweating. There may be diarrhoea* If 
left to himself, the patient may die* The disease is usually slow 
in its progression and the fatal termination is not reached 
for weeks and months. Previous to his death, the patient will 
be confined to bed and will lose flesh and strength. 
22 TREATMENT* 
The treatment is a matter of great importance* We may treat these 
Patients in one of three ways. 
^l~We may try the continuous loecU -application of cold. This 
is really very satisfactory* It is often surprising to see how 
t:aon the patients will get well under this treatment even if they 
have been very badly off. They my recover entirely* In these cases, 
hs there are no calculi in the gall bladder,if the inflammation can 
ke controlled, the cure will be permanent- As a rule,,it is the 
Plan to be tried first* 
^2'-You may aspirate and remove,,as far as possible, the contents 
the gall bladder. You must remember that when the gall bladder 
i^ dilated and inf lamed, the amount and extent of the adhesions 
^■y vary greatly and they may be situated behind the gall bladder, 
^en you aspirate,,you puncture a sac distended with fluid and, 
you only draw off a little bile,it may happen that,after 
have withdrawn the needle, the bile that remains will escape 
trough the puncture in the gall bladder into the peritoneal 
^vity. Should it do this,,it will set up a fatal peritonitis. 
^Sif you aspirate-,you must draw off all the fluid. If you do 
there is no special danger. It is dangerous to make an 
^^P1 o ra to ry punc tu re 1 
23 - 3-You may make an Incision in the abdominal wall,completely 
empty the gall bladder,,and allow it to become obliterated. 
In doing this operation, sew Vie gall bladder to Vie insision/ 
in the abdominal wall. / 
J ' 
- 3-WHEN CALCULI ARE FtRMED IN THE CAIL HJWDER OR HEPATIC 
DDCT^R^UIN THERE FOR -QVE TIME, THEN, PASS INTO TOE INTESTINE.- 
This is,, perhaps^ the most common way fox' them to behave* When 
this happen^ the patient is said to suffer from an attack of 
biliary colic. The termkcnllc* is chosen because the pain is the 
most marked symptom* The calculi vary in theix* size and in their 
ennsis toney, tha t is as tn whether they are calculi or inspissated, 
bile* The calculus u^ay take but a short Ine to get through the 
duct or it may take several days* 
- SYMPTOMS.- 
*-1-In some casethe first symptom will be a chill. It is not' 
cons tan t. 
•2 - PaixLr- As a rule,, the pain comes on suddenly. It is very 
:ev?,^,o The severity of the pain will vary in the different 
patients. It is referred to the epigastric region or to Vie/ 
Lower edge of the liver amid it radiates in various directions* 
24 Occasionally, the invasion of the pain will be gradual instead 
of sudden and,at first, it will be dull and aching instead of 
severe and lancinating* 
If this pain were different from nthex' pains-, it would assist 
us very much in making the diagnosis but it is not and you may 
hot be able to distinguish it from the pain of an ordinary in* 
tettlnal colic? and, to make matters worse,, it is not uncommon 
^or the same patient to suffer at different times from first 
^ne disease and,then, the other. 
patient may have pain due to renal so lieu This is exactly 
the same eort of pain as that of biliary colic. It differs in 
*t» situation, and this often helps us in making the dia^ogis 
&Ut,when the pain is very severe and radiates, it may be very 
difficult for the patient to localize it. The patient may say 
he has the pain ovex* the whole abdomen. Some patients do not 
Ceem tn possess the mental faculty of locating pain-. 
3-There may be nausea and vomiting and these symptoms are 
times severe and distressing* 
•4,- .pho patient may have fever which may accompany the attack 
may follow it for several days. This fever is important, 
some cases^it is developed without inflammatory conditions 
only lasts a day or so after the pain has disappeared. 
25 In these aase&sii is due tp foe pain* 
After the attack, there my an infl*4Mt&-tion of th® rail bladder 
which will, set up % localised peritonitis* Thin peritonitis may- 
last several days "after the of the calculus* There will 
be a fever which will last until the peritonitis has subsided- 
In patients who live in it malarious districts malarial fever 
may follow ths? attack* 
Soothe fever my be developed in one of three ways* 
-^ 5™ During the attack, the puJ.ee is apt to he mnall ^nd feeble. 
- 3-77ie bowels arc constipated both before bnd during the attack* 
- 7'-In some eaee^ there is flatulence* 
- 3-jn gorne case^the pain is so severe as to cause prostratinn, 
syneope^and collapse* 
The collapse has been known to bo fatal but this is seldom the 
case. 
26 S-In a considerable number of the cases,jaundice is developed* 
•At & rule^it makes its appearance within twenty-four hours af ter 
Vie pain has commenced* The jaundice may remain for several days 
then,fade away or it may last for a week or so* Jaundice 
be absent altogether, This is very important to remember* 
would, naturally expect that jaundice would be developed and^ 
a rule,, we are not disappointed but,in some way or other.,it 
possible for a ealcululus not to produce it at all, This is 
specially apt to be the ease if the calculus be small and soft 
Qx> if it be in the form of inspissated bile* We know that this 
pase for we find the calculi in the stools after 
attack of biliary colic in which Were has been no jaundice* 
^10- • The liver is often somewhat swollen and tender during and. 
an attack* The gall bladder may also be swollen and tender 
it maybe Inflamed* The gall bladder may sometimes be felt 
-low the ribs but, as a rula2it is not sufficiently enlarged 
this* 
a. 1 - - There maybe a local peM ton! ti 6* around the gall bladder, 
is not constant and^in cases that I have seen^ithas 
^'Vcn little 'trouble* 
of the attacks o&ly last an hour or part of a day. The 
are generally separated by intervals of weeks or months* 
27 This is the rule when the patient passes hard calculi but,if 
he pass soft calculi nr inspissated bile., the attacks are apt tn 
become more frequent and of longer duration and they may succeed 
each other sc frequent'!?/ that the patient my seem to be ill 
for weeks or months* There will be some pain evex'y day? the 
jaundice will not disappear., the vomiting will continue, there 
may be an irregular febrile movement? and the patient will be 
confined tn bed* 
Many of the cases are- so straight forward that there is no 
trouble in making the cia^csis. This is particularly the case 
when jaundice is present but,when the jaundice is absent or 
slight and the attacks frequently repeated?the diagnosis is very 
difficult* In these the only way to be sure 1$ to find the 
calculi in the stools* If the calculus be hard and of some 
little size.,dilute the faeces., fil tex1 them,and you will get the 
calculus without much trouble* When the calculus is soft er 
when the patient passes inspissated hila, there is often great 
elffieulty in detecting them* StilL>with sufficient care,you 
can generally do it* 
- TREATMENT. - 
- 1 - Of the Paroxysm# - 
The drugs that we use tn relieve the pain are opium,chloroform, 
and ether. If the pain he not very severe^ hypodermic injections 
28 af morphine will cU but, if pain be very severe and if there 
H great cxM will n,ud (> ther or chloroform of a great 
deal ef service* 
if the heart become i*apid and foebl&jgive stimulants and,if the 
Patient vomit, give them hyp ode rado ally* 
in order to as^ifct in the expulsion of the calculus,,it is appar- 
ently of benefit to put the patient in a warm bath and to give 
a G11 ve pu rga t iv e s. 
- g^To Prevent Subsequent Attacks.- 
success in preventing subsequent attacks seems, to depend 
hpon whether or not there be few or many calculi in the gall 
gladder and. whether w not they will make up their minds to 
quiet instead of trying to get nut* 
the calculi be few in number, the patient will pass them one 
^ter- the other ^nd,while he is doing thia^^u must try to 
$^vent the formation of new calculi. This,you can do and,in 
^ese cases,, the prognosis is pretty good. 
there be rna^ny calculi in the gall bladder but if they will 
'$eP quiet, the prognosis is pretty good and,here again,we try 
prevent the fnmotion of new calculi« 
Uiere be many calculi in the ^U. baldder and if they will 
29 net keep quiet but insist upon getting into the bile Huet,it 
is, very difficult to do the patient any good for, al though we 
.can prevent .the formation of new ealeullBwe have no means 
of inducing their absorption noi' of making the patient pass them 
all at once# The more clearly you understand what you eani do 
for these patients and what you. cannot do, the better will be your 
treatment# 
When we try to prevent the formation of new calculi,we are 
guided by the causes of their formation# 
In the first place,we try to prevent the bile from becoming acid* 
This,,we do by giving alkalies# Give the alkaline mineral waters 
or the preparations of soda or potash in considerable Quantities., 
well diluted^and continue their administratlon for a considerable 
time. 
To prevent the excessive production of choles terine,cut down the 
I fats. 
To prevent the tendency to thickening of the bile?make the patient 
drink large quantities of fluid or give drugs that increase the 
quantity of bile and,at the same time,, make it thin and more fluid# 
For this purpose,,you may give the salicylate,phosphate,or cholate 
of ^oda or chloroform,ether,and turpentine internally- 
30 $o cure the chronic inflammation of the gall bladder and bile 
Passages^ there seems to be no way aw good aw to tell the patient 
to travel* 
Regulate -the mode of life* The patient should not be allowed, to 
lead a sednetary llfetoor to live luxwiouHy? nor to drink?nor 
to take no exercise* 
the patient be living in a malarious dis trie tTmake him move 
°ht of it* 
^^aXthGUgh we have no certain means of helping the ^tient 
;calculi insist ujen- getting out of the gall blanker,?stilly 
must de something for him* W& may try to get rid of the cal- 
°hli tn one of two ways* 
J11 the first place^we may Increase the quantity of bile with the 
that this bile will ;^ase into and out of the gall bladder 
^th increased rapidity and will wash out the calculi^or that 
t will distend the gall bladder and cause it to contract and 
^•ee out large numbers of calculi*' For this purpose,you may give 
d1 - p rep a ra ti on s o f s o d a , o r c h 1 o r o f o rm, e the r, and tu rp e n tine 
In «?ome these drugs will cause the patient trf 
rid of a considerable number of the calculi. 
R the- seoend place.? there seems' to'be an' advantage' in giving an 
31 > active purgative from time to time* Of onuree^ the bowels should 
never be allowed to become constipated* 
- 4-CALCULUS becomes impacw in the common bile 
DUCTa - 
This is always very serious* There is apt to be a history of 
one or more attacks of ordinary biliary colic* Then, the patient 
will have an attack beginning like an ordinary attack* Then, 
after a time,, the pain will disappear or will become much less 
severe but the jaundice will continue and will gbt worse. 
At first, these will be the only symptoms* Then,the patient will 
gradually get worse* The jaundice will continue, There will 
always be some feeling of discomfort about the lower edge of the 
liver. Then,the patient will lose flesh and strength and will 
become emaciated: will lose appetite and will suffer from nausea 
and vomitings the bowels will be persistently constipated. Then, 
the tongue will become dry* cerebral symptoms wall be manifested: 
the disposition to haemorrhages will be developed: and the patients 
look like typhoid fever cases. The rapidity with which the patient 
gets worse will depend upon whether or not the bile duets become 
inflamed. If the bile ducts become inflamed, the patient will 
32 get worse more rapidly* This often happens* At first, there is 
a catarrhal inflammation of the larger duets: then,the InflammaioB 
inflammation becomes suppurative:then, this suppurative inflamma* 
tion extends to the liver tissue and abbesses are formed. Then* 
the patient gets worse very rapidly,develops hectic,and dies in 
a short time. The rule is tha^in either eab*e, they do very badly, 
indeed* Sometimes,, they do get well and they may do so after 
having for weeks or months looked as though there were no hope, 
3f course^recovery is caused by the escape of the calculus and 
the calculus may effect its escape even after weeks and months- 
It perforates the wall of the bile duct and crapes into the 
'iuodenum- The calculus excites inf lamination of the bile duct: 
the bile duct becomes adherent to the duneenumsand the calculus 
finds its way through the bile due t> into the duodenum, ;vi thou t 
entering the cavity of the abdomen* When this does take placa, 
the patient gets betten,at firs t, slowly, then, mo re rapidly. The 
Stomach symptoms get better, the cerebral symptoms are not as 
^rked, the jaundice fades out? the tongue cleans,,and the patient 
gains strength- Such a fortunate result is not common. 
TREA.TMHNT, 
^he treatment would be surgical and would constat in cutting 
^own and. removing the calculus*but!when you look at the relations 
33 of the common bile duct,you will see how difficult and dangerous 
this would be* * 
- 5- .A CALCULUS MAY BECOME LODGED IN TILE HEPATIC tR CC^fON 
BILE DUCT,RWkTN TOR YEAH&,AND NOT BECOME IMPACT^.. - 
I would ask your special attention, to the consideration of these 
cases formal though they are not very uncommon they are not gen« 
erally unders tood* A calculus gets into the hepatic duet or. into 
the common bile duct* It is not large enough, to become impacted 
and stop up the ducfyyet,it is not small enough to pass into 
the intestine*. It remains small and movable without occluding/ 
the duet» After- some timo, the ducts begin to adapt themselves 
to its presence by dilatation. This dilatation does not extend 
to the end of the common bile duct at the in tes tina, nor to the 
commencement of the hepatic duet at the liven,but exists between 
these two points. The calculus-,instead of becoming more good- 
natured^also increases in size. As time goes on,both these things 
continue until i-he calculus may be two inches in length,one inch 
in thickness-?and half an inch thick and,yet, the duct will be 
tuffieiently enlarged to allow the calculus to move.. 
The patients give a very long history. The longest case I have 
had lasted fifteen years. 
34 - HISTORY.- 
At first, there will be a history of one nt* more attacks of biliary 
oo 1 ie ♦ Some timeth 1 s hls tory wi 11 be ve r y s traigh t f orward. 
At o ['her times,, the history Mil. not be very clear and you will 
yet something like this. Prom time tn time, the patient has had 
Tain somewhere in the upper part of the abdominal cavity. The 
attacks of pain may or may not have been accompanied by jaundice* 
This begins the history.At first, the general health does not suf* 
Mp. Scathe patient will go on for an indefinite tine with nothing 
but the eclie or the pain already described. Then* the health 
begins to suffer. At first, this disturbance of the health is 
father indefinite and your attention is not drawn to the liver, 
^he patient Mil develop gastric and hepatic dyspepsia: Mil be 
doubled. with nausea and occasional vomiting: Mil lose appetite^ 
Mesh,and strength,and will have the symptoms of functional 
disturbance of the liver* Each year,,he will be a little worse 
^ough^at timen,he may seem a little bettei'.Af tor a time.,he 
Mil become so feeble and emaciated that he cannot attend to his 
and, now, he is apt to become anaemic and jaundice may make 
Ms appearance. But^the jaundice in ro*, present to a marked degree 
this slight jaundice and the anaemia make it appear as though 
35 the patient were suffering from the caneerous cachexia and the 
:^'y Be uh $ taken for one of cancer of the 8tomci.en and livexy 
Some of the p^tient^ 'will continue tn lone flesh and stx'ength 
and ^dll die from exhalation or from intereurrent disease* 
In othey eat,a will be battened by sunpxu^Vive inflammcition 
of the file duets or <?f the ducts within the liver. 
- T1BAWINI1 - 
No treatment is likely to he of any serviee except removal of 
the ccloulvt and. this would be very dangerous^ 
6- -ht-f A CALCULUS FIHDS ITS WA? rNTO THE 1NTESTIM: BY ; 
UirEaAlIONo - 
The calculus remains* in the gxll bladder or in the bile due t 
for a co.'i^de ran?.? time 'rith or without giving sysoptoms^ 
< x... •■.. tiou of && wall af the gall bladder or bile duet 
io rei up '<d t?e^e structures beerxe attached by mean:; ci adhesions 
to the xll of. he intestine. Then^perfora tion takes place* 
Theye calculi are of aonsiderable yiue and^after they enter the 
intestine-? they may beaame larger from deposit'upon them of mat- 
ter from, the faeces. 
- HISTORY.~ 
In noro get the regular symptoms of the pi^senee of a 
caLvuix-. in the T bladder nr bile duct andT Vien^tke symptoms 
of its preuenee in the intes tiaCibu t» in some cases^especially 
36 yhen the calculus has been in the gall bladder, the patient may 
have no knowledge of its px'esenee ther%nor of the inflarm tion, 
her of its perforation# You would U Ink this t$jpossiM.e 
i ^hen the calculus is of site and has passed Init u e inteco 
^ine,lt may remain there for a long tine with hardly any sym^ioms^ 
■ patient way think that he has dyspepsia he nay have m- 
; e^sy feelings about- the abdomen. In other cases, the calculus 
। B^ves rise to considerable pain whieh asay be referred to any 
p>^rt of the abdomen. This pain is often severe. After a tine* 
1 ®aleubxs may interfere with we passage of faeees. Then, 
the patient will have the symptoms of intestineil obstruction^ 
- TRWWTT. - 
treatment consists in removing the calculus and,in the in- 
^^tina, this can bo done. 
37 -AWDu PARWHmTOUS HEPATITIS^ACUTE YELLOW ATROPHY^tR 
MALIGNANT JAUNDICE. - 
As regards the true nature of this disease,we are still very 
ignorant but?judging from logy, we should be inclined to class 
it with those diseases that are known as infectious and probably 
the prison i& in the form of a micro-organism. Fortunately,the 
disease is not common. 
The eharaeteristie lesion is regularly a specific change in the ; 
liver tissue. At first,the liver is somewhat increased in size. 
At other times., the liver remains cut first of the normal size. After 
the preliminary increase,, there is & diminution in the 
size and weight of the liver. This diminution takes place very 
rapidly. The degree varies greatly and the degree of diminution 
is no indices tion of the severity of the disease. In extreme cases, 
the liver will not weigh more than a pound and a half. In other 
cases,,it will only be diminished by. a pound or by half a pound. 
There is also a change in the eol©r of the liver. Most frequently, 
the whole liver becomes a light yellow color: less frequently, 
it will be mottled red and yellow. 
There is sometimes a change in the consistency of the liver. 
This is not constant In some cases., the liver will become soft 
and flabby. 
PATHOLOGY. 
38 *he gall bladder will either be entirely empty nr will eoin tairi 
or will cantMA bile* 
^11 these changes are partly due tn a diminution of the quan- 
tity of blood in the liver but they are also due to changes in 
the hepatic cells. The «ell body becomes coarsely granular* 
^hen, the cells seem to die, hesome neem tis, fall to pieces arid 
break down. after death,you find that many of the cells are 
^eplaaed by amorphous granular matter* Other cells will preserve 
their outline but will be filled with granular matter. These 
Ganges maybe ©ailed either infl^^atory or degenerative. If 
paly a moderate number of the cells die,the patient may recover 
b^t,if most tile, the patient can no longer have a liver* 
^heg© changes may also occur in livers that have been already 
°hanged by cirrhosis or fatty infix tration* as well as in healthy 
diverse Shafter1 death,you may find a faaty or cirrhotic liver 
with the lesions of aeute parenchymatous hepatitis* 
- Secondary Lesions* - 
^l--spleen is regularly enlarged tmd soft as it is in most 
$-hfeatir.U3 diseases* 
-The stomach will be the seat of an acute catarrhal gastritis. 
The intestine will be inflamed and there will be swelling 
39 ef the solitary and agminate follicles. 
- 3-As c- rule, the kidneys are the seat of a well-marked par- 
cnchy^tous nephri tis. 
- 4 - The walls of the heart will become soft and flabby and 
they may be the seat of fatty degeneration. 
•-5---There maybe extravasations of blond in the serous mem- 
branes as in most infectious diseases. 
- ETIOLOGY .- 
The disease is not very common. It is said that it has been 
observed at nearly all age&, that is be.twen one and sixty nine 
years. I an sceptical in regard to the eases that are said to 
have occurred in infants* It is most common between the ages 
of twenty and. thirty* It is more common but not much more common 
in women than in men. The pregnant condition has something to 
do with its occurrence. It may be associated with cirrhosis 
or fatty degeneration of the liver. 
The regular exciting cause is probably the introduction of some 
specific micro-organism and,possibly,in order to have such an 
Infectious inflammation of the liven, we must have first, the 
exciting cause to the inflammation and, then, the introduction 
of the micro-orgahism. We have reason to suppose that the disease 
occurs in the following manner. In the first place-, the patient 
40 has an ordinary gastro-duodenal jaundice but,instead Of going 
on as a simple jaundice,, there is added the introduction of a 
specific micro-organism. This,at once,changes the character of 
ihe inflammation. This theory is for the present merely suppn- 
Titian,yet,it accords with what we know of other infectious diseases 
^d it seems to find support in the clinical history. 
- CLINICAL HISTORY.- 
-- The Invasion,- • 
invasion my be either gradual or sudden. 
^1*-If gradual, there are disturbanoes of the stomachy loss of 
appetite,nausea,and vomiting. These symptoms are accompanied by 
some prostration and malaise. There may be some jaundice. In 
°ther words,, the patient suffers from a gastritis and an inflam- 
tion of the bile duct. This gradual invasion may last .three 
01* four days nr two or three weeks. This is important. 
^2-jf invasion be sudden, the patient will be attacked 
yith marked vomiting and marked prostration and,within a few 
°^^&,he will develop the characteristic symptoms of the disease. 
- The Symp toms. - 
'^'1'-The patient will continue to vomit. -He may not only vomit 
nod but he may vomit blond. This x, due to bleeding from the 
41 IhlOOUB : ■ • t a tiOM&l q entity ufblnod 
be effused IrtQ ui© the patient will have the "•black.1, 
or^enf fee "ground f-v^ tie tuanUty of bland effused be 
large,, th $ patient 1 vot pure blond* The vomiting is apt tn < 
be well >ed ihroughou t u:9 whole ci seat'S. 
--^2~-There are apt to be disturbances of the intestine. Usually, 
the bowels are loons and the. faecal matter Is white, pasty,watery, 
or Gutywaoz^red. The patient 'may pass blend in small quantity 
ar in large quantity. • 
- - Jaundice is a regular t-M early symptom but it may come on 
at aifstages o' the disease* It is estimated that,in twn- 
gl .Ji© cases, the jaundice makes its appearance within 
twenty«four hours after the disease has commenced. In about one- 
quarter of the oases^it does not come on till the f if th, sixth-, 
or seventh day. Tn a few case&,it does not come on till one or 
two days before death and,in e. very few cases indeed,the jaundice 
will be absent® This jaundice is of importance in making the 
dlagnoHi&eWe naturally expect it and,if it ne not present,we 
are apt to be thrown off the track. 
.,-4-Pain is present over the liver and stomach* The pain varies 
greatly in severity. 
42 ' -5--Fever is a .regular symptom throughout the disease* During 
the gradual invasion,it is usually absent but,as soon as the 
disease is established, the fever is regular enough. However, this 
fever is most irregular in character. The temperature will run 
Up and down on different days;it will be higher in some .patients 
fhan in others-it my even fall below the normal; and the height 
Q£ the tcmperatufc-^as nothing to do with the severity of the 
disease. 
"^•6--The pulse varies in different patients and during dif- 
lerent stages of the disease. In some cases,,it will at first be 
th® pulse of high f everyone hundred or more and pretty full. 
P-U other cases.,it will from, the first be rapid and feeble. In 
nibers,,it will at first be rather slow like the pulse of simple 
jaundice but,as the disease goes on, the heart becomes rapid and 
feeble* 
.^7-- Cerebral symptoms are developed early. There will be head- 
: ^he; re s tlessness; atu$ or al tema ting wi th re s tl e ssne ss; de lirium 
[^tornating with stupor. The patient may develop convulsions 
may pass into complete stupor* * . 
The tongue soon becomes brown and-dry. 
The face becomes cyano tic^ anxious, and emaciated. 
43 - It'-From the first, the prostration is marked* 
-■11'-In a very few days, the patient will become much emaciated. 
*-12 - The urine shows changes early. These changes are due to 
the nephritis* The urine will be dirrd.nl shad,, hi gh^ 
may contain blood. The specific gravity does not necessarily 
undergo changes. As a rule,, albumen, and hyaline^granular^and 
epithelial easts are present in considerable quantity. The com- 
position of the urine is .changed, the urea and urie acid are . 
diminished and substances called leucln and tyrnsin make their 
appearance. 
•-15-There may be haemorrhages into, the skin which will still 
further change the appearance nf the patient* The patient may- 
have haemorrhages from the mou th, in tee tins, and kidney. 
- PHYSICAL signs* - 
Ve z&y get physical signa and,if wq do, they are a great help* 
They depend upon the changes in the size, of the liver* The 
physical signs may vary* It may happen that the liver will not 
get very much smaller* The liver may previously have been fatty, 
in which casa^it may not undergo much change in size? ox^ the liver 
My previously have been, amall .and-airrMotiOw In ether yasas, 
you will find that the liver has become, smaller and wu will 
44 very much surprised. to see how quickly this change will t^ke 
Place* It will diminish symetrlc&lly in sixe in twenty** four Z* 
^ours« Tike area of percussion dulnesn will diminish in all di- 
rations and it '^y' disappear al together, fw the lung and inte^ 
^ine will over-rd.de the liver w it becomes smaller* These changes 
he 'well .marked within an hour* 
- DURATION* - 
^ter the invasion of marked symp^ms^ the duration of the disease 
not great. It averages one week* There are especially ma-Z 
^(-.nant case«; that only last t?n or three days or only 
few hourly When the disease lasts longer, this increased duration 
J55 principally due to the gradual invasion but,when the disease 
fairly established,it does not often last longer than a week. 
- -PROGNOSIS*-* 
prognosis is exceedingly bad* The patient,as a rule,dies 
Xri extreme prostration. I have been in the habit of saying year 
ufter 5-ear that I have seen one case recover?! have seen no 
u°rc recover since. 
. - TRFAMiNT* - 
treatment is unsatisfactory. The treatroent of none of the 
^eetiems diseases is satisfactory. Put the patient to bed. 
45 Nurse him and keep him an fluid Quiet the restlessness and 
delirium si tk h^^ide^ehloraljand ^piunu fc aheeh tie vomiting? 
you may give in ooroiderable quantities in the milko 
» 
46 ^CHRONIC INTERSTITIAL HEPATITI&jOR cirrhosis of the liver*- 
This disease is very common and very important. 
- PATHOLOGY., - 
The chronic inf lai:Wb tian has for its product new connective tis- 
L;Ue, The relative proportion of cells and basement substance 
Varies but there is nn previous'stage of congestion, no production 
0 £ s e ru% f ib r pu a, o r granu la ti on t i s t ue n Ho we ve r, c i r rho ti c 
livery may at any time become temporarily congested, 
The: "new connective tissue be arranged in various ways but 
^iii ?~ekes no practical difference* 
j'ome cases^ the new connective tissue will be arranged around 
groups of aoina nd the liver will looh nodular, 
other casethe connective tissue will surround a single 
^•inus and the nodules will be small, 
oomective tissue may be produced diffusely and extend along 
^he capillaries between the hepatic cells,. This form is the 
It1 
other casethe connective tissue will be disposed as bands 
^apta which will divide the liver up into lobules. This is 
®W:Lon with syphilitic cirrhosis, 
production of new connective tissue does not constitute the 
47 whole of the lesion although it is the necessary and. essential 
part* The hepatic cells are changed* They may a trophy,become 
fatty, or disappear* This will be attended by marked changes in 
the function of the liver* 
The new tIve tissue obliterates the small bile duets and 
smr. 11 branches of the portal vein* The obliteration of the small 
branches of -the portal vein^after a while,produces serious changes 
in the circulation through the liver and causes venous congestion 
of all the abdominal viscera* 
Cbliteratian of the smaller bile ducts interfere? with the pro- 
duction. of bile which may become very small .indeed* 
With the^e changes in the substance of the liver, there are some?* 
times changes in its gross appearance and size* In some eases, 
although the r.irnhoUc process be well developed, the sixe of the 
liver will changed* These livers may, ho we ver, be increased 
in weigh > .These are not at all uncommon,especially in the early 
sieges of the disease* 
When the disease is further advanced, the liver usually presents 
changes in size* In many cases^ the size of the liver will be 
much, diminished* Its surface may remin smooth or may become 
nndular9 
48 In other eases, the liver may become very large and its surface 
remain smooth or may become nodular. 
When cirrhosis has lasted for any length of tima,we regularly 
have secondary changes due tn the difficulty the blood has in 
passing t'"pugh the liver. The spleen will become large.,bard, J ,7^' 
&nd congested* The mucous membrane of the stomach will be con* 
| Bested and will be the seat of a chronic catarrhal inflammation, 
or blood nay escape into the stomach and be vomited. There may 
^e congestion and catarrhal inflammation of the small intestine. 
The congestion of the peritoneum leads to effusion of serum 
^d this serum accumulates in the peritoneal cavity, asci tea* 
- ETIOLOGY,- 
The disease belongs especially to adult life,, earl v or late; 
Gaeastonally, it is found in children and,even,in= , . 
infants. The number of cases found in children increases from 
. 3*9ar to year. 
in the production of cirrhosis, there are two causes that are 
^peci^lly efficient* These are habitual in temperen.ee, kep t up 
xor many years.,and constitutional syphilis. If,as in some persons, 
have both, the conditions for the development of cirrhosis are 
e*oeedingly favorable. Patients frequently have cirrhosis without 
49 any appreciable cause. 
- symptoms. - 
The symptoms beem tn depend upon three conditions. 
- 1 - Sore of the symptoms depend upon disturbance of the function 
of the liverjespeclally to the fact that the liver does not 
produce enough rile. Soothe patient will lese fle«h and strength 
and will become anaemic:will develop constipation and flatulence: 
and he may develop the cerebral symptoms due to the non-perform > 
irance of chemical changes in the bl< od as it pauses through the 
liver. 
- 2-Other symptoms are due to the difficulty that the blood 
has in passing through the liver. The patient will have peri ton-* 
cal dropsy and chronic peritonitis may be developed. Me will 
have disturbances of the s tomaoh, chronic catarrhal gastritis 
or he may vomit blood in small quantity or in large quantities 
at long intervals' and he may even bleed to death in half an 
hour. 
The inflamration of the small intestine may extend to the dvoderi^ 
and bile duct and the patient will have severe obstructive 
jaundice.. The inf larva ti on of the rest of the intestine inter- 
feres with the nutrition. The enlargement of the spleen does 
not seem to do much harm It is useful as a physical sign and 
it may possibly assist in causing the anaemia, l- 
50 --3-Same of the caeea, especially those with large livers,will 
have a severe and fatal form of jaundice which is hard to account 
for# It is not obstructive and we can find no mechanical cause 
for its occurrence# It is regularly fatal. 
-PHYSICAL SIGNS.- 
These depend upon the sixe of the /Liver and spleen and the 
presence of fluid in the abdominal cavity. 
The presence of fluid,we determine by percussion or by tapping 
the abdomen with the finger so as to get the wave of fluid, in 
the same we(y that you do when detecting an abbess. 
The of the liver and spleen,you make out by palpation and 
Percussion. 
- Associated Les ions# - 
ft 1ft Important to remember that this disease Is frequently 
^np Heated by diseases In other parts. The patients often have 
^xwio ffuse nephrltfa,endocarditis,endarteritifSand emphysema* 
,hc probability of the coexistence of these lesions should never 
e lost sight of# 
T1 -CLINIHAL HISTORY.- 
^clinical history varies greatly. The patients develop marked 
iferenaee a« to how early they develop syrjptomB. 
51 Soils patients have the disease for months or years with no sym^to^ 
at all. The patient dies of some other disease and it is only 
at the autopsy that the disease is made ou u 
.In other easea, the symptoms may appear very early while the 
anatomical changes are only beginning tn be developed. 
When the symptoms have made their appearance,you must distinguish 
between those that are developed early in t'-.e disease and those 
that are developed late in the disease. The later symptoms, you 
see in dispensary practieej the earlier symptoms,ynu see in pri- 
vate practice. This is very important. 
- The. Earlier 8 yep-toms. - 
Now^you must not expect to find dropsy or changes in the size 
of the liver nor, with any regularity,a change in the size of the 
spleen. So, there are no physical signs* The symptoms are only 
rational and depend upon two conditions. These are disturbance 
of the function of the liver and- Vie chronic gastritis* These 
are all and, yet,if the cirrhosis be left to itself, it may go on 
and prove fatal. There is one other symptom that may appear 
early. This is vomiting cf blood* The patient may either vomit 
blood repeatedly Ln small quantities or at longer interval# in 
considerable quantity* 
52 S^you have tn attend to the synftoms and history an carefully 
a$ passible or you may mistake the cirrhosis for gastritis 
or functional disease of the liver. 
- Symptoms of the Later Stages.- 
The symptoms of the later stages are much more decided than 
th©»e of -the early stages. As a rule they are very clear but 
the patients differ as to which synjptom they will particularly 
^1'-la some sases^dropsy in the legs nr elsewhere will be 
t^e prominent symptom and there will be changes in the size of 
the liver and spleen. These will be all the vyvftdms. 
--in these patient^ there trill be no dropsy but the infaired 
Nutrition will be the marked symptom. 
3Those will develop both dropsy and the inpaired nutrition. 
4--xn these case a, bleeding from the stomach will be the prom- 
^ent symptom. There will be but little dropsy. 
$'-In treue^disturbances of the stomach will be the marked 
tom. There will ne no dropsy and no evidence of disturbance 
the function of the liver. 
These patients will develop the fatal form of jaundice. 
a^uxck of jaundice, the patient may have had 
the other syrptoms. When the jaundice has once begun. 
53 j t gets wox^e and worse. Prom a ligMt yellow,the skin changes 
Xc a brown or gx'een color. The jaundice never lets up. The patient 
rives the sjrf to^s of a bad jaundice. He loses flesh and strengths 
rirtur 'vn Of stomach are manifested and there is consti- 
patinAo Cerebral symptoms are manifested and the patient ales 
in extreme exhaustion. These Patients may previously have had 
the dropsy or the loss of nutrition or both the dropsy and the 
lots of nutrition. The yaundice is only additional. 
- PROGNOSIS.- 
The prognosis depends partly upon the degree of development that 
the disease has reached when you see the case. If you see the 
patient while the changes are in an early stage of development, 
the prognosis is often very good. The disease may stop at this 
Point and go no further,especially if the patient can be properly 
managed. When the disease is further advanced, the prognosis 
is not as good. When dropsy is developed, the rule is that the 
patient will gn on and get worse. The first attack of dropsy 
may go away but others will succeed it and the patient will 
finally die of the dxopsy. Some times,a patient will have consid- 
erable dropsy but it will go away and will not come back* 
54 Although the cirrhosis continue, the dropsy may not return. So, 
you must not give too had a prognosis in dropsical cases. 
As a rule*, the patients v/ith impaired nutrition do badly. If - 
changes in the nutrition be not very marked, the patient may 
imp rove: but, if these changes be very marked, the prognosis will 
be bad. 
Wen the patient vomits blood in small quantity, the ease is not 
warily serious but the large haemorrhages are very dangerous. 
Th & patient may bleed to death from many large haeworrhages 
even from one large haemorrhage. 
^if wo consider all the oases of cirrhosis together, the prog- 
is bad. When you see a case with dropsy,do not be satis- 
until you have found out how much the nutrition is impaired, for^ 
' patient be still well nourished,his chanees of recovery 
T1 be much better than if he were not. The extent to which 
e nutrition is impaired is very inportant indeed. 
- TREATMENT. - 
K$t the best re suite in the early stages of the disease. 
-Treatment of the Early Stages.- 
treatment is very much hygienic* The regulation of the mode 
life is of the greatest importance. If the patient be interperata^ 
55 he must stop the use of alcohol altogether. If the patient have 
constitutional syphilis,it should be treated and it may be proper 
to treat the patient for syphilis although the liver lesion, be 
the only evidence of its existence. The patient must give up 
the use of tobacco for tobacco interferes with the functions 
of the liver. 
You must find out what functional disease of the liver the patient 
has. If the liver do not produce enough bile,give shnlagogues. 
If the patient be constipated, treat the cons tipationn 
More important than anything else,is the regulation of 
the diet and of the mode of life. The diet should consist of 
meat, fresh fruits^and fresh vegi tables. Out-of-door exercise 
is absolutely necessary and the more the patient can have,the 
better it will be for him. 
Your success in treating these cases will depend largely upon 
the willingness of the patient to live in this manner. If he 
will only do so,all the symptoms will often permanentlj^dhsappear 
- Treatment of the Later Stages.- 
The treatment of the later stages of the disease is not as 
satisfactory. 
56 We will consider tibe treatment of the dropsy# You must first 
^otiee how marked the dropsy is. If the patient have fluid in 
the abdominal cavity and if ynu want to get rid of it, it is 
Evident that the fluid must be taken up by the lymphatics of the 
abdomen. Now,if these lymphatics be compressed, they will nr.t 
take up the fluid. So, if the fluid be present in sufficient 
quantity to distend the abdominal wall and compress the lymphatics-, 
^■t will evidently be <uite useless to give diuretics or cathar- 
■tiey or |(0 Kweat the patient. In these cases,all you can do 
tap the abdomen and draw off the larger part of the 
•^luid. The best way to tap the abdomen is with a trocar and 
As the fluid runs out, compress the abdomen with a ban- 
^Be and,if the heart become rapid and feeble,ynu will have to 
^ive stimulants. Is a rule there is no danger attending this 
deration. There is a question as tn whether or not it is proper 
, leave a drainage tube in the wound. If you think that the 
Client is likely to get well,I do not think it is wise to keep 
drainage. No matter how careful you may be with* your anti- 
tic a, ynu run the risk of exciting peritonitis for these patients 
c^e very ready to develop peritonitis. If ynu have a patient 
^ho is in the last stages of the disease and in whom the dropsy 
57 and Impaired nutrition are very marked,I think there often is> 
an advantage in leaving In. a rubber drainage tube. 
When you have drawn c*f the fluid,If you do nothing more,,it 
will,as a rul e,return. This rule is not absolute* Now,a] though 
thox*? Is some fluid in. the abdominal cavity, Here is not enough r 
to compress the lymphatics and they should help take up the flui^ 
So,sweat the patient and give cathartics and diuretics. Tou may , 
do this without tapping toe abdomen if the fluid be present in 
quantity net sufficient to compress the lymphatics. Generally 
spe-kirg, : ' idney^ afford the best channel by which to get 
rid of the fluid. The skin is ijct of much value in this respect 
for you cannot get rid of enough fluid by sweating the patient- 
If you try purging, give hydro gogue cathartics* Purging answers 
fairly well in some cases but the trouble is that you cannot 
keep on purging a nan day after day. The kidneys can be made to- 
excrete an Increased quantity of water for a considerable time. 
Give dV reties. First try sc.diur chloride in ten grain capsules. 
The pttient has to take fro^ sixty to one hundred grains of this 
dr^ during tie twenty four hours but this large quantity 
well born* Caffeine is good. Give it in do sea of gr*J- 
gr*il^ Vree or four times a day. In other oas^j>,you will do 
very nicely wltn pills containing digltalis,squill,and calomel. 
Other eases will do well with acetate of potash. 
58 You must always measure the quantity of drink and the quantity 
of urine for,no matter how much urine the patient may pass,if 
the quantity of drink exceed the quantity of urine, he will no t < 
Set rid of. the dropsy. 
The patients in whom the loss of nutrition Is marked are hard 
to treat* Feed them with articles of diet that do not require 
hlle for their digestion* As a Tula, these patients dn badly, 
the patient vomit blood in considerable quantity,you must do 
Sometiling to stop the haemorrhage and tn prevent its recurrence, 
these oases,It is difficult tn tell how efficient our rem- 
9Qles are for many of the haemorrhages will stop of their own 
Stilly it i3 not possible to stand idly by when a pa- 
^Qnt is bi'inglng up bloqd by Vie half pint* Try tn keep him quiet, 
hypodermic injections of morphine and apply cold tn the 
®S^on of the stomach* In the use of drugs internally,you are 
^^ered by the v wiling* Nitrate of silver in pill form does 
betimes stay down* Give gr. 1,4 every fifteen minutes till the 
^!^nt shall have taken gr*j-grs.ij. The other drugs that are 
are argot and gallic acii but they are of less service 
the nitrate of silver for they do not stay down. After the 
^^edlng shall have stopped-,ynu may continue the pills of nitrate 
silver or you may give ergot and gallic acid. This seems tn 
59 he v? best we can do to stop the haemorrhages 
To ' Tnve^t the recurrence of the haemorrhages,1t io difficult 
to y <ra t to do for the bleeding is due to congestion of the- 
5;u'i3 .. Apparent*1^ the best tiling to do is to keep +he patient 
qui'&t -cr a considerable vimo,keep him on fluid diet^and give 
drugs for the gastritis* Then, treat the gastritis in the ordinal?' 
way* 
The fatal jaundice seems tc be beyond our control* V/e do not 
know its cause and we do not know any remedy* 
60 - SLTPmATIVE HEPATITIS* tR ABCESS tF THE LIVl'K,- 
^ese abcesoes may be developed in several ways. 
^1*-As before statedjabcess of the liver may follow inflammation 
the bile ducts. 
^2- Thrombosis of the portal vein and inflammation of its' 
inches may be followed by abcess of the liver. 
$-Patients suffering from pyaemia or septicaemia may have 
e^ollo abqeBBes in the liver. These abcesses are generally 
small size. 
-Abe^ss of the liver may be idiopathic and it is of these 
^lopathio abcesses that I wish to speak. They are the most 
^Pprtant and' they are often called 'tropical1 abbesses. 
A 'PATHOLOGY OF IDIOPATHIC ABCESS OF THE LIVER.- 
s U is but one abcess and this abcess will be of 
little size. Occasionally, there will be more than one abcess 
irvhen tills is the casa, they will all present the same char- 
^'ter. 
cases.) these abcesses will look just like an ordinary 
In°eBS* T11is form is* perhap a, the best- 
ease a, the cavity of the abcesc will not look like that 
an ordinary abcess. The walls will be rugged* irregular and 
61 neorotic# In the cavity there will be fragments of dead, liver 
tissue and a thin fluid not like pus* The fluid will be stained 
iwith blood. The cavl ty will also contain red corpuscles,pus 
cella,and broken down granular matter# These so-called abbesses 
are much worse than those first described# 
•-5-In other oases,a considerable portion of the liver,as large 
as your fist or larger will be ehanged in. appearance. It 'will i._ 
be yellow and of an abnormal consistency and,here and there^ / 
will be sma»l aboesses containing pus. This form is the worst. 
These are the three anatomical characters that aboess of tlie 
liver may present and I ask you to remember them for they are 
of great importance In the treatment* 
These accesses "ay be situated In any part of the liver# When 
near the surface, they set up adhesive inflammation with, the pro- 
duction of fibrin and the liver will become adherent to the 
surrounding parts. If left to themselves, they increase i $ise 
and reach the surface of Ue liver which they may perforate 
by a large or small opening Thus, the abeess may perforate the 
diaphragm and lung,and,before doing so,it will often set up a 
pleurisy. 
62 It may perforate the stomachy intestine, peri toneum, pericardium, 
Pelvis of the right kidney,or the anterior abdominal wall. 
- ETIOLOGY,- 
The etiology of this disease is somewhat obscure. Climate exer- 
g1$ob same influence upon 1t, Abcess of the liver is more common 
tropical countries,, ye t, i t does oeeur in temperate climates 
it occurs more frequently in some temperate countries than 
others® In New Yorfcjit is comparatively common and it eonsti- 
one of our regular diseases. In some temperate countries, 
is unknown. 
Abeesg of the liver seems to have some tiling to do with colitis./ 
t was at one time supposed that the patient first had dysentery 
theix,-the products of this inflammation were carried by the 
Fertal vein to the liver and,, thera, se t up abcess. But,it was 
otnd that mny patients with access of the liver did not have 
^e'*tery and that many patients with dysentery did not have 
liver, Ye t, the prevalence of the two diseases in 
Se.no countries wcvld make it impossible to say that they 
j Nothing to do with one another. I think that we should 
$ *wo diseases not as depending the one on the 
but as bet* due to the same cause * that both are the result 
63 of infectious inflammation which is characterised by the presence 
of bacteria and,in both diseases,it is evident that the bacteria 
are those that cause the death of tissue., fox\ in both diseases, 
we have death of tissue. 
- SYMPTOMS, - 
The symptoms of the disease are much more marked when it occurs 
In tropical climates than when it occurs in New York. 
When the disease occurs in tropical countries or when the syr^- 
toirs are well narked, the symptoms are the following. . z 
- 1-The patient first has one or more well-marked ehills. 
These are repeated throughout the disease. 
- 2-There will be a fever which may be continuous, rent ttent> 
or intermittent* It is often accom^panied by sweating* 
I- F-Pain is present over the liver. It is usually se^re. 
- 4-Jaundice is not constant and is not marked. 
--E- Vomiting is present in many cases. 
- 6 - According to the condition of the colon, there will or will 
nn* be dysentery. 
--7-If the abcess extend to the surface of the liv«r^ there will 
bo a localized nr general peritonitis. This cay be accompanied 
64 by the pre Bence of considerable fluid in the abdominal cavity* 
^luid In the abdominal cavity may be present without peritonitis* 
When this is the case, the peritoneal dropsy is due to obstruction^ 
tes. 
^3-The liver is tender* ' 
^9--Ay a Tula, the ^pleen is not much enlarged* 
^10-if -the ahoess perforate the anterior abdominal wall, the 
wi.ll escape externally. If it perforate into the peritoneum, 
will be shock,col lapse.,and peritonitis or death* If it 
$erforate the stomach, the patient will vomit the pusjif it 
yerf orate the Antes tine, the patient will pass pus with the stoolst 
^,lf it perforate the right kidney, there will be pus in the 
if the abcess pe rf ora te tlie pericardium, the shock will' 
$ sevei'e and,if the patient do not die,he will have a severe 
Picard1tis. 
these symptoms go on, the patient becomes worse and worse* 
left to 1 ts elf, the disease usually lasts several months. 
h®6 10SyS flesh and strength and,if he be not relieved,. 
^•11 die in -Che typhoid condition. 
1 - PHYSICAL SIGNS*- 2^. 
e liver will be increased in siae,downward,upward,nr to the 
65 xert,ac3ording to the position of the access* 
If the abeess approach the surface of the liver,you will get 
additional physical signs. If the abcess be situated in the lower 
part of the right lobe, tills lobe vvlll project for a considerable 
distance downwards in the abdominal cavity, Enlargement of the 
liver from abaess will not feel like an ordinary enlargement 
It will feci like an inflammatory enlargement o?f any kind in 
the abdominal cavity,soft and boggy. 
If the access be situated in the upper part of the right lob'a, 
the liver will push upwards and will encroach upon the pleural 
cavity# These are the most difficult cases to make wit There 
will be some Increase in liver dulness upwards^ao high as the 
upper part of the fourth rib. If the enlargement be considerable, 
you may get increase of liver dulness behind^not often as high 
as the spine nf the scapula. 
If the abcess be situated in the left lobe., the left lobe will 
descend in the abdominal cavity and you will get the signs of 
the inf laixiatory tu^r. 
66 ^When the Dlbease Oeeurs in New York or in other Temperate 
Regions*- 
oases, the symptoms are not as well marked* We are not 
MPt to see the patient until he has been sick for two or three 
eksn Tnen,we find•- 
'^l--the patient looks as though he were suffering from..some 
^x-ious disease* r * 
-There will be decided emaciation and prostration* 
The cheeks ^1x1 ae a little flushed* 
4* -Thr tongue will be coated and a little dry. 
The conjunctiva will be in je cried and the patient looks 
though he had tji'hold fever. 
inquire into the history of the ease txd you learn that the 
bad a alight ehill an4 a fever and, then,went to bed* 
^■^he lost apetitayfelt ylck^vomi ted, lost fleet and strength,' 
had. chills., fever, wui iwuivm ''b s will be about the history 
^c't you will get* You *nay get the hl^K*'v of a prevlnus dysentery 
condition in which you find the patient is MH nite* 
^en >ZG^ history like this la New York^^v naturally think 
fcver or u b£'d fcr:: of malarial fever* If you get 
1 ^tory of dyoentery>X*^ may think that the dysentery is still 
67 continuing. Then,you will examine the chest and you will get 
nothing except that over the lower part of the right pleural 
abvity,you may get dulness-You examine the abdomen and,if the 
aboess be situated deeply in the right loba,ynu will get no 
physl cal signs that are characteristic. You may get a little 
feeling of fulness and the patient may or may not complain of 
pain during the examination. When things go like thiH,you cannot, 
with ^ertainty,make the diagnosis. If ynv suspect abeesa^ynu 
wi 11 in tr oduc e an asp i ra to r ♦ Now., when you asp i ra to the he al thy 
liver,you will draw off blood that contains a good many white A 
cells. If you do strike an abcess,you will draw off pus or the 
fluid that I described in the pathology. But,if the abcess be 
of the form with much necrosis and no snf tening, you will get/' 
nn pus at all. 
If the abcess bo larger,the diagnosis will be aeasier,especially 
if the abeess bo situated in the lower part of the right or >' 
left lQba>for ynu wil] be able to feel the abcess. 
If,however,the abcess be situated in the upper .part of the right 
lobn,it will be very difficult tn make it nut even though it be 
large. In these casea,you will usually get dulness behind and 
68 you may suspect fluid In the pleural cavity. You will aspirate 
the chest and you may get fluid from the pleural cavity even 
Although -the patient have abcess of the liver,for such an aboeoo 
WH1 set up a pleurisy before perforating the diaphragm* Now, 
are you to distinguish between a pleurisy with. abcess 
the liver ind pleurisy without abbess of the liver? In the 
two cases,there is a difference in the feeling of resistances 
when ynu percuss the wall of the chests This is about all I 
tell you in regard to the differentiation. 
%he early stages of the disease, the diagnosis is very 
*ffloult and,until you can feel the abcess,you must try to 
it out by exclusion. 
; - TREATMENT. - 
you see the case early and if you are able to make the dlag* 
°Gia at that tine-,which is not often done he re, yon may use 
treatment but, remember, that the inflamnation is not a 
forward suppuration,for there is necrosis. Still, the\ 
you *un do to treat the inflamed part: apply leeches 
K (!^ed by continuous cold or heat:purge the patient and put 
to bed cn fluid diet. 
tropical physicians give large doses of ipecac,grs.xx~grc.xxx 
69 ..the at firtit promise well,it may turn out badly from a second 
■ aisess situated deepei' in the livei% You will find this second 
abses^ at the autopsy* 
If the patient suffer from one of the neerntic forms, the prng~ 
nosis will be much worse whether you can open the abcess or not* 
The prognosis will be particularly bad in those eases with much 
necrosis,and but little softening* I have never seen one of 
these cases recover al though the patient may live a long time, 
months and years* 
70 introduce a ueea±e in order to find -the exact position of the 
e^ess and, then, using the needle as a guide,, make a free Incision 
w$th antiseptic precautions* In doing this operation, there is 
°he mistake that it is easy to make, At the time when you open 
the 7abcess? the tumor is large and you are ap t to forget that the 
plural limit of the liver is. the free bordei% of the 1'ibs and 
Wit,after you have taken off' some livex1 will retract* 
your drainage tube at the most dependant portion of' the. 
Mver* ; • 
the aboess be situated in the upper part of the liver,you 
^11 have to operate through the intercostal spaces and,perhaps, 
through the pleura* Whether or not you have to cut into the 
Meural cavity, will depend upon the extent of the 
Weurisy* If the pleurisy have been ex tensive,adhesions will 
been formed between the two layers of the pleura and these 
^wesions will shut off the pleural cavity* tpen the chest at 
side and go through the diaphragm and liver. If no adhesions 
haye been formed between the costal and pulmonary pleurae, you 
have to open trie pleural cavity* 
the abbess be single and if you can once get an opening made, 
prognosis will be oosparatiyely ,good< Some times, al though 
71 .the oa&e at flrnt promise welltit may turn out badly from a seeoi 
-.aims situated deeper in the liver, You will find this seoond 
at the autopsy* 
If the patient suffer from one of the necmtic forms* the prog~ 
nnsie will be much worse whether you ean open the abeess nr noh 
The prognosis will be particularly bad in those eases with much 
neerosls-and but little softening® I have never seen one of 
these oases recover although the patient may live a long time, 
Months and years. 
72 - FATTY LIVER.- 
^ls is not an inflammatory condition. The liver sells are in* 
titrated with fat. Sarthe lesion is very simple* The fat is 
the form of globules. In extreme eases, the fat is present 
great quantity and does much harm by replacing the liver tissue. 
find this disease in all degrees c-f development. A moderate 
^gree of fatty degeneration of the liver is hardly to be e^n* 
^lered as a disease. and you will find it after death in most 
filthy livers When the lesion is well advanced,it may constitute 
^o a t y e ri o u s d 1 s e a s e, 
gross appearance of the liver varies with the degree of in- 
^Xtration. If the lesion be well advanced, the liver will be 
ihex^a^ed in size and this increase will be symmetrical. The liver. 
become harder or softer than normal. The color of the liver 
^11 be changed, it will contain less blood and the presence of 
■^t will make it yellow. It is possible for a temporary eon- 
^e^tion to obscure this yellow color. 
.Ranges niay be found in the larger bile ducts and in the gall 
*Mdera There may be a catarrhal inflammation of the mucous 
. $f these two structures and tills may result in the 
of calculi. The smaller bile ducts and the blood vessels 
hn.dex'-go no changes. 
73 -- ETIOLOGY. - 
The disease is very common. ' It is found at all ages. It 
is more wwm in women than in men and it is especially somaon 
in women that are alcoholic. Patients- who suffer from phthisis 
often have fatty liver. The $hai*aster of the food and the mode 
of life have a great deal to do with its produetion* It is mst 
common among people who take but little exercise and drink much 
wine or beer. In women,it is most own among those of the upper 
classes and among those whor, although they do not belong tn the 
upper classes.,live in a luxurious manner ,,I mean prostitutes. 
~ SYMPTOMS. - 
The symptom vary considerably. Many of the cases give only the 
symptoms of functional disease of the liver with the additional 
physical signs due to its enlargement. 
The patient will become fat but his muscles will become soft and 
flabby and he will become anaemic in spite of his fat. He will 
complain of lassitude and will be indisposed to exertion. He 
will have abnormal sensations of heat and cold and pains in 
various parts of the body. The nervous phenomena will be marked: 
the patient will become hysterical. The stomach is usually dis- 
turbed. The patient may have a good appetite but the appetite 
is generally capricious. There may be nausea and occasional 
vomiting. The patient may vomit small quantities of blood and, 
with the anaemia,you may suspect cancer or ulcer of the stomach 
but?as a rula, the patient does not vomit much blood* 
74 - PHYSICAL SIGNS* - , . 
The is increased in si?e and is enlarged in all dxrec M-cnSe 
the surface 1® Smooth and there is no enlargement of th® spleen* 
*hese tw© paints .distinguish it from cirrhosis. 
-PROGNOSI&,- 
when the disease is not too far advanced,it is amenable to treat* 
4. 
'"i i.-* ., 
x - TREATMENT* - 
^nage the mode-of life. Regulate th© food* Cut off the articles 
$$ > food that contain fat and starch* Generally, the patients ,Z^ 
better off without alcohol in any shape but se^e patients 
better with a. little alcohol. When the anaemia is marked, 
tron« th® bowels be constipated,give laxatives. If the 
^Hent have diarrhoea,rely upon €ne character of the food to 
it* pati^Ut jpst have exercise. If the general health 
*till fairly good,the patient can take exercise himself. . 
ins patient be a women*make her walk or ride horse back. 
If-" ? 
disease be further advanced and the patient be too feeble 
bet ahn^itjemploy massage and passive motion and,after a while, 
'^111 be able to get him out of doors and make him take ex* 
75 The less attention you pay tn the hysteria, the better# If you 
give the bromides and other drugs, you are only apt to make it 
worse* 
Some of the patients do not apply for treatment till the disease 
is far advanced or treatment may not have availed and the disease 
has continued# The liver becomes enormously enlarged# It say 
weigh ten nr twelve pounds. These patients have the same symptoms 
as those al ready described but the anaemia and loss of strength 
are more decided and?finally, the patient will be oonfined to the 
house and$ even th bed* Now,the disturbances of the stomach. and 
bowels become wrse* There is no appetite* The patient may be- 
come a little jaundiced and he looks very much as though he had 
cancer of the liver* The nausea and vomiting are present* p* 
The jaundice makes the patient appear as though he had the can" 
cercus cachexia* The lesion is now really as bad as cancer; it 
it fatal* Fortunately, these eases are not common,but you should 
remember that if the disease be not treated^!t may go on and be 
ft tai. 
The tre?z.tment of these severe eases is the same as that already 
described but it is not likely tn be of great service* 
76 - COLLIGATIONS. - 
1Patients who suffer fam fatty liver are very liable to 
develop acute gastr&«duodenitis with jaundice and these attacks 
of jamdiee are very serious* The feve repros traticm? and cerebral 
s.y^tnms are meh more marked 'than in ordinary eases of jaundice 
and the patient frequently dies* 
'•-2-The patients may behave like those with cirrhosis* They 
way develop the fatal jaundice without gastro^duadenitig* ihi^ 
jaundice looks as though it were obstructive but?after death^ 
T-ve can find no obstruction* When it o^ura, the patient dies In 
the same way that he does when the jaundice is developed with 
cirrhosis* I do not know the cause of this jaundice but it i& 
hnt so very uncommon* 
77 The portal vein and its larger branches may become diseasei* 
Vie may have: « 
- 1 - Thrombosis without inf lairmat ion. 
- 2 - Thrombosis, vi th inf1ammatinn. 
These two conditions behave very differently® 
- 1-THROMBOSIS WITHOUT INFLAMMATION.- 
The thrombus may be in the main trunk of the portal vein or in 
its larger branches* The vein is partly or completely filled 
with a clot of blood which becomes decolorized,firm,and adherent 
to the wall of the vein® This will be the only change but the 
passage of blnod will be more or less completely interfered with* 
- ETIOLOGY. - " 
In some eases., the disease will follow cirrhosis: in others,a 
chronic peritonitis; in others,a severe injuryjin other cases,, 
tumors of the abdomen seem to cause it by pressure on the vein* 
and,in other casesrtwe can discover no cause for the disease. 
- SYMPTOMS. - 
We have first the history of the previous disease or of an injury* 
Then,when the thrombosis is developed, the first and most prom- 
inent symptom is apt to be the rapid development of ascites,due 
to obstruct! on* 
78 This accumulation, of fluid is a.little different from that of 
©irrhnsis. It is produced much more rapidly. The distension of 
the abdomen is very marked and,if the abdomen be tapped,it will 
fill up again© 
^2 -The spleen is enlarged. \ 
" 3-The patient vomits blnod and passes blood with-the stools. 
4--The urine is diminished. ' . . 
' 5--The general health suffers tn some extent. 
-Fever is not a regular, symptom and there are no other 
"Igns o< inflammation* 
^7- There is great prostration due to the loss of blood and 
^erum. 
- PROGNOSIS,- 
The eases do not last long. If the obstruction be complete, the 
save may terminate in a few days. If the obstruction be income 
P-ete3the patient may live for months and he may even recover. 
$o?in some eases., the symptoms go on to death: in others, the symp^ 
toms will not be sn marked and, after weeks or months, the patient 
^y improve nr may even recover; in other cases, the improvement 
on to a certain point,even to recovery, then,in a few weeks, 
the symptoms return&these eases are difficult to understand. 
79 - TREATMENT. - 
The treatment is palliative. We have no knowledge of any treatment 
that will cause the disappearance of a thrombus. Alleviate the 
symptoms and try to keep the patient alive until'the circulation 
has had time to re-establish itself and,as before stated, this 
happy result does sometimes take place. 
Treat the dropsy and the only satisfactory way of doing this 
is to tap the abdomen and you may have to perform this operation 
many times. Diuretics and cathartics are not of much use. In 
addition to this,all we can do is tn nurse and feed the patient./""' 
- 2- THROMBOSIS WITH INFLAMMATION. - 
In this form of the disease, the changes in the wall of the vein 
are quite as decided as those in its cavity» The lesion may be 
in the main trunk or in 'one of the branches. The thrombus is 
not firm but is soft,red,yellow,or. white. It is easily broken 
dnm and the fragments can easily pass into -the veins in the liver* 
These fragments are infectious in character and,when they become 
lodged in the liver, they will produce little patches of inflam- 
mation and these patches of inflammation •may be surrounded 
by little zones of pus. The lesion beginning in the portal vein. 
80 or in Its branches^ it is apt to extend along the ©nurse of the 
Vein within the liver* Snon^it will extend to the surrounding 
Hver tissue* Sethis form of thrombosis is entirely different 
f ram ■ the o the r* 
- ETIOLOGY* - 
*he causes of this condition are(numerous* 
^1 -Actual injury of the portal vein* A fish 'bone or a pie^e 
of soft wire may pierce the intestine and transfix the vein* 
^2 - Inflammation of the umbilical cord* 
5™ Abbesses in any part of the abdominal cavity will be fnl~ 
lowed by thrombosis of the veins leading to the portal vein and, 
then, by inflammation and thrombosis of the portal vein® itself* - 
^hese abdominal abbesses are a very common ®ause ®f the disease, 
Particularly/ those abeesses about th© vermiform appendix* 
^4-Caleuli in the bile ducts* 
Ji-The disease ma> fallow severe injury over the upper part 
°f the abdomen* 
^6-The disease maybe idiopathic* These are - the cases that - ' 
^re apt io particularly attract your attention* 
-S YMPT'OMb • 
^he will vary as to the existence nr non-existenoe of 
81 a previous lesion* 
In some easeyou will get a previous history of abcess? in the 
abdomens thereafter its symptoms have lasted th edr time , the 3ymp^ 
toms of thrombosis will,come on* 
I If the ease be idiopathic the invasion maybe either gradual 
or sudden Xi the invasion be gradual,the patient will have for 
'several days a feeling of malaise and discomfort without pro« 
nouneed symptoms* |He will lose appetite he my have a feeling' 
of discomfort over the upper part of the abdomen,and he may wU 
If the invasion be suddenjit will be very sudden* In a few hours, 
: the patient will pass from perfect health into a serious illness 
When the disease is fairly established,the symptoms are pretty 
marked. 
'-1--Pain and tenderness over the liver* This is constant 
The pain makes its appearance at the out set of the disease and 
eentinues throughout* Sometim^cii a little be tier? some 
it is a little worse:but it is always severe and eentinu^usc 
As the disease goes on,the pain and tenderness may be rendered 
worse and maybe extended by the development of peritonitis* 
This is not uncommon. 
82 ^2~ The. liver will be increased in size* Of ten, this increase 
not very marked and it my only be evident by a feeling of 
fulness which resembles that produced by an abeess* In other 
bhe liver will extend below the free border of the ribs 
upward to the pleura* Stillsyou must not expect too large 
a liver© 
^3- -The spleen is often increased in size and it 
Ju often tender* Still,you must not expect it to* be too large* 
* ex-cuss for lu It will probably extend as far forward as the 
l ^ree border of the ribs* 
^4-jaundice is the rule* It is not always so very marked* 
xt is apparently obstructive and is due to complicating inflamma* 
iion of the larger bile ducts. 
Vomiting is not constant* '■ 
^6--There will be loss'-of appetite as with any inflammation. 
^7--Sone of the p&tidhts will vomit blood. . 
Disturbanees of the intestine are more common than those* 
the stomach. The patient is apt to have a diarrhoea which 
^y be profuse and he may pass blood. 
$-Fever lasts throughout the disease. It is rather irregular, 
height of the temperature is nnt necessarily a test of the 
83 the severity of the disease# The fever is often accompanied 
by sweating and is very much like the fever of ' ^yamla; 
•-10™Chills often occur early and they may be repeated/* They 
are like the ehills of pyaemia# 
- 11 -No* infrequently, there will be peritoneal dropsy but the 
ascites is not as constant as in thrombosis without inflammation# 
It may be absent and it is never very marked# 
- 12 - The peritonitis may become general and you will get the 
regular symptoms# 
--15^~The general condition of the patient is much changed# 
The patient is at once confined to bed and,from day to day, the 
prostration will become more marked. The tongue will become dry# 
The patient will pass into the typhoid state and will develop 
cerebral symptoms# When the delirium and stupor have once set in? 
they'are apt to continue till the close of the disease. 
The duration of the disease is about two weeks# Some patients 
only live a few days:others will live several weeks# 
The cases vary as to how .definite the symptoms are# In some 
eases,? the diagnosis is evident early in the disease# This is 
especially the case when the liver symptoms are well marked, 
when there are pain? tenderness,and jaundice. Other cases may be 
84 ^ore obscure, There may be no pain,tenderness,jaundice,or enlarge* 
^ent of the liver my be U trifling. In some of these eases, you 
cannot be <uite certain of^your diagnosis. After a few days 
^ave passed, you may feel certain & that the patient has some disease 
of this alass but you my not be able to say which It is. For 
instance,,you my not be able to say whether the disease may 
hot be malignant endocarditis or idiopathic pyaemia* 
-PROGNOSIS,- 
^he disease seems to be regularly fatal. 
- TREATMENT, - 
^Ut the patient to bed on fluid diet and apply continuous $old 
°ver the liver by means of the rubber coil. The cold will relieve 
the pain and tenderness and will make the patient more comfortably 
It will also relieve *the vomiting* 
85 These new grwths ar® for the part malignant. We t^l then 
all cancer for convenience. The minute MJde ture of th^se growths' 
differs especially when they are primary but, for alinieal pur« 
pese^it is not necessary to discriminate between them* 
- CMC® OF THE LIVER. ™ 
Cancer of the liver may occur either in the fo^n of nodules 
or as diffuse grwths replacing a considerable portion of the 
liver tissue. 
Seme timers the liver will remain of the normal size. Mere frequently, 
it Mil be increased in size and,of ten,very much increased in 
size. If Us growth be in Ue form of x?odule^ some of U^n will 
be near the surface:if the growth be diffuse, Ue liver will be 
smooth* The cancer my remain in Ue liver er may involve the 
gall bladder?bile duets,and portal vein,occluding its branches. 
The larger number are secondary. Most frequently, the priimary 
growth will be in the stomach but it may be anywise re, When the 
primary growth is so situated and of such size that we can 
readily make it out,we think of such a ease as cancer of the 1 
stomach or cancer of Ue breast and consider the liver turner 
as a secondary affair. 
- W GROWTHS OF WE LIVER. - 
86 primary growth may be so small as to escape observation. 
&na;in such a ease,we would -consider the liver tumor as primary 
&nd would speak of the disease as cancer of the liver. We may 
really have a primary <an®er of the liver. 
- sniPMMS. - 
symptoms are local and general. 
- LOCAL SYMPTOMS^ - 
^ese depend upon changes in the size and shape of the liver, 
^©y are most clearly marked when the liver is increased in 
i;n size and when its surface is nodular. Then, the liver will 
Project down into the abdominal cavity and,as you rub your fingers 
Qver the abdomen,you will be able to feel the nodules. This is 
Straight forward enough but,of course,this might be produced by 
Cirrhosis. If the liver be enlarged and the new growth diffused, 
.Hu will make out the increase in size of the liver but, as its 
BUrface remains smooth., you will not be able to tell whether 
liver my not be waxy, fa tty, or cirrhotic, If the growth be 
diffuse and if the liver be not increased in size,,we will get 
ho information from the liver. 
the new growth involve the branches of the portal vein, either 
them or projecting into their cavities! there will 
87 Abe ascites and ingestion of the abdominal viscera. It is not 
uncomon to find some peritonitis with eaneer rrf the liver This 
peritonitis is usually not of a very active character. It will 
be sub-acute nr chronic^ localized or general* The bile ducts 
will often become the seat of a catarrhal inflammation which 
will lead to obstructive jaundice, 
- GmBAL SYMPTOMS. - 
The general symptoms are much the same as those of a new growth 
anywhere. 
j-1-The 'patient will gradually lose flesh and strength and 
; will become anaemia 
| - -He will develop the cancerous cachexia. 
- 3™ He will lose appetite and' will often suffer from nausea 
; and vomiting. 
- 4a-Later, there maybe an irregular fever.- 
~ 5-- Later, the patient may develop cerebral symptoms. 
- COURSE.- 
As a rule,the disease belongs to people beyond forty years* 
This is of great help in making the diagnosis. 
- 1 - These patients complain first of derangements of digestion 
and they will give the symptoms of gastric dyspepsia and functional 
88 functional derangement nf the liver. The trouble is that these 
symptoms may follow symptoms of the same kind that have existed be* 
fore the development of the new growth, This often wakes the 
diagnosis very difficult for the patient may say that he has 
suffered from the disease for five or six years. Of course this 
Would be impossible if the patient had had cancer all the time, 
You will meet these cases over and. over again* Now,when the 
liver tumor is developed,these symptoms get worse very rapidly. 
The patient loses flesh and strength and becomes anaemic. He 
will become a little jaundiced,will develop ascites,and may 
have dropsy of the leg. If the liver be increased in size,you 
Will be able to make it out but,even now, the diagnosis is not ■ 
easy unless the liver be nodular. You will distinguish these 
eases from cirrhosis by the more rapid development of the symptom** 
and ( by the more rapid increase in size of the liver, If the 
liver be enlarged and smooth, you will distinguish tills disease 
from cirrhosis in the same way, the patient will get worse more 
rapidly when suffering from cancer* There may be a period of 
Weeks during which you will not be able to distinguish between 
the two diseases* 
^2-' These cases are more obscure* They begin in much the same 
89 way with th© symptoms ®f gastritis or derangement of the liver. 
The patient suffers from nausea, vomdting/f la tulenee,, pain after 
eatin^and vague pains over the abdomen and back. So, we cannot, 
say- that- localized pain is a symptom of malignant gx>wths of 
the' liver. The patient gradually loses flesh and strength but 
he does this pretty slowly. So, he will go on for wn ths, always 
getting a little worse. Th^n some cerebral systems.. The patient 
cannot attend to his work. Part of the time, he will be apathetic. 
.He. may develop a little dropsy. All this time, you will get no 
tumor. Yau may be-left in doubt for some time and you may continue 
/to think, that the patient only has gastritis or functional disease 
$f.the liver but^as time goes on^it becomes evident that some* 
thing more than this must be the matter with the patient. 
You may only make the diagnosis a few weeks before death 
dr yw may only make it at the autopsy. 
90 '-3-In these cases, the constitutional symptoms are even less 
decided. The cancer may be veil developed,the liver may be large 
and may even be nodular and, yet, you may be justified in saying 
that the patient has cirrhosis* These cases are not numerous. 
Yen had better disregard them and call them eases of cirrhosis., 
I have seen some of these eases which, al though I ire It sure . 
that they were cases of cancer,I called them cases of cirrhosis, 
for they did not give the symptoms of cancer of the liver, they 
gave the symptoms of cirrhosis. In these cases, the diagnosis was 
^ade at the autopsy. 
^4- When the growth early invades the portal vein,ascites 
Mil he the first marked symptom. This may be accompanied by some 
peritonitis and the fluid maybe due p<^rtly to the obstruction 
^.nd,partly, tn the peritonitis. These cases resemble cancer of the 
Peritoneum and tubercular peritonitis more than they resemble 
dancer of the liver,for the constitutional symptoms will not 
^e marked* 
- WHEN THE GROWTH BEGINS IN THE COMMON BILE DUCT.- 
Hie new growth begins in the common bile duct and it may remain 
there nr there may be a few scattered nodules in the liver. 
91 Sa, these are really cases of cancer of the common bile duet- 
The new growth begins in. the wall of the oiwn die due t near 
ithe point where the duet enters the duodenum./ery soon.it wiui 
surround the due t,«ons trio t the lumen,and obliterate arv .co 
the duct. As a rule, these;,cancers cause death before they -ach 
any great else. Sometimes,the cancer will extend to^he Pancreas 
or to -the adjacent lymphatic glands and. a tumor oi eonsid- abl 
else will be formed. This t^mor will be principally due to the 
secondary growths* The cancer int®ikfcres with the passage of 
bile and tKe hepatic due ts cystic duet, gall bladder, and the duets 
within the liver- will become dilated* 
! This disease also belongs to persons past forty years* 
; - Symptoms* - 
!■- Jaundice. - Al though the lesion, is slow in its development, 
the* jaundice will some on very quickly as if it were due to some 
new. condition* it will be very marked in a few hours and will 
be very, prone.unaed^indeed,.by the end of twenty four hours* 
- 2'-The.re may be severe pain referred to the region of the 
common bile duct. 
- There .may be nausea and vomiting* * 
All these Symptoms are developed suddenly* The combination, of 
92 j)f these' Mtympboms is exactly the same as the anmbination of 
the systems i 1 lary-ee 11 #; yet, the clinical picture often 
differs* In cancer of the bile duet, the pain is not as bad as 
in impaction of calculus? the vomiting is the same?the jaun* 
dice may be present in bo th, but it maybe absent in imp a© linn* 
At firsts the parent does not look very ill bui it dne^ not take 
long for him io gel and, apparently, he gets verse on amount 
of the jaundice* %he symptoms of complete obstructive jaundice 
continue^ The pigmentation gets deeper,the nausea and vomiting 
continue-, the cerebral symptoms became more marked,and the tongue 
becomes dry* The patient ' 'begins to pass into the typhoid 
state* Haemorrhages from the''skin, stomach,and intestine take 
place* in some cases there «rill be ascites. V/hai this has to do 
'vlth the diseasejis difficult to say* It is probably due to 
changes in the blood*Some times,the gull bladder becomes enlarged 
<uid it mayr form a tumor of considerable size. So, the patient 
gets vorse. He vill finally die in stupor,emaciation,and exhauc- 
tinn, the jaundice persisting* . , ? w 
-DUiUTION.- 
The duration of the disease is fm one tn three monthsand the 
disease may last longer* 
93 - PROGNOSIS* - 
The prognosis is entirely bad. The disease is- always fatal. . 
- TREATMENT. - 
The treatment consists in making the patient comfortable. The 
only point of practical importance is to make the diagnosis. 
At first, this is often impossible;but,as the disease goe^ on, 
the diagnosis becomes easier and easier. Cancer of -the common 
bile duet is not such an uncommon disease and you should always 
think of it when, you see a bad ease of jaundice* 
These are all the diseases of the liver that we will consider. 
94 - THE PERITONEUM.- 
- ACUTE GENERAL PERITONITIS.- 
This disease regularly follows one of two anatomical types. 
The inflammation may be . of the cellular variety or it may be 
accompanied with the production nf serum, fibrin, and pus. 
- The Cellular Variety.- 
We find more or less congestion. There is a growth of new endo- 
thelial cells which will cause the peritoneum to loch dull, 
Reddened,and even roughened. This congestion,the change in ap- 
pearance, a few adhesions,and distension of the intestines with 
Bas are all the changes that you will be able to see with the 
naked eye even in fatal cases. With the microscope,we see that 
tliere is a growth of new cells. This form of peritonitis is 
easy to overlook at the autopsy* 
This is the form of peritonitis that will be developed when an 
obsess is shut pp in any part nf the abdominal cavity. It is 
the form that the disease assumes when its course is rapid, 
"specially when puerperal. The patient recover or the disease 
^ay prove fatal or the acute form may be followed by a sub-acute 
nr ehroftic peritonitis and, then,we will find adhesions nf 
neo^ive tissue cells. 
95 This is the more common* After death, the intestines are regularly 
distended with gas*. The peritoneum may ar may not be congested, 
The surface is regularly coated with fibrin in small nr in ^reay 
quantity* The fibrin causes adhesions everywhere* With the fibrin, 
there will be mare or less pus* In the cavity of the pei^itoneum 
there will be varying quantities of serum. The serum may be thin 
and reddish-brown or it may contain pus and may look like pus* 
There will also be death and desquammation of the epithelial cells 
and the connective-tissue cells in the substance of the peritoneum 
will increase in size. In bad cases,the tissue of the peritoneum 
will be infiltrated with pus* 
This form may prove fatal or it may be succeeded by a chronic 
peritonitis and,,when it has become chronic,,it will go on more 
slowly* The patient may eltirely recover, The products of inflH>- 
mation may entirely disappear or connective-tissue adhesions may 
he left* 
- The Exudative Form.- 
- ETIOLOGY.- 
Either form of the disease may be produced by many causes. These 
are very numerous but the causation is always of practical 
importance. 
96 The causes are the following. 
- Wounds or contusions of the abdomen. 
^2- Wounds,ulcers,or new growths of the stomach, 
3_ Inflammation,incarceration,perforation,or strangulation 
of the intestine. 
***4-Inflamination of the vermiform appendix is a very common 
ftause. ' 
5 - pi Borders, inf laminations, and abeesses of the ovaries, fallo- 
pian tubes,and uterus. 
^6-Rupture or inflammation of the bladder arid kidneys." 
- 7 -* Abbesses and hydatids of the liver. Inflammation of the 
Ball bladder, bile. ducts,or portal vein. 
'-8-Similar changes in the pancreas oi* spleen^ 
9^- Suppurative inflammation of the pleura may extend through 
the diauhragnu. ' ...7, 
10 - - inflammation of the bones in the neighborhood of the 
Peritoneum. •, ■ ' 
11 - -It occurs as a complication in septicaemia, typhus fever, 
typhoid-fever, the, ^Mnthemta, and, in fact,in nearly all the 
infectious diseases. / 
:12 - .fee* least frequent caBes are the so-called -idiopathic 
97 Yet, they do undoubtedly occur. Sn,one of the first things tn think 
about is rhe enuse, 
Hany cases of general peritonitis are preceded hy localised 
peritonitis or by an inf 1 animation in some*part of the abdominal 
eavi ty* 
In all eases of pe ribon^tis, the re are two conditions that may 
give the stamp to the disease* On the one hand,direct injury 
or irrita^ion* on the other? the introduction of a special kind 
of bacteria* So? you often hnar of septic peritonitis and this 
18 a proper term if you clearly understand what it mean^- Zn 
the cellular variety,bacteria are least'likely to be present* 
They are ran st frequently present when there is pus. 
- SIMPS'Or'!S -. • 
Whatever be the cause or anatomical variety of the disease,there 
^-re a certain number of common, regular symptoms* 
1-Distension of the intestines,partidularly- the colon,with 
gas& This is apt to be an early symptom and it is very oommon.n 
The gas causes distension of $he abdomen* Generally speaking, 
this symptom belongs to a general peritonitis but this .rule has 
its exceptions and this is of importance in making the prognosis* 
You may have this symptom with localized peritonitis. 
98 ^2- Vomiting.- This symptom is very .common. It occurs at the 
invasion and continues throughout the disease* The patient 
vomit facet, a greenish fluid,a brownish fluid, or? even, faecal 
^tteis Vomiting of brownish fluid,greenish fluid,or of faecal 
^tier regularly marks a bad ease. A patient with peritonitis 
may net vomit at all. This is the exception and you must remem- 
ber it. 
3- As a rule, the patient is constipated as long as the irxflam* 
Nation lasts* This symptom used to be considered more constant 
than we-5at present,consider it. The rule is not absolute. The 
bowels may move every day and there may even be diarrhoea,. 
4- - - Pain and tende me s s are re gu la r symp toms. When the p e ri - 
Unitis is localized,the pain and tenderness usually correspond 
in position to the position of the peritonitis. When these sytnp* 
toms are present, they are generally well marked arid the patient 
"'ill complain of them very mush indeed. He will lie on his back, 
draw up his knees,breathe wiUi his chest,and,even if the bed 
clothes rub the abdomen,the pain will be increased. It is pos^ 
-ibis and,even,not uncommon to have a pad general peritonitis 
^■th no pain and tenderness at all. This,you can hardly believe, 
^en these symptoms are absent, the diagnosis is very trouble-some^ 
99 - 5~As a rule, there will be a fever but this fever is very 
irregular. In mny cases,it will be high at the oommeneement, 
IQ3-104-107 and will continue high throughout the disease. In 
other cases,the fever will run up and down in a most unreasonable 
manner. You may have a fatal peritonitis with no fever at all. 
will not believe until you see it: then,you will. 
- 6-Apparently, the pulse is always rapid and feeble. The more 
severe the inflammation,the<more rapid and feeble the pulse will 
be. J 
- 7~The breathing is often quite rapid and, often, it will be 
so rapid that your attention will be drawn t° the lungs,especially 
if there be no pain in the/abdomen. It seems to be largely due 
.to the tympanitis dis tension of the abdomen. 
- g-position of the ^patient is apt to be changed* While 
the inflammation is going on, the patient will lie flat on his 
back and you will have the greatest difficulty in getting him 
to change his position. Often,-the first indication of the sub- 
sidence of the inflammation will be that the patient will turn 
on his side. The patient will assume the dorsal position even X 
when there is no pain. 
'-The mental condition is a^t to remain very good. This is 
rather a characteristic sys&iom. 'In*other serious diseases. 
100 are apt to be cerebral symptoms. But^no matter how bad 
&e peritonitis.} the patient may even be cheerful and he may 
^yeivyoke. This is sometimes rather shocking. However, this symp- 
tom does not always exist:the patient may develop delirium alter- 
nating wi t^ s tupo r. 
-- IO -0e disease goes on, the patient is apt to lose flesh 
and strengfe. rapidly. The mouth and tongue become dry and this 
dryness seems to measure the intensity of the inflammatory process, 
ft has no definite relation to the height of the temperature. 
Wiese are the characteristic symptoms and the important point 
is that,while they ai*e all regular., to each one, there may be 
exceptions. When you see a patient- with no vomiting, no pain,no 
tenderness.}no. fever,and a good intellect and all you find is 
tympanitles and the patient on his back,you will realize how 
little there is about the disease that is definite. 
-- COURS®. -~~ 
^1 -When Due to Perforating U^eer of the Stomach. - This 
sause is. not un«ommnn. In some «ases, there will be a previous 
history of ulcer but you must remember that thei'e may be no symp- - 
toms of ulcer until the time of perforation. So,ln making the 
diagnosis^you must not exclude this cause from want of history. 
101 The Invasion is very sudden* The ulcer gives way and of 
the stomach contents escape into the ■ abdominal cavity. This 
is at once followed by shocks The degree of prostration varie/ 
but there is always more nr less collapse. Then? within a 
few hours-* the peritonitis will be developed. AX ft vs t5 It may' 
be localized or .it may 'be general almost from the start. Then? 
you will get the symptoms^ to a greater or less d.egree,of periton- 
itis# The patient &&y live one or two days or a week. If he live 
a week.* it my happen that the temperature will fall al though 
he is steadily getting worse. As a rule * the patient does not 
live mere than a week. It Is fatal. 
- 2-The uterus and its appendages furnish us with a good many 
eases of peritonitis. This sori of peritonitis may he either 
localised or general, The ovaries and fallopian tubes most freque^ 
ly eause it by rupture when they contain pus# This is one of the 
results of thwnle inflammation of the ovaries and fallopian 
Vibes# If such a. peritonitis be localized^!t will be confined 
the lower part of the abdcuninal cavity and the patient often 
recovers but she is apt to recover with adhesions and ooiie-etin^ 
of pus left behind and the^e products of inflammation -nay at any 
time become the seat of fr@sh4aeute peritonitis# fnis is true 
of all sorts of pelvic peritonitis in women. 
102 Any-operation on the uterus may set up a peritonitis,even Jie 
f@rel.ble dilatation of the cervix. The more clumsy attempts at 
abortion and the injection of irritating fluids into the uterus 
may set up peritonitis. In these eases^it is not easy to under* 
stand why the patient should develop peritonitis. You would 
naturally think that it would follow an inflammation of the uterus 
but many @f these patients have the peritonitis without inflam* 
mation of the uterus and. I a m at a loss to explain it. 
The puerperal state is a condition during which women are 
Very apt to have a localized or general peritonitis. In these 
easels the disease seems to be developed in many ways., 
- a - The patient has a normal labor and everything goes well 
f o r three o r f ouz' days: then* she has chi Ils s f eve r }102* 104, the fac e 
becomes anxioua,she vomits^and has considerable prostration. 
At this time,these eases do not look like peritonitis. There is 
hb great tendemess,no great twanities. Some of the patients 
will go on and get worse* The temperature will continue high: 
tympanities and tenderness will be developed; the prostration will 
become more marked* the tongue will become dry* and the ease will 
lock more and more like peritonitis. The issue is apt to be fatal. 
^Other eases will begin in the same way and will continue to give 
103 the same symptoms for twenty four or forty eight hours. Then, 
the patient will pass a piece pt decomposing placenta ox1 of de* 
Wnposlng blood <lot from the uterus and,within half an hour, 
all i&e systems will disappear. So, the first symptoms are due 
to -the presence hf a decomposing foreign body in the uterus and 
•this send! tian wan last for several days without the development 
of peritonitis but* if the foreign body be left there ton long, 
peritonitis will follow. ' 
- TREATHl;Nu\ - Provent the occurrence of peritonitis. If you see 
the patient before the peritonitis eommenee&jassist the uterus 
to expel the foreign body "by i irrigations of warm. water containing 
aarbnllo acid or corrosive sublimate. It nay suffice to wash out 
the vagina. 
♦•bw These eases are entirely different. At some time after child 
birth^any time within one er two weeks^ there will be an inflam* 
matt on of the inner surface of the uterus'with the production 
of pus and fibrin^ The fibrin may be s® plentiful as th form 
a false swmhrane* There is also a disposition to necrosis of 
tissue. In many eases> there will in addi tion be changes in the 
.wall of the uterus. The bihod will tnagulat^ in the uterine 
veins and thrombi of an infectious oharaa ter will be formed. 
104 Inf lamination may extend tn the. fallopian tubes and they 
*111 contain pus., Such an inflammation is serious without any 
f^ltonitis. Xt maybe fatal by itself.and the patient will die 
the so-called pyaemia condition. In other cases,periton! tis 
?^11 be added and it may be localized or general. This condition 
very serious and very difficult tn treat* We $an hardly say 
^t we know of any treatment for such a suppurative .me tri tic. 
best we can do is to wash out the p terns with antiseptic ■ 
^^Xutions and give opium in moderate doses but the cases are 
^^h more likely to do badly than tn do well. If peritonitis be 
^ded,employ the. regular treatment. 
G - There will be no inflammation of the cavity of the uterus 
, yg t ' 7 Sfjt re will be thrombi of an infectious character in the 
^ins. The on 1 y way tn - exp 1 a:j.n the se cases is that the bacteria 
"^ter through the uterus without causing inflammation of the 
The patient may do badly with nr without peritonitis. 
may die of pyaemia withnut any peritonitis at all 
- Idiopathic Peritonitis. - These cases are not at all 
°^mnn and we may fail in making the diagnosis from not being 
the Inok cut for them. If the ease be well marked, the patient 
have been in good health up to the time of the attack: then, 
some particularly day,apparently from nn cause at all^ the 
^ttent will develop the symptoms. In some cases, the invasion 
105 will be gradual and will last twenty-four hours:in ether cases, 
jt will be x4apid« 
The caw will begin with chills, mo re or less marked* With and 
succeeding the" chilis, there will be a fever which presents the 
same characters as in the trauma tie Cases. There Is vomiting^ 
especially at the commentement and this vomiting often coniinuex 
throughout the disease* The patient will first vomit then, 
a greenish or brcwniMh fluid or faecal Sohn* the patient 
feels very ill,goes to bed,lies on his hack,and developes tym- 
panitie^ pain, and tenderness. The prostration becomes more marked* 
the patient loses flesh and strength,gets sicker and sicker,passes 
more and more into the typhoid condition without cerebral 
symptoms, and is very apt to die® Whether or not it is possible 
fox* the patient to recover^! do not know. The well-marked eases 
not common and the only certain cases are those in which an 
autopsy is made^for a patient may have symptoms resembling those 
of pe'idtonltin,from some other disease. 
106 TREATMENT OF G.WEIUL P^ITONITIS?R^>RDLESS OF THE CAUSE.- 
treatment of general peritonitis is almost comprised in one 
^nrds This is opium. Give this drug,not by weight nr measure 
^t by the affect that it has on the patient. You must bring 
into a state of semi-narcosis,no matter how much you have 
,c give and this condition of semi-narcosis must be kept up 
long as the peritonitis is going on* You may give the opium 
any preparation and by any method that you choose? the only 
*&lng is that you must give enough. Begin by giving gr* j every 
hours and wateh the effect. If the patient is not- becoming 
^r»o ti zed, increase the dose even up to gr.vj-gr.vij every two 
<Gurso Then,you must keep the patient in semi-narco tism and-, to 
this-, you may give the opium at longer intervals. You must 
ulwayy watch the patient. The rule is not to let the breathing 
below ten or twelve and to keep it at sixteen. The patient 
t!^ould be lying quietly,with no pain,not asleep,looking and feeling 
nr table., and breathing sixteen times & minute. Of course, the 
^tient will sweat a-good deal. When the inflammation begins to 
Reside, the patient w£ll. not bear opium as well and you have 
^udually tn diminish the'dose. Apparently a man can bear more 
^Iut? when he has peritonitis than he can when he has any other 
^ease. 
107 In additicn?we place a great deal of reliance on the continuous 
application of sold tn the whole anterior surface of the abdomen* 
This is very eff latent* The way in whish you tapply the cold 
is a matter of convenienceo The min point is not to apply too 
intense cold but to apply it continuously day and night* The 
sold need not be very intense* There seems to be no advantage 
in using ice water; the water should not be nearly as sold as that* 
Use the rubber coil and keep it on by means of plasters and 
banuages* 
Nurse and f£ed the patient* The indication for the use of stim* 
ulants may some in but,really, this is about all there is tn the 
treatment* 
- TREA.WENT OF LOCALIZED PERITONITIS.- 
The indications are different. These patients do not bear opium 
Particularly wellfnot much better tharn persons in 
good health and they do not appear to be benefitied by semi* 
narcotism. We do give opium but?simply, to control the pain and 
restlessness. The local treatment is the most important* Some 
are better off for leeches,especially in the early part of the 
disease. Some do well with poultices:others>,with cold* I can 
give you no rule as to which do better with cold and which with 
108 applications# The larger number do better with continuous 
$eld. You must'keep the patient as quiet as possible The patient 
Mil often try to get out of bed to urinate nr to defecate and 
• he may v even want to go out of the house and do some work. 
•Of course, you must ant let him do this. 
^hen a localized peritonitis, causes the formation of abcess, 
the .management qf the case is the same as that of an abcess in 
part of the body# Aspirate and draw off the pus or,if this 
do not -cause relief,cut down on the abcess with antiseptic 
Precautions. 
■ 
109 This disease seems to come properly under the domain of both 
medicine and surgery$ for? some Hmos, the physiclan?at other times? 
the surgeon is called upon to treat it* The disease is very eo®« 
mon and it is very dangerous Of course?I speak of it more 
us a medical disease than as a surgical 
tone rally? the vermiform appendix is situated entirely behind 
the caput eoli and is really very much shut, off from the abdomino 
uX cavity* I£ it become inflamed,the inflammation may remain 
localized cor the products of inf lamina tin a will run.up behind the 
caput eoli and they may even run up? behind the peritoneum. as 
high as the pleural cavity* The products of inftion win }" 
be shut off behind or to the right of the caput coll.. 
The appendix my drop domi into the abdominal cavity and into 
the pelvis. It will be free and not shut nff* Now^as toon an it 
becomes inflamed?adhesions will b^ formed and these adhesions 
will mat the intestines together in the right part of the abdom* 
inal cavity and, thuu?form a tumor* 
. INFORMATION 0^ THE VFH^IFOR^ APPENDIX* - 
110 It may happen that no adhesions will be formed and the inflamed 
appendix will not be abut in but will /Set up a general peritonitis 
and no localized peritonitis. 
The inflammatory process is accompanied by the production of 
pus and fibrin and,of ten, With the death of tissue. If we only 
have pus and fibrin,/there will be no perforation of the appendix. 
The appendix will be enlarged,stiff,and erect:it will be infil- 
trated with pus:and it will be coated with fibrin. If the inflam-* 
nation be attended with the death of tissue-, the appendix will 
be.perforated by a large or small opening and its contents may 
enter the abdominal cavity# Sa, the appendix may act as an irri- 
tant in one of two ways: either as an inflamed foreign body,or 
by becoming perforated. In many cases,there will be a foreign 
body in the appendix,hardened faecal matter,a seed,a stone,or 
a piece of o-yster shell. 
There will also be inflammatory changes in the surrounding parts. 
If the appendix be situated behind the colon, the products of 
inflammation may remain as a moderate collection of fibrin and 
Pus or the pus may form an abeess -which may extend upward as 
high as the liver, diaphragry or right" pleural cavity and may 
perforate downwards, upwards, or forwards. When the appendix 
111 Hc.ng the abdominal cavity?we may have a localized peritonitis 
with the produe tion .nf fibrin matting the intestines together/ 
or an may be formed between the coils of in tea tines, or 
there may he a general peritonitis. 
Scathe levion is really double; the lesion of the appendix and 
the lesion, of the surrounding parts and the latter is even the- 
mere important* 
- ETIOLOGY,- 
The is most common in young persons between the ages of 
ten and i^lrty# In many cases, the active cau^e is the presence 
rf foreign body in the appendix,but there may be no foreign 
jbedy, We find inflammation a nd perforation of the appendix 
with typhoid fever, dysentery, and tubercular inf lamination of the 
intestine but these eases are of a different character. Thus, 
in typhoid fever,we may find an ulcer in the appendix like the 
ulcer> ^...Peyer's patches and this ulcer may perforate the ap~ 
pendTix. In tubercular inflammation of the intestine., the ulcer 
will be a tuberculous ulcer* When it occurs with dysentery, the 
inflammation of the appendix is of the same character aS that 
of the colon Theoe cases are not likely to give a good history 
of inflammation of the vej?i&iform appendix* 
112 -CLINICAL HISTORY. -' 
''hen the disease is primary, the history varies in the different 
cases but,in all it is important to remember that the lesion 
Is double. The inflammation of the appendix nay last several 
$ays before the surrounding tissues become inflamed and this 
^oealizied inflammation of the appendix gives but few symptoms. 
The patient does not feel sick enough to gn to bed* He has colicky 
P^ins in the lower part of the abdomen. He suffers from nausea 
^d vomiting. Some times, there is constipation: some times, diarrhoea* 
These symptoms belong to the inflammation of the vermiform 
Appendix. They may lust several days. There is little prostrations 
the patient may even go out of doors. 
when the inflammation extends,other symptoms are added and the 
Patient becomes much worse. Some of these eases terminate by 
Resolution: there is no general peritonitis and no considerable 
formation of pus. There is an extension of the inflammation to 
the parts behind the colon nr tn parts in the abdominal cavity 
^Ut the intensity of the inflammation is not gre^t* These patient** 
&ive first the symptoms of inflammation of the vermiform appendix: 
Senerally, there is no fever. Then,he begins to feel wnrse^he 
has chills accompanied and followed by fever and,with the fever,| 
113 the patient will feel pretty ill and will generally go to bed. 
Now,the pain will be more localized,in the right iliac region. 
The nausea and vomiting may continue. Then,generally by the end 
of forty-eight hours,you can feel that there is something in 
the right iliac region. There will be no abcess nor any real 
tumor but there will be a matting of the intestines together. 
If ynu compare the two iliac reginns,not pressing too hard,you 
will feel that there is more resistance in the right than in the 
left. Then, the patient will go on for a week or a couple of weeks 
with but little fever and with pain and tenderness in the right 
iliac region.Then, the symptoms will gradually disappear and the 
patient will return to his natural condition of heal tin There 
may be some permanent adhesions lef U 
- PROGNOSIS* - The patient would probably get well if kept 
<uietly in bed. Still,we try to diminish the severity and dura- 
tion nf the inf lamination* 
- ^VEAT?®IT*-Always put the patient to bed and keep him quiet 
while the inflammation lasts. Keep him on fluid diet* 
114 Some think it wise to leave the bowels alone even if the patient 
be constipated for fear that the notion of the colon will break 
Up the adhesions and allow the products of inflammation to es^ 
®ape in to the abdominal cavity* Others think it better for the 
Patient to have a movement once in two days for, they say that 
the inflammation does better if the bowels be empty* I belong 
tn the latter class* 
For the inflammation, the best thing is the co'Xd water coil* 
If you do not think it wise to use it,you may apply leeches 
poultices, I prefer to use the ^nil. You may give a little 
upturn to $uiet the pain and restlessness, 
^2-ln these cases, the course of the disease is more severe, 
^hey begin in the same way as the first set of cases. The symp« 
terns of inflammation of the vermiform appendix may last a few 
hours or several days: then;,are added the symptoms of a localized 
inflammation about the appendix. The patient goes tn bed and has 
chills# The fever may be very decided# The prostration is marked 
^nd the patient loses flesh and strength# The bowels follow an 
law. There are loss-nf appetite, nausea, and vomiting. At the end 
°f forty-eight hours,you feel some tiling in the right iliac region* 
^hen this something becomes,' more decided in its character, 
It becomes a tumor which in^y even fluetuate,showing the existence 
pus. Then, the abcess may fnj? a time remain stationary* 
115 However, the patient remains sick. Some times, the patient reaches 
this point in a week; some times, in three ar four weeks-Then,one 
of several things may happen* 
i, ~ There may be a general peritonitis almost at any time: 
some time&,by di ycharge of the adeems into the peri toneum; at 
others?W extension of the inflammatinn* This is more likely to 
happen when the access in is in front of the colon* Then, the 
patient is much more seriously ill and you get the symptoms of 
gene ra 1 pe ri toni tis < 
* b « The abcess perforate into the colon, the pus will be 
discharged,and th/' patient will recover nr he may die* The 
ubcess may perforate into the bladder, the patient will pass pus 
with the urine,and he may recover. The pus may burrow backward^ 
either up nr down- 
*0" The abeess may remain without discharging, perforating, or 
vetting up inflammation and the Patient may get entirely well 
or he may get well and have a relapse- The pus remains but the 
inflammation subsides and the walls af the abcess get thicker, 
'^y the end of several months, the abcess may disappear, the pus 
will be absorbed, and the Patient will have no more trouble. 
Some times, the constitutional symptoms will subside and the patient 
116 *111 go out but the ab«es9 will remain and,after blows or exer» . 
tions or from no cause at all* the inflammation, will come on again* 
^his seems io mean that the abcess has acted as a n irritant 
has set up fresh inflammation* This may be repeated sev- 
61>^1 times and the patient may eventually die or recover, 
^PROGNOSIS*- The prognosis is always serious* It is best when 
abms is situated behind the colon* Many of the patients 
of the general peritonitis and it is important to remember 
this peritonitis may be developed at any time during the 
disease* Some of the patients die simply jfrom the presence 
so large a collection of pu»; they die in the septicemic 
^nditionc Others do not die from the immediate results of the 
^iflammation but they become chronic invalids* this is especially 
uPt to be the case when the pus burrows up the back* In these 
^st cases^the viscera will become waxy and the patient will die 
emaciation* 
TREATMENT* We have at first tn treat a localized inflammation 
faulting in the formation of pus* Now shall we try to diminish 
the inflammation or shall we open the abdomen and treat the ubees? 
any other abcess? Thts question presents itself tn you at 
°hee0 I doubt if it be possible to lay down any rules on this 
^oin^, you must be guided by the condition o£ the p^ttient* 
117 Even with all .the advantages of modern surgery, the opening of' 
the abdomen,is-a dangerous procedure: <m the other hand, it is' 
unwise t© be afraid to perfown an operation when it is necessary* 
If we see the patient early and if he do not seem t$ be very ■ 
ill,we naturally nut him' to bed on fluid diet, give opium for the 
pain,and put on tne cold-water coil and many of tike cases will 
do very well with this treatment.Other patients look more serious* 
iy ill and,,in these,,we, naturally feel disposed to cut* Of course, 
this rule is so Indefinite that it is scarcely to be called a 
Wie at allo Af ter 'the access is fairly formed, there is nt* room 
for hesitation. You aut down on the absesa,after having first 
determined its position .With the needle. 
- 5- These cases are not uncommon and they are of great impor- 
tance. the appendix projects into the abdominal cavity* A gen- 
eral peritonitis is at once set up. There are no adhesions of the 
appendix. The history is, therefore,very different from, that 
of the cases already described. 
firsts the patient gives. ,the indefinite symptoms of inflammation 
of the appendix. These symptoms may last several days and the 
physician may have no- idea that anything serious is the matter 
with. the patient. 
118 suddenly,within half an hour nr an hour,will cnme the severe, 
ne ra 1 p e r 1t o & I ti s & 
rne general peritonitis will present its symptoms and its symptoms 
Ur© very apt to non tinveand^as a rule, the duration. of the oc.se 
^ill "a-, t be v^yy greato Some times,the patient will die in two 
2r three lays; "jand^generally,he does not last over a week. 
^he very worst canes, bo th for the patient and for the 
^ysicrlan* Thev ar^ bad for the patient because he often dies 
py:2di diagnosis navrng been made and they are bad for 
Physic-i&n because he may be very muW hlamedYou must be 
x. -or eases« Wen peritonitis is developed, 
--diy off that treatment is likely to be of 
for peritonitis as soon as possible. The 
ferity of these eases die. 
there are some patients that behave 
■- a ... j. . - 
hh^t. S\^6?e fc&tlw-ts do not locate the pain where it belongs, 
do troublesome ,fny the physician. Why they do this. 
J-- 'A,^,S ^ou zrust be on. the look out for them. 
cu *'misread yoy by-beginning with the symptoms. 
ute eatarrhul-coli'tl^ They may-have the dysenteries pass&g&s 
119 Th^n^come the symptoms of inflammation of the appendix* The symp- 
toms of dysentery may continue after the evidences of inflamma- 
tion of the appendix. 
~ 3.-" The sases in which. the collection of pus is behind the 
caput ®oH and burrows' up the back are always very troublesome* 
If the original collection of pus be small, it is not until the 
symptoms of abbess of the liver or empyema are developed that 
the case will become marked* 
--4-These ^ases develop suppurative inflammation of the portal 
vein. This may-happen when the inflammation of the parts around 
the appendix is not severe. Thrombosis and its symptoms will 
result. In these eases,it is very easy to overlook the original 
disease. * 
--- The lectures on inflammation of the vermiform appendix 
were given before the appearance of Professor Sands' monograph 
on 1 Typhili tds^PeH typhili^^ Perforation of the Appendix** 
Therefore,,i t is <uite possible, that Professor Delafield may 
have changed his ideas on this subject* I.t is for this reason 
that we have pyt in the two succeeding blank pages** Editors^*** 
120 121 122 - CHROMIC PWTONI'HS* - 
*♦ ■ 
The MBt importan. forms.of this disease are three 
in number. These are; - 
x- Feri-Umiti.s with Adhesions* - This form is not preceded 
hy the production, of serum,fibrin, and pus. Ths adhesions are 
formed of new connective tissue from the outset. This form 
exactly resembles ehronis pleurisy with adhesions/ 
2 - Peritonitis with.the production of Serum,Fibrin.Pus,and 
&ew CnunectiW Tissue* 
3- This form is accompanied by great thickening of the peri* 
toneum and th® presence of serum in the 'peri tone al cavity^ 
There is no. .formation of pus nr fibri.no 
■. 1 
This form,peritonitis •with.adhesions, 1 s the least important. 
In most is probably due to a small, collection of pus 
In the abdominal eavityo This collection of pus acts as an ir^ 
^itant and sets ut) inflaw^tian with &e production of new con- 
heetlve tismAe. In o.ther casewe find no exciting cause. The 
■ - PATHOLOGY. - 
123 new emulative tissue taxe-s-we .shape of thin threads and mem~ 
branes and joins together adjacent parts of- -the .peritoneum.In_ 
this manner,the liver, spleen, or omentum may become adherent to 
the abdominal wall. 
- SYMPTOMS. - 
When the disease, is not far advanced? there are really no ir^ntoma. 
If the adhesions be not mime row? the patient will not be aware 
that anything is the'matter. If the adhesions be numerovs-,and 
if they mat'the intestine together, the patient will suffer from 
some' pain and disorders of the intestine but he will not be in 
and he will go about. The adhesions may at any time cause acute 
strangulation of the intestine. When this happenswill 
get the regular symptoms. So,these eases are not of great clinieal 
importance. 
This form of the disease is of great clinical importance,it gives 
decided symptoms and it is regularly fatal. 
After death,the peritoneum shows the changes but it does nut 
always show them in the same way. You find the conne®tive~tissue 
adhesions. These mat together the intestines, often in a solid 
mass. When you pull the adhesions apart,you will find collections 
of pus,serum,and layers of fibrin. You may also fini a consider** 
able quantity of purulent serum occupying a considerable part 
of the peritoneal cavity. * * 
124 ^he cases vary as- to the amunt of serum. 
in swue oases.? the disease will follow an acute general pex'itoni ti$* 
In o+her cases, it follows an acute localized peritonitis. It 
£recently follow lesions of the uterus and its appendages. 
hf may be due to abbesses in the abdominal cavity. There are 
also idiepathi® ©ase^so-called* These, idiopathic eases are not 
uncommon as you might suppose. 
- SYMPTOMS, - 
If the disease be preceded by any of the lesions mentioned above., 
Vou will get their hi Storys then*wlll come the chronic peritonitis. 
.If 'the ®ase be idiopathic then, the patient in-ordinary heal th, 
^11 on Home particular day manifest the symptoms. At first, the 
Symptoms will be gradual and the patient -will not be so seriously 
*I1? then* they get worse. 
"^1.--Pain and 'tenderness over the abdomen* -4- These are apt to 
the first symptoms* They are not constant but they are genera 
^ly present. 
The patient will lose flesh and strength* 
S-With the loss of flesh .and s treng th* the re will be an ir- 
^gular fever. As a' rule., the temperature will not be very high, 
$$-10$ and part of the time normal or below the normal. 
~ The patient will lose appetite and will suffer from^nausea 
^id vomiting* 
125 - y-Aw a1 the bowels are disturbed* Some time as the ice is 
^ons tipa Uon? some times, diarrhaeashut the 'bowel s maybe regular* 
The^e are all. the rational symptoms and,as a rule^ they are 
pretty slowly'developed* The disease generally las is,for months- 
These vary according to the quantity of serum and according to . 
its position* If the fluid be present in very large quantity, 
and if the intestines float upon ^he surfa«e?you will get the 
physical signs of ascites-, flatness over the fluid, the wave-©f 
fluids and tywanitic resonance over the intestines* 
The fluid may-.be present in considerable quantity but, the. in test 
fines maybe held in some other part ef the abdomen by adhesions* 
Then, the intestines may give dulnesss instead of tympanitic reson*' 
ance.. . 1 . '7 
The fluid may be shut in in any part of the abdomen* ' In these. 
eases, you will not get the wave of fluid and you may not.-be able 
to distinguish the collection of fluid-from a cyst* 
in other cases, there will not be much serum and you will >ave 
the feeling of a turner more or less distinct according to the 
degree tl^t the into tines are matted together* In eases,- 
ye't will simply get a feeling ©f resistenee* In ®th«^ 
- PHYSICAL SIGNS, -r- 
126 it will be move like a regular twnor8not like a new growth but, . 
still,solid* Seme times this.-feeling is quite deceptive and you 
^y aonfound it with a tumor* ' ., 
So far as I. know,these patients hever remove r« The natural ten* 
deiwy,. of the disease is to continue, The patient dies in extreme 
emaciation and e^hausiioiU 
Nurse the patient and,occasionally, evaluate the 
■berum if it interfere with hiv comfort* 
/ . ♦ 
•«*»- WM.W 
These eases are not as common as the seeond Glass of eases* 
As to the causation of .the disease,, no thing is known about it* 
, As a rul%it is developed in persons who have been in good healthy 
The sema will accumulate® 'It will either be al ear or^it will 
ke rendered turbid' by the presence of ci few pus cellSo The 
peritoneum lining the wall of' the abdomen, that portion fox^nlng 
the capsule of the liver and. outer coating of the viscera^in 
^ot? the peritoneum everywhere is thie&,dense-?and is uniform 
mass of ne.w connective tissue, ' The peritnneum may even become 
°ne,in>h thick. The'liver will be compressed and made smaller* 
127 'The circulation through'the portal vein is obstructed and the 
liver is put into, a condition practically like that of eirxhosls. 
The stomhuCh will be very mush diminished in size. It may be 
no larger than your fist. It will be the seat of a shroni^ ^t^rrhaX 
gasirtis. To a less degree than the stomach and liverythe Sntes^ 
tines will be diminished in nlze. 
■ 1 . 
These are very slowly, developed* At firsts the disease givey 
no symptoms? after a time8it does. 
- PHYS IC &L SIG^« ^*- The physical signs are thone of the a«rsumu« 
lation of fluid* The thickening of the peri tonwe are not able 
to make out during life. If we draw off the fluid* i* may he 
clear or slightly turbid* The abdomen will be distended# 
*-RATIONAL SYMPTOMS* - The condition sf the stomach gives syrap- 
toms like those of eaneer of this organ* The gradual diminution 
in size'and the Chronic gas tri tie give symptoms very, mwh like iu 
The patient suffers from pain in the stomach* He is unable w 
take food and suffers from pain in the stomach after he has 
taken food, The patient suf ferry from nausea and vomiting. All 
these symptoms keep getting worse-and this disease is frequently 
Confounded with cancer of the stomach. ■ 
The condition of the liver gives us synp-tnmS. Ihe^e liver symptoms 
are especially apt to be developed when the capsule i& much 
thickened. The patient behaves very mush as though he had cirrhosis* 
SYMPTOMS 
128 yov tap the abdomen,,you will be no better off. The liver will 
Qeeome smaller. 
altered condition nf the intestine will give diarrhoea or 
it also gives-a general loss of flesh. The patient 
fxoah and strength and dies in extreme exhaustion? The 
may last for years. 
xhe■disease is not amenable ;to treatmen t< Nurse the patient and 
Relieve the dropsy by tapping. 
1 t .. • 
129 K person who has acute general miliary tuberculosis or who has 
tubercles in the lung, intestine, or elsewhere,^ay have tubercles 
in the peritoneum but these are not the $ases that we are about 
to consider* The «ases that we «.re about to. consider are those - 
in whiehjbesides the presence of miliary tubercles in the peri* 
tonevm? there will be other products of inflamiwiion* 
We find the miliary tubercle^ or large, scattered or aggye- 
g& te d * We also f ind o th erfn f 1 aMaa to ry p ro due t s and ? ® 1 
to the predbminence of one or the other of these r,wiH- be 
the special variety of the disease* 'Thu. in some gas ©Bi there 
will be an excessive quantity of scx-wn in-addition to the .biliary 
tubercJ.oth ^n other easef^ there will be no serum but an excessive 
quantity of fibrin* This fibrin will mat the intestines together 
and will join the inte^Mnes and the other viyeera to the abdom- 
inal wall* The fibrin may even distend the abdomen* Instead of 
the serum and fibrin*wo may-have ,ergan0ed eennec tive- ii^<e 
a4heslen^o These- are the three, regular a&ataaleal types* 
- ETIOLOGY* - ,.. 
Hie disease may oeour at almost any period* »f Ufa. - It tft®M 
c«®urs as a strictly localized tubercular inflawnati^o/ In ®tMr 
- ttjbwular pmwm'is. - 
130 cases,, there will first be a tubercular inflammation of the 
genitourinary tracts this is frequently followed by tubercular 
peritonitis. The patient may first have chronic pulmonary phthisis. 
The existence of other lesions is no safe guard against this 
disease. Thu»,it may follow cirrhosis,Bright*s diseasa,or any 
other disease in the abdominal cavity. 
- PHYSICAL SIGNS.- 
If the tubercular inflammation be accompanied by the production 
of serum, the physical signs will be those ©f fluid* 
If the tubercular inflammation be accompanied by the production 
of fibrin, we have a condition of the abdomen which we never 
get at any other time* The abdomen will be distended with a semi* 
fcolid material. It will feel just as you would expect it to feel* 
The abdomen is evidently not filled with fluid or gas. 
If the inflammation be accompanied by new connective*tissue 
adhesions,you will get a tumor, the coils of intestine. 
- RATIONAL SYMPTOMS* - 
The .rational symptoms are always the same in all cases. The 
course of the disease may be steady with exacerbations or there 
r&y be intermissions. 
*-*1-The patient loses flesh and strength and becomes anaemic. 
131 - 2 -He will have an irregular fever and the pulse will he#*®® 
rapid. 
*- He will have no appetite,he will suffer from nausea and 
vomiting,and he will have disturbances of the intestine* 
*-Pain and tenderness over the abdomen will be present* 
These rational symptoms are really those of chronic peritonitis* 
The course of the disease is slow and it usually lasts for months 
Some times,the disease is mere acute and lasts but a few weeks. 
The patient dies in exhaustion* 
-- THMTMSNT. --We do net knew how to treat the disease. 
- CANCER OF THE PERI TON EUM/- 
The new growth may be anywhere in the parietal or visceral 
peritoneum® It may take the farm @f very small white nodules* 
not larger than a p.ea and very numerous. In other oases, it wlll^ 
assume the form of scattered plates of varying thickness but 
not thick enough to be felt through the abdominal wall* In other 
eases., it will be ia the form of large tumors, as large as a henxs ( 
egg or a man's fist on,even,larger and,if these turners be situate 
in the omen turn, we will be able to feel them with the greatest 
ease* In some eases', the new growth takes the form of colloid 
cancer. Then, the masses are apt to be very large and5xf the 
omentum be involved,it will be spread out like a. large turner* Th^ 
form frequently involves the viscera and the sub ~p-e ri tone al 
•onnec tive tis sue♦ 
132 As a rula, there will be an accompanying peritonitis. This is 
not peculiar to cancers of the peritoneum but the peritonitis 
is apt tn be extensive and to add a good deal to the physical 
signs* Serum or pus may be present or the intestines may be 
matted together by adhesions. 
Cancer of the peritoneum is a disease that occurs in persons 
of forty years or more. 
- PHYSICAL SIGNS.- 
If the peritoneal tumor reach a considerable sisse and if there 
be but little serum,you will be able to make out the tumor easily 
enough. If there be no tumor large enough to be felt and if the 
serum be present in considerable quantity, you. will simply get 
the physical signs of fluid* These eases are much more difficult 
to diagnose: in factiit is often impossible to distinguish them 
from tubercular peritonitis or from chronic peritonitis. 
- RATIONAL SYMPTOMS.- 
The rational symptoms resemble those of chronic or tubercular 
peritonitis. 
**~1 - The patient loses flesh and strength and becomes anaemic 
but he does not do this much faster than the patients with 
tubercular and chronic peritonitis. The disease is very slow 
in its •oti'se and the patient may be out of bed after it has 
been in duration several months. 
133 - 2" There are the same disturbances ef the -stomach as in chr>ni< 
and tubercular peri ten itis* The patient will lose appetite 
and will suffer from vomiting. ' ' ' 
.- There will be the same disturbances >f the intestine, 
- 4-* If the peritonitis be at all active, there may be a fever 
although fever is not as constant as with chronic and tubercular 
peritonitis* • x 
The patient may have had cirrhosis and ascites ^nd 
this may obscure the history® In these ®ase&?it is almost Impos* 
sible to make the diagnosis* 
Cases of cancer of -the peritoneum are hardly fit subjects fo^? 
surgical interference for the new growth is more or less diffused 
and enough of it *ould not be taken away. There is no treatment* 
134 - DIABETES MELLITUS. - 
The ordinary definition of diabetes isellitus is that it is a 
lisease characterized by an increase in the quantity of urine^ 
the presence of sugar in the urine^ and changes in the general 
health. 
The simple presence of sugar in the urine does not cons id lute 
diabetes:a person can have sugar in the urine without having 
diabetes# When a person has sugar in the urine and does hot have 
diabetes,we say that he has * glycosuria8. So,when a person has 
glycosuria,he has sugar in the urineT The presence of this sugar 
^ay be temporary or constant. It is not present in considerable 
quantity and it does not have any affect upon the patient's 
general health# In glycosuria, there is no great change in the 
quantity of urine and there is no great change |n' the general 
healtli. The causes of glycosuria are numerous. They are the 
f( 11owing# 
'-i-The ingestion of certain drugs. - Poisoning by curare, 
by the inhalation of Carbon di-oxide^by cyanide of potasb^hy 
the salts of me reury, andT some time a, poisoning by morphine wilh 
Produce glyeosuria. The inhalation of the nitrite of amyl or/' 
of chloroform and the ingestion of chloral hydrate will produce 
it. In scm,persons^ the condition of chronic alcoholism will/be 
accompanied by glycosuria. 
135 ;-5- Some of the infectious diseases are aecniFpunied by glycos- 
uria. These are cholera,anthrax, severe malarial fever, some times 
typhoid fevertrarely diphtheria,and cerebrispinal meningitis 
either during the disease or durip.g convalescence. 
- 5-Disturbances of- digestion are a common cause. Under this 
heading we would class functional, disease of the liver,chronic 
gastritis,an I the disturbance of the stomach that accompanies 
gout. In some of these oases,sugar will only appear in the urine 
after the ingestion of starchy nr saccharine food. 
4--Severe mental emotions will cause glycosuria for a short 
time. . • 
*-5-Sone of the severer attacks of tri-geminal unc other 
neuralgiae are attended .and followed by glycosuria. 
'-6Concussion of the brain.and cerebral apoplexy. 
- 7-The atrophic form, of Bright's disease. 
- 8-During pregnancy,-there may be quite a good deal of sugar 
in the urine« 
After all,these cases are not of great clinical importance. 
always want to recognize them,for a patient, af t$r suffering 
for years from glycosuria,may develop true diabetes. This is 
especially apt tn be the case when the glycosuria is associated 
with gastric disturbances,funetional disease of the liver,gout, 
pregnancy,or.atrophied kidneys. 
136 So,when you havey^nee found sugar in the urine-, you always 
the patient~wisome suspicion. The only eases ip which treatment 
is indicated </re those in which the glycosuria is associated 
^i th dis turbaries of diges tion, gnu t, a trophied kidney pregnane y, 
nr f^a tiona-V disease of the liver. In these eases, regulate the 
diet and the mode of life and,generally, the sugar wi.Xl disappear, 
I think that this is always a wise precaution. If you treat them 
in this way,I think that they are. less likely to develop true 
diabetes. - ' . 
In adultH,this disease is more $ ammo n in men than in women: in ' 
children,it is equally common in both sexes, the disease is most 
Lemmon in young and middle-aged adults but it is not rare in 
old persons nor in infants, it prevails in almost all parts of 
the world but it is more comin ih some countries than in others, 
^hy this is,we do not know. There seems to be a.wel|*marked' 
hereditary disposition to the disease. The gouty diathesis does/ 
&eem to have something to do with its OGOurpenee?how,we do not 
know. 
- TRUK DIARETES. - 
137 The pathology is not satisfice tory. We find morbid conditions 
enough but none of then-can be looked upends the characteristic 
lesion of the disease- 
In sone cases, there will be changes in the-bruin,especially 
at the base* in the medulla,pons-, or cerebellum, Here, we may find 
tumors nr dilatation of the blood, vessels nr small extravasations 
of blood around the dilated vessels nr,around the -Hated vessels, th04 
there nay be accumulations of small,round cells. 
During the disseise,some of the patients develop pulmonary ph thicis 
or gangrene of the lung and these are a common cause 3eath. 
In u considerable number of the cases-, the pancreas- will he 
atrophied. What thia has - t* do with the disease,we do not 
know- 
Quite frequently, the kidneys become diseased, Generally, this 
uiseu&e of the kidneys takes the form of a chronic nephritis 
but it may take the form of acute nephritis urn either of 
these conditions may be the cause of dee th- 
The liver will often be the seat of fatty inf il tra tion* r 
So, there are no characteristic lesions. 
We are also ignorant as to the true nature of the disease. All 
- PATHOLOGY,- 
138 that we know about It is that In all healthy pertans, there 1$ 
came sugar in the blood and. in diabetes, there is a gaud deal 
of sugar in the blood and that it is the presence of this large 
quantity of sugar in the blood that seers to constitute the 
oisea.se* The sugar escapes in the urixoe on account of the excess 
in the blood* This seems to be the only charge tn ri s tic 'jesioxu 
Why there should be this excess of sugar in the blood,we do not 
know. in health , the sugar enters the bland from the intestine 
and also as the result nf changes going on in the different 
nf the body* Now?(vhy a person with diabetes should have a great 
deal of sugar in the bland:no one knw^u. The 'prohiesn rendered 
irnre obscure by tb.e fact that sose patients with diabetes da no t 
have too much sugar in the blood unless they eat ^tarohy food 
and.,In tlxese the trouble u.ust be with the ranageisent e-f 
the sugar by the viscera:hut,in other eases,we find ^ugar in 
too great quantity in the blood when the patient has n^t eaten 
vtarehes for a long time and,in these eases, the reabon for the 
excess of sugar in the blood Dust he diffei'enU So,we seem to 
run against a blank wall. 
139 - CLINICAL HISTORY.- 
The oases are divided into two classes*: those that are mild and 
those that are severe* This division,you naturally make for your* 
self. 
~ J ii id e - 
These c.re s especially common in elderly persons. As a rule, 
the sugar is not present in large quantity at any ti me. Of 
course.? there is more sugar than there is in glycosuria* The 
quantity of sugar in the urine Till vary on different days and 
on the same day* Some days? there may be none* The sugar is apt 
to disappear so long as the starches and sugars he excluded from 
the diet* Some of the patients have hardly any constitutional 
symptoms. They go about attending io theix* business* The increase 
quantity of urine is not a very marked feature* 
Yet)some of these patients will pass a good deal of urine and 
this urine will contain a good deal of sugar. There rill he sone 
changes in the general health. The patient will develop the 
characteristic thirst, lassitude?and emaciation. But, these patient 
respon! reauily to treatment* 
Severe ^ayes*- 
The quantity of urine and sugar in the urine is re^ilarly very 
large. All the disturbances of the general heal tlx are present? 
The patients are sick: they lose flesh and strength:and they know 
that they are sick. 
140 Hut, there are had eases thatjfor a Long time,may pass but little 
urine and the sugar will not be present in great quantity but 
the constitutional symptoms will he pretty well developed. So, 
you must not he in too great a hurry to say that a patient will 
do well because you find hut little sugar in the urine* 
In both mild and severe cases, the invasion is,as a rule*, so slow 
that the patients do not know when the disease began*. As a rule7 
>e uo not see eases of diabetes until long after the commencement 
of the nise&se* Occasionally, the invasion will he sudden and, 
within a week or. within a few days, the patient will be fairly ill* 
The cases vary as to which will be the first symptom* 
In some cases, it will be the unnatural thirst. Bu t, al though this 
is a well-marked symptom, it may be due to a variety of other 
causes,dyspepsia and indigestion. 
In ether eases, the first thing noticed will he the increased 
quantity of urine. The patient will urinate very frequently 
and he may have to get up in the night to pass water. We may 
get tills symptom also with other diseases* 
In other cases, the first symptom will be a gradual loss of flesh? 
in others,a loss of muscular power. 
In other eases^ the first symptom will be disturbances of digestion 
141 and it it not until you examine the urine that you notice the 
disease* In other cases, the gums 'Till become spongy and Till / 
bleed* 
In all these eases, the changes in the urine exist hut the patient'? 
attention is first called to his condition by one or other of 
the other s^ptomso The larger number come tn us ignorant of 
the true nature of their disease, So,it is almost a ratter of 
routine practice to examine the urine of a patient who comes 
to you with obscure and doubtful syr/ptoms* At, first? some of these 
patients really complain of n4^in^n Some,at first,have no symp- 
toms at all, 
Appareatly, the quantity of urine is always increased and,in most 
cases,it Till be considerably .increased. As a rule, the increase 
in the amount of urine is a fair test of the severity of the 
disease, You rust rer^ember that the increase in the a^unt of 
urine may be very slight, so slight, that you may not make it out 
until the urine is measured# When you ask these patients whether 
they pass too much urine,they will often tell you that they do not# 
The specific gravity of the urine is regularly increases. It is 
not often below 1030, Yet? there may be a good deal of sugar 
with a specific gravity of 1025 and,if the patient have atrophied 
142 kidneys, the specific gravity bay be normal and ^occasionally, 
below the normal* 
Sugar is always present at some time during the twenty-four 
hours* When the disease is far ad vane cd, sugar is always pre tent 
hut,among the milder easet^it is not uncommon to find sugar 
present at some tines and absent at other's* This often causes 
the patient to become very meh confused,for he will send samples 
of his urine to different physicians and will get different 
results. Generally, the sugar is present after exercise. Always 
examine the urine on several different days. 
As the disease goes on, the thirst gets more marked and it is in 
direct proportion to the amount of urine passed* 
In some eases, there will be an unnatural hunger. 
The loss of flesh may be very narked or there may he none. This 
Seems tn depend on the severity of the disease. I an in the 
h< bit of at teaching a great deal of importance to this symptom 
in making the prognosis. 
^rynet's of the skin tund mucous membranes is sometimes much com- 
plained of* As the mucous membranes become dry, they hecome the 
teat of a chronic catarrhal inflammation and are covered by 
an increased quantity of thick,t^naoeous mucus. 
143 In the bad cases^the lass of muscular strength will become very 
decided until the patient can .hardly get about*. 
As the. disease goes on, the disturbances of digestion become more 
marked* A chronic catarrhal gastroenteritis is established 
and this lesion adds tn the loss of nutrition*. 
AThe gums recede from the teeth* Tar tai' is deposited on the teeth. 
The teeth decay and become loose* This is especially apt to he 
the case in bad cases and' in children* 
- COMPLICATIONS* - 
- 1-These patients are very apt to have boils* 
- 2-They may develop inflammation of the kidney. The nephritis 
may de be either acute or chronic and either may be the cause 
of death* 
- 3-in old. persons, the eyes may suffer. They may develop cataract 
- 4™ Inflammations of th eTung s , e s p e c i a 11 y of the tubercular 
variety are common. Chronic phthisis is a frequent cause of death* 
- 5-In old persons, the feet and toes my become gangrenous. 
This is due to the loss of nutrition. 
--6- If the patient be confined to bed,he will be apt to develop 
bed sores* 
*-7 - A moderate, number of the patients are finally attacked 
by diabetic coma* This is more common than was once supposed 
It is apt to follow one of three types. These are;« 
--1 - A patient after some unusual bodily or mental exertion 
passes into collapse,, lies down,becomes cold. The pulse is weak. 
144 Then, the patient becomes sleepy: then,passes into a stupor from 
^hioh he cannot he aroused* In this condition,he remains till 
•-eath which follows in a few hours, 
2-For a week or ten days, the patient will complain of week* 
hets and of indisposition for mental or bodily exertion, The 
bowels will be constipated* There will he loss of appetite,pain 
in the abdomen,a little dyspnoea,and a slight disposition to 
drowsiness. It is important to remember these premonitory symptoms. 
Then, come the cerebral symptoms. The patient has headache which 
is pretty severe* Then,stupor alternates with restlessness or 
elirium. The pain in the abdomen becomes more marked. The 
dyspnoea becomes very marked and the patient has to sit up in 
rrder to breathe. This rapid breathing may be mistake^ for asthma, 
hysterical dyspnoea,or the dyspnoea of Bright's disease. It does 
hot exactly resemble any one of'them hut you may he bothered 
in making the differential diagnosis. Then, the heart becomes more 
^pid and feeble* The delirium and restlessness subside and the 
Patient gradually passes into coma but the rapid breathing will 
Continue and the appearance of the patient will he very char- 
acteristic* The patient does not emerge from this coma but 
^ies in twenty-four hours or twu5threa,or four or five days* 
145 SoTin these. eases, the duration is longer than in the first set 
of patients* 
*- 3-There are no premonitory symptoms. The very first symptoms 
are cerebral symptoms,,severe headache,dizziness^ drowsiness, 
stupnr,coma? and de a th. 
Now,al though diabetic coma is characteristic and fa tai, we do not 
know why the patient^ should develop it nor why it should be fatal* 
Some believe it to b\ due to inspissation of the blood due to 
the increased discharge of fluid by the urine. Some suppose 
the lodgment of fatty emboli in the brain to be the cause. Others; 
believe that diabetic coma is but' one variety of uremia. Others 
believe it to be due to the presence of acetone in the blood 
and say that the patient suffers from acetonaemia*. None of these 
theories is satisfactory. They may apply to individual cases. 
The course of the disease is usually very slow. The milder eases 
may last for an indefinite time and die of something else. In 
the faixvly marked cases, the duration of the disease is from one 
to three years. Some of the patients die at the end of a few 
weeks. This is especially apt to be the case when the patient 
lies in coma hut,after all,we cannot say how long the disease 
lias lasted in these cases* 
146 Tf left to itself, the disease is progressive,yet? the patient 
may have periods of temporary improvement,. 
The mild cases attaend to their Wr£*and do not know that they 
^re sick. The bad cases*are confined to bed and are very miserable. 
Between these two extremes,there are all grades. 
Some of the patients seem to get entiX'ely well* Others get well 
for a time: then,when treatment is discontinued, the symptoms 
eome back* Others do not at any time get well but enjoy preety 
fair health: these patients form quite a large class* It must 
be remembered that,in the last two sets of eases, there is always 
danger of diabetic coma,no matter how well the patients do. 
Some patients die of the complications* Others die exhausted 
by the disease* The latter mode nf death is very long and miserable. 
The patients look like skeletons. Others die in diabetic coma. 
As a rule,children do much worse than adults. In young and middle** 
aged adults?we find all sorts of cases* In old people,the eases 
are most mild,and most favorable. So,the prognosis depends on 
the age of the patient, the duration of the disease, the quantity 
cf sugar,and the general health of the patient. When you have 
taken all these things into consideration,if you are wise?you 
- PROGNOSIS.- 
147 will give nn prognosis until you have treated the patient for 
several weeks and seen how he responds to treatment. A month 
will usually tell you how the patient is going to do. If the 
patient respond to treatment,you think comparatively well of hii> 
This is the only practical way of getting a protasis. 
- TREATMW. - 
Part of the treatment is fairly rational and sensible and ennsiS 
in regulating the diet and enforcing proper exercise. The treat- 
ment by drugs is empirical. 
The dietetic treatment is, therefore-, very important and,in the 
milder eases,it is the only treatment that is necessary. It 
consists in excluding the starches and sugars. But,in doing thiSi 
you are some times met by the difficulty that such a diet will 
decrease the patient's weight. Then, this strict diet cannot be 
carried out- Some physicians do not look at the patient at all. 
They only look at the urine and they do not notice that the pati^ 
is really getting worse in spite of the diminution of the sugar 
in the urine. In these cases,you have tn give a moderate quan- 
tity of starches and sugars. Make the patient take exercise. 
In many casethe regulation of the diet and the enforcement 
of exercise will be all that are necess ary. You may employ 
massage or passive motion and,if possible,make the patient take 
active exercise. 
148 DRWk 
In some cases,we have to give then and we give them empirically* 
We must remember and we must recognize that some cases will not 
beb benefited by any plan of treatment. It is only in the less 
severe cases that drugs are of service* 
1-Opium in any form.- Find the preparation that disorders 
the patten Vs digestion least. In those patients who bear it well, 
this drug is unguestionably of service* But many patients cannot 
take it and thex^e is always the danger of establishing the opium 
habit* So, I think it is wise not to use it at all. 
2 - The alkalies are often of service* You may give the bi 
carbonate,salicylate ,nr any of the preparations of soda or you • 
^y give one or other of the alkaline mineral waters.- the ob- 
jection to soda is that, to be of any service,it has to be given 
in very large daye&,grs*ee in the twenty-four hours* 'Still many . 
of the patients hear it well and are benefited by it* Apparently, 
you will do be tier,however, to give the vichy and Karlsbad waters*' 
The patient wall do much better if. he go to Vichy or Karlsbe^d 
and spend the season there* • 
' 3-Calcium sulphide is of service. This drug does not have 
to be given in very large doses* Give.it in pill form At first, 
Give three times a day: then,increase the dose to grs^iij* 
grs.iv three times a day. It does good in many of the cases*- 
149 It is easy to take and it does ant disorder the patient's diges- 
tion* Another advantage is that it does not have to be ►'iven 
in great hulk* 
•-4"Arsenio has been given. It has been used in a variety of 
forms. The two forms -that are most used are the following. The 
firstis Clemen's solution, the solution of the bromide of arsenic* 
This may be given in loses of m.iij-m.x t.i.d* It only has to 
be given in small loses,most bear it 'veil,and,in some,it is of 
great service* 
In the second place, ai'senic has been used in combination with 
the carbonate of lithium, and carbonic acid water. You add half 
an ounce of a solution of the arseniate of soda of the strength 
of three grains to the pint to three grains of the carbonate 
of lithium in solution in two pints of carbonic acid water* 
The patient drinks this instead of ordinary water. These two 
methods are very convenient* They do not disorder digestion 
and they often have a real affect upon the quantity of sugar and 
the quantity of urine. 
1-5-Jambul*--I have only used this drug once or twice but 
I have obtained from it very good results* Give gr,v in powder 
or capsules three or four times a day. It has succeeded with 
me in cases that have refused benefit from the other drugs* 
150 All these drugs simply reduce the quantity <<f sugar and the 
quantity of urine. 
DMETES INSIPIDUS.- 
*This disease has one symptom like sacchax'ine diabetes: the patient 
passes tor* much urine. Except for* this^the two diseases have 
nothing in common. 
Whim we say that a patient,who has this disease,passes too much 
urine,we do not mean that he dees so for a few days or,even, 
for a few weeks. Hysterical women,nervnus men,and persons suf- 
fering from chronic Bright's disease may, for a short time.,pass 
too much urine* We mean that the patient, without- any kidney 
lesion,losses three or four quarts of urine during the twenty- 
four hours and that he does this for a long time. 
Fortunately, this disease is not common. It is more common in 
males and-in young adults, than in females and old persons. 
- PATHOLOGY. - 
We might imagine that the real cause nf the disease was a dilata* 
tian of the bland vessels of the kidney and that these dilated 
151 vessels allowed too much water to pass through them. Then, you 
would naturally suppose that something must he the matter with 
the vasa^motor nerves of the kidneys. At the autopsy,however, 
we find nothing. 
- SYMPTOMS.- 
*-1- The patient passes a great deal of pale urine of a low 
specific gravity; otherwise., the urine is normal. The quantity 
of urea remains the same during the twenty-four hours. In some 
eases,this will be the only symptom. 
- 2-More frequently, the patient hay other symptoms. These are; 
-1-The patient often suffers from an unnatural thirst. This,you 
would naturally expect from the large amount of urine passed. 
This thirst is often very annoying and the patient will drink 
large quantities of water. 
-2-The patient may lose flesh to a considerable degree. 
The patients are apt to develop nervous symptoms and it 
is difficult to tell how much these are due to the disease and 
how much to the patient's alarm. 
a * The women often become hysterical. 
152 ~h~ As to the men, some of them are always thinking that they are 
getting some other serious disease* Others will have pains* 
others,feelings of heat and cold. Others will become quite unfit 
for business: they will think of nothing hut the disease. 
These nervous symptoms ai'e often the worst part of the disease* 
The patients are continually boring their friends with a plain- 
tive history of their sufferings. 
The disease is not fa tai: some times, you wish it were. You cannot 
tell whether it will get worse:whether it will remain the same: 
o r, who the r i t wi 11 ge be t te r. 
- PiiOGN^OSIS. - 
The treatment, is sometimes satisfac tory: some times, no t. When the 
treatment is satisfaetory, the satisfaction often does not continue. 
A few drugs' are used. They are the following fluid extract of 
er&otjone dram t- i.d*: gallic acid,grs>v. t. i»d*: the preparations 
of valerian: the mineral acids,nuxx Ui.d.. In some cases,these 
drugs will diminish the quantity of urine and the patient will 
feel better. 
Some eases are not benefited by these drugs and, then,you have to ' 
- TREATMENT.- 
153 fall back on diet and hygienic management. Put the patient on 
an exclusive meat diet* It has seemed to me that a tumbler of 
hot water one-half hour before each meal and another before 
going to bed are of benefit* This meat diet often succeeds but 
the trouble is that you cannot keep it up and you have to grad- 
ually add other articles to the diet. Still, if you can keep the 
principal part of the diet meat, the patient will do fairly well. 
- PERIODIC, OR PAROXYSMAL HEMATINURIA,OR HEMOGLOBINURIA.- 
The patients who suffer from this disease,have no structural 
changes in the kidneys. Three different conditions etre included 
under this name. 
- 1-The patient suffers without any apparent cause,the idio- 
pathic cases. 
- 2-The patient suffers from malarial poisoning and he has 
attacks of hematinuria, ins tead oF attacks of'chills and fever. 
- 3-The patient suffers from malignant malarial poisoning 
154 and hiis the disposition to bleeding in various parts of the 
body and,among other places,in the ux^ine. 
- 1-0$ IDIOPATHIC CASES.- 
Most of the patients are males. The disease occurs at all aues. 
In some caBe^?a paroxysm can be brought on by suddenly cooling, 
the skin* This is about all w knov about the etiology* Give 
the patient a cold bath or send him out in the cold and he will 
have a parox^m. Between the paroxysm^ the re is nothing the 
latter with the urine. 
- A Paroxysm. - 
1~ Fira t, the patients have chilly feelings or real chills. 
$hese last a few hours. With the chills, there is often vomiting, 
hau s e a , ma 1 al s a, and p mat ra tion* 
^2 - In some cases, there will he & fever after the chill* in 
o the r on s e $ , th e re wi 11 not* 
3- The urine that the patient fix^t passes after the chill wi: 
he dark,reddish,and bloody. The specific gravity shows no char- 
acteristic changes, As a rule, the urine will contain albumen 
and,perhaps,a few casts. The change in the color is due to the 
presence of the coloring matter of the blood,net to the ri'esence 
• Of red blood cells* This condition of the urine my last a day 
155 or it may last several lays: then, the coloring matter will disap* 
pear. The frequency of the paroxysms varies. Some of the patients 
will have one a day; others,several-. Some will have them every 
day: others, severe several days. The disease is apt to run an 
intermittent course and the patient may be free from the attacks 
for months at a time. 
- 4-The patient may lose a little flesh and strength and may 
have disturbances of digestion but these changes are not marked. 
■-PROGMOSIS.-As a rule,the patient does get well sooner or 
latere Some of the patients get well in a few months: o the rs, 
not for several years. 
The treatment is not satisfactory. Fortunately, the patient will 
get well without treatment. I doubt if there be any advantage 
in treating these patients. Thea Treat the patient's general 
healtli and do not let him be exposed to cold. 
- 2- THE SIMPLE MALARIAL CASES. - 
In these cases,the cause of the disease is different. The patients 
have lived in malarious districts and you can often get a malarial 
history. Instead of having an attack of chills and fever, the 
Patient will have an attack characterized by chills, pros tratinn, 
and disturbance of tine stomach. The chill may or may not be fol* 
lowed by fever. 
156 Then.the first urine that the patient pusses will. have the ' same 
character as that of the idiopathic cases. The attacks will be 
periodic just like the attacks o£ intermittent fever. 
-- Treatment. - 
These eases are decidedly benefited by treatment. Give quinine 
nr arsenic as in intermittent fever. So,you must always discrinh* 
minette between the malarial and the idiopathic cases. 
-- The Ma1ignant Malaria1 Cases-- 
These cases should not be included with the others. The urine 
is dark in color from the presence of the coloring matter of 
the blood but this is only one of the symptoms of the malignant 
form of malarial poisoning. I only speak of it because it is 
Sometimes included with the others. 
157 - THE INFECTIOUS DISEASES. - 
- GENERAL CLASSIFICATION AND INTRODUCTORY REMARKS.- 
This nx.se is Given tn a GyouP diseases in which the morbid 
condition is apparently due to the introduction of a poison 
from without- The poison is in most cases if not in all believe I to 
be pathogenic micro-organisms. These micro-organisms crow and 
multiply in the appropriate part of the body and it is held 
that it is probable that each nf these diseases has & specific 
niero^orGanism. We cannot demonstrate the latter fact fox* all 
the infectious -diseases but we can for some and, from analogy, 
we assume it to be true of the rest. 
We may sub-divide the infectious diseases into th^ee classes 
These are. 
- 1- THE MIASMATIC. 
- 2 - THE CONTAGIOUS. 
- 3-A CLASS Tf WHICH NO GOOD WIE HAS YET BEEN GIVEN. 
- 1~ THE MIASMATIC. - 
This name is Given to those infectious diseases,the poison of 
which seems to live outside of the body,apparently in the ground 
or water. If no person come to the places where they are living, 
158 they seem to dr. no harm but, when human beings pass any considerable 
time in the locality of these micro-organisms,. these micro-organisms 
may be taken into the body; hw,by the air or by the water,we do 
not know* These micro-organisms continue to live in the human 
body and,apparently,particularly in the blood where they live, 
grow,and,perhaps,multipiy. After living for some time in the blood, 
they are in some way eliminated hut,in whatever way they are 
eliminated, they are given 6ff in a form which is not capable 
of communicating the disease tn any one else. So, they are not 
Contagious. 
- 2- THE CONTAGIOUS. - 
The nitro-organ!sms do not naturally live and multiply cutside 
the hody. Their natural home is the human body* It is possible 
for' them to continue to live outside the body hut they do not 
brow or multiply* but, if again introduced into another human body, 
they will ■ again grow and multiply* 
These micro-organisms are also eliminated after a while but they 
^re eliminated in a form capable of infecting another human body. 
The precise way in which they are introduce' into Vie nody varies 
^i.th the disease. Thus,in syphilis, the poison has to be intro- 
duced through an abraded surface: in the exanthemata, the poison 
given off from the surface of the body and is probably inhaled. 
159 Generally speaking,in all these diseases,the poison seems to be 
particularly given, off from the character!stic lesion. 
- THE THIRD CLASS. ™ 
These diseases cannot be classed under the other two heading- 
They are Asiatic cholera and typhoid fever* In the^e diseases, 
■the micro-organloFlj^ multiply both within, 
and igjL^hmi^, the body. Whether these poisons always originate in 
the body or whether they may also originate in th • soil or ^ter, 
we do not know* It seems probable that they can originate In both 
ways. Thus a person may go to a place where cholera or typhoid 
fever has never existed in any human body but, if the pniwna 
have existed in the soil or water,he may get the disease- The 
poisons are eliminated in a state capable of producing infection 
in another person,but only in the faecal matter* So, when these 
diseases-are communicated from one person to another,it is only 
by the faecal matter.' The faecal matter has to be swallowed by 
the second patient- The poisons may at once be taken into the 
bodies of healthy persons and,at once produce the disease: or they 
may remain for some time outside of any human body and, then, 
if introduced, will, as be fore-, produce the disease. 
160 Sgj these diseases differ from the miasmatic and the conta^iouy. 
There are other diseases that we must classify under this head- 
ings This is especially true of tuberculosis. The poison of this 
disease apparently lives and multiplies m the air and it is ap- 
Parenfly extensively diffused- Yet,only a few parsons will become 
infected by these micro-organisms. This different susceptibility 
in different persons seems to depend upon the constitution of 
the individual and the'development of an inflammation in some 
Part of the body: then, the micro-organisms enter the body, live, 
^d multiply. 
besides the infectious diseases,^ have to admit of the existence 
°f a class of infectious inflammations. They all have the fol- 
lowing points in common. P'or their development, the part which 
is to become inflamed must be irritated: then, the poison must 
^eaeh this ' irritated and inflamed part. Gonorrhoea is a good 
example of these infectious inflammations. In the same way, a 
k rge number of the suppurative inflammations are infectious, 
it seems to be true both of the infectious diseases and the in- 
fectious inflammations that some persons are more liable to them 
than are others. Why this is,, we do not know. The degree of sus- 
$ePtibility varies with the disease. Thus,almost all people are 
161 liable to small-pox but many can stand exposure to scarlet fever. 
There are certain atmospheric conditions and conditions of the 
soil and water which allow the micro-organisms to grow with es- 
pecial luxuriance. We know that during some summers.,for instance, 
there will be an unusual crop of weeds,mosquitoeu,or potato bugs: 
and,thus,during certain years,we may have an excessive production 
of micro-organisms, There will be certain years when the the 
conditions necessary to their growth will be especially favor- 
able: then,we will have an epidemic and it is generally true that 
during epidemics., the infectious disease will be unuaually severe. 
In some of the infectious diseases,a, single attack seems to 
protect from subsequent attacks. This is particularly true of 
the exanthemata. Why this i$,we do not know. 
162 ^EPIDEMIC CEBEBRO-SPINAL MWNGITIsA- 
is an infectious disease, the characteristic lesion\?f ^ieh, 
an inflammation of the membranes of the bruin. and spinal 
The Inflammation is of the exudative typejit is aceompan* 
with the production of serum, fibrin, and pus. The serum* 
fibTin,and pus are produced in varying quantitiet. They accumulate 
the tissue of the pia mater of the bruin and spinal eord 
Uril between the pin and the brain. Less frequently, they will 
^o eoat the surface of the pia mater. These inflammatory, pro* 
dhets may also be found in the ventricles,particularly in the 
y6 teral ventricles* In children, the ventricles are more apt. to 
inflamed than in adults. In children, the serum will be pro- 
Qbced in large quantity in the ventricles and it will distend 
ventricles. The frequency with whibh the ventricles are 
^feeted in children accounts for the fact that children rive 
^fferent synptomw from those given by adults, 
Iri most casethe inflammatory products tire pi^sent in sufficient 
^^htity to be readily seen at the autopsy. In some cusea,however, 
*1 though the disease proves fatal, the inf lammatory produc ts will 
v 3o scanty that you will not be able to see them with the 
^ked eye but,if you use a microscope,you will find a production' 
163 of pus and new connective-tissue cells. It is also said that it 
is possible for a patient to die without the presence of inflaw* 
watery products, with staple congestinn. This is said, to be par- 
ticularly trie of the very short eases. 
It is only within a few years that attempts have' been made to 
di seaver the miora-organism and , as within these years the .re have 
been no epidemic^lt is difficult to be sure of the results. 
In a moderate number of eases in which the patients died both 
of pneumonia and «e rebro-spinal meningitta,the same micro-organism 
was isolated and cultivated hot from the lungs and the inflaroma- 
t( ry products in the brain. This was the most common micro-organism 
of pneunonta, the diploeoeeus^pnewoniae. In six cases,that have 
died of ce rebro-spinal meningi tta, alone there has been isolated 
and cultivated a micro-organism which resembles the micro- 
organism of paehmonia but is a little different? it has been 
called the diplGeGocus-introcellularis-me^r^ I ids prob- 
able the disease has a specific ndcro-organism but we do 
not know how the disease is communicated nor how it is contracted* 
164 V* 
e know that the disease occurs in epidemics and as , apo radio 
e^^es when there are no epidemics* Now, we on not know whether 
epidemic cases and the yl>nradic cases are examples 'of the 
b^e disease and,when we de have an epidemic, we do not know 
the poison enters the body 'nut we do know that the disease 
not directly communicated from one person to another, that 
is not contagious 
its well«nmrked forms., it has nccured in epidemics and we 
^ve known of these epidemics since the year 1805, It has oocured 
this form both in the United States in Europe. Most of 
epidemics have not lasted, long, The last that occurred in 
York was short in duration* It occurred between the years 
^2 andlRVS, had several hundred cases but the disease was 
Hr j 
*ut very severe, 
epidemics have been more frequent in spring and winter. 
disease iu mors, common in children, oxy perhaps, children are 
r'G;!?e liable tn the infection, Some of the epidemibs have been ' 
Tns*8 severe thah o the vs. The symptoms not exactly the same 
?n all epidemics. In the same countries where we have the epidem* 
a>G^?we also have the sporadic cases from which u considerable 
165 number of the patients recover* Now,whether or not these sporadic 
cases are examples of the same disease,we do not know* 
- SWTOMS. - 
We muo distinguish between the malignant and the ordinary form 
of the disease. This is true of many of the infectious diseases. 
The malignant cases are the less common and belong to the bad 
epidemics* They are not seen in sporadic oases. 
- The Mal i ; ;nan t 0 a s e s•» - 
The patient, in perfect heal th, will suddenly have one or more 
chi 1J. a f s ve 11 b e c one u no on so i bus , wi 11 remain uno b n so i ou s, 
and"Will dT3~in a few be so sudden that the 
patient may fall while walking in the s treat* 
- The Ordinary Cases-. - 
The Aguiar symptoms of the disease may be preceded by a pro- 
dromio peHodo This prodromic period exists in some epidemics 
and is absent in others. In our last epidemic,it was not present. 
The patient comp Iains of a general headache,of some irregular 
pain^nf loss of appetite,of irregular chills,of a little fever, 
and of a little prostration* These symptoms are not sufficient 
to send the patient to bed. This prodromic period lasts several 
days. Then3comes the invasion. 
y- The Invasion* - 
Th& invasion his characterized by a number of symptoms but all 
166 these are not necessarily present in the same ease. These symptomt 
are ehilla, fever, headache, voxel ting, pain and tenderness in the 
nmsdes of the back and neck,pains elsewhere,delirium,and infla®* 
Nation of the conjunctiva* 
•x-chills may be well marked nr they may be slight. They 
are present in rutny cases but they may be absent* /W- 
*->2-Fever is always present but it varies as tn the rapidity 
■Mrith which i»t is developed# In some eases., the fever will reach 
104 in a few hours. In other cases it will not be over loo at 
£irst* 
3" The headache is very common* It is apt to be localized * 
It it most frequently referred to the frontal region bu t, some times, 
It Is referred to the occipital. The headache is apt to be very 
severe-,so severe that the patient feels as though his mental 
faculties were affected by it# 
^4-Vor itirvj during the invasion belongs only tn a moderate 
dumber of the patients It say he moderate or it may be excessive# 
^or twelve nr tMxty-six hours, the patient may vemit nearly 
^verythl-b; tot h$ takes into his stomach# In the well-marked 
^ates of vomiting, the vomiting will resemble that of an acute 
dasiritis nr,of peritonitis and it may lead your attention away 
' fFom the true disease* 
167 -5--The pain and tenlemes^ in the muscles of the hack and 
neck are present in a considerable number of the oases and are 
very characteristic. These two symptoms and the headache, h raw 
your attention to the disease* / 
- 6 - The general pains are the same as those of many invasions. 
■-'7 - Dcl±riui^ or violent,may be one of the first symptoms. 
The mild delirium makes you think of an inflammation of the 
membranes of the brain but,when the delirium is violent, you 
may Luupect acute mania. When the delirium is violent,the patient 
will fight with his attendants,will want to jump out of the window 
and will break things* N$t unfre<xuently, these patients '4 th vio» 
lent delirium are at first supposed to be suffering fw. acute 
man i a» 
- 8-The inflammation o^f the eyes is often present during the 
invasion. It is nothing out a conjunctivitis but it it rather 
cha rac te ri s ti c. 
.- -The patients are apt to look as though they were suffering 
from an infectious disease* This appearance of the patient is 
rather characteristic al though,at first, you may not be able to 
say which infectious disease it is. 
'-10 - There its more or less prostration. The degree of prostratioP 
varies with the severity of the disease. Some patients will stay 
out of bed for twenty^four hours after the invasion* Others, in an 
hour or sn?will go to b^d and stay there. 
The invasion varies in length with the severity of 'the disease. 
If the disease\be severe, the invasion will only last an hour or so# 
_-w- * 
168 Now, the disease is fairly established. The patient is in bed 
he gives the regular symptoms of the disease. These are-- 
' -1 - Th© headache continues and becomes more severe. It is apt 
still to continue as a front&l or occipital headache but it 
^y become so severe that the patient can no longer localize it. 
Xt is awfully severe. It is sometimes continuous: some times, re- 
Mttent* As the patient becomes unconscious, the headache disap* 
Pe&rs nr,at least,he ceases to complain of it. 
" 2 - Delirium does not always belong to the invasion but,when 
the disease is established,either delirium or restlessness and 
sleeplessness are pretty sure to be present. First,come the . _ 
dutiesGuess and sleeplessness: then,the delirium The delirium 
^y be mild or active. Later, the delirium begins to alternate 
^ith stupor and,as the disease goes on,especially if the case do 
^aoly, the patient will p^ss into unconsciousness. 
3- The intelligence is apt to vary with the severity of the 
headache, the severity of the delirium,and the severity of the case. 
milder eases may continue intelligent- for a number of days: 
the sore severe lose their intelligence early. 
' -General eamulvions belong rather tn children than to adulter 
^tyin adults,al though general convulsions are not common,in- 
voluntary eon tractions r-f the muscles, especially of the muscles 
169 of the face are common enough. These muscular contractions may 
bive the patient a very peculiar appearance* 
- 5-the vomiting may continue throughout the disease and it 
may interfere with the nourishment of the patient* 
- 6 - As a rule? the bowels are constipated throughout but, when 
the disease is far advanced,diarrhoea may set to* This is important 
to remember for,as & rule, there is diarrhoea with typhoid fever 
ana constipation with cerebro-spinal meningitis and this helps 
to distinguish between the two diseases but exceptions are common 
enough in both. 
- 7-If pain and tenderness to the muscles of the back and 
neck were present during the invasion, they are apt to continue 
en:Uif they not p re sent, the y are apt to be developed as 
ugou -rj the disease is fairly established. These symptoms are 
not constant but,when they are present, they are a great help 
in making the diagnosis* In some eases,the pain and tenderness 
will r^r^in confined to the muscles of the back and neck and 
the patient will not complain of them unless you touch him* 
In other cases-, the pain and tenderness wil involve the muscles 
of the whole length of the back and the patient will keep very 
'pile t and will complain of any attempt to move him. If the case 
170 more severe, the muscles will become contracted and the patient 
Mil bA to He on one side., curled up backwards and^ii you 
attempt to straighten him, he will complain greatly* 
8- In umy cases.,especially in. the early stages of the dise<.u:a, 
the skin of the whole body may be hweraes the tie* The patient 
Mil complain of the pressue of the bed-clothes. If you take 
hold of the patient anywhere, he will complain* Later, this hyper- 
esthesia disappears* 
-During the early stages of the disease,the hearing is ap t 
to be unnaturally acute* Ths patient will say thuTTxF*^ in&reaiw 
the head^he and resties'mess* Later, the hearing becomes blunted 
^nd,if you speak to the patient,you must speak very loudly and, 
when the patient becomes unconscious,the hearing disappears* 
In some cases, there will be an actual lesion of the ears and 
the patient may recover with more or less permanent deafness* 
10-During the early stages of the disease, the eyes are un* • 
Naturally sensible to light and the room has to be darkened* 
This seems to be due partly to the conjunctivitis and partly to 
54 sensibility of the same kind that affects the hearing* V/hile 
this Increased sensitiveness, to light exists, the pujils are apt 
to be contracted* Later,it disappears and,'.hen the patient passes 
171 Inta unconsciousness^you may bring a can Ue close to his eyes 
and he will not notice it and one ax* both pupils will become 
dilated* 
-11-The eyes are liable to keratitis and choroiditis* The 
conjunctivitis does not continue after recovery. The keratitis 
is apt to jeave opacities on the cornea or it may destroy the 
cornea altogether* The choroiditis is apt to he suppurative and 
as such,it always destroys the sight after recovery* 
Internal strabismus may make its appearance at any time during 
the disease. 
-12-In seme of the epidemics^ an. eruption has been developed 
on the skin. It is sometimes of an brethematous form^a roseola 
of petechial character appearing in blotches not unlike the blotched 
of typhus fever* In some epidemical t will be very marked; in 
others,it will be absent* In some case&5it will be so narked 
as to give the popular name of Spotted fever8 to the diseo.se 
and it has caused the disease to be mi&tahen for typhus fever* 
172 ^hiring the l^st New York epidemic,, there was no eruption. 
13'-At first, the tongue is coated hut moists later, it becomes 
'^ry, brown, and cracked. These changes are usually in proportion 
to the severity of the disease. 
14-During the greater part of the disease, the pulse should 
he rather full,not over 100 and it is often less frequent, 90- 
80-70-6d-or,even,50. This pulse is rather characteristic and 
helps us to make the diagnosis. A patient with a temperature of 
104 and a pulse of 60 is very apt to have meningitis but,in 
typhoid fever, we sometimes have this-very combination. At the 
invasion,it may very veil happen that the pulse may be more rapix 
^nd it will not be until later that the pulse will become slow. 
In bad cases,when the patient gets within a few days of death, the 
Pulse will become rapid and feeble. As an exceptional condition, 
the pulse maybe rapid throughout* 
^15 - The temperature is always elevated but this fever is of 
^n irregular character. It is not usually very high till the 
last days in fatal cases. In ordinary cases, the temperatures are 
®Pt to run between 100-105: in bad caster, the temperature may 
'^each 107. The height of the temperature is not a good guide 
to .the severity of the disease. If a patient have a temperature . 
173 of 104- -throughout the disease,this will he a had symptom hut 
a patient nay run through the disease with a temperature between 
1O-3«1O2 and be an equally bad case* So?a lew temperature is not 
necessarily a favorable symptom* A fall of the temperature is. 
no Indication that the disease is diminishing. So, it is not 
worth while to attach much importance to falls of the temperature 
for the fever will return. . 
-- 16-In the worst stages of the disease^ the patient passes into 
the typhoid state; the face becomes dusky and emaciated^ the tongue 
dry and brown; the pulse,, rai> id and feeble? there are retention 
of urine and involuntary evacuations of faeces?and,in this stage 
without the previous history,! doubt if you can distinguish 
it from typhoid fever, 
- DURATION. - 
In malignant oases, the duration does not exceed a few hours. 
The ordinary cases last from a week to three weeks. The eases 
that recover seldom do so In a week. The symptoms may he prolonged 
for more than three weeks but this is not •ommon* 
There seems to be a great difference in different epidemics 
as tn the predomlnen.ee of the general and local symptoms? in 
other words,, as to whether the patient seems to be suffering 
from an infectious disease or,simply from meningitis. The eruption 
174 most eantoon In those eases in which the infectious character 
of the disease is most marked and the mere severe- the disease-, 
the no re infectious will be its character, 
In the sporadic oases,the patient can hardly be said to look as 
though he were suffering from an Infectious disease and^invoiun^ 
tarllysyeu do not. think of these cases as'anything but examples 
of inflammation of the brain and its membranes, as cases of men* 
in^itiSr 
Some of the cases will begin to improve and will continue to do so 
far one,two,or three days? then, all the symptoms will o-ome back 
^gain. This resembles the relapses of typhoid fever. In some 
of these relapses^ there will seem to be an exciting cause as- 
had itetjthe px-esence of oompany,or the patient nay- h^ 
told some news that will exsite him. Whether or not the relapses 
he really due to these oause1?,V do np;^ know bu t the relapses so 
often follow them that it is be t ter ?to\ take great care of the 
Patient during convalescence, ; 
- When the Disease Occurs In young Children^- 
In young children, the disease may run the same course as in adults 
hut,in some 'of -these case a, there ^11 be fewer symptoms and I 
think -that this is due to the dilatation of Vie ventricles^ 
175 Tile child will have been well; then3he will have general convul* 
ulans succeeded by others at longer or shorter intervals- At 
firsts the child will be all right between the convulsions* but, 
later,he will develop stupor between the convulsions! The pulse 
••will become rapid; the temperature will be very high® In sone 
eases> these will be the only symptoms until a few days before 
de a th- 
- Complications During the Course of the Disease. - 
In some epidemics,the patients condition will bd rendered worse 
by the following complications. 
*-1-There maybe a severe general bronchitis. 
- 2-There my be a lobar pneumonia* 
--'3" There may be one of the forms of pleurisy,generally sub-acW^ 
'-4- There maybe a pericarditis accompanied by the formation 
of fibrin and of a moderate quantity of serum. 
- 5 -There may be an endocarditis which will involve by prefer* 
ence the valves of the left side of the heart. 
The endocarditis and the pneumonia are the most important of these 
•omplicating inflammations. 
-Complications During Convalescence.- 
Some of the patients will convalesce without special difficulty 
at the end of a few weeks but convalescence may be retarded by;* 
- 1-Especially in children and young adults,the inflammation 
of the ventricles may continue and the puiient will suffer from 
chronic hydrocephalus. 
176 The patient begins tn improve? the fever diminishes: the cerebral 
symptoms become lens mailed: and it looks more and more as though 
he were going to get well. Then, the improvement will come to 
* stand still: then, the patient will fall back a little* Then, 
there will -again be a moderate rise of temperature* The patient 
mi seem dull and stupid and-, after a timer, stupor may alternate 
th delirium and restlessness. Therein a few days more, the 
Patient will begin to lose flesh and strength.* So,he may go on 
£or several #eeks. He is very apt to die. The patient may recover 
hut,most frecently?he dies in exhaustion and emaciation* 
^2-- jf the patient have suffered from the inflammations of the 
0ye, these inflammations may persist and damage the eyesight. 
^3--The deafness may become permanent* 
-in some cases-,for months after recovery, there wi$l be a 
Welded mental feebleness* The physical health will improve but 
the mind will remain feeble. As a rula, 'the mind will improve 
^ter a time and the patient will become all right* 
5 -Some of the patients, especially the women will be left 
^^ernic and hysterical* These symptoms may continue Jor years 
yon may have a great deal of trouble in getting them back 
to a healthy condition. In some case&, the hysteria will be so 
177 decided that you may be in doubt whethex' nr nnt some brain lesion 
may be left* As a rule, there is not , 
- 6-The function of menstruation may be disordered^ 
.- 7.- The patient may develop loss of power in some of the vol- 
untary mus^le&ipartisularly the muscles of the arms or legs. 
Ay a rule? this is incomplete and temporary. 
.-g_ jf acute endocarditis have been developed during the course 
of the diseasejit will persist after recovery and it is capable 
of acting just like any ordinary acute endocarditis, 
- PROG WS IS. - 
The prognosis seems tn vary with the severity of the epidemic. 
Some of the epidemics are exceedingly fa tai; others are mild; 
and?be tween these extremespve hc-.ve all sorts of cases. Generally 
speaking?the sporadic eases are less severe than the epidemic 
cases and we expect a good many of the spoi'adie eases tn recover* 
The disease it always serious, 
- TRPMTIOTT. - 
The treatment seems tn resolve itself into the means we can emplojr 
to limit the inflammatory to relieve the 57W tcm.3,,and the general 
nursing of the patim-t* dn not know of any direct treatment 
for the uisease? 
178 - The Nursing* - 
nursing is very important* Put the patient tn bed as booh 
**s possible,even if you are not <xuite sure of your diagnosis, 
^ftr the prognosis is much modified by the time at which the 
Patient goes to bed* Jfeep him absolutely Quiet* Allow an talking 
the room and allow only the nurse to enter the menu 
*^e food must be fluid,milk,gruels,beef*tea,or the juice nf 
ts * 
•-The treatment of the Inflammation*- 
1"-External Applications* - These consist in the local abstraction 
of blood,counter*irritation by means of blisters,and the local 
application of cold* 
^e local abstraction of blood is advisable when the patient is 
Strong and when you see the case early in the disease. 
use of blisters is so disagreeable that it is not much ep- 
^yed and I doubt if it be necessary, 
continuous application of cold is the most generally useful 
^•tient that we have to limit the inflammation. It does no harmr 
not disagreeable,and it is easily carried out. You may 
the ice pillow, ice caps-, or the rubber cnils. Whichever way 
You use it,ynu must see that it is applied thoroughly, an t only 
179 tn the head but tn the buck of the neck and to all the intervening 
parts* This should be be^ih as soon us you are sure of your 
ditgnosis and should he kept up until the patient begins to re* 
cover. 
- The Treatment of the Symptoms,- 
- 1-The Headache uni Restlessness^- These symptoms are often 
greatly benefited by the cold. Still*the cold vill often not 
suffice and it does not seem to be a good 'thing to. let these 30^ 
symptoms go on* Give the bramides,chloral9or .opium and give then 
in pretty fair •loses so as to, make the patient apathetic. When 
the patient passes into coma,you do not have to use these drugs 
any longer. 
- 2-The Fever. - As a rule,the fever does not require any 
treatment. If the temperature be unduly high and if the patient 
do not bear it well,give antifebrm. Cold baths are hardly indi- 
cated. In the sporadic cases,it is uncommon to have to treat the 
temperature. 
For the meningitis^! tsel£,ergot and iodide of potash are given. 
These drugs are of doubtful efficacy. I seldom use them. 
180 In some cases,the heart requires an treatment: hu t, in the more 
severe case^aM in the later st^es of the ■ Usease., the heart 
becomes rapid and feeble. Give alcohol,ei ther alone or combined 
M. th ei.gi tails , cbnvallaria, caffeine., or s tmphan thus. 
^4 - Vomiting at the invasion is often of short duration and 
Squires no treatment but*if it continue, it must be treated. 
Add bicarbonate of sodium or oxalate of cerium to the milk* 
$ive the milk in small doses at frequent intervals. Generally, 
the patient will ^et enough nourishment in this way. 
^5-For the eonstipatinative enemata or laxatives. The patient 
should have a movement from the bowels at least once in two days* 
181 - DIPHTHERIA, - 
This is a contagious,infectious disease, the characteristic lesion 
of which is a croupous inflammation of the mucous membranes of 
the respiratory tract- 
- PATHOLOGY.- 
The mucous membranes most frequently inflamed are those covering 
the tonsils-, the pharynx, the interior of the nose, the larynx, 
the trachea, and the b ronehi. S time s, one some time y ? twn, some times, 
all of these muting membranes will he the seat of a croupous 
inflammation. As a rule, the inflammation will begin on one mu~ 
onus membrane and will then extend and involve all.* Less frequently 
the mucous membrane of the gums,mouth,oesophagus,stomach,or 
vagina will become inflamed and,even if the skin be abraded, it 
my become the seat of a croupous inflammation, 
Wherever it may occur, the inflammation will have the same 
anatomical character. At first? the mucous membrane wi.ll be Gon- 
Uested and swollen. Then, there is an exudation of serum and white 
blood ceils and & diapedisis of red blood corpuscles and we 
get the serum,fibrin,and puS. These inflammatory products infil* 
trate 'the stroma and collect on the free surface and form a 
false membrane. With these changes, there is added a necrosis 
182 pf laxger or smaller portions of the membrane. This nesmsis 
pay be superficial and only involve the epithelial layer 
pr it may involve the whole thickness of the membrane, 
bacteria of various kinds have been found both in the £ Ise 
and in the infiltrated tissue - 
^w^ali the patients do not develop this characteristic 
lesion in the same There is & difference as to. the exact 
bourse that the inflammation will run. 
^-1--The inflamed mucous membrane will be red,congested,and, 
somewhat swollen. It will not be coated with, a continuous layer 
of false membrane. The false ^mbrane will be in patches. 
^2-There will beeongestion and swelling of the mucous membrane 
and the- inflammation. will involve considerable areas but, at first, 
you wi^l not be able to see any false membrane at all. This 
does not mean that no false membrane is there. It means that the 
false membrane is so thin that we cannot see it* We can often 
bee it by using concentrated light and a magnifying glass, 
"it is important to remember this form. 
3-This form i&,perhaps the most common. At first, the inflam* 
^tion will -only involve a small area,a single tonsil or a small 
part-of the pharynx but>although the inflammation is circumscribes, 
$t is intense and,very soon,you see a patch of false membrane. 
183 then, the inf lamination extends but it retains the same character. 
- Complications and Accompanying Inflammations*- 
- 1 - With the inf lamination of the mucous memb pane ? the re may 
be an accompanying inflammation of the surrounding soft part'd 
p< rticularly the salivary glands and the lymphatic glands of the 
neck. These structures become infiltrated with serum?fibrin*and 
pus and they may suppurate*. They become much swollen? The 
loose connective tissue of the neck may also become swollen and 
infiltrated* 
- 3-In some of the cases, the inflammation will extend to the 
bronchi within the lungs. This is the most serious complication, 
broncho-pneumonia. 
- 3-Less frequently* the inflammation will involve the oesoph- 
agus and stomach. This apparently,does not do the patient any 
great harm but it is rather an evidence of increased severity 
o f th e inf lammtv ti on * 
--4-- In almost all cases, there is a mild or severe acute 
nephritis* 
HISTORY AND ETIOLOGY.- 
Apparently the history of the disease has existed many years 
but definite knowledge of it only dates back to 1820 when 
it was first correctly described in France. Since 'that time, 
there have been many epidemics. In New York) the disease was 
seen for the first time in 1752. 
184 Then* the disease disappeared, but returned in 1771* It was not 
then called diphtheria* In 1826, there was another epidemic* 
In 187L, the disease came back to New York and has.never left 
U£ since* It is very common and very fatal* 
Except that the disease is contagious, we know very little about 
Its cause* It remains an endemic disease* It is more common 
In temperate climates but it is not uncommon in any climate. 
The condition of the soil and the closeness of the inhabitants 
Sees to have no influence upon its occurrence. 
It seem tn prevail regularly in epidemics which may 'be localized 
my involve a large part of the country* The epidemic ray 
Involve only a single village or a single house* In large eitie^ 
it seems*to Remain as an endemic disease. 
$he epidemics have occurred everywhere^in all climates and on 
kll soils* It prevails both in hot and cold weather. 
regards the age of the patients, generally speaking children 
^e more susceptible than adults* A very considerable number 
$f the children exposed to the disease will acquire it. It is 
'Tot?however,rtire in adults. Yet,when adults are 'exposed to the 
-iiaeasej they do not take it regularly. This susceptibility in 
Children seems to be true of most epidemics but,in some of the 
185 epidemics,the adults were mere susceptible than the children* 
The specific micro-organism has not as yet been fully determined. 
A considerable number of them have been de scribed, bo th as bacilli 
and cocci but we cannot say that we know the specific micro- 
organism. We do know that the disease is contagious. Very probably 
the poison is situated in the false membrane and the inflammatory 
products* Probably, the micro-organisms are capable of floating 
in the air and are inhaled* We also know that the poison can 
live for a considerable time outside of the body. It will remain 
in the sick room, in the furniture and in the bed-clothes and 
garments of the sick..* We knox? that this is true, for we know that 
people can get the disease from the rnom,bed?or clothing. Whether, 
like the poison of cholera? the poison of diphtheria, can originate 
spontaneously outside of the body? we do not really know. A few 
years ago?it seemed more probable that it could than it does now. 
Now? we can often trace the disease to direct contagion but? in 
some cases,we cannot and',so.?we have to admit the possibility • 
of the spontaneous origination of the poison. 
The disease does not protect against itself« A person may have 
more than one attack of diphtheria. 
It not only attacks people in perfect health but? al so., patients 
186 ^darle^. fever and measles. This we can understand,fnr, 
in these diseases?the respiratory mucous membrane is inflamed 
^nd,probably, by this, the susceptibility to the disease is rendered, 
treater. 
- SYMPTOMS. - 
1 - The inflammation which charucte vizes the disease regularly 
hemins on one of the mucous membranes of* the respiratory tract. 
Hout frequently?it begins on the tonsil or pharynx:also*?on the 
iarynxsalso?oh that of the nose? rarely?on the mucous membrane 
of the trachea and larger bronchi* The inflammation varies as 
to its# intensity?as to the quantity of false membrane? as to 
the rapidity ond extent of its spreading?as tn how Frreat will 
he the infiltration ant swelling of the mucous membrane and as 
to how r;reat will he the inflammation of the salivary glands* 
**^2- in some eases? the invasion will be marked by one or more 
Wll«Tuarked chills* Some times?these chills will be well marked: 
M other time&? they will simply come and 
^3-A fever will be present in some cases?nnt in allQ In this 
respect?diphtheria differs from most of the other infeetious 
iiseases* In most of the infectious diseases?a well-marked febrile 
Movement is the rule. But?even in fatal cases of diphtheria? 
187 there may at no time be a rise of temperature and the temperature 
nay even be below the normal This is of great practical important 
for ft 1? difficult to realize how ill a patient may be with 
no fever. Stil^,in many of the cases, there is a fever, In some 
ease&?it will mark the invasion and will continue throughout the 
whole disease* Em^even in these oases, the temperature will 
often fall before death In other eases, the invasion will be mark^ 
by fever but this fever will only last a few days but this 
.does not necessarily mean that the patient is any better* 
In other eases, there will be no fever at first® it will not be 
until the disease has lasted several days that fever will be 
developed^ These,you must also be on the look-out for,for they 
are by no means the best cases. 
In New York, the fever generally follows one of two types: either, 
it will mark the invasion and will continue throughout the 
disease or it will not be developed for a few days. 
188 ' 3-If the larynx become involved, the patient will,in addition, 
have the symptoms of severe laryngi tis, laryngeal cough, laryngeal 
Voice or loss of voice,and difficulty in breathing. All these 
Symptoms will be best marked in children. 
' 4.- bronchi and lungs may become involved by extension 
of the inflammt; tior^ The extension to the lungs,or the broncho-' 
•pneumonia may be preceded by well-marked or slight laryngitis, 
^hen the patient will look sicker and, ye t, exeep t for the presence 
of ral os, there will be no other symptoms of the ex tension, for 
the symptoms r.f the laryngitis will mask the symptoms of the broncho- 
Pneumonia This is especially apt to be the case in children. 
In adultspit often happens that trie re will be no laryngeal dysp- 
noea, other laryngeal syrqp toms will be present,but you will think 
that the patient is going to do well: then, the patient will look 
^orsn,you will get coarse tales,an! the patient is apt to die 
of the broncho-pneumonia. 
^5 - Vomiting may or may not be present* It may be severe or 
"light* 
^6- As a rule, there is no disturbance ef the bowels but there 
^y be a diarrhnea. 
^7- The less severe the Uiaea»a,so much the stronger will be 
189 the heart and pulse^and vice versa# This, you .will find to be. 
true without being, in any way modified by the presence -or absent 
of fever# These variations of the heart and pulse are the best 
guide to the condition of the patient. In the bad case a, the 
feebleness and rapidity of the heart will be one of the firs^. 
symptoms: in less severe cases, this symptom will not some on till 
late in the disease.. 
The heart is liable to attacks of sudden weakness- Thegpatient 
will have been doing well or bad Im then, suddenly, the heart will 
.become exceedingly feeble and it may even-cease to beat and the 
| patient will, die in a very few minutes. This sudden heart failure 
| occurs,perhaps,more frequently at the commencement of and during 
convalescence .than during the course of the disease,. The grad* 
*al heart failure may occur at either time. 
•-8-The urine will be decreased in quantity, It regularly con* 
tains albumen and i.t may contain hyaline easts. -These, are the, 
evidences of the nephritis which id almost always present, 
■-9~The prostration is often very marked and may be developed 
at any time during the course of the disease. It is one of the 
bad symptoms. No matter how much fever and ne ma tter how bad 
a throat the patient may have:if the heart be 
190 tration- be not marked, the patient will be doing well and, 
Ylee versa. : ; 
When a person recovers from this disease^the convalescence is 
AP t to be long and interrupted by sequelae. This is trte of 
.Wth mild and severe cases* 
^COURSE, ~ 
- The Malignant Cases* - 
These eases are especially common at the commencement and during 
the height of an epidemic. They are less frequent when the disease 
is endemic Theymay.be divided tato two ©lasses, the sthenic 
And. the as then!a. 
1-The Sthenic Cases. - The patient is suddenly attacked 
with the symptoms. At some hour of the day or nighty he will 
feel seriously ill. In children, the invasion is often marked 
^y general convulsions* In adults, there will first be chills, 
i'Then, there will be a sudden rise of temperature, 101-106. With 
the rige of 'temperature, the patient looks seriously ill. Then, 
in a few heuri^eome the local symP toms. Generally, the false 
Membrane appears, firs t, on one tonsiLs then, on the other. Then, 
it spreads ts the soft palate^ forwards towards the mouth and, 
very soon,as you look into the mouth,you will see nothing but 
An enormous mass of false membrane. At first,it will be white 
191 or yellow: then, it becomes brawn. The fever continues* The lymphatic 
and salivary glands of the neck often become so swollen, that 
the patient's head will be forced back. There are changes in the 
urine* Then,restlessness alternates with stupor. Then Bornes 
delirium* Then, the stupor becomes more continuous. The fever 
may fall but the heart will become more rapid and feeble and 
the disease will usually kill the patient by the end of three 
or five days^ 
- 2-The Asthenic Cases.-At first,the patient seems a little 
cut of order. He does not care to eat and he may vomit* The 
tongue is coated. The patient does not care to work or play. 
Blt^at first, there does not seem to be much the matter with him. 
At first, there will be nothing in the throat,nor will the patient 
complain of any pain there and,even if you do look at the throat, 
you will only see a little redness of the pharynx. Then, the 
patient will keep getting worse from day to day* You notice that 
the patient is looking more seriously ill, the heart and pulse 
are getting more feeble^ the mucous membrane and the skin are 
getting dry ^tnd white,and the expression of the patient7 $ face 
alarms vol. Now,if you look in the throat, you will see more 
inflammation^ 
192 you use great care^yeu may see a little false membrane* But* 
^rthougk ik® patient is to di a, the throat symptoms will not be 
^rked. There may be some swelling of the glands which will 
&id you in making the diagnosis/Then? patient will get worse, 
he will spit a thin brewnisk fluid and this fluid will run from 
mouifh^nd nose® These will be all the symptoms* 
^he patient may only last a few days ar he may live a eoupl.e 
weeks, Then^he will become more feeble and will die very- 
Quietly Of ten, the patient will die in the night and he will die 
$$ quietly tkat it may be several hours before his death is 
discovered. 
*hese rases <xre as fatal as the sthenic eases and'they are very 
trouble same for the Physician* You may not make the diagnosis 
at all. up tn the time ©f the patient's death, you may think that 
thex-e is little or nothing the matter with him. 
^hese malignant oases are fatal and,at present^ they are not 
Common in New York.* 
- The Non-mlignant Cases.- 
The Ordinary Cases. - The first symptom is the lesion 
ir* the threat* The patient complains of sore throat and^you see 
193 the false membrane. Wifi the sore throat, there may at first be 
a febrile movement or there may be none at all* Then, the ins 
mation spreads and the false membrane covers a larger and larger 
area* The fever may still be absent or it may appear. Some 
of the patients will vomit: others will have nausea: o thers nil 
simply lose appetite* The prostration varies: some will go to 
bed at once; others will not go to bed at all. Then,in from 
five to ten days^dne of two things may happen. 
h a - The falgxr membrane will come away, the inflammation will 
rub sideband the patient will convalesce# 
* b - Although the inflammation of the throat will subside, the 
inflammation will attack a fresh tract of mueeus memb rana, as 
that of the larynx or of the bronchia 
Xf the larynx be involved, we will get laryngeal symptom^ the 
prostration will be more marked.,and the patient will look much 
sicker. This is very dangerous, especially in young children. 
When the bronchi become involved, the patients get worse in the 
same way. The heart beats more rapidly and the prostration is 
mere narked. As this condition may exist without respiratory 
'Symptomit is easily overlooked. In ether eases,you will get 
well-marked symptoms* As a rule, these cases do badly. 
194 After a few find in all cases of.diphtheria that there 
is a diminution in the quantity of urine ♦ This urhie contains 
^ore &r less albumen and casts. In eases, the nephritis 
$oes not to an^ considerably 
Again^all eases are liable to heart failure* The heart 'failure 
^•y be gradual or the heart may suddenly become wak and stop 
eA together* 
^3-tn these cases,the tonsillitis and pharyngitis are well 
•parked and,yet, the patients do not seem to bo very ill* Tkey 
*av® no fever and no- yro strati on* The patient may be about his 
Ordinary business* For the patient^himself this form of t>e disease 
is pretty good bu>?&8 he.goeB about among.other people and as. 
Perhaps,,he does not know that h^_ has the di'sc*as^>e"is very 
likely to give the disease to other people and il\ase other 
P^opie -f^y contrast the diSMBS in a much worse 
5--These patients have the inflammation of the throat ku t? 
first, they have'-no constitutional syrptomso Thereafter several 
they will suddenly become worse and will be .ill for a lung 
tlm^jus though they had only now developed the disease* 
^4-This course of the disease is especially common in young 
$^ildrene The disease begins in the mucous membrane of the larynx 
195 and it is not until several days fcave passed that w® get any" 
inflammation of the tonsil or pharynx* First? we get the symptoms 
of a laryngitis and? for this reason? the children are often said 
to hate 'croup* .* At first, there maybe no oonsti tutisnal sympwaS 
at all or there nay be a slight fever* The child does net seem 
to be very sick and he eats fairly well* In other eases? the 
fever and prostration will be marked from the firsts At first? 
the laryngeal symp'tow are not st marked but? in two or three days? 
the dyspnoea becomes'more urgent and constant* The child looks 
a good deal sicker and he may develop cerebral sympt©m&?delirium 
alternating with, stupor* So the ease goes on for two or three 
days or longer* S^me,?especially the very young ehildren^die at 
this time* If they five till the seventh day? they stand a much 
better chance of recovery for? now? the false membrane will become 
loosened and may be coughed up* The inflammation may at any time 
, extend and involve the bronchi?in which case, the prognosis will 
; be made worse* In these days? the ease is seldom allowed to run 
to the seventh day: $ra«heotony er intubation is performed* 
5 - Pro trac ted Cases. - These are most cqmmonly seen in adults 
and older children* -* , ' 
196 These eases begin, tike the ox'dinary cases and, as a behave 
the same way for a week or so* At the seventh$ eighth, or ninth 
the inf larnma tion subsides to an extent but^instead of continuing 
to recover^ the parts of the mucous membrane that have been un- 
levered by the expectoration of pieces of the false membrane^ 
S'galn become coated by a new layer of false membrane and the ease 
^y go on for several- weeks in this way* As a rule, these patients 
Recover after a while* 
-- Complications of Convalescence* - 
^il the oases of diphtheria are liable to' the same disturbances 
convalescence and to the same-sequeilae* I do not mean to say 
that all ca^es convalesce badly but somex de* 
^l~The patient may develop paralysis , of some of the muscles 
2^ the body. This is due to an inflammation of some of the per* 
^hexal nerved The muscles most commonly affected are tho^e 
the soft palate^ those of the larynx, those of the pharynx, 
tyose of the eye* 
^hen muscles of the soft palate and pharynx' are paralysed,/ 
ms,y get difficulty in swallowing* 
■^- the muscles of the larynx be affected, the patient's voice 
be affected. 
with, regard to the muscles of the eye^we may have one ef two 
197 eonditions* The recti or the muscles that regulate aceeasdatien 
my be paralysed* Sa, the patient may have internal strabismus 
oz' imperfect vision* These changes in the eyes are very common 
The arm or a leg or the muscles of the face may be paralysed* 
The y&ralysis is not as a rule collet© in all the muscles* 
in some cass^we may find that the muscles of respiration are 
more or less paralysed and We patient may look as though he 
would die of suffocation* 
|Wwst of al 1, the muscles of the heart may be paralysed* When 
| this happens^ We paralysis is generally developed suddenly and 
pls as suddenly followed by death* 
As a rule,, We paralysis of the other muscles is only temporary* 
It lasts for a few weeks or months and, Wen, goes away* 
As a rule. We nephritis does not give much trouble during We 
course of the disease nor during convalescence hut?in ^ome 
the nephritis becomes sub-acute or chronic and will last for a 
long time* 
- PROGNOSIS. - 
The prognosis depends,first,upon the virulence of the poison. 
If the disease runLa severe course^the prognosis will he poor* 
of aoksthe wilder eases do meh better. Age of the patient 
198 a marked influence on the prognosis. The younger the 'patient, 
the prognosis* Adults do much b e 11 e r" than c hi Id re n. 
^nder two years, the disease is very fatal. If the larynx or 
°*onQhi be involved, the prognosis will be very poor. 
- TREATMENT. ~ 
- Preventative Treatment.- 
1 - Remember that .children acquire the disease, very readily* 
sfykeep them away from any exposure* It is not neces^r^to be 
careful with adults* 
-'The poison seems to come from the diseased mucous membrane 
to be exhaled by the patient. So^you must disinfect the pa- 
$tentM breath by washing out his mouth with antiseptic solutions* 
% should be made to expectorate into a vessel containing eorro* 
®ive sublimate and he must not use any handkerchiefs or cloths 
Unless they are afterward disinfected or destroyed* 
3-Remember that the poison may remain in the room,clothing, 
.^®ddingse te^yfor some months after the patient has recovered* 
$$.?yot must disinfect the clothes- by boiling or some other method 
°^if this cannot be done, they must be destroyed. No matter 
. ^at plan you use to disinfect the room, it must be continued* 
for five or six months before the room will be fit for habitation* 
199 - Local Treatment of Diphtheria.- 
To the nose and throat,we can make applications by means of 
'brushes? sprays, vapor a,'gargle a, etc* and we make them with one 
of three objects-, to destroy £he poison, to dissolve the false 
raemb rancor to diminish the severity of the inflammation* 
-r-To Destiny the Poison*--Foi^this purpose,,very energetic means 
were formerly adopted, the applioation of strong solutions of 
nitrate of silver, the mineral acids5or of carbolic acid to the 
false membrane hut it was found that bad instead of good results 
followed * Physicians new use solutions of corrosive sublimate^ 
♦axbolio acid^boracie acid, bromine^ and salicylic acid but they 
are gradually making these solutions weaker and weaker* The 
bichloride of mercury is very good but it must be well diluted 
for a solution of one in three thousand may act as an irritant 
to the inflamed membrane* On the other hand,we can use carbolic 
a^id in stronger solutions with good results* The best of all 
is a solution of boracic acid* Some use iodoform with gnod results 
- To Dissolve the False Membrane. - Steam,pepsin?lime water,etc*. 
. hare .been used for this purpose* 
200 Sut,as a rula, the false membranes to which we can make these 
applications wili eome away of themselves on or about the seventh 
we can not very well apply these methods to the larynx 
when it is inflamed 
^To Reduce the Inflammation*.- We may use with good results 
solutions of iodoform and astringents* 
•^11 these plans of local treatment are only available to the 
^ose and throat* The applications are not easily made to the 
^rynx* 
^hen the larynx is involved and there is danger that the patient 
Mil be. suffocatedjwe have to fall back o^ either intubation 
°r tracheotomy* In comparing the merits of these, operations^ 
M must remember how the child-will die after them. If either 
$$ performed,, and-syet,death follow,we will generally find that 
U is due to broncho-pneumonia* Some of the patients will die 
M the diphtheria,pure and simple* I hardly think that either 
'these operations affects the development of the bro ne hc-^ pneumonia* 
naturally give the prefemece tc the operation which is the 
^ere easily performed and this is intubation* Indeed,many parents 
Mil allow us to perform intubation when they will net allow us 
perform tracheotomy However^you must not think that intubation 
201 is such .a simple operation. It requires some skill to perform 
it as it should be done. 
- General Treatment.- 
Attend w the nursing feeding, and general managemen t* Then, there 
are three plans of constitutional treatment that have been pro* 
posed; 
■-1- Th© alternate administration of the tincture of the ehlo* 
ride of iron and ef chloride of potash. First, give m.v*m.x of 
the tinetux^e of the chloride of iron,according to the age of th© 
patients Therein an hour^give grs.iij-grs.v of the chloride of 
potash* Therein an hou^retum to the chloride of iron. 
- 2^-The second plan consists in the administration of large 
doses of alcohol as we give opium in peritonitis. Give it in 
the form of whiskey or brandy in large doses well diluted and 
keeg the patient continuously under its influence./Z/ 
- 5" The third plan consists in giving the bichloride of mercury 
in large doses^gr*VoO-gr.vlo well diluted and repeated every 
one or two hours for some days,. 
The plan of const!tutional treatment chosen will defend upon 
the physician Some physicians rely greatly on drugs: others 
prefer little drugging and leave the case more to nature. So, 
some physicians use one plan;ethers use an other. 
202 X know very well what plan nf treatment I adopt, la eases »f 
diphtheria but^as my plan of treatment would probably ©nly be 
eensxdered geea oy myself^ I will not tell it to yeu but will 
leave you to choose one of the other plans. 
203 - ASIATIC CHOLERA. - 
This is an infectious disease characterized by-vofeiting-purring 
cramps and a disposition to collapse. 
The- disease has been endemic in India for same yearso Outside 
>f India-, it only ocOurs in epidemics. These epidemics have 
been of various length and severity. Sa farther© have been 
five ,$f these epidemics. The first comeenced in India and last^ 
/from 1817*162 3: it spread to the countries immediately around 
Jndia but-it. got nt further. 
fte second lasted from 1826-18 37. At first,it was confined to 
India* and the, surrounding countries but,after a tim^lt covered 
nearly tMe whole surface of the globe. 
The third lasted frtm 1846-186 3. It also involved many countries1 
TMe interval between the third and fourth epidemics was very 
short The fourth commenced in the latter part of 186 3 and lasted 
until 1875. .During this epidemio, the disease made its appearance 
in New York^ 1856-1867obut the disease was not of a very bad type* 
At the ^ame tJme-3 the disease located itself in the valley of 
ths Mississippi and,particularly,at Memphis. ' 
The disease again disappeared until 1883. 
- HISTORY AND ETIOLOGY.- 
204 fifth epidemic started in Egypt in 1883 and it 1b still 
going on, In 1884?, it reached France; in 1885,Spain was the seat 
the disease: and in 1886 and 1887,, Hungary and Italy were attacked 
^nd?in these countries the disease is still going on. So far^ 
the United States have escaped this epidemic but, from what we 
knew of former epidemics-? we may expect to find the disease here 
axsn* 
So, we see that the disease seems to originate in India and it 
is carried,principally by human beings from its home te vaxdeus 
of the world* Whether or not the disease can be conveyed 
from one place to another by means of rags, eld clothe a, and paper, 
do.not know and this point is not yet definitely settled. 
$t is possible for the disease to get into a country and? yet, it 
>ay not spread. The conditions necessary for its spreading are 
dirty habits on the parts? of the inhabitants and a disposition 
tr* diarrhoea. A person may swallow the poison with impuni ty 
if his stomachs and intestines be in good senditi©nrfcr he will 
hot get the disease. 
- The Poison.- 
The poison has been isolated and it has been very well studied^ 
-t neems be a specific micro-organism and it is known as the 
Jam bacillus* It was discovered in IBM by a Geraan» 
205 The micro*organism will grew and multiply in the intestinal trae^ 
and this seems te be a very favorable soil for it. The micro- 
organisms are apt to be destroyed by.the gastric, juice and?for 
this reason, they do not get on well in the stomach. 
Growing and multiplying, in the in te s tine, the micro-organism acts 
fas a direct irritant* The irritation which it produces is soon 
followed oy a transudation off serum in large quantities. This 
I is the «au$e of tne watery stools* in rsme aase&,we may find 
an actual inflammation of the intestine. The mi ere- organism 
remins in the intestine until it is discharged with the stools 
ar^in exceptional ease^by the vomit® The mi arc-organism is not 
I found in-the urine, breath? or sputa;notr are they given off from 
the skin." 
* These micro-organisms grow and multiply outside of the body? 
an moist surfaces, moist linen, gelatin, polluted water, in damp 
par th? and in warm moist soils. They are destroyed by dryness, 
j hea boi 1 dug, s treng aeids, e speje.ial 1 y mineral aaids, and by s trong 
* solutions of corrosive sublimate and carbolic acid. 
In ordei' that a. person should get the disease?it is necessary 
that the poison be voided with the faeces of a patient and, then, 
in some way^be taken into and lodged in the alimentary wanal of 
206 the person in ordinary health- 
- PATHOLOGY. 
only oharas teristic lesion is- the- condition'of wh inte-stin^ 
to the presence ef the cholera < There may be no . " 
Change at all in the mucous membrane and- alt we k&j find wilj - ' 
°e the watery^ or 'rice-water* discharges containing Me'-peisch ' 
»$ -,b 
suspend on& In Giner eases, the mucous membrane will be pale, 
-It maybe congested,or it jay be inflamed* 
• ®^en a person dies of this disease either in the stage of invasion 
| Q> in the'stage of collapse^ the re ap t te be a xd^e &f. temper** 
; ^ture af ter death. The rigor mortis soon fellows and .Xasi^ for 
$su®h longer time than is u^ual« Ihe skin is dWk^pBl gra^l^h^ 
*XQ 1 py-Q w f iage and toes sonn "become P VX*P 1 ^th;«• The 
^hpia body 1> shriveled. • .. 
the Minuses of the dnra c^ter and in some of its '1'argertveins, 
^e will find that the blood is dense and - thiclu 
x^e pia matei4 may be normal,oi' it may be infiltrated wxth geru*% 
n- the're may be extravasations of blood into its subs tance^or 
may be inflamed. .. ■ '' ' 
^ese inflammatory conditions ai'© most frequently met wlht when : 
Patient dies in the stage of reaction* 
207 The lungs may become anaemic or they may he the seat of 
commencing inflammation^ 
The heart is generally found to be normal* 
The peritoneum may be slightly inflamed. 
^The mucous membrane of the stomach may he the seat of a catarrhal 
inflammation or it may be pale or it may be normal. 
The colon may he normal or it may be inflamed. In our last epi- 
demic 1866, the colon was inflamed. ■ ; 
The kidneys are generally the seat of a parenchymatous nephritis* 
Inflammatory conditions are mo^st apt to be found in patients 
who have died during the stage of reaction. In these cases, the 
pia and larynx will be inflamed* There will be a pleurisy with 
effusion and the stomach and intestine are generally inflamed. 
- SYMPTOMS. - 
The symptoms are not very nwerous. For convenience, they are 
divided into four stages. ' 
208 - 1 ■- The Stage of Invasion. -* 
The invasion my take one of two forms. 
Form. - The patient is -going about in his ordinary health 
^hen he suddenly has pains in the abdomen, a number of loose 
Pascal movemen island he may have attacks of vomiting. The pains 
colicky and there are s tiffish,,cramp-like contractions of 
the muscles of the abdomen* When this stage begins in this way, 
it may be of short duration., half-an-hour. • - 
Second ^orm. - The patient has an ordinary diarrhoea with. 
Wo- $ th re or four loose passages dally. On the next day, the pas* 
$ages are more numerous and the patient does not feel as well*/- 
Ye^he has no regular pains and he goes on in this way for some 
days or,, even a week gradually getting worse* 
- Second. S tage. ~ <> 
This stag© is the same in all the jpatipnts* It differs only 
in regard to its severity. The diarrhoea continues and the 
passages are like thickened water containing white particles 
in suspension. These are the 1 rice-water1 discharges of •helera* 
They my be light or dark colored* The movements frequent 
and large and the patient loses a great deal of fluid from the 
My. The vomiting %till continues and whatever i? taken into 
209 the stoniath is thrown off* We may have 'rice-wa ter •vomiting, 
The patient will he very thirsty and will want to drink all the 
time. There may be painful cramps of the muscles of the legs 
and abdomen. The temperature falls below the normal and the heart 
and pulse become rapid and feeble. The face is anxious and pinched 
The urine is diminished in quantity* 
The duration of this stage is from three to fifteen hours. The 
patient may die or^at the end of the second s tage^ improvement 
may take place or he may pass on to the third stage. , - 
- 3- The Stage of Collapse.^- <3^ 
The vomiting and purging still continue but are not as severe. 
The cramps continue. The heart becomes more feeble. The radial 
pulse may disappear and you may have to yut yoiir ear to the 
chest to see if the heart still beats. The skin is dusky and 
shriveled. The mucous membranes are pale. The patient is very 
feeble. The urine is diminished in quantity. The temperature 
falls still lower. There are restlessness and sleeplessness^ 
grec>,t thirsty and complete exhaustion* 
As a rula, this stage does not last longer than twenty-four hours 
anJtin it most of the patients die. 
210 ^4™ The Stage of Reaction*-- 
Paring thi^ Biaggi t seesM as though the system were trying to 
hoover itd&lf but? as a rul$$ the attempt is unsu®&#oful» The 
^witmg and purging stop and the qawi hack to the 
$orwl* trouble tn ih^i the temperature d$w not atop the 
formal but ^c^tlaue# iato a w^ll-markod fevexy 1^'1^ that 
are mo^t apt to have the inflammatory aondi tions* 
PROG POU X.S» 
Mell the ismasion be slw &M W thus ft ^hanee H treat - 
the pfttient before the see^ni ^tage is developed^ the pro-gr^sts will 
cad for^after the ce^ond etft^e is devclopedjwe can do ne tiling 
toi ^jie tcr'u.in.ation of the eaee will depend upon the constitution 
MM vitality ©f the patient* , 
- THMMW. ~ 
fee wft Important thing to prevent the spread of the disease 
by q^rantine butyls ma Hex* of faotjthis is net vexy sues esisful 
the disease do^s spread* 
Aftex- the disease has gotten into a country,we can try to prevent 
it from spreading still further* Rewxobes, that the poison is 
In the intestine and is discharged with the faeces and,except- 
ionally by the vomit® Sai we must attend to the stools of th^ 
211 patient. If you renerhor how sick the patient if^you will see 
that it is very difficult to manage this. The movements oome 
on suddenly without warning and the bed-clothes*night shbrt,and 
the patient^s body are covered with the faecal matter. Ths 
disease may be acquired by drinking water in which the clothes . 
have been washed. The discharges should be •ollected in $uit« 
able vessels containing corrosive sublimate or strong solutions 
of caroolic acid before being washed. The body of the patient 
should be washed two or three times a day with antiseptic so- 
lutions. The physicians and the nurses should wear rubber glovers 
and should wash their hand^ frequently in corrosive sublimate* 
for the disease is often taken by nurses getting the poison 
on their hands and,, then*putting their hands to their mouths. 
If we see the case early and if the invasion be slow^we E^ay try 
to abort tl<e disease. Put the patient tn bed and restrict the 
diet. Then,give a mild and pre^t laxative. Thea,give opium 
or opium with the mineral acids. 
212 is an infectious disease which seems to resemble ehelera in that 
^•t seems to be endemic in sone parts of the world and that it 
is only by importation that it gets to other parts. Still,it 
^a-s never travelled in the same way that cholera has:it has 
gone as fap, Xt is endemic in the West Indies on the Gulf 
pf Mexic&?and in some places on the west coast of Africa. In 
these places., it prevails regularly every year. In order to pre* 
vail anywhere else,it has to be carried. It has been frequently 
carried to the southern parts of 'the United States. It has also 
keen carried up the Mississippi. Less frequently, it has been, 
tarried to the northern parts of the United States,even as far 
?^inc hut it is now a considerable number of years since it 
Uhm been carried to the northern parts of the United States. 
H has been carried to South America and Spain. In all. these case#, 
Si seems to have been transported by ships containing either 
er infected clothing. ¥/hen it has get ten inU a ceuntr^ 
•^t requires tolerably favorable c$nditi$&s to take reet and spread* 
Jt requires a regular temperature of at least 70 F». It is mere 
likely to spread where the habits of the people are ddrt^wi33?e 
water is feul<where there is crowding, insufficient 
- YEJ/LOV/ F.WTt. - 
213 and inattention to privies. Almost every year, yellow fever 
is bought to New York. Spme», the larger number of the eases are 
stopped, at quarantine. Some do slip through, yet, it is a great 
many years since we have had anything like an epidemic* 
The inhabitants of the plates of its habitat are not nearly as 
liable to the disease as are visitors who are almost certain 
to get the disease if it prevail. Some natives seem to be unable 
te take its this is true of a great many. 
To a tertain extent, the disease protects against itself. It 
does no* do so absolutely but it,is rare for a person to have 
it twite. 
Cities are more liable to the disease than are country places 
and unal! towns. Negroes are less liable to the disease than X* 
are white people. 
As yet,wo have no exact knowledge as to what the poison is nor 
in what part of the body it is to be found. It seems probable 
that the disease is caused by the entrance of a micro-organism 
but we. do net know in what part of the body it grows and multiple 
It would seen probable that the special place in which the poison 
is to be sought is the liver.for the most characteristic lesion 
is in th* liver and the rule is that the poison is to be founds 
214 the seat of the characteristic lesion. ti , 
■^re seems to be ne question that th® disease can be carried 
vx*0Xa place to place* Apparentlywe would never have it in New . 
unless it were brought here* The disease can be transmitted 
rom one person to another* ''The disease can also be carried. 
? redding and clothing that have been in contact with yellow 
tether the poison is given off from the skin-or by the faeces 
^d urina?we de net know but it is given off* We do not know 
people acquire- it? whether they inhale or swallow the poison • 
the disease ean be communicated to a great many people., 
susceptibility t® the disease is very great* If it be 
x^trodueed into a city under favorable eonditi^ns^it will attack 
^.ny people. Yellow fever is especially fatal te Physicians 
and nurses* 
- PATHOLOGY- - 
^he only thing that seems to constitute anything like a charac* 
Kristi® l^sien is the change in the-liver. This is present in 
^11 the casese The liver cells are affected. 'Their composition 
is changed. At first* they ar© swollen? then, they break down* 
lit other wo rd»j the liver is the seat of acute* parenchysaatous 
215 hepatitis* The cells may only be swollen or they may die* The 
liver changes to a yellow color. In other wordthe liver re^e-m^ 
bles the liver of acute yellow atrophy.* 
We also find very regularly an acute parenchymatous nephritis. 
The kidneys will be increased in size, the i*enal epithelium 'wTlI~ 
desquamm^te,, and, some times, cast matter and blood will be found 
in the tubules* 
•The only other characteristic change is the tendency to haemorr- 
hage. The lungs will be congested. The stomach will be con- 
gested and eechymcsed and there will be blood in. the stomach. 
There will be blood in the intestine and extravasations of blo&d 
in the skin. In fact, there maybe haemorrhages almost anywhere. * 
We expect to find jaundice of all the tissues of the body, 
- Period of Incubation.- 
When a person is exposed to yellew fever, there seem^/t© be a 
great deal of variety as to the length of the'period ef incubati^ 
As we do not know how the poison ig taken in, we do net really 
know when a person is exposed. In some cases, the leng th, of 
the period of incubation will be several hours? in o ther&, several 
days?and,in ethers,several weeks. All these lengths of the peid^ 
.. -■ 
of incubation have been stated. 
216 d© mboM about the period of intubation. 
' *. *-^rws9- ■' 
- The Invasion* -- 
In mast aaseSjthe invasion is sudden but, occasionally, it is 
gradual and occupies several days- ' * 
If the invasion be gradual, the patient will at first complain 
of -headachy vertigo, sleeplessness and restlessness at'hight,/^%S'y 
de lust $n&$ less of appe tits, or, perhaps, vomiting but he will not 
be sick enough to go to bed. H® will have one pr more of these 
Symptoms. 
If^as is mere common, the invasion be sudden the patient will 
at ahce be attacked by chills, and a febrile movement* In some 
eases,, the invasion will be even more decided and will be ushered 
in by.©ne ©r mere general convulsions If the disease begin with 
$©nvulslon&, the fever will als® be present* * The fever io vexy 
tens tan t and the patients vary principally as to haw high it will 
be* In most eases*,during the first twenty*four hnur&,it will not 
be higher than 102: in the worst eases^if^ill reach llGsand, 
between theses there are all sorts of variations in the height 
«f the temperature* Seethe fever is high, impox* tan t, and constant* 
In many eases,with th© fevers, the pulse will be full during the 
first few days,,80-120,like the pulse of pnpumonia* 
217 In other eases,, the pulse,while full,will not be increased in 
rapidity. It will be slow like the pulse of meningitis- 
The patient is apt to have a severe and distressing headache 
and pains in the back and limbs. He suffers from .restlessness 
^nd sleeplessness. He may have delusions and fancy that he 
secs things that do not exist. He may have delirium* There will 
be nausea and the patient will vomit the contents of the stomach 
and mucus. As a rule., the bowels are constipated* The face is 
flushed. The tongue is coated. The urine contains albumen and 
casts. As yet, there is no jaundice. This is the stage of invasion, 
or the first stage and it lasts from two io si u days* It odeas* 
ionally happens during this stage that, al though the patient is 
sldkjf.br some reason or 0then,he is not much prostrated and doe5 
not go to bed. These are called the 4walking casesa of yellow 
fever. In this respect, the disease resembles tyju^id fever and 
pneumonia. As a rule., the patients do go to bed. 
- Second Stage. - 
Now, the pain in the head and in other parts diminishes. The 
temperature falls either nearly or quite to the normal. The 
pulse.will become quite normal or about normal and the 
patient will look better in every way. The restlessness, s tupor, 
and delirium will diminish. 
218 nausea and vomiting will stop. This change takes .place' in 
a few hours. In favorable cases, the patient will go on to 
convalescence and recovei'y and this seems to be the time for 
kim to recover if he ever intend to do so* 
the bad cases, the second stage will last a day or two days 
^Hd, then, the patient will rapidl^ydevelop' a new set of symptoms^ 
tie symptoms of the third stage. 
- «fhi rd S tage. - • 
lh'e vomiting will return and will be more severe. The jaundice 
*111 make its appearance. The patient will become dull and stupid 
^ud will get more and more into complete stupor. The disposition 
to bleeding is present. The patient may vomit blood that has 
keen acted upon by the gastric juice and is black and grumous, . 
the 'black vomit®* There may be bleeding from the .intestine 
^d blood will be passed with the stools* There may be bleeding 
f£om the nose,, from the kidneys^ and from the bladder and blind 
win 
be passed in the urine. There may be haemorrhages into the 
s^in and the skin will'be mottled. The changes in the kidneys 
*ill become more marked: the urine will become scanty and it may 
suppressed. The stumor or the stupor alternating with delirium 
*ill become more decided. The heart will become more rapid and 
219 feeble and,as «a .rule, the patient dies* 
If the patient is to recover, either after the first or second 
stage., the convalescence is,as a rule, rapid and not attended 
by complications. The whole disease is short and acute. Hie 
whole mortality is very large and,generally speaking,it is 
one of the worst of ' the infectious diseases. 
In trying to prevent the spread of the disease.,we are hampered 
by not knowing much about the poison* The best we can do is to 
isolate the patient and destroy his clothing. Whether or not 
the faeces and urine of the patient are capable of conveying 
the diseasa,wC- do not know, sa,it is better to disinfect them 
as we do in cholera. 
- TREATMENT. - • . 
I confess that 1 do not feel at all qualified io say much about 
the treatment of yellow fever* We know hardly anything of the 
disease in New York. I have not seen more than three or four 
cases. The best' that I can do is to give you the experience of 
others and the experience o£ those physicians that have had . 
the most to do with the disease is that there is no treatment 
of practical efficacy. The treatment differs in each place in 
which the disease occurs. So the treatment is mainly symptomatic 
Temperatures of 110 are dangerous and,if the temperature get 
above 104>, you should reduce it by applying cold in some way to 
the surface of the body. 
220 ^e reduction of the temperature by drugs is not indicated. 
headache and pains are often marked and it would seem proper 
to try to control them. During the first stage, the heart is 
$Ocd and you may use the bromides,.chloral,or,even,opium. 
i0 control the vomiting!;-* Keep the patient on fluid diet,milk, 
^Pio^i^ed milk,milk with bicarbonate of soda,or milk with oxalate 
cerium,or milk alternated with beef tea<' 
scanty urine occurs during the third stage and you can not 
much for the kidneys® In the third staga?I doubt if you can 
anything but feed and nurese the patient and give stimulants* 
221 TYPHUS 
This disease is also called exanthematous typhus fever,putrid, 
feven7>amp fever,jail fever,ship fever,and spotted fever. 
- HISTORY AND ETIOLOGY. - 
Typhus fever is a disease that always exists in some countries , 
rather than in others.and the countries of its preference are <> / 
Ireland,England,and Russia.'in these countries, it exists every 
year. If'do^s not' seem to havela regular home,as cholera and 
yellow fever do. There seems to be no reason why the disease 
should not prevail and remain anywhere but it is most steady 
in Ireland,England,and Russia. When there are wars and famines 
and where people are overcrowded, the disease is especially apt 
to prevail. In o^her words,it is associated with overcrowding 
and bad feeding. 
When there have been wars and famines, it has prevailed in all 
part3 of Europe. in, the United States,we have had a moderate 
amount of the disease. Here,it has prevailed mostly in epidemics 
and has been due to importation. The last epidemic in New York 
cccurcd in 1865*1864. Then, there was a great deal of the disease* 
In Hellenic,alone tlyerc were five wards filled with cases. 
Since then,we have had occasional cases. In 1882^ there were a 
222 ^^iderable number nf cases hut nothing like an epidemic* 
^eV;Sn far as we can see, there is no reason why we should not 
the disease here at any tine. 
TWus fever prefers young penpie. Of course,people nf any age 
^y have the disease but fully one-half the cases occur between 
^e a^es of ten, an- thirty years. The season nf the year seems 
have no Influence upon the occurrence of the disease except, 
^rhaps, that in winter people are more apt to-be crowded together. 
disease has a poison of its own* What this poison lstwe do 
n°t>as yetjknnw but it seems evident that the disease is oonta* 
Sinus and that the poison is given off by the skin and is inhaled. 
typhus fever belongs directly to the class nf contagious 
ideations diseases and resembles ue exanthemata. We find that 
^e poison will live for a considerable time in cinching and 
Wring which the patient has uyed. Still,for the umst part, 
^■e disease is transmitted by direct ''xpn&ure. Those who are 
specially liable to the disease t.i'O those that are exposed to 
U for the longest time. Sn?nurses and physicians are very liable 
to it» It is found that persons previously badly fed will 
a°ntract the disease more readily than people in perfect health. 
virulence of the poison is increased by crowding patients 
223 toge'thex'e If there he but one patient in a we 11-ventilated roe®, 
all the attendants may very well escape. The disease protests 
against itself in a good many patients. It does net always 
do so but it is very uncommon for a person to have it twice.. 
Whether or not the disease san originate outside the body, 
we da not knew. It is very possible that it may do so. Of th® 
cases that o®eur in New Y®x'k,most seem t® be du® to direst 
eon tagion. 
The ordinary period of incubation seems to be fro® eight te 
twelve days but we find a ^ood many oasts in whieh the length 
of the period incubation is different. Thus,in some cases, 
it will be but a few hours and the history of these eases is 
so straight-forward that I think we must admit that they are 
true. We have histories of oases in which the period of incuba- 
tion was j^erxtyrone days. It seems possible that these eases 
might have had this long period of incubation but I do not think 
them as probable as the oases with the short period of incubation 
The only aharacteristie lesion is the eruption &ut,in addition 
to this^we find a number of morbid conditions. 
- 1 -We may have the lesions of acute meningitis. 
- PATHOLOGY. - 
224 ^2-- The throat, pharynx, and larynx maybe the seat of a catarrhal 
011 croupous Inflammation. 
In the stor^ch and intestines, we may find a catarrhal 
xnt lamm txon» 
-In the lungs,we may have a Gongestion,hmnehi ids, or broncho* 
Vs -rwwwm^ 
Pneumonia. 
^5--The kidneys my be inflamed* 
We my find changes in the heart muscle which may be 
e i the r de gene ra tIve c- r inf lamma tn ry. • 
^7--In the muscles of the body,we may have changes which may* 
either be called inflammatory or degenerative.. 
- blNrrOMb, t 
1 - There is regularly a change in. the appearance of the 
^MienV^ face and thiu change is somewhat eharac terleiia^ 
during the fiwt wek^nnleHS the delirium be marked, the cypres* 
uion of the face is dull and uninteresting* patient is in : 
kS'Cand doeb- -uo t seem to have any vivid conselnTHWiess of whaf 
is going There is a general ^-nge^ien of the skin of the 
£^ee and often of the ennjunc-Liva- For the po3t part, this is a ' 
XSlpous congestion an-' the face is dusky and Urrid. At this ti^e^ 
the face is not emaoia?ted aad the che^riUt are not fallen 
/ ■ . . _ .<z 
225 During the second week,the face has the appearance of the typhoid 
state* The congestion still continues* Now, the face shows eaa- 
eiation* The cheeks fall in* The lips are dry and'coated with 
sordes. The appearance of the patient's fate is always one of 
the factors in making the diagnosis., especially during the first- 
week of the disease* In the second week, the patient's face re-sem* 
hies the face, of a patient suffering from typhoid fever or 
any other infectious disease* 
*-2 - At first, the tongue is coated with a thick white fur and., 
the tongue is moist. La ten, it becomes dryer and dryer and change? 
to a brown color and may be fissured or cracked. The lips are' . 
also brown,dry,and cracked *' 
- 3-The eruption is very cons-bant. It is not always present 
to the same extent and there seems to be a variety in'different' 
epidemics as to the extent of the eruption. It regularly makes . . 
its appearance, between the fourth and seventh days of the di,sease' 
It appears, in.. a single crop which may last from seven to ten , 
days? and; then5fades away. It is mo^t commonly in the form of ' 
pound or irregular spots and blotches not unlike those of measles 
Th^ eruption appears on the arm^body,and legs. Ai firsts it is 
a light pink; then,it becomes darker. -In »oae c awes, it will 
226 be dark at the beginning. In addition there may be a deep mottling 
of the skinedue to Memorrhages into its sub stance? This Bottling 
. will io be situated deep down in the skin and it'will 
be irregular. It looks not unlike the mottling that we see 
°n corpses in warm weather* 
In some $ase&$ there will be a general ere them tons blotch. 
When the eruption has subsided,it is regularly followed by des- 
QUamma&ion and this desquamation is in proportion to the extent 
of the eruption. 
fever is always decided. From the commencement of the 
disease the temperature at ones runs up pretty rapidly.. In 
Meet reashes its maximum from the second to the tenth 
day, Most frequently?it-is highest between the fourth and seventh- 
days. In bad oase% the temperature will be very high by twelve 
or twenty-four hours# At first, the fever is pretty continuous. 
This is the case for the first week. In the second week^ the 
fever will not infrequently remit in the morning and^if the 
^seis to terminate favorably, about the fourteenth da^ th® 
temperature will suddenly fall and will not rise again. In1 
bad oasse^ there will be no remissions of the temperature. 
^5~The wise is subjest to a good deal of Variety* In some 
227 it will be 100 and,at first,full. The first sound of the heart 
trill be distinct. Later,it will become mere rapid and feeble 
but it will not be bad at any time. This is the character that 
the pulse vill often have in roild cases. 
In basi eases.,it will be rapid and feeble throughout a large 
part of the disease. 
In other cases,the pulse will be slew and feeble. This is not 
at all like the pulse of cerebre-spinal meningitis,which is slow 
and. full. 
With the feeble heiirt.either rapid or slow,.the first sound 
will be much loss long,much less loud,and much less distinct 
and it may bery well happen that this change in the first sound 
of the heart will precede any weakness of the pulse. Sa,it is 
the rule to listen to the heart every day in order to be ready 
for heart failure. 
- 6--At first,we have no symptoms from the lungs. VTith the 
high temperature, there may be rapid breathing but that is all.. 
Later,,if there bo extreme congestion and oedema, the breathing 
will be insufficient and this will help to kill the patient. 
If bronchitis or pneumonia be developed,you will get their 
physical signs and rapid breathing. These inflammatory lesions 
of the lungs beleng to the second week of the disease 
228 7-also belongs to the seo©nd week but-it gives 
no ror the patient already has cerebral sy^toms 
the- exists nee cf the meningitis may not be found out till 
Mier deaths 
*"'■'•8-A« a Tula, the stomach wi. 11 not be disturb e d» The pa t ten ts 
Xos& appetite and they may vomit simply as some patients vosit 
$rom any disease^ 
* -Aa- a rule^ the bowels are odhstipated till near the elese 
th* disea^^wher^ there will be. diarrhoea or invc-luniary evae* 
l&ti-mw bit ^aeoeop A patient iaay have diarrhoea throughout the 
.^nd^.wl^n thi^ o^un^ii is undo3? ia5.for it makes 
the disease harder to distinguish fwm typhoid fever* 
Sidneys are regularly InflaMd* In wat easea, this 
nephritis will not be severe and will only cause 
to appear in the urine* Occasionally it will 
more severe and the patient will be mde wrse® The urine 
.^lll be ed in quantity and it saay even be sugarsssed> 
v1® patient will h&ve ber,ebral ©specdaily a»Bvulsi®ns* 
^hen we liava this severe nephriti&> which is seldom it eeeurw 
Uie 528^^4 third weel of Vie disease^ 
^11^ Aho e^pte^ are always marked^and you 
229 often have difficulty in distinguishing the disease from menin* 
gitis. The cerebral symptoms are the same in ho th,delirium 
alternating with s tup or, dreams, and delusions. The delirium, 
if marked^vuries as to the time at which it is worse. In a 
moderate number of the eases, it will be violent from the outset 
of the disease. The patient will want to jump out of bed:he 
will try to break things: and he will try to assault people. 
In other cases., and in the larher number of eases,it will not 
be worst until the end of the first week. Generally speaking, 
the de^imm is worse at night than during the day time. Then, 
the delirium occupies less and less of the twenty four hours 
and the stupor more and more and, in the second week, the patient 
will pass into pretty profound stupor. About the only voluntary 
ust you will be able to get him to do is to swallow but,when 
he passes into the full condition of unconsciousness,this also 
disappears. 
In a fee cases,the patient developes the lcema vigil1. The patient 
will be in stupor but his eyes will be wile open. The pulse will 
be rapid and feeble: the breathing, quick and shallow: the surface, 
sold: and the patient will resemble a patient in collapse. The 
insensibility of the patient to what is going on about him 
230 is rendered mo to marked by his staring eyes. 
Headache comes on early and is very constant. It continues 
until the profound stupor. If is often as severe as the headache 
°f cerebrospinal meningitis 
*** 12 - There are pains in the back and limbs as in many of the 
Severer dise ase s. 
***13-The patient loses appetite but does not often vomit. 
"**14-Inmost cases,there is not distension of the intestines 
^i+h gas as there is in typhoid fever but,in some cases of 
iyphus,it may take place during the second week. 
"**15 -The prostration is marked from the outset but it will 
unt be as evident if the delirium be marked. Then,it is often 
difficult to restrain the patient and he may act as though he 
^ure very strongsbutsif the delirium be not marked? the pmytra* 
lion will be very decided and,in the second week of the disease, 
j the prostration is usually very marked. 
j 16- Some of the patients will have muscular tremor. Other 
Patients will have involuntary contractions of the muscles of 
ihe face as in acute meningitis. In other patients,we will have 
automatic movements of the limbs. 
17-During the second week, there 4s often paralysis of the 
231 ^phineter muscles 'of the pharynx,rcetur^and bladder. This causes 
TetenTToh of urdne^involuntary evaluations of faeces, and diffi- 
culty is swallowinga 
- COURSE* 
In some of the patients, the invasion is preceded by a prodromic 
^erind which last& from one tn seven da3^. During this time* 
the patient complains of lassitu#^ lassi tudyheadand dis- ;,• 
^Iness. Whether it have existed nr nc:t?the invas^n- is usually 
sudden. Sy there will be first the chills and rapid rise of 
ten&erutury headache, paintyloss of appeti te,sou■tM ion^aey 
.restless or dexx h ixm ci SL x iing <dh ntupoh^and de appea:i-'anc e 
of being seriously ill. All these syinpWms will d^miop in from 
six to twelve to twenty-four hours . The patient on in much 
the same for the first week. Thenybetween the fourth, and 
seventh day$?eaxaos the erw/Unn^ Therein the second we^ the 
swptoms are uore max'ked,especially the cerehreTrT^ and 
the pa ti. e n « p u i> l* e s into the typhoid state, The ton^ie. will be 
ary and coatM^the stupor xrill\e more ^rke.d? the urine ylll 
be re the patient will pass faeces involuntarily there 
will he muscular contractions and au tom tie movement^ and the 
heart will become rapid and feeble. 
- DU?JAT1 OH, - About two weeks but the disease may terminate 
sooner or later* The patient '^y recover at any time be tween the 
f irw t an^ tmrd weeks but most frequently at the end ci the second* 
232 heath may ^ke place any time between the firyt and 
hhe third week. There are exceptional cases of death in* a few 
hnu rs , ma 1 ignaa t typhus. 
the case is to end in recovery, the recovery is as a rule 
JL?1-. The temperature suddenly falls and, with this fall of 
temperature, there is a subsidence of all the other symptoms# 
^en the .temperature falls, the patient is apt to go to sleep* 
$he want of sleep is one of the most distressing symptoms of 
disease. The heart's action will become loss rapid and more 
x^reibleT the patient will look better and,by the end of twelve 
°r twenty-four hours,he will appear entirely different. 
- Complications and Sequellae#- 
The bronchitis or broncho-pneumonia may continue. 
Gangrene of the lung may be developed during the second 
*oek# 
3--The inf lamination of the pharynx and larynx may reach an 
'^usual degree of sever!ty,especially if croupous instead of 
Catarrhal* 
^4--in some cases, the disposition to haemorrhage is marked, 
-here will be haemorrhages into the Jrin;into the stomach,and 
-he patient will vomit blond: or into the intestine,and blond 
'^ill be pav&ed with the stools. 
233 The patients often vomit a good deal of blood and they may bleed 
to deaths There mj be extravasations of blood into the muscles 
and &c]?nu& membranes but these give no special symptoms. The 
disposition tn bleeding marks the bad and malignant cases. 
*-5 ~ buppura tive inflammation of the parotid gland is not at 
all an uncommon symptom. It seems to have nothing special to do 
with typhus* 
- 6-The blood may coagulate in the larger veins and form 
thrombin This takes place e?jpe dully in the femoral vein,usually 
only in one. You will get pain and tenderness along the enurse 
of the vein and oedema of the parts below. As a rule, this does 
no harm. It keeps the patient in bed and gives slight constitu- 
tional symptoms. But,we may have thrombosis of the sinuses of 
the dura mater with cerebral symptoms, the most constant being 
hemiplegia. 
- patients exhibit a great tendency to bed sores* The 
citoas? is short but you will be unirprised to see how quickly 
the';c sores will form and how large they will become. 
3-.-v/hen the patient gets over the disease,,he may seem to be 
perfectly well but,yet,he does not feel as he did before he was 
sick. The disease seems to take a good deal out of a man and 
234 the patient does not go back to his former physical and mental 
condition. Perhaps this is the more marked with the mental dis* 
turho-nces and the patient Joes not do his work readily, for 
tenths. In a few eases, this will be exagge rated and a condition 
of mental imbecility will be left. The patient will be almost 
silly and. this condition may la.st for weeks or months. Then? 
at a rula, the patient recovers. 
In other cases?the bodily strength will suffer. The patient will 
he feeble and anaemic and generally good, ferine thing. This 
condition will last for weeks and months: then?as a mln? the 
Patient will get well. 
- PROGNOSIS. - 
The prognosis is always very serious: the mortality is always 
great. Apparently? the disease is more fatal in middle-yared 
^nd ®ld people than in yomng people,. In old persons^ the ti-'-aje 
It exceedingly fatal. The previous condition of the patient 
influences the. j^roftnositu If the patient he already weakened 
hy privation and want of food? the disease is vex'y apt to pxwe 
-atal. Soothe epidemics that follow famine are especially fatal* 
Some of the epidemics are much worse than others In any 
235 epidemic the disease is mure... apt tt be fatal at the beginning 
of the epidemic ,• thn when the ^idewie is dying nute 
- Preven11five Trea tmento - 
The most effectual in which ta prevent the sp eud of the 
disease is t>. isolate the patient and destroy his clothing 
and bedding People liv Ing under ordinary condition^ do not 
contract the disease unless they c^me in contact with the patient 
or his els things City boards of health should guard against 
the passible spontaneous origination of the disease: they should 
seee that there is no overcrowding among the , poor^ 
W^en the disease does prevuilp^ can do a great deal in prevent 
its spread even among those are exposed* The principal 
way of doing tliis consists in diluting the poison with fresh 
air. The less the number of patients in the room and the better 
ventilated that room is^so much the less dangerous will the room 
be to the attendants* 
None of the articles of clothing should be handled before being 
disinfected* 
236 ^ressh air is of the greatest consequence, So much so? that it 
becomes necessary to disregard whether or not the patient may 
take cold-. If you can keep the air in the room at a fair tem« 
Pena tune., so much the betters if n^^why even then? the windows 
should be open* Keep the patient on fluid dieudraw eff the 
urine if neeessaryT.keep the patient clean?and look after the 
faeces if there be incontinence of faeces* Keep the patient's 
back as clean as possible for fear of bed sores. 
^or the cerebral symptoms,? we can do something. During the first 
and second weeks?it is net wise to give opium to any great extent. 
You cannot tell how much nephritis the patient may have, Give 
the bromide chlo rah? and the compound spirits of ether- If there 
be but little ne ph ri tiis you may give opium, 
towards the end of the twelfth? thirteenth? or fourteenth aay> 
ix we find that the patient still continues wakeful.?and? y® 
w Igxw that the time has come for the natural termination ^f 
the d:Uease^ there is an advantage in giving two or three large 
do^es or opium to na^ten recovery* Give it in the old**fashioned 
•wwxuiOwmWMw#; 
way?in a c^. of strong coffee. 
^he tempo nature is generally high but the duration of the o.isg^g 
- Ac tua 1 T re a tme n t. - 
237 is not great, Sa, al though the temperature is highlit is not 
neteusary to be in too much of a hurry to reduce it. See how 
the patient is bearing it. If you think that the high temper- 
ature lb making the patient worua, it must be treated. The tem* 
perature la best treated by the external application of cold 
by mean.^ of. sponger, the cold water ooil>or the noderately cold 
bath. In addition,it would be effitaeiews to give 
or antifebnin. Whichever method you employ you must note the 
results. If you give u, ooli bath or antipyrin in the morning 
and this is followed by a reduction of the temperature by several 
degree3 and this reduction last$ several bourse you are doing 
the proper thing and should continue it. If,however, the temper* 
ature goes up again rapidly and abruptly in a few hour^yn* 
are not doing the patient much good. If you are only able to 
keep the temperature down for a little while, the patient 13 con*- 
3tantly vibrating between a high and low temperature and, when 
this is the case., I think he might just as well go on with 
a high temperature. 
Give great attention to the heart during the second week. In 
some patients, from the first, the pulse will be feeble and the 
first sound of the heart will be indistinct. Give alcohol in 
238 form of hr^niy ^r whivkey in considerable auantity* In. none 
•^ses3you will do well with alcohol alone. In ether cases,you 
^11 do better if you add oonvallaria.digitally or caffein to 
T4 $ alcohol. Give such quantities of alcohol afe are necessary 
J 
,r make the Mart more forcible.. In some cases?you may only have 
'fi give half an ounce of alcohol every three or four hours* 
4 y. w fT-.-r-^r- 
4,11 others,you may have to give half an ounce every hour? in 
°thers?an ounce or even four ounces every hour will be necessary* 
some cases,the tolerance of altohol is very remarkable and 
Resembles the opium tolerance in peritonitis. You should always 
^ee how much brandy or whiskey the patient needs to make the 
^Qurt strong. Some of the eases are made decidedly worse by 
jj'leohol in any form. So,you must not give the stimulants blindly 
yuu must watch their affect upon the patient. 
239 - TYPHOID FEVHH. - 
In lecturing upon this disease,I go more into detail than I 
do with any of the other diseases. Typhoid fever is a most 
important disease because it is so common in all parts of the 
United States. Further,typhoid fever surpasses almost all 
other diseases in the variety of forms that it assumes. 
- PATHOLOGY - • 
Typhoid fever is an infectious disease-characterized by a fever 
end by certain, lesions of the lymphatic glands of the intestine 
end mesentery and lesions in the spleen* These are the charac* 
teristic changes* 
The glands of the intestine that are most frequently affected 
ere the solitary and agminate glands of the lower part of the 
ilium* By the second-day, they are swollen and. infiltrated and 
they continue to become larger during the first week* In the 
tecond week,smaller or larger parts of the glands die,are cast 
♦f into the dates tine, and are discharged with the faeces. In 
this way,ulcers are formed* In the fourth and fifth weeks, the 
Meali ig process takes place,the swelling subsides, the dead tissue 
is removed,and clean ulcers are left* Then, the ulcers are heaie.1 
by granulation or cicatricial tissue* Sa, the patient gets well 
with some of the lymphatic glands of 'the intestine lacking. 
240 cases vary in their severity. In the Mid cases, the changes 
the glands only go on to enlargement. There is no death* 
110 formation of ulcers? no cicatrizations and the patient- recovers? 
he usually does?with normal lymphatic glands These cases 
not, common. In the more ovdinax'y sases,we get the three 
°huruc teris tic changes? swelling? death, nice ration? and eicaiM« 
2Mion. In more severe oases*dhe same process is unusually 
Severed 'The lesion in the glands begins with great swelling, 
CAwr*sive death?deep ulcers which ex tena even tn rough tne mvs- 
°hlar and peritoneal coats and perforation of the intestine takes 
^laee, 
the majority of cases?a considerable number ef the glands 
^111 be involved but, as a rule? the changes will .be more decided 
*Pa the glands in the lower pax^t of the ilium than in any other 
^^t but- all the glands are attacked at the same time. 
*h other eases? all the glands are not at tacked at the same time. 
t? those in the lower part of. the ilium will be attacJ^ed? 
i^e.n? two on three weeks later? the glands higher up Mil be attacked. 
eourse?will protract the ease* 
some oases.-, the glands in the colon -Mil be inflamed. The 
Ghaageu glands of the •olon,especially those in the upper 
241 part of the colon?will be the same as the changes in the glands 
of the ilium. In some*cases,similar changes will be found in 
the glands of the verj|if©rm appendix when sloughing and perfor- 
ation are liable ho occur. 
The mesenteric glands are changed in the same way. They are 
considerably swollen, As a rule, the inflammatory process dees 
not go on to necrosis but it may -in so and? then, the glands ^ill 
suppurate. In these cases? there is always danger of peritonitis 
which may be local or general. Very much'less f requently?mesen»* 
teric glands which have enlarged but have not suppurated will 
give rise to peritonitis which maybe local nr general. 
The spleen will become larger and softer and the size and con- 
sis tehey of the spleen <11 vary with Uie severity of the disease 
and they will also v^-ry in the different patients. 
- Complicating LesioAs.- 
Besides? the characteristic lesions? the patients are very liable 
to accessory and complicating lesions. These are:- 
- 1*-There may be a general inflammation of the mucous membrane 
of the small or large intestine. Thio inflammation maybe either 
catarrhal or croupous. If it be caWrhal?it -vill simply inoret.se 
the diarrhoea. If it be croupous? the paid ent may die from the 
242 $~^upeus dysentery although he might have reooverel from the 
typhoid fever. 
'*-*2'-Peritonitis is a very common complication* It maybe lue to 
•Perforation of the intestine,sloughing of the vermiform appendix, 
Suppuration of the mesenteric glunls,or to reasons that we can 
not discover. 
3-In 8ome cases, the spleen will become so soft that it will 
Rupture and blood -Till escape into the peritoneum. When this 
1 happen^the patient will die very quickly. 
^4-- In some cases, the parotid glands will suppurate. This 
Suppuration may reach a considerable degree of development. 
' 5--There' is almost always a nephritis but, in jnn^t cases,it 
'^ey not become of any very great consequence. However,in' the 
long-continued cases,those that last five,six,seven,eight,or 
•bine weeks^the. changes in the kidneys do reach a considerable 
degree of development* In the cortical portion of the kidneys, there 
^111 hardly be any healthy epithelium left and this does probably 
h&ve something t$ do with the death of the patient,for it seems 
scarcely possible,even if the patient should recovei' from the 
typhoid fever-, that he cfuld recover frcm the kidney lesion* 
6'-The walls of the ventricles of the heart may become soft 
243 r,n5 flabby and they may degenerate but these changes are rather 
uncommon. . . 
- 7 - 77x3 mucous membrane of the larynx and pharynx may become 
the se^t of a catarrhal or croupous inflammation. The catarrhal 
inflammation of the pharynx is very common. A croupous pharyngitis 
is much less common- We may have a catarrhal or croupous in* 
flammation of the larynx 'but these are much less common than 
the changes in the pharynx* 
- 8"-In the lung^,^ may simply find congestion or oedema of 
their dependant portions and, if these changes do not involve 
toe much of the lungs-, they will do no harm# I£f however, they do 
involve a considerable part of the ItegSr, the patient will be 
made considerably worse by them, for he will only breathe with 
the unaffected parts. So,the patient may have rapid and shallow 
breathing® 
.- g - A general inflammation of the larger bronchi is very common* 
It may occur at any time during the disease- However,it is not 
usually a serious matter. Less frequently, the patient may have 
a bronchopneumonia which my also be developed at any time and 
is very serious. The patient may also have a lobar pneumonia 
and this is' also very serious* 
244 io-Inflammation nf the membranes of the brain occurs only 
ki a moderate number of the cases. 
11- Changes in the voluntary muscles,especially in the mus- 
°les of the a. iterior abdominal wall are almost the rule. Tin? 
fi-*res degenerate in a variety of ways. Sometimes, the fibres 
will rupture and blood will be extravasated. What these chi-ages 
Amount to>we do not know. Probably, they io not amount to much* 
^12 - There is a disposition to the formation of bed sores* 
^nd of little pustules in the skin and, seme times , little abbesses 
*re formed' deeptr^In the skin. 
*^*13--in the later stages of the disease, the blood may coagulate 
seme of the larger veins. Thrombosis of the femoral and 
external iliac veins with swelling of the leg and some inflammation 
the vein are very common. Less frequently, there will be 
■thrombosis of the sinuses of- the dura mater,. 
- T^ Micro-organism.- 
Ml work has been d&ne on/^is micro-organism and most observers 
agreed that it is known*'4t is commonly called the typhoid 
^fOillus. Although it has been cultivated and studied hy many 
^serversr,our knowledge of i$ is not very great. It has been 
^und in the spleen, the intestine, the mesenteric glands^ tfce live©. 
245 kidney,and faeces both within and without the body. The spleen 
iu the place where it is easiest tn find it but it is not easy 
to find the micro-organism anywhere* It is not present in as 
large numbers as you would think. S til further, the micro- 
organism is not only found in the characteristic lesions but 
it is also found in the blood* In the faecal matter,we would 
naturally expect to find it hut we d© not in all cases. 
It has been found that the bacillus can live and multiply ou> 
side of the body, particularly in dirty water,in milk,and in 
decomposing faeces. It can also live for a considerable time 
but cannot grow and multiply in the dry condition and it can, 
therefore be transported by the air* 
The disease prevails in all climates but it is perhaps more 
•nmm®n in temperate climates than in other climates* People 
between the ages of fifteen and twenty years are especially 
liable to iv Before five years and after fifty, typhoid fever 
is rather rare. This is a very good general rule. 
The disease occurs in epidemics:also as an endemic disease but 
even then it will be more prevalent at some times than at others: 
and also as isolated cases. 
- ETIOLOGY.- 
246 local epidemiss are • the cases in which it is easiest to find 
* cause for the disease. It often happens that the inhabitants 
a single house or of a group of houses will be attacked 
'vhiie their neighbors are not attacked and, In these cases, the 
^ost common cause is the contamination of well water. The con- 
tamination seems regularly to take place in one of two ways* 
^irst>by the entrance into the water of faehal matter containing 
poison and derived fram the privy: and,secondly,by washing 
clothing of a typhoid fever patient neax' the well and then 
having the water in which the clothes have been washed leak intt 
ihe well* In these cases, there is often a history of contamination 
the privy with typhoid faeces, Water simply contaminated wi th 
-e.ecey may do no harm, or it may give rise to a mild dysentery 
scess«pocl fever8* Whether it is always necessary that the 
^eoal matter that i» introduced into the privy should contain 
^e bacillus or whether a peculiar putrefaction of the faeces 
^y originate the poison,we do not know* At any rate, we often 
^Ve a direct history of a typhoid fever patient contaminating 
* >rivy and well in a town where typhoid fever has not existed 
then, three weeks after the people-have drunk this water, 
you will have the localized epiiemic confined to the drinkers 
247 pf the water that wellr Tn other iMsal epidemic^-lt smemtr 
is though the patient get the disease by handling or washing 
the clothes soiled by the excreta of a typhoid fever patient. 
In this way, he will get the germs on his handand thenrwhfle 
eating or drinking,may convey them to his mouth* In some epidem* 
io h3 it does seem as though the poison was eowunirated by the 
&ir to the attendants* This is not the rule with typhoid fever. 
Ara rule> the • attendants dd not get the disease unless they get . ■ 
it from the water. 
We have now to consider the disease when it is endemic* .Wery 
year, there are some endemic eases but the disease shows a marked 
preference for the autumn months* Still fur the rt there will always 
be years or succession of years when the disease is more prev- 
alent tlia< at other times. This is true both of cities and 
villages. When the disease assumes this epidemic character 
it becomes more, virulent* 
248 the disease should prevail mor-e in one year than it does 
anathemas it does in New York for example,we hardly know* 
H 1b »aid that its increased prevalence is due to the dryness 
the previous summer* I thiik that our knowledge on this point 
is by no means exact* 
SUU more difficult is it tn account for the isolated cases, 
^specially in cities* A single person in a tenement house,for 
ex^mpler^in have the disease* It is possible that in these eases 
disease may be due to contaminated ice for the typhoid 
o^eillus can live in ice for a considerable time* 
- SYMPTOMS* - 
-The most oonstant and most important stop tom is the fever 
^ioh continues throughout the disease, The regular duration 
the disease and of the fever is four weeks hut it may not 
^b-$t as long as this or it may last considerably longer* During 
i^is time.j the temperature follows a certain regular type for 
M,oh week* 
^ring the first weekt the temperature rises a little every 
but5every day, there are marked differences between the 
gening and morning temperature* The evening temperature will 
e the higher. ' 
249 During the second week the morning temperature will continue 
ebout the same from day to clay and so will the evening temper- 
ature. There will be the regular rise in the evening and the 
regular fall in' the morning. 
During the third week, the evening temperature will remain about 
is it 'was during the second week but the rooming temperature 
will fall much more than it did during the second week, 
During the fourth week, the discrepancy between the morning and 
evening temperatures will become more marked but the evening 
temperature will also fall and,finally, they will both get down 
to the normal. 
Now,you must remefber that you are not to expect to find this- 
exact temperature' cum in any of the patients. Some,as a rare 
thing,give it pretty nearly. Yet, in all of the cases, the temper- 
ature curve corresponds more or less to this • type and, enough sa, 
to help us in making the diagnosis and in following the course 
of the disease* 
The maximum temperature on each day is between five -bM^and 
twelve In most of the patients the most convenient time 
to take the maximum temperature is between five and six P*M. 
The minimum temperature each day is between six and eight A,M* 
and the best time 'to take it is between seven and eight A,M. 
It is best to -take the temperature only at these times fe®, 
beside the great regular rise and fall, there are lesser variations 
250 <ue to transient Gauses. Now, we want to learn how the disease 
is running and the incidental variations of the temperature 
only serve to mix us up. 
^he enmplicutlng inflammatianj of the lungs and peritoneum 
-ay cause the temperature to rise. The haemorrhages from the 
hovel may cause the -.temperature to fall* A patient may have a 
Sudden fall nf the temperature and, theny the temperature may 
^un up again and we may never know the cause. 
^here.ure a certain number of regular variations to the temper- 
Mure curve and th^se variations occur very frequently These are*« 
During the First Week.- Instead of the temperature rising 
Gradually,it may run up very rapidly and may be as high as 104 
^y the end of the third, second?or even of the fii^st day. This 
is an 'important xuriation and also rather a common variation* 
in these patient^- there may also be distinct chills preceding 
the first rise of temperature and recurring for several days, 
^hen the temperature assumes this type? the picture is such as 
in make you at once think of a malarial fever. 
^During the 'Second Week. - There are several variations. 
•* a -There will be no difference between the morning and eve- 
ning tempe ra ture s-. 
251 - b - The evening temperature will be unusually high and the 
morning tempex^ture will be unusually low and you will think 
of remittent fever. 
- 0 - The morning temperature will be higher than the evening 
temperature but this variation is less frequent. 
" d - Towards the end tof the second week, there maybe a pretty 
abrupt fall there is in typhus. After the temperature has 
fallen5 the patient may go on to convalesce ar$ins tea-d,by the 
end of twenty four hours, the temperature -nil go up again and 
the patient 'Till go on with the disease. 
- e - The nalemty of the patients will not go on with exactly 
the same morning temperature and exactly the same evening tem- 
perature during the second week. 
- During the Third Week. - 
- c - During the third week we will not unfrequently have the 
highest temperatures of the disease. 
* b - At any time, there may be an abrupt fall which may he fol- 
lowed by convalescence ar the temperature may rise again 
k- c-There may he -the same variations from day to day as during 
the second week. 
- During the Fourth Week. - a - There may at any time be an 
abrupt fall which may be followed by convalescence os,after 
twenty-four hourly the temperature may rise again. This variation 
i^ more common during Uie fourth tlion luring the second and 
third weeks . 
252 * b « During this week,we are especially apt to have the haem- 
. orphages from the bowel which will cause the temperature tn 
fail. ■ ' 
* c « During this week, we are especially apt tn have those falls 
which occur without discoverable cause. 
* d The patient go on for five or six weeks with no morning 
temper? turn but an evening rise of temperature which may be fol* 
lowed by sweating. 
*£* Th? disease may continue for five?six,eight,nine,nr 
ten weeks vwith a temperature similar to the temperature of the 
second or' third week. Some of the oases seem interminable, 
in the fatal eases, the temperature usually remains high up to 
the time of death. .Occasionally, we find that the tempe-rature 
^111 fall several days before death but the patient is 
evidently no. better and he dies with a temperature of 101*102. 
Some of the patients do not at any time have a high temperature 
although the disease prove fatal but, ay a rule-, the higher the 
temperature,'the worse off the patient Yet,we do find cases 
^nd bad cases ton in which the temperature will no t at any time 
had?99*100 or 102*10 3,yet,it is evident that they are just 
in as the patients with high temperatures. A patient with 
253 high temperature may do very well and may never be very, ill 
although the temperature may reach 104-105. Still,as a rule, 
the higher the temperature, the worse off the patient. 
- 2--The characters of the heart and pulse are of much conse- 
quence. Du ring the first week,in most of the eases, the pulse 
will be between 80-100 and will he fairly full and the heart 
will be fairly good and the first sound of the heart will be 
good® 
During the second and third weeks, the character of the heart 
and pulse changes. The pulse will become more rapid and feeble 
anc' it may he dicrotic. The heart will be less strong and more 
rapid anJ the fii^st sound of the heart changes in character. 
At this stage of the lisease, the pulse is increased in rapidity 
but it may be slow an i feeble like the pulse of typhus. 
In some eases, the pulse will be unusually slow throughout the 
disease. In the first week,it will only beat from 60-80 times 
a minute and this slowness of the pulse often makes it difficult 
to distinguish the disease from cereb ro-spinal meningitis and, 
ifoas is sometimes the case,the delirium and oilier cerebral 
symptoms be marked,and,If the temperature be high.you have a 
combination that might belong to either disease. Curiously 
254 Plough, gome patients although they may finally mover huve a 
^pid pulse throughout the-disease. ■ ,,, 
the third and fourht weeks^the feeble heart is of much oon* 
'■^ Iwaos for venous congestion nf all tbs viscera will take 
$laea. In some nf the patients,the feeble heart will cause 
eynoope^in othe cnllapsej and it is not at all uncommon fdr 
patient to die of heart tailure on account of this feeble 
^urt acting 
Cerebral Symptoms. These are very'common. During the first 
^ok^the patient suffers from headache, restlessnes^irrttability? 
uhd sleeplessness- hatep,he developed the characteristic apathy 
of typhoid fever. This apathetic condition is eo muoh the rule 
•^tj'Vhen it is abu@nt?wo &re very apt to be misled as tn th? 
^^vuGter of the disease. If the patient seem bright and intel* 
^L'ent,take an lowest in thing^und volunteer remarks:we are 
v<?ry apt to think that he has not #nt typhoid fever* Yetjthe 
^uthy my be absent altogether* 
DeHrium occurs in most of the cases* It is generally most market 
night during the third and fourth weeks*. Violent delirium 
^y mart the invasion. 
-The Characteristic Eruption* The eruption takes the fom 
255 of lenticular, rose-colored spots* They ^re raised a little 
above the level of the skin. They are regularly situatea on th- 
anterior abdominal wall but, if it be extensive,it may involve 
the skin of the chest and,occasionally, the back. The color always 
disappears on pressure. It may app'ear on any day between the 
fcurht and the twentieth but it generally domes out between the . , 
seventh and twelfth days and,generally,it appears pretty soon 
after the seventh. The cases vary as to the extent of the eruption* 
As the cases have occurred in New York during the last few years, 
they have not been characterized by a marked eruption but, if 
you look closely over the anterior abdominal wall, you will find 
the eruption in most eases. In some epidemics,the eruption has 
been very marked You must not expect too much of the eruption 
of typhoid fever. The eruption occurs in successive crops and-, 
ultogether, the eruption may last from a week to three weeks. If th® 
patient suffer from a relapse,the relapse is regularly acGompuniel 
by a fresh crop of the eruption and,even after the beginning 
of convalescence,, fresh crops may still appear. 
Fur then, unfortunately and not unf recently, the eruption may 
be entirely absent- This is very tiresome.- You may watch a case 
of typhoid fever throughout the whole disease and,at no time 
may you have an eruption. 
256 ^5'-At firsts the tongue is moist, coated with a broad strip 
nf white fur down the middle,an:i the edges are Glean# Yet, there 
^y be a general thin ana ting. If the disease be not severe, 
the tongue will remain l&ke this throughout the disease. If 
^he ease be one? of fair severity, the tongue will gradually n 
become dry? the fur will remain: and, then, the tongue will be dry' 
^hd coated# The dryness may extend to the lips and mouth. In 
nther eases', the coating will disappear but the tongue will be- 
°°me dry and,sometimes fissured. 
^6-Nausea and vomiting are common at the commencement of the 
^•i^eaue and may continue throughout* In other cases,.there will 
be nr, vomiting but the accumulation of gas in the intestine 
*111 cause the patient from time to time to discharge the con* 
of ths stomach with an • eruo tation of gas* In some cases, 
is very serious and it will come on in a few hours after 
have given the patient food. 
peritonitis he developed* nf course,the patient may vnmit. 
^7-^ The accumulation nf gas in the intestine seems to be 
constant# Fortunately,in many of the patients,it dney 
^t reach a great degree of development and the patient is not 
^de worse or more uncomfortable by it. But,it may be developed 
257 to an unusual degree and, then,it is very serious. These are bad 
eases. The distension is exceedingly distressing,it gives the 
patient pain,it gives rise to the eructations, and it interferes 
with the nutrition. 
The distension may be so great as to push up the liaphrugm 
«t,nd interfere with the heart- and lungs* In some eases, this will 
only cause dyspnoea but,in other eases,it will cause the patient 
tn cough up large quantities of blooy mucus. as a patient might 
do at the invasion of a severe bronchitis. If this take place 
after a week or so,al though it is serious, it does not interfere 
with your diagnosis and it is at this time that it is most likely 
to occur. But,it may be one of the very first symp tomsand, when 
this is the case, you can see how difficult it is to make the 
diagnosis. In some cases,I think it is impossible to do so at 
first until other symptoms em. 
- 8-Gurgling and pain in the %;ght iliau region are spoken 
of as regular symptoms but I think that they are of little con- 
sequence. I dor? t think it r^kes buch difference whether you 
percuss the right iliac region of a typhoid fever patient w or 
no^. 
-- 9- The enlargement of the spleen does not help us much in 
making the diagnosis. The enlargement is not usually so consider- 
able as to make the spleen come down into the abdominal cavity. 
258 erM in tvphalb feve^-, th* wtomaeh always •ontain* a litt.la f00^ 
which vill aeswiiate in the posterior part of 
your percussion vill be interfered with. - do not think -h^ 
you can make out the size of the spleen by percussion in .yphnld 
■^evep® 
lo - Diarrhoea iv a regular symptom. The liychargev V-ok like 
Pea scupo it may occur during the first days ^f unu 
$r hntil two,three,or four weeks er not until the patient 
taken a purgative medicine. When it has appeared, it may 
b^t c. few days or it may last throughout the disease* 
usually speaking, the worse the diarrhoea, the worse off the 
Patient* A mild diarrhoea is not of much consequence* 
is not at all uncommon for the diarrhoea to he absent and 
hay particularly been the ease in New York during the 
c<^t few years and,furthermore., the bowels may be very constipate!* 
^11-DIeeding from the intestine may take place in one of two 
c'ys. In the first week,it-may be due to sin-pie congestion of the 
m.embrane of the intestine and does not amount to much® 
mare frequently, the patient bleeds from the ulcers* This 
of bleeding most frequently takes pierce during the third 
^*-d fourth weeks when the sloughy are separating. You may have 
' - during the second week or net until the sixth or seventh 
259 or eighth week or the patient way bleed' in this way during 
convalescence. The source of the bleeding is from the ulcers* 
A patient may have only one such haemorrhage or he may heve a 
number day after day or he may have a number in a day. .The haem* 
orrhages may he either small or large. When we have bleeding 
from the ulcers, sze always look upon the case with apprehension. 
It is always possible for the patient to recover and he may do 
So but you are always justified in being frightened. Not 
only is the patient in danger of bleeding to death or of weaken* 
ing himself so that he can not recover but the haemorrhages 
signify that the ulcers are deep and are liable to perforate. 
Generally speaking,when such a haemorrhage takes place, there 
will have been a previous diarrhoea but a patient who has had 
no diarrhoea, may have the haemorrhages. 
Once in a while,it will happen that ii the third <r fourth 
week of the disease,you will be sent for and will be told that 
the patient has suddenly passed into collapse, By the time that 
you get to the house, the patient will probably be dead. 
260 these cases, there has been a lax'ge and sudden haemorrhage 
the blood has not been voided* Not infrequently,if you move 
^he patient, the blood will escape from the rectum hut it may not 
SO. 
13-Nose bleed® As a rule, it is not of much consequence but 
H may be unusually profuse and it is said that the patient 
bled to death from the nose. 
13- When the patient is well in to the disease,the pupils 
somewhat dilated, La ter, when the patient is in stupor, the 
Phpti^ are widely dilate J and insensible to light, 
14~ Early in the disease, the he aiding will be exaggerated, 
^terjthe patient becomes deaf. Occasionally,there will be 
suppurative inflammation of'the middle ear and the pus will 
discharged through the tynptmusi. 
xb--in roe third and fourth weeks,we may have involuntary 
anhtractions of the muscles of the arms and legs, automatic move- 
$erHs of the limbs?and the patient may pick at the bed clothes.' 
exceptional cases, there will be general convulsions and you 
^y have these convulsions without tlieir signifying any great 
^Verity of the disease. This happens most f'ce^uently in young, 
k^terioal womenThey have exaggerated muscular movements and, 
261 then,general convulsions, However, the convulsions do not. seem 
to do ^ny great harm. . • > 
,- 16-The changes in the urine vary with the character of the 
nephritis which is regularly mild. • The urine may be normal' 
or it may be diminished m quantity and contain a few casts and 
a little albumen, 
*-17- The bed sores should never occur. We ought.always to 
be cble to avoid them but the degree of care necessary to do 
so is often very great. When, they are formed, they are of a 
great deal of consequence and add to the dangers of the disease. 
The patient often seems to die from the bed sores rather than 
from the typhoid fever. 
- IB - Inflammation of the bronchi and lungs may occur ea^ly 
or late in the disease as a bronchitis,a broncho^pneumonia,or 
c v ?? di Xobar pneumonia , The bronchitis is very common. Broncho* 
pneumonia is not at all uncommon, Lobar pneumonia is rather 
rare. These comp 11 cations are of a great deal'of consequence 
yet.it is surj) rising how many of. these patients will recover 
both from the typhoid fever and from the inflammations of the 
lungs. 
- It-The catarrhal inflammation of the pharynx is very common. 
The patient complains of the sore throat* It is of no 
262 an special •onsequenoe* 
20-The inflammation of the larynx is sometimes more serious* 
The patient may have laryngeal cough,vtite,and dyspnoea and the 
■^ryngitis has often to be treated. However,as a rule, the laryngitis 
Jees no harm. It may cause oedema of the glottis and, t^en,it. 
very serious* 
^21--Thrombosis of the veins,especially of the femoral and 
internal iliac belongs to the third and fourth weeks of the 
•isease and. it may even occur during convalescence. At first, 
the vpin becomes hard and a little tender. Then,the tenderness 
will extend along the course of the vein. Then,there will be 
^ome swelling and oedema of the leg.* This will keep the patient 
ih bed. With this, there may be an exacerbation of the temperature 
^hich is especially noticeable if the thrombosis occur during 
Gconvalescence*■ This is about all tire harm that it does. After 
c few days, the pain,tenderness,and dropsy disappear And the 
^eg returns to its former condition. 
course, thrombosis of the sinuses of the dura mater is of 
x'°re consequence. It is accompanied by softening of the brain 
c-uid extravasation of blood upon the brain* The symptoms will 
^ry according to the part of the brain that is affected* .This 
i^uion may cause death or may leave paralysis* 
263 ^22-Inflammation of the intestine, - If the inflammation 
be of the catarrhal v^Het^lt will only increase the diarrhoea, 
if there be a croupous inflammation of the colnn^it will be 
of a great deal of consequence, The croupous inflammation i s 
apt to invade the rectum and it may occur at any time during 
the disease or it may occur during convalescence. The patient 
will have the pain,passages,fever,and prostnation of a croupous 
dysentery. It is a very serious complication. It is possible 
for the patient to recover from both diseases but the eroupouo 
dysentery makes the prognosis much more serious. It is especially 
apt to occur in a series of cases in the same place. Whether 
it is infectious or not,I do not know. A few years ago in 
Roosevelt Hospital?almost every patient during convalescence 
from typhoid fever would have croupous colitis and® finally? I 
insisted that the patients should leave the hospital as soon 
as convalescence commenced, 
- 23-Perforation of Ulcers, -This is* a very fatal accident. 
It occurs most frequently during the third and fourth weeks 
tut it may occur during the second week or,even during conval* 
Escenee. It is most apt to take place in the worst cases hut* 
ccoasi anally, it will occur in a mild casc„ 
264 When it, takes place-, it is sometimes quite evident. The patient 
^ill suddenly become worse,will exhibit shock,the heart will 
become rapid and feeble,the heart will become rapid and ieeble, 
^d the skin will become cold. Then,after a few hours, the 
temperature will rise, the abdomen will be dis tended,and acute 
Peritonitis will set in. 
other cases,you will not be able to say when the perforation 
t^kes place ant will you even be able to say that it has taken 
Place. The reason for- this is that some of the patients already 
appear as ill as is possible and,when the perforation takes 
Place,you will notice no change in their condition. There are 
Very fc^v patients who recover from this accident. 
24 - Peritonitis as a result of inflammatinn of the mesenteric 
6 land a, ne c r o s is of the spleen, or from reasons, that we can not 
^seover. This always makes the patient worse^ It often gives 
ordinary symptoms and it may very well prnve fa tai, yet, it 
not nearly as regularly fatal as the peritonitis that follows 
Perforation. From this kind nf peritoniti&, the patient may very 
jell recover. Some of the patients seem to have a number of 
Attacks during the disease. . ? ? 
265 -- Period of IncUba tion-■ 
The period of incubation varies considerably* It is said that 
it varies between two days and four weeks* The most ordinary 
period is two weeks but you will find many cases in- *vhich you 
-i 111-nmnie>wni»iw»w m*w* mw w 
can not- soy what the length of the period of incubation was, 
for you do not know when they enntraMted the disease* 
cours e* *~™ 
In many cases, there vill.be a prodramie, period which, may last 
< few jays or a few weeks* The patient does not go to bed but 
complains of bodily and mental fatigue,headache,disturbance 
of the bowels,or a lit tie fever- This period, is common but not 
constant and the invasion may follow apparently good health 
but the prodromic period is so common that wa always look for 
it* 
The invasion is usually gradual. The patient has fever rising 
from day to day^he may have feelings of heat and cold* There 
are nose bl^ed, inflammation of the pharynx,pains in the head, 
backhand abdomen. The tongue is coated. There are nausea: some times* 
vomiting?-dlarrhoea or constipation? and passages containing 
blood. The patient will look sic.and will feel sick* The symp* 
toms get a little worse from day ' to day during the first week. 
266 Sa, these o,re the symptnms of the first week. There are exception** 
invasion my he sudden# Either after the prndmmae or after 
nrdinary health, the patient will suddenly be attacked with ehills 
^d a fever which runs up pretty rapidly#. The patient is pretty 
*ick and he goes to bed* Then, the case goes on regularly. 
^e case may begin with a severe bronchitis* This bronchitis 
may occur after prodrome or it my come on without them. The 
Patient will have chilli, fever., cnugh,expec tnration, feeling of 
P^in and oppression over the they t, rapid. breathing, and you will 
^t the ordinary physical signs of bronchitis Then,after sev* 
G3?al days, the case will look more and more like typhoid fever 
^d t,he patient will go on in the regular manner. 
^e case may begin with a sudden end violent delirium as thphus 
^ver does# Then,after several days, the delirium continuing 
^htii then, the patient will go on in the regular manne r# 
most eases,it is difficult to say when the invasion began, 
especially when it is gradual# Generally,we date the commenee- 
^nt of the disease from the time that the patient goes to bed. 
•f CGu^e, this is very arbitrary fox* some patients go to bed. 
before others# It is really a matter of importance to fix the 
on which the disease begun,for we count the days and 
267 nf the disease,we know the symptoms of the, different weeks and 
we know when the patient ought to improve* 
- Second Week.- The fever becomes move continuous and the 
heart and pulse become more feeble# The mental condition is 
changed: the apathy is more maAej and alternates wihh delirium# 
The patient becomes deaf#. The tongue becomes dry and brown* 
The eruption makes its appearance# We may have diarrhoea,bleeding 
from the ulcers, or constipation. The patient may have timpani tie? 
which will become more and more decided* The patient may have 
the muscular tremor, involuntary movements of the muscles, or 
general convulsions, The patient may now dle«he may convalesce: 
or,after a short period of improvement, the disease may go on to 
the third week. There may be no break at all in the disease. 
*-Third Week* - ^he patient is worse than during the second week# 
He is getting emaciated and feeble* Tae heart and pulse are 
more feeble# The cerebral symptoms become move marked and the 
patient gets more and more into'the typhoid, state. 
268 'Hie face is drawn and anxious. There is muttering delirium 
ternating with stupor* Now, we are more likely to have the 
^■rge haemorrhages from the rectum, the perforation of ulcers^ 
Peritonitis, retention of urine^and involuntary evacuations of 
^■3e&. At the end of the third week., the patient may dismay 
•onvalesce^ there may be. temporary improvement, or there may be 
ho break at all* 
The Fourth Week* - The beginning is much the same as the 
thirt week* At the end of the fourth week-, the patient may die, 
may convalesce,or he may begin to get be tter and, then,go on 
M.ain* There may be no bre<xk at all and the disease will continue* 
''^en the disease does continue., you can hardly say how much longer 
will last. Some times, i t will only last a week longer but it 
go on for ten weeks* Even after this long duration, i t is 
^ways possible for the patient to recover but his chances are 
^ueh less. ~~~ s - 
typhoid fever has nne peculiar feature., namely, that the patient 
^fter beginning to recover may have another attack,or a relapse, 
^'hen this is the case,it almost seems as though the patient 
^feef. rj himself. The patient will first go thi'ough the ordinary 
bourse of tlie disease and this course may be either mild or 
<evGi-'eJshort or long. Then, the original attack will come to an 
269 end and convalescence rill oommence. The fever will go away 
and the patient may go on all right for any time between three 
lays and three weeks. Then,will come the re lap co which will have 
all the symptoms of the original disease* It may last for any 
time between ten days and three weeks but usually it does not 
last longer than two weeks* As a rule, the relapse is neithe'? 
so bad nor so long as the* original attack hut it may he much 
more sever*© and the patient may die during the relapse. Still, 
the rule is the other way and the patient usually recovers from 
the relapse. A single relapse is not uncommon# Less frequently, 
the patient will have two relapses and,when this is the ease, 
the ime consumed by the disease may reach very considerable 
limits. • . 
VAHMTIONS OF THE COURSE. - 
There are three. T^o are important- These are the insidious • 
onsets and the short eases. The thirl is typhcwnalarial fever. 
- The Insidious-- 
All the symptoms are present but they are but slightly developed# 
The pulse will hardly be any quicker* The temperature will be 
nnrnul or 99 or 100 during part of the day*. However, the patient 
will be sick for three or four weeks- He may have feelings nf 
270 ^eat or cold. There will be headache. The patient will be sleep* 
and irritable. The bad temper of the patent is often a 
striking feature. The patient will have no appetite. There will 
a little nausea. The bowels may be normal or the re may be 
$fuw tipatinn or diarrhoea.. Most of the patients will not be in 
they will sit in the house and grumble. Others will have 
additional bronchitis. In others., the nausea and vomiting 
^11 be marked. So, the patients -.io not at any time appear very 
*11 and,unless typhoid fever be prevalent,we generally cannot 
^ke the diagnosis. These cases are easiest to make out when 
^ere is a localized epidemic of typhoid fever in a single 
Most of these patients get well without any special 
double but,occasionally, the patient will have one nr more 
*^rge haemorrhages from the bowels* an ulcer will perforate' the 
*htestine, or the patient will suddenly develop an active delirium 
these cases, the disease runs its entire course in two weeks, 
this time, the patients are sometimes very ill hut we may 
^•v© all the varieties between the mild and severe cases. The 
u^iptnms simply seen tn be compressed and the pourse of the 
'^bease seems tn be more active. When the symptoms subside, 
The Shnrt Cases. 
271 they subside more rapidly than in the ordinary Ga3eu« Most 
of these cu^es do- wil nrwnqh "hut they are liable to the complin 
cations arji, particularly, tn the relapses. Southey in not seem 
tn come nut any Letter than the others. 
- Typho-Malarial. - 
A patient may at the same time have typhoid fever and malarial 
fever. Then,he will suffer from the symptoms of both diseases. 
He will give the symptoms and lesions of typhoid fever but the 
fever Till assume the malarial typ&. It does not belong tn 
New York tn any extent- Of course?a patient with typhoid fever 
and without malarial poisoning may have marker! differences in the 
temperature curve. A patient may also suffer from malarial fever 
of a severe and Gnntinunus type and he may pass into the typhoid 
state but he will have none of the lesions of typhoid fever 
nor will he have heen infected by the poison of typhoid feverP 
These last two examples are not properly speaking typho-malarial 
fever. 
4 
- CONVALESCENCE. - 
The patten-is who recover from typhoid fever convalesce- This 
convalescence is always protracted. 
272 1$ weeks and months before the patient ceases to feel the 
Effects of his long illness. Convalescence is often interrupted 
n2? retarded. Several conditions may in teriupt or retard oonvales- 
♦ence. 
^1-In some eases., the mental condition will be bad for weeks 
^'1 months. You can not say that these patients are likely to 
°eeome insane but they are unfit for mental work. This condition 
^y and often does exist without sufficient attention being paid 
it. The bodily health improves and the physicians may allow 
Patient to go back to his work when he is really unfit for 
*t* You should always pay attention to this,particularly in 
^ung people. 
^2*-When there has been hemiplegia as a result of thrombosis, 
iis hemiplegia will continue during convalescence. 
3--it is also said that there may be paralysis resulting 
■^om. inf lamination of the cerebral arteries. This paralysis will 
®°ntinue for a greater or lesser time® 
-There maybeLan inflammation of the peripheral nerves 
Web. will result in loss of power in various j-roups of muscles, 
'o--gome of the Patients will continue t<- have a fever for a 
dumber of days after the disease-,itself has really come to an 
273 They will not'have very much fever hut, ev^ry'af terne on, they 
will have a little rise of temperature, 
-- 6 - Convalescence may be abruptly interrupted by perforation 
or by a large haemorrhage, Kither of these may cause death.. 
i-7-During the disease,the catarrhal gastritis nay he developed 
to an unuSual degree and it may continue after the subsidence 
of the fever as a * sub -acu te* gastritis, It may give a good deal 
of trouble arid it may develop into a chronic gastritis which 
may last for months or years. 
'-8" The croupous colitis may be developed and will interrupt 
the convalescence, 
•- g-jn g-me eases,the heart and pulse will be too rapid. 
This may last for weeks and months. 
- 1G - Some of the oases will begin to convalesce after a pretty 
severe attack. The fever will stop but the patient really does 
not get any better. The appetite and strength do not return. 
The Patient will lie in bed day after day making no progress. 
After a few days or weeks* some of the patients will gra dually 
i rd rove and I have seen them do so when their eandtilnn wh 
exceedingly alarming. Others do not imp rove. They will remain 
in this condition, for weeks and, then, they will die,not from the 
oomplieations but because of extreme feebleness. They seem to 
f a d e aw ay. 
274 - PROGNOSIS, - 
The prognosis Is always doubtful. You never can feel sure of 
a typhoid fever patient until convalescence has been established 
for one or tm weeks. This is true of the mild eases as well 
.at of the severe cases. The wild cases may have a fatal relapse, 
peritonitis,or an intestinal haemorrhage and die. 
Generally speaking, the higher the temperature throughout, the 
^orue off the patient. . 
If the diarrhoea be marked*, the prognosis will be rendered graver* 
Excessive tympanites is a bad symptom. 
If the j>atient have haemorrhages, they are bad symptoms, for the 
Patient may bleed to death or the ulcers may perforate. 
If peritonitis be established,it will almost always be fatal. 
The- cases in which the peritonitis is net fatal are those in 
^hieh it is not due to perforation# 
Much muscular tremor in the second, third,or fourth weeks is 
aPt to be associated with deep ulcers. It is a bad symptom, 
Specially if it occur in a male* In the women,you must allow 
for d.n hysterical element. 
If the patient get to bed early in th© disease,so much the better 
for him. There can be no question about this. 
275 The character of the epidemic and the period nf the epidemic 
during which the ease occurs are o^- great impWtance. Some of 
the epidemics are much more fatal than others* During any epi- 
demic,., the ease is much more apt to he fatal if it occur during 
the beginning or height of the epidemic that if it occur when 
the epidemic is declining. In one epidemic in New York, the 
mortality as high as twenty ar thirty per cent. Since the 
beginning of the fall, there has hardly been a death in Roosevelt 
Hospitals Soothe character of the cases influences the prognosis 
to a marked degree- On this account, you must not attach too 
much importance to plans of treatment* This fall, we have scarcely 
used any treatment at all and any plan of treatment would have 
given good results* When we do have a had epidemic^ none of the 
plans of treatment stand the test very well Sn^when you read, 
of successful plans of treatment in books and Journals, you must 
always allow for this. 
To Prevent the Spread of the Disease.- 
- treatment. - 
Pay attention to the liner^clo thingy faecal matter andjpossibly, 
tn the urine. These must be rendered inocuous. We 
must remember that the bacillus is not easily killed. The best 
antiseptic is a solution of corrosive sublimate 1-200 or 1-300. 
276 The dirty linen should be taken from the body and bed of the 
Patient and should be put at once into a tub containing this 
~olu.tion, Then, it should be allowed to soak for a considerable 
time in the solution before being washed. 
The faecal matter and urine should be discharged into vessels 
containing the solution, In any case, you must not be contented 
'vith pouring the solution on the excreta. The solution should 
stirred. up with the excreta and the excreta should be allowed 
to soak in the solution for some time before being put in the 
water closets 
There seems to be but little danger to the physicians and atten- 
dants* Still,it is better to dilute the poison with atmospheric 
air, in the same way that we do in typhus fever. The disinfectants 
are of no use* 
Those of you who intend to practise in the country where cess- 
pools and privies and wells abound-, will be of inestimable service 
to the community if you will make Ute inhabitants understand 
that these three things should not communicate with each other. 
This.,you should do whether typhoid fever be prevalent, or not 
- Actual Treatment. - 
Suppose that you are Celled in during the commencement of the 
277 disease-, during the first days. The first thing to do is to put 
the patient to bed and you will not always find this as easy 
us you think. Some of the patients ^111 have a good deal of 
strength* frUny of the patients will only promise to go t^ bed 
at the end of a few days,,even if they have a temperature of 
lO^lOi* Remember that the prognosis is greatly modified by the 
time at which the patient goes tn bed. 
Regulate the diet. The food should be fluid throughout. If the 
patient can take milk, it is the very Mst thing he can take. 
Give nim two or three quarts a day. If the patient can not take 
the plain milk?he will sometimes be able to take it. 
boiled or cold with the addition of bicarbonate of ; 
sodium or oxalate of cerium. If the patient can not take it at 
all,give beef juice or soups* Do not give beef tea. Sometimes, 
it is safe to give scraped meat with the beef juice. You may 
give gruels. The. feeding of the patient is important for several 
reasons. The character of the food influences the height of the 
temperature,, particularly,during the latter stages of the disease 
and during convalescenceI In the second plaee^ the disease is 
very long and it is important to have the patient well fed and 
well nourished. The aharicter of the food influences the diarrhoea* 
278 the food be not well digested, the diarrhoea will be in«re'a8ed« 
the food be not well digested, the tympanitis is apt to be 
^creased. The stomach is apt to be relaxed,especially during 
!-e second and third weeks. It will be like a soft hag and,if , .... 
Tou give too much food, you will distend it* If you do distend" 
the stomahh? the patient will vomit all his food* This precaution 
of considerable i^ortan^e. Physicians are gm much impressed 
^ith the necessity of keeping up ths patient's strength that 
they only think of giving enough food and do not re^^bet ih^t 
this food* to be of any use,must be assimilated. 
the headache^ res tlessnesjs,and sleeplessness? g'b/e -the h^Q** 
and chloral together. In tmme ease^you will do betted 
;it.o opiunv later, the patient becomes apathetic and quiet enoWh- 
*f- the patient vond ts the vomiting can usually be relieved by 
^g'ulating the food and giving it in sm&ll doses at regular 
tenvals 
<4- the patient be eonstipated,it will not be wise to allow runs 
^hstipatinn to continue. Generally speaking, it is best relieved 
°V enema-.a. The enema ta should be repeated every other dav- 
Homs cases, it is as well to give gentle laxatives. 
the disease begin with a sharp attack of bronchi tis» 
279 Hrnnehi ti jr^y require treatment. If the bronchitis he aceow*^ 
panled by evident dyspnoea and congestion of the lungs,these are 
best relieved by many dry cups or some other form of decided 
c ounte r-irri tatinn. 
Gene really speaking, the heart and temperature do not require 
much attention during the first wekk. 
- The second week. - The temperature requires treatment. You 
must notice how high the temperature is and also how the patient 
is bearing it. In the majority of cases, temperatures below 
104 in the afternoon had better be left alone. If,however, the 
temperature be 105 or 106 and if the patient be bearing it 
badly,it may be proper to reduce the temperature. This,we may 
do either by the application of cold or by the use of drugs. 
It is impossible to lay down any rules as to which of these 
means will be the better in any particular case. 
The cold may be applied*. by sponging or sprinkling the Patient 
with cold water:by the cold wet pack: or by the cold bath, If 
you use the cold bath?it should not be too cold and the patient 
should be allowed to remain in it for five, ten,or fifteen minutes, 
We may apply cold by means of tdie rubber coil. 
As to dx»ugs.,as a rula?we now use only two. These are ^tipyrin 
aai antifobrin. Each is a very powerful and certain antipyretic. 
280 ■^e antipyrin has the disadvantage that it must be given in 
^rge doses and has killed: the antifebrin may be given in.smaller 
^oses and it has not killed. Whichever method you adopt,you 
should try to keep the temperature down somewhat,102*103 during 
whole of the twenty-foui' hours. But, to manage your antipy* 
^etics so that,at one time, the temperature is 99 and,a few hours 
ter, 105: is of no service at all and, if you cannot do better 
than this, you had better let the temperature alone. 
heart requires treatment. It is apt to 'be rapid and feeble* 
'PParently, the best drug is whiskey or brandy. Give a dram,an 
^nee,op even four ounces every halftone, two, three, or four 
h^Urs,according to the affect that it has. I am not sure that 
gain anything by adding the other cardiac stimulants to the 
^eohol. Still,if alcohol alone do not answer the purpose,it 
^ill be good treatment to give them. 
^5 the diarrhoea be not profuse,let it alone: if it be profuse^ 
^ive opium with bis^th or the alkalies. You do not expect to 
*i$P the diarrhoea, you only expect to moderate it. 
. the timpani ties be not marked, let it alone* if it be marked, 
must be treated. The tympanities may be due tn the feeding: 
so,regulate the feeding. The application of cold to the abdomen 
relieve it. The internal administration of assafoetida: 
281 turpentine or,better, terebin: or carminatives. Generally, the most 
efficient means are the regulation of the diet and the external 
application of cold or heat. 
The intestinal haemorrhages come from eroded vessels and it is 
not likely that drugs will stop them. StilL, apply cold,ahd Rive 
ergot, gallic acid,and opium. As to myself, I think so little of 
these means' that if I had typhoid fever and should have intestinal 
haemorrhages, I should much rather be let alone thatn he bothered"' 
with them, 
When there are muscular tremors, the compound^spiri ts of ether 
is sometimes of real service. If the tremors be due to hysteria, 
$ive assafoetida. 
- The Third Week.- The indications for treatment are much the 
tame as during the second week. Look out for bed sores,, the 
retention of urine,and the involuntary evacuations of faeces. 
If peritonitis should be developed,employ the regular treatment.^ 
- The Fourth Week. - The treatment is the same as during the 
second and third weeks. 
Just as convalescence begins,the treatment is often of great 
importance. The rule is to give no solid food until four days 
after the temperature has gnt down to the normal: then, give meat. 
282 Give a little meat once a day. Then,if the patient do well, 
a few days,add the other articles of diet. 
Some of the patients continue to have a little rise of temperature 
ln the afternoon and,in these eases,you had better give meatZ 
M the commencement of convalescence,, some of the patients will 
anaemic. Give iron and quinine with the food. 
before convalescence commences-, some of the patients will. have 
€ low morning temperature and a high evening temperature* In 
t&ese eases,, give quinine in the morning. 
283 - RELAPSING FEVER.- 
Thia disease occurs, for the most partjin epidemics. These epi- 
demies last for a certain time ands then, the™^ disappears 
altogether. The epidemics are especially aptf to follow X dJ u> • 
It has prevailed in Ireland'since 1739. In England and Scotland, 
it appeared between the years 186 3 and 187 3. In Russia and 
Germany, the disease appeared at the same time. In New York, there 
was a slight epidemic in 1847 and another between the years 
1869 and 1870. In India,there was an epidemic which lasted from 
1877 to 1880. So, it is a disease that has not yet appeared in 
many countries and,when it has prevailed,it has subsequently 
d1sappeared altoge th e r. 
When there is an epidemic,the disease seems to be as contagious 
as typhus fever. It is apparently communicated by the air. 
The disease may also be acquired from the sick room and the 
clothes of the sick. The disease can probably originate spun- 
taneouslyjfor the epidemics succeed one another at great 
intervals. 
284 persons who suffer from relapsing fever are liable to many sebon* - 
^ary lesions™ These are the following. 
The patient not uncommonly becomes jaundiced* > 
2 - The re may be pupura haemorrhag'd a a* j 
*7* 5.- There may be a eal&rrl^ croupous inf Taxation of the 
^pynx. 
' -4-There maybe congestion of the stocka .catarrhal gastriti&> 
0 -ceding into the stnm^ch?aad extravasations of blood into the \ 
^11 of the stomachs 
5 - The intestine is liable to the same lesions as the stomachs 
^bere may be a catarrhal or croupous inflammation of the intestine. 
" 6-The liver and spleen are more decidedly swollen than in 
"O^t, of infectious diseases* 'They can genei'ally be made out# 
*hey also become soft* The spleen is Especially liable to be-esme x 
and it may rub furs either ^rmtaneously or from some slight 
^^ement on the part of the patient. . 
7?e ri toni ti s is ^n occasional complication but it is not h . 
common* " 
There are the siime changes in the wall of the heax^t as 
^ere in typhus and typaoia fevers. 
285 '-9-There maybe a complicating general bronehi tis-, broncho * 
pneumonia, lobar pneumonia, ox' pleurisy. 
-_10~in the kidneys,we find various degrees of nephritis. 
The only lesion that we can call characteristic is the change 
ig the blende In the blood, we regularly find a spirllliKn. The 
micro-organisms are present in considerable numbers in the blond* 
It is present in especially large numbers during the febrile 
Stage of the disease. Then,if we draw the blond from the finger, 
we will find considerable numbers of the micro-organisms* As 
yet,we do not know a great deal shout the history and mode of 
growth of the mi ere-organism, for the disease is rare. We only 
know that the disease can be communicated t-o monkeys by inoculating 
them with the blood of a poison who hat relapsing fever. 
-The Period of Incubation.-- 
The period of incubation seems to vary so much that it can 
hardly be stated. In some eases,we are told that it is only a 
few hourSe It has also been observed that two or three days 
m two or three weeks elapse before the patient gives symptoms. 
Sn3if we please,,we can say that the period of incubation varies 
from a few hours to three weeks. 
286 - The Invasion.- 
^•s a rule, the invasion is sudden* The patient suffers from 
.^ills,headache,pains in the back and limbs, general malaise, 
prostration. Then,in a few minutes pr after several hours, 
temponature runs up very high indeed. With these symptoms, 
patient feels pretty ill. The temperature may suddenly 
Sjp 105,s 106 10%, or 108. The heart and pulse will he from 
^0 to 140. The tongue will be coated hut,often moist* 
*uere are often disturbances of the stomach. Besides loss of 
^petite, the patient may have nausea, and vomiting. The patient 
vomit food or he may vomit a greenish or brownish fluid 
$*s the patients do who have peritonitis. The patient suffers 
the restlessness and sleeplessness of a high temperature. 
* the enlargement of the liver and spleen be- marked, you can 
^nerally make them out by percussion. The patient may complain 
pain and tenderness over the liver and spleen. Jaundice may 
^Ppear quite early. 
k°,%he patient will go on from three to ten days with *11 the 
Symptoms* Then, there is an abrupt change. The temperature will 
T&ll ag rapidly as it went up~Tnd,in the milder eases, there will 
$ & cessation of all the symptoms. In the more severe eases, 
^e fall ©f the temperature will be accompanied by profuse 
287 bleeding from the nose,atomueh,w bswelssor a very prQfise 
sweating witJu marked prostration: or diarrhoea: or excessive pros- 
tration almost like collapse.. 
Then, the patent will go on for about a week without any fever 
and, perhaps^! thou t any symptoms. Then,comes the relapse. All 
the symptoms come back. The temperature again runs up and all 
the other symptoms return. This relapse lasts from one to seven 
days, most frequently, for three. Then, the re will be a rapid fall 
of temperature with or without complications and this second 
fall of temperature will,as a rule>,mark the close of the disease. 
It is possible for the patient to have three on,even,four relapses 
with the corresponding intervals. 
•-NOTE. - In the description of the feven,we omitted to insert 
that the morning temperature might be higher than the evening 
temperature. • , 
As a rule, there is ne sharasteris tic erup tion, ye t, in some epidemic 
there has been an eruption like the eruption of typhus fever. : 
When this eruption disappears,it may be followed by desquamation* 
288 *he febrile period-, the heart is fairly strong, though 
Wid:but?during the intervals^ the heart may be normal or it 
be feeble. As a rula, the bowels are constipated but?in bad 
c&se^we get bleeding with the stools and this is especially 
aPt to occur during the sudden fall of the fever. In other 
^41 eases? there will simply be a diarrhoea when the temperature 
^\ls, 
jaundice usually appears on the third or fourth day of the 
^ir^t paroxysm. It may not appear until the second paroxysm. 
xu seems to be an indication of the severity of the divease, 
^he urine will vary with the severity of the nephritis. If the 
Nephritis be mild? the urine 'will contain a little albumen and 
a few casts. If the nephritis be severe-, the urine will be dimin** 
is he 4 in quantity and will contain blond and the albumen and 
casts will be plentiful. 
during the disease and-, even? during convalescence-.. yn me of the 
Patients will complain of pains in the joints. Thc-^e pains do 
uot seem to be due to inflammation of the joints but the patient 
complain ojf them greatly. Othex' patients will have muscular 
Pains. These pains resemble in character those of rheumatism. 
As a ruler, the oerebral symptoms are not very marked* Some of 
289 the patient^ there. may be delirium* O^sasionally,wi th., the sud* , 
den fall of temperature,, there will bo one or more general con* / 
vulsions. 
- Comp 11 s a ti on s • - 
The som^licalions are for the most part due to the*aomplicating 
inflammation^ Thus:* . •. 
1 -The inflammations of the lungs maybe very serious, partis* 
ularly if we haw a pneumonia. The pleurisy and the bronchitis 
do not amount to wch> 
*-2-The inflammations of the pharynx and larynx are not of 
great consequence unless they be croupous, ' 
3*-Rupture of the spleen la, of course,fa tai. . . . 
•-x-y^e- inflammation of the colon may give rise to* dysentery 
and the dysentexy may be severe and my kill. 
- 3 -Thero maybe a complicating peri ton! tis». 
'-5 -As the patient recovery, there maybe a loss oC power in 
eoi^ Gf vphintary muscles- Thi?? is prebably due U^inflaK* . 
ma tian of the peripheral nerves. The palpalysis usually* involves 
but groups of muscles. It is not complete and only lasts a short 
time. 
290 *^7--As in spinal Bening!tis, the patient Bay have 
xhf ef the eye a, particularly ®f th® ch^ratd oeat and 
bcdy^ These lesions may dest-rey sight. 
the disease is ef a bad type^we Bay have the disposition 
bleeding a bad nephritis^ marked cerebral symptom^ inflame 
the lungs?,colon, and peritoneum. The prostration between the 
^ttaeks may amount to eollapse and the patient say die in cel« 
^pse# When the ip&tient die^he. usually dies from one of the 
'®°nipii^*iOnKa ' , 
PROGNOSIS. -~ 
The mortality varies very considerably in the different epidemics. 
When we ha.d it in New York,it was not at all a serious disease. 
some epidemies have been very fatai^ especially those that oeeurred 
India and Ireland and fallowed famlntB. ' 
- TilEAWT. - 
New York-5 the did very well and were not very 
ho astive treatment was indioated. 
^on in *he mid «ases<? the rise of temperature 1$ considerable 
it lasts but a few days,it is not apt io do much harm, 
*®t> the less it rises, the more comfortable the patient will be 
beams to be just to give antipyretics pretty freely 
291 to make the patient more ©oaf or table* There 1b lie harm in keep* 
Ing a patient under antifebrin or antipyrin fer a few days* 
If we did thia? we would probably find that-jas we diminished 
the temperature^we would diminish the other symptoms and the 
patient would not feel as siek. 
The heart's action does not require treatment except between 
the paroxysms. Give alcohol or other stimulants. 
The nursing and feeding of the patient are the same as in typhoid 
fever except that in relapsing fevep^we do not have V) be as 
careful about it* 
292 - THE MALARIAL FEVERS. - 
na&e is given to a grou^p of fevers, the poison of which 
originate, 11 v&, and grow in the earth and,from the earthy 
s ♦ossmunicated to human beings. The ^eigon is not transmitted 
.*** one person to another:each acquires it afresh. The disorders 
for the mosst part characterized by a febrile movement but 
$ame poison can cause other disorders in .which the fever 
be absent* The latter,we call the malarial cachexia.. With 
, e malarial cachexia,we have changes in the blood,in the healthy 
in the nutritlon but these changes are often unaccompanied 
y fever. 
many eases,,malarial poisoning is only an inconvenience: in ' 
PUiex4 oase%it causes some of the most fatal forms of fever 
v^e know* Between these two extremes, the disease exists in 
grades of severity. 
- ETIOLOGY,DISTRIBUTION,AND NATURE OF THE MALARIAL 
T FEVERS,- 
malarial fevers are especially distributed over the temperate 
torrid zones. The disease is not found in cold climates. 
e most severe examples are found in tropical countries, India, 
293 other parts of Asia,China,and Africa. In these places, the malarial 
fever-?? prevail eonstantly in whatever locality they may he and 
ai'e continuous,,year after yeax\ It is in these countries that 
we are especially apt to find the continuous forms of the fevers 
here also, we find the malarial cachexia developed to a great 
degree® ' ■ 
As the disease oecurs in temperate countries, we may separate 
these countries into divisions according to the type of the diseas8* 
In some of the temperate climates^ the disease is pretty severe 
and may cause death, but it is not of the extreme severity' 
that we find in the tropical climates. This form, we find in the 
western and southern parts of the United States and in some 
parts of Europe. Eut, in these places, the disease does not always 
remain in the same locality^ In some years it will be more preva* 
lent and more severe than in others** In some years-, there will 
be no eases at all* The disease may disappear from one locality 
ahd appear in another* 
In the middle and eastern parts of the United States and in 
some parts of Europe,the disease is mild and seldom proves fatal* 
In these local! tie a, we find developed to even a greater degree 
the power that the disease has of coming and going® It is always 
294 1 e oX mak „t t3 ^ppearanc a whe re it has. ne ve r been b e f g re. 
^>it may happen that some day you will want to buy a country 
kouse and you will find one in a village where malarial fever 
unknown. Then,after you have lived there a few sumerS) 
^Urial fever will break out. 
S&>where the disease is at its worst,it stays?where it is less 
sevex^it comes and go e.s sand, where it is mildest-, this property 
coming- and going is most marked. 
tropical countries,it is especially prevalent during the rainy 
s®ason:in tho^e temperate climates where it is severe.-,it is . 
specially common during the summer and autumn;and, where it is 
is especially tommon in spring and autumn-. 
to the way in which its prevalence is modified-by the sell 
formation of the country,we find that in tropical oliBatest 
ihere are some definite rules to guide us. There^ the severity 
^hd prevalence of the disease diminish with the altitude® Where 
^re are marshes and stagnant water, the disease is" especially 
^evalent and,vice versa. If marshes and ponds be drained se as 
leave wet earth exposed to the sub, the disease will become 
prevaTenOSFit^waf before. Wen soil is first •cultivated, 
disease will make its appearance and,if cultivated lanSs 
295 be left uncultivated, the disease will became especially prev» 
alent. In tropical, countries,these rules hold pretty well. In 
temperate countries., they are no longer as satisfactory and the 
milder the type of the disease, the less does it seem to follow 
any rules. It will come in marshes and high dis tidets:when 
ponds are drained and when they are not drained: and,in the 
eastern and middle parts ©f the United States^ most physicians . 
have made up their minds that there are no rules as to its 
prevalence or non-prevaleno^ 
The disease will exist in districts where no human beings have 
ever been before. * y . 
The conditions that are favorable for the growth of the poison, 
you can deduce from what I have already said, namely,ho t climates 
cultivate it, cold climates destroy it and, in temperate climates? 
it grows and lives in a somewhat milder form. It is found that 
diffeiuent individuals and races differ very much in regard to 
their susceptibility. Some persons and races never get the diseas® 
no matter how much they may be exposed:others will acquire it 
readily from moderate exposure. 
296 - PATHOLOGY. - 
the severer forms' of the disease,it hag long been known that 
there is a discoloration of different parts ©f the hody^partie* 
^arly Gf ^he liver and spleen,less frequently, of the brain and 
tissues* It was supposed that this discoloration was due 
?° a Pigment but it was found that this pigment existed in the 
^i5o^>not in the visesra. This was all that was known until 
^81. Then,a French physician in Algiers found that there were 
^kularly present certain changes in the blood besides the 
Essenes of the pigment* In 1885., the subjec t was worked up by 
Bome Italians. They found the same changes in the blood and found 
very constant* Since then, the pathology has been more 
^refuiiy studied* The changes that are found in the blood 
due to the presence of a micro-organism. This micro*organism 
b Ma vegetable but seems to be a little animal,a form of 
'^tozoa* it seems to find its way into the red blood cells. 
11 the red blood cell^we find little crescentic figures which 
be stained. These bodies may be pale er they may contain 
granules of pigment* This constitutes the early growth of the 
13* ^organism. We also find larger bodies free in the bloo4 
^jin these,we very constantly find particles of pigment. 
297 These are evidently the Same bodies that have grown up. 
We also find other bodies free in the blood. These are. called 
the 'flaggelate bodies1. They consist of a central, rod-shaped 
body and, at one extremity are attached little filaments. These 
little filaments move about under the mioroseojpe. The flaggelate 
bodies constitute fee fulL-^rown micro-organism. 
The micro-organisms are found in the largest numbers in the. 
severest forms of malarial poisoning,during a febrile attack 
and,occasionally, in the blood of people suffering from the malar* 
ial cachexia. In fee mild cases that occur in New York,they 
can generally be found without much difficulty. Prick the patient 
finger and put the blood under the microscope and you will be 
pretty sure to find fee small and large crescents. You will not 
often find the flaggelate bodies. After fee patient has taken 
quinine,, fee micro-organisms almost always disappear* So,quinine 
seems to have'a direct poisonous affect upon the micro-organisms* 
We also find,especially in fee eases of malarial cachexia feat 
the red. blood cells will diminish in quantity and the patient 
will become anaemic. We also find that the spleen is increased 
in size. Moderate or considerable enlargements of the spleen 
are very eoamonf These are all fee lesions. 
298 When a person acquires the poison, the result is -chill# a^d fere®, 
tevC3? and ague, ox* iutermittnent fever. 
- Period of Incubation." 
•^he period of incubation seems to vary very much. In some eases, 
it is very long,weeks and months. However, the length of the 
Period of incubation seems to depend very much indeed upon the 
Character of the poison:the more virulent the poison, the shorter 
be the period of intubation. 
kQn a person has once had the disease,he is apparently capable 
carrying the poison in his body for many years and only 
r^ifesting symptoms on occasions,year after year, without any 
^esh exposure to the poison# 
$ js-SYMPTOMS OF INTERMITTENT mr®. - 
Ahe symptoms oeour in paroxysms which are apt to succeed each 
;ther at regular intervals. Some times,, they occur once a dayv 
other timeonce a week,every seventy hours,every forty-eight 
*phrs.3O3? patient may have two attacks a day. The patient will 
the attacks at the same time each day. The attacks may 
-come more frequent or less frequent. 
? a complete paroxysm, there are thx'ee stages: the cold^ stag&> 
212* »tage,and the stage of sweating. - 
299 - Th© Cold Stage.*-This stage begins the paroxysm* It comes 
on suddenly. The patient shivers and feels cold. The surface 
of the body feels cold. There will be a disposition to nausea 
and vomiting* The heart will became more rapid. Yet, the ther- 
mometex' in the rectum will alredy show an increase in the tem- 
Perature. This stage will last from h^lf an hour to two hours. 
Then, pretty rapidly comes the het stage. 
--The Hot Stage. -The patient feels very warm. The face is 
flushed. The pulse becomes full and rapid. The temperature runs 
u^. The patient is apt to have a severe headachy pain in the 
backhand prostration. This stage will last from two to twelve 
.hours. Then,it goes away pretty rapidly. 
The Stage of Sweating. ™ The temperature falls rapidly. It is 
apt to fall below the normal. The patient sweats. All the other 
symptoms disappear. The patient gradually feels better. He is 
apt tn go to sleep and,when he wakes up,he is apt to feel as 
well as he did before. 
The cases vary principally as to their severity. 
~ Irregular Attacks. - 
These are not as eommcn as the regular attacks but they are 
common enough. 
•-1-These cases are very common where the disease is mild as 
in New York. The cold stage and the atage of sweating will be 
absent altogether. There will only be the hot stage^ the fever. 
300 countries where the disease is more severe, there 
a number of variations. These are;- 
in the western, and southern states, the pigment of the blood 
appeared in the urine-see Paroxysmal Haemtinuria* 
^in dis trie ts^we find the pernicious cases. These 
all serious. They are the fatal eases of malarial fever. 
ey are ap* to kill either in the first,second,o ar Shi rd par* 
These pernicious eases differ a little. 
J^he Algid or Cold Form.- The patient has the chill but eon* 
-ues to feel cold. This is accompanied by a feeble heart action 
P&timt passes into collapse and is very apt to die. 
U *^e Diaphoretic Form** The patient gets through the first and 
P °and stages but,in the third stage,, the sweating is unusually 
The profuse sweating is accompanied by a feeble and 
heart and collapse. 
Th*^16 Syncopal Form. -The sleeps takes place during the chill. 
Atlant get® no farther but becomes unefoscious. 
'-'Orebral Cases.-The cerebral symptoms come on during the 
jitage. Besides the fever® the patient will become comatose 
^Qlsntly delirious. The delirium somewhat maliacal. 
'"■^n these case a, th© lungs become congested during the second 
301 stage. The patient will have the cough,dyspnoea,and profuse 
expectoration. 
these cases,,we have an inf1 animation of the digestive tract* 
In the second stage,in addition to the fever;, the pattent will 
have severe pain over the upper or central and lower.parts of 
the abdomen. 
If the stomach be involved, the patient will vomit mucus,food, 
and blood. 
If the intestine be involved, there will be large watery steh^s 
or the patient will pass blood with the stools. 
All these pernicious cases are extremely dangerous. In all of 
them, the patients are greatly'pros trated and they frighten you 
very much. The patients frequently die. 
- TREATMENT. - 
- Prophylactic Treatment.- 
This seems tn consist in the daily use of fair doses of quinine. 
If the Patient be obliged to go into a malarious district, in 
addition to advising him to avoid being out in the evening air, 
you give grs.v of quinine every morning before breakfast. As 
to whether it is proper to give whiskey with the quinina,opinion' 
difjfer. 
302 x.- - To Abort a Par^you • - 
Sow can abort a paroxysm ItwsijpWf^ 1% 
*ess severe^ Thiasyou ean do in one of several 
"'■ " ^0U ©ay g3Ve a hypodermic injection containing g ivl/$ 
ar® §£^2 ©f sulphate S£ morphine. 
2~-y^ ^y give a large dose of opiun. in ^ny 
S--xqu may give dram*J*dram ij of chlonofexi^well diluted* 
you ^y g£ve oonsdderable dose^ of antifebrin ©r aril- 
Y1*^ ~~~ 
Ail ct these methods ar? only of use during the ehill. Later 
w*oi tn is. 5. you cannot-aboiH. 
- Curative Treatments - 
x"xe dxsug^ that we oenmonly us$ are quinine^arwnie^and Uxat 
of quinine with other things known as Harburg3 s 
tunes«The eases vary as to whish drug will be the best and 
• w whioh is the best way to give these drugs* 
of the eases can be treated perfectly well by quinine alone* 
may give the quinine in any form» The best way to give it 
solution with a mineral acid but this is also the most ■ 
agreeable way. If you give the quinine in pills^powdery or 
^Psule&jit will be rendered more potent if the patient drink 
303 one of the dilute mineral acids at the same time*-., • ' 
The best time to give the quinine is between .the.•paroxysms, 
either in one large dose or in divided doses* In adults,we may 
call twenty grains between the rarexysms an average dose but 
some patients have to take much more than this,others need not 
take as much. • ' ' ' 
In some oases,you will want to, get the patient'; rapidly under 
the influence of the quinine,especially if you think that he ' . 
is apt to have a pernicious paroxysm# Then,you give the quinine 
hypodermically* Fgi* this purpose,use the preparations that are 
most readily soluble* ' 
In some cases-, quinine will do nn good at all* This is especially 
apt to be the case in patients who have had the' disease far a 
long time and have been treated by quinine* Then, you will semetin^* 
effect a cure by adding arsenic to the quinine* Then, the quinine 
does not have to be given in such large doses* If you give 
arsenious acid,give gr«l/60 t«i»dc. If you use Fowler's solution, 
give anv t«i^d*#It will usually suffice to add grs.xv |of 
quinine to these arsenical preparations. 
304 Bam® easethese means will not succeed and, then, s 
tincture* of ten does very well. You may give it in its original 
or you may have it evaporated and put into- capsules. Al J 
^^ggists now have it in capsules^ fee Une ture, itself is pretty 
^^ty. The directions that the inventors of v Is preparation 
&iv$ are the following® The night before,let the patient take 
Pretty active cathartic* Then,the next morning,let 1 - .. take 
the drug on an empty stomach, Give dr.lv of the tincture or its 
eQuivalent in the form of Capsules# Then, for three hours, the 
^tient should not eat or drink anything^ Then,he should ha^e 
aether dose. In the milder cases.,it is not neoe»sax?y to follow 
directions; it will ef ten do to give dr.ij t»i#4« without 
restrictions. The tincture must loosen the bowels somewhat* 
^i^you must expect. In some of the protracted cases,you will 
$et good results by putting the p&tieat on pretty fair doses 
iron and arsenis. 
305 - RWITTPJNT FEVER,BILIOUS REMITTENT FEVER, OR BILIOUS FEVER,- 
In addition to these three names, most of the localities in which 
it occurs have some especial name for the disease/ 
The invasion may take place in. one of three ways. 
- I -The patient may at first have several intermittent parox- 
ysms. 
"2-There may be a prodromic period lasting from' one to three 
daySe During this period, the patient suffers from malaise. 
•- 3-The invasion may be abrupt and sudden . .. 
If the invasion be abrupt or if there be a prodromic period, 
the invasion will be marked by chills' or, simply, feelings of 
coldness. Then, the temperature rises evbn while'the -patient 
feels cold and it soon reaches 102,10 3,104. With the fever,the 
face becomes flushed: there is headache?there are pains in the 
back and limbs? the pulse is rapid and full: the tongue is coated:' 
and there may he nausea and vomiting* 
.The disease goes on day after day. The patient has the fever 
during the whole of the twenty-four hours but the fever remits. 
Generally, the remission takes place in the morning but there 
may be a second remission in the evening. The remissions may 
come at other times. The bowels are regularly constipated and 
306 c,;. . 
so. 
P10 urine is diminished in quantity^decidedly acids^ a high 
^Pecifio gravity* and high, colored, at? in all fevers# A. nephritis 
not seem retpjlarly to belong t° this di seasea 
^t®r7 the temperature becomes higher and mox^e continucts and 
the remissions become less and less decided# So the ca&e will 
MG & from f ive days to three or four weeks and it tey^laSi longer# 
^ny patients who recover will have no more . trouble but 
fibers will go on With paroxysms of Intersilttent fiver. 
oases vazu^ very much to their sexferiiy«/ •' • .. 
these casethe temperature not run 
high^lM and the patient is not at any tlse ve^Wiek® . i 
2* °ourse^the ml it? nt goes to bed but vou de not feel arrKiou^ 
him 
j Severe Oases* - In these the tempo feature wt'll he hlgh^ 
1-05, ICS-j 10'7 and?wh.en the parent is fairly into the diseas^ 
e iever is pretty continuous,. Ah these c^ses go Ih^k 
more like typhoid fevezu They become emaciated* The 
^gue and lips be com dry and bx'c^'^ Dclirivr& alternates with 
ihpoy* There may be retention of urine and involuntary evacuations* 
307 of faeces* The patinat develops 
passes into the typhoid state* v 
The appearance of the patient is about the same as the appear- 
ance of a patient in the Second or third week of typhoid fever 
and^ in /making the diagno^i^we have to depend upen the histery 
and the prevalence of •remittent fever or ©f typhoid fever in 
the locality, These foes are serious and give you great anxiety* 
- 3-The M&llfpwH -X& a very few da 5^ the patient is ) 
very rapidly overwhelmed with the disease* The cerebral symptoms 
are developed early and are very max'kod* The patient developed 
the disposition to bleeding fro th® taa^u0 membranes and int© 
the skin. There is a well-marked disposition t® jaundice which 
appears early* 
The height of the temperature varies It may he very high or it 
may not* Theo eases are very fatal and you can see how easy ' 
it would be to confound theB with yellow fever* 
3'-Typhe-Malarial fevers-See typhoid fever* 
- TRFA^WT OF RWITTWT PWMO - 
Put tiie patient to bed and keep him there* Feed and nurse the 
patient as in typhoid fevex^especially in Vie severer eases* 
Now., you wopld naturally give the same drugs as in intermittent 
fever and,in same case^, they are of use butjin other easethey 
are of no use at all*. 
308 this the the best you 0^ do is to give these drugs 
* trial but* If they be of nc servlve^do not -non tlvuo thegu 
f Its t give Uem pretty fairly^ freely^ At the k&glnhinfe ef 
disea^X should net hesitate to give tat -t'^ 
°r even one hundred grains of quinine in Ure twenty feu? hours 
X should give it in solution* Give it by pieeWreuo^^ ^ring 
x-emis^i omn 1 should not he^tat# to continue th.ero large 
°S^s fop a •»?©$&* thens if tbsy did zxo good,, I sbavld ho d'*u^ 
«»-IT far a week or two wets* Then? I wuld try agyin and «he 
'eight now very we^l suoceed^ fels queey^ 
ig true of Warburg2 8' tine tni^ & rul^ov^enlu -is not 
veil sd^pted for ths •remittent for the into ur.l tie nt voses/' 
Mtlqh of quinine and- Warburg3 s tincture efyen i?^wve< y 
>' preceded b.y a, mercurial purge* Whether or n^t it- i® 
wisS to bleed, X do hot 11 is oe^siena'i! y .tUr^ 
the patient t>ass into the typhoid statas give. 
tost re^i&hie are 'Whiskey and brandy which have t© 
6 ^iven in very considerable 'dotesk To 'the>%yBU W® 
cardiac stimulants but you must y-ve the alcoho'U - THE MAIAKIAL CACHEXIA. - 
This form of the disease is especially apt te.be developed in 
persons who live in malarious districts for a long tise^months 
and years* It, belongs to the inhabitants of those districts and 
not seen in New York* In some ea^es. the malarial cachexia will 
follow attacks of intermittent or remittent f ever: in o ther oases* 
it will come on by itself. 
The first thing that is noticed &b$ui the patient is that his 
skin and mucous membranes become white* This is due to anaemia* 
There is also a change in the nutriti®^ The patient loses flesh 
and strength and is indisposed t© bodily ®r mental exertion. 
The spleen often becomes increased in size and?often eensiderabiy 
increased.in adze* Some timeit will f@rm an abdominal tumor 
and will give the patient inconvenience. It s^y sag down and 
interfere with the other abdominal vi^cexu* 
The patients often become melancholy or unnaturally irritable 
and peevish* They are very liable to pains such ag headache 
and neuralgia. These pains are apt t® be periodic and are ®fte» 
severe® There my b© disturbances ©f digest!©^gas trie dyspepsia 
with all it® ©r functional derangements of the liver 
310 all Its symptoms. .. . \ \ 
4**" 
Wrt ^TWe^^TtwMi * • , 
first thing to do is to remove the patient from the malar* 
district: otherwise,treatment will not be of permanent " 
$uefit. jn addition,it is necessary to give drugs. The anaemia 
r\ to be treated with iron and oxygen: of ten, you will do better 
y' iron and arsenic in pretty fair doses. 
must treat the digestive disturbances. You must find t the 
^t way in which to feed the patient in spite of the faht 
neither ,the liver nor the stomach are performing their 
^etions properly. If necessary, treat the gastric dyspepsia 
Y $ functional disturbance of the liver in the ordinary way. 
must bring up the general nutrition. Pay attention to the 
^Mliness of the skin. Employ massage and passive motion 
make the patient take exercise in the open air. 
for the direct treatment: - Usually, the best drug to give is 
^^enic in fair doses. Keep up an intermittent course of -this 
for some time. 
311 The forms of malarial fever that occur in New York have certain 
peculiarities and require peculiar forms of treatment. In New- 
York, the patient may suffer from intermittent or continuous 
symptoms. 
- 1-The Intermittent Cases.- 
- a - A certain number of the patients will give a perfectly 
straight-forward history of intermittent paroxysms with the 
regular stages and should be treated in the regular way# 
- b -These patients have no stage of sweating and no stage of • 
ehill# They only have the fever but, with the fever, they will 
have certain other symptoms# Thus,they may have headachy sleep- 
lessness, an irritable temper,palpitation of the heart,nausea, 
loss of appetite,disturbances of the functions of the liver.,or 
feelings of numbness,heat,or cold,or pains# One or more of these 
symptoms may accompany the fever* They are only present with the 
fever* During most of the twenty-four hours, the patient is up 
and attending to his work but,every day or every other day, 
most frequently late in the afternoon,evening,or night, will 
come the slight rise* of temperature,99,100,101, which will be 
accompanied by one or more of the above-mentioned symptoms* 
These symptoms will last several hours* then, they will go away 
and, the next day, the patient will feel perfectly well* 
312 n Some closes, the paroxysms will go on for weeks and months 
but little change in the patient's health but,in other cases 
^tep & time, there will be a loss of flesh and s trength'and 
ie digestive disturbances will continue on between the paroxysms* 
may also the headache and palpitation of the Mrt Then, 
Patient will be worse during the paroxysms but he will 
^c,t be in good health between the paroxysms* When left to them* 
they often are, they will go on in this way for an 
Retinite time* Each day, they think that they will be better 
e next day* The history often lasts for months. 
•''-These patients have the intermittent paroxysms late in the 
-mioon,evening,or in the night but,with these attacks^ there 
f-o rise of temperature* Yet,.it is evident that the patients 
® nave a paroxysm which goes off after several hours. They 
^1 or one or more of the symptoms mentioned as belonging 
the second class of patients but there is no fever* These 
vill coine on evening after evening,every day or every 
These patients will also suffer month after month^ 
v * very apt not to go to a physician. These cases are 
Coinmon indeed and, al though the history is characteristic 
very easily overlooked. We are apt to be very huch 
** fenced by what the patient says and these' patients do dot 
us that they have uaalarial fever. . e . _r, ,H. . 
313 - TREATMENT*- 
The first set of cases is to be treated in the ordinary way. 
As to the treatment of b and c it is easy to ♦ure some of them, 
very diff ieult, to cure others. 
Some of the patients will get rid of all the symptoms within 
twenty-four hours after they leave the city and the symptoms 
will not some back for some little time after the patient has 
returned. Other patients are not benefited by any change of 
tlimate^no matter where you may send them. 
As to quinine: - If it is to do good at al^it will do good in 
small doses,grs.x-grs.xij in the day. More is of no 'service. 
Under the quinine treatments some of the patients will get better 
in a week and you will cure them. This is really very satisfactory 
and, to make your glory still greater., the patient may very well 
have been to seme other physician who has not been able to do 
him any good. 
In some.,quinine is of no service'whatever. In others, the same 
thing is true of quinine and arsenic. Some do well with iron 
and arsenic: in other eases, it does no good. Others will do well 
with Warburg's tineturasothers will noU I 
In other aases,quininq and antifebrin answer pretty well and, ' 
given together, they se|em to me to be the mest reliable e$sibi»atl«Ep 
314  ,. ' I , .... 
of daoh and keep them up ter a ^onMderabli 
\ - • 
* t <• 
giving these drug%lnok to the patient's general health* 
his food and Ms exercise® Treat the disturbances of the 
and liver, especially in thes<;'patients who are net 
Pldly benefited by dj.wjs,,^ y^u san stop 'the pax- 
or not,you ean Improve th^« D^Uwt's general health. and 
W. fee® better. V ' * 
t-g~The Centinuoiw Therms in New-Xar'k® •' ' 
l-^^^ese patients develop a fever whieh-regularly 
tjhe.morning and higM-ln the evening* rae temperature will 
between 1C^ and 1(M«> With the fever, the patient feels 
enough to go to bed and stay there* HeadaeM iq. often pres* ... 
*i* The tongue is., often eoated and it 1$ -often as 
as in typhoid fever® a rul^t thexe is ne dis.^rMnes. ; 
. tile bowls but there wiy be a mode nite twpaniti^ The 
P^Un sometime?? quite abrupt M o.ther U&esjit will be 
J^-eded for several days by ir4$finit9 feelings of indispe* 
When tM yatient U bed,tlw atlasts 
°^t two weeks® Ther^ the te^exature falls to the normal aM* 
315 in ya&er an irregular type. Tn some cases, you will watch the 
patients through the whole course and not be able to say whXo* 
disease they haves in others,?you will make up your mind . n a v> y 
few day®. It is probably an account of these eases? that many 
plmlalan^ think that typho-malarial fever is prevalent in 
few ferk. You haft, better tall these eases typho-malarial fever. 
Then? if the patient really have this form of malarial fever 
he will recover: very goodLhe had a mild attack of typho-malarial 
fever® If the patient really has typhoid fevex4 and dies,very 
good &pd.>fhe had a bad at task of typho-malarial fever. 
- Treatment. ™ These oases are not at all benefited by quinine 
or any of the othex* drugs that we give in malarial fever. If 
you do not believe thia? you may make the experiment for yeurselv^^* 
^ke the patient eomfor tab la? Relieve the headachy make Ue patient 
sleep at night?and reduoe the temperature if it seem U cause 
the headache. 
- e- The temperature is continuous but it is not high®- The 
morning temperature will be 99^100: the evening? 100*102. 
316 opr . ' ■ 
symptoms axe apt to come -on very gi*adually,und,oftexH 
patient tan not tell you when the disease begun* The patient 
not enough to be in bed but he is up and about* Yet, 
^es not feel at all well* He is miserable and good-fo^nothings 
^es on with his work but does not take any in teres h. in ilk 
patient loses appetite^flesh,and strength. The heart is 
^tinuously rapid with th® fever. •;•*/ •■ . . 
patient# go on for weeks and months* They often-do sot 
'^e'^eveT all and do not go to a physician. If left 
themselves they will go en indefinitely* 1 have seen aase-s that 
Ve &on® on for four months* . 
patients have the fever but the fever is not. actually' 
l^^nuous. It varies from week to week and from month to month*. 
$ week or one month, the patients may have no fever at all and - 
K$t better in every way. Then, the fever will ^ome back* 
A^3e patients will go on in this way for yeans* 
- WJVMmT Of b and o, - 
^atment is the same us in the intermittent eases* Some 
satisfactory to treat:others^not. You always ... 
^etter but it ,is often difficult to cure them, to-make 
i-*10 fever. You will get rid of th& fever fer a< 
•$ or month anti, then,back it will «»ue. 
317 - THE EXANTHEMATA. - 
The exanthematu constitute a we 11 -marked group of infectious 
dib'ea^es. :^ch has a specific poison and all are contagious. 
The are capable of floating in the air and are thus 
transmitted from one person to another. The poisons san also 
remain alive in clothingrooms, and articles of furniture for* 
a ennsiderable time# Each disease has a regular period of* incu- 
bation and of invasion ard.a characteristic eruption which lasts 
for a definite time. Each runs a characteristic course. None 
originate spontaneously? each person acquires them from another 
As a rale,, in these diseases-, one attack p ro tea ts against 
subsequent attacks* The degree of protection varies somewhat 
with the different members of the group. There is also a dif* 
fereim with different members of the group in regard to the 
susceptibility of individuals to them. Some are taken by almost 
everybody ex^osedg o ther%no t* 
Most of the exanthemata have existed for a long time and^no% 
our knc^-ledge of them is in. many respects complete, Each runs 
a definite coui'se that there are no diseases so completely 
a3 j rib ed ih"Hie Text books. I have really nothing new to tell 
you about them. 
318 p1® characteristic lesion of siaall-pox is the eruption whieh 
2s developed in the skin and in. the mucous mmbranes, 
*pv 
4'e eruption first appears in the form of a little round dis^ 
^^icratien of a brownish eelor, It seems to be situated in the 
^iokness «f the skin and mucous membranes, Then^lt seem# w 
*^Uire a little tM<kness>4ue to the* development of inflammatory 
Inducts in it® It Is now a papule, Then, the papule beq^mes a 
^Hle thicker and larger and?of its inflammatory pro due ts$ the 
e®rum developed-in excess and it becomes a vesiele. 
Pus produced, The pus mixes with the serum in. the v® sic la 
finally Infiltrates all ef the original lesion, Sa^ the 
. $&i$n becomes a pustule. The f^^cation pus marks the eomplati^n 
the inflanmtery- pmeess, ThenT the pus and serum escape or 
^e absorbed® Graduallvs the infLwzation subsides but a 
tissue results and a little depression is left?due to an 
destruction of tissue, 
e eruption is found on all parts <;f the body and in th® mueous 
emby^e^ of the eye^nos®'^ throaty pharynx larynx^ and oesophagus, 
_.^e^ the inf lamination is at its height, an ordinary inflammation 
developed between the pustules and we will have a.diffuse 
- S M A L L - F o X ,- 
319 thickening and reddening of the .skin and mucous membranes. 
This diffuse inflammation does net as a rule go on-^to suppuration 
noi' does it cause destruction of tissue. The skin j-s simply 
infiltrated with serum. In the mucous membranes, the accompany- 
ing inflammation is regularly of an. acute catarrhal character. 
- Associated Legions* -~ 
- 1-There may be an acute nephritic - 
- 2- The liver and spleen may be the s^t of an acute paren- 
chymatous inflammation which will make the^-larger and softer. 
- 3-The lung may be inflamed* 
.- 4- Less frequently, there will be an inflammation of the spinal 
cord. 
- 5-There maybe a disposition to haemorrhage from different * 
mucous' membranes,and extravasations of blond into the mucous 
membranes, the skin,and serous membranes may take place, 
Now-a-days, in most countries, small-pox is not a very prevalent 
and not a very fatal disease. Not many years ago.,it was both 
very prevalent and very fatal. All persons seem to have a marked 
susceptibility to it at all ages* The number of unprotected 
persons who are exposed to the disease and do hot get it is very 
SKiall. w 
320 Still,in most eases,, it pretests pre tty thoroughly against itself 
the rest of the patient's life. Some people have had the 
disease twice but tills is the rare exception. 
The disease is directly contagious. The poison can remain alive 
articles of clothing for a longer time than the poison of 
other infectious disease^ for months and years. The poison 
^ems to be given off from the human body from the time of -she 
*nvusion of the disease until the complete recovery of rhe patient# 
*he prison can not only be transmitted through the air from one 
Person to another but it can be given by the pregnant woman to 
fe&tus in utere. Bodies of people who have diea while the 
"^sease was in progress can give the disease to other people. 
-Period of incubation. - 
"hen a person has been exposed to the poison of small-pox,he 
not develop the disease until from ten to thirteen days 
* terwads. During this timer, the re are n© symptoms and the person- 
u net capable of transmitting the disease to anyone else. 
$ - The Invasion.- 
Keemes the invasion. The Invasion has a definite length,froia 
to three days. It is sudden. The patient-has chills and a fever 
321 which runs up. rapidly and reaches its maximum by the second or 
third day. The temperature will range between 104- and 107* 
The pulse becomes more rapid and full,100-120. The breathing 
is also rapid, the bx'eathing of fever. Very soon, there is marked 
prostration^ The tongue x'apidly becomes coated© ,i ue re may 
nausea and vomiting. There is apt to be a severe headache. 
We may have delirium alternating with stupor. We may have general 
convulsions. There is regularly a pain in the back which is1 
more severe in small-pox than in any other disease. 
The eases -vary as to the severity of these symptoms. In some 
eases., they will be so severe that the patient will die right'here. 
Now, the patient is capable of giving the disease to other* people# 
Then, comes * * 
- The Characteristic Eruption^™ 
The eruption regularly begins on the upper part of the forehead 
and scalp. Then,it extends downwards ©ver the x^est ef the ody. 
By the second day of the eruption,it assumes the papular form. 
By the sixth day of the eruption, the vesicles ax*e fairly fcr&ed. 
The vesicles assume a characteristic shape. You have the pa^ul^ 
in the thickness of the skin and/comiag u^ fr«m th© papule is 
the vesicle which is depressed at the centra,er gumb 1 Heated4♦ 
322 Then comes the formation nf pus-and, by the eighth or ninth 
^y of the eruption, the eruption assumed the pustular form. 
is at this time that we have developed the associated inflam'* 
^tions of the skin and mucous membranes- 
the patient passes from the invasion to the eruptiethere 
3-$ a change in his condition somewhat for the better? The 
Perature regularly falls and it my fall several degreed The 
other symptoms abate. This improvement is most marked during 
^e first days of the eruption but,as the vehicles chang® into 
Pustules and as 'there is added the aeaompanying inflammation of 
^ke skin and mucous membrane the. temperature again, rise^ the 
Prostration again be-cnmeu marked, we patient again has the chill* 
"am in the head and backhand delirium alternating with viurozu 
Ike patient may look worse at Uiis period th^ at any other 
time during the disease and it is at this time-that he moot 
^equently dies. 
xf th© patient is to recover, the eruption and acsomrany^ng 
inflammation of the skin and mucous membranes begin to suhsiae 
^ith this subsidence,which takes place on the eleventh or twelfth 
of erup tion*, there is a subsidence of the constiiu tional 
B^Wtoir^. The pustules will become smaller. Some of Uiem will 
323 will open: others will dry up: and the patient will be covered 
with little scabs due to the drying up of the pustules. Then? 
the scabs will fall off and leave little depressions. 
It takes a lang time for the skin and mucous membranes to return 
to their natural conditions, several weeks. 
Convalescence takes place in six or seven weeks and it is often 
interrupted and retarded^in the following ways. 
1-The damaged skin may become the seat of ether inflammations, 
furuncle a, erysipelas,, and gangrene. 
- 2-The conjunctivitis often remains for months or years. 
- 3--It takes a long time for the mucous membranes of the mouth 
and throat to get back to their normal condition. 
•-4-The laryngitis may be dangerous and there may be attacks 
of pleurisy and pneumonia. 
- 5 - The patient may have a disseminated myelitis which is 
regularly fatal. . 
- Irregular Cases.- 
Besides the regular ease a, there are others that are wee severe. 
324 ^1-Some of the patients will have an excessive development 
the eruption. The eases are straight-fo:Edward enough bu t the 
eruption is developed to such a degree that the pustules are 
contact with each other. When this is the ease, the patient 
is said to have the 'confluent form4 of small-pox* Otherwise, 
these patients only differ in that they are worse in every 
than the regular eases, The invasion is'more severe. The 
institutional symptoms ax^e more severe. The patients are especially 
^Pt to die durcing the invasion or when the eruption has reached 
maximum If they recover* they suffer in a special degree 
from all the complications of convalescence, 
' 2-- These are called the haemorrhagic oases. The patients will 
develop,, the disposition to bleeding. There will he bleeding 
lnto the vesicles and pustules* There will be extravasations 
blood into the ski^moceus membranes,and serous membranes* 
* he 11 be hie eding from the no h a, mou th* b ronehl* M 
uterus. Some of the patients will lose a great deal 
blood.'This haemorrhagic form may be associated wife, either 
'discreet* er ^confluent3 form;but it regularly isarks a bad 
3- The Malignant cases. - Thig farxa of the disease is 
325 decidedly irregular. The period of invasion is very marked in 
all -the symptoms exeept in the rise of temperature. There is 
always some fever but the rise of temperature may not be as marked 
as in the non*malignant oases • Some of the patient'S will-have 
a high tempei'ature during the invasion* o thers^ no t. The marked 
symptom during the invasion, is the marked prostration. Not only 
is the period of invasion decided but it is short,eighteen to 
thirty-six hours. Ye t, al though it is short, the patient may die 
in it. If the patient live^ the period of invasion will be suc- 
ceeded by an eruption but this eruption is of an irregular 
character. No longer do we have the gradual formation of papules, 
vesicles,and pustules but the skin of the trunk and extremities, 
especially of the anterior abdominal wall and the inner sides 
of the thighs will become the seat of a diffuse redness and 
swelling as in scarlet fever. In this area of redness., there 
will be extravasations of blood mottling its surface. In addition? 
there may be a few regular spots and vesicles of small-pox. 
The patients develop the disposition to bleeding in different 
parts of the body. The prostration which was so marked at the 
invasion continues during the eruption* Th^ patient gets weaker 
from day to day and,regularly, in a few dayfl or a week.,he dies. 
326 Men _ m1'1 ♦ *TB-Ct V & ®V.t UU $-. ftSS 
^hese mllRnant eases are very dxxxie_lt «• • ^-ii 
smii.-pax oe prevalent but,ether-w.se, Ue whole cisele at jmaii 
Pox is ehapac tex'istie. ' t 
-Small-pox my occur in a person wh© has been vaccinated# 
^en, the disease will run a somewhat different course# This 
Modified small-pox is called ^varioloid®. It is not a different 
disease? it is smll«p$x. Thia, it is important remember,for 
•a Person with "varioloid8 may give small-pox in ^ts wrst forms 
the unvaxscinated, Sa, ^varioloid8 is just as dangerous as 
SM1-pox as regards contagion# 
Th® eruption has the same character as that ef ordinary -^mall* 
bu^ no^ nearly as extensive,, the s^^^ptoms ax'e less 
uevere and the course is shorter# During the period of invasion, 
patients are not nearly as sick as those with ordinary 
They have some fever, some headache^ some irati^n, 
a©nie pain in the backhand seme disturbance of the -sUioaGM* 
h$s© symptoms maybe so slightly developed that the patieat 
^y be walking about* When the eruption the constitutional 
y^Ptcms are not nearly as max'kec a.« in true smallThe 
exhp tion follows the regular course but the pustules are not 
^ariy ay numerous nor as large and deep as those of ordinary 
327 small*pox< There is not as much destruction of the skin nor is 
there anything like as much interpustular inflammation of the 
skin. When the vesicles are changing into pustules, we do not 
have as marked constitutional symptoms. The pustules dry up 
more rapidly. The course of varioloid is shorter and convales- 
cence is mere rapid and is not attended by as many complications. 
- PROGNOSIS.- 
In true small-pox,the mortality is considerable. The discreet 
form is the least fatale The confluent is more fatal. The 
haemorrhagic and malignant forms are almost always fatal. The 
disease is very fatal in young children and,.if they be not 
vaccinated,very few recover. Soothe whole mortality in unvaecin* 
ated people is very considerable. If the patient do recover, 
he''will recover with "pox marksB.,cicatrioes left from the destroy^ 
skin. This is a serious deformity and it never disappears. 
In varioloid, the prognosis is very good indeed. It is rather 
the exception for the patient to die and the deformity left 
behind is not nearly as great as in ordinary small-pox. 
328 TRMMEN'T, 
$®ed &nd nur^e the patient as In any Severe Infectious disease® 
Keep him in bed on fluid diet and keep him aleaa* It is important 
that the patients should not be erewdsd together* They should 
separated and the air of the s i wk tws should b^ onst&ntly 
^d thoroughly changed* 
- Prevent!five Treatment* - 
isolate the small-pox patient and destroy all his el®thing and 
Adding* Avoid the romm he has coupled* Introduce as much. . 
^sh air into the row^as possible * The real prevent! tiv® treat* 
sonsists in vaccinatien and the,p:u tee ti®n that thig wans 
*fords is mere perfect than that afforded by all the other 
^^ns put together* 
'-■Treatment of the Aruptim. -■ 
deformities that ax^ lef t by the eruption are ps^yneni 
^hd^as they are* a great disfigursment^s try t® prevent ih^ir 
°®^urrenee« Thi^w may d< by trying prevent the u^ruraixeu 
^bioh leads to the des true ti^n af tissu®* The pus in ea^M ptti* 
*dle is exactly the saw sort ©f Pus that we have in surgery*. 
^-a^day^if a surgeon gets suppuration?he know very wee 1 that 
is not a natural seejueme of events nor does'he blame uivxne 
for its @eeurren#e« He knows that there Is'enly 
person t® blame and that person ds himself* th® . 
329 Scathe pue in the pustule is to be managed in the same way as 
the pus in surgery® Exclude the air from the inflamed tissues 
and apply solutions that have the power of destroying 
Lj O' X • ' * $ ; ~ •"■■•'>• G eause suppuration* So?we may bathe the 
•i i.- X'-' skin in solutions of corrosive sublimate carbolic acid, 
or boracic acid* We 'may then exclude the air by smearing the 
shin with f^w?eithdr simple fats or fats impregnated with 
•anti»ey Of this would take a good deal of time and 
trouble but you can Bee that it would limit suppuration® 
On amount of vacHrin&tior^is now very rare and many 
praeti stoners never see a ease during'their whole lives® 
Children should be vaeeinat^d before they are three months old® 
330 - CH I C K E K-P 0 X 0 R VARICELLA. - 
disease is very somoni We see it very frequently, yet, it 
not $< much eonseauence,for the patients are so little 
*S fS * * 9 * • 
with the disease* It belongs especially to children,so 
s^,that it is sometimes said that it never ooeurs in adults# 
is not soj I have seen the disease in adults X have seen 
k 0 &l#ea&e originate in the children of a family and, the&, 
taken by all the adults one after another# It is important 
_ Remember that the disease dees, eoeur in adults for the 
..J^tion 'of modified small-pox and the eruption of ohicken-pox 
same, often exactly, Uiat,when an adult has ohi^eken® 
z^y say that he has varioloid, ' ■ 
xr^°uBh the disease is net severe-if i?? pretty oontahiou^w 
*^0 -s -■ " . * 
the children exposed, to the disease will acquire it* 
against itself but not very ^orcughly^ 
Dv^.£'epiod of incubation is from thirteen to seventeen days« 
the period of incubation, there "are no 
or/^7? invasion#. The invasion is shert^ene er twe day^ 
^n.ox'ter0 It is not marked by any decided .constitutional 
^here may be a little fever or there may not# 
a^y ipss appetite and may have nausea and vomitings The 
331 conjunctiva may become a little yellow© The Child waX'Mag about 
©r he 'may w^ni tc lie dowu Ye^a^ a r^le^none of these syspptwS 
amount to mbh aj^^ef ti%the peried of invasion Is not observed 
at all andrthe firs thing that will be noticed will be the 
eruption* In aduits^the invasion is apt to be more marked* 
The adult will buffer from headachy feven, and prost ration* 
ooms the oupiion# Tt begins tike the eruption of assail* 
pox? fire ty& the^a papula and then^a vejd^lx* I t siay 
stop at thltTpolni and. go ne x'artuer, the va^Icls will d^y up 
and leave the sxaooth\sld.n behind lu The fcuMtiion of veeioles 
is nst attended by any de^tnwtion of the true s&liu In oUier 
ease^^nwe all of the veyleles will change into p-ustule^ 
In exuption will appear1 on the skin of the face 
and af the whole body^frequer^ly the soalp® Somettaesyit 
appears on. the aueous mewbrane^ e^peoially €nose of the pb.arynM 
and mouth© The eruption usualIjr begins on the upper* part of th© 
body andtj thensextends 'Sow of the vesicles will have dialed 
up while cvheiui are still in developments The duration-of the 
eruption in from two to five days* 
332 If • X 
k .inf lamma ti on only assume the vesicular form, there will 
' destruction of the .true skin. If we have $us tules*when 
~ scabs have mW awjjlittle eilattices like those of small* 
"&e left but these eieatriees are net nearly as had and.. 
। Nearly numerous aS those of smll-pox. While the erupti-^ 
, deiag developed, the patient may have a little fever and -the 
maybe a little disturbed but, generally* the ehild i^ 
V6ry Ke will be up and around the house and, in seme - 
there will be no constitutional, s yap tows at all. -The 1 
that us^ially give the ©ost diseeiafort are the itoning/^w- 
^,^cxie throat if there be asty vesicles in the th:eoa^ 
the eons ti tutten&l .d^aaptew a:?e ^pt te be ©ore deoi^ai' 
will be sore feve^pws tratior^and' 
trh the erup tion has sms iW eours^,. the child will be wellU 
, , ■ - mMTMhNT, -- 
'■ require vei^y little treatment and but very 
Sq Of eourse^they may give the disease to other ^xlopnf 
^.5 ^!'ey he kept by themselves. They had just as well be,;.up 
^L*V"r If they wish.. If .^^<1. 
be warm, it will net be necessary t$ keep the. patt^shy- 
hpuse an^^in eold weather only keep the patient Jte 
333 the house for a few days after the eruption has subsided. 
To allay ^xe itching^ I know of nothing better, than to the 
skin with, dilute alcohol or cologne and,, then^powdex* the skin* 
If the itching interfere with the child's sleep,give Dover's 
powder at nights • • -- 
If the sore throat trouble the ©hild^paint or spray the throat 
with Goeaine* 
• 1 * 
< 
334 -E A S L E S . - 
T> 4 . 
is one of the most contagious of all the exxhthemata; 
JXc^Pting small-pox,perhaps, the most contagious. Chileren are 
•-ore susceptible than aaults ana children are very susceptible 
>G the disease. Many adults also take the disease readily. 
u a great many countries, the aibeaqe. seems to exist all the time: 
J*^t will be much more prevalent at some times than at (.there. 
hxr. tesnx *c. QUe +o the fact that^every four or five 
there is a new crop of children who have not has. the 
ana who are ready to take it* 
^Ien adults are congregated together,as in armies,large prisons, 
^n besiegea cities or towns, the disease will assume an ep* 
^Q®mic character ana a much larger proportion of adults will 
be There ax*e years auring which the aisease will 
'J^?eeially prevalent from causes that we an not uncerstane. 
ib contagious during its entire course$invation,eruptirn, 
^^s^uammution. 
Poison teems to be given off from the surface of the boay* 
o Qun be carried by the air from one person to another. It 
^Ito be carried through the ail' for some little distance* 
wiH go through a house easier than Scarlet Fever. It will 
335 The poison of Measles will remain in bedding and clothing for 
some little time but it does not seem to be vei'y curable. 
i y inoculating a person with the blooa of a patient who has 
the Measles,we can give him the disease. Scathe poison exists in 
the blood.. . 
In the better classes of socle ty. Measles is one of the mild 
diseased. When it occurs in tenement houses,asylums,ana chil* 
am' s hospi taisx 11 is much, more serious. In these cases, the 
patients are much more apt to go badly ana they do badly,not 
sg much from the Measles,as from the complications. So,among 
oifferent physicians, you will fine a good aeal of difference 
Gf opinion as to the seriousness pf Measles. The opinions vary 
according to the class of practice that the physicians see. 
The tenement house doctors a read it. 
When Measles is first introduced into a community,it is apt 
to be very severe. This,we see when it is first introduced 
among savage tribes. Under these circumstances, 11 is apt to be 
very prevalent one very fatal. These patients will not die from 
the complications: they will aie from the Measles. 
336 iiet^lec cceuix in acults?it it regularly more severe than 
^-n it gccuxt in chila^n and,when the disease noouru in aaults 
are ocr^egatea together in armies,it will be very severe 
very fatal- Under these ciroums tances, the ©ortality has 
ku tv from twenty to forty par cent- 
aharus teri^ite lesion is the eruption which appears in the 
^in ana nucous K@^r§Ae^a Uhere it# &l$o a diffuse inflammation 
^tween the eruption as there is in Thus,not only 
'^-11 the tkin be wcllen anc canbet;tec with the eruption,but 
^tre will be an inflawatian of the akin between the eruption. 
th is tendsnsy to diffuse inflammation will be very mrked 
^:- the xueous membransto The tnud&US membrane of the eye, 
;i?-rynn-?anu larynx often become the seat of an acute catarrhal 
f:e:u tlcn andy occa^lanally, though not of ten, of a cx'oupout 
le^mation« These membranes may be the seat Gf a complicating 
^j-Phthsria§ if so5 this diphtheria is apt tc come on late in the 
^sease0 
may be a bronchitis or a bronoho«pneumonia- 
A<ere may be a eat&rrhal inf lamina tian Gf the stomach ana intes- 
^nesft 
^ere may be an acute nephritis- 
*ae lymphatic glanaa-particularly the bronchial ana cervical 
337 The adeni tis may be simple or tubercular. 
- The Period of Incubation.- 
The period of incubation usually lasts from ten to fourteen days* 
We are much in the habit of thinking of two weeks as the usual 
length of the period of incubation. When the disease is oom- 
muni ca tea by inoculation, the period of incubation is only one 
week but this is only of scientific interest ana has no prac- 
tical value. 
A considerable number of the patients go through the period 
of incubation with no symptoms at all- Others will have some 
disturbance of the general health, a little irregular fever, 
some loss of appetite,,a disposition to nausea ana an indispo- 
sition to work. These symptoms ao not amount to enough to \eep 
the patient in bea or,even to keep him in the house. \ 
- The Invasion.- 
At the enc of xhe period of incubation comet; the invasion. The 
invasion usually lasts four days: some times, only twelve hours: 
some time a, five or six days: yet, four nays is the ordinary length* 
The invasion has a number of symptoms which vary in their sever*' 
i ty and in the rapidity with which they are neve loped. 
There are chills which alternate with feelings of heat* The 
338 temperature-will rise to 100*10^,according tc the severity of"' 
the invasion.* The temperature will often be highest on the first 
oay of the invasion ana will fall on the second and third days*. 
In tome children, the first symptom will be general convulsions. 
This is not as common with Measles a» with Scarle%Fever. 
The patient has headache and painA in the back m limbs. 
Nausea and vomiting are frequently present. Thore may be 
diarrhoea. The amountof prostration will vary with the severity 
of the invasion. Some of the patients will go to bed and stay 
there: others will not go to bed at all during the invasion. 
Iy the seoend?third or fourth aay»we get the catarrhal inflame 
Nation of We. eye and nose, We sore thro&t, some times pain in 
the forehead from extension of the inflammation of the nose 
to the frontal sinuses,cough cue to the pharyngiti&tdeafness 
due to inflammation of the Eustachian tube, the laryngeal cough 
and. dyspnoea,and the vomiting ano diarrhoea of catarrhal infl&m* 
nation of the stomach and intestines. So,you first have the 
fever and its symptoms or general convulsions* then, the fever 
symptoms continuing,you have the symptoms of the inflammations 
°f the mucous membranes. 
Jn many cases,this period of invasion is very regular indeed 
339 In* other eas^th^inUsien will be less regular and less severe. 
The fever^ constitutional symptoBB., and inflammations of th® 
mucous membranes' will be very slight and it may very well happen 
that you will not make the diagnosis until the appearance- of the 
eruption. 
- The Eruption. - 
The eruption really first makes its appearance in the mucous 
me^^nes. So, we really" recon w^th the period of invasion one 
or two dayfe that belong to the period of eruption, St^when 
you suspect measles always lokk for the eruption in the throat, 
mouth,and roof of the mouth, for it is in these places that it 
usually first makes its appearance. We usually date the eruption/ 
from the time that it first appears on the skin. 
The eruption is at first macular and it may remain so or the 
macules may change into papules or vesicles, The macules ought 
to be crescentic and they often are but^in many eases^you can 
not make out their crescentic shape and the macules will be in 
the shape of irregualr blotches. The macules may be close tor. 
gether pr. they may be separated,confluent or discreet form- 
340 Then,as the eruption is developed, there will be adaed more or 
less inflammation of the skin ana mucous membranes between the 
eruption ana generally speaking,the severity of this accompany* 
ing inflammation will be in proportion to the severity of the 
eruption, In cases with a severe eruption, t^e skin of the body, 
arms,and face will be much swollen. The severity of the accam* 
Panying catarrhal inflammations of 'the mucous membranes will 
also be in proportion to the severity of the eruption. 
The eruption is found all over the bocy but it begins on the 
£aee, It usually reaches its maximum by the second to the fourth 
Qay of ter its first appearance, In some eases,it comes out very 
Rapidly in o thers, gradually. Generally speaking, the quicker 
the patients get it out, the better it will be for them. Then, 
the eruption continues for several cays,fading where it first 
began and,by the end of a week or ten aays.,it 'will have entirely 
disappeared® 
ten to fourteen cays from the commencement of the eruption, 
desquamation, which consists of fine epithelial scales. 
febrile movement is apt to increase during ths eruption and 
^he fever is apt to be at its height curing the two nays when 
elation is at its height® As a rule this is the worst parti 
341 of the disease, Of ten^ there will be restlessness and sleepless-* 
nesse There may even be stupor alternating with delirium and, 
in some ea^e^wo may have actual convulsions* These symptoms are 
apt to be wor^t during the two days when the fever is at its 
highest© In some case^ the restlessness and sleeplessness will 
continue on while the fever is subsiding© 
While the eruption, is going on9we have the complications© These 
are- « 
*- I-The inflammation of the pharynx causes a cough which is 
ver:/ harassing and often constitutes the worst feature of the 
disease* 
*-2 - The patient say have a severe catarrhal laryngitis© Thia 
will give the laryngeal coughs voiceband dyspnoea* The dyspnoea 
wjbll may be alarming© If the inflas^ticn of the larynx beef 
the croupous variefy5 the g^to-«s will be much more marked and 
the dyspnoea may be fatal© 
- 3'-The bronchitis my only involve the larger bronchi© Then, 
w will ^et the regular smjw ^nd the regul&r phpnc&I sig^^n 
It ^-y isu/nlve the smaller bTe^ohi* Ther^l:^ addili^^ 
belonging to the brenchiti^we will get rapid and difficult breath^ 
lag ajxd the chaxac teristia physical 
342 a bronchitis may prove fatal,especially in young children. 
^4'-There maybe a complicating broncho-pneumonia. Then, the 
°hild will be much worse off • He may die or he may develop a 
shronte broncho-pneumonia. This is the most common complication 
during the eruption. 
-The catarrhal inflammation of the stomach may give rise 
to pain and vomiting and it may be difficult to feed the patient. 
^6--The catarrhal enteritis will give pain and will be accom- 
panied by diarrhoea. 
^rom two to seven days after the eruption has reached its height) 
H and the constitutional symptoms subside. Then, comes conva- 
^seence which commences from the tenth to the fourteenth day 
**om the beginning of the eruption. The cases vary very much as 
to how rapidly-the eruption is developed and as to how long it 
The inflammations of the mucous membranes are apt to 
^ntinue a little while after the eruption has subsided but 
they usually subside in from ten days to two weeks after the 
Commencement of the eruption. 
--Course.-- 
^e cases vary in regard to their severity. 
-Many cases run a very mild course and are not sick enough 
343 ^to require any special treatment* 
•- 2'--These eases are well marked and fairly severe. They are 
common* The things that will strike you most arc the cerebral 
symptoms, the height of the tempo rature-, and the sick appearance 
of the patient* These usually recover,yet,for a few days^you 
may feel a little anxious* The stupor and delirium may be very 
marked;the temperature may run from 104*105; and the j^tient 
will look just as sick as a person with a bad pneumonia. But, 
these symptoms will subside in a few days and the patient will 
go on all right* 
•-3-Measles without inflammation of the mucous membranes* 
Since we have become more acquainted with German Measles, we are 
levs disposed to admit these cases without inflammation of tie 
mucous membranes as examples of true measles. They probably 
belong tn German MeaslesJ 
.- 4.-.Malignant,or Black Measles. - The characteristic rash is 
not well developed. It is not abundant and it is not of a 
straight-forward character. It will be dark and almost livid 
and the appearance of the skin will be still further changed 
by .extravasations, of blood. ' ■ 
344 delirium and stupor are developed to an unusual degree. 
^ere is marked prostration. The heart becomes rapid and feeble. 
^e tongue soon becomes dry and brown. The patient passes partly 
^to the typhoid state cxid, partly, in to collapse. The patients 
have haemorrhages f mm the nosa, mou th, s tomach, in te s tine, and 
ladder. F^om the beginning,these cases are bad. They are rapid 
their bourse and regularly terminate fatally. 
- PROGNOSIS.- 
^e prognosis is worse in children under two years of age and 
adults than in older children. Children between the ages of 
ei&ht and ten years have the measles most comfortably. The disease 
more apt to be severe from its complications when it occurs 
tenement houses and asylums. It is more severe as measles 
^en it occurs in new districts and in armies. Stilh?as most 
us see it»we do not think of measles aa,in itself,dangerous 
to life. 
- TREATMENT. - 
- General Management.-- 
^at of the patients are better off in bed, at all evenly during 
^■b eruption. Yet? sone seem so well that it does not seem to be 
^seoary to p<t them to bed. The room must be well ventilated. 
345 The skin must be kept clean and in good condition® Wash the 
entire skin every day with soap and water* There is no harm 
in doing this and it is of decided value® While the eruption 
and fever are eontinueing, keep the p^tieat on fluid diet; la ten, 
you may give solid food® You must remember that, after recovery, 
the mucous membranes that have been inflamed will readily become 
inflamed again® Sa,in cold weather,do not let- the patient go 
out of the house too soon® In warm weather., you do not have to be 
as careful in this respect® The milder cases need no further 
treatment at all* 
In other cases^more treatment is required. 
In some easethe fever will be high and not well born and you 
can make the patient more comfortable by reducing the temper- 
ature® You ma 3/ sponge the skin with alcohol and water or you 
may give antlfebrin in small doses at regular intervals* Do not 
try to bring the temperature down to the normal, 101 or 102 will 
do® 
In sone eases., the sleeplessness restlessness, and delirium will 
distress the patient- In most of these cases, the best drug is 
opiui^ given i^ g^n dosea^ If the patient do not bear it well, 
you may give the bromides. 
346 In other eases., the irritation of the skin will be developed to 
an unusual degree. Sometimes^ this is best allayed by bathing the 
skin with dilute alcohol?at other times^by smearing the skin 
wi th e 1 in? and, at 0 the r t ime a, by pain ting the skin wi th c o« 
Gaine* 
The conjunctivitis does not a# a rule require more than hot 
or odd applications- If the conjunctivitis give much pain? 
just drop a few Einw of a four per cent solution of cocaine 
into the eye* 
If the pharyngeal cough give much trouble, you can sometimes stop 
it with cocaine either used in a spray or applied to the back 
of the phar^x with a brush. 
For the laryngitis^apply heat to the neck by means of sponges 
wrung cut in hot water* Give antimony in small doses* If you have 
spasmodic dyspnoea,give an emetic. If the laryngitis be of the 
Oroupous variety^you may have to fall back upon, intubation or 
trache 0 tomy* 
If the inflammation of the stomach be marked^feed the patient 
with milk or with cream and water* Add bicarbonate of sodium 
^nd oxalate of cerium to these foods and give them, in small 
Guan t -L ''I' ' 1" If the pain in the stomach be marked, 
give opium or morphine in small doses. 
^or the diarrhoea and pain in the intestines^give opium. 
347 - SCARLET FEVER. - 
The characteristic lesion of this disease is the eruption whiph 
appears on the skin. It does net extend in any great degree to 
the mucous membranes* With the eruption,,they is not the samd 
disposition to u general inflammation of the skin as there 1$ 
in .small-pox,and measles, Sometimes, indeed? there will be a dif" 
fuse inf lamination but it not constant* 
- Accessory Lesions* - 
- X'-The patients are very liable tn have an inflammation of 
the throat? pharynx,,and tonsils* This inflammation my be oatar-^ 
or croupous nr it my be attended with gangrene of the menus 
merob rane- 
- 2 - Very frequently,indeed, there will be an inf lama tian of 
the kidneys. I doubt if there be any cases that do not have 
some nephritis and,in many eases,it is developed to such a 
gree as to become a decided feature of the disease. 
3--Less frequently?perhaps, there will be an inflammation 
of the lymphatic glands, particularly those of the neck. 
- 4-There maybe an inflammation of the eustachian tube and 
of the middle.ear. 
,- § - Not so very frequently? there will be a bronchitis or a 
broncho^pneumonia. 
- 6- At some times and in gome places,many cases will be coni'* 
plicated with diphtheria. Why this should bo, we do not know. 
We often see it in New York- 
348 *he seems to be given off from the surface- It- can float 
in the air and can be transmitted from one person to another® 
it remain in clothing bedding and rooms* It differs from the 
poison of measles in more than one respect® It is not as diffuse 
lb le,? not as easily carried about? and many people cannot take 
the disease. This last- statement seems to be true even of children* 
Many children #an sleep in the same bed with a patient ansUyei^ 
&ot get the diseases Y^^ihe pdis®n of. scarlet fever retains 
its vitality mu oh longer than the poison of measles and the 
^ick room can give the disease for months after the patient has 
^eft ife 
^he predisposition to. scax'let fever is greater in children than 
in adults Children between the ages of two and seven years 
*re especially liable to the disease^ infants are net a© liable 
tb.es e older children® Ye even between the ages of W® arid 
«'oven year^many children can not take it® Some time a? this 
^.mlty from scarlet fever seems, to run in families- In inost 
^ses-one attack of soarlet fever see^;^ to be a thorough pro* 
testier frem subsequent attacks® 
many ® pun trie scarlet fever prevails allies t all tb.e time^ 
^ctnfxvm time to tisi^it will became more prevalent^ and?from 
to tisie^it will be^eme more severe- 
349 The period of incubation lasts seven days. Exceptional cases 
will develop the disease in twenty-four hours; others,not until 
three weeks* 
- Period of Incubation.'- 
- Period of Invasion.*- 
As a rul&? this is short, In many cases, it will not last over 
twe Ive h ou r s; in o the r e a s e i 1 wi 11 last fwe n ty- f o u r, th i r ty^ 
six, or forty-eight hours:in exceptional eases,it will last sev0^ 
days- Yet,as the eases run, twelve hours is the regular durati°n 
of the invasion It is usually attended with well-marked symptom 
and the different eases will vary as to which symptom will be 
the prominent feature. 
All the eases have a fever but, in some*, the fever will be un- 
usually high and will constitute the prominent feature. 
In other cases,, the prominent symptom will be one or more gen®3^ 
convulsions* 
In other ease#,, the first symptom will be a sudden vomiting whi^ 
will come on without any preliminary nausea. 
In other cases*, there will be an inflammation of the pharynx 
er tonsils with pain and discomfort* 
la all cases^ the invasion is sudden and each of these promia^^ 
350 s^ptoms will come on suddenly* 
- The Eruption* ™ 
^®n,ooxae8 the eruption* It usually first appears in the form 
small,red points,not blotches,not larger than the head of 
* Pin* Sometimes, these points will be scattered: at other times, 
they will be in patches: at other times, the patches will be 
^ge and will give a general red color to the affected portion 
the skin* As a rule,the face is not as much covered as the 
Gthep parts* Some times,the eruption only appears on the trun>» 
betimes-,only on the face: some times, only on the arms: but, gen- 
e^Uy,it appears on the neck, armband thighs* In some case&, 
eruption winn be'fully developed in a few hours: in others, 
until three oi* four days* In some cases,it will last but 
*£ew hours:more frequently,it remains for a number of days, 
* ^e days,four days,or a week. So,it is the most capricious 
Mh of all the eruptions of the exanthemata and we make more 
Stakes with scarlet fever than with any of the other exanthem* 
There is no place where the rash is sure to appear first: 
^u can never be sure that it will involve any great part of 
2/e body* and, worst,you can never bo sure how long it will last* 
short and uncertain duration gives us more trouble than 
351 anything else. It often happens that the desquammatinn will 
prove that the eruption has appeared and, yefc,no one has seen • 
it. The surest proof that we have that it has appeared is the 
-III -III W-■ • » 
desquamation that regularly follows. This desquammatinn begins 
some nays after the rash has subsided and is usually completed 
three weeks after the eruption first appeared. The epidermis 
comes off in larger flakes than it does in measles. 
- CONSTITUTIONAL SYMPTOMS. - 
- l~The fever is often very high. Temperatures of 104 or 105 
are not at all uncommon in oases that otherwise do perfectly 
well. The fever continues during the eruption and often continues 
for a week from the beginning of the period of invasion. 
.- 2-Cerebral Symptoms. - The convulsions maybe repeated. 
There may be restlessness and sleeplessness or alternations nf 
delirium ana stupor. 
- 3-There is more or less prostration. 
- 4-There is more or less sore throat. 
- 5 - During the invasion or shortly after., the tongue will gen- 
erally be coated with a white fur. The tongue remains like this 
for three or four days and, then, cleans off but the papillae will 
be left swollen and congested, the "straw-berry tongue* of scarlet 
fever. 
352 - COURSE. - 
f ortunately^ the disease behaves very differently in the dif- 
*erent patients* 
Ri-- Regular Cases*-We first have the history of exposure* 
*ken^in a weektwe have the sudden invasion which will often come 
nh in the night. The invasion will be marked by a rapid rise 
temperature^ sore throaty or convulsions. For twelve hours, 
f patient will go on with feven, res tiessness,and discomfort, 
^enjwill come the e.xmptioru The eruption will appear.on the 
R^ks ehest,and extremities* It will reach its full development 
the third or fourth day. Then,in a little while., the eruption 
^11 begin to Subside and, in a we eh, the child will be much better* 
R the fifth to the tenth day? the eruption will have entirely 
Reappeared*.But, the patient has not yet finished with the 
v3i*ease«. We must allow twd weeks more as the regular duration 
R the Jiseas^no matter how slught the symptoms may have been* 
R- child still has the disease but he has no decided symptoms* 
ken, in the third week,comes desquamation and, in the fourth 
the disease is finished and convalescence commences* 
-Irregular and Complicated Cases.- 
l^Very Mild Cases. -The constitutional symptoms are at 
353 no time marked and they only continue for a few days* Perhaps, 
the patient will not be sick enough to go to bed or to attract 
attention* The rash will only involve a moderate part of the 
bodyjit will not be distinct:and it wiftl last but a short time. 
Yet, these mild eases have the disease for the full three weeks . 
and they are as liable or nearly as liable as the severe cases 
to the complications. 
- 2-In these cases,the disease runs an unusually severe course 
particularly as regards the constitutional symptoms. The fever 
and cerebral symptoms are decided at the invasion and continue 
well into the third week. The eruption is not always we^l marked* 
It may be marked or it may be slight. 
-- 3-These cases run the ordinary course and go through the 
periods of invasion and eruption but,instead of the temperature 
falling at the end ng the first week,it continues into the second 
and third weeks and it may even last longer. 
--4--The Malignant Cases.- These patients get worse very 
rapidly- The invasion is malignant, There are at once marked 
cerebral symptoms, In some cases^the temperature will be very 
high,in other cases,the temperature will not be very 
high. When the temperature is not high,we regularly get marked 
prostration approaching to collapse., the skin is cold and the 
354 ^art is rapid and feeble* The patient rapidly gets worse from 
^our +o hour* 
J^ere ray be extravasations of blood into the skin and the patient 
^y have haemorrhages from the nc$e?mnuth? stomach, and other 
vheous membranes. 
■^ese patients die in a very short time* some times, in a few hnurj 
before the rash has appealed and few survive the second or third 
q^y* 
5-In these cases, the re is no eruption at any time and the 
°aly symptoms arc the fever and inflammation of the throats 
- Complications* -* 
1*-The most common complication is an acute inflammation of 
the kidneys. It belongs to all cases,mild and severe* It may 
^Pear at almost any tine during the disease*. As a rule.it 
/■^t gives its symptoms about the fourteenth day?next in fre- 
dheney,about the twenty-first: next, the seventh;but the patient 
^y develop symptoms at any time and the nephritis may even 
Ggin after the patient has finished with the disease,in the 
r'brth,f if th, or sixth weeks. 
nephritis varies in two ways; first, in its sever! ty: secondly, 
C'E to whether it is transitory or permanent* 
355 In many cases, the nephritis will be very wild. There will be 
a little albumen and a few easts in the urine but th>-re will 
be no constitutional symptoms. - 
Other eases,will give well-marked symptoms and the nephri^s wil 
seem to be pretty severe. There will be the changes in the urine. 
The urine will be diminished on, even, suppressed. The aiminu t->-ou 
in the quantity of the urine may lust a week nr two weeKS and 
the suppression may last several days. The specifio gravity is 
rather high. The urine is red from blood and contains consider- 
able quantities of albumen,casts,and red and white blood cells. 
The nephritis '7111 give a fever which my only be moderate or 
the temperature may reach 10 3-104, The patient will lose appe- 
tite* There are often nausea and vomiting. The patient < 11 be 
fretful and restless or the restlessness will alternate with 
drowsiness, After a time.,he will became anaemic and pale. All 
these symptoms belong to Me nephritis. They will last a few 
days, a week,or two weeks; then, in favorable eases, they will 
subside and the patient will get well. In other cases of this 
same will dropsy and more marked cerebral symptom^ 
delirium, convulsions,stupo®,and coma?. Further,in these cases, 
high arterial tension will be developed. The pul^e will be rapids 
fulh,and hard? the heart will be rapid,labored,and tumultuous, 
as. ii striving to overcome some obstaele;and,in some aase&, the 
left ventricle will become enlarged. 
356 ^n$t of these eases do very 'veil although they seem seriously 
^1* As a rule, they permanently recover* Of course^it is pos- 
sible for the patient to die in a few days but this is the ex* 
e-P t ion. 
P^er patients may at first give either mild or severe symptoms- 
Wy may only give the changes in the urine,albumen and casts: 
^?with these changes in the urine, there maybe dropsy^ cerebral 
*Xiptoma,and changes in the circulation;but these patients do 
^°t recover nor do they lie of the acute nephritis* The nephritis 
'-•comes chronic and goes on for months and years, When you see 
of these eases of acute nephritis,I imagine that there is 
o;r felling whether it will be temporary or whether it 
become chronic and permanent, ihe mildness of the symptoms 
no evidence that the nephritis will be temporary, You can 
T^y wait and see but you always have the knowledge that tide 
will be temporary in the great majority of eases® 
v -The inflammation of the throat may be developed to an 
^hsua,i degree® The inflammation will involve the mucous membrane 
the pharynx and tonsils and, pe Than u, of the eustachian tubes* 
° may be only Of the catarrhal variety and will be attended 
Pain, and fever* 
_^y be enpu^nus and a false membrane will be formed and this 
itaont any diphtheria* Fever will also be present* 
357 The inflammation of the tonsils may be suppurative in character 
and an abcess will be formed. This suppurative tonsillitis 
will give pain, fever, and prostration. Either of these conditions 
may add to the sickness and discomfort of the patient but,as a 
rule, they are not dangerous. dut, rarely,a gangrenous form of 
tonsillitis will be developed and the destruction of tissue 
my extend to the surrounding soft parts. This is fortunately 
rare for it is regularly fatal. 
- 3-Suppurative Inflammation of the Middle Ear.--This gives 
decided symptoms* The patient has a great deal of pain in the ear. 
If the patient be a young child-he will not be able to tell you 
where the pain is but it is evidently some where in the 
head* There is apt to be a rise of temperature and cerebral, symp** 
toms maybe developed,restlessness and stupor or, even, delirium 
alternating with stupor. The otitis lasts for a few days; then? 
as a rule^ the membrana tympani is perforated by the pus and the 
s yr P t sub $ ide o 
- 4-Inflammation of the .L^chatic glands. - This usually takes 
place about the middle or Sie end of the second week and the 
glands of the n^ek are particularly apt tn be inflamed. The 
adenitis may be simple or suppurative. Y/hen it is suppurativa, 
an abees$ will be formed and this abbess may reach a very con 
uiderable ima* It may extend to the connective tissue of the nec&» 
358 to the parotid and submxlllai*y glands^ If the adenitig be 
H^Ple and not sever®.,Here willl be ne constitutional gyntptasiss 
* It be suppurative and more severe^ there will be a good deal 
pain and a x'lse ef temperature. '■ . 
. frequently, perhaps., we have an inflammatinn of the ' 
^nts and muscles. Tills is often called the rheumatism of 
°^xilet fever but it is doubtful at* to whether it has anything 
do with rheumatism. It is Regularly developed as the exuptien 
going away, some times, after it has gone. Generally speaking 
does nothin the same patient, involve both the muscles and 
^ints. The joints generally involved are tho^e ef the hands 
feet© They wi.ll be swollen,red,and tendu^. Sometime^but 
'°i often, the wrist and knee will be involved. The muscles 
rally affected are those of the neck, shoulders, and.'back* 
,'/;S Mireles will be painful and tender and they may become 
^^anently contracted. The pain in the muscles is often severe^ 
^ether the muscles or joints be involved, there is apt t« be a 
.^ver» in some oases., this complication does not amount to much* 
?c '^111 give the patient pain and tl>.e parents and nurses thlijk 
v, good, deal of it but,as a rule^it does not amount to much. 
fever and pain may be very decided and the patient will 
'$ &ade very siek by this complication. 
359 Acute Pericarditis or Xrute -^Mther of 
these GampliGatdens will give iis oharaTteHstio symptoms* 
Either may be temporary or permanent. If they be temporary, they 
will subside itTid X ■save no permanent changes behind theia* If th®/ 
be permanent,either permanent adhesions will be left between th® 
layers of the pericardium or the valves of the heart will he 
left permanently damaged. * * t.' 
--7'- Acute Meningitis. - It is not common.. 
.- g.- There may be a peritonitis but it is- not common. 
*-There may be a dry pleurisy-,a pleurisy with' effusion., 
a bronchitis., er a broncho-pneumonia but these, also are not com* 
mon. - ' 7 
- 10 -A Camplieating Diseas&,Diphtheria. - Either disease 
may cow first or they my bath come together. Wy. these two 
diseases should be so fond of associating with each otb.er,we. dQ 
not kwrt nor do we know why they should be more apt to do sn 
in some places than in others. Unfortunately^in New Yox% at th® 
present then,it Is very a-orann to find them / 
It is hard enough, for sum ahildxw, to get well from searlet- fev®1" 
and harder far the® to get well of diphtheria but, to get well • 
of both diseases,is almost too much to ask. ' , . 
360 $ - Complications of Convalescence- ' , 
^^rrhen a patient lias recovered, he has not yet finished with 
the .bad things that belong to" the disease* Tihe disease 
bad results behind it# ' .. 
we have seen? the patient may be left with a chronic 
This is very serious* As a mla? the patient does not 
well and, at last, the nephritis kills him. * 
b-- The inflammation of the lymphatic glands may last a long 
There will be a chronic adenitis and the. patient will go. 
for months and years with enlarged glands in the neck* If . 
chronic adenitis be tubercular in chaise ter, the patleat will 
r exposea to all the dangers of a localized tubercular inf lain- ' 
" '^ ■'*, />. V * • t 
* ' * • 
The inflawtation of the ear and eustachian tube is vety 
7^ to he followed by deafness and many of' the cases of deafnes-s 
* vo j^ee a.re due to scarlet feve:r^ 
.The inflasmiion of tho wso'les may continue for a long 
TM& Till be followed by a permanent contraction of the 
This -will causes a deformity which may last a long ti»l> 
^7 require surgical, aid for its cure® 
6^-The organic heart disease may continue and ©/.ten-does* 
361 *- 6™ Some of the patients will be left in a condition of impair 
ed health for months. They do not oare to play or to go tn sthool 
but they hang about and fret and they may become anaemic. This 
condition may last for weeks and months. •*.'.*•' ■" • . 
"7--A few of the patients will be left for a considerable time 
with a well-marked impaix^ment of the mental faculties. • Biey'' 
gradually return to their natural condition but tey may. take 
months to do so. ' 
- TREATMENT. 
- General Management. . 
The first thing to remember is that the natural duration of the s 
disease is three weeks. No matter how well the patient may appeal 
he has the disease during this time and,during • this time^he 
•an transmit it to other people. No matter how well he may bee, 
he is still liable to the gobligations. In some patients, the . 
disease even lasts several days longer,desquammation may. not 
take place till then. - ' '' 
While Ue fever and ecnsti tutional symptoms' are preg^^keep-^ 
the patient in bed. In. the second and thirl weeks, if iAe oon* 
stituVionaX symptoms have subsided, tb,o patients are 
ip and' dressed but they must be kept in the howe and in 
362 and they met not be avowed to fatigue themselves. 
• 'MU the fever continues, give fluid food. After the fever has 
suWtded.j you may give eggn, starches and fruits; yet, they rale is 
give no animal for three weeks. ■ 
add to the comfort of' the patient if you keep the skin 
Q*ean« Wash the skin every day with soap and warm water. After 
• yatient^yo'd »T annoint the entire body with vaselir^ 
the poison is given off in large quantities from the skin, 
anno in ting of the skin would seem likely to prevent the 
v°^on from floating in the air. It also seems to give comfort 
,0 a certain number of the patients®. . • 
£ the fever be unusually high,it seems but just'to give moderate 
antifebrin. 
the restlessness and the inability to sleep be marked,it may 
proper to 'give the bromides or opium. 
the inflammation of the pharynx and tonsils be developed to 
unusual degree,you will generally do best with soothing' 
^Pli^Uons^solutions of ♦oeain^alumn,borax,or boracic acid. 
■ j inflammation of the throat be croupous or gangrenous-, 
may do better-.with stronger solutions of boracic acid or 
^th corrosive sublimate 1-4000® 
363 If the kidneys give symptoms^ it may be necessary to treat the 
nephritis* You must bear in mind thatsin most oases?although 
the symptoms? may be well developed? the disease has a natural 
tendency to recovery and? as a rule? the acute nephritis will run 
Its course in about two weeks* You. must also x'emember that when 
the disease assumes the chronic form,it is because the acute 
nephritis was of a different anatomical type from the first 
and you can not prevent the nephritis from becoming chronic* 
The ordinary oases do not subsequently become chronic as a 
rule* 
Suppose the symptoms are moderate® The urine will be diminished* 
The child will perhaps pas?; but several ounces during the day-/oZ^ 
The urine will con win blood? albumen, and casts* The pulse will*' 
be more rapid* The child will have, a little rise of temperature* 
He will be? peevish and fretful and will not seem as well* You 
may find a little swelling of the skin of the hands and feet*/^~ 
Many of these cases require no treatment at all and you may 
confidently wait for the two weeks?when the kidneys will go 
back to their natural condition* If the case be more severe/? 
the urine will be push diminished and may even be suppressed foy 
a day or for several days* The fever is apt to be higher and th® 
iriitibility and restlessness are apt to be more marked* Now, 
it is important that this suppression of urine should not go 
on ton long,yet?it is not well to be too much brightened about 
A child may pass no urine for several days and?yet?get perfectly 
well* 
364 S f *7 
v'u'-^ynu do not wi him to do sc* The reason for the suppress 
J*on of u-rine Ib tM of >e nephritis* Sa*you 
vust try to diminish the severity of the nephritis* One of the 
to reduce the inflammation is to apply heat to the 
^^rtor of the body- You may either apply to the whole of 
he^ exterior of the body or only to the hack* In children^ it 
. better to apply it' to the whole body® This^y^ «an-do by 
J^ns of the het air bath or by means of the hot water pack 
" r^<y ^ve to repeat two or three times during the twenty^ 
*°ur hQur^i ft also seeCT to be of benefit to give 
every ho%r until five or six grains have been taken or 
the bewail act* This ealoml^you may repeat on alternate 
^ayse Th3re is no great object in giving diuretics and aathartioaa 
^int not expect that in twenty^four hours after you J^ave 
child will pass more urine: thighs will 
do for several days and you must not be frightened- The 
nQt more urine until the inflammation of t>e 
j ^ney^ shall have begun to subside* 
. ' ®ase^you will find dropsy and more marked cerebral, 
general eonvulsioas and delirium alternating with stumor. 
365 The dropsy ray reach a considerable degree of development. 
As a rule^ the pulse will be hard, full,and labored* If the dropsy, 
aione be present,it will as a rule take care of itself and will 
nyt renuire any active treatment' If you chonsa^yoy may rive 
purgatives or you may sweat the child. As a rule>? you will only 
do harm with diuretics until the acute symptoms have yuh^ldedo 
The o^rehra? symptoms are m^h more alarming and Are mn^b store 
likely to prove fatal. As a rule^you will do best with rtredieg 
directed to the sirculatier^ for these cerebral sy^tora are 
due to high arterial tension. In these cases? the urine n^y 
be plcntifcl.scanty,nr noSial® In some aa^e^you win do ^ell 
with «hl oral hydrate., -gr.v, every three or four hnurjj^nr 
with opium in dose:u or with morphine* on with pilnca^pine^ 
or with porphine and piloea^iMjgiven inte^niLHy htpcfo "uKe-« 
ally. In addition?you sweat or purge the p.atient in. order 
to get rid. of of the serum of the blood* ' In adults,it may 
be advisable to bleed or to uae wet pups. 
If the inf?;.amotion of the lymphatic glands in the neck be 
narked, and9 if you see the patient in the early hago$ of thio 
inflametinur?yc^ -an sometimes limit it 'by the Continuous ap^ 
plication of cold or the intermittent ^rplicatiow. of heat„ 
If ^urpnation lake plasopen the abcess and tr^at iT35 the 
n;;^fn^r»T w&ve - 
366 - G E R H A N 'M E A S I E S . - 
disease is also called Rubela^l^'theln, and Roseola- Roseola 
a name that is applied to many other conditions besides 
®&an Measles. In America, we are in the habit of calling the 
*»eas$ German Measles and it is not a good nama,for disease 
2,8 not a form of measles and,probably,has nothing to do with 
Rasies. 
knowledge of the disease only dates back a few. years# It 
■ 8 formerly .confounded with scarlet fever and measles* Perhaps^ 
knowledge ..of it is as yet inaccurate and we may include 
than one disease under the* name of German Measles^ 
disease is distinctly contagious* The poison 1$ given off 
the Surface of the body* floats in the air?ar;d remains in 
•^^thin^, Yet^its poison is not very virulent Many pedons can 
^°t take the disease and the poison can not remain in rooms 
any length of time. 
** occurs as an epidemic and endemic disease but it is never 
^valent scarlet fever and measles nor does it evince the 
ehdency that these diseases have of x'emaining in the same place. 
York?for exanip.l&,w^ do not have it every year and this 
been abseiled in other place3* 
367 Toth children and adults are moderately susceptible to the diseaS®* 
One attack of Geroan Measles regularly protects against another 
attack of German Measles but it does not protect against an 
attack of Measles or Scarlet Fester, 
Epidemics of German Measles are apt to occur where Measles and 
Scarlet Fever are prevalent. YMl- is particularly true of Measles 
and you wee Measles and German measles in the same child 
with but a moderate interval between them* 
The period of incubation is from one to three weeks5most frequent* 
ly, two weeks. During this time-, the patient gives no symptoms* 
Now-,when we come to what should be the period of invasion,we 
find that it is often absent altogether and the ^tient is in 
good health until the eru.ption appears. Yet,in some cases,, we 
do have a period of invasion which lasts twenty-four hours 
and is marked by headache,, nausea, vomiting,inflammation of the 
conjunctiva, so re throat, or inflammation of the lymphatic glands 
of the back of the neck, This invasion makes it look like scarlet 
fever or measles. 
Then,comes the rash. It appears in the form of small macules. 
The size of these macules varies very much in the different case^» 
They say be as large as the spots and blotches of Measles 
and they may even be.crescentic^ 
368 other c&sey the macules will be very small and will be sit* 
very close together and there wi^l be a diffuse blush 
$sesibling' scarlet fever. The eruption of German Measles never 
j^c^ly resembles either that of Scarlet Fever or that of 
^^leyyet>il regularly follow one or other of these two typ$s* 
u?5 ve^dem diagnosis difficulty In a great many casey 
rash will go no further than the macular form Su yin sone 
the macules will change to papules, vesicle yand pustules- 
M-hex' the vesicles nor the pustules are large nor do they 
XV * , 
those of small-pox or chicken-pax- They are small and 
v>°^° together and resemble what you get when you rub the skin 
9^2112112^^ 
43 eruption is out of all proportion to the severity of the 
futional symptoms which are not at all marked. The rash 
. *1 f 
from one to seven days. It is found on the i^/ca,body, 
"i 
When the duration of the rash is considerably 
generally effected by the successive appearance of the 
difxerent of the body. As a rulydesquammation 
This i^ important to remember: yet it does sometimes 
Place wiien the eruption is very well developed but the 
iS never very njarked. 
369 - Cons titutional S ymptons* ~ 
As a rule-, the rash is well developed but the constitutional 
symptoms are not marked. Thore may or may not be a feves. The 
tongue may be coated and there my he nausea and vomiting. 
Tlie eonjunetivitie and inflammation of the pharynx may cause 
discomfort- The swelling of the glandt? of the back of the neck-, 
although verj" constant and of service in making the diagnosis 
as a rule-sdoes no ham.w 
Tn a fw eaBei#yni may get <w InflaEmation of the muscles and 
joints as in bearlet Fever- The muscles will be tender painful? 
and contrastc-.U The joint will he swollen^red^and painful. 
The patient may develop bronchi tie or broncho -pneumoniae It 
is not easy to say whether the bronchitis and. broncho-pneumonia 
are real complications or whether they are accidental. 
- Prognosis. 
The is perfectly good.- The patients always do well. 
The only way in which they are troubled is by the excessive 
development of the conjunc tivi tis^pharyngi ti^ nr inf 1 animation 
of the susales and joints As a rula5 the patients are seuraely 
U* ** O ■o * 
- TreatKient. - 
Keep the patient, in the house until ^he rash has disappeared* 
370 0 
txv> of the muscles and joints and the conjunct 
the same measures as you wuld minder erd'lnary sir- 
^tanan^ 
V» * W»>W 
■^n> . * 
h.ave finished the Exanthemata, nnw come tn t-vn nf the 
A*^UXous? infectious diseases called Mumps and Whooping Cough* 
371 - M UMP S • - 
Mumpor infectious parotitis is a contagious infectious diseas©* 
The characteristic lesion is an inf lamination of the salivary 
, 4% OW&tM»iMSa**»sW 
glands. Most frequently,the parotid gland is affected:less 
f i^cquently, the sub-maxillary glands:and,least frequently, we 
also have an inflammation of the Same kind in the breasts or 
testicles* 
The disease is directle contagious*. The poison can float in the 
air and can remain in rooms and clothing but it is not very 
virulent* It usually requires a pretty thorough exposure to 
contract the disease* doth children and adults are liable to th© 
disease but a very considerable number of each can not take it. 
The disease protects against,itself with one curious exception* 
This exception is that a person, may have mumps only on one side 
and this will not protect him from a subsequent attack on the 
other side* 
The period of incubation is usually two weeks but it may very 
veil be three. 
SYMPTOMS* 
The of the parotids may come first off the constitu- 
tional symptoms may come first nr they may both come together* 
The constitutional symptoms are fever,pain in We head,back, 
and limb sc some tines-, nausea and vomi ting: and, usually, a good deal 
of irritability,restlessness,and discomfort* In most cases, thes® 
toms are not very severer- ™ 
372 time tn time,especially in adults, the symptoms will he 
^ch n*nre ma^hedn The fever may reach 105< The pains may be very 
&*vere. The mUessness and sleeplessness may give great dis* 
with the high temperature, there may be marked prop* 
^tinn.Still? the rule is that the cony titutienal symptoms will 
$°t be severe* 
t^e inflammation of the parotids may and,usually does begin 
o gland. It may remain there' or,after several days, the 
gland may also become inflamed and the patent will 
the disease enmvlete at one time. The first sign of the 
of the parotids is that pain is felt at the angle 
^e jaw when the mouth is opened and shut. As a rule? this 
cedes the swelling. Then, the gland becomes larger and larger 
1x1 it 1 s of t? n ns ide rab 1 e s i z e. Whe a, i t i $ of so me s 1 s a, i t 
oe quite painful and tender and the pain and tenderness 
increased by movement of the jaw. Talking and eating 
Xn many aasss, there will at the same time be a general 
^'T?y\fntio and thi^ will add to the pain and discomfort. 
•£.0f> 4 .W. 
beginning in one on both parotids,generally 
its height in from one to six days^ Then,for two days 
'''$*?it will remain stationary^ Then^it will gradually sube. 
•;ie^ inflaKma.tion seems nevex* to go beyond the simple ex* 
<►' 4. • \ 
' -'i^n of scr'um- It dees not go on tn suppuration. It is not 
373 followed by i-.ny chronic- inflammatory process* 
If the d?Lsease be 'confined to one parotid or if it begin in 
hot at the Sam time,, as a rule-, the entire disease will only last 
ten da^s or less* If at first .one parotid be inflamed and, then, • 
after a few day$? the other become inf lamed, the ease will of 
course be protracted-, two weeks er a little longer. 
If the complicating inflammations of the testicle and mammae be 
developed,these will of course add to the pain and discomfort. 
They may bo developed at any time during the course of the par- 
otiti&w In both the mammae and epididymis, we find the same 
Staple exudative inflammation. but,in these si tu a t i'. i n n, a ■ chronic 
inflammation may fellow with the production of interstitial 
connective tissue and more or less atrophy of the gland elements 
end, when the patient Ms recovered from the pareti tis> she may 
go on for months wi-th one or both mammae tender or,if the patient 
be a he may be left with a painful testicle which may 
atrophy^. 
?.ny chronic- inflammatory process. 
parotid or if it begin in 
entire disease will only last 
parotid be inflamed and?then? 
inflamed? the ease will of 
PROGNOSIS. 
As a rvle7; the progno^i^ is perfectly gG$d* If the patients suffer 
from the complicating inf damnation of the testicle or mammae, 
fey buffer more and are liable to the subsequent pain and 
374 ^ndemess from protracted inflammation, 
some time$5 though very rarely, meet with more severe cases, 
may take one of two forms, 
^eve may be a high temperature and marked cerebral symptoms^ 
there :^y be marked prostration, feeble heart, and a condition 
approaching to collapse* These severe eases are very uncommon* 
- lltHAlidENT. 
treatment is directed to. the comfort of the patient* In 
S(W eases,, there is so little discomfort that it is only 
^ry Keep the patient in the house* Never let him go out 
^til the inf lamination has subsided, 
*x the pain be more severe^apply moderate and continuous 
heat to the parotid gland by means- of bags of warm water.poul tices, 
u sponges wrung out in warm water* If the pain be still move 
^vere,?and if the patient be restless and sleep less-,give a 
kittle opium at night* Always keep the patient in the house* 
375 - W H 0 0 P I N G-0 0 U Ct H . 
Pertvsriy a c curtail'em infectious diseaee^ . 
e^paeierized by a 5pS®SS3ie cough and an iMAammatinn of tM '. 
menus membranes of the respiratory tr&ot* 
The characteristic lesion is an acute catarrhal inflammation 
Of the laF/nx? traehe<^^ As a rule^ the inflammation 
is most marked in the larger bronchi* . , 
• - Additional Lesions. - 
- 1-'True broncho -pneumonia. This is vex^y serious and it is 
very Gon3non>especially in childrens 
,- 2 - Occasional]y9 ve^icula? or interlobular* 
The pol&on, seems to be eafSTe 1 by the SIT end thus '5o^mni=n • 
eated from one person to another,, The poison iy not very virulent 
It requires pretty thorough exposure to con tract the disease 
persons are net susceptible to im 
Children are more susceptible to Whonplng*4ou^h ihan are. adults- 
but the d:ls'ea&e iw not u^snmmnn in adults and .you nay even find 
it in very old people* You unay very well see a grand-father 
or a grandther with Whooping-sough* 
376 a rule,, erne attack of whooping-cough protects against subse- 
^ont attacks and this protection is pretty complete. There is 
°he exception* This is that grown persons?who have had the 
disease when they were children and have been day after day 
^posed to it?while they do. not develop a true attack of whooping'* 
$°ugh?^111 develop a spasmodic cough like that of Whooping-cough* 
Aether or not this spasmodic dough is another mild attack of 
^oo ping-cough, we do not know. 
Period of incubation lasts two weeks and,during this time, 
re are no symptoms. 
y16 invasion is apt to be gradual. At first, the child will have 
ordinary cough like that of a mild bronchitis0 With this sought 
^ere will at first be no fever and no physical signs. But, this 
Qold* continues. The child continues to cough and the cough 
z^oomes more frequent and severe but it is not as yet spasmodic, 
^en^we begin to get the physical signs of bronchi ti% co arse 
?$d sub-ci'epitant rales over both lungs. Now, if the bronchitis 
sufficiently severe.,a fever ^y be t4deda Fe-yer is not a 
^oe^^ary syir^tom&in who op ing-cough. It belongs rather ta the 
'''^onehitis* After .this?in a week nr more-, the character of the 
"f,^gh begins to change and it becomes spasmodic. The child will 
377 have an attack of coughing and will cough and cough and cough 
and cough and, all the time that he is coughing he will held his 
breath* Than? after the paroxysm has cow io an end^ the long** 
continued holding of the breath is fallowed by a dee^^nois? 
inurdrut i on ?known as ' the eharaeteMstle Shoops.. When the disease 
has reached thd^ pointy it may be considered at its heights The 
sMld will go on with the ordinary cough of the bronchi Uy in** 
terruptoa by paroxysms* The paroxysm® are often followed by 
vomiting* ... 
Soothe patient goes on from six io twelve weeks* Part of this 
tire? the disease will ba at its height; then,it will subside^ 
and the paroxysms will become less severe but»after the par- 
oxpyms have yub^ided tn a considerable extent, the cough will 
still continue and,until the papo.xysms have entirely subsided, 
the child should not be allowed to go with other children* . < 
. coibse. - 
Th^ .aases vary very meh in severity and duration* • • 
- X™Mlld Cases* - These patients are not vex^y sick or vex'y 
unm^Portable, The bronchitis is at no time accompanied by fever* 
ThiUyardiypnn^ al though they :^y be aeca^anied by vomi ting? have 
no- marked affect upon the general health and the &ase lasts 
378 jdx weeks or a little longer* 
s -These oases are not nearly as mild. 
* a - In these eases, the things hat give the most trouble are 
frequency and severity of the paroxysms which may be very 
^rked* The child will hardly be able to eat or sleep* These 
^ildren will lose fles& and strength and will pass into a very 
^Plorable condition* Sometimes, the paroxysms will be so severe 
that they will cause convulsions* When these severe cases occur 
&dult$,especially in those that are plethoric the patient 
fall to the ground and my remain unconscious for a con- 
^de^le time* 
- * In these., the bronchitis is severe and extends to the 
s^aii9r bronchi* The patient will have fever., rapid breatheing, 
^I'ebral symptoms,etc. In some of these cases., the brnncho« 
^^umonia ^ill be developed with its characteristic symptoms, 
hi - PROGNOSIS.™ 
Ae prognosis is,for the most part,good. The cases that dia, 
a ^-^die of the broncho "pneumonia* As a rule^ those patients 
are reduced by the frequent paroxysms and the vomiting, do 
die® They may make 3TU very anxious and it is possible for 
^hiid to die from inanition produced directly by the Whooping* 
379 - TRJ5A.TMENT.'- 
The treatment 18 not very satisfactory* New remedies are being 
constantly proposed and the very number of these shows that 
none Is very reliable* Fortunately., the disease does get well by 
dtuolf but, in the severe ease^good treatment is iwt earnestly 
desired* 
In order to control the paroxysms and to shorten the disease 
the means employed are the following* 
--I--Counter^irritation over the chest and it is customary tn , 
use fluids spirits of turpentine^ stimulating liniments,or mix-' 
tuxw containing ether or alcohols Rub the chest wljh these 
once or twice a day* 
,- g - Another method of treatment consists in giving .sedatives 
oi ium? belladoanajbromiaer,hydrocyanic acid, valerian, assafne tida* . 
or conium* 
•-■ 3-You may treat the bronchitis and-, gene rally, the best drug 
for this purpose is ipecac in small and repeated dnses* 
**-4--You my improve the general condition by means of stryehni11®1 
quinine 3ron? oxygen,or eod^liver oil and, sa*hope to diminish 
the coughs " I 
*-5™ You may consider that the cough is due to an, irritable 
state of the posterior nares and you may apply cocaine in solu- 
tion? /-* - ' 
380 may hope to destroy the poison of the disease and you my. 
^.-sider that the poison.-grows on the mucous membranes of the 
ieatery tract* With this idea^you may let the patient inhale 
aoid^ turpentine^bromine^ete* and there are many other 
J toms of treatment* 
the bad ^se%yuu will have to try one plan of treatment aft$* 
c^ther until you strike one that will work. 
381 ™.E,H Y S I F E I.- A S , - 
This is a contagious infee Viaus disease of which the character^ 
is tic lesion is an inflammation of the skin and, sometimes of th® 
sub-cutaneous areolar tissue* In the mild eases, the skin alone 
will be inflamed;in the more severe^ the areolar tissue will 
also be inflamed* When the skin alone is inflamed,we call the 
disease cutaneous erysipelas and the inflammation presents the 
character nf an erythematous'bio teii, varying in extent, slightly 
elevated,and,when it is extending,it is surrounded by a well« 
marked hordes When the inflammation is on the decline, this 
marked border is absent* The color of the blotch will vary from . 
a pink to a dark red according to* the severity of the disease* 
The poison of the disease is a micro-organism and it has been 
cultivated and lunoculated*- In most eases, the poison enters 
the body through a wounds Thi?? form is called trau^.tic oryjlp^l^5 
often seen in surgical px'aotice* But, the poison of ery- 
$iipela$j may enter the body when there is no wound or abrasion 
of the surface® This form is called 3idiopathic erysipelas1 
and it is this form, that comes more especially under the care 
of the physician This idiopathic form is rare* The eases 
of erysipelas that we are most frequently called upon to treat 
are those that occur upon the face,facial erysipelas* 
382 -Acute inflammation of the inner surface of the dura mates, 
€ $ute pachymeningi ti s. 
2'- TSrombosis of the veins« 
3-Acute inflammation of the kidney. 
Inf legation of the mucous membranes of the-nose,mouth, 
$^oachd, and larynx. 
^5--Broncho-pneumonia or lobar pneumonia. 
6-Pericarditis or endocarditis. 
7 pe 1 ^1 tj 9 
3 -- Hetaetat ia abbesses. 
T'he«e compilations occur in the bad oases and add very much to 
dahgers of the disease. 
- SYMPTOMS OF FACIAL MfSIPH&AS* - 
first symptom is usually some x'ise of temperatux^preceded 
^d accompanied by ehills® The height of the temperature and the 
^Verity of the ehills mark the severity of the ease* There are 
of appetite^ some time %vomi ting? and more or less prostration* 
within a few hours,comes the inflammation of the ykin. 
is apt to begin on one ear nr on one side of the nose and, 
'H fi^st,it occupies only a small area^then,it spreads. 
~Additi anal Le s i ons♦ - 
383 In the milder eases,which are very common,the constitutional 
sympt:ms will not be severe and the inflammation will not extend 
very fam As a rule, these eases only last one or two weeks. 
In more severe cases,the inflammation will involve the entire 
skin of the faca, scalp,and skin of the neak. This spreading 
i^ for the most part continuous but, occasionally, it will skip. 
It is especially apt tn skip if it extend to the thorax. The 
perts first inflamed will often have time to get well while the 
others are being inflamed. The fever is higher, the prostration 
It greater,and restlessness and sleeplessness alternating with 
stupor or? even, delirium maybe added* These cases are sick f<c£ 
several weeks,yet, the termination is usually satisfactory* 
In the very severe eases, the inflammation of the skin is not 
merely exudative but goes on to the production of pus and gan- 
grene* The inflammation of the skin is much more severe and th® 
swelling is much greater* With this, the tempex^ature will be very 
high, the prostration is very marked and cerebral symptoms are 
developed. Although some of these cases get well, they are always 
Very serious. It is especially to these eases that the compli- 
cations ■ belong. The complications give their characteristic symp*4 
toms. The complications are always serious® The first bad ease 
of erysiptelas that you sea, you will remember for a very long tii^* 
384 - mEAWENT. - 
T - Constitutional Treatment.- 
is a natter of tradition tn give the tincture of the chloride 
iron ih large doses® Why it should he of any use^it is diffi* 
^•t to say® Stilly I think that it is of service and that it 
$ our duty to give the drug. 
In the more severe cases,you have to feed the 
^tient and give stimulants as they are required®. 
$ -Local Treatment. - 
*old treatment consisted in the application of the lead and 
wash, This is old and good and is still to be recommended® 
■'nre recently,attempts have been made to treat the disease 
regard to its true local conditions® We know. that the mi** 
yii£ooel are in the lymmhatia snaces of the inflamed tissue 
। -a. ■-"-w-r.. - ■ ** 
we ^7 try to destroy them by the continuous application 
"■ Pretty decided cold to the skin®This is agreeable to the 
&ient and it does seem to diminish the severity of the inflame 
With the same idea®-re may rub the skin with unguents 
^-eates of mercury or you may use carbolic acid* This ought 
good treatment out.so far.®it has not been attended by 
^'7 good results® The plan recommend# itself to reason. 
385 In the third place ?^i th the same ideate may inject solutions 
of corrosive sublimate or carbolic acid into- the skin. This 
is rational but it has not preyed very successful* 
I think it is best to follow the old treatment but, ins teal of 
using the lead and opium ^rash, to use a solution of corrosive 
sublimate 1-1000 and 'the. regular-amount of opium* Thus,at the 
same time.?jTou disinfect any rags that you may use* 
386 -ANTHRAX.- 
is an infectious disease belonging in the herbivorous 
but it may be communicated. to human beings and,also, 
Bone other animals. 
poison of anthrax has been more thoroughly ytudled than the 
^^son of any other infectious disease- It is a bacillus of con^ 
^^rable sise.. The bacilli are present in large quantities in 
. n biP£<L -he poison hay time and time again been cultivated 
innoculated, 
acquire the disease from the food they eat, fram ' 
^ter they drink,and from the air they breathe, 
0 e Poison can not only live inside the body but it can live 
the body for a considerable time.,in the ground, in the 
^^^in the bodies of diseased cattle that have been buried and, 
v8?the poison may into the ^ater. It is believed that the 
0an originate outside the body, especially in marshy 
^tilh, i t is ordinarily communicated from one animal to anoih^r, 
human beings., the poison is usually communicated in one of four 
Wq<ys, 
1 
^^-^y innoculation. - This method of communication is especial*- * 
common among people whn handle hides*, cattle flesh,and wofcl. 
387 If these persons have an abrasion an their hands and then handl® 
the -wool?flesh?or hide of an infected animal? they can acquire 
tli? diseaseo • 
- 2- Mosquitoes nr flies may first bite the infected animal 
anK then?bite a human^oel^ and?thus?ianoculate him This way 
is less common* 
- 3-The disease may be acquired by eating the flesh nf ani« 
mals that have died of the disease* This should never happen, 
but it occasionally does. 
- 4-Through the air. - The disease is most frequently communi**' 
G<ited in this way to persons whn work in hides?hair? and wool* 
These substances will be moved about and the dust from them? 
containing the poison?dll get into the air and will be inhaled* 
In human beings?we find the bacilli present in considerable 
numbers in the Mood?in the oedematous infiltration of the 
Sub"CuWieouy tissue?in the pustules? and in the intestine* • 
As we see the disease in human beings?it is apt tn take one of 
three forms These are: 
- 1 - malignant PUSTULE. - 
- 2-}ULIGNANT OEDEMA. - 
- 3- INTESTINAL ANTimx. - 
388 - 1 - miGNANT PUSTULE .- 
i4iu,y is;?perhaps? the most ocmon form of the disease* Xi is the 
_ of the ■ disease that is communisated by innoeulation either 
^Ugh wound or by the bite of an insect. 
^srlod of Incubation* - The length of the period of incubation 
J. S is •• ' ' ~ 
^ot charaeteristie* It varies from a few hours to two weeks* 
- S ymp toms * -~ 
the first thing no ticed Is that at the point of innnculatiGn> 
■^re xh a ifttle swelling like a flea bite outsat the centre 
$ 4 - , / . ' 
-ne swelling*is a little black koint* The swelling soon becomes 
Then^a vesicle is fomed* beneath the vesicle^ there is 
necrosis of the skin© Then? the thing looks like a boil* 
^arouncle® It oe of considerable size* It is surrounded 
indurated and Inflated basee This is the malignant pustule 
^when it is fully developed*it will be surrounded by a con* 
$.1* stable 2 one of swollen and oedema toils skin. 
$ general ^y^ptoms make their appearance a little after the 
aumnencedj-sixty hours after* They ate 
well marked? fever?prostration? fairly well developed 
^-rebral symptoms?and the patient is apt to pass into the typhoid 
°^ition or into rapid collapse. 
389 The eases vary very much as to their duration. The worst cases 
are very short? They last two or three days and are very fatal. 
It is in these cases that we have the tendency to collapse® 
Other cases will last ten, twenty,or thirty days. It is in these 
cases that the patient is apt to pass into the typhoid condition* 
It is in these long cases that we have had a moderate number of • 
recoveries. The length of the case depends upon the virulence 
of the poison. 
This form of anthrax occurs after the ingestion of contaminated 
fond or after the inhalation of contaminated air, In either ease* 
the symptoms appear in from eight to forty-eight hours® The 
patient will develop the symptoms rapidly* He will have chills, 
nausea, vomiting, pain in the abdomen, and marked prostration 
soon running on to collapse.® After a few hours nr after several 
days?we will find in different parts or in. a single part of the 
body,a diffuse s veiling. The swelling is due tn c, diffuse infill 
tratinn of the sub-cutaneous connective tissue with serum® 
This symptom gives the name of amalignant oedema* As a rula, 
these cases do very badly® The patient generally dies in a few 
day^in extreme prostration. 
- MALIGNANT OEDEMA, - 
390 T - intestinal anthrax. - 
form of he disease is produced by eating flesh which ebn* 
c<ins the anthrax poison. 
$ - SYMPTOMS. ~ ' 
.^e patent suffers from prostration,pains everywhere, vomiting, 
^rhaea,d1saharges of b1gcd with the vomit and s t oo1a,re s t~ 
delirium alternating with stupor. Sometimes, there is 
Voided rise of temperatures at ether times^the temperature 
^111 b© normal or below the normal. These oases usually die in 
* days. 
}er death?we find that the mucous membrane of the stomach 
intestine is congested and necrosed and there will be areas 
s ihe mucous membrane that are Infiltrated with serum and pus+ 
u^klignant Pustule is the best form of the disease and of 
^gnant .Pustula, there have been a number of recoveries. 
- TREATMENT OF ANTHRAX. - • 
, -Prophylactic Treatment. -- 
e most efficient way in which to prevent the spread of the 
$ease is by destroying it in the diseased cattle. The cattle 
"Quid be killed and burned. Another way is to isolate the 
391 diseased animals but tMs is less efficacious. In the third • 
plasmin some counties., particularly in FwSeattle and sheep 
have been extensively innoculated in order to prevent the spread 
of the disease- 'The anthrax bacillus is.cultivated and, then, 
innoculated . The cattle are only made slightly sick by the 
innoculation and the protection is,believed in many oases to be 
very efficient although the evidence of its. efficiency has not 
been as satisfactory as we would wish* In England and Germany^ 
the results have not been very satisfactory# 
- ACTUAL TfflWT IN •MEN*.- 
---~ MALIGNANT PUSTULE* "**"*■ 
As. soon as the diagnosis is made? the best thing to do is to 
remove the diseased portion of skin, either by cutting or by 
caustics- Even when the pustule is larga, it is proper t<o remov® 
it although the results are not as good as when it is small* 
In addition?we give large dowes of carbolic acid and corrosive 
tublimate internally but? this has really been of but.little us©« 
- MALIGNANT OEDEMA AND INTESTINAL ANTHRAX- ■ 
In these forms of the disease-?we can only ^ive the 'carbolic 
acid and corrosive sublimate* 
In all cases of anthrax,, the free use of alcohol in very con** 
siderable doses is indicated* Give it in the form of whiskey 
or brandy* Most of .the cases of recovery have been those of , 
malignant pustule and,?in these., the surgical treatment has don® / 
the most good* ' -- - 
392 r - GLANDERS., OR F A R C Y # ~ 
is an infectious disease that belongs to the horse tribe 
it is also found in the ass and mule and,from time to time, 
is communicated to man, 
characteristic lesions are a specific bacillus and the 
■;v'eiopment of inflammatory lesions in the mucous membranes 
/\ Thilc nose and throat and in the lymphatic glands* skin* and 
butane ous connective tissue in different parts of the body. 
fording to the part in which the inflammatory lesion is devoid 
. the disease is known by one or the other name. If it he 
lieu lari y the mucous membranes of the noye and pharynx that 
inflamed,the disease is known as glanders; if the lymphatic 
principally affected, the disease is known as farcy, 
aro ^1C popular names and this is the popular distinction 
them but glanders and farcy are the same disease- 
see it in man*it is regularly communicated by innoeulatiexu 
s table -men who wash horses occasionally become innoculated* 
kJ; Period of incubation usually lasts from three to eight ds^s 
>cu ^'ve histories of cases in which the period of incubation 
two ox' three weeks# 
-SYMPTOMS.- 
er^0 ^e characteristic symptoms. The patient complains 
393 of headache^ pains all over, pre tty decided pros trail on, marked 
restlessness and sleeplessness or delirium alternating with. stu* 
Poland a more or less well marked fever* The patient passes 
pretty rapidly into the typhoid state and looks like a case 
in ths third week of typhoid fever* 
- Local Symptoms*- 
In a certain number of. the c^sc^we can make out the point of 
inoculation and^hera,it is found that there is a little swelling 
in the yw?stance of the skin. This little tumor is formed by; 
the pretty rapid growth of little round cells* Very soon, the 
eeels die and the tumor softens at the centre. Then,it -sloughs 
and a little ulcer is left* In the neighborhood of the ulcer, ' t 
the lymphatic glands and vessels undergo changes. The glands 
swell- This- swelling of the glands is due to the growth of th® 
same sort of cells that formed the tumor,, The same changes take 
place in the lymphatic vessels and, in both eases,,ulcers or 
abbesses will be formed in the sane way as -in the tumor* 
We also find an eruption of the skin: first?papular; the.^v^situla 
then?pustular;and the pustules may •hange into ulcers and look 
very much like those of small-pox* The mucous membrane is th© 
seat of a catarrhal inflammation but?at the same time.,nodules 
394 formed which may produce ulcers. The inflammation may also 
ihyade the mucous membranes of the mouth, pharynx, larynx and 
bronchi* 
■- Course* - 
^e course varies very much* 
^1 - in these casesjthe symptoms are very acute and the patient 
^y die in one? tw&, or three weeks' or he may recover, 
2--These cases are chronic, Neither the -constitutional nor 
^be local symptoms are so greatly developed and the patient is 
at any time as sick as in the acute cases* The lesions are 
hot as extensive* These patients may suffer a number of months, 
™ Prognosis* - \ 
prognosis of the acute cases is wery bad Indeed* The prog« 
hosiy of the chronic cases is rather better* Fortunately, the 
disease is quite rare. 
- TREATMENT.- 
regard to the treatment? there is not much to be said* If 
We see the patient early and if we can make out the point of 
Peculation, excise or destroy the tjmor- Give carbolic acid? 
Corrosive Sublimate,and alenhol in large doses. 
395 ~ n Y D n 0 P H 0 U I A * - 
This is an infectious disease which belongs to dog^ foxe^> and 
wolves. It is Mill uncertain whether or not it ean originate 
spontaneously in these animals. At present? we think that it 
does not originate spontaneously in dog$* 
The poison seems regularly to be present in the saliva* It ig 
apparently eosounisated 'by this fluid and.} in &rder that the 
poison should be introduced^ there muM he an abrasion* In most 
sases^this abrasion is caused by biting A good SHy attempts 
have been aade to find out the nature of the poison butt wo ^a2» • 
we can wearBely say that these experiments have been success* 
ful- We wbuld naturally think that the poi^n was a micro-organi^ 
It is fcund that the spinal eord eont&ins the poison and tiie 
disease e*«n be eotoinieated by inoculation frcm the spinal cord* 
Thi^ iy aB- fey anyone (jone w3.th certainty* 
In ^1^5 t-he di^e^e never occurs ypon^neou^ly and the poison is 
regularly corounie&ted to- man by the bites of animals that have 
the disea^e-o Unless a do& have h^drophobia/he san not give the 
disease* A man nay be bitten by mad dog and?yvt,escape the 
disease?particularly if he be bitton trough the clothes® Only 
about one^half of the persons bitten by rabid animals get the 
disease* . - - 
396 r - LESIONS.- 
are none that are character!Stic. The symptoms point to 
-isnrCer of the spinal cord and brain but,after death? al though • 
cord contains the poison? there are no characteristic 
^^tomical lesions there or anywhere else, 
length of the period of incubation is uncertain* In the most 
eases^it has been from twenty to sixty days. 
y- have a great many doubtful cases with a stated period of 
^;^ubatinn of a number of months* We can hardly say how long 
period of incubation is but it is always long* During this 
there are no symptoms* 
^enjas a rule? the first symptom is the development of abnormal 
in the cicatrix of the bite* Thethere is a condition 
general depression, and patient complains of headache,, 
"-$$s of appeiitesand sleeplessness. He feels anxious but he is 
in bed and often attends to his work. This period of de* 
j^ssion may last a few hours or one or twn days* 
^■•Qn^ecme the characteristic symptoms. At first?we have symptoms 
^ferable to the spinal cord* The first^is abnormal condition 
the muscles of deglutition. These muiolea will contract 
397 and, if the patient take anything1 into his mouth, .these muscles 
■vill contract •spasmodically,irregularly, and painfully and,soon* 
they will do this even when the patient thinks of swallowing. 
Then?come spasmed1o,irregular,and painful contractions of the 
muscles of respiration* then, of the voluntary muscles Then, there ■ 
is a decided increase of the saliva. The saliva accumulates 
in' the mouth and the patient spits it out all the time in order 
to avoid swallowing it, There is often vomiting. 
Then come cerebral symptoms* The patient developed delusions 
and hallucination#« He may try to escape from imaginary objects* 
The patients often pas^ into a condition of acute mania, The 
heart becomes rapid.-The skin is congested* There may be a liitl®' 
fever a-<?genera 11 yy there is not* Albumen is present in the * 
When the symptoms of the brain and spinal cord are well develop^ 
zhe cases are very charae toristic* Then, you will see the patient 
tied town in bed* Tao skin will be congested and^from the con** 
geution of the skin and the involuntary contractions of the 
nu.sclfS*,the expof the .^^tienVs face will Ie very horriM®' 
The patient will: fight ^ho Umehhe Will bp it everywhere-; 
at?dr?every few minute^will \come the muscular contractions and 
398 patient will teem to shake or have convulsions. As a rule, 
symptoms continue until death and the patient diet? in 
Avulsions dr exhausted in from one to ten days* 
^idet these real cases,!t happens from time to time that a 
^cuii^r nervous condition Is developed which simUtes the 
please, These patients have not been inoculated; they have been 
'^ten by a healthy dr&6 They have read or studied the symptoms 
hydrophobia and give symptoms resembling ^particularly 
spasms of the different muscle^ Either from -the existence 
* these nervous cases,or from that wdsh for notoriety that 
all possess more or less?, some persons and,even,some physicians 
'^iu+ain that there is no such disease as hydrophobia. As we. do 
these nervous cases, the existence of the real disease is 
°ifficul t to prove to them* Such person!'; will not believe in 
ihe exit tense of Hydrophobia until they see a real ease; them ' v 
have no doubt that they will< 
T - T R E A T M E N T . ™ 
treatment is unsatisfactory. Most of the patients die but- 
^r>I^e have recovered. This has pir.bably been due to the fact 
^t,in the cases that recovered, the inoculation was not severe* 
that they ktood the poison better than most people do, : 
399 The drugs' that. would seem to be indicated are these that pax^ 
alyze the muscles, The most efficient of these is qujarea 
More recently the treatment by dnoeulati^r, has come into vogue. 
The method Is* as follow* You obtain the saliva Of a mad dogV 
Therewith tMusyou inooul&to a rabbit, You kill the rabbity 
remove the Spinal ooi^and allow the spinal, oord to dry© yhen^ 
with portions of the spinal cord, you inoculate other rabbity- V 
and'/so on9up.til you finally f®t $ modified poiwnJwit^ which • , 
you inoculate human beings© This method is preven t\tive 'and the ? 
lang period of incubation gives time to carry it ou& It has 
been larhely u$ed in'France. In other countries^!t has not been, 
largely carried out© The testimony as to Its efficacy is eon^ 
trodictoryJ It^ advocates claim that a large number of persons< 
who have been bitten by rabid dpgs and who have been inoculated 
have not developed Hjdmhobia» Its opponents claim call attend00 
to the fact that it is possible to be bitten by rabid animals / 
and^yetjnet get the disease andworse^yes,what is worsa, they ■ .' t 
elaim that,Vin some oases, the inoculation has caused tb^ diseased 
There the question seems to stand wd I doubt if we shall know 
much more about it until the treatment is tried in other coun<> 
trdes^ - - i . • • • ... • 
400 t - T K I 0 H I N 0 S I S ♦ - 
ditease oiffert altogether from the other diseases that crig* 
hate in &nimals„ The poison is not a microworganism but a 
.^tle worm of appreciable size, This disease belongs to swine 
^?when get it, they cnly ge t it in one way? namely, by eating 
the fie^h of diseased swine* The flesh contains the wornu 
a man has eaten the flesh of a diseased pi£, the process 
digestion soon allows the worms to become free,especially z . 
the small intestine* These worms are not affected, by the 
^iees of the alimentary uanal* They flourish in this position • 
a few days? they t>row to full size, Thens they Z'eproduce 
j ^^'csh crop of blind trihhinae,in considerable numbers in the 
; h tey tine. The youny, ins tead of remaining in the dates tine? 
it ^nd find their way into almost all the vpluntary muscles' 
^y remain in the voluntary muse les? ceil themselves upland set 
change of tissue around them?and a little capsule is formed. 
ea.ch wornu In their capsules, uiey remain for a considerable 
^e. Some will remain alive in the voluntary muscles for a 
Gr,^tiderable time,and?if introduced, into the alimentary canals 
401 other animals,will reproduce the disease* More of ten, the 
worms die'and-tlbe capsules become ^felewd and infiltrated 
with the salts.of lime, These' calcified nr infiltrated capsules .-• 
remain/ for the. rest of the patient* 6 life, 
~ SYMPTOMS,- , 
Th$'symp tarns. vary with the number of worms eaten, 
the number of worms introduced be small, the symptoms will 
not be particularly severe. There will be some little .disturbane0 
of the y.tcmaeh and intestines,a 11 title fever,,and pain and ten* 
dement? about the voluntary muscles* But, none-of these symptoms 
are severe and h e parent will get well with the dead worms 
in the voluntary muscles where they will remain- for. the rest . 
If eonsideMble number of the worm® be taken, after a few • 
hon^ or several clays, the patient will, give symptoms. At firsts 
he will give syu^tnm^ refei^able to the alimentary tract. He 
will.fuave r:aln in the ghtiomen,nausea,vomiting,diarrhoea,and • 
aons?idprable prostration. Then, in a few days more,usually about 
ihe seventh day, the symptoms change their character* It is 
Wually about the seventh day that the fresh brood of worms ' • 
iS produced and^aftei^ this iiiae,wc get other s.W toms besides ' 
402 referable the sipm^h and intestines. The fever may 
Continue- the proetratloh will be wre mrkeds th# nusoles will 
| ®wqilent painful te^ contracted entjin consequent 
Hs^iratlon dr voice may be There By be oedema® 
oedema is especially apt tn appear beneath the skin 3f 
eyeitd# but it may alec appear in the face or extremltie-®^ 
ph© patient may develop tnOa&wtory conditions of the. lut^ 
^nachitis or bwn$be*pnetTOn^ He may develop cerebral Byapte®®* 
^6 may develop l®fW®»tory condition® of the skin» Tht&>fhe 
^tlent P&o@8 into the |W^oW sHt© wt, to a great extent^ ' , 
ether sywtMB paos away* The patient emoiatBStliBS quietly 
B^r^- alternates with delirium the tongue is dry and brown, 
.■^d there are retention of urine &$< inoontlnehee o'# faeces^ 
these severe eaees^whether the patient ig to die or is to 
^ewer^the ey^tosw are opt io oonUnue for a considerable 
limits of th© nr© frw eleven t© 
h^udved and twenty da^» In the ordi^&ry ^vsre gm^bs the 
$*Wase lasts threesfeungfivefOr si® we'ekit 
Wry 3^Rea?tho resemblance to typhoid fever will be quite ;> 
Of oMiXWyif you wee the patent at the beginning of 
di^ea^yfjy &re not likely to make the mistak^far. the Bymp«r 
exao tl.y what you would'expect them to besbut^ if yoiv 
403 see the case later and are not able to get the history, you may 
well Ms take it for typhoid fever# 
- TR^hTM^T.- 
Tfie' treatment is principally directed to the avoidance of 'the 
'disease and this is best carried out by such laws as will pre^'' 
vent the selling of the flesh of the diseased hogs* In German^ 
'this is effected by a Government Supervision in the establish*- 
merits in which the hogs are slaughtered# In this country,&lthough 
the' disease is <uite prevalent, there is no law on the subject 
and' the flesh can be sold# But,fortunately, the cooking process 
destroys the worms and renders the flesh inoeuous# For this 
reason, the disease is not very prevalent in the United States* 
if a person has eaten the infected flesh containing the live 
worm&5apparently,we can do nothing except during the period 
before the young worms are born,for,until that tima, the worms 
do'hot penetrate the muscles# Then? we can try t© get the worms 
out'by emetics and cathartics# After the young have been produo 
and have entered the muscles, there is no longer any dire?. t 
treatment and we can only nursa, feed and support the patient# 
404 have finished all toe infectious diseases* ^e art about 
take up two disease^ known as Rheumatism and Goui» 
Mex* these two aame^we include a number of morbid conditions^ 
because we are sure that they have anything to do with 
'other but because they have may points in common and . 
•^au^e it has been the custom to do so for a great many years. 
• ^^we Mve several divisions of Rheumatism* These arei« 
™ 1 ~ acute rheumatism* ~ 
™ 2~ SUB-ACUTE RHEUMATISM* - 
_ S^CmOKIC RHEUMATISM* - 
- 4™ gonorrhoeal rheumatism, - 
™ S'™ muscular rheumatism. - 
_ 6 -rheumoid arthritis* - 
405 ~ A C U T E RHEUMATISM® - 
This ie defined as a general disease of which the characteristic 
lesions are an inxlammation of the joints and of some of the 
connectives tissue membranes* 
^he'most frequent lesion is the inflammation of the joints* 
This seems to be an acute exudative inflammation of the syno« 
j-. -. * ■ 1«.KM»^ha2fr< ■•■-*/- 
vial mamtrune with congestion? swelling the production, of 
"/a. 1 n some case a? with t&0 production of pus* In the 
majority of cases?the inflammation does not go on to tlhe pro** 
ductioh of ^u$u Shafter death? it may very well happen that you : 
will find nothing^for the swelling and congestion may disappear* 
If 'there have been an unusual x?reduction of serum or if pus 
have been produced^ aS ter death? you will find in the Joint a 
aon^dderable 'quantity of serum or more or legs serum mixed with 
pus* 
Ihe'inflammations of th® eonneet^ve-tissue membranes ooour fre^ • 
. * ' 
cjuently enough cut not nearly frequently as t-lwie of the 
joints The eohxieetive«tissue membranes most fre)|uenUy inflamed 
are of the heart? the ondoeardium and perioardiur^ ijaoh 
of thes£ is frequently inflamed* The pathology of acute endO"' 
carditis and acute pericarditis has been fully given in the 
firet;volume and it has not been -thought necessary to reproduce" 
it hero^M. - - 
406 1(4 I. rj , 
^quentlyjwe get inflammations of the csnnec tive-tissue 
Qu"'^6^ Thus, we may have an acute meningitis with the pro- 
of serum,fibrin^and pus. The pleura or the peritoneum 
inflamed. 
the inflammations of the connective-tissue membranes, 
$ ^y have certain complicating inflammations. The coats of 
J eye may become inflamed and, thus, we will get a well marked 
eUmatic iritis or an irldo-choroiditis* There may be,a pneu- ' 
There may be a nephHtis5S^ nephritis may be quite 
marked* 
1 - E T I 0 L 0 G Y - 
Rheumatism is a disease that prevails in nearly all parts 
j the world but it it especially common in temperate climates* 
■ sr.^ oases* there seems to be a well marked tendency to the 
SU S /. * ' » 
. uease,which,in some cases?is heredi tary? in others,not. A person 
। y inherit a disposition to having but one attack or he may 
^^rit a disposition to having more than one attack and this is 
he r,f features of the disease. Although no age 
, > exempt from acute rheumatism,persons between the' ages of ten 
tldrty are especially liable to it. 
407 Whether a person be strong and robust or whether he be fHbie> 
Mims Vo make no difference. 
~ Invasion. -- - 
fee disease is apt to commence in one of three ways.' 
- For several hours or fax' several days, the patient will 
have headache and will be generally good-for-nothing# He will 
lose appetite and his twxgue will be coated. The skin will be 
muddy eleven, yellow. He will have feelings of- heat ard cold. 
He will be irritable and sleepless The urine win be diminished 
in quantity and it is apt to scald the urethra. The urine will 
deposit an unusual quantity of urates upon standing# There will 
be a feeling of stiffness in the joints. 
***2-In these cases 1 the first symptoms are pain and stiffness 
in some of the joints which.some on withoat constitutional dis*' 
iurbanoes. Some of the patients will think; that hhey must have 
strained the joints. Then,after a few days,come the regular 
Symptoms. * • 
•** S-In these cases? the invasion will be very sudden. There" 
will be marked chills and a high fever and? within a few hours, . 
*111 oome the inflajwxtion of tho .joints* 
# Xo matter how the disease commenced, when it is well established* 
there are a certain number of regular jj^uptoms* 
408 - S Y M P T 0 M S - 
. - General Symp tons.- 
1-The fever is usually proportionate to the severity of the 
tism. 
2*-With the fever, the pulse will become full ana rapid. 
6-The skin will be either hat and dry or hot and perspiring, 
perspiration is acta and often has a peculiar smell. 
.j--The tongue is coated. 
The bowels are generally constipated. 
-The urine is diminishea and eon tains an excess of urates. 
5-As a rule, the mind is clear but the patients show a de- 
Gf irritability and restlessness which is often rut of pro* 
.^tion tn the height of the temperature and the inflammation 
the joints. 
There is marked sleeplessness. 
- Locals ymp' to ms.- 
^ther one joint or several joints will be swollen, rec,hot, 
pinful?ana. tender. The cases vary as to the severity of the 
.^'lamination and alsc as ty Uie proportion between the amount of 
lamination ana the amount of pain ano tenaerness. The eases 
409 in which the joints are markedly swollen are not neoeaBarliy •J 
those that have the mo^t pain* The inflammation of the joints 
nay be so slight that you can not appreciate it by inspection - 
and,yet, the pain may bo excruciating. The cases also vary as to 
how-many joints are inflamed. There may be but oneor there may 
be two, three^or all. The cases also vary as to the exact way 
in which the inflammation is developed* In some cases, several '• 
joints will become inflamed at the same timejin others*one 
joint will be inflamed and will g^t we IL, then* ano the r will do" 
h e same thing and so on, or the inflammation may. begin .again 
in the joint that was first inflamed. . '. 
The eases in which we Lava the regular constitutional symptom#/ 
and regular inflammation of tM joints are called the single' . 
unoomp 11 cated cases and they only differ as to their severity*' 
besides theser,we frequently enough have complicated casesi 
These complicated cases are the following* 
*-l~ These eases have a very high teaperatura, 107, 108,109,110* 
These cases may begin as if they ^ere going to have either a 
mild or a severe attack and?f^r several daya, they will go on 
regularly. Then* they will hav# the sudden rise of ten^ei^tum. •< 
Within a few hours, the temperature will run up several degrees 
The inflammation of the joints will diminish« If the patients 
h«.ve been sweating, the sweating will stop* The tongue becoma> 
410 pulse becomSM rapid and feeble. The breathing becomes 
The irritability and resUe$ are well developed. 
^^plessno^i* ^®li marked. We get decided cerebral sycjM 
h 'beadach^ involuntary con true Uon^5 cmywl^ons? delirium 
k^^ting with stumor,or complete c». This hyperpyrexia 
ue of tn® most fatal complications and a large number of f 
Patients who are attacked by i^diee 
frequently have the inflammations of the pericardium 
k ^Mocardium. These conoid cations seem to be more common, 
g ^'^ng people than in old people. They occur as wen in mild 
L es in severe cases. As a rul&? they do not come' on until 
k ehai days after the joint lesion has been developed but they y 
k* °ecur during the first days of the rheumatism and may even 
iho inflammation of the wu* t?u ™ the of 
S p®^l^^diti^ and aouta endGsarditir» have been already 
g'^ibed in the First Volusae and it would only be waste of 
and Sfpace to repeat them here. The only additional point 
k it is necessary to remomte s In ooa^nec. tion wi th these lesions 
L they complicate acute Rheu:^atl^i^ that their symptoms 
be #0 slight that they are to be overlooked and?on thio 
I °°,Untiyou should listen to the heart cvexy day^-Edc - 
411 The milder cases of endc-cardi tls do notadd io the dangers of 
the disease: the more severe ai'e often alarming but, yet, 
a considerable number of these recover from hct> diseases® 
The worst thing about these heart is not the trouble 
that they give during the Rheumatism but the damage that they 
Cleave behind them. The my go on for to r^t of his 
life with damaged valves and?wwi? In some cases,the inflammation 
will continue and iW patient '-rill judder for a long time from 
chronic endocarditis* Sa, endocardium is on® of the bad oompli* 
cations* 
---2-In these case^we will have the aon^tdiuUnnal symptoms 
but no inflammation of the Joint® and the v^iUardi tis or endow 
carditis vrill be the ohare-euristio lesion ffce difOasiv 
- 4-In these oases,,we will have thia complicating inflammations 
of the lungs,,pleura,or pia mater© 
The inflammation of the lungs is apt to be a lobar pneumonia 
and it gives its regular symp'U^* 
We may have either a dry or- ple",u'i£ty with adhesions 
either of which will give its. regular symptoms© 
The meningitis will give its TG^lar symptoms© 
When we have the complies.tiiig inflammations of the eyer?a special- 
ist is generally called in io treat iham.-, . 
412 |e -Duration.- 
juration of acute Rheumatism varies. In a moderate number 
ease a, the disease will only last two days and I have 
** one sage in which the disease only lasted twenty-four hours but 
86 short cases are the exception. As a rulo, the disease will 
* three weeks at least and many of the eases are sick for 
^ch longer time. This long duration is another of the bad 
of the disease, ' • 
-PROGNOSIS.- ' 
Of casett recover altogether. In other ease a, the recovery 
hot.be as co^lete and satisfactory, The constitutional 
!^toms will subside but one joint will remain inflamed. In • 
of these eases,it really'locks as though the Rheumatism 
v ^one away and a synovitis had been left and this synovitis 
better or it may get worse, If it get worsatpu$ may be 
the cartilages and bones will become eroded and the pa^Bt • 
1 suffer from arthritis* ' • 
k °ther cases, the acute symptoms will subside and, apparently, 
^tient is well but he has no a^petita, the tongue will be 
|^e^he will suffer from nausea and eoxisUpatioa^he will nob 
L^.X^sh and strength and he is really getting Neither better 
| ^orse* At the same tim&, the joints will remain a little .. 
413 tender ©nd a little painful but patient will be able to 
use the joints* This condition may last for weeks or months. 
Other patients will have been getting for clays or weeks* 
Then? they will have a second attack and this second attack 
may ooms! (Hi hq %ciq& after the first tha* it will look like a 
relapse* These rer> « pses jr'V **> \ '•<■■ ;?* , C ' ' ■•"*• ■■- >'. ' f.. :,v 3 on J? U tu to ano the r 
of* the disagreeable features of the disease* When you once 
begin with Acute Rheum-tium? you hoEy know when you will get 
rid of itc 
,The. fatal oases die of the complioatioatf^ t&e high temperature^ 
'heart lesions*lun« lesions e W© I 
~ TRMTMWT* -4 
treatment is local and general. / . 
Local Trea,i®eni* *p 
The lae&l treatment is addre^^ed to then inflammation of the 
joints you may treat thl?j inflame tn on. without fear of doing 
£be patient As a mirths lew t&e inflammation of 
$he joints^ the less will be the general ^ywtoms# 
The most efficient s^ans of loefel treatojent are the application^ 
of heat br cold* If yon e&plo^ coldjiet it be continuous. Use 
the rubber coil or clothe wrung out in ice waterror put ice 
414 ''^^•^Wund the joint day and night. If you use heat,it is best 
'inte rn Let .the heat be as decided as the patient 
Ip bear it. Use sponges wrung out of very hot water, applied 
fjy© to ten. minutes every half hour and keep this up hour 
J&w* Of 2SK less efficiency are the alkaline lotions 
y* blwters. . • 
Wt and cold are* especially applicable to' the early stages. 
pter a week, they are not of as, much service, , . ' 
® tjie later stages,blisters and pressure are of service. In 
^$later stages,it is also of service to put the limb n.h an 
^bending apparatus# 
. -General Treatment.- . . 
?e drugs'most commonly used are opium, the alkalies, the sal- 
®ylate<,antipyrin,iodide of pdtash,coIshi cum, s tryuhnine,and 
r sometimes, we use one of these* drugs? some times, ann the r, 
J^ording..to* the character of the case. 
a--1^. mild $ases-?with only one joint inflamed,keep the 
^•tient in bed,apply heat or cold,and give a little opium at 
for, then, the pain is usually .the worst, 
ordinary eases in which the constitutional symptoms 
well' developed' and the inflammation is travelling from one 
415 Joint to another,give the salicylates* You may give salicin, 
'salicylic acid*salicylate of soda,or the oil of vintergreen- 
The salicylate of soda is the one that is most commonly used* 
It must be given in large dose$, gr$*xxx*»grs* e in the tweniy*- 
four hours. In naany casesjyou give this drug in capsules . 
or in solution and there .will be no bad results and the Rheuma*3'** 
will be controlled*but,in w<w caseg^ynu A.y get poisonous synp** 
toms>cerebral symptoms,vamiting,and a disordered stomachs If 
the poisonous symptoms be not very marked, discontinue the us® 
of the drug for twenty^four hours; then, go on again* if they b® 
very marked,you will have to give up, .the use of the drug* 
In some cases,the salicylate of soda alone will not give good 
results and, then?you will often got good results by combining 
opium or belladonna with iU 
If you give the oil of win tergreen, give m*x-uuxx every two hours* 
This drug does not give poisonous, symptoms and it often' Succeed^ 
when the salicylate of soda, fails* 
Salicin is just as good as the salicylate of soda- It should 
be given in the same doses as the salicylate of soda and it i^S 
not as ofteja followed by poisonous symptoms but it is not much , 
used in this country^ • 
416 drugs can diminish the fever^ the severity of the const!- 
^tiaaal symptoms-,and the pain and inflammation in the joints 
you must not expect too much of them, they will, relieve the 
^eumati'sm but, as a rule., the patient will go on with the disease 
or two, three, or four weeks. You need not expect that this 
Treatment will prevent the occurrence of relapses, These drugs 
•^ve but little affect upon the inflammations of the pericardium 
endocardium*' ■ . 
, r 5 -These patients seem to be managed better in a different 
v^' The y are large? f a t ? we 11 -nou ri shed, s trong^ and o f ten fl c rid 
^Ults; They have urates in excels in the urine and are apt tn 
disturbances of the liver. They are better treated by the 
^Mliesv Fuller's plan of treatment is the best. It is as follows. 
7 ery three or four hours-, give two .dram^ of bicarbonate of soda, 
^ttle. lemon juice,and an ounce of water. Repeat this a few 
until the urine becomes alkaline and keen the urine al- 
jjw ]/ ■ 
Give a cathartic every day so as to keep the bowels open* 
the urine has become fairly alkaline give ^instead of the 
/ ^rbonate of sodar three grains of quinine some lemon juice, 
half a dram of tfee bicarbonate of potash,in waters Keep this 
uxitii the patient becomes convalescent. If you select your 
i3eas the alkaline treatment is better than the salipylic. 
417 --4--In these eases?the constitutional symptoms are well mark6^ 
but?apparently, the inflaiimtlon of the joints is not severe* 
tf ten, you would not know that the joints were inflamed even if 
you looked at them but they are extremely painful* The patients 
•will not move at all and the pain in te joints will even be 
inoreused by shaking the bed- The pain in the joints is present 
even when the pad tent is quiet and,if you take hold of the joints 
he will cry out* The pain overshadows all the other symptoms* 
In these oase^give antipyrin in considerable doses, grs<>v^grg*^ 
every two hours nr every hour* If this drug work properly,as 
often will,within twelve hours-, the pain, will markedly diminish 
and, by the end of twenty-four hour%Tit may very well disappear 
and?by keeping up the use of the drug, the pain will'not return* 
But, antipyrin poisons many people* When it does .scathe patient 
wi 11 -become depressed, the heax^t will become weak,and the patieft'*' 
will manifest collapse; but? fortunately for people with Acute 
Rheumatism, these bad results of antopyrin are much more likelf 
to occur when the- drug is given as an antipyretic in other 
conditions than when it is given in Rheumatism as a specific 
for the pain* Still?if you do not know the susceptibility of 
p<?.tlent,begin,of course-,with small doses but you must not con* 
tinue with small doses-,xor they are simply thrown away^ 
418 give the drug in large doses, Fortunately, in 
^^esjynu do not have to give opium, 
$*** These ouses ure not benefited by any of the foregoing 
J^ns of treatment. These patJienta are apt to be feeble and 
Pernio before they are at tasked by Rheumatism. They have th# 
institutional and looal symptoms but they are not well marked^ 
Prostration is more marked than the febrile movement* In 
^3© eases, give Iron and quinine. In addition,ynu may give 
^•Uver oil.inhalations of oxygen, or iodide nf potash. You 
remove the pi tients from home. 
In these cases>the Rheumatism is modified by the gouty 
*u thesis In these eases, there is often difficulty in drawing 
line betvenn the gout and the Rheumatism. Whatever other 
you give, the salicylates, the ulkalies,iodide of potash, 
* untlpyrin,you must give colchisum in larger or in smaller 
pQes. 
n all ouses of Acute Rheumatism,make the local applications 
£ ^e joints. 
you have the excessive temperature^hyperpyrexia, I think the 
thing to do is to apply cold to the surface of the body. 
internal antipyretics are >nt of much use. The best way 
419 in which to apply the cold is to give a moderately cold bath. • 
Let the tempera tuire of the bath be 98 or 99* You may kkep the 
patient in. the bath for a considerable time and the baths have 
often tobe frequently repeated* In addition,the feeble heart 
and the disposition to collapse call for alcohol and the other 
cardiac stimulants in considerable doses? 
When you have the complicating bndoaardi tls.,peri<ardi tisfpn^ 
mania?pleurisy,or meningitis employ the ordinary methods of 
treatment® 
After the disease has finished, some of the patients will be 
left wiAh an inflammation,usually, of one joint* At first, this 
will only be a chronic synovi tiss bu t, if left alone, it may become 
a chronic arthritis* In these eases, the drugs that we use for 
the Rheumatism are of no use* Treat the chronic synovitis* 
At first,keep 4he joint quiet and apply pressure* then,after a 
time,employ frictions or frictions with srulphur ointment,passive 
motion,and .electricity* Attend to the general health* 
• they patients will recover altogether from the Rheumatism but 
they are' lef t feeble?emaciated-yand good-for-nothinge These 
cases often require treatment fnr weeks nr months before they 
recover good health. 
420 the trednentyleave the lUieumtism nut of consideration* 
,*ethe vu tien t5and give fats,ivon , and bi tter tnni c s. Some 
better off for the use of stryotoine,others for quinine, 
others for ma usage and passive motion. 
- RELAPSES.- • 
0 Clatter what plan of treatment ynu adopt, the patients are 
iable to relapses. These relapses come on af.ter the mild eases . 
a 'veil -as after the severe. They are very annoying? the disease 
8 had enough anyway® We may try to prevent the occurrence of 
^lapses by continuing the use of the drugs that we gave during 
Rheumatism. As a matter of fact?I doubt if this plan of 
l^atoent is followed by any decided results and, fur thermo re, 
* has seemed to me that this plan not only does not prevent 
the occurrence of the relapses but?when,. the relapses do oome,* 
Z10 drugs that we continued are not as efficacious as they we it 
^ore® As to the salicylates,no one claims that they cure 
^eumatism and it is hardly reasonable to expect that they will 
*ct as prophylactics Sa,I only continue the use of the original 
^8^, whatever they may ba,until the symptoms of the Acute 
^^umatism are well diminished and the pidn is gone and there 
no decided inflammation of the joints. Then,I diminish and 
Hop their use. Then,if u relapse enme, ths drugs will jUlt 
good as they were before. 
421 -SUB-ACUTE RHEUMATISM. - 
In, uny the term sub-acute is not very definite arid this 
is true when the tern is applied to Rheumatism. Yet, there .are 
&ome 'eases of Rheumatism to which the term* sub-acute'doe a yee^r" 
fairly applicable- It is the same disease as Acute Rheumatism 
but the ^ymptomj ^e different* , ■ 
Thu symptoms are apt to be developed slowly and gradually. 
The fever either may not.be very marked or it may be absent, 
The inflammation of the joints is not at any tme severe and the 
patient goes on using the joints al though they hurt him- Rut, 
there is soon developed a marked depreciation of the patient's 
general heal tX This strikes you at once. The patients lose ap^ 
pe ti te^ flesh, and s length and become anaemic - These symptoms 
become more decided from day io day- The bowels are constipated 
and,as a rule, the'patients suffer from disturbances of the stomal 
and 11vera 
These cases are meh moire difficult to treat than those of acute 
Rheumatism and7for the most part, they are not benefited by the 
same drug#* 'However^ in some of the easea^we do get good resnlis 
from the salicylates or antipyrin but these cases are not very 
numerous, - 
- TREATMENT. ~ 
422 these drugs.do not succeeds yon can nnly treat the general 
of Ums patients Attend tc the dislurbances of digestion* 
$ive eod*liver oil ^id try to iMjrove the appetite by bitter 
, Tvy mssage aM passive ration® Give wra or alkaline 
.^We The patients arb ^ften benefited by the natural mineral 
^Ux^^spesially the sulphur and alkaline* The nation t should 
to the springs and dri. •■ xk t- ~e t?<.i te x* s </v*'A the baths, A 
^'*nge of ailsau will ofm ao good ; 11 else fails. 
^crjQ g:p ^ese a^es are very satisfaot^vy to treat but all of 
task your skill very muohe There is the same liability 
endocarditis that there 13 in Acute Hheumatism* 
423 - M U- S C U L k Tl R H 13 U M A T I S M . - 
This is an affection of Ub muscle^ apparently inflamma.toxy- 
in character. The muscles Become ter^ex^?*5^ ^g into ■ 
a condition of haw no very exact knowledge 
us to the changes in the muscle# Mixt we believe them to be in* 
f lumma to py. The inflammation does not go on to the produoion of 
inflammatory products,at losUnct to my great extents The 
muscles most frequently affected are those of the shouldernepk, • 
and back. It is one Of the complica'iioiw of scarlet fever. ' * 
It occurs after' exposure to cold and wet. We find it with Asute*^ 
Articular RheumatlsjiU But, although the cause of the disease* 
varies,,its character is always ti e . ; 
The patients differ very much in regard to the number of muscles 
that are Inflamed and in regard to the severity of the, inflamaMnl!U 
•-1-In the mildest $asss,only or two muscles of the neck 
or shoulder will be inflamed. pain and tenderness will not! 
be very marked. The patient will the house or in be<I» 
~2-These casts are wie severe. The'dumber of muscles involye^^ 
is greater? the inflammation is moro severe? and the pain, tender* ♦ 
ness«,and con traction will be mo^ deGidad. The pain take on ' 
the neuralgic charactor; that 1-3 it will he out of proportion to * 
the lesion and win be present all* the but will be worse • 
at som times .than at others. 
424 ■ 3-- The Worst Cases. - Many muscles are involved* The inflam- 
^tlon is so severe tMt t*e patient dll lie in bed a ad dll 
be able to move on account of the painc He will be confined 
*° bed for a number of daySc 
the mild ease^ there are no consUtutienal syuptofcs at alU 
the more severe eases^ there may be & moderate fever and 
helplessness from the pain and sleeplessness, will be so 
that the patient will feel sick* 
~ TR^TM^NT. - 
treatment dll vary with the severity and cause of the disease# 
slider eases hardly require any treatment at all. The in- 
'^Witlon will subside in a few days by itself. 
. vue mox»e severe cases5 the pain is often very bad and we'must 
$ Something to relieve it Xf the attack occur in connection 
acute articular rbeumaU^^^ ths same remedies as you 
*°^id in an ordinary aase'of articular rheumatism# If' it come 
? iMependently of abute rheumatism^ these drugs will be nf 
services tyuzitiuyrln i^ oft^ of service* You may give 
vi " ' 
^bemiuBc In som cuse^gelsemlum will relieve the pain in a 
^7 short time bust it iu- always an uncertain drug and wmy 
s^ons get its poisonous af^a-ots before they get the remedial* 
425 .In other /caseiodide of potash in ten ox1 fifteen grain doses■•. 
seems tope of real iJ^rviGS, 
In addition,you MMt make local applications to the muscles* •. 
mus tax'd, plait' teru, con tinuous heat, lg tions of belladonna,or the. 
continuous application of the mild faradio current? some time• 
one: some timeano ther* - 
In some case^ the pain will not be controlled either by the drd^'! 
or by the applications and$ then, you must give mnrphino ixypO" 
dermically? In the eases that bear morphine tbi^ treatment 
is very sahtsfac.those patients ^ho do not bear iy - 
well, and the up ^re i- *9hom morphine produces exoitementr. 
naMsea,and vomiting or vho are kept u"rake by iy you are often 
troubled by its bad results and oan not give if as freely u< . 
you would wish. 
Most of the patients rooover without any bad results but,oc* : .t 
Gasio.nalJmz,especially in childrens the inflammation will befollcx®^ 
by a conjunction (>f the mt^olesa. In theb^ eases^i'se the faiW^-c 
or direct current and ^passive mtillS tAdn^i 
thF^uscTes' will come sondi tion„ 
c 
426 $ - G 0 N 0 R H H C 2 A L RHEUMATISM. - 
Ms generally occurs in the later stages of gonorrhoea. It 
^ore common in males than in females* Some persons are more 
^bl@ +-0 :[r than others* The majority of patients who have 
jyn°rrhoea do not have gonorrhoeal rheuwtism at all.The inflaaw 
7^'on in and about the joints seems to be the direct result 
. the gonorrhoeal poison, for we find the same micrococcus 
n the effusions,in 'and about the joints as we do in the pus 
$ the urethra* In oases? the rheumatism will occur when 
Q discharge from the urethra is stopped and,if the discharge 
,e allowed to some on again,the inflammation of the joint will 
® better 
a, re two anatomical varieties of this disease* 
^^One or more of the joints will be somewhat swollen,painful^ . 
8^«wxd tender. The swelling is diffuse and the in fl animation 
really not to be in the synovial membrane but in the tissMf 
°^t the joint. The influmrr^tion and redness of the skin may 
® developed to such a degree as to look like erysipelas but 
joi^3 thing to do with erysipelas. Most frequently, the ankle 
^nts will be affected in this ways less frequently, the ankles 
* other joints: or the inflammation may at first involve many 
427 joints and,then?disappear in all but nnee The inflammation. is 
apt to continue for days and wets cad the caws vary us tn • 
the iijuteness of the inflammtiono tn some ba^e^the inflammaii^ 
will be developed rapidly and rill be severe? in others? it Till 
not be developed as rapidly and is apt to last longer,11 sub- 
acutea coeSa. ' ' 
In one or- two wwelSjthe inflaw&tion may subside and' the 
may get well sample to ly? in other ease the inflammation will 
snntinue so long that it will produce thickening about 
the joint? the joints Till be-left ana painful on motion 
and this may keep the patient from talking fo^'i'ome timOe 
In other casepus Till be pmr-dueed in the tissued around the 
joint and this infiltration of pus may form an ^baesi of con- 
siderable size beneath the skin* 
■■ ' TVSATMI^Te ~ 
There is no direct treatment for th$ rheumatism* We treat:the 
gonorrhoea and -the rule is that the gnn6rrhoea> should not be 
treated too rapidly* Use very wa^ injections o$ give those 
drugs internally that cau^e tive gonorfbcca k» gradually subside* ■ 
428 ^p the patient ^uiet in bed* In none casethis is all we can 
$n* . In o the r&, espe c ial ly the * sub - a cu te5«as $ c nun te r-i rvd ta ti on 
'^nut the joint does do some good® In >thoi case%steady and 
^Aiform pres sure will he nf ye ?vioo,' When inflammation sub- 
3 ides,employ rubbing and passive motion# if ubces^s form^opep 
and treat in the usual manner^ ^t? the be-st curative 
Merits are rest and times Vvs other means are no of decided 
®^ficaey. ' 
/ *r- 
2*-These* cases are less oommn^ The in^lamutlon does in» 
volve the 'synovial membrane and tic knee &vo mo^t frequently 
^^eetedjpne ar both* Tie inflaa^tion is rather, ^ub^aaut®-1* 
*he synovial sac is distended with serum and there is a certain 
^unt of palm and tenderness about the joint* In cases, 
Y will go no further* In more severe eases,pus is produced and 
sue will he distended wf Q: purulent ^9rums. Then? there is 
'^uys danger that tlie inflammation will extend to the ligamen^ts 
^d ends ef/the ho::c^s if it do St\9u suppurativa arthritis will 
® developed® This is-, very 
he ordinary surgical treatment of synovitis,of a tsub~acutet 
u^ovitis?or of a suppurative arthritis as the ease may be. 
429 This name is given to a specific form of inflammation of the 
joints which comes an slowly and gradually* Prom the first,it 
involves the syno v1 al near?and it shows & disposition to 
spread from one joint to ano the r but it does hot leave the 
joint in which it first began® It is important to distinguish 
these cases, from the protracted or ^sub-acute seases of Acute 
Articular Rheumatism* A person with Acute Rheumatism may have 
his attacks protracted for week^ and months but he really suff®^ 
from Acute Articular Rheumatism* In the true cases of7Chronic 
Rheumatism, the inflammat^ in the synovial membrane. 
From the first?it is chronic and it is-developed, so slowly and 
gradually that, at first, the patient pays no attention to it. 
The synovial membrane is thickened and serum exudes into the 
synovial sac* The eases vary as to the relative amount of ' thick* 
ening and the amount of fluid* Then, the inflammation extends to I 
the ligaments* capsule^ and articular cartilages, The ligaments . 
and the capsule become more am more thickened? the cartilages 
become softened,eroded,and destroyed* it may extend to -the 
bones which will become either eroded or hardened* Sa,when dt 
is fully developed,it is a general arthritis and destroys the 
- C H H 0 N X C R H E U M A T X 8 M . 
430 ^Gidons of the joints You m&t not suppose fext^in all ouses^ 
^1 the tissues will be involved» Tn plenty of eases^it neve# 
beyond the thickening of the synovial ^nhrane and the 
^dation of scrum? however long the ease go on® 
patients are vary &$t to have Emphysema>Chr^^ Bright* s 
^fcease?especially the Atrophic levy: and chronic ^da^teri- tig* 
^y are not particularly liable to have perlaarditig and an- 
'•nearditib- chronic Rheumatism belongs to the later yeviM^ of 
^Ult life^ It is not sown even in aarly adult 3dv/e find 
in people vho have passed fifty y$wrs» It is wch vnve e^nwn 
^hg poo? th,<u'i among the better elapses* It is especially 
among people who are exposed to cold and wet weather 
!Md prtrtieu'larly id they be badly nourished* 
Aether nr not the .disease have any connec tic.n with, acuta 
extremely d$ubtf&U X think Qab it ha» not although a person 
^y have acude Rheumatism for yean; and^in this sense? the disease 
^y be ?jaid to be Ghr^niGe 
- SWTOMSe ™ ■ ■• 
--General Symptom^" • • 
^ere are no general sz^sptoms belonging to the disease?itselffr 
431 If the Endarteritis, Emphysema, or Bright's disease exist: they, 
may affect the health. Except for the joint trouble, the patient 
is 'veil: all the symptoms are local. 
-Local Symptoms*- 
At first, the patient will complain that nne nr more joints are 
painful on motion an-1 tender on pressure. At firsthand often for 
a long time, this will not stop the patient from using the joint 
The are so gradually developed that the patient becomes 
habituated to them* Then, as time goes on, the will become 
more disabled* The thickening and effusion of serum?innepen 
dently of the formation of pus,make the joint useless* Then, 
the disease goes on in the original joints for weck^ron th:>, 
and yearly some times, it will be better at other times* wor^e,, 
Thermo the r joints will become inflamed and will go on in the 
So, the disease goes on for months and years, If only the 
joints of the hands,wrists,elbows5and shoulders be involved, 
the patient will still be able to get about and it may very well 
happen that the inflammation will act get beyond a certain 
point* But,in bad cases,one joint after another will he involved 
and the inflammation will attack the ankleu,knees,and hip? ann, 
soon,the patient will be confined to bed and will be unable io 
move hand or foot* 
-Local Symptoms.- 
432 . as the patient it? unable to move about he will emaciate 
..?on aeseunt of ths- enforced quieUhe will become feeble and 
St •. 
* A'd'C le e 
,• -*"- PROGNOSIS. ' 
prognosis is always rather serfeoud; yet,i t is mue> better' 
'•' $eme cases than in others for some manage to get about and 
•Qt*) X'T' 
e< :; a .pre tty fair 'th^ disease involve one joint 
another^ there is no condition more deplorable. 
•-• TRIGATMSNT. 
treatment is not at all satisfactory. As a rula, the remedies 
" -^uts Rheumatism have no affects There seem to be two things 
w$ ean do which will retard the disease for a number of 
rpx first of these is to attend to the general health* 
^e^nd consists in tne regtUar use of the alkaline and 
s-:amineral waters and baths at the watering ^laceso 
X&V-.. the patient i?3- well fed and that he gets enough fat. 
Up the nutrition, by massage and passive motion. Let the 
take as such exercise out of doors as possible but they 
require the ms sage and passive , motion* 
t the use of the mineral waters and baths only 
" i'^-re^ to he kept up for a couple of months each sumer. If the patient® ^rill to the spring 
a greai deal of difference to $be rest ©f* the y^y- 
and it will also retard the advance gX the 
Further than this^I^now of nothing fet rewiet* The 
ordinarp re^ediei? that in AeuW ^t< nr>^ 
of no u^e but they often sake the patient »7orye by disordering' 
his di^^tione 
434 - RHEUMATOID A R T H ® I. T I S . - 
disease is also known by th A name» of Arthritis Deformans 
Rheumatic Gout> 
J10 disease resembles chronic Rheumatism but it is really dif* 
erent. Arthritis Deformans is a chronic inflammation which 
,e8ins in one or more joints and, then,spreads to others;but, 
this disease,the inflammation begins in all the tissues of 
Joint at once and,especially.in the ends of the bones- 
°w,if y0U take one person who has suffered from Chronic lUieuma* 
and anothei* who has suffered from Arthx'itis Deformans, 
,^e condition of the joints will be about the same in each 
^tjin Arthritis Deformans,the inflammation began in all the 
^sues-of the joint at once and it is only after a long time 
K the condition of the joints will be about the same in 
°th diseaseSo t * 
J* Rheumatoid Arthritis,the cartilages become eroded and destroyed* 
ends of the bones may also be somewhat eroded buyout of 
, Proportion to this erosion,is a new gx^owth o^ bone and the 
'^ieular extremities become enlar.geJ^and deformed. "At the same 
the inflammation goes on in the synovial membrane and the 
■nthep tissues of the joint and thickens them but the deformity' 
435 of the ends of the bones is the important part of the lesion. 
The disease usually begins in the small joints of the hands and 
feet? this form is especially Gammon in poor person^ womer^ and 
persons over thirty years of age. After a time* it extends to the 
other joints? , 
In other eases*it will, begin in some oft the larger joints* 
This form belongs to people advanced in life but it is mere eos^ 
mon. in mades than in females. 
Not very frequently*we may have either of these forms in 
children "but this is the exception. 
- SYMPTOMS.- 
At first) the symptoms are very much the same as those of Chr^ni® 
Rheumatism. Ilie joints become painful and tender* the patient 
cun no longer use the joints as easily as before; the joints 
'become stiffer:and*later* the joints become very much de formal* 
The joints >My become immovable or dislocated? Ilie will 
a trophy and tills will bring out in bolder relief th e~ enl^rgemcn t 
' af the heads of the bones 
436 Sr <' 
n we joints become deformed and.useless, At first and for 
time,? the symptoms are not very bad and do not have any 
upon, the patient's health. but?as more and more joints 
invo] ved? the patient will no longer be able to get about 
t-he general health begins to suffer, N04 infrequently^ 
have as complications Emph y s e ma, Ch r 0 n i c End arte ri ti^ and 
* ip°nie Nephritis and these complications Mlp to ninTdown the 
'• 
the disease is slow but progressive. The patient 
lives for years but?each year,he will be a little worse 
„ he ^,3 the year before, The* patient will often go on for 
months without any special trouble; then, the j 0 un ts vi 11 
b6^0^ acre tender. This exacerbation may be accompanied by fever 
/the fever subsides .and the joints are left wors^ than they 
' V "x 
reform Then,in several months more, there will be auohher 
^v-e^oatxon^ 
>^-',ut-nGSxSc - The prognosis is even worse than that of CMroni^ 
^timatism^ The patients Jo not die of the disease hut it render 
very he Ini ess and miserable, 
' , - The trea tmen t i s mo re unsa ti sf ac to vy than th a t 
Chronic Rheumatism^ V/hen the disease has .once begun3it continues# 
437 We mu.y perhaps? in some eases?render the course of the disease 
slower^ The best we cun do is to attend to the general 
the general uu trition and recommend the regular use every year 
of sone of the sulphurous .or alkaline mineral waters and baths* 
438  "GOUT,-* 
disease seems t<n -have some relation withPlieumatism but 
*t is entirely distinct disease, ' It seems to be related 
in Rheumatism in the fallowing way, The S-^SlQ* «t»£XCl L t idual often 
Bhffers from both diseases and it is often difficult to tell 
Whether his attacks are gouty or rheumatic® Ye there can be nd 
^nubt that Gout and-Rheumatism are distinct diseases *It is 
eUstomary to divide Gout into Regular Gout and Irregular Gnut: '. 
Either of which may be acute or Ghronie® 
Although Gout has prevailed for many years,we are still very 
•touch in the dark as regards its true nature and its causes. < 
*he theory mo.st generally accepted is that of fJarrod 'of London. 
, le essential feature of this theory is that the patient has"" 
abnormal quantity of urate of soda in the blood' and that this 
^t is deposited in different This is his 
^eoryo xn add!tion^it is held that in gouty person^ there is 
in the kidneys This change may be s tuuu tural • and> very 
a92anonly IsTo^rFmay be funetional^ ^heh a p^Kon has an attack 
Goutjit is believed that the bleed becomes less alkaline 
tliat there is an increased quantity of urate of- soda xn the 
*&od or u diminished excretion of urate of soda by the kidneys*. 
439 At regards these facts,there can be no question. The blood has 
often been examined,especially during and before the attacks 
and it has been regularly found that there is this- increase of 
. the urate of soda, In the intervals between the attacks, the 
urate will not be present in excess but in the blood of persons 
■who suffer from chronic or irregular Gout, the urate <1.11 be in 
excess all the time, We also always find deposits of urate of 
soda in different parts of the body,especially in the cartilages 
of- the joints and the fibrous tissue around the joints? and,in 
most cases,we find structural changes in the kidneys. But, why 
. should these people have this excess of urate of soda in the 
blood and why should some people never have Gout? This question 
has never'boen satisfactorily solved. There can be no do'abt 
that the. disease is often hereditary and is handed down from 
generation to generation. This hereditary tendency is distinctly 
marked, It is also apparently possible for a person to acquire 
tie disease without any hereditary tendency and this he may do 
in one of two wayssby eating and drinking too much nr by eating 
.too little a When a person eats and drinks too much, the tendency 
»to. the jdisease will be increased if he do not take enough 
440 This is jail that we know in regard to the cause of the disease. 
Why, in inherited or acquired. easethese persons should develop 
^is excess of urate of soda in the blcod?has never been solved. 
»A very Important feature of Gout is the liability of gouty. 
P^tsons to develop lesions in different parts of the body^ 
They are very apt to have branch! hl s $ especdally chronic?pulmon* 
u*y emphysema? chronic, endarteri tis* chronic endocardl.Hsrinfla©* 
^tlons of the skin? especially eczema? they are more Hade to 
diabetes than other people? they of'Ten have chronic inflammation 
the mucous membrane of the stomach and in les tine? fune tional 
disturbances of the liver?and nearly all develop changes in- the 
Sidneys, These complications are so common that it doe-s seem 
though the Gout caused them but it is important to rerOmber * 
^t a person may have these diseases without having' gout. 
^The gouty causation of these disease has a great deal to dd with 
their proper management, • y 
Person may su'ffer from Acute Regular Gout and3as a rule, thia ' 
the best way to have the disease^for the general health is 
the le«st affected, u '» 
/• ACUTE GOUT /- 
This form of .the disease manifests itself in attacks and we 
a|Ml often find a cause for the attack. Of ten, it is due t* a 
441 slight injury of the joint that is inflamed® In other oases, 
the a Hack 'rill be brought on by exposure to cold and wet: by th® 
indulgence in some particular article of food? or the use of win® 
or beer® In other cases.3 there will apparently be no cause. 
The first attack often comes on without warning but the subse- 
quent attacks are apt to be preceded by a prodromic period 
and, even, the first attack maybe precede by constitutional symptom* 
This pridromic period of constitutional symptoms-may last a fe^ 
days or many days® These disturbances consist in disturbances 
of, digestion and® some times a fever® The uatient loses appetite* 
He may have* the symptom?? of gastric dyspepsia* oppression after 
outing: nausea: some times 5bu t no t of ten s vomi ting: flatulence? and 
his bowels are apt to be constipatedo The urine will either be 
diminished and high colored or- it may be more abundant and pale* 
There may be a fever® If these symptoms occur in a person who 
has already had an attack of gout? you know exactly what they 
mean:but,if they acme on before the first attack and last a 
number of day&?you may very well not think of Gout ataall and 
go on creating the patient for something else,malarial fever, 
tor example.® 
442 < -An Attack. - 
*** thing that first attracts attention is that one joint beeWMH 
^Pidly swollen,painful,and tender. Generally, the joint of the 
J^eu t toe is af f e o ted hu t, ins tead, the ankl % kne e, o r s eve ral 
Joints may be affected. The skin aver the joint becomes red and 
^onse. The pain and tenderness are very marked, The urine is 
^iniinished,high colored,and acid. There my be some fever. 
height of the temperature is usually proportionate to the 
•everity of the inflammation of the joints When, the joint is 
hot severely inflamed, there my be no fever. The patinet will 
^80 have disturbances of digestion;he will have no appetite; 
tongue will be coated: flatulence is often resent? and there 
^y be nausea and eons tiuation© The patients a good deal 
to how sick they feel;some will not feel very sick? others 
^111 be as irritable and restless as patients with Acute Rheumatlsttt 
other cases,the will be a considerable amount of prostration* 
Sometimes,an attack will only last a few days?it often lasts 
$ week:and,not infrequently, two weeks;and it may last longer; 
"Ut most of the attacks terminate in one or two weeks, 
^Geasionally, the patient will never have but one attack but 
almost all the patients do have other attacks© The attacks vary 
^8 to their frequency and as to the interval between them. 
443 A# the patient gets elder the attacks os apt th because we' 
fre<ueni and the iaMW-lS apt to be^bw'Sorter* 
'■ . , o „ . ^SreaWnt an iitw&'n . ' •. . . 
Bear zt^is, in de* patina,'the better 
•■iff' they ^411 be, net* w& regard# the sate and of that 
'present attack but as regard# the'general heal thaf ter the at* 
taolu When a person Im the gouty vill be amh • 
better' off if he have oooairXonal of'-Write Gput# Sa, 
Jet the att&ek run^ne^Xy its £ull oouree ,md let''the patient * 
.get, the .full'Wnefit'Of eours^^the p.a'U^,t dhes not like 
! idea and you have , to 
surne ti^a, to huznov dc\hisi good® 
JQ^e/first, thing tir do 1# io hoop hi^ See,, that .there is. 
no, pressure w the'ihfia^d Joint? ^he Wlu/Mn often be relieved 
wrappings the joint looooly vitdi-wooi wet^wi^ bejladonna; or 
^ul^hate of--atropine .and*, over th- oil"io keep in 
airy Xn so;:^'^a^e^this simpl.e 
Jreatxneht still eantrol ike pain to »uah an -extpnt th^t you do' 
•Mdt^haye to do anything else* In.njore severe'danas^iitv&ll not 
444 A 
*eihin additions we must attend to the <iiet« Feed the patient 
n farinaceous food byt do not give him too much to eat. 
not allow the patient to use stimulants* The patients are 
$^ter off if the bowels are kept open and, for this purpose,you 
give Rochelle salts or magne slum 
us^n& these mean&5 the pain" i? So threat that the 
will not tclerate it! you will have to do one of two 
}ngs. You may give opium in sufficient quantity to make the 
la hearable? or you my give of the drugs that are specific 
$ouv Of these soeeificss the most efficient is eolchicum. 
either give it alone or you may combine it with salicylate 
8odu or with an alkali5bic-arbonate of ioda or bicarbonate 
4 You may give the wine of cnlchieum In doses of from 
^Iz^-dram.j or ,/QU m3?. g4ye acetous extrac^gr.j-gv.ijr 
^ou ^ive ihe«e dosers three times a day, The larger dooes> 
4x« more efficient than the smaller not infrequently cause 
of the stomach and intestines and produce nausea, 
ir J3 diarrhoea j and colicky pains but these symptoms do not 
fe./r^ere with the good effects of the drug^ After the first 
4$* days.,you diminish the dose to such quantities as will not 
^ie stomach and intestine^ and you continue its use 
the pain is endurable. 
445 X^ter the uttabhsyou. dubt regulate *he mode 'of life so as to , 
;$void fresh attacks* The general rules are plain enough. As 
Xpo&i4he patient should not eat. ton much'nor too little but 
he should eat just as-mush he 'oan digest.® \He should avoid 
■ft®^ut should not go ^thbut them altogether* 
Jke •.drink ^st3eTes trio ted. The patient should drink nothing * 
but wtetyn® 'alcoholic beverages at allo Hov^ve^man'y patients, 
will insist upon drinking alcohol in so^ shape or other. 'Theih." 
Sou try to find that 'dn^ or liquor that "dH give'him the leas* 
■ad^aomf or t« this will vary nutient cut the malt liquord' 
4nd Sweet wines are .always badQ -here o.an be no question but • * 
;^hat drinkihg alcohol does these patients h^r^u • ' '» 
*fhe mode islo:? the greatest ^nsegw^Qo; The, more 'the 1 
^patient, can iive eu: d^ the lass likel^'will'.he be to s 
^av.e -an.attaeST The more Siereise he hav^tha' better. This* 
^egniation of the mode of life in even of mow iH^.Qrtana;e than-.; 
^ihe\'regulation of, 'the foo<c • ? ' '\. 
•.the patients must'have.'a movement from the bowels',!and you may- • 
giv.e laxatives er regulate the diet in order tceffeet this. 
rThe mor$ pronounced eases are benefited by th'e alkaline mineral 
'waters ai^d the alkaline baths* They Should go; to the springs 
446 overy year. Mast of the patients find that" there are some pax 
^loular articles of food that Till almost invai'iubly bring on 
attack of Gnuta Then? these articles of food must be avoided. 
They 
vary with the different patients? in some, it «dll be stru^ 
^^^ries?in others, some other article of fphd0 , . ; 
tween the-attacks,the general health.is often very good:but , 
ftther patient's will suffer from Chronic•Gout between the attack! 
°f Acute Gout; other patients who have never Jiad A^ute Gout • 
have Chronic Gout* \ ■ 
-^>0 H R ONI C G 0 'U. T-. . - 
^M^en the a tucks 3 the patients health'is no'tgoodjhe lose> 
^^h and strength and becomes anaemic® The changes in the 
^niuts go on slowly and' no 1g ri th any great amount of pain but . 
become worse® The 'joints become thicker and larger:deposits 
ft?'urate of soda form in the joints and1 aisoisome times,in the 
w7^ and in the connective tissues in otM'f parts of the body and 
Ui®se deposits .may/reach a very considerable size# The joints 
^re useful although inflamed# 
447 These patients are very apt to suffer from disturbances of 
digestion, gas trie dyspepsia, intestinal dyspepsia, functional 
disturbance of the liver,, and flatulence® These affect the gene^ 
health® They are very apt to be troubled by the complicating 
di seas e s., Chroni c Bronchi ti $s Emphysema^ Chronl a End oeard i tis, 
ShroHic Endarteritis,many have Diabetes, arid, worst of alh, a 
large number develop Bright* s disease and? regularly, the atrophi® 
form. These complications give the had character to the diseas®* 
The Chronic Gout,itself would not do so very much harm® It woul<i 
simply give a little pain and discomfort but would not be a 
matter of great consequence but it is these complications that 
give the disease its bad character and a person who suffers fro» 
Chronic Gout is pretty badly off,for he is almost certain to / 
develop some of the complications. His health becomes worse and [ 
worse and he dies of sow of the complications,most frequently 
from the complications in the kidneys® 
~ WA»T« - 
In treating these patients,we follow very much the same rules 
that we do between the attacks of acute gout* Enforce exO^ris® 
and regulate the die t, drink, and mode of life® This treatment 
of a good deal of consetuence but its good results are not 
nearly as conspicuous as in Acute Gout where they are generally 
very marked.If a patient with Chronic Gout have a well-marked 
diathesis,, al though you may ameliorate his eondi tion, the Gout 
will &o on * *-* -- 
448 ^.the gouty diathesis be' not wse want will'b*?- of 
u Ureat deal of service, The regular use o^ the mineral' wu.Wrd 
^cii summer is even oft more inpnrtarwe tha^.,it is in persons '. / 
Mio suffer 'from Acute Gout. The robust patients •should taki ,th£ 
•Jtrong-alkaline mineral watery in considerable quantities. If ' 
patient tend to eonstipatfan5he should take the lastly* ■ ' 
Valine mine hi 1 waters If the patten V ba ■anaemic,he • Should*- 
.the alkaline baths and shouM drink oi<n;dde^ 
* the -vara wters but he should not take the strong alkaline/ 
Mineral <vtlte^s, -Look after the gastric disturhaao^s &n$l 
turbanees of the livers ■ ... 1 ( '' , 
of the patients 'Vill not get on well .unless" they take.-d^oad 
''hg* Many will do well with Uie >H' the' year round*. ': 
^ve the bioarbnnate of sodter^ the bicarbonate of potassium* •••. 
* we e&rbonate of lithium well diluted* la other oases,you . . 
J*v« to give colchiSS although you know U)at it is not good 
the patients for the joint trouble, will be very marked* ' ' ' 
t ve the oolehlbum in mix noses for a considerable time^ 
Jto.P its uses and then go on again. 
449 Some are benefited by iodide of toi.d. >well 
• * « • ~^***'*'**7*'*"*^«mmi^^ 
diluted. 
When the patient becomes anaemia^give irono 
So> instead of having one disease to treat?y^u have many and^ 
■ in one ' tien i t wi 11 b e' @ne s ®ap 11 o a ti oa? in ano the es ano the r 
th^t wlll'demand attention® - 
450 -IRREGULAR GOU T * - 
parents de not have the characterisUa inflammation of 
joints either in acute or chronic form* T^-y the ^omty 
a^thesis but this eauses no joint legion at all* They have a 
^rietyz of other troubles and. these T&&y come on in either ax 
**ute or chronic manner* 
-ACUTE IRREGULAR GOUT.- 
patients who suffer from this form of the disease have at« 
in the same way as patients do who suffer from Acute 
Aguiar Gout but5 instead of developing pain and inflammation 
ln one og their joints they will develop pain in.some ether 
of the body. 
on some easethe pain will be in the stomachs The patient will 
"^^enly have severe pain in the stomach, nausea, vomiting and 
prostration* These symptoms will last hours or days and 
then disappear and the patient will go on in his ordinary 
u other cases.} the heart will be affected* The patient will nude* 
have great pain and oppression about the heart# The heart 
viTl become rapid and feeble and the patient may pass into syncap% 
451 These attacks resemble Angina Pectoris and it is often very dif* 
floult to discriminate between the two* The attacks will last 
for hours or for days and,then,will disappear* 
Others will give syciptoms ref erab 1 e. 1q ' the brain* There will be 
& sudden and severe headache. This may be tlhe only sympt«sm oc, 
in addition, there my be an acute delirium* These symptoms will 
last a short time and, then,will disappear. 
Others wiM have symptoms referable to the lungs* The patients 
will have an attack of spasmodic asthma due to Gout* 
So, in these different way, the patients will have the symptoms 
of Acute Gout without any joint symptoms. 
-CHRONIC IRREGULAR G 0 U T . - 
These patients have no joint symptoms at all hut they have all 
the complicating conditions that we find with Chronic Gou to 
They have the same disturbances of digestion; the same tendency 
to diseases of the heart* kidneys and arteries; and they become 
anaemia They are more apt to have Diabetes thait other people. 
In these cases,* it requires a good deal of judgment- to make the 
diagnosis, Tho only expression of the gouty disposition is th# 
development of one or more of these.complicating conditions 
which may cecur in other people and it is often difficult to • 
^ell whether these are due to Gout or not® 
452 n- - 
, ~ ureaWrit depends upon the diagnosis.. If the patient really 
ha\>j crOU^^ treat for Chronic Gout and we know that the prog«_ 
^°sis is the samy as for Chronic Gout* If the patient benot- 
$$uty?we do not have to trouble ourselves with the Gout? I 
M not tell you how to differemtiate between these two sets 
| cases but I can tell you that it is very difficult to dOo 
0X1 must learn .it'.for yourselves* 
453 - D I S E A 3 E S. Q F T H « B LU 0 D . - 
> .... "■ 
- T-"SIMPLE ANAEMIA.'- 
- 2 - PERNimOVS ANAEMIA. ~~ 
- 3-ADDISON'S DISEASE. - 
- 4- PSEUDO-LEUKEMIA. - 
- 5 - LEUKEMIA. - ..' - ' 
All these diseases resemble one another in as much a^ln all 
of the the lesion is in the bloody In none^do we know why 
these changes in the blood are developed but we d-o know that^ 
in each one of "these diseases^ there ai*e well-marked'changes in 
the composition of the blood and these changes in the blood 
Seem to institute the lesions© 
It toH be useless to go into the n^p^sition and physiological 
and cheMwl properties of the but are certain 
points regarding its tion' that you must remember Thei*e 
should re fipje mlII7^ in every GUo;milo of blood* 
The war should te in the proportion of one to / 
W'©e hundred fifty u . the red eof-pv.wle'So These proportion^ 
yw remember fer^in these disease-s^you have tp< count the 
fe^puftele^© The blood plaques are not u&^y as easily seen 
a.s the ^oi^oole^for they are rery-^mall and t* 
454 They are present in the proportion of one t@ twenty red corpus* 
Mes. Although, in these diseases, there^may be 'changes in the 
Tlasma3We do not what they are# In these diseases, t&e whole 
Quantity of blood may be either too great or too little# 
- SIMPLE ANAEMIA, OR CHLOROSIS., - 
is,,perhaps, the best of these blood di s e as~eS^^WherFVe say 
^t a, person has simple anaemia,we do not mean that he has * 
^^viously suffered from some other disease aq4> thus,become* 
mean that,without any other disease,he develops 
®ertain changes in the bloods we mean thaf anaemia is the primary 
^sease# 7 
lesion is very simple. There ie a diminution in the number 
$ red blood corpuscles and in the quantity of the coloring 
Seme of the patients,in addition* will have too much 
°°d in the vascular system? others, too little;but these changes 
ure Of le^ consequence. The first two lesions are the important 
The cases vary as to which will be the mere marked feature, 
ie diminution of the red blood corpuscles or the diminution 
the quantity of hemo giobine: in some cases, the diminution in 
th will be'very marked. The cases also vary as to how far 
Ie lesion will be developed. In some cases, there will be 
455 fur million red corpuscles and seventy-five per cent of hemo- 
globine: these cases are mild. In other cases there will be 
only three ox* two million red.corpuscles and fifty? forty, or 
thirty per cent of the normal quantity of hemo glob Ine-these eases 
are severe®. You can measure the severity of the disease and make 
the prognosis bybexamining the .blood® 
In a very modex^ate number of the patients, we find, a congenital 
tallness of the aoria and other'arteries? it was formerly thought 
that this was'"mb re common than it is® 
- ETIOLOGY® - 
The disease is particularly common, in women and has a marked 
preference for people between tie ages of fourteen and twenty* 
four years® It is comparatively rare in men® It has been observed *n 
a great many countries® It is equally common in country and city 
life,, among th$ rich and the jwot, and among people who have 
been living under causes that deterioate^he health and those 
who have been living under the best conditions® It must be rememr 
be red that we are speaking of the px'imai'y anaemia? the cause is 
unknown* \ 
- SYMPTOMS. - 
As a rule, the disea.se is slow in its development bu t it maybe 
rapid* The mucous membranes become white and pule but, occasion* 
ally, this will not be particularly well marked although the 
patient suffer from pretty bad anaemia* 
456 ^t the color of the skin and mucous membranes is a good guide* 
gradually lose muscular strength,are less and le^s able to 
^t about,and are unnaturally fatigued* In some ease,hysterical 
Symptoms will be developed* All the patients develop dyspnoea 
^'■i Palpitation of the heart upon exertion. These are perhaps 
th© -two most common symptoms. The heart regularly beats too 
^pidly; sometimes, feebly: sometimes, tumultuously: but, always, too 
^apidly* In many cases but not in all,we get a systolls murmur*, 
murmur may be so loud that it will be heard over the whole 
ieart: in other Cases, it will be heard in the second left inter-- 
^stal space; in other eases, over the up ext You will see in 
^*t books that fthls murmur is always present; this is simply 
^nt so* In most cases,aS the patient gets better, the murmur will 
^sappear but,in others, it will not* You must remember that you 
get this murmur in persons who are not anaemia at all* 
considerable number of the cases will develop an hypertrophy 
1 the left ventricle whish will regularly diminish as the anaemia 
^sappeays. 
°^e of the patients are troubled with cough: this seems to He 
^^terieal or nervous* \ 
have disturbances of the stomach. Some only have pain: 
°thers,loss of appetite: others,,oppression af ter eatingtand oth#r% 
457 nausea and vomiting* A moderate number will vomit binode- This 
vomiting of blood resembles that of ulcer of the stomach or 
cirrhosis* The blood is vomits in considerable quantities and 
is fresh* This vomiting of blood is not very frequent in the 
same patient but it is a very common symptom® 
In many easesr there is eons tlpation? in fac? t? most women are 
constipated* This constipation is found so often that many 
physicians have considered it as the eause^of the disease and 
have called the disease faecal anaemia. This can haMly be the 
cause,for many of the patients are not eonstipatedo The urine 
is usually somewhat turbid, e sue daily with the v» ho abates 
It is often increased in quantity, not infrequently alkaline^ 
and occasionally it will contain albumen but in very ^mall quan« 
■WWM«WM»WI». 
ti ty« 
Menstruation is. generally disturbed* Sometimes this symptom will 
precede the anaemia^ •sometimes, fellow it? In some eases, the 
menstrual flow will be regular but scanty and light colored® 
In others,it will be 11^t colored but will only occur at long 
intervals* In Cithers^ it will be profuse but light colored? ibis - 
is rare* You muft not think that these menstrual disturbances a3^ 
458 always due to anaemia. Tn many cases, the?© is dtopsy, general 1 
the feet and legs»les8 frequently,of the thighs and face, 
At some time of the disease.,many of the patients will have a fever* 
Th© fever belangs&o to the more advanced oases. The temperature 
Xs not very high,100-101, There is usually a daily rise and 
^11. - . 
As we $ee the^e patients, we find a good deal of difference as 
which symptom will predominate and this causes us io make 
Errors in the diagnosis. • • 
111 the most straight forward and plain cases? the first symptom 
x$ the change in color of the skin and mucous membranes, feen? 
QfW palpitation of the heart and dyspnoea on exertion. The 
^tients gradually lose strength but do not lose flesh and?if 
^1 these symptoms go on the diagnosis is oasy« 
^i>many will simply develop hysteria,or the symptoms of gastric 
^y^pepsia,or sudden vomiting of blood,nr dropsy with a little 
^i^umen in the urine while the anaemia will not be marked? 
these oases are very difficult to diagnose and the first 
thing that you should think of in these young women is whether 
^ey rj^y have anaemia. 
459 - TREATMENT. - 
The is simple and straight-forward. It is almost 
exactly trie same in all the patients. You do not have to pay 
muel attention to the other symptoms;all you have to do is to 
t/$at tie anaemia. Iron is the drug. You must give it in suf* 
Relent quantities. The patients only differ in regard to how 
well they bear it. Many 'Sear it well or it will only produce 
constipation us a bad result. In other eases,it is not as well 
borne and, then, you have to begin with smll deses and try first 
one and then another preparation of iron until you find one that 
the patient can take. 
The best preparation of iron is Blaud's pilltnext, the iodide: 
and, then,come a great number. But, the sulphate in the form of 
Hlaud's pill is the most certain. In most eases, the giving of 
the iron will be all you h^ve to do. In other eases, the consti* 
pation will enter into the treatment,fon,as long as the patient 
remain cons tips ted, they wiftl not improve as rapidly as they 
otherwise would. So,give laxatives. In all oases, the iron 
should be given in oonsideral|e quantities. Begin with twelve 
grains of the sulphate a day. 
460 nm it up to twelve grains three tdmes a day,as the patient 
^y require it* In a good many eases-, there is an advantage in 
Saving Inhalations of oxygen for ten minutes three or four times 
day. These inhalations are especially useful in those patients 
^P do not take the iron well but,when it can be readily done, 
prefer to give inhalations of oxygen to all* 
kere is a curious feature about the patients who suffer from 
of toaemiain which they differ f^om those who suffer i 
any of the other forms of anaemia* The anaemia of Brights | 
isease for example can often be relieved by proper food and j 
^°°d air without the use of iron and if you do give iron in the I 
of Bright* s disease,, the results are not nearly as satis^ | 
^^torya'S in primary anaemia. Furthermore, in seme of the an^emioh 
follow,al though they have the same blood lesion as simple | 
is as a rule of no use at all and makes no change 
^•tever in the composition of the bloods This is very qusem, 
'^2- 1$ a dix^eot specific for simple anaemia and we cannot ex* 
its good' action by assuming that it 3imply produces more 
Further,in simple anaemia,iron is the only drug and 
. only thing that will do any good* You may send these patients 
as much as you please and,until you giv<5 iron, the^ will 
i®^ove. 
461 -PERNICIOUS ANAEMIA,- 
Thiy diyea.se is also called idiopathic anaemia,or essential 
anixeMia^ The changes in the blood are just the as in Simple 
Anaemia- The only different is that they are developed to a 
greater degree* Yet,it is important to remember that you may 
very well see a ease of Pernicious Anaemia in its early stages 
and the changes will then be no more marked than in Simple 
Anaemia but, later, the lesion will reach a much higher degree 
of development* 
As accessory lesions,we may have a fatty degeneration of the 
heart and inner coat of the aorta and extravasations of blood 
in different parts of the body* 'Generally speaking the patients 
will not lose flesh or, at any rate,not until late in the diseas® 
but, occasional!y^ the emaciation is a marked feature. 
Although Pernicious Anaemia is a disease of which a good many 
examples have been seen,we are still very much in the dark in 
regard to it, It is as ecmmon in men as in women. Age dees not 
have the same predisposing effect as it does in Simple Anaemia* 
Pernicious Anaemia is more common in young people but it is by 
no means rare after -thirty and I have seen i t in a'man of sixty* 
As to the abuses, there are different opinions and this is due 
462 0 the 'fac'i -that there are two different iaeas in regard to 
nature of' the disease* Many believe that it is simply a bad . 
and can be caused by any of the causes of anaemia. 
.1 '''his theory be txw, the disease may follow Simple Anaemia, 
anaemia of'Bright3 s disease, the anaemia resulting from 
of blood,etc** Others believe that it is a aistinet disease 
itself am that,for. this reason,it is not likely to be aevel* 
from Simple Anaemia and that it is due io causes that we 
QA , .. . 
u°t understand* At the present true,X think that,perhaps,most 
believe it t® be a bad four of anaemia.. For myself, 
confess that I believe it io be a primary? distinot aiseMe* 
ShW^fOMS ■ - 
A$ . ' ' " •. 
. ^'Ule5the disease begins blowby and insidiously arid i^- 
^^btract9d for moa ths 5 time for years# Sometimes it 
^/ir^eveloped quite rapiely am will run its course in a few 
Qi 3?i5vO-I.Ql O o V.A.A »x^on bu u.:).fortunately, they 
k. although all do not knew of their-existence ♦ 
, uie Gourde is slow^i hoAM She symptoms* 
Simple Anaemia:changein the color of the skin and ' 
ec'hs .membranes«dyspnoea palpitation of Vie heartsand 
braduax lass of muscular strengthryet,in a gooa many oases , 
463 even early in the disease,these patients really do not look 
like the patients with Simple Anaemia,* They look sicker. 
The change in the color of 'the &k■ ux i s me taxes a little dif^ 
ferentx i1 assumes not a deMi white but a brownish white co lot* 
This color of the skin-,yw find all over the body* Further, 
the loss of muscular strength is apt to be more marked and 
there is apt io be a little, though not very marked,loss of men- 
tal capacity* There will be the $&me gastric dyspepsia and 
pain in the stomac;^vomlting and vomiting of blood,eonstipationr 
murmur,dropsy^and x^.pid hearij that we get with Simple Anaemia* 
In the same way, tho wi-H be a feve2? but 4he fever is much 
more constant and the tempo raturn is apt to be higher thaxfc 
in Simple Anaemia* The disposition io bleealng is much more 
marked than in mL .11 .h J Xi 0 mia* The pay.cn is wi ih Si:^le 
Anaemia do not often bleed except from the stomach or they 
md>y,but not ©j- ^en,cough, up a x-».tv{-e ua.G'OU'O' 
464 Patients with Pernicious Anaemia may have extravasations ' 
1 to the retina and haemorrhages from the gum?mouth^ 
^xnaeh, intestines, ana rec turn. The haemo rrhage a aiff er from 
• Wse of Simple Anaemia in that they are. apt to belong- ' 
-^Gatinueo and fxkequent* The patient will not lose hlaod in 
*^rge quantities a£ any one time but the haemorrhages villi. 
. ?r'h tinue aay after nay* . 
fii'st, the patients will not lose flesh ana many will not ; 
^Se flesh at all but others will emaciate after .a time and- 
:c emaciation may become extreme. ' . • 
• t may vei*y well happen that the patient may at the' same tier e 
cone other disease,as Bright^ disease or Gastritis anA 
diseases will ana their symptoms* ■ ; 
. r* rule>when the disease has once begun?it continues but? 
$ost cases® the course is an interrupted one* At times, the 
^i^nt will be better?at other times,worse* The impi^vei^enV 
/kou^h temporary?may be aeciaea and the patient may go aboi u t 
* ^°ht and attena to his work. If* the course of the disease ' • 
• * short and rapid? the symptoms generally continue up to, deaths z 
&w,you will notice that my aescription of Pernicious Anaemia^ 
। a very like the aesci'iptic*n of Simple Anaemia ana you laay 
FBry well ask how you are to distinguish between the two*#*- . 
465 Yon want to make th©. dis Una tic-n, for Fernioious Anaemia is' 
almost always fatal* Really, the aifficulty in aistinguishiag 
between the two diseases is not great as you might suppose* 
Some times,in the early s tages, the differential diagnosis may 
be impossible* ye t, in many cases, I think you will fine that 
you can make the diagnosis easily and the only way in which 
you will be able to do this io by seeing the patients# 
* ■ PROGNOF IS o - 
The prognosis is bad® Cases of recovery have been reporter but 
I have no great belief in them* I believe that there was a 
mistake in the diagnosis and I d^ubt if eases of Pernicious 
Anaemia ever recover* 
- TREATMENT^- 
The treatment is unsatisfactory. You would think that iron 
would be of use but you will find that tills is not so . Iron 
makes absolutely no difference either in the condition of the 
patient or in the composition of the bloods The same thing is 
true of oxygen. Arsenic is the only drug that is of any servi«e* 
Give it in large doses nearly up to the point of poisoning# 
Then,keep the patient on it? then,discontinue its use? then,give 
it again# With arsenic,I think it is well to give iron and ' 
466 JhMalatiens ef Wygeru Considering what I have said about the 
Efficiency of iron and oxygen^ the foregoing siateaeni may 
bEhi contradictory and I asa not sure that it is no U Yet,you 
c^n no* help having the lingering hepe that if you give arsenie 
^th the iron and oxygen, then, the iron ana oxygen saay de some 
Booa, 
- ADDISON'S f bS E A S E . - 
i£ another ft rm of essential anaemia, It was fir^t ue* 
I j r% >■*■*-■ <• ■-ww- ■ 
v- $ oy Dr, Addison as a disease characterized by anaemia, 
^SUty, debility, a feeble heart,an irritable peculiar 
a* of +£e skin,and disease of the supra*renal capsules* 
was better s tudiea,® ther authors classed in ths same cat^ 
tients who suffered freea disease of the supra*renal 
^^hlet .and anaemia but who had no tint of the skin? and others* 
^Uents who suffered from the anaemia and pigmentation of the 
lri but who haa no disease of the supra*renal capsules* 
467 These three Glasses are now grouped together under the name 
g? Adelson's Disease. The moot certain eases are those that 
correspond to Dr. Addison's original definition. 
When the supra-renal capsules are involved,they may he the seat 
of a chronic tubero^^ with the proouc tion of 
tubercular tie sue, containing, the tubercle bacillus,and tending 
to cheesy degeneration and the formation of connect^ tissue. 
Sojwe fine them enlarged and adherent to the surrounaing parts. 
This is the most constant change, but cases of Addison's disease 
have also been observed in which the capsules were only atrophi®^ 
Geiers,in which they were absent altogether:ana others,in which 
wey were perfectly normal* 
'Rie coloration of the skin is cue to a aeposit of pigment in 
ȣ& deeper layers of the skin ana in the epithelial cells of 
we cutis* 
Jn some cases,the spleen will be considerably enlarged 
in some cases,theye will be changes in the abdominal sympathetic 
nfrves,an increase in the connective tissue ana a regeneration 
of the nerve fibres. 
The changes in the blood are the same a$ those in Pernicious 
Anaemia, Some have stated that they have seen cases of Aadison'^ 
Disease without changes in the blooa. Thit^is aifficult to 
believe. Certainly,the larger number of the patients ao aevelop 
anaemia. - 
468 - ETIOLOGY.- 
rhe disease has been observed to occur between the ages eleven 
and fif ty^eight years but it is more common in adults than, in 
^ildren. I t is rather more common in males than in females* 
is more common in the laboring classes -than in the upper 
sasses. In a certain number of the cases,you will get an 
^rediury history. It is hot a common disease^ Few physicians 
*ee more than one or two cases. 
x - SYMPTOMS. - 
11 the best marked cases, the' first symptom is a less of muscular 
strength ^Ixd the patient becomes listless ana irritable and 
^^posed to boaily or mental exertion* This general languor, 
J thou t, a t firn t, any loss of flesh er less 0f nu tri tion,1s very 
Uris ti®. As the disease goes on, this symp tom becames 
°x'e and more markea until the patient is with difficulty per» 
^^aeo. to move about ana he becomes very unwilling to exert 
mind* The irritability almost approaches to Insanity and, 
J* tais account, the patient'cannot be trusted to go about alena. 
e patient suffers dyspnoea and palpitation of the heart 
The heart is continually more rapid and feeble. 
oft..cn 4&e syttolie anaemia murmurs hat the irritability 
^d 
-'eob^oness of the heart are more marked than in the pre^evs 
of feebleness of the heart May cause syncape* 
469 Then, the functions of the stomach become disturbed. The patients 
have oppression after eating, pain, loss of appe ti te, nausea, and 
vomi ting* 
The patients often develop pains in other parts of the body 
and feelings of heat ana cold. The patients often become very 
kMxiaus abott themselves* 
While all these symptoms are going on, the patient's weight and 
nutrition are not diminished but the patient becomes anaemic, 
his skin and mucous membranes become white ano pale* 
Then,is anded the characteristic pigmentation of the skin* This 
pigmentation is especially marked in those parts of the body 
that are uncovered, as the face and hand & and, in laborers, 
the arms and chests The parts of the skin which normall contain 
pigment are the parts where the pigmentation of Addison's Disc*** 
is especially apt to be well developed* The cases vary as to 
the extent and intensity of the pigmentation* Many patients 
will only become cusky* others will be almost black and,in thes®* 
the mu-coW^ membranes may also become dark colored. The pig- 
mented parts of the body will appear darker than the really ar* 
by contrast with the pallor of the rest of the skin* 
Same go on slowly: others,mere rapidly. The disease nay last 
470 ** three years or ®nly a few maths* Most-of the patients 
one, two* or three years* As a rule, the patient exhibits 
^P^vement* During these periGcc of impxwemeni^ 
e patiepi will feel better and may even attend t* business 
a tiae^ the s;n^ to come on as before*'Seethe patl&Mr^ 
4 Yonatan Uy going up and down hill but they, gradually get 
and worse off* • * 
u' late? stages,all the symptr^ are very marked* The patient 
V develop alternations of stupor and delirlw or general een* 
heart will pe so feeble &at the patiexH will 
j* ^ly be able to get about* He will he able t© "^ke but little 
He will be eonflneu U bed^ The patient die either quietly 
\f02a ^akne&s er in an attack of c^nwltnUns- ©>r from-sudden 
^^TEHuFe. ' ■ 
* uanes vary a great deai as to the period of the disease 
' -h the pigmentation ©f the skin will be developed* In 
no t be -develox^d fer s^thg and yeartvin otheraj, 
the first symptarn-andVoss^een these extremes* there 
Th-^13, grades* ' , ' 
3$$^® a very few case?? in whiah the course of the disease • 
Tb.e^e patienW exhibit but the systems'-* 
471 will not be at all The patient'^-y not appear to be 
sick.and he isay'not see a phytiaian' for month's br years* Ther* 
will not be. the progressive change for the wor&e that we see !• 
the ordinary'oases* but$ after a time* the patient will get worst 
•very rapidly and^in a few'days*he will develop the extreme 
symptoms and will aie* ?hese cases are exceptional*- • 
■ - WWL -• 
There is no specific treatment h^rn for this disease*'^e • •/ 
best we can do is t© treat the trie.'dyspepsia* 
the -anaemlaj the feeble hv.; and -^0 Iqo streng-^ By thes* 
means.jwe can often p^fient much ^ore comfdrtable and» 
even so much mre that he is . ; 
going to . ge-t we 11 ;bui? ar. a ruleS ' th^ d ; **■ 'h-enU die,. ' 
472 - .1 E U K E M I A * - . . 
«is disease Ie also known Leupo^the^ 8 a** 
^inution &f red corpuscles and h&emoglobfne in thi preceding 
Se^tes bvt^ln addition, we find that the whi te'. corpuscles are 
increased-in number and considerably inereasea in 
we also find changes in other parts of the beayand 
th f*'n<* ^ete changes so cons to tly that they seem to' constitute 
te ri side lesion These additional lesions are the following. 
। ^-We find changes in the aednll& ^ie bone#?especially 
■ the sternum,ribs9and vertebras^ V/e find a gxwth of -cells 
the cells f^und in mTrfw &nd,wi^i thenars 
• ";'L® resembling the whits (wrpusoles and, some Unes, cells re« 
^^°ling the red corpuscles* Se, the narrow will leok more opaque 
normal marrow and will be of a reddish er yellow color/ •' 
lesien seems to'be very c*nsian-t» In a eertaih number of 
&ea^lt will be the only lesion in addition to the changes in 
bleed. ' ' • ■ . 
We will find the spleen enlarged* It will be hypertrophied* 
growth of all its normal constituents and the hypertrophy 
Always considerable* •■ • 
3^We find a simple enlargement of the lymphatic glands. 
473 ■Any of the lymphatic glands may' become enlarged, those of the 
neck,those in the chest ana abdomen, the inguinal glands,or all 
of t these maybe enlarged* In some oases, there will be a growth 
of lymphatic tissue in parte of the body where it is not nor* 
•nally founds thus,we may fina the liven, kianeyr-., lungu, stomach, 
intestine ft, and peritoneum infiltrated with l^^phatM tissue. 
~4~When a person oies of this disease,we of ten'find extrava* 
sations of blood in different parts of. the Loey. The dispositie® 
td bleeding is greater in Leukemia than in any*of the ether 
blood diseases. We may have extravasations blood in the mu co®' 
membranes, in the vise era, in the serous membranes, and in' the 
skint but, where we find the large st ex travasa ticna, is -behind the 
peritoneum covering the posterior abaominal and 'the extra*®* 
sations of blood in this, situation may be as large as these 
from a rupture of an aneurism of the abdominal aorta. 
- 5--In a considerable number of taMa'aser,, we fina* as an oc- 
casional lesion,an inflammation of the. retina with haemorrhages 
into the retinae This resembles the retiniUs of BrighVs Disea^ 
^6-- Not infrequently, there will be a fatty ae gene ration of th- 
heart The important lesions are' the changes'in the bloodkin 
' the bones,in .the lymphatic glanan9ana in the spleen. 
474 V - meLOGY, - . 
disease is tolerably o$mone. It has been observed to oocur 
Almost any a^e$fraa a weehs to sixty or seventy years® 
<?3S 'particularly oasKWB between toe ages of thirty and forty 
> It is more mwn in '^n in women* In some case a, . 
disease follows protracted aalarial °A£i£^ia' sane cases, 
|5 MH be .developed after a wcZ-. to &utoy of ©uns.titutlenaJ 
uphills, in soae caces,there will be a perfectly clear history 
? severe 'hyu^y over 'the spleen*this will be followed at firs* 
,snlargeincni of tb.o spleen 
Xj' . ' - SWTOMSe. - 
toas-will vary with the dQyeloimeni or n^n-aevelopraent 
oh&nga^ in thn bcneg^spyAll toe patients 
the c'L«.ngs■ 1 n the bleed® The wsst coisis^w oases are those 
fre^uencc^^^sie those with toe 
benee and spleen wi thw&t changes in the glands®, 
jj'** in f^-equsncy^wi.to ths bones and glanas involved 
without changes ih toe spleen® The least eowssn eases are 
that have no changes in el A^z toe spleen er the lyaphatio 
^VQ only toe chasxges. in too bipod and boneso 
^oaie eases5we. will fi^«t toe history of never© malarial 
475 of injury ©ver the;spleen* 
tf- a* Odi» o u'r- fi p L'-i-'■<>'•;•■• 6 ' ■: ■ •• JL p\ X i t> j fi jj kiO 2E fiLjMjl LixO 
.fire V syup ten wiirb-^ the enlargement of the spleen or glands 
<0margement 21 bo«th -t.. $hen*. c p a 'bn e n x m & s e ?« trdng tlx' and. ■ ' 
. they may bee flesh; /Then* the'patient becomes more aad mere 
feeble anafafter a Ume^esawiated and* finally*very wch emaciated 
.The skin and mucous 'membranes beco&e pale and. X0 5 XEfib bee 
'sfdre and deeidedo Fex>h<p'&5 patients thai ' 
i>ee _are? Uiesc with Leu'k^te&. a gys>4ual less ©f menial 
Ml treng th &n< the •■ p a ilea t be orae 1 • p e ey and 1 yr 1 tab leP. • The 
' re tint ti s des st Iwair® visi'©^® The heart bwe&et 
'eens'UnUy mre feeble?and irritable- 'The patient b.ee^eF 
less, a&d lees able -tb'hxeri hixself and we get the sy^tGlie 
■'AHrwrs^ ; • • .• 
ntikeFthe pM&ejkti Mth Addison^ Di©ea»e9 these patdeat® iaay 
Phave attacks >f 2ynpepeidisiurbane^s ef the funetl^n/^f the 
| ^wisaoktPala>l»o of appe ti isnausea? am vest Ung^ndstee tixae&*■ 
.di-arrhoea which saay be wy have ; • 
duodenitis ^n< jaundice m^y be ncs^al or inorea^ed 
■in quantity .the-■■quantity of urea say be inar-easeu^ Mens'tnft'*' 
a-tibn is scanty ant irz^^ular and lr/ apt w aeasea c 
476 the patients often beoesse dropeicalo The d[r$psy may be * 
t^al or 'it my'be general and'involve the serous cavities but 
y * not generally as extensive as UixSo 
some cases? there may from time to time be a fevex as in 
^niolGus Anaemia* The temperature will range between 101 and 
$$$♦ The fever will be very .irregular and ephemeral* 
time to time5especially in the later stages of the aiseaea, 
patient will have haemo rrhageau These are very qcwb* 
patient may bleea from Sienoe or mouth ©r gumsshe will 
up blood5vomit it^and pass it with the stools; and there* '* 
u be bleeding from the uterus or bladder and extravasations 
the skiru The largest haemorrhages are those that take plaoe ; 
Uie 'peritoneum an&? the first time you see one of these 
^*ae§hit will surprise you.-. The patient will have been having 
ordinary vdymp;toBS$when^he will suddenly become much prostratMU 
.; win go. U bad^will h^ve a rauid and feabel pulse.®and will 
^e&AnA 
'8&ejat the appearance of ^IX&p^eo Xf you look at the abdomen 
'6& after'the extravar^tio^jy^ w^.H obeerye no change but^ 
3^u continue to look at it?sne side €.f the abdomen will beee^* 
^na ef sgm© little ssnslstencyh The swelling will be* 
largev and larger until cne side of the abeomen will 
477 project eutwardsa This tumor will of ten be formed within a few •. 
hours* Of owm? thin retroperitoneal haemorrhage fs regularly* 
•fatal The ether haemorrhage® may "also he fatal* 
Jn; aidi ,<!©»>. we. have the phy&Leal signs of enlargement ef the 
Xpleen and lyn^hatid glands® The •-enlarged spleen is easily 
Biade out o are enlarged glands which may seen.and 
felt in to neck the chesty their presence s&y%e aetermin** 
>y per andj.in the abaementby yalyaUene • . । 
[There are often na^ymptco referable ta the bones bu.i the pati**. 
:*inay complain of &aln/in the bones. v 
;As a.rule^the duration of the' disease is very long,months and 
ye&pfu There are of ten Periods of temporary improvement arid' 
these maybe very-decided but the syap terns eome back.' and most 
■of the patients die exhale ted or from one of the large haem* 
^rrhage^® In ^one oases^ the course of the disease is much m©r® 
rap^/ than. 1$ ptherg and the patien'ts differ as to hov; $arly '. 
i^.,;ihe disease they develop the enlarged spleen and*1 enlarged 
1^>hatie glancss* In many cdee&^'the enlargement of tbe spleen 
'.will ••^&.-! before Che* oonetiiutlonal ©yapide® but the ^kangee 
-will >te prepent in biaed® Thio ip shotil* 
always eaam ae &e bl&Gti of a patient who presents' an inlarged 
478 In other cases, the enlargement of the lymphatic glands will 
precede the constitutional symptoms: in these cases,also,examine 
the bleed,for the changes in the blood will be present* In other 
eases, the cons titutional symptoms will precede the enlargement 
Of the spleen ana glands but the rule is the ether way* • 
- TBMMWT. - 
These patients are sometimes so much benefited by treatment 
that we should treat them and, f rem time te time, cases of cures 
are reported* -If the disease have been preceded by syphilis , 
or malaria^ treat these conditioner CC C O 
5*0r the direct treatment of the disease, the fellawing means 
have been recommended*.ir$n and oxygen and arsenic in considerable 
<juanti ties? pnospheroug in large aoses? the m ox electricity 
over the spleen, the application of heat and cold over the spleen, 
injection of the spleen,ar$&9 aven, the extirpation of the enlarged* ■ 
spleen ana enlarged glands* None of these means has proved 
Satisfactory but each one will do enough good to make you hope 
that,in another ca^e^yc^ will Mve better results* So,you are 
hardly justified in leaving these cases alone* 
479 - PSEUDO - L E U K E M I A . 
This disease is als® called Peeud&*Leucocythe]aia^y^^ 
Anaexiia>an< Heagkin5s Ddseaseo 
la tiiis disease?we nave changes m the Mocm which consist in. 
a disdnution in the number of v?d corpuscles and a divinuU^n 
in the quantity of hae^globine# There is a change in the ,^edulja 
of the bones and an enlargement of the spleen fend lymphatic 
glands. The changes in the blG^d xve as marked as in Pernicious 
Anaemia but there is no in -he mono er ot white oieed 
cells as there is in L^ke:idh« Hie cMnget! in the ^e4.ulla of 
the bones &xe the && in Levkeniao Ihe en^^'^o^n t of the 
.splaen is not as a$w.on nor -&e ^xked in Leuke^lju The en* 
lsw-r/' ' of the ly®ip^ia.ti0 glands and the of new ly^phati* 
tissue ar^ very ^rked featnr^k The oervlcal^axlllary^ingulnaif 
reti?o«per5 toneal^aese .. •- 3es a .? c w ■: .ym; glands my 
become very considerably enlarged^ They a&y fersa tumrs ©f 
considerable else and . v, a st e tra aguajihe bla*d 
vessels and nerves cf the neak^or >e larger bwnehi and blood 
vessels la the shea u In the &bdo»en3 they my ao®®>revs the 
blood vessels and displace the vlt&eriu We my also -have new 
gxwths in ^ny different ylac6fcs The ©f the 
. . * 
GescphaguSb|.ste3sach|!sx^all or large intestinea3liver.^oyoee^^kidney^* 
Ixn&uy ovari as^ond tea tides my $e the seat ^dul®F 
& r of oiffitsely A<i •■* ha tie 
480 Lymphatic nodules may be found in any part of the body where 
there is eernectiye tissue,? So far as the glands and new growths 
*re concerned? they give rise to mechanical symptoms* They 
form tumors that we can see in the neck or make out by palpatio* 
end percussion in the abdomen and They give symptoms 
due to pressure?laryngeal &r tracheal dyspnoea and venous con* 
feestion of the face and neck which :®ay give the patient a her* 
^ible appearance and his head may seta so heavy that he will 
'kave to support it with his hands* The patient may have cere* 
bral symptom© due to venoms congestion. When the glands are in 
th© thorax? they interfere with the breathing? heart? and elroula* 
^on o* blood* Xn the abdomen,-they de not as a rule give much 
•double for they have more room to grow* 
ehinges in 'she tion of the blood give symptoms sim* 
.liar to those of Pernicious Anaemia« The skin ana mucous mem- 
'®raaes become paid® The patient suffers frem dyspneea on ex- 
^tiex^a y^,id and irritable weakness^and a med* 
er&^e degree of drcPsyo There is the sasae disposition i© bleeding 
there is in the ©ther diseoo but it is not as Barked 
im Pernicleus Anaemia and Leukemia but the patient may bleed 
f?©2i the nose and me^th in the same way* They W&y devdlej; soie symptoms as in Addison1s 
irritability of temper and hysteria^ $,& tiests9 towards the 
•lose of the diseabe^will develop ttw cerebral sympto®#> 
deliriums ecsia^r ddnvulsionbo They say develop irregular 
ephemeral fever as ?e vicious An^esnia St Jj S CL^ 3 IKI ® 
W«R^\ant : I ) ■'; J •. S*> M 
S 7 Sh? U* «. V*-* < 
- 1-In these patients? the first &y&o tax will be anaemia *nd 
the growth of glandular tissue will nsi take place ^ntil sob© 
time later® 
- 2" la these eases^the ejilargesaent cf the glands will precede 
the anaemia® 
- 5-In these eases^w will first have an erlsrgeae^t of a 
nvsber of glands in different parts of the bedy» Thenfwill ae»® 
the 4&'33Xd Bo© 
As the disease g®es $n,s the eases differ as w the degree ®f 
<evelap»n $? |i iv? C- •> v t-«-3.■ >-c •aetas the ly^haii® 
timers will fonr. -Ute praninexii gyapim of aiseaso? this is 
pa^Slr&l&rly the e<Mre the are formed is, -the nech 
they will give bad fro^ prsr^vec £& other&tihe 
.devel^pm^t of glandMl&r tissue will be but moderate; the tw»®3?t 
will not give trouble by the syaphSM will,for 
nosi par t> belong to the anaemia® 
482 is to be remembered that a person may have tumors of lymphatic 
glands without suffering from this alsease. Without having 
"^eud,o •Leukemia,a person may have lymphatic glands of eonsiderabkei 
$ize in the neck ar .'thorax and these lymphatic tumors may either -i 
bening^or malignant* • ' ' ( 
disease goes on month after month and, as a rule?the patient 
gradually worse and worse although there may be intermissisn# 
the course of the disease* Some di® feeble and emaciate© from/ 
disease itself? others, from the mechanical pressure ofth© z 
p*^rs: others^fwm intereurrent .disease* , ' 
.. • " ~ • r *- • • - 
^e treatment is not satisfactory. The bert we 
e®d. the patient,especially with pate. Give iron in large 
^ses as possible* We also give arnenie anct iodine internally 
earry these drugs almost up to the point of poisoning; thenr 
discontinue their use$-then,go on with them again* 
n Regard to. the enlarged glands, the Question of surgical in*, 
^^ferenoe often comes up* The enlarged glands are frequently' 
Mirpated and I think this is good practice when it can be 
one without danger to the p&ti^tc This surgical treatment is 
^^ferable ■to •awter<4.rriiatluh or the use ©f electricity. 
483 - THE KIDNEYS.- 
•The minute anatomy of the kidneys,as given by Professor Delafield 
in no way differs from the minute anatomy as given by Quaia 
and Gray. For thic reason, it has not been thought necessary to 
• reproduce\it here® However, there are two paints to which special 
attention 'should be called. The first is that, under the micro- 
sc op a, the epithelial cells of the kidney seem to be filled 
with, granules. These granules are the points of intersection 
of a net-work of which they are composed. The second point is 
that we now believe that the watery constituents of the urine 
• are filtered through the Malphigian tufi^gwhile the solid con- 
stituents are removed by the epithelial cells of the convoluted 
tubes from the bleeds It is necessary u> know rhe different 
appearances presented by the epithelium of the kidneyjin order 
to recognise these cells when they appear in the urine* 
The function of the kidneys may he disturbed in a variety of 
ways. These are the following. 
- 1- Changes in the tissue of the kidney^especially in the 
glomeruli and convoluted tubes. 
•--2 - Changes in the bleed will disturb the function ef the 
kidneys* The blood may be altered in <ual^y or may circulate 
484 the 
;■<. » ' * ■• 
^^Mlncyi^ / 
-Die turbandes ®f othex* viscera, the lungB^hear^liver,^..- 
Wtataa*^^ ■. . ~ *™"\. . ' 
^■5-^Affe«tienS urinary trac t below the kidney, of the 
pelvis of the kidney® ureter,bladder,or urethra® 
■WMmb e >jnn, 
.. .. - .A • A 
; D ISEASES OF THE K I D N E T S . - . 
' -- ■■ / - 1 - MIGHT'S DISEASE. - ' v.\ 
^-8-SUPPURATIVE AND TUBERCULAR DISEASES.-' '\ 
' - 3-~flW GROWTHS. -' 
- 4-RENAL CALCULI.- 
-■«- PERINEPHRITIS, - 
485 - BRIGHT'S DISEASE.- 
Ie include unaer this name, three conaitions,Acute bright's 
Disease .Chroma bright's Disease,ana Chronic Congestion of the 
Aianey. All these have a certain number of symptoms in common 
and it will be convenient tc describe these symptoms before 
jroaeeding to the special aescription of each disease. 
-SYMPTOMS . - 
In all of these conaitions,we frequently have changes in the 
urine. 
- 1~ CHANGES IN THE URINE . - 
•-a-The Urine may be Diminished in Quantity or Suppressed. 
The diminution may last weeks ana months ana the suppression 
ray last a number of cays. This symptom may be c|ue to any acute 
cr chronic inflammation:any acute or chronic congestion:a severe 
injury of the ure thra; or occlusion of the ureters, not merely 
preventing the escape of urine but bringing the function of the 
kianeys to a a tana still. When the diminution in the quantity 
urine is not considerable,!t aoes no haint. When the urine 
is very scanty,one or two ounces in the twenty four hours or 
when it is suppressed.,if these changes do not continue too long, 
they will not no a great ceal of harm; they may last for hours 
or days or,even,one week or two weeks,without having any very 
marked ef feet:but, there is always a limit to this. This limit 
is reached sooner by some patients than by others but,when it 
is reached,we get symptoms. •- - 
486 The first symptom is. marked pros trull on* Then, the patient pusses- 
into the typhoid sta teethe tongue becomes dry and brown, the ' face 
emaciated and anxious,etc. With this,he may develop a mildy 
mu tiering delirium and stupor^ He becomes a little more feeble 
&M, finally, dies in extreme prostration ana exhaustion but.; • 
without any very active symptoms. -These are the regular results 
of the abolition of the functions of the kidneys. 
Diminution of the urine is not necessarily attended by increase 
in its .specific gravity* ' . '-y' 
^b-The Urine may be Increased in Quantity. The most marked 
examples of this are not connected with Bright's Disease but 
belong to Diabetes. In a certain number of the cases with Chronis 
• .wwwm#^ 
inflammation of the kidney,we do get a marked increase in the 
Quantity of urine. The patient will pass from ninety to one. .. 
hundred ounces of urine in the twenty four hours but,in Bright's 
Disease,this increase in the quantity of urine is regularly 
fctiandM by a fall in. its specific gravity. The very large, 
increaso in the quantity of urine that belongs to Diabetes does 
have it§ effect upon the patient's health. In Bright's Disease, 
-f the increase in the quantity of urine be not very great,'the. 
general health does not suffer-bu t,when the patient passes oyer 
487 one hunched ounces curing the twenty-four hours,it would seem 
as though part of the emaciation ana loss of nutrition were due 
tw cause, 
- o-Changes in the Specific Gravity, - When you test the urine 
Gf a patient whom you suspect of having BrighVs Disease, the 
specific gravity of the urine is the first thing you should 
noticed The specific gravity of the urine igives the relative 
proportion of its watery ana soliq constituents in a general way- 
In Acute Bright5 s Disease ana in Chronic Congestion of the kianeyt 
the changes in the specific gravity are not of a great asci of 
importance' there may be no change at alitor the specific gravity 
nay be a Mttle shove or a li ttle below the normal. 
In Chronic \right5 s cisease,the changes in the specific gravity 
are of the gratest consequence,for they are frequently present# 
The sp e o, if i c gfavT ty i s f r e qu e n tl y p e r s i s ten tl y 1 o we re a ■ and 
this shows that the kidneys are not exere ting uolid matters as 
they should and,if it continue,it means almost with certainty 
that there ax^ chronic inflammatory changes in the kianeys. For 
a long time, this change in the specific gravity may be the only 
symptom ana it is the first that you should look for, 
r-a-In a certain number of the patients with Bright's Disease^ 
488 Hlld binfid in the urine, This blood comes from the kidhey^* 
may fine BIgog in the urine in any of the forms of Acute 
^hht's Disease ana the blooa may be present in large ox* small 
^hantity. in some of these cases! the quantity of blooa will be 
increased by a complicating Acute Cystitis. 
Chronic Bright's Disease,we may also fine blooa in the ux*ine< 
^is regularly means that the chronic nephritic has unc-ergone tax 
Exacerbation and has, thus, temporarily become acute. As a sone* 
*hat unusual feature of Chronic bright's Disease,the bleeaing 
be profuse.' This has only been observe in advanced cases 
which the kianeys were atrophies In one patient, the renal 
hemorrhage has caused deaths this is rare. 
is often stated that you find blooa in the urine in Chronic 
section of the Kianey.- This is very rare, The chronic oon^es^tt 
•Purely or never goes on to iM escape of blaoa. 
We may fina Albumen in the Urine* There are a number of 
different kinds of albumen ?houno in the urine. Of these, there 
t3?e four that are of real imj;orfencev The first two are serum 
Albumen ana serum F-Jobulinc Both cf these belong to the serum 
the blood ant,when they are present in the urine, they sig» 
^Ify that the serum of the blooa escaped from the blooa 
v®*sel& in the kicney and has mingled with the urine. Thi-c^you 
489 Wst remember. rath of these are detected by first aeidulaUit^ 
the urine with acetic acid ano, then, he a ting it. If an opacity, 
is proaucea,ada a few c^rope of nitric acid ana,if the opaci ty- 
Goes not then disappear,it is the coagulated albumens,one or hn-W 
The two other albumens are present much less frequently^ and are 
of a different nature. They are peptone ana para-pep tone. They ,< 
are the products of gastric and pancreatic tionr They entetf 
the blood from the stomach ana intestine or.,less frequently! 
as a.result of some of the processes of tissue change or when 
a patient is getting rid of an effusion due to inflammation. 
When 'they are present in the blood in excess,we find them in 
the urine. They are not detectecLby the same tests as the serum 
albumens. Neither of them is precipitated by heat norr,when the 
urine is heatea,by nitric acid. They are precipitated by meta-, 
phosphoric acid,acidulated brine,picric acia,potasso-mercuric 
chloride,and cold nitric acid) but, in all cases,the eoagulam 
will.disappear if you heat the urine. The cola nitric acid test 
is the simplest test. These albumens are not bnearly as common 
the serum albumens nor are they present in the urine in anything, 
like as great quantity. So, the albumen in the urine may have 
one of two sources^first, the blood ana this does not mean that ' 
the kianeys are excreting anything they should no U secondly, 
some fault in the patient? s tlon,.aot in the kidneys. 
490 order that. the^erum of the blood should escape from the 
^Icod vessels of the- kidneys anc^appear in the urine? we must 
^ve one or more of the same causes that make the serum of the 
^lood escape from the vessels in other parts of the bocy® If 
Patient have pleurisy with effusion?the serum will escape 
*r°m the blooa vessels of the pleura ana will accumulate in 
pleural cavity: or? if he have chronic peri ton! its? in the 
^^itoneal cavi ty: ana, in Bright5 s Disease, the appearance of 
serum in the urine may be cue to the same causes* The es* 
Qape of serum from the blooo vessels regularly takes place unacr 
Olie of three conditions:in connec ticn with inflammation: in con* 
Action with obstruction io the venous circulation? or in con* 
tion wi th anaemia® 
either acute or chronic inflammation of a part may cause the 
to escape from the vessels but we fine the escape of serum 
^st marked in sub-acute and chronic inflammaticns?as,for ex* 
^Ple? sub*aou te pleurisy ana chronic perl ton! sis® Yet,as a 
^tter of fact?we ao not knew exactly why the serum of the blood 
^ould escape fx;om the vessels in inflammation* The only way 
account for it is to suppose- that there is some change in 
walls of rhe vessels and that this change re limits the serun 
w pass through the walls® This change is not structural in 
491 character or,at least, we can not make it out* You may look at 
the blooa vessels of an inflamea pleura as much as you please • 
ano you will be able to see no change* 
When dropsy is due to venous congestion,we can unaerstana it 
better* Take Cirrhosis wiM obliteration of the portal vessela^fQ? 
example:here, the dropsy is cue to obstruction* 
In anaemia,there is no mechanical cause ana we have to fall 
back upon the same explanation as in inflammation. The changes 
in the composition of the blood are not sufficient to account 
for iV 
Now,when serum albumen and sexum globulin appear in the urine* 
it means exactly the same tiling: that the kianeys are inflamed 
or are the seat of a chronic congestion or that there is some 
change in the character of the patiently blood. This point is . 
of the greatest importance ana it it not brought out in the 
text books at all* It is the point that I wish you to remember. 
So,it is perfectly Possible for a patient to have albumen in 
the urine without having inflammation of the kidneys* the other 
causes being congestion, anaemia,and the character of the patient'• 
digestion. 
When a person has albumen in the urine without having inflaamtio* 
492 cf the kianey,he is said to have Physiological AlbumenuriaA, 
name, the propriety of which is ques tionablec As more and more 
these cases of Physiological Albumenuria^ave been observed, 
they have been divided into several different clashes which aTe 
the following* 
The first class is callee Paroxysmal, or Cyclic Albumenuria, 
ihe albumen is not present in the urine all th& line but it is 
pi'esent at a certain regular time every nay. This form is ©spec®* 
tally common in young Eiales and, al though they not have Bright's 
disease, they are not in'gooa health* They are generally anAemlc 
fend are troubled with neuralgic pains ana headaches. They are 
kadly nourished and suffer from bodily and mental languor. They 
°ften have disturbances of the stomach,liver,and intestines. 4 
The albumen is regularly absent during the whole or greater 
hart of the night: bu t, generally, in the morning, some times,at 
a regular hour in the morning ana a regular hour in the evening, 
the albumen will appear and, then,graaually,disappear* Now, 
Although the albumen is regularly present at these fixea hours, 
its quantity can be increased by various means. In some cases-, 
it can be increased by making the patient stand up a gooa aeal.' 
in other cases, the quantity will be increased if the patient'be 
493 £ude tc exert mine or body to an unusual decree. In o ther-cases,, 
the quantity of albumen will be increased by giving the patient 
an extra amount of food. If you keep these patients in bea all 
day, there will be no albumen in the urine. In these ease's^ the 
quantity of albumen ip fairly well marked but,as a rufe^ there 
are no casts. As a rule, if you improve the general heal th'by 
exerciseTJie t,iron, e tc. , ano get ria of the anaemia, the distur- 
bances of digestion,ana nervous symptoms,you will get ria of 
the albumen which will not return as long as the patient Is * 
in good health.-. This form is not at all 'uncommon* 
The second form is called 'Dietetic Albumenuria. It occurs at 
all ages. This form is also common. The quantity of albumen is 
quite small, of ten, a mere trace. 11 is not accompanied, by- casts. 
This form of albumenuria may be brought on in different ways • 
in different patients. Some patients will not have the'albumen 
in the urine unless they eat some particular articles of food, 
especially cheese,pas try,or eggs. In other cases,any full meal 
will cause the appearance of the albumen,especially if the meal 
be accompanied 'by indigestion. 
494 In other cates, the 'albumen will appear if the patient take a 
full meal ano. then take exercise soon after etUng. 
in these cases, the presence of albumen is or no consequence at 
all• except that it signifies edges tive c.isturbances, 
in the third class of cases, the albumen appears after severe 
and protracted muscular exertion* This form'is especially eom^ 
mon in young ana miaale-agea aaul ts* They are often strong and 
mbutt and have no errors c-f digestion* During most of the time^ 
there, is no albumen in the urine. This form is often found in- 
soldiers, zwinera? walksThe quantity of the ' 
albumen is distinctly appreciable and we may get castia' in these 
oases?, the presence of the albumen does seem to depend upon dis* 
turbanoes of the circulation in the kidneys and thi$ form is 
too re suspicious than the others. If theue patients keep on having 
Albumen in the v.rina9you can not help feeling suspicious ana 
they bear watchings 
The fourth form is the least common, Xi in'called s Simpler, Per- 
sis tent Albumenuria1, It is generally found in young and mid~ 
dle«aged adults* The albwen^is present nearly all the time. 
There is not much albumen c.nd there are no cas tS^ The quantity 
uf the albumen amy be increasea by the ingestion oW food or 
495 by exercise, These cases are the most suspicious of all, Some, 
yc u will follow for a long time ana the health will continue 
gooc bu t, ye t,when a patient goes on in this way, you always 
suspect a chronic nephritis after a time. ' 
In Acute Brigat's Disease.,we regularly_find albumen in the urine* 
In Chronic Bright's Disease.,we find it in -some patients but not 
in others. In Chronic Bright's Disease,we fina it in the lar^ 
?est quantities in those cases in which the blooa vessels take 
an active share in the inflammatory process; ana, in least quan* 
tity, in those cases in which the blooa vessels go not take an 
active share. So,a patient may have Chronic Bright's Disease 
for a long time without having albumen in the urine. In Chronic 
Congestion of the kidney, the albumen may be present in small 
quantity ana will be present in some eases and not in others, 
- f-We may fine Casts in the Urine# Casts consist of coagu~ 
able matter which has remainea for a longer or shorter time in 
the tubules of the kiancy and has then been washed- away. They 
are composed of a coaguable matter resembling coagulated albumen 
and derived from the plasma of the blood! We fina them in the 
kianevs most constantly in the straight tubes of\ the uvramids 
496 uic cortex which are lined with transparent epithelium* Leos 
frequently} we fine them in the convoluted tubes. The oasts vary 
in appearance and in size accamin^ to the size of the tube* . 
Sore of the casts are caller., hyaline casts* These are little 
trtnsiarent cylinders composes of an almost homoaeneous substance* 
They may be small or lar^e. 
Other easts are callee waxy casts* These seem to be hyaline 
ts which have remained in the tubes for a longer timm anuV_ 
have acquire-; a §re&ter c(ensl^y. They are no evidence of waxy 
^generation of the kic^neyS. 
• then casts are callee epithelial casts. These are simply hyaline 
WWJW5WB9 -Wife' 
°usts in which are entangle ah the epi theliai cells of the kiu- 
hey. 
Othex»s ai'e callee pus casts. These are hyaline casts that have 
en tana lea white bl* . cells that nave emigrated from the blOGG 
^tsels of the tufts, 
•thers are callee nue leaded easts. These are hyaline oasts in 
^hich are embedded the nuclei of the ci-ithelial cells of the 
kianey. 
Others are callee FAi'anular easts. These are hyaline casts con* 
J a 1 * *w»M«a*hra»w. t 
^ininp granular matter derive^ from Uie disinteBratea cells 
497 the kidney* 
Wther oasts ai4© called fatty casts* They we hyaline 
taining globules of /at*'" * . 
• ther casts are called blood casts* These are hyaline caste 
containing red blood, cells* / * } 
We may have little casth composed of red blood cells oomp^edsed ' 
together. * 
; Generally speaking* the number of casW in the urine is an in- 
[di.cation of the number os? casts that have been formed in the 
kidney and of the number' that are now present in the kidney^bui. 
this rule has its exceptions and they are important. There may*. b 
be a great many casts in the kidney and but few in the urine. • • 
or there may be many easts in the urine and, after death, you nay./ 
find but few in the kidney* in the latter case,, the production, 
of casts was rapid but 'they were foxy eq in the tubes of the- 
pyramids and were quickly washed stay* Soothe number of casts 
in the urine is not always an, indication of the acuteness 'of 
the inflammation. Wo .also find in the & quantity of 
coaguable matter that does not -take the shape of casts* It 
pears in the shape of globules, granules, and irregular masses* t 
We sometimes find a pant of this in the urines till re taining'• - 
its irregular shape: but,more frequently')11 iTmainB in th^- 
kidney or comes away disintegrated and appears in the urine 
ag. amorphous? granular matter0 
498 *-Gth the easts ano[ the matter indiQ&te the- ^ame 
thin^nnwels^ that the kianoys arc the SE&trOf an inflt.inn»-tGry 
I^eeas in which b« ^o^ve chuwt Mi< 
ttiQt the ptemO* bi Wit hat inW the tubules. 
Sgj the a&e£s'lTnG^ the kieneys are inflamed or are the. 
of a there is tome change in 
»-*«**«****- » • 
the biros vessels. 
*e fine the ofrSt^present in rhe J^^egt numbers in the well* 
Marked inf lamma tions5partioularlv of the events type but we 
fino therj in tnLilex' ^u^ntltiee in Chronio Congestion of 
the kidney i.ncLwe n\ny findLthem when the kioneyt ^re neither ■ 
influrjeiknor the ^CQf;Gf n ohr^tiv aom$esti$&V Thus, the o^use 
Gf the presence- of onsf^ ah<t enee of ^Lbuiren in the 
Urine is the Generally sjueh.kinu<when there Ik a ^reut 
^al c.f albumen i|^ the urine, there will be n^ny easts;but you 
^ay fine l j,reut ae-ul of aJbuuen ansL^t/ o^iiSjin'u may have few 
*^stt ana no albumen,or you may at one time find, oasts ana ,at 
^nc)the r time, fimcL albumen.. 
499 2 *"- DROPSY® -- 
Dropsy of the sub-cutanedus connective tissue and of the dif- 
ferent cavities of the body I'd a very common sympto-ixu It is- due) 
t» the escape of the serum of the blood® The regular causes of1 
dropsy arenas I have- sail., inflammation of the parts; a change . 
in the circulation of the blood,a change in the composition of, 
the blood,and a change in the blood vessels* Newlin bright's 
Disease.,all the patients do not develop dropsy* It is not a 
necessary symptoms it is some tiling added® The causes of the 
dropsy of Dx'ight's disease are the following. 
*-a-In some cases, there are well-marked changes in the cir- 
culation. These change's may be due to chronic inflammation of the 
walls of the blood vessels^ to acute inflammation of the walls' 
of the blood vessels,or to a spasmodic contraction of the small 
arteries. This results in too little blood in the arteries and 
too much blood in the veins and the serum escapes from the 
blood vessels. • ' ' 1 i 
- b - Many of the patients rapidly become anaemic. This change. ! 
in the composition of .the bleed is likely to be followed by the 
ordinary dropsy of anaemia,due to changes in the vzalls of the. 
blood vessels and changes in the composition of the blocnU; 
500 **-c - Some ' of the patients develop an 
This will be: followed by venous congestion and, dropsy. 
Not infrequently, these patients will also have an acute or*' ' / 
chronic Endocarditis and the changes in the valye^by^w&tag 
venous conges ti on, will aid in producing;^ dropsy/'/' ■ ' ' 
•-e - Many hold, that there is another e^use, of the dropsy of ?. 
Bright's Disease? nape ly, the diminished 'excretion of urine. This 
seems plausible bat you at anee notice .that th® patients'who 
. develop the most dropsy are those that pass a fait amount' of , 
trine and those who <o nob develop -the'trapsy are frequently 
those in which .the urine is diminished! 'So^if this >e a aaise ' 
;-at all,it can'only apply to a very few cases, • /t ' '• * 
■ - 3-DISTURBANCE tF* THE STOMACH 'FUNCTIONS, rr/ ? 
'The patients who have Acute Bright's disease,will vomit1 at .the' 
beginning of the disease,apparently a$-"a patient vomits witJi , 
; any acute inflammation* V ' t ' 
Tn chronic Bright's Disease,a persif?teh't form of vomiting may 
•be developed which continues for weeks monthsr Ih some of the£e. 
: OaseSf, i t has been found that there has.b^^n a dropsy/of the h 
:• stomach, u t \ '* *. 
Other cases vdir.develop an ordinary C^rpAle Gastritis 'frith' , 
_itsi oxxiinary symptoms* s ,. • . • • > 
501 p^ 'they pass into the so-called uremic con- 
hfiti.on?will vomit and^when they come out of it, the vomiting 
'•xlir cease. v> 
few of toe very old and very bad cases., there seems ta be 
an'accumulation of urea in the bloods The urea will escape 
^Ito the stomach' and set up a vexy bad and persis tent, form of 
'Vomiting® In these oases, we may find the',urea- in the vomit or 
the jirea may decompose and, then? the vcmii will smell strongly 
hq£' ammonia... \ ' . . 
» le ■-'4^blSTORlMN(^ OF TH® FUNCTION dF THE INTESTINES.- 
?The patients may have' diarrhoea which seems to be drop ^ieal 
and is due to an escape of serum into the intestine* This sort 
,'of diarrhoea is sometimes a relief to, the patient? in other cases, 
it will continue and' will be uncontrollable* 
In o ther cases, there will ^e a ehzunic diarrhoea due to a low 
grade of catarrhal colitis; There will be. loose faecal passages 
containing pus cells and mucous but,at the autopsy,you will 
' find but little colitis. In a few of the-very had ana qla eases, 
<,we' will have a sort ■of uremic diarrhoea* -The urea will escape 
..'into the' intestine .and will .either be found as such in the stools 
.'pr it will decompose and the stolls will have an ammoniacal 
♦ • ' "' > " 
I / ' - 5~LUNG SYMPTOMS.-* 
Tj^. first of these is dyspnoea* Thi$ is X^'t always of toe- same 
' character. It may be due. to dropsy of toe'. lungs> The serum will 
accumulate in the air spaces and vesicles a you will get sub- 
crepitant and caarse, -rales., 
502 "'rt z^.y 'be vf fluid -in -the ■ 
pleural'cavi ty ane^ the conferession; which this fluid.,, exerts- 
upon the lungs* Xn -these c^ses^we ge*t. U).e-oi'dinary j\ 
■fluid, • . .... v ; z-. ■ ' . \ < * 'h - A.'' " , "y 
*^6 - Dyspnoea' nay 'aocompany the uremid"Mttacks ahd-be/-^ to • 
'the' same causes the uremic at-tacks* • • 
' - - . ■ . ■ ' • _ t CHANGES. IN THE VISION*.- 
' these change we, And with Acute Bright*? with Chromic, 
Brigh'V s Disease,with Chronic Congs s..Udn of the. -Kidney*. Ay 
These changes x^y be of'several kinds*' \ .; • .'• . ' , ? 
a - 'Au s j -usher of the case ay the-loss of .vision; will..- . 
be ■ developed without any lesion in the eye slat all* The patifen-is^i 
■ besoms almost o-r ousyletely blind and there will be;.np-changes 1 
in the eyn.yiaible. to the op thalmQshup'a or W be fowd; after t 
deaths This1 ih p^rtlculaMy aomMn lyith Acute Bright^'s .Dis^set." 
' particularly with - the Acute Bright's Disease of Pregnancy*- 
Why.these patients become blind, we do no't knows we have not even 
a- plausible theory^ „ • • '■ 
'^■b- The patients may have a simple ,Neuro«Re.ti^i tis* This, will 
be at tended by .an infiltration of -the re, Una- and op tip nerve 
with sexumo. These ,s U^c tores will appear • swollen and. opaque* 
» ' ., >* •MiWamx'WsWK'-* ' ' • / 4 
' ' • / 
503 when'1 you' look at them with the ophthalmoscope. There will also 
Ke .particles of caagulable .matter in the\ vitreous. This form 
z we find in. Acute and .Chronic Bright's Disease and^if the patient 
. .get .be tter or welXythe zietlnitis generally gets better or well 
>180* \ 
.The patient may have a Nephritic Retinitis. There will be 
•rS€rum is -their#tina and optic nerve but* there will also be 
extravasations into the retina and degenera Ure changes in the 
^e.tina.- Tills -form is particularly common with Ch ren t a Bright^ 
pis^aee':but it may occur with Acute Bright^ Disease. It is 
peim&hent. ,. 
-jvi'th chronic Congestion of the Kidneye^we may have loss 
. <f .vision due to* haemorrhages into the eye with no retinitis 
■'at,all® In some ease^Tih^ &ight will be' p^HQanen tly damaged? 
• in.- Octher&9 the .sight will be but slightly damaged* this depends 
• upon the situation and extent of the haemorrhages^ 
'These are not particularly common* They are generally referred * 
. to -/the head am face but they may exist in other parts. They are 
severe and suaden and run along the course of a nex've. They 
504 last for minutes or for hours: then? they go away? and, then? 
they come on again*. They resemble the pains of Locomotor Ataxia. 
They are most common with Chronic Bright's Disease* 
- 8-CHANGES IN THE COMPOSITION OF THS BLOOD.- 
Most of the patients develop these changes sooner or later and 
they are of great, eonsequenc'e* 
The most common change ih the bl eon is the development of Anaemia* 
a diminution, in the number of red blood cells and. in the quan- 
. . . . * - •«.««. ^'^w.'.wnum' 
tity of haemogloomeAlmost all eases of Bright's Disease* 
Acute and Chronic?have same Anaemia and it is a most important 
symptom. In Acute Bright's Disease?it is surprising how quick- 
ly these changes in the composition of the blooa will take place* 
in a few days or?even?in a few hours* In Chronic Bright's Disease* 
they are developed somewhat more slowly^ 
In torn cases? there will be an increased quantity of urea in 
the blood. It was at one time supposed that all eases had it; 
but this is not so? in some cases? there is even a diminution 
in the quantity of urea? bu t? in • the wo rut cases* the increase 
in the quantity of urea in the biaoa will be very marked. 
In some .casea? there is apparently too much blcou in the blood 
vessels. This blood con tains •'too few rea blood cells ana too 
little haemoglobins. This is most marker in the cases of hy- 
droemic plethora that occur with the Bright's Disease of Pregnancy. 
505 Although thin name is not particularly f,ooa,it hat become 
'pretty well fixed. These uraemic symptoms occur in a certain 
number of the patients. All the patients ac not develop them. 
&any of the cases of Chronic bright5 s Disease never have them. 
Keeause a person has uraemic symptoms, he neea not necessarily 
have disease of the kidney but he almost always does have aiseas® 
Of the kianey. They are of two kinds,acute ano chronic. 
1- CHRONIC. - The chronic uraemic symptoms are developed 
slowly ana gradually ana,when once developed,continue for a 
considerable time. They are apt to belohf; to the baa cases ana 
they continue until death, They are the fol lowing There is 
a chants in the mental condition? the patient becomes dull and 
sluggish and indisposed to menial exertion* Ke becomes inais- 
posed to bodily exertion* Then, la Ur, he will aevelop stupor • 
'which-may gradually become more ana more profound until the 
Patient becomes comatose or may, from time to time, al ternate 
.with restlessness ana delirium. There is rapid loss of flesh 
and strength. The patient passes into the typhoid condition. 
The temperature is generally bel6w, the normal. In rare cases, 
the patient will develop heaaache,muscular twi tohinRS,and ^ener&* 
.(Krnvulsionstbut most of the patients pass into the typhoid 
.feta te•« 
- 9-UlvAMC SYMPTOMS.- 
506 Titles form is especially apt io be found in those oases in which 
there is a large amount of'urea in the bloca. It is particularly 
common with Chronic Bright* s 'Disease and obstruction of' the 
ureters by calculi. With A^ute Bright3 s disease^!t is not common 
but we sometimes find it?espectally in chose cases in which 
the suppression of urine lasts for a long time ana there is an 
accumulation of urea in the.bloode. This is the worst form of 
iremic symptoms, for, when they are once developer they generally 
mean that the patient will die without emerging from them. 
The Acute Form. ~ In the acute form, the symptoms are generally 
developed-suddenly, some times., very suddenly al though,in some 
eases, there may be a little premonition,, They only last a 
moderate time? then, they may disappear and the patient may or 
may not have 'them again. Previous to the attack., the patient 
may have been in ordinary health or he may have exhibited other 
symptoms of Bright's Disease, The symp-toms are the following 
and the patient may have one or more of themsheaaache?drowsiness 
or sleeplessness?delirium 'or stupor? involuntary contractions 
Of different muscles or general convulsions? or hemiplegia? or 
the patient may suddenly become coma tone? or he may develop a 
sudden blindness?or the dyspnoea or vomiting may be the prom- 
inent symptom. 
507 symptoms may only last a few hours or they may last several 
daysi They vary in'severity. We fine, these acute uraemic synt to^ 
with Acute Briefs Disease,in Chronic Bright's Disease,ana 
in Chronic Ganges tian of the Kicneysin Pulmonary Emphysema, 
'Without disease of the kidney,in pregnancy,without disease of 
the kianey,ana in Chronic Endarteritis,without disease of the 
Sidney. So-, they may occur without kidney disease. 
In most of the oases that develop these acute uraemic symptoms, 
we find,before and aurina the attack,increased, arterial tension 
■and venous congestions This increased arterial tension is the 
rule and it may fairly be returnee as one of the causes but we 
do not always find it ana this is important to remember. 
We also fine,as a rule, that,before anc curing the attack., the 
urine is diminished, in quantity,of specific gravity,and 
'contains lest than the normal amount of urea. let, there are 
also exceptions to this. Some yf these patients may pass a nor* 
mal quantity cf urea or,even toe much: the specific gravity may 
be normal ana the quantity of urea normal also» 
We also fine changes in the composition of the blood. In many • 
.^.asesyv^e will find the anaemic condition. In others,especially 
that occur with pregnancy,we find an increased quantity 
508 Qf blood. In some cases, there will be a marked increase in the 
quantity of urea in the blood: in o them, there will be no such 
increase of urea; and in still others, the quantity of urea in 
the blood may be cimini shea. This difference in the condition 
r»f the circulation and in the composition of the blood makes 
it very difficult to explain the cause of these acute uraemic 
attacks. The chronic uraemic attacks co seem to be due to a 
Change in thc composition of the blood cue to changes in the 
function of the kidneys. The acute uraemic attacks cannot all 
explained in the same way ana we have to aamit that they are 
sometimes cue to one cause, some times, to another. The greater 
number seem to be cue to the condition of high arterial tension 
which may be caused by the irritation of the arteries by the 
altered blooa3by inflammation of the walls of the arteries,or 
hy spasmodic contraction of the arteries. Vut,we must admit that 
^cme are the- airec.t result of the accumulation of urea ana other 
exerementitious matters in the blood, have still further to 
^Umit that,in pregnant women, the hycroemic plethora ana the 
strain of labor can cause these acute uraemic symptoms. 
509 All the patients with acute Bright's Disease ex not present the 
seme lesions ex* the same symptoms-. So, we have to aiviae Acute 
/light's Disease intn/thx*ee classes* These are?- 
X / - 1Z-ACUTE EXUDATIVE NEPHRITIS* - 
- 2-ACUTE PARENCHYMA TWUS NEPHRITIS.- 
- 3-ACUTE DIFFUSE NEPHRITIS.- 
ry Acute Exudative Nephritis,I mean an acute inflammation of 
the kicneys in which the blood vessels take the principal share 
in the morbid process* Consequently? we find congesiion ana escape 
of sexum?pus?and red blr.oa cells from the vessels. It is sud- 
denly developed?lasts but a short time?ana terminates either 
in death or in recovery. 
In Acute Parenchymatous Nephritis, the blood vessels go not take 
an active share in the inflammatory process, The epithelial 
cells of the kianey are principally concerned* As ~arule?it is 
secondary to other diseases* Generally speaking,it is not severe, 
it is only temporary?it is not associated with marked symptoms, 
ana it a act not kill* 
In Acute Diffuse Nephri tia? there is from the first a change 
in the stroma, a production of new connective tissue which oc- 
curs at'"tKe~commencement of the disease ana becomes more ana 
more marked* It may begin suddenly.or in a sub-acute manner. . 
Its most marked feature is that it lasts fol' a long time* mon ths 
and? some times? years* -* 
- A C U T E H R I G H T1 S DISEASE.- 
510 - ACUTE EXUDATIVE N E P H H-I M S 
Although in Acute Exudative Nephri tis, all the cases and all 
the kianey lesionu resemble each other,we have still further 
to subdivide the cases into classes,namely, the very mild 
Oases, the well marked cases, those in which the production of 
pus is effected to an unusual degree,and those -that last for 
&• long time* 
- PATHOLOGY,- 
If the kianey lotion be very mild ana the patient has aiea of 
some other disease,we may fine absolutely no changes in the 
kidney after death- Now, there is no tiling tn very surprising 
6r very unusual about this, There was simply mi la congestion 
^nd exudation ano. none of the inflammatory products remained 
in the kianey. 
In the well-marked cases, we do fine, changes in the kidneys 
^fter death. In the first place.,we fine changes in the gross 
appearance of .the kidneys* They will be too large: their surfaces 
will be perfectly smooth: the capsules will not be adherent: and 
the cortex will be thickened,white,or white mottled with red. 
The whole kianey may be too rec ana there may be extravasations 
blood in the Malpighian Dodies and in the stroma. If the 
Production of pus have been marked,we will find little white 
511 spots,especially in the cortex. These foci of pus may be so 
large as to lock like small accesses ana,if the pi'oauction of 
pus be unusual, there may be destruction of tissue ana the forma 
of abcesses. We find all the changes most marked in the cortex. 
Here,if we look at the tubes unoer the microscope,in many cases, 
we will find that they are alia tea; the epithelium lining them 
will be flattened against their walls; ana we often fina casts 
ana coaguVole matter in the tubes* In other warns, it seems as 
though the inflammatory products had been so rapidly effusea 
into the tubes that the epithelium had become flattened ana the 
tubules alia tea. We also find a greater r,r lesser quantity of 
red ana white blood cells in the tubules. In other cases, the 
changes in the epi thelium of the tubes will be different: the 
epithelial cells will swell,break down,ana aesquamma te, In these 
cases,we win also find the other changes,dilatation of the tubeso 
casts,etc.* As a rule,we find no changes in the tubes of the 
pyramids,excep t,perh^s,we may find cast matter in them. 
In some cases,we find that the sti'oma is normal: in other cases, 
it will be infiltrated with serum: in others, inf iltra ted with pus 
and extravasations of red blood cells: but, in no case,is there 
any growth of new connective tissue. 
512 of the oases,we will fina that the halpijhlwi boaiew 
but little changedrthere will be seise swelling of Ehe cap* 
cells ana some swelling of the cells of the walls of the 
vessels. In other cases, the capsule cells will be very 
swollen and. coagulates matter will be fauna in the cavity 
the capsule/ In other cases, the cells covering the tufts 
vessels will be increased in number ana size,the coils of 
^tselt will became mattea together, ana the tufts will look 
^■ke a solid mass, The capillaries of the tufts may be cistenawd 
VI th tea blood cells, or they may contain an increased number 
white blooa cells,or the endothelial cells covering them 
be swollen, . 
to the blood vessels of the kidney,we may,in the first place* 
pM an accumulation of blooa in the veins ana capillaries. 
the congestion have been excessive,we will find extravasation 
blood and of rec blooa cells. In a considerable number of 
cases,there will be a marked swelling of the muscular coat 
the small'arteries. This may make the arteries appear as 
^&ugh they are Spasmodically contractea. This swelling,however, 
not narrow the lumen cf the vessels. In some cases, the 
a^pillary veins of the cortex will be fillea to an unusual at* 
Afee with white blooa cells. 
513 At to those cases that last a long time:-Nicut of the oases 
of Acji±£<^xucative Nephritis only last a few cays or a few 
nonths^4Jccasi anally, the disease will continue ana the patient 
will thenhave a chronic nephritis which may last for years 
but this chronic nephritis will retain many of the characters 
of the acute. The blood vessels continue to take an active 
share in the inflammatory process ana the serum?,fibrin,ana pus 
are still exuaea but the stroma will, be pretty diffusely ana 
pretty symmetrically thickened. 
- ETIOLOGY.- x 
The disease it especially common in young children?in young 
persons,ana,even?in infants. In a certain number of cases,the 
disease will be idiopathic ana will occur aftex1 exposure to 
cole ox* from no cause that we can determine. You must remember 
that this disease is very common?especially in children between 
the ages c.f one ana ten years. 
It may be secondary to Scarlet Pevcr^heaslesjanc Diphtheria. 
It occasionally complicates Typhoid Fever ana Acute General 
Tiberculosis. It occurs in a moderate number of the cases of 
pneumonia. It occurs with Acute Pericaraitie,Peritonitis,Dysentery? 
Erysipelas,anc Diabetes. 
514 ^y of the infectious diseases ana any of the severe inflarrutlon» 
liable to this complication. • , 
.' - CLINICAL HISTORY'.- 
' ■ - 1- MILD CASES. - 
the n»ild cases, there are no constitutional symptoms at all. 
only symptoms are We changes in the urine. The urine will 
ie diminished in quantitysits specific gravity will be normal 
slightly increased? the quantity of albumen will often be 
J°ntlae Table sane the urine will contain white blood cells,rec 
cellsjcxna ccis ts Ox c«l a kxnae. 
J^^yetjwe co find in young children,whose kidneys after aeath 
^°llow the type of the mile form of the disease,cases in which 
^'changes in the urine are very marked ana in which there are 
^°Uie constitutional symptoms. The albumen,casts,ana white blood 
^Us will be present in large quantities in the urine. The 
^tient will Lave fever ana prostration ana may Ki e of the nephritis* 
^®se cases are very exceptional. When they go occur,! t means 
.^t the nephri tie, al though mild,was mere than the child could 
'6^t. So,we generally find these cases in young children ana in 
children who have already been enfeeblea by disease. 
515 - L--- v. ELL KiAHkEL CASES. - 
The urine it ceciaecly ciminished in quantity. The patient may 
not path more than one or two ounces in the twenty-four hours* 
The urine may even be suppressed, Thin diminution or suppression 
may last four or five nays: it may even last one week, two weeks, 
or three weeks, the child passing but little water all the time 
and,in exceptional eases,none at all. The specific gravity 
may be normal,somewhat increased,or,occasionally,somewhat lowered: 
this does not tell us much. 
The quantity of albumen present will be very considerable. The 
urine may become entirely solid upon boiling. This means that 
there has been a large escape of serum from the vessels. 
We fina large numbers of hyalineblood 
casts. The white and rec blood cell/; are generally present in 
small or large quantity. 
We find granular matter ana epithelial cells. The epithelial 
cells seem for the most part to come from the bladder and pel- 
vis of the kidney. We do not often find many from the tubules* 
If you look at the urine under the m j- exoseope,you will often 
see cells looking like renal epithelium but,if you look more 
closely,you will see that,in the majority of eases, they ax*e 
516 simply large pu$ cells. This has led. to much confusion/ The 
Epithelial cells from the .bladder and pelvis of the kidney may 
&1sg look lik renal epithelium* 
Generally speakings the quantl ty of albumen and the numbei* of 
oasts are an inaication of the severity of the inflammation. 
t, there may be a good deal of albumen and many casts with 
rather mild nephritis and. the reverse is true. The latter 
exception is due to the fact that the products of inflammation, 
remain in the' kidney* This is especially ap t to be the case in ' 
those patients in whom the inflammation is accompanied by a 
Marked production of pus* 'These are the most severe cases, yet, 
the quantity of casts and albumen in the urine may very well' 
not be very large* This is a curious fact which it is rather ' 
difficult to explain. • • 
- Cons ti tu tional Symp toms. -• 
Shore is regularly a feve-r which may >e marked or slight. Gener* 
6-lly speaking?it is higher in children -than in adults. There 
a certain amount of prostration varying with the severity 
the ease. There -are loss of appe ti te, nausea,and, frequently,- 
vomi ting. Within a moderate length of time, the patient will 
decome anaemic. This pallor of the skin and mucous membranes 
really due to anaemia. In a goo< many cases, these wiljzbe 
517 the <only 
In nther cases, we may have additional symptoms which are the 
following. Some will develop nropsy of the face,legs,feet^hands, 
the whole bodysor of the serous cavities. Dropsy is not a neces* 
sary symptom of Acute Exuda tive Nephri tiori t is some thing added-. 
Some will develop disturbance^ of the action of the heart and 
of the venous and arterial circulation. The arteries will be 
ha rd, tense, and contracted. In consequence of this, the heart 
will become too forcible and tumul tuou&. Sometimes, the lef t 
ventricle will incxease in size, There will also be venous 
congestion. These disturbances of the circulation are not 
necessary syrup toms-. 
In some cases, there will be very marked cerebral symptoms;head- 
ache • deli rium, mi Id o r ao tive: s tupo r; c oma: o r, even, one o r mo re 
general convulsions* Thes^ cerebral symptoms are not necessary 
symptoms of Acute Exudative Nephri tie but they are added in a 
certain number of the caaes. 
Those cases in which the pixiduction of urine is very scanty 
for a considerable length of time,are liable to pass into the 
typhoid condition and,in this condition, there will be more or 
less mild delirium or stupor. 
518 The length of time* that such a nephritiX lasts,varies. There 
are but few eases in which it will ncyt last several weeks® Sa, 
Although we say that the disease is Xante, you must not think 
that it is acute in the same way a# tonsillitis^ A great many 
physicians expect too much of a patient with acute exudative • 
nephritis* They not only exnWt him to'get well but they expect 
him to g^t well right away; This, you must no t expec t® These 
eases may give you a good deal of anxiety and may frighten. you ' 
well and, al though ihe prognosis is good-, you must not think 
that you are seeing a short, trivial disease- If yon 'think the 
disease is' trivial and find that the patient is getting sicker*. 
You will, at once become.- excited and will employ vigorous treat* 
^ent that is unwarrantable when the patient is really doing • 
°nly just what he is entitled to do®- 
There 
WOKS Th 
worst cases and those most difficult to dlagnotmsare the 
e^*eo in rzhich the production Of pus is'effected to an unusual • 
degree„ They are not uncommon and have only been lately recog- 
nized. These cases occur both in children and in adults but 
they are more common 'in children and we see them even in very 
y°Ung children?cue, two.,and three years of 'age, Most of the cases 
have been primary or have'co^liea ted Diphtheria,Searle t Fever, 
Measles. 
519 The canstitutional symptoms are marked. The fever will be well 
developed. With the fever, there will be pretty marked prostra^ 
tion. There la a goods deal of restlessness and there may ^ven 
be delirium which may alternate with drowsiness and stupor. Soe^ 
patients complain of headache. Th^y lose flesh and strength 
pretty rapidly and,if they do badly, they pass into the typhoid 
condition* hut, there will not he any aropsy or it will be bui< 
slight: there will be no marked disturbances of the circulation: 
and the only constitutional symptoms will be those just given. 
Now?you would naturally think that there would be marked changed 
in the urine but'this is not the case, During the first du ya, 
the urine may not even be diminished in quan ti ty, there may be 
no casts and no albumen^ In most cases,before the close of the 
disease, the urine will be diminished in quantity and will con- 
tain casts and albumen?but,in' the more rapid cases, the patient 
may die without any ehcuiges'in the urine. 
The symptoms much more resembl-e those of acute Meningitis than 
those of Acute Nephritis. In order not to make mistakes, the 
best you can do is to be on the look out for these eases and, 
when you see a child with high fever,marked pros tra tion, and 
marked cerebral symptoms, remember that it n\ay be one of these 
520 'dge of thebe cases of Acute Nephritis and,if the albumen ana 
easts appear early eno«Ugh,you may make the diagnosis in time. . 
These cases are tolerably common. 
- PROGNOSIS. - 
Generally speaking the prognosis is tolerably gcaa. It varies 
^Lth the age of the patient,with the character and severity of the 
nej^hri tis,ana with the Existence or non-existence of other 
^J-seases* The younger the ehila, the worse the prognosis. The 
^orst form of the disease is that with the excessive production 
Of pus:this foim is very fatale Ye ^taking it all in all,Acute 
Educative Nephritis is not a baa disease. Most of the cases 
S^t well within* a moderate length of time. The active symptoms 
^111 subside by the end of three or four weeks. The urine will 
continue to contain oasts for three or four months afterwards: 
then, the casts will disappear. It is a temporary disease. 
Tt is not uncommon for the changes in the urine to continue 
f&r a year or even lohgerrauring this time, the urine will con- 
kin a few casts.anc a little albumen: then, the nephritis will 
Entirely disappear. In some teases, a chronic nephritis will follow. 
521 - j" 0 UTE PARENCHYMATOUS NEPHRITIS. - 
J116 term parenchymatous is exceedingly objectionable^ 1 wish 
J epuld think of 8Q©0/ term to i is place* 3ome people call 
deep infl Tarnations, parenchyma tons InflammaticnSs in order to 
distinguish them from external inflammations The term is also 
used to designate an inflammation in which the tistnie of an 
organ is inflames as distinct from th© bloocx vessels which are 
'not involved^ the Wxx is often used in thi« way* It in useo to 
designate an inflammation which begins in the substance of an 
organ and involves the blood vessels secknaarily* Others apply 
jh® term to inflammations which only involve the cells of glands* 
.There are many other ways in which the term i« used* In anditioih 
it is difficult to say whether we ought to. bay parenchymatous 
inflammation or parenchymatous acgeneration* 
By the term Parenchymatous Nephritl^I mean an inflammation of 
the kinney which involves the cells of the tubules ana the cells 
Of the capsules of "the Malpighian booieo. The morbid process 
may remain confinea to these structures or it may be sc intense 
that exudation from the blooa wusels will take place but Uiis 
exudation! is seccncary* 
- E T I • L 0 G Y . 
This disease is an exceedingly oowon complication of 
all the infec tious diseasei;, of all severe inflamnaticnsj^a 
of all yevex-e injuries* Some of the infectious disease ^especially 
Yellow Fever ano. Acute Yellow Atrophy will aevelop a Parcnchy* 
inatous Nephritic of an unusually severe fom* ~ - 
522 Some of the poisons,especially phosphorous,arsenic,ana mercury 
will cause this form of. nephri ti&f either in a mi la or severe 
form according to the severity of the poisoning. 
- P A T H 0 L C G ¥ , - 
In mild eases, there will, be but little change cf the gross ap* 
pearance of Uie kianey® The kianey may,perhaps,weigh a little 
more than it should, It ip not congestea* The cortical portion 
may look rather paler than it should. 
In wore severe cases., the gross appearance of tee kidney will 
be exactly the saw as that of a kianey that is the seat of 
an Acute fex.ua a tive Nephritis* It will he increased in size® 
the cortex will be thickened, whi te or white mottled with red, 
or the whole kianey may be congested® 
Under the microscope,we ^y fine only an increase in size of 
the epithelial cells of the convoluted ana straight tubes and 
of the cells of the capsules of the Malpighian bodies,' This 
increase in size is due to a swelling cf. their net work,which 
jeay now become visible^ 
In other cases? in add i tiun9 .the cells will be ini titrated with 
tlobules of faU ' 
>sh other cases., the ceils de become necrotic® This necrosis may 
Result may result in death ana disintegration of the cells or 
523 the cells may die but not break aewn but will be converted into 
smaller and more transparent bocies* The la tter change in She 
cells is called "coagulation necrosis®. If Ute cells ale in 
either way? they will desquammate ano the tubes will be fixlea 
with them If the patient continue to live, this ceath and - 
quammation of the cells may be follower: by a proouc ticn of. new 
cells to take their places.. 
The moment th&se changes in the cells are dtevelepee with any 
degree of in tensity, we find, in addition, an exudation of serum^ In 
addition to this escape of sexto there may also be a moderate 
escape of white am red blood? cells from the vessels. The amount 
of exudation will regularly be in direct proportion to th© sever*- 
ity of the changes in the epithelium. 
- SY M P T 0 M S , - 
We often fine changes in the urine,but not always The changes 
that we find in 'Ul^e urine are cepenaaat not upon the changes 
in the epithelium but on the education from the blooa vessels* 
So, if we have no thing but th® changes in the epithelium, the re 
will be no changes in the urine or,perhaps, the urine will not 
be as abuncant a& it should,but there will be no casts ana no 
albumen^ If we do have exudation,we will fine casts ana albumen* 
524 tn moftt cates, the exuet tian is scanty: so?we generally find but 
little albumen ana but few easts* If the nephritis be especially 
severe as it is apt to be with Acute Yellow A trophy. Yellow Fevcr^ 
and arsenic and phosphorous poisoning: the urine will be ceoiaed* 
ly diminished o r, even, suppress ea ana we will get much albumen 
fend many eras ts 5 re a blooa cells,ana white blooa cellar 
' -Constitutional Symptoms.- 
In ordinar oases,we have no constitutional symptoms at all, 
\The nephritis is regularly seoonaary to some other disease 
fend it adds nothing to the constitutional symptoms* 
In the severe cases, thGse that occur with Acute Yellow Atrophy, 
Yellow Fever,and phosphorous and arsenic poisoning,there may 
be constitutional symptoms but no cerebral symptoms, no dyspnoea, 
fend no dropsy. All we fine is pros tration5a tenoency to become 
sore and more feeble ana emaciatea ana to pass into the typhoid 
condition and to aie in it, But,even in these cases,aeath is 
generally due to the original aisease? the nephritis only helps. 
s&,although we have to recognize this form of nephritis,it is 
not of great clinical con'>equenee^ It is a secondary eoncition. 
It makes the patient worse off but it gives no symptoms but. the ■ 
changes in the urine and,in the severer cases? acai tir^nal pros- *• 
trail on* . 
525 In this form of the ai&ease,we fine changes in a consiaerable 
part of the kianey. It is the most xs^orteit form of all becaut* 
the lesions are of a permanent character ana,if the patient 
escape death in th® early pari of the disease,he. is apt to ale 
later. So,it is also th© most fatal form of Acute Bright's 
Disease, 
It is the most frequent primary form of Acute Bright's Disease* 
It is so frequently primary that? when you find that a person 
is developing Acute Bright's Disease that is not secondary .to 
some other disease,,you instantly think of the diffuse form. 
It also complicates Scarlet Fever, Diphtheria, ana the puerperal 
state. 
-ACUTE D I F F U S E NEPHRITIS. - 
- P A T E C L 0 Q Y . - 
When the disease has nevi las tea a long time, only for a few weeks 
or for a few months, the gross appearance of the kidney will be 
the saw as in Acute ExuaaUve Nephritis. When the ala-ease half 
lasted longer,as it well may, a or two., the kianey will still 
be increased in size but the cortex will be ^hite ana tM kid- 
ney will be harae r ana f xrmer« Iu> 2-1 have laistea still langen, 
several years,which is passible^ th© kianey may still be in- 
creasea in size wi tii a L'-' • rtex crsiiwieCmQ. , X t may be atro* 
plied down to quit® a small muss. 
526 It will then be uneven, the cortex will still be white,but the 
^hole kioney will be hard ana aensea 
^haer the microscope,we find all Ue changes that we fine in 
Acute Exudative Nephri tis, the changes in the walls of the blooa 
vessels, the education, the extravatatics of white anc rec blooa 
<^1 Is, the changes in the epithelium of the tubes ana in the 
epithelium covering the Malpighian tufts,and. the cast matter 
^nd coagulatea matter in the tubessbu t, in acai tian,we fina other 
•hanges. At the very commencement of the aisease,we fina two 
lesions that ao not belong to any of the other kinas of Acute 
^ejihritis. These are: first, a growth of new connective tissue 
In the stroma and,secondly,a marked growth of the cells lining 
the capsules of the Malpighian boaies, 
^he growth of connective tissue Is not at first aiff use. 11 is 
arranged in the shape of little strips or weages which run from 
the cortex into the "outer part of the pyramids. At first, these 
strips are very small ana regularly follow the course of a- 
■Urge artery or vein. At first, there will be no changes in the 
tubes but,as the strips become "arger, the tubes become atrophies 
^pressure and,finally, 'this connective tissue replaces a certain 
Portion of* the tubular part of the kianey* 
527 The cells of the capsules of the Malpighian bodies increase in 
number and change in shape and occupy a consiaeTable part of 
the cavity of the capsule and compress the vesselse Then, they 
are finally convex*tec into connective tin sue and the pressure 
of this becomes sc gre<&» t tha t the Maxpighian bodies are destroyed* 
This change,also,is not distributed diffusely throughout the 
kidney but takes place with a certain degree of regularity and 
symmetry. Here and there in the cortex, we will find an artery 
with its branches and the Malpighian bodies at the enas of the 
twigs ana all the glomeruli at the ena of this artery will show 
this change. At this time, the arteries on either side ,,perhaps^ 
will not have their glomeruli affected at all® Then,further on, 
we will find another group or cluster of glomeruli affected 
and the growth of connective tissue about the arteries will only 
take place around the arteries whose glomeruli are affected# 
We also find changes in the epithelial cells. They may simply 
be flattened as in Acute Educative Nephritis or they maybe 
swollen,broken aown,or desquammatea as in Acute Parenchymatous 
Nephri tin. 
If the patient die when the disease has only lasted a few months^ 
528 tke: kixin^y^ will appear as I have said, increased in size ana 
will show the lesions of Acute Educative Nephritic, the strips 
Of connective tissue, ...nd the changes in the KnJ.pigh.ian bodies, 
but, if the patient live a number of years, there will be a dif- 
fuse growth of new connective tissue which will occupy the spaces 
between the wedges and there, will be a. destruction of many 
of the Malpighian" In & 0 €» I && 1*n number of cases, there 
will also be a well,marked thickening of the walls of the ar ter* 
*es* 
S^tif the disease last a long time, the kidneys can never go 
back to their original condition* This gives the disease its 
bad character. Even if the patient recover, the kianey is always 
damaged* In most oases,however, the disease continues and fi* 
' ^lly proves fa tale 
- Change s in the Urine « - 
In the acute cases, the urine will be scanty or suppressed* 
It will contain large quantities of albumen and many casta, white 
and rec blood cells,and aegmerated epithelium from the bladder 
and kidney. Sa., at first, the changes in the urine will be just 
the, same as in well-marked cases of Acute F^u native Nephritis*. 
S Y M P T 0 M Se 
529 If we ex? pine the urine Ffter the nephritis has laste/ a men th 
or so or if we examine it in those cases in which ilie invasion 
is sub-acute? it may be in normal quantity or, even/increased 
in quantity: the specific gravity is regularly lowered?albumen 
will he present in considerable quantity?but thy easts ana rea 
2nd white bland cells are not as abundant. / 
If we examine the urine af te X Cb X *l"Cvvi».C iXas tea months or 
years,it will aiffer curing different weeks a/a on different 
cays® Part of the time, it will be increased in quantity and of 
low specific gravity:at other time it will be diminished in 
qu an ti ty b u t s ti 11 o f J.0 W V0"X S» X 0 S Cw v ^.y <. i c«\j cf the time, 
it will contain thirty^fortyvor fifty per cent of albumen:at 
other times, only a trace? and some time a 3 the albumen will eisap* 
pear for aayc,weeks,or montMo Sometzhne^ the casts will be quite 
Rumerotw.at other times, they will be scanty at- altogether absent* 
It is the same way with the white and blood eello^ These / 
cifferences in the condition of the urine max*k the up and a own 
t tages in the severity of the nephX4itis« Tlie nephritip .ie,P'W> 
of the time,better,at other times,worse® 
530 - C one ti tu ti ona 1 S ymp toms • - 
The cons ti tu tional symptoms are well marked. 
In the more acute eases and in the sub*acute cases curing the 
times when the nephritis is especially severe,there will be a 
fever, vaX'ying in height with the severity of the nephritis. 
The patient will lose flesh and strength ne re or less rapidly. 
He will have but little appetite and will often suffer from 
nausea and, even, vomi ting* He will rapidly became anaemic. These 
symptoms, we find in all the patients In most,in addition, we 
find dropsy, disturbances of the circulation, acute cerebral symp- 
toms, and changes in the eyesight. In Acute Stuaative Nephritis, 
these additional symptoms are not at all necessary?but,in Acute 
diffuse Nephritie, the rule is the other- way, In Acute Diffuse 
Nephritis-, some of them are nearly always developed, Of these 
s yup toms,dropsy is the most common and it is often the most 
marked feature of Vie disease, host of the patients develop 
the dropsy early and continue to have it off ana on during the 
disease. It oiften reaches a considerable degree of development 
&nd it may appear on the first cays of 'the disease and continue 
^ntil improvement or death or,if the disease be protracted,it 
Mil come and go. 'There are two peculiar featurse about this 
^ropey:it may very well exist without any disturbance of the 
531 the circulation at all. In the teecna r.laee?in a considerable 
nurber of the cases,it may exist ana may increase although, the • 
patient is passing an unusual quantity of urine,one hundred 
ounces a day. With these crop sic al patients, we get rapid anaemia 
which is very no tic sable* So.? the dropsy is one of the common 
features of Acute Diffuse Nephritis* 
Somewhat lets frequently*we get cerebral syuptoma,varying in . 
character ana severity* One of the most common of these is 
headache.,persistent and aisagxecable^whieh the patient may have 
day after day, mon th after month* This may be the only cerebral . 
symptom* In other cases, with or without the headache, there will 
be restlessness and sleeplessness* These two symptoms are not 
likely to last as long as the headache? they last cays and weeks* 
then, they go away? then,perhaps,ec^ back* Other patients will 
o eve lop aeli Mum alternating with ship or? ox they may pass into 
complete coma; or they may have involuntary contractions or gen* 
eral convulsions ana the convulsions may be repeated & number 
of times. 
The patients ax^e very apt to develop the complicating inflamma- 
tions of the retina* The patients with Acute Exudative Nephritis 
may have blinanets without retinitis or they may have a simple 
532 re tini tis? bu t these patients with Acute' Diffuse Nev&ritis often 
cev©lop a re txni tic which may be either simple or nepbritix, 
* ei j/ a* v^uc;i v.iyj the pc»tien,t& will have dyspnoea which may be 
cue to oeaema of the lungs,fluid in the pleural cavity, or it 
may be spasmodic* 
Not infrequently, in addition to the dyspnoea, the patients will 
have a cough,depending upon a complicating catarrhal bron« 
chi tie which is usually not severe* 
In addition, to the ordinary nausea and vomiting, the patients 
may have the spasmodic vomiting* 
Not infrequently, the patients will have diarrhoea which is 
Tor the most part, associated with the cropsy ana is oue to ed- 
ucation of serum* 
A certain number of the patients will also develop changes in 
the circulation* The heart will become too rapid, too forcible, 
ana, some times, tumul tuous. The arteries a.na capillaries will be 
eontracten. The arterial tension will be increased* If these 
changes last eny time, the left ventricle will become hypertron 
Phiea. The presence or absence of these disturbances of tloe 
circulation and of hypertrophy of the left ventricle are alv/ays 
things io which you should pay a great neal of attention. 
533 The earlier you fine them,so much the more sure are you that 
the patient is not suffering from Acute Exuaative Nephritis but 
•from Acute Diffuse Nephritis ana from an Acute Diffuse Nephritis 
from which he is not likely io recover. 
-COURSE.™ 
- 1- In a moaerate number of the cases, there will be an acute 
invasion with marked development of all the symptoms and the 
patient will aie in a few cays or in a few weeks, Yet, these 
cases are not very common* 
- 2-In these cases,there will be the same acute invasion 
ana the patient will continue in this eondtion locking seriously 
ill for cays or,even,for weeks. Then, the acute symptoms will 
subside ana the aitease will become sub-acute. Then, the patients 
co not have the fever. Of ten, they are not nick enough to be 
in bed. We fine that the specific gravity of the urine will be 
lowered but the urine will -contain a fair amount of albumen 
ana casts. The dropsy, nausea, headache, loss of strong thy ana other 
s ymp toms c on tinue * 
534 When the patient has passed into this conciticn,he may go on 
for several montht,not infrequently,for several years, In some 
of these cases, there is no real intermission in the course of 
the ci scats. The urine always contains seme albumen ana some 
easts. There is always tome arepsy and anaemia and,al though 
the patient is walking around,he is sick. Then he will die. 
In other cases?when the disease has become sub-acute, there will 
be intermissions curing which all the symptoms will cisappeai\ 
The dropsy will go away altogether. The appetite and the color 
of the patient will become good. The urine will return to its 
natural conaition and the patient will feel better. Hut, in most 
cases., this siqply means that the nephritis is not active for 
the time. Therein a few months, the symptoms will return. There 
may be another intermission and the patient may last ror years. 
Now., these cases may get well; this does not often happen: but it 
is possible ana the patie&t will then be rid of the symptoms 
of Bright's Disease for the rest of his life, 
- 3 in these cases,the invasion is sub-acute. There are not 
at any time any active symptoms.,no fever and no other symptoms 
of an acute invasion. This form-is especially common in the 
primary cases. It is not uncommon in those cases that follow 
535 Scarlet Fever or in those that occur with pregnancy* It may 
very well happen that the patient can not tell yon when the 
disease began* In some patients, the first thing that will 
attract attention is that they are passing too little urine? 
others will first notice that they are passing too much urines 
• thers will first notice that^in the afternoon or evening when 
they take off their shoes, their reel will be swollen* Others 
first notice loss of appetite ana nausea^ Others have headache* 
Others cannot sleep well, In others, the disturbance of vision 
will be th e first syup tom* 
If, however, in these cases,you examine the urine, you will find 
the changes pretty well marked, The specific gravity is often 
normal but there will be a considerable quantity of albumen and 
casts* The albumen is present in greater quantity than the easts* 
Then the patients will develop more and more of he regular 
symptoms* They will develop the headache and other cerebral 
symptoms* The dropsy becomes more marked* The patient will de- 
velop the hypertrophy of the left ventricle. The arterial tension 
will become either increased ox* diminished. The patient will 
lose flesh and will develop the dyspnoea ann other symP toms* 
These patients may go on for months ox* years?continuously or 
536 intermittently. Now in these patients, the prognosis is the worst. 
Acute Diffuse Nephritis is always a bad disease but the worst 
oases are always these sub-acute cases. 
T It F A T M F N T OF ACUTE B 11 I G H T> S - 
- DISEASE^ 
- 1- Treatment of Acute Parenchymatous Nephritis.- 
In regard to Acute Parenchyma teus Nephritis,it cun hardly be said 
that there is any treatment* Fortunately, i t is not,us a rule, 
severe form of the disease. It is always a secondary condition 
unci our inability to treat it as a rule; docs no harm,for,if the 
Patient recover from the original disease^he will recover from 
the nephritis. A moderate of the cases, those that occur with • 
Acute Yellow Atrophy and Yellow Fever and phosphorous,mercury, 
bna arsenic poisoning,we would like to trouts yet I think that we 
JHist confess that we know of no method of treatment. In these ; 
severe oases, the renal epithelium dies and it is evident that 
there is no me then of preventing their death or in which to 
bring them buck to life aj. ter they are qoucI. 
** 2- Treatment of Acute Exudative Nephritis and' of Acute Diffuse 
Nephritis.- 
may consider the treatment of these two forms together.- 
537 Exudative Nephriiis^we- expect and get a great deal 
netter results thfea w do in Acute Diffuse Ne pari tiia ye t> tht 
MMcaiions for treatment are t& saSe in bo& 
fe will first consider the treatment during the acute stage v 
either of these forms* The first thing that present itself 
for treatment is the inflamma.tion of the kidneys and) apparently 
we can do some thing for it The first thing to do is to put 
the patient .to bed and keep him the re e Put him on fluid diet 
Mik. See that the bowels move every day. For, the nephritis^ 
we may apply wet or dry cups or heat over the lumbar region* 
as near the kidneys as possible in order to diminish the con* 
gestion* We may try to do the same thing by applying heat to 
the w^iole surface of the body* This -swe may do either by first 
putting the patient in a warm bath and then wrapping him in 
blankets or we may use the hot air bathe We thus try to proaucc 
a congestion of' the skin in order w relieve the congestion of 
538 Now these plans of treating the inflammation of the kioneys 
belong fnly to the earlier stages of the disease, the first 
one or two weeks: ter this, nephri tis no longer has the same 
active character and the indications for these plans of treat- 
ment no longer exist* 
In order to treat the inf lai^tion of the Kinneys, we .may also 
give drills in audition to the means described. The drugs 
that are most uuful are calomel,magnesium sulphate,opium ana 
the tincture of adonite* If you give calomel or magnesium 
sulphate, give thase drugs small and repea tea doses' until the 
bowels act. We do not give these drugs to make the bowels act: 
we give them for the nephri tis^bu t,as soon as the bowels have 
acted, we s top the use of time drugs? then, the next day or the clay 
after,we go on with them again ana,so on. Opium seems to have a 
direct effect upon the nephritis.. Give it in small doses at reg- 
>lar intervals* of 'the fexmis of upturn or morphine will do. 
I prefer Mo Munn? s elixir or the cieoneriKea tincture. If you 
bive the tincture of aconite,give ij at regular intervals. 
The use of these arugs may be continuea for three,four,five, 
°r six weeks. 
In the patients who give only fever, scan ty urine, pres iratie»t 
539 aad disturbance of ths o kxraoh, this will he all the treatment' 
that will be neoe£$vi;y5 for these methods are also of service 
for the other sy d • ke th® patient more comfortable; 
You must remember that you do not expect these patients to get 
well at once nor do you expert that they will at once pass a 
large quantity of vrino^ You must allow from two to six weeks 
for the nephritis to run its course and for the symptoms to 
eoniAnue and you must not expect much improvement until the end 
ef? the second u r f o d th week a Then,i^ you can treat the nephritic 
successfully, the nephritis will subside and the patient will; 
get well. You must not treat these patients for passing too 
little urine* This mistake is often made and the physician will 
direct all his energies to this one to m> The reason that th® 
urine is scanty is because the kidneys are inflamed. Think of 
the nephritis all the time. 
In o ther casesthe additional symptoms will require treatment 
but,in these caseyou must not sto^. treating the nephritis. 
We will first consider the treatment of the acute cex^ebral symp* 
toms, the acute uraemic attackfio The first thing to do is to 
see if there be any increase in the arterial tension. Feel the 
pulse and see if the artexy be hard and contracted* Listen to 
540 the heart aha see if its action be rapid ana tumultuous ana if 
it seems t© be wording against pressure, The quickest ways in 
Which to get rid of this-oondi ti©n of high arterial tension 
are the following* You may give chloral hyarate,grs*v every three 
or four hours* opium in large ao^es by Vie hypoaermic me thou* 
nitrite o.f' amyl by inhalation,or you may apply heat to the 
surface of the bony* or you may bleea the patient* If these means 
succeed, the symptoms will disappear* But, if there be no increased 
arterial tension, you will often benefit the patient by giving 
Grugs that increase the arterial- tension and the force of the heart's 
action* You may use nigi tails ?ccuvallariaT caffeine, and utrophar> 
thus and* of ten, these drugs give, gone results* In other cases; 
there will be .no increase of arterial tension and no feeble 
heart. These are the worst cases to treat and, for them, we have 
no efficient treatment. In these cases, the symptoms really $eem 
to be due to the blond poisoning* I know of nothing better to 
^g than to sweat and purge the patient# But?often we cannot get 
the bowels and skin to act and,in many cases-, even when we aot 
the patient will not improve# 
$n Acute Exudative Nephritis' and in the first weeks of Acute 
diffuse Mephritis, the aropsy is often uevelopea to a moderate 
541 or even io a considerable degree but you need not worry much 
about 1 t, unless it involve (he lungs or pleura w a great extent* 
At this period of the dir^as^yyou really cannot do much for., the 
dropsy. Later on,it often becomes very amenable to treatment. 
For this reason,if the breathing be not affected,! am very much 
in the habit of letting "the dropsy alone and of telling the . 
friends of the patient that the dropsy will take care of itself 
and,in Acute Exudative Nephritis,it usually doc?; go away as the, 
nephritis gets well* In these cases of Acute Diffuse Nephritis 
tha t b e c ome s ub - a cu te, the d ro p s y bee o me s mo re ma r k e a and is ap t 
to require treatment* 
In those cases of Acute Diffuse Nephritis in which the invasion 
is sub-acute, the indications for treatment are quite different* 
At the commencement,!t is best to put the patient to bed even/ 
if he feel well enough to go about* Should put him on a fluid •" 
diet,milk and keep this diet up. In addition, we must treat the'' 
nephritis. Per this kind of nephritis,active measures such as» 
cups,heat,and aconite are of no sex^/ice. 
542 In theye cases, there is only one urug that has seemea to me to dr. 
any gooa* This a rug is opium* It should be given in small noses 
Qt regular intervals*. I an not mean to say that this a rug as 
satisfactory as we would wish it'to be but I think that it is 
the best that we. have. You must treat ths <J#1 4 ct w iixJ- &U& There are 
only three things that will do the anaemia any good* The first 
two are Iron and oxygen® These are of some use ana,often of con- 
si< arable value but you must, not expect them to give the results 
^hioh follow their use in simple anaemia* The thira thing eon« 
sists in getting the patient out of doors if the weather be warm 
ano the sun be shining® _ • 
1g "the aropsy^-al though the a ropsy may be quite' tr^uuru^ 
somejyou will find that9at first,you can not do much for it- 
If it is going, to be beneifi tted- a t all9it vdll be by rest in bed, 
the mi Ik ■ di e t, and opium in small doses and, in some eases, these 
^ans win get rid of it pre tty 1 romp tly; but, if it be n^t re- 
lieved by these means,it will pn>bably not be relieves, at <J.l® 
V»e will now consider the treatment of the later stages of the 
$isease.9 the treatment of those cases of Acute Diffuse Nephritis 
^at become protracted* The .dropsy continues and we must treat 
543 it>for it continues and annoys the patient* Fortunately,it is 
now more amenable to treatment. We can get rid of the fluid 
by three channels,the kidney, the skin,and the intestine but,in- * 
order that the fluid should be removed,it must be taken up by 
the lymphatics. In treating the dropsy,you must remember the ' 
causes., In the first place,!t is due to ad abnormal condition- 
of the wails of the blood vessels* Thi& is due to the altered 
■aondition of the blood or the general condition of the patient 
which is the result of Bright's Disease. You must also remember 
that venous congestion may cause and keep up the dropsy* You. 
must see how much dropsy the patient has gbh. If there is so 
much fluid that the lymphatics are compressed, there is no use ' 
in trying to get rid of the fluid by the shin,kidneys,or bowels* 
In these cases,you must first draw off some x^f the fluid from, 
the pleural and peritoneal cavities and punc uhre the skin in 
a number of places with needles,in order to relieve the pressure* 
Then, the kidneys, skin, and intestines will.take up the x^est of 
the fluid* You must remember this* If you do not believe if is 
.true,you may try thia experiment in the first case you get* 
Unless you first relieve the pressure,you can't get rid of the 
fluid* When you have relieved the pressure, you may sweat the 
patient cr give diuretics and cathartics* 
544 W;U oo'O po tention to the die U Ai first, the patients were 
Xx fluid diet and it Io difficult to &ay how long this diet 
. 2 •.'. 2.• y, \ > To. i voi v* * m ••>./- IsO to find out 
when they should go b&dk to a solid aie% If the patient is 
net X'-e&dy f•■ k solid diet,you will find that the nephritis will 
get worse and^if you leou them on fluid too long,the 
• : onniinue® You have to s. in each patient# 
She 3«ple is tba> Xe fluid diet belongs to the early stages 
of the disease and to the e^aeerbaiions and tx.d solid diet 
belongs io the la tar ^hen the nephri tis is. 1 •aeu te. 
The oace 'thing is tru® abCut letting the patient'drihk. large 
of water and mineral z-zxerv. lAiring the early stages 
and during the better off' for. it* . ■ 
U\ If you continue thei-r usa^you will keep up a dropsy that 
yo ipuid ( ' < i ' . i xe later ^.taged^ynM will often 
tind Shabby Gutting down the fluff.;/r-u will get rid .of the 
dropsy, 
Attend to the heart and arteries* If the heart be too feeble, 
give 'digitaHa^■oonvaHax'i'a,ofeifelne^and s «^ipphan thus# the 
arterial tension he Mghs^ive chloral h>urate,opium,nitro-. 
gly'Ge:rine9oxs nixrito of amyl to dilate the arteries, and oap- 
illarient 
545 You must treat the anaemia. This,you do by sending the patient 
to a climate where he can live out or doors and by giving iron 
and inhalations of oxygen. 
You have to pay attention to the condition of the skin and 
sub-cutaneous connective tissue. The patients get rid of the 
dropsy better if you keep the skin clean,if you ercploy massage 
and passive motion,and if they can live out of doors in a warm 
climatee In the earlier stages of the disease,, they get rid of 
it better if they are kept in bed than if they are allowed to 
go about. 
Now, in order to get rid of the dropsy, you also have to increase 
the amount of urine,or give purgatives,or sweat the patient.' 
Sometimes one of cue s c me ana, sometimes,another will be the best* 
If you give diuretics,you may give sodium chloride, squill, 
digitalis, ace tate of potash,or iodide of potash- If these act 
properly, they will assist the patient in getting rid of the 
dropsy. - •• 
If you employ the bowels as the channel by which to get rid of 
the fluid,give hydrogogue cathartics. 
If you employ the skin,you may sweat the patient by the ho* 
air bath or you may give pilocarpine, but,you must always remem- 
ber that the removal of the fluid by the skin,kidneys,and bow- 
els is only an accessory part of the treatment of the dropsy. 
546 Now., we have finished with the treatment of the dropsy but there 
are many other things that we must treat. 
Select food that the patients can digest well and readily. The 
more you can improve • general health* the better for the 
nephritic. 
We have to treat the condition of the blond* the anaemia. 
The patients may develop acute cerebral ^y^ toms.*headache or 
delirium or coma or convulsions or blindness or great dyspnoea, 
these* you treat in the same way as in the acute cases. 
We have to treat the nephx'i Us, itself and the treatment of the 
nephritis is the same as 11© treatment of a sub-acute or chron- 
ic inflammation of any other viscut. The best ^y to treat it 
is by climate: there is no treatment that qm compare with it. 
Send the patient to a climate that is warm enough to allow of 
his being out of doors for a considerable part of the time. 
Whether this warm climate should be at the sea" shore or in the 
interior,will vary with the different patients. If the patient 
is in a position that will allow you io do the best thing pos- 
sible for him and if he has been taken sick in New York, you 
see that,for several wintero?he parses all the bad months in 
a warm climate: thecas the summer comecshe gradually travels 
547 north. This treatment,you keep up for several years. If you 
can carry this plan cf treatment out? same of the patients will 
do very well indeed. 
- . - 
There is another form cf Acute Bright' s Disease that requires 
special attention. This is the 
- ACUTE B n I G H T'S DISEASE 
0 F 
P K EG M A N C Y . - 
In epeaking of the Acute Bright's Disease of Pregnancyjwe ex* 
elude those cases that had Chronic Bright's Disease before they 
became pregnant. Dy Acute Bright's.'Disease of Pregnancy we mean 
an inflammatory condition of the kidney which is developed during 
pregnancy and which would not have been developed had the woman 
not become pregnant. 
No«|We find that $ueh acute changes in the kidney are much more 
common in pluiperae than in primipar&e? in the first pregnancies 
of young women than in the first pregnancies of older womens 
and with twins than with single gestation^ It is not infrequently 
repeated in the w:^.n in successive pregnancies. It is 
regularly developed during the second half of pregnancy* It 
548 said that it never cecurs before the third month and, in most 
sea, it does not occur iMtil the $1$ th, seven U>,jeight^ ninth 
pH th. We find that,when the have once commenced, they 
^^ularly increase and become more marked as the pregnancy con* 
ttnues and the worst symptoms are apt to be developed at the 
of labor. It happens that women in the puerperal.condition- 
develop symptoms of much the same character and, in some 
these., there will be real changes in the kidneys in others, not* 
sample,many women during the latter months of pregnancy, 
Hu 
develop a well-marked anaemia and hydroemic plethora but. * 
this may very well be developed without kidney disease. In the. 
^tter months of pregnancy, it is not an uncommon thing for women* 
become somewhat dropsical and this dropsy may exist rfthout 
kidney disease, further, it lb probal<U,not as certain-as was 
one time thought, that women may during pregnancy have marked 
Oe*ebrai symp tow,headache^ene^l cosiwision&gblindness^hemi- 
Hegia,eto. ,with no kidney d:Ue^?je at hllc Most frequently,, 
however,when these patients develop anaemia,dropsy,and cerebral . 
bMptoma,it does mean Acute NephriUSc 
- PATHOLOGY.- . . L ; -t 
We may find either the lesions of Acute Exudative NephrdrtK' .. 
549 fry the lesions of Atute Diffuse Nephritis. It is stated by good 
authorities that we say sometimes find the lesions of Acute 
Parenchymatous Nephritis* I do not know whether this is true 
or not. I have never seen a case that showed the lesions of 
Acute-Parenc^iymatons Nephristill, this statement is made 
by perfectly gohi author!t0s. 
-k Y M F T 0 M S = - 
If. we follow the whole eduxse of the pregnancy,we find that, 
in some casea, there will be no symptoms but the changes in the 
urine,albumen and easts,day after day. In other case a, we will 
find in addition <SbTX<X K/ £3v $nyviroc p.Le ci-nd. ciropsy. Yhen^, 
after parturition, these symptoms will disappear. These are the 
mild cases. 
In other eases, the disease will be mere severe and,in addition 
to the changes in the urlr.e?iirdp>sy5and aru-.emia^we will get 
cerebral symptoms. Some of /mese ca^es will only have headache, 
fthers will develop blindn/ss without any lesion in the eye. 
550 In the severe cases,we will have general convulsions ofteh with 
periods of coma between them and hemiplegia without structural 
changes in the brain® These acute cerebral symptoms are most 
•ommon at labor but they may take place a few nays before labor 
or a few days after labor* In these ease a, the urine is regularly 
diminished in quantity and it is especially apt to be diminished 
before and during the attacks of acute cerebral symptoms. The 
Urine contains a good deal of albumen but, as a rule,not a great 
tony casts* The urea in the urine is somewhat diminished and 
you my find an increased quantity of urea in the blood. In 
toot t case a, there is a well-marked increase of arterial tension. 
- P H C G N 0 S I S e ~ 
Ab a rule the milder eases do well. When the child is bom, the 
*yt'Ptoms diminish and it only takes a few months for the patient 
to become entirely well. This is the rule and it is the rule 
boeatwe most of these cases are examples of Acute Exudative 
Ne?hriUs. Du t?it .may happen that the nephritis was a Diffuse 
Nephritis and-, then,although the patients get better for a tima/ 
*hey suffer from the protracted form, of Acute Diffuse Nephritis* 
They may live several years but they usually die eventually. 
When we have the acute cerebral symptoms., the prognosis is 
551 always serious and bad,no matter at what time the cerebral symptoms 
occur and a good many of the women die from them* 
- TREATMENT.- 
The treatment of these cases is of a good aea& of importance. 
For this reason?it has become a habit among a great many prac- 
titioners? to examine the urine once a week during the latter 
months of pregnancy as a matter of routine. The mere finding 
of albumen in the urine is no indication for treatment* If the 
patient is doing well in other respects, you simply watch her 
closely, But,if the urine is diminishing in quantity and the 
patient is getting anaemic ana dropsical,regulate the diet and 
give more fluid food?keep the bowels freely open,and give iron 
in suth quantities as the patient can bear. Also notice if,at 
this time, the condition of increased arterial tension be present: 
if so., give the dilators of the arteries and capillaries. Then, 
let the patient go on but watch her carefully and?if you are 
for tuna te, no add i ti o na 1 t re a tme n t wi 1 1 be re qu free. 
but,it may happen that the acute cerebral symptoms will be 
developed* When this is the case^ treatment is not of as much 
service; still,you must do what you can* In many cases., bleeding 
from the arm is decidedly inaicated in order to relieve the 
552 venous congestion and the high arterial tension and this isz 
often done* It is also proper to give opium in considerable . 
doses^ the mo re active purgatives^ and .chloral in s^all doses 
at considerable intervals* If she convulsions come oh during 
parturition/hasten parturition* If the convulsions come on or 
threaten io cone on before the birth o'f the ehild3 the Question 
of producing pwaafirs labor oowi* "h •Ink that most of the 
conservative obstetricians are not Mich .in- favor of being in 
too much of a hurry about It shsmld not be done without 
very good Reason but it should uuduuM^lyr^ dene-» 
553 - CHRONIC B RIGHT'S DISEASE.- 
Chronic Bright's Disease is much more common than Acute bright'S 
Disease. Chronic bright's Disease is one of the most common 
diseases that we are called upon to treat. 
- E T I 0 L 0 G Y 
The disease is more common among males than among females. It 
la most common among the ^inhabitants of temperate climates. 
It is most common between the ages of forty five and fifty five* 
In many cases?we can get a history of in temperence, syphilis 
gout,rheumatism,or privation. These conditions evidently dis- 
pose to the disease. The disease will run in some families for 
generations. It is not as distinctly hereditary as phthisis but 
that it is hereditary,I have no doubt. In some cases? the cisease 
comes on without cause. Acute Nephritis,especially Acute Diffuse 
Nephritis maybe followed by Chronic Bright3 y Disease* Chronic 
Congestion of the kidney is frequently followed by Chronic Bright 
Disease. People who suffer from, organic disease of the heart, 
Pulmonary Emphysema,Phthisiu,Ci rrhosiu,pro trao tea suppuration 
in any part of the oGczy? v r pre* tx*ac ted inflamma tidn of the joints 
and bones are more liable to Chronic Bright2 s Disease than other 
people. 
554 We 'usually find pretty well-markec. changes in the kidneys• 
feese•changes will vary in oharacter according to the length, 
of the disease anc according to the patients 21aae of death,, 
that is to say, whether he dies cd nephritis or of something . 
else. The disease is ^Diffuse Nephritis and the changes in* 
Velve many parts of the kidney. In all cases,we find changes • 
in the epithelium of the exudation-in the tubes,^^, 
changes in the stroma,in the kOpighlan boaies,ana in the arterite^ 
but 'the kidneys show a difference as to which particular part 
will be most diseased* In some cases, the mosh marked changes 
will be in the epithelium of the tubes? in. others, .there will be 
good deal of education;in 0thers, there will be marked changes 
in the s troma? and, in others, there will be marked changes in 
the-Malpighian bodies* So, if we try to sub^diviae these caswa, ' 
we may do so in the following mannerc 
-* 1-'Some follow the type of exudative nephritis with a good 
deal of albumen and many casts* 
2-'-others follow the type of Acute Diffuse Nephritis and . 
show the strips of connective tissue.ana the other changes* 
3~ In 0 there, there will be a waxy degeneration of they 
■ P A T H 0 I. 0 'G Y 
555 the Malpighian bodies ana of the arteries* 
- 4--In other cases,the most marked changes will be in the 
t troma. 
The cases also aiffer u. to how rapidly these changes are uevel* 
opea. In all oases,the disease is chronic but? in come caseu, 
the length of the aisease will be much shorter and the lecionc 
will be much more rapiaTy developed than in others^ Thus,come 
cases will only last two or three years* o there will last ten, 
fifteftn,or twenty years and,in these long -cases.? the reason why 
the patient continues to live is because the changes are devel* 
oped so slowly* 
Of all the forms of the disease, the one that is regularly the 
slowest is that in which the stroma is involvea, that in which 
new connective tissue is produced. Still? some of these will 
only last one or two years but the rule is the other way. 
In all cases? we find that the share that the blood vessels take 
is indicated by the quantity of albumen in the urine. 
When,we examine these kidneys after death, we find that some 
of them retain very much their natural size,shape,and color, 
when looked at with the naked eye* 
Others will be increased in size and often considerably increased 
in size. The cortex will be thickened and white or white mot- 
tleo with rea or,part,red and,part,yellow. 
556 In other eases, the kidneys will be diminished in sise,atrophied 
to a considerable degree, 
Generally, the capsules, ache rent. The surface may be smooth 
or nodular, Generally, the changes are less marked in the pyra* 
aids than in the cortex* 
In some cases^we find small or large cysts in the kidneys. 
In the gouty easea?we may find little deposits of urate of soda* 
The changes in the grosb appearance of- the kidney will someiimOB 
give us-an idea of what the minute changes will be; pome times, 
not. On this account,much confusion has arisen in speaking of 
the "large white kidney "and theft atrophied kidney8 as though 
these names meant some definite lesions^ This, is particularly 
common with English ana American authors ana. they mean that 
in the "large white kidney1,, there will be marked changes in the 
epithelium of the tubes and,in the "atrophied kidney8,, there 
will be a great growth of connective tissue. This it true in 
a certain number of the cases but ws may fine connective tissue 
in the "large white kinney8 and we may fine changes in • the epithel* 
ium in the "atrophied kiane:y%. Th^ clinical history is often the .. 
same in both* Sa, thl^ system ef nomenclature mxght very well 
be dropped but, 1% has become do not very .- 
557 Almost all the patients with Chronic Bright's Disease have 
other lesion or mime other lesions* This rule it almost abso*H M 
lute; it has but few SiM^pt^na* ,. . 
•- *X-Perhaps, the lesion that we most frequently fkid is in the^ 
hea^t* -In some of these cases? there is first a history of ChrdatA 
&eooarditi> with changes in'the valved This heart lesion-i< 
* -followed by Chronic Congestion of Kidney uxd, than, by Chronic 
Bri^hV^ Disease* So,ln h^e the heart^leMen oomes firs^ 
and is the direct cause Chronic Brlbhv^ Disease* 'p 
. In .other eaae^|.after the Chronic Disease' has existed ' 
for some time, there will he an h^f-rir^phy the ?<eft ventriclf 
without Endocaraitis ar there may be alla^tkm of the left " ? 
v'entriele without,as a rule.^wy chaafeev in the valves^ Hera, 
the heart lesion is the result of the Chronic Britt's Disease-. * 
In other ^sea^Chrcmio Disease &nd Dh^nla Endocardi.t±j$ 
will ewe on about the same ih^ and neither .can be ba^d to, 
■ Me the cause of the oiher^why this should ba^we. go 
558 --2- Another very common declination Ar changes in the ar* 
teries throughout the booy* The arteries may be the seat of 
a chronic inflammation by preference the inner coat 
and leading to narrowing the vessel^ ri giait-y of their walls, 
or, irregularity of ..theix3. lumen which will tend to the formation 
•f pouches* Such an endarteritis way involve the aorta,many of 
the larger'arteries, or may:*br the smaller ar teries: but, most 
frequently, it will* involve gome arteries and not others* Thus, 
• In one ease,it. will involve the aorta^in another, the branches 
ef the aorta$in another, the cerebral arwies0n another, the 
arteries in the abdomen^ 2 to* .■ The legion is of most importance 
when it involves the oerebr&l arteries or when it involves 
many arteries: these are the worst cases* 
Without being inf lamed, the muscular coat of the arteries may be 
hypertrophied* This is especially evident in the small arteries* 
In some case n, the ar Uries will become contracted ana will remain 
so for a considerable time-* This cGntrac^on may last houru, 
weeks,or months* In these oases, there it xu in.Alarmation* 
The arteries may have an unusual capacity for allowing the serum 
to transude through theix^ walls* 
These are^ the changes that we may find in the arteries* 
559 • The changes in the heart and. toe changes In the arteries- arei 
the most common accessory lesions* We also tind lesions inowi 
parts of the bony but they are not as common* 
-- Pulmonary Emphysema is very common We cannot exactly 
say that one disease causes the other but the patientsa ^re- 
liable to both. , / 
- 4-Changes in the pia maten^Chrdnio Meningitis* ' * / 
•-5- Dilatation of the ven triples wife increase of serum in/ 
the -ventricles and feickwing of the epenayma*. 
- G™,Some of the patient have apoyle.^ course,'id'-- 
^hronie Endarteri tiiu 
•-7--Some develop Aou hr ?e<i, 'A Ct •'*• •> sot ax' Fneum^nl^ FleuriS^ ' 
PeritoniUe^or Cirrhosis of fee Liver* -' "4 
All these Qomplioatiorw are oo:amvn, that it is a rare thing - / 
to find a case of froronte. BrikhVs Disease without one or other/ 
of - them. 
- S T M ? ? e M S f. - ■ 
The symptoms are the seine as feoee of Acute Bright3^ ]>^?es&se'' 
but they are uevel-oped in a niffs rent v^y*. They are the 
560 - 1-CHANGES IN THE URINE.- 
As & rule,the specific gravity is lowered, 1016,1012 or even 
lOGt or 1007. Occasionally, the specific gravity will only be 
1000. This low specific gravity is kejjf up for a long to. 
V^hen it is once developed, it usually continues, even when there 
is an exacerbation and when fee urinp is scanty as well as whesu 
it is abundant. Sa^it is one of the constant changes. Sa constant 
is it that,if I could only choose one way in which to examine 
the urine in Chronic Bright's Disease^I should choose to take 
the specific gravity. The lew specific gravity means that the 
patients are not excreting enough urea and other exo remen titious 
matters and, fee lower fee specific gravity, fee more evident is 
it feat this function of fee kidney is deranged. Sa, fee patients 
whose urine has-fee specific gravity of 101* are doing fairly 
well as regards getting rid of excisemen it few bodies but feewd 
wife a specific gravity of 1010 are not and this is very serious# 
The quantity of albumen is often not at all considerable^ In 
some cases, there will be a great deal* in o feers,none, This 
presence or absence of albumen is nb inaication 'Of bow great 
the structural changes in fee kidney are. All feat i t feows ic 
how active a share the blood vessels are 'taking in fee 
561 inflammatory process# So,,you ao not think any better of a patient 
when he has but little albumen in the urine nor any worse of 
him when .he has a great deal. It is important that you should 
remember thitu 
As a rule, the casts are not presentin great numbers When there 
is a great deal of albumen,we may get quite a numbez* of easts 
but^in many oases., there will be no easts at all. There may be 
a fe.w easts when there is no albwen or there may be a little 
albumen and no casts or both the easts and albumen may be present 
at the same time# 
- 2- CEREBRAL SYMPTOMS* - 
These are common. They may be developeu slowly and gradually 
and last some time or they may dome on in sho rx, severe attacks. 
The symptoms slowly developed are the following. Headache and 
aleeP ■>. e s s neas are very common tweed0 • Then, there is a giwual 
failure of the mental powers and a disposition to become arowsy 
ana stupid during the cay or the patients may even aeyelop a 
mild delirium. The acute cerebral are just the same 
as those of acute BrighVs Disease, 
562 - 3- NEURALGIC PAINS. - 
These are net uncommon. They may be localized on a nerve or _• 
run along the course of a nerve. They come on in attacks and 
they may be the first symptoms of the aisease. 
- 4 DISTURBANCE OF THS FUNCTIONS OF THE STOMACH. - 
The patients may have Chronic Gastritis* Others will have Gas trie 
Dyspepsia,will suffer from oppression aJfter eating, loss of 
appeilia,nausea and vomiting,and may have the suaden vomiting. 
- 5 - THE TEMPERATURE. - . 
In some oases, the temperature will be below the normal,especially 
when the patients develop the chronic cerebral symptom^ In other 
oases, the temperature will be too highs this is especially apt 
•to be the case during the acute uraemic a b lacky Lut we may find 
a rise of temperature at other times. 
w~ S- CHANGES IN THE BLOOD. - 
Tb.e patients will become anaemic but this anaemia will not be 
ae ye loped nearly as rapidly in'Chronic Bright* s Disease as in 
Acute Bright* & Disease. Yet, sooner or la ter, we do gel anaemia. 
- 7 -CHANGES IN THE GENWh NtJlRlflGN.- 
The general nutrition suffers son<ner or later. The patients 
flesh and strength. This is feet developed nearly as quidly 
as in .Acute Bright's Disease but,in all cases,we get it sooner 
563 or later* 
- 8- CHANCES IN THE CIRCULATION. - 
The patients with Chronic Bright's Disease are even more liable 
to changes in the circulation than the patients with Acute bright'S 
Disease. They depend upon changes in. the heart, or in the walls 
of -Tie arteries,or upon a spasmocic contraction of the arteries 
and capillaries all of which,I have described. They are .very 
common and you must always be on the look out for 'th^m but you 
must not think that all cases have them* Most do* Now, that we 
have come to recognise them,we are apt to exaggerate the fre- 
quency of their occurrence* 
- 9- NEURC-RETINITIS. - 
This may either be simple or nephritic. . 
We always have as a part of the clinical history, the symptoms 
cue to one or more of the complications. This is the hardest 
feature in understanding and treating these cases* Furthen, you 
must always remember that there are other* conditions that give 
many of the symptoms of Bright's Disease,,Chronic Enuooardi tis, 
Chronic Enuarteritis,and Emphysema,for example^may give renal 
symptoms. Thia,you must always keep firmly fixea in your mind 
or you will be making a good many mistakes with Chronic Brights 
Disease^ *- -- 
564 BOURSE* - 
The course of the eiseatA varies th the character of the in* 
fItohaiion of the Blaney and the existence or non*existence 
of complicating lesloxfb* Sc^we nay divide the cases thus* 
- y? i'JJ J ft;.'"..:' K b/.H O«Aj .S JSS e . T" 
These xun n dM X!auid $owe and are characterised 
by me constant large Quantity of ^Ibtoen in the urine wgi a 
well marked disposition to dropsy. These cases are very conwn 
and resemble end edme nd.l dnvfn -o fce'grtm^ea 
T/nn'nny To called the srlih n alsposi^on to ' 
exuaatiGn^ 
The urine nn:y be ond dm en. xn q^ntliy or it be abundant* 
The albuhjen ed mm d mve "mm exact quanti ty of albraen 
akd casts nnndu at different The specific gravity Is 
low* 
The dm. *:-, mmdd It eed fjgt immm all the U^e but 
Gd^es and ^ces em. Ie wree at some -iime ximn at dthera» Head* 
ache md a^le apt tr» eontiuue 'dn o. 
dy dy patients have Qn*onic Endocardiiis dien 
le otwn accompanied >ey vq^ yemne^ m 
a feeble heart* They ao 'mi -.yme 3.eym<myei arterial tension* 
565 These patients often have dyspnoea but thle is more apt to be 
cue to dropsy^ to the endocaiui iis,or to ©edema of the lunger 
than to be spasmodic* Anaemia is a w&ll rrarkee symptom throughout 
the disease. These patients are very liable to simple retinitis 
or to the nephritic neuro*re tinitisu They are not very liable 
to uraemic attack^ ye t? towards the clone of the disease, they 
do develop alternating delln.un and stupor which continue until 
death* 
These eases usually last several rears ana they may last longer, 
five or six years* Tet^even the long eases preserve tAe Char- 
acter of acuteness^fox,al though they continue tn liva-.it is 
beeaum' the neubrit"s frea time io tiae w come to a stand 
still but,when the nephritis comes on again, they again go down 
hill. So., in some catuy^ the course is nearljr continuous min others, 
thex,e will be vex'y sxarked pex'iodt? of impiovemen h 
Some of the patients, co no a at any time have xmeh dropsy or 
much albumen in th© urine x.rd they are net nick enough to stop 
business ioT ymoe e^oet vary in &euteness« Butj&t ^buy time 
or o the it, they do got worse anc^xf they no .not aie from some 
in ter current disease,, they will oie fxum the nephritise 
566 The disease does not really eyer acme to a st&Ad stiJ.l.-an.^ toward, 8 
the end^all the symptoms will be well marMecU 
w n p a t- u p v n> ..^L 
The treateni of these cases its much w»e M Aza treatment 
of the sub-acute case® of Acute Diffuse Nsphibltic. We manage 
the dropoy* improve tnc condition of the .^aMen t and of the 
blood* and make the nephritis run slow a oouree &» pc trills 
and we do this in muoh the in the ease?? 
of AcuM Diffuse Nephritis* / 
2"- ^LOW^Rk CASES« 
In the&e oaoeej.the^ if? as xule a oomiiderab.Ie forsnation of 
connective tibvne in theiioneyi^ lev kianeyit not aftzopMod 
and they are of ten increased ixx sise yet there will be 
charge in the stroma and^at the smw:: tten? ther#? will be con* 
Biderablo exudation from the blond vewelflb 
The t^Obific g-ravi^ of the uxdne io regularly low» The albumen 
is tiometidien?ahcnaa?^iL;?c/ret:kde^t-y» The albumen casts 
are no repent in an lax^e 'juantHieas in the fir^i set of 
oa»eB<» Instead- of from fMty to eighty.per cent of 
will only be eighteen to twenty per eent^ Although yva 
do find cast^they are not very nume.iuus^ 
567 The aropoy is not particularly markea. From time to ti.ne^ ciie x e 
may be some dropsy of ide feet ana lego but there is no general 
anasarca, no accumulation of fluid in the serous cavities. Ac 
to headache,if anything^ these patients are more liable to it 
than are the first set of patients. They are also more liable 
W the neuralgic pains, They are not as liable to Endocarditis# 
They are* more apt to have hypertrophy of the left ventricle 
without valvular lesions. They are more liable to Chronic 
^dartexd tis,^^ Cirrhosis of the Liver.- They are 
liable to the high arterial tension attacks and,<ith them, they 
will have the acute uraemic systems. They are liable to the 
spasmodic form of dyspnoea rather than to tie dyspnoea aue 
to dropsy of the lungs or dropsy of the pleura. There is the 
same disposition to anaemia am loss of flesh ana strength that 
there is in the first set of cases* 
These case^ vary as to their severity ana miration. Some will 
only la$t a year^cthe-ro will last several years* Some will ex- 
hibit all the tom»mothers only a few. Some may have inter- 
mlss'i^ns curing which-all the toms will disappear but,if 
not killed by some other aisease, they will ale of tie nephritis* 
They are more liable to ale suddenly,in an acute uraemic attack 
568 or in ,the chronic uraemic condition* A few die quite suddenly 
from no reasons that we can. discover* They will not have been 
sick.enough to he in bed,when,they will suddenly fall down dead 
without, any ceitbral symptoms, at all., 
- B •' -j ' ; ■ -- T R k A T M E N T . - 
The treatment is directed principally tc the nephritis- and to 
the acute uraemic attacks* 
As to tie nephri tis^you do not expect to cure i t> ye t, i t ones 
seem passible to prolong, life for a considerable time. Thi^you 
go by treatinb the general health. 
As a rulef the acute uraemic attacks are due tn incT*ea£ed artpr*. 
ial tension. Solute the dxu&s already set down* 
v j ' - 3-VERY SLOW CASES, - "' 
In thes^ cases.! the changes are principally developed in the 
stroma* There is a production .of new connective tissue ana 
mare or lets obliteration of the tubes and Malpighian bodies, * 
So-,as a rule> the kidneys are atrophied. The blood vessels do 
not tak^- Ln active shaie in the inflammatory process. 
As a rule, the urine does not contain albumen at all, 11 it gen- 
erally of low specific gravity. Most of the time it is increased 
569 in* quanti V and contains little pt na albumen ^na few ar no 
^asts. The albumen ano. casts may be absent altogether. 
As a rule, the earlier stages of the disease are marked by no 
symptoms at all- The inflammation begins in a very slow way and 
may take years to reach any degree of development; the kidneys 
continue to perform their fw iions fairly well? the patient 
becomes aeexs tamed to it and his general health continues fairly 
good. We know that this i® true, for, at the autopsies of the 
patients who have died of other find these kidneys. 
As the disease goes or^it will reach a point when we begin to 
have syap tons * Ab a ru 1 a t .f i rs i, th> &:i 1 j s/tom •A yJ C* changes 
in the urine. Many of the path eats vd.ll go on for months cr 
y^ars with no o the? . syup Ihe neat symptom is usually the 
hiper trophy of the left ventriel^ this is apt to preeeed any 
other marked symptoms, Befor®.sat the sane time?or-following 
the hyp ar trophy of the ven tri el e.? the patient is apt to have 
CMrohi# h-nhr teri ti^hvlmonaoy Emphysema,or Cirrhosis* These 
c o np 1 i e a iing di & ea. se g a re o f te n de v eloped before any evidence 
<?rf BxdghVs disease,except the changes in the urine* Sa?it is 
in those <aaset that the complications are of the most importance, 
570 This it the foxui of Bright's Disease that scuty people sx*e apt 
tn have* 
Ng^ some of, these patients will cn year after year without' 
much trouble and will die rf some other citease. 
Others 'will gradually show changes in the nutrition. They will 
lose freshhand s treng th,will have disturbances of digestion, 
will become anaemic,and will have headache from time to tiire> 
They will gradually ^et a little worse and a little worse but 
there win he no dropsy. After a considerable time? some of these 
patients on some particular day,till die suddenly:why?you never 
know* others will gradually get weaker and will &et to bedj then? 
they will cat hets and less,will become more and more feeble, 
will develop alternating stupor and delirium,and will gradually 
de* ! 
O'tben- will develop acute uraemic attacks,either with acute 
cerebral symptoms,dyspnoea,or vomiting These patients are very' 
liable tc acute uraemic attacks ano. they are just as liable tn 
them when, they have not ^iven any other symptoms of Bright's .• 
Disease as when they have. So,it is not uncommon for a person, 
apparently in perfect heal th? to develop general convulsions? . 
571 or suddenly to become comatose5or suddenly become hemiplegic, . 
tr to develop an alarming dyspnoea or an uncontrollable vomiting. 
The patient may die in this first attack but it is not at all 
Incommon for a patient to recover from a first attack and 
then, to suffer from subsequent attacks. Ye t, al though-i t is not 
uncommon for the patient to recover from the first attack, the 
rule is that,after this, there will be marked changes in the 
general health.As a rule,while the attack is going on, the urine 
is diminished and is apt to contain more albumen than at other 
times. Sometimes, these attacks arc due to contraction of the 
arteries and capillaries and this disturbance of the circulation 
is rendered still greater by the complicating hypertrophy of 
the left ventricle,, the complicating Cirrhosis, the complicating 
Emphysema,and the other complications. 
• thers will be in ordinary gooc health till they develop an acute 
inflammation,a pericarditis,pneumonia,or pleurisy. As soon as 
one oif these inflammations is developed, the patient will,in 
aadi Hon, give renal symptoms. The urine will be diminished and 
will contain more casts ana albumen. The patients will develop 
cerebral symp toms, ei the r ucute or chronic. These patients are 
very likely to die in a very short time. They may recover from 
the complicating inflammation but the renal symptoms will 
572 continue anc the patient will die in a few weeks or in a few 
mon ths after the intetcurren t inflammation has b youth t out the 
kidney disease. 
In this class of patients, the prognosis is better than In either 
of the others* If you could look at the kidney^you would not 
believe this but it is true. Mot that these patients are likely 
to L^t well,but they may enjoy pretty fail' health year after 
year. The:/ may even live twenty years after you have made the 
aiaanosis and,during all this time, they may attend tn work. 
This favorable prognosis may be very much aided by mana^ein^ 
the patients made of life. Make the patient avoid overwork. 
Make him take long, holidays:make him avoid bad habits and excesses: 
and take care of hie food. If you can only do this,you will be 
surprised to see bow well they will do. 
When these patients have the uraemia attacks,&ive the dilators 
of trie arteries and capillaries. 
Of course, these three divisions are very rou^h and arbitrary. 
Ygu may find many cases that will not fit into any of them but 
a hood many will and. it is & ^ood way to f3rnup them. 
-TREATMENT 
573 - CHRONIC congestion • f the kidney.- 
Chronic congestion is not at all peculiar to the kidney:it is 
found in other viscex'a. It is regularly due to. & mechanical 
interference with the circulation of the blood>which lasts a 
considerable time. The most - frequent cause is a change 
in the valves of the heart which results ?:rom Chronic Endocar- 
oiti&,or dilatation of the ventricles of the heart which comes 
on without discoverable Less, fre<ue^ily?we find that 
pericarditis with extensive adhesions or large effusions of 
s e rum? an aneu ri sm o f the ao r ta? Pu Imonary Emphysema 5 Pleu ri sy 
• that lasts a long timber tumors pressing upon the aorta will 
produce it* 
Curiously enough^ al though these disturbances of the circulation 
are due to central causey there is a great- deal of difference 
in the different patients as to which vd^qus will be the teat 
of the chronic congestion* You would think that all the viscera 
would be congested but this is not Ite case> In one pat:x e x & v y i t 
will be the lung; in ano thethe s icmach; in ano thethe 
kidney. So^a disturbance in 'the cireulatian and insulting venous 
congestion is no aseurence that the patient conges lion of 
the kidneythe may or he may note In other casea^ the kidney will 
be the only viscus that is congested. 
574 In whichever one of these viscera Chronic Congestion is estab* 
lished,it remains fox* a considerable time, simply Cm Cm 0 2*1 *• 0 i X V 
congestion. This will make the viscus larger and firmer but there 
will be no structural changes. New? this simple congestion con* 
tinuint?^e two things may happene In some cases, the viscus 
will still perform its functions fairly well, In other eases? 
with nothing but congestion, there will be a disturbance of the 
functions of the viscus;dyspnoea,if the lun^s be congested? 
vomiting, if the stomach be conges ted| or pain in the stomach; 
ox* the patient will not pass sufficient urine,if the kidneys 
be conges ted. Why some can stand this congestion and others 
can not,we do not know. Apparently,some people are toucher than 
others* 
Then,no matter which viscus be the seat of the congestion, after 
a time, there will be structural changes* These structural changes 
are of two varieties? first,chanset in the capillary vessels,and^ 
secondly,a chronic inflammation* 
The character of the chronic inflammation varies with the viscufe* 
In the kidney,it will either be a chronic parenchymatous inflame 
mation or a chronic diffuse inflammation* 
If the inflammation be of the chronic parenchymatous variety, 
575 the kidney will be enlarged,the cortex will be pale and we will 
find changes in the epithelium of the tubes. 
Iff the inflammation be of the chronic diffuse variety,all the 
tissues of the kidney will be changed* We will find changes in 
the ei ifeelium,new connective tissue, thickening of the walls 
Of the arteries,and atrophy and destruction cf the Malpighian 
bodies. 
Before the in -lamma tion is established and we simply have chronic 
conges tion, th., kidney will be larger, heavier^ harder, and red 
with blood but there will be no stiuq tural changes. When the 
parenchymafeus inflammation is added, fee kidney will still 
be increased in size^but the cor tex, ins lead of being dark red, 
will become pink,pale,or even white. When fee chronic diffuse 
•inflammation is added,the kidney may be increased or diminished 
in sige but it will still be hard and will retain the appearance 
of general congestion. 
.Now,when & patient has any of fee causative diseases that have 
been mentioned, these conditions will continue for a longer or 
shorter time without establishing G.'.ir. onic v;O.'...ge£ tron in any 
part of fee body. The patient goes on wife these mechanical 
conditions existing,yet, the circulation is carried on as it 
576 Should be. Then, after this period of comparative comforts the 
circulation does become disturbed and in one way* Throughout 
the body, the blood leaves the arteries and accumulates in the 
veins and we have a chronic congestion of one or other Qf the 
Vise era. Now when the kidney becomes the seat of 'this chronic 
congastion, the patient develops symptoms that he did not have 
befare-and these symptoms depend partly up on the condition of 
fhe •-kidney ^nd partly upon the condition of the circulation 
throughput the body* So.,when we have cardlao,pulmonary,or stomach 
disease and, then,have added a chronic congestion of the kidney/ 
the patient will have cough, dyspnoea, haemorrhages, or loss o:t 
appe ti te, , vomiting, and severe pain referred to the* s tomach; then, 
in addition, there will be limi ted or general dropsy cerebral 
symp toms,s tup or alternating with de ?.ixdum, headache., convulsions-, 
or coma* These latter symptoms are due tc the kidney* In addition 
the patient will lose flesh and strength* He will become anaemic 
on account of changes in the composition of the blood.* The 
i^rine will be diminished in quanti ty,no t as a rule suppressed* 
the specific gravity will be normal or,even higher* The urine 
wlll.'.edhtain a small quantity of albumen and a few casts* 
Now^hl'thouth these changes in the urine are but slight,-the 
577 functions -of the kidney are more disturbed than you would think* 
So,al though-the urine appear but little changed, the patients 
fail to tet rid of the proper quantity of excrement! tious 
substances^' 
Now,'some of these patients remain in this condition with these 
symp toms: then, they will pet worse and will die with the greater 
number' of the symptoms* 
Or,it may very well happen that,after exhibiting all these tymp* 
toms for a time, the viscera will disgorge themselves, the symptom® 
will disappear,and the patient will return to fair heal th: but 
when, he has had one at tack, he is apt t^ have more, the succeeding 
attacks are apt to be worse,and he will finally die in an attack. 
In other cases, the symptoms will not be bad enough to cause 
ceath but the circulation will not return to its normal con* 
oition* The- congestion of the kidney will not po away* The patient 
will have inflammatory changes in the kidney and he will po cn 
with symptoms,partly made up of the symptoms of the causative 
lesions and,partly,of the symptoms of Chronic Bright3 s Disease. 
So jin Chronic Congestion of the Kidney, there are always two 
things to be taken into consideration: the causative lesions 
and the kidney lesion. a 
578 In t^e majority cf oases, the development of the symptoms will 
be g^dual^-t first, there will be one sjtP tom, then,anomer and 
another will follow? but, from time to time, you will see cases 
with, a sudden invasion of 'the symptoms* You will see patients 
whtl hevc suffered from heart disease or Emphysema for years 
wiih^but little ut no inconvenience, then,on some day, they will 
suddenly develop an acute-pleurisy or an acute pericarditis or 
without even this,with no additional lesions at all, they will 
suddenly develop a dis tressing dyspnoea,dyspnoea so severe that 
the pa.tient can not lie down,can not ileey,but has to sit up 
on accoun t of i to The dyspnoea continues and, soon,.the other 
symptoms follow,loss of flesh and styen^ th,dropsy,disturbanee- 
of the 5 tomaehjoereb ral s^np iom^.e ta< These symptoms succeed 
Che dyspnoea in a few d & s &* rulev the patient will die in. 
a few days* he may last several weeks-?but the majority of these 
]>aiHnts die at -ihe end of a few daj^n Why this sudden change 
In nhe condition c-f the circulation, uhculd come,is ^vevy hard to 
decide^ Yhan the Fleuxigy or the Pericarditis is developed, 
erhaps, are stiff icion t io ae-count f0r i t: bu t, when the 
patient is well the day before and diej? a few dayf? afterwards. 
It is:very difficult to determine the cause? in fact, it is i®*, 
j^o»ilble< 
579 - TREATMENT < - 
Treat the ciraulation, Sa^beur in mind thais when you have charge 
cf a patient with ah.ro.nie heart disease er Emphysema^he :U 
always in danger of having Chx*onio Congee then of the Kidney* 
S$?be on the look out for .the moment. when these .distuxhances 
in the circulation are developed* The moment you find the pulse 
becoming tm> strong cr toe feeble or even the beginning of in^ 
created arterial tension treat the airculaUon^far it it much 
easier tn treat it in the earlier tugte than in the later ttaget;* 
If you find that the heart is an ting fairly well but *»! th some 
little disposition to become too rapid and irregular and the 
arteries a little harder hran -they should be^glve iodide of 
potash in five to twenty grain 10^^5^000rding to the suscept* 
ibili -y ansj of pfctient- Continue its uee until the aotiwi 
Of the heart beaj:n«o more what it should be^ 
In oho.sr a a s e *y -yi; vdll find the heart decidedly feeble and 
irregular. Give'digi talit,caffeInejGOnvallaria^or s troph&n thus 
aiui^ li wi th .th • s feeble hearty there be t dispesitibn to oontractive 
of the arteries combine iodide of potash with theme 
If you find the eon traction of the arteries alonejglve opium 
in Small dose £ 5 ehlorals nitrite of amyi5and m tro<* glycerine and 
continue their use day after day. 
580 Now,in the patients in whom these disturbances of the circulation 
are not very marked, this treatment is exceedingly satisfactory* 
The patient feels better immediately aijd may continue to feel 
better for a considerable time* The longer the disease has lasted,* 
the less efficient will these remedies be but you have no others. 
'Those sudden cases with marked dyspnoea do not respond to treats 
ment at all and you will fall back upon opium-in considerable 
dosea,simply to make the patients more comfortable. 
581 - 2-SUPPUR ATI V E. N E P H R I T 1 S . 
The suppurative inflammation may involve the mucous membrane 
of the pelvis and calices of the kidney, the tissue of the kidney, 
or both. It may be due to injuries directly over the kidney cr 
to penetrating wounds of the kidney: to the lodgement of emboli 
in the kidney: it may succeed inflammation of the bladder,enlarged 
prostate,or the presence of calculi in the ureters or pelvis 
Gf the kidney: it may follow stricture and gonorrhoea: or it... 
may be idiopathic. - ' . 
-Suppurative Nephritis Following Injuries.- 
The injury may be a gun shot wound passing- through the kianey 
or an incised or penetrating wound of the kidney but, most fre* 
quently, this form of Suppurative Nephritis follows severe blows 
over the kidney, if the injury be severe and involve both ; 
kidneys, the patient will be apt to die from the immediate, ef* 
feets of the injury before any considerable degree of inflam- 
mation is s e t up,, f o r, a 1 thou gh the k i d ne ys a re small organs., an y 
severe injury of them is incompatible with lifeo If the injury 
be less severe or if only one kidney be involved, the patient 
will live and develop a suppurative inflammation of the kidney. 
If the injury was a gun shot wound or other pehe tra ting'wound, 
suppurative inflammation will commence at the injured part of 
the kidney and will extend and involve more and more of the. 
tissue of the kidney. - - 
582 If the injury be external, we have at first a simple death of 
part of -the kidney. This is rather a curious effect of-injury 
but we also get if after blows over the liver. Then, this dead 
portion of the kidney will change color,will become dry and 
yellow. Then, the dead tissue will shrink and soften and sup* 
J^urative inflammation will be set up about its edges. Then, this 
Suppurative inflammation will ex tend and involve a larger part 
of the kidney .tissue. 
So,we first get the history of -the original injury: then, the shock 
Sue to the injury of so important an organ as the kidney: and, 
then, there is an interval of one or more days. Then, the suppur- 
Vtive inflammation commences and the patient has chills and fever. 
The chills are often repeated. The fever- often continues throughout 
the diseasejit is of the hectic type: and is often accompanied 
by sweating. There, are loss of appetite: of tea, vomiting* and paia 
over the affected kidney. The urine is diminished, some times 
suppressed and it.will contain blood or blood-and pus, Sometimes, 
these symptoms will go on for a number of days: then, gradually 
tub side ;and the patient will get well. Whem this happens, it means 
that the part of the kidney that was affected was small:but 
kuch a x*ecovery is not common. More frequently, the symptoms 
583 continue and the patient will pass into the typhoid state and. 
will die in it. 
- Treatment. - 
The treatment is surgical. Cut down on the kidney, remove, the' • 
suppurating and neetic tissue,and treat the wound antiseptic 
cally. 
- Suppurative Nephritis Resulting from Emboli.- 
Emboli become lodged in the branches of the renal arteries* 
In order to produce such a suppurative inflammation, the emboli 
must have an infectious charac ter.,mus t contain some micro-or- 
ganism, generally,micrococci. So,patients suffering from Malig- 
nant Endocarditis and infectious thrombi in the veins are liable 
to this form of Suppurative Nephritis* This form of the disease 
is moi of great importance as a kidney lesion. The patients 
give the symptoms of the primary disease* After death,we find 
the kidneys studded with little accesses* The patients do not 
have any kidney symptoms and there is no treatment for the 
kidneys. 
584 - Idiopathic Suppurative Nephritis.- 
As a rule,it is impossible to tell whether the suppurative in- 
flammation began in the substance of the kidney or in the mucous 
irembrane of the pelvis of the kidney, for, as a rule, the disease 
lasts for a considerable time before causing death. As arule, . 
only one kidney is involved. 
After death, the affected kidney does not look like a kidney. 
You find something that has the general shape of a kidney but 
this something is no longer composed of kidney tissue. It eon* 
sists of a cavity containing pus. The walls of the cavity are 
composed of connective tissue with,perhaps,a little kidney tissue, 
tn the outside.,you have the capsule and, passing inwards from 
this,are septa and,be tween the septa,are cavities containing 
pus. The capsule is usually thickened but,occasionally, the sup- 
purative inflammation will extend and sinuses will be formec 
in the soft parts of the back. The inflammation is chronic and, 
throughout its whole course,it presents the same sluggish char* 
ac te r. 
The invasion is not particularly well marked. Of ten, the patient 
can hardly, tell you when the disease began. The patient grad- 
ually loses appetite, flesh, and strength. He develops an irregular 
585 fever which comet and goes® The temperature is not very high® 
The fever is often accompanied by sweating® The patient contin- 
ues to lose appe ti te, flesh ana strength® He develops nausea and 
there maybe vomiting® He becomes anaemic® 
The local'symptoms are the following® The patient develops pain 
over one kidney® The pain varies -in severity and constancy®. It 
is not necessarily one of the first symptoms but,when it is de* 
velopedjit becomes more marked® 
For a considerable time., these-will be all the symptoms, 
Then?after a. time, there may be an escape of pus into the ureter 
and bladder; .The cases vary as to how large the evacuations of 
pus will be® As a rule,, the pus is not passed in equal quantity 
esch day. It seems to-..be possible for these patients not to 
yass any pus at all with the urine* 
Then, after a time longer^ the kidney may form a tumor that you • 
•an make out in the abdominal cayi ty* But, this tumor is not 
constant* It- maybe absent® His particularly when the pelvis 
of the kidney is distended with pus that a tumor will be formed and, 
ifjat the same .time, the patient pass pus in the urine, the tumor 
will diminish in size after each evacuation of the puss then, 
the tumor will get larger again and will again diminish in size 
with the next evacuation, of pus® 
586 If the suppurative inflammation extend to the tissues behind 
the kidney, the pus may burrow upwards to the diaphragm or down- 
wards to the pelvis and these tracts may perforate the skin 
and sinuses will be formed* The pus may burrow through. the in- 
testine and be discharged with the stools. 
Generally, the disease lasts .months and years and the patient 
gradually gets worse. II? he be not cut- off by some intercurrent 
disease^e will develop waxy degeneration of the liver, spleen, 
and nthe r k 1 dney and wi11 die 1 n extreme emaelation and exhau£- 
ticn. 
In these cases, the trouble is in making the diagnosis in time 
to do any good. If you have these changes in the general health, 
pain over the kidney, the formation of a fluctuating tumor, and 
the discharge of pus in the urine^ the diagnosis is easy enough: 
but if the pain come and ga, and if there be at no time any tumor 
or discharge of pus in the urine, the diagnosis is very difficult. 
- Treatment. - 
The only treatment that is likely to be of service is surgical. 
Either remove Cie kidney or open it fairly and convert this 
Mhkealthy cavity into a heal thy cavity. If this can be done 
before the development of waxy changes in the other viscera, 
.the patient's chances of recovery are fairly good. 
587 Suppux^tive Nephritis as a Result of Cystitis* - 
Cystitis is one of the most common causes of Suppurative Nephritis. 
The s^^urative inflammation of the bladder may be due to oper* 
stiohs on the: ure thra,bladder,or u terus; to calculus? pax'aplegia; 
or may be secondary to gonorrhoea,enlarged prostate,or stricture 
of the urethra. 
We will firAt consider these cases in which the cystitis is 
cue to stricture of the urethra* The cystitis maybe either 
acute or chronic. Thereafter it has lasted some time, the sup- 
purative inflammation will extend along the ureters to the 
pelvis and calices of the kidney and will also involve the medulla 
and cortex of the kidney. As a rule,bo th kidneys are inflamed 
to the same extent. After death,we find the kidneys increased 
in size and studded with large or small foci of pus* The whole 
character of the inflammation is infectious. We find micro- 
organisms in the pus in the bladder and in -the abcesses in the 
kidney. '"'.Z 
- .S Y M P T 0 M S 
The symptoms vary with the causes We will first consider those 
eases in which the.- Cystitis is due to e trie ture, calculi in the 
bladder?paraplegia?or operations on the urethra or bladder. 
588 First, we have the symptom of Cystitis ano the** symptoms n^y 
last considerable time before the kidneys become inflamed. 
Of course,many of tie se patiente nevw develop suppurati^ 
nephritis but all of them are in conEtant danger of it. If the 
danger is realised,we find that, on seme particular day? the 
patient,still having hit Cys ti tis^ill have chilli and a fever. 
The chills are apt to be repeated. The fever is ap t to continue: 
It is of the hectic type?and is often accompanied by sweating. 
Then,in a day or zl 0 £ i»-•- * u • Ch iient rapidly x*un down?lose flesh 
and strength and go to bed. Thenjhe will pass into the typhoid , • 
©end!tion, the tongue will become dry and brown and there will * 
be alternations of delirium and e tupcs,e to. ?and the patient will 
^et worse and worse® 
As W- the changes in the urine, they are partly due to the Cystitis 
and,from this causa?we find blood,mucus?and pus in ihet urine; 
but?when the kidney lesion is added, the urine will be diminished 
and often considerably diminished or even suppressed,it will ,, 
Contain an increased quantity of blood and pus. 
This, form of Suppurative Nephritis is,apparently,always fatal. 
^e' will now consider those cases in which the Cystitis was due 
to Gonorrhoea. 
589 These eases are sweally mu^h more rapid, First, the patie>t 
has Gonorrhoea. Then, the inflammation ex tends to the bladder^. 
Gonorrhoeal Cystitis. The Gonorrhoeal Cystitis is apt to be 
severe and acute and attended by well marked symptoms. Then, '. 
the inflammation ex tends to the kidney and Suppurative Nephritic 
is developed. Then, the patient 'gets woxve very rapidly, There 
are chills,fever,and a rapid loss of flesh and strength: but the 
cerebral symptoms are apte to be well developed, marked delirium 
alternating with stupor which are apt continue till death. 
The patient may die five days after the inflammation of the 
urethra is developed. !~ 
We will now consider those cases in which the Cystitis was due p 
to an enlarged prostate* We first get the history of an enlarged 
prostate. An elderly man cannot pass his water as well as he 
•ould before. At first,he has to pass hil water too frequently,* 
Then,he can not pass it at all and has to use a catheter. Then,' 
he will go on for years with this inconvenience* In some at 
these cases,a Cystitis will be added after a time.. 'This Cystitis 
is at first chronic and does not give much trouble. It will causa 
some pain and you will find some mucus and pus in the urine. 
The patient may go on in this w&y for some time. 
590 Then> there will come a day when the patient will not-be able to 
pass hit water at alle The patient introduces his catheter but 
draws off no water* he may draw off' a little bloods Then, he is 
very much alarmed® He sends for his physician who does the same 
thing,he introduces the catheter and' either draws off no water 
or a little water and blood® Then,in a few hours.* the patient 
becomes very weak:he has no chills,no fever:he simply passes 
very little water and is much prostrated® Then,he "becomes ex- 
eeedingiy res Ue tx, hi a heart becomes rapid feeble, the surf- 
face of his body becomes cold,he passes into collapse.,and dies. 
St,all the forms of Suppurative Nephritis that follow Cystitis? 
are regularly fatal. 
The- real treatment is prevent! tive. See that these patients co • 
BOt.'have Cystitis® Even if they do develop Cystitis, if this 
tan be cured in time, they will not develop Suppurative Nephritis. 
i, * * 
591 - TUBERCULAR N E P'H E I T I S . - 
This disease is not very uncommon. As a rule,the tubercular •• 
inflammation does not only involve the kidney but also the ureter* 
blander,seminal vesicles, tes tide,and prostate in the malesand 
the uterus,ovaries,and fallopian tubes,in the female# So,it ic 
really a tubercular inflammation of the ^enito-urinary tract 
and it is regularly confined to one side rf the body* 
IiS all these different parts, the inf lamination has the same char* 
aeter. It is attended with the production of tubercular and 
granulation tissue both of which rapidly die and undergo cheesy; 
degeneration. In the kidney, the inf lamination will begin in the 
pyramids and will extend to the cortex and we will find a con- 
siderable part of the kidney tissue converted into cheesy matter. 
In the same way, the walls of the pelvis of the kidney,of the 
ureter,and of the seminal vesicles will be changed into cheesy, 
matter. In some cases,the inflammation will begin in the kidney 
and, then, ex tend to the other parts* In'other cases,it will begin 
in some of the other parts and, then, ex tend to the kidney. Rut, 
when the inflammation has once begun,!t is apt to extend and. 
involve a considerable part of the geni to -urinary tract on that 
'tide of the body. 
592 In many oases, this will be the only lesion in the baby. Other 
oases will after a time develop a general tuberculosis, a tuber* 
crular peritonitis,or pulmonary phthisasor there may he a Chronic 
He। hritis Vv 1 th wa^y depone tion o f ^he v e ese xs, Invo 1 ymp th*s 
ether kidney^ So, the disease' fs dal only dan^ercufe In Itself 
but bee au s e th e p a ti e n t % - 1$ ab ] a U> t ub ereui a r A f 1 am ma ti c as 
of other parts of the body and to Briaht-s Disease of the other 
, kidney* As a rnle$ the disease kills in one. of these two ways* 
v 7 T 0 L 0 G V • . L~- 
. j-i J- v x,/ & 
The disease is more common in males then in females in the 
'proportion of two to onec It is very much more oummon in middle* 
&^ed adul ' ■ < 
< - s y m T T 0 h s? - 
-The-first symptoms are apt to be the changes in the urine. The 
• urine will contain blood in smal/er 02? larger cyanti ty.pus,and 
.granular matter. In additiem, there will be mucus and broken 
.down kidney tissue- be more albumen than can be 
eceountec for bj^ the blood and pus and no change in the 
quantity of the urine. Thnn^after a time,we regularly set the 
Chronic Nephritis in the ouhex' kidney^ Then, the urine will be. 
lame times increased., some times ^diminished in quantity* The spe» 
Gifie gravity will be 1^ and it will now contain -albumen in 
593 ^uantitytin larger quantity than can be ac e run ted 
for by the blood and put/ 
The patient suffers from pain over the inflamed kidney. This 
pain lb sometimes dull, some timet,paroxysmal. With it, there nay 
be tenderness over the kidney* He develops an irregular fever 
who which oomes and goes,is not marked,and is often accompanied 
by sweating. He loses appe ti te,flesh,and strength and becomes 
anaemic. In some oases,we can make'out a tumor in .the position 
of the inflamed kidney. This is due to enlargement of the kidney 
but the kidney may remain of the natural size or it may become 
^mailer* 
The patient may have symptoms of tubercular inflammation of other 
parts of the genito-urinary tract. If he have a tuberculous 
inflammation of the bladder,we will get the symptoms of Cystitis: 
if of the prostate,we will get enlargement and inflammation of 
the prostate? if of the testicle, we w? 11 get the enlarged, tuber- 
culous testicle: and if the p?-tient have a tuberculous inflammation 
of the iterus?we will get the symptoms of tubercular metritis. 
The disease is apt io go on and last for years. If the patients 
are left to themselves, the disease is apt to prove fatal. They 
die of the tubercular inflammations of other parts,of Bright's 
Disease of the other kidney,waxy degeneration of the other vis- 
eera,or of exhaustion. - - 
594 It doe® seem possible for a patient tc recover without treatment. 
'This is only true when the inflammat' on involves the kidney 
alone, We. knw that this can happen,for,at autopsies, we find 
'kidneys with one quarter of their tissue converted into cheesy 
: matter and,previous to deafly the patient will have given no 
. symptoms of Tubercular Nephritis at all- But such a recovery 
' is rare and these patients do require treatment and the real 
treatment is surgical and consists in extiipaiion of the kidney. 
The earlier this operation can be performed, the better for the 
patient, Make the diagnosis as soon as possible and, then,extir- 
^pa te« 
595 - T U M- 0 R S OF THE KIDNEY. 
Tie most important'are the sarcomata and the adenomata. 
The sarcomata are. connective tissue tumors,formed of connective 
tissue cells and a basement substance. 
The adenomata follow the type of glandular tissue and resemble 
somewhat the renal tubules. 
Either of these farms may begin in one kidney and will usually 
grow pretty rapidly and will attain a pretty considerable size* 
but,occasionally,especially the sarcomata will grow pretty 
slowly and will exist months and years before reaching any eon. 
siderable size?but, the rule is the other way. 
Many of th^ tumors will preserve somewhat the normal shape of 
the kidney,even when they are very large?but,at other times, 
the tumor will begin in some one part c-f the kidney and will 
form an irregular tumor. In a certain number of the cases, the 
kidney will remain in its natural position and,growing rapidly, 
will push up the peritoneum and will projectforward into the 
abdominal cavity. In other cases,the kidney will become dis* 
located and will sag forward and downward and you will feel it 
as a tumor,more oi' less movable,but still capable of being 
pushed back into its natural position. 
596 Whether they he fixed nr movable, mo st of the tumors will pro- 
ject forwards but..occasionally^one will grow upward, and, if you 
do not see the patient until the tumor is of some kittle size, 
you may not be able to distinguish it from an enlarged liver. 
These tumors regularly begin in one kidney and they may remain 
confined to one kidney: in other cases,secondary growths will 
be developed in'the other kidney: and, in still other cases, there 
may be metastatic growths in other parts of the body- 
- E T I 0 L I G Y . - 
They are rather more common in children than in adults and, in 
»hildrenswe sometimes find them at so. early an age that they are 
probably congenital, 
y. ■ . . -SY MF T 0 M - - - 
The symptoms consist in pain over kidney, the formation of 
a'tumor, the presence of blood in the urine,,and,af ter a time, 
♦aehexia. ' 
In some cases, these symptoms will be well markeda First wd.ll 
tome the pain. Then,from time tu time, the patient will pass 
blood in the urine* Then, in a few months, you will be able to 
make out the tumor. Then, the pAtient will lose flesh and strength 
and will pass in to • the cachectic condition. In these cases,,- 
597 the diagnosis is easy but it is not certain until you can make 
but the turner* Thermit is s traight-forward enough. But,even 
after the tumor has reached z. considerable size, the'se patients 
often do not show as much cachexia as you would expect* 
tther patients,and there are quite a number of them,will not 
have all the characteristic symptoms and, then, the diagnosis 
is very difficult and uncretain* Some do not at any time have 
blood in the urine. Others do not have a tumor that you can 
make cut. In other cases, there will be no blood in the urine and 
no tumor. In others, the pain will not at any time be markedo 
The most important and only certain symptom is the- tumor, 
it is of . the greatest importance to make out the new growth as 
soon as•possible,for the only treatment that is of any service 
consists in extirpation of the kidney. If this can be done early- 
enough, while there are no metastatic growths or growths in the 
other kidney, the prognosis will be goods but, even if there he no. 
metastatic growths,if the tumor be large and if the pai ent is 
a child, the prognosis will be bads I doubt if it be worth while 
to perform this operation in, children, for they do not seem tc 
be able to bear it. In adults, the prognosis is better bur,even 
then,if the tumor be large, there will probably be new growths 
in the other kidney* '• 
598 - R ENA M CALCULI , - 
fee solid constituents of/die urine, especially the urates,uric 
acid,,phosphates,and oxalate of lime are capable of being de~ 
posited from the urine in the tubes,pelvis,or calices of the 
Sidney., • . * A 
tn young infants,a few days old,it 'a' the rule to find deposits 
of the urates of soda and ammonium in the larger tubules of the 
pyramids® As a-rule, these deposits do no harm.. They are so ccm* 
mon that,if we do. not find them,it is generally because the 
.•hild was still born. This is one way of distinguishing between 
children who were still born and children who lived a few days* 
The rule is not absolute® 
In children a little older,one to seven years of age,we not 
infrequently have little calculi in the pelvis and calices of 
the kidney® As a rule they are not of great size but,occasion* 
ally, one of them will be large enough to nearly fill the pelvis 
of the kidney. For the most part, they are formed of uric acid, 
•coasionally they will have a covering of oxalate of lime,. Oc*- 
easionally,they will be formed of oxalate of lime alone:oecas* 
tonally, of cystine. The phospha tic calculi are rare. As a rule, 
we only find these calculi in one kidney in these young children* 
599 Th^re may be several small calculi or one large calculus® They 
may remain for some time in the kidney and do no harm* If small 
enough) they may pass into the bladder and be discharged with 
.the urine® They may be too large to he discharged and may re- 
main in' the pelvis of the kidney and set up an inflammation of 
'the pelvis or an inflammation of the kidney attended with the 
production of new connective tissue or of new connective tissue 
and pus* They may remain in the pelvis of the kidney and nc t 
set up inflammation bu t, simply, dam up the urine and produce 
dilatation of the pelvis and calices,hydronephrosis* 
in-adults, these renal deposits may take one of three formsy renal 
sand,gravel, or calculi* Renal sand is a very fine deposi t, almos i 
.like ordinary sand and composed of uric acid and the urates* 
Gravel is a larger deposi t, composed of uric acid and concretions 
of -urate of soda,but small enough to pass into the bladder and 
be voided® So,sand and gravel are regularly discharged by the 
urine, soon after their formation* The ••rue calculi are larger 
still. Many are composed of uric acid® Some are composed of 
uric acid with a shell of oxalate of lime: o thers,of oxalate of 
lime alone: some,of the phosphates: some,of cystine* They may 
only be the size of a pea or they may be considerably larger. 
600 'Some are round, Others take the shape c f the pelvis of the kid- 
ney and send out prolongations fitting into the calices. We 
find these calculi either in one or both kidneys and they may 
be developed in ho th kidneys at the same time or, first, in one 
kidney and, therein the other. As a rule the smaller calculi 
'do not remain in the kidney for any length of time but escape 
into the bladder where they may remain or may be voided with 
the urine. But,when there are several calculi in the kidney, 
they will not all escape at the same timet they will escape one 
after the other. Even a small calculus may remain in the pelvis 
of the kidney and give trouble for months and. years before it 
will escape. The larger calculi will remain in the kidney. Even 
seme of these large ones will get a little distance into the 
ureters and, there, remain. When they remain in the pelvis of the 
.kidney or in the ureter, they may cause hydronephrosis, a trophy 
of the kidney,or inflammation of the mucous membrane c f the 
pelvis or inflammation of the kidney tissue with the production 
of pus or with the production of new connective tissue. * 
So, no age is exempt from Renal Calculi. - They are more common 
in males than in females. App a ren tly, climate and the character 
of the drinking-water do have something to do with their pro- 
duction but,exactly how,we do not know. The calculi in children 
601 o$cur frequently among, the children of the poor. In adults, 
they are equally coalmen among the rich and po®r. Apparently, • 
the gwty diathesis and a sedentary mode of life predispose 
to Renal Calculi. How much the large eating of meats and drinking 
of wines hatve to do with their formation,we de not know. It 
is evident that?fr.r their production, the urates,uric acid,phcs- 
phate^and cystine must be present in increased quantity or, if 
this be not the case, the urine must be le^s capable of holding 
them in solution. One very simple change in the urine that would 
cause them to be deposited is a diminution in the quantity of 
the urine. Changes in the reaction of the urine would cause . 
them to be deposited* Thus.,if the urine should become tee acid^ 
the uric aeid,urate^and oxalate of lime would be precipitate^ 
If it should become alkaline, the 'phosphates would be less read* 
ily held in solution, In add!tf^n,any chronic inflammation of 
the mucous membrane of the pelvis of the kidney might be attended ■ 
by the forma tian of phospha tic calculi. 
The sand and gravel give no symp toms, exsep t that we find them . 
in the urine. Some times, the gravel will be large enough to 
stop for a time in the ureter and give a little pain. The presence, 
of sand and gravel in the urine shows that the urine is in a 
condition to form larger calculi* 
602 -We now come to the. calculi 'that are larger but are ;still smell 
enough to pass. Some.,al though nearly as large as a pea will 
slip through the ureter and urethra without any trouble, More 
frequently,as they 'pass through the ureter, they give rise to 
attacks of Renal Colic. 
--R E M A L COLtC.- 
A small calculus escapes into the first part of the ureter and, 
then, the patient at once begins to have pain and this pain is 
the first symptom. The pain is regularly referred to- the kidney 
and radiates down the ureters. It comes On very suddenly: the 
patient may even he attacked, by it in the street. The pain may 
even radiate to •_ the testicle or thigh or, less frequently,i t 
will radiate upward towards the diaphragm or forwards to the 
abdomen. At the same time, there is apt to he a retraction of 
the testicle on the same side and the testicle may become swol« 
len and tender. The pain is dreadfully severest may he so severe 
that the patient will faint or pass ir o convulsions^ The patient 
may vomits- tecasionally, there is a fever. There is often irri- 
tability of the neck of the bladder. This will make the patient 
.feel the desire to pass water frequently but it will give him 
great pain to do so and he can only pass .his urine in drops and 
it will frequently be bloody. Some of the patients do not have 
603 this irritability of the neck 6f the biaauer ana. blood 
in the urine. 
In post of the eases,when the ealeulus behaves in this way,it 
is confined to one ureter and the other kidney will on per- 
forming i ts function: but) from time t© time,a patient will at 
the same time have a calculus in both ureters* Then, the patient 
will stop pa^sins water altogether and,if - the calculi are unable 
to escape., the suppression of urine will continue and, uni ess the 
patient be relieved by opera tion?he will develop chronic uraemia) 
will pass into the typhoid stateTand will die* 
Some people,ana the number of them is'considerable^only have ' 
one kidney, ei ther as a congenital condition or because the other 
kidney has been destroyed. Now, they may have a calculus in the 
ureter of this kidney and,if this calculus be unable to escape^ 
these patients also will develop fatal chronic uraeaia. ■ •• 
As a rule,however,such a calculus only involves one ureter,people 
do have two kidneys, and the calculus dees pass:but the time that 
the calculus? takes to pass down the ureter varies very consid- 
erablyoln sere cases,it will only take a few hours and, then, 
the patient will be just as well as he was before* In other cases, 
|he calculus will take several days: tc pass. Then,as a rule,) 
604 It go along foya certain distance giving, pains then,it will 
e top, the pain will eease,and yr-u will think that the patient 
has passed it; therein a few hours, it will move on again? and, sc 
cn: and it may he several days before the patient really passes 
the calculus. In other cases, the attack will last an unusually 
long time because the patient will pass one calculus af ter another* 
Jk^yc-u may have a patient undex* observation for one nr two 
weeks,suffering pain all the time. 
§ome patients, those who are fortunate only have one attack and, 
Jhen?never have any more trouble, This is not a very uncommon 
history. More frequently, the patient does have more than one • 
attack butjhow many he will have and how long they will last, 
•t6u can not'say. Some will suffer from repeated attacks for years* 
^hen» they suffer very much,not 'only from the .pain of one attack 
hvt .from the fear and apprehension of having another, A person 
who has had one'attack of Renal Colic is very unwilling to have 
another, The pain is probably the worst sort of pain that there ' 
is: it is something terrific^ 
In some oases, the calculus will engage in the ureter,will pass 
some'.little way down it, and will remain for the rest of the 
605 patient's life. It is apt to-. gradually increase in size and, 
if the patient live a considerable time, the calculus may become 
one inch in diameter. As a rule,it dees net destroy life. 
Situated in the ureter, the calculus will eithei' completely or 
partially prevent the escape of urineu 
If the obstiucticn be complete,it is apt w he follower. by atrophy 
of the kidney* The ether kidney will became hypertrophied and, 
after a time, the patient will practically only have one kidney. 
If the obstruction be incomplete, the kidney will still continue 
to produce urine but?as this urine has some difficulty in es- 
caping, the calices and pelvis of the kidney will gradually be- 
come dilated. In some of these cases, the renal epi thelium, 
Malpighian bodies,strona,and blood vessels may remain in fairly 
good condition. In others,a chronic interstitial inflammation 
with the produc tion of new connective tissue and atrophy and 
obliteration of the tubules will be set up. Either of these 
oondi tions,hydronephrosis or the interstitial inflammation is 
not as a rule dangerous to life,for the other kidney becomes 
hypertrophied* But the patient may very well suffer from pain 
Mid discomfort and the calc-plus may very well set up an inflam* 
mation.in the ureter which will extend to the surrounding soft 
>artB and increase the pam,^/ . 
606 '♦ther calculi remain in the pelvis of the kidney. When this is 
the case, in some patients? there will be absolutely no symp toms 
at alls We find these calculi at the autopsies on patients who 
have died-of toher diseases. It is generally attended by atrophy 
Of the kicney but VAX S 0 Till6 r kidney will become hypertrophied* 
More frequently, these calculi do givv trouble. 
In some cases?there will be no inflammation either of the mucous 
irembrane of the pelvis, of the kidney or of the kidney itself, 
When thi^ is the case, the patient only has two symptoms. These 
are jpain and blood in the ui^ine and?al though the lesion is eon* 
S tan t5 these symptoms, as a rule?only come on from time to time.? 
in at tacks that last for hours or days and? then? go away. A 
patient with such a calculus ?af ter having had several attacks? 
may very well have no more although the calculus is still there. 
Sa?unless a calculus in the pelvis of the kidney set up inflam* 
mation? it is not after all such a serious lesion* 
In other cases?the calculus will set up inflammation of the 
pelvis of the kidney and of the kidney itself* Then? the Patient 
is much worse off< He has pain over the affected kidney. This 
pain is sometimes continuous some tames, i t comes on in attacks* 
607 The urine will contain blnqd- aM pus. Not inf requently, the other 
k±dn.ey will be the seat of Chronic Bright's Disease* Then, the 
urine will contain albumen and casts and will be of low specific 
gravity^ The affected kidney sometimes increases in size, some- 
times, diminishes in size,and may become dislocated. Sometimes, 
the inflammation will expend to the surrounding soft parts and 
the patient will then have Perinephritis. While this is goi^ 
oh, the patient has an irregular fever and loses flesh end strength- 
He is in danger of having Bright's Disease in the other kidney 
and of waxy degeneration of the liver. So, these eases are very 
serious. ' 
In some cases, for tuna tely not in many, large calculus will be 
formed.in the pelvis of each kidney. As a rule,these cases give 
an obscure history and, generally speaking, we can not get much. 
The'patient may say that he has b.een running down for years. 
He may complain of pain over one or both kidneys. He may have 
noticed that,from time to time,his urine has-been diminished 
in quantity. So,for a long time,he has gone on,not very sick. 
But,as the calculus becomes larger, the functions of the kidney 
become more and more interfered with, the patient loses flesh 
and strength, be comes less- and less able to attend tn work, and, 
finally,he becomes so feeble, that he is confined to the house. 
608 New, the urine becomes much •'diminished and i t m&y'be-su&lpreo 
Then, towards the close c.f the disease, the patient will develop 
alternating stupor and delirium,or he may become comatose,or 
he may have convulsions* Finally,!® will die and,at the autopsy, 
you will find the pelvis of both kidneys filled with large, 
bx*anching calculi®.The diagnosis is 'certainly very difficult. 
As a rule, it is only made at '-the autopsy, 
. - T RE A T M E N T o - 
•When a pexxon has passed one'-calcu'Lua,you want to stop the for* 
matron of. more* If the patient be one ^.c ie liable to have 
uric acid calculi,we try . th prevent the precipitation of the 
uric acid in the following '.ways* Regulate the'made of life. It 
is of the greatest importance that the patient should live out 
of doors as much as possible and should have sufficient exercise* 
Regulate the diet. The patient can eat a sufficient quantity 
of food but, to a certain ex tent, he should avoid the starches 
and sugars® He is much better oft without alcohol in any shape* 
In order to Increase the 'Quantity of urine and to diminish the\ 
acidity of the urine,let the patient drink 'the alkaline mineral 
waters as.ordinary water. He; should drink one or two quarts 
every day. If he can not gef the alkaline mineral waters,we 
609 give the alkalieg,benzoate or phosphate of sodium or lithium 
combined and in solution in a sufficient quantity of water;but 
these are not as good the natural mineral waters* This treat* 
ment is to be kept up for years* 
In order to. prevent the formation of phospha tie calculi, we 
can not do as much. The patients who are likely to have them 
are those that hahi tually pass an excess of phosphates in the 
urine*. The formation of these phospha tic calculi seems to . 
depend upon the mode of life and derangement of the liver and • 
is further favored by inflammatian of the pelvis of the kidney * 
and a diminution in the quantity of urine. So,we regulate . the, 
mode of life: we make the patient live out of deers and take 
plenty of exercise* Then,we have to try to treat the functional 
disturbance of the liver* This is very difficult io dOo Some 
of the patients will he.benefited by' hie prolonged use of cor- 
rosive sublimate.,ipecac^magnesium sulphate,c.r hydro-chloric 
acid,or of Karlsbad salts every morning* For the diminution 
in -the quantity of urine,give fluids in considerable quantity, 
but give acidulated fluids,fluids containing hydro-chloric acid,, 
sulphuric acid,or ni tro-muriatic acid, As to the inflammation 
of -the pelvis of the kidney,we can not treat it; some give tu?r* 
pen tine: but whether it does any good or not, I do not know. 
610 Now suppose you are called to see a person who has' an• attach 
of renal colic® The means that we have to relieve the pain are 
hypodermic injec tione of morphine,inhalatione of ether, or in- 
halations, of chloroform® Of these methods, the first is the best, 
the last is the worst# The morphine is sufficient in most cases®. 
There are,however, very severe and protracted eases inwhich me Whine 
will not answer® Then,keep the patient practically under the 
infleunce of ether for the whole length of the attack' Thia, 
you can do without much trouble® The objection to chloroform . • 
is its danger and that we -can not keep it up- as long as we can 
either. I have seen a case in. which chloroform produced a pretty 
bad insanity .for a number of weeks after the attack had ended# 
The immersing 'of the body in a warm bath is apiparently c.f ser- 
vice to favor the passage of the calculus® Belladonna in pretty 
fair doses also seems tc be off service in this respect# If the 
patient be not vomiting and if the attack be prolonged,it is 
apparently of service to make, him drink large quantities of 
wa te r. ■ 1 ' ' 
When a calculus is confined to the pelvis of one kidney and does 
not set up inflammation,we have seen that it does no harm and 
I think that it is good practice to let it alone® Of course, 
611 you mist try to prevent the formation of new oaleull. As to 
aissGiving the calculus.* I think that we can scarcely say that 
we knew of ^y means that will da it7al though it has been at~ 
tempted* Centre 1 the attacks of pain and lock after the general 
healths Bu-tjshould such a calculus se.f up inflammation*I wink 
that the only treatment is surgical, hemove the calnulu^or 
lit the kidney be much disorganize^remove the kidney. 
612 - P E R I N E P S H I T I S . - 
This is really net a disease of the kidney but of the tissues 
around the kidney,s till,di is customary to describe it here* 
It is a suprxrraUve inflammation Gf the connective tissue be* 
net th and around the kidney,especially beneath the kidney. As 
a result of this,ah abcess is regularly formed* As a rule/thie 
abceev is behind the kidney, In some cases,!t will he entirely 
shut off in this position but,more frequently,af ter a time, the 
suppurative inflammation will extend backwards to the muscles 
of the back,downward io the perineum and scrotum^or it may 
perforate the peritoneum or colon,especially the caput coll, 
the bladder or vagina or it may perforate the diaphragm and 
set up an empyacma. * 
The kidney is only changed secondarily. It may be simply ccm* 
pressed or the .suppurative inflammation may extend to the cap- 
sule oxr" tr.. the kidney itself and the patient ^dll have Suppurative 
Nephri tis. 
Perinephritis may he either secondary or primary* When secondary, 
it is the result of extension of inflammation fi-om abcesses 
in the neighborhood,abeetses with, caries of the spine,excesses 
of the ovaries^.or of the vexmiiorm appendix In these cases, 
the Perinephritis is not as a rule of great importance* 
613 The primary 'eases are especially important. They may he caused 
by exposure to er Id and wet or injuries, over the kidney nr tn 
no cause that we can discover. These primary cases occur at 
all a^es hut most of them have occurred between the apes of 
twenty ana forty* 
We also have complicating cases* Patients with. typhoid fever, 
■typhus fever,, small-po^, or other infectious diseases may develop 
a complicating Perinephritis. These cases are not of treat 
clinical importance. 
- SYMPTOMS OF THE PRIMARY CASES, - 
The patient complains,and usually rather suddenly,of pain and 
tenderness in the lumbar region between the free border of the 
ribs and the crest of the ilium. This is the rule: ye t, some patients 
will locate the pain higher up,even as high as the pleura or 
low down over -the pelvis or hip. If the pain is located in the 
lumbar region,Perinephritis is one of the things that you think 
of:but,when the pain is 1 c c a te d elsewhere,you may think ,of 
something else. Thus,if the pain is located over the chest,you 
may very well think of pleurisy: or, if over the hip, you may think 
of disease of the pelvic benes. 
614 The patient usually ha® chills which are generally repeated, 
Ab -a m6j lucre &• wito an evening cZ'fc<£** 0 e rb a ti c n. Af te r 
a time, the fever is accompanied by sweating- The chills and 
fever ars an^ng the fir^t symptoms and continue The patient 
has vc appetite: he may vomi t» and he loses flesh and strengtia. 
A® a rule, these will be the only symptoms for one or two weeks* 
During this time, the patient is generally in bed* Then,we get 
additional syrup tcm.su Now, the skin over the lumbar region becomes 
swollen congested and cedem^texi^ and leek® like the skin over 
an. ahcetk^ The patient keeps the tbihh on the affected side 
ixm^tanily flexed anc^df ycv. attempt to stxiai^hten ii?it gives 
him ^veat pain whie?c is an a rule referred to the kidney. Then, 
ths swelling in the affected lumbar region will became more marked 
and we get .fluctuation. The abcess may suddenly 'perforate into 
<he re ri toneumand set up a sudden gerxtoni via: of v t mac rfox^K 
into thu cclon and the put will be dis»c'harg;ed with toe stools 
and,fcm a the patient will be better* Or it may perforate 
into the bladder, the yvk will be discharged with the urine.^aad 
the ratient will feel better for a ^r5'- Or it my perforate the diaphragm and set up an Empyema. 
If left to themselves,we find that & very few of the patients 
get well before an access of any considerable sir/.e is formed. 
They will have the symptoms for a week? Uoer-the symptoms will 
subside and the inflammation will -terminate by resolution* 
Such a fortunate result is the rare exception* In the larger 
number of case b, the suppuration will produce an aM<BB of. some 
Bixe wM^h^if left io itself and allowed to run through its 
course}my perforate the peritoneum and cause im?cdiate death 
or it my perforate the intestine er bladdertbut hesc openings 
are not sufficient for a real cure^ The guppuMtion goes on and 
the inflaBEBatiOB estends to the surrounding soft pax*ts and the 
(a^eht goes on for jnsnths or years with a ohronie The 
pa tien i b e eojje s ej aeia tethe ■> 1 seera beoome waxy ? and the 
jatient died in emeiationa More frequently*} the abeess is opened 
by the ^x'rgeon'ap.d?he be properly ^reated?he my get 
well and the cavity will fill up ^ith granulation tissue* Yet, 
these case^ are always serious and>even when best treated? they 
my die* 
At the aonmncemnt>keep the patient in bed,apply continuous 
-TREATMENT.- 
616 cGid?keep the patient on fluid diet,keep the bowels open,and 
give opium- Thi&?ynu continue to do for several days,watching 
fcr evidences of abcess, These evidences generally make their 
appearance at the end of week; then,even,if they do net corns, 
yrn aspirate *gj» the pus- Then,cut down on the abcess and treat 
it with antiseptic precautions. 
¥ 
617 Hysteria can be defined as a neuro si presenting symptoms which 
are such as belong to disturbance of the function of the spinal 
a ord, brain* and peripheral and sympathetic nerve»< So*it is a 
disturbance of the function of the eh tire nervous system and, 
yet, there is no recognizable lesion* Such diseases are the most 
obscure of all diseases. furthermore, the symptoms are character* 
ized by ah exceedingly arbi trary, unreasonable, and transitory 
chax'ac ter* Although there is no lesion to account for this diseaea, 
we do not often find an hysterical person who is,atherwise,per- 
fectly healthy* It is jpossible that we may but the rule is the 
other way. We frequently find disturbances of diges tion,fune tion* 
al disturbances of the liver, stomach, and intestine.* We may find 
actual lesions or functional disturbances of -the sexual appara- 
tus* Anaemia is often present. We often find changes in the whole 
nutrition: the patient will be badly nourished*. 
- HYSTERIA. - 
The disease is much mere common in women than in men but men 
do have it* The disease is generally found between the ages of 
twelve and twenty years but you may find it in young children 
and in old persons* 
- ETIOLOGY* - 
618 There seems to be a well marked hereditary tendency to hysteria* 
It will run for generations in families. Apparently* persons 
who do not have this hereditary tendency may acquire a tendency 
tc Hysteria by suffering from disturbances af the general health 
or in the diges tion* or by disease of the ovaries and Fallopian 
Wbes.or by anaemia. Persons who have this Hj^terieal disposition 
may go on io death without developing it unless there be an 
exciting cause, as disturbances of the general heal th} severe 
mental emotions,or the force of imitation. 
There are & good many evmp tons?ye t, you are net to suppose that 
all of them are developed in each patient, Some will exhibit 
one group ox symptoms: o therstano ther: and the patients not only 
differ at- to the number of the symptoms but as to their duration 
and severity, 
-- 1 - Bisturbances of Sensation*- These may affect the eyes. 
The patient may have photophobia2asthenopia,or he may see objects 
that do not exist, nr he may become temporarily blind . 
They nay affect the ears. The hearing may become unnaturally 
acuteor the patient may hear noises or voices that do not exi£t> 
er he may become partially or altogether deaf. 
- SY M P T 0 M S 
619 The disturbances of sensation may affect the taste* The taste 
may be perverted* The patient may have an abnormal taste for 
things not usually eaten* 
They may affect the skin* The patient may develop hyperaesthecla 
of large or small parts of the body* These hyperaes the tic areas 
may symmetrical or they may be irregular* There may be loss 
of sensation or of tactile sensibility. The loss of sensation 
to pain may he so marked that youcan cut or bum the patient 
without causing pain* 
- 2-pain*™ Pain in different parts of the body is a very com- 
mon. symi tom* The pa tients may have headache of any sort. He 
may have pain along the course of the fifth nerve or other forme 
of neuralgia* The patient may have pain referred to the throat, 
la' ?mammary glands5heart* abdomen,ovarlee,bladder,vertebral 
column,or to the hip nr knee joints^ The patient may have inter* 
postal neura'ig?. These exceedingly common and they 
are of ten distinctly localised and are go continuous that it 
is ft to dis ' them from real lesions* This is 
P^riieularj.y the ^v^}. the pain® in the heart, e tomach,in* 
te K' V' i-A/.k' \ \ •• / ''.z '» ■ t joints,perhaps mere true of the pains in 
the jo4 «/ \f 3* 4» 1 *f any of he ethers. 
620 3-hio tor Disturhanees* - These may take the form of spasmodic 
oy involuntary contrac tions or of paralyses, 
Cf the spasmodic ccntraetians, perhaps the most common is a spas* 
wdic contraction of the muscles of the pharynx* This is usually 
attended by diff lenity in swallowing and a feeling if some* 
thing wzre in the throat, The patients often say that they first 
felt some thing low down in the chest ands thens that thin some- 
thing seemed to rise up into the throat and stick there* Some* 
times, this contraction of the muscles of the pharynx will give 
•a spasmodic cough instead. This cough is attendee with a good 
deal of muscular effort. Ii it; juti the soi t of couth that one 
would employ to expel a foreitr. body from the pharynxc The patient 
will have this couth every few minutes or every few secrnas 
and it will some times last for months, 
They may have involuntary coatracticns of the stomach and intes* 
tine So This may tive rise to vomitint gt to the frequent expul* 
tion of This is very common. 
The contraction may affect the muscles of the larynx* This usually 
gives a cough which is very frequent and5of ten5long continued. 
Less frequently} €iere will he a spasmodic ccntraction of the 
glottis with laryngeal dyspnoet. which will last a short timet 
621 In some way or other, these patients will have attacks of spas* 
modie asthma which resemble severe attacks of tr$e spasmodic 
as Wna. 
The diaphragm may eon tract spasmodically and cause hiccup which 
will often la&t a long time. 
The muscles ox the bladder may be affected and the patient will 
either have retention of urine bi too frequent micturition. 
This is quite common. 
Any of the voluntary muscles of the arm,legsor trunk may be 
the seat of these involuntary contractions which will last a 
certain time and5finally,disappear. The patient may have uni* 
lateral convulsions or general convulsions of the ordinary epi* 
lep tiform eharac ter. 
- 4-Motor Paralyses. - These occur in many of the patients. 
The stomach and intestine may be paralyzed and then they will 
become enormously distended with gas* This takes place suddenly 
and,in a few minutes, the abdomen may become enormously swollen* 
Paralysis of the pharynx and oesophagus may cause difficulty. 
i. n & wa 11 o wi n t> • 
Paralysis c>f the lar^nm may cause aphonia or the patient may 
only be able to speak in h whisl er. 
Any of the of voluntary muscles may be paralyzed or the 
patient may have hemiplegia or pa^ple^iae These more extensive 
paralys^u may last for weeks or months. 
• Dis turbance of the heart* - Of ten have palpi tation, rapid 
ivxetular or feeble heart ac tion, sudden attacks of fainting 
z,ay be disturbances of the circulation. •- ~ 
622 In a certain number of the patients, especially those that are 
anaemia, there will be a disposition to bleeding from die nose, 
rou€*x,s tomach, intestine, and into the substance of the skirt; but 
this belongs more to the complicating anaerda than to the Hysteria. 
The patients often complain that, in certain parts of the irdy, 
they win have abnormal sensations of heat and cold or abnormal 
perspiration. These may occur in ^ny part of the body. They 
ere due to disturbances of the nerveasof the bleed vessels* 
As comp 11 eating &ymptome,we have those of gastric and hepatic 
dyspeyM.a, anaemia,or uterine disease# 
In some cf the cases, men tai disturbances will be added. I think 
that we are too much in the habit of thinking that all cates 
of Hysteria have mental disturbance?^ 'Afe find many patients 
in whom the mental faculties are perfects Yet,some do give 
mental dig tnrbancee and.the moment that they are added, the 
becomes much more serious Some of the patients are only rather 
■ over excitable. Others become peevish. Others have an unnatural 
desire to be no bleed and attended to. Others will be a greater 
deal too fond of certain people and will dislike other people 
in an unnatural way. Others lose self control. In the worst cases, 
623 w .have hallucinations of all kinds, actual delirium stupor, 
n^.^leie coma,or melancholia# These mark the border line between 
Xx&sanity and some of these patients become fairly 
r*» A A ♦•* 0 
See**? patients with Hysteria will have a fever and this often 
dij^^zxooiib sr©ry e.i4fiSi^xil ?zobi the enumeration. of the 
to?npiyou can see how many rbsctsyg Hysteyia pi^ulates and, 
when you get a fever, and the -, • e v <1 tp» e bx e <& <• h 102$ 10 3$ 104, 
you can see hew very closely it ;iiay simulate real diseases# 
Oo.ve pa tier; is develop the symptoms very suddc*niy® At some tiia^ 
either after sudden ema tlcn ox' from no cause, there will be a 
sudden attack of the symptoms# 
lu other cases, the symptoms will come on very (.radually® At 
f ma, t,-ha.- Patient will develGp one or M^re of the milder symptGS©» 
Thon} the others will come one after another and the patient will 
pa^s into the full development of the disease* 
In a tor.d cf fh.e cases, th<? sytp toms will come oti in attack^ 
during which the patient will eAaihit one or more of the sym tosaS 
and the attacks, the patient will be in ^ood he'alth« 
tu the fm-hu^'aey of the a titers and the length of the in* 
iorvals between them, there is a ^reai difference in the dif- 
ferent Patients, 
624 • ther eases will continue for months and years without at any 
time any real intermiaaioiu 
The patients also differ greatly as to the severity and number 
'of the symptoms. 
- PROGNOSIS 
Ih the milder eases,the prctnosis it fairly ^ocd and the patients 
pay pex'manently recover, 
tn the mere severe eases, the prognosis is by no means as hood. • 
Some of them do t^t better for a time but, then, there will be 
a return of the symp toms, then,ano ther return,and the patient 
never really tet£ well. In other cases,insanity will follow. 
In a few casesjpatients have died of Hysteria. They died in 
treat exhaustion and emaciation and,after death,no lesion wac 
found. How the disease causes death,I do not know. 
In the milder cages/the treatment is more a matter of common 
sense than anything else. In the first place.,you have to recog* 
nize the disease. If the patient have an hysterical cough, 
dc*n't treat him for a pharyngitis or-laryngitis that he has 
not got. Pay as li ttie-attention as possible to the particular 
local symptoms* If the patient have a cough,don't treat it: 
T R E A T M E'M T . - 
625 if he have a pain,don' t try to relieve it?but treat the whole 
general healths Attend to the diet,mode of life., and exercise, 
and -read the anaemia® In this way, these pa{jL & a xo are often 
a omp; e te 1 y cu red» 
In the more severe eases,al though the indications for treatment 
are the &ame,it is by no means as easy to carry them out, It 
requires a ^reat deal of courage and self•reliance oh the part 
of the physician® It is the hardest think in the world to keep 
from beln& led aside from the real disease® It is very diffi* 
cult to ^et them to do what you want ther.i to do and to keep them 
from, drink what you do not want them to do* The best think to- 
do with them is to take them away frcom he .a?. Isolate them, and 
ehut them up. This is the first thin^ you, have to do or treatment 
will not be of avail. Then,improve the' general health and use 
maesa^e and passixe me tian® 
- The End of Volume IT. -- 
626 I K D E X- 
Calculi5 Biliary, ,,*17. 
Calculi * Hanai*«,,. , 0\ . • • *«,».599 
U&mUCC i. Of LlVO A © a- c> «c a » « & • p o » 0 a » o WS 
Cancer qf Peri to ne urn©, © P » 
Ce veh ro - Spinal Menlngi ti 3^ • 1 & 3 
il X 00 0L *' x Q jX c- a- c o • a q. a q c <> © £ v c- ® ' c 3 31 
' / h X 0 X\ •' S 11> © o © o < a © cve©cpri>©c»eo<>«>oo Xb5 3 
( J h 0 X £* • * *A $ h. *> X uX O a © e o » o © d © ® o 6 9 0 
Diaoe tes5 IntdpiaUs* .©«• • <e<151. 
U X <.*X1 ) L) 2/1^ X 1 3- 1/ a © © © © © © ©•.©.©.♦•©I <53 
Diph the ria©. © * * © • * ♦182 
Epidemic Cerebro-Spinal . ' 
Meningi ti a o «16 3 
r.i I' y w 1 "C e X a !b a o • « » eo p P o P a stoop » a • A • 3^ E 
ATee&s of the Live^a.^ioaoa.^l 
li.1.' (v J. uJODP s> jL l 5>eaEsC ci 9. 0 p; a 9. >$ p u tg e e, "1/0 i 
□AnaOmia,Pe rnicioub*. t •.,«- v. < a O462 
f^naC m. ca) or nip re.& » o»^«o* »«»••■* ^i*5u 
An th ra?Ka iO a o i? © tJ * c • » o • • *©»'•©a. 
An th rax $ In tey final &. o.. <... . u ^1 
Ar th ri ti t ? Kheuma ioid»X<.. .,,,4:35 
Asia Ue Che le ra,o«204- 
Bi liary Calculi,. 17 
Bloody Disrates of,6 . c«. 3.454 
Bright1s Diuease,,,.486 
Brigh V $ Dis&ase Acute„.,,«s o»510 
Brigh t? s Di«ease Adu te 
Treatment of o..15 37 
Eright5 s Disease3Chronic,.. ♦. ,554 
'Eright's Disease of Pregn.ancy,548 
627 Farcy. 39 3 
Fever* In termi ttent............ 299 
Fever, Malarial. 29 3 
Fever,Re lapsing* .............. 284 
Fever,Remi ttent.* 306 
Fever, Searle t*. •»• ****** • c4o 
Fever,Typhoid-* a.*............, 240 
Feve r, Typho"Malarial***.♦♦..** 272 
Feve r,Typhus^222 
Fevermeil0w.<•»»• •. •»««<*.►-♦ <# ♦ 21 3 
German Measles.367 
Gland e rtu .«•*♦«* ® 3 
Gone rrho e o.l Rheuma ti sm........ 427 
Gou t, I rregular Acu te*........ .451 
Gou t, I rregular Chronic. *..... .452 
Gou t, regular Acu te. .441 
Gou t, Re gu 1 a r Chroni 0..........447 
iema tlnuria, Pe riodic* 154 
Jepa ti ti$rAcu te Parenchyma tons. 38 
depa ti ti s, Chronic In te rti ti tial .47 
He pa ti ti s 5 Suppura live... 61 
Hydrophobia. 396 
Hys teria. 613 
Inte rmi ttent Fever. 299 
Jaundice, ♦ ..••.••.*...<.••9 
Jaundice,Malignan t. *. ♦ . .33 
kidneys, The. ............. .434 
kidneys, Chronic Conges tion of..574 
kidneys,Biseases of..435 
kianey^Tumors of.<596 
Leukemia.° • <47 3 
Leukemia, P seud o . 48f 
,Live r, Abcess of ................. 61 
Liver Acute Yellow Atrophy of. . .38 
Liver,Cancer of... .............. 86 
Liver,Cirrhosis of.. *47 
Liver,Fatty....... .73 
628 Livex^Fune tional Diseases tf. .>.4 
Liver,New Growths of. 86 
Liver,Physical Examination of...1 
Malarial Cachexia,The......... 510 
Malarial Fevers,Etiology of &c29 3 
Ma 11gn<?xnt Oeuemao...**.....®.© 0 
Malignan t Pus tule 389 
Measles.. 335 
Measle s,German ® 367 
Mumps. 372 
Muscular Rheuma tism........... 424 
Nephritis,Acute Diffuse .526 
Nephri tis,Acute Exudative.... .511 
Nephri ti s, Acu te Pa renehyma tons522 
Nephri tis, Suppura tive.. •.... © .582 
Nephri ti s, Tub ercular. ....•>••• 592 
Oc: ema,Malignant. 390 
Perinephri tis • . . ♦ 613 
Peri Uni tis^Asu te General.... .>.95 
?e ri toni ti s, Chronic............12 3 
Pe ri toni ti s, Tubercular 130 
Peri toneum^Cancer of........... 132 
Pertussis......♦ •>♦. $76 
Pcrtai Vein,Thrombosis of.......78 
Pregnancy,Bright}s Disease of..548 
Pseudo-Leukemia. .......480 
Relapsing Fever....... .284 
Remitten t Fe ve r...............«306 
Renal Calculi....599 
Rheuma ti urn, Aou te • 406 
Rheuma tiym.Chronic.............430 
Rheuma ti sm, Geno r rho eal........ •427 
Rhe uma ti s m, ku s cu 1 a r 424 
Rheuma ti sm, Sub -Aeu te . 422 
Rheuma to i d A r th ri ti s 4 $5 
629 Searle t Fever. 3tR 
Small-Pox..................... 319 
Suppurafive Mephri Us.........582 
Thrombosis of Portal Vein......78 
Trichinosis.. 401 
Tube rcular NephriUs..........592 
Tumors of the Kidney..........596 
Typ^hoid Feve r.240 
Typho-Malarial Fever........ 272 
Typhus Fever...................222 
Varicella.• © >. ar • O ♦ j» a .• o ® • ♦ 331. 
VariolCit e . w a • . • u « w . w « -e. w • 319 
Va rx o x o x d. e-r o v <» o o <» «.»• • «• • • • if •» r^2>T7 
Vermiform Appenai% InflamiaationllO 
Whooping-Cough. «. • 376 
Yellow Fever..................e213 
630