|| jiijililiiiiiji ! Ip|li{»!!|!;?!!!ii«:!:-:ii; Hf!Ill i'i! 'irji<> v (o ILL US TEA TED PHILADELPPIIA \V. B. SAUNDERS 925 Walnut Street 1897 Copyright, 1897, by W. B. SAUNDERS. ELECTROTYPED BY PRESS OF WESTCOTT & THOMSON, PHILADA W. B. SAUNDERS, PHILADA. PREFACE. This work is meant to introduce the student to the present state of our knowledge of the practice of medicine in general and of the diagno- sis, differential diagnosis, and treatment of disease in particular. The historic development of the subjects treated has been either briefly given or intendedly omitted, since this scarcely falls within the scope of a prac- tical treatise on medicine. Although the book as a whole is submitted to the critical judgment of a learned profession, it may be pardonable to emphasize, provisionally, a few features pertaining to the mode of treat- ing the separate subjects, or the arrangement of the material under the latter—to indicate some of the more salient lineaments, so to speak, in the general design. Since in medical schools it is taught from a separate chair, the pathology (special) of the individual affections has almost in- variably been taken up before the etiology ; from this point the student will find the story of each affection a continuous one. The practitioner, however, must ever aim to associate the clinical symptoms with the morbid lesions. Under special etiology the bacteriology has been prominently men- tioned, since we owe to it the rapid progress that is being made in the study of the causation of disease. The differential diagnosis has in many instances been tabulated—an ear-mark that I confidently believe will be found especially helpful. It may be stated that not less than fifty-six diagnostic tables are scattered throughout the work, and that by far the greater number of these are my own. Such formulae have been introduced into the text, and only such, as a more or less extended experience has shown to be possessed of real thera- peutic importance. Whilst these, and all additional points relating to the treatment of the single affections, may serve as guides, particularly to the beginner, I fully appreciate how often the practising physician is 3 4 PREFACE. placed in a position in which he is compelled to form a therapeutic judgment for himself. Whenever the dosage is stated, the metric equiv- alent is placed in parentheses, the number of grams being stated in round numbers (sj—4.0; 3j—32.0) in order to render it of greater practical value. In all instances, however, in which this would involve an im- portant difference in quantity the exact decimal figures are given. A considerable variation from the usual classification of diseases may be observed, but this is accounted for in the text wherever it occurs. Preference has been given to the modern orthography and termi- nology, not only because it is more euphonious, but also because of its adoption by the standard lexicographers. I have gleaned without stint from medical literature with a view to bringing the book up to date, and if I have failed to give full credit in every instance, my grateful acknowledgments are here due and are cheerfully made. The chief results of my personal experience and obser- vation, extending over a period of two decades, and derived from both hospital and private practice, will also be found upon these pages. I wish to thank Prof. W. C. Hollopeter, who has written some of the articles upon the diseases of children, as measles, chicken-pox, mumps, whooping-cough, and the acute diarrheas, and who has kindly aided in the preparation of those upon diphtheria and scarlatina. My cordial thanks are due also to Dr. C. L. Furbush for kind aid in preparing some of the illustrations, to Doctors Robert N. Willson, Howard S. Anders, and Geo. W. Pfromm for valuable assistance while the work was passing through the press, and to Dr. A. M. Davis for preparing the index. JAMES M. ANDERS. CONTENTS. PART I.—INFECTIOUS DISEASES. PAGE Typhoid Fever.............................. 17 Mountain Fever............................ 66 Typhus Fever............................... 67 Relapsing Fever............................. 72 Malarial Fever.............................. 78 Dysentery................................. 96 Catarrhal Dysentery.......................... 98 Amebic Dysentery (Tropical Dysentery)................. 99 Diphtheritic Dysentery.........................102 Chronic Dysentery...........................105 Cholera (Epidemic)............................108 Yellow Fever...............................118 Cerebro-spinal Meningitis.........................123 Lobar Pneumonia.............................132 Secondary Pneumonia........................ 15/ Influenza.................................1^8 Dengue..................................167 The Plague................................169 Erysipelas................................170 Diphtheria................................1'9 Septicemia................................19" Pyemia..................................199 Acute Articular Eheumatism........................202 Subacute Articular Rheumatism............. .........213 Gonorrheal Arthritis............................213 Variola..................................pi 5 Vaccination................................£-■' Varicella.................................231 Scarlet Fever...............................234 Measles..................................245 Rubella..................................248 Whooping-cough .............................^?1 Parotitis................................|o8 Tuberculosis................................^6q Chlorosis.......................... 491 Progressive Pernicious Anemia................. ^>q The Secondary Anemias..................... 400 Leukocytosis...................... 40^ Leukocythemia........................ ' 437 Pseudo-leukemia ....................... 4.4 Anaemia Infantum Pseudo-leuksemica............... 44 s Chloroma ............................. 4.-^ Diseases of the Ductless Glands.................... ' a?q Diseases of the Suprarenal Capsules................. ' 4c,. Addison's Disease.............. ........ ' /rn Diseases of the Thyroid Gland....................' " . -, Thyroiditis......................... 4^4 Goiter........................... . . . 455 Exophthalmic Goiter.....................' ' 4'r- Myxedema.......................... ' 4^, CONTENTS. 7 PART IV.—DISEASES OF THE RESPIRATORY SYSTEM. I. DISEASES OF THE NOSE. PAGE Acute Rhinitis..............................465 Chronic Rhinitis.............................466 Autumnal Catarrh.............................469 Epistaxis.................................470 II. DISEASES OF THE LARYNX. Acute Catarrhal Laryngitis.........................471 Chronic Laryngitis.............................473 Spasmodic Laryngitis...........................475 Tumors of the Larynx...........................477 Edema of the Larynx...........................478 III. DISEASES OF THE BRONCHI. Catarrhal Bronchitis............................478 Acute Bronchitis ...........................479 Chronic Bronchitis...........................483 Brochiectasis.............................487 Bronchial Stenosis.............................490 Asthma...................................491 Fibrinous Bronchitis...........................496 IV. DISEASES OF THE LUNGS. Circulatory Disturbances in the Lungs ..................498 Congestion of the Lungs........................498 Active Hyperemia.........................498 Passive Hyperemia........................499 Pulmonary Edema.............................500 Hemoptysis...................;............502 Pneumorrhagia..............................508 Pulmonary Embolism...........................508 Chronic Interstitial Pneumonia.......................510 Broncho-pneumonia............................512 Pulmonary Atelectasis...........................519 Emphysema................................ 522 Interlobular Emphysema........................522 Vesicular Emphysema ........................522 Compensating Emphysema.....................523 Hypertrophic Emphysema....................523 Senile Emphysema.........................529 Gangrene of the Lungs...........................529 Abscess of the Lungs............................532 Pneumonokoniosis.............................533 New Growths of the Lungs.........................536 Carcinoma of the Lung.........................536 Sarcoma of the Lung..........................537 Hydatid Cyst of the Lung.......................538 V. DISEASES OF THE PLEURA. Pleurisy..................................539 Acute Plastic Pleurisy........................539 Sero-fibrinous Pleurisy.........................542 Empyema..............................556 Chronic Pleurisy............................560 Pneumothorax................ ...........562 Hydrothorax..............................567 New Growths of the Pleura........................568 Diseases of the Mediastinum .................. • • 569 Inflammation of the Mediastinum....................569 Tumors of the Mediastinum.......................570 Diseases of the Thymus Gland.....................572 Mediastinal Hemorrhage........................572 8 CONTENTS. PART V—DISEASES OF THE CIRCULATORY SYSTEM. I. DISEASES OF THE PERICARDIUM. PAGE Pericarditis...............................573 Acute Plastic or Fibrinous Pericarditis..................573 Sero-fibrinous Pericarditis.......................576 Purulent Pericarditis .........................581 Hemorrhagic Pericarditis........................582 Adhesive Pericarditis.........................582 Hydropericardium............ ................584 Hemopericardium.............................585 Pneumopericardium............................585 II. DISEASES OF THE HEART. Endocarditis..............................586 Simple Acute Endocarditis.......................586 Ulcerative Endocarditis...................... . . 590 Chronic Endocarditis..........................594 Aortic Incompetency............................597 Aortic Stenosis..........................., . . 603 Mitral Incompetency............................605 Mitral Stenosis..............................611 Tricuspid Incompetency..........................615 Tricuspid Stenosis............................618 Pulmonary Incompetency..........................619 Pulmonary Stenosis............................620 Combined Forms of Cardiac Diseases....................620 Cardiac Thrombosis...........................634 Hypertrophy of the Heart.........................636 Dilatation of the Heart...........................643 Myocarditis ..............................648 Acute Myocarditis...........................648 Chronic Myocarditis .........................649 Disease of the Coronary Arteries......................653 Degenerations of the Heart......................... 654 Fatty Degeneration..........................654 Fatty Overgrowth..........................656 Brown Atrophy............................657 Calcareous Degeneration........................657 Amyloid Degeneration.........................657 Hyaline Degeneration.........................657 Cardiac Aneurysm.............................658 Rupture of the Heart...........................659 Minor Affections of the Heart........................660 New Growths.............................660 Parasites...............................660 Misplacement.............................661 Floating Heart...........................gP2 III. NEUROSES OF THE HEART. Palpitation............................... gg2 Tachycardia................................gg3 Brachycardia...............................ggg Arrhythmia................................gg7 Angina Pectoris..............................ggo, IV. CONGENITAL AFFECTIONS OF THE HEART. Arrested Development...........................g-0 Fetal Endocarditis...........................' g^g V. DISEASES OF THE ARTERIES Acute Aortitis..............................g~g Arterial Sclerosis........................... * g-.g Aneurysm...............................' ggQ CONTENTS. 9 PAGK Aneurysm of the Thoracic Aorta . ...................681 Aneurysm of the Abdominal Aorta.................. 690 Aneurysm of the Pulmonary Artery...................691 Aneurysm of the Coronary Arteries...................691 Aneurysm of the Celiac Axis......................691 Aneurysm of the Splenic Artery.....................691 Aneurysm of the Hepatic Artery....................691 Aneurysm of the Superior Mesenteric Artery...............692 Aneurysm of the Inferior Mesenteric Artery...............692 Aneurysm of the Renal Arteries.....................692 Arterio-venous Aneurysm........................692 Congenital Aneurysm.........................692 PART VI.—DISEASES OF THE DIGESTIVE SYSTEM. I. DISEASES OF THE MOUTH. Stomatitis.................................693 Catarrhal Stomatitis..........................693 Aphthous Stomatitis..........................694 Membranous Stomatitis.........................696 Ulcerative or Fetid Stomatitis......................697 Parasitic Stomatitis..........................699 La Perleche............................. . 701 Gangrenous Stomatitis.........................701 Mercurial Stomatitis..........................703 II. DISEASES OF THE TONGUE. Glossitis................................704 Acute Glossitis............................704 Chronic Superficial Glossitis.......................705 Glossitis Desiccans...........................706 Lingual Glossitis...........................706 Leukoplakia Oris...........................706 Angina Ludovici...........................707 III. DISEASES OF THE SALIVARY GLANDS. Hypersecretion..............................707 Xerostoma................................708 Symptomatic Parotitis...........................708 IV. DISEASES OF THE TONSILS. Acute Tonsillitis..............................709 Chronic Tonsillitis.............................715 V. DISEASES OF THE PHARYNX. Pharyngitis................................718 Acute Pharyngitis...........................718 Membranous Pharyngitis........................719 Chronic Pharyngitis..........................720 Acute Infectious Phlegmon of the Throat ..................721 Retropharyngeal Abscess..........................722 VI. DISEASES OF THE ESOPHAGUS. Esophagitis......... ......................722 Acute Esophagitis...........................722 Chronic Esophagitis..........................724 Ulcer of the Esophagus...........................724 Carcinoma of the Esophagus........................724 Rupture of the Esophagus.........................726 Neuroses of the Esophagus.........................727 Muscular Spasm............................727 Paralysis of the Esophagus.......................727 10 CONTENTS. PAGE Dilatation of the Esophagus.........................728 Esophageal Diverticulum..........................729 Stricture of the Esophagus.........................730 VII. DISEASES OF THE STOMACH. Methods of Diagnosis...........................733 Examination of the Gastric Functions..................733 Physical or External Examination....................738 Malposition of the Stomach.........................741 Gastroptosis.......................'.......741 Dilatation of the Stomach.........................742 Inflammatory Diseases of the Stomach ...................747 Acute Catarrhal Gastritis........................747 Toxic Gastritis............................750 Diphtheritic Gastritis.........................751 Acute Suppurative Gastritis......................751 Chronic Catarrhal Gastritis.......................752 Gastric Ulcer...............................761 Carcinoma of the Stomach.........................769 Hematemesis...............................776 Neuroses of the Stomach..........................777 Nervous Dyspepsia...........................777 Neuroses of Secretion.........................780 Hyperchlorhydria.........................780 Neuroses of Motility..........................782 Increased Peristalsis of the Stomach.................782 Diminished Peristalsis of the Stomach................782 Neuroses of Sensation.........................783 Cardialgia............................783 Hyperesthesia of the Stomach....................785 Anorexia..............................785 Hyperorexia...........................786 VIII. DISEASES OF THE INTESTINES. Methods of Diagnosis..................'.........786 Enteroptosis...............................789 Intestinal Catarrh.............................790 Diarrheas of Children............................798 Acute Gastro-intestinal Catarrh.....................798 Celiac Disease.............................802 Phlegmonous Enteritis...........................803 Croupous or Diphtheritic Enteritis......................803 Cholera Morbus..............................804 Intestinal Infarction............................806 Intestinal Ulcers..............................806 Duodenal Ulcer............................806 Follicular Ulcers.......................... . 809 Stercoral Ulcers............:..............809 Simple Ulcerative Colitis........................809 Solitary Ulcers ,............................810 Diffuse Catarrhal Ulcer.........................810 Cancerous Ulcer.............................810 Appendicitis...............................810 Chronic Appendicitis..........................822 Recurrent Appendicitis.........................823 Intestinal Obstruction.......................... . 826 Carcinoma of the Intestine.........................833 Habitual Constipation...........................836 Dilatation of the Colon...........................840 Neuroses of the Intestine..........................840 Secretory Disturbances..........................840 Membranous Enteritis.......................840 Sensory Disturbances..........................841 Enteralgia...........................841 Diminished Intestinal Sensibility.................' 842 CONTENTS. 11 PAGE Disturbances of Motility........................843 Nervous Diarrhea.........................843 Enterospasm.................. ........843 Constipation...........................844 IX. DISEASES OF THE LIVER. Anomalies in Shape and Position......................845 Jaundice................................84b Catarrhal Jaundice..........................84/ Other Forms of Jaundice.........................850 Biliarv Calculi . . .........................851 Chronic Obstruction of the Duct by Gall-stones..............8o4 Obstruction of the Common Duct..................854 Obstruction of the Cystic Duct...................855 More Remote Effects of Gall-stones...................856 Carcinoma of the Bile-ducts.........................859 Stenosis of the Bile-ducts..........................°b0 Icterus Neonatorum............................862 Vascular (Circulatory) Affections of the Liver.......=........°bd Anemia...............................863 Hyperemia..............................°£> Acute Hyperemia...........................°°^ Passive Hvperemia..........................*^ Diseases of the Portal Vein.........................°°j? Thrombosis and Embolism.......................°bo Suppurative Pylephlebitis.......................8bb Stenosis................................°°° Affections of the Hepatic Blood-vessels....................°°° Atrophy and Hypertrophy of the Liver...................°b8 Hepatic Infiltrations and Degenerations...................°o» Amvloid Infiltration..........................°°* Fatty Infiltration...........................^ Fatty Degeneration..........................°/_-- Perihepatitis.............................. '„ Acute Perihepatitis..........................°,1^ Chronic Perihepatitis.........................°'jj Abscess of the Liver............................°'° Acute Yellow Atrophy...........................°°± The Liver in Phosphorus-poisoning.....................°^ Cirrhosis of the Liver...........................^ Carcinoma of the Liver......................." " ' ' Sfi Other New Growths in the Liver......................°yo X. DISEASES OF THE SPLEEN. 898 Dislocation of the Spleen.......................... " Splenic Hyperemia........................ ' „„„ Splenitis......................... ' q,.-. Amvloid Degeneration of the Spleen.....................™f Morbid Growths of the Spleen.......................JJjf Rupture of the Spleen...........................yuJ XI. DISEASES OF THE PANCREAS. Acute Pancreatitis . . . . ;................. " _..„ Hemorrhagic Pancreatitis..................... ' .. Suppurative Pancreatitis................• • ' „ . Gangrenous Pancreatitis................... " „„,, Chronic Pancreatitis...................... ' g^ Pancreatic Hemorrhage.................. ' ^ Carcinoma of the Pancreas.................• ' ^ Pancreatic Cyst.................... q^o Pancreatic Calculi............................. 12 CONTENTS. XII. DISEASES OF THE PERITONEUM. PAGE Acute Peritonitis............................910 Localized or Partial Peritonitis.....................915 Chronic Peritonitis ............................919 Ascites........... .....................922 New Growths in the Peritoneum.......................927 Carcinoma of the Peritoneum......................927 PART VII.—DISEASES OF THE URINARY SYSTEM. I. DISEASES OF THE KIDNEY. Mobility of the Kidney..........................929 Circulatory Disorders of the Kidneys.....................933 Active Hyperemia...........................933 Passive Hyperemia...........................933 Special Pathologic States of the Urine....................934 Hematuria..............................934 Hemoglobinuria............................936 Albuminuria.............................937 Peptonuria and Albumosuria.....................941 Indicanuria..............................941 Pyuria................................942 Chyluria..............................943 Choluria...............................944 Urobilinuria.............................945 Glycosuria..............................945 Acetonuria, Diacetonuria, and Oxybutyria................948 Lithuria...........'....................949 Oxaluria...............................950 Phosphaturia......•......................951 Leucinuria and Tyrosinuria.......................952 Cystinuria................... >..........952 Various other Conditions........................953 The Nephritides.......... ..................955 Morphologic Constituents of the Urine in Renal Disease..........955 Dropsy of Renal Disease........................957 Uremia................................958 Amyloid Kidney.............................962 Nephrolithiasis..............................964 Acute Nephritis.............................970 Chronic Nephritis (Exudative).......................977 Chronic Nephritis (Non-exudative).....................981 Pyelitis . . . _...............................989 Hydronephrosis..............................993 Perinephric Abscess............................996 Cystic Kidney...............................997 New Growths of the Kidney........................999 II. DISEASES OF THE BLADDER. Cystitis.................................1001 Acute Cystitis.............................1001 Chronic Cystitis............................1005 Neoplasms of the Bladder.........................1006 Vesical Hemorrhage............................1007 Neuroses of the Bladder..........................1007 Irritability of the Bladder.......................1007 Neuroses of Micturition........................1010 PART VIII.—DISEASES OF THE NERVOUS SYSTEM. Introduction...............................1012 CONTENTS. 13 I. DISEASES OF THE PERIPHERAL NERVES. PAGE Acute Ascending Paralysis.........................1026 Neuritis.................................1028 Neuromata................................1032 Neuralgia ..............................1032 Neuralgia of the Head.........................1034 Neuralgia of the Neck and Trunk....................1034 Neuralgia of the Extremities......................1035 Diseases of the Cranial Nerves.......................1037 Diseases of the Olfactory Nerve.....................1037 Diseases of the Retina, Optic Nerve, and Tract..............1038 Diseases of the Motor Nerves of the Eyeball...............1042 Diseases of the Fifth Nerve.......................1046 Diseases of the Seventh or Facial Nerve.................1048 Diseases of the Auditory Nerve..................... 1050 Meniere's Disease.........................1052 Diseases of the Glosso-pharyngeal Nerve.................1053 Diseases of the Pneumogastric Nerve..................1053 Diseases of the Spinal Accessory Nerve.................1057 Torticollis............................ 1057 Paralysis of the Spinal Accessory Nerve......... .......1059 Diseases of the Hypoglossal Nerve....................1059 Diseases of the Spinal Nerves........................1061 Diseases of the Cervical Plexus.....................1061 Diseases of the Brachial Plexus.....................1061 Diseases of the Lumbar and Sacral Plexuses................1063 II. DISEASES OF THE SPINAL CORD AND ITS MENINGES. Diseases of the Meninges..........................1064 Pachymeningitis..................,.........1064 Leptomeningitis............................1065 Acute Leptomeningitis.......................1065 Chronic Leptomeningitis......................1066 Hemorrhage into the Spinal Meninges..................1067 Disturbances of Circulation in the Cord...................1068 Hemorrhage into the Spinal Cord......................1069 Acute Myelitis . . ...........................1070 Chronic Myelitis .............................1073 Anterior Poliomyelitis..........................1074 Essential Paralysis of Children.....................1074 Acute, Subacute, and Chronic Poliomyelitis in Adults...........1076 Abscess of the Spinal Cord......"...................1077 Unilateral Lesion of the Spinal Cord.....................1077 Locomotor Ataxia.............................1078 Hereditary Ataxia.............................1083 Spastic Paraplegia.............................1084 Primary Lateral Sclerosis........................1085 Secondary Spastic Paralysis.......................10S7 Congenital Spastic Paraplegia......................1087 Ataxic Paraplegia...........................1087 Combined System Sclerosis.......................1087 Reflex Paraplegia...........................1088 Intermittent Paraplegia.....................• . . 1088 Multiple Sclerosis............................» . 1088 Bulbar Paralysis..............................1091 Progressive Muscular Atrophy (Myelopathic)...............• . 1092 Syringomyelia...............................1094 Compression of the Spinal Cord ......................1096 Tumors of the Spinal Cord and its Membranes...............1097 Lesions of the Conus Terminalis and the Cauda Equina............1101 III. DISEASES OF THE BRAIN AND ITS MENINGES. Diseases of the Dura Mater.........................1101 Diseases of the Pia.............................1104 14 CONTENTS. PAGE Disturbances of Circulation of the Brain...................1105 Hyperemia..........'...................nofi Anemia...............................n 07 Edema of the Brain...................•......]|^ Embolism and Thrombosis.......................jJV* Vascular Degeneration.........................jjj* Inflammation of the Brain.........................jj^ Focal Encephalitis...........................|||^ Diffuse Encephalitis............. ............j|j^ Cerebral Hemorrhage........................... 4 1 • ....;......I US Aphasia.......................... 11'^ Intracranial Growths...........................wqir Chronic Hydrocephalus...........................\\i(\ External Hydrocephalus........................j|f° Internal Hydrocephalus........................jj|' Sclerosis of the Brain............................Wiq General Paralysis of the Insane.......................^^ Cerebral Palsies of Childhood........................jjj" Acute Delirium..............................lL66 IV. DISEASES OF UNKNOWN PATHOLOGY. Epilepsy.................................\\H Migraine.................................Ji|2 Acute Chorea............................... .- Chronic Chorea..............................\Vf Rhythmic Chorea...........• ;................||^ Choreiform Disorders ...........................War Paramyoclonus Multiplex........................j™ Chorea Electrica............................}}J/ Fibrillary Chorea...........................Waq Athetosis 1148 Habit-spasm...................'..........}}f® Tic Convulsif.............................\\™ General Tic..............................}}°£ Saltatoric Spasm............................lj^ Chorea Major.............................jj£> Paralysis Agitans.............................j1^ Other Forms of Tremor..........................j-J^ Tetany..................................l^" Infantile Convulsions............................1|58 Occupation-Neuroses............................Wro Periodic Paralysis.............................1162 Hysteria...................•.............1]^ Neurasthenia...............................11m Acromegaly _.....•..........................1178 Astasia-abasia...............................1181 Caisson Disease..............................1182 V. VASOMOTOR AND TROPHIC DISORDERS. Angioneurotic Edema...........................1183 Hydrops Articulorum Intermittens.....................1184 Raynaud's Disease.............................1184 Progressive Hemiatrophy of the Face....................1186 Scleroderma Diffusum...........................1188 Morphea.................................1189 Ainhum.................................1190 Erythromelalgia..............................1190 Acroparesthesia..............................1191 PART IX.—DISEASES OF THE MUSCLES. Myositis.................................1192 Infectious Myositis...........................1192 Progressive Ossifying Myositis.....................1193 Progressive Spinal Muscular Atrophy....................1193 CONTEXTS. 15 PAGE Neural Progressive Muscular Atrophy..................1193 Pseudo-hypertrophic Muscular Paralysis...................1195 Dystrophia Musculorum Progressiva "(Erb)..................1196 Dystrophia Musculorum Progressiva (Dejerine-Landouzy)............1198 Hereditary Muscular Paralysis.......................1199 Arthritic Muscular Atrophy.......................1199 Muscular Atrophies.......................* . . . 1200 Muscular Hypertrophy.........................1200 Thomsen's Disease.............................1200 PART X.—THE INTOXICATIONS; OBESITY; HEAT-STROKE. The Intoxications.............................1203 Alcoholism..............................1203 Ginger and Cologne-water Inebriety...................1210 Morphinism.............................1210 Plumbism...............................1212 Arsenicism..............................1215 Mercurialism.............................1216 Food-infection and Ptomain-poisoning.................1218 Grain- and Vegetable-poisoning.....................1220 Obesity..................................1221 Heat-s'troke...................• •...........1226 PART XL—ANIMAL PARASITIC DISEASES. Psorospermiasis..............................1232 Distomiasis................................1233 Nematodes................................1234 Ascariasis...............................1234 Ankylostomiasis............................1238 Trichiniasis..............................1239 Filariasis...............................1243 Dracontiasis............................. 1245 Other Filarise......................•......1246 Other and Uncommon Nematodes....................1246 Cestodes.................................1247 Taeniae or Tape-worms.........................1252 Taenia Nana..............................1256 Taenia Cucumerina...........................1256 Taenia Flavopunctata........................1256 Parasitic Arachnida............................1256 Other Parasitic Insects...........................1257 Pediculosis..........................•. . . . 1257 Cimex Lectularius...........................1258 Pulex Irritans...........................1258 Pulex Penetrans...........................1258 Ixodes................................1259 Dermanyssus Avium et Gallinse....................1259 Culicidae...............................1259 Hirudo................................1259 Estridaa................................1259 Muscidce...............................1259 PART I. INFECTIOUS DISEASES. TYPHOID FEVER. (Enteric Fever; Abdominal Typhus; lleo-typhoid; Nerven Fieber.) Definition.—An acute infectious disease of which the definitive cause is the specific bacillus of Eberth. It is characterized, patholog- ically, by hyperplasia and sloughing of Peyer's patches; and clinically by its slow, insidious onset, peculiar temperature-curve, swelling of the spleen, rose-colored spots, diarrhea, tympanites, and a liability to cer- tain complications (intestinal hemorrhage, peritonitis, etc.). The disease has an average duration of from three to four weeks. History.—Although known beyond the reach of tradition, typhoid fever was clearly distinguished from typhus at a comparatively recent date. Louis of Paris in 1829 proposed the term typhoide, but it re- mained for Gerhard of Philadelphia to discriminate typhoid from typhus fever as the result of his own precise clinical observations. His account of the disease wras ably corroborated by the writings of E. Hale and James Jackson, Sr. (1838, 1839). Later, Shattuck of Boston and Jenner of London made important contributions to the subject. Shattuck's experiments on typhus and typhoid fevers at the London Fever Hospital in England, and Alfred Stille"s studies of the former affection in Dublin and Naples, and of the latter in Paris, in- creased greatly our knowledge of these diseases. As a result of the labors of the above-mentioned American authors the true nature and identity of typhoid fever were appreciated in America at an earlier day than in either France or England. Briefly, the decade from 1840 to 1850 witnessed, on the one hand, the overthrow of erroneous notions concerning the similarity of typhoid and typhus fevers, and, on the other, the establishment of their points of dissimilarity. Pathology.—The lesions produced by typhoid fever may conve- niently be divided into two groups: (1) Primary lesions, due to the direct effect of the special bacillus upon the lymph-follicles of the intestines, the mesenteric and other lymph-glands, and the spleen. (2) Secondary lesions, due chiefly to the long-continued fever and to secondary infection, for the occurrence of which the essential lesions of typhoid fever furnish the golden opportunity. (1) The primary morbid changes in the Peyer's patches and solitary glands of the intestines are divided, usually, into four stages: (a) The Stage of Infiltration.—The lymph-follicles become engorged 2 17 18 INFECTIOUS DISEASES. (hyperplasia), particularly Peyer's glands in the ileum and near to the valve, and, to a lesser extent, in the lower part of the jejunum. Fre- quently, the solitary glands in the small intestines, the colon, and rarely the rectum, become similarly infiltrated. In about 33 per cent, of the cases the chief morbid lesions are confined to the large intestines. In mild cases a few Peyer's patches in the lower part of the ileum are alone the seat of infiltration and subsequent changes. The follicles are grayish- white in color, and may project—particularly the patches of Peyer— from 3 to 5 mm. or more. Rarely, the solitary glands, which vary in size from a mustard-seed to a large pea, become very prominent and show a bold attempt at pedunculation. The histologic changes at first consist in a marked dilatation of the capillary blood-vessels, which later are more or less compressed (as a consequence of cell-infiltration), giving to the follicles their whitish, anemic appearance. The cellular elements partake of the nature of lymph-corpuscles. Some of these cells are larger and are epithelioid in character, with ten or more nuclei. The mucosa and muscularis ad- jacent to the glandular structures may be similarly infiltrated. From the eighth to the tenth day the stage of infiltration terminates either in resolution or in necrosis and sloughing. The infiltrated cells may undergo granular or fatty degeneration, followed by absorption. This process—resolution—during its progress produces pitting of the swollen follicles. In consequence of these minute points of necrosis the plaques now present a characteristic reticulated appearance (plaques a surface reticulee). When resolution occurs, accompanied by destruc- tion of the follicles, small hemorrhages may take place into the glandu- lar structure. These hemorrhages may occasion pigmentary deposits in the follicular depressions, giving rise to the so-called "shaven-beard" appearance. Resolution, however, terminates the stage of medullary infiltration with relative infrequency. Far more frequently the hyper- plasia of the lymph-follicles ends in (b) Necrosis or Sloughing.—In all save the milder grades of cell- infiltration the hyperplasia of the lymphatic tissue cannot subside before necrosis occurs. The latter process results partly from com- pression and choking of the blood-vessels by the cell-infiltration, and partly from the direct action of the typhoid bacillus, leading to so-called anemic necrosis. Thus, necrotic crusts (sloughs) are formed, which are gradually separated and cast off. While not all of the glands of Peyer which are the seat of cellular infiltration undergo subsequent necrosis, as a rule those situated in the lower portion of the ileum do, and show the process in its completest development. The depth to'which the necrosis extends is quite variable. It may involve only the most super- ficial layers of the mucosa, or it may extend in depth till it reaches, or even perforates, the outer or serous coat; but usually this work' of destruction does not dip below the submucosa or muscularis. The necrosed portions become detached—a process that proceeds from the periphery toward the center—leaving behind the typhoid ulcer The stage of necrosis and sloughing begins between the eighth and tenth days, and ends on or about the twenty-first day. (c) Stage of Ulceration.—The size and shape of the ulcers corre- spond exactly to the necrosed areas in these respects. A single gland TYPHOID FEVER. 19 of Peyer generally presents several ulcers of irregular outline separated by strips of mucous membrane. Rarely, the entire plaque is implicated, in which case a large oval ulcer is the result, and at the lower end of the ileum the ulcers often coalesce until they almost encircle the bowel. The ulcers of the solitary glands assume a rounded form. The character of the floor of the ulcer will vary with the character of the intestinal coat which forms its base, though usually it is clean and smooth. The edges are usually irregular, engorged, soft, and frequently overhanging. In the lower segment of the ileum ulcers may be numerous, whilst in other portions of the gut Peyer's plaques may be merely hyperemic. In about 25 per cent, of the cases the typhoid ulcers are found in the large intestines—/'. e. in the cecum and colon. Perforation of the large bowel is exceedingly rare. Exceptionally, the appendix is the seat of ulcer. Osier having dissected a case that died three months after an attack of typhoid fever, in which he found a localized abscess due to perforation of the appendix. Hemorrhage usually results from erosion of a vessel—an accident which is occasioned by the separation of the sloughs—but small bleed- ings may take place from the swollen, hyperemic edges of an ulcer. Perforation of the bowel occurs in a small percentage of cases (about 6 per cent.). In the majority of instances it is attributed to a perfora- tive necrosis; hence it is that the sloughs are usually found attached to the orifice. Perforation may also occur after the separation of the necrosed portions during the stage of ulceration. The perforations may be multiple, though they are usually single and rarely exceeding two in number. The small, deep ulcers are more apt to lead to complete per- foration than larger ones, and the site of the orifice is usually some- where in the course of the lower third of the ileum. The lesions of peritonitis are invariably present, and during the stages of necrosis and ulceration a catarrhal state of the mucosa of the small and large intestines exists. The diarrhea which usually accompanies this affection is to be ascribed chiefly to the catarrhal state of the large bowel. (d) Healing follows promptly upon the formation of the ulcer. At first a granular tissue covers its floor. The mucous membrane is replaced, including the glandular elements and epithelial layer, and, as in the stage of necrosis and sloughing, so the healing process advances inward from the border of the ulcer. Indeed, it is this process that dis- lodges the necrotic crust. Occasionally, ulcers are seen extending in one direction while healing in another. The cicatrix formed by the healing of an ulcer presents a smooth and often pigmented surface. The stages thus far described do not, strictly speaking, follow one another, since two or more may be illustrated at once by a group of ulcers occupying the same section of the intestine. Again, when death occurs during a relapse fresh ulcers are observed by the side of others that are partially healed. The Mesenteric Glands.—Changes in the mesenteric glands occur simultaneously with those in the intestines, and those situated opposite to the lower third of the ileum, the portion of the bowel showing the most extensive ulceration, are most profoundly involved. Hyperemia, and later swelling due to cell-infiltration, are among the earliest 20 INFECTIOUS DISEASES. changes, and correspond with the lesions noted in the intestines (vide supra). The mesenteric glands exhibit great variations in size, rang- ing, as they do, from that of a pea to a hen's egg. Their color-appear- ance is a grayish-red. Resolution occurs quite commonly, but, if it does not take place, then necrosis of the central portion (due, most probably, to the same causes that produce necrosis of the intestinal lymph-follicles) occurs, and suppuration has been observed in some cases. Still other glands become hyperemic and swollen (retroperi- toneal, bronchial, etc.); but these almost invariably tend toward resolution. The Spleen.—With rare exceptions the spleen becomes enlarged in typhoid fever. At first hyperemic, the tissue then grows soft and gran- ular, and at times is almost diffluent on section. Infarction is not a rare occurrence and may lead to suppuration. In some few cases, either spontaneously or as the result of injury, a rupture of the organ may occur, and the records of 2000 post-mortems at the Munich Patho- logic Institute furnish 5 instances of this nature. (2) Secondary Lesions due chiefly to the Continued Fever and to Sec- ondary Infections.—The lesions in other organs are of subsidiary import- ance, and are, for the most part, secondary in nature, though we can- not, in the present state of our knowledge, draw a sharp line of dis- tinction between these lesions and those that are primary. While the pathologic changes above described are chiefly due to the direct action of the specific bacillus of typhoid, yet a few of them are ascribed to secondary infection, and, at all events, they do not belong peculiarly to this disease—c. g. suppurative processes, etc. Further, in connection with the clinical history of the affection I shall point out that in a small percentage of cases the initial specific lesions may be localized, either in the throat or in the lungs or kidneys. It is to be emphasized, therefore, that whilst the essential pathologic processes of the disease have been described above, a classification of the lesions into primary and secondary, based upon the involvement of particular organs, can only be approximately correct. The liver early becomes hyperemic, and later is softer and paler than is natural. Handford has described necrotic areas, and Wagner minute lymphomata. Infarction and abscess occur in rare instances. The mucosa of the gall-bladder may show catarrhal inflammation, and in very rare instances a croupous, diphtheritic, or ulcerative inflammation of this organ may occur. The bile is thinner and paler than the normal. The microscope reveals parenchymatous and granular degeneration. The cells contain an abundance of fat, whilst their nuclei have lost, in great part, their outline. The kidneys, like the liver, exhibit parenchymatous degeneration They are somewhat pale-looking, are cloudy on section, and slightly swollen, and under the microscope granular and fatty degeneration of the epithelial cells of the convoluted tubules is observed. More rarely the lesions are those of acute hemorrhagic nephritis. Small areas of round-cell infiltration may develop late in the course of typhoid and these may present an appearance similar to lymphomata or may undergo softening and suppuration, giving rise to miliary abscesses. The ml TYPHOID FEVER. 21 cous membrane of the pelvis of the kidney is not infrequently the seat of a mild grade of catarrh, and, rarely, of diphtheritic inflammation. Vesical catarrh is still more common, and the bladder may also be the seat of diphtheritic inflammation. Rarely orchitis is encountered. On making cultures from sections of the kidneys not a few observers have been able to demonstrate the specific bacillus of typhoid, particularly in the softened areas. In the lungs are found morbid lesions in nearly all cases of typhoid fever, and belonging to the essential pathologic processes is bronchitis, due to a congested and catarrhal state of the bronchial mucous mem- brane. The lesions of lobular pneumonia present a complicating con- dition in many instances ; those of lobar pneumonia also may be present, though less commonly. The so-called hypostatic congestion is often found, but is, I think, less frequent than is supposed by many authors. Embolic infarctions, having their origin in thrombi occupying the right side of the heart, are sometimes present. Gangrene may also occur. Pleurisy is sometimes, though rarely, met with. It is most fre- quently of the plastic variety, although empyema occurred in nearly 2 per cent, of the Munich cases. The larynx and the pharynx may manifest changes. Ulcers have been observed on the epiglottis and posterior wall of the larynx, and I have more than once seen them on the pharynx. When situated in the larynx they may extend in depth till they reach the perichondrium, causing perichondritis, with or without edema of the larynx as an associated lesion. Typhoid bacilli have been found in the ulcers (Eich- horst). Catarrhal, or even croupous, pharyngitis may occur, and a swelling of the follicles of the pharynx and base of the tongue is to be noticed in many cases. True aphthous changes, affecting the mouth and pharynx, may be present as a secondary event. The mucosa of the stomach is sometimes congested, and may even ulcerate, although this is very rarely seen. Peritonitis is always found in fatal cases in which the bowel has been perforated. The condition is a general one, save in the rare instances mentioned below, and there is usually much fibrino-purulent effusion present. Diffuse peritonitis may be present without perforation, and results sometimes from a localization of the typhoid poison in the peri- toneum, from rupture of suppurating mesenteric glands, but more fre- quently, I think, from direct extension of intestinal inflammation to the peritoneum. The heart may be the seat of morbid changes. Acute endocarditis may be a very rare complication, while pericarditis occurs relatively more often—viz. in 14 of the Munich post-mortems before mentioned. Myocarditis is a not uncommon event, the cardiac muscle exhibiting parenchymatous and, less commonly, hyaline, degeneration, and the lat- ter change sometimes leads to sudden rupture of the muscular fibers, with a fatal result (myocardite se'gmentaire). It is, however, a signif- icant fact that in the majority of instances, even of the severest type, the cell-fibers may show slight, if any, noticeable change. Out of 48 cases, 16 showed granular or fatty degeneration, and 3 a proliferative endarteritis in the small vessels (Dewevre). The arteries have, in a number of instances, been found to be the 22 INFECTIOUS DISEASES. seat of two forms of arteritis (Barie): (a) Acute obliterating arteritis, and (b) Partial arteritis. These conditions may affect the smaller ves- sels, particularly those of the heart, but they occur most commonly in the arteries of the lower extremities. Thrombi are found in the right chambers of the heart and in the veins—most frequently in the femoral, and less often in the cerebral sinuses. The voluntary muscles undergo parenchymatous and, occasionally, a hyaline, change, though this is not a feature peculiar to typhoid fever. The latter form of degeneration does not affect the whole muscle, only certain fibers being involved, and as a rule the recti abdominis, the dia- phragm, the adductors of the thigh, and the pectorals are the seats of the lesion. The parts affected are pale and possess a grayish, waxy luster. Histologically, the process implies the transformation of the muscular fibers, and especially the cement substance, into a homogeneous, pliable mass. Regeneration of the fibers thus destroyed occurs during convalescence. The nervous system presents no gross lesions, if we except menin- gitis, the latter occurring as a complication; but it is exceedingly rare, having been present in only 11 of the 2000 Munich cases. In a few instances large cerebral hemorrhages have been met with, but these are apparently coincidental, while capillary hemorrhages into the cortex may be numerous. Meningeal hemorrhages may also occur. Slight edema of the cerebral cortex has been noted. The peripheral nerves are, not infrequently, the seat of parenchymatous change, with or with- out local neuritis, and the ganglia of the trunks of the vagi exhibit an inflammatory change, which Levin feels is the cause of certain symp- toms and conditions, such as laryngitis, pharyngitis, pharyngolysis, arrhythmia, etc. The blood shows few important alterations. The red blood-corpuscles are relatively increased during the febrile period and markedly dimin- ished during convalescence, but the great loss of water during the former period and a reabsorption during the latter will explain these interesting facts (Henry). Leukocytosis is absent, and there is often an actual decrease in the number of leukocytes. The mononuclear forms are more numerous than in health. Etiology.—Bacteriology.—The bacterium which is the specific cause of typhoid fever was discovered by Eberth, whose researches were later confirmed by the careful investigations of Gaffky. It is a short thick bacillus, about three times as long as it is broad, with rounded ends (Fig. 1). It is motile, due to the presence of cilia on both sides and when stained exhibits vacuolations that have been mistaken for spores It is easily stained with all the anilin dyes. It has been found in the intestinal tract, in the lymph-glands, contents of the intes- tine, spleen, liver, and blood; in fact, it has been found in nearly all the organs of the body. I pon gelatin plates it develops in grayish translucent colonies with irregular borders and ridged surfaces Ur,on agar the growth is not characteristic; upon the potato, especially if it has been rendered slightly acid, it forms a perfectly transparent growth that is only evident as a slight apparent increase of moisture unon the surface, and as offering a greater resistance to the point of the needle when scraped across it. It neither coagulates milk, liquefies gelatin TYPHOID FEVER. 23 nor produces indol. The organism never forms spores. Gaffky de- scribed the formation of spores, and his observation was afterwards con- firmed by Chantemesse and Widal, but Buchner and Pfeil subsequently showed that the suspicious bodies were merely conglomerations of pro- toplasm that had undergone a plas- molytic process. Moreover, the ba- .""""' cillus has no more powers of resist- A ance than the ordinary bacteria. 4F / Inoculated into lower animals, it fre- v quently causes fatal results without / producing the lesions characteristic of it typhoid in human beings, although \, ** occasionally typical typhoid ulcers r have been found. The susceptibility * • of lower animals, though normally %. * . ' 1 slight, can be increased by prelimi- lk ,^V*" J W nary injections of saprophytic bacte- ^^fc j ^f ria, this result having been observed ^ . ^ ,#*» -' bv Alessi when he exposed animals ,4" v • to the gases produced by putrefying FlG'x-^^ bacim with fiageiia; x 1000. matters. The poison is probably a toxin, and it is quite possible to render the lower animals immune to disease. Usually in making a bacteriologic diagnosis the typhoid bacillus is to be separated from those organisms that morphologically resemble it and present almost identical characteristics upon various culture-media. Particularly is this true of the bacterium coli commune, which differs, though not invariably, in the fact that it produces fermentation of the saccharine media, or forms indol in peptone bouillon, and coagulates milk, with the production of an acid reaction. Eisner has proposed cultivation of the fecal organisms upon acid glycerin potato to which 1 per cent, of potas- sium iodid has been added. At the end of twenty-four hours the typhoid bacillus has formed minute, grayish-white points upon the culture-media, while the bacterium coli commune has formed luxuriant colonies. At the end of forty-eight hours the typhoid bacilli appear in clear shining drop-like and finely granular colonies, and the bacterium coli commune in much coarser granular colonies that are brownish in color. Of late this method has been found more or less inaccurate, and Eisner himself admits that it is untrustworthy. The real poison of typhoid fever must, therefore, be a chemical sub- stance secreted by the bacillus—typho-toxin—and Brieger has extracted the latter agent, finding that it produces the fever, nervous symptoms, and the other manifestations characteristic of the affection. Most authors agree that the bacilli cannot maintain a permanent existence outside the human body. From time to time, however, the conditions indispensable to the growth and development of the typhoid germs prevail, and cor- responding with such periods of time more or less extensive epidemic outbreaks of the disease may occur. It is known that the typhoid bacilli may retain their vitality from seven to fourteen days in water, disappearing from the same on account of the presence of saprophytes; but an epidemic or an endemic of typhoid fever implies persistent con- 24 INFECTIOITS DISEASES. tamination of the drinking-water. Multiplication of the bacilli may take place in water, in milk (very rapidly), and in the soil (where they preserve their vitality under favorable conditions for months). Freezing does not kill them, as they may live in ice for several months (Prudden). They have been discovered in infected water, but are thoroughly destroyed by boiling. Predisposing Causes.—Typhoid fever is particularly prevalent in tem- perate latitudes and in every quarter of the globe. Among the influ- ences predisposing to the disease are— (a) Geographic Location.—In temperate zones it prevails con- stantly and to a greater or less extent. But, though the disease occurs most frequently in temperate climates, it cannot safely be inferred that climate per se exerts any marked influence over its appearance. Thus it has been shown in recent times to be comparatively common in the tropics as well as in many cold latitudes (Iceland, Norway, etc.). (b) Seasons exert a decided influence upon the frequency of the occurrence of typhoid. According to the statistics of Murchison, Bart- lett, Osier, Hirsh, and others, the time of greatest liability to typhoid fever is during the late summer and the early autumn, the months in which cases are most frequent being August, September, and October. The remaining summer and autumn months yield a relatively larger number of cases than the winter and spring: again, in winter more cases are met with than in the spring, which furnishes fewer cases than any other season of the year. After dry summers typhoid fever is especially apt to be prevalent, and, according to Baumgarten, a rela- tively large amount of dust in the atmosphere may disseminate the typhoid germs. (c) Condition of the " Ground Soil."—Pettenkofer and his disciples contend that when the standing water in the soil reaches a high level fewer cases occur, and when it falls to a low level or below the mean height the cases become more numerous. This dictum, however, has not as yet been conclusively proven with reference to many localities. Whilst the condition of the soil as to moisture, etc. cannot explain all of the peculiarities noticeable in the behavior and distribution of the disease, certain characteristics of the soil may furnish the conditions essential to the growth, development, and multiplication of the typhoid bacillus, and it is certain that epidemics of typhoid fever occur repeatedly without regard to the condition of the ground-water. (d) Age.—Typhoid fever may occur at any age. It is, however, especially frequent among young, robust individuals between the ages of fifteen and thirty years, Later in life it becomes progressively less frequent, though cases have occurred at or beyond the seventieth year. Young children are not exempt, and cases among them are of rather frequent occurrence, if we except those under one year of age. (e) Sex probably does not affect the degree of liability in typhoid fever. (/) Individual Predisposition.—This may be acquired or inherited. An instance of acquired predisposition is to be noted in the great sus- ceptibility which exists among persons who have recently moved from rural districts to cities. Thus, Louis found "that of 129 cases, 73 had not resided in Paris over ten months, and 102 not over twenty months." TYPHOID FEVER. 25 To account for this fact we have the influence of a change both of sani- tary surroundings and of the habits of life. That the predisposition to this affection may also be inherited I have no doubt. We must assume in these cases the existence of certain peculiarities of the family soil to account for the heightened receptivity that is so often observed in and throughout successive generations. Most persons, however, and perhaps most families, seem to enjoy natural immunity from the affection. (g) Intestinal Catarrh.—It is quite probable that a catarrhal state of the intestinal mucosa produces local predisposition to infection with the typhoid poison. I have observed cases of influenza, writh marked catarrh of the gastro-intestinal tract, to be followed promptly by the symptoms of typhoid fever (vide Influenza). The occurrence of typhoid fever confers an approximate, though not an absolute, immunity against subsequent attacks. (h) Nervous Influences.—Great mental excitement and overwork are among the predisposing nervous causes. In this connection two questions present themselves for consideration: (1) What are the methods of conveyance of the poison into the human body? In the first place, isolated cases and epidemics of typhoid fever are alike to be attributed to antecedent cases of the disease, and this fact presupposes that the bacillus of typhoid leaves the body of the sufferer during the attack. This it does in the stools, which are practically the only primary source of infection and contain the bacilli or their spores in great numbers. From the dejecta the bacilli may be conveyed to well persons by— (a) Infected Drinking-water.—In the vast majority of instances the poison is transmitted from those affected with the disease to those in good health through the drinking-water supply. This has been especi- ally true in those extensive epidemic outbreaks in which the mode of origin has been traced. Wells, storage reservoirs, springs, and rivers may alike become contaminated and cause epidemic prevalence of the disease. In the spring of 1885 a most instructive, though deplorable, epi- demic occurred in Plymouth, Penna., a town of 8000 inhabitants. At first the nature of the affection was not recognized, and before it ceased to appear 1200 persons were affected, with 130 resulting deaths. This epidemic was investigated by Shakespeare and L. II. Taylor, and was found to have arisen from a single case of typhoid occurring in a house on a hill which sloped toward the water-supply of the town. This patient was ill during January, February, and March, while the ground was frozen and covered Avith snow, upon which the dejecta were thrown by the attendant. On March 25th there was a considerable rainfall, followed by a sudden thaw, and the water, unable to sink in the frozen earth, ran at once through the various surface channels into a brook, which in turn emptied into the reservoir. Coincidently with the thaw the patient had frequent and copious stools, and, strangely enough, for certain reasons the infected water-supply was at the same time more largely drawn upon than usual. On April 10th other cases of the dis- ease appeared, and careful investigation showed that those citizens who 26 TNFECTIO US DISEA SES. obtained their water from other sources than the infected reservoir escaped the disease. (b) Infected milk frequently conveys the poison. It may become polluted by water which has been used either to wash the cans or for diluting purposes, or the bacilli may be transferred to milk by the unclean hands of the milker. Numerous instructive epidemics, origi- nating in infected milk, have been reported (Murchison, Ballard, Alm- quist, and others). Solid forms of food (salads, celery, fruits, etc.) may be contaminated by infected water or dust or by the fingers of the nurse or the patient. A fly which has alighted on the soiled linen of a typhoid patient in a ward may subsequently contaminate the milk or other food (Osier). H. W. Conn has shown that oysters while being fattened or freshened may become infected, and the careful studies of Foote teach us that the tvphoid bacillus will not only retain its vitality in the salt water in which the oysters are fed, but that it will live even longer in the oyster itself. (c) Contagion or Direct Transmission.—This necessitates direct con- tact with the typhoid stools, and its possibility cannot be denied. It affords a ready explanation for contraction of the disease by nurses who attend to the stools, the bed, and the body-linen of the patient, and by laundresses who are also obliged to handle the soiled clothing, and who are affected with great relative frequency. (d) " Ground Soil."—According to Pettenkofer's view (vide supra), the typhoid bacilli are rarely, if ever, transferred directly from the sick to the healthy. On the contrary, he contends that the typhoid poison which leaves the body of an infected person must undergo modification or development in the ground-soil before it is potent to cause the disease in question. These facts are opposed to the view that typhoid fever is transferable by contagion. (e) Sewer Gas.—The typhoid stools frequently find their way into the sewers, and if they have not been thoroughly disinfected may there meet with all the conditions favorable to the growth and propagation of the bacilli. Moreover, if under these circumstances the house-drain be defective, typhoid bacilli may escape into and contaminate the atmo- sphere of homes, infecting receptive occupants. Alessi's experiments go to show that animals are rendered highly sensitive to the typhoid bacillus by the inhalation of gases of putrefaction. But the recent researches of Bergey and of Abbott seem to show that sewer gas is not decidedly deleterious, and it certainly cannot of itself cause typhoid fever. (2) Through what channel or channels does the typhoid bacillus gain entrance into the human system ? (a) Almost invariably the bacilli are swallowed with drinking-water or food, particularly milk. It must not be forgotten that bacilli when inhaled may find lodgement in the mouth, pharynx, etc., and then be carried along into the stomach with the next food or drink that is ingested. In the stomach they meet with the acid gastric secretions which often destroy them. They may, however, pass into the intesti- nal canal, where the alkaline juices of the small intestines furnish every condition necessary for their further growth and development. They TYPHOID FEVER. 27 penetrate the mucosa and attack primarily the solitary follicles and Peyer's plaques. Next they invade the mesenteric glands, reaching the circulation, spleen, liver, and other organs a little later. (b) The possibility that the bacilli may reach the blood-stream through the respiratory organs must be conceded; and hence the added possi- bility that they may set up initiatory lesions either in the tonsils or lungs, passing thence into the circulation, must also be granted, although cases rarely originate in this manner. Clinical History.—I. Incubation.—The average duration of the period of incubation, or the time between the introduction of the poison into the system and the appearance of the first active symptoms, ranges from ten days to three weeks, though it sometimes lasts for a longer, and oftener, I think, for a shorter, time. During this period the patient may experience no deviation from health, but in most cases there are prodromal symptoms, such as languor, loss of appetite, nausea, headache, neuro-muscular pains in the back and limbs, a disinclination to exercise, etc. These symptoms last usually from a few days to a week or more. n. General Symptomatology and Course.—On account of the peculiar temperature-curve in typhoid fever its course falls naturally into three periods—the stage of development; the acme or fastigium (correspond- ing to the height of the disease); and the stage of decline or deferves- cence. It is convenient to speak of the various weeks of the affection when referring to these stages. Thus, the first week represents the stage of development, the second and third weeks (in cases of average severity) the fastigium, while the fourth week in the typical form (the third week in mild cases) corresponds to the third or declining stage of the disease. (a) Stage of Development.—The invasion, as a rule, is not sudden, but gradual, the symptoms being chilliness and feverishness, with in- crease in the severity of the prodromal symptoms. Typhoid fever rarely starts in with a distinct rigor. At or about this time nose-bleed betrays the nature of the disease in a considerable proportion of the cases. The symptoms just described are quickly followed by a prostra- tion sufficiently well marked to compel most patients to take their beds. From this latter event is usually dated the onset of the affection. It is safer, however, to regard the time of occurrence of the above-mentioned symptoms (elevationof temperature, with its attendant discomforts) as the time of onset, since many patients continue in their avocations for days after the appearance of the first symptoms. With the progress of the initial period the symptoms usually increase in severity with considerable rapidity; the temperature rises day by day, till, at the end of four or five days, the second stage, or fastigium, is reached. Anorexia is complete, thirst is great, headache rather in- tense, the skin hot and dry to the feel, the tongue coated, the sleep dis- turbed, and constipation often marked. The patient may complain of fits of chilliness, alternating with flushings of heat, and there is a slight cough with some thoracic oppression. The pulse is quickened (from 90 to 110 per minute) and is full, though rarely, thus early, is it dicrotic. The physical signs are not prominent. The abdomen is often slightly distended and tender; the spleen, on palpation, is found to be somewhat swollen. 28 INFECTIOUS DISEASES. (b) Fastigium, or the second stage, commences usually on the fourth or fifth day of the disease, and lasts, in typical cases, about two weeks. During the first week of the fastigium (the second of the disease) the general symptoms become more marked. The fever remains high (the evening temperature usually reaching 103° or 104° F. (40.° C), and exhibits the continued type. The pulse is accelerated but not dicrotic. The headache disappears, and mental dulness and slowness are conspicu- ous, but there may be mild delirium, particularly at night. There is a dry cough and the physical signs indicate more or less extensive bron- chitis. The tongue is coated and may become dry, the belly is some- what swollen and tender, and diarrhea replaces constipation. The spleen is decidedly enlarged, and about the eighth day of the disease a number of roseate spots, which are pathognomonic, appear on the trunk. During the latter part of this week a grave or even fatal condition may be developed as a result of intense nervous or pulmonary symptoms, in- testinal hemorrhage, or perforation. During the second week of the fastigium (the third week of the dis- ease) the marked general symptoms already noted persist in severe types of the affection. The pulse varies from 110 to 130, and the tempera- ture may approach the remittent type. In addition, this period fur- nishes the most numerous as well as the most untoward complications (lobular pneumonia, hypostatic congestion of the lungs, intestinal hem- orrhage, perforation, peritonitis, etc.), and in the absence of serious local complications grave general conditions may be presented. (c) Stage of Decline or Defervescence.—At the end of the second stage, and about the twenty-first day of the disease, in favorable cases the fever begins to decline, and with it the other general and local symptoms gradually disappear. This is followed by true convalescence. In protracted cases, however, the fourth week of the disease may present much the same clinical indications as the third, and these may even be intensified. Frequently an aggravated type of the typhoid state is now superadded, the symptoms being stupor, muttering delirium, subsultus tendinum, a rapid, feeble pulse, a dry, brown tongue, marked diarrhea, greatly swollen belly, and an involuntary discharge of feces and urine. Inflammatory complications may add to the perils of the condition. In not a few cases the febrile period is prolonged into the fifth, and rarely into the sixth or even the seventh week, and the fever observed when defervescence is retarded presents an irregular type. I have else- where reported a case in which it lasted not less than seven weeks.1 About this time recrudescences and relapses may occur in typical cases. Different epidemics of typhoid fever, however, vary so greatly in their clinical characteristics as to make it impossible to include all cases in any outline of the course of the disease that might be attempted. The above sketch embraces the more or less nearly typical cases III. Chief Clinical Features in Detail—(a) Course of the Fever.— During the stage of development (the first four or five days) the temper- ature usually rises in " step-ladder " fashion. The evening exacerbation is on each day from a degree and a half to two degrees higher than on 1 "A Case of Typhoid Fever; numerous Intestinal Hemorrhages the Amount of Blood Lost being Seventy-eight and one-half Ounces ; and Obstinate Vomitine with Recovery," International Clinics, vol. i. 5th series, April, 1895, p. 29 TYPHOID FEVER. 29 the preceding, and the same is true of the morning remissions. A glance at the temperature-charts (Figs. 2 and 3) will show that the morning remissions touch a level from one-half to one degree lower than the preceding evening registers. When the fastigium is reached, the evening temperature may be 103°, 104°, or 105° F. (39.4°-40.5° C), and is usually thus main- tained, with slight morning remissions, during the first and some- times during the second week of this period. More often, during the latter half of the fastigium (the third or fourth week of the disease) the morning fall of temperature becomes decidedly greater. According to my own observation, the height of the fastigium is reached a day or two after its onset or at the end of the first week of the affection. Marked morning remissions are a favorable indication. On the other hand, and contrary to the general rule, the morning temperature may be higher than the evening, forming a somewhat unfavorable symptom. Morning temperatures of 104° F. (40° C.) or over are indicative of a serious type. In many instances of mild grade the evening temperature at no time exceeds 103° (39.4° C), but oscillates between lOOf° and 102f° F. (38.1°-39.2° C). In cases of average intensity the morning remis- sions touch 102°-102|° F. (39.2° C), and the evening exacerbations reach 104-104f° F. (40.3° C). When the temperature rises above 105° F. (40.5° C.) hyperpyrexia exists. Ampugnani made studies of hourly charts from 200 cases of typhoid fever, and found the maximum tem- perature to occur between three and six o'clock in the afternoon, and the minimum between four and eight o'clock in the morning. The duration of the fastigium exhibits a wide range and is dependent upon a variety of conditions—e. g. the degree of mildness or severity of the type, the presence or absence of complications, etc. In cases of a mild character it lasts from a few days to one week; in cases of average severity, from ten days to two weeks; in the severest forms, from two to four weeks. In typical cases the end of the fastigium marks the beginning of the last stage (that of defervescence), and during this period the tempera- ture falls by lysis. Measured by days, it declines by degrees, both the morning and evening temperatures being often one or two degrees lower than on the preceding day. Thus is formed a more or less regu- lar step-like line of descent. To this general rule there are two nota- ble exceptions: From the beginning of the period of defervescence the morning remissions may strike the normal point, while the evening ex- acerbations become less and less marked, until they also touch the normal. Under these circumstances the temperature-curve resembles somewhat that of the quotidian intermittents, and rarely the tertian type of curve obtains. In comparatively rare instances the morning temperature shows a deeper remission on each successive day, while the evening temperature remains high for several days, when it also declines. This period lasts from one week to ten days—a longer time than in the first instance. In the severe and protracted forms of typhoid fever there occurs between the second stage (fastigium) and the third stage (defervescence) another, to which Wunderlich has given the name of the " ambiguous period." This lasts from a few days to a week or more, and is charac- typhoid. TYPHOID FEVER. 31 terized by a striking diurnal range of temperature, with marked irreg- ularities. It is probable that it is sometimes produced by an auto- infection. Abnormal Course of the Fever.—The pyrexial peculiarities yet to be pointed out are less usual than the foregoing, though of suf- ficient frequency of occurrence to demand a brief description. The first stage varies but little from the regular course described above. A sudden elevation of temperature, however, is seen in those rare cases that begin with a severe rigor, and frequently with accom- panying pneumonic symptoms. The first stage is but rarely noted by the physician for the reason that the patient does not come under ob- servation at an early period. As before pointed out, the fastigium exhibits the widest variations as to its duration. In the lightest forms it may be practically absent, defervescence setting in upon the first day of the fastigium. There is also a class of cases in which, throughout the greater part of their course, the fever is distinctly intermittent or remittent, and in which careful blood-examination fails to disclose the plasmodium malarice. The same characteristic marks the temperature-curve in those rare instances of typhoid fever which occur in subjects previously infected with malaria. These two classes of cases run a favorable course as a rule. Sudden deep temporary drops in the temperature may occur during the fastigium. (1) This may take place during the early part of the fastigium without obvious cause. (2) Intestinal hemorrhage almost invariably produces a sudden, and sometimes a great, fall of tempera- ture. Osier has reported a case in which a drop of 10° F. (5.5° C.) followed melena. The blood does not appear in the evacuations of the patient for six to twelve hours or more after the temperature has begun to fall; and hence a critical decline of temperature during the latter part of the second and the third week of the disease suggests that hemor- rhage has probably taken place. (3) The occurrence of peritonitis is marked by a sudden and considerable fall of temperature.. (4) In the female, abortion or premature delivery occurring in the course of typhoid fever produces a decided lowering of the temperature. (5) Collapse of the circulation sometimes occurs with a notable remission of temperature—an ominous association of events, and one which I observed in two cases occurring in females in the Medico-Chirurgical Hospital. In one of these cases two such periods of collapse occurred, and in the other three, though both finally recovered under prompt and continuous stimulation. Occasionally hyperpyrexia is observed in typhoid fever, and most frequently just before dissolution, when the thermometer may register 108° or even 109° F. (42.7° C). A fresh rise with marked irregularity of temperature may occur during the latter part of the fas- tigium or the period of decline, and is often dependent upon some local complication (late pneumonia, parotitis, etc.). The stage of defervescence is sometimes much prolonged, though most frequently there is simply a slight evening elevation (99° to 100° F.— 37.7° C), the morning temperature being normal. The causes of retarded decline are, for the most part, obscure. I believe that many of them are ascribable to a mild grade of auto-infection, and in my hands a mild saline laxative has been the means of cutting them short in a number 32 INFECTIOITS DISF. 1SFS. of instances. An examination should, however, be made for some localized inflammatory complication, though this is not always dis- cernible, as in the case of suppuration in the mesenteric glands, etc. Sluggish typhoid ulcers, which refuse to heal promptly and are due to the now well-known post-typhoid anemia, may act as a cause of the slow decline. Post-typhoid Elevations of Temperature.—After both the evening and morning temperatures have become normal, fresh temporary eleva- tions (102° or 103° F.—38.8° or 39.4° C.) frequently appear. They are, as a rule, unassociated with any other symptoms, and at the end of a few days the temperature falls rapidly to the normal. These are termed recrudescences, and are to be distinguished from true typhoid relapses. They are probably produced in various ways—by errors in diet, consti- pation, mental emotion, excitement, etc.—and there are cases in which the presence of the fever seems to be really a nervous phenomenon (Osier). It is most common in children and in persons of a decidedly nervous temperament. Certain local sequelae may cause post-typhoid fever, such as abscess, periostitis, etc. Rarely during convalescence a sudden and marked elevation of temperature, accompanied or not by rigor, occurs, but it is usually of short duration and seldom is of serious import. I recently saw, with the attending physician, Dr. Modell, a case in which the temperature had been normal for six days, when rigors, followed by steep elevations of temperature, occurred several times and at intervals of thirty-six or forty-eight hours. These high temperatures were followed by a rapid decline to the normal, and by sweating, leaving the patient profoundly exhausted. Subsequently the convalescence was slow, but uninterrupted. Afebrile Typhoid.—As the term indicates, typhoid fever may run a course attended with all of the characteristic symptoms save the fever. Cases of this kind are of great rarity. (b) Skin.—The eruption is highly characteristic, and usually decides the diagnosis. It makes its appearance on or about the eighth day, and sometimes a little later. Occasionally it does not appear until the tenth or twelfth day of the disease. It consists of distinct, rose-colored, and slightly elevated papules, having a rounded or lenticular form and a diameter varying from one or two to three lines. The papules are almost invariably found upon the trunk, and especially upon the upper part of the abdomen and the lower part of the thorax, to which regions they may be wholly confined. They may, however, be absent from the usual seats and present elsewhere, so that the sides of the trunk the back, and the thighs should always be inspected. They disappear upon pressure, but reappear promptly when pressure is removed. These rose-colored spots last three or four days, and appear in successive crops, each one being made up, usually, of a few spots—a half-dozen to a dozen. Rarely the eruption is abundant on the trunk, even extend ing to the extremities and head; but there is no direct correspondence between the extent of the eruption and the severity of the cases Occa sionally the spots are entirely absent—a condition most frequently met with in children, and less often in elderly persons. Other eruptions are often present, and their negative diagnostic value must be kept in remembrance. Minute pearly vesicles (sudtmina) TYPHOID FEVER. 33 may appear. They are limited to the abdomen, the axilla, and to the inner surface of the thighs as a rule, and are in great measure due to profuse sweating. A scarlet-colored erythematous eruption sometimes appears at a com- paratively early period in typhoid fever, distributed chiefly over the abdomen and chest, and rarely spreading to the extremities as well. Urticaria and petechiae are rarely seen, though the latter may occasion- ally result from the transformation of a rose-colored spot. Extensive ecchymoses may occur, but are rare, and merely symptomatic of the hemorrhagic diathesis. Cutaneous boils and abscesses due to secondary infection with the pyogenic coccus are a comparatively frequent and late development in the course of the disease. Peliomata typhosa in the form of little bluish subcuticular spots (the '* t&ches bleuatres " of the French writers) may appear, but they are not related specially to typhoid fever, and in a recent case of my own were undoubtedly due to pediculi. Gangrene, chiefly of the lower extremities, has been noted in a few instances, and is probably due to an obliterating endarteritis, thrombosis, or embolism. Profuse sweats form a conspicuous symptom in many epidemics of the disease, with or without accompanying fits of chilliness or rigors, and mark the sudoral form of typhoid fever (Jaccoud). Some of these instances closely resemble ordinary intermittents (vide infra, Diagnosis). Edema of the skin is sometimes observed and is due most frequently to anemia or cachexia, though sometimes to nephritis. A local form of edema affecting the leg is not uncommon, and for this form thrombosis of the femoral vein is chiefly responsible. A peculiar "musty" odor is exhaled from the skin in some instances of typhoid fever, and mainly in those whose skin-surface has been more or less neglected. In all such cases, and in all cases of prolonged duration, bed-sores are likely to develop. They are most prone to occur on the nates and the heels, and, once started, they are apt to spread till they attain to large dimen- sions, with extensive undermining of the skin. The condition is now serious, and may be the cause of an unfavorable termination, even after the patient has successfully resisted the fever. During and after the conclusion of convalescence the hair falls out, but, fortunately, it is invariably renewed. The nails sometimes become roughened and brittle, and in rare instances drop off, while transverse pale lines or ridges can usually be observed in them, marking the impairment of nutrition during the disease (vide Relapse). (c) Digestive System.—The symptoms referable to the gastrointes- tinal canal, though not very striking in most cases, are of the utmost importance and interest because of their direct connection with the pathognomonic lesions of typhoid. Beginning with the intestinal canal, and thence proceeding to the symptoms presented by the stomach, spleen, liver, throat, and mouth, will be a natural and convenient order in which to study the symptoms connected with the alimentary tract. At the onset of typhoid fever constipation is the general rule, and this may persist to the end of the illness, though more commonly a moderate diarrhea appears. During the second week of the affection the stools number, on the average, from two to four or more daily. It is only in comparatively rare instances that ten or twelve or more move- 3 34 INFECTIOUS DISEASES. ments per diem occur, the severity of the diarrhea depending more upon the degree of catarrh, particularly of the large intestine, that may be present, than upon the degree and extent of the ulcers. When, however, as rarely happens, the ulcerative process is chiefly limited to the colon, it is an important factor in the production of the diarrhea. Indeed, in those instances—not altogether rare—in which there is urgent diarrhea of a dysenteric character, the ulcers are especially marked in the colon, with diphtheritic inflammation of the mucosa as a frequently associated lesion. Involuntary discharge of the feces may occur. The stools present a characteristic yellow appearance, suggesting by their color and consistence a comparison with pea soup. They are usu- ally either fluid or of the consistence of jelly, and are offensive and of an alkaline reaction. On standing they separate into two layers—an upper, liquid, cloudy layer, and a lower, thick yellow, sedimentary layer, in which, on macroscopic examination, remnants of food and grayish yellow fragments (necrotic crusts of Peyer's plaques) from a half to an inch in length may be detected. Microscopically, they have been found to contain undigested particles of food, epithelial debris, blood-corpus- cles, crystals of triple phosphates in abundance, and innumerable bac- teria. Laboratory experimentalists have been able to demonstrate the presence of the typhoid bacillus in the dejecta. Tympanites, mainly affecting the colon, is a common though rarely a striking feature, and cases of the most serious nature are observed in which the abdomen presents a concavity throughout the entire illness. The latter is less unfavorable, by far, as a symptom than excessive tympanites, which interferes with both the respiration and heart action. Tympanites is apt to be most marked in serious cases which have diarrhea as a promi- nent symptom, though the latter may not even be present. It is due to the generation of gas from decomposing food, and to the arrest of peri- staltic movements in consequence of the degeneration of the muscularis of the intestines. Pain is absent in the majority of cases, and when present is not intense, save in rare instances. Pressure upon the ileo- cecal region usually causes a gurgling noise, but, although this symp- tom is commonly present, it is not characteristic of the disease. There is generally also a slight degree of tenderness of the abdomen under pressure, most marked in the right iliac fossa, and hence, in all proba- bility, due to the presence of ulcers in this region. Absence of tenderness, however, is not a safe indication of the absence of extensive ulceration. Extreme sensitiveness generally denotes peritonitis (often without per- foration), though the symptom may be quite well marked as a result of constipation only. Intestinal hemorrhage occurs in from 4 to 7 per cent, of cases its frequency varying with different epidemics. The hemorrhages appear almost invariably during the latter part of the second and third week, being caused by the opening of blood-vessels during the necrotic or ulcerative process. Bleedings may also take place from the soft and hyperemic edges of the ulcer (vide supra), and when it occurs quite early in the disease it may be in consequence of an excessive hyperemia of the lymph-follicles. The amount may be so small as to be scarcely discernible by the naked eye, or it may be from one to two or three pints (0.5-1.5 liters), or even more. In one of my own TYPHOID FEVER. 35 cases at the Medico-Chirurgical Hospital the total amount of blood dis- charged from the bowel was 781 ounces, or very nearly 5 pints (2.5 liters), and yet the patient recovered. The blood presents a dark hue, and that which is passed last may be tarry. The significance of intestinal hemorrhage, however slight, is always grave. On the other hand, recovery is possible even if the hemorrhage be copious and oft-repeated, as is shown by the case before cited from my own experience; and in general terms it may be said that death supervenes in from 30 to 40 per cent, of all cases. A fatal result may occur as the direct effect of a sudden profuse hemorrhage. When death does not follow immediately, however, the signs of collapse (more or less intense) and of anemia appear; yet intestinal hemorrhage some- times exerts a favorable influence, and particularly on the temperature and nervous symptoms. In a couple of instances I have observed stupor and delirium quickly giving place to perfect consciousness. Lastly, when typhoid fever occurs in the hemorrhagic diathesis melena may manifest itself in connection with hemorrhage from other outlets of the body. Perforation, which almost invariably produces fatal diffuse peritonitis, is the accident most to be dreaded. It does not bear a fixed relation to the severity of the affection, but in the 2000 Munich cases (vide supra) perforation occurred in 114; and according to Fitz, who tabulated 4680 cases of typhoid fever, there is a mortality of 6.58 per cent, from perforation of the bowel. It is much more common in males than in females, and appears in a ratio of about 71 to 29. Age has a decided influence, the complication being most marked between ten and forty years old, whilst in children it is rare; and, though perforation may occur at any time in the course of typhoid fever, it is most common be- tween the second and fourth weeks of the disease. In the cases ana- lyzed by Fitz perforation was found in the ileum in 81.4 per cent., in the large intestine in 12.9 per cent., in the vermiform appendix in 2.5 per cent., and in the jejunum in 1.29 per cent. The accident is usu- ally announced by the sudden advent of acute pain in the abdomen, quickly followed by the symptoms of collapse; and the fact that diffuse peritonitis, following perforation, may develop insidiously must be recollected. The abdomen becomes greatly distended as a rule, and is exquisitely tender to the touch. Fluctuation can sometimes be elicited. On percussion splenic and hepatic dulness are often absent, and in this connection there is danger in making an error in diagnosis, since hepatic dulness is also wanting when the distended intestines lie in front of the liver. The general collapse of the circulatory system is evidenced by the pinched features, hollow cheeks, vomiting, and the small, frequent pulse. No other complication is so grave as peritonitis. Its causes have been pointed out previously (vide p. 21), but from a clinical point of view a division of all the cases into two classes—those due to perfora- tion and those due to other agencies—is desirable. The instances that develop independently of actual perforation are not of infrequent occur- rence. They usually assume the local or circumscribed form of peri- tonitis, which is occasioned by direct extension of the inflammatory pro- cess from the intestinal ulcers. The condition presents corresponding 36 INFECTIOUS DISEASES. areas of tenderness under gentle, and especially under prolonged, pres- sure. It is, however, confessedly difficult to diagnose between the intra- and extra-intestinal states, which are accompanied by sensitiveness to gentle palpation, particularly when peritoneal inflammation exists in a mild form. Generalized peritonitis may succeed to the circumscribed variety in consequence of the extension of inflammation to the peri- toneal sac, and Avithout perforation. The mesenteric lymph-glands may soften or suppurate (vide Pathol- ogy), and, as before mentioned, may be the exciting cause of a recru- descence, or they may rupture and cause diffuse peritonitis. The Spleen.—With few exceptions the spleen is enlarged in ty- phoid fever, the edge usually being palpable below the margin of the ribs, on or before the commencement of the fastigium. It generally goes on increasing in size till near the beginning of the third week, and lessens during the latter part of the third and fourth weeks. In four of Osier's autopsies it weighed less than normally. Swelling of the spleen is sometimes absent after a copious intestinal hemorrhage, as well as in elderly typhoid subjects. As before mentioned, the enlargement in many cases is not demonstrable by percussion when the tympanites is excessive, but by means of careful palpation we can in most cases satisfy ourselves of its existence or non-existence, despite the great distention of the bowel. Suppurative infarcts, or softening of the spleen may start a peritonitis. Rarely, rupture of the organ may occur, which is manifested usually by intense pain in the splenic region. A slight swelling of the liver can sometimes be detected, and as a rule paren- chymatous degeneration takes place. Among the least frequent of complications is jaundice, and abscess of the liver also rarely occurs. The Stomacli.—The stomach offers no characteristic symptoms. Of the anorexia, which is constant until recovery begins, enough has been said, but during convalescence the appetite returns, becoming even voracious. Nausea and vomiting may occur during any stage of the disease, and are most common at the beginning, but when they appear as late symptoms they are probably excited either by gastric ulceration or by peritonitis. Nausea is usually traceable to definite causes—either to errors in diet or to the use of irritating medicaments, but that vomit- ing does occur from unknown and inevitable causes in very rare in- stances I am fully convinced. This sort of vomiting was present in the afore-mentioned case reported by myself in which there were profuse hemorrhages. It may become a serious or even fatal symptom. The Pharynx.—The pharynx frequently shows catarrhal irritation, and the patient may complain of dryness or a burning sensation in the throat. Actual sore throat may be present at the time of onset, and this may be associated with a diffuse erythematous rash, suggesting scarlatina. The Tonsils.—There is a special form of typhoid—tonsilh-ti/phoid or pharyngo-typhoid—in Avhich there appear upon the tonsils peculiar patchy elevations, whitish in color, which undergo subsequent ulcera- tion. It is not improbable that these lesions result from the local action of the specific bacillus in an unusual situation. Thrush, affecting the mouth, throat, and even extending to the esophagus, not infrequently arises as a complication. The tongue is heavily coated, as a rule with TYPHOID FEVER. 37 a yellowish-white fur; later it clears off near the edges and tip, while the center becomes dry or brown and sometimes fissured. The lips are also dry, sometimes fissured, and often covered with dry, black crusts (sordes). Ulcerative stomatitis may occur if the mouth be not kept clean. Under these circumstances secondary lesions evincing unpleasant and even serious symptoms may also arise in organs more or less remote from the mouth, and among these is parotitis, which is most probably caused by the staphylococcus or streptococcus reaching the parotid gland by way of Steno's duct. The condition is betrayed by such symptoms as pain, redness, and finally by fluctuation, with an elevation of the bodily temperature. It is a late-appearing develop- ment, and is usually unilateral, though it may be bilateral. Suppura- tive otitis media, a rarer complication, arises in a similar manner, the pathogenetic agents passing from the throat to the ear through the Eustachian tube. (d) Respiratory System.—As pointed out in the section on Pathology, bronchitis is almost invariably present, but in the majority of instances the cough is slight. The condition is recognized by the existence of numerous sibilant rales. Very rarely is it a striking feature in the early stage of typhoid fever, and then, except this fact be remembered, room for error of diagnosis exists. Moreover, in cases that are im- properly treated the bronchial secretions are apt to accumulate, and a well-marked bronchitis may be the result. It may be said, however, that, as a rule, bronchitis does not assume a severe type in cases which receive proper attention from the beginning, provided the patient be not unusually stupid or unconscious. AVhen the nervous phenomena are pronounced, however, and the patient maintains the dorsal decubitus (expectorating little or nothing), bronchitis of a severe grade and affect- ing the smaller bronchi is almost inevitable. The occurrence of an intense generalized bronchitis is also favored by certain other con- ditions, such as corpulence, advanced age, emphysema, etc.; and these are the cases that are apt to lead to lobular infiltration—the so-called aspiration pneumonia. Lobular pneumonia may take on a putrid nature and the consoli- dated area may become gangrenous. As a sequel, pleurisy with effusion or empyema may originate in consequence of the infiltrated lobules being contiguous to the pleura. If these lobules, occupying the periphery of the lung, become gangrenous, perforation of the pleura, leading to pyopneumothorax, may result. Lobular pneumonia may be attended with hurried breathing or troublesome cough. More com- monly, the local symptoms are either altogether wanting or feebly marked, and this is especially true of the severer forms of lobular pneu- monia, which occur in patients in whom profound nervous prostration coexists with more or less complete unconsciousness. Sole reliance is to be placed upon the results of a physical examination, which even in the absence of subjective symptoms should be repeated daily. Points or surfaces of dulness, most marked near the bases of the lungs and frequently on both sides, are found on percussion. Fine moist rales, most marked toward the bottom of the thorax, form a very character- istic sign, and are heard in every direction on auscultation. In order to ensure a certain diagnosis of lobular pneumonia both the circum- 38 INFECTIO US DISEASES. scribed dulness and moist rales must be found present in the same situation. Lobar pneumonia is a not uncommon complication. In a small per- centage of cases it develops early, and is most probably the result of a special concentration of the poison in the lungs, giving rise to the so- called pneumo-typhoid fever (vide infra, Varieties). These cases are often mistaken for primary lobar pneumonia. Their onset may or may not be marked by a rigor, but it is usually more gradual than that of primary lobar pneumonia. Characteristic typhoid symptoms soon follow, and at the end of the first week or thereabouts the pulmonary symptoms gradually abate, while those most characteristic of typhoid (enlarged spleen, roseate spots, etc.) occupy the foreground. Lobar pneumonia more often develops as a late complication—in the second or third week, or even during convalescence—but it is not attended by the usual phe- nomena (rigor, cough, rusty expectoration, intense chest-pain, etc.), and hence may be easily overlooked. The temperature may be either quite elevated or at times only moderate. The diagnosis is to be made from the physical signs, together with the peculiar temperature-curve, which may present marked irregularities. Pulmonary infarction and abscess of the lungs are occasional complications. Hypostatic congestion of the lungs, due to enfeeblement of the cardio- pulmonary circulation, is a comparatively frequent concomitant, appear- ing in the third week of the disease. It is generally bilateral, affecting the base of the lungs, and is promoted by the effects of gravitation. It is almost always associated with more or less edema of the lungs. The subjective symptoms, including fever, are usually negative, while the objective signs are those of partial or complete consolidation of the bases (defective resonance or dulness, broncho-vesicular breathing, with moist rales). Miliary tuberculosis rarely develops as either a complica- ting affection or, it may be, as a sequel. A spasmodic or jerking inspi- ration when pneumonia does not exist is a precursor of coma (Flint). Laryngitis, indicated by hoarseness, is an occasional complication. The laryngeal ulcers may extend in depth to the perichondrium, and in this way may rarely promote that grave though not necessarily fatal condition, perichondritis with edema of the glottis. The symptoms of laryngeal stenosis are apt to develop. Lpistaxis appears early in a large number of cases, and is a valuable diagnostic symptom. It may also occur during the fastigium, and par- ticularly toward the latter part, when it is of little or no diagnostic but of grave prognostic, significance. It is apt now to be troublesome,' and may even, as in a case I saw recently with Dr. I. Newton Snively, be so persistent as to lead to a fatal issue. (e) The circulatory system presents no characteristic symptoms. The heart-sounds are but little affected, as a rule. In cases of asthenic type and in severe typical instances the first sound of the heart may grow- quite feeble and ultimately resemble the second (embryocardia). Under these circumstances a soft systolic murmur may be faintly heard alone* the left border of the sternum. Among occasional complications pre* sented by the heart is pericarditis, and still less frequent is endocarditis" Myocarditis is somewhat more common. The sudden development of circulatory collapse in the course of typhoid fever, as previously noted TYPHOID FEVER. 39 may be due chiefly to myocardial inflammation ; and there may be a brief though alarming derangement of the heart action, due to func- tional disturbances of the sympathetic and pneumogastric nerves. The pulse is accelerated, but not, as a general rule, in proportion to the height of the temperature until late in the affection. Its average rate is from 84 to 108, but it may go much higher, and Avhen the pulse is maintained at 130 or more for days together it is of ominous import. The temperature, moreover, may be of average height, while the pulse is normal or only slightly quickened throughout; and hence the increase in the pulse-rate cannot be due solely to the elevation of temperature. As before intimated, the extreme debility Avhich comes on during the third Aveek in severe cases may have, as one of its manifestations, a very rapid pulse, reaching to 160 or more (the so-called running pulse), and Avith or Avithout marked irregularity. Slight irregularity is sometimes observed, either during the height or decline of the affection, but as a rule this soon disappears, and proves of no serious consequence. Marked temporary accelerations are often caused by undue exertion or mental excitement. The lowered arterial tension is shown by a dicrotism of the pulse—a symptom which is not characteristic of typhoid fever, how- ever, since it is well marked in other acute infectious diseases, though less frequently. During convalescence the pulse often becomes sub- normal in rate, and brachycardia is oftener a sequel of typhoid than of any other acute infectious disease. Venous thrombosis occurs in 1 per cent, of all cases (Murchison). Its most frequent seat is the left femoral, and the next most frequent the right femoral vein, and it is the immediate result of cardiac weak- ness, except perhaps in those rare instances that arise early in typhoid. For the latter no definite cause has as yet been found. Coming on, as it usually does, during convalescence, it manifests itself by swelling and edema of the extremity affected. There are pain in the thighs and calves, and tenderness (on pressure) over the course of the femoral vein, and often in the region of the calf of the leg as well. It causes fever of a moderate grade and irregular type, and then in the course of from two to three weeks the swollen member may be reduced to its normal dimensions. This complication is usually not of a serious nature. Occasionally, however, clotting extends into the pelvic veins, or even into the vena cava, Avhen the condition becomes more serious, and sudden death has resulted from the detachment of emboli. The thrombus may undergo suppuration, to which systemic septic infection may be a secondary event. Thrombosis, and less frequently embolism, in the arteries, combined with renal, splenic, and pulmonary infarcts, may be encountered in typhoid fever. The large or small arteries may become obliterated, either by em- bolism or thrombosis, in extremely rare instances, but Avhether the thrombosis under these circumstances is brought about by a peculiar condition of the blood which favors clotting, or by a localized arteritis, or in consequence of the operation of these combined factors, is not definitely known. If, as is usual, the femoral artery be involved, the blood-supply to the foot and leg is cut off and gangrene of those parts must folloAV. The condition may be bilateral. It may be detected 40 INFECTIOUS DISEASES. early, OAving to the absence of a femoral pulse, before the signs of gan- grene appear, but the condition is highly dangerous. Recovery ensues in perhaps more than half of the cases. The blood presents certain changes, some of Avhich are valuable for diagnostic purposes. In those rare cases in which copious diarrhea or profuse sweats are present the red corpuscles may be relatively increased in number during the febrile period, owing to loss of Avater. There is, however, in the majority of instances, little or no decrease in the num- ber of red corpuscles till the end of the second week. They are mark- edly diminished, as a rule, during convalescence. Indeed, the oligo- cythemia may attain to an immoderate degree. In one of Osier's cases the number of red corpuscles was as low as 1,300,000 per c.mm., but I have personally never found the blood-count under 1,800,000. There is a greater relative decrease in the amount of hemoglobin than in the number of red corpuscles, and the restoration of the hemo- globin in the convalescent period takes place more sloAvly than that of the red corpuscles. The number of Avhite corpuscles remains at or a little below the health standard until late convalescence, Avhen it sinks to a moderate degree—furnishing a count of about 2000 per c.mm. This fact is an important aid in the differentiation of typhoid fever from acute inflammations and infectious (febrile) affections accompanied by exudation, in Avhich leukocytosis is marked, and from all suppurative processes in Avhich the polynuclear neutrophiles are moderately increased. In typhoid fever there is also a relative preponderance of the mono- nuclear forms in addition to the absolute decrease of the leukocytes The blood-characters in typhoid are shoAvn in the accompanying chart (Fig. 4). TYPHOID FEVER. 41 (/) Nervous System.—The persistent headache that is almost always present is among the most prominent symptoms during the first Aveek, but it diminishes steadily during the early part of the second, as a rule. It affects the temporal, occipital, and cervical regions, and Avhen the onset is comparatively sudden, pain in the back is also a more or less conspicuous feature during the first feAv days of the illness. In a small class of cases, hoAvever, the effects of the typhoid bacilli or their toxins are manifested solely in the nervous system from the very onset. In such there are violent headaches, retraction of the head, rigidity, pho- tophobia, and muscular tAvitchings (rarely convulsions)—all of Avhich symptoms indicate meningitis. The diagnosis of meningitis as a com- plication must be made Avith extreme caution, since, no matter how com- plete the clinical picture may be, the post-mortem examination usu- ally reveals a total absence of meningeal inflammation. It must not be forgotten, however, that meningitis is one of the rarest of the complications of typhoid fever. Vertigo may accompany the head- ache, but it seldom outlasts the latter. Before delirium manifests it- self wakefulness and restlessness at night are very annoying, and later the same symptoms may be observed associated with the delirium. In cases of moderate severity mental dulness, and even actual hebetude, are almost invariably present. Questions are apt to be answered inconsist- ently and in monosyllables, and the patient sleeps poorly, notwithstand- ing the pseudo-somnolent state in which he almost constantly appears. Delirium is frequent in the severer cases. It is, hoAvever, not an uncommon event for those of moderate severity to be free from this symptom throughout the attack. It is, as a rule, most marked at night or at some time Avhen the patient is left alone. His delusions may impel him to attempt to leave his bed, but more commonly there is mild or noisy delirium, Avith more or less restlessness. He may lie somnolent, soliloquizing in a loud whisper (muttering delirium), and this so-called typhomania may gradually give place to actual coma to- ward the close of the middle period of the disease. In not a feAv cases —mild or severe—coma is developed suddenly, and is often a mortal symptom. Still another unfavorable sign is a picking at the bed-clothes or a grasping at imaginary objects (carphologia). The delirium may assume an hysteric type, the patient usually ex- hibiting the saddest emotions, and if he be an alcoholic he may be seized with delirium tremens. In a case of typhoid fever that I saw recently Avith Dr. S. W. Morton hysteric delirium developed during convalescence, but did not last more than twenty-four or thirty-six hours. The motor nerves also present notable disturbances in association with the sopor and the forms of delirium previously described. Slight tAvitchings of the muscles of the face and extremities are quite common, and Avhen they affect the tendons of the Avrist and fingers the term sub- sultus tendinum is applied. The lips, tongue (especially Avhen pro- truded), lower jawT, and even the extremities, are often in a state of con- stant tremor. During this motor irritability the reflexes are increased, but Avhen profound coma comes on they are either largely diminished or totally abolished. The toxins and chemical secretions of the typhoid bacillus, acting poisonously upon the nervous centers, are undoubtedly the cause of the nervous symptoms in typhoid. 42 INFECTIO US DISEASES. yervous complications and sequelce may arise. Chief among these is paralysis, Avhich is most probably due to neuritis. The lesion may involve one, tAvo, or more nerves, and in this Avay Ave may have either a paralysis of one limb or, more rarely, a true paraplegia. Aphasia may be a sequel, particularly in children. Hemiplegia, due to hemorrhage or a localized encephalitis, may occur either as a complication or sequence of the disease. FolloAving typhoid fever, the patient may ex- hibit evidences of mental enfeeblement, and even insanity where a pre- disposition to this condition has existed; and insanity is relatively more common after this disease than after any others belonging to the same class. I have seen tAvo instances, both of which recovered, while Osier has seen five, four of which ended similarly. It is in most cases, as pointed out by Wood, a confusional insanity, due to exhaustion and impairment of the nutrition of the nerve-centers, Avhile in a smaller contingent it takes the form of a true melancholia. After the conclusion of typhoid, as Avell as during its course, neuralgia affecting the occipital and other cranial nerves is not infrequent. Great hyperesthesia of the skin and muscles is common during convalescence, attacking the loAver extremities by preference (Striimpell). The so-called " typhoid spine " (Gibney) has also been observed, and consists in an acute inflammation of one or more vertebrae following typhoid. The chief symptoms are pain in the back and hips of a lancinating character. The point of origin appears to be the small of the back; thence the pains extend paroxysmally up and along the spine and to the abdomen. They subside gradually, leaving the back Aveak and painful on attempts at turning in bed, etc. Plantar and other skin-reflexes increase, and the knee-jerks are pre- served. (g) The Urinary System.— Urine.—The urine is lessened in quantity and high-colored, with an increased specific gravity up to the arrival of the stage of decline. About this time, and rarely earlier, it grows light in color, larger in quantity than the normal, and the specific gravity is relatively diminished. Both urea and uric acid are increased during the earlier stages, and sometimes throughout the attack, while during convalescence both are diminished. On the other hand, the chlorids are diminished during the active stages of the disease and in- creased during its decline. Afebrile albuminuria is quite common, but is of no clinical importance. Acute nephritis may develop as a complication in the earlier or later course of the disease, and can be recognized to a certainty only by a thorough appreciation of the urinary phenomena. The urine is dimin- ished in quantity, being often scanty, and there may be retention It contains characteristic morphologic elements (albumin, casts blood and epithelium). The development of the typhoid state in this affection is rendered much more probable in the presence of this complication and moreover, uremic symptoms often put in an appearance at this juncture' and then the situation is really serious. Acute nephritis may arise at one or other of three different periods, and its significance varies with the time of onset: (a) at the beginning of the fever, when it often obscures the true nature of the malady. This is the nephro-typhoid of the German authors, and will be referred to hereafter (vide infra Varie ties); (b) in the early part of the fastigium or the second week of the TYPHOID FEVER. 43 disease. Coming on at this time—an event AAThich I have observed in tAvo instances—its relation to the typhoid bacillus or its toxin is not definable. It is probable, hoAvever, that it is to be ascribed to the local effect of the toxin upon the renal tissues. Both of my OAvn instances proved fatal, and in both an autopsy was refused. Wagnerl has had 5 cases of recovery in succession, but the high mortality mentioned by Amat— 10 deaths in 12 cases—is the more common experience, (c) Acute neph- ritis may arise as a sequel of typhoid, when, Avith the usual symptoms of acute nephritis, there is almost invariably associated a decided edema. In this category of cases recovery is to be expected. The lymphoma- tous nephritis of Wagner (vide supra, Pathology) is usually Avithout symptoms. Diabetes mellitus is, in extremely rare instances, developed after typhoid. Hematuria has also been observed as an occasional symptom of the hemorrhagic diathesis. The diazo-reaction of Ehrlich is an aid in diagnosis, but, unfortunately, may be present also in acute phthisis, meningitis, measles, and other acute infections attended Avith fever. To obtain it two solutions (a and b) are needed: We mix 1 part of solution (a), Avhich consists of a 0.5% solution of sodium nitrite, with 40 parts of solution (b), Avhich consists of 2 grams of sulfanilic acid, 150 c.c. of hydrochloric acid, and 1000 c.c. of distilled water. To this an equal volume of urine is added, and the contents of the test-tube are then thoroughly shaken. A layer of ammonium hydrate is noAv superimposed, and at the line of contact a ruby or pink ring develops. I have found the reaction rarely absent during the fastigium or after the eighth or ninth day. A brownish ring is given by normal urine. There is a post-typhoid, diphtheritic pyelitis in which the pelves and calices of the kidneys are primarily the seat of membranous exudation, and later of erosion and ulceration. The urine generally contains blood and pus. Osier has met with this condition in 3 autopsies, in 1 of which it was associated Avith extensive membranous inflammation of the bladder. Simple vesical catarrh is a rare complication except as the result of catheterization for retention. Orchitis and ovaritis are occasional sequels. (h) The Joints.—Almarticular arthritis may arise as a complication, and often proceeds to suppuration. Poly art!wit is also occurs, but it is by no means so common. These conditions are due to accidental infec- tion. (i) The Bones.—Periostitis, leading to necrosis, is a not very rare sequel of typhoid. The favorite seat is the tibia, though in a case of typhoid under my oavii care at the Philadelphia Hospital it affected the os calcis. Osteomyelitis may also occur. (/) The Muscles.—As in the case of the heart, so the voluntary muscles exhibit hyaline degeneration; and abscesses, in consequence of secondary infection or of infection Avith the typhoid bacillus itself, may be located in the muscles. Associated Acute Infectious Diseases.—Malarial fever may be com- bined Avith typhoid, though the relationship is not a vital one. In an 1 Deutsche Archiv fur klin. Med., Bds. xxv. and xxxvii. 44 INFECTIOUS DISEASES. analysis of 2122 cases of malaria typhoid fever was associated in 8.1 Many instances of so-called typho-malarial fever Avould be shoAvn to be pure typhoid by a careful blood-examination, as the presence of chills, sweats, and an intermittent temperature-curve are sometimes observed in this disease (vide supra). Pseudo-membranous inflammation, as above intimated, may occur in the naso-pharynx, larynx, gall-bladder, and genitals. Measles, scarla- tina, and chicken-pox have also been knoAvn to arise in the course of, or during convalescence from, typhoid fever. Erysipelas is a rare secondary affection coming on either during the height of the affection or (more frequently) after its close. Typhus fever may be associated with typhoid, but is an exceedingly rare occurrence. Clinical Varieties of Typhoid Fever.—These are numerous, and may groAv out of peculiarities manifested during the course of the affec- tion, as may be observed not only in different epidemics, but also in the same epidemic. The groups of cases described here have reference par- ticularly to the degree of severity of the type, which varies between the Avide limits of extreme mildness on the one hand and extreme severity on the other. The course of the disease may also be modified by the occurrence of one or more of its manifold complications. (1) The Mild or Rudimentary Form (Typhus Laevissimus).—Of this variety many cases occur, and especially among children. The charac- teristic typhoid symptoms are scanty, and at times even entirely Avanting. The spleen is almost always enlarged, the roseate spots are sometimes present, while the temperature is moderately elevated and often partakes of the same character as that of true typhoid. The fever, however, may pursue the remittent type. Complications presented by special organs are usually absent, but grave accidents (intestinal hemorrhage, perforation) are not impossible. The diagnosis is always difficult, OAving to the feeble development of the characteristic symptoms, and in the total absence of the latter is out of the question; but the recognition is greatly aided if a causal connection betAveen them and typical cases can be shoAvn to exist with great probability. (2) The abortive form has a sudden onset, and is often marked by fits of shivering. The characteristic features of the disease (enlarge- ment of the spleen, abdominal symptoms, rose spots, etc.) appear earlier than in the usual type, and soon become quite well marked. The fas- tigium is short, and the temperature, from the seventh to the twelfth day of the illness, declines by a prompt lysis, with profuse sweating. With the rather rapid fall of temperature there is a no less rapid im- provement in every other leading symptom. Convalescence is speedy. (3) The Ambulatory Form (Latent or Walking Typhoid).—The pa- tient continues to walk about, either experiencing but slight disturbance or being unwilling to take to his bed. Such cases do Sot come under the care of the physician in many instances. Others, on account of debility, anorexia, diarrhea, and other vague symptoms, finally consult their physician, who may discover the presence of all the characteristic •' " TSiCoCKmSiCati!>iI18 °f Malaria'" Jourml °f the American Medical Association vol xxiv. p. 919, by the author. """> v"1. TYPHOID FEVER. 45 features of the disease. A third contingent, belonging to this form, continue to move about, or even to folloAv their usual vocations, till seized suddenly with profuse intestinal hemorrhage or general diffuse peritonitis following perforation. The likelihood of these grave devel- opments is much greater in the case of persons who go about or travel long distances while suffering from this disease. (4) The afebrile is an exceedingly rare form of the affection—in this country at least. Liebermeister, hoAvever, has met Avith a number of cases at Basle, the symptoms being lassitude, depression, headache, neuro-muscular pains, anorexia, sIoav pulse, furred tongue, constipa- tion or diarrhea, Avith enlargement of the spleen and roseate spots. These cases are often confined to bed, and there are occasional attempts at evening exacerbations of temperature (100.5° F.—38° C). Sub- normal temperatures are sometimes associated, but I have seen only a single instance that I regarded as belonging to this form. (5) Severe or Grave Forms.—These may be dependent either wholly or in great part upon the degree of virulence of the typhoid poison. Under these circumstances there avill be a profound intoxication of the system, as shoAvn by high temperature, violent nervous symptoms, and great prostration. The grave types may arise in the course of cases of average severity from the development of serious complications. Again, to serious forms belong those cases that begin with the characteristic symptoms of a localized inflammation—e. g. the cerebrospinal form, in which the nervous symptoms greatly predominate at the onset; the nephro-typhoid (before alluded to), in Avhich the preliminary symptoms are those of acute Bright's disease; the pneumo-typhoid (vide supra), which begins with the manifestations of a more or less frank pneumonia. Pleuro-typhoid.—The cases begin as an acute pleurisy, having its special characteristics, and these are followed, soon or late, by the diag- nostic evidences of typhoid fever. Talamon * distinguishes these cases from simple pleurisy by the intensity and continuous course of the fever, by the general depression, headache, and vertigo, and by the sleeplessness. Should any doubt remain, it will be dissipated by the eighth or ninth day by the presence or absence of rose-colored spots, enlargement of the spleen, and other features characteristic of typhoid. The sudoral form and tonsillo-typhoid (before described) also belong to this category. Many circumstances connected with the individual influence decidedly the general course of the affection, and these may be expressed in part in the several forms following, which are based upon such factors as age, habits, etc. (6) Typhoid Fever in Children.—The onset is rather more abrupt than in the adult, and certain prodromal symptoms are very generally absent (epistaxis, chilliness, etc.). On the other hand, bronchial and nervous symptoms are often quite pronounced. Again, during the fas- tigium some of the characteristic features may be missing—e. g. diar- rhea and tympanites—while the eruption may either be entirely wanting or less copious than in older subjects. Intestinal hemorrhage is rare and perforation almost never occurs, but, as previously pointed out, aphasia is a more common sequel than in adults. The same is true of arthritis and the bone-lesions. The mortality is not over 1 per cent. 1 La Medecine moderne, Paris, 1891. 46 INFEC'l 10US DISEASES. (7) Typhoid Fever in the Aged.—The course of the affection presents no regular type. The temperature is not as high as usual, but there is marked adynamia and serious danger from certain complications, such as pneumonia, nephritis, coma, etc. The diagnosis is difficult, OAving to the prominence of the nervous and pulmonary symptoms on the one hand, and the frequent absence of the more characteristic symptoms of typhoid on the other (rash, enlarge- ment of the spleen, and peculiar temperature-curve). Diagnosis.—Unless all. the chief characteristic features be pres- ent Avith a clear history, it is a golden rule not to make a positive diag- nosis. Obviously, then, the physician at the first visit cannot, in many cases, diagnosticate typhoid Avith absolute certainty. In the majority of instances he is called after the case has progressed to or near the close of the first Aveek. If the case have been a typical one, the history of the gradual development of the disease, marked by such symptoms as languor, anorexia, headache, dulness, slight chills, increasing fever, and sometimes nose-bleed, will be obtained, and justify a strong sus- picion of typhoid. When, in addition, diarrhea and the objective symp- toms, splenic enlargement, tympanites, gurgling, with tenderness in the ileo-cecal region, are present, the diagnosis of typhoid is made highly probable. After the lapse of a feAv days—the beginning of the second Aveek—the roseate spots usually appear, and then all doubt is removed. In atypical cases a positive opinion, particularly if the rash be absent, must often be Avithheld till an advanced stage is reached. In such in- stances the sudden occurrence of a significant symptom, such as intes- tinal hemorrhage or a characteristic decline by lysis, is exceedingly helpful. The etiologic circumstances need to be considered carefully, since to shoAv a causal relation between an obscure case and one that is clearly typhoid leaves little to be desired. Briefly, the most trustworthy diagnostic features are the gradual on- set, peculiar temperature-curve (made up of the "step-ladder" stage of development, the continued type of the fastigium, and the decline by lysis), enlarged spleen, and the rose-colored spots. Investigations by Pfeiffer upon the specific bactericidal substances de- veloped in the blood of animals immunized by injection of typhoid bacilli have furnished a practical and reliable means of diagnosis of this disease from blood-serum. It remained, however, for Widal and other! to show that if to a drop of blood-serum, or to a drop of water contain ing a solution of dried blood from a typhoid patient, a moderate num- ber of typhoid bacilli were added, a very peculiar reaction occurred Johnston of Montreal has simplified the technic: The blood i* ob- tained upon a clean glass slide from a needle-prick of the ear or finder of the suspected case. It is allowed to dry, and is then carried to the laboratory. A loop of bouillon-culture of genuine typhoid bacilli is placed upon a clean cover-glass, and to this is added a lar*e loopful of a watery solution of the dried blood-specimen. The coveJUass is in verted over the concavity of a hollow slide and sealed at the°euVes with melted vaselin Lnder the microscope, with a high-power dry°lens or with a one-twelfth oil-immersion lens a rapid clumping of the bacilli in the hanging drop can be observed,1 and their motions cease almost instantly! 1 Medical News, Nov. 14, 1896. ers IS TYPHOID FEVER. 47 If this specific reaction is not obtainable in a case sick over a week, typhoid fever may be excluded. It is to be remembered, however, that in persons Avho have had typhoid fever within ten years the reac- tion may take place. The cases that, in the beginning, manifest the special evidences of an infectious disease, Avith the Avell-defined local inflammatory lesions previously referred to (tonsillo-typhoid, pneumo-typhoid, pleuro-typhoid, nephro-typhoid, etc.) cannot be recognized at the outset. The same local inflammatory condition may, independently of typhoid fever, be combined with a genuine typhoid state. In all instances of typhoid fever in which, at the time of onset, early localization occurs in the throat, lungs, or kidneys, the general features (degree of fever and prostration) are apt to be out of proportion to the local, and the former are apt to continue to develop after the subsidence of the latter. A careful observation of the symptoms after the first Aveek Avill detect, either immediately or in the course of a few days, undoubted symptoms of typhoid; and in any acute affection in Avhich the symptoms of the typhoid state coexist Avith a local inflammatory process the existence of typhoid fever should be suspected and the appearance of the eruption daily anticipated. Cultures may be obtained by puncturing the spleen, but the Avisdom of this procedure is very questionable, since the bacilli may be obtained in quantities from the stools. Differential Diagnosis.—(1) Typhus fever is to be differentiated by its appearance as an epidemic, by its sudden onset, by the deeper stupor, the besotted expression of the features, the injected conjunctivae, the contracted pupils, the appearance on the fourth day of macuhe Avhich are speedily transformed into petechise; by the shorter course and the abrupt termination by crisis. (2) Acute miliary tuberculosis has been, and still is, frequently mis- taken for typhoid fever. The former is to be differentiated from the latter by the greater frequency of the pulse and respirations, the prom- inence of the cough, and in some instances by the bloody expectoration ; by the pronounced cyanosis, the presence (sometimes) of choroidal tu- bercles, and the existence (constantly) of leukocytosis, Avhich does not occur in typhoid. Blood-examinations have occasionally shown the presence of the tubercle bacillus. There is an absence of the peculiar temperature-curve and also of the characteristic lenticular spots and abdominal symptoms of typhoid. (3) Malarial fevers may assume, more or less nearly, the continued form, and there are also typhoids Avhich affect a remittent or an inter- mittent type of malarial fever. The latter can ahvays be differentiated by the therapeutic test with quinin, and by a careful blood-examination for Laveran's hematozoa, which are present in the blood. Should typho-malarial fever be suspected, and should the typhoid symptoms be unequivocal, the finding of the malarial organism will dif- ferentiate the hybrid from pure typhoid. (4) Relapsing fever is distinguished by its abrupt onset Avith rigor, high fever, pain in the epigastrium; by the brief duration, termination by crisis, and the occurrence of a relapse at the end of a week; by the absence of the characteristic eruption ; by the temperature curve ; and 48 INFECTIOUS DISEASES. by the marked nervous symptoms of typhoid. The finding of the spirilla, however, reliably discriminates relapsing fever. (5) Meningitis.—In striking contrast with the specific typhoid svmptoms meningitis exhibits marked hyperesthesia, intolerance of light and sound, exaggerated reflexes, and often muscular rigidity before the sta«-e of effusion ; also restlessness, peevishness (unlike the dulness ob- served in typhoid patients), vomiting, and constipation (vide Acute Miliary Tuberculosis). The temperature maintains a loAver level on the average, and is more irregular in type than in typhoid; the pulse is more irregular, and the nervous symptoms assume greater prominence in the earlier stages, particularly headache and delirium. On the other hand, the absence of true typhoid symptoms aids in the discrimination of acute meningitis. (6) Tuberculous meningitis gives a characteristic previous or family history, occurs usually in young subjects, and the tendon and cutaneous reflexes exhibit the widest possible variations as to intensity, within brief periods and throughout the Avhole attack. An examination with the ophthalmoscope may reveal choroidal tubercles. There is a leu- kocytosis. (7) Catarrhal enteritis in children, Avith prominent abdominal symp- toms, may simulate typhoid fever very closely. In the former the symptoms are all gastro-intestinal save perhaps the occurrence of slight febrile disturbance and certain nervous phenomena, while typhoid fever manifests a Avider range of symptoms (some of which are peculiarly its OAvn—notably the greater prostration, more marked fever, enlargement of the spleen, and, above all, the characteristic eruption). In young children the last-named symptom may be either Avanting or atypical, in Avhich case the coexistence of enlargement of the spleen Avith other phenomena more or less characteristic of typhoid must suffice. (8) Salpingitis on the right side may resemble typhoid. In the former there is usually a clear history either of antecedent vaginitis or of an abortion, and there exist special evidences of local peritonitis, Avith which may be associated the typhoid state, but not the classic features of typhoid fever. A digital examination per vaginam detects in sal- pingitis a tender mass occupying the right side of the pelvis, and the womb displaced to the left. The diagnosis between typhoid fever and lobar pneumonia, with associated typhoid state, and appendicitis will be considered in the special discussion of these diseases. Prognosis.—As in all other acute infectious diseases, so in typhoid the prognosis depends upon three main considerations • (1) The severity of the type of the infection, which is indicated in great measure though not solely, by the degree of fever. A tempera- ture of 106 F. (41.1 C.) is a serious symptom, and, if maintained at this point for a few days, an almost certainly mortal one. I have not seen a single instance in which the temperature has touched 106° F (41.1° C) for two or three successive days that has recovered. If the temperature mounts to and keeps at 105° F. (40.5° C ) for 1 period than three or foul days, the case is also likely to prove honewT according to my experience. Temperatures above 106° F. (41 1° CM I have not seen, and would regard their occurrence as offering no hope 0f TYPHOID FEVER. 49 recovery. When the fastigium is prolonged, even though the fever be not exceptional, the prognosis is usually grave, Avhile, on the other hand, marked nocturnal remissions show the course to be favorable. A sudden, deep fall, however, implies danger, and denotes intestinal hem- orrhage, peritonitis, collapse, etc. The researches of Isaac Ott have taught us not only that fever is due to an agent from within or without, which deranges the harmony of the thermotaxic, thermogenetic, and thermolytic apparatuses, increasing primarily tissue-metabolism, but also, that while high temperature is an indication of danger in specific fevers, it is not ahvays the cause of it. He very properly regards high temperature as being only a part of an infectious process, and points out that the thermotaxic centers of the cortex may be so disordered as to alter the harmony between the heat- production and heat-dissipation. Under these circumstances a specific fever of severe form may be associated Avith a slight elevation of tem- perature. The power of resistance to the influence of a greatly elevated tem- perature is quite reliably indicated by the condition of the heart. So long as the pulse is regular and its rate does not exceed 110 or 120 beats per minute, and provided the first sound of the heart is distinct, the outlook is favorable. When, however, the pulse maintains an aver- age rate of 130 or more—a condition with which there is usually asso- ciated some degree of cyanosis, pulmonary congestion, and edema—the outcome is to be regarded as doubtful. Collapse is apt to follow the occurrence of sudden complications (perforation, hemorrhage, etc.), but it may also arise independently of such a cause. It is attended Avith grave danger for the patient. Serious types are also shown by the occurrence of certain nervous symptoms, that may assume unusual gravity. This is particularly true of delirium, stupor, and the symptoms of motor irritation. (2) Circumstances of the Patient.—Certain individual peculiarities render the prognosis highly unfavorable. It is bad in very fat persons. In such cases there is a great and constant danger of sudden collapse, and this fact also holds to a lesser degree with reference to those persons who are subjects of certain chronic diseases (Bright's disease, heart-dis- ease, gout, emphysema, etc.). Age is an influential modifying factor. After puberty the gravity of the disease increases with increasing years. After the fortieth year the relative death-rate augments much more speedily than prior to this period. Indeed, it may be said that, as a rule, typhoid has an unfavor- able prognosis in persons past forty years, and chiefly for the reason that at this time of life there are dangers from an added liability to pulmonary complications and failure of cardiac reserve. In children (vide Clinical Varieties) the tendency to hemorrhage and peritonitis is reduced to a minimum, while the disease shows little tendency to assume a grave type. Hence in childhood typhoid gives the most favorable prognosis. The puerperal state renders a typhoid patient liable to many acci- dents and peculiar complications, and it seems that independently of pregnancy the disease is more fatal among females than males. Chronic alcoholism is apt to be complicated with delirium tremens, often pre- 4 50 INFECT 10 US DISK. ISES. ceded by pneumonia, and to the latter disease the patient is very prone, perhaps to an equal extent Avith heart-degeneration and exhaustion. The surroundings of the case affect materially the prognosis, poor sanitary conditions and poor attention greatly diminishing, and the opposite conditions greatly augmenting, the chances for recovery. Im- proved methods of treatment in recent years have also effected a decided loAvering of the death-rate. Here it may be said that the average mor- tality of typhoid is from 8 to 10 per cent., as against 15 to 20 per cent. formerly. It must ever be remembered, hoAvever, that epidemics differ widely as to their mortality list—a fact Avhich makes a precise statement regarding the question an impossibility. (3) The third and last consideration is the presence or absence of dangerous complications and accidents. These have all been enumerated and their prognostic significance stated (supra). To merely reiterate some of those that lend fresh peril to the typhoid patient, arranging them with some regard for the order of their relative gravity, may prove helpful to the student. They are—perforation Avith diffuse peritonitis, intestinal hemorrhage, lobar pneumonia, lobular pneumonia, sudden col- lapse (due to cardiac Aveakness), excessive tympanites (often Avith marked diarrhea), and hypostatic congestion of the lungs. The fact that these complications and accidents of the disease are responsible, in a large measure, for many fatal results deserves especial emphasis. Relapses of Typhoid Fever. A relapse is a repetition of all the characteristics of typhoid after the latter has run its course. As a rule, the return occurs from one week to ten days after the beginning of convalescence, though it may be either earlier or later; and occasionally a relapse develops before the temperature has become normal, as occurred in 11 out of 21 cases recorded by F. C. Shattuck. The cause is a reinvasion of the blood by the typhoid bacilli or their secretions, but whether this is attributable to a reinfection from without or from within (most probably the latter) cannot be definitely stated. The pathologic lesions differ in no essen- tial way from those described as belonging to the primary attack, but the stages through Avhich they pass are not quite as loner. In the interval between the primary attack and the relapse there may be present suspicious features, such as a slight enlargement of the spleen, a trivial evening exacerbation of temperature, In unnatural apathy or dulness, and a more profound prostration than is usual In the majority of instances, however, the relapse is announced by a reap- pearance of the characteristic febrile career, with an utter absence of any premonitory symptoms. The onset is rather more sudden than in primary typhoid. The temperature, however, rises in the characteristic step-ladder fashion, reaching the fastigium or second stage in two or three days, and the same relative abridgement of the fastigium and de fervescence is observed. It follows that a relapse has a shorter duration than a primary attack, and, indeed, it rarely exceeds two to three weeks It sometimes happens, however, that the temperature touches a higher limit in the relapse than in the primary attack, but, with rare exception* when the primary typhoid is of average or even a greater than average TYPHOID FEVER. 51 severity, the temperature in the relapse does not reach an equal height. The characteristic rash appears earlier—from the second to the fourth day—and is someAvhat darker and coarser than that of the first attack. The spleen swells rapidly and diarrhea often is present. Diagnosis.—Upon the points that are distinctive of a primary attack of typhoid fever rests the important diagnosis betAveen a relapse and a recrudescence. The latter is usually attributable either to errors in diet, to undue muscular exertion, or to great mental excitement: and, whilst it occurs during convalescence, it seldom lasts longer than one, two, or three days, and is not characterized by the diagnostic features of a relapse (peculiar temperature-curve, enlarged spleen, and specific eruption). The prognosis of relapses depends very much upon the severity of the primary attack, those folloAving severe attacks being relatively milder than those that folloAV the rudimentary, primary attacks. The frequency of relapses differs widely in different epidemics. Hence the fact that the percentage of relapses as estimated by differ- ent authors ranges from 3 to 15 per cent, need excite no surprise. The relapse may repeat itself once, tAvice, or even thrice, and tAvo relapses occur in about 1 per cent, of the cases. In a case Avhich Il reported three successive and typical relapses occurred. The pale line or ridge Avhich Avas mentioned (vide Clinical History) as noticeable in the nails after typhoid occurs similarly after each relapse, and in the afore-men- tioned case of my OAvn four distinct Avhitish, transverse ridges Avere per- ceptible after the conclusion of the third relapse. Recurrences.—The term recurrence should be applied only to those instances in which successive attacks are separated by longer or shorter intervals after complete recovery from a previous or the primary attack. Typhoid fever usually bestows complete and lasting immunity against subsequent attacks, but this is not an invariable rule. Eichhorst has studied 600 cases, and found that in 2j>- »tcrrn_£i^c-d \.F. Age °~^ Rjuv^S mw Nativity.... ^r- .& .<^T..___ _______ Occupation... ^^r^oJ^TT............. * --" -- -3 Residence. 0~ Ho 1A.~>^lo-»~ XM- J: t > -« 9_ TYPHOID FEVER. 61 0.259), to be followed by a second dose of equal size in four hours if necessary. The heart is ahvays to be guarded by the use of stimulants Avhen internal antipyretics are exhibited. (6) Intestinal antiseptics are much used to destroy the bacillus of Eberth or to counteract the ill effects of its toxins. Unquestionably they meet neither of these leading indications, but they are called for in an affection in Avhich extensive intestinal ulceration and moderate tympanites are usual manifestations. The bowel antiseptic which I have employed quite extensively, and with uniformly good results, is salol, this drug; being broken in the intestinal canal into carbolic and salicylic acids, and being capable of controlling meteorism as nothing else has done in my hands. The dose is 2 to 3 grains (0.1296-0.1944) every three hours, preferably administered in capsule. With it I usu- ally combine quinin in doses of 1 to 2 grains (0.0648-0.1296) each. Henry speaks strongly in favor of thymol, which he prescribes in pill or capsule (gr. iiss-0.1620) every three or four hours. I have employed this agent recently, and Avith gratifying results, in a feAV cases in which debility Avas a prominent feature. Lactophenin (gr. vij-xv—0.4536-0.9720 per dose), in starch capsules, up to 1^- drams (6.0) daily, according to the indications, is highly rec- ommended (Jaksch). Carbolic acid, iodin, and other antiseptic agents have their advocates, but my OAvn experience with them has been too limited to Avarrant an expression of opinion as to their value in this disease. Turpentine fulfils in some cases a leading indication. When the tongue is dry and brown, the abdomen distended, the general prostra- tion marked, and often muttering delirium present—symptoms of the typhoid state—the use of this agent, together Avith alcoholics, consti- tutes the best mode of treatment. Turpentine is best given in a capsule in the form of white turpentine—dose, 3 to 5 grains (0.1944-0.3240) every three hours. Its routine administration, hoAvever, is to be un- qualifiedly condemned. (7) Curative Inoculations with Cultures of Serum.—The brilliant results obtained from the use of antitoxic serum in diphtheria and certain other affections have led to attempts at curative inoculations in typhoid fever. Though their specific virtue is yet to be demonstrated, it is deemed proper to state the results Avhich have been obtained as concisely as pos- sible. E. Frankel and Manchot have treated 57 cases of typhoid fever with a sterilized liquid derived from a culture of the bacillus of Eberth in thymus bouillon and heated to 140° F. (60° C). Of this, \ c.cm. Avas injected deeply into the gluteal region. No reaction folloAved the first injection. The next day 1 c.cm. was introduced into the other buttock. This produced an elevation of temperature Avith chilliness, followed in three or four hours by decided sinking of the temperature. The fever, hoAvever, rose again if the injections Avere noAv omitted. Moreover, when the latter were continued at intervals of two days in augmenting doses (1 c.cm. each day), the fever assumed the remittent type and dis- appeared altogether after a feAv days. The splenic enlargement and roseate spots, hoAvever, persisted. Rumpf, following the methods of Frankel as to preparation and ad- ministration, treated 30 cases of enteric fever with cultures of the bacil- 62 INFECTIOUS DISEASES. lus pvocyaneus, Avith like results. F. Kraus and Bushwell, after treat- ing 12 cases Avith the sterilized pvocyaneus bouillon, hoAvever, concluded that this method possessed no specific curative value. Hughes and Carter treated a number of cases with blood-serum de- rived from convalescent cases, but apart from a decided lowering of temperature the general course of the disease Avas not perceptibly modi- fied. More recently, Klemperer and Levy have obtained the blood- serum from dogs (after inoculating them with bouillon-cultures of typhoid bacilli), and found it to be capable of immunizing susceptible animals, as the guinea-pig, etc., against the action of typhoid bacilli, and also of curing them Avhen infected. This treatment Avas employed in 5 cases of human typhoid, all of which pursued a mild course. Quite recently Pfeiffer and Kolle have shown the presence of a bac- tericidal substance in the serum of enteric-fever patients, as Avell as in that of certain immunized animals, but the result of their important researches has furnished a means of diagnosis of the disease rather than a specific means of cure (vide Diagnosis). (H) Treatment of Individual Symptoms and Complications.—Headache. —Early in typhoid the headache demands relief. Absolute rest and cold to the head frequently suffice. Depressant analgesics are to be avoided so far as may be, though it sometimes becomes necessary to resort to them. At such times those least objectionable are to be selected. I have found that a mixture containing sodium bromid (gr. x to xv —0.6480 to 0.9720) and the deodorized tincture of opium (Tfl.iij to v— 0.199* to 0.3330) in each dose, given at intervals of three or four hours, exercises a striking palliative influence. In occasional instances the above mixture fails, and then phenacetin (gr. ij to iij—0.1296 to 0.1944) may be substituted for the opium in the same combination or separately in capsule. Insomnia.—The cold baths or other measures calculated to relieve the headache often procure for the patient refreshing sleep. It is im- portant not to allow him to go too long without sleep, since this tends to the development of a pronounced " typhoid state " and its concomi- tants. When the agents recommended for the headache fail, I employ morphin hypodermically in small doses (gr. Jg to 1—0.004 to 0.008) during the evening hours, Avith excellent results, and have vet to wit- ness the unpleasant after-effects or the unfavorable influence upon the secretions that have been described by some authors. Codein, sulfonal and, more recently, chloralamid, have proved useful. Chloral is more certain in its action than the above agents but I have abandoned its use for the reason that it apparently produced cir- culatory collapse in two instances. Belirium.—Since the introduction of the Brand method delirium rarely calls for special medication. I have observed, in common with others, particularly during the advanced stages, that in cases in which the circulation was feeble and in which typhomania was a prominent feature the administration of st.mulants with a free hand completely dispelled the nervous phenomena, If alcohol fails, ether (TTl x—0 666— at a dose) maybe given hvpodermically, and repeated in one or two hours if necessary. To combine with the arterial some nervous stimu- lant (musk, valerian, etc.) will be found serviceable, particularly in ca.es TYPHOID FEVER. 63 in Avhich the delirium assumes an hysteric type. Of special value in meeting this symptom are the bromids, hyoscyamus, the persistenj use of ice to the head, and the other agents suggested for the headache and insomnia. Vomiting is rarely troublesome. Its chief cause is the irritation of the gastric mucosa, Avhich may be caused by improper diet or medica- tion. The best measure for the relief of this symptom, after the removal of the cause, is the use of ice, taken in small pieces and SAval- loAved. If vomiting occur during the period of development, minute doses of calomel, combined Avith sodium bicarbonate, may be pre- scribed Avith good effect. If it occur during the fastigium, the amount of milk taken should be reduced by one half, peptonized, and then diluted, preferably Avith lime-water. If the patient experience a strong aversion to milk, it must be suspended temporarily and liquid beef- peptonoids or broths substituted. Dry champagne may be administered simultaneously. Excessive irritability of the stomach calls for perfect rest of the organ for a period of not less than twenty-four hours, the patient being meanAvhile supported by rectal alimentation and subcu- taneous medication. Diarrhea more than any other single symptom claims special atten- tion. Two to four movements daily do not constitute diarrhea and do not demand treatment, but if this number of stools be exceeded, the condition should receive consideration. It may be caused by overfeed- ing or by improper food—as shown by the stools, as a rule—in Avhich case regulation of the diet is curative. It is often due to ulcerated and catarrhal lesions of the intestines, and particularly the large boAvel, and in such cases requires medical interference. Unquestionably, the use of proper intestinal antiseptics and such as possess the property of insolu- bility to a high degree is most valuable. Astringents may be combined Avith the latter or given separately. The subjoined formulse have yielded better results in my own hands than numerous others Avhich have been tried : B/. Bismuth, salicylate sij(8.0); Betanaphtol, 3j (4.0). M. et ft. capsulge Xo. xxiv. Sig. One to be taken every three hours. Or, B/. Salol., 3j (4.0); Bismuth, subgallat., 3ij (8.0). M. et ft. capsulse Xo. xxiv. Sig. One every two or three hours. Or, B/. Plumbi acetat, gr. xxiv (1.555); Ext. opii, gr. iss-ij (0.097-0.1296). M. et ft. pil. Xo. xij. Sig. One every three or four hours, as required. The last formula may be administered in the form of a suppository, both ingredients being doubled in quantity. Late in typhoid fever, Avhen the ulcers are fully developed, opium is 64 INFECTIOUS DISEASES. the remedy par excellence, since it tends to arrest the peristaltic action Avhiph keeps up the diarrhea and favors the spread of the inflammation to the peritoneum. I have recently observed brilliant results from the use of rectal injections of an astringent solution (tannic acid 1-2 per cent.), alternated Avith an antiseptic solution (salicylic acid 1-2 per cent.), each given once daily at intervals of tAvelve hours. Constipation, Avhich is often present, and particularly until the mid- dle of the second Aveek, is to be relieved by simple enemata of soapsuds every second day. Calomel may be used in the early stage of dynamic cases. Its employment in this manner may be folloAved by symptoms of a milder type than are ordinarily encountered. If constipation exists during the third week; accompanied by an oscillating temperature-curve, as rarely occurs, saline laxatives in small but repeated doses may cut short the attack. Tympanites.—This is sometimes a most distressing symptom, and is often associated with marked diarrhea. The claim has been made that if turpentine be administered in suitable doses throughout, both tym- panites and diarrhea are controlled. Turpentine is a good remedy, but only when certain indications exist (vide supra), and it is Avithout the power to influence the general course of the affection. As a remedy for tympanites it is excellent and richly deserves a trial. When em- ployed for this symptom alone I prefer to apply it in the form of stupes over the abdomen, although Avhen, as is frequently the case, the gases occupy chiefly the large bowel, turpentine enemata should be given, and, these failing, a long rectal tube should be passed. The meteorism is often increased by the milk taken, and a change of food from the latter to liquid peptonoids, meat-juices, and albumin- water cures some and helps others. Hemorrhages from the bowels, however slight, demand prompt and close attention, and complete rest must be secured immediately. The boAvel-movements, if the hemorrhage has been copious, must be alloAved to pass into the draw-sheet. The ice-bag (suspended if possible) should be applied to the right iliac region, and ice freely given by the mouth. Opium, to control peristalsis, is our chief reliance among medicinal sub- stances. It should be administered in small doses at frequent intervals and, by preference, hypodermically. It may be combined with full doses of the acetate of lead to arrest the bowel-movements. Cases in which slight oozing appears from time to time are best controlled by the latter combination in pill form. In similar instances turpentine is quite efficacious, and it is also warmly recommended for copious hemorrhages by many authors. Ergotin may be used (hypodermically, to be repeated every hour) in severe bleedings. The amount of food should be greatly restricted for about twelve hours. Peritonitis.—When, this complication is due to perforation of the in- testine the patient in almost every instance passes quickly beyond hope though recovery does rarely take place when nature, with or without the aid of the physician, limits the inflammation by the formation of adhesions. Morphin should be given hypodermically to relieve suffer- ing, and the laparotomist should be called immediately. Operation offers little hope of cure, on account of the previous unfavorable local and general condition, but with the progress of convalescence the TYPHOID FEVER. 65 chances of recovery from this accident improve. Peritonitis due to direct extension of the infectious inflammation of the bowel without perforation often admits of successful treatment. Unless perforation be suspected the physician is justified in administering saline purgatives, at the same time controlling pain by means of small doses of morphin, which is Avithout harmful effects, save that it somew7hat delays the recovery. Pneumonia.—Broncho-pneumonia Avas formerly (under the old re- gime) the most frequent pulmonary complication, and is to be treated in the manner indicated in the section on this affection. Lobar Pneumonia.—The treatment of that form of pneumonia which occurs in the advanced stage of typhoid will be considered hereafter (vide Secondary Pneumonia). That variety of lobar pneumonia which rarely inaugurates typhoid requires the same treatment, until the true typhoid symptoms arise, as adynamic forms of lobar pneumonia (vide p. 154). The hypostatic congestion of the bases of the lungs due to cardiac weakness and the decubitus of the patient is to be met by heart-stimu- lants and by changing the position of the patient. Bronchitis.—No special measures are necessary when the bronchitis is confined to the larger tubes, as in typical cases, while, if severe and diffuse, its management is identical with that of broncho-pneumonia, to which it leads. Laryngitis.—For this condition, which rarely develops in typhoid fever, counter-irritation should be tried, and if this brings no relief a small blister may be applied below the angle of the jaw on either side. For edema of the larynx scarification and the inhalation of simple or medicated steam are measures to be used. Then, should suffocation be- come imminent, tracheotomy should be performed without delay. Bed-sores.—The preventive measures have already been considered, but the smallest bed-sore demands active treatment. It is to be kept clean by means of a weak solution of some antiseptic, and may then be dusted with a powder composed of equal parts of boric acid, calomel, and bismuth; if sluggish, Avith a poAvder made up of aristol and iodo- form. I have found unguentum balsami peruviani (1: 30) to be a valu- able remedy in bed-sores. Should the edges of the ulcer become under- mined, a drainage-tube is sometimes necessary. Thrombosis of the femoral vein is best treated by elevating the part and keeping it at perfect rest. The folloAving ointment may also be applied along the course of the vessel: B). Ung. ichthyol., Lanolin, da. 3ij (8.0); Ung. belladonnse, q. s. ad 3j (32.0). Sig. Apply three times daily. After the swelling has subsided an elastic stocking should be worn for a couple of months. (9) Management of Convalescence.—Some of the points connected Avith this subject have already been discussed (diet, time for getting up, etc.). I may add that should a recrudescence occur the patient should be kept at rest in the recumbent posture and a return made to the liquid forms 5 66 INFECTIOUS DISEASES. of food. Often a moderate laxative serves a good purpose, particularly if an indiscretion in diet have been committed. The ulcers may not be healed, though the temperature may have been normal for a Aveek or ten days; hence the patient should not be alloAved to stir about for a period of twro weeks after the temperature has returned to the normal. At first his movements should be slow; he may soon, hoAvever, be allowed to exercise gently in the open air during seasons of favorable Aveather. Mental excitement is to be avoided, since it may produce a recrudescence of fever. Occasionally, during convalescence the diarrhea persists, being due to colonic ulceration, and is best treated by restricting the diet to milk and other light forms of albuminous food. The patient must be confined to bed. Medicinal treatment by the oxid of zinc internally and the use of astringent and antiseptic rectal injections, as before indi- cated, usually proves successful. Constipation may be a troublesome symptom in convalescence, and is best relieved by simple enemata. Most patients require tonics. We should begin Avith a vegetable salt of iron in combination with a simple bitter (such as the infusion of gentian), and later an inorganic salt of iron, Avith quinin and strychnin, may be resorted to. If there be a predisposition to tuberculosis, cod-liver oil and creasote should be given for a period of two or three months. Re- lapses are to be treated as primary attacks, and recurrences in the same manner. Mountain Fever. The term "mountain fever" should be regarded as applicable only to that condition Avhich develops shortly after ascent to a very high alti- tude. There is no definite pathology nor etiology, but the symptoms are attributable to the effects of a rarefied air upon the organic functions (respiration, circulation, etc.). The Symptoms are a much quickened pulse, urgent dyspnea, head- ache, vertigo, and at times nausea and vomiting. There is a subfebrile movement, the temperature touching 100° or even 101° F. (38.3° C). Thirst is present and the appetite is lost. Malaise and a sense of ex- haustion on attempting exertion are experienced. Hemoptysis has been noted, but rarely. The effect upon the human economy of high altitude varies Avith the extent of the differences in individual reserve nerve-force. Rest and acclimatization will almost invariably restore healthy function. Different clinical observers have depicted as mountain fever various forms of illness Avhich might have been as properly referred to other well-recognized diseases, especially typland fever. The lesions of typhoid fever w7ere present in tAvo instances that were necropsied. Curtin, how- ever, has reported four cases all evincing the signs and symptoms of lobar pneumonia. It must not be forgotten that high altitude may alter the clinical peculiarities of the acute infectious diseases. TYPHUS FEVER. 67 TYPHUS FEVER. (Ship-fever, Camp-fever, Jail-fever, etc.) Definition.—An acute contagious disease of unknoAvn specific eti- ology. It is characterized frequently by an abrupt invasion, and is marked by rigor,.high fever, early nervous symptoms of great promi- nence, a maculo-petechial eruption appearing betAveen the third and fifth days, and a termination by crisis. Historic Note.—This affection has been known from time im- memorial. In 1759 the name typhus, which is at present universally employed, was given to it by Sauvages. In presanitary times it pre- vailed extensively in epidemic and endemic forms, particularly in Ire- land and Russia, and also, though less frequently, in the seaport towns of our OAvn country. It constituted one of the chief plagues of the olden times, if not the chiefest, and its devastations among the armies Avere more destructive of human life than even Avar itself. In 1812 typhus fever first appeared in America in the NeAv England States. Its ravages did not cease until every Eastern State had been visited by the plague, Avhen it totally disappeared. In 1836 it reappeared in Philadelphia in virulent form and Avith deadly effect. It was at this period that Gerhard began his careful studies, Avhich resulted in the separation of typhus from typhoid. During the last half century com- paratively feAv instances of typhus have been met Avith in this country, though it still appears constantly in certain quarters, abroad (Great Britain, the eastern portion of Germany, Poland, Russia, and some parts of Southern Europe). All isolated cases and small groups of cases that have been observed in very recent times here have been properly attrib- uted to importations from other countries, and chiefly from Ireland. Since the epidemic in 1836 the disease has not gained a foothold on our shores, although in the early part of 1893 it appeared in New York City, and 150 cases resulted. Pathology.—The various viscera present no characteristic lesions. After death the eruption continues to be visible, and often large ecchy- moses are observable on the dependent parts of the body. Certain organs may present pathologic appearances, but they are not constant and are the result of the secondary infection Avhich the typhus invites. The serous membranes—the pericardium in particular, and at times the gastro-intestinal mucosa—are the seat of ecchymoses. There is hyperplasia of the lymph-follicles, but no subsequent ulcera- tion. Hemorrhagic extravasation may also occur into the muscles, the latter being dark and often shoAving hyaline and granular changes; the heart-muscle is especially apt to undergo a granular degeneration. The spleen is considerably enlarged, soft (even diffluent at times), and of a dark (frequently bluish) red color. The liver is somewhat SAVollen and may be softened, while the kidneys not rarely manifest the changes belonging to nephritis. In other instances they are merely congested. In the lungs are found a variety of lesions peculiar to different compli- cating conditions (bronchitis, lobular pneumonia, lobar pneumonia, pul- monary congestion Avith or Avithout edema), and occasionally pleurisy (sero-fibrinous or purulent) may be present. Nervous lesions are con- spicuous by their absence. An effusion, either serous or sero-hemor- 68 INFECTIOUS DISEASES. rhagic, into the subarachnoid space and the ventricles may be noted, and quite commonly there is cerebral congestion. In rare instances there may be a meningitis. The blood-changes are marked, the color being dark, the fluidity much increased, Avhile the coagulability is greatly diminished; and the intima of the aorta is frequently blood- stained. Etiology.—The direct cause or special micro-organism connected with the typhus contagion has not, as yet, been isolated, notAvithstand- ing the fact that the morphologic and biologic studies of the blood obtained by Brannan and Cheesman from the finger-tips of six patients during the mild epidemic of typhus in 1893 showed the presence of a bacillus that proved pathogenic for rabbits, guinea-pigs, and white mice.1 LewascheAV2 has also detected in the blood of typhus patients a distinctive micro-organism. Further observations, however, with a view to showing the constant presence of these micro-organisms in typhus fever, are necessary to demonstrate that they are the specific cause of the disease. It is a known fact, nevertheless, that w7hen typhus arises in a locality in Avhich it was previously unknown, it is dependent upon a transference of the typhus virus from Avithout, and does not arise spontaneously; this cannot be too strongly emphasized. The different modes of con- veyance of this poison from one place to another are not known posi- tively, but Ave can be confident that its source is in a preceding case, and that it may leave the body in the expired air, in the epithelial scales thrown off, and in other excretory or secretory products of the body. The poison is apt to be transmitted by contagion from the patient to others who approach him; and there is convincing proof that it may be transferred by means of fomites (wearing apparel, articles of furniture, etc.). What its precise gateway into the body is we do not definitely know, except that it is more likely to enter through the respiratory tract (by inhalation) than through the alimentary canal. Predisposing Causes.—The influence of insanitary surroundings upon the spread of this affection is positive and vital. Among special conditions may be mentioned filth, poverty, famine, and overcrowding, and here it may be inferred that typhus is a disease of the lower classes'. Broadly speaking, any condition of the system in which the natural vitality and resistance to bacterial invasion are loAvered increases sus- ceptibility to the disease, and among additional influences which possess considerable etiologic influence are overwork, intemperance, depressing emotions, etc. Age has no direct influence. Obviously, however, the young and middle-aged furnish a preponderant proportion of cases, owing to the fact that they are more liable to exposure to the virus than during other periods of life. Sex has no positive influence, and the season plays only a minor part. Epidemics may, however, occur rather more often in winter than in the other seasons, since the homes of the pauper popul a- tion are not so well ventilated, and hence are less cleanly in winter thai during the rest of the year. Clinical History.—Incubation.—This lasts from nine to twelve 1 Annual of the Universal Medical Sciences, 1893, p. 60 section H 2 Ibid., p. 61, section H. TYPHUS FEVER. 69 days. There may be prodromal symptoms during the concluding days (one, tAvo, or more of this period), such as anorexia, general malaise, etc., but in most instances invasion is sudden. Pre-eruptive Stage.—The early symptoms are either a series of chills or one severe rigor, accompanied by vertigo, tinnitus, headache, muscu- lar pains, profound prostration, and fever. The temperature quickly ascends to a high level, reaching 104° or 105° F. (40° or 40.5° C.) as early as the second or third day. The fever is continuous in type, and in severe cases a serious systemic condition may often be developed. The pulse is accelerated proportionately to the temperature and is of good volume. Bronchitis may be present, the appetite is lost, and the thirst is excessive, Avhile a thick, yelloAvish-Avhite coating covers the tongue. Vomiting occurs, and may be a prominent symptom. The urine is often scanty, its specific gravity is increased, and it may contain a trace of albumin. The cheeks are flushed and the eyes are injected. Nervous symptoms appear early—in the worst cases at the very onset —and are quite pronounced. At first there may be either mild or active delirium, but soon there is stupor or even actual coma, and the face takes on a dull, stupid look. With feAv exceptions the spleen on palpation is found to be enlarged. Eruptive Stage.—Between the third and fifth days of the invasion the characteristic eruption appears without an accompanying decline in the temperature. The rash comes out first upon the trunk, chest, and abdomen, extending thence over the rest of the skin-surface of the body, but, strangely enough, often sparing the face. The crimson-red maculae are changed in two or three days to a darker hue, becoming hemor- rhagic (petechiae), and Avhen coalescence occurs Ave have the spotted effect that has caused the name of spotted fever to be given to it. This name is also given to cerebro-spinal meningitis, in Avhich the eruption, though it resembles that in typhus fever, does not appear at any given time and is extremely inconstant. Not all of the maculae are converted, but some may remain as rose-spots, and these disappear Avhen pressed upon, while the petechiae do not. It is chiefly in the milder grades of typhus that the rose-spots fail to become petechial (vide infra). The skin-surface between the spots is sometimes diffusely hyperemic, and the eruption is usually rather abundant, though in well-authenti- cated cases it has been scanty or even Avholly missing. Lnlike many other eruptive diseases in the stage of eruption, the symptoms of typhus fever assume an aggravated type in typical and severe cases. The tem- perature continues high, often reaching 106° F. (41.1° C.) or even higher, with slight nocturnal remissions. The pulse becomes quite rapid (120-140 or more), feeble, and possibly irregular (often dicrotic), and the respirations increase markedly in frequency. At this time severe bronchitis, leading to broncho-pneumonia, is apt to occur as a complication. The tongue is broAvn, fissured, tremulous, and occasion- ally black and rolled up, without power to protrude from the mouth. Sordes form on the teeth and lips. The urine is scanty, high-colored, and often albuminous, and there may be retention from paralysis of the bladder. The nervous disturbance is intense, and may take the form of typho- mania, leading to complete coma or maniacal delirium. The patient 70 INFECTIOUS DISEASES. often lies with eyes open, staring into space, yet unconscious and in the condition knoAvn as coma-vigil. The motor nerves show derangement (tremors, subsultus tendinum, etc.), and carphologia (picking at the bed- clothes) is a common symptom. The decubitus is dorsal, as a rule; the flushed cheeks gradually become dusky, the face expressionless, and the pupils often contracted. The prostration reaches an extreme degree, and absolute exhaustion often terminates life. As a rule, in favorable cases the end of the febrile period comes by crisis betAveen the fourteenth and seventeenth days of the disease, and the temperature drops in the course of twenty-four or thirty-six hours to normal. Immediately preceding the crisis there is generally a great and sudden rise of the temperature (perturbatio critica), and the decline may be interrupted by slight irregularities or fresh exacerbations. The occurrence of the crisis is marked by rapid improvement in the symp- toms in general. The stupor suddenly gives place to a clear mind (sometimes folloAving a profound sleep), the eruption fades quickly, the facial phenomena disappear in inverse order of their appearance, and the general strength is rapidly recovered. Leading Symptoms and Complications.—Course of the Fever.—Al- though the temperature, as stated above, rises rapidly on the first day of the illness, it should be added that the highest grade is usually reached as late as the fifth or sixth day. Maximum temperatures of 105°, 106°, or even 107° F. (40.5°-41.6° C.) are common. Hyperpy- rexia usually heralds a fatal termination, the temperature mounting to 108°, 109° F. (42.7° C), or higher, though in light cases the acme may not exceed 103° F. (39.4° C). During the height of the affection the temperature pursues the continued type (slight morning remissions), with moderate oscillations, till the occurrence of the crisis which has been described. The fall of temperature may occasionally be more gradual than before indicated, though this is a comparatively rare phe- nomenon. The lungs frequently present complications (vide Pathology), among which the most common are bronchitis, broncho-pneumonia, and hy- postatic congestion. Broncho-pneumonia is especially dangerous, its development often preceding a fatal termination, and it may lead to pulmonary gangrene. If the gangrenous, consolidated areas connect with the pleura, empyema commonly results. Sero-fibrinous pleurisy also may occur as a secondary event, as may lobar pneumonia, and to recognize the latter the local physical signs must be fully appreciated, since the rational symptoms are feebly expressed. The heart in typhus continues to grow progressively weaker until, in many cases, a fatal issue is reached. This is manifested by the change in the character of the first sound, which becomes more and more indis- tinct as the case progresses, A systolic murmur (probably of hemic origin) may be audible at the apex. The nervous phenomena have been sufficiently detailed. Meningitis has been met with, but is very rare as a complication. Reference has been made to the occurrence of the ordinary febrile albuminuria in this disease, and it remains to be pointed out that hemorrhagic nephritis very rarely intervenes. During the febrile period the uric acid and urea increase in quantity, Avhile the chlorids decrease. TYPHUS FEVER. 71 The digestive tract rarely presents distressing symptoms and compli- cations. Hematemesis is most common, and cancrum oris has been noted occasionally. Cases in Avhich the mouth does not receive proper care are apt to develop parotitis, which often passes on to suppuration, and septic processes, causing abscesses in different parts of the body (joints, subcutaneous tissue, etc.), may arise as complicating events. Among the sequelae, neuritis, followed by paralyses, deserves first place, and gangrene of the remote extremities (toes, fingers, etc.) has also been observed. The general course and duration of typhus are variable. There is a mild type whose course is run in from seven to ten days, and in such the crisis occurs soon after the appearance of the eruption, Avhich may not proceed to the petechial stage. In this type the development of serious symptoms or grave complications is the exception. A malignant type, however, also occurs (typhus siderans), and this often proves fatal before the time for the appearance of the rash. Some epidemics are characterized by the relative frequency of light forms, and others by the severer types of the disease. Diagnosis.—On the known presence of an epidemic with special causative factors (unhygienic surroundings, exposure to the poison, etc.), and with the course and characteristic symptoms, the diagnosis of typhus fever can be made. Of special value is the eruption—its time of appear- ance (third to fifth day), mode of distribution, petechial character, and peculiar behavior under pressure. The recognition of lighter types, on the one hand, and malignant, on the other, is not possible from the symptoms alone, but it is so from the light afforded by a definite knoAV- ledge of the existence of an epidemic in the vicinity. Differential Diagnosis.—Typhoid fever is distinguished from this affec- tion by (a) its gradual onset, unaccompanied by severe rigor; (b) the relatively diminished violence and the later development of the nervous symptoms; (c) the less intense lumbo-muscular pains; (d) the less abun- dant eruption, Avhich is non-petechial and appears on the seventh or eighth day ; and (e) the gradual convalescence. Cerebro-spinal meningitis may be distinguished by a more intense headache, by retraction of the head, hyperesthesia, intolerance of sounds, photophobia, palsies of the eye-muscles (strabismus), a greater tendency to convulsions, and, finally, by both the absence of the typhus eruption and the countenance absolutely devoid of expression. Uremia is excluded by the absence of the previous history which it always gives (headache, vomiting, and diarrhea extending over a varia- ble period of time), by the presence in typhus of high temperature and a petechial eruption, and by the absence of edema of the extremities and face. Characteristic urinary phenomena are associated in uremia, and it must not be forgotten that among the rarer complications of typhus is acute hemorrhagic nephritis. In pneumonia the mode of onset is not unlike that of typhus, but the early development of the local physical signs, the absence of the typhus eruption, and the non-epidemic appearance of the disease are points which serve to distinguish the former from the latter disease. Relapses are among the rarest of clinical events, and one attack, as a rule, bestows immunity for life. 72 INFECTIOUS DISEASES. Prognosis.—To arrive at a correct prognosis it is necessary to con- sider (1) the degree of severity of the particular type from Avhich the patient is suffering, (2) the number and character of the complicating conditions present, or likely to occur if the case be of a severe grade, and (3) any peculiar circumstances connected with the individual, among which his food-supply and his sanitary surroundings are deserving of chief mention. In general terms, typhus fever is a grave disease, but its frequency of occurrence, and also its virulence, have been markedly reduced in consequence of better sanitation. The mortality-rate has been, during the last half century, lowered immensely, and is between 10 and 20 per cent, at the present day. Treatment.—This need not be discussed at length, since it em- braces, in the main, the same principles that were evolved in the treat- ment of typhoid fever. Prophylaxis demands thorough disinfection and absolute isolation. A special hospital for contagious diseases is ahvays to be preferred to the best accommodations obtainable in private families. When, hoAvever, patients cannot be transferred to special hospital wards and must be treated in private houses, the sick-room must be kept clean, well-ven- tilated, and at a temperature ranging from 60° to 65° F. (15.5° to 18.3° C). Xo one other than the doctor and nurse should be allowed to occupy or even enter the room. The thorough disinfection already described under Typhoid Fever must be enforced with equal care, and the importance of supplying fresh air to typhus patients has been abun- dantly shown by the great reduction in the mortality-rate among those treated in tents as compared Avith that in the hospital Avards. The general management, including the use of stimulants, in this disease does not differ from that advised in typhoid fever, except that a more prompt return to solid food can be made during convalescence than in typhoid. Fresh water should be given freely, and, in vieAv of the blunted sensibilities of the patient, should be offered at regular intervals. Hydrotherapy constitutes the best means at our command for controlling (by virtue of its stimulating effect upon the cardiac and respiratory cen- ters) the temperature and the nervous symptoms, Avhile at the same time it obviates dangerous complications. In addition, the use of antiseptic agents and tonic measures is to be recommended. The fact that typhus is a self-limiting affection, and therefore curable if life can be spared until it has run its usual course, gives those measures that are intended to combat exhaustion high rank in the treatment of this affection. RELAPSING FEVER. (Febris Recurreus ; Relapsing Typhus.) Definition.—An acute infectious disease caused by the spirillum of Obermeier, and characterized by febrile periods Avhich usually last six days, and are separated by afebrile periods of the same duration. Historic Note.—The first accurate account of this affection was published in 1739, though it is known to have prevailed in Europe and RELAPSING FEVER. 73 Ireland prior to that period. During the next century numerous epi- demic outbreaks, more or less extensive, occurred, and in 1844 the dis- ease made its first appearance in America at the Philadelphia Hospital, being brought by immigrants from Ireland. Subsequently small groups of cases occurred, and were reported by Flint and others, and in 1869 it prevailed considerably in Philadelphia (Avhere it was studied especially by E. Rhoads and William Pepper) and in other large cities of the coun- try. This Avas the last epidemic appearance of the disease in the United States, though in the years 1885 and 1886 Russia Avas visited by an epidemic of considerable magnitude. Pathology.—The solid organs of the body present no characteristic anatomic changes, though when death occurs during the febrile period the various viscera (heart, liver, kidneys) are the seat of cloudy SAvelling, and sometimes of hemorrhagic infarct and extravasation. The spleen shoAvs the most constant alterations, being enlarged, but in size it ex- hibits a great variability. Infarction is frequent, and the lymphoid ele- ment of the bone-marroAv often shows hyperplasia. If jaundice has been present during life, it is visible after death. Etiology.—Bacteriology.—In 1873, Obermeier discovered in the blood of patients suffering from relapsing fever a special organism, the spirillum Obermeieri, and subsequent investigations by others have fully confirmed his observations with refer- ence to the causal relation of this mi- cro-organism to relapsing fever. The specific agent, or spirocheta, is a deli- cate filamentous organism of spiral form and much elongated, its length equalling four to six times the diam- eter of a red blood-corpuscle (Fig. 8). Examined under the microscope dur- ing a pyretic period, it is seen to ex- hibit active motion among the blood- cells, this motion being spiral and folloAving the long axis of the organ- ism. It is aerobic, and may be dem- onstrated in dry blood by staining Avith anilin colors, but the spirillum has never been found in other fluids or secretions of the body. It is also apparent in the blood only during the paroxysms, and Dr. Van Dyke Carter's careful studies have shown that by inoculation of the blood containing spirillar organisms or their germs the disease may be conveyed to neAv or old subjects. Shortly before the crisis the spirilla disappear from the blood, and are, as a rule, absent during the Avhole of the succeeding apyrexial period, and inoculation now fails to produce the disease. After death they are found in all the organs, but they have not been cultivated successfully on artificial media, and little is knoAvn of their life-history. Predisposing Causes.—Age.—The complaint is most common in young adults between fifteen and tAventy-five years. Sex.—A larger proportion of males than females is affected. Fig. 8.—Bacillus of relapsing fever (from human blood); X 1000 (Giinther). 74 INFECTIOUS DISEASES. The disease is especially apt to prevail in times of famine, and, in short, the same unhygienic surroundings that produce typhus also pre- dispose to relapsing fever. Clinical History.—The incubation period ranges in its duration from four to ten days, though sometimes it is even briefer ; and in this stage certain symptoms (malaise, fugitive pains, etc.) may appear. The invasion is quite abrupt, often occurring on awakening in the morning, and commonly the attack is ushered in with a severe rigor, though there may be only a repeated slight shivering. The chief accom- panying symptoms are frontal headache, vertigo, severe pains in the loins and limbs, and marked physical prostration. The temperature rises soon, and often rapidly, reaching 105°-106° F. (41.1° C), or higher still, on the first or second day. The skin is dry and pungent, and pre- sents very soon either a "characteristic dirty-yellow color" or a dis- tinctly bronzed appearance. The cheeks are flushed, the eyes sunken, and profuse perspirations often take place (sometimes alternating Avith chills), in consequence of which sudamina are frequently observed. Other forms of eruption have been described, but none that are either constant or characteristic. In certain epidemics herpes labialis has been very gen- erally noticed. At first the tongue is moist and coated with a yelloAvish- Avhite fur, and later it may become broAvn, dry, and fissured, with sordes on the teeth. Ulcerative stomatitis has been observed occasionally, and catarrhal pharyngitis and mild tonsillitis may be evidenced by pain on SAvallowing and other symptoms. Among the earlier symptoms are ex- cessive thirst, anorexia, nausea, and vomiting. The vomitus may be yelloAvish-green, green, or even black in color, and consist of bile in varying proportions (rarely, also, blood) and gastric secretions. Con- stipation often precedes invasion, and is apt to continue throughout the attack. The pulse rises rapidly Avith the temperature, though the normal ratio betAveen the tAvo is not maintained. At first the pulse is full and strong, and its beats number from 100 to 140 or more per minute; but in serious cases it becomes Aveak, irregular, or even intermittent, while at the same time the heart-sounds grow more and more feeble and indis- tinct. Hemic murmurs may be audible. The nervous derangements are not of a grave character, but the headache persists and is severe throughout, and the patient is restive and sleepless. Delirium is not common, and, though occasionally this symptom assumes a prominence toward the crisis, the intellect remains clear as a rule. The urine pre- sents the ordinary febrile characteristics, and may contain albumin and casts. It also contains bile-pigment Avhen jaundice is present. The respirations are accelerated, and immediately preceding the crisis urgent dyspnea may be developed. The physical signs during the febrile paroxysms are few. The epi- gastric region and the nerve-trunks are tender to the touch, while the skin-surface and certain muscles are often hyperesthetic. 'Palpation detects a variable degree of enlargement of the spleen and liver and the signs of bronchitis, of lobular pneumonia, and of hypostatic'con- gestion of the lungs may be present. The symptoms above detailed persist with slight daily fluctuations of temperature till there occurs a turning-point. RELAPSING FEVER. 75 The Crisis.—This occurs from the fifth to the seventh day, and rarely as late as the tenth. It is sometimes heralded by a critical rise of temperature, the mercury touching 108° F. (42.2° C), but evidenced chiefly by a rapid fall of temperature (within twelve hours) to or below the normal, Avith profuse sweating. Coincidently, all other symptoms disappear Avith marvellous rapidity. The critical sweat may be replaced by diarrhea, intestinal hemorrhage, metrorrhagia, or epistaxis, and then follows a speedy afebrile convalescence, so that after the lapse of a day or two the patient expresses himself as being well. During the intervals betAveen the paroxysms the skin may exhibit a faintly jaundiced tint; there maybe trivial evening exacerbations of temperature, particularly if complications be present and outlast the fever stage; and the spleen is evidently enlarged. There may be, though rarely, but a single paroxysm. As a rule, at the expiration of the second Aveek there Avill be a recurrence of all the active symptoms of the primary attack, including the rigor or fits of chilliness and fever. Quite frequently a third pyrexial stage takes place, and rarely a fourth or even fifth. The duration of the first relapse is briefer than the primary pyretic stage, and if there be subsequent relapses, each succeeding one is sepa- rated from its predecessor by the usual apyrexial period, but is briefer 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 - 1 -it t t i- U I i\ , , ... ......I\ l 7tC ,- hEf- 410 fit,.! r rr. 41 h4JSt3 _ fv r »H4P U r- -, 4- J dut \t A ttlt tt H 40° * ^ t 3 T 1 A -*J t ^ 38° - ,-11 t -i EUl. _/ 7 * J\t E-> -^ -.3 t t 3-it SS I*-2 t- - *AU jjt 4P tsr t -^jbi. 37° / y iV ' f / * r 01 1 / \/ i f \ \ A 1 . 1 I -.-■ 1\J 36° J Zt *^1 First intermission. First relapse. Second intermission. Fig. 9.—Temperature-curve of relapsing fever. and lighter. Hence, should a fourth or a fifth febrile period occur, it is, as a rule, quite rudimentary. The relative duration and severity of the different febrile periods, their manner of recurrence, and the course of the fever are considerations that can best be appreciated by a glance at the accompanying temperature-chart (vide Fig. 9). Complications.—These are not frequent. At the head of the list stands lobar pneumonia, and next comes broncho-pneumonia, Avhich is always secondary. Other conditions, belonging to the latter class, are septico-pyemic processes, iritis, irido-choroiditis, suppurative parotitis, laryngitis, entero-colitis, and neuritis. In pregnant Avomen abortion 76 INFECTIOUS DISEASES. may take place. Epistaxis has been noted, and has even proved dan- gerous in some epidemics. Acute hemorrhagic nephritis is a very rare but serious complication Avhen it does occur, and may be dependent upon a primary affection. As the result, most probably, of the very high temperature the heart may become exhausted, and the occurrence of sudden paralysis is not unknoAvn. Clinical Varieties.—The difference in the general course of cases in different epidemics, and even in the same one, is, for the most part, the direct result of the varying degrees of intensity of the infection. Thus very light or even rudimentary cases occur in Avhich the Avhole course may be made up of one or two brief febrile periods, and their resemblance to ordinary intermittents may be close. The so-called " bilious typhoid," which is a form of relapsing fever, occupies the other extremity, being of malignant type. It is sometimes characterized by the usual symp- toms of the disease, only greatly intensified ; but more often, perhaps, the condition early merges into a typhoid state, to which are added cer- tain grave features and complications (marked icterus, hematemesis and hemorrhages from other outlets of the body, uremia, sudden collapse, etc.). Septic and pyemic processes, including infarctions, are common accompaniments, and the outcome is frequently unfavorable. Diagnosis.—The prevalence of an epidemic in Avhich the cases pre- sent similar symptoms ; the sudden onset; the course and intensity of the fever Avith its concomitants ; the termination by crisis on or about the seventh day ; and the peculiar manner of repetition of the fever- attacks after an afebrile period of equal duration,—are points that dis- tinguish relapsing fever from other affections Avhich simulate it more or less closely. Additional symptoms that are of special value for diag- nosis are—enlargement of the spleen and liver, a negative character of the nervous and a prominence of the gastric phenomena, and jaundice. To be able to state that relapsing fever is positively present the spiro- cheta Obermeieri must be found in the blood, and this is particularly true in the earlier cases of an epidemic, before they have passed through their typical relapses. To demonstrate the presence of this parasite in the blood during the fever-stage is not a difficult task. A drop of blood obtained from the finger-tip is to be examined microscopi- cally Avithout previous dilution. On account of their size and motility the spirilla can be readily detected, and usually the attention of the ex- aminer is first arrested by the peculiar joggling movements of the red blood-corpuscles. Then the real disturbing agents appear as slender spirals Avith a snake-like motion. Their identity may be confirmed by staining with anilin colors, and, in exceptional cases, by injecting them into the blood of the monkey, in whom thev produce the disease. Differential Diagnosis.— Typhus fever may be mistaken for relapsing fever, since both have the same predisposing causes, both prevail epi- demically, both are characterized by an abrupt onset, with or without prodromes, and by a continued type of fever. On the other hand, cer- tain points of distinction serve to separate them reliably. In relapsing fever the eyes are clear but hollowed, the cheeks are flushed, and there is a dirty-yellow tint of skin ; in typhus the eyes are injected the pupils contracted, the face wears a stupid, inanimate expression and there is in addition the characteristic maculo-petechial eruption' In RELAPSING FEVER. 77 relapsing fever the intellect remains clear, or there may be delirium toward the height of the febrile paroxysm; in typhus stupor develops early, and later there is coma or coma-vigil, with acute or low-muttering delirium and adynamic symptoms. In the former disease the primary period of fever is briefer than in typhus by a ratio of 7 to 14. Re- lapses are the rule in relapsing fever, and the exception in typhus; Avhile in the blood of relapsing fever patients may be found the spiril- lum, which is absent in typhus fever. Pel and Ebstein have described a febrile condition which sometimes occurs in pseudo-leukemia and simulates that of relapsing fever; but it may be distinguished by the absence of the spirilla from the blood, the general enlargement of the lymphatic glands, as well as of the liver and spleen, and the fact that the pyrexia! periods do not tend to grow shorter. Prognosis.—The prognosis of relapsing fever is good, but of "bil- ious typhoid " it is bad indeed. Apart from the type, we must consider, in this as in all other acute infectious diseases, the number, character, and frequency of occurrence of the various complications. As stated, these are few, infrequent, and mostly benign. Among those signalizing danger are severe hemorrhages (epistaxis, metrorrhagia, hematemesis, etc.), premature labor, signs of uremia and syncope, marked jaundice and excessive vomiting, urgent diarrhea, etc. Perhaps the most fre- quent causes of death are pneumonia and acute hemorrhagic nephritis. Individual circumstances exert an influence upon the prognosis, and of those that render it more grave are the want of good nursing, privation, a previously enfeebled system, and old age (the disease being more fatal in elderly than in younger subjects). The duration depends upon the number of paroxysms, since the latter are of definite length. In the majority of cases there is but one relapse, and in this event the disease lasts from eighteen to twenty days. Treatment.—The general management, including the time and use of stimulants, must be based on the same principles as are employed in typhoid fever. The fever, as well as the nervous and other leading symp- toms, is to be opposed by the cold or gradually cooled bath, employed as indicated in the article on the treatment of the latter disease. If, as may happen, there are adequate reasons Avhy balneo-therapeutics cannot be used, then cold spongings, with the ice-cap or the cold pack, may be tried. Internal antipyretics may be reserved for use in cases in which the tem- perature is very high and the above-mentioned means are impracticable. Small doses of phenacetin (gr. ij to v—0.1296 to 0.3240) or acetanilid (gr. ij to iij—0.1296 to 0.1944) are to be administered, at the same time guarding the heart, and the signs of collapse must be promptly met by the free yet prudent use of stimulants (strychnin, alcoholics, ammonium, etc.). Vomiting often induces marked debility, and calls for the use of ice or iced champagne and small doses of cocain, morphin, or dilute hydrocyanic acid, preceded by a mercurial laxative. Counter-irritation over the epigastrium is also useful. For the intense muscular pain, restlessness, and sleeplessness nothing is so good as morphin given sub- cutaneously, and Dover's powder may be employed if the pain be of moderate severity. During the intermissions the patient should be kept indoors for ten days or more, lest exposure or sudden exertion 78 INFECTIOUS DISEASES. predispose him to a relapse. Solid food may now be gradually resumed, and tonics judiciously given. The treatment of relapses differs in no way from that of the first febrile period. MALARIAL FEVER. (Chills and Fever; Fever and Ague; Swamp Fever.) Definition.—An infectious, non-contagious disease caused by the hematozoa of Laveran. It is characterized by splenic enlargement, brief febrile attacks Avhich recur periodically, melanemia, and a tend- ency in protracted cases to irregular fever and extreme anemia. The folloAving sub-varieties will be discussed: (I.) Intermittent fever; (II.) Pernicious intermittent; (III.) Remittent fever; (IV.) Malarial ca- chexia; (V.) Masked intermittents; and (VI.) Malarial hematuria. Historic Note.—There are few diseases with which the profes- sion has been acquainted longer than Avith the more typical forms of malaria, and chief among the earliest known hot-beds of this disease Avere the city of Rome, the Pontine marshes about the latter, and the SAvamps along the lower Danube. Except in the extremes of latitude there are feAv localities in which malaria has not been endemic, with seasonal epidemic outbreaks; yet it is pretty generally believed that the prevalence of the disease long has been, and still is, diminishing. This vieAv is fully corroborated by my OAvn observations. A similar progressive decrease, Avith slight annual variations, was noted during a period of five years (from 1885 to 1889) Avhen the cases from four leading hospitals of Philadelphia Avere considered together. The total number of cases for this space of time Avas 1132. It was also found that a tracing representing the number of cases of malaria ad- mitted into the Pennsylvania Hospital yearly during the period extend- ing from 1853 to 1S93, inclusive, shoAved a similar tendency to decline, though in a somewhat less striking degree. Osier has called attention to the fact that the diagnosis of malaria was much more frequently made before the discovery of the parasite than has since been the case, and that, therefore, early statistics of this disease are apt to be mis- leading. New England, once a region in Avhich the disease was very prevalent, now affords few cases. In the southern portion of the United States. also, the severer forms of malaria prevailed extensively, but a marked tendency to progressive reduction in the number of cases has also been observed here. It must not be forgotten, however, that in some districts of the United States, from Avhich malaria had disappeared, it has re- appeared, Avhile other localities, formerly free from the disease, have become more or less malarious. In foreign lands (England, France, Germany, etc.) the constantly decreasing prevalence and virulence of this disease have been noted by numerous careful observers Pathology.—The chief and most constant morbid lesions are attributable to the direct effect of the malarial parasites upon the blood. MALARIAL FEVER. 79 The symptomatic anemia (often quite pronounced) results from the de- struction of red corpuscles, which may be observed in all stages, by the parasites. There is a marked tendency to an accumulation of pigment in the blood and in certain of the internal organs, particularly the spleen and liver. To account for this is the fact mentioned in the de- scription of the amebse (infra) that the hemoglobin of the blood is con- verted into melanin (pigment) by the organisms. The malarial parasite also engenders a toxin Avhich may be in part responsible for the morbid lesions of the disease. The spleen is engorged Avith blood, and at first is SAvollen (chiefly during the febrile paroxysm), but it soon becomes permanently enlarged (" ague-cake "). A rare accident in intermittent fever is rupture of the spleen. Hemorrhagic infarcts are occasionally presented by this organ. The liver is also engorged, but not to the same extent as the spleen. The heart-chambers may be found to be acutely dilated. Htiology.—(1) Soil.—It is a generally accepted fact that a certain condition of the soil, especially as regards a considerable humidity, is essential to the development of the malarial poison. Marshes are often highly malarious, and particularly the swamps, that are overfloAved at certain seasons and exposed to the influence of the atmosphere at certain other seasons, are breeding-places for malaria. Freshwater marshes favor the development of the malarial organism, and are most fruitful in influencing its growth Avhen located near the coast and tainted Avith salt Avater. Again, marshy districts affording luxuriant vegetation are notorious as malarial foci. Keeping in remembrance the foregoing facts, Ave can readily see Avhy malaria is unusually prevalent in certain coun- tries (chiefly tropical), and Avhy it is confined to the loAv-lying estuaries and the deltas of rivers. The same facts explain satisfactorily why certain districts which Avere very liable to the affection should have become, as the result of denudation of the virgin soil and its subsequent drainage and cultivation for longer or shorter periods, entirely free from the complaint. On the other hand, the upturning or removing the sur- face of the virgin soil may be followed by the appearance of malaria in localities in Avhich it has been previously unknoAvn. While we regard the soil as the natural "home and cradle" of the malarial poison, Ave are not acquainted, as yet, Avith all of the telluric conditions upon which its presence or absence depends; and it is an error even to regard all marshy districts as being necessarily malarial, since the disease has been met Avith on dry, sandy soils, and even on distinctly rocky strata. (2) Climate.—Malaria is more prevalent in tropical and subtropical than in temperate climates, and more common in the latter than in the polar zones. Hence it occurs more frequently in the southern than in the northern States of our OAvn country. Temperature, per se, consti- tutes the indispensable factor, the virus of malaria being inactive at temperatures below 65° F. (18.3° C), while very high temperatures may arrest the plasmodial growth. For the development and propagation of the malarial parasite the presence of an abundance of atmospheric oxygen is also apparently essential, though the influence of moisture in the air upon the malarial germ is little understood. (3) The winds may transfer the poison from place to place, but trees planted in roAVs or clumps often successfully intercept the poison as it 80 INFECTIOUS DISEASES. is being dispersed by air-currents through the lower strata of the atmo- sphere. Strong winds tend to dry the soil by hastening the surface evaporation, and become an influential factor in combating one of the conditions of soil essential to the development of malaria. (4) Rapidly-growing trees also dry the soil by absorbing enormous quantities of water. They are probably efficient, however, only in localities that have no natural subsoil drainage l—a condition often met with in malarial districts. In the Roman Campagna extensive experi- ments have been made with the eucalyptus tree, and the results have been remarkable, districts protected in this manner becoming almost entirely free from malaria in a feAv years. (5) Seasons.—In temperate latitudes most cases are developed in the autumn, the maximal period corresponding with the month of Septem- 1200 z < —> CD U U. a-< 5 O. < > < 5 W z —> 5 —> O < I-" Q. UJ CO r-O O > O z O UJ Q 1200 1100 1100 1000 1000 900 900 /\ / \ / V 800 / \ 800 / / , 700 700 1 1 1 1 600 1 600 500 400 » 400 300 200 300 200 --- 100 0 <*■ O s o o ro CO o CO CO to 00 en o ■* 100 0 GO Fig. 10,-Chart showing the seasonal variations of malarial fever. The line increases in incre- ber, as is shown by the tracing on the accompanying chart (Fig. 10), which is based upon 4841 cases of malaria gathered from the records of the leading Philadelphia hospitals. Authors who state that malaria is more prevalent in the spring and 1 House-plants as Sanitary Agents, by the Author p. 263 DESCRIPTION OF PLATES I. and II. The drawings were made with the assistance of the camera lucida from specimens of fresh blood. A AAinckel microscope, objective % (oil immersion), ocular 4, was used. Figures 4, 13, 23, 24, and 42 of Plate I. were drawn from fresh blood, without the camera lucida. PLATE I. The Parasite of Tertian Fearer. 1.—Normal red corpuscle. 2, 3, 4.—Young hyaline forms. In 4, a corpuscle contains three distinct parasites. 5, 21.—Beginning of pigmentation. The parasite was observed to form a true ring by the con- fluence of two pseudopodia. During observation the body burst from the corpuscle, which became decolorized and disappeared from view. The parasite became, almost immediately, deformed and motionless, as shown in Fig. 21. 6, 7, 8.—Partly developed pigmented forms. 9.—Full-grown body. 10-14.—Segmenting bodies. 15.—Form simulating a segmenting body. The significance of these forms, several of which have been observed, was not clear to Drs. Thayer and Hewetson, who had never met with similar bodies in stained specimens so as to be able to study the structure of the individual segments. 16, 17.—Precocious segmentation. 18, is), 20.—Large swollen and fragmenting extracellular bodies. 22.—Flagellate body. 23, 24.—Vacuolization. The Parasite of Quartan Fever. 25.—Normal red corpuscle. 26.—Young hyaline form. 27-34.—Gradual development of the intracorpuscular bodies. 35.-Full-grown body. The substance of the red corpuscle is no more visible in the fresh specimen. 36-39.—Segmenting bodies. 40.—Large swollen extracellular form. 41.—Flagellate body. 42.—Vacuolization. PLATE II. The Parasite of ^Estivo-autumnal Fever. 1, 2.—Small refractive ring-like bodies. 3-6.—Larger disk-like and ameboid forms. I-~^R1i?g;11ikec!?od.y wit-h a feY Pigment-granules in a brassy, shrunken corpuscle 8, 9, 10, 12.—Similar pigmented bodies. ^ 11.—Ameboid body with pigment. 13.-Body with a central clump of pigment in a corpuscle, showing a retraction of the hemo- globin-containing substance about the parasite. u ul Lne Ilemo- 14-20.—Larger bodies with central pigment clumps or blocks 21-24.-Segmentmg bodies from the spleen. Figs. 21-23 represent one bodv where the entire ^n^V^t^tion^si^Fi^ T^LSegm|nts' ei^en in numbe?, were accumte y 2.0-33.— Crescents and ovoid bodies. Figs. 30 and 31 renresent nne hn/W ,„>,;„>, .. „ extrude slowly, and later to withdraw, two rounded protrusions y' Was Seen to 34, 35.—Round bodies. 36.—" Gemmation," fragmentation. 37.—A'acuolization of a crescent. two of the flagella had already broken away'from themother^iodv geUa aPPeared; at ^ 41-45.-Phagocytosis. Traced with the camera lucida. y" 1 These illustrations are reproduced by permission from the arH«in k. ^ m,. son in The Johns Hopkins Hospital Reports, vol v., 1895 lcle by Drs- Thayer and Hewet- The Parasite of Tertian Fever 3 4 Plate J. *S- >■ , * ^ Q ^% ?St ■ ,■■■ >•*£*' "*3 -!-'.*>>U 24 25 The Parasite of Quartan Fever. r 3 , -' *- * »* , >. ~N 4>'-*>- The Parasite of Aestivo Autumnal Fever ;qs o Plate II. ^ 38 4$ *u> O ■w >o fr*> MALARIAL FEVER. 81 autumn than in summer and Avinter in temperate regions are probably in error. An inspection of the tracing will convince the most skeptical that the spring, unlike the autumn, is unattended with increased preva- lence of the disease, which is in abeyance not only during the winter, but also practically during the spring, although the cases are seen to increase during the latter period. In the tropics the case seems to be different, and tAvo maximum periods—spring and autumn—and two minimum—summer and winter—obtain. Autumn has, however, the greater number of cases. (6) Gravitation.—The malarial poison escapes from the soil into the superjacent strata of air. That it does not rise far above the earth's surface is shown by the fact that persons occupying the upper stories of a house or living on slight elevations are affected with relative infrequency. (7) Race exerts little influence in other lands than our own, but in the United States negroes are less susceptible than are the whites. (8) Sex is Avithout effect when men and women are equally exposed. Cases are, however, vastly more frequent among males because of their increased liability to exposure, and particularly while following certain occupations (agriculture, marsh-draining, etc.). The 5044 cases col- lected by myself gave the numerical proportion of 6 to 1 in favor of males. The Malarial Parasite.—In 1879, Klebs and Tommasi Crudeli isolated a Ioav vegetable organism—the bacillus malariae—and claimed it to be the special agent producing all forms of malaria. The evidence afforded by subsequent experiments of other observers, however, failed to corroborate their investigations, and it remained for Laveran in 1880 to discover the specific parasite in the blood of patients affected with malaria. The announcement of his discovery failed to attract wide- spread attention until 1883, when Marchiafava, Celli, and Golgi pub- lished the results of their confirmatory investigations. Since then the claims of Laveran have been abundantly corroborated by Councilman, Osier, James, Dock, Koplik, and others in the United States, by Van Dyke Carter in India, and, more recently, by numerous French, Eng- lish, German, and Russian observers. It Avould seem, therefore, as though the evidence as to the specificity of this organism were almost complete, and, at all events, it has invariably been found to be associated with the different forms of malaria. The malarial parasite belongs to a sub-class of the protozoa known ^ as hematozoa. Of the latter, three varieties, corresponding with the three leading clinical forms of the infection, have been distinguished, and the evolution of two of these parasites at least takes place Avithin the red blood-corpuscles. They enter the red cells in the form of small, non-pigmented plasmodia, exhibiting ameboid motion, and then feed upon their host, transforming, at the same time, the hemoglobin of the latter into dark pigment-granules as they develop. When the intra- globular plasmodia have consumed the red blood-corpuscles the granules of pigment accumulate in the center of the parasite, while on its periph- ery the processes of subdivision and sporulation are taking place, forming fresh generations of hematozoa. These young parasites assume the form of minute, more or less spheric, hyaline bodies, which again 6 82 INFECTIOUS DISEASES. enter the red blood-corpuscles and start on a new cycle of development. It is probable, as Golgi suggests, that the third variety is not intimately connected .Avith the circulating medium, but that its evolution princi- pally takes place in the internal organs (spleen, bone-marrow, etc.). The special varieties of the malarial parasite will be described sepa- rately. (1) The Ameba causing Tertian Intermittent Fever.—This begins its cycle of evolution in the red blood-corpuscle as a small pigmented ameba. Its development is attended with the appearance in its inte- rior of fine, broAvn, motile granules in the form of pigment, and Avhen matured it about equals the size of a normal red corpuscle. It now assumes a spheric form, the pigment collecting centrally, and sporulation into fifteen to twenty or more segments follows. The tertian parasites are exceedingly numerous in the blood, and pass through the various stages of their life-cycle almost simultaneously, the sporulation of an entire generation occurring Avithin the space of a few hours (Golgi). The occurrence of the malarial paroxysm follows the process of sporulation, Avhich is attended, most probably, with the development of a toxin, and the symptoms of the disease may be attributable chiefly to the effects of the latter. The red corpuscle that includes the parasite becomes enlarged and decolorized as the latter develops. The parasite of tertian intermittent runs its cycle in about forty-eight hours. Hence infection by a single generation would result in sporulation every second day, folloAved by the malarial paroxysm. Quite commonly, infection by tAvo groups of parasites occurs on successive days, and, since each has a definite period of evolution, a daily malarial paroxysm is the result (quotidian intermittent). Multiple infection with this parasite may occur, but Avith great rarity. (2) The Ameba causing Quartan Fever.—This cannot be distinguished from the tertian parasite at the beginning of its brief career, but later differences are clearly perceptible. Its ameboid movements are more deliberate, and its pigment-granules are coarser, darker, and also less motile than those of the tertian organisms. Unlike the latter, it does not attain the size of the red corpuscles, and during sporulation the seg- ments (five to ten in number) encircle in an orderly Avay the central pigment-mass or clump, "rosettes " of great beauty thus being formed. The red blood-corpuscle that harbors the quartan parasites contracts upon its destroyer, appears shrivelled, and its color changes at the same time from the normal to a deep greenish or bronzed tint. It sporulates about seventy-two hours after it enters the red corpuscle; hence, if only one group of parasites be present, febrile attacks occur every fourth day, forming the simple quartan intermittent. On the other hand, double quartan infection results in paroxysms on tAvo successive days, followed by an intermission lasting one day, while triple infection, or the presence of three groups, causes daily paroxysms—the quotidian intermittent. Infection by more than three groups of the quartan parasite may occur, but is very rare. (3) The Ameba causing Estivo-autumnal Fevers.—The cycle of this variety is evolved, chiefly, in certain of the internal viscera and the microscopic examination of the blood in the various stao-es of the dis- ease does not give a positive result, as in the tertian and quartan types. MALARIAL FEVER. 83 The organism invades the red blood-corpuscle, but to what extent is not definitely knoAvn. It is a quite small hyaline body, its size at maturity scarcely equalling one-half the dimensions of the red corpuscle, and it accumulates very few fine pigment-granules. The parasite is not to be found in the later stages, except in the blood from certain internal vis- cera, such as the spleen, bone-marroAv, etc. After the condition has lasted a Aveek or more characteristic oval and crescentic bodies, which are more or less refractive, may be observed in the fresh blood. These so-called "sickle-form bodies" shoAV central rods and clumps of coarse pigment, and are especially connected Avith this category of malarial fevers. The red corpuscle, at Avhose expense the parasite develops, as- sumes a brassy hue, often becoming shrivelled and sometimes notched. The time occupied by the life-cycle of this parasite is still an un- settled question, but it is generally believed to vary between the ex- tremes of twenty-four and forty-eight hours. In one of my OAvn cases the febrile paroxysms recurred every seventy-tAvo hours. For the differ- ences in the period of evolution there is no satisfactory explanation, though the variation may be connected with the circumstance that it frequently (though by accident) penetrates into the red blood-corpuscle. Cilice, or flagellar, exhibiting active motion, may groAv from all of the before-mentioned varieties, and not infrequently they become detached and float free in the blood-stream. They are most common in blood aspirated from the spleen, but their true significance is not knoAvn. The ciliated forms, according to Manson, probably do not exist in the blood inside the body, but develop very shortly after it is drawn, espe- cially in the estivo-autumnal type. Usually the presence of the cilia is only indicated by occasional oscillatory movements of the red blood- cells surrounding the parasite. Mode of Infection.—The exact manner in Avhich the malarial para- sites are transferred from the sick to the healthy is not Avell understood. It is known to a certainty, however, that the disease can be communi- cated by injecting the blood of a patient into a healthy individual. On the other hand, it is in no sense a contagious disease, since the poison, after it enters the body of a human being or inferior animal, cannot escape in an active form from the latter into the surrounding atmosphere. Most probably the poison enters the system through the medium of in- halation, and rarely through the digestive tract. Immunity.—Persons Avho have had malaria are more liable to fresh attacks than before, although they experience no inconvenience so long as they reside in a non-malarial district. Incubation.—The period of incubation varies in different cases and according to the different clinical types. Thus it is, on the Avhole, briefer in the remittent than in the intermittent forms of malarial dis- ease, the time usually ranging from five to tAventy or more days. (I.) Intermittent Fever.—Symptoms.—The clinical history pre- sents itself under two heads: (a) the paroxysms, and (b) the manner in which the paroxysms recur. (a) The Paroxysms.—There maybe premonitions lasting from one to several days, and most significant, yet not distinctive, are headache, pain in the nape of the neck, yawning, a yelloAvish complexion, and a slight splenic enlargement. In a large proportion of the cases, how- 84 INFECTIOUS DISEASES. ever, the onset is abrupt. Typical paroxysms present three stages— chill, fever, and sweating. The chill is intense, causing more or less shivering, and often chattering of the teeth. Malaise is marked, the skin is cool and pale, and the face slightly cyanotic. This stage usu- ally occurs in the morning hours, though the time of onset is by no means constant; its duration, also, varies greatly, generally lasting from one to two hours. The internal temperature rises rapidly during the time of the chill. The hot stage succeeds the chill, and, in striking contrast Avith the first stage, the face wears a decided flush and the skin is burning hot to M E M E M E M E M E M E M E M E M E M E M E M E M E M E M E M E M e ^ 1 E UO WKLS Daily AmU ¥ _L ^sd ,^ Jf1 «A vi ^ ^ rV JS >>i t -._ 0 <{ i§ - v*» 4 ^ r^ ,^ > ~ - a ^ 5 - - & ^ - - * i- ^ v> & > t\ ^ * r^P* • t3 *^ 5? "^ ^ ** ^ -$< ■^ ^x£> , < Or S^ ^ «> "S: Mi "S? ^ ^ *i ~3^ ^0 "^ <* ^V ^ --S) ^ V! i 3.S, -?to U ._ _ Q ""* ., ., . &£ ia It 'T ' T^ 1 Iv "\ _f"* '\ 1 • \ \ 1 S \ J| §lORO ^ \ \ \ N^ *! - \ J - •£** O \k ,i 1 J i s — - 0 3£ \\ A 3 . J1 y, \ 13 s \ M \ - L!! \ "J +j v H k ^ -1- - ^ S 8 1 § \ K 1 t 1 — - — ~ <£ r , \ — "fl \ ^ 1 A M > 3 'i — "V - ^ 1 ^ \r\r\o V ^ V ^^ 4 ^S r\r\o . 1 >' \ i- 'T ^s , ^K> r V •'$ -*•>< s ._. t »*J — — ^ ' 4- 4 A & ~~* i —■ i \ f- — S 970- — ■*• A ^ q — Dayo/Dis 1 r Pulse. .. u'H V-ft bHi !*& $% %1 % Pit % * %. &* 6Xo 8fy % fy'1 '*ti Besp. y #36 V-20 its 'Mt % f% % It/ 'M % % % Jtt k h 'H 9ft Date. ,)§; r - u ' " ■2/ - " m 42° 40° 39c 38° -37° 36° 35° Fig. 11.—Temperature-curve in a case of double tertian fever. C. F. C, aged forty-one years. the touch. The temperature continues to rise, but not so rapidly as in the first stage. Its maximum level, usually from 104° to 106° F. (40° to 41° C), is soon reached, and may either be maintained uniformly for several hours, or the curve may show tAvo small summits if the tempera- ture be recorded frequently (Fig. 11). The pulse is full and bounding, MALARIAL FEVER. 85 except in the rare instances in Avhich acute dilatation of the heart en- sues, when it is quite feeble and sometimes irregular. The length of the second stage exceeds that of the first, being from three to six hours. The temperature generally begins to decline before the close of the febrile stage. When siveating, which soon becomes profuse, sets in, the symptoms of the hot stage are promptly relieved. The temperature falls by crisis, touching the normal level in a feAv hours; the decline, however, is less rapid than the rise at the beginning of the paroxysm. The fall may be unbroken by any fresh elevations of temperature, though more often the latter occur, and less frequently defervescence occurs by steps, the tem- perature dropping one or more degrees, and remaining at the new level for a short period (Fig. 12). It again drops about an equal distance, Fig. 12.—Temperature-curve in a case of tertian intermittent fever (Sahli). and so on until the normal is reached. Usually, folloAving the parox- ysm, the temperature becomes subnormal (about 97° F.; 36° C). The length of the typical malarial paroxysm ranges, in all save exceptional instances, from eight to twelve hours. (b) The Manner in which the Paroxysms Recur.—The special cha- racteristic of this form of intermittent is the regularity Avith Avhich the paroxysms recur in cases that are not under treatment. The intermis- sion, or time betAveen tAvo successive paroxysms, is most frequently tAventy-four hours (quotidian intermittent fever); almost as often it is forty-eight hours (tertian intermittent); and less frequently it is sev- enty-tAvo hours (quartan intermittent). If there be tAvo paroxysms on one day—a rare occurrence—the term " double quotidian " is used to designate the case. Of the above types, as stated in the life-history of the parasite, two only—the tertian and the quartan—have been clearly 86 INFECTIOUS DISEASES. distinguished. The quotidian ague (the most frequent clinical variety) is generally due to double infection by the tertian parasite, and very rarely is it to be attributed to the presence in the blood of three groups of the quartan parasite, resulting in daily sporulation. It sometimes happens that the paroxysms recur a couple of hours later each succes- sive day, Avhen it is called a " retarding " intermittent fever, or they may recur a little earlier, when the term "anticipating" is employed. Other More or Less Characteristic Symptoms.—Apart from the par- oxysms and the regularity Avith Avhich they recur, splenic enlargement is almost always present, and hence is of considerable clinical import. After the first paroxysm or two the swelling is usually marked and demonstrable, especially by palpation. The organ can be shown to in- crease in size Avith each succeeding paroxysm. Tenderness is elicited on pressure, and commonly outlasts the course of the affection for a con- siderable length of time. Moderate enlargement of the liver may be present, but this is neither so significant nor so constant as enlargement of the spleen. Connected Avith the skin are two symptoms of considerable diagnostic value: (1) a yellowish-brown discoloration, the so-called "malarial com- plexion," due to the deposition of pigment; and (2) herpes. The latter occurs usually on the prolabia or on the nose, though rarely elsewhere. Other skin-eruptions, as urticaria, purpura, etc., have been described by authors, but they have no real clinical worth. As stated under Pathology, acute dilatation of the heart may develop, attended Avith the usual physical signs of this condition, but it rarely lasts longer than the brief febrile paroxysm. Murmurs of functional origin may also be heard in the heart during the attack, and the lungs upon auscultation sometimes present the signs of a dry bronchitis. The urine may contain a small amount of albumin during the pyrex- ial period, and rarely there is acute nephritis, but only in the severest types. There is a temporary increase in the amount of urea eliminated during the febrile movement, and this may be observed from two to six or eight hours before the chill, so that an approaching paroxysm can be foretold if a quantitative analysis of the urine be made at the proper time (Jaccoud). The increased proportion of urea in the urine is occa- sioned in the same manner as in fevers generally. G-astro-intestinal symptoms may be present, but are not prominent, if we except a diarrhea which is sometimes considerable. Catarrhal jaundice may be observed, but this is limited to the graver forms of intermittent. Clinical Varieties.—Besides the typical attacks, mild or rudimentary forms are met with, these either being due to slight infection or appear- ing as the remnant of cases of usual severity after active treatment. The separate stages of the febrile attacks are not well marked, and one or more may be missing; thus the chill may be absent (dumb ague), and less frequently the SAveating stage may fail to appear. In children there is no rigor noticeable. They grow pale the vis- ible mucous membranes often being slightly livid during the chill and the paroxysms may be initiated by a convulsion or by other nervous phenomena. (II.) Pernicious Malarial Intermittent.—This truly serious form MALARIAL FEVER. 87 occurs chiefly in highly malarial districts, and rarely also in the wide- spread regions in Avhich the simple variety prevails. Hence in the United States it is encountered most frequently in the Southern and Southwest- ern States. In this form of malaria the parasites of estivo-autumnal fever are constantly associated. The paroxysms do not recur with strict regularity, and the primary paroxysms are rarely pernicious in charac- ter ; but second or subsequent attacks may, in addition to the usual symptoms, present the gravest phenomena. Pathology.—This type of malaria may arise (1) as a fresh infection, and (2) as a reinfection. (1) Infection.—The blood is more or less hydremic, and the blood- disks are in all stages of disintegration. The spleen is considerably swollen, soft, and its parenchyma is turbid and lake-colored, all its tissue elements being more than naturally pigmented, though this may not be macroscopically appreciable. Upon microscopic examination, however, pigment-granules and red corpuscles containing parasites and phagocytes are observed, particularly in the pulp adjacent to the arte- rioles. The liver is enlarged, soft, and turbid, and pigmentation occurs, but it is also microscopic. In the minute vessels phagocytes and para- sites containing pigment are perceptible Avithin the red corpuscles, and numerous small necrotic areas have been observed. The kidneys show microscopic pigmentation, most marked in the vicinity of its blood-sup- ply. Minute areas of cell-death are sometimes seen. The brain may be abnormally colored, assuming in severe cases a chocolate tint, and in mild types a lighter hue. The brain-tissue is often anemic, and more rarely edematous. Occasionally there is congestion. The minute vessels and capillaries are literally blocked with phagocytes and blood- disks more or less disintegrated (containing parasites), and perivascular infiltration and minute hemorrhages may rarely occur, producing a focal lesion. (2) Reinfection.—The blood is often extremely hydremic. The spleen may or may not be much enlarged, and is usually quite firm, Avith a well-marked pigmentation that is obvious to the naked eye. The liver is. as a rule, increased in size to a moderate extent only, and is some- what indurated, Avhile macroscopically it is seen to be deeply pigmented. The changes presented by the kidneys differ in no essential manner from those of the liver. The microscopic appearances of the liver, spleen, and kidneys, apart from the fact that the amount of pigment present is relatively greater, are entirely analogous to those met Avith Avhen a fresh infection occurs. Clinical Varieties.—Three varieties merit description : (a) Congestive Chills (Algid Form).—These are accompanied by raging gastro-intestinal symptoms (vomiting, purging, etc.), inducing systemic collapse, which simulates to a nicety the algid stage of cholera. The temperature of the interior of the body is much elevated. True dysenteric symptoms may arise, and in a certain proportion of the cases jaundice, followed by grave nervous symptoms, may be a secondary development. This condition is to be discriminated from yellow fever, with which it has frequently been confounded. The parasites in this affection center in a special manner in the gastro-intestinal mucosa, in the vessels of which they may be seen in unusual numbers, sometimes 88 INFECTIOUS DISEASES. forming distinct thrombi. In the United States this is the most com- mon among the pernicious forms. (b) Hematuric Pernicious Malaria.—In this form the chill is severe and prolonged, and during the hot stage the urine is bloody and scanty, containing considerable albumin, with bloody epithelial and granular casts. Hemorrhages from other outlets of the body (mouth, rectum, vagina, nares, etc.) may also occur, together Avith larger and smaller cutaneous ecchymoses, and the yellowish-brown malarial complexion is intensified. The mind may remain clear throughout, although the patient is restless and anxious. Urinary suppression may ensue, and uremic toxemia be superadded; the greatest dangers being cardiac fail- ure, uremia, and delirium (or coma independently of the latter). Death is rarely the direct consequence of excessive loss of blood. (c) Comatose Form.—The chill may be absent. Grave cerebral symptoms, as acute delirium or sudden coma, seize the patient violently. The hot stage is attended with high fever, and if the patient survives the paroxysm, the violent nervous symptoms either disappear suddenly Avith the appearance of the sweating stage, or may outlast the latter by several hours. Primary paroxysms rarely prove fatal, but recurrences bring imminent danger. This dangerous variety is due to an inordinate localization of the malarial parasites in the brain, where they form com- plete thrombi, and induce, as a consequence, pathologic lesions in the adjacent structures. (III.) Remittent or Continued Malarial Fevers (Bstivo- autumnal Fever).—On account of the intensity of the gastro-intes- tinal symptoms this variety is also termed bilious remittent fever. Its severity exceeds that of intermittent malarial fever. It prevails for the great part in Avarm and truly tropical climates, though it is also seen in its milder forms in temperate climates. The estivo-autumnal parasites previously described are the specific cause of the disease. Pathology.—Melanosis of the spleen, liver, and brain is generally observed; on the other hand, in rare instances in which the specific parasite had even been demonstrated during life, the internal organs Avere found to be non-pigmented on autopsy. The degree of the pig- mentation depends upon the length of time that the patient has been infected, as Avell as upon the frequency of reinfection. The spleen, if it be a fresh infection, becomes swollen, but is soft; in protracted cases it become permanently enlarged and firm. On microscopic examination the pigment is seen to be most abundant in the splenic pulp and within and around the splenic veins. The liver is enlarged in like manner. The pigment that is found in the form of granular masses in all the hepatic tissue elements (especially Kupffer's cells, vessels, vessel-walls, and perivascular tissue) gives to the organ a bronzed appearance ("bronze liver "). As in pernicious malaria, so in this affection, the brain, and particu- larly the gray matter, is in long-standing cases of a dark broAvn or almost black color. Here, again, most of the pigment is in and around the arterioles. The latter are often found stuffed Avith phagocytes and blood-disks which contain pigmented parasites. Punctate hemorrhages may occur in the brain. < )ther organs and tissues of the body, includ- ing the lymphatic glands and the skin, become more or less deeply pig- MALARIAL FEVER. 89 mented. The blood shoAvs marked hydremia, with partly or wholly de- generated red blood-disks in abundance. Symptoms.—There may be prodromal symptoms, such as headache, anorexia, and epigastric oppression, lasting a day or tAvo, but these signs are variable. There may be daily or bi-daily paroxysms of fever which resemble the ordinary quotidian and tertian intermittent forms, with this difference, hoAvever, that the febrile paroxysms are of longer duration (tAventy hours or more). Both the rise at the onset and the decline at the end of the paroxysm are more gradual than in true intermittent malarial fever, and the initial chill may even be Avholly absent. The febrile attacks are often "anticipating," so that it may happen that the succeeding paroxysm Avill begin before the elevated temperature of the preceding touches the normal level, giving rise to a remittent type of fever Avhich often exhibits considerable irregularity. The remissions may become shorter and shorter, producing finally a continued type of curve—continued malarial fever. In typical cases of remittent fever a chill generally occurs at the on- set, but is less severe than in malarial intermittents. Shortly after the chill the temperature rises rapidly, so that in ten or twelve hours it may reach 104° or 105° F. (40.5° C). The pulse is full and accelerated to 100 or 120, and there is rending headache. Nausea and vomiting are common; oppression in the epigastrium is intense, and there is well- marked tenderness in the latter region. The spleen is found to be en- larged on palpation. Nervous symptoms (delirium, coma, etc.) may develop speedily, and rarely a mild bronchitis may also arise. About midnight the remission in the temperature and sweating begin, in consequence of AVThich the headache and gastric symptoms largely disappear. The temperature usually drops to 100° F. (37.7° C.) by the next morning, to be folloAved by a new exacerbation of fever, wThich commences about noon of the second day. The same symptoms noAv repeat themselves. The affection has usually, by this time, reached its acme, and the temperature may have risen to 106° F. (41.1° C). Grave nervous symptoms may also have appeared. The urine is greatly diminished in amount or even suppressed; it is often slightly albumin- ous, sometimes even bloody, while either a slight hematogenous (?) or marked hepatogenous jaundice may appear. Herpes labialis is quite common. The nocturnal remission again ensues, and in the mild types or in those brought promptly under suitable treatment the febrile parox- ysms groAV briefer until the remittent is merged into an intermittent form of fever. The course of light cases is run, usually, within tAvo Aveeks. In severe types or in neglected cases the separate febrile paroxysms groAv longer until the remissions become slight and simulate continued fevers. These are the cases that are distinguished by the same symp- toms as those that mark typhoid fever, save the eruption Avhich is pecu- liar to the latter. The discovery of Laveran is of the highest practical value in this category of cases. The course of the attack, if not prop- erly treated, generally prolongs itself to three, four, or more Aveeks, and under these circumstances the salient features of pernicious intermittent may suddenly appear and the disease may terminate life. On the other hand, mild forms, in Avhich the fever is of the continued type, also occur, and these yield promptly to the specific—quinin. 90 INFECTIOUS DISEASES. (TV.) Malarial Cachexia.—This is an exceedingly chronic condi- tion, and is usually a remnant of one of the acute forms, particularly of the ordinary intermittents. When the latter are not properly treated, they are apt to drag on, and finally assume the characteristic features of chronic malarial cachexia. The condition may, hoAvever, develop in truly malarial localities without the intervention of primary acute mala- ria. It originates, however, only in truly malarial districts. The symptoms are varied both in character and in intensity. There is fever at intervals, but chills do not occur, and the temperature-curve is typical neither of remittent nor intermittent fever, but may approxi- mate either the one or the other. Again, the fever is sometimes Avholly irregular, though its range is not high, and it seldom excels 103° F. (39.4° C). The skin often presents the dirty yellowish-brown com- plexion to a marked degree. The spleen is enormously enlarged and indurated, and hypertrophy Avith hardening of the liver may also be pronounced. The blood is profoundly anemic, the count in one of my OAvn cases shoAving but 1,300,000 red corpuscles per cubic millimeter. Many of the local and general symptoms that remain to be given (including, in part, the fever) are chiefly dependent upon the well- marked anemia. Among general features may be mentioned debility, frequent SAveatings, and dropsy. Nervous symptoms may also be notice- able, and chief among these are tremors, neuralgia, palsies, vertigo, Avakefulness, and nervous palpitation of the heart. Among the rarest concomitants of this condition is paraplegia. Slight cough and dys- pnea evidence the presence of mild bronchitis; and anorexia, nausea, diarrhea, and other symptoms mark the presence of chronic gastro- intestinal catarrh. The joints and voluntary muscles may be painful. Hemorrhages from the various mucous surfaces and into the retina are common; and I have seen one case in which spongy, easily-bleeding gums, Avith cutaneous ecchymoses and numerous petechia, pointed to the existence of associated scorbutus. Tuberculosis finally developed and carried off the patient. Not only the latter affection, but also chronic dysentery, chronic Bright's disease, and amyloid disease, may develop and prove serious complications. These cases do well, gener- ally, if the patient can be removed permanently from the malarial district and if proper treatment be persistently pursued. In long- standing cases the spleen does not return to its natural dimensions. In all other instances, however, complete recovery may be expected, though it may require months or even years to bring it about. (V.) Masked Intermittent.—This presents itself in much the same forms as chronic malarial cachexia, but with the important difference that there is no fever. This type comprises a long list of conditions, at the head of which stands neuralgia, most frequently involving the supraor- bital branch of the trigeminus. Often a striking periodicity is observed, the painful paroxysms usually beginning in the morning and terminating in the late afternoon hours, the patient's sufferings increasing steadily in intensity until just before the close of the attack, when they sud- denly abate. Among other nerves implicated with relative frequency are the occipital, the intercostals, and the sciatic. Except the blood- appearances be characteristic or unless the attacks yield promptly to quinin, a certain diagnosis of malarial neuralgia should not be ventured MALARIAL FEVER. 91 Masked intermittents may assume the forms of paresthesia, anesthesia, convulsions, or paralysis; non-febrile intermittent malaria may also appear under the guise of edema, hemorrhages from the various mucous outlets of the body or into the skin, intestinal flux (diarrhea, dysentery), dyspepsia, etc. But, since these affections may all obey the laAv of periodicity, caution should be used in pronouncing in favor of malarial infection. Indeed, unless they yield readily to the therapeutic specific, a positive statement had better be Avithheld. (VI.) Malarial Hematuria and Hemoglobinuria.—I have pre- viously described a hemorrhagic form of pernicious intermittent in many cases of which hematuria is a prominent symptom. Among other gen- eral features are jaundice, prostration, nervous symptoms, and nephritis (Plehn). The blood shoAvs non-pigmented parasites (forming rosettes) and sometimes crescents and pigmented leukocytes. Boissonx in 3 cases of hemoglobinuric fever, occurring in soldiers attacked with malaria in Madagascar, found an enormous reduction in the red corpuscles, reaching 670,000 in 1 case, Avhile 7 out of 10 red cells contained parasites. I have observed several instances of malarial hematuria in the Kensington district of Philadelphia, and find that they are met with Avherever the moderate forms of malaria prevail. The symptoms consist of a mild cold stage, a subfebrile temperature to wrhich is added hematuria, or more often hemoglobinuria. The par- oxysms may recur daily, bi-daily, or at longer intervals, and in severe forms the hemoglobinuria may be continuous, Avith aggravations at def- inite intervals. The diagnosis demands the demonstration of the ma- larial parasites in the blood, and of the hemoglobin in the urine. Tyson recommends Teichmanns (hemin crystals) test to shoAV the presence of hemoglobin. The earthy phosphates are precipitated, filtered out, and a small portion placed on a glass slide and carefully Avarmed until com- pletely dry. A minute granule of common salt is carried on the point of a knife to the dried mass and thoroughly mixed with it. Any excess of salt is then removed, the mixture is covered with a thin glass cover, a hair interposed, and a drop or two of glacial acetic acid allowed to pass under. The slide is then carefully Avarmed until bubbles begin to make their appearance. After cooling, hemin crystals can be seen by the aid of the microscope, and, though often very small and incompletely crystal- lized, are easily recognizable by an amplification of 300 diameters. Chemically they are hydrochlorate of hematin. Complications.—The author's analysis of 1780 cases of malaria showed complications in about 10 per cent. The more common among these Avere not particularly grave in nature, as may be seen by a glance at the subjoined list, in which they are placed in the order of frequency of occurrence: Enteritis (16), nephritis (14), rheumatism (10), typhoid fever (8), lobar pneumonia (5), jaundice (5), and dysentery (4). The opinion of the profession is, and long has been, divided upon the ques- tion, "Has pneumonia any special connection with malaria?" but, ac- cording to the results of my OAvn collective investigations, lobar pneu- monia cannot be regarded as being frequently in association Avith the latter disease. That it is so rarely, however, cannot be denied, since the diagnosis in two of the cases was confirmed by autopsy. 1Rev. de Med., May 10, 1896. 92 INFECTIOUS DISEASES. Typhoid fever is a complication of malaria, according to these re- searches, but the relationship betAveen these two leading affections can- not be close. Diagnosis.—(1) Of Intermittents.—This is quite difficult, unless the brief febrile paroxysms, Avith their characteristic stages and other more or less diagnostic features (enlarged spleen, malarial complexion, and herpes), together Avith the rigid periodicity of the paroxysms, be present. The diagnosis is assisted by a knowledge of the fact that the patient resides in a malarial district. In cases in Avhich a microscopic examination of the blood cannot be made early a positive diagnosis is rarely possible until after the patient has been observed long enough to ascertain the manner in Avhich the paroxysms recur, in addition to noting the symptoms presented. The only unquestionable method of diagnosis is by means of a microscopic examination of the blood, Avhich -will shoAV the tertian or quartan parasite (vide infra). Differential Diagnosis.—Non-malarial affections, exhibiting an inter- mittent form of fever, are often mistaken for malarial intermittents. Of these (a) pyemia is very apt to be thus confounded, owing to the fact that it may present a similar temperature-range. It will be observed, hoAvever, that the chills recur at more irregular intervals, and in this disease the more profound prostration and other general features during the intervals between the febrile exacerbations serve to distinguish it from intermittent malarial fevers. The etiologic factors and place of residence are also to be considered. In doubtful instances every effort should be made to examine the blood microscopically, and, if this be im- possible, the therapeutic test will, as a rule, remove the doubt. Leu- kocytosis is common in pyemia and absent in malaria. (b) Acute tuberculosis and, more rarely, incipient chronic tuberculosis may present a febrile movement in no Avay differing from quotidian intermittent, except that in the former the pyrexia develops in the after- noon, instead of the forenoon, as in the latter. A clear history, the associated local and general symptoms, along with the results of a care- ful physical examination, usually render tuberculosis probable and dis- tinguish it from malarial intermittents. Leukocytosis is common in tuberculosis and is absent in malaria, Avhile in tuberculosis the chills recur despite the use of quinin, and this is not the case in malaria. (c) Ulcerative endocarditis may exhibit an intermittent pyrexia, but in this affection the history is different, and the associated clinical fea- tures are more numerous and, as a rule, decidedly more grave. In en- deavoring to eliminate a disease of so serious a character as ulcerative endocarditis, when the symptoms are strongly suspicious of the latter a blood-examination should be made Avithout delay. The irregular forms of intermittents are difficult in the extreme to diagnosticate. If, in sus- pected cases of " erratic " malaria, quinin is resisted, we cannot feel cer- tain of our diagnosis unless we obtain the microscopic evidence of the presence of the malarial parasite in the blood. (2) The diagnosis of remittent fever would be easily made if it did not sometimes bear a strong resemblance to typhoid fever. On account of this fact its certain diagnosis demands the detection in the blood of the estivo-autumnal parasite. This, at first, is a small hyaline, motile body with little pigment, but in cases lasting a week or more assumes the oval MALARIAL FEVER. 93 or crescentic shape Avith much pigment. In typhoid fever the history points to a more gradual onset, the remissions are less marked, and there is not the epigastric oppression witnessed in remittent fever. Again, typhoid has its characteristic eruption. Remittent fever must not be confounded Avith typho-malaria, nor with continued thermic fever (Guiteras). The folloAving Avill be found a ready and efficient method of examining the blood: The finger or lobe of the ear should be carefully cleansed, and then slightly cut with a sharp lancet. The first drop of blood should be Aviped aAvay and the second collected on the center of a clean cover-glass, Avhich is immediately placed upon a clean slide and the blood alloAved to spread in a thin film. The examination should be made Avith an oil-immersion objective. If desirable to preserve the specimen or if impossible to make the micro- scopic examination at once, smears should be prepared by laying another cover upon the first, allowing the blood to spread in a thin layer, and then sliding them apart quickly and drying in the air. The specimen may then be fixed in a mixture of equal parts of alcohol and ether by heat or one of the other usual methods. The most satisfactory stain is methylene blue. A few drops of a Avatery solution should be placed upon the cover-glass, allowed to remain about a minute, and Avashed off with clean water. The specimen can be examined in water or dried and mounted in Canada balsam. The organisms appear as small blue bodies, often containing pigment. Eosin may be used as a counter-stain. For the crescent and oval forms, wThich are sometimes difficult to find, it may be advantageous to alloAv a drop of blood to dry upon the cover-glass without spreading, fix as before, and then Avash with dilute acetic acid; wash thoroughly with water and stain as before. The red cells are dis- solved, and only the white cells and the parasites remain upon the slide. Prognosis.—All cases of uncomplicated intermittent fever under prompt and proper treatment will probably recover, though fatalities sometimes occur. It is to be borne distinctly in mind that in certain malarious regions and in certain seasons pernicious types are prevalent, but, since these arise only after one or more preceding mild attacks, they are preventable. Primary pernicious attacks are moderately dan- gerous, while recurrences are highly so. The mortality-rate in this variety of malaria is between 20 and 25 per cent., and simple intermit- tent fever may, if not checked, suddenly develop into the most malig- nant type and result fatally. In remittent fever a fatal issue may be due to asthenia, particularly when the type is severe and when, following the typhoid state, wrong notions as to treatment prevail. The severity of the infection may be estimated by appreciating the degree of fever and the severity of the nervous symptoms. Suppression of urine, followed by uremic Symp- toms, hemorrhages, and intense jaundice, are the chief untoward com- plications. Treatment.—1. For intermittent malarial fever there is an almost infallible remedy in quinin. "When shall its use be commenced?" is a pertinent question. It Avould certainly seem highly desirable to check the course of the disease as soon as possible, and especially since trans- mission of the simple intermittents into the pernicious forms may occur if the disease be not arrested. At the present day specific treatment is 94 INFECTIOUS DISEASES. often delayed in order to give full opportunity for making a blood-ex- amination with a view to completing the diagnosis. There is no decided advantage in commencing the use of quinin during the first paroxysm, Avhen the blood may be examined; but on finding the case to be one of malaria, quinin should be administered after the paroxysm, so as to pre- vent a recurrence. For like reason, if the history at the physician's first visit, combined Avith the symptoms presented, make the diagnosis of intermittent malaria reasonably certain, and there is no opportunity to examine the blood microscopically, the principal antiperiodic remedy should be commenced at the close of the paroxysm, especially if the patient be living in an infected district. The quinin cures malaria by acting directly upon the intracorpuscu- lar hematozoa. During the paroxysm we should aim to make the patient comfortable. He is to remain in bed, is to be well covered, and external heat applied during the cold stage; and he is to be lightly covered, given cooling drinks and cold spongings during the hot stage. During the apyrexial intervals the patient may leave his bed, pro- vided that he feel strong enough, and, as before intimated, the specific remedy is given during the afebrile period. Certain authors recommend that the entire daily quantity be given at one dose from four to six hours before the succeeding paroxysm is expected, the object being to surcharge the blood at the time when the hematozoa sporulate. Others give the remedy in divided portions, administering the last dose from four to six hours before the next paroxysm is due. It may matter little which of these tAvo methods is pursued, yet my own experience leads me to favor the divided doses rather than the single large ones. The total amount per day required to cut short the intermittents is from 16 to 20 grains (1.036 to 1.296) in most temperate climates. When this fails more may be given—24 to 30 grains (1.555—1.944). My OAvn prac- tice has been to administer immediately after the close of the SAveating stage gr. iv or v (0.259 or 0.324), repeating the same dose a few hours later, and the remaining 8 or 10 grains (0.518 or 0.648) (or one-half the daily dose) six hours before the time for the next paroxysm. I have thus escaped the slight toxic symptoms (tinnitus, deafness, nausea, etc.) Avhich are apt to follow single large doses. The remedy is best given in capsules, followed by a few drops of dilute hydrochloric acid, with a vieAv to dissolving the quinin in the stomach. After the attacks cease to recur quinin should be continued in amounts of 6 to 8 grains (0.388 to 0.518) daily for several days. If quinin cannot be taken per oram, it may be tried by enema or by suppositories in appropriately large doses. Rectal irritability may thus be produced, yet in very young subjects, Avho cannot be induced to swallow capsules, I have for a long time administered quinin by suppository. The physiologic effects of the drug can be quickly obtained by administering it hypodermically. Hence, if there be no time for ab- sorption from the stomach (four hours being the shortest period it is safe to allow), the drug should be thus employed. For this purpose the more soluble salts (hydrobromate, etc.) of quinin are to be preferred to the ordinary and more insoluble sulphate, Avhich requires the addition of a mineral acid. MALARIAL FEVER. 95 Many preparations of cinchona other than the salts of quinin may be tried, and among these cinchonin administered in the same manner as the latter is the best substitute. Some contend that the sulphate of quinidin has antiperiodic power, almost equal to quinin. In prolonged cases the salts of quinin and other preparations of cinchona sometimes lose their specific influence, and arsenic is then to be employed, either alone or in combination Avith the former agents. The dose of the arsenic, beginning Avith TTLiv (0.266) t. i. d. of Fowler's solution, must be slowly increased until its full physiologic effects are produced. Arsenious acid often does better service than FoAvler's solution, although it has to be administered in augmenting doses to the amount finally of gr. \ (0.0162) daily. So soon as the disease is controlled the dose of arsenic is to be greatly reduced, but the drug is not to be altogether AvithdraAvn for several days. Administered as above indicated, this rem- edy is most efficacious in malarial cachexia and masked forms of inter- mittents, and should in the latter conditions be combined with iron and quinin. While in charge of the out-patient service of the Episcopal Hospital, Philadelphia, I employed in chronic malarial cachexia, Avith very satisfactory results, the sulphate of cinchonidin in daily doses of gr. xxx—xl (1.944-2.592). In this class of cases Warburg's tincture (3ss (16.0) three times a day) has been warmly recommended. 2. The Treatment of Pernicious Intermittents.—(a) Prophylaxis.—By treating all ordinary intermittents actively after the first paroxysms the occurrence of pernicious forms can be obviated. Not to pursue this course in seasons and in localities in Avhich these serious types are known to prevail, but to delay for second and third paroxysms in order to be able to study the blood, is criminal. (b) The first pernicious attack must be treated immediately, and there is not a moment to be lost. Hence in all varieties of pernicious inter- mittents quinin should be administered hypodermically until the patient is fully cinchonized—a condition that must then be maintained for sev- eral days. In all varieties stimulants are to be used freely if the heart's action becomes feeble, and the patient is to be well nourished through- out. There are other details, though of relatively minor importance, and they vary Avith the individual forms. Thus in "congestive chills " external warmth is useful, and morphin combined with atropin should be given hypodermically, this combination tending to allay gastro-intes- tinal symptoms as well as to warm the extremities, and meeting really important indications. Rectal feeding must be resorted to should the stomach refuse to retain nourishment. In the comatose form the ner- vous symptoms are most successfully combated by prompt and energetic antiperiodic treatment, together Avith vigorous stimulation and feeding, since they are not due to cerebral congestion, but to the intensity of the infectious process. (c) During the apyrexial period every effort must be made to prevent a recurrence of the paroxysm, and to this end the patient must be kept fully cinchonized until the time for the next paroxysm is over, and then be removed from the malarial to a non-malarial district. 3. Treatment of Remittent Fever.—The mode of treatment in this form differs somewhat from that appropriate for intermittents. At the onset a mild mercurial is advantageous (calomel gr. \ (0.0162) every hour for 96 INFECTIOUS DISEASES. three doses), followed by a saline laxative (Rochelle salts, 3ij ; 8.0). During the febrile exacerbations cool spongings of the body, together Avith the use of the ice-cap, are serviceable. The gastric symptoms demand chipped ice by the mouth or small doses of cocain, and a mus- tard plaster externally. Immediately after the first remission sets in quinin must be exhibited, and large doses are now indicated (gr. xv (0.972), to be repeated at 8 or 9 A. m.). A third and even a fourth dose of the same size may be required. The exacerbations of fever gener- ally yield to this remedy, but if, as rarely happens, they do not, then small doses of pilocarpin (gr. \ to \ ; 0.008 to 0.010) may be adminis- tered hypodermically during the height of the fever. This causes free SAveating in many instances, and in consequence renders the remission more marked and more prolonged; thus, in short, rendering the course of the affection speedily favorable. The heart, hoAvever, must be care- fully guarded Avhen this depressing agent is prescribed. A case that has been allowed to run on for one, two, or more Aveeks is often greatly benefited by the use of AVarburg's tincture, as before recommended, for several days, when quinin may be re-employed. The patient, especially if the case be protracted, must be vigorously fed, and per rectum if it cannot be accomplished by the mouth. In typical cases, Avhich are promptly controlled by quinin, stimulants are rarely needed, or at least not until the convalescent stage is arrived at. In severe and neglected cases the indications for their employment may be presented early, and they should then be given, the physician con- forming to the same rules as in typhoid and other acute infectious dis- eases. The renal congestion and anuria are to be met by internal dia- phoretics (pilocarpin, etc.) and by saline laxatives. Most efficacious, perhaps, is a combined hot-water and steam bath. The patient is placed in hot water, and then a blanket is put around the neck, its free ends being allowed to extend over the edges of the tub. This may be re- peated, if necessary. 4. Treatment of Malarial Hematuria.—The treatment of hematuria as a symptom of grave types has been embraced in the treatment of hem- orrhagic pernicious malaria. The use of quinin in moderate doses (gr. xvj—1.036—daily) successfully relieves the hemoglobinuria occurring in connection with mild forms of malaria, and its subsequent use in smaller doses (gr. iij (0.194) to gr. vj (0.388) daily) will prevent a recurrence. It is claimed by some Avriters that quinin may produce hematuria (Plehn, Richardson, and others), and also that this remedy is of no value in combating this symptom. The specific remedy should not be abandoned, however, and large quantities, such as might act as an irritant to the renal tissues, are not necessary to effect a cure, except in pernicious forms. DYSENTERY. Definition.—An infectious inflammatory disease of the large intes- tine, characterized anatomically by ulceration of the intestinal mucosa and clinically by frequent mucous and bloody discharges, tenesmus DYSENTERY. 97 fever and prostration becoming profound, a tendency to abscess-forma- tion in the portal system, to paralysis, and, finally, to pronounced anemia. It is a truly epidemic disease, yet it also occurs constantly in endemic form, and particularly does this occur in temperate climates. Historic Note.—Few diseases have been longer known than dys- entery, of Avhich we have a description by Hippocrates. Galen local- ized the chief seat of the affection in the colon, and in 1626, Sennertus defined its sporadic and epidemic character and some of its leading clini- cal features. To Morgagni belongs the credit of having made the first postmortem anatomic study of the disease. Further and more accu- rate pathologic contributions were made in the earlier part of the present century by Cruveilhier and Rokitansky, and, more recently still, the whole subject of the morbid anatomy of this disease has been care- fully investigated by Virchow, whose results have settled most of the questions connected Avith the subject. In the United States dysentery has prevailed epidemically upAvard of a century, the time of greatest prevalence in different districts having been about the middle part of the present century (1847-55). WoodAvard has given us the only com- plete record of the various outbreaks in this country, and an account of the ravages of dysentery in both armies during the War of the Rebellion is given in his Report, Avhich records 259,071 cases of acute and 28,451 of chronic dysentery. The disease is far less frequent than formerly, owing to the advance made in recent times in sanitary science, in con- sequence of Avhich some of the predisposing conditions have been over- come. Htiology.—As stated below, there are three distinct clinical types of the affection, each of Avhich has special etiologic factors. A few general etiologic considerations, having reference to the different forms in common, may be adduced here, and, as each variety presents different anatomic lesions in leading particulars, their pathology will be con- sidered separately. Among disposing factors, season heads the list, dysentery being most common in the summer and autumn; great and sudden changes of tem- perature are more potent than equal changes in humidity. Climate has a marked effect, and high temperature must be regarded as a pow- erful agency, since the disease is much more prevalent in warm than in cold climates, though it is met with in epidemic form as far north as Norway. Malarial districts suffer more than non-malarial. This may be due to the fact than an attack of malaria may leave the body of the sufferer more receptive to the specific poison of dysentery, or the ex- ternal conditions which favor the development of the plasmodia may also favor the growth of the dysenteric poison. The latter view gains some support from the well-known fact that water taken from stagnant pools in marshy localities (in which malaria is apt to prevail) may give rise to the symptoms of dysentery. Unhygienic conditions, as shown by the local epidemic outbreaks in jails, barracks, institutions, etc., predis- pose to the affection. Among factors connected with the individual are (a) catarrhal con- ditions of the intestinal tract, particularly if the latter be caused by unripe fruit or other unwholesome forms of food; (b) Age. Although no age enjoys immunity against dysentery, most cases are met with in 7 98 INFECTIO US DISE. 1SES adults under thirty-five years. Sex and race are probably Avithout appreciable influence. Catarrhal Dysentery. Pathology.—There are tAvo forms: (a) In this the solitary follicles are affected chiefly, and are the seat of hyperplasia, folloAved by necro- sis, Avith the formation of small ulcers. This is common in children. (b) Here a purulent inflammation of the entire mucosa, Avith more or less erosion of the surface and superficial ulceration, exists. In both forms the lesions are mainly confined to the large intestine, though the ileum is sometimes implicated to a lesser extent. Special Etiology.—The specific bacillus of catarrhal dysentery is not knoAvn to a certainty. It is probable, hoAvever, that it will be shown to be the bacillus coli communis, Avhich may become pathogenic Avhen the state of the mucous membrane of the boAvel is altered by sudden changes of temperature, etc. (Arnaud, Maurel). Clinical History.—There may be prodromes, lasting one or two days,. Avhich take the form of a mild gastro-intestinal disorder (anorexia, slight pains in the abdomen, folloAved by diarrhea). The characteristic symptoms are mild colicky pains in the abdomen, followed by discharges from the boAvel, which at first number from three to six daily. Soon they become frequent and are accompanied by straining and tenesmus, and noAV their number ranges from ten to no less than one hundred or more per day. Indeed, the desire to go to stool may be almost constant, and the rectum is the seat of intense burning sensations during and after each evacuation of the boAvel. The character of the discharges varies Avith the different periods of the affec- tion. During the first thirty-six or forty-eight hours they are feculent (sometimes scybalous masses), rather copious, and intermingled Avith some mucus and blood. For the next four or five days the stools are scanty, measuring from 2 drams (8.0) to \ ounce (16.0), and are made up of a sero-mucous fluid or of a muco-purulent material with blood. The chief constituents of the stools are mucus, blood, and pus, any one of which may preponderate, thus giving rise to mucous (most frequently), purulent, or bloody stools. Microscopic examination of the usually glairy stools shows red blood-corpuscles, numerous leukocytes, generally large, oval or round epithelioid cells containing fat-globules, vacuoles, and bacteria (espe- cially those of putrefaction). Occasionally the Cercomonas intestinalis is seen (Osier). A few shreds (portions of necrosed mucous membrane) may appear from time to time in the discharges, and particularly in severe forms of the affection. These usually increase in number at the close of the first week, and a little later the discharges become less frequent and the amount of mucus and blood diminishes. The stools are now of a greasy broAvn or dark-green appearance, fecal matter reappearing in them, and soon they are again fully formed. Other Symptoms Referable to the Alimentary Tract.—The tongue has a greasy coating—moist at first, dry later—and at last may become red and glazed. Anorexia is present, Avith excessive thirst, and vomit- DYSENTERY. 99 ing may rarely occur. A distressing though uncommon symptom is hiccough. There will usually be tenderness over the line of the colon, but there is an absence of tympanites, and the abdomen is apt to be flat and someAvhat tense. The general symptoms are Avell marked in the severer types. The patient is much debilitated, sometimes even collapsed, as shown by the small, frequent pulse, cool skin-surface, the rapid Avasting, and Aveak, hoarse voice. The temperature is not much elevated, though it may touch 103° or 104° F. (40° C.) at the outset, and the curve is an irregu- larly remittent one. Diagnosis.—This can easily be made upon the intestinal features and from the character of the stools—frequent, small, slimy (or bloody) discharges, accompanied by distressing tenesmus. Differential Diagnosis.—Symptoms simulating dysentery may appear in the course of certain rectal affections, such as strangulated hemor- rhoids, syphilis, and epithelioma. In these conditions, hoAvever, there is a different history and the symptoms of proctitis are usually less acute, Avhile a physical examination of the rectum will settle the diagnosis in doubtful cases. Prognosis.—The duration of mild cases is from eight to ten days, and in severe types from three to four weeks. The prognosis varies in different epidemics or according to the type of the affection; but com- monly this is not aggravated and recovery is generally to be expected. Occasionally, however, a dangerous condition arises. Besides the pro- found prostration and circulatory collapse above referred to, serious ner- vous symptoms (great restlessness, delirium folloAved by coma) may de- velop and cause a fatal termination. When death occurs it is usually due to exhaustion, and is seen particularly in persons previously enfee- bled or in the aged. Complications influencing the prognosis are excep- tional, though peritonitis and liver-abscess may rarely appear. Amebic Dysentery (Tropical Dysentery). Bacteriology.—This form of dysentery is caused by the amoeba coli or the amoeba dysenterice (Councilman and Lafleur). The amoeba dysenteriae is a unicellular, motile organism, in size 3 to 7 times the diameter of a red blood-corpuscle (15 to 30 micromillimeters). Its pro- toplasm consists of two zones—an outer colorless (ectosarc) and an inner granular zone (endosarc), with a visible nucleus and one or more vac- uoles. This micro-organism Avas first described by Lambl (1859), but it remained for Losch, and especially Kartulis, to show its close associa- tion Avith dysentery. It is noAv generally held to be the specific cause of tropical dysentery. The ameba (amoeba coli mitis) is occasionally found in healthy individuals, and also in other bowel-affections than dysentery (mucous enteritis, simple diarrhea, proctitis due to engorge- ment), and two species are recognized—a virulent and a benign form (Quincke and Roos). The ameba is found not only in the discharges, but also in the pus from the secondary liver-abscesses. Hehir has found the bacillus dysentericus associated Avith the amoeba coli, and considers it to be pathogenic. He describes it as a short, straight bacillus, usually of a length about equal to one-third the diameter of a 100 INFECTIO US DISEASES. red blood-corpuscle, Avith rounded ends, sometimes jointed, rarely curved. Later investigations, hoAvever, have not entirely confirmed the claims of this observer. The mode of transference of the ameba is not definitely known, though the chief source of the dysenteric germs is most probably the drinking-water. The poison is feebly communicable by contact. Amebic dysentery is not confined to the tropics, but is met Avith also, though less frequently, throughout Europe and North America. Pathology.—The lesions are almost ahvays situated in the large intestine, though rarely the ileum may be invaded. The first visible change is a hyperemia of the mucosa, most marked in the descending colon and rectum; but the changes Avhich produce the characteristic dysenteric ulcer begin with infiltration and SAvelling of the submucosa, followed by necrosis, which involves the overlying mucosa with its epi- thelium (Kruse and Pasquale). Hoav the amebse reach the submucosa has not yet been observed. The visible infiltration occurs usually in circumscribed areas which are oval or hemispheric in shape, and project above the level of the surrounding mucosa. The submucosa presents a grayish-yellow appearance, and is soon throAvn off in the form of a slough. The ulcers take various shapes—chiefly irregular, and less frequently round or oval. Their edges are ragged and undermined, and the floor, which is more or less covered with pultaceous material, is rough or crater-like, and formed by the muscularis or the outer serous coat of the intestine. From the manner in which the ulcers are formed it is obvious that cellular infiltration (followed by necrosis) may occupy the sub- mucosa for a greater or less distance beyond the borders of the ulcers. In this way fistulous channels may be produced beneath the mucosa and connect tAvo or more ulcers. Usually this ulcerative process affects only certain portions of the large gut, especially the flexures—hepatic and sigmoid—and the rectum; but it may be general, and I have seen one instance of this kind. Similar cases are not uncommon in which the ulcers are so numerous as to include almost the entire mucosa of the large intestine. Healing is attended with the development of fibrous tissue along the edges and in the base of the ulcer, and secondary contraction of this new connective tissue is often productive of colonic stricture, which is usually either partial or irregular. The cases that come to autopsy often show diphtheritic inflammation as a secondary or terminal condition. The microscope reveals proliferation of the fixed connective-tissue cells, and the presence of amebae in the Avails and the base of the ulcers, in the lymph-spaces, and rarely in the blood-vessels. Pus can only occasionally be detected. The liver may be the seat of prominent lesions. These are (a) ab- scesses, Avhich may be single or multiple, the latter being small, and the former often large. The single or solitary abscess is "usually situated near either the upper convex or the lower concave surface, while the ab- scess-cavity is formed in a manner similar to the intestinal ulcers. The area affected is at first infiltrated; it then becomes necrotic, and finally more or less liquefied. Upon the full development of the first stage the part invaded is a grayish-yellow pultaceous mass, but in the second or DYSENTERY. 101 necrotic stage the abscess contains a yelloAvish or greenish-yellow, spongy material with beginning liquefaction. The contents of the mature abscess consist of a greenish- or reddish-yelloAV purulent material and of rem- nants of liver-tissue. The walls of the recent abscess are irregular and ragged, those of an old abscess being dense and fibrous, and a section of the abscess-wall shows an inner necrotic zone, a middle zone (in which there is great proliferation of the connective-tissue cells, compression and atrophy of the liver-cells), and an outer zone of intense hyperemia (Osier). The contents of the abscess show either few or many amebae, and only rarely pus. When pus is present it is due to a secondary infection by the pyogenic germs. In Avhat Avay the amebae gain access to the liver is not definitely known, but it is probable that in multiple abscesses they are propagated along the blood-current, either from the ulcers or from a single primary focus. Cultures are generally sterile. (b) The parenchyma of the liver may be the seat of numerous circum- scribed necrotic spots, Avhich are supposed to be due to the action of the chemical secretions of the amebae. The lungs sometimes show changes similar to those in the liver, which are the result of direct extension of the hepatic abscess through the diaphragm into the lower lobe of the right lung. Clinical History.—The mode of onset is variable except in a small proportion of the cases, in which it is sudden with well-marked symp- toms. When, as generally happens, it is insidious, the initial symptom is often a trivial diarrhea. The affection is then characterized chiefly by intermissions and more or less marked exacerbations of diarrhea, the liquid stools containing necrotic tissue of a grayish-broAvn and sometimes yellowish-gray color. The latter are often bloody and mucoid, particu- larly at the outset, and in fully developed cases are fluid. The number of discharges per day is exceedingly variable in different epidemics, and even in individual cases, though in most instances they range from six to eight or ten daily. Microscopic examination of the feces during the exacerbations dis- closes amebae that are almost invariably endowed with motion, though usually not Avhen the stools have become formed. Tenesmus is not a prominent feature in most cases, and may be entirely absent. Colicky abdominal pains are rare, and nausea and vomiting are equally so. General Symptoms.—The febrile movement is usually present, but it is slight and exhibits marked variations. In certain instances, hoAvever, the temperature is below the normal curve throughout the entire or greater part of the course. From the time of onset there is gradual though progressive loss of flesh and strength, and anemia usually be- comes well marked. Complications.—The most common is hepatic abscess, and second- ary to the latter may arise abscess of the right lung. Authors are not agreed as to the frequency of occurrence of liver-abscess1 in amebic dysentery, but it is certainly comparatively rare in this country, not exceeding, perhaps, 3 per cent, of the cases. Peritonitis may result from perforation of a dysenteric ulcer, causing death. The point of per- 1 For the diagnosis of this condition the reader is referred to the section on Hepatic Abscess in the article on Diseases of the Liver. 102 INFECTIOUS DISEASES. foration may, however, be in the rectum, Avhen periproctitis is the result; or it may be in the cecum, Avhen perityphlitis is the sequel. In tropical or subtropical countries the disease is often complicated Avith malarial affections, and in malarial regions intermittent and remittent fevers are among the commoner complications. The presence of an intermittent fever is not, hoAvever, sufficient to Avarrant the assumption that malaria complicates dysentery; and in order to show the latter combination Ave must be able to demonstrate the presence of the plasmodium malarias. In pyemia and in suppurative processes generally—conditions sometimes met Avith in dysentery—the temperature-curve is often distinctly inter- mittent. Typhoid fever is a rare complication. The latter disease can- not be said to coexist with dysentery unless all of the characteristic symptoms are present. Certain cases of dysentery are characterized by the development of the typhoid state, and pyemia and septico-pyemia may appear late. Among special manifestations of the latter are pyle- phlebitis, pericarditis, endocarditis, pleuritis, and rheumatoid pains in the joints. Diagnosis.—The sIoav course, marked by intermissions and exacer- bations of bloody fluid stools, the mild general symptoms, apart from emaciation and debility, are characteristic features, but a positive recognition of the affection demands a microscopic examination of the stools. Cases have been recorded by Councilman and Lafleur in Avhich the diagnosis rested upon amebae being found in the sputa, the latter being complicated Avith pulmonary and hepatic abscesses Avhich discharged through a bronchus, Avhile the intestinal symptoms Avere negative. Prognosis.—The prognosis is graver than in the catarrhal va- riety, and the mortality-rate in certain epidemics has been frightful, particularly among soldiers in the field (amounting to 70 or even 80 per cent.). In sporadic cases the danger to life is less, the mortality-rate in temperate climates being not over 5 or 6 per cent. The complications Avhich render the prognosis unfavorable are various (peritonitis, hepatic and pulmonary abscess, pyemia secondary to the latter, broncho-pneu- monia, malaria, etc.); death may be due to hemorrhage or peritonitis, but in a preponderating proportion of the cases to asthenia. A dan- gerous degree of debility is indicated by great nervous depression; a cool, clammy skin; a sunken, pinched facies ; a dry tongue ; a feeble, rapid pulse ; and by restlessness, alternating Avith marked apathy or Ioav muttering delirium. Course and Duration.—The average duration ranges from eight to ten weeks in uncomplicated cases; the disease can, however, be cut short by appropriate treatment. It manifests an innate tendency to pursue a chronic course, interrupted by frequent exacerbations or true relapses, and convalescence occupies a long period of time in consequence of the marked anemia and debility Avhich ensue. Diphtheritic Dysentery. This is an intestinal inflammation (usually colonic), accompanied by a croupous, or true, diphtheritic exudation. Two clinical forms are recognized: DYSENTERY. 103 Primary Diphtheritic Dysentery. In mild grades of this rare affection a grayish-yelloAv, croupous exu- date appears upon the inflamed mucosa, with a necrosis of the epithelial layer that is often limited to the top surface of the folds of the colon. In other instances the diphtheritic infiltration involves all the layers of the boAvel, Avhich noAv becomes greatly enlarged, its mucous membrane being converted into a yelloAvish-broAvn, thick, elastic mass, sometimes extending along the entire length of the large intestine. The changes may be confined to the circumscribed areas, and thick sloughs may be cast off, leaving behind ulcers of corresponding size and depth. Again, these gross lesions may be limited to certain sections of the large bowel, as the rectum or the flexures of the colon. In protracted cases cylin- ders of pseudo-membrane of considerable length may become separated and evacuated Avith the stools. Clinical History.—The affection usually has an acute onset and one characterized by the appearance simultaneously of severe local and general symptoms. There may be an initial chill, and there is fever, Avhich rises rapidly, together Avith a marked and early appearing pros- tration and delirium. Severe abdominal pains are complained of, and the discharges are apt to be very numerous, containing shreds and large sloughs, or even tubular pieces, of false membrane. When these elements are present in the stools the latter are of a dark-broAvn color, emitting a fetid odor and generally containing more or less blood and mucus. Tenesmus may be present, and particularly Avhen the rectum is involved. The physical signs are often prominent. The belly in most instances is greatly distended, and on pressure very tender—signs due to the fact that the lesions are situated chiefly in the large boAvel, and not, as a rule, to peritonitis. The diagnosis rests upon the intestinal symptoms and the charac- ter of the dejections, associated Avith a grave general condition suddenly developed in a previously healthy individual. The prognosis is almost Avholly unfavorable. Occasionally recov- ery folloAvs, though more frequently the disease takes on a chronic course. Secondary Diphtheritic Dysentery. Here the lesions are similar in kind to those of the primary form, but in the majority of instances of a less intense grade. Rarely they may be both extensive and severe. This variety is met with as a ter- minal condition in not a few acute and chronic diseases; among the former it is Avith great relative frequency seen to develop in pneumonia (Bristowe), and less frequently, though in not rare instances, in typhoid fever, according to my own observation. Among chronic affections, upon Avhich this condition may become engrafted, are nephritis, organic disease of the heart, and pulmonary tuberculosis. Clinical History.—No characteristic symptoms attend upon its in- vasion. There may be slight diarrhea—tAvo to four liquid stools daily —but it is not often accompanied by tormina and tenesmus, and the discharges rarely contain any noticeable amount of blood or mucus. 104 INFECTIOUS DISEASES. Very rarely shreds of pseudo-membrane are passed Avith the stools. Secondary diphtheritic dysentery often induces fatal asthenia. The diagnosis is in most cases merely conjectural. Sequelae.—A relapse is most likely to occur, and each attack in- creases the liability of the patient to subsequent attacks. Moreover, in persons who have recovered from acute dysentery Ave often observe a disordered digestion and irritability of the bowels. Rarely, chronic nephritis folloAvs dysentery. The most interesting sequel, however, is paralysis, Avhich occurs mainly in the form of paraplegia (S. Weir Mitchell). Stricture of the bowel may be a sequel, but it is surpris- ingly rare. Treatment.—Prophylaxis.—This embraces isolation and a thorough disinfection of the discharges, which contain the specific germ of the disease, as soon as passed. The drinking-water during the epidemic prevalence of dysentery should be thoroughly boiled, and healthy per- sons should avoid the use of improper food, while unhygienic surround- ings (overcrowding, etc.) are to be corrected as far as possible. All sufferers from dysentery must be kept in bed, and should occupy a well- aired apartment. The diet should consist of milk and light animal broths during the period of active intestinal symptoms, and in the amebic form of the dis- ease it is well to allow easily digestible solids, as rawT oysters, eggs, well- boiled rice, foAvl, fish, etc., in small quantities. During convalescence a return to the usual dietary is gradually to be made. Stimulants.—With the development of asthenia and cardiac failure stimulants must be employed, as in other acute infectious diseases, and alcoholics may be supplemented by the use of strychnin in cases of extreme debility. Medicinal Treatment.—If scybalous masses be passing still, the treat- ment should be commenced by administering a dose of castor oil or a saline purge, and this may be repeated if necessary. It is Avell to con- vert dysentery into diarrhea, thus cleansing the bowel thoroughly, if the case be seen early. In the later stages purgatives are attended Avith baneful effects. Ipecacuanha has long been, and still is, regarded as possessing a specific influence in" cases of dysentery. Its administration is usually preceded by a dose of opium (laudanum or morphin) Avhich is given when the stomach has been empty for a few hours. Most authors rec- ommend that large doses—gr. xx to $j (1.29 to 4.0)—should be admin- istered ; but it is probable that a small dose—gr. | to l (0.010 to 0.016) every half hour—is quite as effective; and in children the smaller doses are to be preferred and will be found to be quite efficacious. Other remedies should also be employed, and among these opium is particularly beneficial in combination with ipecacuanha or in the form of Dover's powder, which contains both agencies. Three chief symptomatic indi- cations are met by the opium—pain, restlessness, and undue peristalsis —and to obtain the best effects from the opiate it should be adminis- tered in the form of morphin hypodermically. In cases in Avhich tenes- mus is an unusually distressing feature an opium suppository (gr. ii__ 0.1296) or laudanum (tTUxx—2.0, by enema) exercises a beneficial effect. Bismuth in full doses is useful (3ss-j—2.0-4.0 every tAvo hours) DYSENTERY. 105 and in cases of sporadic dysentery I have frequently found the follow- ing formula productive of happy effects: fy. Pulv. ipecac, et opii, 3ss (2.0); Bismuthi subnitrat., §ss (16.0); Salol, • 3ss(2.0). M. et ft. chart. No. xij. Sig. One every hour or tAvo. Among other intestinal antiseptics recommended in highest terms by some are naphthalin and mercuric chlorid. I am entirely con- vinced that the vigorous employment of supportive measures (appropri- ate food, alcoholics if necessary) is of far higher importance than the use of any knoAvn medicaments internally, since unfavorable cases tend naturally to asthenia and death, while favorable ones tend as certainly to recovery Avithout energetic medicinal treatment. Antiseptic irrigation of the boAvel Avould be, if properly carried out, a curative measure, since by this means Ave may destroy the amebae, and solutions of numerous antiseptic substances and astringents have been recommended for this purpose. Unfortunately, the bowel is frequently so irritable as to seriously interfere with this mode of medication. If, on this account, large injections cannot be given, small ones should be substituted and the quantity gradually increased. Preliminary to their use Ave may also employ cocain in the form of a suppository, or a small quantity of a solution of cocain (4 per cent.), or a laudanum enema (Hlxxx—2.0, in starch-water), after Avhich a large injection may be toler- ated if administered slowly and the flow be interrupted at short inter- vals. Among the best agents are silver nitrate (gr. ss-j—0.032- 0.064—ad 3j—32.0),- tannic acid (1 to 2 per cent.), salicylic acid (1 to 2 per cent.), and mercuric chlorid (1: 6000). I have for a number of years been in the habit of employing these astringents and antisep- tic solutions alternately, administering each once daily. The tannic- acid and the salicylic-acid solutions are best borne during the more active stages of the disease. The temperature of the Avater should, at first, range from 100-° to 110° F. (37.7°-43.3° C), and subsequently this may be slightly reduced. The patient during the administration of the enemata should assume the dorsal position or that upon the left side, but in either case Avith the hips Avell elevated, so as to aid the flow by gravitation. In amebic dysentery Avarm injections of quinin (strength 1:1000-1: 5000) have been used Avith good effects by some authors, but Avith directly contrary effects by others. Local means in the form of hot fomentations, light poultices, and turpentine stupes often afford much comfort. The various complications must be met by appropriate treatment, as under other circumstances. Chronic Dysentery. This form of the disease almost always succeeds an acute attack. Very rarely is it chronic from the start, and particularly if it be the amebic variety. Pathology.—In most instances the large intestine is still the seat of 106 INFECTIOUS DISEASES. ulceration. Some of the ulcers show no signs of healing ; in others this process is going on ; while in still others it is completed and puckered cicatrices are presented. The ulcers are deeply pigmented, as is the unulcerated mucosa, Avhich often presents a slate-gray or blackish color. The submucous and muscular coats are hypertrophied, as a rule, with occasional narroAving of the lumen of the bowel, and cystic degeneration of the intestinal glands is sometimes observed. It is to be noted that in a certain, though small, percentage of the cases ulceration does not occur, the mucosa everyAvhere presenting an uneven, puckered aspect, due to deposits of fibrous tissue. Symptoms and Diagnosis.—Many of the most characteristic fea- tures of the acute form are either but feebly expressed or altogether Avantino-. This is particularly true of the tormina and tenesmus. Cer- tain elements found in the stools of the acute type (blood, shreds of pseudo-membrane, and tissue) are also rarely present. True dysenteric symptoms, however, may arise during acute exacerbations and without pain or tenesmus ; then from three or four to a dozen or more fluid dejections are passed daily. The latter are often frothy (when starchy articles of food are taken), being composed chiefly of fecal matter and undigested particles of food, with considerable mucus; and in severe forms blood and pus may be constantly present in the discharges. In many cases the stools are semifluid (pultaceous), and rarely they contain scybala; or the rather frequent liquid or semifluid discharges may alter- nate with constipation. In such instances the lesions are apt to be situ- ated in the loAvest portion of the large intestine. The character of the discharges is much influenced by the sort of food taken; thus when a mixed dietary is partaken of, they are thin, more frequent, and contain more undigested masses of food. Gaseous distention of the intestines is often an annoying symptom. The physical signs are negative, save for slight tenderness along the line of the colon. Associated symptoms referable to other organs are not without value in the diagnosis. The gastric digestion is poor, the appetite generally impaired (though variable), and the tongue is clean, red, and glazed, presenting the appearance of raw beef. There are progressive emacia- tion and asthenia, which eventually reach an extreme degree. The skin- surface becomes dry, harsh, and cool, the facies grim, the pulse exceed- ingly feeble, the mental faculties greatly weakened in the advanced stage; and, as in the acute form so in the chronic, death is usually due to asthenia—with this difference, that in the latter the end is reached more slowly. Rarely peritonitis in consequence of perforation of the boAvel is the immediate cause of death. Differential Diagnosis,—The disease is discriminated from chronic diarrhea, often Avith great difficulty. In chronic dysentery there is the history of an antecedent acute attack, Avith the appearance from time to time of exacerbations, at Avhich periods mucus, pus, and often blood are contained in the discharges. The latter are, at the same time, more fre- quent and apt to be accompanied by more or less abdominal pain and tenesmus, and the presence of these features would serve to eliminate chronic diarrhea. From tuberculous ulceration of the intestines it is dis- tinguished by the absence of any history of tuberculosis, family or per- DYSENTERY. 107 sonal, and of tuberculous neAV groAvths in other portions of the body, particularly the lungs. The complications are the same as in acute dysentery, if we except the greater liability, due to the great and protracted weakness of the patient, to certain serious intervening diseases (chronic nephritis, tuber- culosis, pneumonia, etc.). Ulceration of the cornea has frequently been noted. The duration is long, the disease lasting for many months or even several years. Treatment.—This should be directed mainly to the local condition, and should consist in methodic irrigation of the bowel with a view to promoting the healing of the ulcers. Formerly it was sought to accom- plish the latter indication by the use of certain remedies internally, as silver nitrate, balsam of copaiba, bismuth subnitrate, etc., but the only preparation which I have found to be useful is the zinc oxid (gr. v-x— 0.324-0.648) three times daily. The latter preparation is markedly pal- liative, sometimes even curative. Intestinal irrigation is to be tried, and should be alternated with various disinfectants and astringent remedies, as advocated in the acute form. Among individual remedies the silver nitrate (gr. ss-ij—0.032- 0.129) every second day is doubtless the best. On intervening days antiseptic remedies may be used in solution, such as mercuric chlorid (1: 6000) or salicylic acid (1 to 2 per cent.); and of other useful agents I may mention tannic acid, alum, acetate of lead, creolin, and quinin sulphate. Prior to the use of any of the above-mentioned enemata the bowels should be Avell flushed with a large injection of tepid water, so as to remove the fecal and other irritating materials. The same details are to be observed in carrying out this mode of treatment as in the acute forms of dysentery. Gallay1 has related the curative effects of large enemata of a solution of crystallized silver nitrate in distilled water, a scruple to a quart (1.296 per liter), to which 20 or 30 drops of laudanum have been added. Amelioration follows the third or fourth Avashing, but a course of sixty is recommended to secure permanent relief. I agree with the late Austin Flint that the loAver part of the rectum should be examined Avith the speculum, and appropriate topical applications made if ulcers in this situation be discovered. The dietetic treatment in chronic dysentery is of the utmost import- ance, and the lightest forms of albuminous foods are to be adhered to strictly, to the exclusion of vegetable substances. Milk is excellent when it can be taken. It is well to examine the stools, and if on microscopic examination curds or numerous fat-globules appear, the amount of milk should be reduced or skim-milk substituted. Other forms of food that are allowable and useful are egg-white, meat-broths or beef-juice, Avhey, and the like. The patient should wear flannels next the skin, so as to protect against the vicissitudes of weather, and, while open-air exercise is useful, it should be moderate. During inclement weather the patient should remain in-doors. I have known change of climate, with proper regula- tion of the mode of living, to be productive of rather brilliant results. 1 "Radical Cure for Chronic Dysentery of Recurrent Type," British Med. Journal, No. 1779, p. 276. 108 INFECTIOUS DISEASES. Tonics and alcoholic stimulants are sometimes required to assist the appe- tite, digestion, and systemic strength, and among the most efficacious tonic remedies are iron, strychnin, mineral acids, and arsenic, Avhich may be used in succession. CHOLERA (EPIDEMIC). (Asiatic Cholera; Cholera Algida, etc.) Definition.—Cholera is an acute, infectious, epidemic disease. Its specific cause is the spirillum of Koch, and its most characteristic symp- toms are copious Avatery dejections, painful cramps, collapse, and suppres- sion of the excretions. In some localities it is endemic. Historic Note.—During the Middle Ages cholera made deplor- able ravages, chiefly along the belts of the Ganges, and has probably been endemic in India for centuries. Only during the present century, however, has the disease been widely known in Europe and America, and when it has appeared it has always been in the epidemic form. The march of epidemics has been from east to west, and alwrays along the lines of commerce and travel by land or sea, sometimes spreading over the en- tire globe. While interesting, it Avould not be profitable to the student to detail here the progress of the various epidemics of cholera in Europe and America. It will suffice to state the years in which the chief of these occurred: in 1831-32, in 1835-36, in 1847—49, being brought by immi- grant ships from Europe ; in 1852 in Europe (touching our shores in 1854 and prevailing extensively); in 1859 (Europe), in 1866-67 (mild out- breaks in America), in 1869—73 (America in 1873), in 1884 (in Europe), and in 1892-93 (abroad). It is seen that there have been no epidemic visitations in America since 1873, though a few small groups of cases have on several occasions been brought to our shores. Pathology.—The body is generally much emaciated, the features sharp and drawn, and the skin of the dependent parts presents a mottled appearance. A post-mortem rise of temperature often occurs. The tis- sues are dry, owing to the draining of the liquids of the body, and hence putrefaction is delayed. The kidneys, liver, and heart, as Avell as other organs in a less degree, show excessive cloudy swelling and often consid- erable fatty degeneration of the parenchymatous tissues. Rigor mortis comes on directly after death, is persistent, and the muscles often con- tract so as to cause the body to assume various uncommon positions. The Visceral Lesions.—The chief of these are confined to'the intestinal canal, and depend greatly upon the period of the disease at Avhich death occurs. In the early stage the serosa of the small bowel is congested, presenting a roseate hue. The muscularis is relaxed. The mucosa is the seat of catarrh, being deeply injected, swollen, at times edematous, and often coated in the early stage with more or less tough mucus. Shortly the coils of intestine are filled with an almost transparent or slightly tur- bid liquid ("rice water"), and, occasionally a small amount of clotted blood is seen in the bowel. The solitary follicles and Peyer's patches are at first swollen, and may later, in rare instances, become ulcerated. De- CHOLERA. 109 nudation of the epithelial lining—most probably a post-mortem change— is the rule, and large or small ecchymotic spots are visible in the intestinal mucosa. If the patient has died late in the disease (stage of reaction), patches of false membrane (diphtheritic), sometimes dark-brown in color and fetid, may be found anyAvhere along the intestinal canal, though chiefly in the large bowel; and this secondary croupous-diphtheritic pro- cess may attack other mucous surfaces (bile-ducts, vagina, etc.). The bacilli are observed in the mucous membrane of the intestine and in the dejections. The stomach shows changes similar in character to those found in the intestines. At first the mucosa is congested; then, as the result of trans- udation, it becomes filled Avith " rice-Avater " material. Soon the hyper- emic mucosa becomes swollen and ecchymoses appear. At last the organ is empty and collapsed. The esophagus also exhibits about the same changes, though with an absence of the characteristic transudation. The spleen, contrary to its condition in other infectious diseases, is small as a rule, though if death occur late it may show some degree of enlargement with softening. The liver presents marked passive hyperemia and cloudy SAvelling, with minute spots of beginning fatty change. Desquamation of the epithelium of the cystic mucosa may occur and lead to a blocking of the bile-ducts. The kidneys show important lesions, being enlarged from passive con- gestion, especially the cortex, and the capsule being somewhat adherent. They exhibit cloudy swelling and decided coagulation-necrosis. Desqua- mation of the epithelium in the uriniferous tubules is extensive. Micro- scopically, the histologic changes are those of acute nephritis in the cases in Avhich death takes place in the advanced stage. The bladder-changes differ in no way from those of other mucous mem- branes. Its mucosa is congested, ecchymotic, and sometimes the seat of diphtheritic deposit. The ureters and the pelves of the kidneys may also present identical appearances. The Circulatory System.—The pericardium is dry, the parietal layer being covered with an adhesive secretion, while the visceral layer is the seat of more or less ecchymosis. The heart is dry and anemic-looking. The left ventricle is contracted, while the right is often distended with blood and soft clots, the latter sometimes extending to the pulmonary artery and the superior and inferior vense cavse. Outside of the heart the veins, including the cerebral sinuses, contain most of the blood. The latter is thicker than normal, and its color darker, resembling " the juice of huckleberries;" its specific gravity, albumin, and corpuscles are all increased, while its saline constituents and coagulability are decreased. Respiratory Organs.—The larynx, trachea, and bronchi are hyperemic, and at first covered Avith tenacious mucus; later they may present ecchy- moses and diphtheritic processes. When death occurs before the stage of reaction the lungs are bloodless and collapsed, and the mouth of the pulmonary artery may be distended with blood. If life is prolonged until the third stage, the lungs may show congestion and edema (particularly at the bases) or pulmonary infarction. The post-mortem of a case in this stage, and especially during convales- cence, may exhibit the lesions of broncho- or lobar pneumonia. 110 IN FECI 10 US DISEA SES. >y I- fe< -^1 / The brain and its membranes may be the seat of hyperemia, except when death takes place at a late period, and then the brain-substance may be more or less bloodless and edematous. Etiology.—The causes are (a) specific and (b) predisposing. (a) The specific cause is the comma bacillus of Koch, which is found in the intestinal canal of persons ill of cholera. Recent investigations into the bacteriology of the affection show that almost uniformly the cholera spirillum is associated with certain bacteria, most commonly the bacillus coli communis. It has also been shown pretty clearly that true cholera is a nitrite-yoison'mg, the result of the growth of the specific spirillum. The comma spirillum is not found in any other disease. Its form is that of a slightly curved rod, and its length about half that of the tubercle bacillus, but it is thicker and sometimes has the form of the letter S (Fig. 13). It is to be classed as a spirocheta, and has been groAvn successfully on media of various sorts and equally success- fully inoculated upon inferior ani- mals. The organism is found in a variety of positions—in the intes- tine, the dejecta (even quite early), and in great profusion in the pathognomonic rice-Avater stools. Kemp in his revieAv has shown that the comma bacillus }S often absent from the evacuations, and that in these cases the bacterium coli is usu- ally present and sometimes streptococci. He believes, hoAvever, that the apparent absence is due to faulty technique. To find it in the vomitus, however, is rare. On the other hand, it may be seen in the stools of Avell persons during epidemics, displaying virulent proper- ties. Cholera spirilla have been repeatedly found in the outer Avorld, and almost invariably in water. C. Frankel during the European epidemic of 1892 studied them in flowing Avater, and in other epidemic outbreaks they have been found in the Avater used for drinking-purposes. (b) Predisposing Causes.—(1) Locality.—Near to the sea-coast cholera is more common than in the inland districts or tOAvns, and the frequency of occurrence lessens with increasing altitude, this fact possibly being due to a gradual decrease in soil humidity and porosity. (2) Atmospheric Temperature.—The spirillum of cholera can only flourish in a Avarm temperature or in a Avarm climate; hence the dis- ease is endemic in certain tropical and subtropical climates only; and hence Ave see in temperate latitudes the epidemic prevalence of the dis- ease only, and that during the warm season. (3) Seasons.—From what has been stated it may be seen that cholera can have no permanent home except in very Avarm climates in which all the other essential conditions prevail. For equally obvious reasons it is more common in the Avarm than in the cold months, most epidemics Fig. 13, -Comma bacilli (from the mouth) j X 1000 (Gunther). CHOLERA. Ill both in Europe and America, having occurred tOAvard the close of sum- mer and in the early autumn. (4) Age, as a rule, has no decided effect. It should be stated, hoAv- ever, that old people are very prone to the affection. Sex is Avithout perceptible influence. (5) Debilitating Causes.—Whenever the private conditions corre- spond to rigid scientific requirements during epidemic outbreaks cholera becomes less prevalent and also less virulent. On the other hand, the deplorable state of municipal sanitation, individual disregard of proper hygienic rules, nervous depression, intemperance, overcroAvd- ing, etc. all predispose markedly to the disease. (6) Mere attacks of intestinal disorder due to improper diet, cold, etc. are potent, and are the sole agencies by means of Avhich the disease is disseminated. Modes of Infection.—The spirilla leave the body Avith the stools, but the most frequent bearer of cholera-poison is the drinking-water. Natur- ally, the individual susceptibility varies greatly (many persons being even insusceptible), and yet the degree of contamination of the drink- ing-Avater and the virulence of epidemics are almost strictly proportion- ate. As an illustration, Vienna had enjoyed exemption from cholera for nineteen years—a fact attributed to the excellent quality of the drink- ing-water and to hygienic improvements. In the same city the mor- tality-rate in the more recent epidemics has been small (7 per 1000) for a like reason. On the other hand, in 1872 there occurred in a single commune (Hamburg), which had a polluted water-supply (the Elbe) and no filtration plant, 17,862 cases, Avith the enormous death-rate of 42.3 per cent. Biernacki demonstrated the presence of spirilla in the spring- water of a house in which 13 cases of cholera occurred. The choleraic poison may be conveyed with the water used for washing, cooking, and other purposes to other fluids imbibed by man (beer, milk, tea, etc.), and also to food-stuffs taken by him (lettuce, cresses, and other raw vegetables, fruits, meats, bread, butter, etc.). The organisms live and maintain their virulence on these articles of food from four to seven days at least. The infection may reach the esophagus with the water used for Avashing the mouth or teeth, or that used for washing the utensils, dishes, food-receptacles, etc. Again, the hands, commonly those of laundresses and nurses, may become soiled in the careless handling of bed-linen or garments Avorn by cholera patients or the stools, and convey the poison to the mouth or lips, to be carried into the stomach along Avith the drink or food. It is quite possible that flies may transfer the infectious element to food-articles (ISimmonds). Cholera is not contagious from mere contact Avith those ill of the disease. The disease is not acquired by inhalation (Shakespeare), and, since desiccation rapidly kills the spirillum, there is little probability that the latter is wafted by the wind-currents or is air-borne. Nor is there any clinical evidence to shoAV that the poison may enter the sys- tem through the skin-surface. Probably the germs are swallowed, and the acid gastric juice may then destroy them if the size of the dose of the poison is not too large, or a sufficient number may pass into the intestinal canal and there manifest pathogenic powers. It is to be borne in mind that after the spirillum reaches the intestine, Avhether or not an 112 INFECTIOUS DISEASES. attack of cholera is the result depends both upon the size of the poison- ous dose and upon the personal degree of immunity. Opposed to the drinking-Avater theory of this disease is that of Pet- tenkofer, Avhich contends that the spirilla found in the serous evacua- tions of cholera patients must enter an appropriate soil and there under- go further development before becoming truly pathogenic. While soils possessing a certain degree of moisture and perviousness and contami- nated Avith organic matter favor the growth and multiplication of the specific organism, these telluric conditions are not essential, as is shown by the virulence of the intestinal discharges when swalloAved in ample quantity. Pettenkofer also claims that the fully developed poison rises from the subsoil into the loAver atmospheric strata as a miasm, especially at the time of the subsidence of the ground-Avater level in summer. Immunity is not conferred by a previous attack of cholera. Clinical History.—The incubation period varies from a few hours to five days, and averages about two days. During this prodromal pe- riod the patient is either quite well or (during the latter portion) ex- hibits certain local symptoms. These are occasionally nausea, a feeling of distress in the abdomen, increased peristalsis which may be visible or palpable, slight pain and tenderness, and either a mild or a decided diar- rhea. The discharges are feculent, colored, and semifluid, or more rarely quite fluid, and may be quite copious. These symptoms may all be present, though oftener a feAv, and rarely a single one, is noted; moreover, they are not distinctive unless seen during an epidemic and unless the patient have been exposed to the poison. General symptoms, as a rule, are not present, though rarely prostration may be marked and there may be slight muscular cramps. The so-called premonitory diarrhea may terminate in recovery at the end of from one to three days, but if not it is followed by an attack of true cholera. This has three stages: the stage of serous diarrhea, the algid stage or collapse, and the stage of reaction. (1) Stage of Serous Diarrhea.—The dejections are generally painless, very frequent, odorless, copious, and fluid or watery, and usually present the characteristic " rice-water " appearance. Rarely they are distinctly colored Avith bile, and in severe cases with blood, and rarely also are they frothy. Suspended in them are numerous small, whitish, mucous flakes ; their reaction is neutral or alkaline, and they contain a small percentage of solid constituents made up largely of albumin and sodium chlorid. The microscope brings to view epithelium, mucus, triple phosphates, and numberless micro-organisms, of Avhich latter the only ones characteristic are the comma bacilli (spirilla) of Koch. In cholera sicca these serous evacuations are absent. Death comes quickly, and post-mortem exami- nation shows the intestine to be filled Avith rice-water material, which is probably retained because of almost instant paralysis of the muscular coat of the intestine. Gastric symptoms appear early. Vomiting soon becomes frequent, and at first the vomitus may be bilious; later it is characteristically serous, like the stools, and excessive in amount. Thirst is almost intol- erable, anorexia is complete, and the tongue often has a thick coating which early becomes dry. Gastro-intestinal pain is not severe but a feeling of pressure and of burning in the abdomen is experienced, and occasionally there are griping pains with tenesmus. The physical signs CHOLERA. 113 are few. The belly is usually flat and flaccid, though it may be scaphoid and hard, and in some places palpation detects fluctuation due to the presence of much serous fluid. Painful cramps in the muscles form an early and characteristic symp- tom. They affect the voluntary muscles of the legs and feet (especially the calves), more rarely the arms and hands also. Their duration is only a feAv minutes, but they recur at brief intervals, and are probably due to the local effect of the circulating toxins. Owing to the Avithdrawal of fluid from the lymphatics and blood- vessels the tissues become dry and shrivelled and the blood much thicker. This condition of the blood obviously increases the labor of the heart, which beats rapidly, and there may be at first a distressing palpitation, but soon the heart grows more and more feeble and venous stasis ensues. The pulse is at first rapid, soft, and small; it may then be lost at the wrist. The cardiac impulse may disappear with increasing asthenia—a condition Avith which the heart-sounds are in direct relation. The facies and general appearance also indicate loss of fluid. The cutaneous surfaces of the face and extremities grow cool: there is rapid general emaciation, which may become most pronounced, and the skin is wrinkled. The complexion assumes a livid or blue-gray tint, while the lips become quite dark. The extremities are cyanotic (the finger-tips in particular), the orbits are deeply sunken, the cheeks hollow, the features intensely pinched, the voice husky and feeble, and there is utter prostra- tion. The surface-temperature drops below the normal, even to 96° or 95° F. (35.5°-35° C), while, per contra, the internal or rectal tempera- ture rises to 102° F. (38.8° C.) or over. The mind may remain clear until the close, but oftener the patient is apathetic, and in grave cases this condition may deepen into stupor or even actual coma. The reflexes are greatly diminished, and restlessness and jactitation may appear, but rarely. The urine becomes very scanty and is highly concentrated, the stand- ing specimen depositing a heavy sediment. On analysis albumin and casts (chiefly granular) are found. In the serious forms the kidneys fail to eliminate the urea, and there is finally complete anuria, which may last for a couple of days or until life is terminated. (2) Stage of Algidity or Collapse.—The symptoms Avhich characterize this grave condition are the same as those noted under the latter part of the first stage, only intensified. Asthenia is extreme ; the pulse is miss- ing and the heart beats faintly; the voice is lost; respirations are per- ceptibly shallow; lividity is intense; the surface ice-cold; and there is usually stupor or even coma. The excessive serous discharges have given place to mere dribblings from the now relaxed anus. During this stage, which may last a few or many hours, the faint glimmerings of the vital spark are often extinguished. (3) Stage of Reaction.—This sets in promptly, and leads as promptly to complete recovery after a mere "premonitory diarrhea;" and when reac- tion follows the first stage directly the case may pursue a favorable course, with return to accustomed health by the end of a week or ten days. The first urine passed is usually albuminous and contains tube-casts and some- times blood-cells. Relapses into the stage of collapse may occur and be repeated; in many instances, however, this stage is both protracted and 8 114 INFECTIOUS DISEASES. dangerous. It is aptly termed cholera typhoid, since a genuine typhoid state of the system Avith more or less fever develops. The skin may pre- sent so-called choleraic eruptions (macular, roseolar, erythema, purpura, etc.). Recovery may noAv take place, or a great diversity of local second- ary inflammations may supervene (vide Complications). Acute nephritis, which may or may not be an essential part of the process, may arise in this stage and lead either sloAvly or directly to uremic poisoning, as shown by the projection upon the clinical picture of grave nervous phenomena—headache, vomiting, delirium or coma, and convulsions. A fatal result may be looked for. Complications.—In this place are to be enumerated the conditions due to secondary infection, including (most commonly) septic and pyemic processes. Diphtheritic inflammations affecting most mucous surfaces, but especially the throat, colon, and the external genitals, are among the more common. Bronchitis, pneumonia, and pleurisy may arise, and erysipelas and parotitis are not rare. During convalescence digestive disorders may show themselves, and indiscretions in diet may precipitate a relapse. Clinical Types.—(a) "PremonitoryDiarrhea."—This type has been outlined in the foregoing discussion, and will not need further description. (b) " Cholerine," in which the symptoms are similar to those of cholera nostras. Many of the symptoms characteristic of true cholera are also present, particularly the cramps and prostration, cold extremities, and scanty albuminous urine. The stools, however, are not, as a rule, typical of the disease, but are feculent in character, as in ordinary cholera mor- bus. The duration is from seven to ten days, subject to relapses. (c) The more typical forms—both moderate and severe—have been described under the Clinical History (supra). (d) The Foudroyant or Asphyxic Form.—This may kill instantly; more frequently the patient lives for a feAv hours, Avith or without vomit- ing and purging. Cholera sicca should be classed with this type. The virulence of the cholera-poison explains the intensity of the symptoms. Differential Diagnosis.—This is difficult in the absence of an epidemic unless bacteriologic and microscopic tests be made, and yet these alone differentiate a sporadic case. The disease most commonly mistaken for cholera (especially cholerine) is cholera morbus, and the fol- lowing points pertaining to the latter disease will eliminate it: 1. No connection with a previous case, but a frequent history of dietetic impru- dence. 2. Absence of "rice-water" stools, which remain turbid with feces or covered with bile or blood. 3. Presence of colicky pains, but absence of painful tonic cramps of legs and feet. 4. Absence of cyanosis and collapse, as a rule, and of urinary suppression. 5. No cholera spirilla in the stools. Arsenic-poisoning and other forms of gastro-enteritis must be discrimi- nated by the history, the character of the stools, the absence of violent muscle-cramps and of the effects of great loss of fluid (cyanosis, shrunken body, profound collapse, etc.). Chemical tests are not to be neglected if the history points to any form of corrosive poisoning. Prognosis.—This is dependent mainly upon the type. Thus " chol- erine " is very rarely fatal, Avhile, on the other hand, the asphyxic form is almost as rarely survived. It is impossible to state the averao-e mortality CHOLERA. 115 since it varies with each epidemic, but it has been found to range from 20 to 80 per cent. Many deaths occur during the latter part of the first day or during the algid period; still more during the stage of reaction, the dangers of the latter period being as follows: asthenia, cholera nephritis with uremia, and the various complications (vide supra). The persona] circumstances which render an attack grave are old age, alcohol- ism, previous ill-health, and debility. On the other hand, the death-rate may readily be loAvered by prompt and judicious treatment. Treatment.—Prophylaxis.—Prevention is of greater importance than cure, and is easily accomplished as compared with the eradication of the disease. It has been OAving in great measure to the efficient quarantine system of the United States that cholera has not gained a foothold on our shores since 1873. Individual Prophylaxis.—In the first place, those nursing the sick can prevent the spread of cholera by prompt and thorough disinfection of the vomitus and stools, as Avell as of the receptacles containing them and anything that may be soiled by them. The dejecta may be disinfected by pouring upon and mixing Avith them an equal part of a 5 per cent. solution of carbolic acid or an equal volume of a freshly prepared solution of chlorid of lime. The discharges thus treated must be covered and allowed to stand from fifteen minutes to half an hour, and then emptied into a pit in the earth containing quicklime, Avith Avhich they should also be covered. It is of the utmost importance to guard against a pollution of the Avater- supply by these pits. Soiled clothing, linen, etc. should be promptly disinfected, and bedding had better be burned; none but the attendants should be permitted to enter the sick-room. The dishes used should be disinfected immediately after use or before leaving the sick-chamber. Shakespeare further recommends that the remains of the patient's meals should be disinfected and destroyed. After handling the patient or any- thing that he has soiled the attendants should first disinfect and then carefully Avash their hands, these ablutions being performed invariably before eating. After vomiting and after an evacuation of the boAvels the mouth and the parts around the anus should be wiped with a cloth wet with a solution (1: 2000) of mercuric chlorid. If convalescence super- vene, the patient should be kept isolated for a week and the stools should be disinfected during that time. Persons exposed should use boiled milk and water only. Certain forms of food must be avoided, especially salads and unripe fruits ; also alcoholic stimulants. All uncooked food may be pernicious. Such per- sons should lead regular lives, avoiding fatigue, excesses, etc., and in- testinal disturbance must be met speedily by the use of antiseptics, opiates, and astringents. In India, Haffkine1 has used a protective virus with encouraging results. Thus, " of 1735 persons not inoculated in a certain section, 174 took the disease and 113 died, whereas of 500 inoc- ulated but 21 Avere affected and 19 died." He has made, altogether, 70,000 injections in 40,000 patients Avithout a single accident, and claims that the results have been entirely favorable. Behring and Ransom have also succeeded in obtaining an antitoxic serum. Klein concludes against Haffkine's anticholera inoculations, shoAving that there is no certainty as to the protection against the specific poison in the intestines, even 1 Munch, med, Wock, Jan. 29, 1895. 116 INFECTIOUS DISEASES. though there may be protection against the effect of intracellular poison. Klemperer has produced immunity by using a toxin. Treatment of the Attack.—(a) Premonitory Diarrhea.—When the prodromal period exists it must be quickly combated, and if this were attended to appropriately few cases of cholera would follow. In the instances which are not preceded by premonitory diarrhea opportunity to prevent the attacks does not present itself. In this stage a double indi- cation is presented—"to restrain the development of the bacilli in the intestine and to neutralize the cholera-poison." To meet this Cantani proposes tannic acid by irrigation (enteroclysis). He injects into the in- testine ^ to 2^- quarts (liters) of water, or infusion of chamomile contain- ing siss to 3v (6.0 to 20.0) of tannic acid, gtt. xx to xxx (1-20) of laud- anum, and 3Ar-xij (20.0-50.0) of gum arabic. The temperature of the liquid should be 80°-104° F. (26.6°-40° C), in order not to chill the patient. Injections should be repeated four times a day, and in grave cases after each evacuation.1 To this should be added a regulated liquid diet, with rest and recumbency. For the same purpose acetate of lead and opium, or large doses of bismuth with or Avithout Dover's powder, have been much employed with good results. (b) Stage of Serous Diarrhea.—The chief indication is to restore to the blood the Avatery elements withdrawn by the diarrhea. Not a moment is to be Avasted. Opium, and preferably the salts of morphin, should be administered hypodermically, the dose not being small, but gr. 4; to ^ (0.0162-0.0216) to be repeated at intervals of about eight hours. To opium given per oram or in the usual way there is a serious objection— namely, its slowness of action. Cantani advocates the injection of an artificial serum (hypodermoclysis) containing 1 dram (4.0) of sodium chlorid and gr. xlvj (3.0) of sodium carbonate per quart (liter) of ster- ilized water warmed up to 104° F. (40° C.) into the subcutaneous con- nective tissue. This solution may be introduced through the cannula of an ordinary aspirator, the fluid flowing by gentle pressure. Shakespeare recommends for hypodermoclysis a fountain syringe with a long flexible tube furnished with a cock ; with another shorter tube, one end attached to the cock, the other having a needle-pointed cannula, a little longer, stronger, and Avith a someAvhat wider caliber than the ordinary hypo- dermic needle (Fig. 14). The tube and cannula are first perfectly filled with a fluid, and then the cannula is inserted Avell in between the skin and deep fascia of the flanks, buttocks, or interscapular region. The fluid should be made to Aoav slowly, allowing fifteen to twenty minutes for the introduction of one quart. This is preferred to intravenous injec- tion, in Avhich the liquid is diffused slowly. The indications presented by the premonitory stage must be met as above stated. The vomiting is to be relieved by bits of ice, small amounts of brandy and water at brief intervals, cocain, or by lavage. In this stage reme- dies by the mouth should be avoided, since they aggravate the gastric dis- turbance. Heat should be applied externally with a view to assisting the peripheral circulation as Avell as the reaction, and, on the other hand to obviate collapse. Warm baths have been recommended for this pur- pose. Stimulants must be used to fulfil the same indications. They are of superior value even to the above-mentioned measures, and are to be 1 Annual of the Universal Medical Sciences, 1893. CHOLERA. 117 given hypodermically, and either brandy, ammonia, or strychnin may be employed in large doses. (c) Stage of Algidity.—If this develop, the case is desperate. In this stage the folloAving measures and procedures, which have been de- tailed in the treatment of the preceding stage, are to be persevered with: FIG. n.—1, fountain syringe; 2, cock; 3, attachment for cannula; 4, needle; 5, cannula; 6, soft- rubber rectal tube, with two lateral openings, one a half inch from the end (not visible), the other two inches from the end. The latter is to be introduced by a combined rotatory and pushing motion to the depth of ten inches in enteroclysis, and the fluid then allowed to enter the colon slowly. enteroclysis and hypodermoclysis, hypodermic stimulation, and the ex- ternal application of heat. Additionally, intravenous injections of fluids have been strongly urged by its champions. For this purpose the fol- loAving standard of saline fluid may be chosen : sodium bicarbonate 1 part, sodium chlorid 6 parts, boiled Avater 1000 parts. The temperature of the fluid when injected varies according to circumstances from 100J-0 to 104° F. (38°-40° C), more frequently the latter (Shakespeare). The quantity demanded may be 1 or 2 quarts (liters), and the injec- tion may need to be repeated in from one to three or four hours. Despite the physician's best efforts, patients in this period usually succumb. Treatment in the Stage of Reaction.—During this stage the tannic acid may be replaced by a solution of salt in water (10 or 15 per cent.) for enteroclysis (Cantani), and it may be well to continue hypodermoclysis in some instances. Further than this, the treatment is essentially symp- tomatic. Food of the blandest sort and in small quantities must be allowed at frequent intervals if Ave would avoid enteritis and other unfa- vorable complications. Tonic remedies should be given cautiously, and rest and careful nursing insisted upon. Complications must be met in accordance with general principles. 118 INFECTIOUS DISEASES. YELLOW FEVER. (FebrisJiava; Gelbfieber, Ger.) Definition.—Yellow fever is an acute, highly infectious (but non- contagious) endemic and epidemic disease. It is characterized by a sharp period of invasion, followed by a period of remission, and the latter in turn by a relapse and certain symptoms peculiar to the affection (black vomit, jaundice, suppression of urine). Historic Note.—Yellow fever is endemic only within certain geo- graphic limits, Avhere it also prevails epidemically when the conditions are favorable. According to general belief, it first appeared in 1647 in the Barbadoes (West Indies). Subsequently, it Avas conveyed along the chan- nels of commerce until it became widely disseminated, and chiefly in sea- port towns. In 1699 an English vessel carrying slaves transported the disease to Mexico from the Atlantic coast of Africa. Guiteras classified the areas of infection thus : (1) The focal zone, in which the disease is never absent, including Havana, Vera Cruz, Rio, and other Spanish- American ports. (2) Perifocal zones, or regions of periodic epidemics, including the ports of the tropical Atlantic coast in America and Africa. (3) The zone of accidental epidemics, betAveen the parallels of 45° N. and 35° S. latitude. YelloAV fever was brought to the United States (Boston) in 1693, and since then has invaded in epidemic form numerous sea-coast cities, being carried thence to a number of inland towns. The belief that the disease never originates outside of certain territorial limits was ad- vanced for the first time by the College of Physicians of Philadelphia (1797), and the efficacy of rigid quarantine regulations in preventing con- veyance of the poison by vessels having yellow-fever cases on board was pointed out by the same organization. Pathology.—The skin is jaundiced (hepatogenous) and often large or small ecchymotic spots are observed, but neither the internal viscera nor the blood shows characteristic lesions in cases of average intensity. In severe forms congestion, hemorrhage, and degeneration are the changes noted, especially in the liver and the gastro-intestinal mucous membranes. After death the liver is anemic, as a rule, but in the early stages of the disease it is markedly hyperemic. Its color varies, ranging from pale yellow to an orange hue, and punctiform extravasations cause mottling of the surface. Its size varies little from the normal. Parenchymatous de- generation of the hepatic tissue is common, though in places it may be entirely normal. The liver-cells are swollen, containing fat and granular matter with indistinctness or absence of nuclei. The gastro-intestinal mucosa is the seat of numerous minute hemor- rhages, similar spots of extravasation being found on the various serous membranes of the body (meninges, pericardium, pleura, etc.). Hemor- rhagic infarctions may be found in the various internal viscera. The lesions of acute catarrh are seen in pronounced form in the gastric mucosa, which may also present erosions. The black-vomit material is found in the stomach, and less frequently also in the smaller intestines, which pre- sent the evidences of acute catarrh of their mucous walls. The spleen is dark and friable, but is not enlarged. The kidneys show the lesions of parenchymatous nephritis, the microscope revealing YELLOW FEVER. 119 cloudy swelling of the epithelium of the tubules with fatty degeneration, and the tubules themselves being occupied by casts, chiefly granular. The heart-muscle looks pale, and may be the seat of granular and fatty degeneration. The brain and its meninges are hyperemic, and degenera- tive changes have been described in the sympathetic ganglia (Schmidt). The blood is dark, and many of the red corpuscles, having disorganized, set free hemoglobin, as in malaria. Certain significant lesions of a gen- eral character—such as a fatty degeneration of the walls of the small blood-vessels and the capillaries—have been noted by competent ob- servers, and these, by allowing filtration of the blood-serum through the vessel-walls, may account in great measure for the concentration of the blood. Etiology.—The fact that yellow fever occurs chiefly in epidemics of varying extent must be borne in remembrance, and when the first cases appear in a fresh outbreak we may feel certain that the disease has been transported from some distant point. Its bacteriology is as yet an unsettled problem. Among predisposing causes season heads the list. The disease prevails chiefly in summer, being completely arrested by one, or at most two, se- vere frosts. The affection is to a far greater degree under the influence of the temperature than of any other meteorologic element, requiring, as it does, at least 72° F. (22.2° C). Long-continued elevated temperature therefore favors a spread of the disease, and atmospheric humidity also favors its propagation. The poison is more virulent at night than in the daytime; and unhygienic conditions, as overcrowding, filthiness, ill-ven- tilation, etc., are important disposing factors. Age and race have some degree of influence, children being more liable than adults, males than females, and whites than blacks. Other factors Avorthy of special mention are—intemperance, physical exhaustion, sexual excesses, fear, depressing emotions, etc. One attack usually bestows permanent immunity, and natives of an infected district are far less liable to the disease than new- comers. The poison is not given off by the severe form of yellow fever in the mature or active form, but only becomes so after it has undergone further development in a favorable soil. It may, however, be carried to short distances by currents of air, and may be transferred over any dis- tance by fomites—clothing, baggage, letters, and packing-cases being the most frequent carriers. The specific poison manifests great tenacity of life. In a large city the infected district may be small, and, although it tends to extend itself, the process is a slow one. The march of an epi- demic may be interrupted or even completely arrested by apparently triv- ial agencies—e. g. watercourses, rows or clumps of shrubbery or under- brush, high fences or walls, and so on. Clinical History.—Incubation Stage.—This varies greatly, ranging from one day to two or even three weeks. During the incubation certain general symptoms may appear, such as languor, headache, anorexia, etc., lasting several days. Invasion Stage.—The onset is abrupt, an initial chill usually occurring, but it is very seldom severe or prolonged, a reactionary fever following promptly and the temperature rising to 103°, 104°, or even 105° F. (40.5 C). The temperature is apt to be highest at the beginning, and then falls gradually, hyperpyrexia being rare. The chill and fever are 120 INFECTIOUS DISEASES. accompanied by headache and pains in the loins and legs, often of great severity, and a little later restlessness, mental confusion, and a delirium that is sometimes violent in character may develop. In the majority of instances, however, the mind remains clear. The pulse is accelerated, but not in proportion to the height of the temperature, and is full and strong at the start, diminishing in strength and frequency soon after. The face is flushed and in severe forms quite dusky. The eyes are suffused and intolerant of light. The tongue may or may not be coated, and nausea and vomiting may occur, the latter being one of the most characteristic symptoms of the disease. Associated with these symptoms there are epigastric oppression and burning sensations, with decided ten- derness. The vomitus may be blood-streaked or contain chocolate-colored particles, and occasionally unaltered blood is vomited. Constipation is usually present, the stools showing a deficiency of bile. The urine is diminished in amount, dark-colored, and often contains a slight amount of albumin : this early transient albuminuria is a very characteristic symptom. The initial stage may last from six or eight hours to two or three days, or even longer, and is longer in the milder forms of the dis- ease. With the termination of this stage the fever remits and the other symptoms disappear with surprising rapidity, the pulse becoming remark- ably slow. Stage of Remission.—From this moment convalescence may begin and proceed to full recovery Avithout interruption, the happy event being often marked by critical discharges. In most instances, however, the patient presents certain symptoms and signs of ill-health during this period (more or less prostration, epigastric distress with tenderness, mental dulness or even stupor, and a yellowish tint of skin and urine), Avhich lasts from a feAv to twenty-four hours, when another stage Avith its more striking symp- toms supervenes. Stage of Secondary Fever or Collapse.—The patient becomes extremely weak, presenting the signs of profound collapse. The surface of the body is cool (extremities often positively cold), the skin in nearly all instances assuming a yellow or bronzed tinge, from which the disease receives its name. The pulse is rapid and compressible, and soon vomiting becomes very distressing. Hemorrhage into the stomach generally occurs, the blood being acted upon by the gastric secretions, and producing the material which is expelled as the characteristic "black vomit." Occa- sionally unaltered blood may be vomited; the stools also may be tarry. In the worst cases hemorrhages from other mucous surfaces are common (epistaxis, hematuria, metrorrhagia, etc.), and cutaneous hemorrhages also now occur. In this stage the tongue becomes dry, broAvn, or even black ; less frequently it is smooth, red, and fissured, and sordes may often be observed on the teeth and lips. In most cases the urine is deficient, containing albumin and casts, and in rare instances there is complete anuria. The latter may precede the development of grave nervous symptoms, as convulsions, or even coma, Avhich may be uremic. In some instances the temperature rises during this period (secondary fever), and in favorable cases terminates by lysis, or it may assume the typhoid form and result fatally. In all cases that pursue a favorable course convalescence is slow and gradual, and may be uninterrupted by YELLOW FEVER. 121 relapses, but this is an unusual course of affairs. The duration of the en- tire attack (composed of three stages) is variable, though as a rule it covers about one week. Clinical Varieties.—Many different varieties have been described, each characterized by one or more prominent features, but none seem more justifiable than Finlay's1 classification, in which he distinguishes three forms: (1) the acclimation fever, or non-albuminuric yellow fever; (2) the plain albu>ninuric yelloiv fever; (3) the melano-albuminuric yel- low fever, characterized by the presence of blood or "black vomit" in the stomach or intestines. Diagnosis.—The symptoms that justify a diagnosis in the initial stage, provided an epidemic be prevailing, are the sudden onset, head- ache, severe lumbar pains, peculiar facies, nausea, and vomiting of biliary matter. In the early stage intense capillary congestion of the surface of the body is diagnostic and indicative of a severe form of the disease. In the third stage the coexistence of jaundice, the black vomit, and suppres- sion of urine, Avith evidences of collapse, makes the diagnosis easy. The first cases that appear in a locality hitherto free from the disease are often diagnosticated Avith difficulty, especially if they present anomalous cha- racters. In such, a certain diagnosis is possible only by exclusion. Pernicious malarial fever has not the deep jaundice, the slow pulse, the peculiar temperature-curve, the intense capillary congestion of the surface of the body, the black vomit, the early albuminuria, and the clear mind—all symptoms that mark yelloAV fever. On the other hand, the organism of Laveran is pathognomonic of pernicious malarial fever, as is the effect of quinin upon the disease. Kemp has made a microscopic, spectroscopic, and chemical study of the black vomit of yellow and malarial fevers, and found that the pigment in each case was derived from the blood, which had been acted upon by the juices of the stomach. The vomitus in malarial fever, however, contains in addition considerable quantities of bile-pigments and bile-salts, which are wanting in that of yelloAV fever. Further, in the latter the vomited matter is much more highly acid than that of malarial fever. Prognosis.—Different epidemics show widely different death-rates, and the most potent factor is the particular type of the disease in indi- vidual epidemics. Some have been characterized chiefly by the lighter forms of the affection, and in such the death-rate has been as low as 1 per cent. In other epidemics the type of the affection has been so virulent as to make the mortality list run extremely high, even to 100 per cent. In general terms, mild epidemics give a mortality of 5 to 10 per cent., and severer forms one of 30 to 50 per cent. The death-rate is lower in private than in hospital practice. Among the gravest symptoms intense capillary congestion, coming on during the first stage, deserves special emphasis. Equally serious, in most cases in Avhich they occur, are suppression of urine, intense jaundice, and uremic toxemia. The black vomit is not as fatal a sign as the symptoms previously mentioned. It has been noted that a larger number of men, proportionately, than women and children succumb to the disease, and that it is less fatal among negroes than among Avhites. 1 Edinburgh MedicalJournal, Edinburgh. 122 INFECTIOUS DISEASES. Treatment.—The measures that are employed in yellow fever may be considered under three main heads: (1) Prophylaxis; (2) general management; and (3) medicinal measures. (1) Prophylaxis.—The patient must be quarantined, and if the area in a city that is infected be definitely known, it should be shunned by well persons, and particularly if the latter are not acclimated. Persons living in infected localities Avho have not been immunized by a previous attack had better go elsewhere if such a course be practicable. Every available means to prevent a dissemination of the poison by fomites must be enforced, and most important is the thorough disinfection of all personal belongings, bed- and body-linen, mattresses, clothing, etc. The room occupied by the patient must also receive proper attention. Dr. Domingo Freire has introduced and advocated protective inocula- tion with diluted virus, and Ashmead1 recommends immunization after Murray's method, as follows : (1) Instead of carrying the patient to the infected region, take the infection to the patient; inoculate with the blood-serum of a partially-immune subject (a negro), and inoculate a second time with perfectly-immune blood-serum of a Avhite subject Avho has had yellow fever. (2) Expose infected blood-serum to frost before inoculating, and follow this at once with a second inoculation of immune blood-serum. Frost always modifies the virus. (2) General Management.—The sufferer from yellow fever must be put to bed at once, and an abundance of fresh air (without exposure to strong drafts) must be supplied, The medicaments and the nourishment are to be administered through a tube or spout-cup, so as to obviate raising the patient's head. Body- and bed-linen should be kept scrupulously clean, being changed frequently, and the patient must not be allowed to leave his bed on any account. The diet should be of the lightest sort and entirely liquid, beginning Avith peptonized milk, koumiss, or light broths, and in small quantities. (3) Medicinal Measures.—At the outset it is well to gently stimulate the various excretory organs, and mild laxative diaphoretics and diuretics answer this purpose. Hydrotherapy may be employed to maintain the nervous tonicity and reduce the temperature, but when the spontaneous fall of temperature sets in this method must be promptly discontinued. During the first stage the neuralgic pains, which attack principally the head, loins, and nerve-trunks, are to be relieved by morphin given hypo- dermically ; and for the same symptom Bemiss highly recommends quinin by the rectum (gr. xx—1.296). Intestinal antiseptics may also be used throughout the attack (salol, betanaphtol, etc.). During the stage of remission the powers of the system are to be fully maintained by a suitable dietary and by tonics and stimulants if required. In the last stage, which generally supervenes, supportive measures must not be forgotten, everything that gives promise of aiding the vital powers being brought into prompt requisition. Rectal nutrient enemata should be employed if marked gastric irritability prohibits feeding by the mouth. Stimulants are demanded, and these should also be administered per rectum if not retained by the stomach, or they may in some measure be administered hypodermically. The stomach is, as a rule, more tol- erant of iced champagne than of other forms of stimulants.' 1 Medical Record, New York. CEREBROSPINAL MENINGITIS. 123 If irritability of the stomach be present, ice and hydrocyanic acid may be tried. Sodium bicarbonate (gr. x to xx—0.648 to 1.296) in Vichy, Apollinaris, or Seltzer water is a most useful remedy, and Stern- berg has used it in combination with mercuric chlorid with success in the following formula: B/. Sodii bicarb., 3iv (16.0); Hydrarg. bichlorid., gr. ss. (0.032); Aqu.e purse, Oj (480).—M. Sig. For a severe case tAvo teaspoonfuls every hour, day and night; for a mild case, every hour by day and every two hours by night; administer always ice-cold. Perhaps the chief indication for the use of sodium bicarbonate is the extreme acidity of the various secretions, especially the gastric and renal. Sternberg contends that by fulfilling this indication we prevent in great measure the occurrence of acute nephritis and suppression of the urine. Hemorrhages and other symptoms must be treated by the usual means. If the stage of convalescence be reached happily, tonics (especially quinin) are to be administered, and the customary diet can gradually be resumed. CEREBRO-SPINAL MENINGITIS. (Spotted Fever; Cerebro-spinal Fever.) Definition.—An infectious disease, caused most probably by the Micrococcus lanceolatus. • It is characterized anatomically by inflamma- tion of the meninges of the brain and spinal cord, and clinically by an irregular course, a moderate febrile movement with somewhat character- istic and profound nervous symptoms (excruciating headache, pain in the back and upper part of the spine, contraction of the muscles of the nucha, hyperesthesia, delirium, and ofttimes coma). The disease may occur sporadically or in epidemics, or may even assume pandemic pro- portions. Historic Note.—Cerebro-spinal meningitis was first recognized and described as late as the beginning of the present century (1805) by Viesseux of Geneva. During the next decade numerous limited epi- demics were observed both in Europe and the United States, and subse- quently recurring epidemic and pandemic visitations were noted, though at comparatively long and variable intervals of time. In nearly all the large cities in this country it may be said to have become endemic, and in Philadelphia since 1863; yet the affection is, without doubt, becoming less and less prevalent. Pathology.—The cases that prove speedily fatal do not present gross characteristic changes, but by the aid of the microscope leukocytes are discovered immediately around the cerebral vessels, and round cells in the cortex of the brain. In some cases the characteristic evidences of 124 INFECTIOUS DISEASES. encephalitis are already noticeable. On the other hand, the eases in which death occurs after the disease has been fully developed shoAv the lesions of suppurative inflammation of the meninges of the brain. The arteries, veins, and sinuses are much engorged ; the ventricles are dis- tended with liquid, but the pia mater is principally affected, its vessels being greatly enlarged, and a more or less copious sero-fibrinous or sero- purulent exudate occurring into the meshes of its network. The longer the duration of the case the more purulent is the exudation. The ven- tricles of the brain are filled with a similar exudation, and red blood- globules may be present at an advanced stage. The color of the exu- date is at first almost clear (being composed of serum); it then changes to a milky turbidity, to a pale yelloAV, and at last, when it becomes thick, takes on a greenish-yellow color ("leek-green"). The subarachnoid space may be occupied by a uniform layer composed of fibrin and pus, which exhibits the greatest thickness along the longitudinal fissure. The brain-matter is congested, and sometimes softened in spots, and on section the gray matter may present punctate extravasations. When resolution occurs recovery may be complete, but more frequently the pia mater remains thickened, and here and there are imbedded in its tissue flattened cheesy masses. The exudation may follow the auditory and optic nerves along their lymph-sheaths, and pus has been found in the internal ear as well as in the chambers of the eye. Wrhen the cases tend to become chronic the membranes are thick and adherent, Avhile the cortex shows areas of soft- ening or atrophy. The membranes of the spinal cord manifest lesions identical with those of the brain. They are vascular engorgements, folloAved by sero- fibrinous, and later still by sero-purulent, exudation beneath the arach- noid. The changes are more marked on the posterior than the anterior surface of the cord, and the exudate increases in amount in passing from above downward, in severe cases sometimes assuming the form of a sheath which completely surrounds the cord throughout its entire length. The pia mater is congested, and may be thickened, shaggy, and in places adherent to the cord, of which the gray matter may be the seat of serous infiltration, and rarely of softening. The lungs may exhibit the changes peculiar to bronchitis or pneu- monia. In the heart endocarditis may be noted, though rarely, and both the pleura and the pericardium may show inflammatory lesions and con- tain a serous or sero-purulent exudation. I have noted one malignant case in which hemorrhages into the serous membranes and into the skin had taken place. The spleen may be moderately enlarged, the increase in size and the degree of fever being proportional, and the liver is hyper- emic. The kidneys are congested, and bacterial forms have been found associated in the latter with the lesions of acute nephritis and hemor- rhage—conditions of which they were most probably the cause. Etiology.—Bacteriology.—It is probable that the Micrococcus lance- olatus is the specific cause of cerebro-spinal meningitis. Flexner and Barker found the micrococcus uniformly present in all cases in an epi- demic Avhich occurred at Lonacoming, a mining town in Maryland.1 Other bacteria are, however, constantly found associated (streptococcus pyogenes 1 Annual of the Universal Medical Sciences, 1895, vol. ii. A-65 CEREBRO-SPINAL MENINGITIS. 125 staphylococcus aureus, etc.), and there is little doubt that these, sometimes give special characters to the clinical bacteria. Predisposing Causes.—(1) Age.—Most cases occur among children and young adults, though no age enjoys perfect immunity. Occasionally epi- demics have affected adults chiefly. (2) Climate.—The disease is unknoAvn in tropical climates, but has oc- curred in all parts of the temperate zone, and is most prevalent in the more northerly portions of the latter. (3) Season is not an important factor, though the disease prevails largely in cold weather. (4) Unhygienic Influences.—Those who live under unfavorable sanitary influences are especially liable, and hence the disease often appears in illy- ventilated and overcroAvded habitations—among the poorer classes, among soldiers croAvded together in barracks, and among prisoners. For like reasons excessive physical or mental exertion or bodily fatigue, as after prolonged marching, may heighten the susceptibility to the disease. In certain epidemics the disease has raged exclusively in villages that afforded the least hygienic conditions. Cerebro-spinal meningitis is not unfrequently associated with other epidemic affections, especially scarlet fever and measles. Modes of Conveyance.—Precisely hoAv the contagion is transferred from an infected person to a healthy one is not knoAvn, though the disease is probably not contagious. There is considerable evidence to show that the poison may be conveyed by fomites, though even this seems to be limited to the cases furnishing intensely virulent poison. As to the manner in which infection occurs or the virus gains entrance to the system our knowledge is very imperfect. Clinical History.—The period of incubation must be brief, though its duration can only be approximated in the present state of our know- ledge. The prodromal symptoms exhibit considerable variety in different epidemics, and may even be absent Avhen the invasion is sudden, a patient in vigorous health often being stricken down as though by a blow. In some of these rapidly fatal cases there is a short prodromal period, during which the patient complains of lassitude, headache, rachialgia, muscle- and joint- pains, and sometimes nausea and vomiting. In ordinary forms the premonitory symptoms may last from a few hours to a week or more, and the patient's complaint may be limited to cervical and occipital pains last- ing a day or two; then, without any initial chill, the invasion period su- pervenes. In milder, and usually in sporadic, cases the symptoms consist chiefly of languor and debility, headache, pain in the back and limbs, vertigo, vomiting, and sometimes diarrhea. Most cases begin abruptly, and with few exceptions the hour of onset is between noon and midnight. The symptoms Avhich are often most dis- tinctive and violent are chill (often severe), fever of a moderate grade, a full and somewhat accelerated pulse, raging headache, and vomiting. In children the ushering-in symptom may be a convulsion. These symptoms are followed in the course of a few hours by pain in the back and cervical portion of the spine—an early and characteristic symptom. Attempts at flexion or rotation of the head increase the pain in the neck, and in like manner movements of the body augment the spinal pains. Later, the muscles in the cervical region contract, at the same time becoming rigid, 126 INFECTIOUS DISEASES. and produce the condition of opisthotonos. The patient may be unable to swallow on account of the excruciating pain Avhich the act is apt to excite. The temperature is but moderately elevated. In a certain percentage of the cases it rapidly rises to 104° or 105° F. (40.5° C), but soon falls to 102° or 103° F. (38.8° or 39.4° C), at which level it is maintained with irregular undulations until defervescence, Avhich takes place by lysis. In fatal cases death is preceded by a sudden great elevation of temperature to 108° and even 110° F. (43.3° C). There may be a rapid fall of tem- perature, followed by collapse. In the very young the thermometric range is loAver than in adults. The pulse is but slightly accelerated, if at all, in the early stages of the disease. Later, in tAventy-four to thirty-six hours, it may in severe cases leap to 120 or even 140, its chief characteristic being the variability in its rate. In the early stage it is of good volume and tension; later, it may be soft and compressible, and Avhen a fatal termination is impend- ing it becomes small and feeble. The respirations, as a rule, increase in frequency and are sometimes quite irregular; but marked dyspnea, with slowing of the respirations, may be observed during the advanced stage, being due to pressure ex- erted by the exudation upon the respiratory center. Cheyne-Stokes breathing and sighing respirations may be present. Nervous Symptoms.—The headache is racking and often persistent, though it is subject to remissions; and is intensified by light and sounds, being so violent as to cause the patient to groan even Avhile profoundly comatose. There is vertigo in nearly all instances. The pain referred to the spine may be general or limited to either the lumbar or cervical region (rarely the dorsal), and the general myalgic pains are often in- tense, especially in the extremities and the abdominal region. With the cephalalgia and abdominal pain may be associated vomiting. Hyper- esthesia is a prominent symptom, the gentlest touch being extremely painful; anesthesia may also be noted, though less frequently, and usually follows the hyperesthesia. Any voluntary muscular movements, however, excite pain. In some cases delirium appears early, and in others rather late, Avhile in the worst types death often occurs before de- lirium develops. On the other hand, in a small percentage of cases this symptom is absent throughout the entire course, and always its character and intensity exhibit a remarkable variety. It may be mild or it may take the form merely of incoherent answers to questions. Active delirium, however, is common and is accompanied by hallucinations, during which the patient shouts loudly, and, unless restrained, gets out of bed. This form of delirium occurs in paroxysms that are most apt to appear at night, and in the female it is sometimes hilarious or hysteric. An erotic tendency, Avith priapism or seminal emissions, has rarely been ob- served in males. The " maudlin " delirium of the drunkard is sometimes seen, but sooner or later somnolence appears and may deepen quickly into coma, the latter symptom perhaps being temporary, though more often it continues until recovery or death. As before stated, vomfting is common, though it may appear late in the disease; it is doubtless of-cerebral origin. Symptoms of motor irritation are among the prominent phenomena of CERE BR O-SPINA L ME XING IT IS. 127 the disease, twitching of single muscles or groups of muscles often being seen, and occasionally muscular tremors. Muscular contraction is an almost constant feature. After a few days a tonic spasm of the muscles of the extremities sets in, as the result of Avhich the arms are bent upon the chest, the forearm upon the arm, and the thumb upon the palm ; the thigh is also flexed on the abdomen and the leg on the thigh. The opis- thotonos previously alluded to may be folloAved by trismus, which can be considered a mortal symptom. Convulsions do not occur in adults, but are common in children ; occasionally, hoAvever, there are paralysis, especi- ally of the muscles of the face, and paretic hemiplegia. Organs of Special Sense.—Photophobia is a prominent symptom, and the condition of the pupils is very variable. They may be dilated or contracted (more frequently the former) or remain normal; and in the majority of cases they are unequal in size and react poorly to light. These pupillary changes may come on early or late. Strabismus is fre- quent, being usually temporary, though it may recur several times during the attack. Rarely it is permanent. Conjunctivitis of moderate inten- sity and keratitis may occur, the former being more frequent than the latter, however; and ptosis is almost always present. Intense purulent irido-choroiditis sometimes occurs ; either temporary or permanent blind- ness is met with, and, much more rarely, nystagmus is noted. Among optical sequelae are cataract and atrophy of the eyeball. Deafness is by no means an infrequent symptom, there being an early intolerance of sound and a marked tinnitus aurium. Later, suppurative inflammation of the middle ear, followed by rupture of the tympanum and otorrhea, may occur. The internal ear may be similarly involved, and in such cases the gait may become uncertain from implication of the semicircular canals. The deafness may after recovery be found to be permanent, though, as a rule, it is incomplete. Cutaneous symptoms appear, some of Avhich possess considerable diag- nostic Avorth. Pallor and lividity of the skin and visible mucous mem- branes often characterize the period of invasion, and shortly after the onset herpes facialis appears in more than half the cases. This symptom is significant for diagnosis. The separate lesions are extensive, and often coalescence of tAvo or more is witnessed. Herpes facialis belongs in a peculiar sense to cerebro-spinal meningitis—herpes labialis to malaria, and less frequently to pneumonia and meningitis. A petechial eruption is common, and has been most frequently met Avith in the early epidemics, and more frequently in America than in Europe. To this symptom the disease owes the name, long since given to it, of "spotted fever." It may, hoAvever, be absent, and when present it is sometimes limited to a small superficial area, though more frequently it is diffuse. At first the eruption may be bright-red (erythematous), later becoming darker, or it may be distinctly petechial from the start; purpuric spots of considerable size and sometimes large ecchymoses may appear, but these are most common in the more malignant types. Other forms of eruption are also seen (sudamina, urticaria, ecthyma, erythema, erysipelas,* etc.), but are devoid of diagnostic value. Gangrene of the skin is occasionally noticed, and in some cases bed-sores are liable to arise ; but there is no fixed time for the skin-lesions of cerebro-spinal fever to appear, and their duration is exceedingly variable. 128 INFECTIOUS DISEASES. Of gastro-intestinal symptoms vomiting is the most common. It usu- ally lasts only for a brief period at the onset, though it may recur later at longer or shorter intervals, and is of nervous origin. The appetite may be good, but in many cases it is soon lost, the tongue, in a large pro- portion of the instances, being only slightly coated. In cases assuming the adynamic or typhoid type the tongue is apt to become dry and of a brown color, with the formation of sordes. Under these circumstances the abdomen is tympanitic and the bowels relaxed, and diarrhea may be urgent, resisting all efforts aimed at its relief. Retraction of the belly is common, and constipation instead of diarrhea is the general rule; the spleen may often be felt a little distance below the costal margin. Renal symptoms are not prominent, though the amount of urine passed is often above the normal despite the febrile movement. It may be below, though rarely, while in still other cases it is found to be about normal; and retention on the one hand and incontinence on the other have been observed. Albuminuria is sometimes met with, and sugar has been detected in the urine in rare instances. Complications.—Many of these have already been mentioned in the portrayal of the symptoms, particularly those taking the form of destructive inflammations of the eye and ear and the paralyses of the cranial nerves. The purulent inflammations of the serous sacs which were referred to in discussing the pathology (pleurisy and pericarditis) are among the frequently associated conditions, and secondary bron- chitis is also common. Pneumonia (lobar and lobular) is a frequent and much-dreaded com- plication. Atelectasis may occur. Hemorrhagic nephritis, usually of mild type, may appear afe a com- plication. Special and Atypical Forms.—(1) Mild or Rudimentary.—In this type the characteristic signs are either undeveloped or wanting, and the diagnosis is possible only during the prevalence of epidemics, which furnish typical cases. The symptoms vary and are indefinite, but per- haps the most constant and significant are severe headache, languor, ver- tigo, nausea, and occasionally vomiting. Fever and contraction of cervi- cal muscles are absent, as a rule. The duration of rudimentary cerebro- spinal fever is brief, the more noticeable symptoms rarely exceeding three or four days. (2) The Abortive Form.—Here the initial symptoms are severe, but after two or three days they rapidly subside, leaving the patient conva- lescent. The disease is cut short by the acquisition of immunity, and not as the result of medical interference. (3) Intermittent Form.—In this variety the symptoms, however in- tense, remit or almost Avholly intermit every day or second day; these re- missions are followed by a decided exacerbation or recurrence of the dis- tressing features of the disease. Intermissions may occur at the begin- ning of a case, though more often they occur at an advanced stage and tend to prolong its course. There is not observed the strict periodicity that is seen in malaria, and neither is the temperature-curve typical of the latter disease nor are the malarial organisms found in the blood (4) Typhoid Form.—In a certain though small proportion of the cases CEREBRO-SPINAL MENINGITIS. 129 the special features are characteristic of the " typhoid state," but their course is more protracted than is usual. (5) Fulminant or Apoplectic Form.—The symptoms characterizing this most malignant type of the affection are rather inconstant. There may be severe chill, loss of consciousness, folloAved by deep coma and death, the whole course occupying the space of a feAv hours only. I saw two such cases in the same family : the first, a girl of five years, was stricken at 2 p. m. and died at 9 p. m. ; the other, a boy of seven years, was taken ill on the folloAving day about the same hour, and died at 10 P. M. Other instances pursue a someAvhat slower course, though manifesting the most striking malignancy. These begin with intense chills, violent head- ache, vomiting, early stupor, great prostration, contraction of muscles of the neck, moderate fever, and a feeble, progressively slowing pulse until it sometimes reaches 50 or even 40 beats per minute. The eruption, when it appears, takes the form of purpura. This form is most apt to be met Avith early in an epidemic, and with few exceptions proves fatal. Diagnosis.—The most important symptoms for diagnosis are the abrupt onset; intense pains (cervico-occipital and lumbar); prostration ; vomiting ; vertigo; somnolence, alternating with local or general tonic or clonic convulsions; delirium (often sportive in type); tonic contraction of the muscles of the neck, extending to the back ; marked hyperes- thesia ; a slow, followed by. a more rapid though variable, pulse; irregu- lar temperature-curve; and certain eruptions, especially petechial and herpetic. Differential Diagnosis.—The disease, especially the sporadic form, is apt to be confounded with certain other affections. (1) Tubercular Meningitis.—In this affection there is usually a tuber- culous history—either personal or family—with prodromes extending over many days (occasional vomiting, unnatural peevishness, constipation, etc.). The invasion-period lacks the sudden onset of cerebro-spinal meningitis; the degree of retraction of the abdomen is greater than in the latter dis- ease, while the arching of the neck is less ; the general myalgic pains and the hyperesthesia are also less marked than in cerebro-spinal fever; the herpetic and petechial eruptions are rare in tuberculosis and common in cerebro-spinal meningitis; while Cheyne-Stokes breathing and the well- marked changes of pulse belong peculiarly to the tubercular type. By the aid of the ophthalmoscope choroidal tubercles may sometimes be de- tected, and are signs of an invariably fatal complaint. (2) Pneumonia.—This affection may be complicated with a meningitis that affects chiefly the cerebral cortex. Hence, Avhile there will be motor spasm (more or less localized) and tremors, there will also be less retraction of the head and less myalgic pain than in cerebro-spinal menin- gitis. Again, pneumonia precedes the development of the meningeal symptoms, and when not seen early we cannot be certain in sporadic cases which was the prior affection. (3) Typhoid Fever.—The cerebral type of this affection may simulate closely the disease under consideration. In both may be observed fever, delirium, somnolence, retraction of the neck, spasm, tremor, and profound prostration. The mode of onset, however, is different, being slower in typhoid and unaccompanied by vomiting, muscular spasm, or hyperes- thesia. In typhoid there is also the characteristic mental dulness; the 9 130 INFECTIOUS DISEASES. fever is higher, with a typical temperature-curve; the roseate eruption is characteristic, appearing in crops at a definite time and runs a definite course; and there is greater enlargement of the spleen. Sequelae.—The leading sequelae are permanent blindness (due to optic neuritis with atrophy) and deafness, which sometimes terminates in deaf-mutism ; and in many cases headache outlasts the disease for months or even years. Chronic hydrocephalus and mental enfeeblement are not rare sequels (Ziemssen). Various local paralyses are observed, affecting either single extremities or single groups of muscles or the muscles sup- plied by the different cranial nerves, and recovery is to be expected in these cases after a feAv months. They are most probably due to certain peripheral lesions (neuritis and perineuritis). Immunity.—Permanent immunity is rarely conferred by the occur- rence of cerebro-spinal meningitis, relapses being common, and second attacks having been occasionally observed. Duration and Prognosis.—In very mild forms the duration is from one to four or five days. The most malignant type runs an even shorter course, when, as is the rule, it terminates fatally. If recovery ensues, it is after a long, serious, and protean illness. The abortive form is neces- sarily of brief duration. In the ordinary type convalescence usually sets in at the end of one or two weeks, though not a few cases are met Avith in which the latter period is much delayed, and a slow convalescence, hin- dered by numerous complications and sequelae, is the rule. The prognosis is influenced especially by the degree of severity of the type. Apart from the fulminant form, which nearly ahvays proves fatal, the severity of the infection may be appreciated by noting the degree of fever and the intensity of the nervous symptoms, especially the vomiting, coma, headache, opisthotonos, character of the respirations, etc. Compli- cations may likewise affect the prognosis, pneumonia, and suppurative in- flammations of the pleura or pericardium, rendering it particularly grave. Circumstances connected with the individual are also potent, and particu- larly the age. In children under two years the disease is very fatal, this period giving the highest mortality-rate; between two and five and after thirty years it is a more serious disease than during young adult life. The death-rate of cerebro-spinal fever varies greatly in different epidemics, ranging from 25 per cent, in the mildest to 80 per cent, in the severest. Treatment.—(1) General Management.—The patient should be iso- lated, aud the sick-room must be quiet and somewhat dark. All excite- ment is to be avoided; the patient must not be allowed to leave his bed until convalescence is firmly established ; and the rules for preventing the spread of infectious diseases are to be strictly enforced. The diet should be composed of nutritious liquids, such as milk and animal broths, etc., and as soon as convalescence begins the dietary should be increased by the addition of semisolid substances (rice, eggs, milk- toast, etc.), and, finally, the more easily digestible solids. The general course, and particularly the period of convalescence, may be much abridged by the systematic administration of appropriate articles. Water must be offered to the patient frequently. Medicinal Treatment.—Many and Avidely various modes of treatment have been recommended by as many different authors, but in my opinion it is best to treat individual cases according to the special indications pre- CEREBRO-SPINAL MENINGITIS. 131 sented. I regard it as extremely improbable that any case of this affec- tion has been benefited by venesection. Cold or gradually cooled baths, when the handling of the patient does not excite too much pain, are of great value, and warm baths Avill prove highly beneficial by lessening the tendency to tonic spasm of the muscles. Among medicinal agents narcotics are the most useful. Morphin, par- ticularly Avhen administered hypodermically, affords prompt relief from intense headache, myalgic pains, muscular contraction, and other nervous symptoms, and at the same time spares the heart. If the respirations be irregular, atropin may be combined with the opiate, and if the heart threatens to fail, strychnin may be administered. In young children Ave must rely upon the bromids rather than the opiates, and the former are quite effective in young subjects. In older children Ave may employ opium if Ave do so cautiously, and I have found the deodorized tincture of opium and paregoric to be the best preparations under these circum- stances. For the tonic contraction of the muscles, especially Avhen associated with violent cerebral symptoms, cannabis indica should be tried. Con- vulsions call for warm baths or ether-inhalations. Mercury has been, and still is, firmly advocated by certain authors, and, cerebro-spinal men- ingitis being an infectious disease, this drug may be given for its anti- septic virtue (mercuric chlorid gr. -£% (0.002) every four hours to an adult; calomel, gr. y1^—rV (0.005—0.004) every four hours to chil- dren). Belladonna and ergot have been employed to diminish the con- gestion of the cerebro-spinal capillaries. They should be administered in the early stages, and, thus employed, I have found them in my experi- ence not Avholly without value. Antipyrin, acetanilid, and phenacetin are not to be thought of in the treatment of this disease, owing to their depressing effect upon an already overburdened heart. Stimulants are required if signs of heart-exhaustion appear. They may be freely exhibited in accordance Avith the rules that obtain in other acute infectious diseases. During the advanced stage or after effusion of the exudate has taken place the narcotics are to be replaced by agents that promote absorption, and particularly the potassium iodid in full doses. The local means are also important. When tub-baths are not available, cold should be used locally, since it is both of value and very grateful to the patient. An ice-bag is to be put on the head, and, if possible, long ice-bags placed along the spine. In rare cases of asthenic type we may employ small blisters at the nape of the neck or over the mastoids: these should be applied early, though they are also useful during the stage of effusion. In the usual form of the disease it is better to apply the thermo-cautery lightly over the mastoid region. If the patient be not too much enfeebled, we may abstract a small amount of blood by means of leeches or by a few wet cups placed behind the ears. Convalescence is prolonged, and requires to be diligently and judi- ciously treated. We must rely upon the generally accepted tonics—iron, cod-liver oil, arsenic, and strychnin ; the potassium iodid and the mer- cury also being continued for their influence in promoting the absorp- tion of the exudate. Special attention is, however, to be paid to the hygienic management of this period. An abundance of fresh air, sun- 132 INFECTIOUS DISEASES. shine, and easily assimilable food must be furnished at all hazards, and electricity and massage, judiciously employed, Avill hasten recovery. LOBAR PNEUMONIA. (Croupous or Fibrinous Pneumonia; Pneumonitis; Lung Fever.) Definition.—An acute infectious disease caused by the Micrococcus lanceolatus, Avhich produces a specific inflammation of the parenchyma of the lung and marked constitutional disturbances—chill, extreme prostra- tion, and fever which terminates by crisis. Secondary septic complica- tions are frequent. There are different forms of lobar pneumonia, classi- fied according to their clinical or pathologic peculiarities, as primary lobar pneumonia, secondary lobar pneumonia, and lobar pneumonia Avith the formation of new connective tissue, etc. I shall describe the first tAvo forms under the present heading, and the third separately (p. 510). Pathology.—Usually the lesions are confined to the Avhole of one lobe; less frequently to the whole of one lung, and rarely to parts of both lungs. From Jurgensen's analysis of 6666 cases the following statement, showing the different situations of the lesions and their relative frequency, was taken : Right lung, about 54 per cent. ; left lung, about 38 per cent.; and both lungs, about 8 per cent. In the right lung the lower lobe was involved in 22 per cent., the upper in 12 per cent., the middle in nearly 2 per cent., and the Avhole lung in about 9 per cent. In the left lung the lower lobe was involved in about 23 per cent., the upper in about 7 per cent., and the whole lung in about 8 per cent. Both lungs were implicated in 8 per cent. The lesions of pneumonia are those of three stages : (a) Stage of con- gestion or engorgement; (b) Red hepatization (consolidation); and (c) Gray hepatization. (a) Stage of Engorgement—The part or parts implicated are of a dark- red color, and firmer to the feel, but less resilient and crepitant, than normal. The cut section drips a blood-stained serum, and dark blood exudes from the distended capillaries. The air-cells do not collapse, though they are not solid, since excised pieces float; but the Aveight of the lung-tissue is much increased and the air-sacs are distended with the corpuscular exudate. Collapsed portions may be observed which may readily be insufflated from the bronchus, and areas of extravasation may occasionally be noted near the pulmonary pleura. On microscopic examination the alveolar epithelium is seen to be swollen, the capillaries greatly distended, and the air-cells filled with alveolar epithelial cells, red corpuscles, and a few leukocytes. Similar elements occupy the small bronchi, while the mucosa of the larger bronchi is often hyperemic. (b) Red Hepatization.—The affected tissue is solid, airless, and firm, resembling, as the term indicates, liver-tissue. It is reddish broAvn (ma- hogany) in color, presenting a dry, mottled appearance, and when, as is usual, an entire lobe is involved, it is more voluminous than normal and LOBAR PNEUMONIA. 133 its surface is often furrowed by the impress of the ribs. Being airless, the affected portion does not crepitate, and its weight and specific gravity are increased. It cannot be inflated; is extremely friable, and its lace- rated surface presents a finely granular aspect, this latter appearance being due to the minute plugs of inflammatory matter (fibrin) which fill the air-spaces. The air-passages and small bronchi are distended with similar material, and granular masses can be removed from the air-cells of a cut or lacerated surface by carefully scraping the latter. If death takes place during this stage, the ante-mortem, dry, inflammatory exudate soon softens, and may Aoav from the cut section as a grumous, viscid fluid ; the consolidated tissue sinks rapidly in Avater. The pulmonary pleura is covered with a fine sheet of fibrin, and in cases preceded or complicated by marked pleurisy the fibrinous, inflammatory exudate forms a thick coating upon the pleural membrane, and the sac contains more or less liquid effusion (pleuro-pneumonia). Microscopic examination shows the air-spaces filled with clotted fibrin, in whose meshes are held red blood-corpuscles, pus-cells, and changed alveolar epithelium. The interlobular connective tissue may be infiltrated Avith leukocytes and fibrillated fibrin, but the blood-vessels in the walls of the alveoli remain pervious. The pneumococci (micrococci lanceolati), less frequently also streptococci and staphylococci, are revealed by the microscope. (c) Gray Hepatization.—In this stage the fibrinous exudation becomes decolorized, the surface at first resembling granite in color, and later appearing uniformly gray. Associated with this change, and following it, there is fatty and granular degeneration of the inflammatory exudate, in consequence of which the latter becomes moist and soft. The exudate loses its granular character, while at the same time the friability of the lung-tissue is further increased, and from the surface of the cut section there flows usually a grayish-white or yellowish-Avhite purulent liquid. Not less than one-half of the fatal cases die in the early part of this stage. The pleura that invests the involved tissue is usually covered with a fine fibrinous exudation. Microscopic examination shoAVS the air-cells stuffed with leukocytes, while the other histologic elements (fibrin, red blood-cells, etc.) have disappeared; and the full development of gray hepatization marks the beginning of resolution, though the latter process may in reality begin with the commencement of the former. The exudate is now softened into a liquid material, with disintegration of cellular elements, and is absorbed by the lymphatics. Resolution usually corresponds in time with the occurrence of the crisis, though it may begin later. Again, the pro- cess may be much prolonged. Among unfavorable terminations may be noted— (1) Purulent Infiltration.—Here the lung-tissue becomes very soft, fri- able, and is bathed in purulent material; and microscopic observation shows the pus-cells densely infiltrating the interalveolar tissue and filling the air-spaces as well. This impairs the nutrition of the lung-tissue, and may thus cause rupture of the septa, producing (2) Abscess.—This is to be attributed to subsequent infection by streptococci, and hence is a complicating lesion. The abscesses vary in size Avithin the widest limits, most frequently being situated near the base 134 INFECTIOUS DISEASES. of the lung, and may occupy the periphery and rupture into the pleural sac, causing pyo-pneumothorax. In most instances the abscess-cavity has a fistulous connection with a bronchus, but occasionally the abscesses become encapsulated in fibrous tissue, their contents undergoing first caseous, and then calcareous, degeneration. Rarely they open into the pericardium, and still more seldom externally. They may be small and multiple, in which case they sometimes coalesce, forming large abscesses. (3) Gangrene may rarely follow, but is due to a specific cause, and hence does not belong especially to the pneumonic process. (4) Induration.—A. Frankel states that in a few instances (about 1 per cent.) pneumonia ends in induration, and is found upon section to be smooth and its tissue resistant. The surface of the cut section sometimes shoAvs a peculiar transparency, with characteristic yellow specks, due to the collection of cells which have become fatty. Microscopically, the alveoli are seen to be blocked up by connective tissue resembling polypi and containing vessels. By its structure it re- calls the process of organization in a thrombus, and is probably due to secondary infection with a specific bacillus. It may also be observed after broncho-pneumonia. Changes in Other Viscera.—The heart often appears pale and is flabby, but upon microscopic examination the muscular cell-fibers of the organ are not found to be degenerated, except in rare and usually protracted cases. The cardiac chambers, particularly the right, are distended with firm, tough clots, which are usually removable en masse from the great vessels in the form of arboreal casts. To account for the great tendency to coagulation of the blood in pneumonia is the fact that its fibrinous ele- ments are vastly increased. Pericarditis occurs in about 5 per cent, of the cases, and is relatively more frequent in left-sided or double pneumonia. Endocarditis is more common, especially the ulcerative form, which was present in 11 out of 100 autopsies (Osier). With malignant endocarditis the lesions of men- ingitis are often combined, but as a separate complication meningitis is rarely encountered. The spleen is congested, moderately enlarged, and softened, and the liver is likewise hyperemic and somewhat swollen. In the kidneys are found the lesions of parenchymatous inflammation, and with remarkable frequency also thosfe of chronic interstitial inflammation. A catarrhal state of the gastro-intestinal mucosa (often with jaundice) is common; and a frequent complicating change is croupous inflammation of the colon. A true diphtheritic colitis, however, occurs but seldom. Etiology.— Bacteriology.—The generally accepted specific cause of pneumonia is the Micrococcus lanceolatus of Frankel. It is a lance- shaped (slightly elliptic) coccus, united in pairs (a fact to which it owes its name of diplococcus), and is present occasionally in the nose, Eu- stachian tubes, and larynx of healthy individuals. Netter found it'in 20 per cent, of the specimens of buccal secretion taken from well persons, and to the presence of this germ is to be ascribed the form of septicemia induced in animals by inoculation with saliva. It is present in about 90 per cent, of all instances of pneumonia, and in persons who have had the disease it is detectable for many months or even years. It is gen- erally present in pure culture, but may be associated with pyogenic organ- LOBAR PNEUMONIA. 135 isms. It is probable that Friedlander's bacillus and other micro-organ- isms may also have the power to cause the disease; and Wassermann * suggests that specific forms of pneumonia may coexist in the same indi- vidual, as, for example, lobar pneumonia and influenzal pneumonia, the latter being due to the bacillus of Pfeiffer. The Micrococcus lanceolatus (Fig. 15) can be readily demonstrated in the sputum by treating a cover- Fig. 15.—Diplococcus pneumoniae, from the heart's blood of a rabbit; X 1000 (Frankel and Pfeiffer). slip preparation " with glacial acetic acid, and then, after washing off the acid, dropping on anilin oil and gentian-violet, which is to be poured off and renewed two or three times." The mode of infection is not positively known, but it is highly probable that the pneumococcus is inhaled. The first and chief effects of the germ are local—in the lung, though it may reach more distant portions of the body, such as the pleura, pericardium, endocardium, meninges, etc., and the latter structures may rarely be invaded in the absence of involvement of the lung. To the widespread distribution of the pneumococcus is due, in part, the septicemic process sometimes observed. Usually, then, the disease is a local one at the start, but soon the toxins of the Micrococcus lanceolatus become diffused throughout the system, producing a general disturbance. Secondary infection with other specific organisms (strepto- cocci, staphylococci, etc.) commonly occurs in the various organs of the body. Predisposing Causes.—(1) Endemic Influence.—Among the popu- lace of a community sporadic cases constantly occur, although persons leading an out-of-door life in rural districts are less susceptible to the dis- ease than are residents in cities. That endemics of pneumonia, often of 1 Deutsche medicinische Wochenschrift, Leipzig, Nov. 23, 1893. 136 INFECTIOUS DISEASES. serious type, may occur in solitary buildings (barracks, tenement-houses, institutions, etc.) cannot be successfully denied, and here the disease appears to make for itself, rarely, a permanent home. We may, with justice, attribute these outbreaks to defects in local sanitary conditions, which favor the propagation of the specific agent and tend to lower the bodily resistance to bacillary invasion. (2) Epidemic Influence.—From time to time pneumonia prevails exten- sively, and appears to spread throughout a considerable percentage of the entire population of urban and rural districts. It may also originate in the endemic form in tenement-houses and institutions, and increase in its scope until it assumes an epidemic character. The epidemic form of pneumonia is at times confined to private homes (house epidemics), and in the Avinterof 1894 I saw, with Dr. W. K. Mattern of Philadelphia, 3 cases develop in rapid succession in one family. A Sister of Charity, after nursing tAvo of the patients faithfully for a period of ten days, was also attacked and died of the disease. There are many similar instances on record in which several members of the same family have contracted the disease at about the same time, and it is possible that the house- epidemic form may spread by contagion. An instructive epidemic is reported by W. B. Rodman, Avho states that 118 cases of pneumonia, with 25 deaths, occurred in a prison population of 735 ; and numerous epidemics of similar character have been observed in other localities, both at home and abroad. (3) Geographic Distribution.—Pneumonia may be said to be an almost universally distributed affection. It prevails, however, more exten- sively in certain countries than in others, and occurs more frequently in certain sections of the same country than in others. Thus, Delafield1 points out the fact (based on the eighth and ninth census reports) that in the United States the disease is of more frequent occurrence in the South than in the North. Climate, per se, does not, however, exercise a notable influence. (4) Season.—Of 5905 cases collected by Seitz in Munich, 36.8 per cent, occurred in the spring, 32 per cent, in winter, 15.7 per cent, in autumn, and 15.3 per cent, in the summer. The period of maximum frequency of the affection in temperate climates is usually from the begin- ning of February to May, inclusive, and the next most frequent period is from December until February. In London most cases appear between the end of March and the end of June (Herringhan). The period of greatest frequency will be found to correspond in time with the period of the greatest vicissitudes of temperature and humidity, though it cannot be affirmed positively that there is an essential connection betAveen the latter condition and pneumonia. Richter2 claims that when the atmo- spheric pressure is high the cases are more numerous; Avhile, on the other hand, when it is low the cases are much feAver in number. (5) " Catching cold " is often folloAved by pneumonia, but frequently there is no such history. In this condition the mucosa of the respiratory passages is so altered as to become more susceptible to infection Avith the pneumococcus, and hence the so-called "cold" is a predisposing cause. 1 '•' Diseases of the Lungs," American Text-Book of the Theory and Practice of Medicine Pepper, vol. ii. p. 540. 2 The Journal of the American Med. Assoc, Aug. 4, 1894, p. 188. LOBAR PNEUMONIA. 137 Such facts as these also explain Avhy pneumonia occurs with undue fre- quency in persons following certain occupations exposing them to those external influences that are apt to excite " cold." (6) Traumatism.—Following injuries, especially of the chest, pneu- monia occurs quite frequently. Contusions of the thorax by loAvering the vital power and resistance of the tissues probably produce the same local effects as taking "cold." (7) Age.—Lobar pneumonia is common at all periods of life, and during the first two years of life lobar pneumonia is quite frequent. Be- tween two and tAventy years of age there is less liability, and between twenty and forty it is again increased; Avhile from forty to sixty years susceptibility again diminishes. After the latter period it augments rapidly. (8) Sex.—Males are, on the Avhole, more frequently attacked than females, the discrepancy in the relative number of cases being greatest from the twentieth to the fiftieth years of age, and being due to the dif- ferent degrees of liability to exposure in the two sexes. (9) Unhygienic Surroundings.—The disease is more frequent among the loAver than the higher classes—a fact due to the improved hygienic surroundings of the latter, since, doubtless, anything that will lower the vital energy will serve as a predisposing factor. (10) Circumstances connected with Individuals.—The alcoholic is espe- cially prone to this disease, any or all habits that tend to depress the ner- vous system acting as predisposing causes. Certain chronic diseases may exert an influence (chronic Bright's disease, organic heart-affections, car- cinoma, diabetes, etc.); but, contrary to Avhat is observed in other acute infectious diseases (typhoid fever in particular), susceptibility is not so great among immigrants and new-comers as among the natives and the older residents. (11) Prior Attacks.—One attack undoubtedly leaves the system more susceptible to the disease, so that repeated attacks may occur in the same individual. And yet Avhile it is true that persons have had nu- merous attacks—ten or more—this predisposing influence has probably been overestimated by most Avriters. Immunity.—The results of the investigations of Behring and Kitasato with the blood-serum of animals which had been immunized against tetanus and diphtheria led Drs. G. and F. Klemperer to experiment upon the lower animals Avith Frankel's diplococcus. They found that the rabbit could be rendered immune by intravenous or subcutaneous injections of large amounts of the fluid bouillon-cultures or of the glycerin-extract. From 10 to 20 c.c. of serum taken from a non-receptive animal were injected into the veins of an animal that was suffering from typical pneumonia (artificially produced), whereupon the symptoms subsided rapidly and the animal entered upon a speedy recovery. The same serum, used in a similar manner upon healthy receptive animals, rendered them non-recep- tive. The important truth that the serum of the blood of patients dur- ing convalescence from pneumonia contains an antitoxin Avhich, when injected into the venous system of infected animals, is found potent to cut short the disease, has also been demonstrated by these observers. They have employed the blood-serum of pneumonic patients after the crisis, injecting it into other patients before the crisis with a vieAv to 138 INFECTIOUS DISEASES. inducing the latter, and success has attended their efforts in 6 cases. The question of serum-therapy for this important affection in man is not finally cleared up, and is still beset with difficulties ; but that the pneumococcus engenders a virus—pneumotoxin—which produces eleva- tion of temperature, etc. has been clearly demonstrated by the Klemperer brothers. Again, that this substance, acting upon the albuminous ele- ments of the body, generates an antipneumotoxin Avhich circulates in the blood and neutralizes the pneumotoxins as they are formed, inducing the crisis, has also been clearly proved. Antipneumotoxin, however, has not as yet been isolated. Clinical History.—Prodromes are rare, and Avhen present consist merely of a slight general indisposition, lasting a day or more. Rarely, there is cough, thoracic oppression, and slight chest-pains (simple bron- .chitis), that may or may not be connected with the pneumonic process. When this is the case, however, the invasion may be marked by sudden, great thoracic oppression or by a gradual development of the local and general symptoms. Usually the onset is very abrupt, being marked by a severe rigor, Avhich has a duration of from half an hour to an hour, during which pe- riod the patient feels most uncomfortable, and is, indeed, very ill. The initial chill may occur at any hour of the day or night, the fever rising immediately and rapidly, and the temperature often mounting to 104° F. (40° C) or even higher in the course of a feAv hours. The skin be- comes harsh and dry, the face flushed, and the cheek on the side affected often shows a circumscribed deep-red spot. Prostration is pronounced, and headache and other nervous disturbances (restless delirium, etc.) accompany and folloAV the ushering-in symptoms. The thoracic symptoms folloAV closely upon the termination of the chill. Inspiration, particularly if deep, causes a stabbing pain in the affected side ; the respirations are hurried, somewhat jerking and shallow (panting), while the pain persists, and later dyspnea may become marked, Avith accelerated breathing. Cough sets in early, and is dry and pain- ful during the first day or even longer, and may be attended with expec- toration, which generally presents a characteristic rusty or blood-stained appearance. The physical signs rarely appear before the end of the first day, and sometimes as late as the third (central pneumonia); in the latter form the local symptoms, as cough, dyspnea, and sometimes pain, are either wanting or feebly marked during the first three or four days, and the clinical picture is composed of the general features only. Anorexia is usually complete; thirst is excessive, and there may be vomiting at the onset, the bowels being generally constipated, though diarrhea may not infrequently be present. The patient in most instances lies upon the affected side until the pain has in great part subsided, and then he is apt to assume the dorsal position, exposing to full view an anxious countenance, with a characteristic flush upon the cheek Avhile the alse nasi are seen to dilate forcibly during inspiration. Very frequently herpes on the lips or nose appears about this time, and forms a valuable diagnostic symptom. The nocturnal remissions are slight, the temperature being of the continued type, and the fever con- tinues high—104° to 105° F. (40.5° C.)—for from five to ten days, and generally terminates by crisis. The pulse is somewhat quickened but LOBAR PNEUMONIA. 139 the pulse-respiration ratio is not maintained. The other general features last until the crisis occurs, or even increase in severity, but do not out- last this period; many of the local symptoms, hoAvever, and particularly pain, are greatly improved before the crisis is reached. As will be seen hereafter, the general course of pneumonia is modi- fied by a variety of interfering conditions that have relation to compli- cations, individual circumstances, severity of the type, etc. In the in- stances in which the crisis is reached convalescence is rapidly established. The crisis may be accompanied by special symptoms, as copious sweat- ing or diarrhea. Leading Symptoms in Detail.—Local or Respiratory Symptoms.—In- creased frequency of the respirations is a characteristic symptom, the rate varying from 40 to 60 per minute in adults, and in children from 60 to 90 or more. It is panting in character, particularly Avhen pneumonia occurs in old subjects, and both inspiration and expiration are brief, though sometimes separated by a rather long pause. Expiration is usually accompanied by an audible " grunt," indicating great oppression, and while actual dyspnea is a frequent symptom, it may be absent or as the case progresses may become either increased or greatly diminished according to the severity of the type. The chief causes of the rapid and labored breathing are the involve- ment of a large portion of the lung, associated severe general bronchitis, pericarditis or extensive pleurisy, cardiac failure, collateral congestion with edema, fever, and the intense pain in the side. The pulse-respiration ratio is disturbed, the relation noAV being 1 to 2, or even 1 to 1.5, instead of 1 to 4, as in health (see Fig. 16). Pain in the affected side is in most cases developed Avithin a few hours after the initial chill, and after lasting tAvo or three days gradually dis- appears. It is stabbing in character, and usually referred to the region immediately below the nipple or to the axilla, and rarely to other points (abdomen, flank, etc.). In most instances it is not severe until greatly intensified by the cough, which always aggravates this symptom, as does deep inspiration. The pain is due to implication of the pleura covering the inflamed lung, and may be entirely absent, though usually in the aged only. The cough, like the chest-pain and respiration, is someAvhat charac- teristic, being frequent, short, dry, and voluntarily repressed, because it is attended Avith increased suffering. Yet there are cases that run their entire course Avithout cough, and this especially in the aged and in drunkards. The Sputum.—At first mucoid and frothy, it soon becomes of a cha- racteristic rusty color. It consists of a frothy, fluid mucus containing an abundance of small viscid masses of a yelloAvish- or reddish-brown color, from admixture of blood. The chief peculiarity of the sputum in fully developed cases is its viscidity and tenacity, often adhering to the receptacle even though the latter be inverted; OAving to its adhesive quality it is ejected from the mouth with considerable difficulty by the patient. About the time of the crisis the sputum usually becomes more abundant, distinctly purulent, and its expulsion easy, but rarely it may be absent after the crisis. In severe types of the disease it may, at the outset, consist largely of pure blood, and in adynamic forms it is often 140 INFECTIOUS DISEASES. thinner and darker in color (prune-juice). There are cases in which there is an abundance of muco-purulent expectoration when extensive associated bronchitis occurs, and, on the other hand, instances are met with in Avhich nothing is expectorated save a little light-colored mucus. In old persons or in those previously enfeebled there may be no expec- toration whatsoever. The amount is therefore exceedingly variable, not only in different cases, but also in different stages of the affection. Under the microscope the sputum is seen to contain red blood-cor- puscles, alveolar epithelium, the Micrococcus lanceolatus (usually with other micro-organisms), pus-corpuscles, and small fibrinous casts. General Features.—The Fever.—As I have already stated, the fever rises rapidly during the initial chill, so that in eight to twelve hours the temperature reaches 104° or 105° F. (40.5° C). It then remains high until the crisis, pursuing the continued type, with nocturnal remissions amounting to a degree or over, Avhile the daily fluctuations correspond Avith the normal, except that they are now someAvhat exaggerated. In children the rigor is almost always replaced by convulsions. The tem- perature has a loAver average range in persons previously debilitated, in old people, and in drunkards, than in healthy adults and children. During the febrile period there may be observed a pronounced fall of temperature—pseudo-crisis—but the temperature again rises to its former height. This may occur quite early, though more often it precedes the true crisis by a day or two; and rarely it may take place repeatedly, and the temperature-curve bear a strong resemblance to the remittent or even the intermittent type, regardless of any malarial affection. The temperature may be unusually high, 106° F. (41.1° C.) or even 107° F. (41.6° C), these striking elevations sometimes immediately preceding the crisis (perturbatio critica); but this does not belong particularly to pneumonia. It is especially characteristic of pneumonia, hoAvever, that the fever terminates by crisis; hence a mere glance at the temperature- chart may serve to complete the diagnosis in doubtful cases (see page 141). The crisis may occur anyAvhere from the end of the third to the fourteenth day, but in the majority of instances it is on the fifth or the seventh. The temperature usually falls during the night, and the drop is accompanied by copious perspiration, so that by the folloAving morn- ing the thermometer is found to register at the normal, or more often a subnormal, point (96-95° F.—35° C). This fall in temperature may also be interrupted by fresh though slight exacerbations. The duration of the period of decline is usually from eight to twelve hours. It may be much shorter, but more often is much longer, just as when the decline takes place by lysis. The latter mode of termination is usually due to some complication, and when the high fever persists for an indefinite period (twelfth to fourteenth day or longer), it is usu- ally due to delayed resolution. Circulatory Symptoms.—Most important is it to study the condition of the heart and pulse in cases of pneumonia. The average pulse-rate in typical cases is about 100 to 108 per minute, and when it exceeds 120 there is just cause for alarm. The rate may be increased either suddenly or gradually, but in any event augmented frequency implies danger, since it is a certain indication of failure of heart-power. The latter may be due to the influence of the poison secreted by the diplo- Fig. 16.—Chart of a case of lobar pneumonia with favorable course. A. T., ajjied thirty-two years; lower right lobe affected. Black, temperature; red, pulse; blue, respirations. 142 INFECTIOUS DISEASES. cocci, to previous organic disease of the heart, or to some complicating condition (pericarditis, collateral edema, etc.), and the period of great- est liability is in the advanced stage of the disease. At first the pulse is small, but a little later full and bounding. With complete and ex- tensive consolidation the pulse is apt to become small, due to the fact that a lessened amount of blood reaches the left ventricle and the gen- eral systemic circulation. Dicrotism is sometimes noticeable, and an irregularity in the volume and rhythm of the pulse may be observed; it is an unpropitious sign. In the aged and the debilitated a small, feeble, and frequent pulse may be present throughout the attack. The heart-sounds are clear, and owing to increased tension in the pulmonary vessels the pulmonary second sound is accentuated. This is the state of things throughout in favorable cases. With failure of the right ventricle (a not rare event) there arise the signs of dilatation of this chamber (extension of cardiac dulness to the right, epigastric impulse, a Ioav systolic murmur, shortening of the diastole, or fetal heart- sounds, signs of venous stasis, and indistinctness of the pulmonary sec- ond sound). The strength of the right ventricle, upon Avhich so much depends in pneumonia, is indicated by the character of the pulmonic second sound. A soft, low-pitched murmur is sometimes audible in the mitral and pulmonary zones. The blood-appearances are somewhat characteristic. The researches of Lache1 shoAv that leukocytosis is of some value in determining be- tween the crisis and pseudo-crisis, continuing in spite of the fall of tem- perature, etc. in pseudo-crisis, Avhile it disappears with the true crisis. Stienon2 finds that in the febrile stage the polynuclear forms predom- inate, but as soon as these diminish the eosinophiles begin to increase. The red corpuscles and hemoglobin remain little changed during the course of the disease, but show a marked decrease almost immediately after the actual crisis.3 The prognostic significance of absence of leu- kocytosis Avould seem to be considerable, as this symptom serves to dis- tinguish pneumonia from influenza, in uncomplicated cases of Avhich it does not occur. The blood-plates are also increased in number (Hayem), and the micrococcus has been found in the blood, though rarely. Cerebral Symptoms.—Headache sets in early and may be a prominent and persistent feature. In many cases, and particularly in children, the disease is ushered in by convulsions, this symptom occurring more often in the apical than in the basilar form of pneumonia. Delirium may come on during the acme of the disease and may assume a maniacal form, but more often in my experience consciousness has been retained during the whole attack in all but the severest cases. In the drunkard delirium tremens usually develops, and may anticipate the symptoms referable to the lungs; and I fully agree with Osier in stating that it should be an invariable rule, if fever be present, to examine the luno-s in delirium tremens. These cases may often be appropriately termed " walking pneumonia," since they go about until excitement gives way to a coma that deepens into death. In adynamic forms a low muttering 1 Berliner klin. Woch., 1893, Xos. 36 and 37. * La Presse Med., July 13, 1895. 'Sadler, Fortschritteder Medicin, 1892; Leichtenstein, Ueber der Hdmoglobin-gehalt des Blutes, etc., Leipzig, 1892. 3 * LOBAR PNEUMONIA. 143 delirium is frequent, and is sometimes accompanied Avith more or less coma. In the so-called cerebral pneumonia the nervous phenomena are quite pronounced, and simulate closely cases of cortical meningitis. It is often associated Avith excessively high fever, except in the aged, Avhen the cerebral symptoms are also Avell marked, but the fever is moderate. Most authors contend that apical pneumonias are apt to assume the cerebral type, but, according to my OAvn experience, this dictum is cor- rect as relating to children only. Most authors also state that double pneumonias are characterized frequently by severe cerebral symptoms, yet I have seen several instances in the adult Avithout unusual nervous phenomena. The Cutaneous Symptoms.—As stated before, herpes is common and its diagnostic importance is considerable. Naso-labial herpes is but little less frequent in this disease than in malaria, being present in about one- third of the cases. It usually comes out from the second to the fifth day of the disease, and rarely may appear upon the cheek, lobe of the ear, the genitals, forearm, or upon the mucosa of the tongue. Sweats are not common during the height of the disease, but usually accom- pany defervescence, when they may be copious. The deep-red circum- scribed spot upon one cheek (mahogany flush), usually on the side of the affected lung, has already been mentioned. Urticaria has been ob- served, though rarely. Digestive System.—The mucous membrane of the mouth is dry, the tongue has a coating of a yellowish-Avhite color, becoming dry and brown in cases representing a low form, and anorexia and thirst are present. Vomiting is not uncommon at the outset, and may be repeated, Avhile constipation is the general rule and diarrhea the frequent exception. The above symptoms spring from the marked fever. Splenic enlarge- ment of slight degree can usually be detected on palpation, but the liver is not perceptibly increased in size. Urinary Symptoms.—The urine is febrile, diminished in amount, and high-colored, the urea and uric acid being greatly in excess. On the other hand, the chlorids are, according to the older authors, either diminished in amount or absent during the febrile stage, presumably for the reason that they pass into the inflamed lung-tissue. They are not, hoAvever, constantly absent, and sometimes they are not even lessened, in pneumonia; moreover, their disappearance is not peculiar to this dis- ease. The above-mentioned facts justify tAvo important inferences : (1) The absence of chlorids is a symptom of little diagnostic value ; and (2) their reappearance in the urine tOAvard the close of pneumonia is of small prognostic Avorth. Slight (febrile) albuminuria is common. Physical Signs.—Stage of Congestion.—The density of the lung is increased, but the involved tissue is not consolidated and the pleura is not yet covered Avith fibrin. Inspection.—The movements of the affected side (especially if the base be involved) are defective, the degree of expansion being much diminished. In double pneumonia the costal type of breathing, com- bined Avith a vigorous play of the abdominal muscles, is observed. Palpation.—There is a slight increase in the tactile fremitus over the congested area. 144 INFECTIOUS DISEASES. Percussion.—The note may be normal, though more often it is briefer, higher-pitched, or even distinctly tympanitic. Auscultation.—The breath-sounds are weak, and sometimes become broncho-vesicular upon deep inspiration, while over the unaffected lung- tissue they are exaggerated. If, as often happens, inflammatory prod- ucts due to associated bronchitis occupy the small bronchi, subcrepitant rales may be audible. The crepitant rale, hoAvever, is rarely heard until the close of the first stage or until fibrin coats the pleural sur- faces, and I cannot agree with the view of certain authorities who claim that this rale is produced in the air-cells and finer bronchi. Stage of Consolidation.—Inspection.—There is little or no expansive motion of the chest over the affected area, while upon the unaffected side it is increased. The volume of the thorax on the diseased side is increased, as shown by mensuration, but the intercostal depressions are not effaced. Palpation renders clearly perceptible the defect or absence of expan- sion. Vocal fremitus is usually much increased, though in exceptional instances it is diminished or absent—a circumstance which can, as a rule, though not invariably, be attributed to an associated pleurisy with more or less effusion. Frequently a friction-rub is felt before complete consolidation is established. Percussion.—Varying degrees of dulness are obtained in this stage, and before the lung-tissue becomes thoroughly solidified the note may have a tympanitic quality. After complete consolidation there is usu- ally marked or absolute dulness posteriorly, while the note may be more or less tympanitic anteriorly, where the vibrations are more apt to reach the air in the larger bronchi. A sense of resistance is offered to the pleximeter-finger, but not to the same degree as in the case of a pleurisy Avith effusion. When the latter condition is associated the percussion- note will be flat. Deadness is less marked in old people in whose ribs senile changes have taken place, which render them more resonant, or in cases in which the consolidated areas occupy the central portions of the lung. Above the solidified part Skodaic resonance is usually obtainable. Auscultation.—Bronchial or tubular breathing is heard, as a rule, over the solidified lung, but it may be absent in consequence of the plugging of the large bronchi with exudate (so-called massive pneu- monia). Bronchophony is usually obtainable over the portion of the lung affected, though this may also be absent, and for the same reason as in the case of the bronchial breathing: it sometimes takes the form of egophony. Subcrepitant rales, due to associated bronchitis, are sometimes heard, and the crepitant rale at the end of inspiration, sup- posedly very characteristic, is best heard at the beginning of consolida- tion, when the pleura receives its coat of fibrin and while the lung is yet capable of sufficient movement to produce fine pleural friction. A distinct friction-rub may also be heard occasionally. Stage of Gray Hepatization.—With beginning resolution the solid con- tents of the air-cells liquefy and are removed, so that air now re-enters the air-cells and permits a consequent increase in the movement of the lung. Inspection.—The normal expansile movement of the affected side gradually returns. Palpation.—Tactile fremitus progressively diminishes. LOBAR PNEUMONIA. 145 Percussion.—The dull or tympanitic quality of the note is gradually lost, though the fact must be emphasized that the abnormalities in the note vanish more slowly than the other abnormal physical signs. Some degree of deadness often remains long after recovery is apparently com- plete. Auscultation.—With increased movement of the lung there may be a reappearance of the crepitant rale, due to interplay of the pleural sur- faces, and the softened exudate in the air-cells gives rise to subcrepitant rales, heard both on inspiration and expiration, Avith coarser rades over the bronchi. Bronchial breathing gradually gives place to broncho- vesicular, and the latter in turn to normal breathing. Complications.—Doubtless many of these are due to the primary infection by diplococci. Pleurisy is, of necessity, associated in all instances in Avhich the con- solidation reaches the pleura. It is to be looked upon as a direct result of the pneumonic process, since in a great proportion of cases examined the presence of the diplococci has been demonstrated. Cases are met with, hoAvever, in Avhich the truly pneumonic symptoms are overshadoAved by the intensity of the pleuritis, and to these the term pleuro-pneumonia has been applied. In this form there is often a copious effusion which is exceedingly rich in fibrin—a circumstance Avhich distinguishes it from other forms of acute pleurisy. There may be the ordinary grade of pleurisy on the side affected by the pneumonia, and a severe grade on the opposite side, and Avhen effusion occurs under the latter exceptional conditions it is apt to be purulent. Indeed, empyema has of late been shown to be a frequent complication of pneumonia, but, as far as my own observation goes, it would appear to rank as a sequel rather than a complication, coming on as it usually does several days after the crisis. Its development is accompanied by replacement of ordinary dulness by flatness with great resistance, and by the disappearance of rales and breath-sounds, normal and abnormal. Other characteristic features of empyema are present, but in the event of doubt surrounding the diag- nosis the needle should be introduced. There is a prompt rise of fever, the temperature leaping to 103° or 104° F. (40° C.) quickly, after Avhich it is decidedly remittent in type, but there are no hectic chills. Fistulous connection with a bronchus, hoAvever, and the establishment of empyema necessitatis are common events in this form of the disease, and may be preceded by diurnal chills, sweats, etc. The occurrence of septic phenomena is a certain indication of second- ary infection by streptococci. The pus is absorbed very rarely, and more frequently becomes encysted. I saw one instance in which the effusion measured 8 liters, while ordinarily the amount ranges from 2 to 5 liters. Removal of the effusion by aspiration is promptly folioAved by the disappearance of the fever, but reaccumulation generally occurs, Avith another rise of temperature. Finally, if defervescence takes place by lysis or if the "critical" decline is absent, a residual purulent or sero-fibrinous effusion may be considered as the likely cause. This latter complication is attended by a paroxysmal cough Avhich is excited by movement, and is not usually accompanied by expectoration, while the temperature rises, though not 10 146 INFECTIOUS DISEASES. so high as when the effusion is purulent. It remains to be pointed out that rarely also there is a primary empyema, due to the pneumococcus. Acute general bronchitis may pre-exist or may arise as a complication, and often proves formidable, intensifying the fever and increasing the dyspnea, the tendency to heart-failure, and the cyanosis. The expec- toration of mucus is freer than in uncomplicated pneumonia, and over the bronchi moist rales intermingled Avith sibilant and sonorous rales are audible. Pericarditis.—This is one of the most important complicating affec- tions. It results from a direct extension of the adjacent pleuritis, and hence is more common in left- than in right-sided pneumonia, and chil- dren are more prone to it than adults. Although generally of the plas- tic variety, it is not infrequently sero-fibrinous, and rarely the effusion is purulent. The diagnosis can be made in the same way as when other conditions attend its development, but it may be readily overlooked by the careless observer. I Avould say, hoAvever, that the occurrence of in- creased dyspnea, Avith or Avithout precordial pain, should serve as a Avarn- ing and lead to a physical examination. Endocarditis.—This is far more frequent than pericarditis, and par- ticularly in the ulcerative form. Out of 209 cases of malignant endocar- ditis collected by Osier, 54 cases occurred in pneumonia, and my experi- ence fully agrees Avith his statement as to its great relative frequency in this disease. There are no reliable symptomatic indications of this condition, and of those symptoms that do appear the physical signs are least trustworthy. Frequently murmurs are entirely absent; and, on the other hand, the presence of a murmur, even though it be loud and harsh, is by no means diagnostic of the condition. Some claim that a rough diastolic murmur is quite significant; this has not, hoAvever, been present in any of my OAvn cases. The development of septic manifesta- tions, especially irregular fever, chills, and SAveats, renders the case highly suspicious, and Avhen in addition there arises distinct evidence of embolic processes the diagnosis becomes highly probable. If, now, the symp- toms of meningitis should supervene, little doubt would remain as to the character of the complications, since meningitis and endocarditis are often combined in pneumonia. Netter, Weichselbaum, and Bignami have shown bv microscopic examination and cultivation that acute endocarditis may "be caused di- rectly by the diplococcus of pneumonia, and; from the presence of this bacillus in the right ventricle, that it is far commoner than the forms due to other causes.1 Chronic Endocarditis.—This predisposes to acute endocarditis, both simple and ulcerative, but, independently of the acute form, pneumonia arising in the course of chronic endocarditis is apt to be attended by cardiac failure, Avith venous stasis as the consequence. The murmurs of chronic valvular disease often disappear with the development of pneumonia. Cardiac clots (ante-mortem) may form, but are rare. They result from weakness of the ventricular wall, especially in the rio-ht heart- and are most apt to arise, therefore, in cases in which the death-ao-ony is much prolonged. Venous thrombosis is rarely seen, and embolism of 1 Practitioner, London, Aug., 1894. LOBAR PNEUMONIA. 147 the larger arteries is a rare complication. Cerebral embolism, causing aphasia and even hemiplegia, has been observed but seldom. Acute purulent meningitis is a comparatively rare but very grave com- plication. It is often related etiologically to pneumonia, and its symp- toms are not clearly defined; particularly is this true Avhen it develops during the invasion-period and the basilar meninges are not involved. Hence its diagnosis is often impossible. The presence of intense and persistent headache, rigidity of the nucha, Avild delirium, folloAved by stupor deepening into profound coma, affords a basis for a probable diagnosis. Its frequent association Avith ulcerative endocarditis and the symptoms of the latter have already been pointed out. Peripheral neuritis is among the rare complications of this disease. Its presence is attested by the usual symptoms. Parotitis is also sometimes seen, and may cause a fatal termination of the case. I have seen tAvo instances, hoAvever, in Avhich this Avas a complication, and both ended in recovery. It is thought to be associated usually with endocarditis, but in neither of my OAvn cases Avere there any symptoms pointing to the latter affection. Arthritis.—This may arise at any period in the course of pneumonia, and at the start may closely simulate rheumatism. It soon, however, takes the form of a purulent arthritis, and may be associated Avith other suppurative inflammations (meningitis, endocarditis). The pneumococci have been found in the affected articulation.1 Gastro-intestinal Complications.— Croupous gastritis may rarely inter- vene, but croupous colitis is a more frequent concomitant, giving rise to tympanites and marked diarrhea, and it may prove a serious condition. Peritonitis occurs, but with great rarity. Jaundice may be observed in all types of the affection, though, on the Avhole, it is more frequent in serious than in mild forms of the dis- ease. Apart from the cutaneous and conjunctival discoloration, Avhich is rarely intense, it has no symptoms in the majority of instances, and yet even in such it is most probably obstructive (hepatogenous). I have observed cases in which the evidence of a certain degree of ob- struction was unmistakable, and these are to be ascribed to the presence of duodenal catarrh with extension into the ducts. Acute nephritis, generally of a mild grade, is a rare sequel or com- plication, and its recognition is entirely dependent upon the discovery of albumin and casts in the urine. Clinical Varieties and Anomalous Types.—(1) Typhoid Pneu- monia.—This relates to an adynamic type of the disease Avith typhoid symptoms, and not to typhoid fever. It is often secondary to Ioav fevers, to septicemia, diabetes, and chronic nephritis, and is also the variety met Avith in drunkards and in persons previously enfeebled on account of unhygienic surroundings. The onset is more gradual than in typical pneumonia. The physical signs may be Avell marked or ill defined, but in either event the general features are at once striking and characteris- tic. Prostration is extreme; there are delirium and often stupor; the temperature may or may not be high ; Avhile the respirations and pulse are almost ahvays frequent. The skin is dry, and not infrequently there is a dusky tint or slight jaundice. The tongue is dry, often broAvn, and 1 Bernheim, La Medecine moderne, Paris, Feb. 21, 1894. 148 INFECTIOUS DISEASES. vomiting is more common than in ordinary pneumonia; the sputa may be rusty or decidedly hemorrhagic. Splenic enlargement is often clearly perceptible. In this form of the disease there are numerous perils to pass, and when recovery ensues convalescence is long and tedious. This clinical form is not to be confounded Avith pneumo-typhoid, in which typhoid fever begins with pneumonia. (2) Epidemic Pneumonia.—This is often of malignant type. The symptoms exhibit noticeable variations, according to the special etiology and to different epidemics. The pneumonias that have developed so frequently in the course of epidemic influenza have been complicated with or preceded by general bronchitis. The heart-power in many cases became exhausted early, and then followed congestion and edema of the lungs. The physical signs are often slight, even in fatal cases. In certain epidemic forms of pneumonia still other complications may be pronounced (cerebral, intestinal, etc.). In this connection should be mentioned so-called " larval pneumonia" in which the general symp- toms are mild and the local signs ill defined. This sub-variety is ob- served in those epidemic outbreaks that occur in institutions, tenement- houses, jails, etc. (3) Latent Pneumonia.—To this class belong central pneumonias, which have been described briefly under General Symptomatology. In these instances the sputum is to be stained and examined microscopi- cally, when the pneumococcus Avill be found. When pneumonia arises in the course of emphysema a physical examination often gives negative results, and hence, the dilated air-cells not being filled with the fibrinous exudate, dulness is less marked than in typical pneumonia, and tubular breathing is often absent. The sputum is gummous and rusty, as a rule, and should be studied bacteriologically. Generally, but not al- ways, before the crisis occurs consolidation advances to the periphery, Avhen a physical examination will give positive results. (4) Migratory Pneumonia.—By this is meant an extension of the spe- cific inflammation to other parts of the lungs. This may occur at the time of the appearance of abundant moist rales in, and free expectora- tion from, the lobe first affected. Such extension prevents the occur- rence of the usual crisis, and often occasions an exacerbation of the general pneumonic features. (5) Bilious Pneumonia (" Malarial Pneumonia ").—When lobar pneu- monia occurs in persons Avho are subjects of malarial poisoning the ini- tial chill is prolonged and the fever paroxysmal or decidedly remittent. Jaundice and vomiting are more common than in the ordinary type. (6) In children, particularly in the very young, the first symptom is often a convulsion. Cerebral symptoms, as delirium, stupor, or even coma, may appear early. The upper lobes of the lungs are more fre- quently involved than in adults. Unless the objective indications be examined for, the disease is frequently overlooked. The characteristic sputum is rarely seen in juvenile pneumonia. (7) In old persons pneumonia runs a peculiar course and is danger- ous in the extreme. Most cases begin less abruptly than in younger persons, the initial chill being often absent or replaced by moments of chilliness. There may be nausea and vomiting, and anorexia is usual. Prostration sets in early and is profound, and there is fever LOBAR PNEUMONIA. 149 but this does not range so high, and its type is more irregular than in non-senile pneumonia. Nervous phenomona, sometimes prominent, are not uncommon, but the local symptoms (cough, expectoration, and pain) are feebly developed or Avholly absent. The area of lung-tissue impli- cated is often insignificant, the physical signs being slight or even entirely wanting; and Avhen present there is usually dulness on percus- sion (Avith a tympanitic quality), tubular breathing, and a feAv subcrep- itant rales. The physical signs are often sharply localized and their character variable. This affection, as it occurs in old people, is a most deceptive one, the cases very generally ending fatally after an illness of an apparently mild degree of intensity. Relapses.—These are among the rarest of events, and are usually rudimentary when they occur. Recurrences are ordinary, hoAvever, second, third, fourth, and even more attacks having been noted in the same individual (vide Etiology). Course and Duration.—In cases which recover the febrile stage lasts from three to thirty or more days. In most instances, hoAvever, defervescence occurs on the fifth or seventh day, and resolution is com- pleted about one week later, making the total duration from tAvelve days to tAvo or three weeks. Convalescence may be delayed when complica- tions outlast the primary disease or Avhen sequelae arise, and fatal cases are most apt to terminate on the seventh, eighth, and tenth days of the disease. It remains to be added that the regular course of pneumonia is often greatly modified by the various complications (endocarditis, pericarditis, meningitis, etc.). Termination.—(a) Delayed Resolution.—The process of resolution, con- sisting in softening of the exudate and its subsequent removal (partly by absorption, partly by expectoration), may not begin until the fourth, sixth, eighth, or even tenth week. Usually defervescence with a mod- eration of the other general features has taken place long before the physical signs indicate resolution. When the latter change occurs it may lead to complete restoration of the functional and anatomic en- tirety of the lung-tissue, or proliferation of the interstitial connective tissue may arise during the period of postponed resolution, producing (b) chronic interstitial pneumonia. This is very rare, however (vide supra, Pathology), (c) Abscess and (d) gangrene are also rare sequelae. For their clinical description the reader is referred to the description of Diseases of the Lung. Diagnosis.—The diagnosis is determined by special local and gen- eral symptoms, together Avith the physical signs. Of these, the abrupt onset Avith rigor, the course of the fever with termination by crisis, the stabbing chest-pains, the dyspnea, the peculiar type of breathing, the abnormal pulse-respiration ratio, the cough, the rusty expectoration, and the signs of consolidation of one or more lobes of the lungs, are the most characteristic. Deviations from the usual type are frequent, and these do not present many of the distinctive features just mentioned. Among the latter the so-called " typhoid pneumonia" and the other clinical varieties Avhose most valuable diagnostic features have been given, are often difficult of recognition. It must not be forgotten that repeated physical examinations of the chest Avill often detect more or less extensive consolidation, even though local symptoms are entirely 150 INFECTIOUS DISEASES. wanting Again, Avhen in the course of certain chronic affections (phthisis, cancer,°Bright's disease, diabetes, and organic affections of the heart) more than the customary degree of fever is developed, physical explora- tion of the heart and lungs is imperatively demanded. Be it remembered that in this class of cases "the physical signs are obscured, because respiratory action is enfeebled by the primary condition " (Musser). Differential Diagnosis.—This relates to (a) acute pneumonic phthisis, (b) typhoid pneumonia, (c) meningitis, (d) broncho-pneumonia, (6') acute pleurisy with effusion. Fig. 17.—Lohar pneumonia: 1, unaffected area (upper lobe); 2, consolidated area (middle lobe); 3, resolving area (lower lobe); 4, heart in normal position. (a) Primary Lobar Pneumonia. There may have been prior attacks. Sudden, Avith severe rigor and rapid rise of temperature. Fever of continued type, terminating by crisis. No drenching sweats, except at time of crisis. Acute Pneumonic Phthisis. Inherited predisposition or previous tu- berculous disease. Generally more gradual—repeated fits of chilliness (rarely severe rigor), often following exposure or " cold." Fever of remittent type, often becoming intermittent, without crisis. Drenching sweats present and oft re- peated. LOBAR PNEUMONIA. 151 Herpes common. Not much emaciation. Pulse-respiration ratio considerably dis- turbed. Sputum rusty-colored, viscid, and sticky ; contains pneumococcus. Duration of febrile stage shorter. Physical signs, as a rule, first referable to base of lung. Absent. Rapid emaciation. Less so. Sputum may be blood-tinged; is more purulent and more copious, and con- tains numerous bacilli and yellow elas- tic tissue. Duration longer. First referable to apex. Fig. 18.—Acute pneumonic phthisis, posterior view: 1, cavity: 2 and 3, consolidation ; 4, infiltra- tion ; the white spots indicate rales. Usually limited to one lobe or the lower Usually extension from apex to base. portion of one lung. Signs of consolidation, followed by reso- Signs of consolidation, followed by cavity- lution. formation, with large gurgling rfdes at apex. Apex of healthy side not involved. Apex of opposite side generally in- vaded. Prognosis not hopeless. Hopeless. Tuberculous disease of other organs does Often does. not follow as a rule. 152 INFECTIOUS DISEASES. (b) Typhoid pneumonia must be diagnosed from pneumo-typhoid, and the blood in the two conditions may be of service in the discrimination. Leukocytosis usually exists in pneumonia, and there is hypoleukoeytosis in typhoid; but this fact is only of value when there is marked increase or decrease of the leukocytes, sinee figures about normal may occur in either condition. Widal's test will be a decided aid. His assertion that a drop of blood from a patient with typhoid, added to a pure culture of typhoid bacilli causes the cessation of the motion of the bacilli and their collection in clumps, and that this does not occur with blood from other diseases, is, I think, satisfactorily proved. (c) Meningitis is sometimes mistaken for pneumonia, and particularly Avhen the latter occurs in children. The initial symptom of pneumonia in the very young is often a convulsion; whereas, though in meningitis this form is not uncommon, it is more apt to manifest itself later. When headache occurs in pneumonia it is frontal. It is almost invari- ably complained of in meningitis, but is occipital, and is associated with rigidity of the cervical muscles. Before the occurrence of pressure- symptoms in the latter disease the patient is very restless and morose; his reflexes are exaggerated and there is marked hyperesthesia. The temperature-range is loAver, more irregular, and there is no crisis, while the pulse is more variable and often irregular in meningitis. In pneu- monia with latent local symptoms the pulse-respiration ratio is greatly altered and the type of respiration peculiar (vide ante). The important rule, to examine for the physical signs in doubtful cases, must not be neglected, and if the subject be young the apex region in particular. The differential diagnosis between pneumonia and broncho-pneumonia and pleurisy with effusion Avill be found on pages 517 and 551. Prognosis.—The mortality from pneumonia in hospitals averages about 25 per cent. It is less in private practice—about 15 per cent. The death-rate, hoAvever, is greatly modified by the type of the indi- vidual epidemic, and by so many conditions and incidents that a pre- cise statement as to the percentage of fatal cases cannot be ventured. The above mortality-rates have been based upon all of the accessible statistics at my command. Wills collected 223,730 cases, which gave a mortality of 1K.1 per cent. The elements that enter into a correct prognosis are in the main identical with those in other acute infectious diseases, and concern (1) the severity of the type of infection, (2) the presence or absence of complications, and (3) circumstances peculiar to the individual m Severity of the Type of Infection.—In asthenic cases this is shown by (a) the temperature-range, (b) the degree of heart-power, (c) the in- tensity of the nervous symptoms, and to some extent by (d) the size of the area of lung-mduration. It has been demonstrated, experimentally, that the absence of leukocytosis is indicative of a grave type 1 In case the diplococcus be found in the blood, the prognosis must be considered very grave, as it has never been found there during life, except in cases that are in themselves very grave or seriously complicated. A continu- ance of marked leukocytosis Avith a drop in temperature would point to a pseudo-crisis, (a) The Temperature-range.—A continued high tem- 1 Yon Jaksch and Tchistowitsch, Annual of the Universal Med. Sciences vol i 1893 LOBAR PNEUMONIA. 153 perature, as, for example, 105° F. (40.5° C), on two or three consecu- tive days Avithout material remissions, is ominous, (b) The Degree of Heart-power.—A steadily rising pulse-rate after the fifth day indicates real danger, since it points indisputably to gradual cardiac failure. The same thing is shoAvn by a diminution in the intensity of the second pul- monary sound, particularly the giving out of the right ventricle, (c) The Intensity of the Nervous Symptoms.—Active delirium is not favor- able at any stage, and is particularly unfavorable if it develop early. When it assumes the form of delirium tremens the case has usually passed beyond hope of recovery, (d) The Size of the Area of Lung- induration.—I have observed that extension of the consolidation at an advanced stage belongs to serious types. The same may be said of double basic pneumonias. Typhoid pneumonia, being of asthenic type, gives an unfavorable prognosis, notwithstanding an absence of high temperature and of extensive inflammation of the lung-tissue. (2) Presence or Absence of Complications.—Cases in Avhich there is involvement of a single lobe or tAA'o lobes, if it occur on the right side and without complications, generally terminate in recovery. In nearly one-half of the instances complications occur, and these greatly increase the death-rate. Among the most common is pleurisy, Avhich, unless accompanied by considerable effusion, does not add fresh danger; Avhen pleurisy attacks the unaffected side, hoAvever, it does. Empyema, fol- lowing pneumonia, generally terminates in recovery unless secondary septic phenomena appear. Extensive bronchitis is a most perilous com- plication in my judgment. Pericarditis decreases the chances for re- covery, but by no means to the same extent as endocarditis. Cardiac clots may form, but usually the patient is already moribund. Abscess of the lung and gangrene form highly unfavorable complications. Con- gestion and edema of the uninvaded portions of the lungs render the outlook bad, and these, together with cyanosis, are apt to be dependent upon failure of the right heart. Acute meningitis is exceedingly grave. Femvick, as the result of an analysis of 10,000 cases, found that the quantity of albumin in the urine is of considerable prognostic value. Gastro-intestinal complications occurring at the outset are unpropitious. (3) Circumstances connected with the Individual.—Of these age heads the list, and after the tAventieth year the mortality increases progres- sively until the seventh decade. It has been claimed that nine-tenths of the deaths after the seventy-fifth year are from lobar pneumonia. Under the tAventieth year, according to the analysis of 708 cases at St. Thomas's Hospital by Hadden, H. W. G. Mackenzie, and W. W. Ord, the mortality is 3.7 per cent., Avhile in infancy it exceeds that of early childhood. Sex has little influence, though the disease is believed by some to be more fatal in females than in males. In the debilitated the danger is greater than in the vigorous, and the alcoholic rarely escapes death. Modes of Death.—Most frequently death is immediately due to heart- failure, Avhich results from tAvo causes: (1) ovenvork, as Avhen an exten- sive area of lung-tissue is involved; and (2) the direct effect of the pneumotoxin upon the heart. The complications mentioned may prove fatal, hoAvever, and in one of my own cases thrombosis of the coronary 154 INFECTIOUS DISEASES. artery killed the patient. This may be a not uncommon terminal con- dition. Treatment.—General Management.—The patient should occupy a Avell-aired apartment, Avhich should be maintained at a temperature of 65° F. (18.3 C), except in pneumonias occurring in the very young, Avhen it should be several degrees higher. The patient should not be allowed to leave his bed for at least one week after the occurrence of the crisis; and as pneumonia is a self-limited affection, the principal object is to support the poAvers of life until the crisis is passed. To this end nothing contributes so much as proper feeding. The diet should be light, chiefly liquid, but of the most nutritious sort. Alimentation should be especially vigorous when there is the slightest tendency to increasing debility. On the other hand, in un- complicated cases and in those in which the disease is limited to a single lobe there is not the same need of supporting the vital powers, since these cases have an intrinsic tendency to recovery. 3Iilk should consti- tute the chief article of diet; meat-broths or meat-juices, egg-Avhite, and light farinaceous substances may also be alloAved. The food, and particularly the milk, is to be administered at stated brief intervals and in definite quantities. When resolution is delayed stronger forms of nourishment (scraped meat, etc.) may be given. After the crisis a gradual return may be made to the usual forms of solid foods. Cardiac stimulants are often indicated. It is well to begin their use as soon as the slightest tendency to cardiac failure is shown. The evi- dences of the latter conditions are to be found in the state of the pulse, the first sound of the heart, and the pulmonic second sound. The pulse becomes more and more accelerated and feeble, the first sound of the heart less distinct on auscultation, and the pulmonic second sound loses its accentuated character. From the first moment that these unfavor- able features or marked nervous symptoms appear alcoholics must be used. At first they are to be employed in moderate doses (| ounce— 16.0—of whiskey or brandy every three hours), to be increased if the favorable effect be proportionate Avith the urgency of the indication. There is a great tolerance of alcohol in this disease, and in the pneu- monia of drunkards its early and free use is to be recommended. If the alcoholic stimulants fail to meet the above indications, other cardiac stimulants must be administered simultaneously. Of these, strychnin has been the most serviceable in my own hands, its mode of administration following the same rules as have been mentioned for alco- holics—at first in moderate-sized doses, to be increased as occasion de- mands. Should urgent need of stimulation arise, however, either sud- denly or more gradually, strychnin should be exhibited hypodermically. It is my custom in desperate cases to use subcutaneously as much as gr. ^ (0.0043) every two or three hours. So soon as the condition of the heart denotes restoration of cardiac power the size of the dose is to be reduced, but the agent is not to be withdrawn until the disease has run its course. In no other disease does strychnin possess greater potency for good than in pneumonia, if wisely employed. For sudden heart-failure ether, administered hypodermically, is also very efficacious, and digitalis may be combined Avith the strychnin or given separately' Like strychnin, digitalis may become a life-saving drug if its adminis- LOBAR PNEUMONIA. 155 tration be guided by sufficient judgment. Ten minims (0.666) of the tincture may be given every three or four hours internally or hypo- dermically if needful, and I have found that the association of a small dose of nitroglycerin (TTLJ; 0.033, every three or four hours) consid- erably aids the action of the digitalis. Nitroglycerin is especially in- dicated Avhen the renal secretion is scanty and the urine contains more than the usual trace of albumin. Ammonium, in the form of the aro- matic spirits or the carbonate, is an excellent stimulant to the feeble heart of pneumonia. Respiratory Stimulants.—Beginning cyanosis is the signal for the use of respiratory stimulants, of Avhich the best are oxygen by inhalation, strychnin, and atropin. The oxygen must be administered in large amounts, and if the patient be so severely ill that almost constant inhala- tion of the gas becomes exhausting, it may merely be allowed to escape near his nose and mouth. Hydrotherapy.—This is especially useful, but I have abandoned the rigid cold-bath method. The gradually-cooled tub-baths are the best, and should be employed, except in cases pursuing a 'very favorable course or those in Avhich little besides rest and good nursing is neces- sary. In meeting high temperature, marked nervous symptoms, dys- pnea, cardiac Aveakness, etc. they offer many superior advantages, and in pneumonia the effect of the baths upon the cardiac, respiratory, and nervous centers is especially desirable. It is of importance that the patient Avhile being immersed put forth no muscular effort. He must be held and supported while in the bath, and gentle friction to the skin- surface must be made. The temperature of the baths should not be too low at the start: at the beginning it should be 90° F. (32.2° C), and then be lowered according to the degree of sensitiveness of the in- dividual patient. It is rarely necessary to go beloAv 80° F. (20.6° C), and in the aged, the very young, and in persons previously debilitated it is unwise to use any other than tepid baths. The duration should not exceed ten to fifteen minutes on the average, and more than three —or at most four—baths daily are not required. Cool sponging, com- bined Avith the ice-cap or the Avet pack, may serve as a substitute Avhen full baths cannot be employed. Abortive Method of Treatment.—Petresco has found that large doses of digitalis (3J-ij ; 8.0, of the digitalis-leaves in an infusion daily) ad- ministered at the onset will jugulate the disease. His experience cov- ered 1102 cases, and shoAved the surprisingly low mortality-range of 1.22 to 2.66 per cent. This plan of treatment is rational, since it aims at meeting the chief pathogenic indication of pneumonia by passing through the lung-tissue an adequate proportion of leukocytes, and thus re-establishing the cardio-pulmonary circulation. In the few instances in which I have adopted the plan it has failed to cut short the disease, though the cases terminated favorably. After the full development of consolidation I Avould urge caution in the use of digitalis unless cardiac failure threaten. Venesection.—It has been claimed by some that free bleedings at the onset will abridge the disease. Doubtless it is a good measure in sthenic cases (which occur Avith relative rarity in cities, but are not uncommon in rural districts), the temperature falling, the pain, the 156 INFECTIOUS DISEASES. dyspnea, and the nervous symptoms being relieved and the pulse soft- ened. Later in the course of pneumonia venesection is to be resorted to if cyanosis and the signs of collateral pulmonary edema—due to a failing right heart—arise, and if cardiac and respiratory stimulants have proved futile. At this stage, however, bleedings rarely yield good results, though affording temporary relief. Antiseptic Methods.—This aims to destroy the pneumococcus or, at all events, to neutralize the poisonous products of the latter in the blood, thus moderating the general disturbances. The method is based upon etioloo-ic indications, and is most rational. The best antiseptics are car- bolic acid (Hlj ; 0.066, every four hours), thymol (gr. ij-iij ; 0.129-0.104, every four hours), mercuric chlorid (gr. T^-¥; 0.0006, every four hours). Treatment of Special Symptoms.—The initial pain, Avhich is of an acute, agonizing character, is relieved by the hypodermic use of mor- phin at intervals of six or eight hours. This counteracts the shock pro- duced by the invasion-period, but it is to be omitted if the bronchi con- tain secretory products, since morphin dries these and favors their accumulation rather than their removal. Rarely is it necessary to con- tinue this remedy after the second or third day of the illness. Fever.—The fever of pneumonia is a temporary affair, and instead of being hurtful may prove beneficial, since it furthers tissue-metabo- lism, and this aids in the destruction of the specific poison of the dis- ease. Fortunately, internal antipyretics for the purpose of combating high temperature are not so largely used at the present day as for- merly. It is true that they possess the power to reduce temperature, but their use is attended Avith danger from their action as cardiac depres- sants ; while, if it be true, as before stated, that pneumonia usually kills through the heart, it follows that cardiac power must primarily be con- served. Apart from the above-mentioned serious objection to internal antipyretics, it is to be remembered that they do not possess the import- ant additional advantages to be derived from cool baths. In my opinion, their use should be limited to those cases in Avhich cool baths or their substitutes (cold pack and cold spongings) fail to effect a reduction of fever. It must not be forgotten that unless the temperature exceed 104° F. (40° C.) it had better be let alone. When called for, however, the best among the antipyretics are acetanilid and phenacetin. The dose of these should be small—gr. v (0.324) of the latter and gr. ij-iij (0.129- 0.194) of the former, to be repeated at intervals of four to six hours if required. Like internal antipyretics, arterial sedatives are to be used sparingly, and when used their effects must be carefully noted. In cases in Avhich venesection is indicated the tinctures of veratrum viride and of aconite have been much vaunted as substitutes. The tincture of veratrum viride produces a good effect upon the local condition, since it relaxes the arterial walls, and thus bleeds the patient into his own vessels, but, since it also acts as a cardiac depressant, it is questionable whether its disadvantages do not outweigh its advantages. The tincture of aconite, OAving to its depressing influence upon the heart, should not be employed. The nervous symptoms are successfully met, as a rule, by hydrother- apy (including the ice-cap), by the arterial stimulants, and by the use of morphin, as before recommended. SECONDARY PNEUMONIA. 157 Cough during the early stage is controlled by the morphin needed to combat the pain. In the more advanced stages, if there be present numerous moist r&les and a scanty expectoration, stimulant expecto- rants (ammonium muriate, terebene) may be employed Avith happy effect; but ordinarily they do harm rather than good. Pilocarpin may aid resolution when this is delayed (Reiss); the heart, however, must be carefully Avatched over. Complications.—The management of the complications does not differ from that which is appropriate Avhen they occur as independent affec- tions, though all depressing measures must be positively omitted. I would add that in pleuro-pneumonia aspiration is not Avell borne, ac- cording to my observations; hence, unless urgently needed, I Avould postpone this procedure until the crisis has passed. Local Measures.—When in doubt as to Avhether venesection should be employed or not, it must be remembered that early local bloodletting (cupping and leeching) is folloAved by relief from pain and dyspnea, but that these measures should be reserved only for robust persons. Coun- ter-irritation by means of sinapisms is useful at the onset. The cotton jacket has certain advantages in maintaining the free, local action of the skin, and may be employed; before the days of hydrotherapy it Avas quite commonly used. The topical use of cold in the form of ice-bags has been practiced extensively by Lees of England and Mays of America Avith brilliant success, cold thus applied relieving the pain and dyspnea and diminishing pyrexia. In my limited experience Avith the'applica- tion of cold I have found cases in Avhich it could not be tolerated by the patient, and in such, warm applications (poultices, etc.) exerted a sooth- ing revulsive effect. Lepine has used with success very dilute mercuric chlorid injections into the affected lung-tissue. This mode of treatment has not been followed in sufficient cases to warrant an opinion as to the extent of its usefulness. Secondary Pneumonia. Pathology.—The lesions are identical in character with those of primary lobar pneumonia, but the areas involved have not always the same regular distribution. Congestion surrounding the hepatized lung- tissue is not infrequently extensive. We see, post-mortem, a tendency to commingling with small areas of lobular pneumonia. Both the strep- tococcus and the micrococcus lanceolatus are frequently found on micro- scopic examination. Htiology.—Most instances are secondary to the acute infectious diseases, and it is probable that the specific causes of certain of the latter (Eberth's bacillus, Pfeiffer's bacillus, etc.) have the power to ex- cite the morbid changes of acute lobar pneumonia. Colon-pneumonia, due to the bacillus coli, is the result of hematogenous infection either from the intestinal or from the urogenital tract. In the majority of instances. hoAvever, in which this disease develops in the course of the acute infectious diseases the latter are to be regarded as merely furnish- ing the opportunity for infection by the micrococcus lanceolatus. Symptoms.—The rational symptoms are often absent. Close ob- servation may, however, detect more or less dyspnea, cough, and in- 158 INFECTIOUS DISEASES. creased fever, and rarely the attack is heralded by a rigor, followed by fever, the pneumonic type of breathing, pain, cough, and the character- istic expectoration. The physical signs, Avhen carefully observed, usually serve to enlighten the physician as to the nature of the affection. Hence it is a natural corollary that repeated physical examination is demanded in all cases in which there is danger of intervening lobar pneumonia, Diagnosis.—This rests chiefly upon the physical signs, which are the same as in primary lobar pneumonia. Obviously, Avhen the local subjective symptoms and the characteristic sputa are present a correct diagnosis is easily made. The fact must be emphasized that broncho- pneumonia arises in the course of infectious diseases far more frequently than does lobar pneumonia. Prognosis.—The occurrence of lobar pneumonia as an intercurrent affection adds greatly to the gravity of the primary disease. It is espe- cially dangerous Avhen it appears as a sequel during convalescence from acute infectious diseases. The treatment is similar to that of primary lobar pneumonia, though less satisfactory. INFLUENZA. (La Grippe; Epidemic Catarrhal Fever.) Definition.—Influenza is an acute contagious disease, caused by the bacillus of Pfeiffer. Its chief symptoms are due to catarrh of the respiratory and digestive tracts, together with profound muscular and nervous prostration, and grave complications (especially pneumonia) often present themselves. The disease may be endemic, though more often it is epidemic or pandemic. Historic Note.—Every quarter of the globe has been the scene of visitations of epidemic influenza. More rapidly than any other dis- ease belonging to the same class does it traverse a region of country, and hence within a remarkably brief period of time a Avhole nation may suffer. As a rule, influenza develops into epidemic proportions in the East, whence it spreads with unparalleled rapidity in a Avesterly direc- tion. The first epidemic of the disease in the United States appeared in 1647, and was subsequently described; and, though it has since then frequently prevailed, the outbreaks have not observed any regular pe- riodicity. The last true pandemic of the affection originated in Bok- hara in May, 1889, reached St. Petersburg in the following October, Paris in November, and London in turn early in December. In Amer- ica the cases began to appear about the middle of December, and rap- idly multiplied into an explosive epidemic, which reached its maximum in January, 1890. Influenza reappeared in epidemic form, though less extensively, during April and a part of May, 1891, and again in a briefer and lighter form in the winter of 1891-92. During the Avinter of 1892-93 only a feAv sporadic cases occurred. In the early part of INFLUENZA. 159 1895 the disease assumed epidemic prevalence, and it again appeared at the beginning of the present year (1897). Pathology.—There are no special anatomic lesions that charac- terize the disease. The rare instances in which death occurs in uncom- plicated cases simply show marked catarrhal implication of the respira- tory, and usually also of the gastro-intestinal, mucosa. There are practically no changes in the glands of the digestive mucosa, except in the abdominal type of the affection, in Avhich there may be enlargement of the glands of Peyer and of the solitary follicles. As will be seen hereafter, most of the fatal cases exhibit lesions Avhich are to be ascribed to the complications. Among the latter are pneumonia (either lobular or lobar), Avith Avhich plastic pleurisy is usually associated, sero-fibrinous pleurisy, empyema, purulent pericarditis, nephritis, and rarely cerebro- spinal meningitis. Etiology.—That the disease is microbic in origin can no longer be doubted. Bacteriology.—Early in the year 1892, Pfeiffer discovered a bacillus which he has shoAvn to be the true cause of influenza—the bacillus of Pfeiffer. It is of about the same breadth as the bacillus of mouse-sep- ticemia, and only one-half the length of the latter. When stained with Ziehl's carbol-fuchsin it may be observed as a small dumb-bell, having knobbed ends connected by a rod-like shaft. These bacilli are obtained from the sputum, and their number bears a definite relationship to the intensity of the disease. They are found only during the attack, and are never present in any other disease. Pfeiffer has shoAvn that they may penetrate the peribronchial tissue and pass out to the pleura. They have also been found in the blood. This bacillus can be culti- vated in agar and other media, but not in gelatin, and when inoculated into rabbits and other animals it causes more or less typical influenza; these experiments, however, are not in themselves conclusive. Modes of Conveyance.—Naturally, a specific germ that is propagated Avith the unusual rapidity that marks the bacillus of Pfeiffer must be air-borne. Even this view, hoAvever, fails to explain satisfactorily the coincidental prevalence of the malady at Avidely-separated points. Pep- per suggests that the micro-organism may be almost universally dis- tributed, but only capable under ordinary circumstances of causing occasional and sporadic cases; and that under certain extraordinary atmospheric or telluric conditions it acquires a degree of virulence that renders all subject to its attack. There is no doubt that influenza is communicable by contagion, and evidence is not Avanting even to shoAv that it may be transferred by fomites. Manner of Invasion.—How the contagion enters the system has not been positively determined, though it is probably Avith the inspired air through the respiratory tract. Some authors contend that it may enter through the alimentary canal, while still others believe that the primary point of infection is not rarely the conjunctiva. Predisposing Causes.—These are few and unimportant, since all per- sons are liable to the contagion. Age has slight influence, the period of greatest susceptibility being from the twentieth to the thirtieth year. The very young are less liable than older subjects, and during an epi- demic are apt to be affected last, Avhile old persons (particularly if debil- 160 INFECTIOUS DISEASES. itated) are frequent sufferers. The same is true of those Avhose vitality is loAvered by neuropathic heredity or chronic maladies, these being among the first to be affected during an epidemic. On the other hand, it is to be remembered that the healthiest are not exempt. The affection is only slightly influenced, if at all, by meteorologic conditions. Immunity.—A primary attack of influenza does not bestow immu- nity, since relapses are very common, and sometimes after long inter- vals. Many persons, too, suffer from the disease with the reappearance of fresh epidemics, so that two, three, four, or even more attacks may be observed in the same individual. Antagonism.—Recent investigations have shown that a decided an- tagonism exists between influenza and malaria,1 and that during epi- demic prevalence of the former the latter has repeatedly suffered a great decline. Clinical History.—General Symptomatology and Course.—The in- cubation period is quite brief, rarely exceeding two or three days. The onset is generally sudden, with either a severe rigor or repeated slight shiverings, accompanied by a rapid elevation of temperature which may touch 104° or 105° F. (40.5° C), intense headache, distressing myalgic pains, and great prostration. The primary fever, however, varies greatly in severity. The same is true of the character of the symp- toms—both local and general—presented by different cases as well as by different epidemics. Profound prostration characterizes the vast majority of instances during the invasion period. Depression of spirits, restlessness, insomnia (more rarely undue somnolence), and frequently delirium, are among the more prominent nervous phenomena. In cer- tain epidemics the affection may be ushered in by vertigo—a symptom that sometimes also appears late in the disease. The most striking symptom is pain, which in a certain percentage of cases is referable chiefly to the forehead, temples, occiput, eyeballs, and root of the nose. General neuro-muscular pains, hoAvever, are apt to be present. Their principal seat is often in the region of the lumbar spine (rachialgia), Avhence they are apt to dart upward to the neck and downAvard to the lower extremities. With the universal myalgic pains there is a general soreness, and I have frequently noted cutaneous hyperesthesia. The pains take the form of neuralgia of individual nerves or of pleurodynic stitches, or there are localized areas of burn- ing, boring muscular pain. The temperature may, as before intimated, mount quite high at the beginning, and if so it usually remits during the first night. It subsequently remains at a comparatively low point, with evening exacerbations, until the normal level is reached, Avhich often occurs as early as the second or third day, but may be postponed until the end of a week. The temperature-curve is markedly irregular, and often terminates by an apparent crisis. The pulse is small, feeble, irregular, and even intermittent, and I have sometimes observed it to be unusually slow, cardiac debility being prominent and at times reach- ing a dangerous degree. In many cases dyspnea is a rather conspicuous 1 " A Statistical Study of Influenza; its Potency to Lessen the Receptivity of the Body for Malaria, as well as to Increase the Receptivity for Pneumonia and probably Typhoid Fever," by the author—Phdadelphia Hospital Report, 1895 vol iv INFLUENZA. 161 symptom, occurring independently of inflammatory pulmonary compli- cations. The same is true of cyanosis. Clinical Types.—Different types have been described based on the differences in the local manifestations. But it is to be mentioned that influenza is remarkably protean in its clinical features, and that the enumerated types quickly and frequently merge into one another, (a) Respiratory Type.—Local catarrhal symptoms usually develop in the course of one or tAvo days. They are, as a rule, evidenced first by a suffusion of the conjunctivae, Avith excessive lacrymation, frequent sneezing, and slight pharyngitis. A little later, in most instances, hoarseness and cough come on, the latter being hard, racking, parox- ysmal in character, and resembling whooping-cough. The cough and other local symptoms are due to intense, dry laryngo-tracheal irritation. In most instances the expectoration is scanty, and in these the physical signs are very generally negative. In a smaller proportion of the cases there is considerable expectoration, and the physical signs of ordinary bronchitis are manifested, (b) Gastro-intestinal Type.—The catarrhal symptoms sometimes center in the digestive system, and most frequently in children. In such, vomiting comes on early and is apt to be repeated at longer or shorter intervals. There is diarrhea, more or less urgent, Avith sharp abdominal pain, as a rule, (c) The cardiac group of symp- toms that occasionally supervenes comprises heart-failure and distress, with a rapid, feeble pulse, (d) The typhoid type presents a continued fever, with the signs of the typhoid state. Nervous symptoms are very marked, such as stupor or delirium, dry, brown tongue, etc. (e) The rheu- matoid type manifests itself by violent pains in the muscles all over the body. There is no visible change in either the joints or the nerve^trunks. After the temperature has become normal profound prostration is apt to continue, and hence the patient shows no disposition to muscular or mental exertion. In cases of average severity convalescence is usually someAvhat protracted, and in the severer forms decidedly so. Complications.—(1) Pulmonary.—An ordinary bronchial catarrh may be properly regarded as belonging to the peculiar processes of the disease, but severe bronchitis, particularly affecting the capillary tubes and leading to broncho-pneumonia, is a common and very serious com- plication. As a secondary result Ave are apt to observe the development of collateral pulmonary edema, Avith its usual fatal termination; and, Avhilst this complication is prone to develop in the so-called thoracic type of influenza, it is by no means limited to this class of cases. In the latter it originates apparently in the profound prostration of the nervous system—a condition Avhich also annuls in great part the phago- cytic action of the leukocytes. In nearly all instances, hoAvever, this form, as Avell as croupous pneumonia, may be definitely traced to ex- posure. The bronchial glands may become acutely enlarged. Lobar pneumonia is also a frequent and very fatal complication. It may arise early and in rare instances insidiously, but it is much more apt to manifest itself after influenza has about exhausted its force upon the vital organs or during the early part of convalescence. The symp- toms of invasion—severe chill, high temperature, followed by the usual physical signs—are sudden in their onset and lead rapidly to an ex- tremely serious condition. 11 162 INFECTIO US DISE. 1SES When lobar pneumonia develops early in the course of influenza (a rare event), its symptoms are modified, the preliminary chill and pain in the side being often absent, and more frequently still the characteristic crepitant rale. Subcrepitant rales, hoAvever, are audible, and the dys- pnea is out of proportion to the area of lung-tissue involved. Most of the peculiar features just pointed out may also be observed in connection with the pneumonia that appears during convalescence, though, accord- ing to my OAvn experience, they are then more feebly expressed. The recognition of broncho-pneumonia is in many instances quite diffi- cult. Here, as elsewhere, it is secondary to general bronchitis affecting the larger tubes. I have observed this condition in cases in which the physical signs of bronchitis Avere not presented prior to its onset. In other instances, however, a few scattered sibilant and sonorous rales, intermingled Avith a few moist ones—the usual auscultatory signs of severe general bronchitis—are noted, and then broncho-pneumonia supervenes. Immediately preceding the signs of consolidation in broncho- pneumonia (less frequently also in croupous pneumonia) the respiratory murmur becomes exceedingly Aveak, and later an abundance of subcrepi- tant rales becomes audible over the affected area. Bronchial breathing may be associated, though it is rarely marked; but Avhen the spots in- volved are of considerable size, they may give rise to corresponding zones of dulness on percussion. According to some authors, the nature of the condition is variable, and the symptoms that simulate more or less closely those just depicted are ascribed to congestive collapse and other conditions, rather than to the ordinary type of broncho-pneumonia. Congestion associated with edema of the lungs occurs as a complication of influenza, as I have learned from personal observation. Acute enlargement of the bronchial glands may also be noted, and the recognition of this condition may be aided by careful percussion over the upper four dorsal vertebrae, Avhere dulness will be obtained. Plastic pleurisy is commonly an associated condition, especially in cases of lobular or lobar pneumonia. Other forms of pleurisy also occur, though less frequently (sero-fibrinous and empyema). Gangrene and abscess of the lungs may arise as terminal complications. Cardiac Complications.—Heart-failure often manifests itself, and may prove fatal, though rarely. Purulent pericarditis is a rare complication, and is often secondary to pleurisy or pneumonia, Avhile attacks of angina. which usually interchange with simple weak heart (often associated°with arrhythmia), have been noted in certain epidemics (Curtin and Watson). Gastro-intestinal System.—There may be severe gastro-enteritis, with frequent vomiting and purging and intense abdominal pains, and, more rarely, hemorrhages occur from the stomach and bowel. Catarrhal jaundice may appear, due to duodenal catarrh, but these gastro-intes- tinal complications are more apt to be met Avith in young children than among adults. Nervous System.—The most frequent symptom is perineuritis, Avhich probably causes much of the patient's sufferings. Delirium of 'a most active form sometimes appears, and particularly Avhen certain other complications have arisen, such as pneumonia, pericarditis etc. Cere- bro-spinal meningitis occurs as a rare complication, and Avhen it arises INFL UENZA. 163 is to be attributed to secondary infection with the streptococcus. I have observed symptoms identical with those of meningitis appearing suddenly, and in the course of a day or tAvo disappearing just as sud- denly. The symptoms under such circumstances must be due either to the action of the specific poison upon the nerve-centers or to congestion, and hence a diagnosis of suppurative meningitis is to be made Avith ex- treme caution. In addition to the presence of the symptoms Avhich characterize the affection, Ave should have the existence of suppuration elsewhere in the body (otitis, purulent pericarditis, etc.) or the presence of pneumonia. Cerebral abscesses have also been noted (Bristowe). Genito-urinary Tract.—Renal congestion, and even acute nephritis, may appear as a complication. A case of cystitis with hematuria has also been reported (Coinby and Le Gendre). The diagnosis of influenza except in ill-defined, sporadic cases rarely presents serious difficulty. In obscure cases the discharges should be studied bacteriologically. (a) Climatic catarrhal affections are sometimes hard to discriminate from sporadic cases of influenza. The former are usually attributed to sudden and great vicissitudes of temperature or exposure to strong drafts of air, Avhile the latter come on independently of seasons of the year and of such agencies. Again, in influenza we usually observe the general features (nervous symptoms and debility) outweighing the local (catarrhal manifestations). Simple catarrhs do not tend to traverse the entire system Avith the same remarkable rapidity as influenzal catarrhs. (b) Typhoid fever, particularly in its early stages, is often closely simulated by influenza Avith intestinal symptoms. Danger of confound- ing these two affections can be averted by remembering the facts that influenza gives a different history, begins suddenly, does not have the typical temperature-curve of typhoid, may present splenic enlargement —but by no means to the same extent as typhoid—and has no charac- teristic eruption. (c) Pneumonia has quite frequently been mistaken for influenza, and especially when the thoracic symptoms in the latter have been unusually distinct. As already stated, lobar pneumonia may early complicate in- fluenza in rare instances; but pneumonia is generally unilateral, Avhile the lung-involvement in influenza is generally bilateral. In the former the physical signs indicative of consolidation are clearly marked; in the latter (unassociated.with pneumonia) we often meet with those sug- gestive of congestive edema (impaired resonance, stationary crepitant and subcrepitant rales). The general features also present dissimilari- ties. Thus the nervous depression and the myalgic and neuralgic pains are more marked in influenza, while the pulse and respiration are apt to be less frequent than in pneumonia. (d) Cerebro-spinal meningitis may manifest features that are almost identical with those characteristic of influenza. Thus during certain epidemics many " grippe " patients suffer from intense headache—oc- cipital and frontal—rachialgia, fever, prostration, delirium, and stiffness of the muscles, with slight retraction of the head. There may be con- vulsions and vomiting at the outset. Here the history Avith reference to the character of the prevailing epidemic and the attendant circum- 164 INFECTIO US DISEASES. stances must be carefully considered, but an absolute diagnosis is some- times impossible unless a bacteriologic investigation of the discharges be made. Sequelae.—Among the pulmonary sequelae are phthisis, chronic bronchitis, abscess and gangrene of the lungs (the latter two being rare), tachycardia, and angina pectoris. Chronic gastro-intestinal catarrh is not rare as a remnant of the acute form when the latter arises during the influenzal attack. Chronic nephritis, and less frequently cystitis, may also be mentioned. Among nervous sequelae Avhich are both numerous and important are to be noted especially insomnia, neuralgia, migraine, melancholia, mania, meningitis, acute ascending myelitis, locomotor ataxia, peripheral neur- itis, and perineuritis. The organs of special sense manifest a great variety of sequelte, such as otitis media, otitis interna, mastoid abscess, conjunctivitis, keratitis, iritis, irido-chorioiditis, acute glaucoma, paral- ysis of accommodation, etc. Prognosis.—The' prognosis is, on the whole, good. Almost all fatalities are due to complications, especially pneumonia, and, less fre- quently, pulmonary congestion and edema, pleurisy, pericarditis, cere- bro-spinal meningitis, etc. The circumstances connected with the individual case often affect the outcome. Thus influenza runs a more severe course, and hence offers a correspondingly more serious prognosis in the very young, the very old, and those enfeebled on account of previous chronic disease (phthisis, valvular disease of the heart, emphysema, nephritis, etc.) than at other periods of life. During severe epidemics of influenza the mor- tality-list in the latter diseases is considerably augmented. Though epidemics vary as regards the mortality, the general average death-rate is a little under 1 per cent. In some epidemics it may reach 2 per cent., while in others it may be less than J of 1 per cent. Duration.—The duration of the attack is brief, though subject to variations. In mild forms it is from tAvo to four days, in the severe from seven to ten days; but complications and previous infirmities may greatly prolong the attack. The duration of particular epidemics rarely exceeds from four to six weeks. Treatment.—Prophylaxis.—Experience has shown almost conclu- sively that the various drugs Avhich have been counselled for their pre- ventive effect (quinin, salicin, etc.) are devoid of value. The strongest persons are not immune, and those Avho are at either extreme of life or Avho are enfeebled by chronic organic disease should be most carefully protected by proper Avearing apparel, and should not be exposed to the direct influence of the changes of Aveather. In this Avay Ave may hope to lessen, in a measure at least, the totality of the cases, since the in- mates of hospitals and prisons have been knoAvn to escape absolutely when the community all around them Avas suffering from the disease. Isolation should therefore be carried out in hospitals and, under certain conditions, in private families, especially Avhen the disease appears in households in Avhich there are young children and aged persons. Dis- infection of the catarrhal discharges, particularly the bronchial, Avhich, as a rule, abound in the bacilli of Pfeiffer, must be rigidly carried forward. INFLUENZA. 165 Treatment of the Attack.—In considering the treatment of the attack the cases may be grouped under three heads: (a) Mild or Rudimentary Form.—The cases belonging to this type re- quire little besides careful hygienic management. However light the attack, the patient should remain in-doors and, if languid or prostrated, in bed for a period of two or three days. The diet should be light and nutritious (milk, eggs, rice, gruels, fresh vegetables, steAved fruit, etc.), and cooling drinks are to be preferred to hot ones, among the former lemonade or cold oatmeal Avater Avith lemon, and effervescent mineral waters (Apollinaris, lithia, Seltzer) being the best. The boAvels should be moved regularly, aAroiding, hoAvever, all purgation. Stimulants are not needful, though well borne as a rule, and the use of light Avines is not objectionable if desired by the patient. In all cases of influenza, even of the mildest grade, I prescribe moderate doses of quinin ( gr. iv —0.2592, three or four times daily), and if there be much headache this drug may be combined Avith Dover's poAvder and monobromate of camphor (of the first tAvo gr. iij—0.194, each, and of the last gr. j— 0.0648, in capsule), the dose to be repeated at intervals of three or four hours. To overcome the languor and debility, Avhich are marked, I have found nothing so successful as strychnin. (b) Cases of Medium Severity.— General Management.—This class of influenza patients betake themselves to bed, and should be kept there till convalescence is Avell advanced. During the febrile period the diet must be light, liquid, yet nutritious, and the food should be given every tAvo or three hours. Although the patient has no desire for food, he should be urged to eat with regularity, no matter how small the quan- tity at each feeding. Moderate stimulation is also useful. The medicinal treatment is, for the most part, simple and symptom- atic. The neuralgia and myalgia may be relieved by the use of quinin, Dover's poAvder, and camphor, as before stated, but if the pain be in- tense, morphin administered subcutaneously is sometimes required. The temperature is somewhat reduced by these remedies, and especially by the quinin and Dover's poAvder, the latter of Avhich acts as a diapho- retic. In addition, I am in the habit of ordering cool sponge-baths at intervals of tAvo or three hours if the temperature be above 102° F. (38.8° C). If not controlled in this manner, Ave may combine Avith quinin some antiseptic, such as salicylic acid or salol. I have found it necessary to add to the foregoing small doses of phenacetin (gr. ij—0.129), or acetanilid (gr. ij—0.129), the former being preferred, since it is superior to acetanilid in controlling insomnia, Avhich is so often a troublesome symptom. Sleeplessness may, hoAvever, demand other and more potent hypnotics, such as sulfonal, chloralamid, opium, etc. The local catarrhal conditions (coryza, laryngo-bronchial irritation, true bronchitis, etc.) must be treated according to the special indications presented in individual cases. For the coryza inunctions of animal fats over the forehead and bridge of the nose are useful. A flannel cap may be worn if agreeable to the patient. Steam inhalations through the nares and mouth often act beneficially, both upon the coryza and laryngo-bronchial irritation. For the latter common condition the fol- lowing formula will be found serviceable: 166 INFECTIO US DISEASES. B/. Codeinae sulph., gr. iv (0.259); Ammon. chloridi, ,"v (20.0); Syr. prun. virgin., fjij (60.0); Spts. junip. comp., q. s. ad fgiv (120.0).—M. Sig. One teaspoonful every two or three hours. If this prescription fail to mitigate the cough, Ave may resort to morphin hypodermically, but ahvays in small doses. In the later stages, particu- larly if bronchitis be associated Avith free secretions, the oil of eucalyp- tus (TTLiij to v—0.199 to 0.333), in capsule, every four hours, has in my experience proved useful. To obviate pulmonary complications I have been much gratified with the results from the use of strychnin (gr. -fa— 0.0021), combined with vin Mariani (sss—16.0) at intervals of three or four hours. Chest-pains may be relieved by the use of turpentine stupes and sinapisms, both of Avhich agents are also valuable in averting the more serious complications. (c) Severe Forms.— The general management is similar to that recom- mended in cases of medium severity, excepting that freer stimulation is usually demanded. The medicinal treatment must also be more active than in the previous form, and often is heroic. Especially must quinin be given in full doses and continued, since it not only serves to reduce the temperature somewhat, but also to control the nervous symptoms and lessen the tendency to inflammatory complications. Nothing that exerts a depressing effect should be thought of, since the cardiac as well as the respiratory forces, must be conserved. Should there be sudden cardiac failure, it must be promptly met by the various forms of stimu- lants, including strychnin and the cardiac tonics. In addition to alco- holic stimulants, the aromatic spirits of ammonia is usually borne well, and should be administered. Strychnin must be given in full doses hypodermically every third or fourth hour. The various inflammatory complications that may arise must be treated as under other circum- stances. The Convalescence.—In all grades of cases the convalescence from influenza demands most rigid supervision, and the greatest injury to patients at this time comes from going out too early. Usually the tem- perature is subnormal for several days—a circumstance due to the weak- ness of the patient—and so long as this condition obtains the patient is highly susceptible to a chill. Hence it is a good rule not to allow ex- posure to the external changes of temperature until the temperature has been normal for several days. The diet should noAv be more liberal, and tonics, such as gentian, iron, and quinin, may be administered and con- tinued until complete restoration of the patient's health has taken place. In every way possible exposure to reinfection during the period of con- valescence is to be avoided. The treatment of sequelae must be conducted according to general rules. DENG UE. 167 DENGUE. (Break-bone Fever.) Definition.—An acute infectious disease occurring epidemically in tropical and subtropical countries. Its chief symptoms are—a double febrile paroxysm (separated by an interval), arthritic and muscular pains, and a skin-eruption in about one-half the cases. Historic Note.—The disease was prevalent in Java as early as 1779, in India in 1824, and later in the West Indies, Spain, and in some of the southern American States. Mild epidemics have visited Philadelphia, NeAv York, and Boston, but, as a rule, it has not traversed regions beyond 32° N. latitude. Its pathology has not been studied, death being the rarest of events. Btiology.—McLaughlin of Texas has isolated from the blood and cultivated a micrococcus Avhich he claims is the specific cause of the disease. Predisposing Factors.—Its prevalence is favored by the summer sea- son, and also to a slight extent by faulty hygienic conditions. On the other hand, age, race, sex, and social status are all Avithout effect, most persons being susceptible; and, according to Matas, primary attacks are not protective in character, Avhile other authors contend that they even predispose to subsequent ones. The epidemics spread along lines of travel by land and sea, and most authors agree that the disease is con- tagious. Clinical History.—There is a period of incubation that lasts about four days and exhibits no prodromes. Invasion then is abrupt with a slight chill; fever folloAvs, the tempera- ture reaching its maximum—103° to 106° F. (39.4° to 41° C.) or over— at the end of the first or on the second day, and is accompanied by head- ache and by muscular and arthritic pains. The patient's sufferings are in- tense, the pains being described as "breaking"—a peculiarity to Avhich the disease owes the popular name of " break-bone fever." The joints become red, SAvollen, and very tender to the touch. The respirations and pulse are much quickened; there are anorexia and sometimes slight nausea. Febrile albuminuria is rare, delirium and mental torpor also ; but prostration may become marked, and an erythematous eruption com- monly appears. DeBrunl noted carefully the symptoms of dengue during the epidemic at Beirut (1892), and states that the eruption is roseolar, morbilliform, scarlatinous, or papular. He distinguished three groups of cases: 1. With high fever and marked associated symptoms, and Avith eruption; 2. Fever absent, the symptoms mild, with eruption; 3. The eruption the only symptom. The eruption may appear early, but has no fixed time, is evanescent in mild cases, and is never constant in cha- racter. It is attended Avith burning and itching, and DeBrun noticed desquamation of a varying intensity. Hemorrhages from the various organs (nose, gums, stomach, bowels, lungs, kidneys, etc.) may occur, and reach even a dangerous extent. The lymphatic glands are often SAvollen; the mucosae of the nose and throat are hyperemic; the eyes are congested and the face flushed. The initial fever lasts three or four days, and ends Avith a deep 1 Rev. de Mid., No. 6, 1894. 168 INFECTIO US DISEA SES. remission accompanied by profuse SAveating. All the symptoms noAv vanish save a slight soreness and stiffness, but after an interval of two or three days the characteristic symptoms (including the eruption) re- appear. This second febrile 4paroxysm is usually milder and shorter than the first. The duration of the disease is from seven to ten days, the attack being folloAved by a sIoav convalescence, Avhich may be interrupted by a relapse. The slowness of the recovery is due to persistent mental de- pression and marked physical prostration. Complications.—Meningitis has been noted, but in extremely rare cases. Convulsions sometimes occur in children, and severe catarrhal inflammations of certain mucosae (bronchial, gastric, etc.) may develop. Insomnia is common. Hyperpyrexia and pericarditis occur very ex- ceptionally. Diagnosis.—The diagnosis of the usual form of the disease (epi- demic) is an easy one after observation of the first feAv cases, but a more difficult task is the discrimination of sporadic cases from rheumatism. The course and degree of the fever, hoAvever, differ in dengue and in rheumatism, Avhile the eruption belongs to the former alone. Influenza in many of its manifestations resembles dengue very closely, and the differential diagnosis is a difficult one. In the former condition the herpes is usually the only eruption; the joints are rarely involved; there is neither a remission nor a recurrence of the fever; and serious complications are more frequent. The discovery of the bacillus of in- fluenza is of course decisive, and the existence of an epidemic of either condition strongly suggests the true nature of the disease. Svarlet fever has an erythematous eruption, but the fever is continuous and the arthritic symptoms are usually Avanting. Yellow fever has been mis- taken for dengue, but is characterized by a single paroxysm; jaundice, black vomit, albuminuria, and grave nervous phenomena are features that are never seen in dengue. The prognosis is with rare exceptions favorable, dangers arising only from the extremely rare serious complications. Treatment.—The case presents a double indication : (a) to harbor the patient's strength, and (b) to meet certain leading symptoms. The first is to be accomplished by enjoining rest in bed, by a generous though carefully regulated diet, and by the timely use of stimulants and tonics. Among the symptoms that demand treatment is the fever, and when this is very high hydrotherapy is indicated. When moderate, cold sponging of the general surface, conjoined with internal antipy- retics (phenacetin, acetanilid) in moderate doses, may be resorted to. For the intolerable pains morphin is to be administered hypodermic- ally, this remedy often relieving the insomnia at the same time. If not, chloralamid and the bromids should be tried. Convalescence may be hastened by a suitable change of air. THE PLAGUE. 169 THE PLAGUE. (Bubonic Plague; Black Death.) Definition.—A specific contagious disease, occurring chiefly in un- sanitary surroundings and characterized by high fever, cutaneous symp- toms (petechiae, etc.), and later by an inflammatory enlargement of the lymphatic glands (buboes). It occurs in epidemics. Historic Note.—The plague is an Oriental disease, and has long been endemic in certain parts of India. Most European countries have in the past been visited by epidemics of the malady, but it is at present writing almost solely confined to its native habitat (India), to South China, and to parts of Asia. In May, 1894, a severe epidemic pre- vailed in Canton and Hong-Kong, to which cities it Avas imported from Northern India, and in the latter part of 1896 and the early months of 1897 another SAvept over India Avith devastating results. Etiology.—Kitasato and Yersin both discovered during the epi- demic at Hong-Kong a special bacillus Avhich is probably the cause of the disease. It stains deeply at the ends, giving the appearance of a pair of micrococci, but is really a short rod-bacillus Avith rounded ends. Pure cultures are readily made, and Avhen animals are inoculated Avith these the clinical characteristics of the disease are produced. Modes of Entrance into the Body.—According to Kitasato, the bacil- lus enters either the digestive or the respiratory tract or by means of excoriations of the surface. Predisposing Causes.—These are embraced in the single phrase—un- hygienic conditions. It is safe to assert that Avithout these fostering influences the plague would not prevail. Clinical History.—The incubation period lasts from tAvo to five or six days, and among prominent invasion symptoms are intense pains in the head, back, and limbs, and a dizziness causing the patient to walk with a staggering gait as if intoxicated. The temperature rises rapidly, sometimes to a hyperpyrexial level, preceded usually by slight shiver- ings or a chill, and delirium sets in early. There are torturing thirst, anorexia, and not rarely nausea and vomiting. Petechiae, ecchymoses, and, in malignant types, hemorrhage from the stomach, bowels, and kidneys, may occur, and soon a typhoid condition develops Avith a marked tendency to circulatory collapse. At the end of tAvo or three days, if life be spared until then, buboes appear, and form the most marked and characteristic accompaniment of the disease. The inguinal and femoral glands are most generally swollen and inflamed; the axillary, submaxillary, etc. less frequently. This glandular enlargement may terminate in (a) resolution, (b) suppuration, (c) gangrene (rarely). Suppuration is generally favorable in import. Carbuncles may attend, but are comparatively rare. Diagnosis.—The disease has been mistaken for typhus fever, but in the latter disease there is an absence of the early tendency to collapse, the characteristic buboes, carbuncles, extensive petechiae, and hemor- rhages. On the other hand, in the plague there is an absence of the characteristic typhus eruption. The geographic limitations of the plague should be borne in remembrance. 170 INFECTIO US DISE\ 1SFS Duration and Prognosis.—The duration is brief—from three or four to eight or ten days—and extensive suppuration may prolong the attack. The prognosis is a very grave one, and the disease may prove fatal, like cholera, Avithin a feAv hours. Treatment.—This is largely preventive. All hygienic defects are to be corrected as quickly as possible, especially inadequate seAvage, un- clean surroundings, and impure Avater-supply. Isolation of the sick and thorough disinfection of the sick-room, the bed, and bed-linen, the vom- itus, and the stools, are matters of paramount importance. Kitasato advocates steaming the bedding at 212° F. (100° C.) for one hour, or exposure for a few hours to sunlight, and that all infected articles be burned. " After recovery the patient is to be kept in isolation at least one month." The diet should be liquid, concentrated, and nourishing, and stimu- lants are demanded to obviate collapse. So far as known, medicines do not exercise any controlling influence, and hence they are used merely to combat the symptoms as they arise. As it is possible, however, to ren- der animals immune to the disease, it is reasonable to anticipate that an antitoxic serum will soon be available for treatment. ERYSIPELAS. {St. Anthony's Fire.) Definition.—A specific, acute contagious disease, characterized by a special inflammation of the skin and subcutaneous tissues, with a tendency to spread, high fever, moderate prostration, a disposition to mixed infection (suppuration, gangrene, etc.), and an average duration of fourteen days. It usually occurs in persons under forty years of age, and commonly in endemic, though also in epidemic, form. Pathology.—Erysipelas is a specific inflammation involving the skin, subcutaneous and mucous surfaces, but the latter far less fre- quently. If uncomplicated, no other structures are involved. When inflammation extends to the subcutaneous connective tissue, there fol- lows, as a rule, suppuration. The claim, however, that the' inflamma- tion may penetrate the skull and attack the meninges lacks convincing proof. Osier in one case traced the extension from the face along the fifth cranial nerve to the meninges, where an acute meningitis and thrombosis of the lateral sinuses were excited. The specific cocci are found in the superficial lymph-vessels and spaces of the affected skin, being most abundant in the ever-advancing elevated margin. Beyond the border of the inflamed region they occupy chiefly the lymph-vessels, where they are finally overpowered "by the phagocytic action of the leukocytes. Microscopic examination of the involved area reveals the changes of simple inflammation. Etiology.—Bacteriology.—The specific cause of the disease is the streptococcus erysipelatis of Fehleisen, which is probably identical with the ordinary pus-producing streptococcus. Frankel and Kirchner have ERYSIPELAS. 171 investigated, experimentally, the streptococcus of erysipelas, and con- tend that their results offer convincing proof of the separate identity of the streptococcus pyogenes ; but most observers hold that the latter can- not be distinguished from the streptococcus erysipelatis by any knoAvn test. The streptococci of erysipelas assume the form of a serpent or chain (chain-forming coccus of Cohn), and are very small, somewhat variable in size, and thrive on all kinds of culture-media. Their favor- ite situations are the lymph-vessels and the cutaneous connective tissue, where they are found in colonies composed of myriads of cocci. They are rarely found in the blood-vessels, and in blood-serum they are caused to disappear by the action of the phagocytes; yet in exceptional cases intra-uterine infection has occurred. That the streptococcus erysipelatis is a saprophytic organism is shown by the fact that the identical cocci have been discovered in inanimate and decomposing animal and vegetable substances. Predisposing Causes.—Among the most important disposing causes of erysipelas are— (1) Season.—In a paper on " Seasonal Influences in Erysipelas, with Statistics "* I have shown, as the result of an analysis of 2010 cases collected from different sources, that the various seasons of the year exercise a potent influence upon the frequency of this affection. Thus month by month the cases increase, in slightly varying ratio, from August to April, the latter month giving the greatest number, and then there is a rapid decrease from April to August, Avhen wTe find the small- est number. Again, one-half of all the cases occur during the months of February, March, April, and May, and 15.9 per cent, during the month of April alone. It would appear that the Avinter and spring months, though more particularly the latter, increase the susceptibility to this disease. It was found that a Ioav barometer and mean relative humidity invariably correspond Avith the annual period in which the greatest number of cases occur, and that the highest percentage of rela- tive humidity corresponds with the months affording the feAvest cases. (2) Age.—From the notes of 1894 cases I found that in 25.8 per cent, the age of the patient Avas betAveen tAventy and thirty years. From thirty to fifty years the cases sloAvly decreased in number, and after fifty years quite rapidly, while more than 15 per cent, of the cases occurred before the age of tAventy. The great liability of neAvly-born infants is well known. (3) Sex.—This factor was noted in 1767 cases, and a marked pre- ponderance of the male over the female sex Avas noted (about 3 to 2). (4) Previous Attacks.—Of 450 cases, there had been previous attacks in 39 (8.6 per cent.), in one instance, four, and in another seven, ante- cedent attacks having occurred, Avhile second and third recurrences were not uncommon. (5) Family predisposition exercises a slight though decided influence. It Avas noted in 4 of the 450 cases. (6) Certain Antecedent Affections.—Dr. M. Booth Miller examined the history of 301 cases, and found that acute coryza preceded the attack in 13 instances. Slight lesions of the Schneiderian mucous membrane may be assumed to exist in such instances, offering a condi- 1 Proceedings of the American Climaiological Association, 1893. 172 INFECTIOUS DISEASES. tion favorable to specific infection (vide infra). Testimony confirming the now Avell-knoAvn fact that certain chronic diseases (chronic Bright's, phthisis, organic heart disease, chronic alcoholism, syphilis, etc.) aug- ment a receptivity to the complaint has also been brought to light by my own researches. (7) Slight Injuries, Abrasions, etc.—Erysipelas will not develop on a surface which does not present a break, but with this present may do so though the latter be so trivial as to escape observation. Slight abrasions and fissures, either in the mucous membrane of the nose or in the skin of the face or ear, as Avell as all forms of slight injuries, are liable to furnish a path of ingress to the specific organism. Y^et in 643 out of the 2010 cases mentioned above and examined Avith reference to this point, previous lesions Avere noted in but 13. Women Avho have been recently delivered and persons subjected to surgical operations are pecu- liarly liable, and any deeply-seated focus of irritation, as an area of necrotic bone or a chronic abscess, such as sometimes occurs in sup- purative arthritis, appendicitis, etc., may give rise to repeated outbursts of erysipelas. (8) Antihygienic Surroundings.—These doubtless predispose to the affection, as has been shown by the prevalence of erysipelas in hospitals and institutions in Avhich the sanitary arrangements are markedly faulty. 1 Modes of Conveyance of the Contagion.—The latter may be air-borne. It has been collected from the air of rooms and Avards occupied by ery- sipelas patients; but to what distance and precisely under what circum- stances it can be conveyed is not definitely known. It may also be transferred for a longer or shorter distance by fomites, by instruments, unclean hands, etc., the infection being a result either of contagion or inoculation, and the direct avenue of entrance for the specific coccus being a break in the skin-surface or mucous membranes. Clinical History.—I shall discuss only the so-called medical or idiopathic erysipelas, the traumatic variety falling more properly Avithin the domain of surgical treatises. Incubation.—This is someAvhat varied, though it ranges usually from seven to fourteen days, and the prodromal symptoms are, for the most part, general in character, consisting in headache, restlessness, cough and sore throat, anorexia, and general slight or moderate pyrexia. These endure for a very variable period—from a few hours to several days— when the invasion Avith its characteristic features develops. Invasion Stage.—The symptoms are—(1) local and (2) general. (1) At first the affected part feels hot, tense, painful, and is tender to the touch. Very soon a small circumscribed area becomes red, swollen, firm, and shining, and simultaneously the subjective symptoms (pain, heat, etc.) become aggravated. The point of election is usually on the nose, but it may be on the ear, the face, or elseAvhere about the head, and thence the inflamed, SAvollen zone spreads, chiefly in the direction of one or the other side of the head. Separating the diseased from the unaffected skin there is a sharp line of demarcation in the form of an elevated braAvny ridge, Avhich can be seen and felt. While the inflam- mation is advancing there may be noted, beyond the border of the latter, little red streaks and spots that grow in area till at last they become confluent. The degree of redness increases in intensity as the case ad- ERYSIPELAS. 173 vances, but any natural prominence or fold in the integument may pre- vent further extension of the inflammation (e. g. naso-labial folds, border of the hairy scalp, etc.). In cases of average severity the face is much SAvollen, the eyes closed on account of tumefaction of the eyelids, the ears greatly enlarged (far better marked on one side than the other, as a rule), the scalp swollen and tender, and the facial lineaments often changed beyond recognition. In a minority of the cases the inflamma- tory process extends from the head to the arms, to the trunk, and even to the loAver extremities (erysipelas migrans), and in such instances the face may be healed Avhile the disease is yet extending over other por- tions of the body. Even in the ordinary form, Avhich is usually con- fined to the face, ears, and portions of the scalp, those parts first affected pale Avhile yet the local inflammation is extending its boundary lines. When the progress of the inflammatory process has become arrested the peripheral ridge ceases to extend and grows pale; the inflammation then subsides, and finally disappears altogether. The epidermal layer may become elevated over circumscribed areas, giving rise to larger or smaller vesicles or bullae (erysipelas vesiculosum). Suppuration may attack these large vesicles, Avhereupon they fill Avith pus (erysipelas pustulosum). As the result of intense infiltration the part or parts may become gangrenous—erysipelas gangrcenosum. Enlarge- ment of the cerebral lymph-glands is also common. Desquamation fol- lows erysipelas, and the face often presents a more delicate complexion than before the occurrence of the attack. (2) General Symptoms.—With the onset of the local disturbances or even somewhat earlier, the patient is seized Avith repeated fits of chilli- ness or shivering, or, less commonly, there may be a severe rigor. Im- mediately, and more rapidly than before, the temperature rises to a height of 104° or 105° F. (40°-40.5° C.) on the evening of the first day. As a rule, the temperature reaches its maximum (105° to 107° F.—40.5° to 41.6° C) on the third evening. Marked nocturnal remis- sions of temperature (2° to 5° F.—1.1° to 2.7° C.) are the rule, but the evening temperature may in rare instances be to an equal degree lower than the morning. In a Aveek from the appearance of the eruption the temperature declines rapidly to normal, and usually within twenty-four or thirty-six hours; sometimes, hoAvever, the course of the fever is much more prolonged and defervescence may be less critical. In erysipelas migrans a long and decidedly irregular temperature-curve is presented, the period of decline also showing many deviations from the normal curve Avhen complications are present. The pulse is frequent, of good volume, and soft. I have been able to confirm the observations of DaCosta, Striimpell, and others that the cutaneous inflammation in ery- sipelas (particularly erysipelas migrans) may advance to a slight extent even after the temperature has returned to the normal grade. The tongue is furred, the anorexia intensified, and there are apt to be nausea and frequent vomiting. The bowels are usually constipated, though I have observed a feAv instances in Avhich marked diarrhea de- veloped late in the attack. The inflammation may extend to the mucous membrane of the throat and larynx, causing SAvelling and edema of the parts. It may also involve the serous membranes, though rarely. The nervous symptoms may or may not be conspicuous, but there are apt to 174 IN FECI 10 US DISE. 1SES. be intense headache and restlessness, Avith some mental aberration at night. Actual nocturnal delirium appears in the severer forms, and in erysipelas occurring in drunkards delirium tremens may suddenly de- velop. The urine presents the usual febrile characters (high color Avith increased urea and diminished chlorids). Quite commonly it contains a little albumin, and rarely acute nephritis occurs as a complication. Abundant observation has shoAvn that there is a direct correspondence between the intensity of the local and constitutional disturbances in this disease. Often in severe types (such as are apt to arise in old, much enfeebled, or intemperate persons) of facial erysipelas the typhoid (adynamic) con- dition is developed. The tongue is dry and broAvn, the lips and teeth are covered Avith sordes, the pulse groAvs very rapid and feeble, and the boAvels are apt to be loose. Ataxic nervous symptoms show them- selves. Complications and Varieties.—An analysis of 1674 cases of erysipelas Avith particular reference to complications gave an interesting series of results, and one at variance with the notions of most authors. Some are given here briefly, the complicating conditions being placed in the order of frequency of occurrence: Abscess, 105; rheumatism, 20; delirium tremens, 10; lobar pneumonia, active delirium, phlebitis, pleu- risy, each 7 ; acute nephritis, 6 ; synovitis and diarrhea, each 5; ton- sillitis, 3; catarrhal pneumonia, otitis media, pharyngitis, edema of the larynx, acute bronchitis, each 2 ; endocarditis, meningitis, each l.1 The fact that acute articular rheumatism is a relatively frequent complication of erysipelas is Avorthy of special notice, for the reason that the attention of the profession has not hitherto been called to it. The symptoms of rheumatism usually come on several days after the onset of erysipelas. " So long as the specific agent upon which rheu- matism depends is not known, so long must Ave remain in ignorance of the true explanation of this combination of diseases." In a feAv in- stances pneumonia appeared early, being due most probably to special localizations of the specific streptococcus. To such cases the term " pneumo-erysipelas " may be appropriately applied. The cases—2 in number—in which acute nephritis developed during the first few days of the attack should in like manner be termed " nephro-erysipelas." With few exceptions, however, the complications enumerated are second- ary affections. Meningitis Avas present in a single instance only, and hence active delirium in this disease points to a severe type of infection, but not to meningitis as a rule. Many different varieties have been described. Apart from those already referred to more or less at length (cutane- ous, gangrenous, vesicular, "pneumo-," " nephro-," and migratory ery- sipelas), two other forms—namely, phlegmonous, or cellulo-cutaneous, and relapsing erysipelas—should be mentioned. The former exhibits an inflammation of the subcutaneous connective tissue which tends to suppurate, and a glance at the complications of the affection shoAVS that suppuration occurs Avith the greatest frequency among complicating conditions. But the so-called phlegmonous erysipelas cannot be properly laThe Complicating Conditions, Associated Diseases, and Mortality-rate in Ery- sipelas," by the Author: The Int. Med. Mag. for Oct., 1893. ERYSIPELAS. 175 regarded as a distinct type, since the atypical manifestations are due to secondary infection Avith the pyogenic organism. Relapsing erysipelas, hoAvever, constitutes the chronic form of the disease, recurring at longer or shorter intervals, and usually in the same locality. It is commonly due to some deep-seated focus of suppuration. Sequelae.—The hair often falls, but it is usually replaced by a fresh crop. Abscesses in various parts of the body, particularly the eyelids, are of common occurrence (vide Complications), and chronic otitis media and chronic nephritis may date from an attack of erysipelas. Per contra, erysipelas is reputed to be curative of certain affections (eczema, lupus, carcinoma, sarcoma, rheumatism, etc.). Out of 476 cases collected by me relapses occurred in 54 (11.3 per cent.), and in 1 of these instances 5 relapses occurred; in 2 others, 4 ; and in 3 patients, 3. First and second relapses Avere still more common.1 The diagnosis is made with ease after the eruption has fully devel- oped, and its appearance, seat, and behavior, particularly the manner of extension of the brawny, ridge-like edge (best marked on the fore- head), are the features that should serve to distinguish it positively from every other disease. First, erythema produces superficial redness, but is not attended with heat, SAvelling, or fever. Urticaria assumes the form of pale-red circu- lar Avheals, Avhich cause marked itching and appear in successive crops, often disappearing in the course of a feAv hours. Acute eczema of the face, Avhen intense, may someAvhat resemble erysipelas, but it lacks the peculiar border and mode of progression so characteristic of the latter disease. Again, eczema produces particularly troublesome itching, and the SAvelling is less than in erysipelas. Chronic erythematous eczema is met Avith later in life, is without fever, Avithout any considerable swell- ing or pain, Avhile, on the other hand, it excites intense itching. Eczema nodosum is characterized by its nodosities at their usual seat in the vicinity of joints. Course and Duration.—In my own experience, based upon 1880 cases,2 the average duration (including the prodromal stage and period of convalescence) in persons under forty years of age is fourteen days. The course of the disease is much lengthened by complications or by the pre-existence of chronic affections, and increases with-age after the fiftieth year. The prognosis is favorable, and it is rare for erysipelas to assume a malignant type. Perhaps the chief dangers lie in certain complica- tions, especially extensive suppuration, pneumonia, acute nephritis, de- lirium tremens, etc. Acute articular rheumatism, though relatively frequent, is comparatively harmless; but previous debility, especially if dependent upon chronic diseases, as syphilis, chronic rheumatism, gout, tuberculosis, organic disease of the heart, and the like, increases the percentage of deaths considerably. Again, age has a positive influence upon the mortality, Avhich it augments moderately after the forty-fifth year, and most decidedly after the sixtieth year. When death occurs it is due to exhaustion. 1 Journal of the American Medical Association, July 22, 1893. 2 "Points in the Etiology and Clinical History of Erysipelas," by the Author: Journal of the Am. Med. Assoc, July 22, 1893. 176 ' INFECTIOUS DISEASES. The mortality-rate is low, as shoAvn by the results of my own collec- tive investigations into the subject.1 I found the general average death- rate to be 0.6 per cent., Avhile in cases from private practice it was 4 per cent. In persons under forty years of age it was only 3.5 per cent., Avhile in those over seventy years it Avas 46 per cent. The traumatic cases gave a mortality of 14.5 per cent. Treatment.—The treatment of erysipelas falls naturally into three subdivisions : (1) Dietetic ; (2) Constitutional; (3) Local. (1) Dietetic.—Proper attention to the diet is of the first importance. It must be generous and composed of highly nutritious articles, and if the temperature be high, only liquid forms of nourishment should be admin- istered in definite quantities and at regular, brief intervals. Rectal alimentation should be resorted to if the stomach rejects a suitable diet- ary, and I feel confident of the fact that liberal feeding is of greater service to the patient than any of the recognized forms of medicinal treatment. Lack of attention to the patient's diet during the primary attack tends to increase the frequency of relapse. In persons over fifty years of age, and in those in Avhom the vital processes have been lowered on account of previous chronic diseases, correct alimentation is of para- mount importance, often abridging the othenvise much protracted course of the affection. There can be no question but that the typhoid state of the system met with in many cases of erysipelas is attributable, in- directly at least, to malnutrition. When nourishment is exhibited in a proper manner stimulants are rarely required. (2) Constitutional Treatment.—When, despite an appropriate diet, the pulse becomes very rapid and feeble, the heart's first sound indis- tinct, and the tongue dry or broAvn, indications for the use of stimulants are present and must be heeded. Alcoholic stimulation is most apt to be required in the aged and in patients previously enfeebled by chronic disease. When needful, the alcoholics may be given with a compara- tively free hand, 12 to 16 ounces (360.0-480.0) of Avhiskey daily in di- vided portions. Strychnin gives prompt results, and may be used in association with the alcoholics. In marked gastric irritability cham- pagne is to be preferred. The tincture of the chlorid of iron was first extensively used in this disease by English authorities, and was formerly regarded by most clin- icians as a truly specific remedy. In 74 cases of erysipelas which were treated by this remedy alone, the average quantity being 1 dram (4.0) daily in divided doses, in the Pennsylvania Hospital by Drs. Lewis, DaCosta, Longstreth, Meigs, and others, the death-rate was 4 per cent.2 At the present day the profession are, for the most part, agreed that other preparations of iron are at least equally efficacious. Quinin is a valuable remedy in erysipelas, and during the past twelve years I have employed it in not less than 30 cases, confining its use to instances in Avhich the temperature touched 103° F. (39.4° C), and, with a single exception, in uncomplicated cases (22 in number) the nocturnal remis- sions were decidedly greater and the evening exacerbations less marked. In every instance iron in some form was administered simultaneously. J. M. DaCosta first used pilocarpin in erysipelas at the Pennsylvania 1 Loc. cit., p. 3. 1 " The Treatment of Erysipelas," by the Author: Therapeutic Gazette, July 16, 1894. ERYSIPELAS. 177 Hospital. His experience shoAved that Avhen given hypodermically (crr. ^—0.010) in the very early stage, and repeated three or four times at intervals of two or three hours, it often aborted the attack. If we except this use of the drug, it is only in cases attended Avith high tem- perature with slight morning falls that pilocarpin should be employed; and the condition of the pulse and heart can be relied upon as a guide to its administration. Whether or not the favorable results from the use of pilocarpin are to be ascribed to a property possessed by it of stimulating phagocytic action is not yet clear. Numerous antiseptic remedies have been recommended, and I have for a decade and over been exhibiting mercuric chlorid in moderate- sized doses throughout the febrile stage, Avith some amelioration of the symptoms. Of late various bacteriologists have been endeavoring to obtain a serum antagonistic to the toxin of erysipelas. Experimentally, the success has been all that could be desired, but it has been difficult to obtain a serum of sufficient potency for therapeutic purposes. The most successful is that of Marmorek, now manufactured extensively, and, although Petruschky has declared it useless, the results of earlier and later investigators (Bornemann and Merieux) cannot be ignored, and it must be recognized as possessing considerable value. Certain symptoms demand internal medication. When the fever, as sometimes happens, is alarmingly high, its reduction must be accom- plished, and the best method is by means of cold spongings combined with the ice-cap, or cold or gradually cooled baths. The happy effects of this agent—cold—are manifold. Guaiacol has recently been em- ployed for the purpose of reducing the temperature, and found highly efficacious. The tendency to spontaneous remission of fever in this dis- ease must, however, be-steadily borne in mind. For marked nervous phenomena, such as pain, sleeplessness, and active delirium, hyoscin hydrobromate (gr. y^-g-—0.0006) has been tried hypodermically in numerous cases at the Medico-Chirurgical, Pennsyl- vania, and Philadelphia hospitals, and has given promise of being a valuable remedy. It should not be employed Avhen the heart-power is found to be deficient, and to fulfil the same indications Ave may utilize the folloAving: Sodium bromid, gr. v (0.324) every two hours, or gr. xx-xxx (1.296-1.944) at night; morphin, gr. -| (0.008), and chloral, gr. x (0.648), in combination every half hour for three doses; potas- sium bromid, gr. x (0.648), and tincture of cannabis indica, TTLx (0.666), in combination at bed-time; atropin, gr. -fa (0.0008), and morphin, gr. i (0.0108), hypodermically. The treatment of the various complications must be conducted in accordance with general principles applicable to each. (3) Local measures have ahvays held a prominent place in the treat- ment of erysipelas. The list of agents that have been used topically is long and embraces all classes of therapeutic substances. In the paper previously cited it is stated that in the three series of cases (247) that were treated at the Pennsylvania Hospital, together with a few collected from other sources, no less than fifty different remedies and preparations had been employed locally. Among those most frequently used were elm (37 cases); lead-Avater and laudanum (20 cases); carbolic acid (1 to 12 178 INFECT 10 US DISEASES. 40), injected subcutaneously (18 cases); zinc oxid (14 cases) ; mercuric- chlorid solution (14 cases); ichthyol ointment Avith lanolin (8 cases), etc. Many of these preparations Avere prescribed for their effect in excluding the air—a leading indication. This I am in the habit of meeting by the use of carbolized vaselin or cool carbolized oil. A knowledge of the microbic nature of erysipelas has led to the local application of numerous antiseptic remedies, and it is along this line that the greatest advances in the treatment of the disease are to be ex- pected. Mention has been made of the method of injecting carbolic acid. Here the aim is to check the spread of the inflammatory process by inserting the needle at numerous points just beyond the inflamed border. The method (introduced by Heuter) has been much practised by Henry at the Philadelphia Hospital, and more recently by Osier at the Johns Hopkins Hospital, and is especially applicable in erysipelas migrans. In the statistics before given a solution of mercuric chlo- rid (1 : 4000) Avas used locally in 14 instances, to Avhich I can add the results of 12 others at the Medico-Chirurgical Hospital and in private practice. In nearly all of the cases it Avas employed in the form of a lotion over the inflamed surface. In a few it Avas injected beneath the skin, as in the case of the carbolic acid. More recently it has been recommended to scarify the affected part and follow Avith the application of a solution of mercuric chlorid. In view of the fact that the strep- tococcus is found chiefly in the more superficial channels of the corium, it folloAvs that it may be attacked directly by the mercuric-chlorid solution Avhen the latter is used after scarification; and this method of treatment is at once most promising and rational. In 8 instances (3 of Avhich have been previously reported) it Avas attended Avith brilliant re- sults, limiting the spread and allaying the severity of the local inflam- mation. At the Pennsylvania Hospital uniformly good results were obtained from the local use of ichthyol ointment Avith lanolin (DaCosta and others). ZeleAvsky found ichthyol efficacious in every form of ery- sipelas, being superior to other remedies. He prescribed the agent as follows: B/. Ammon. sulpho-ichthyol, Spts. aether., da. 1 part; Collodii elastici, 2 parts. Thomas advocates thorough rubbing of a strong ointment of ichthyol Avith vaselin or lanolin into the red area and into the adjoining healthy skin, covering the parts Avith lint or the ordinary surgical dressing. Whalen1 has recently reported most strikingly favorable results in 4 cases of facial erysipelas from the use of external applications of guaiacol. Many special modes of treatment in erysipelas have been brought forward recently, but of these only tAvo are deemed Avorthy of brief notice: (a) Method of Koch. By means of a soft brush Ave apply a thin and regular covering of the following pomade : R. Creolin, 10- Iodoform, 4,0- Lanolin, 10.0. 1 Journal of the American Medical Association, April 28 1894. DIPHTHERIA. 179 The parts are then covered Avith leaves of gutta-percha, (b) Method of Hallopeau.1 A mask of several thicknesses of linen is soaked in a solution of sodium salicylate (1: 20) and applied over the parts, which are then covered with rubber bands to prevent evaporation. Relief is said to be almost immediate, and a cure is had in from three to five days. DIPHTHERIA. (Diphtheritis; Angina Maligna ; Croup.) Definition.—An acute, contagious disease caused by the Klebs- Loffler bacillus, and characterized, anatomically, by a croupous-diph- theritic inflammation of the mucous membrane of the pharynx and upper air-passages. Clinically, it is characterized by irregular fever, prostration, and, frequently, albuminuria; also by the secondary devel- opment of toxemia, and often of croupous laryngitis, or cardiac failure. It is often folloAved by peculiar paralyses. In large municipalities it behaves endemically, and from time to time epidemically. Pseudo-diphtheria.—There are forms of inflammation occurring most frequently in the pharynx and adjacent air-passages (and also in many other parts of the body) that are attended Avith the formation of a pseudo-membrane, and are not caused by the Klebs-Lbffler bacillus. These cases have been studied exhaustively by Prudden and others, Avho have usually found the streptococcus to be the specific cause of infection. The latter, hoAveA-er, has been found occasionally in the pharynx of healthy children and in the inflamed mucous surfaces met Avith in ery- sipelas and measles. "Pseudo-diphtheria," so called, is very common in scarlatina. Pathology.—The true diphtheritic inflammation has for its chief pathologic peculiarity the production of a fibrinous exudate. When the inflammation is superficial and of a mild grade, a croupous mem- brane is produced Avhich can be easily removed from the mucosa, which it covers. Its formation is accompanied by a necrotic process that does not extend beloAv, but practically replaces the epithelial layer of the mucous membrane. In the severer types of the affection, hoAvever, the fibrinous membrane infiltrates all the layers of the mucosa, Avhich undergoes necrosis more or less nearly complete. In the severest forms the submucous layer may also become necrotic. It is to be borne in mind that the production of the fibrinous exudate in croup or diph- theria is always preceded by coagulation-necrosis of the epithelium. The mucous membrane surrounding the exudate is hyperemic, more or less edematous, and the seat of muco-purulent secretions. The Pseudo-membrane.—Its composition comprises fibrin, pus, disin- tegrated leukocytes, flakes of necrosed epithelium, bacilli, and some- times red blood-corpuscles. The fibrin has tAvo main sources: (a) "The fibrinogen of the inflammatory matter," AA'hich transudes through the capillary Avails; and (b) Disintegrated, migratory leukocytes, Avhich form branching fibrillse. Weigert holds that the inflammatory exuda- 1 Journal of the American Medical Association, vol. xv. p. 334. 180 INFECTIOUS DISEASES. tion is coagulated by a ferment derived from the disintegrated leuko- cytes. The Klebs-Loffler bacilli are found, chiefly and in varying relative numbers, in the meshes of the fibrillse, but also in the granular fibrin and on the adjacent mucous membrane. Frequently other micro-organ- isms are associated (streptococci, staphylococci, etc.). The membrane presents a grayish-white color, and, if croupous in character, can, as before mentioned, easily be removed. When the mucosa is deeply involved the membrane is thicker, firmer, and more adherent, so that its removal entire cannot be effected without great difficulty, and Avithout, as a rule, injury to the surface, as shoAvn by bleeding, etc. The character of the pseudo-membrane is affected by the nature of the underlying structure; thus in the pharynx it is firmer and less easily separable than in the larynx and trachea, Avhere a distinct basement membrane is found (Flexner). As the membrane becomes older its color is apt to groAV darker, becoming yelloAV or even dark broAvn. It sometimes becomes gangrenous, and softens or disintegrates with the production of a very offensive brownish, semi-liquid excretion. The advancing edge of the false membrane is usually thin. On the other hand, when the process has become arrested the edge is apt to look raised or wrinkled, and later it may be distinctly curled up. The membrane may extend downward into the ramifications of the bronchi. In such cases there is apt to be a lobular pneumonia, and this latter condition may occur without extension of the membrane. Occasionally there is a lobar pneumonia. A generalized bronchitis ex- tending to the smaller bronchi is common from the irritation of aspi- rated substances. In rare cases the membrane has spread into the esophagus and even into the stomach. After separation of a croupous membrane repair consists merely in a restoration of the epithelial layer—a process Avhich is initiated by the fragments of epithelium that remain along the edges of the diseased area, and proceeds centrally. On the other hand, in true diphtheria, with necrosis more or less nearly complete of the mucosa and even the submucosa, sloughing occurs, and the missing structures are replaced by cicatricial tissues. The Heart.—The muscular structure and the nervous mechanism suffer most. The histologic changes may be of the parenchymatous va- riety, but only in mild instances; whereas in severer cases fatty degen- eration is conspicuous. In still other cases the chief pathologic charac- teristic is an interstitial myocarditis, and rarely the lesions of peri- carditis and endocarditis have been noted. The heart is by no means ahvays involved. The spleen is commonly enlarged, though not to an excessive degree. The blood is dark, its coagulability is greatly diminished, and Canon and Frosch have in a few cases found the bacilli in the blood of those dying with diphtheria. The red-corpuscles are somewhat decreased in number during the course of the disease, Avhile the white corpuscles are increased. Bouchut and Dulinsay consider the grade of leuko- cytosis of prognostic value, and claim that it varies directly with the severity. GraAvitz has determined in numerous cases a higher spe- cific gravity of the blood during diphtheria. The lymphatic glands DIPHTHERIA. 181 of the neck become swollen as a rule, but they show little tendency to suppurate. The Kidneys.—The kidneys shoAV degenerative changes, the usual kidney-lesion being a hyperemic SAvelling Avith edema of the interstitial tissues, and often hemorrhagic spots in the cortex. Sometimes there is a marked glomerulo-nephritis, and more rarely a diffuse granular degen- eration of the epithelium. Minute areas of necrosis have been observed in the internal organs, in Avhich fibrin has been found deposited (Oertel). Welch and Flexner have produced, by artificial inoculation upon guinea- pigs, kittens, and rabbits, foci of cell-death in the lymph-glands through- out the body, in the spleen, liver, lungs, heart, and intestinal mucosa. When the dose is small and the animal lives several Aveeks, the paralysis AAThich belongs to the disease may develop. The nerves, in cases of paralysis, have shown parenchymatous and interstitial inflammatory lesions. In paralysis of throat-muscles (i. e. those near the locality of the pseudo-membranous inflammation) the latter show also round-cell infiltration and fatty degeneration of the fibers. The glands, especially of the neck, are often much enlarged, and there is, in pronouncedly septic cases in Avhich a mixed infection is found by culture, a good deal of tumefaction of the neck, this sometimes even obliterating the normal contour from jaAv to clavicle. Etiology.—True diphtheria is caused by the Klebs-Lbffler bacillus, and all cases of supposed diphtheria in Avhich the bacillus is absent are to be regarded as non-diphtheritic. The etiologic is, therefore, quite different from the pathologic significance of this term. Recent researches have removed all doubt as to the specific nature of the Klebs-Lbffler bacillus. Bacteriology.—The bacillus diphtherias nearly equals in length that of the bacillus tuberculosis, and is tAvice the diameter of the latter. It has rounded extremities, which are also frequently bulbous, giving it the appearance of a dumb-bell. At times one end only is clubbed, or, more rarely, one or both ends appear pointed. The bacilli are immobile, do not form spores, and stain readily, the best agent being alkaline methyl-blue. Their manner of taking the stain is important. The bacilli show alternating segments of darker and lighter stained areas, and often minute dots shoAving a most intense and deep staining. They grow on most culture-media, but for clinical purposes Lbffler's blood- serum is important (3 parts blood-serum and 1 part neutral or slightly alkaline nutritive bouillon, containing 1 per cent, of glucose). Inocu- lated on this, they outgroAv all other organisms that may be present, and AA'ithin eight hours or less show numerous spots, one-half to one millimeter in diameter, Avhich have a dull surface and a dense white or someAvhat yellowish color. There are usually present also smaller points Avhich have different appearances and Avhich are colonies of other organisms. The former are the colonies of the bacillus diphtheria, and from these microscopic preparations and (by further cultivation) fine cultures can be obtained. The bacilli are semi-anaerobic, and thrive at the temper- ature of the human body; a temperature of 122°-136.5° F. (50°- 58° C.) causes their destruction in ten minutes. Pseudo-diphtheria Racillus or Bacillus Xerosis.—From many cases, 182 INFECTIOUS DISEASES. often showing no lesions, an organism may be obtained that is identical in appearance, manner of culture, growth, etc. Avith the bacillus diphtheria?, but inoculation Avith it causes no lesions. The Avorks of Abbott, Roux, Yersin, and others seem to shoAV that this is an attenuated form of the true bacillus, and varying grades of pathogenicity may be found betAveen the two. The distinction from the pathogenic bacillus can only be made by determining the lack of infection after inoculation. Site of Infection.—In the human family the seat of election of the bacillus diphtherias is usually the faucial mucosa, and less frequently other abraded skin and mucous surfaces. The bacilli do not penetrate the mucosa, and hence do not find their way into the lymphatic or cir- culatory system, but remain at or very near the site of the local changes. The Toxins.—Toxins are absorbed from the diseased spots by the lymphatics and blood-vessels, and produce the general phenomena in un- complicated cases. They have been isolated from artificial cultivations of the microbe, and Avhen inoculated the chief ptomain of the Klebs- Lbffler bacillus so modifies the solids and liquids of the body as to render the subject immune (Behring). Another, hoAvever, if employed in like manner, produces dangerous and even fatal symptoms (convulsions, paralysis, etc.). It is certain that the bacillus can maintain an existence for months outside of the body, though its usual habitat is unknown unless it be the organic constituents of the superficial soil. The virulence of its products is modified by many individual conditions, and chief among these is a healthy and intact condition of the mucous membranes, Avhich greatly reduces the susceptibility to the disease. Associated Microbes.—With the Klebs-Loffler bacillus are frequently found other microbes, especially streptococci and staphylococci. These pass beyond the site of local infection, reaching the internal viscera and other structures, and, as will be seen hereafter, give rise to the serious septic element of the disease. Modes of Infection.—When the bacillus leaves the body of the sick it is contained in particles or shreds of the diphtheritic membrane, or in the expired air. Infection may then occur (a) By direct contact with the shreds of membrane thrown off—e.g. when the latter are ejected by coughing and lodge upon the conjunctivae or faucial mucosa of bystand- ers. Under this category come the cases in Avhich the deadly poison is transferred to the physician and attendants, Avith resulting infection, from the sucking of tracheotomy-tubes, (b) By inhaling the air sur- rounding the patient (contagion). Infection- by contagion, however, does not extend beyond a radius of a feAv feet from the patient, (c) A very leading manner of conveyance of the bacillus from the sick to the healthy is by fomites. The contagion adheres tenaciously to a great variety of objects (toys, clothing, library books, letters, slates and drinking-cups in the public schools, etc.), and in this way the germs of diphtheria have been transferred over great distances and have given rise to the disease long after. The latter fact renders it difficult to trace certain cases to previous ones, to Avhich they invariablv OAve their origin, (d) Sewer gas, per se, is to be regarded as non-pathogenic, or at least so far as this affection is concerned (Laws). It may however become a carrier of diphtheritic poison, (e) I regard it as highly DIPHTHERIA. 183 probable that the disease may be communicated by domestic animals (fowls, cats, etc.). As to the exact conditions under Avhich infection occurs, our know- ledge is as yet incomplete. We know definitely the usual point of local infection in man, and also that a catarrhal mucosa or an open lesion of a mucous surface invites infection. It is not certain, hoAvever, that even a slight lesion of the mucous surface is essential to infection, though it is very questionable Avhether the diphtheritic germs ever find lodgement in the perfectly healthy mucosa. Some writers claim still that the Klebs-Loffler bacillus may enter the blood through the respiratory system and give rise to primary constitutional symptoms, the local manifestations in the throat being secondary. I have met with a single instance that would lend support to this view. Predisposing Factors.—(1) Age.—This is the most important factor, diphtheria being, in the main, a disease of childhood. Most cases occur between the second and seventh years, Avhile the receptivity diminishes rapidly after the tenth year. Instances have, hoAvever, been observed up to the fiftieth or even the sixtieth year. During the first year of life also it is rare. (2) Sex.—This is Avithout appreciable influence. (3) Season.—Cases are more numerous in winter and spring than at other seasons. (4) Climate.—Diphtheria is met Avith less frequently in tropical than in temperate and cold climates. Humidity favors the propagation of the diphtheria germ, and hence damp cellars also promote the spread of the disease. (5) Unhygienic Conditions.—Unfavorable sanitary sur- roundings tend to loAver vitality, and in consequence to increase the susceptibility to the specific virus. Most epidemic outbreaks have held more or less intimate relationship with decomposing organic matter, defective drainage and sewage, cesspools, etc., though it is to be espe- cially remembered that the disease often prevails in sparsely-settled rural districts. Immunity.—A single attack does not confer perfect immunity. Second and third attacks not infrequently occur in the same individual. Symptoms.—Incubation.—The duration of this period is from tAvo to seven or ten days, and in a small percentage of the cases it may be longer. In virulent epidemics and Avhen the disease is produced experi- mentally the incubation-stage is short—from tAvelve hours to two or three days. The prodromal indications of diphtheria are not strikingly characteristic. They may either be acute in character or very mild; but usually the child will complain of feeling Aveary and indisposed to play, of being chilly and cold, and of pain in the head, back, and limbs. There is nothing in this early stage of the disease to distinguish it from many of the other affections of children, such as simple pharyngitis or tonsillitis. There may be some fever, not very high, and an elevation of one or tAvo degrees at most. The child may often complain of dis- comfort in SAvallowing, and on examination the fauces Avill be found to be reddened, and in a short time the exudate will be found on the ton- sils or soft palate. This is the usual type of simple tonsillar diphtheria. Pharyngeal Diphtheria.—The symptoms are usually sloAver of devel- opment than in tonsillitis. The child is sluggish, looks heavy-eyed, languid, and pale for several days. The fever may not rise above 101° or 102° F. (38.8° C). On examining the throat, however, it is found 184 INFECTIOUS DISEASES. to be SAvollen and red, and if lividity is more pronounced than the swell- ing, it suggests the true nature of the disease. The membrane begins on the tonsils in the form of small patches of yellow exudate, scarcely distinguishable from the thick, cheesy plugs of inspissated dead epi- thelium and secretion Avhich issue from the mouths of the follicles of the tonsils during the course of acute or chronic tonsillitis. The mem- brane spreads from the tonsils to the soft palate and half arches Avithin a few days, and it may also appear on the pharyngeal Avail. During this stage the throat may become much swollen and the tonsils greatly enlarged, frequently meeting in the median line. The glands immedi- ately beneath the angle of the lower jaw on one or usually both sides become hard, painful, and slightly enlarged; the swelling of these glands is not usually great in mild forms, although their presence, in association Avith the foregoing symptoms, is an infallible indication of the disease. The child, as a rule, shoAvs grave constitutional symptoms for a feAv days, and loses its appetite. The temperature is not charac- teristic, as a rule not being high, and the pulse is rapid and Aveak, being out of proportion to the general indications of the disease. In mild cases the symptoms abate by the end of the first week, and the pseudo- membrane separates, leaving a red, inflamed surface behind. The child is prostrated for a number of Aveeks, and in about 20 per cent, of all mild cases the toxic effects of the disease may show themselves in the form of a neuritis, with its accompanying paralysis. Variations in Manifestation.—Diphtheria may exhibit a number of variations as regards the seat of attack and the severity of the poison- ing. In some epidemics the Klebs-Lbffler bacillus seems to be more active and more numerous, or perhaps more virulent, than in others. The severity of the attack does not seem to depend on the amount of the pseudo-membrane, but rather, according to Rotch, upon three fac- tors : (1) the virulence of the bacteria; (2) the local resistance; and (3) the general resistance. The false membrane is most frequently seen on the tonsils, spreading gradually to the soft palate and uvula, though the mucous membrane of any part of the body may be the seat of the groAvth. Malignant Diphtheria.—The symptoms are severe from the com- mencement. There are one or at most two days of slight illness, and then alarming symptoms manifest themselves, cardiac failure possibly setting in Avithout a specially severe local lesion. Vomiting and high fever, resembling the onset of scarlet fever, may initiate the attack ; and within a feAv hours Ave may find extensive SAvelling at the angles of the jaws, with a feeling of stony hardness, a very offensive, bloody dis- charge coming from the nostrils, accompanied Avith difficulty in opening the mouth. If the throat is examined, there will be found extensive swelling of the tonsils, even to meeting, the uvula and soft palate being edematous and covered writh much sloughy-looking membrane. The temperature in severe cases soon reaches a point betAveen 103° and 104° F. (40° C), while the heart-beats become exceeding feeble. In a day or two the cellulitis extends, the face becomes edematous, the skin pits all over the face, neck, sternum, and chest-walls. The patient soon becomes drowsy, cyanotic, and occasionally an ervthematous rash appears about the face, neck, and chest, Avhile a purpuric rash is not in- DIPHTHERIA. 185 frequent in malignant cases. Death occurs in such cases within one Aveek from toxic poisoning. Malignant cases of diphtheria resemble very closely malignant scarlet fever, though the pulse in scarlet fever will be of assistance in the absence of the characteristic rash. Nasal Diphtheria.—In all severe cases of pharyngeal diphtheria the inflammatory process is likely to extend to the nasal mucous membrane. In some cases the nasal mucous membrane is found to be the first in- volved, and it may spread to the tonsils, but in these cases the exudate will be found to involve the back of the soft palate and pharynx as well. In many cases of nasal diphtheria no membrane may be found during life; there may be only a purulent discharge wTith blood, the presence of which in the nasal passage obstructs breathing, giving rise to a bubbling sound, and rendering sleep troublesome and noisy. Many cases have also been reported of formation of pseudo-membrane in the nose Avith mild general symptoms (often insignificant), and from which bacilli identical with diphtheria bacilli were obtained by culture, the bacilli often persisting for months. Sometimes the cases have recurring mild attacks of pseudo-membranous inflammation of the nose, while the bacilli may be constantly present. It is probable that these cases may give rise to in- fections of like nature, and even of true diphtheria. In nasal diph- theria the symptoms are quite as severe as in faucial diphtheria, and in cases in which the soft palate, tonsils, and nasal mucous membrane are involved the general symptoms, the depression, and also the albuminuria, are Avell marked. In this place it is well to remember that in measles we sometimes have a form of membranous exudation occurring on the nasal mucous membrane and as a primary disease Avhich is not diphtheria. This disorder runs a more favorable course, the membrane being thinner and less adherent, than in diphtheria. " Rhinitis fibrinosis " is of favor- able prognosis. In all cases of coryza with fever we should be guarded as to opinion, especially if an epidemic of diphtheria is prevalent at the time. The diphtheritic inflammation may spread from the nose to the conjunctivae, with the formation of a false membrane, and much purulent discharge may escape from the eyes, the- lids of which may be greatly swollen. Wound-diphtheria.—A diphtheritic membrane may grow on the lips, tongue, vulva, or glans penis. The bacillus will not live on normal skin, but Avhen the skin is cut or bruised, as after blistering or an eczematous condition, and when a moist, raAV surface is present, the bacillus freely flourishes. Granulations also form a favorable soil. The diphtheritic germs may be introduced into the system during an operation, such as an excision of the tonsils, or even a vaginal examination; and in neAv-born infants the granulating surface left after sloughing of the cord may be- come the seat of diphtheritic inflammation. Laryngeal Diphtheria or Membranous Croup.—In many cases the Klebs-Lbffler bacillus produces its influence first on the mucous mem- brane of the larynx, and in these cases the mucous membrane of the nose and pharynx may never give evidence of a false membrane. In laryngeal cases the first symptom is a cough of a harsh, metallic, ringing character, and never to be forgotten Avhen once heard. The temperature may be slightly above normal, or even, in many cases, normal. The toxic absorption is slight, on account of the locality affected, and the 186 INFECTIOUS DISEASES. constitutional symptoms are usually mild. The local symptoms, hoAvever, are very alarming, as they are the results of laryngeal obstruction, there being marked dyspnea with retraction of the intercostal and supraclavic- ular spaces, and later of the epigastrium and lower chest. These are associated with an increasing cyanosis. The child is soon very restless, is forced to sit up to breathe, and for the same reason bends forward with its head throAvn back. In these extreme cases, unless relief is soon gained, the child dies of suffocation. In many cases the slower form of suffocation may result from the extension of the membrane dowmvard to the bronchi. Complications.—Local complications may be mentioned, as when we have hemorrhage from the nose and throat in the more severe ulcera- tive cases. Skin-rashes are not unusual, especially the diffuse erythema. Sometimes urticaria will be noticed, and in very severe cases purpura will mark the skin. Broncho-pneumonia is the most serious pulmonary complication of diphtheria. It is not produced by the Klebs-Loffler bacillus, but by pyogenic cocci which have been taken in during respiration. Broncho- pneumonia is very frequent, and most usually terminates laryngeal cases that have been operated upon. Albuminuria is really a part of the disease, and can scarcely be re- garded as a complication. It is the most constant symptom, and is almost as certain in establishing a diagnosis of true diphtheria as a bac- teriologic examination. It is met Avith in both mild and very severe cases, and the greater the amount of albumin the more severe the case. When acute nephritis complicates diphtheria it is usually not accompanied by edema or anasarca. Dysphagia may, by its constant existence throughout the disease, pro- duce a profound impression on the general nutrition. Involvement of the conjuncture is a rare and very grave complication. Otitis media occurs frequently, and may be a very troublesome com- plication as Avell as a sequela. The most frequent sequelae are anemia, chronic naso-pharyngeal ca- tarrh, peripheral neuritis, and its associate paralysis. Anemia may so prolong convalescence that the child will frequently be exposed to some intercurrent disorder. The chronic naso-pharyngeal catarrh may be so marked as to offer a favorable ground for new diph- theritic invasion. Neuritis and paralysis will not be noticed until the third or fourth Aveek, the paralysis usually being first seen when the child attempts to SAvallow and the food is regurgitated through the nose. This is due to a paralysis of the muscles of the soft palate, Avhich will also be noticeable owing to a peculiar alteration of the voice. The paralysis may take a general form, such as is seen in multiple neuritis, the lower ex- tremities being affected and the knee-jerks absent. The paralysis is fre- quently quite extensive; it may extend to the external ocular muscles and cause squint, to the ciliary muscles and cause dimness of vision from unequal accommodation, or to the muscles of the trunk in general, pro- ducing a very general paralysis. The child, not being able to hold any- thing, may stagger about as if intoxicated, so much so as to suggest the existence of a cerebral tumor. The disturbance of vision and the ab- sence of the patellar tendon reflex has in adults led to a mistaken diag- DIPHTHERIA. 187 nosis of locomotor ataxia. Loss of taste, deafness, and a disturbance of sensation are not infrequent. Thus, paralysis is to diphtheria what dropsy is to scarlet fever—a proof positive of the disease. To make one step more, in many sudden deaths occurring in early diphtheria we must recognize paralysis of the heart outside of all toxic influence, and the fact that in cases of sudden death, which are by no means uncommon during the disease, we have some sudden disturbance of the vagus brought about by means of its cardiac branches. The prognosis in all cases of post-diphtheritic paralysis is very favor- able. Myocardial weakness tends to supervene as a sequel. It is evi- denced by the sudden accession of pallor, nausea, sometimes by vomit- ing, and also by weak heart-sounds and a feeble, broken, irregular pulse, etc. Diagnosis.—The diagnosis of a pharyngeal diphtheria (the usual typical form) is not difficult if an epidemic be prevailing. The false membrane on the fauces and the presence of albumin in the urine give us a practically certain diagnosis. From follicular tonsillitis we differ- entiate diphtheria by the seat of the membrane, that of the former being in the tonsils, while diphtheritic membrane is over the tonsils and over the soft palate. Moreover, in follicular tonsillitis the fever is high, the onset is sudden, and it is most usually associated with gastric disturbance. Albuminuria is generally present in diphtheria, while it is present in fol- licular tonsillitis in exceptional cases only. The histories of the tAvo cases are quite different. In many cases clinical distinctions will entirely fail us, it being uncertain whether or not the case is one of mild diphtheria, and then the most certain evidence of the disease is the finding of the Klebs-Lbffler bacillus in the membrane. In many cases of so-called diphtheria the membrane is only formed by streptococci or staphylo- cocci. The croupous or membranous angina may offer some doubt, yet in this disease there is no tendency to spread to the nasal mucous membrane or to the larynx; there is a diminution in the glandular enlargement; there is no albumin and the onset is more sudden. A mild case of diphtheria in a house may be followed by a malignant one. Moreover, mild cases may at first not contain albumin, and fail to shoAV its presence until later in the disease. Diphtheria frequently is associated with a rash, rendering it difficult to distinguish the condition from scarlet fever; but in diphtheria the rash is erythematous in charac- ter, while in scarlet fever the rash may be absent. The glandular SAvell- ing and sloughy condition of the throat, however, closely resemble diph- theria, and a positive diagnosis without a bacteriologic examination is often impossible. An immediate diagnosis without the use of culture is often possible by making a smear-preparation of the exudate from the throat (see Fig. 19), when the Klebs-Loffler bacilli may be present in sufficient numbers, and may be quite characteristic to an expert. In this connection may be given the following statement by Park, Avho has had an exceptional experience : " The examination by a competent bacteriologist of the bacterial growth in the blood-serum tube, which has been properly inoculated and kept fourteen hours at the body-temperature, can be thoroughly relied upon in cases in Avhich there is a visible membrane in the throat if the culture is 188 INFECTIOUS DISEASES. made during the period in which the membrane is forming, and no anti- septic, especially no mercurial solution, has lately been applied. In cases in which the disease is confined to the larynx or bronchi, surprisingly accurate results can be obtained from cultures, and although, in a certain Fig. 19.—1, A tube of blood-serum ; 2, a sterilized cotton swab in test-tube. Rub the swab gently but freely against the visible exudate, and without laying it down, after withdrawing the cotton plug from the culture-tube, insert it into the latter, and rub that portion which has touched the exudate gently but thoroughly over the surface of the blood-serum with- out breaking its surface. Now replace the swab in its own tube, plug both tubes, and place them in the box provided by the health officials. This is to be sent to the baeteriologic expert. In laryngeal diphtheria the swab is to be passed far back and rubbed freely against the mucous membrane of the pharynx and tonsils. proportion of cases, no diphtheria bacilli will be found in the first, yet they will be abundantly present in later cultures. We believe, therefore, that absolute reliance for a diagnosis cannot be placed upon a single cul- ture from the pharynx in purely laryngeal cases." When a baeteriologic examination cannot be made the practitioner must regard as suspicious all forms of throat-affections in children, and carry out measures of isola- tion and disinfection. In this way alone can serious errors be avoided. Mistakes do not usually occur in a more pronounced membranous sore throat, but in the lighter types, many of which are in truth due to the Klebs-Lbffler bacillus. Prognosis.—Diphtheria is at the same time the most prevalent and most fatal of all the diseases with which the general practitioner has to deal, and, I may add, the least understood. The mortality is enormous, though it differs widely in different epidemics, and the most fatal variety is unquestionably the laryngeal. In laryngeal diphtheria the mortality may be as high as 75 per cent., and the younger the child the more unfavor- able the prognosis, the strong and healthy seeming to share the same fate as the weakly. Of especially unfavorable prognosis are those cases that shoAv large quantities of albumin in the urine, general adenitis, cervical glandular enlargement, excessive nasal discharge, a necrotic state of the throat, vomiting, and partial or complete suppression of the urine. Al- though the temperature in diphtheria is never very high, yet a sudden fall of temperature to subnormal and an irregular pulse are also very unfavorable symptoms. Recovery from a severe attack in which there is extreme depression and much albumin is unusual, especially in a child under six years of age, though recovery takes place very frequently in Avhat would be regarded as hopeless cases. Suppression of urine, if it continues thirty-six hours, is generally fatal. A fall of temperature in scarlet fever, if we have a strongly-acting kidney, is an encouraging in- dication ; the same, however, is not true in diphtheria if it is associated with vomiting. The results of Morse's extensive observations are opposed to those of Bouchut and Dulinsay, who claim that the degree of leukocy- tosis is of prognostic value (see p. 180). The cases of neuritis invariably DIPHTHERIA. 189 recover. A child Avho has had diphtheria once is most likely to contract it again, and if he recovers is liable to suffer from its effects for years. The causes of death in diphtheria, in their order, are as follows: in- volvement of the larynx ; membranous croup or laryngeal diphtheria ; septic infection, Avhich may be a slow death ; sudden heart-failure—paraly- sis of the heart; broncho-pneumonia, following tracheotomy or occurring during convalescence. Treatment.—Prophylaxis.—The best preventive measures against diphtheria are a clean nose and mouth. Insist upon a careful toilet of the nose in all children. The slightest appearance of a coryza must be overcome at once by the use of a mild antiseptic wash; all accumulations of crusts, dust, dried blood, etc. should be removed from the nose twice daily, especially in children attending school or during the prevalence of an epidemic. The child should be early taught to employ a small anti- septic gargle as a daily routine, using a weak solution of hydrogen dioxid, listerin, or even a mild dilution of alcohol. The teeth should be care- fully cleaned daily, and all decaying teeth should be filled or removed. If it is true, as one authority claims, that over two hundred different spe- cies of bacteria find a happy home in the oral cavity, this fact should make all parents attentive to the proper physiologic condition of the mouths of their children. All cases of sore throat should be examined for the Klebs-Lbffler bacil- lus, and, if it is found, the individual should be isolated; and all cases of diphtheria should be kept isolated until the membrane has disap- peared from the nose and throat. This is especially true in schools and asylums. Moreover, the throats of all persons exposed to this disease, and of those caring for diphtheritic patients, should be frequently ex- amined for the Klebs-Lbffler bacillus, and if it be found the person should receive immunizing doses of antitoxin. The fact that the Klebs-Lbffler bacilli when found in healthy throats may not be active is no argument against isolation, because it is well known that if the same germs were to find such favorable soil as a broken or catarrhal membrane they would rapidly develop. The seed being there, the soil only requires prepara- tion for its reception. An unrecognized feature in the prophylactic treatment of the disease is seen in the uncertain period of convalescence. It has frequently hap- pened that long after all membrane has disappeared active bacilli may still cling to the throat. This condition may continue from two to six months, and even longer in deeply fissured tonsils; and the disease may be communicated by such throats in the act of kissing young children or adults with sensitive throats or with a broken mucous membrane of the mouth. For this reason the indiscriminate kissing of young children on the lips should be interdicted by the physician. Sufficient importance has not been been given to the milder cases of diphtheria as to their isolation and disinfection, and this fact explains the occurrence of many house-epidemics. Treatment of the Attack.—The treatment falls very naturally under sev- eral departments: (a) the hygienic measures to limit the diffusion of the dis- ease ; (b) the local management of the throat to destroy early the toxic germs; (c) medication to antagonize the effect of the toxins, and event- ually to overcome the complications and sequelae. 190 INFECTIOUS DISEASES. (a) Hygienic Treatment.—The patient should be in a room well ex- posed to sunlight and fresh air, as diphtheritic germs grow Avell in poorlv- lighted and damp chambers. No stationary washstand should be alloAved in the room, and Goodhart well says that many cases seem to have their origin in the proximity to foul-smelling drains. The physician should never consent to be responsible for the recovery of a patient in a room in which there is a washstand Avith its uncertain connection with the main sewer. If possible, the patient should use two connecting rooms, one during the day and the other at night, so that one while not in use may be thoroughly aired and disinfected. Even in mild cases the patient should be kept in bed throughout the attack, and in more severe cases also for some time during convalescence. This is especially important Avhen there have been symptoms of cardiac depression during the acute stage. The general comfort of the patient is enhanced by two daily sponge baths of tepid salt-Avater or of alcohol and water. Feeding.—Nursing infants may be fed on breast-milk obtained by a breast-pump, but should not be placed at the mother's breast (Holt). The feedings should be regular, yet lighter in quality and quantity than in health, remembering the tendency to vomit in all acute febrile affec- tions, and the fact that gastric disturbance is closely associated with diph- theria. The rule must be, less solids and more fluids than in health. Milk in some form being our main dependence, it should usually be diluted, and for young children partially if not wholly peptonized. The greatest difficulty comes in the latter part of the disease, when the child is septic and most likely has a strong objection to be disturbed. At this time vomiting is most easily provoked, and SAvallowing is rendered very difficult on account of the swelling and pain. We must not neglect the feeding even if it does cause discomfort, and here forced feeding by means of gavage is most valuable. Gavage is more desirable and likely to be more successful Avith children under three years than rectal alimen- tation. In older children, Avho object to the tube through the mouth, it may be passed through the nose with very little difficulty, and gavage by this route, even in intubated cases, Avill be extremely satisfactory. Con- centrated broths, meat-juice, and even milk-punch or raAv eggs, may be given in this way. Stimulants.—Alcohol no longer holds a debatable ground in the treat- ment of diphtheria: it is the most powerful drug in our possession to off- set the ravages of the disease on the nervous centers and for the control of the circulation. Stimulation should be commenced as soon as there is a reasonable certainty as to the correctness of the diagnosis, and by com- mencing early with whiskey or brandy we may prevent the depressing effects of the poison of diphtheria as seen in the pulse and general con- dition of the child. The indications for alcohol are marked prostration, feeble pulse, and a weak first sound of the heart. The quantity must be adjusted to the age and gastric condition of the child, and usually one ounce (32.0) of good whiskey or brandy, well diluted, in twenty-four hours is sufficient for a child four years old. In very bad cases five or six times this quantity may be given, the only limit being the tolerance of the stomach. As a rule, the stimulant should be mingled with the food, as the child may rebel against taking both food and stimulant. Strychnin stands next to alcohol in importance in the treatment of DIPHTHERIA. 191 diphtheria, and usually it is given in too small doses. For a child four years old gr. -fa (0.0021) may be given every six to eight hours, and may be administered in little tablets by the mouth or hypodermically. Digitalis does not hold an important place in the heart-weakness of diphtheria, and yet it is strongly indicated on theoretic grounds. Clinic- ally, it has been found to have an unfavorable action on the stomach before its good influence can be had on the heart itself. The same may be said of camphor and ammonium carbonate. The aromatic spirits of ammonia is valuable for rapid effects in syncopal attacks. In cases of threatened heart-paralysis occurring late in the disease Holt has found nothing so valuable as morphin employed hypodermically, the drug being given in full doses and repeated every two hours, keeping the child under its influence for some days. Internal medication should be avoided until absolutely necessary, and such symptoms as vomiting or diarrhea are to be met Avith sufficient treat- ment only for their control. (b) Local Treatment.—For the direct attack upon the membrane in the throat nearly all the remedies of the Pharmacopeia have been used. Garg- ling, swabbing, painting, spraying, and washing the throat out, all have their advocates, and every physician has his favorite remedy or combi- nation. And, as all adult pharyngeal diphtheria tends to recovery, it would seem reasonable that this form of treatment should not be neglected ; yet since the acceptance of the antitoxin treatment medical opinion has suffered a decided change, especially as to the importance of local meas- ures. The very best local application for pharyngeal or nasal diphtheria consists of hydrogen dioxid, diluted one-sixth, and used both as a gargle and spray as most convenient; this is usually sufficient in the early stage. The tincture of iron and glycerin is a valuable local remedy applied by means of a swab. The object of local treatment in the light of our neAv pathology is a more thorough cleanliness, and not the destruction of the bacilli, yet it does still more good by preventing the systemic absorption of the ptomains. Hence a careful toilet of the nose and throat is import- ant in preventing the spread of the disease. This part of the work is more easily directed than accomplished, especially in rebellious children, and we have frequently felt that new lesions Avere created in the mucous membrane of the nose and throat by an undue ardor in making applica- tions. To avoid new lesions the spray alone should be used, and for the nose boric-acid solutions or hydrogen dioxid, 1:10, will be most service- able. In this work the utmost tact and kindness must be maintained, for it is truly pitiable to force a struggling child, endangering the strength to accomplish so little. Warm, weak solutions, most thoroughly applied by means of the fountain syringe, Avill be better than the more frequent use of the hand-syringe. In older children Avho will use it a gargle of boric acid, listerin, or Dobell's solution, well diluted, may be used to keep the nose and mouth clean. In laryngeal diphtheria the child should inhale an atmosphere laden with the vapor of slaking lime, or, Avhenever practicable, an atmosphere saturated wTith Lbffler's solution (menthol 10 grams, dissolved in sufficient toluol to make 36 c.c, liq. ferri sesquichlorid, 4 c.c, absolute alcohol, 60 c.c). The development of the signs of actual stenosis, as shoAvn by stridulous breathing, cyanosis, etc., furnishes an indication for either in- 192 INFECTIOUS DISEASES. tubation or tracheotomy. According to my own observations, the results of intubation have been quite favorable, and I would strongly recommend 1 2 3 4 6 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 MlE MEMEMEMEMEMEMEMEMEMEMEMEMEMEMEMEMEME MjE 106° 1 3 1 -t 1 O- t -ff -C < / . / - ■ ' •*- /- -A- P —UL p / a ... -T ^m ^ /til _.. t\ .A _, it ioic - 1 \ K \ \ /v ' ■ /' A i . r f ..... . 1 ■/ i A ' i / i ' / ■ 1 / W / i \ ' ,nn-=t* ! LhlhtM 2 - zt- -^- ' tF HE t 2 ? 3 zt "It 15,_ ' / i 7t -i \^A K 2 j t" A t-*5^ J? k-^ ►-j-4 tZ ts /sz/ " . or0 i J2" ts CA 98 * -* -*■ V-^- V v .,J>„7.° _________ ... ,. ,. , _ ...... Fig. 20.—Temperature-chart of a case of diphtheria. a trial of this procedure before resorting to tracheotomy (see temperature- chart, Fig. 20). (c) External Applications.—External applications to the throat have no effect on the course of the disease. They are useful, however, in relieving the pain and the SAvelling in the lymph-glands. Careful massage of the neck with camphorated oil, as hot as the skin will tolerate, is very sooth- ing ; and soap liniment may be used in the same way, or if much pain exists chloroform liniment may be substituted. Poulticing for the relief of pain is not desirable, as it seems to favor suppuration. In older chil- dren the ice-bag has been used with good effect, and it soon brings grate- ful relief from the tension and subdues inflammation. All manipulations about the child, however, should be carried on as gently as possible, so that its rest may not be disturbed. Serum-therapy; the Antitoxin Treatment.—This has now passed be- yond the stage of uncertainty and experimentation, and must be regarded as one of the most positive advances made in practical medicine. Its utility rests upon the discovery that animals may be rendered immune to diphtheria, and that the blood of an animal so treated, when introduced into another animal, protects the latter from infection by the diphtheria bacilli. The studies of Behring, Roux, Kitasato, and others have demon- strated that the use of the blood-serum of the lower animals, artificially rendered immune against diphtheria, has a powerful healing influence upon diphtheria that has been contagiously or spontaneously acquired by man. These experiments Avere first published in December 1890. The principle was first shoAvn to be true of tetanus, and, late in 1892, Behring further showed that the blood of an immunized animal had the power DIPHTHERIA. 193 both of protecting and of curing susceptible animals Avhich had been in- oculated either with the toxins or the bacilli of diphtheria. In preparing the blood-serum it is very desirable, of course, to have a uniform strength or standard. One-tenth of one cubic centimeter of what Behring calls his normal serum will counteract ten times the minimum of diphtheria poison, fatal for a guinea-pig weighing three hundred grams. One cu- bic centimeter of this normal serum he calls an antitoxin unit. The serum prepared by his method is labelled in three strengths. No. I. is sixty times the strength of the normal serum; No. II. is one hundred times as strong; and No. III. is one hundred and forty times as strong. To a child of two years or over not less than 800 or 1000 units should be administered at the first dose ; hence solution No. I. is rarely employed at the present day. Should a favorable result not be attained, then, on the following day, 1500 to 2000 units should be administered, and a third dose after a similar interval if necessary. The latter dose should be em- ployed at the outset in very severe cases and in those not seen until they are far advanced. The sites to be selected for injection are various. In very young children either the buttock or thigh is to be preferred, while in older children the flanks or subscapular spaces may be chosen as well. The injections should be made deeply into the subcutaneous cellular tissue. In fortunate cases the influence of the serum soon becomes apparent. Within twenty-four hours the faucial swelling diminishes, the membrane exfoliates, the temperature falls, the pulse becomes slower and stronger, and the general condition of the patient quickly improves. In cases of moderate severity and when injections are employed early the improve- ment in the throat and the constitutional symptoms is very decided; and the earlier the case comes under treatment the better are the results. There are, however, many cases of great severity in which the antitoxin has been used early, and yet has not shown any benefit. A danger in serum-therapy may be the development of local abscesses, which, if full antiseptic precautions be taken, must be rare indeed. I have escaped them altogether. Certain skin-eruptions have been observed after injections, mostly urticarial, though sometimes scarlatiniform. The latter form has given rise to apprehensions of scarlatina. Widerhofer had one case which Avas isolated as measles, but never developed any symptoms other than the suggestive eruption. Rarely, joint-pains and SAvellings, with general prostration, supervene. Two fatal cases have been reported—one1 that of a healthy boy five years old, the result of an injection of Behring's fresh serum as a preventive, dying Avithin five minutes; the other occurred in Berlin.2 For establishing immunity in subjects exposed to infection the injec- tion of 60 units (1 cubic centimeter of the No. I. serum) affords pro- tection. In order to arrest the development of the disease during the period of incubation 100 units (1 cubic centimeter of No. II. serum) is probably sufficient. A large number of preparations are on the market, many of Avhich are good, yet great caution must be exercised in their selection. The use and value of antitoxin in private practice are best shoAvn in 1 Journal of the American Medical Association, April 4, 1896. 2 Medical News, April 18, 1896. 13 194 INFECTIOUS DISEASES. the following summary of the report of the American Pediatric Society's investigation of the subject: 1. The report includes returns from 615 physicians. Of this number more than 600 have pronounced themselves as strongly in favor of the serum-treatment, the great majority being enthusiastic in their advo- cacy. 2. The cases included have been draAvn from localities Avidely sepa- rated from each other, so that any peculiarity of local conditions to which the favorable reports might be ascribed must be excluded. 3. The report includes the record of every case returned, except those in which the evidence of diphtheria was clearly questionable. It Avill be noted that doubtful cases that recovered have been excluded, while doubtful cases that Avere fatal have been included. 4. No new cases of sudden death immediately after injection have been returned. 5. The number of cases injected reasonably early, and in w7hich the serum appeared not to influence the progress of the disease, Avas but 19, these being made up of 9 cases of somewhat doubtful diagnosis, 4 cases of diphtheria complicating measles, and 3 malignant cases in which the progress was so rapid that they had passed beyond any reasonable pros- pect of recovery before the serum Avas used. In 2 of these the serum was of uncertain strength and of doubtful value. 6. The number of cases in which the patients appeared to have been made worse by serum was 3, and among these there is only 1 case in which the result may be fairly attributed to the injection. 7. The general mortality in the 5794 cases reported was 12.3 per cent., and, excluding all cases moribund at the time of the injection or dying Avithin tAventy-four hours, it was 8.8 per cent. 8. The most striking improvement was seen in cases that Avere injected during the first three days. Of 4120 such cases the mortality Avas 7.3 per cent., and, excluding cases moribund at the time of the injection or dying within twenty-four hours, it was 4.8 per cent. 9. The mortality in 1448 cases injected on or after the fourth day was 27 per cent. 10. The most convincing argument, and, to the minds of the com- mittee, an absolutely unansAverable one, in favor of serum-therapy is found in the results obtained in the 1256 laryngeal cases (membranous croup). In one-half of these, in a large proportion of Avhich the symp- toms wTere severe, recovery took place Avithout operation. Among the 533 in Avhich intubation was performed the mortality Avas 25.9 per cent., or less than half as great as has ever been reported by any other form of treatment. 11. The proportion of cases of broncho-pneumonia (5.9 per cent.) is very small, and in striking contrast to results published from hospital sources. 12. As against the two or three instances in which the serum is be- lieved to have acted unfavorably upon the heart might be cited a large number in which there was a distinct improvement in the heart's action after the serum wTas injected. 13. There is very little, if any, evidence to show that nephritis Avas caused in any case by the injection of serum. The number of cases of SEPTICEMIA. 195 genuine nephritis is remarkably small, the deaths from that source num- bering but 15. 14. The effect of the serum on the nervous system is less marked than upon any other part of the body ; paralytic sequelae being recorded in 9.7 per cent, of the cases, the reports going to shoAv that the protection offered by the serum is not great unless injections are made early. SEPTICEMIA. Definition.—A disease due to an introduction into the system of the products of putrefaction (sapremia) or to a microbic invasion of the blood and tissues (true septicemia), Avith or Avithout the presence of a local seat of infection. Pathology.—After death the body putrefies early. The macro- scopic changes in the viscera are sometimes feAv and often Avanting. The muscles present a brownish color-tint. The pia mater is generally con- gested, and, together Avith the nerve-centers, may be the seat of ecchy- moses. The blood is dark (" tar-like "); its coagulability is diminished, and, microscopically, it shoAvs an abundance of micrococci and bacilli. The spleen is someAvhat softened and its lymphoid elements more dis- tinct, and almost invariably ecchymoses are found in the serous mem- branes, especially the pericardium and peritoneum. In protracted septicemia more marked alterations exist, and among them may be briefly enumerated the folloAving: endocarditis (rarely ulcerative); gastro-intestinal catarrh (of the duodenum and rectum in particular) Avith punctiform extravasations; enlargement of the lym- phatics and spleen, with softening of the latter; cloudy SAvelling of the liver (rarely the so-called emphysema of the organ due to putrefaction); edema and catarrhal inflammation of the uriniferous tubules; conges- tion, sometimes associated with edema of the lungs; and inflamma- tion of the pleura, pericardium, and peritoneum, Avith ecchymoses and trivial effusions. Microscopically, the internal organs shoAv numerous small foci of in- flammation, some of wThich may be the seat of "coagulation-necrosis." Bacteria are found in abundance in various situations, such as the exu- dations, the capillaries of the inflammatory foci, and especially in the renal glomeruli. Etiology.—Bacteriology.—Septicemia is due to micrococci Avhich Koch has shoAvn to be considerably smaller than pus-cocci, though no one form of bacterium has been found constantly present to the exclu- sion of all others. Besser, as the result of careful experiments, con- cludes that septicemia is caused solely by streptococci, Avhile Rosenbach and others have found both staphylococci and streptococci. Doubtless in many instances of human septicemia the clinical manifestations are due partly to bacterial poisoning and partly to septic intoxication Avith the poisons (ptomains) developed by the organisms, and the ptomains probably kill the patient before the bacteria can propagate themselves throughout the system. Laboratory experiments teach us that in the 196 INFECTIOUS DISEASES. loAver animals septicemia can be produced both by chemical poisons and by bacterial infection, and these tAvo types are observed in human beings. With reference to the bacterial form Warren1 states: ''Whether this process is caused solely by the multiplication of bacteria, or is depend- ent in part upon the liberation of intensely poAverful poisons, or is due to some ferment-like substance capable of reproducing itself like the poison of the serpent, as are diphtheria and tetanus, much more ex- tensive studies upon the human subject will be necessary to enable us to say." Modes of Infection and Introduction of the Poison into the System.—(1) Wounds, either surgical or the result of injury, Avith which Ave have nothing further to do in this Avork. Since the days of rigid anti- septic precautions this mode of entrance is, comparatively speaking, uncommon. (2) Through the uterus, following labor, miscarriage, or abortion. Generally in these cases there are accompanying local changes, but in a feAv the poison appears to pass the unguarded portals of the organ, while the latter exhibits nothing abnormal. (3) The cases in which the poison gains entrance into the body without obvious wounds or raAv surfaces are relatively more common. When the skin is quite natural, septic infection or intoxication can- not occur, but the slightest abrasion or cut, bed-sore, etc. may serve as a gate of admission. These slight lesions " may be almost com- pletely healed by the time the severe symptoms of the disease are developed" (Striimpell). (4) Mucous membranes often admit the virus, being less protective in nature than the skin. The numerous bacteria—benign and pathogenic —that are constantly present in the intestinal canal may also find in local lesions (as in typhoid fever, dysentery, etc.), or catarrhal inflam- mation even, points of lodgement and cause a systemic infection. To this category belongs that form of septic infection which follows gonor- rhea. The so-called cases of "spontaneous septicemia" are also usu- ally occasioned by absorption from the mucous surfaces. Rheumatic or septic manifestations often folloAV attacks of tonsillitis, and it is probable that the tonsils are more frequently points of en- trance for the organism than has hitherto been supposed (Wade, Ban- natyne). (5) " Sepsis Intestinalis."—This special form of poisoning is caused by canned meats, ice cream, sausages, and cheese. Vaughan, to Avhom Ave are indebted for the first description of "sepsis intestinalis," found in cheese a ptomain Avhich he named tyrotoxicon, and Avhich he regarded as the active agent in this group of poisoning cases. The symptoms are due, according to his statement, to poisoning by chemical substances, being instances of sapremia; but it may yet be found that the intes- tinal micro-organisms play a more or less prominent part in the process. (6) Ogston2 recognizes as one of the mildest forms of sapremia the sickness and nausea produced by a bad smell, Avhich, he claims, is but a ptomain of putridity that may, under certain contingencies, produce serious symptoms. On the other hand, persons Avho are habitually ex- 1 Surgical Pathology and Therapeutics, p. 340. 2 Warren, loc. cit. p. 342. SEPTICEMIA. 197 posed to bad odors (Avorkers in seAvers, in the dissecting-room, etc.) may acquire a considerable degree of immunity against poisoning of this sort. The fever in these cases corresponds in severity to the dose of the poison. (7) Septicemia may be associated Avith or follow osteomyelitis. Clinical History.—(1) Symptoms of Sapremia.—The fact that this form may occur Avithout bacterial infection, either local or general, must be emphasized, but more frequently there Avill be either local infection or putrefactive changes, with the production of a grave general condition due to the absorption of the poisonous chemical products. In certain other acute infectious diseases (diphtheria, tetanus, typhoid fever, ery- sipelas, etc.) the general symptoms are similarly engendered. Perhaps the most typical examples of sapremia seen by the physician are those due to tyrotoxicon and to the unaccustomed inhalation of foul odors. At the beginning a chill may occur, but this is more generally Avanting. In " sepsis intestinalis " marked local symptoms may initiate the attack, as nausea, vomiting, colicky pains, diarrhea, etc., and in all forms there is fever, the temperature often rising rapidly to 101° or 103° F. (38.3°- 39.4° C.) and sometimes higher. Prostration and anemia, particularly the latter, may be prominent symptoms. Microscopic examination of the blood generally shoAvs leukocytosis, and always a marked reduction in the number of red corpuscles. Sapremia folloAving childbirth is a most typical sub-variety, and, apart from the special history, the symptoms are much the same as those above detailed. It is the form most amenable to treatment, the removal of the cause being folioAved by a rapid disappearance of all alarming symptoms. (2) Symptoms of True Septicemia.—There is an incubation-period which is of variable duration, though usually averaging several days. The onset is more gradual than in the previous variety, and is rarely marked by a chill. Accession of fever following surgical procedures, with head- ache, anorexia, prostration, sometimes vomiting and diarrhea, and espe- cially dulness occasionally amounting to mild stupor, announce the affection: these symptoms should also excite suspicion in the absence of obvious causal factors. They become intensified, and noAv the attack may closely simulate certain other infectious diseases (typhoid fever, acute miliary tuberculosis, ulcerative endocarditis, etc.), the clinical picture as outlined presenting nothing characteristic. There are, hoAv- ever, more or less distinctive features, Avhich Avill be considered seriatim. (a) The Fever.—This is usually of the continued type, and tends to increase in degree, fatal cases often terminating in hyperpyrexia. At the beginning the temperature may rise quite rapidly, and in some cases it may even be subnormal. Deep morning remissions may be observed. (b) The Circulatory System.—The pulse is frequent, and near the end becomes very wreak. In subacute cases characteristic lesions (endocar- ditis in particular) may develop, but are difficult of recognition, since they do not, as a rule, give rise to audible murmurs or other physical signs. In other instances soft murmurs may be heard, but it is indeed hard to discriminate these from functional sounds. Moderate leukocy- tosis is sometimes observed, and the presence of micrococci in the blood during life has been demonstrated. 198 INFECTIOUS DISEASES. (c) G-astro-intestinal System.—The spleen may become perceptibly enlarged, and gastro-enteritis is usually present, either in an acute form Avith vomiting and frequent serous discharges or more often merely with a diarrhea of moderate intensity (septic diarrhea). (d) Cutaneous Symptoms.—Punctiform hemorrhages into the skin are of prime importance in the diagnosis. Occasionally more extensive ecchymoses appear, scarlatinal eruptions also shoAving themselves, but these are less characteristic. Among rare appearances herpes, roseola, edematous inflammations, and faint jaundice (affecting the skin and conjunctivas) may be observed. The icterus is probably due to disinte- gration of the red blood-corpuscles in the liver. (e) Renal Symptoms.—The lesions constitute the so-called "septic nephritis," the urine often containing a fair amount of albumin, epi- thelium, tube-casts, and red and white corpuscles. Diagnosis.—(a) Sapremia can be distinguished by the history, the immediate appearance of the symptoms, their character, and by the prompt effect of the removal of the exciting cause. The diagnosis often requires a most careful search for the knoAvn etiologic factors, though even Avithout the latter Ave can sometimes arrive at a correct conclusion by a careful process of exclusion. (b) True Septicemia.—Here the existence of an incubation period, the continued fever, mental apathy, faint jaundice, splenic enlargement, and the characteristics of septic nephritis, all combine to form a Avell- defined group of symptoms. A careful blood-examination should be made for micrococci, etc., and cultures should be undertaken in spon- taneous septicemia and other doubtful examples of the complaint. The surgeon should look to the condition of the Avound if one is present. Course and Prognosis.—The course may be brief, virulent at- tacks sometimes terminating fatally Avithin forty-eight hours, this being especially true of sapremia Avhen the dose of the poison is large. The gravity of the case in the latter form is in direct proportion to the amount of virus that enters the system, the outlook being good Avhen the cause is removable. On the other hand, in true septicemia this avails nothing, the progression tending steadily to the end. The mildest types may, in rare instances, reach a favorable end, but the effects are not dependent upon the dose, and the minutest quantity may lead to specific results in their fullest intensity. It must not be for- gotten that septicemia may pursue a chronic course in Avhich the symp- toms are milder, though the termination is very generally unfavorable, as in the acute variety. Treatment.—Of first importance is the removal of the cause when- ever practicable, this part of the treatment often falling within the domain of surgery. The physician must support the patient's strength by a suitable dietary and by the judicious use of cardiac stimulants; the former should consist mainly of liquids (milk, egg-white, meat-juice, etc.), and the latter of alcoholics, together with strvchnin and am- monia. Of medicines, internal antiseptics (mercuric chlorid, creasote, etc.) richly deserve a trial, though striking results have not been obtained from their employment. The fever calls for antipyretics, such as quinin, phenacetin, acetanilid, together with hydrotherapy. Cardiac depressants, as acetanilid and phenacetin, should not be resorted to PYEMIA. 199 hoAvever, Avhen great cardiac asthenia exists. To meet the renal condi- tion the free use of Avater, together Avith the least irritating of the diu- retics, is to be advised and encouraged. The other internal organs should also receive careful attention. PYEMIA. Definition.—A disease of the blood invariably associated Avith sup- puration, and due to an absorption of pyogenic organisms. Pathology.—The cadaver does not undergo putrefaction as early as in septicemia. Briefly considered, the pathologic lesions that fall within the physician's province arrange themselves under the folloAving heads: (1) Thrombosis and Embolism.—At first the veins leading to and from the seat of the local changes from Avhich pyemia arises contain thrombi which may soften into a puriform material. Thrombi are also found frequently in the lungs, a circulating embolus first finding lodgement in the pulmonary artery and its branches; they may be present in the liver, kidneys, spleen, cortical substance of the brain, and in other localities. (2) Abscesses.—These so-called metastatic abscesses are set up by septic emboli or result from the thrombi (chiefly pulmonary and portal), and are found in the various internal organs, mainly, perhaps, in the lungs, liver, spleen, and kidneys. They are not large, but may coalesce and form cavities of the size of an apple. The kidneys are the chief organs of elimination in this disease, and hence it happens that numer- ous clumps of micrococci, producing miliary abscesses, are frequently seen in the regions of the Malpighian bodies. Infarction may be ob- served also. There are many other, though rarer, seats of abscesses, as the muscles, submucous and subcutaneous tissues, bones, the parotid gland, brain (cortical portion), ovaries, and testicles. (3) Lesions of the Skin and of Mucous and Serous Membranes.—At the post-mortem examination hemorrhagic extravasations and pustules are often visible in the skin. The mucous membrane of the alimentary tract is rarely affected, differing in this point from septicemia, though occasionally ulcers may be noted, and most commonly in the stomach near the pyloric orifice (in puerperal cases) and in the large boAvel. Prob- ably they are ahvays secondary to the submucous miliary abscesses. The serous membranes (pleura, pericardium, meninges of the brain, synovial membranes) may be the seat of purulent inflammation and of hemor- rhagic extravasations. (4) Cardiac Lesions.—Ulcerative endocarditis forms the chief morbid lesion. It begins in the form of small nodular vegetations upon the valves (most frequently the mitral), which disintegrate and leave ulcers behind (vide Ulcerative Endocarditis). Etiology.—Bacteriology.—Experimental investigations have shoAvn conclusively that the organisms usually responsible for this condition are the staphylococcus and the streptococcus. Whether the former or the latter be the agent of infection in the given case depends chiefly 200 INFECTIOUS DISEASES. upon the condition of the tissues at the starting-point, especially with reference to the character of the local defensive processes; also, though to a lesser extent, the degree of virulence of the micrococci. Other important pyogenic micro-organisms are the gonococcus, pneu- mococcus, bacillus pyocyaneus, bacterium coli communis, bacillus tetra- genus, and many of the specific micro-organisms. Paths of Infection of the Body.—(a) Almost ahvays the entrance is by the blood-vessels, the special varieties of micrococci that cause pyemia, reaching the veins and producing thrombo-phlebitis. Less frequently they reach the arteries and produce thrombo-arteritis. From the former con- dition emboli may be disseminated throughout the system, Avhile from the latter the emboli are arrested in the neighboring capillaries to which the tributaries of the vessel lead. Micrococci independently of emboli may be found wandering in the blood-stream. (b) Another path of entrance is the lymphatic system, but here the cocci meet Avith greater forces opposing their attempts to spread than in the blood-vessels, and hence it is a much rarer mode of propaga- tion. (c) In spontaneous pyemia, in Avhich there is no wound to act as a point of departure, we must presuppose the existence of either a trivial lesion, as in " spontaneous septicemia," or an area of lessened resistance. The latter may be produced by inflammation, by a contusion, and in other Avays, and all that seems necessary is a loAvering of the tone of the general system (Warren). I am certain that ulcerative endocarditis is not frequently the %starting-point, but is usually secondary to foci of inflammation elsewhere, as claimed by Osier. The appendix is often the primary or original focus in this category of cases, micrococci local- izing themselves here in consequence of a preceding disturbance of the circulation or catarrhal inflammation. I recollect one case in which no original abscess was found at the post-mortem. Predisposing Causes.—(a) Epidemic Influence.—It has been proved by abundant experience that certain seasons are characterized by epi- demic outbreaks of the disease. (b) Cases have sometimes been noticeably more frequent in the early months of the year (February and March) than in other seasons. (c) Age and Sex.—Males are more frequently affected than females, and most cases occur about the middle period of life or at the time of greatest danger from traumatism. Clinical History.—Incubation.—The disease sets in from a week to ten days after the reception of the wound or even earlier, and always develops secondarily to suppuration someAvhere in the body. A most conspicuous symptom, and usually the first, is the chill: it may, hoAvever, be preceded for a variable time by fever of a continued or intermittent type. The fever of pyemia is of the suppurative type. Profound prostration develops early; the skin presents an icteroid appearance; and gastro-intestinal symptoms may appear, but are not prominent. The signs of abscess of the lung, liver, and other organs may develop in some cases, while in others the whole clinical picture is colored by the ill-defined characters of ulcerative endocarditis. (a) The Chill.—This may be mild, though oftener it is quite severe. It is repeated at someAvhat irregular intervals, and rarely it may recur PYEMIA. 201 several times on the same day. Chills are most apt to occur during the daytime. (b) The Fever.—A rapid rise of temperature accompanies the chill. The fever-curve is of the irregularly intermittent or profoundly remit- tent type, with intervening periods, showing slight or marked variations, and as decided deviations may occur within a short space of time, a tAVO-hour record should be kept. The temperature rarely falls to the normal level; it may do so, hoAvever, and remain there for one or twro days. To explain the peculiarities of the curve in this disease Ave need only recall the great variety of pathologic processes before noted. With the sharp fall of temperature sweating occurs, and leaves the patient more or less exhausted, though only temporarily so as a rule. (c) Respiratory System.—Symptoms referable to the organs of respi- ration appear early. The pulmonary abscesses are usually latent, but may give rise to dyspnea, cough, and occasionally a purulent expectora- tion. Pain is present if they are superficially located, and under such circumstances the physical signs of cavity or of pleural effusion may be noted. The signs of pneumonia at one or both bases may also develop, the expectoration now becoming rusty. (d) Splenic and Hepatic Symptoms.—The foci of suppuration in the liver are difficult of recognition unless they become large as the result of coalescence and are superficially located (see article Hepatic Abscess). Splenic infarction may also be safely diagnosed if there are pain and great tenderness (due to localized peritonitis) in the left hypochondrium, with progressive enlargement of the organ. In one case I detected distinctly crepitant sounds over the site of the spleen during life. (e) Cardio-vascular Symptoms.—The pulse at first is accelerated, but moderately full and regular; later it becomes exceedingly rapid and feeble. Frequently cases in which ulcerative endocarditis develops are apparently of spontaneous origin. (For a discussion of this grave con- dition the reader is referred to the description of endocarditis in the sec- tion on Diseases of the Heart.) Among the blood-appearances during life are leukocytosis and a rather marked reduction in the red corpus- cles, with moderate poikilocytosis. The blood-plaques are increased. (/) Cutaneous Symptoms.—The most prominent is a mild yet decided grade of jaundice, that is probably hepatogenous in nature. SAveating has already been alluded to as a troublesome symptom, between the febrile paroxysms as Avell as immediately after. The skin finally shrinks from emaciation. Skin-eruptions are common, and particularly in the form of erythema, purpura, and pustules, and the general surface is often decidedly hyper esthetic. (g) Genito-urinary Symptoms.—The urine is concentrated and urates are copiously deposited. There is albuminuria which may be due to the pathologic changes or may be, to some extent at least, ascribable to the febrile movement. The microscope discloses the presence of tube- casts, micrococci, pus- and (more rarely) blood-corpuscles. Albumose has been found in the urine. (h) Nervous Symptoms.—The mind generally remains unclouded un- til an adAranced stage is reached; then delirium sets in, and is followed by a terminal coma. This order of clinical events is not observed Avhen metastatic purulent meningitis exists, the symptoms of which (hemi- 202 INFECTIOUS DISEASES. plegia, strabismus, ptosis, deafness, etc.) may appear at any period of the disease. (i) Symptoms may be presented by the joints and bones. Metastatic arthritis" usually suppurative, is a not unusual concomitant, and in some cases it is combined Avith similar involvement of the long bones. In- deed, an acute osteomyelitis may be the only ascertainable source of the pyemia. Differential Diagnosis.—The disease is often confounded with malarial intermittent fever, the distinctive features of Avhich have been given under the differential diagnosis of the latter disease, but a diagnosis may ahvays be made from the effect of quinin upon the fever. A few points of contrast, by means of Avhich septicemia and pyemia may be differentiated, are tabulated below: Pyemia. Septicemia. Always associated with suppuration. Suppuration may be absent, but there may be a sloughing Avound. Multiple chills. A single chill. Irregularly intermittent fever-curve. Continued type of curve. Profuse sweats accompanying febrile Absent. attacks. Rapid emaciation and profound prostra- Less marked. tion. Nervous symptoms usually come on Earlier. late. Hyperesthesia. Absent. Slight jaundice. Less marked (very faint). Metastatic abscesses. Absent. Prognosis.—Pyemia may kill after an illness lasting but a few days. On the other hand, it may become more or less protracted, so that a chronic form has been distinguished. In this variety the symp- toms are milder in character, and the tendency to the formation of metastatic abscesses is not as great in the acute form. Hence, Avhile the prognosis is on the whole very bad, not a feAv of the more chronic cases terminate in recovery. Treatment.—So far as the physician's province extends, the treat- ment is identical with that of septicemia. His efforts must be directed toward assiduously maintaining the vital poAvers. For the sweating the best agents are aromatic sulphuric acid and atropin ; the latter may be given Avith agaricin (atropin, gr. y^-—0.0005 ; agaricin, gr. \ to \— 0.008 to 0.016), at bedtime. Prompt surgical interference must be re- sorted to, not only Avith a view to asepsis of the primary Avound, but also to evacuating the primary and all secondary foci of suppuration. ACUTE ARTICULAR RHEUMATISM. (Rheumatic Fever.) Definition.—An acute febrile disease, the exact nature of Avhich is unknown, though it is probably infectious. The chief local manifesta- tion is a multiple arthritis, and its chief complications are cardiac (endo- and pericarditis). Hueter first advanced the germ-theory to account for ACUTE ARTICULAR RHEUMATISM. 203 the disease, and, although the specific causal agent has not as yet been discovered, this vieAv is the only one that offers a satisfactory explana- tion for the production of the lesions, the acute onset, the clinical course, and the complications of the disease. Rheumatic fever is sub- ject to, and apparently obeys, the laAvs of infectious maladies in general, and the frequent involvement of the joints in many diseases belonging to this class may properly be regarded as supporting this theory. The disease is, in numerous localities, endemic, and at times also epidemic; but, on the other hand, in not a feAv regions (especially European) is practically unknoAvn—e. g. England, Belgium, and Russia. Striimpell points out the fiict that in Leipsic, Avhere articular rheumatism is one of the most frequent of acute diseases, it has been observed for years that at certain times there are only a feAv cases, Avhile at others there is a striking increase in the number. Pathology.—The disease does not show peculiar lesions, and, al- though the joints are the chief seats of invasion, still in many instances, and even in aggravated cases, the changes presented are slight or alto- gether Avanting. Usually the synovial membranes of the affected joints are injected and SAvollen, and their surfaces may be more or less coated Avith fibrin. The effusion is mainly serous, but contains fibrin and often leukocytes, and occupies the joints. A similar exudate infiltrates the periarticular tissues. The tendinous sheaths may also be inflamed; the cartilages in protracted cases may become eroded; and rarely a purulent exudate may be seen. Fatal cases, except Avhen death is due to hyperpyrexia, usually shoAv the changes peculiar to endocarditis, pericarditis, or myocarditis, and less frequently those of pneumonia or pleurisy. The fibrin-factors of the blood are augmented. Btiology.—Bacteriology.—Maragliano1 has found in the blood of typical cases of acute articular rheumatism tAvo micro-organisms—one resembling a bacillus and non-pathogenic, Avhile the other is a micro- coccus and (he thinks) the special infective agent of the disease. This organism resembles the staphylococcus aureus, but it is only half its diameter (0.5/i), and is massed in groups of six to ten. It is motile, is stained easily by anilin dyes, and is readily cultivated on gelatin. It develops at the usual temperatures, and especially at or about 98° F. (36.4° C). Upon injection into rabbits the symptoms of acute articu- lar rheumatism (polyarthritis, endocarditis, pericarditis, etc.) Avere re- produced. Guttmann, Collin, and Sahli have found the staphylococcus in the articular exudate of patients suffering from complicated or recur- rent cases of acute articular rheumatism, and Sahli is inclined to include the disease in the group caused by this organism. Netter, however, has found the streptococcus, and Lang a peculiar bacillus. Singer has no- ticed a relation between the number of pathogenic bacteria in the urine and the severity of the symptoms in cases of acute rheumatism; but Chvostek has not been able to confirm this result. A number of cases have been reported in Avhich there is some evidence of direct contagion. Predisposing Causes.—(1) An infective lesion (septic Avound, attacks of angina, etc.) that has preceded for some time the appearance of the pain and articular manifestations may often be found, and this may be 1 Gaz. degli Ospedale e delle Clin., June 20, 1896. 204 INFECTIO US DISEASES. conceived to form a portal of entry for micro-organisms (Sacaze). The frequency Avith Avhich an attack of tonsillitis precedes the development of acute articular rheumatism almost indicates a pathological relation betAveen the tAvo diseases (Cheadle, Wade, Gerhardt). (2) Seasons.— The months of February, March, and April furnish the largest percent- age of cases, though the disease is also quite prevalent in the remaining cold months; on the other hand, the disease may sometimes be espe- cially frequent in summer. (3) " Catching cold" Avas formerly classed among exciting causes, but while this affection often follows exposure to abrupt changes of temperature, it merely predisposes to the disease. (4) Climate.—The disease is most prevalent in temperate latitudes, beino rare both in the cold and tropical zones. (5) Occupation is of primary importance, especially if it entail oft-repeated or prolonged exposure to the influence of Avet and cold or to severe changes of temperature. Hence those who follow certain avocations are attacked Avith great relative fre- quency—e. g. coachmen, laborers, sailors, and servant-girls. (6) Age.— Primary attacks are most common from fifteen to thirty-five years of age. Out of 65~) cases, 80 per cent, occurred between the twentieth and fortieth years (Whipham). Cases are also rather numerous between ten and fifteen years, and I have met Avith 4 under the former age. Suck- lings rarely suffer. (7) Sex.—Acute articular rheumatism is someAvhat more common in men than in Avomen, and possibly owing to the fact that the former sex more often follows predisposing occupations. (8) Hereditary influence can be traced in many families, and if chorea, re- current tonsillitis, and chronic heart-disease are accepted as evidences of the rheumatic diathesis, it unquestionably plays a very important role. (9) Conditions of ill health, particularly digestive and hepatic disturbances, seem to exert a slight though decisive effect. (10) Chronic endocarditis renders its victims very prone to attacks of acute articular rheumatism, and some contend that the two diseases are etiologically one and the same. An attack of acute articular rheumatism is not protective in charac- ter, and rather renders the individual more susceptible than before. In this respect the disease resembles certain other infectious diseases (pneu- monia, erysipelas, etc.). Clinical History.—Of the incubation period nothing is knoAvn, though prodromata, both local and general, may be observed. These may be malaise, slight fever, angina, laryngitis, etc., and last from a few hours to a day or tAvo. The invasion is usually abrupt, with fever and synovitis, affecting one or oftener several joints, and a chill or a series of chilly sensations may accompany or precede the rise of temperature. The involved joints are tender, often red and swollen, and exhibit the local signs of a rapidly developed inflammation. Pain is a most promi- nent symptom. The medium-sized or larger joints (knee, ankle, and wrist) are first involved, and especially those of the inferior extremities; next the shoulder-, elbow-, and hip-joints; and lastly the fingers, toes, and intervertebral articulations. Quite unusual articulations may become implicated (vide infra). One of the chief peculiarities of the disease is in the fact that the joints that are affected are not all the seat of ana- tomic changes simultaneously, but that the process migrates from one joint to another from day to day, and often crosses from one side of the ACUTE ARTICULAR RHEUMATISM. 205 body to the other. Sometimes this occurs at longer intervals. Hence the number of joints involved at one and the same time may be either feAv or many. In cases of average severity the general features are subordinate to the local symptoms. The fever is usually moderate, the temperature not exceeding 103° F. (39.4° C), and the temperature-curve is of the irregularly remittent type, corresponding in severity Avith the joint- symptoms. Defervescence is by lysis. The skin is bathed in a copi- ous perspiration Avhich is not dependent upon a previous fall of temper- ature. Nervous symptoms are rarely observed. The general course of the disease exhibits Avide variations, both as to the duration and intensity of the symptoms. It may not outlast several days, appearing Avith mild symptoms; on the other hand, cases sometimes persist for six to eight weeks. The latter instances, and even typical cases, are apt to shoAv brief periods of marked improve- ment, alternating Avith equally marked exacerbations of someAvhat longer duration. Cases in which the symptoms are distinct from the start may terminate in recovery Avithin a shorter time than those in which the features are of mild character. As will be seen hereafter, the disease frequently manifests complications, especially cardiac. Leading Symptoms and Complications in Detail.—(1) Joints and Sur- rounding Structures.—As I have stated, pain is much complained of, and is greatly augmented by motion and by pressure of any sort. It may be out of all proportion to the degree of the anatomic changes. The joints affected are generally swollen (most markedly in the knees), and the swelling is due partly to effusion into the joint and partly to inflammatory edema of the periarticular structures. The sheaths of the tendons, the bursae, and often the adjacent muscles and fascioe exhibit inflammatory changes ; hence it is usual to see an extension of the SAvell- ing for a variable distance from the joint, the backs of the hands often showing this to a marked extent. The skin may present a pink or rose- colored blush, often limited to circumscribed areas or taking the form of streaks. In even mild cases there are usually tAvo, three, or more joints in- volved, though it often happens that one bears the brunt of the disease, little complaint being made of others less severely implicated. Hence it should be a golden rule to examine carefully all the joints at each Arisit. Involvement of a single articulation (monarticular rheumatism) does sometimes occur, but the diagnosis of these cases offers great diffi- culties. On the other hand, an existing polyarticular rheumatism may become centered in a single joint and there linger Avith great obstinacy. In severe cases numerous joints may be invaded, Avith an involve- ment of the joints of the symphyses, of the jaAv, of the ribs, and the sterno-clavicular articulations. Under these circumstances the patient assumes a dorsal decubitus, and seeks to relieve his excruciating pain by holding his limbs in a semiflexed position and absolutely motionless. If now an attempt be made to change his posture, he complains pit- eously of darting pains in the affected joints. The fug acity of rheumatic arthritis has already been alluded to. The inflammation, hoAvever intense, may quickly subside in one joint, while at the same time an acute disturbance appears in another. Lsu- 206 INFECTIO US DISEASES. ally resolution is complete, no trace being left of former inflammation, though the disease may recur in the joints primarily involved. Suppu- rative arthritis may supervene, though rarely, and its occurrence points indisputably to mixed infection. This complication may lead to anky- losis—a sequela which does not belong to pure rheumatism. (2) The Cardio-vascular Symptoms.—The pulse is quickened to 100 beats per minute or over, but is soft and full, and Avhen cardiac or other complications arise it sIioavs special characteristics which are described in appropriate sections of this Avork. In rare instances it is very rapid, feeble, and irregular, apart from the influence of the cardiac involve- ment. The results of a careful blood-count shoAV a high grade of symp- tomatic anemia, which may develop Avith marvellous suddenness. Leu- kocytosis is also present. Great importance attaches to the cardiac affections that so frequently complicate this disease. They may arise in any case, even the mildest, or at any stage of the disease, and hence the conscientious physician cannot afford to neglect the matter of closely and regularly examining the heart. It must be recollected that the symptoms announcing the development of cardiac disease are neither constant nor characteristic. At first Ave may note an increase in the febrile movement, more or less palpitation, sometimes dyspnea, and precordial pains, Avhich often do not amount to more than a sense of soreness. There may also be attacks of angina pectoris of apparently purely nervous origin (Striimpell). (a) The most frequent cardiac complication is acute endocarditis, which is present in 25 to 30 per cent, of the cases. We are, hoAvever, sadly in need of reliable statistics upon this point. It usually takes the form of simple (verrucose) endocarditis, and affects most frequently the mitral valves. But, though usually indicated by an apical systolic mur- mur, it is hard indeed to eliminate the functional murmurs that may also develop in the course of this disease. Unless combined Avith the symptoms detailed above, the presence of a bloAving systolic murmur does not afford trustworthy evidence of the existence of acute endo- carditis. While it rarely endangers life and may leave no trace, in the majority of instances the acute endocarditis does not undergo complete resolution, but leads to sclerotic changes and terminates in incurable chronic valvular disease. (b) Next in the order of frequency is pericarditis, Avhich may or may not be combined Avith the former. Its nature may be sero- fibrinous or plastic (less frequently), and in children the exudate is sometimes purulent; it is .distinguished chiefly by its pathognomonic friction-sound, though also by other characteristic signs (vide Pericar- ditis. It is of graver import than endocarditis, so"far as immediate danger to life is concerned, though it rarely proves fatal. I have wit- nessed two instances in Avhich endocarditis preceded the arthritic mani- festations, and the same observation has been made by others with reference to this complication as Avell as to pericarditis. (c) Myocarditis is often present to a slight extent in rheumatic endo- carditis and pericarditis Avhen these occur independently of each other, but more often and to a more marked degree Avhen endo-pericarditis ex- ists. Hence it is far less common than either endocarditis or pericar- ditis. The changes and symptoms occasioned will be discussed under ACUTE ARTICULAR RHEUMATISM. 207 Mvocarditis. In this connection it should be pointed out that the con- dition Aveakens the cardiac Avails and leads to dilatation of the ventri- cles (usually the left). If Ave consider rheumatism an infectious malady, Ave can readily un- derstand why the local manifestations should appear not only at the dif- ferent articulations, but also in the cardiac structures, and, as Ave shall see, in other viscera. (3) The Skin.—Rheumatism produces copious perspiration. The sweat emits a sour odor and gives at first an acid reaction, though later it may be neutral, and rarely alkaline. The temperature-curve in most cases is not materially influenced by the SAveats. Occasionally the drops in temperature and the free SAveats are concurrent, but the latter symptom is apt to persist despite the oscillations in the temperature. Sudamina appear, often in extensive crops. Among other skin-erup- tions less frequently observed are forms of erythema (especially E. nodosum) and urticaria, which latter may be associated Avith purpura (urticaria hemorrhagica). The association of the latter condition Avith polyarthritis is knoAvn as peliosis rheumatica, though, according to some Avriters, this is not rheumatic in nature. Cutaneous ecchymoses, and even extensive hemorrhages into the skin and from the mucous mem- branes—a general hemorrhagic diathesis—may also be encountered. Subcutaneous Rheumatic Nodules.—In 1881, BarloAv and Warner called attention to the fact that during and after acute articular rheu- matism, particularly in children and young adults, small subcutaneous nodosities attached to the tendons and fasciae may in exceptional in- stances be observed. These nodules are rather firm, someAvhat mova- ble, and usually painless The skin over them is simply elevated, Avith no traces of inflammatory action. They are most frequently found at certain points of election (fingers, Avrists, edge of the patella, malleoli, and over the back of the elboAv), though also seen less frequently else- where; they may disappear, and after a brief interval reappear. On microscopic examination it is seen that round and spindle-shaped cells enter into their composition. I met Avith one case of the sort which occurred in a male aged forty-two years, in Avhich acute articular rheu- matism AAras also complicated Avith endo-pericarditis and pneumonia. Most of the nodosities Avere of the size of a bitter almond, a feAv being even larger, and the crop Avas extensive. The case proved fatal. (4) The Fever.—The fact that the fever fluctuates materially in this affection has already been noted. It remains to be pointed out that if suppuration occur as a complication, the fever may be of the hectic variety; also that rarely hyperpyrexia is suddenly developed, and with it marked cerebral symptoms (restlessness, delirium, and sometimes convulsions, finally merging into stupor) are usually, though not neces- sarily, associated. This serious condition usually develops after several days of illness. Delirium may be present from the time of onset, though more often it comes on either shortly before or after the acute development of the hyperpyrexia. The pulse becomes excessively rapid and feeble and physical prostration extreme. The temperature may rise rapidly Avith slight interruptions until it touches 108° or 109° F. (42.7° C), and as the fever reaches its maximum death usually ensues. The temperature may continue to rise after death. The cause of "hyper- 208 INFECTIOUS DISEASES. pyretic rheumatism " is not definitely knoAvn. It has been claimed that the intemperate are most apt to be attacked, but this belief is not cor- roborated by many clinicians. In a case of my own, hoAvever, of acute articular rheumatism, in Avhich pericarditis with hyperpyrexia occurred, the patient Avas an " alcoholic." It is reasonably certain that the symp- toms are due to an intense infection, Avith concentration of the poison upon the nerve-, and especially upon the thermal, centers. (5) The Muscular and Nervous Symptoms.—It has been stated that the adjacent muscles and fasciae may exhibit inflammatory changes. They may also show more or less SAvelling, and are often very tender to the touch, while in long-continued cases muscular atrophy ensues. The cause of this change is not clear, but the most likely vieAv is that it re- sults not so much from disuse of the muscles (the old theory), as from some trophic disturbance due either to the arthritis, or peripheral neur- itis, or, to some extent at least, from extension of the rheumatic inflam- mation from the nearest articulation. Other theories have been advanced, but are scarcely tenable. Mention has been made of the grave nervous symptoms that are at- tendant upon hyperpyrexia, but, independently of the latter condition, nervous phenomena may be present. There may be restlessness, sleepless- ness, and active delirium, the latter being usually associated Avith a tem- perature of 104° F. (40° C.) or higher. In adynamic types, Avhich are rare, Ioav muttering delirium merging into stupor, and even coma, may be observed. Active mental symptoms are sometimes due to cerebral embolism secondary to acute endocarditis. When pericarditis is a com- plication, wild delirium, with or without hyperpyrexia, or the low mut- tering variety Avith stupor, is not unusual. The drunkard may develop delirium tremens. Coma, leading quickly to a fatal result, may develop without other previous or associated nervous symptoms, and DaCosta has reported cases in Avhich a fatal coma Avas of renal origin, and hence uremic. Rarely coma develops during the period of convalescence. Convulsions may be noted, generally preceding the coma, though rarely as an independent symptom. Melancholia may arise in the course of the disease, but more frequently at its close. Meningitis must be numbered among the rarest of complications. Chorea is a not infrequent sequel of this disease in children, and more rarely is associated with it. Of 554 cases analyzed by Osier, in only 88 Avere chorea and rheumatism associated. These instances may or may not be accompanied by acute endocarditis. (6) Pulmonary Symptoms.—Pleurisy occurs, and is generally excited by an extension of inflammation from the pericardium, and from the pleura the inflammatory process may be propagated through the dia- phragm to the peritoneum. Bronchitis is sometimes present, but is rarely a part of the rheumatic morbid process; it is secondary, and in most instances is occasioned by the co-operation of the factors that are at work in every disease in which enforced recumbency and great prostra- tion coexist. In like manner, broncho-pneumonia may be produced. Lobar pneumonia rarely occurs, and is confined to aggravated cases, but pulmonary congestion is occasionally seen, and may prove fatal. Pul- monary complications are also prone to develop secondarily to pericar- ditis, and especially to endo-pericarditis. ACUTE ARTICULAR RHEUMATISM. 209 (7) The Renal Symptoms.—The urine is diminished in amount, is high-colored, and of high acidity and density. The standing specimen deposits urates. As in other infectious diseases, there is commonly present a slight febrile albuminuria, but acute nephritis is extremely rare. The chlorids are sometimes diminished, but rarely absent. (8) The spleen is slightly enlarged in some cases. The saliva has sometimes an acid reaction, and, according to certain writers, the sul- focyanids are in excess. Clinical Peculiarities of Acute Articular Rheumatism in Children.—The arthritic symptoms in children are in abeyance Avhile endocarditis and pericarditis are predominant, and these cardiac conditions may appear before the joint-lesions are observed, but it is quite probable that endo- carditis folloAvs the joint-lesions twice as frequently in children as in adults. Parsons lays stress upon reduplication of the cardiac second sound, audible at the apex only, as an indication of the development of endocarditis. This sign is to be distinguished from reduplication heard at the base, sometimes as the result of Bright's disease and sometimes as the consequence of pulmonary obstruction. Acid SAveats are slight in children. Rheumatic tonsillitis is quite common, and may precede, accompany, or follow attacks of rheumatism in children. Erythema is a frequent concomitant, and is often mistaken for scarlatina. The fe- brile movement lasts usually but a feAv days. Diagnosis.—The acute development as a primary affection of poly- arthritis Avith fever is a combination of symptoms on Avhich a diagnosis can be usually based with considerable reliance. Pyemia must be care- fully separated, since here also Ave have the implication of the joints Avith fever. In pyemia, hoAvever, the general condition is more grave as a rule; fever is more apt to precede the local manifestations, and the curve is irregularly intermittent, Avhereas in rheumatism it is irregularly re- mittent. Rigors also occur in pyemia at irregular inter.vals, accompa- nied by a rapid rise of temperature, and are absent in rheumatism; sup- purative processes are early set up in the various viscera and skin, which latter also shoAvs slight but decided jaundice. The symptoms, both gen- eral and local, in acute articular rheumatism fluctuate greatly, Avhile this is not so in pyemia. The multiple SAvelling of the joints which develops after labor is to be regarded as septic in nature. Gout will be distinguished from rheuma- tism in connection with the consideration of the former disease (vide p. 398). Monarticular rheumatism is with difficulty differentiated from a group of affections Avhich simulate it closely, (l) The so-called gonor- rheal rheumatism often affects a single joint, especially the knee; but in this disease there is usually a definite history of recent infection, and the local features (pain, swelling, etc.), unlike true rheumatism, are far more pronounced than the general. The course of gonorrheal arthritis is longer in duration, and is generally connected only wTith a single joint from the start; Avhile acute articular rheumatism almost ahvays begins as a polyarthritis, with subsequent fixation in one articulation. Cardiac complications are rare in the former disease. (2) Acute osteomyelitis is generally single, and is sometimes mistaken for rheumatism, from which it differs, however, in the localization of the 14 210 INFECTIOUS DISEASES. lesions in a single joint from the start, the greater prominence of the local symptoms, and in the implication of the epiphyses and the shaft of the affected bone rather than the joint, and in the graver general symptoms from the time of onset. (3) There is a liability to mistake the acute arthritis of infants for rheumatism. This attacks by preference the hip or knee, and is a puru- lent inflammation due to pyemia (Townsend), hence having no relation to the disease under consideration. (4) Scrofulous arthritis, particularly in children, has been confounded with rheumatic monarthritis. The former is less indurating, the SAvell- ing presented is less symmetric, and the course is far less acute than that of the latter. (5) In the course of the hemorrhagic diseases, scurvy, purpura, and hemophilia, effusion into the joints, either hemorrhagic or serous in nature, occurs with great frequency and is associated Avith rheumatic pains. The differential diagnosis is to be made from the tendency to hemorrhage, and in scurvy by the lesions of the gums. The absence of fever is usually decisive: unfortunately, it is frequently present in these joint-affections. Prognosis.—Recovery is the general rule. As in other infectious diseases, so in rheumatism, the chief immediate danger springs from the great intensity of the type of infection, as manifested in hyperpyrexia with grave nervous symptoms, the development of the general hemor- rhagic diathesis, etc.—happily rare occurrences in this disease. Certain complications, such as pericarditis, endo-pericarditis, pneumonia, etc., may render rheumatism grave or even hopeless, and rarely the endocar- ditis that complicates the disease is of the ulcerative variety and leads to fatal pyemia. Pulmonary embolism may occur during the course of acute articular rheumatism, causing speedy death. The influence of personal factors may impede recovery, such as in- temperate habits, great obesity, the existence of previous organic dis- ease of the heart or Bright's disease, etc. Treatment.—(1) Sanitary Environment, Diet, and Stimulants.—The sick-room should be well ventilated, and its temperature maintained at 65° to 70° F. (18.3°-21.1° C), but draughts should be avoided. The patient should be lightly dressed in flannels and covered Avith a sheet of the same material. The diet should be liquid and nourishing, milk be- ing the best food-article as a rule, and being well borne. Skimmed milk, milk and Seltzer water, buttermilk, milk and lime-Avater, meat- juice, egg-white, and solids (other than animal) may all be employed if ordinary milk cannot be taken in adequate amount. I begin the use of the more nutritious and easily digested forms of animal food as soon as defervescence has occurred. Stimulants may be employed if indica- tions for their use are present, and the customary mode of administra- tion may be followed. Fortunately, these do not arise as often as in many other affections belonging to the class. * (2) Internal Therapeutics.—There has been of late a surprising unanimity among clinicians in commending the use of the salicylates in the treatment of this disease—more so than at any previous time since their introduction. They are employed in most of the larger hospitals both in Europe and America. Differences hoAvever, ACUTE ARTICULAR RHEUMATISM. 211 relating to the mode of administration and the particular salt to be selected still exist. Woodl favors ammonium salicylate, for the reasons that it is freely soluble, is rapidly absorbed, and Avhen given in sufficient amount quickly produces the symptoms that mark salicylic action, Avhile, in addition, it is less depressing than the other salts of salicylic acid. It is best given in milk and is usually Avell borne. My experience Avith this salt in acute articular rheumatism, though as yet someAvhat limited, has been satisfactory. L'ntil the present time sodium salicylate has met with more general favor than any other single salt of salicylic acid. The pure acid is also used, though not to any great extent at the present day. As regards the mode of administration, the total daily amount taken is of higher importance than the size and frequency of the dose. The amount given in tAventy-four hours should not exceed 2 drams (8.0), while often 1^ drams (6.0) of the sodium or ammonium salicylate is sufficient. My method is to give gr. x (0.648) every tAvo hours during the first day, or until the pain and other local features have largely dis- appeared ; then the remedy is given at longer intervals, but not omitted entirely. In this manner fresh exacerbations are most probably averted. If the latter occur, however, larger doses must be instituted, so as to cut them short. Some recommend that the medicine be stopped as soon as the pain has been controlled. If salicylic acid be employed, it should be given in capsules. According to certain observers, salol is to be pre- ferred to either the pure acid or the salicylates : in my experience, how- ever, the use of this drug has not been folioAved by good results in the severe acute forms of the disease. Doubtless the reason for this lies in the fact that salicylic acid can neither be introduced into the system in sufficient amount nor rapidly enough in the form of salol. Kinnicut has recommended the employment of the oil of Avinter- green, a salicylic compound AAhich does not generally produce the un- pleasant toxic symptoms so apt to be excited by the salicylates or sali- cylic acid. The dose is TTLx-xx (0.60-1.25), given in capsules or in milk, to be repeated every two hours. Salicin (gr. x—0.648, every hour, increased to gr. xv—0.972) is sometimes efficacious and invariably agrees. Salophen, in daily doses of 1 dram (gr. xv—0.972, every four hours) until pain is relieved and temperature reduced, has been Avarmly adArocated. Though almost specific in its effects, the drug does not pre- vent either the spread of the disease to new joints, fresh exacerba- tions, or cardiac complications. Sodium salicylate enemata (sj—4.0— of the salicylate and TTLx—0.60—of the tincture of opium in each in- jection) may be of advantage in certain cases. The remedy is absorbed from the rectal mucosa, though more slowly than from the stomach. The treatment with the salicylates or salicylic acid mitigates the fever, relieves the pain, and shortens the stay in bed by a feAv days, but does not curtail convalescence. The statistics of Williams go to show that the salicylate treatment also tends to protect against the develop- ment of cardiac complications, though it does not seem to influence the course of the complications once they are established. In my experi- ence the alkaline treatment operates potently to obviate the occurrence of the heart-complications and shortens the period of convalescence, but exerts slight, if any, influence upon the fever-curve and pain. These 1 University Medical Magazine, Jan., 1895. 212 INFECTIOUS DISEASES. facts led me long since to use the specific and alkaline treatment in com- bination, giving, in addition to salicylates or other salicylic compounds, as above indicated, an alkaline remedy, such as sodium bicarbonate, potassium citrate, etc., in sufficient doses to render, and then maintain, the urine of slightly alkaline reaction. There are a few other remedies that should be referred to, and, although more or less serviceable, they are Avithout specific influence. The foremost among these is antipyrin, which may be used advantage- ously during the acute period of the disease, the heart being at the same time Avatched over carefully. Loomis says of the drug: " I have come to employ it almost to the exclusion of all other remedies for the relief of the arthritic pain, and in many cases it has seemed markedly to shorten the duration of the disease." Potassium iodid and the prepa- rations of colchicum also belong to this category, and should be tried. Their effects are most beneficial in cases that drag on after the acute stage is over. Recently lactophenin has been brought forAvard by Roth as a most useful remedy in acute rheumatism, but it does not rival the salicylates. (3) Local Measures.—These occupy a subordinate place in the man- agement of acute articular rheumatism. Their number is legion, but only a feAv of the more valuable can be adduced here. In mild cases the affected joints should be wrapped in cotton batting or in flannel. If the pain is severe despite the use of the salicylates internally, fomen- tations as hot as can be borne or hot cloths lightly wrung out of Fuller's lotion (sodium carbonate, 3vj—24.0; laudanum, §j—30.0; glycerin, §ij—60.0 ; and water, %\x—270.0) are beneficial. As salicylic acid is absorbed through the skin, it has been combined with other agents for local use in the following formula: Rj. Acid, salicyl., Lanolini, ad. 3iij (11.65); 01. terebinthinae, giij (11.25); Adipis, 3iij (11.65). M. et ft. ung. Sig. Rub freely over the affected joints and follow by wrapping in cotton. Cold compresses and the ice-bag to the joints have been strongly ad- vised, particularly by German authors. The affected joints should be kept at perfect rest, and this is best accomplished by padded splints and a roller bandage. Blisters near to the joints involved and the light application of the Paquelin thermo-cautery are sometimes serviceable, but they are to be thought of only when the above-mentioned local means have failed. The treatment of the complications will be considered under their appropriate headings. I desire, hoAvever, to emphasize the fact in this connection that should hyperpyrexia occur during the progress of the affection, it is to be relieved by cold baths, since large doses of antipyrin or other internal antipyretics are of themselves dangerous. It may also be stated that the cardiac complications—endocarditis, pericarditis, and endo-pericarditis—rarely require special remedies. If marked cardiac asthenia appears, as indicated by the feeble first sound, the salicylates GONORRHEAL ARTHRITIS. 213 may be replaced by salicin, Avhich is less depressing in its effect upon the heart. Cardiac stimulants may be required. A copious pericardial effusion calls for paracentesis (vide Sero-fibrinous Pericarditis). During convalescence the patient should not be alloAved to get out of bed too early. My OAvn rule has been to keep him in bed for a Aveek after the temperature has returned to the normal and after the pain has disappeared, except it be during the hot season. These precautions are taken to avoid the occurrence of relapses. After the patient goes into the open air he should be told to avoid cold, and Avet in particular. During this period iron is to be employed until the blood-examination fails to shoAv anything abnormal. For the stiffness and SAvellino1 that sometimes persist, or disappear very sloAvly after the acute attack, massage and the application of hot water or warm baths seem to yield the best results. SUBACUTE ARTICULAR RHEUMATISM. This is, as a rule, a sequela of acute rheumatism, and may occur, though rarely, in persons who have not had a previous acute attack. Both the local and general features are of a mild type, but the course is apt to be prolonged into tAAO, three, or more months. Usually the local symptoms are confined to one or tAvo of the larger joints, Avith little swelling or redness, and the pain is slight except on movement. The temperature rarely exceeds 101° F. (38.3° C), and at times may be practically normal. Though the course is prolonged, the joints usually return to their normal state ; occasionally, hoAvever, the disease becomes chronic. As in the acute form, so in the subacute, anemia becomes Avell marked and cardiac complications are not uncommon, particularly Avhen the disease occurs in children. The treatment embraces, in addition to the usual antirheumatics, the use of iron, quinin, cod-liver oil, and, when practicable, a change to a AAarm climate. The affected joints demand hot applications and massage. GONORRHEAL ARTHRITIS. Definition.—A septic synovitis caused by the gonococcus, and hence having no connection with true rheumatism. It usually manifests itself towrard the close of an attack of gonorrhea, but it may develop during the active stage of the disease or at any period during the course of gleet. Pathology.—The signs of ordinary synovitis are generally found in the affected joints, though, not rarely, the inflammatory process is periarticular rather than articular. LTnder these circumstances the in- flammation may travel along the sheaths of the tendons for a consider- able distance. Synovial effusion may occur, and rarely may be puru- lent, this being most frequent in gonorrheal inflammations affecting 214 INFECTIOUS DISEASES. the wrist and hand. Gonococci have been found in the effusion, though this is not generally the case, and it is now thought by many Avriters (Finger, Councilman, and others) that the gonococcus may be the only infective agent concerned in the morbid process. Others contend that the metastatic inflammation of the joints is due to the presence of pyo- genic cocci, since they have been found to be frequent companions of the gonococcus. In this and other forms of secondary inflammation it must not be forgotten, however, that gonorrheal arthritis may be due in great part to the absorption of ptomains from the urethra. The disease occurs much more frequently in men than Avomen, and some claim that it may follow any urethral discharge in the male or may be associated with menstruation or leukorrhea in the female. Clinical Symptoms.—Two leading varieties, acute and chronic, are encountered. (1) Acute Gonorrheal Arthritis.—This may be very mild, amounting merely to slight fugitive pains and some stiffness of one or more joints, without noticeable SAvelling or redness. The typi- cal, acute form, hoAvever, presents the symptoms of a severe fibrinous or sero-fibrinous inflammation of a single joint, developing quickly. The pain is often violent; there is SAvelling of the joint with extension along the course of the tendons, and the condition is obstinate. Unless pus be present (a rare event) the constitutional features do not corre- spond in severity Avith the local, there being little fever and slight im- pairment of the general health. There are many instances in Avhich the complaint begins as a polyarthritis, Avith subsequent concentration upon one or tAvo of the larger articulations, especially the knees or ankles. Fibrinous ankylosis usually remains as the resulting condition. Acute endocarditis may be of gonorrheal origin. In the inflamma- tory products of this condition Hering has found the gonococci, as has also Councilman, in the heart-muscles (gonorrheal myocarditis). Rarely, gonorrheal endocarditis assumes the ulcerative or malignant form. As the result of invasion of the blood by the gonococci suppurative arthritis may also be occasioned, and now the clinical picture is that of general septico-pyemia. I observed one case in which pleurisy Avas associated, and among the numerous widespread complications iritis deserves special mention. (2) Chronic Gonorrheal Arthritis.—This occurs (a) as a serous effu- sion (hydrarthrosis), and (b) as a chronic inflammation of the articular and periarticular structures (synovial membranes, bursae, periosteum, and tendons with their sheaths). The former is usually monarticular, settling with especial frequency in the knees, and may be Avholly pain- less. The latter is more or less painful—causes dense swelling of the joint, and frequently of the structures for some little distance above and below the latter. Both forms lead to great restriction of motion. The diagnosis cannot be determined positively apart from the his- tory of urethral infection. The acute form is distinguished chiefly from acute articular rheumatism by the intense pain, the extent to which the periarticular tissues are involved, and the negative character of the general symptoms. The chronic variety must be discriminated from chronic synovitis due to other causes, and this often proves a difficult task. Treatment.—I have never seen the slightest benefit from internal VARIOLA. 215 medication in gonorrheal arthritis, except possibly from the use of mer- cury until the patient was brought decidedly under its influence. Local measures, however, are of paramount importance. Absolute rest to the part is indicated, and the limb should be placed upon a splint; then, after making an appropriate anodyne application (ungt. ichthyol or ungt. bella- donnae), it should be bandaged as firmly as possible. Before doing this in acute cases the patient should be anesthetized, and after the procedure, if pain be great, a hypodermic injection of morphin may be given. In chronic forms the aim should be to remove the effusion (if present) and the swelling, and to restore the natural motility so far as possible. For the latter 1;avo indications massage and passive movements are best. Swell- ing may also be diminished by the use of the thermo-cautery at intervals, and blisters are highly serviceable in causing a disappearance of the effusion. Careful surgical attention should be bestOAved upon the urethral or vaginal condition. VARIOLA. (Small-pox.) Definition.—Variola is an acute contagious disease, characterized by its sudden onset and severe period of invasion, followed by a remis- sion of the fever and an eruption of papules, Avhich pass through the stages of vesicle, pustule, and scab. The stage of pustulation is accom- panied by secondary fever. Historic Note.—Small-pox has existed from the earliest anti- quity in India, Africa, China, and other Eastern countries. During the thirteenth century (1241) it entered England, in the early part of the fourteenth Ireland, and in the latter part of the fifteenth Germany. In 1507 it Avas imported to America, and first appeared in the AY est Indies; a little later (1520) the Spanish troops conveyed the disease to Mexico, Avhere it destroyed not less than three and a half millions of people in its pestilential march. It was brought to the LTnited States from Europe in 1649, and gained its first foothold in Boston, Avhence it progressed at intervals in a Avesterly direction till it finally reached the western coast-line nearly a century after its first introduction. At the present day there is a very limited opportunity to observe the affection except in its modified form (varioloid), since small-pox certainly does not prevail in an epidemic form where vaccination is practised with fidelity, and only among uncivilized peoples who are ignorant of or in- different to this certain prophylactic power. Pathology.—The eruption of small-pox consists in an inflammatory cellular infiltration of the rete mucosum and has four successive stages— (1) Papular, (2) Vesicular, (3) Pustular, and (4) Scab. (1) The Papule.—At first there is a hyperemia of the papillfe of the skin appearing as small red spots. These soon become round, discrete patches that may be rolled like shot under the skin, and then, becoming elevated, OAving to the increase in the cells in the rete mucosum, they form the typical papule. 216 INFECTIOUS DISEASES. (2) The vesicle appears at the apex of the papule, and results from a circumscribed elevation of the superficial layer of the epidermis in con- sequence of the mechanical pressure exerted by the fluid exudate, Avhich is excited by active peripheral inflammation. The vesicle is not uni- cellular, but is loculated (by fibrinous reticuli), and contains serum, leukocytes, fibrin-filaments, etc. If a section of a vesicle in the very early stage be made through the deeper layers of the rete mucosum, an area of coagulation-necrosis is observed, Avhich is due to the presence of micrococci (Weigert). The vesicle shows central umbilication, Avhich corresponds Avith the necrotic area, and is well marked just before the pustules are formed. (3) The pustule is formed by the filling of the reticuli Avith leuko- cytes. Cellular infiltration and swelling of the true skin beneath the pustule occurs, as a rule, as the result of diapedesis. Moreover, sup- puration may involve the cutis vera, and as a consequence scarring re- sults. When the suppuration is limited to the rete mucosum pitting does not take place. In hemorrhagic small-pox the reticuli are occupied by an abundance of red corpuscles Avhich have passed in from the adjacent blood-vessels, and may infiltrate the upper as well as the deeper layers of the epidermis surrounding the vesicles or pustules. The pustules may dry up, but commonly rupture, and in either case the result is (4) scabbing. The mucosa of the mouth, pharynx, and, rarely, the esophagus and the rectum may be the seat of a variolous eruption, and the plaques of Peyer may be somewhat swollen. The eruption also appears in the larynx, the trachea, and bronchi, where ulcers rather than true pustules are seen, and the conjunctiva and nasal mucosa frequently show the specific lesions. Hemorrhagic small-pox presents extravasations occurring in the serous and mucous membranes, the connective tissue, the parenchyma of the various viscera, and also, though much less frequently, in the nerve-sheaths, bone-marrow, blood-vessel Avails, and the muscles. In this form the spleen is firm (Ponfick, Osier), and the liver is sometimes enlarged and the subject of fatty degeneration. Hemorrhagic infarction of the lung occurred in 5 out of 7 cases examined by Osier. " In 1 instances the pelves of the kidney Avere blocked Avith dark clots, which extended into the calyces and doAvn the ureters," and in a proportion- ate number of cases Peyer's glands Avere swollen. Secondary Lesions.—The catarrhal inflammation of the larynx may extend in depth till it touches the perichondrium of the cartilages (peri- chondritis), and a croupous exudate in the larynx may often coexist with edema. Lesions are present in the lungs, some of them frequently (general bronchitis, broncho-pneumonia), and others rarely (hypostatic congestion, lobar pneumonia), and a low type of inflammation of the pleura may be observed. Cloudy swelling, diffuse inflammation, and sometimes fatty degeneration of the liver, have been noted, the spleen being enlarged and pulpy as a rule. The heart may show myocardial alterations—chiefly parenchymatous and fatty—and rarely endocarditis and pericarditis occur in the nature of true complications. The kidneys show cloudy swelling, and occasionally nephritis develops, although not until quite late. Attention should be called to the observation of Wei- VARIOLA. 217 gert, wrho found that at the commencement of the stage of suppuration the microscope revealed "small-pox cylindric masses" in the various organs (liver, spleen, kidneys, and lymphatic glands). The cylindric masses are in reality capillaries filled Avith micrococci, which are derived from the eruption, and probably find their Avay into the circulation through the lymphatics. These small areas of coagulation-necrosis may be the seat of leukocytic infiltration, which in turn may result in a cir- cumscribed miliary abscess if septic material be also absorbed from the pustules. No special microscopic appearances are presented by the blood. Btiology.—Bacteriology.—Loeb and Pfeifferl have described certain protozoa found in the blood or in local lesions, to Avhich they attribute an etiologic significance. J. Christian Bay2 has isolated from small- pox lymph and vaccine points an organism (dispora variola) Avhich he believes to be the causa morbi of small-pox and vaccinia. The long diameter of the bacterium measures Q.Qp-lp, and the short diameter from 0.2^-0.3^. The organisms contained tAvo spores, one at either end, and Avhen reared on artificial media developed in colonies, and Avere readily stained Avith anilin blue or violet. A further study of the dis- pora, hoAvever, is essential, and experiments having for their object the reproduction of the affection in the loAver animals have not been suc- cessfully conducted as yet. Hence the exact role played by the organ- ism in the causation of variola has not as yet been definitely determined. Predisposing Causes.—The receptivity for variola is Avellnigh uni- versal, though in rare instances persons are insusceptible, and among the few who have enjoyed complete immunity against small-pox Avere three distinguished physicians—Diemerbroeck, Bperhaave, and Mor- gagni. It may be said that one attack confers permanent immunity, but in rare exceptions a second or even a third may occur. Vaccination, also, if successful, affords future protection against variola, but to this rule exceptions are not infrequent. Age.—All periods of life are liable to the disease, but the very young are affected in a relatively larger proportion than older persons. During the entire puerperal stage there is an increased liability to the disease. It rarely affects the fetus in utero, and most babes even, Avho are ex- posed to the virus at the time of birth, will not take the disease if immediately and successfully vaccinated. Sex is Avithout influence. Race.—Among uncivilized peoples variola spreads Avith frightful rapidity, the negro and other very dark races being affected in larger numbers and more severely than whites. A dread of the infection pre- disposes to its occurrence. The Contagion; where Found; Modes of Conveyance and of Infection.— One case of variola is prima facie evidence of the existence of another, and that the poison from the latter was somehow transferred to the former. The specific poison exists in the blood and in the secretions and excretions (most probably), but mainly in the pustules and dry scabs and in exhalations from the lungs and skin. Its conveyance from the sick to the healthy or from one person to another is not a difficult 1 Loel>, Centralbl. fur Bacteriologie und Parasitenkunde, ii. 353, 1887; Pfeiffer, ibid., ii. 126, 1887. 2 Medical News, January 26, 1895, vol. htvi. p. 94. 218 INFECTIOUS DISEASES. matter, and may take place in one or other of the several following Avays : (a) Inoculation Avith either the blood or the contents of the erup- tion or the dissolved dry scabs is folloAved by variola, (b) Contact with, or proximity to, a patient suffering from small-pox is very apt to convey the poison, Avith resulting variola in the person thus exposed. To what distance the contagion can be conveyed through the air is not known, but it is probably considerable; and all authors are agreed that it is one of the most infective diseases with which Ave are acquainted. It is contagious from the earliest active stage to the end of convalescence, and, according to some observers, even during the stage of incubation. (c) Transmission by fomites is common, the poison adhering to clothes, body- or bed-linen, etc., and evidence is not wanting to shoAV that the poison is highly tenacious of pathogenic poAver. Its vitality is retained after death, and the room occupied by a patient, the bedding, and the articles of furniture all serve to convey the disease unless thorough dis- infection be enforced. The avenue of entrance for the poison into the system is not known, but it is most probably the respiratory tract, the poison being inhaled and thence taken into the general circulation. Clinical History.—Incubation.—This stage varies with the mode of communication of the poison. If folloAving inoculation, the symp- toms appear in six or seven days; when originating in infection, usually in tAvelve days, though this stage may be either lengthened by a day or tAvo or shortened to an equal extent. During a portion of this period complaint may be made of certain ill-defined symptoms, but these are usually absent, and the onset is sudden and accompanied by character- istic signs. These are—a severe rigor, high fever, headache, and intense lumbar pains. Instead of the usual severe rigor, repeated chills, ex- tending over tAvelve to twenty-four hours, may occur, the headache, intense pain in the loins, and the fever continuing for several days unless relieved. During the same period the respirations are accelerated, the pulse becoming decidedly more rapid, and there may be general bron- chitis. The tongue is coated and the patient may make complaint of slight pharyngitis. There is anorexia (often complete), generally vomit- ing, and constipation or rarely diarrhea. Restlessness, wakefulness, delirium, and stupor are the most important nervous symptoms observed. Infective albuminuria is not uncommon, and in the female menstruation is apt to be brought on. The physical signs are few, and consist of a feAv dry and, later, moist rales, heard on auscultation. Palpation detects splenic enlarge- ment. From the second day the so-called initial rashes may appear: (a) the diffuse scarlatinous eruption, Avhich in no Avay differs from ordi- nary scarlatina ; (b) the measly eruption, which may be diffuse and identical Avith that of true measles. Either associated Avith these or occurring independently there may be a hemorrhagic eruption (usually purpura), the petechiae coming out by natural selection, mainly upon the hypogastric region or the inner surfaces of the thighs and in the axillae (Simon). Rarely the knees, elboAvs, and extensor surfaces pre- sent this eruption. The initial rashes occur in a considerable propor- tion of cases (10-15 per cent.), and of these the petechiae outlast the other pre-variolous eruptions. The stage of invasion just depicted lasts three days as a rule, and the intensity of the symptoms is generally in VARIOLA. 219 direct proportion to that of the stages that folloAV. At the end of the third day or on the fourth the temperature declines rapidly, Avhile at the same time the true variolous eruption appears upon the skin and mucous surfaces. Noav begins the stage of eruption, Avhich develops first upon the face, particularly upon the forehead and the hairy scalp, and spreads in a dowmvard direction till it reaches the legs, Avhere it last appears. The skin in the femoral triangle rarely shoAvs the true variolous eruption. Each pock passes through the various stages noted in the pathologic description—viz. papule, vesicle, pustule, and scab; and Avhen the stage of pustulation has been reached a secondary fever develops. During the folloAving remission of fever the headache, lumbar pains, etc. subside. The fever of suppuration Avhich then succeeds is accompanied once more by marked constitutional disturbances, particu- larly nervous derangements (Avild delirium, etc.), and at this time com- plications are also apt to develop. On the eighth or ninth day of the eruption (the tAvelfth or thirteenth day of the disease) the pustules begin to dry up, forming yellow crusts; the redness and SAvelling of the skin subside; and tAvo or three days later the scabs loosen and are throAvn off. During this stage the fever again declines in company with the con- stitutional symptoms, and convalescence ensues. As previously stated, when suppuration involves the true skin scars are the inevitable result, and these remain to the end of life. The hair drops off sometimes, even to the extent of total alopecia, but is generally reneAved. Reading Symptoms and Complications.—(a) Eruption.—As before stated, the eruption makes its appearance at the end of the third or on the fourth day, coming out first upon the forehead, particularly along the border of the hairy scalp, and spreading in a downward direc- tion in regular progression. It appears in the form of slightly .elevated maculae, which are at first of a pale-red color, and later assume a darker red hue, resembling small fleabites. These increase in size during the next forty-eight hours, at the end of which period they are developed into (1) papules. The change of character is accompanied by itching and burning of the skin-surface. To the feel they are papular—like shot under the skin—and if the finger-tips be rubbed over them lightly they are distinctly satin-like. The eruption is ahvays most abundant upon the face and scalp, while the hands and fingers are the next most favored seats. At the end of the third day (the sixth day of the disease) the conical apices of the papules contain liquid, forming thus (2) vesicles. The latter increase in size till the entire papule is converted, at the same time acquiring more and more decidedly a central umbilication. Punc- turing a vesicle does not cause it to collapse, but allows only a small por- tion of its liquid contents to escape, owing to its reticulated character. As the vesicle increases in size its contents become opaque, and in three days more, or about the sixth of the eruption, the vesicles become (3) pustules. Umbilication now disappears, and the pustule looks full and well rounded, and is surrounded by a red border or "halo." If the pocks be close set, as on the face, wrists, and fingers, the intervening skin is inflamed and SAvollen and the itching and burning become almost intolerable. The pustules may coalesce along their edges, and thus the eruption becomes confluent. The eyes are closed as the result of swell- ing and tumefaction of the face, and the hands and feet assume a rounded, 220 INFECT 101 rS DISE. 1SES. ball-like appearance. The face, as a whole, is markedly misshapen and is ultimately disfigured. When the pus is not liberated (a comparatively rare event), its desiccation begins on the ninth day (the twelfth day of the affection); if the pustule is ruptured earlier (as when confluence occurs), it begins at an earlier day. (4) The scabs noAv form, and remain until about the twelfth day of the eruption, and when pits or scars result they are at first distinctly hyperemic, but gradually fade until at last they remain as permanent Avhitish spots. The eruption upon the mucous membrane develops simultaneously with that of the skin, and among favorite surfaces for its appearance are (as pointed out under Etiology) the mouth, tongue, soft palate, and pharynx (causing dysphagia), the nasal chambers (causing coryza), the larynx (causing hoarseness), the trachea and bronchi (causing bronchitis). This mucous efflorescence does not proceed to the development of pustules, but forms ordinary ulcers as a consequence of early maceration of the super- ficial layers of the mucosa, and these ulcers also may become confluent. The skin also presents certain complications that are ahvays secondary and are deserving of mere mention (erysipelas, abscess, gangrene, bed- sores, etc.). (b) The Fever.—The temperature at the onset rises rapidly, and may touch 103° or 104° F. (40° C.) on the first day, its range being high and of the continued type during the invasion period. Evening tem- peratures of 105° F. (40.5° C.) or higher may be observed, and in three days (or with the first appearance of the papules) the temperature remits, but does not intermit in true variola. It remains at a low elevation till the stage of suppuration is reached, when a fresh rise, sometimes to its Fig. 21.—Temperature-chart of a case of variola, from a patient in the Municipal Hospital, Phila- delphia. A. F---, aged three years; not vaccinated. original height, occurs. This secondary fever-curve is apt to show a decided irregularity, Avith exaggerated points of elevation and deep re- missions. The latter may be due to complications, but are most gener- ally the result of septic absorption (the fever of suppuration). This period lasts from one to three or four days in typical cases. When desic- cation of the pustules begins defervescence also commences, and proceeds in a gradual manner by lysis. There may be a post-variolous rise, and if so its presence is to be attributed to some sequel or other. VARIOLA. 221 (c) The Circulatory System.—The pulse is soft and much accelerated (100 to 130) and of good volume during the invasion stage. It is slower during the period of remission, only to- be greatly increased in frequency during the second stage of fever. During the latter period it may, owing to cardiac failure, become very rapid, much enfeebled, and finally irregu- lar or even intermittent. The pulse-rate will vary according to differ- ences in the previous general condition of the individual. Simple endo- carditis rarely, and pericarditis somewhat more frequently, occur as complications. (d) Respiratory Tract.—The laryngitis and pharyngitis which are due to the presence of pocks in the mucosa of the respiratory passages have already been mentioned. The most serious events, however, connected with the respiratory system originate in secondary infections, if we except laryngeal perichondritis with edema of the glottis, the latter perhaps being the result of a direct extension of the pock-ulcers to the perichon- drium. Chief among the secondary complications is broncho-pneumonia (inhalation pneumonia), and lobar pneumonia also occurs, though rarely. Pleurisy, however, is not infrequent, particularly as an associated condition in broncho-pneumonia. (e) The Digestive System.—A frequent seat of the variolous efflorescence is in the buccal and pharyngeal mucosae, where it causes exceedingly un- pleasant symptoms (vide ante). It may also be an agency in predisposing to a secondary inflammation in adjacent organs—e. g. suppurative otitis media, suppurative parotitis, pseudo-diphtheria, etc. Palpation almost ahvays shows an enlarged spleen, and not infrequently an enlarged liver. The vomiting which is usual at the onset is not due to the presence of pocks in the stomach, but to a catarrhal condition of the organ. Consti- pation is common, but diarrhea is also sometimes met with, being- excited by a catarrh of the large intestine, and is especially common in children. The pocks may, however, be found in the rectum, where they sometimes excite dysenteric symptoms. (/) The Nervous Symptoms.—The chief of these have been already pointed out, as Avell as the fact that complications and sequelae are by no means rare. Violent delirium (previously referred to) may be followed by fatal coma, and in children convulsions may be seen. Very rarely para- plegia has been observed during the attack, though it is more common during the convalescence, and is then due to different causes, such as peripheral neuritis and disseminated myelitis (Westphal). Multiple neur- itis may be a sequel or the pharyngeal nerve may alone be affected. Among other conditions rarely arising during convalescence are insanity, epilepsy, and hemiplegia. (g) The joints may be swollen and painful after small-pox, the con- dition being secondary and rheumatic in nature, and in rare cases peri- ostitis may be observed. (h) Renal Symptoms.—Apart from the febrile albuminuria already re- ferred to, renal complications are of great rarity, and, with one exception (hemorrhagic nephritis), are of little practical import. Hemorrhagic nephritis may occur, and is ahvays of a serious character, though, for- tunately, it is very rare. (i) The Special Senses.—The pustules may form upon the conjunctivae and eyelids, and several important conditions result from this variolous 222 INFECTIOUS DISEASES. involvement of the eye—viz. conjunctivitis, keratitis, choroiditis, and panophthalmitis. Hebra met with ocular complications in 1 per cent, of 5000 cases of small-pox. Otitis media has already been mentioned. Special Clinical Forms.—There are two unusual types of variola that are important in being severer than the moderate (discrete) form already described. (a) The Confluent Form.—This is the result of an abnormally severe infection, but cannot be said truly to be atypical. The ushering-in symptoms are very severe, and the eruption may appear as early as, or even before, the third day, when the temperature remits, though not to any great degree. The separate papules are, perhaps, somewhat smaller than in the discrete variety, and vastly more abundant and close-set; and after the stage of pustule is reached the face and hands present an unin- terrupted area of suppuration. The deformity of the countenance is correspondingly pronounced. Naturally, the local symptoms are intense and the fever and its concomitants are in exact proportion. The nervous symptoms often predominate. Salivation is frequent, and vomiting is excessive in adults, while diarrhea is equally so in children. The erup- tion may also entirely cover the mucous surfaces. The lymphatics of the neck may be greatly swollen—a circumstance that contributes to the patient's unparalleled disfigurement. The various complications previously adduced are of comparatively frequent occurrence, and following these a general pyemic process may then develop. When death occurs it is usually preceded by the development of the symptoms that belong to the typhoid state (typhomania, tremors, subsultus tendinum, a rapid, feeble pulse, dry, broAvn tongue, and diarrhea). On the other hand, if recovery ensues, it is tardy and often interrupted by complications and sequelae. (b) Black Small-pox.—In this form the blood is much changed, so that hemorrhages into the skin, mucous membranes, and various viscera occur. It is important to distinguish several sub-varieties, as follows: (1) A benign form, in which blood is infused into the pustules when patients are allowed to leave their bed too early in convalescence. Here the condition is due to the effect of gravitation, and hence is confined almost solely to the lower extremities. (2) Doubtless the ordinary variolous eruption may become slightly hemorrhagic without aggravating the constitutional con- dition. Often this is seen in debilitated and intemperate subjects. (3) In the same class of subjects a dangerous hemorrhagic tendency may be manifested. During any of the eruptive stages—papular, vesicular, or pustular—hemorrhages may occur into the eruption, and, moreover, free bleedings may take place from the various mucous surfaces (hematuria, epistaxis, hematemesis, enterorrhagia, etc.). The initial symptoms are usually intense, the eruption abundant, and in consequence of the hemor- rhages collapse often occurs. The most serious complications, pneumonia, diphtheria, and nephritis (followed by uremia), are also apt to develop and terminate life, and even should recovery ensue it is very tedious. This and the subsequent sub-variety are truly anomalous. (4) A not uncommon form of hemorrhagic variola is met with in which the acute hemorrhagic diathesis develops during the period of invasion. Its onset is characterized by the usual symptoms intensified, and as early as the second day ecchymotic patches appear upon the skin-surface and grow rapidly by peripheral extension, the mucous surfaces also shoAvin^ more VARIOLA. 223 or less extensive ecchymoses. The regular variolous eruption rarely ap- pears, though occasionally shot-like papules may be detected here and there. The temperature may be slightly elevated, but is rarely high, and not infrequently it may remain normal or subnormal. Death often occurs before the time for the appearance of the characteristic eruption, and very rarely does the patient survive the fourth or fifth day. There are also varieties of small-pox that pursue an abnormally mild course. Of these (c) varioloid deserves first place. By this term is usually meant small-pox occurring in individuals Avho have been protected by a successful vaccination, but it may also be the result of natural insuscepti- bility. Hence variola and varioloid are one and the same affection, the latter name, howTever, representing a milder form of the disease than the former. The initial symptoms of varioloid do not differ either in charac- ter or severity from those of true variola, but the general course of the attack is peculiarly prone to manifest irregularities. In the pre-eruptive stage an erythematous rash is very common, and its appearance is regarded by many as being of value in discriminating varioloid from variola. When the regular eruption appears the fever falls to normal and re- mains there. The rash comes out by the end of the first or on the second day, the papules being scanty, and quite as liable to appear first upon the trunk as upon the face. They are identical with the papules of variola, as is true also of the vesicles ; but pustulation rarely develops, for the reason that resolution takes place, as a rule, before the latter stage is reached. The secondary fever is either very slight or entirely Avanting. The mucous surfaces are affected but to a correspondingly slight degree, and thus the general course of the disease is characterized by irregularity. Papules and vesicles may be found in close proximity; not so in variola. Desiccation begins betAveen the fifth and seventh days of the eruption (the eighth and tenth of the disease), and hence, as compared with variola, the course is cut short and serious complications almost never occur. (d) An abortive form is occasionally observed. It is characterized by the great intensity of the invasion symptoms, but these promptly subside, and the patient enters at once upon a stage of speedy recovery. An exceedingly mild type may arise during seasons of epidemic preva- lence of the disease, either Avith or without a scanty and undeveloped erup- tion, when the diagnosis is made entirely from the etiologic circumstances. Diagnosis.—With a clear history and the presence of the character- istic features a positive diagnosis is a simple problem. But at any period before the papules are fully developed it may be confounded with certain other acute infectious diseases, notably cerebro-spinal meningitis, pneu- monia, typhus fever, scarlatina, and measles. Differential Diagnosis.—In typhus fever the onset is very like that of small-pox. The former may, however, be distinguished by its peculiar etiologic factors, especially its origin by importation or its non-prevalence in the vicinity ; the appearance of the eruption, first upon the trunk (chest and abdomen) in the form of maculae, and later becoming petechial; and by the fact that it is neither papular, vesicular, nor pustular, as in small- pox. Moreover, in typhus the temperature does not remit with the appear- ance of the eruption, but persists, and may even rise higher. From hemorrhagic small-pox typhus is sometimes distinguished with great difficulty. In the most virulent type of the former death often 224 INFECTIO US DISEASES. occurs before the eruptive stage is reached. When it does not, the causal data are most important factors in making a discrimination. In typhus shot-like papules are never detected upon the skin-surface of the hands and head, Avhereas they are sometimes found in hemorrhagic small-pox. The diagnosis from scarlatina may early be made from the erythema- tous (scarlatinous) rash Avhich often precedes the appearance of the vario- lous eruption. This is, as a rule, neither so intense nor so uniformly dis- tributed over the skin-surface of the body as in true scarlatina. Lobar pneumonia begins with many of the symptoms that character- ize the initial stage of small-pox, but in addition there are sharp pain in the side, cough with rusty sputum, acceleration of the respirations out of proportion to the temperature and pulse, and the cheeks are bedecked Avith the typical mahogany flush. Meningitis may be eliminated if the patient has been exposed to small- pox, and if, being unprotected by vaccination, he suddenly develops the .symptoms of the initial stage of this disease—severe rigor with high fever and intense pain in the loins. To confirm the discrimination from men- ingitis we may note the absence of involvement of the ankles and other joints, the irregular temperature-curve, the herpes and opisthotonos, and marked hyperesthesia. The macular stage of the eruption may be confounded Avith measles. The absence of the characteristic prodromes and symptoms of invasion belonging to the latter disease, the redness and swelling of the conjunctivas, the photophobia and marked coryza, the stubborn cough, and increased fever after the eruption appears, make the separation easy. In measles the maculae do not develop into hard, shot-like, conical papules as in variola. Nothing, however, could be more difficult than to differentiate certain mild cases of discrete small-pox (in the non-vaccinated) and varioloid from varicella. In the table below, however, may be found a few con- trasted points of distinction, Avhich, I trust, may prove helpful: Variola. Varicella. History. Absence of previous attack. Same. Previous or present case in the vicinity. Traceable to previous or present case of varicella. Xot successfully vaccinated. Negative. Occurs at any age. Almost always in childhood. Characteristic pre-eruptive stage —rash Eruption not preceded by prodromes. on the third day. Eruption. Appears first upon the forehead, extend- Appears first upon the neck and trunk— ing downward. no regular progression over the body. Vesicles uniform in size, umbilicated, and Vesicles vary much in size, are rarely deeper seated. umbilicated, and are more superficial. Eruption contains serum, later pus. Only serum. Most abundant on face and fingers. Most abundant upon back and lower ex- tremities. Various stages of eruption observed at Various stages side by side. points removed from each other. Pin-prick does not cause collapse of ves- Does cause collapse, being unicellular. icles, being multicellular. Secondary Fever. Usually present. Absent. VARIOLA. 225 Prognosis.—The prognosis depends upon (a) the degree of severity of the type, whether mild or intense, the severer forms (confluent and certain of the hemorrhagic) being grave. The hemorrhagic variety, in which large cutaneous ecchymoses suddenly develop, is almost invariably fatal, and often before the cases have advanced to the eruptive stage. The aggregate number of pocks that appear and the gravity of the infection are, as a rule, proportionate. (b) The prognosis is modified by individual peculiarities (age, race, in- temperance, etc.). Thus it is much more fatal in the very young than in older subjects, much more fatal in dark- than light-complexioned races, more fatal in the intemperate than in the temperate, and so on. (c) Complications increase the death-rate considerably. Of these, broncho-pneumonia, lobar pneumonia, acute nephritis Avith uremia, septico- pyemic conditions, pseudo-diphtheritic angina, and pericarditis are most potent for evil. Among the foremost serious symptoms may be mentioned excessive vomiting, wild delirium, coma, a temperature of 106° F. (41.1° C.) or over, urgent diarrhea, and dysentery. The death-rate has been computed to be between 15 and 30 per cent., varying, however, with each epidemic, and thus rendering an exact esti- mate out of the question. Treatment.—The varied indications in the treatment of small-pox will be considered separately : (1) Prophylaxis.—The rules that have been laid down elsew7here (vide Treatment of Typhoid Fever) for disinfection in infectious diseases must be rigidly enforced in this affection. Quarantine (public and pri- vate) must be secured if the deadly progress of small-pox is to be averted, and it would seem altogether unnecessary to adduce arguments to show the correctness of this dictum. In the homes of the poorer classes, however, and even in those of the higher, absolute isolation cannot be carried out successfully, and in view of this fact special, well-equipped hospitals should be provided for the reception of the disease. Without a rigid en- forcement of these hygienic rules the spread of small-pox cannot be pre- vented. It is important also to remember that persons who have been afflicted Avith the disease cannot, Avith safety to others, resume their former places, either in the family or in society at large, before they are completely convalescent. The best means of prevention, howrever, is vaccination, and this subject will receive separate consideration (vide p. 229). (2) General Management.—Apart from perfect isolation and thorough disinfection, there are other hygienic requirements that must be complied with. The room occupied by the patient should be large and freely ven- tilated (an essential matter, though strong drafts are to be avoided), and all carpets, curtains, and articles of furniture not absolutely needful should be removed. The diet is an element of treatment that demands most careful atten- tion, and should be varied according to the stage of the affection. During the initial stage it must be restricted to liquid nourishment (milk, animal broths, etc.), and in addition cooling drinks, including ice, lemonade, and other of the various fruit-juices (diluted). During the stage of remission of fever we may add soups, jellies, eggs, toast, etc., and with the onset of the stage of suppuration a supportive diet, reinforced by the judicious use of stimulants, is a highly essential part of the treatment. Light forms 15 226 INFECTIOUS DISEASES. of nourishment must noAv be given in definite quantities at short inter- vals, and stimulation carefully carried for Avar d in accordance Avith the rules that ordinarily govern this class of affections. (3) The fever and associated symptoms during the invasion stage are best controlled by the cold or gradually cooled baths, Avhich possess all the advantages in this disease that they command in typhoid fever. Their effectiveness, together with the fact that in some of the various forms of variola the temperature-chart registers a normal or even a subnormal grade of body-heat, shoAvs the fallacy of regarding temperature as the sole, or even the chief, indication for the use of the Brand method. Cold sponge-baths, the ice-cap, or the cold pack may be resorted to if cold immersion baths are not accessible to the patient. The internal antipy- retics must be given Avith a sparing hand, if at all, and should be em- ployed as antiseptic agents rather than as direct antipyretics, on account of their depressing effect. The therapy of this stage also embraces the treatment of certain symptoms. The vomiting may be incessant and exhausting, and chipped ice, champagne, dilute hydrocyanic acid, and cocain hydrochlorate should be tried in the order mentioned. If diarrhea be severe, it should be checked (though neither Avholly nor suddenly) by the use of arsenite of copper, the acetate of lead (gr. ij—0.1296) and opium (extr., gr. \— 0.0162), in combination, or by bismuth salicylate (gr. v—0.324) and /3-naphtol (gr. iij—0.1944). The nervous symptoms are usually re- strained by the cold-bath treatment, but occasionally a wild delirium may necessitate further therapeutic interference, and at such times a com- bination of sodium bromid (gr. x-xv—0.648-0.972) with the deodor- ized tincture of opium (ntv—0.333), given every two or three hours, is of signal value. Very often the Avise administration of stimulants re- moves all necessity for the use of further means of overcoming the ner- vous symptoms, and in maniacal delirium ether may be cautiously admin- istered with great benefit. The catheter must be used if retention of urine should occur. For the intense pains that belong to this stage no other remedy can be compared with morphin sulphate (gr. \ to \—0.008 to 0.016), to be administered hypodermically, and repeated if neces- sary ; this measure also ensuring good sleep, which would be otherwise impossible. (4) As previously stated, the eruption appears with the termination of the initial febrile period, and deserves the closest attention. The indica- tions are twofold: (a) to limit the eruption as far as is possible, and (b) to modify its course, so that extensive suppuration and consequent dis- figurement may be prevented. Ablutions with lukewarm water, to which may be added some antiseptic (carbolic acid and glycerin, or, better, a mercuric-chlorid solution—1 : 5000 or 1 : 10,000) will be found of great use. To prevent pitting many local applications have been used. For- merly, a common mode of treatment was to open the pustules as early as possible and touch them Avith silver nitrate—either in the solid stick or brushed over in a strong aqueous solution. Painting the skin with the tincture of iodin was a practice frequently followed in the past. The formula of Schwimmer, herewith given, gave excellent results in a case of my OAvn: VARIOLA. 227 R. Acid, carbolici, 4.0-10.0; 01. olivae, 40.0; Cretae praeparat., 60.0. M. et ft. pastamollis. Another serviceable combination is one of equal parts of carbolic acid and glycerin, to be applied only to the pustules. It has also been recom- mended to touch each pustule Avith carbolic acid, and then to apply this agent in equal parts with the oil of thyme (Sansom). It is important that only a certain proportion of the pustules be touched at once, this to be followed by an equal number on successive occasions. The parts must be kept aseptic and clean, while irritation from scratching, etc. must be carefully avoided. Moore of Dublin and Fingen have recently recom- mended the use of red curtains or shades to cut out certain chemical rays. This treatment Avas first practised by John of Gaddsden, a court physician of the fourteenth century. During convalescence, or as soon as the general condition of the patient will admit of it, warm baths, with the free use of carbolic soap, are to be given at intervals of tAvo days until several baths have folloAved the separation of the crusts. Any cutaneous sequelae that may present themselves must be attacked in accordance Avith ordinary principles. (5) The Period of Remission of Fever.—There are very rarely any symptomatic indications apart from those presented by the eruption. It is of first importance, howrever, to thoroughly support the poAvers of the system by means of tonics, and especially by quinin, in addition to an appropriate diet and the moderate use of stimulants. (6) The Suppurative Stage.—All measures tending to support the strength of the patient are needed—the mineral acids, with the elixir of calisaya, quinin, strychnin, etc. Stimulants are often required, and it may become necessary to give them unsparingly, the character of the pulse and of the first sound of the heart, as Avell as the nervous symp- toms, being the physician's guides. Gradually cooled baths of the usual duration or Avarm baths someAvhat more prolonged give excellent results. In this stage certain symptoms may require special treatment. The ulcers in the mouth and throat are best relieved by the use of a saturated solution of chlorate of potash' in water as a gargle or in the form of an atomizer spray. Ice allowed to melt in the mouth is also valuable. Hemorrhages demand prompt interference, and full doses of ergot must be given subcutaneously. Internally, large doses of the tincture of the chlorid of iron, gallic acid, the mineral acids, or turpentine may be administered. The complications, as before intimated, are not numerous, and are for the most part secondary in nature. Those connected Avith the respiratory passages should be prevented if possible, and, OAving to the fact that they indicate danger, should receive active treatment if they occur. By fre- quently changing the position of the patient when bronchitis is present, and by encouraging him to cough frequently, as Avell as by the timely use of stimulants and the proper care of the mouth, pulmonary complica- tions can often be obviated. Should lobular pneumonia occur, the plan of treatment Avhich is likely to meet Avith most success may be briefly put thus: Free stimulation, the assiduous use of the cold or gradually cooled 228 INFECTIOUS DISEASES. baths, tonics, and nourishing foods. Laryngeal perichondritis wTith edema of the glottis may suddenly demand tracheotomy. To avoid the develop- ment of bed-sores an air-cushion or a Avater-bed should be provided, if needful. Care should also be exercised to prevent ocular complications, and their occurrence demands a vigorous form of supportive treatment. I have much confidence in the use of cold compresses, instilling into the eyes at the same time a solution of boric acid (gr. x to xv—0.648 to 0.972—to fsj (30.0). (7) Special Modes of Treatment.—These Avould be found to be numer- ous were Ave to enumerate all of them, but only those based on the prin- ciple of antisepsis are worthy of notice. According to one plan, which has many advocates, antiseptic agents are administered internally. The remedies that have been most frequently employed in this manner, and with perhaps the most promising results, are the sulphocarbolates, salol, sodium salicylate, carbolic acid, creasote, mercuric chlorid, and the sul- phites. Zuelzer states that xylol given internally is potent in coagu- lating the contents of the pustules, but experience does not corroborate this opinion. Kinyoun, Lundmann, and Bdclere have used the serum from vacci- nated subjects (human beings and the lower animals) or from variolous patients in advanced stages of the disease in the treatment of small-pox. The cases, however, are insufficient to Avarrant deductions. Special Methods of External Medication.—Dr. Galewouski1 reports brilliant results in the treatment of variola with baths of potassium per- manganate. The salt is added till the water is of a rose-red color, and GaleAvouski claims that by its application the temperature is lowered, the pustules disappear, and recovery speedily ensues. Talamon2 recommends a special plan of external medication in the form of a mercuric-chlorid spray for small-pox vesicles and pustules, his object being to keep the surface under the influence of an antiseptic. The mercuric-chlorid solu- tion is prepared after the following formula: B^. Mercuric chlorid, gr. xv (1.0); Tartaric acid, gr. xv (1.0); Alcohol (90 per cent.), ftjss (6.0); Ether to make • fgjss (45.0). Sig. To be applied as a spray three or four times daily for one minute. It is essential to exercise the precaution to protect the eyes, which may be covered by layers of cotton dipped into a saturated solution of boric acid. Talamon advises the commencement of his method on the first day of the eruption, the application to be preceded with a vigorous washing of the face with soap, which may be rinsed off with boric acid and then dried with absorbent cotton. After the spray has been used the face should be covered with a layer of a 50 per cent, glycerolate of mercuric chlorid in order to keep the skin continuously aseptic. After the fourth day the number of sprayings per diem is gradually lessened, so that by the seventh day they may be discontinued; but the application of the glycerolate should be continued. 1 Med. Press and Circular, 1890. 2 Journal of Cutaneous and Venereal Diseases, February, 1891. VACCINATION. 229 Talamon added, in the confluent and other grave forms of the disease, general mercuric-chlorid baths, lasting for three-quarters of an hour to an hour. The buccal and pharyngeal eruption is to be treated by gargles and lotions of boric acid. Internally, the therapy is limited to sustaining the strength of the patient by means of alcohol (^iij-iv ; 90.0-120.0 daily), according to the gravity of the case. VACCINATION. Historic Note.—One of the first steps in preventive medicine was the practice of inoculation as a method of protection against the in- fection of small-pox. It had been practised in China and other Asiatic countries for centuries, and Lady Montague, the wife of an English am- bassador to Turkey, early in the eighteenth century introduced it into England, after which time and until vaccination was known, it Avas very extensively practised there. Pus taken directly from a small-pox pustule was introduced beneath the epidermis, and the person inoculated developed variola, though in a milder form than when arising from ordinary infection. The attack ran a more rapid course, having feAver pustules, rarely terminating fatally, and protected the individual from subsequent attacks. The objections to this method were that it did not always produce a mild form of variola, a small percentage of cases having a fatal termina- tion, and that, however mild the attack, other unprotected persons brought in contact with it were as liable to contract small-pox in as virulent a form as if contracted in the usual way. In a paper published in 1798, Edward Jenner, a physician of Glouces- tershire, England, and a pupil of John Hunter, first made known to the world the value of vaccination. Twenty years previous he had observed that persons employed in dairies, who were accidentally inoculated with cow-pox, were insusceptible to the contagion of small-pox, and, after ex- perimenting all these years, he became satisfied that inoculation with the vaccine lymph was a preventive against small-pox. After the publication of his paper he was subjected to ridicule and abuse by the profession, but through his persistence he Avas finally allowed to practise his method of vaccination in the wards of a hospital, and in the course of a few years it became generally recognized and wras practised in France and America, as well as in England. Later, the method fell into disrepute for a time, owing to the fact that certain persons who had been vaccinated subse- quently contracted the disease, it not being knoAvn then that a revaccina- tion was necessary from time to time. Strange to say, hoAvever, in the century that has passed since the first vaccination by Jenner there has practically been no change or improvement either in the method or the vaccine used. Vaccinia, or cow-pox, is a mild eruptive disease that occasionally occurs among cattle, a similar disease being produced in them by inocu- lation with the small-pox virus from man. It is communicable by con- tact only, and is usually carried from one cow to another by the hands of the milkers; hence being usually found on the udder or teats of milch 230 INFECTIOUS DISEASES. cows. Since Jenner's time many theories have been advanced as to the exact nature of this disease in cattle, and at the present day the subject is still in dispute. It is noAv, however, generally conceded that if cow- pox is a distinct disease, originating only with the cow, the eruptive dis- ease produced in this animal either by inoculation of small-pox virus from man or of "grease " from the horse is, at least in all essential respects, a disease not to be distinguished from primary or idiopathic vaccinia. Guarnieri has described certain parasitic organisms, the Cytorectes Guar- nieri, found in corneal lesions produced by the injection of vaccine lymph. This observation has been confirmed by Pfeiffer and others, but the pathogenic nature of these protozoa has not been determined. The vaccine virus consists either of the liquid contained in the ves- icle or of the scab resulting from the desiccation of the pustule. The former is furnished from vaccine farms, of which there are several in this country, is then dried on ivory points, and, if kept in a cool place, re- tains its virtue for a week or ten days, or, possibly, longer, but should be used as fresh as possible to ensure a successful result. It is also some- times preserved in capillary glass tubes, sealed at both ends, or between glasses, and kept in this way it is less liable to infection through unclean- liness in handling. The scab from the cow is not used. The Site.—The point usually chosen for vaccination is on the arm over the insertion of the deltoid muscle ; but in girls, for cosmetic reasons, it is sometimes preferred on the leg, and the most common site is over the junction of the two heads of the gastrocnemius muscle. Technique in Vaccination.—The part selected should be made sur- gically clean ; then gently scrape the skin with a lancet or other in- strument, which has also been made aseptic, until serum begins to exude. If, by too vigorous scraping blood should be drawn, it should be care- fully dried with a piece of sterile cotton before the lymph is applied. The charged end of a point, which has been previously dipped in tepid water, is now gently rubbed over the abraded spot and the limb left exposed to the air until the lymph has been dried upon it. It may then be protected by a piece of gauze strapped on it or by one of the shields made for the purpose. Some physicians still prefer the humanized lymph, and Avhen this is used the " arm-to-arm " vaccination is best. The lymph is taken from a characteristic vaccine vesicle (from the fifth to the seventh day of its de- velopment) of a healthy child and applied directly to the arm of another. When this method is not practicable, hoAvever, the virus may be dried and preserved for use just as in the case of bovine virus. The scab resulting from a vaccine vesicle on a healthy child was for- merly quite generally used, and it could be kept a long time without losing its virtue. It was sure in its action, and offered the advantage to the physician of being easily preserved; but it was more liable to become infected than the lymph when preserved in the usual way, and, since the vaccine farms are so conveniently located, lymph may be obtained from them at any time without delay. There are no valid reasons why the humanized should be preferred to the bovine lymph, and the possible danger of conveying syphilis or other constitutional disease from one person to another by means of the former should be sufficient reason for the use of the latter. VARICELLA. 231 Period of Life for Vaccination.—It is usually advised to vaccinate infants within a few weeks or months after birth, but, unless small-pox is prevalent, it is best to Avait until the latter part of the second or the beginning of its third year, as the child has then passed through its teething period and will be better able to resist the effects (slight though they may be) consequent upon vaccination. Time for Revaccination.—To ensure the individual against infection he should be revaccinated at puberty and every few years afterward, or at any time when small-pox is epidemic or liable to become so. Symptoms.—After vaccination no local or constitutional effects— except the slight irritation due to scarification—are noticed until the third day, when a small red papule appears. By the fifth or sixth day a vesicle appears. By the ninth day it is fully developed, and, like the vesicle of variola, is filled with colorless lymph, is umbilicated, multi- locular, and has a distinctly inflamed areola of deep red color, accom- panied by heat, itching, and tenderness. By the tenth day this may ex- tend an inch or two from the vesicle. Quite frequently the axillary or inguinal glands (depending upon the location of vaccination) are swollen and tender, and in a tubercular child they may go on to suppuration. After the tenth day all these symptoms gradually decline; the pustule dries up, and then forms a brown scab which is usually detached in the third or fourth Aveek, leaving a permanent cicatrix. Complications.—Occasionally one or more additional vesicles are formed at a little distance from the point of inoculation, and, rarely, there is a general vesicular eruption, due to absorption of the lymph. An erythematous rash is not uncommon, and appears, if at all, about the sixth day. Erysipelas may occur as a complication, and, if it is preva- lent in the house, vaccination should, as a rule, not be performed; if deemed necessary, however, the greatest care should be taken to ensure cleanliness. Sometimes, owing to injury to the vesicle or to uncleanliness, an ulcer forms, which may be weeks in healing. Eczema and other skin-affections are usually aggravated during the course of vaccination, and it should not be forgotten that it is possible for syphilis to be inoculated with the vac- cine virus. Any of these complications call for the same treatment as when occurring independently. VARICELLA. (Chicken-pox.) Definition.—An acute, contagious disease, characterized by a cutane- ous eruption of papules, passing into vesicles and pustules; also by slight fever and mild constitutional symptoms. For a long time it was con- founded Avith varioloid, but its distinct character has now been recognized for many years. Complications and sequelae are infrequent. Etiology.—It is well established that the contagium of varicella is found in the vesicles, as the disease has been communicated by actual 232 INFECTIOUS DISEASES. inoculation with their contents. The specific poison has not been satis- factorily isolated, although it is suspected that certain protozoa are the direct cause, but, as in the case of vaccinia and small-pox, positive proof is wanting. Varicella may be transmitted by exposure to another case or possibly through the medium of a third person, the school and asylum being the most frequent points of its origin. It affects children of all ages, and usually one attack is protective. It closely resembles measles in its contagiousness. Symptoms.—The incubation period is uniformly from fourteen to sixteen days. If there be a prodromal stage of the disease, certainly in the vast majority of cases it cannot be recognized, though a slight fever and general indisposition may be noticed for twenty-four hours before the appearance of the eruption. In many cases the eruption is the first symptom. This occurs in the form of small reddish puncta, from which rapidly develop rosy-colored maculations, and these become tensely dis- tended, transparent, or slightly yellowish vesicles of the average size of a split pea. The eruption appears first upon the upper part of the body, the chest and back, neck, scalp, and face (on the latter quite sparingly), and always upon the hairy scalp. Frequently the vesicles form on the mucous surface of the lips, inside the cheeks, on the tongue, palate, con- junctivae, and in the progenital regions of both sexes. At times the glands of the throat become slightly enlarged and painful, the vesicles are superficial, the child has the appearance of having received a shower of boiling water, and the firm papule which precedes the variolous rash is altogether wanting. The vesicles are at first transparent, and their contents plainly show through their translucent roof-wall which is com- posed only of the stratum corneum of the epidermis. Umbilication rap- idly occurs at the apex, and the contents of the vesicles become lactescent, and gradually sero-purulent. The areola is most distinct when the vesicle is fully formed and fades as the latter dries. Crusts form which drop off in from five to twenty days, depending upon the depth to which the skin has been involved. On the trunk, as a rule, no mark is left, but after the more severe attacks, when the true skin has been involved, scars remain, and frequently there is quite deep pitting. The marks are usu- ally on the face when the skin has been unprotected. On the hands and feet the vesicles appear without having been preceded by a papule, and sometimes there is no areola, each vesicle resembling a drop of water upon a healthy skin. Pustules may develop in consequence of irritation or infection, as the result of scratching, or in feeble or poorly-nourished children and in unhealthy children deep ulceration may occur, lasting for weeks. In rare cases there may be necrotic inflammation about the site of the pox (varicella gangrcenosa). In mild cases only ten, twenty, or thirty spots may be found on the body, but in severe cases the skin may be almost covered in certain regions. The eruption, however, is never confluent. The temperature is highest on the second or third day, Avhen the eruption is appearing. In mild, uncomplicated cases the thermometer registers 101° or 102° F. (38.8° C.) for two or three days at most, but in severe cases the tempera- ture may be as high as 104° F. (40° C). This is usually due to broken health prior to the acute illness. The temperature falls gradually as the rash fades, and presents a temperature-curve similar to that of measles. VARICELLA. 233 There is usually neither coryza, vomiting, cough, nor diarrhea, and in their place is only the general indisposition Avhich is associated Avith any febrile disease. Complications.—Erysipelas occasionally acts as a serious compli- cation in delicate children. It may develop about the pocks, particularly when they are deep and associated Avith some ulceration, and scratching Avith unclean fingers is its prime causal factor. Adenitis, mild and isolated, and suppuration Avith abscesses in the deeper cellular tissue are occasionally seen. Nephritis is infrequent, but may occur in unhygienic surroundings or in carelessly managed cases, just as it may folloAV scarlet fever or measles. Varicella is also quite frequently complicated with other infectious diseases, and varicella, scarlet fever, and measles have been seen curiously blended in epidemic form. Varicella and measles, however, are most frequently associated. The diagnosis of varicella offers no special difficulties. The erup- tion comes out slowly and in crops, so that papules, vesicles, and crusts may be seen upon the skin in close proximity. Again, it should be noted that the umbilication is due only to the fact that the drying up of the vesicle begins at the center, and that the pocks may appear on the mucous membrane. Varicella is distinguished from urticaria by the presence of fever, and from eczema pustulosum by the mild febrile symptoms of the latter, the discreteness of its pustular lesions, the absence of itching and of infiltration of the skin in patches, and by its tendency to symmetric development. Variola and varioloid of infants are to be distinguished from varicella by the prodromal symptoms, and by the greater rise of temperature, though the distinction between mild varioloid and severe varicella in infancy and childhood will ahvays tax to the utmost the skill of the keenest diagnostician. The sooner it is understood that intermediate forms are likely to occur, which cannot be positively assigned to one or the other category, the better it will be for both the profession and the laity. The prognosis in private practice is always favorable. Only in the slums or in hospital cases complicated by erysipelas, adenitis, or nephritis may grave results be anticipated. The milder cases may, however, leave slight monuments of their existence in the form of one or more depressed cicatrices Avhich may mar an otherwise beautiful face. Treatment.—Isolation should be enforced in schools and in all in- stitutions containing many young children. In private houses, unless the younger children are delicate, quarantine is unnecessary. The disease may be transmitted to others as long as the crusts are present, and hence isolation should be maintained until they have fallen off. In most cases constitutional symptoms of the disease are so mild as to require no treat- ment. It is best at the outset to place the child in bed for a feAv days, and sponge daily with warm carbolized water; the local itching may be allayed by sponging with a weak solution of carbolic acid or by the use of carbolized vaselin. When the crusts have formed, especially on the face, an ointment of zinc oxid containing ichthyol (2 per cent.) should be applied, and care should be exercised to keep the skin clean and to prevent scratching. In all cases the urine should invariably be examined several times during and folloAving the attack. 234 INFECTIOUS DISEASES. SCARLET FEVER. (Scarlet Rash; Scarlatina.) Definition.—Scarlet fever, or scarlatina, is a self-limiting, acute, con- tagious disease, characterized by vomiting, fever (more or less typical), angina, and in tAvelve or twenty-four hours by a diffuse, punctiform, scar- let eruption, followed by membranous desquamation and, frequently, by nephritis. It is a disease of childhood, but may occur at any time of life. Scarlatina is a widespread disease, though perhaps less universal than measles. It is endemic in all the large cities of the globe, and at inter- vals the cases multiply into more or less extensive epidemics. Smaller towns and rural districts are visited, and the epidemics are usually trace- able to importation of scarlatinal poison, so that it may be stated that they never originate de novo. Pathology.—There are no pathognomonic changes. When death occurs early the chief lesions are presented by the throat, while in addi- tion engorgement of the viscera is noted, especially of the brain. The exanthem is rarely visible. In malignant types, however, in which the eruption is not seen during life, it makes its appearance rarely after death, and this aids in establishing the nature of the affection. When death occurs at an advanced stage the lesions are those either of nephritis (with dropsy), or of septico-pyemia, or of inflammation of one or more of the serous surfaces (pleurisy, pericarditis, endocarditis, menin- gitis, etc.). Additional changes in the various viscera are, for the most part, identical with those met with in other acute infective diseases, and hence need not be described here. The blood, it should be pointed out, is dark, fluid, and coagulates feebly, owing to a decrease in its fibrin fac- tors. The process of desquamation may be observed, together with more or less emaciation in protracted cases. Among other lesions which are more or less peculiar to the disease are (a) The eruption, Avhich is a dermatitis of very mild grade, (b) Scarlatinal angina, which in its mildest form presents hyperemia and a slight swell- ing of the mucosa of the tonsils, soft palate, and pharynx. In the severer grades the inflammation is phlegmonous (scarlatina anginosa), and some- times terminates in ulceration. There is great SAvelling (especially of the tonsils), and the formation of abscesses, due to secondary infection, is com- mon. Extension of the purulent inflammation to the connective tissue of the neck produces marked induration, and more or less extensive ab- scesses may take place. Gangrene sometimes supervenes, (c) In certain epidemics a membranous exudate accompanies the scarlatinal angina, and this may or may not be truly diphtheritic. When it appears early it is non-diphtheritic, as a rule, the streptococcus of erysipelas being often found; on the other hand, Avhen it comes on late it is often diphtheritic in nature and shoAvs the presence of the Lbffler bacillus. Other second- ary inflammatory processes occur that are due either to direct extension or to metastasis, but these will be considered later at sufficient length (vide Clinical History), (d) The Nephritis.—The renal lesions, so prom- inent and so common in scarlatina, are included in the description of "Acute Bright's Disease." Etiology.—The bacteriology of the affection is unknown as yet, al- though the fact that it depends upon a special poison cannot be doubted. SCARLET FEVER. 235 As early as 1892, Doehle described a peculiar variety of protozoa which he found in the blood of patients suffering from some of the eruptive fevers, and among them scarlet fever. He found a ciliated and a con- tractile form, occurring both within the red blood-cells and free in the plasma, and staining well with methylene-blue. This observation, how- ever, has not been confirmed, and as the streptococcus pyogenes has been found in nearly all the inflammatory complications of the disease, espe- cially scarlatinal pneumonia and angina, some pathologists (Babe's, Berge", Klein) have held it to be the cause. Marmorek, Raskin, and Mosny, however, believe that it is an example of mixed infection, the streptococ- cus being merely a secondary factor, and Marmorek has been confirmed in this view by the results of his experiments with antistreptococcus serum. The general receptivity for scarlet fever is not so great as in certain other exanthemata (e. g. small-pox, measles); hence in a household in which there are several children some are apt to escape the disease, even though all have been equally exposed. The virus is probably contained in the excretions from the throat and in the epidermal scales thrown off from the surface of the body. It is also present in the blood of scarlatina patients. Modes of Conveyance.—The majority of the cases are produced by con- tagion, and I have observed that in many instances a single contact of a healthy child with a scarlet-fever patient has sufficed to convey the dis- ease. It is also communicated by fomites, and the poison of scarlatina contained in clothing retains its infective power for months—a fact that shows conclusively its great tenacity of life. The patient himself is a center of infection until the end of the period of desquamation. Again, any objects (furniture, utensils, library books, toys, etc.) which the patient has touched or handled may serve to communicate the poison to healthy children. The disease may also be transferred by persons wTho have been in the sick-room, while they themselves escape. Transmission through milk has been observed, infected dairies having been known to dissemi- nate the poison and give rise to epidemics. The infection may also be air-borne, though not for any great distance. Mode of Infection.—The precise way in which the infection of a healthy person takes place is not quite clear. Most probably the poison is inhaled into the throat, where infection usually occurs, but it may gain entrance to the body through the alimentary tract. Infection may also take place through the blood, as is shown by the fact that children have been born in all stages of the disease. Artificial inoculation with the blood of scar- latina patients has resulted in more or less typical forms of the complaint. Whether or not an open lesion of the mucous membrane of the throat or other surfaces is necessary for the entrance of the poison into the circula- tion has not been determined positively, but fresh wounds ahvays predis- pose to infection. Predisposing Causes.—(1) Age.—The period of chief liability is from the second to the tenth year, after which it diminishes. It is rare under the age of one year, and especially so under six months. (2) Recent wounds—accidental or surgical—increase the susceptibility to the pecu- liar poison. (3) Women in childbed, for the same reason as (2), but care must be exercised, lest this class be confounded Avith septic affections. (4) Season.—The autumn and winter months furnish the most cases. 236 INFECTIOUS DISEASES. Immunity.—Single attacks during the life of a person form a rule to which there are rather frequent exceptions. Clinical History.—The incubation period is extremely brief, lasting usually from two to three or four days. It may rarely, however, be longer—five to eight days—or more rarely still shorter—less than twenty- four hours. The invasion of scarlet fever is generally quite sudden and, as a rule, active. The child feels uncomfortable, looks stupid, complains of sore throat and decided nausea, and in the great majority of the cases vomits. The tongue is furred. If he be very young, nervous symptoms are prom- inent, and he may exhibit convulsions. The pulse, which is a strong diagnostic factor, is rapid and hard, reaching 140 to 160 at the very on- set. The temperature rises quickly to 104° or 105° F. (40.5° C), and remains high. Eruption.—Within the first twenty-four or thirty-six hours the charac- teristic rash appears, and is, as a rule, first seen on the neck ; there is no certainty about this, however, as it may first come out on the abdomen or back of the hands or on the thighs, and not be seen on any other part of the body. Frequently it is found on the dependent portions of the trunk. At first it is slight, but perfectly characteristic, and usually takes two days to mature. In mild cases it disappears within thirty-six to forty- eight hours, and at no time is more than a very fine rash, but when typical it cannot be mistaken, especially if accompanied by the premoni- tory symptoms. When seen from a short distance at the end of the first twenty-four hours of its appearance the whole body (except the face) is of a uniform bright scarlet color. If we examine more closely, we find that the eruption consists of a multitude of red points that correspond to the hair-follicles. These points are surrounded by zones of erythem- atous redness, which, joining Avith one another, give a generally diffuse red appearance to the whole skin. Frequently, however, the rash con- sists of points representing the hair-follicles without the erythema, and in rough skins the rash may be more punctiform—that is, more strictly a condition of "goose skin." Sudamina are quite frequent. Pressure by the finger causes a pallor which at once disappears when the finger is removed. The patient's lips and chin are pale and in striking contrast with the vividly scarlet cheeks. In some cases the rash is patchy, espe- cially on the limbs, and in these cases it may suggest measles, the patches consisting of clusters of fine papules or points with much surrounding erythema, Avhile normal skin is present between the patches. In severe cases the rash may be hemorrhagic in character, minute extravasations of blood taking place in the skin; this may occur even in mild attacks, and not be seen until after death, but more frequently it is seen in malignant cases. Purpuric patches are frequently found after death when even in life they did not appear. There is itching, which may be either mod- erate or intense throughout the eruptive sta^e. By the end of the first week the rash, which has been fading for sev- eral days, is succeeded by a desquamation that will be extensive or slight according to the intensity of the fever. In mild cases the tonsils, palate, uvula, and pharynx are deeply congested, and the mucosa of the cheeks, palate, and tonsils may show the eruption. In severer forms the tonsils are red and inflamed, and covered Avith tenacious secretions, SCARLET FEVER. m 237 while minute yelloAV points corresponding to the tonsillar crypts are usually prominent. (Jlde Malignant Scarlatina.) The nasal chambers are swollen, producing a free discharge, and the deeper cervical glands at the angle of the jaAv are frequently enlarged. The tongue is coated with a thick, dense Avhite fur (dead epithelium), and frequently shows a dry, glazed central band. In a feAv days the dead epithelium is cast off, clearing the tongue, Avhen Ave have a red, clean, glazed tongue Avith greatly enlarged fungiform papillae, giving us the straivberry tongue of classical history. The eyes are frequently swollen and the conjunc- tiva injected. Sleeplessness and mild delirium often mark a typical case, suggest- ing a congested state of the meninges, but it is neither usual for the child to be violent nor for the delirium to continue long. The pulse is usually a strong diagnostic feature, and is ahvays hard, quick, and wiry, varying from, 140 to 160; it is out of proportion to the temperature and the general condition of the child. Leukocytosis is commonly noted. The temperature in average cases reaches 104° or M E M E M E M E M E M E M E M E M E M E M E M E M E M E BOWKLS / / / / / / / / / / / / Urine ZJaWy Am'l 104° 103° 102° 101° 100° 99° 98° Vai/o/Dis Pulse. Resp. Date. A A /' r /' . i , A ' \j \, \ A \ K , V v A / v V j it J Y A 1 Y I M I \y I A V V 1 1 A i /\ [ j '' \J A Y A L, ' \J Y r A G '\ I 1 A || i i * J| \J l| V L |! \ A v \ J \ 1 y L \ / v / Z 3 4- 5 6 y 8 9 /o // /z /3 /❖ ■-W m ■' ,''' Fig. 22.—Temperature-curve of a case of scarlatina with favorable course—William C---, aged seven years. 105° F. (40.5° C), and in severe forms it may touch 106° F. (41.1° C), the nocturnal remissions being slight and defervescence gradual (vide Fig. 22). The urine is scanty, thick, and contains urates, Avith a small quantity of albumin. Within one Aveek, if no complications have occurred, the attack will have reached its height and the symptoms have begun to decline. The 238 INFECTIOUS DISEASES. rash gradually fades, temperature falls, the tongue is less red, the throat less injected, and the child seems more natural. If at the end of one Aveek the fever continues, it suggests the many possible complications, the most frequent of Avhich is a throat or tonsillar ulceration, inflammation of the cervical glands, otitis, or, most probably, acute nephritis. It must be Avell understood that no tAvo cases of scarlet fever are alike. Clinical Types.—Mild Scarlet Fever.—In very many cases of scar- let fever all the premonitory symptoms are absent, and the rash is the only indication of the trouble. There is neither vomiting nor fever to be recognized, and no tonsillar trouble of any importance, Avhile the rash is neither uniform nor Avell marked. In these cases Ave must be very careful not to confound the eruption Avith urticaria or some of the many medicinal rashes. The most difficult cases of all to diagnose are those in Avhich sore throat is present Avithout a rash, inasmuch as there is nothing characteristic about a scarlatinal tonsillitis. During house epidemics Avhen several children are affected it fre- quently happens that a child has sore throat and the " strawberry tongue" Avithout a development of the rash. This may also occur in adults, and is the so-called scarlatina sine eruptione. These very slight cases of the fever are the most to be dreaded, as they may be followed by the most severe attacks of nephritis. Malignant Scarlet Fever.—Death occurs usually by the end of the first Aveek in severe cases, Drs. Ashby and Wright reporting a death Avithin the first tAventy-four hours (atactic form). In malignant cases, such as usually occur among the unhygienic and delicate, the tonsils may be covered by a membranous exudate, and the system quickly receive an overAvhelming dose of the poison ; death then results from septic causes (anginose form). In cases in Avhich death occurs early a child soon be- comes cyanotic, restless, or more frequently somnolent. In all these cases the temperature remains high—105° to 106° F. (41.1° C), and very frequently 107° F. (41.6° C). Diarrhea is frequently a trouble- some factor in severe cases; coryza is very abundant; there is much glandular SAvelling and cellulitis, the neck becoming enormously enlarged and hard, the skin dull and livid in color; the extremities groAv cold; the heart gradually becomes irregular, losing a beat, and finally fails. If life is sustained through such an ordeal, the tonsils slough and the lungs may eventually become the seat of a septic pneumonia. In many desperate cases Avhen life is prolonged to the end of the second or even third Aveek general septicemia is most likely to occur. In this condition the tonsils ulcerate, sloughing patches appear on the fauces, the glands about the neck become enlarged and doughy, and the nasal mucous membrane gives out a purulent secretion in abundance. The temperature may remit, but continues high; the urine is albuminous; pus Avells from both ears; and thus the child is gradually consumed and perishes. In all these cases pleuro-pneumonia will be found, together with hemorrhagic kidneys, and most probably small abscesses will he found in the latter at the post-mortem. A third variety (hemorrhagic) shoAvs at first cutaneous petechiae, which groAv rapidly into large ecchymotic patches. Hemorrhages also take place from the mucous surfaces, epistaxis and hematuria being very common. Death, as a rule, follows in tAvo or three davs. SCARLET FEVER. 239 Desquamation.—By the end of the first Aveek the rash commences to disappear, the skin is (or soon becomes) mottled, dry, and rough, and gradually the scarf skin begins to separate. This process usually begins about the neck and trunk, and frequently large flakes are de- tached, the Avhole cuticle of the hand or foot sometimes coming off in one mass like a glove. The degree and character of the desquamation bear some relation to the severity of the eruption. In some cases the hair and nails have been cast off. In many cases desquamation is pro- longed to the eighth Aveek; it is usually longest on the hands and feet. Complications.—Otitis.—The inflammation may extend from the throat along the Eustachian tubes to the middle ear, and pus be formed in the tympanic cavity, making its exit by perforating the membrane. This complication may occur either during the fever or at some time during convalescence. Suppuration in the middle ear is one of the common causes of a continued high temperature after the disappear- ance of the rash. Pain in the ear may not attract our attention to this unfortunate complication; most frequently, hoAvever, the child will place its hand on the ear and shake its head, as if to get clear of some source of irritation. Pyemia.—Pyemia and abscess of the lungs may folloAV, and throm- bosis of the lateral sinus may occur. The tonsils may be the seat of deep ulceration, and the soft palate may slough and shoAv cicatrization of the soft parts of the throat in cases Avhich may yet recover. The cervical glands may become enlarged and suppurate, either during the fever or Avhile the child is convalescent. In debilitated or strumous children this complication may be very troublesome, Avith the formation of deep ragged ulcers, slow to heal, and in rare cases exposing the larger blood-vessels. Broncho- or lobar pneumonia may occur, and is most usual during the second week, being due to extension downward of the lesion from the throat. Pneumonia folloAved by empyema may also occur during convalescence. Arthritis, Synovitis, and Rheumatism.—In unhygienic surroundings or Avhere careful nursing is not carried out the joints are likely to be- come SAvollen and tender at the end of the first or the commencement of the second Aveek. The Avrist and the small joints of the fingers are most prone to be affected; the synovial membranes and the sheaths of the tendons at the back and in the palms of the hands are attacked. The elbows and joints of the vertebrae, the ankles, the knees, and soles of the feet may be affected; movement causes pain, and these parts are generally SAvollen, red, and very tender. The trouble is not severe, being fugitive and seldom returning to the same joint. Etiologically, this form of trouble is not true rheumatism, but is analogous to gonor- rheal synovitis. The knees may be most severely affected, remaining swollen for several weeks, and in unusual cases suppuration may take place and be followed by pyemia. Such cases are usually fatal. Nephritis.—No other complication of scarlet fever can equal nephritis in importance or interest, this condition ahvays giving rise to anxiety in othenvise mild and hopeful cases. During the height of the fever, as is the case in all exanthemata, there is a trace of albumin in the urine that has no special significance, and it is possible for the kidneys to escape Avithout greater damage than occurs in other acute febrile affec- 240 INFECTIOUS DISEASES. tions. Independently of this febrile albuminuria, there are two forms of nephritis which it is important to bear in mind, though they have been frequently confounded: (a) Septic Nephritis.—In severe forms of scarlet fever, when the throat symptoms include sloughing tonsils, involvement of the soft palate, and general adenitis, the urine quickly becomes loaded with albumin, but sIioavs scarcely any blood and but feAv casts. No renal symptoms will be recognized, and if present they may be masked by the general condition of septicemia. There may be neither dropsy nor uremic phenomena, but the patient usually dies by the end of the second Aveek, Avhen a typical pyemic kidney is found containing minute abscesses. This condition of the kidney is only one part of the general pyemia, and merely illustrates the fact that this organ suffers during the course of the general inflammation. (b) Post-scarlatinal nephritis is the form most likely to occur about the third or fourth week, and is the one generally known as scarlatinal nephritis. The kidneys are undoubtedly involved in an active sympa- thetic inflammation, and at the end of the fever, more than at the be- ginning, are engaged in carrying off waste products of the fever itself. From the nature of the disease they are in an irritable condition and prone to take on inflammatory changes, just as the bronchial tubes and the lungs are left in a very susceptible condition folloAving measles and Avhooping-cough. In this Avay the uriniferous tubules become choked up by the desquamation that is going on inside. The number of cases that suffer from post-scarlatinal nephritis varies according to social con- ditions, the nature of the epidemic, the season of the year, the nature of the treatment received during the disease, and especially the care received throughout convalescence. Ashby and Wright fix the rate of those Avho suffer at 6 per cent, of hospital cases, but this is, undoubtedly, too low, since hospital cases receive better care during convalescence than private cases. The usual time for this form of nephritis to occur is from the end of the second up to the fourth Aveek, but it usually begins very insidiously. Traces of albumin may be found for a few days be- fore the blood and larger quantities of albumin occur, but it is often im- possible to date the commencement of an attack. Usually after the fever has subsided the patient for a feAv days feels well, but very suddenly groAvs restless, is feverish at night, is thirsty, has a quick, hard pulse, and passes a small quantity of dark-colored urine. If care has been exercised, it will be found that the urine has been gradually diminishing for several days, and a slight puffiness about the face frequently an- nounces the beginning of the trouble. Later the face becomes pale and puffy, while there may be edema of the feet and scrotum, and some vomiting. Under favorable treatment improvement may take place, large quantities of urine may be passed, and the child resume convales- cence. The nephritic symptoms may, however, deepen until uremia appears, the pulse becoming sIoav, the temperature subnormal, and the tongue dry and broAvn. Vomiting is now a frequent occurrence; diar- rhea is not unusual; nose-bleed and hemorrhages from the various mu- cous surfaces, and muscular twitchings may be noted, and most likely the end may be reached in a general convulsion. In all cases of nephri- tis great care must be taken to recognize heart-changes, and fatal results SCARLET FEVER. 241 are more frequent from cardiac failure than from the uremic convulsions. The constant effect of nephritis is to raise the blood-tension, and this continued tension in the blood-vessels is folloAved by dilatation of the heart. Another not unusual result is endocarditis or pericarditis, with possible embolism. Sudden death frequently occurs during the course of nephritis. The child may be doing well, possibly sitting up in bed and playing with its toys, Avhen an attack of dyspnea occurs; the face becomes livid, the pulse disappears, and death quickly takes place. Death in such cases is usually said to be due to edema of the lungs: the dilated heart, how- ever, has been overlooked, and, Avhile edema of the lungs is present, it is only secondary to the cardiac failure. It is not unusual for a false membrane to form upon the larynx. This is not infrequently due to the streptococcus pyogenes, but the Klebs-Lbffler bacillus is oftener found (Ranke found it in more than half of 92 cases). A bacterial examination should ahvays be made early in the disease, and if the diphtherial nature of the infection has been determined the serum-treatment should be employed at once. Diagnosis.—A typical form of scarlet fever offers few difficulties in diagnosis. The period of incubation is short in comparison with that of any of the other exanthemata, particularly variola, measles, and varicella. The vomiting, which is almost a constant factor in the early stage, associated with high fever, would also exclude the other eruptive diseases. The pulse in itself is most strongly diagnostic, being quick, hard, and wiry, striking the finger at the rate of 140 to 180 per minute; no other disease has a similar pulse. The early sore throat and the in- tense hyperemia of the whole mucous membrane, associated Avith severe constitutional symptoms, make it easy to differentiate from measles, varicella, and variola. The punctate erythematous lesions that appear during the stage of efflorescence of scarlet fever are not found in any of the other eruptive diseases. ( Vide table on page 247.) The differential diagnosis embraces the discrimination of those rashes that follow the use of certain drugs (quinin, belladonna, potassium bro- mid and iodid, chloral, etc.). The characteristic invasion-symptoms (vomiting, angina, etc.) of scarlatina are absent; also the high fever and frequent, hard pulse of the latter disease. Drug-rashes are seldom so vivid or diffuse as the eruption of scarlatina. Scarlatina. Acute Exfoliating Dermatitis. Onset is sudden, with vomiting, angina, Sudden, with fever only. fever, and frequent, hard pulse. Eruption appears first on neck, face, and Appears first on trunk. chest, soon becoming diffuse. Duration, three or four days. Duration, five or six days. Desquamation begins after eruption has Desquamation begins earlier, often before faded, often one week later. eruption has faded, and involves the hair and nails. Ear and throat complications common. Absent. Nephritis is a common sequel. Not so. Relapses exceptional. .Relapses common. The prognosis in regular, uncomplicated scarlet fever is in almost every case favorable, and, unless the treatment is unusually indifferent, 16 242 INFECTIO US DISEASES. the patient will recover. Severe types, hoAvever, and especially malig- nant scarlatina, are very fatal. Complications arise that Avill most seriously endanger life. The treatment of scarlet fever is that of the symptoms, together with an attempt at arresting the complications. Prophylaxis.—The patient should be strictly quarantined in an upper room for at least eight Aveeks or until desquamation has been completed. A competent nurse should be put in charge, and, Avhether a member of the family or otherAvise, she should Avear a Avashable dress, and should not mingle wTith the family, except her clothing be changed or thoroughly disinfected. The room is to be stripped of all superfluous hangings and furniture. Inunctions are required as soon as desquamation commences, with a vieAv to preventing the diffusion of the dried epidermal scales; and the best preparation for this purpose consists of cosmolin, menthol, and carbolic acid, ten grains each of the latter to one ounce of cosmo- lin, after the plan of J. LeAvis Smith. Carbolized water, 1: 40 (thor- oughly shaken), may be used to sponge the surface and may be agree- ably folloAved by cocoa-butter. The disinfection of the physician himself, I am sorry to state, is fre- quently neglected. He should generate chlorin gas by the following simple method, and allow it to permeate his clothes thoroughly before going into other families: A dram of powdered potassium is placed in a saucer, and a small quantity of hydrochloric acid added. The dish is then placed on the floor, and the physician stands over the vapor chlorid as it arises until it penetrates all his clothing. This, with the free use of the Avhisk and thorough hand-Avashing, renders him non-contagious and safe in entering any home or sick-room. Perhaps a less disagree- able method is to have in the patient's house a linen duster or surgeon's apron that has been dipped in a bichlorid solution and alloAved to dry. This is slipped over the clothing before entering the sick-room, and is removed after leaving. In the room, if the case be a severe one involving the throat, I keep the gas or an alcohol lamp burning under a small dish of Avater, so that steam may be constantly generated. To the boiling Avater I frequently add carbolic acid or oil of eucalyptus; this saturates the room very pleasantly, and at the same time, I believe, limits the extent of the contagion. General Management.—The sick-room should be large and well ven- tilated, and should be kept at a uniform temperature (68° to 70° F — 21.1° C). A light flannel night-dress should be Avorn by the child, and the bed-clothing should be light as Avell. The diet should consist of milk, broths, egg-Avhite, and fruit-juices, and after the temperature has declined soft diet may be alloAved. A few days later the return to ordi- nary solid foods may be complete. The evidences of heart-enfeeblement often arise and call for the judicious use of stimulants. It is to be pointed out that this class of agents is remarkably Avell borne in this affection, and hence may be freely administered. To a child of four years I give one dram (4.6) of brandy or whiskey every second hour, and often increase the dose as required. The preparations of ammonium, particularly the carbonate and the aromatic spirits, have also been Avarmly recommended as stim- SCARLET FEVER. 243 ulants in this affection. They should be administered in milk as the vehicle to prevent gastric irritation. Special Treatment.—Bathing is recommended in scarlet fever by the best Avriters, yet often in such an indefinite and uncertain manner as to give the busy practitioner neither any encouragement to resort to it nor any guidance in the matter of technique and mode of procedure. In the classical Avork of Thomas Watson, noAv over fifty years old, he hints in his treatment of scarlet fever " that, if the heat on the surface be very great and distressing, he should not recommend the cold effusion, but cold or tepid sponging Avould be very refreshing and beneficial." This senti- ment finds its echo in most Avorks on practical medicine at the present day. Unfortunately, the majority of medical practitioners do not give their instructions for the thorough sponging of their scarlet-fever cases, chiefly through fear of objections from the family. The physician must quietly but firmly insist upon the patient being most thoroughly sponged three or four times daily, according to the severity of the individual case, using carbolized Avater (1: 60), mercuric chlorid (1 : 8000), salt Avater, or alcohol and Avater, at a temperature of 70°-100° F. (21.1°-37.7° C). Systematic bathing in this manner and inunctions as above described protect the body from certain disas- trous complications and sequelie. The ice-cap may be combined with cool spongings. In extreme cases, Avith marked nervous symptoms and high temperature, the cold pack, Avith cold affusions applied to the head and nape of the neck, may be cautiously employed, and a description of the method of giving a cold pack may be found under the treatment of Typhoid Fever. The gradually cooled bath may be substituted if open objection is made by the parents to the cold pack. In regard to the use of internal antipyretics, I prefer phenacetin for older children, combined with quinin in capsules. Acetanilid is better for younger children, and I generally give one-half as many grains as there are years in the child's life. When medicine can be exhibited in the form of capsules, I always prefer to combine it Avith quinin or strychnin to overcome the tendency to depression. Phenacetin and acetanilid act successfully in controlling the nervous element, relieving headache and fever, promoting diaphoresis, and inducing refreshing sleep. Acetanilid is much more prompt in its action than phenacetin, but its effects are not so lasting. I therefore choose it for young children, and exhibit it in small doses in the form of a poAvder, and if the boAvels are torpid I combine Avith the acetanilid small doses of calomel and soda. These agents are rarely required, and are not comparable in their good effects to hydrotherapy. Internal Antiseptics.—Those remedies that are purely antiseptic, administered internally, have not given proof of their utility as yet. The sulfocarbolates of zinc and of sodium, on account of their breaking up in the system and liberating carbolic acid, cannot be used in a suf- ficiently large dose to meet with success. The syrup of phenic acid is used by many physicians, but their success does not as yet seem to Avar- rant its being classed as an efficient remedy. Marmorek has used his antistreptococcus serum extensively, and, although it does not act as a specific, he claims that it prevents the serious complications and invari- ably renders the attack very mild. 244 INFECTIO US DISEA SES. The care of the nose and throat, and eventually of the ears, will re- quire all the skill of the medical attendant, and by commencing early in the case to give careful and constant attention to these parts we may prevent much trouble and danger later on. The attendant should use a small atomizer filled Avith Avarm Avater containing a solution of sodium bicarbonate (gr. xv-^j—0.975-32.0). If decided inflammation should occur, a solution of hydrogen peroxid and cold water or glycerin (1 : f>) may be used, and then be followed by an oily preparation, such as liquid albolene containing menthol (a 5 per cent, solution). If the patient cannot tolerate an atomizer, an application of the anti- septic oil directly to the posterior nasal spaces, by means of an aluminum applicator, may be made. Faithful attention to the removal of the secre- tion from the nose and throat will prevent accumulation, and thus pre- vent regurgitation up the Eustachian tube Avith its associated ear-troubles. In this Avay diphtheria can be prevented from gaining its full lodgement, and, if it gains ground at all, little trouble is experienced Avith this dreaded disease. For the appropriate treatment of this complication the reader is referred to the treatment of Diphtheria. If pain in the ear should indicate the extension of the trouble up the Eustachian tube, we must redouble our efforts, even though the desquamation within the Eustachian tube itself may be quite beyond the reach of our detergent wash. The external auditory canal may also become blocked by desquamat- ing epithelium, and this must be removed by gentle sponging. If the tension of the ear-drum becomes very great, it must be punctured. The crude method of dropping laudanum and SAveet oil in the ear is to be condemned, as it serves as a nidus for a collection of dust and dirt, inde- pendent of the rapid accumulation of dead epidermis. Scarlatinal rheumatism I have encountered in but a small proportion of cases, and then it was of a transient character, leaving no damaged heart-valves behind. I am inclined to attribute this fortunate result to the faithful use of daily bathing and inunctions, long continued and at least until after completion of desquamation. The most constant complication of scarlet fever is nephritis. The specific poison of scarlet fever is peculiarly obnoxious to the kidneys, and is largely eliminated through them; and upon this fact hinges the scientific part of the treatment of this disease. The more active we render the skin the less likely will there be danger to the kidney. If the urine is examined throughout the Avhole course of the disease, Ave will find in the earlier stage that it grows less in quantity and becomes more laden with the waste of the body, at times being nearly suppressed by mechanical blocking of the uriniferous tubules. If noAv the skin is not invited to act to its fullest extent, we will soon find our patient re- duced to a comatose state. Free bathing has the happy effect of vica- riously eliminating the poison, and in this Avay it removes the undue pressure placed upon the kidneys. (For the treatment of nephritis the reader is referred to the discussion of acute Bright's disease under Dis- eases of the Kidneys.) MEASLES. 245 MEASLES. Definition.—An acute contagious disease, characterized by an initial coryza, general catarrhal symptoms, fever in the earlier stage, followed by a peculiar papular eruption on the face and body. Pathology.—In uncomplicated measles we have no pathologic lesions. The only post-mortem changes found, as a rule, are those of catarrhal pneumonia and acute nephritis. All the internal organs are gorged with blood, and minute hemorrhages are found on their surfaces, Avhile occasionally croupous pneumonia may be found involving a lobe or small portions of a lobe of the Jung. Btiology.—Measles occurs in epidemics, yet Ave have frequent sporadic cases in the larger cities. There is an epidemic prevalence in large centers of population every eighteen months or tAvo years, but the different epidemics vary in their extent and fatality. It generally happens that Avhen once the disease enters a home, street, or small court, scarcely any one escapes Avho has not been protected by a pre- vious attack, those who suffer being for this reason, in nearly all cases, young children. The adults and older children may enjoy immunity in consequence of a prior attack, although this does not always follow. The susceptibility to measles in children, hoAvever, is very great. A most notable example of this Avas the epidemic that occurred in the Fiji Islands in 1875, and raged for four months, 40,000 of the natives dying out of a population of 150,000 (Corney, quoted by Callir). Biedert* found that only 14 per cent, of unprotected children escaped. In the Faroe Islands, under similar conditions, only 1 per cent, escaped (Madsen, Pannum). There is the same experience in schools and hos- pitals : wThen a case incubating the disease is admitted, the whole un- protected junior population is attacked. The epidemics occur mostly in the fall and winter, yet the season seems to have but little influence. Bacteriology.—Micrococci, especially streptococci, have often been found in the secretions of the respiratory tract, but they have not been proved to be specific, as they are not ahvays found and cultures from them do not cause the disease. Canon and Pielicki2 found in the blood of 14 cases, as Avell as often in the sputum and nasal and conjunctival secretions, a special bacillus of irregular size, Avhich colored irregularly with methylene-blue. It was decolorized by Gram's method, did not groAv on solid media, but did occasionally on bouillon. Czajkamski3 described motile bacilli, 2.5 to 5 micromillimeters in length, which did not color by Gram's method. They could not be cul- tivated on gelatin or agar, but greAV on glycerin-agar, bouillon, and blood-serum, and killed mice by producing septicemia. Neither of these observations has been advanced to any firmer position in the eti- ology of the disease. One attack of measles does not seem always to exhaust the soil, as in the other exanthemata: one, two, and in several cases families of children, including the parents, have had four attacks in successive years. 1 Jahrbuch. fur Kinderheilkunde, vol. xxiv. p. 94. 'l Berliner klinische Wochenschrift, 1892, S. 377. 3 Centralblatt fur Bacteriologie, vol. xviii. Nos. 17 and 18. 246 INFECTIOUS DISEASES. Clinical History.—The period of incubation is from seven to four- teen days, and in inoculated cases from seven to ten days. Catarrhal Stage.—The early symptoms are those of a cold Avith some fever. The child has marked coryza, watery eyes, sneezes, and has a dry, croupy cough. Frequently the symptoms are those of a catarrhal laryngitis and bronchitis, the fauces and tonsils being hyperemic, with abundant secretion; and, in addition, an examination of the eyelids reveals a conjunctivitis. The patient may be acutely ill, the tempera- ture rising several degrees in the evening, and falling slightly in the morning; the fever continues high until the rash is fully developed. The rash, consisting of one or more distinct papules, may be seen on the hard palate fully twenty-four hours before it appears on the face. The eruptive stage is very characteristic, and usually makes its appear- ance at the end of the fourth day. The neck, face, forehead, and trunk receive the eruption in the order of mention. The Avhole physi- ognomy of the child is so characteristically altered that a well-marked case may be diagnosticated at a glance. The face is flushed; the eyes are red and Avatery; a short, dry cough, frequently metallic in ring, is present; and the nose and cheeks are covered Avith crops of dusky-red papules surrounded by a zone of erythema which sharply contrasts with the normal skin betAveen the patches. The rash on the face is both dis- crete and confluent, or may be arranged at times in small crescents, and in the course of a day or two the whole trunk is invaded, but in a slighter degree. By the fifth, and seldom the sixth day, the eruption has reached its height, and commences to fade, first on the face and neck, then on the body and limbs, followed by a fine desquamation. By the seventh or eighth day the rash is nearly gone, leaving a blue, mottled stain over the body. The temperature, Avhich has reached 103° F. (39.4° C.) or even 105° F. (40.5° C), falls Avhen the rash is fully estab- lished—i. e. on the fifth or sixth day—Avhile the headache, the severe bronchial cough, and the general features subside with the fever. If the temperature continues high after the rash is out, we may look for some com- plication, such as severe bron- chitis, pneumonia, or acute ne- phritis (vide Fig. 23). Complications.—In some iniM fever. Eruptive fever. epidemics the character of the Eruption. \ , Fig. 23.—Temperature-curve of a case of measles. disease is Very Severe, being marked by high fever (105°- 106° F.—41.1° C), a dry, brown tongue, delirium and convulsions, and feeble heart-action, due to the intense hyperemia of all internal organs—lungs, brain, kidneys, etc. I have observed cases in Avhich the eruption was petechial. The main complications are presented by the lungs. The accompa- A A \ V I \ / V \ A A j v , A / l\ / ' \ A / V V V J / k V A k MEASLES. 247 nying bronchitis manifests a strong tendency to extend to the bronchioles, with resulting broncho-pneumonia. The extent and seriousness of this complication are largely dependent upon the degree of the previous de- bility. Lobar pneumonia is rarely met Avith. Catarrhal or membranous laryngitis is frequent in the pre-eruptive stage or as a sequela. Quite rarely edema of the glottis occurs. Oph- thalmia may occur in anemic and strumous children if strict eye-toilet is not enforced. Glandular involvement may take place in the cervical glands. Otitis is frequent during desquamation, suppuration taking place in the middle ear and the membrane being perforated. This may be avoided, hoAvever, by cleansing the post-nasal spaces frequently dur- ing desquamation. Cancrum oris and noma pudendi may also appear as complications of the disease. Diarrhea is frequent at the end of the eruptive period and as a sequela. The health of the child often remains impaired for a long time after an attack of the measles : it is at this period that Avhooping-cough, diph- theria, nephritis, and, later on, acute tuberculosis, may arise. Tuber- culosis Aery frequently gains entrance into the system from the existence of enlarged and cheesy bronchial and mediastinal glands. Nervous sequelae occur, but are very rare. They usually take the form of paral- ysis (hemiplegia, paraplegia, etc.). Diagnosis.—The disease is the most variable of all the exanthem- ata. Epidemics may be characterized by irregular forms of the disease, and the diagnosis of sporadic eases is often very difficult. We cannot recognize it by its dermal lesions, but by the prodromal symptoms, by the fall of temperature after the eruption is well out (differing here from scarlet fever), and by the character of the pulse, tongue, and desqua- mation. A feverish period of four days, associated without catarrhal symptoms of the eyes, nose, and upper air-passages, a few papules on the hard palate, followed Avithin twenty-four hours by a papular efflor- escence on the face, will differentiate the disease from variola, varicella, scarlet fever, and rubella. The accompanying table, from Rotch, gives the diagnosis between the eruptive diseases at a glance : Measles. \TARIOLA. 1 ,v A ARICELLA. Scarlet i R Fever. klbella. Incubation . . . 10 days. 12 da vs. 17 davs. 4 days. 21 days. Prodromata . . 3 days. 3 davs. A few hours. 2 davs. A few hours. Efflorescence . . Papules. Macules. Papules. Vesicles. Pustules. Vesicles. Erythema. Papules. Desquamation Purpuraceous. Large crusts. Small crusts. Lamellar. Complications and Eye and lung. Larvnx. Kidney, sequela? . . . Lungs. ear, and 1 heart. The mortality differs according to the surroundings of the patient. In healthy children under favorable environment the mortality is prac- tically nil, while in tuberculous and wasted children it is very large, this being especially due to complications and sequelae. Infants may be born with the rash on them.1 1 Hem. Med. Chronicle, May, 1890; Brit. Med. Journal, vol. i. p. 612, 1890. 248 INFECTIOUS DISEASES. Treatment.—We are unable to shorten the disease, though it is self-limited; nor is there any means of producing immunity from the disorder. The treatment is necessarily symptomatic ; hence our efforts should be directed to protecting the various organs that are most likely to become involved by complications, remembering at the same time that the nose, ears, eyes, and throat are involved during the feverish stage, and that the skin is in a very susceptible condition. The patient should be placed in a large dark, Avell-ventilated room, Avith a uniform temperature betAveen 68° and 70° F. (21.1° C). He should remain in bed until the temperature has been normal for one Aveek, and until the efflorescence has nearly faded and the desquamation is almost complete. The diet during the period of fever should be milk, bread, and light soups. Near the end of desquamation, if all symptoms are favorable, a more generous dietary may be allowed. The bronchial cough, which may be very troublesome during the first few days, can be readily relieved by some simple expectorant mix- ture, as— R>. Potassii citrat., §ss(16.0); Succi limonis, 3j (32.0); Tr. opii camph., 3ij (8.0); Syr. ipecac. 3ij (8.0) ; Syr. tolu., q. s. ad gij (64.0).—M. Sig. 3ss-3j every tAvo or three hours, according to the age and condition of the patient. This will serve as a fever mixture as Avell as an expectorant. For the coryza I have found that atomizing the nares with some oily vehicle (oleum petrolatum album, etc.) is advantageous. The skin is in a state of great irritation, and from the very com- mencement of the disease until the end of desquamation a daily Avarm bath (95° to 100° F.—35° to 37.7° C.) should be given the patient. The body should be carefully dried and cocoa-butter then thoroughly rubbed over the entire surface. The child should live in an equable temperature for at least three weeks, and longer if desquamation has not then ceased. For months he should be protected from sudden atmo- spheric changes in order to avoid general respiratory troubles. If he be predisposed to tuberculosis, cod-liver oil and creasote should be pre- scribed for a period of tAvo months or more. RUBELLA. (Rotheln; Rubeola Notha; German Measles; French Measles.) Definition.—An acute contagious disease. It has no prodromal stage, and is characterized by slight fever, coryza, and an efflorescence upon the skin. Etiology.—Rubella was not distinguished from measles and scarlet RUBELLA. 249 fever until about the middle of the eighteenth century. Since then con- siderable controversy has arisen at different times as to its nature, the theory being at one time strongly advanced that it Avas a combination of these two diseases, as many of the milder cases have symptoms com- mon to both. That there is a difference, hoAvever, in the character and course of these diseases has been proved beyond doubt to careful ob- servers by the facts that rubella occurs independently of either measles or scarlet fever; that contagion from this disease produces a similar dis- ease ; that one attack affords immunity to subsequent seizures (although those Avho have had other eruptive diseases are as liable as those that have not to contract this disease during an epidemic); and that its onset and clinical course are characteristic. Rubella is contagious, and may occur epidemically or sporadically. It is like measles and the other exanthemata in its being of undoubted microbic origin, although, as is the case Avith them, the specific organism has not been isolated. When that is accomplished the diagnosis will be more easy and certain. In hospitals or Avhere persons are croAvded and living under unhy- gienic circumstances the disease is very contagious and the epidemic Avill be quite general; but in family practice it is but slightly so, and the epidemics are limited, often being confined to a single household and attacking perhaps but one or tAvo of the family. As stated by EdAvards, it is spread by the cutaneous exhalations, breath, fomites, and clothing, and is probably contagious from incubation until far into con- valescence. Clinical History.—The incubation stage lasts from ten to twelve days, though this period may vary and the disease appear three or four days after exposure. On the other hand, cases have been reported in Avhich it Avas as long as three Aveeks. As a rule, the period of incuba- tion is longer perhaps than in measles. The stage of invasion covers from one to three days, but in mild cases the rash is very often the first indication we have that the child has developed an infectious disease. For a period of a feAv dayTs before the rash appears there will be noticed chilliness, pains in different parts of the body, a dull, heavy feeling, perhaps feverishness, accompanied by sore throat, enlarged ton- sils, coryza, and suffusion of the eyes, constriction over the chest, and a dry cough and bronchitis. Enlargement and induration of the cervical and other lymphatic glands, together with the sore throat, are common symptoms. Just before, or with the appearance of, the rash there is a rise in temperature to 99° or 100° F. (37.7° C), or in severe cases as high as 103° F. (39.4° C.) or more. Again, the invasion symptoms may be absent or so mild as to escape notice, and the first sign of infection be the appearance of a rash which first shows itself on the face and extends downward over the body. In some cases it does not folloAV the regular course, and is confined to one part of the body, and cases have been re- ported in which it only appeared on the roof of the mouth or on the tonsils. In other cases every part of the body, including the palms of the hands and the soles of the feet, may be covered. The eruption consists of papules, is multiform, confluent, and of a pale or rosy-red color. The patches do not assume any regular shape 250 INFECTIOI\S DISE. ISES. or form, and the skin betAveen them may become hyperemic and cause itching. The rash reaches its height on different parts of the body in succession, fading in one part Avhile appearing in another. Its duration is from tAvo to five days, and possibly longer in some cases. A slight desquamation usually occurs, and a slight pigmentation of broAvnish color after the rash fades is frequently noticed, disappearing after a few days. The temperature-curve is variable, but as a rule it remains between 100° F. (37.7° C.) and 102° F. (38.8° C.) while the eruption is present. As mentioned above, sore throat is nearly always present, with enlarged tonsils, a dry cough, and bronchitis. The glan- dular enlargement will also continue with the rash, and in severe cases the axillary and inguinal glands may become involved. The pulse varies Avith the temperature and respiration. Vomiting has been noticed as occurring during the eruption in severe cases. After a period varying from three days to a Aveek, Avith the disap- pearance of the rash, convalescence begins and the child rapidly regains its former health, and the Avhole course of the disease may be so mild that the patient cannot be persuaded to remain in bed. Complications.—The most common are affections of the respir- atory tract (pneumonia or severe bronchitis), and in some cases Ave have a gastro-intestinal catarrh of a troublesome character. Diphtheria or other contagious diseases may occur. A relapse is not uncommon, and may be as severe as the initial attack. Diagnosis.—Rubella may be distinguished from measles by its less severe onset and course, by the lighter color and more diffuse character of its rash, and by the irregular shape which the patches assume. The presence or absence of an epidemic is an important factor in the diag- nosis, and in cases occurring Avhen there is no epidemic the diagnosis betAveen this disease and measles of a mild type is difficult if not alto- gether impossible. From a well-marked case of scarlatina the diagnosis offers no diffi- culty. The absence of its initial vomiting, the straAvberry tongue, the character of the rash (Avhich in scarlet fever is erythematous), and the shorter duration and milder course of rubella, all help to render the diagnosis easy. Rubella. Erythema. Urticaria. Occurs first on the face. On the hands and feet. In wheals on arms and legs. Marked coryza present. Xo coryza. No coryza. At first no itching. Burning pain. Intense itching. Contagious. Not contagious. Not contagious. Microbic origin. Reflex origin. Gastric origin. The prognosis in uncomplicated cases is invariably good, but when the surroundings are unhygienic, or in cases in which the child has been delicate previously, it is more serious. Complications, especially pneu- monia or diphtheria, may prove fatal, and in some cases the mortality reported has been as high as 9 per cent. Treatment.—The treatment is simple and principally symptomatic. A mild cough-mixture, such as is recommended in measles for the bron- chitis, nutritious but easily digested food, and medicine to regulate the bowels when necessary, fulfil all the indications for internal medication. WHOOPING-CO UGH. 251 As in measles, cool sponging should be resorted to before and during the rash; and, Avhen the fever is high, a cool tub-bath, Avhere practicable, will be found to reduce the temperature, quiet the patient, and hasten the appearance of the eruption. During convalesence, if the child does not rapidly regain his appetite and strength, tonics, such as tincture of nux vomica and syrup of hydriodic acid, are indicated. The complications are to be treated as they arise, but the sponging should not be discontinued until the temperature reaches its normal level. WHOOPING-COUGH. (Pertussis; Tussis Convulsiva ; Keuchhusten.) Definition.—Whooping-cough is a highly contagious disease Avhich is characterized by a catarrhal inflammation of the respiratory tract, associated Avith a peculiar spasmodic cough, ending in a whooping inspiration. Pathology.—There is no lesion that can be considered characteris- tic of Avhooping-cough, and there is no distinct causal lesion around Avhich all the symptoms and complicating lesions are grouped. In the beginning there is catarrh of the naso-pharynx, and this may be the only lesion coincident Avith the development of the characteristic cough. In advancing cases this naso-pharyngeal catarrh becomes generalized by extension to the lachrymal ducts, the conjunctivae, the Eustachian tube and the middle ear, to the glottis, trachea, large and small bronchi, and the air-vesicles. The more decided pulmonary lesions—emphysema, pulmonary collapse, pulmonary congestion and edema, and broncho- pneumonia—are advanced pathologic conditions accompanying the later stages or more intense forms of the disease (W. W. Johnston). The post-mortem table does not give us much information as to the pathology except as to the sequences of the disease. In the early stages swelling and redness of the respiratory and digestive tracts will be found, together with a large quantity of viscid mucus. Etiology.—The disease occurs in epidemics, yet occasionally may appear sporadically. Pertussis seems to have a tendency to occur in epidemics every two years, although in large cities the disease is gener- ally endemic. There is no doubt that it should be classed with the spe- cific diseases, yet for a long time, like mumps, it hovered betAveen the specific and the catarrhal diseases for a home. Pertussis is directly contagious, though scarcely so in houses and school-rooms unless it be for those of a specially susceptible nature. It is possible, hoAvever, for the disease to be propagated in schools, though not to the same extent as measles and scarlet fever. It seems that a more decided and pro- longed personal contact must be made, as Avith members of a family, to ensure transmission. One attack practically protects the child, yet ex- ceptions to this rule may be found. The influence of the seasons does not seem to have any effect, though perhaps fall and spring are the more frequent periods ; the station in life, whether hygienic or unhygienic, does 252 INFECTIOUS DISEASES. not modify the disease. Bad ventilation, however, may propagate the disorder, and cause additional cases by favoring the increase of germs in the immediate surroundings. The previous condition of health, espe- cially of the respiratory mucous membrane, seems to possess some pre- disposing influence, weak, delicate children Avith an irritable digestive tube associated Avith a catarrhal state, more readily contracting Avhoop- ing-cough than those in robust health. There seems to be an intimate association between Avhooping-cough and measles, and it is a Avell-recognized fact that an epidemic of measles will be followed by Avhooping-cough in the same sufferers. This is pos- sibly due to the sensitive condition of the mucous membrane left by the measles, Avhich is so favorable to the lodgement of the germs of pertus- sis ; and the association of the tAvo diseases must be more than acci- dental. There exists a certain individual susceptibility to Avhooping- cough, as Avell as to other infectious diseases, and yet many children never contract them, though frequently exposed. Age exercises some influence on the development of Avhooping-cough, most cases occurring before the tenth year ; after this time the frequency of the disease rapidly diminishes. West states that one-half of all cases develop under three years, but he must have based his knoAvledge upon an experience in hospitals and children's homes, as the experience of others does not sustain his statement. The disease occurs in adults but rarely, this being due partly to the fact that so many have suffered from it while young, and partly because of a lessening of the suscepti- bility with advancing years. It occurs frequently before the first year, and Avhen it does it is the most fatal of all the diseases of childhood (Goodhart). The sexes are about equally divided as regards susceptibility; many writers, however, seem to think that girls are most liable. Ofttimes one close exposure in a susceptible child is sufficient to ensure an attack. The germs seem to be located at first in the secretions of the respiratory tract, and are thus disseminated through the air, the disease being most highly contagious, therefore, during the paroxysms of coughing. Good- hart reports a case in which a third party was the medium in conveying the disease from one child to another, thus suggesting a possibility of the contagion being ponderable. The highAvay of the contagion of whooping-cough into the system is evidently through the respiratory tract, though this fact has not yet been definitely settled. Published cases of pertussis in the neAv-born would even seem to make its transmission possible through the fetal circulation, yet the reports are neither numerous nor satisfactory, and cannot be depended upon. Nature and Bacteriology.—The true nature of whooping-cough has been thoroughly discussed, but is not, as yet, fully settled. Many writers claim it to be a simple bronchitis due to " cold " associated with a certain nerA'ous habit or mimicry. The cough is started by the bron- chial irritant, and soon tends to become a habit, thus returning again and again, until it dies out in the oblivion engendered by more healthy and regulated discharges of nervous energy (Goodhart). This theory fails to account for the nervous element and the decided paroxysmal character of the cough. It has been held that the disease is a lesion of WHOOPING-CO UGH. 253 either the pneumogastric, phrenic, sympathetic, or recurrent laryngeal nerves, or perhaps even of the medulla. If this ground is valid, it is simply a neurosis. Eustace Smith says it is caused by the pressure of the enlarged tracheal and bronchial glands upon the terminal filaments of the pneumogastric nerve. Whatever the direct cause, the highly contagious character of Avhooping-cough, its appearance in epidemics, its incubating period, and the possible immunity from subsequent at- tacks seem to prove beyond argument that it should be classed among purely infectious diseases. While this is generally accepted as true by the most recent inves- tigators, it is not a new idea, and science only repeats herself in this instance. Linnaeus (to quote Dr. J. P. C. Griffith in the American Text- book of Diseases of Children) attributes pertussis to the presence in the nose of the larvae of insects. Poulet discovered bacteria in the expired air of patients suffering Avith the disease. Letzerich found a micrococ- cus in the sputum Avhich he believed to be the specific germ, and claimed to have been able to produce the disease in animals by introducing the secretion into the trachea. Deichler-KurloAv claimed that there Avas always present in the sputum an organism of the nature of a protozoon which possessed ameboid motion. And, Avhile other investigators have repeatedly described various organisms as existing upon the respiratory mucous membrane, the researches of Afanassieff in 1887 have attracted the most attention. This observer isolated a short bacillus, Avhich he named the bacillus tussis convulsivce, and of which he Avas able to obtain pure cultures upon various media. Animals inoculated upon the respir- atory mucous membrane Avith these cultures exhibited some of the symptoms of the disease and developed catarrhal conditions of the respiratory tract, Avith a tendency to broncho-pneumonia. These ob- servations have been confirmed by others, and a toxin has also been reported as present in the urine of patients suffering Avith pertussis which is identical Avith that produced by Afanassieff's bacillus. Even though it be admitted as most probable that some micro-organism is the cause of the malady, it is by no means clear how the symptoms are pro- duced or where the principal seat of the infection arises. Some Avriters have claimed that the trigeminal nerve is in a sensitive state, and that it is the irritation of its terminal filaments by the infectious catarrhal pro- cess on the nasal mucous membrane which brings on the paroxysms by a reflex action. The careful investigations of Myer-Huni and of von Heroff, hoAvever, indicate that the catarrhal inflammation is most pro- nounced in the mucous membrane of the nose, larynx, and trachea doAvn to the bifurcation, but especially so on the posterior Avail of the larynx in the interarytenoid region, the so-called "cough region." Kuoloff believes that the parasite of whooping-cough is a specific micro- organism, a protozoon, and has found uniformly in the fresh sputa of patients ameboid organisms with spheric spores characterized by con- centric laminations.1 Undoubtedly Ave have in Avhooping-cough an in- fectious catarrhal process which affects the mucous membrane controlled by the superior laryngeal nerve, and the value in many cases of purely local treatment indicates that the abode of the germs is in this region, Avhence the poisonous products of their groAvth are absorbed. 1 Medical News, Nov. 9, 1896. 254 INFECTIOUS DISEASES. The nature of the " Avhoop " has been frequently discussed to show the nervous origin of the disease, yet the infantile larynx is capable of responding to purely neutral stimuli OAving to the flexible nature of the young cartilage. If we carry a young sleeping child from a warm room out in the cool air, the same characteristic Avhoop may be produced, showing that this reasoning cannot be depended upon. Clinical History.—The period of incubation varies from four to four- teen days according to the extent of catarrhal trouble in the child existing at the time. Goodhart gives several authenticated cases in which the in- cubation ended on the eighth day. In the beginning the symptoms are those of a slight bronchial cough, which has a tendency to be more pro- nounced during the night. After a feAv days the cough assumes an in- fluenzal character, and at the same time it gradually grows metallic in ring and shoAvs a laryngeal type. There is some fever present. This catarrhal or feverish stage lasts for a week or more, when it is followed by the paroxysmal stage, and. these stages are divisions of the symptoms Avorthy of recognition, as the treatment in the first is not applicable to the second. Many authorities speak of a third stage as one of decline, Avhich does not sharply occur, but includes the sequence of the disease. The catarrhal stage lasts about one Aveek or ten days, during which the child is ill at ease, is feverish, and has a hoarse, dry cough. The symp- toms may either be entirely laryngeal at first or bronchial, with a loss of appetite and broken rest at night. Auscultation at this time will reveal a few moist or dry r&les in the larger bronchial tubes, but there is very little secretion. The cough seems to be out of proportion to the physical signs. As the catarrhal stage proceeds the cough commences to indicate its character by becoming more noisy, increasing especially at night. The physiognomy of the child commences to change, the face is swollen, the eyes suffused and watery, the under lids SAvollen and pink in color. This is one of the most decisive indications of the trouble, and may be recognized by a careful observer a few days before the " whoop " begins which stamps the disease and ushers in the second stage. The commencement of the paroxysmal stage is quite different from the easy and more constant coughing of the first stage. If the child is in bed, the onset of a paroxysm is usually quite sudden, but if he is up and playing, there is a period of restlessness, a premonition of the coming storm similar to the aura in epilepsy, and the child may even have time to run to his mother or nurse before the paroxysm comes on. Usually the paroxysms are induced by a quick inspiration, as during drinking, eating, or crying. The first (expiratory) part is short, and followed by a short whoop; this is very quickly followed by a long series of short expiratory efforts and a second and longer whoop, Avhen the paroxysm may cease. In some cases a third and a fourth may quickly follow,' un- til the child is quite exhausted. The paroxysms, whether short or long, generally terminate with vomiting or eructation of a quantity of stringy mucus. Food is ejected, and in most cases a little blood is'mixed with the vomited mucus. At this stage of the disease, if at all severe, the countenance of the child is characteristic, and so much so that a mistake is no longer pos- sible: the features are swollen, puffy, and dusky in color; the eves are injected, the lids swollen and pink ; the skin livid, due to a minute WHOOPING-CO UGH. 255 ecchymosis of the smaller capillaries. In many cases there will be ex- travasation of blood beneath the conjunctiva, due to the violence of the congestive cough. If the chest be examined at this stage, it Avill tell but little, provided Ave have no broncho-pneumonia, though a feAv moist rales may be found scattered through the larger tubes. The spasmodic stage of Avhooping-cough has no set duration and varies frequently in intensity. In severe cases it may consist of tAventy to forty paroxysms during the twenty-four 'hours. Some spasmodic coughs are not accompanied by a whoop, and the absence of this sign may be noted in very young children, as Avell as in those that are very ill Avith broncho-pneumonia. Some children vomit after a coughing spell Avithout the Avhoop. It is frequently observed that long after the spasmodic spell has come to an end the paroxysms return again and again, perhaps years after- ward, Avith almost characteristic features, evidently acting under the stimulus of some perfectly neutral catarrh. Complications.—In severe cases the complications are likely to be numerous. Epistaxis often occurs in children; hemoptysis when vomiting is fre- quent ; ulceration of the frenum linguae in violent coughing; convulsions in vigorous children; and broncho-pneumonia, pleurisy, pericarditis, laryngitis, and hernia in severe, prolonged coughing. Convulsions and broncho-pneumonia are alarming; in young children a profound stupor takes the place of the convulsions, and the latter then become of graver significance. Sequelae.—Acute nephritis frequently occurs, and is as severe as that found in scarlet fever, although the condition has not received the recognition it should from the authorities. In a series of over 200 cases I have found the kidneys affected in 20 per cent. Emaciation is a very important sequence of pertussis. All the viscera are liable to fatty de- generation, and nutritional changes open the door to cheesy, glandular alterations, and eventually to a secondary tuberculosis. Atelectasis, by curtailing lung-space, frequently7 brings about a general collapse, and this condition very frequently explains the flattened chest found in young adults. Emaciation may also be due to mucous disease, a chronic gastro-intestinal catarrh of long standing. Prognosis.—Associated Avith its complications, pertussis is a very fatal disease, especially in children under tAvo years of age. Dolan re- gards it as third in rank among the fatal diseases of England, Avhere the death-rate per million is five thousand annually. The deaths occur chiefly among children of the poor and in bottle-fed infants. Goodhart regards whooping-cough as the most fatal of all the dis- eases in children under one year of age. He places the mortality as high as 12 per cent., and thinks that this is not too high; his state- ment, hoAvever, is hardly warranted, as he includes the deaths from the many sequelae which we cannot estimate. Ashby and Wright place the mortality at 7.6 per cent. Diagnosis.—Young infants usually do not "whoop," but cough spasmodically. Children with pleurisy or pneumonia do not Avhoop, yet Ave diagnose Avhooping-cough by the preceding catarrhal fever. From influenza in its early stages it is most difficult to differentiate the 256 INFECTIOUS DISEASES. affection. The pink under eyelid has to me been the most certain sign. When the Avhoop appears and during the existence of an epidemic, hoA\r- ever, the diagnosis may be rendered certain. The diagnostic point prior to the Avhooping stage, enunciated by Eustace Smith (viz. " If a child be made to bend back the head, so that his face becomes almost horizontal, and the eyes look straight upAvard at the ceiling above, a venous hum, varying in intensity according to the size and position of the diseased glands, is heard Avith the stetho- scope placed upon the upper bone of the sternum. As the chin is now sloAvly depressed the hum becomes less loudly audible, and ceases shortly before the head reaches its ordinary position ") has not been very satisfactory. It is true that we do recognize the hum caused by the enlarged bronchial gland, but it occurs long after other symptoms are manifest, and thus its importance is much lessened. I have for several years been able to place considerable value on the peculiar puffiness of the mucous membrane of the eyes and the swollen or edematous condition of the whole face and almost dusky color. This condition may exist for days before the catarrhal symptoms have ex- tended throughout the respiratory mucous membrane. The cough at this stage may not be at all suggestive: it may be, in fact, purely bronchial. This symptom of fulness about the eyes, which is quite as constant as in measles, Avould in fact suggest that disease, and must be differen- tiated from it. As we are able to diagnose measles by its appearance first on the hard palate, so I contend we may diagnose Avhooping-cough in its earliest stage by the characteristic SAvollen condition of the eyes and face. I insist upon this factor as of the greatest importance, as its recognition will enable us to institute specific treatment early, Avhen the disease is yet local and may be brought more speedily under control. Treatment.—The gravity of pertussis is scarcely appreciated either by the general physician or the public, and there is more crim- inal neglect in connection Avith whooping-cough than with any other disease. Medicinal treatment is exceedingly unsatisfactory, although the therapeutic measures are boundless: just as in phthisis and diph- theria, they cover the Avhole domain of the Pharmacopeia, and Ave have as yet found no specific. The remedies most in use are the antispas- modics and the germicides. Whooping-cough has a striking parallel in diphtheria, in that it has in its early stages a local manifestation in its strong tendency to fasten itself upon the throat. How long this period exists we know to a certainty no more than Ave know just how long diphtheria is purely a local throat-poison; yet there is undoubtedly a period in whooping- cough, as there is in diphtheria, long or short, in which the virus—if it could be recognized—could be destroyed and the disease terminated. To abort cases thus within two weeks is not unusual, and this explains the number of reported cures made by germicidal remedies. I have notes of 2 recent cases in which the characteristic whoop com- menced at once with the general catarrhal symptoms, and was cut short by a hydrogen-peroxid gargle. I think these 2 cases illustrate very clearly the fact that the germs of the disease will locate on the mucous WHOOPING-CO UGH. 257 membrane of the respiratory passages and bring about a nerve-discharge which ends in the characteristic Avhoop. In my treatment of this dis- ease I find the greatest necessity of recognizing the nature of the trouble early in the catarrhal stage. If I can satisfy myself that I am dealing with a case of early pertussis, my methods of procedure are much differ- ent from Avhat they would be if the case were Avell advanced. We must remember that the tAvo stages are not sharply defined, and that many cases entirely lack the catarrhal stage, just as there are many cases that do not whoop. Pertussis, as Ave all know, is a notoriously unsatisfactory disease to manage, and if we put our Avhole confidence on a single remedy, we are likely to meet with keen disappointment. The drugs I have found most efficient in the catarrhal stage have been hydrogen peroxid in sterilizing the naso-pharynx, and asafetida, occasionally used for the paroxysms. Belladonna is to a high degree beneficial in young children. I push this drug until I get the full toxic effects, Avhen I am generally reAvarded with a diminution of the suggestive characteristics of the cough. To be more explicit, I will detail the methods of procedure in a fam- ily in Avhich I have instituted my plan of thorough treatment: A child of four years attending kindergarten was brought to me Avith a suspicious cough. The history was given of an exposure of over tAvo Aveeks prior. The child had coughed for a few days, more at night than in the daytime; was feverish during the evenings; shoAved slightly SAvollen eyelids, thus suggesting the nature of the impending trouble. I ordered hydrogen peroxid and pure glycerin in equal parts, which were Avell diluted and thoroughly sprayed through the naso-pharynx every four hours. The diet was light and digestible; out-door life Avas encouraged, except on windy days. All excitement Avas avoided, so as to avoid the precipita- tion of any additional paroxysms. At night the child was placed in a large, Avell-ventilated room, and over its cot was erected a mosquito net- ting, so as to prevent any unusual draught—a procedure which I have found highly beneficial, as it materially lessens the number of the noc- turnal paroxysms. When the cough Avas fully established and was accompanied by eructations of stringy mucus, I commenced the exhibi- tion of the mixture of asafetida J dram (2.0) every tAvo hours. The record of the paroxysmal stage was as folloAvs: The first week averaged six coughing spells per day; the second week averaged ten per day; the third week, four paroxysms; and the fourth and fifth Aveeks aver- aged about two paroxysms during the tAventy-four hours. When the younger brother, but eight weeks old, commenced to show evidences of the disease, I first used hydrogen peroxid as in the older brother, and immediately followed it Avith asafetida. This case continued scarcely four weeks when all symptoms subsided. Mistura asafcetida, however, is at times disappointing, even in younger children. My second choice is the tincture of belladonna, exhibited in doses of one drop for every month of the child's life, the doses being rapidly increased until toxic effects are reached. Then I gradually in- crease the amount as tolerance of the drug seems to be established. In very young children I have obtained good results from the use of a freshly-prepared belladonna plaster placed between the scapulae, and the physiologic action of the drug seems thus to be more constantly 17 258 INFECTIOUS DISEASES. maintained. The plaster may be changed at the end of one Aveek. In a number of very troublesome cases in young children I have gained a decided advantage by an application of a 2 per cent, cocain solution directly to the naso-pharynx. This treatment, hoAvever, does not pre- clude the use of hydrogen peroxid, which should be continued through- out the catarrhal stage. Bromoform Avas resorted to in fully 20 per cent, of my cases, and was a keen disappointment; it seemed merely to stupefy the patient and did not apparently shorten the progress of the disease. The coal- tar products, pushed to the toxic limit, modified the disease but slightly. Belladonna and antipyrin in combination gave better results than either alone. Quinin, chloral, creasote, carbolic acid, I found to be of little practical use, owing largely to difficulty in administration. This out- line of the drug-treatment in whooping-cough has reference solely to the catarrhal and paroxysmal stages of the disease. As important ad- juncts to the management of the disorder careful hygiene must be en- forced, and a diet of the simplest character and a uniformly quiet life maintained. Throughout the whole course of the disease out-door life, as far as possible, should be encouraged, and if convenient a sojourn at the sea-shore will shorten the progress of the trouble and limit to a great extent the number of sequelae. PAROTITIS. (Mumps; Parotiditis; Epidemic Parotitis.) Definition.—An acute contagious disease, characterized by an in- flammation and swelling of the parotid gland, and occasionally by an involvement of the salivary glands, the testicles, and in the female the mammae. Pathology.—Opportunities for post-mortem examinations are rare, leaving in some doubt the pathologic course of the disease; but it probably begins as a catarrhal inflammation of the ducts, involving the periglandular connective tissue. The inflammation is seldom severe enough or of such a nature as to produce suppuration. Etiology.—Mumps is undoubtedly a constitutional or blood-disease with local manifestations. "It is a question," Goodhart says, "with mumps whether this disease shall be placed with the specific diseases or with those affecting the parts or organs with which the symptoms more particularly concern themselves." The disease is no doubt of microbic origin, but the specific organism has not yet been isolated, and, while there has been some reason to be- lieve that it is a bacillus, this has not been proved and is still doubtful. It is highly contagious, and at times, usually during the sprincr and autumn, becomes epidemic. It is communicated principally by the breath and exhalations, the greatest source of contagion being the salivary secretions. It may, however, be carried by a third person or by fomites, and is most liable to be communicated during the berin- PAROTITIS. 259 ning of the attack, although the contagiousness continues until after the subsidence of the febrile symptoms. It occurs mostly among children and young adults, infants and old persons being rarely affected, Avhile males are more liable than females. One attack usually gives immunity from a second attack in the same gland. Clinical History.—The average period of incubation is fourteen davs, but it may develop as early as ten or as late as twenty days after exposure. The invasion is marked by languor and a temperature from 101° to 103° F. (3S.3°-39.4° C), with possible headache and vomit- ing; the patient complains of pain at the angle of the jaw, and this is greatly increased if an acid (such as vinegar) is swalloAved. With these symptoms is noticed a pyriform swelling of the parotid glands, the one on the left side usually appearing first, and the other one soon following. Occasionally cases are seen in which but one gland is involved, or the SAvelling may begin in both at the same time. This increases gradually until some time betAveen the third and sixth days, inArolving the other salivary glands and causing marked disfigurement; the swelling fills the depression beneath the ear and extends to the cheek and neck, the most prominent part being just beloAv and pressing outward the lobe of the ear. .The salivary secretions are generally much increased, though there may be the opposite condition of marked dryness of the mouth. When the swelling has reached its height, pres- sure on the adjacent tissues causes a disagreeable sensation of tension, and cheAving, SAvalloAving, and even speaking, are at times painful and difficult. The skin over the affected part may be of a pale or of a dull- red color. Ringing in the ears and a dulling of the hearing is common. The nervous system may be affected, causing headache and delirium, or a low typhoid state may be present. The duration is about one Aveek (six to ten days), after which time the SAvelling subsides, and by the tenth or twelfth day entirely disappears. Diagnosis.—The diagnosis is easy, the nature and position of the swelling and the course of the disease being characteristic, Avhile the fact that the tonsils are seldom involved prevents a diagnosis of acute tonsillitis. Occasionally, hoAvever, in the course of septic infection or after operations, or OAving to the extension of inflammation along the duct from the mouth, the parotid gland becomes the seat of an acute inflam- mation at first hardly distinguishable from mumps. The existence of a possible source of infection, and the fact that the gland under these circumstances usually undergoes suppuration, should lead to the recog- nition of the true nature of the case. Complications and Sequelae.—Mumps, as a rule, runs a mild course Avithout any serious symptoms, but occasionally complications arise that tax the skill of the physician to the uttermost. The most common of these are orchitis in the male, Avhich may be folloAved by atrophy of the testicle; and mastitis, ovaritis, or vulvo-vaginitis in the female, especially after puberty. These complications appear after the subsidence of the swelling of the glands of the neck, only occasionally developing Avhile the glands are still affected, though cases have been reported in which the disease first manifested itself by inArohTement of the sexual organs. This complication lengthens the course of the attack 260 INFECTIOUS DISEASES. and increases the constitutional symptoms, but the rule is complete re- covery. Otitis media sometimes occurs, and a lesion in the auditory nerve, with more or less deafness (Avhich, unfortunately, may be perma- nent), has been observed. Meningitis, with active brain-symptoms, facial paralysis, convulsions, albuminuria, and arthritis, have all been noted in certain cases. Treatment.—The patient should be kept in a well-ventilated room of even temperature, and in bed if the fever is at all severe, and should be isolated from those Avho have not had the disease. Either hot or cold applications to the SAvelling will often give relief, and support to the SAvollen gland by means of cotton and a bandage is very comforting. Saline laxatives may be given, and aconite or some simple fever-mixture at the beginning of the attack is usually indicated. These simple measures are all that are required in an ordinary case, Avhile complica- tions or unusual conditions must be treated as they arise. TUBERCULOSIS. Definition.—A chronic (less frequently acute) infectious disease, caused by the bacillus tuberculosis. This organism produces specific lesions, taking the form either of separate nodular masses or diffuse groAvths, infiltrating the tissues, while aggregations of these element- ary tubercles give rise to large tubercular masses. Tubercles undergo caseation and sclerosis, followed in turn by ulceration (in consequence of secondary pyogenic infection), or, more rarely, calcification. Historic Note.—Prior to the discovery, in the early part of the nineteenth century, by Bayle and Laennec, of the tuberculous new growth as a distinctive body, this disease had been studied chiefly from a clinical point of view. At this early period the disease Avas believed to consist chiefly of a suppurative process, and in its observation the physician was unaided by auscultation. Later, the tubercle Avas recog- nized as a small rounded nodule without any special histologic cha- racteristics. Villemin in 1865 performed his epoch-making experi- ments, and the tubercle was no longer distinguished by its anatomic characters alone. Though the theory of the infectious nature of tuberculosis had been previously advanced by Buehl and others, it was first clearly demonstrated by Villemin's beautiful inoculation- experiments upon rabbits and guinea-pigs Avith particles of tubercular and cheesy substances, producing the characteristic lesions of tubercu- losis. It then remained for Koch to discover (in 1881) the specific cause of the most important of all human ills—the tubercle bacillus. So soon as the specificity of the disease Avas definitely established it became clear that the associated inflammatory processes, that were for- merly believed to be primary and to hold first place, were secondary. The important role, however, played by the latter, particularly in the production of the general features of the disease, will be shown here- after. Geographic Distribution.—Tuberculosis prevails in almost every TUBERCULOSIS. 261 quarter of the globe, but is more prevalent in certain latitudes than in others. Thus, in general terms, it may be said to prevail less exten- sively in warm than in cold countries, though it lessens in frequency as we approach either pole. Local conditions, however, exercise a more decisive influence in engendering predisposition than mere geographic position. It is of quite frequent occurrence in all densely populated municipalities, and more especially in the overcroAvded sections of the latter; this fact explains Avhy the inhabitants of cities of the North are but little less spared than those of the cities of the South. On the other hand, residents of mountainous countries, owing to the purity of the atmosphere and the elevation, are rarely among its victims. The influ- ence of race in predisposing to tuberculosis should also be mentioned here, the South Sea Islanders, the Indians, and the colored race being peculiarly liable. General Pathology of Tubercular I,esions.—Distribution of the Lesions in the Body.—Tuberculous neAv growths elect, most fre- quently, the lung, and Avhen the disease occurs in the adult this organ is almost invariably implicated. Next folloAV the larynx, intestines, peritoneum, urogenital organs, and the brain. The other chief viscera of the body (spleen, liver, heart, etc., particularly the latter) are less fre- quently the seat of tuberculosis. In children the lesions exhibit a dif- ferent distribution, the favorite seats being the lymph-glands, intestines, bones, and joints. In them the distribution corresponds pretty closely, if we except the bronchial and mesenteric glands, to that of surgical tuberculosis. The Elementary (Nodular) Tubercle.—This may be developed in any tissue to which the tubercle bacillus has found its Avay, and the presence of the bacillus is its sole distinguishing feature, since the self-same bodies are generated by other micro-organisms—e. g. certain of the worms (eggs of the distoma), actinomyces, aspergillus glaucus, and even as a result of irritation by certain foreign bodies (podophyllum). Various forms of pseudo-tuberculosis have been described, but all are due to bac- teria that differ from the bacillus tuberculosis. Mallassez and Vignal described a form produced by a micrococcus occurring in a zobglea, and this observation Avas later confirmed by Nocard, Eberth, and others. Charrin and Rogers have described still another form, in Avhich they found bacilli about 1/7. long, actively motile, and groAving freely upon ordinary media, but not groAving upon glycerin and agar, and not lique- fying gelatin. The various stages in the development of a tubercle are— (a) Proliferation of the fixed-tissue elements (connective tissue, en- dothelium of the capillaries, etc.) of the part infected, due to the local, specific irritant action of the bacilli. These anatomic products are transformed into epithelioid and giant cells. The epithelioid cells assume various shapes, chiefly rounded and polygonal; they have vesic- ular nuclei, and soon shoAV tubercle-bacilli in their interiors. A certain proportion of the epithelioid cells, as the result of increase in their size and a repeated division of their nuclei, become giant cells. The latter occupy the center of the tubercle, and also contain bacilli, the number of giant cells and of the bacilli being largely reciprocal. Thus, the giant cells are numerous in tubercular lymph-glands, joints, etc., in 262 INFECTIO US DISEASES. which the bacilli are relatively feAv; on the other hand, they are scanty in miliary tubercles, in Avhich the bacilli are numerous—tAvo facts that lend support to the view held by many authors that giant cells display phagocytic action. (ft) About the site of infection a diapedesis of leukocytes occurs in the nature of a defensive inflammatory process. At first the leukocytes are of the polynuclear variety and are quickly destroyed; but later mononuclear leukocytes (lymphocytes) appear. These latter resist the action of the bacilli, and I think their true function is a phagocytic one. The various forms of cells described are connected and sur- rounded by a reticular stroma "formed by the fibrillation and rarefac- tion of the connective-tissue matrix " (Baumgarten). The fully-developed tubercles are small, nodular bodies Avhose diam- eters range from -^ to 2 or 3 mm. At first they are almost transparent, but soon lose this quality in consequence of the further changes de- scribed beloAv. They are non-vascular bodies, and invariably undergo (a) caseation and (b) sclerosis. (a) Caseation.—This implies "coagulation-necrosis"—a destructive process proceeding from the center tOAvard the periphery of the tubercle, and the result of the local action of the bacilli or their chemical secretions. The cells are thus transformed into a uniformly yellow- ish-gray, structureless matter. When the foci are numerous and close- set, fusion may occur, with the production of larger or smaller homo- geneous masses (cheesy pneumonia). The latter may soften, resulting in the formation of cavities: this is due, usually, to secondary pyogenic infection, causing ulceration. Less frequently the cheesy masses under- go calcification or become encapsulated. Such masses may remain in- definitely and are practically harmless. (b) Sclerosis.—Preceding and during the time that cell-destruction is going on in the center of the tubercles the protective forces of nature are asserting themselves, though too often Avithout avail. In the first place, hyaline transformation, with conversion of the cellular elements into fibrous tissue, occurs. Frequently, noAv, the center of the tubercle is caseous and contains bacilli, while the peripheral parts are quite hard and do not contain bacilli. The fibroid change may pervade the entire tubercle. Again, the fibroid element in the tissues immediately sur- rounding the tubercle may be greatly increased and form neAV connective tissue, and this process be folloAved by secondary contraction, convert- ing the tubercle into a firm fibrous nodule. The fibroid change in its completest development is observed in tuberculosis of serous membranes, especially of the peritoneum. Whether in any given case the destructive forces, on the one hand, or the conservative, on the other, shall come off victorious depends upon several conditions. Though natural immunity is probably unknown, yet under certain circumstances and at certain times tissue-soils may successfully resist bacillary invasion. The bacilli of tuberculosis doubt- less produce special toxins (vide Etiology), and hence there is a reason- able probability that the tissues and liquids of the body manufacture an antitoxin. The latter agent may therefore constitute one of Nature's chief means of defence. There are also soils that are moderately recep- tive, and these may become infected; but sooner or later the destruction TUBERCULOSIS. 263 of the invading parasite may be determined by altered soil-conditions— changes induced by Nature's benign and curative efforts. It is prob- able that in such instances the favorable issue is sometimes to be ascribed to the fact that relatively few bacilli find lodgement, so that the average phagocytic activity and other protective processes suffice. But Avhen the bacilli fall upon a soil that is altogether favorable to their groAvth their pernicious influence cannot be arrested, since the usual means that turn the scales in favor of a cure are Avanting. We are now prepared to understand the coarser appearances pre- sented by tuberculous lesions, especially of the lungs. Fusion of mi- nute centers of infection or of miliary tubercles results in the formation of larger nodules or areas, which lead by a process of local extension to diffuse tuberculous infiltration (gray infiltration of Laennec). An entire lobe may become similarly involved (tuberculous pneumonia), and " there may also be a diffuse infiltration and caseation Avithout any special foci, a widespread tuberculous pneumonia induced by the bacilli " (Osier). The term " gray infiltration " is misleading from a pathologic point of vieAv, since the morbid changes differ in no essential manner from those described as occurring in the miliary or nodular tubercle. More- over, the latter also presents a grayish appearance. The apparent dif- ference between a miliary tubercle and diffuse tubercular infiltration lies in the fact that the latter displays a greater tendency to spread by direct extension. Associated Inflammatory Processes.—The tubercle bacilli excite asso- ciated inflammatory processes in the organs affected, and if the tubercu- lous lesions run a sIoav course, a limited Avail of true fibroid induration circumscribes the area involved. By means of this induration the nat- ural protective forces, either temporarily or permanently, check the progress of the local lesions, and the change is strictly analogous to the sclerosis that takes place in the peripheral parts of the elementary tubercle or immediately surrounding the latter, as in tuberculosis of serous membranes. On the other hand, Avhen the tuberculous infiltra- tion is less tardily developed the secondary inflammatory processes may show changes similar to those of catarrhal or croupous pneumonia. It is a noteAvorthy fact that the constitutional features in tuberculosis are not so much dependent upon the primary as upon a secondary infection, chiefly Avith the streptococci. The latter are responsible for the serious septic element in the various varieties of tuberculosis (especially pul- monary), and some contend that the tubercle bacilli can excite suppura- tion directly. The pus, however, in this instance does not contain the streptococci, and is sterile. Mixed infection is, I believe, the rule (vide Pathology of Pulmonary Tuberculosis). Etiology.—The Specific Cause and its Physical Characteristics.—In 1881, Koch discovered the tubercle bacillus, Avhich is the sole bearer of the disease. This bacillus is rod-shaped, straight or someAvhat bent, and slender, its length equalling about one-third or one-half of the diameter of a red blood-corpuscle (Fig. 24). Its extremities are slightly rounded, it is non-motile, and on the interior of the bacilli small colorless spots can be observed on microscopic examination; these clear spaces in the bacilli represent plasmolysis, and have nothing to do with spore-forma- tion. Spores undoubtedly do occur, but have not yet been demonstrated. 264 INFECT 10 US D1SE. 1 SES. Fig. 24.—Tubercle bacillus in sputum (Frankel and Pfeiffer). When stained the bacilli have a someAvhat beaded appearance, this bein» probably due to slight bulgings caused by the presence of spores. The tubercle bacillus is one of the few varieties of bacteria that retain the anil in dye after washings Avith acids. Biology.—The bacilli can be groAvn on culture-media, but not Avithout difficulty, since they demand an even temper- ature between 98° and 100° F. (37.7° C), or that of the hu- man body. The best soil is blood-serum previously coag- ulated by heating. Over the latter may be gently rubbed tuberculous tissue, wdiich is then allowed to remain on the surface. The growth of the bacilli requires about two weeks, when colonies appear as dry, grayish-white or gray- ish-broAvn, thin scales or masses on the surface of the culture-medium. From such cultures others may be groAvn on glycerin-agar or on the potato. Inoculations into the guinea-pig and other animals are succeeded in two or three weeks by the appearance of elementary tubercles—first, locally, and then in other organs of the body. Chemical Products.—The growth of the bacilli is probably attended by the formation of secretory products. Thus an albuminoid substance has been separated, and this when injected into the body of an animal produces fever, lasting a day or two. The albuminoid sepa- rated for cultures of tubercle bacilli is a nuclear proteid, and not a spe- cific toxin. There have also been isolated a ptomain and, some contend, an extract Avhich displays pyogenic properties (Koch's tuberculin). The constitutional features of the disease may be ascribed, in part, to the circulation of these poisons in the blood, but they are probably infinitely less important in this direction than the products of suppuration. Sources of the Bacilli.—The chief source of the bacilli is the sputum of tuberculous patients. It has been shoAvn that in the advanced stage of pulmonary tuberculosis several billions of bacilli are expectorated daily (Nuttall), and the desiccated sputum is wafted into the atmosphere in the form of dust-like particles containing innumerable bacilli. When the facts that tuberculosis is almost universally prevalent, and that each patient throAvs off countless millions of bacilli are remembered, it is clear that abundant opportunity is everywhere presented for infection, or, in other words, that secondary sources of infection are numerous and varied. Distribution of the Bacilli.—The tubercle bacillus is exceedingly tenacious of life, this being its chief distinguishing characteristic. Hence it is found in a viable condition, both (a) inside and (b) out- side of the body. TUBERCULOSIS. 265 (a) Inside of the Body.—As before stated, the number of bacilli found in tuberculous groAvths varies Avithin Avide extremes. In general terms, it may be said that the more rapidly the process advances the greater the number of parasites present. It must not be forgotten, hoAvever, that the activity of the tuberculous processes is intimately con- nected Avith the degree of resistance offered by the tissues. A chronic tuberculous focus may establish a fistulous connection with a vein or a lymph-vessel, and thus scatter the bacilli to the remotest parts of the body; and in such instances (as the direct effect of the original number of bacilli present) a chronic is quickly converted into an acute form of tuberculosis. The bacilli may also be found in the bodies of non- tuberculous persons. Strauss1 demonstrated virulent bacilli within the nasal cavities of healthy persons whose positions necessitated their asso- ciation Avith, and frequent presence in rooms occupied by, tuberculous patients. (b) The Bacilli Outside of the Body.—Tubercle bacilli can maintain their existence almost indefinitely7 outside the body. On the other hand, they probably do not develop or multiply under the usual external influ- ences, though, as I have said, their vitality is extraordinary. Their destruction cannot be effected by freezing nor by desiccation, and they survive for months in water. Their power to resist chemical agents (nitric acid, etc.) is also very great, but they may be destroyed by boil- ing for four or five minutes or by exposure to the direct solar rays. Tubercle bacilli are undoubtedly present in all inhabited places, and it is obvious that they may be conveyed for long distances by means of water, milk, and in many other Avays. The sputum dries and flies into the atmosphere in the form of dust, which not only floats in this medium, but also settles upon articles of furniture, the floor, the walls of living-rooms, hospital wrards, draperies, clothing, bed-linen, etc. ; and from these resting-places it may be con- veyed back into the atmosphere. It has been shown, experimentally, that the dust obtained from the Avails or from the air of rooms and hos- pital Avards occupied by tuberculous patients is frequently, though not invariably, infected. It is the in-door atmosphere, laden Avith bacilli, that is especially7 liable to excite tuberculosis Avhen breathed more or less constantly. In places only rarely frequented by consumptives the dust is usually free from virulent bacilli. Modes of Infection.—(1) Inhalation of the Bacilli.—In the vast ma- jority of instances the bacilli are inhaled Avith the inspired air, but it is important to recollect that the exhaled breath of tuberculous patients is not infectious. It is the dried sputa floating in the atmosphere that are pathogenic ; and occasionally, Avhen infection occurs in this manner, the bacilli may attack first the upper respiratory passages, producing primary tuberculosis of the larynx and nose. Almost invariably, how- ever, primary infection takes place in the smaller bronchi, or less fre- quently in the lungs ; and that these are the points of election is shown by the fact that healed tuberculous lesions are often met with on post- mortem examination in the bronchi and lungs of persons Avho died of other diseases. Under similar circumstances the bronchial glands may be found to present tuberculous lesions. Thus, in 8 out of 30 cases in 1 Munchener medicinische Wochenschrift, Munich. 266 INFECTIOUS DISEASES. which both old and recent tuberculous lesions Avere absent II. P. Loomis found the bronchial glands infective to rabbits. It is obvious that the bacilli which cause fresh cases come indirectly from other tuberculous subjects, and it has long been supposed that tuberculosis is a contagious affection; unlike small-pox, scarlatina, and other acute contagious diseases, hoAvever, tuberculosis is not trans- mitted by a single contact with a person ill of the disease. On the other hand,.Flick and others have shoAvn that persons Avho come into contact Avith, or Avho live in close proximity to, affected persons fre- quently fall victims to the same affection. (" The latter is as truly con- tagious as the former, differing only in degree.") We can safely say, therefore, that, though less liable to be transferred by contact than certain other affections, yet on account of the fact that tuberculosis usually pur- sues a chronic course there is every opportunity for prolonged or re- peated contact Avith resulting infection. Flick's elaborate topographic study of phthisis in the Fifth Ward of the city of Philadelphia, extending over a period of twenty-five years, shoAvs conclusively that consumption obeys the laAvs of infectious and contagious diseases. His researches furnish incontestable proof that the tuberculous virus is limited to centers, and that the latter owe their existence to previous cases in the same house or locality; that a house Avhich has had a case of consumption Avill probably have others Avithin a few years, and may have a very large number of cases in rapid succes- sion ; and that approximate houses are considerably exposed to the con- tagion. The contagious theory of tuberculosis gains support from the fact that husbands have been frequently observed to contract the disease from their wives, and the latter, since they are more constantly con- fined in the house, to become infected yet more frequently from the former. Weber has observed the case of a tuberculous husband Avho lost four wives in succession, another Avho lost three, and four others Avho lost two each. In like manner, the statistical studies of Cornet, Niven, Baer, and others shoAv that the disease spreads through factories, prisons, cloisters, and even among the physicians, nurses, and attend- ants in hospitals for the reception of tuberculous patients, producing a mortality-rate from this disease ranging from 45 to 75 per cent. Sev- enty-three per cent, of nurses up to the age of fifty die of tuberculosis (Whittaker). It is obvious that those Avho are engaged in making the beds, dusting and sweeping the rooms of patients, are most exposed; and on the other hand, better hygienic living among these classes of individuals, and improved hygienic arrangements in prisons, institutions, and hospitals, have been found to reduce, decidedly, the death-rate from this dread affection. This result is to be accounted for by the following facts : (a) There is thus established a greater tissue-resistance to the bacil- lus tuberculosis on the part of the persons exposed; and (b) The germs are thus to a greater extent disseminated. Obviously, then, in institutions in which the proper sanitary precautions are used there may be few if any instances of communication by contagion; and from the records of the latter, facts opposed to the contagious theory of the disease can readily be furnished. (2) Infection by Swallowing.—(a) That the milk of tuberculous ani- TUBERCULOSIS. 267 mals contains the bacillus, and that the use of contaminated milk may infect the human subject, are well-established facts.1 Gerlach and Klebs long since observed the occurrence of the disease in animals fed with milk from cows affected with the so-called "pearl disease." It is not even necessary that the animal infected should have tuberculous mammitis (Ernst), though some are of contrary opinion (Flick, Sidney Martin, and others). The exact frequency of this mode of infection is not knoAvn, but there is some little clinical evidence to support it. Infected animals, especially coavs and pigs, that suckle their young very frequently trans- mit the disease to the latter, the infection usually resulting in intestinal and mesenteric tuberculosis. Hence it is obvious that the bacillus of tuberculosis is, in this instance, SAvalloAved and finds lodgement in the prima? vice. Bang has even shoAvn that butter made from the milk of tuber- culous cows may be infectious. It is entirely analogous in the human race, bovine and human tuberculosis being one and the same affection; and hence the tuberculous mother is likely to transmit the disease to her suckling offspring. This explains, adequately, Avhy abdominal tuberculosis is frequent in children. (b) The meat of a tuberculous animal may rarely be infectious, but the bulk of experimental evidence Avould seem to sIioav that, unless the parts consumed are the seat of tuberculous deposit, infection does not follow. The authentic instances that have been recorded in Avhich human tuberculosis Avas the result of the use of infected meat are rare indeed; but that this is a possible source of tuberculous infection in man must not be forgotten. Again, the possibility of contamination during the course of preparation for the market, as wrell as during its transportation, must also be recollected. The experiments of Aufrecht, Chauveau, Klebs, Trappeiner, Parrot, and others show that tuberculosis may be communicated by incorporating Avith the food the expectoration from tuberculous patients. (3) Infection by Inoculation.—Tuberculosis may be transferred by direct inoculation, as shown originally by Yillemin's beautiful experi- ments upon the eyes of guinea-pigs. Infection may take place, though this is rare, through slight cutaneous lesions (cuts, fissures, excoriations, etc.), but only as the result of accidental inoculation of tuberculous matter. In this manner there is produced a local tuberculosis of the skin, as a rule. Rarely, the contagion is conveyed by the lymphatics to the glands in the vicinity of the point of infection. Persons Avho folloAV certain occupations are more or less liable to this mode of infec- tion—e. g. butchers, handlers of hides, dissectors of dead bodies, and, rarely, surgeons. Tuberculous virus may be introduced into the tissues through any open lesions and the characteristic local change follow; hence quite rare instances of transmission by inoculation occur in divers ways (the bite of a consumptive, a cut from the broken spit-glass of the latter, or even from his pocket-knife, as I have seen in one instance). The handkerchiefs, body- and bed-linen of the patient may infect by inoculation those who handle or Avash them frequently, if they chance to have a fissure or excoriation upon the hand. No doubt lupus also 1 See the elaborate statistical studies of Dr. George Cornet: " Die Tuberkulose in den Strafanstalten," Zeitschrift fur Hygiene, Bd. x., 1891. 268 INFECTIOUS DISEASES. arises in the same Avay. Czerny has reported 2 cases of infection by transplantation of the skin ; Collings and Murray. 3 cases by tatooing (?). The contact of the lips of tuberculous operators with surgical wounds (as in sucking the latter) may be the means of transmitting the disease; in this way tuberculosis may be, and undoubtedly has been, communi- cated during the performance of the rite of circumcision. (4) Direct Hereditary Transmission.—In exceptional cases the bacillus is found in the fetus in utcro. In such instances the disease may re- main latent, to break forth during childhood or later in life; and even though the fetus itself may display no evidence of tuberculosis, the fetal viscera may yet be infective to guinea-pigs (Birch-Hirschfeld). Lehmann l has reported an undoubted instance of intra-uterine infec- tion. The tuberculous mother died of tuberculous meningitis three days after the birth of her child, and the child lived tAventy-four hours. In its spleen, lungs, and liver were found nodules resembling tubercles and containing tubercle bacilli in large numbers. Galtier has inocu- lated a pregnant animal Avith the disease, and found that the offspring was, in consequence, tuberculous at birth. The vieAvs of Baumgarten upon this question should be accorded careful consideration. This author believes that the contagion may be transmitted and become pathogenic at a variable period after birth—first, because .the affection is very frequent in young children, even during the first months or weeks of life; and, secondly, because certain structures, not apt to be accidentally infected, are commonly the seat of tuberculous lesions in children—the bones and joints. He states that hereditary infection may occur in three Avays: by the passage of bacilli through the pla- centa ; by infection of the ovum from the internal tissues or fluids; and by infection carried in the fructifying sperm. After birth the ba- cillus may at any time either lose its vitality or take on a luxuriant growth. It is not known, hoAvever, in Avhat percentage of these cases the lungs, intestines, peritoneum, and lymph-glands are free from tuber- culous lesions. Again, there are certain interfering conditions that must be borne in mind. Of these, two deserve to be emphasized: (a) the fact that a child born of tuberculous parents is more receptive to the tubercle bacillus than one born of healthy stock, and (b) that it is more liable to accidental infection, as by SAvallowing the virus (particularly if breast- fed) or by inhalation. The instances of direct transmission that have been traced definitely have occurred through tuberculous mothers. The observations of Csokor 2 upon hereditary tuberculosis in cattle also corroborate this dic- tum ; but as the result of carefully conducted experiments by Yignal3 it is reasonably certain that invasion by heredity is very rare. Predisposing Causes.—(1) Race and Nationality.—The effect of nation- ality upon the receptivity to tuberculosis can be studied advantageously in America on account of the cosmopolitan character of the population. The tuberculous tendency on the part of Indians of this continent, among whom the death-rate from this disease is not less than 25 per 1 Berlin, klin. Woch., July 9, 1895. 2 Deutsche medizinal Zeitung Berlin, Jan. 29, 1892. 3 La Semaine medicate, Paris, Aug. 1, 1892. TUBERCULOSIS. 269 cent., even in the most favorable climates, has been observed repeat- edly, and the fact that the negro race is highly receptive to tubercu- losis is also Avell known. Osier l gives the folloAving corroborative sta- tistics : " Of the 427 cases of pulmonary tuberculosis at the Johns Hop- kins Hospital for the tAvo years ending June 1, 1891, there Avere 41 cases in the colored—/. e. about 1 : 10. The ratio of colored to Avhite of all patients in the wards has been 1 : 7." Sears 2 found that in 200 cases of tuberculosis nearly 50 per cent, belonged to the first and second generation of Irish immigrants. Such facts serve to show that differ- ences unquestionably exist as regards certain nationalities. (2) Hereditary Predisposition.—The percentage of cases in Avhich heredity can be traced has been variously estimated at from 10 to 40. As before intimated (vide Direct Hereditary Transmission), a child reared by tuberculous parents runs great danger of being infected acci- dentally ; and again, a person living in an infected house (with or with- out the presence of a tuberculous patient) is very liable to become infected, whether his antecedents give a tuberculous history or not. It folloAvs that a correct estimate of the number of cases of phthisis in Avhich hereditary influence plays an etiologic part cannot be obtained. Too much importance has heretofore been attached to the influence of inherited constitutional peculiarities to the exclusion of other potent factors. Moreover, the latter may be acquired as the result of certain debilitating influences (childbirth, defective food-supply, close living- or working-rooms, etc.). An inherited tendency to tuberculosis is more unfailingly transmitted through the mother than the father. Children begotten of parents Avho are drunkards, or Avho suffer from certain chronic incurable diseases (syphilis, cancer, etc.) at the time of the birth of their children, are liable to inherit a condition of the system which renders them peculiarly liable to tuberculosis, unless the tend- ency is overcome by a proper environment, together with systematic physical training, during the first years of life. Moreover, persons Avho have the so-called tuberculous diathesis are frequent sufferers from catarrhal affections, especially of the respiratory organs. The latter condition forms a marked predisposing factor; yet, on the other hand, tuberculosis is met Avith in persons Avho are robust and have apparently well-formed chests and lungs. The older authors of medical text-books describe tAvo types of con- formation—the tuberculous and the scrofulous. The latter has a heavy figure, thick lips and hands, large thick bones, and an opaque skin; the former, a light figure, bright eyes, thin skin, oval face, and long, thin bones. The phthisical type of the chest will be referred to in connec- tion with the physical signs of pulmonary tuberculosis. In this connec- tion emphasis should be given to Cohnheim's view, which is for the greater part correct, to the effect " that the so-called phthisical habit is not an indication of a tendency7 to, but actually of the existence of, tuberculosis." Whilst the recognition of the tubercular diathesis has its practical bearing, it must be recollected that the term implies merely a " delicacy of constitution, incomplete groAvth, and imperfect develop- ment " (Fagge). 1 Text-book of Medicine, p. 204. 2 Boston Medical and Surgical Journal, April 4, 1895. 270 INFECTIOUS DISEASES. (3) Previous Infectious Diseases.—That there is no tendency to the tran- sition of other diseases into tuberculosis, as Avas formerly supposed, cannot noAv be questioned in view of the undoubted specific nature of the latter disease. Tuberculosis is, hoAvever, embraced among the sequelae of such affections as acute infectious and chronic diseases—influenza, measles, Avhooping-cough, typhoid fever, cirrhosis of the lungs, and diabetes mellitus (the latter disease involving a predisposition to the former)—for the reason that they render the tissue-soil, especially that of the respira- tory tract, more favorable to tuberculous infection. It seems proper to mention here the fact that certain other diseases display an antagonistic effect (chronic valvular disease, pulmonary emphysema, etc.). Our knoAv- ledge of the subject is as yet quite incomplete, but of an affection which occurs so very frequently and carries off so large a percentage of the population as tuberculosis a more accurate and extended knowledge Avould be welcomed by the profession. (4) Age.—This affects predisposition decidedly, though tuberculosis may occur at any or all times ; and the relation betAveen age and the distribution of the lesions has been previously indicated. Certain forms of tuberculosis are especially frequent in young children (meningeal, mesenteric, and lymphatic). Pulmonary tuberculosis is most common betAveen twenty and thirty. It is more rare during early childhood and in the aged, but may appear at any period of life, and the cases that occur in young children are apt to be more rapid in their progress. (5) Sex.—Predisposition has but slight relation to sex. Females are, hoAvever, somewhat more liable than males, and pregnancy in particular is a disposing factor. Again, when tuberculous females become preg- nant the progress of the affection is accelerated, and even more so by the period of lactation. Regarding tuberculosis as being pre-eminently a house-disease, females are more exposed to contagion than males, because they are more closely confined in-doors. (6) Climate and Soil.—Humidity of the soil and abundant atmospheric moisture increase the prevalence of tuberculosis. It is especially com- mon in regions Avhere sudden variations of temperature, or protracted cold Avith dampness, prevail. This increase is most probably associated Avith a heightened vulnerability, due to an increased tendency to ca- tarrhal affections of all kinds (Osier). It has been shown that proper drainage of marshy districts has diminished, to some extent, the fre- quency of this disease (Buchanan), and, on the other hand, mountainous districts are often remarkable for freedom from the disease. Local Causes.—(1) Occupation.—Persons Avhose employment exposes them to different forms of irritating inhalations are particularly liable. In such, hoAvever, there is usually first developed a fibroid induration, and the latter in turn is folloAved by pulmonary tuberculosis. The con- tinual inhalation of an atmosphere laden Avith noxious particles, such as is met Avith in ill-ventilated and overcroAvded working or living apart- ments, renders the tissue-soil more vulnerable. (2) Bronchial Catarrh.—An acute catarrh of the small bronchi pre- pares the soil for tuberculous infection. Frequently, hoAvever, this is the first step in tuberculosis, since the latter disease almost invariably begins as a local catarrhal process, involving the smaller apical bronchi. TUBERCULOSIS OF THE LYMPH-GLANDS. 271 The fact may here be pointed out that gastro-intestinal catarrh increases the bodily receptivity for tuberculosis. (3) Tubercular Pneumonia.—In like manner, pulmonary tuberculosis may folloAV an unresolved pneumonia, but such cases are, as a rule, in- stances of tuberculous pneumonia primarily. (4) Hemoptysis.—According to some authors, hemoptysis is potent in producing pulmonaiy tuberculosis. It is, hoAvever, certain that in most instances in Avhich it appears to precede phthisis, and have a causal con- nection Avith it, it is in reality a symptom of existing pulmonary tuber- culosis. (5) Pleurisy may be, though rarelyT, the starting-point of phthisis. Its predisposing effect may be attributable to compression of the lung, thus interfering with the respiratory excursions, or to the bronchitis Avhich is frequently associated. Pleurisy sometimes initiates fibroid in- duration, which may then terminate in a tuberculous affection; but the fact is to be emphasized that a very large proportion of the cases of apparently primary pleurisy are tuberculous in nature. (6) Intrathoracic Tumor.—Tuberculosis is often associated Avith intra- thoracic tumors, and especially with aneurysm. Fehde1 has reported 3 interesting cases of the kind. (7) Congenital or acquired contraction of the orifice of the pulmonary artery predisposes markedly to tuberculosis. (8) Trauma.—Injuries to the chest-wall, Avith or without ulceration of the lung, are frequently followed by pulmonary tuberculosis. The explanation of this association is to be found in the fact that trauma increases largely the susceptibility of the parts injured by diminishing phagocytic activity—the natural power of resistance. It is a familiar observation in surgical practice that after injuries to, or operations on, joints, tuberculosis commonly ensues. Again, operations upon tuberculous lesions are succeeded by general tuberculosis—often acute—in about 8 per cent, of the cases. Tuberculosis of the Lymph-glands. (Scrofula.) Scrofula implies tuberculous infection, and scrofulous material inocu- lated upon susceptible lower animals, especially guinea-pigs and rabbits, invariably causes tuberculosis. The virus is, however, less virulent than that derived from other sources, and this explains the sIoav progress and often latent character of tuberculosis of the glandular system. A major predisposing factor is age, this form of tuberculosis preponderating in children. Hecker, from an examination of the records of the Munich Pathological Institute, found that in 147 cases of tuberculosis among children the lymphatics Avere affected in 92 per cent.; and it is generally conceded that in young adults tuberculous adenitis is not uncommon, and that it is rarely met with during and after the middle period of life. The lesions generally remain limited to the glands first infected—i. e. the cervical, mesenteric, etc., as the case may be—and this for the reason that the natural poAvers of resistance in the tissues are often able 1 " Lungentuberculose mit Brusthohlengeschwulste," Inaug. Diss., Leipzig, 1894. 272 INFECTIOUS DISEASES. to oppose the march of the destructive forces. Another predisposing condition is an acute or chronic catarrh of the mucous membranes. The cases are all divisible into tAvo groups: (1) Local tuberculous adenitis, and (2) general tuberculous adenitis. (1) Local Tuberculous Adenitis.—(a) Cervical.—This is the most fre- quent form, and is especially common among children. Of 2035 per- sons examined by Yalland, enlarged cervical glands were found between the ages of seven and nine in 96 per cent. ; betAveen ten and tAvelve in 96.1 per cent.; between thirteen and fifteen in 84 per cent. ; between sixteen and eighteen in 69.7 per cent.; and between nineteen and tAventy-four in 68.3 per cent. Tubercle bacilli were found in the cer- vical lymph-glands in about 68 per cent, of adults. Negroes are found to be more prone to the affection than Avhites. Etiology.—I have stated before that tubercle bacilli are sometimes found on the nasal mucous membrane of healthy persons. The pres- ence of an acute or chronic catarrh of the nasopharynx may noAv loAver the resistance of the tissue-cells, so that the bacilli may gain ■ access to the lymph-current, and through the latter to the neighboring glands, setting up tubercular adenitis. Though often the seat of tuber- cular invasion, the cervical lymph-glands do not furnish a highly favor- able soil for the growth and development of the bacilli, and hence the tendency toAvard latency7 of tuberculous disease of these organs. The tonsils, OAving to their free communication with the atmosphere, in which there is a wide diffusion of tubercle bacilli, may be primarily infected. But here also, as in the case of other glandular structures, there is a tendency for the affection to become latent, for the reason that the tissue-soil after a prolonged contest generally gains the ascendency over the invading bacilli. The latter may, hoAvever, under certain favorable conditions, break doAvn the barriers opposed by nature and effect a lodgement elsewhere, or even become widely diffused through the economy. Thus Kinckmann in 64 autopsies found 25 cases of tuberculosis, in 12 of Avhich the tonsils were affected. A third mode of infection of the cervical lymph-glands is through the medium of slight injuries and abrasions of the skin or certain forms of skin-eruptions (eczema, etc.). These serve as doors of entrance for the bacilli, Avhich find their Avay into the neighboring lymph-glands through the lymph-channels. Compared Avith infection from Avithin, this mode is most probably much less frequent. Symptoms.—The main feature is a visible enlargement of the af- fected cervical glands, chiefly the submaxillary. At first the glands are too small to be even palpated ; later, they can be felt as small, firm tumors underneath the skin. By and by they appear as visible protuber- ances, ranging in size from that of an English Avalnut to that of a hen's egg or even larger. The skin over the enlarged gland is freely mov- able, as a rule ; less frequently it becomes adherent—an indication of suppuration. When an abscess forms and is allowed to open spontane- ously, there remains a chronic discharging sinus. Suppuration is at- tended Avith fever, anemia, and emaciation. In well-marked cases the separate tumors coalesce, forming large and irregular masses. The affection is usually bilateral, though almost invariably it is more marked on one side than on the other. TUBERCULOSIS OF THE LYMPH-GLANDS. 273 Not infrequently, in addition to the enlargement of the submaxillary, post-cervical, and supraclavicular glands, there is also involvement of the axillary, as was the case in a fatal instance in my OAvn practice. The patient Avas a male child, eight years of age, Avho developed pul- monary tuberculosis. In such instances it may reasonably be assumed that the bronchial glands also become implicated, and frequently become the exciting cause of the lung-tuberculosis. The diagnosis is based upon the history, the associated evidence of the tuberculous diathesis (keratitis, conjunctivitis, eczema of the scalp or face, nasopharyngeal or bronchial catarrh, etc.), together with the enlargement of the superficial cervical glands. Bacilli have occasion- ally been found in the purulent discharge from abscesses. The course of this affection is exceedingly sIoav, often extending over a number of years. Many cases, however, recover if surgical in- terference be employed. On the other hand, neglected cases are a menace to the life of a patient, since they may be followed by diffusion of the bacilli, with the development of a fatal form of disease. (b) Bronchial.—Tuberculosis of the bronchial glands may be primary, or secondary to infection of the lungs, and it is commonly preceded by or associated Avith bronchial catarrh, Avhich is its chief predisposing cause. The primary form is met with frequently in young children, the medias- tinal lymph-glands being affected uniformly in 127 cases at the New York Foundling Hospital (Northrup). The bronchial and tracheal glands are the receptacles for all foreign substances, including the tubercle bacilli that are not dealt with by the broncho-pulmonary phagocytes. After infection Avith tubercle bacilli the lymph-glands become SAvollen, tumefied, and are the seat of caseous change; later they may undergo calcification or proceed to abscess-for- mation. The latter may rupture either into the lungs, into the trachea or the bronchi, or into a pulmonary blood-vessel. Symptoms.—If a fistulous communication be established with the air- passages, cough and expectoration of purulent material, blood, and caseous matter containing bacilli will be noted. Secondary infection of the lung may occur in this manner. When rupture takes place into a vessel systemic infection promptly follows. Tubercular adenitis involving mediastinal lymph-glands may also lead to infection of the pericardium and then proceed to tuberculous peri- carditis. (c) Mesenteric (Tabes Mesenterica).—This may be primary or sec- ondary, the latter being very common and a secondary infection to intestinal tuberculosis. The former is rare, however, and the intestinal catarrh with Avhich it is associated is doubtless tuberculous in the vast majority of cases. The mode of infection has already been pointed out. The lesions pre- sented are similar to those met with in tuberculous bronchial glands. The symptoms are not ahvays distinctive, and may be entirely nega- tive during the life of the patient; hence the condition is often incident- ally discovered during the post-mortem examination. The local symp- toms Avhen marked are due in the main to an associated peritonitis. The abdomen is painful and more or less swollen. Peritoneal effusion is present, and sometimes sufficient in amount to be detected by the cus- 18 274 INFECTIOUS DISEASES. tomary physical signs. Large and small nodules may sometimes be felt. Diarrhea is a marked and obstinate feature and is usually due to tubercu- lous intestinal ulcers. Fever of an intermittent type is almost constantly present, causing emaciation, and the objective changes (pallor of skin, mucous membrane, etc.) due to anemia become pronounced. This form of tuberculosis may persist as a local condition, but there is danger of extension to other organs (pleura, lungs, etc.). On the other hand, in the adult pulmonary tuberculosis may be followed by involvement of the mesenteric glands Avithout involvement of the intestines, and in such in- stances there occurs an extension by contiguity along the course of the lymphatics that pass through the diaphragm, and finally, in adults, pri- mary tuberculous new groAvths may be met with in the mesenteric glands. Diagnosis.—A probable diagnosis can usually be made if careful at- tention be paid conjointly to the symptoms, physical signs, and course of the affection. The detection in a child of a tumor Avhich may he moderately hard, doughy, or even fluctuating will aid materially in the diagnosis, and will also afford evidence of tuberculous disease in other organs. (2) General Tuberculous Adenitis.—This term implies tuberculous dis- ease of the lymph-glands throughout the body, with little if any involve- ment of other organs; this is a rare condition. The affection may begin as a local tuberculous lymphadenitis, nearly all of the rest of the glands of the body becoming secondarily implicated. The primary seat of the trouble is perhaps most frequently the cervical lymph-glands, though in one instance observed by myself the mesenteric glands first became affected, the case terminating in pleuro-pulmonary tuberculosis. Symptoms and Diagnosis.—There is protracted fever, the tem- perature being of the remittent or intermittent type. Wasting and debility are progressive until the patient presents a decidedly puny aspect, while the lymph-glands that are accessible to inspection and palpation are more or less enlarged and manifest a marked tendency to suppuration. The affection is usually chronic, though very exception- ally it may exhibit an acute course. One of the chief dangers over- hanging the sufferer in this affection is that, OAving to liberation of the bacilli, the meninges or the lungs may become tuberculous; these cases may also terminate unfavorably from asthenia. Cases in Avhich the glands are but little enlarged, Avhile the general features are marked, are puzzling. On the other hand, Avhen the superficial lymph-glands are greatly enlarged the affection may bear a striking resemblance to Hodgkin's disease. Acute Tuberculosis. This form of tuberculosis is characterized anatomically by the rapid development of miliary tubercles in many and widely-separated parts of the body. In some instances the neAv groAvths are pretty evenly distrib- uted through all the organs of the body, manifesting the clinical symp- toms of an acute general infection. In other instances there is a tend- ency to centralization of tuberculous groAvths, as, for example, in the lungs (pulmonary variety) or in the meninges of the brain and spinal cord (meningeal variety). ACUTE TUBERCULOSIS. 275 Pathology.—The fact is to be emphasized that someAvhere in the body there is an old tuberculous focus. Apart from this primary lesion, the anatomic changes consist in the Avidely disseminated miliary tuber- cles. Their most frequent seats are the lungs, liver, and spleen; less frequently, the marroAv of the bones, the heart, the choroid, and the meninges. In some of the organs, particularly the meninges, lungs, etc., the tubercles may be readily perceived by the naked eye, Avhile in others they frequently eannot be detected Avithout the aid of the micro- scope. It must not be forgotten that in some of the more protracted cases the nodular tubercles may grow into foci of considerable size, ranging from that of a lentil to that of a pea. Btiology.—This has been, in the main, given in connection Avith the general etiology of tuberculosis (vide supra), though a feAv special points remain to be adduced. The acute forms of tuberculosis are decidedly more frequent during infancy and childhood than during adult life, and with feAv exceptions the cases are secondary to a local tuberculous focus in one or more lymph-glands (tracheal, bronchial, mesenteric, etc.) or in the lungs. More rarely a pre-existing tuberculous focus in the kidneys, the bones, or the skin may give rise to the affection, as may the occur- rence of certain other acute infectious diseases—such as measles, Avhoop- ing-cough, and influenza, in children, and typhoid fever and lobar pneu- monia, especially Avith delayed resolution, in adults. Modes of Infection.—Most frequently there is established a fistulous connection betAveen the local tuberculous focus and a vein. The tuber- cle bacilli thus find their way into the circulation, and general infection promptly follows. This occurs in a great proportion of the cases in the thorax, a pulmonary vein being opened in such instances. A second mode of infection, though decidedly more rare than the above, is the rupture of a tuberculous focus into the thoracic duct, in Avhich case the tuberculous material passes almost directly into the subclavian vein. In these cases, according to Ponfick, the disease is less rapid in onset and less acutely evolved. Clinical History.—That miliary tubercles may exist in many organs of the body (liver, heart, etc.) Avithout giving rise to symptoms is a noteworthy fact. Cohnheim and Manz have discovered miliary tu- berculosis of the choroid Avhen the condition was only detectable Avith the aid of the ophthalmoscope. The folloAving forms of the disease may be distinguished: General Miliary Tuberculosis. typhoid form. The symptoms are those of a general infection of the body, there being in most cases a period of incubation, during which the patient complains of malaise, headache, chilliness, feverishness, and increasing debility. Rarely, the onset is comparatively sudden. The reaction of the nervous system against the poison, which is now scattered to all parts of the body, is shown by such symptoms as the fever, Avhich rapidly increases, a rapid, feeble pulse, and mental dulness or delirium. The tongue becomes dry, and sometimes also brown. The respirations are accelerated, and there is more or less cyanosis, Avith Avhich symptom is 276 INFECTIOUS DISEASES. associated a peculiar and characteristic pallor of countenance. Coinci- dently with the febrile exacerbations the cheeks may wear a circum- scribed blush. Among the rarer early symptoms is epistaxis. The patient soon becomes profoundly prostrated or experiences a feeling of anxiety : if, as sometimes happens, the course is protracted, Aveakness, anemia, and especially emaciation, are well marked and assume diag- nostic importance. These cases sometimes pass into the pulmonary or the meningeal form, the patients often succumbing speedily to such localized developments. Fever.—The temperature usually pursues a high range, although there are not a feAv cases in Avhich the entire course is afebrile. Ao-ain, it occurs not infrequently that the temperature is normal or nearly so for a short period. The usual temperature-curve ranges at first between 102° and 104° F. (38.8°-40° C), and then continues to rise, with the development of the serious general condition in a Avay exactly similar to that observed in typhoid fever. In many instances the fever is irregularly remittent, at least at intervals, if not so constantly. Thus, periods of irregular fever may alternate with others of continued, and later deeply remittent or distinctly inter- mittent, fever. Nervous Symptoms.—In most cases the nervous symptoms are not prominent. In a smaller number headache, vertigo, delirium, and often stupor, become marked at an early stage and may persist. They are due to the general infection. Circulatory System.—The pulse is small, and its rate is out of pro- portion to the fever, varying from 100 to 140 or higher. It may be- come irregular, particularly if the meninges be involved. Respiratory System.—The breath is somewhat hurried and labored; there is a cough, but it is not annoying as a rule; and there is a slight expectoration, Avhich is not characteristic. If there be present simul- taneously in the lungs an old tuberculous focus, the expectoration may be more profuse and typical. The bacilli are also absent from the spu- tum unless an old tuberculous lesion pre-exist in the lungs. The physical signs are those of a moderate, diffuse bronchitis, though local signs of consolidation or pleurisy may develop late in the course of the affection. On the other hand, such signs may be evidences of an old tuberculous affection. Digestive System.—As before noted, there "are anorexia and a dry tongue (symptoms due to the systemic infection), Avhile vomiting may occur at the outset and excessive thirst is common. The spleen usually becomes enlarged, though only to a moderate extent. Ocular Symptoms.—The important symptom presented by the eye is the presence of choroid tubercles, which may be determined by a care- ful ophthalmoscopic examination. Their absence does not militate against the diagnosis of general miliary tuberculosis, since they may be too few to be detected, or possibly absent altogether. Their demon- stration is ahvays exceedingly difficult, and only possible Avith the skilled ophthalmologist. Diagnosis.—This form of tuberculosis is often with difficulty dis- criminated from typhoid fever, but in the folloAving table I have endeav- ored to contrast points of dissimilarity : ACUTE TUBERCULOSIS. 277 Acute General Miliary Tuberculosis. Typhoid Fever. Family history of tuberculosis, or pres- Coexistent with an epidemic or following ence of a pre-existing focus. previous cases of typhoid. Less characteristic. Evolution of the disease is character- istic. Absent. Epistaxis a common early symptom. Curve of a decidedly irregular type. Temperature-curve of the continued type. Pulse rapid, out of proportion to fever. Pulse often dicrotic; slow in proportion to fever. Much increased and labored. Respiration moderately increased. Face dusky, with peculiar pallor. No duskiness of face. Abdominal symptoms are not suggestive. Abdominal symptoms (stools, enlarged spleen, tympanites, etc.) suggestive. No characteristic eruption. The eruption (appearing in successive crops) is pathognomonic. Present or absent according to involve- Knee-jerk never wanting. ment of meninges. Leukocytosis present (if there be sup- Leukocytosis absent. puration). Choroid tubercles may often be de- Choroid tubercles absent. tected. Tubercle bacilli rarely demonstrable in Cultures from punctured spleen may the blood. show typhoid-bacilli (dangerous pro- cedure). Verv exceptional. Hemorrhage from the bowels common. Absent.1 Perforative peritonitis often present. PULMONARY FORM. Though all gradations between the typhoid and the pulmonary types occur, the latter should be recognized and briefly described. It may develop suddenly, the ushering-in symptom being sometimes a chill, though more frequently there is a premonitory period, during Avhich the general health fails materially. The affection may follow promptly upon some acute illness, such as measles or whooping-cough, in children, in Avhich there has been marked catarrhal bronchitis. The respiratory symptoms are early prominent, and later preponder- ate in the clinical picture. From the start there is dyspnea, and this gradually increases until the respirations become rapid (40 to 60 per minute). When dyspnea becomes pronounced the face assumes a cha- racteristic cyanotic pallor. The cough, at first, is moderately severe, but soon it becomes troublesome, being now frequent and attended Avith a slight expectoration, which is non-characteristic. The physical signs are those of broncho-pneumonia, and the latter may or may not be preceded by the signs of general bronchitis. With the onset of broncho-pneumonia there appear spots that yield either dulness or a tympanitic resonance on percussion, and broncho-vesicular breathing Avith numerous subcrepitant rales on auscultation. The general symptoms are marked from the beginning. The fever is high—from 103° to 105° F. (39.4c-40.5° C.) or often higher. The pulse ranges from 100 to 140, is small, feeble, and sometimes irregular, and it may be more rapid still during the advanced stage of the affec- tion (see Fig. 25). Cerebral symptoms rarely appear. 1 See also Differential Diagnosis of Typhoid Fever. 278 INFECTIOUS DISEASES. The course, as a rule, is more prolonged than that of general miliary tuberculosis, except in children, in whom it often runs an exceedingly acute course. As the end approaches the signs of suffocation are gradu- ally intensified, and finally lead to a fatal termination. Diagnosis.—The diagnosis is difficult; but a family history of tuberculosis, a knoAvledge of the pre-existence of a tuberculous focus or of an antecedent predisposing affection, will aid in its recognition. Tubercle bacilli are perhaps not demonstrable in the sputum unless an old tuberculous lesion coexist. In doubtful instances, hoAvever, an attempt should be made to detect the bacilli in the blood. Occasionally either tuberculous meningitis or peritonitis supervenes, and aids in removing the doubt, and in a small percentage of the cases choroid tubercles are detectable. These points, together with the more marked general symptoms, Avill usually aid the clinician in distinguishing this variety of tuberculosis from non-tuberculous broncho-pneumonia. cerebral or meningeal form (tuberculous meningitis). This variety is of quite frequent occurrence, appearing in not less than 50 per cent, of the cases of miliary tuberculosis. When it devel- ops the symptoms referable to other organs than the meninges are in abeyance. With reference to the etiology of this form one fact needs to be emphasized—namely, that most cases are observed between the ages of tAvo and seven years; it may, hoAvever, be met with at any time of life. The affection frequently has its origin in tuberculous bronchial glands (Jacobi), and the history of a fall is common. A few cases have been found to be associated with erythema nodosum. Exceptionally the meninges are primarily involved. Pathology.—The chief site of the tubercles in children is the pia mater at the base of the cerebrum (basilar meningitis), Avhilst in adults the pia at the vertex is more apt to be involved. The membrane sur- rounding the tubercles may not be inflamed, there being a simple tu- berculous deposit. On the other hand, more or less inflammation, with sero-fibrinous or fibrino-purulent exudation, is generally present in the region of the base. This exudate is usually abundant in the Sylvian fissures, and may find its way to the external surface of the hemispheres. It is gray in color, transparent, and gelatinous, and contains in its meshes the tubercles, which appear as grayish-white bodies, and which, in cases of equal severity, may be either numerous or scanty. They may be scarcely visible to the naked eye, but may vary from the size of a pinhead to that of a French pea. The branches of the Sylvian artery may be implicated, either OAving to the direct pressure of the exudate or to the obliterating arteritis produced by a tuberculous infil- tration. The pia looks like Avet blotting-paper over the quadrangle at the base (Gray). Elsewhere it is thickened and opaque, though easily detachable. Osier says: " The arteries of the interior and posterior perforated spaces should be carefully withdrawn and searched, as upon them nodular tubercles may be found when not present elsewhere. In doubtful cases the middle cerebral arteries should be very carefully re- moved, spread on a glass plate with a black background, and examined with a low objective. The tubercles are then seen as nodular enlarge- 280 INFECTIOUS DISEASES. ments on the smaller arteries." Involvement of the chief vessels that nourish the walls of the ventricles and the ependyma, and stretch from the vermis cerebelli forward over the quadrigemina, explains the con- stant presence of a turbid fluid in the ventricles, with softening of their walls. As the result of undue intraventricular pressure the cerebral convolutions become more or less flattened, Avith effacement of the sulci. The cortex, to a variable depth, is generally the seat of red softening, and more rarely of white softening alone. The tuberculous infiltration involves the cranial nerves. Histology.—The tubercles groAv in the perivascular sheaths, which are often distended Avith lymphoid and epithelioid cells, and there is observed not infrequently a thrombosis of the arteries and of the venules of the pia, obliterating their lumen. The pia mater is gradu- ally thickened through cellular infiltration, and in a small proportion of the cases the spinal meninges are similarly involved, chiefly in the cer- vical portion of the cord. Symptoms.—There is a prodromal period Avhich lasts one or more weeks, during Avhich the patient (usually a child) is pale, peevish, has headache and photophobia, and grinds its teeth during sleep ; the tongue is coated, appetite impaired, and there may be occasional vomiting, either propulsive or regurgitative. Constipation is present and may he marked. Among rare premonitory symptoms are slight hyperesthesia of the abdomen and a diminished urinary secretion. A tendency to emaciation is quite constant. These prodromal symptoms present varia- tions as to their number and combinations in different cases. In few instances only is the onset acute. The symptoms usually indicate basic meningitis, and at first there is associated considerable mental excite- ment ; later there are pressure-symptoms (caused by the exudate), with total loss of the mental faculties. (1) Stage of Cerebral Excitement.—The invasion is generally gradual, or even quite insidious, its most characteristic phenomena being seven vomiting, marked headache, and chills followed by fever. Certain other symptoms noAv arrest the attention, such as extreme irritability, scream- ing, and great obstinacy, and occasionally droAvsiness appears early. When the onset is sudden the disease may be disclosed by convulsions, paral- ysis, wild delirium, or coma. The established disease exhibits certain distinctive features. The pain is often most excruciating, causing the child to utter short penetrating screams (hydrocephalic cry), and in rare instances the sharp cries may be continuous and lead to physical exhaus- tion. The headache is increased by light, noise, or movement. Vertigo is common; the pupils are contracted at this period; the face pales and then flushes; the pupils alternately dilate and expand; and the expres- sion is sometimes sad, though more often stupid. Generally hyperes- thesia or dysesthesia may appear, and there may be a slight mind-wan- dering at night, though active delirium is rare. Tdches cer'ebrales may be obtained, but are not characteristic. The patient is intolerant of every form of disturbance. All the symptoms of the prodromal stage are now aggravated; slight muscular twitchings and sleep-starts occur; the vomiting is apparently causeless, and" may be frequently repeated; and constipation persists. Fever is present, but is of slow development, and rarely rises higher ACUTE TUBERCULOSIS. 281 than 102° or 103° F. (39.4° C.) in the evening. The skin is dry and harsh, as a rule. The pulse is slow or moderately accelerated, but soon quickens to 120 or even 130, and later it may be irregular. At times the pupils are unequally contracted, and ptosis may also be looked upon as an early sign. (2) Second or Transitional Stage.—The symptoms of cerebral irrita- tion noAv abate, the patient becoming more quiet, Avhile mental dulness often supervenes. The vomiting and headache subside gradually, and the child cries out only occasionally. The abdomen is noAv distinctly scaphoid and the head occasionally retracted. Constipation is obstinate. The evidences of localized organic foci, such as slight tAvitchings of the muscles of the face, folloAved by strabismus, ptosis, or paralyses of the face or limbs, may appear. Generalized convulsions may occur, and muscular tremors and athetoid movements may appear. Both pupils (or one only) may be dilated as intracranial pressure develops; patchy flushing of the face is common. The respiration is nowT irregular and sighing. (3) The Stage of Paralysis.—On account of the exudation the mental faculties are abolished, so that the patient is comatose, though convul- sions or localized spasms of the muscles in different parts of the body (neck, back, limbs, etc.) may be observed. Optic neuritis develops, while the paralysis of the ocular muscles above noted deepens. The pupils are dilated, the eyes are partly closed, and the eyeballs at inter- vals sloAvly and alternately move in a lateral direction. Hemiplegia sometimes develops, and more rarely monoplegia, affecting the face or one of the extremities. There may be paralysis of the third nerve, Avith involvement of the face, hypoglossal nerve, and limbs on the opposite side (a combination of symptoms first observed by Weber), consequent upon a lesion localized in the internal inferior portion of the crus. Monoplegia of the right side of the face has been observed in a few instances, associated with aphasia. Exceptionally aphasia and brachial monoplegia have been combined. The temperature in the early part of this stage usually rises to 103° F. (39.4° C.) or higher, but later it may drop to a subnormal level, and in rare instances as Ioav as 94° F. (34.4° C). Immediately preceding the fatal termination the temperature may rise to 106° or 107° F. (41.6° C), the pulse becoming frequent, small, and irregular. Gradual anesthesia comes on wTith general muscular relaxation. Occasionally a typhoid state (great prostration, dry tongue, diarrhea, etc.) may develop, and Cheyne-Stokes respiration is almost invariably present, preceding the fatal event. Leukocytosis has been observed in all stages of the disease. Ophthalmoscopic Examination.—The ophthalmoscopic appearances sometimes form important points in the diagnosis. At first hyperemia of the disk is noted, and later the changes belonging to neuritis (swell- ing and striation) appear, while rarely tubercles may be detected in the choroid.1 Clinical Types.—(a) Mild Type.—The marked or alarming symp- toms (tetanic rigidity of the muscles, convulsions, and paralysis) develop at a late period. In this class should be placed those cases in Avhich the 1 The differential diagnosis is given in the section on Meningitis. 282 INFECTIOUS DISEASES. meningitis is but feebly indicated—e. g. Avhen it is but a small factor in the condition of acute general tuberculosis. (b) Malignant or Rapid Form.—This type is comparatively rare, oc- curring most frequently in adult life, while the lesions have their seat almost exclusively upon the convexity. The onset is marked by the most frightful tetanic convulsions, Avhich precipitate a fatal termination in a couple of days. (c) Chronic Type.—Cases pursuing a chronic course are rarely en- countered, and the symptoms usually point to localized cerebral lesions (Jacksonian epilepsy, etc.). Prognosis.—The disease lasts from two to four or five Aveeks, though chronic cases may continue for several months. When the con- vexity is implicated, however, the duration is only one or two weeks. It should be emphasized that frequently in the course of well-marked cases a decided remission in the leading symptoms occurs, so that con- valescence is suggested; but this is deceptive, and is almost invariably followed by a renewal of the unfavorable features of the affection. A feAv cases only are recorded in medical literature as ending in recovery. Freyhan has reported a case with recovery in which the diagnosis was proved by puncture of the spinal canal and the withdrawal of fluid, in the sediments of which tubercle bacilli Avere found. A. Jacobi has met Avith 2 cases that terminated favorably, and Leube has also reported a case in which the symptoms Avere characteristic, and at the autopsy, some years later, old tuberculous lesions Avere found in the meninges. It is to be recollected, however, that the course of tuberculous menin- gitis is probably uninfluenced by human agency. Acute Pneumonic Phthisis. (Acute Phthisis; Florid Phthisis; Galloping Consumption.) This may be primary or secondary, the latter form being consequent either upon a localized tuberculous area in the lung, tuberculous pleurisy (acute or chronic), tuberculous peritonitis, or tuberculous disease of some other organ. Acute phthisis may occur at any age, though it is rela- tively more frequent in childhood and early adult life, but whether primary or secondary, the infection of the lungs is rapid. Pathology.—Two forms may be recognized: (1) This reveals the appearances of an acute lobar pneumonia, one lobe only being impli- cated, as a rule, though sometimes the whole lung is involved. The process leads to a destruction of lung-tissue, so that a section may shoAV the existence of cavities. The latter are usually small, while surround- ing them may be seen tubercles in hepatized tissue, and here and there caseous masses of a yellowish-white color may be visible. These often indicate old or pre-existing foci. It is sometimes exceedingly difficult to distinguish a tuberculous croupous pneumonia from the ordinary form, and the most careful inspection may fail to reveal the presence of ele- mentary tubercles in the acutely consolidated tissue. In cases in which this disease is suspected, hoAvever, the opposite lung, the bronchial glands, and the peritoneal and other organs should be carefully examined. The lesions presented by cases that have run a long course are somewhat characteristic, though not ahvays the same. If the case has ACUTE PNEUMONIC PHTHISIS. 283 had a duration of eight or ten Aveeks, apical softening with more or less extensive cavity-formation often occurs. Less frequently, a lobe or an entire lung is found to be consolidated throughout, u and converted into a dry, yellowish-white, cheesy substance, in wThich condition it may remain till the end." (2) Presenting the Appearances of Broncho-pneumonia.—This vari- ety is more common than the previous, especially in children. The evidences of bronchitis affecting the finer tubes, together with con- solidation of the lobules to Avhich the tubes lead, are striking. As in ordinary broncho-pneumonia, so here, the solidified areas appear as grayish-red masses in the early stage, while later they are of an opaque- Avhite. The products that fill the air-cells may caseate and break doAvn, with the formation of irregular cavities that vary in size. When large areas are involved they are the result of the fusion of contiguous smaller areas of hepatized tissue. The trouble often begins in the upper lobes and spreads doAvnward, though not infrequently the loAver lobes are most extensively involved. In not a feAv cases the masses are small, multiple, and Avidely dissem- inated throughout the lungs, and miliary tubercles in the lungs or pleurae are associated with the broncho-pneumonic lesions before de- scribed. In nearly all cases signs of pleurisy may be noted, as is shoAvn by pleural adhesions or by deposits of lymph on the pleura. The bronchial glands are also usually infected, and, particularly in chil- dren, are the seat of tuberculous processes. Baumler has called attention to a type of tuberculous inhalation pneumonia consequent upon hemoptysis, the blood and contents of the cavities being drawn into the finer tubes in respiration. This form of broncho-pneumonic phthisis sometimes follows pulmonary tuberculosis in the early, though more often in its late, stage. On microscopic ex- amination tubercle bacilli are found, though rarely in abundance, in the infiltrated masses and in the walls of the cavities. Clinical History.—(1) Acute Cases.—Preceding the attack, the patient may have " taken cold " or have been in a run-doAvn state ; more often, however, he has been apparently healthy. The onset is sudden, marked by more or less rigor, pain in the side, fever, cough, and great prostration, and there may be bronchial hemorrhage which may last one or more days. The total amount of blood expectorated may be consid- erable. In the majority of cases the expectoration is mucoid at first, and then becomes rusty-colored, often containing tubercle bacilli, though at first they may be absent, and indeed not appear until late in the disease. Dyspnea appears early, and may soon become extreme, and the fever quickly rises to 104° F. (40° C.) or over. It may be of the continued type or it may early assume the remittent or hectic type, and Avith the latter forms of fever, Avhich usually begin about the end of the first Aveek, are associated night-SAveats and rapid emaciation. The prostration of the vital poAvers is now extreme. The expectoration is more abundant, muco-purulent, and often greenish-yellow in color. In the course of one or two days after the onset we obtain physical signs that vary with the extent of the lesions. Usually, as before stated, these cases present the anatomic appearances of acute lobar pneumonia—viz. the complete consolidation of one or more lobes, which 284 INFECTIOUS DISEASES. is usually followed by signs of softening, provided the patient survives the first Aveek or ten days. The physical signs during the stage of con- solidation are precisely the same as in lobar pneumonia. The signs of softening and of cavity will be given in detail in the description of Chronic Phthisis. The course is usually rapid, occupying from two to six weeks on the average, though rarely cases that reach the stage of cavity-formation are protracted to three or even four months. Considering the brevity of the attacks, the extreme degree of emaciation (shoAvn especially by the holloAV cheeks and temples, pinched nose, and thin hands) is truly remarkable. The patient usually maintains a hopeful state of mind, notAvithstanding the rapid doAvmvard course of the affection, and it may be admitted that recovery is possible. The parts involved are in such cases destroyed and replaced by fibrous tissue, and it should be remem- bered that the apex is involved in most cases. It sometimes happens that consolidation only is present in the second lobe affected, while in the upper lobe one or more cavities have already been developed. The pleural crepitating friction is often audible before consolidation is complete. Diagnosis.—The onset, symptoms, and course during the first week may be those of ordinary lobar pneumonia, but in some cases certain symptoms may arise Avhich Avill excite suspicion of their tuberculous character in the early stage. Thus, hemoptysis rarely occurs in a pneumonia due to pneumococcus infection, and, Avhat may also serve as a point in diagnosis, the appearance of the patient, as Avell as his pre- vious and family history, may be suggestive. The points of discrimi- nation have been fully set forth in the section on Lobar Pneumonia (pp. 150, 151). (2) Subacute Cases (rarely acute).—The onset is less sudden than in the former type, Avhile the patient's antecedent condition may either be good or below the standard. At the beginning he has repeated chills, though hemoptysis may be the first symptom Avhich indicates a pre- existing tuberculous focus. The fever rises high, and is apt to be irregu- lar from the start; the pulse and respirations are rapid, and there is a- muco-purulent expectoration which may either be profuse or scanty. Occasionally it is fetid, and the sputa may early contain elastic fibers and tubercle bacilli, though more often these are noted after the affection has become fully established. During the progress of the case, also, hemoptysis may arise. Later, drenching night-SAveats increase the exhaustion and emaciation, Avhich speedily reach an extreme degree, and soon or late a typhoid condition of the system is developed. The physical signs are, at first, those of general bronchitis, Avith or without indications of pleurisy. Later, small areas of consolidation, which often increase in size, are indicated by impaired percussion reso- nance or dulness and by broncho-vesicular (rarely tubular) breathing. with subcrepitant rales. These signs may be unilateral, though more often they occur bilaterally. In many cases softening with cavity-for- mation ensues, with the usual physical signs of this condition. Course and Duration.—For some time the patient may remain out of bed, though in most instances the disease constantly progresses. Less frequently there are exacerbations and remissions. A small CHRONIC TUBERCULOSIS. 285 percentage of these cases recover Avith a loss of more or less lung-tissue, though the condition may pass into chronic phthisis. It is important to recollect that the local lesions may become extensive, as the result of fusion of small consolidated masses, until an entire lobe is involved, and Avhen this occurs the symptoms and course simulate those of the acute type. The duration ranges from tAvo to eight Aveeks or more. Diagnosis. —This variety is frequently confounded Avith non-tubercu- lous broncho-pneumonia, and the chief distinctions will be mentioned in connection with the latter disease. Bronchiectasis may be accom- panied by emaciation, fetid expectoration, night-sweats, and the signs of cavity, and these cases have been mistaken for acute phthisis. Im- portant in the recognition of the latter, hoAvever, are marked fever and emaciation. Moreover, the physical signs are more frequently referable to the apices, and the disease is more steadily progressive, running a shorter course than bronchiectasis. Acute Broncho-pneumonic Phthisis in Children.—The belief that the form of broncho-pneumonia that so frequently follows certain infec- tious diseases (measles, Avhooping-cough, etc.) is in the majority of instances tuberculous has been steadily gaining. Osier recognizes three groups of cases: (a) Those in Avhich the child suddenly becomes ill while teething or during convalescence from fever, with high tempera- ture, severe cough, and the signs of consolidation of one or both apices. Death may occur within a few days. To the naked eye the lesions do not appear to be tuberculous, (b) In this group the children show the ordinary symptoms of broncho-pneumonia, and the cases are more pro- tracted, death occurring about the sixth Aveek. (c) The child feels ill during convalescence from an infectious disease, fever, cough, and dys- pnea being present. The intensity of the symptoms abates within a fort- night, and the physical examination shows the presence of diffuse bron- chitis with scattered minute areas of consolidation. Many of these cases develop into chronic phthisis. Chronic Tuberculosis. (Chronic Pulmonary Tuberculosis; Chronic Ulcerative Phthisis) This form is much more common than the acute, the term embracing sub-varieties to which attention Avill be incidentally directed. Its most typical clinical form folioavs a mixed infection as a result of a septic ele- ment superadded at some time to the primary tuberculous infection. The Causal Factors have been detailed under General Etiology. Pathology.—The pathologic characters of tuberculosis in general have been already presented, but it will be necessary to describe briefly the special anatomic conditions met with in chronic ulcerative phthisis. The post-mortem appearances of the lungs in chronic pulmonary tuberculosis are remarkable for their great diversity, not only in the extent of tissue involved, but also as to the character of the morbid processes. Often the associated lesions form no unimportant part of the picture. In nearly all fatal cases the most advanced and extensive lesions are found near the apex, and, as a rule, the entire upper lobe of one of the lungs is implicated. In addition, it is observed that the destructive process has extended to the lower lobe of the same side as 286 INFECTIOUS DISEASES. well as to the apex of the opposite lung, the lower lobe of the primarv lung generally being invaded before the upper part of the other. Though both lungs are affected in fatal cases, they represent different stages of the disease. The case is very different in an old and cured tuberculosis of the lungs, such as is frequently met with in persons who have died of some other affection. Here the lesions may occupy but a small part of one lung, and usually near the summit. Kingston Fowler has investigated the question of the points of elec- tion and paths of distribution of the lesions in chronic phthisis, and has found that the primary lesion is not, as a rule, at the summit of the upper lobe, but that it occurs from 1 to IJ inches (3.79 cm.) below this point and near the postero-external borders. Favored by normal respiration, the lesions advance downward, so that on physical examina- tion the first evidences of disease are to be found posteriorly over the lower part of the supraspinous fossa, Avhile anteriorly the early signs are met Avith immediately beloAV the middle of the clavicle, extending along a line running about IJ- inches (3.79 cm.) from the inner end of the second and third interspaces. The starting-point, though less fre- quently, may also be indicated by physical signs in the first and second interspaces beloAv the outer third of the clavicle, Avith subsequent doAvn- ward extension. From personal observation of the post-mortem lesions of this disease, and from my studies at the bedside, I feel convinced that the initial lesion is frequently located anteriorly and near the apex, corresponding on the chest-walls to the clavicle and the supraclavicular spaces. This site has seemed to me to obtain more often on the right side than on the left. Kingsley has shoAvn that Avhen the loAver lobe becomes involved the consolidation begins about 1|- inches (3.79 cm.) beloAv its apex pos- teriorly, and corresponding externally to a spot opposite the fifth dorsal spine. From this point it spreads doAvnward and laterally in a line fol- lowing the border of the scapula " when the hand is placed on the oppo- site scapula and the elbow rests above the level of the shoulder." The middle lobe on the right side is usually invaded by direct extension from the upper. The seat of primary infiltration may even be the* lowrer lobe, but this is an occurrence of great rarity. The relative frequency of involvement of the tAvo sides varies accord- ing to different authorities. A careful analysis of my own records, and the results of some statistical investigations into the subject, shoAv that out of a total of 1236 cases 72(3 occurred on the left side and 510 on the right. In all cases the primary lesions are due to tuberculous infiltration, AA'hich at first is confined to certain lobules, though it may later involve extensive areas of lung-tissue (tuberculous broncho-pneumonia). In most instances the starting-point of the morbid changes is in the smaller bronchi and also, according to Payne, the inside of the alveoli. fci<>on the bronchioles and the corresponding air-cells become blocked with in- flammatory products. These areas then undergo caseation and present the usual opaque, grayish-yellow appearance, a cross-section of these yellow nodules showing the central bronchus usually plugged with exu- date and surrounded by caseous matter. Softening and sometimes complete liquefaction, with expectoration or absorption of the altered CHRONIC TUBERCULOSIS. 287 morbid products, may take place, and this disintegration is associated with ulceration in the Avail of the bronchus, consequent upon secondary pyogenic infection, and a resulting formation of small cavities. Ulcers may form in the bronchioles before necrotic processes supervene, and they are generally shallow, with sharply-defined edges. Recovery may ensue as the result of calcification Avith encapsulation of the cheesy masses, or the affected area may undergo fibroid transformation—a con- servative process and one that may lead to actual cure. It often happens, hoAvever, that old and apparently healed tuberculous lesions take on ulceration, when the calcareous masses (pulmonary calculi) may be dis- lodged and expectorated, and the more rapidly the caseous masses are formed the more liable are they to softening. Surrounding the healed areas the tissue may be the seat of atelectasis, though more often of emphysema. Destruction of lung-tissue also results from interstitial inflammation Avith the formation of neAV connective tissue, the latter in turn compressing and finally obliterating the alveoli. Cavities (Vomicce).—These result chiefly from progressive necrosis and ulceration. They are formed mostly by dilatation of the bronchi, whose Avails are tuberculous and suppurating. But they may also arise independently of the bronchi. Cavities vary largely in number, size, form, and in other characteristics. They are often multiple, though usually not far removed from one another, and unite as they increase in size. In this Avay large cavities, involving the Avhole of one lobe and even an entire lung (except the extreme anterior margin), may be formed, and a variable number of small pockets connecting with the bronchus may thus originate. The walls of the cavities are almost invariably irregular. Vomicae may be classified as (1) progressive and (2) non-progressive. (1) The progressive are divisible into (a) New cavities and (b) Old cavities. (a) New cavities have soft, necrotic, friable Avails so long as the de- structive processes are rapidly progressing, and the same state of things prevails in the cavities of acute phthisis. They may develop near a healed focus or near old cavities Avith limiting Avails, and Avhen situated near the periphery of the lung they may rupture into the pleura, caus- ing pneumothorax. (b) Old cavities, as a rule, have sharply-defined walls that vary considerably in thickness. At first they consist of a fibro-vascular zone, Avhich has-an inner suppurating surface; subsequently the lining of this zone is converted into an exfoliating membrane. The contents of vomicae are muco-purulent or purulent, and often consist of a shreddy and sometimes a bloody fluid. Barely they are gangrenous. Cavities also contain tubercle bacilli and other micro-organisms. Percy Kidd has studied the question of the relation of tubercle bacilli to tuberculous pulmonary lesions, and states that they7 are invariably present in neAvly- developed tubercles and fresh cavities, but frequently absent in old nodules. Trabeculae composed of blood-vessels and remnants of pul- monary tissue often traverse the cavities. In old cavities excavation may be complete, not a vestige of normal or diseased tissue remaining in them, though the blood-vessels, many of which are beaded by small aneurysmal dilatations along their course, are the last to disappear. 288 INFECTIOUS DISEASES. Their removal is effected by an obliterating inflammation. Rupture of these miliary aneurysms or the erosion of a large vessel is an event that gives rise to copious hemoptysis. Cavities having dense walls may also increase in size by encroaching upon and destroying the surrounding tissue, huge cavities often having thin, tense walls. But, Avherever situ- ated, they usually begin toward the summit of the upper lobe. Another common seat is the mid-dorsal region. Non-progressive Cavities.—Quiescent cavities are usually small though variable in size, according to the stage at which the process of contraction is arrested. Medium-sized and large vomicae do not be- come totally occluded. They may be multiple, though more often per- haps single, and associated with them may be observed dense, fibrous nodules representing healed foci. Their interior may be lined with a smooth, cuticular structure resembling mucous membrane. Interstitial Pneumonia.—In the course of chronic phthisis interstitial inflammation of two sorts will most probably arise: (a) A consolidation excited by the tubercle bacilli themselves, and hence manifesting a de- structive tendency; (b) A slowly-developed interstitial pneumonia which aims at arresting the progress of the affection. It develops in close proximity to caseous masses and around cavities. The new connective tissue thus formed in obedience to the well-known pathologic law tends to contract secondarily, and thus vomicae are often partly, though sel- dom entirely, obliterated. The shrinking of the connective tissue may also result in compression, and finally in the destruction of pulmonary tissue, just as in a tuberculous inflammation. The process in this in- stance, hoAvever, is on the whole conservative and calculated to repair tuberculous lesions. Disseminated Tuberculosis.—Miliary Tubercles.—This form has for its chief characteristic miliary tubercles, which are scattered not only about the tuberculous area, but also throughout the rest of the lung, and usually in the loAver lobe. Most of the tubercles undergo fibroid or fibro-caseous change. These minute, hard gray or grayish-yellow nodules vary in size from a mustard-seed to that of a pea, and lung- tissue that is more or less studded with chronic miliary tubercles is apt to look pale, Avhile the surrounding air-cells are emphysematous. The condition may lead to pneumonia, and the Avhole aspect then becomes altered. Here, as before described, fusion of miliary tubercles results in larger masses which become caseous, and hence the method of cavity- formation is identical with that observed in tuberculous broncho-pneu- monia. In the disseminated form tubercles may also be found in many other organs than those indicated (pleura, trachea, larynx, bronchial and other lymphatic glands, peritoneum, spleen, kidneys, liver, brain, mu- cosa, testes, etc.). Lesions of the Pleura.—This membrane is hyperemic and coated with fibrinous exudation coextensively with the affection of the parts in chronic ulcerative phthisis. The pleural membranes are only more or less thickened by organized adhesions, but in the latter and also in the pleura tubercles or cheesy masses may be found. Simple and other forms of pleurisy are also met with—sero-fibrinous, purulent, and hem- orrhagic. Lesions of the Bronchial Glands.—At first these are enlarged and CHRONIC TUBERCULOSIS. 289 edematous, containing tubercles, and later they present foci Avhich often undergo purulent disintegration and sometimes calcification. Other lymphatic glands than these may be affected (mesenteric, etc.). Lesions of the Larynx.—The larynx is frequently the seat of tuber- culous infiltration and ulceration, particularly in certain parts, such as the vocal cords, posterior Avail, ary-epiglottidean folds, etc. Lesions of the Heart.—Tuberculous endocarditis is present in about 5 per cent, of the cases, and congenital stenosis of the pulmonary ori- fice is noted in not a few instances (Chevers). The right heart is often hypertrophied or dilated. Other organs may present lesions in chronic phthisis, and these will be spoken of in connection Avith the clinical history. Tuberculosis of the intestinal canal is a common though late lesion. Amyloid degeneration of certain organs is a not unusual secondary event, especially of the kidneys, liver, spleen, and intestinal mucosa, and in like manner enlargement of the liver due to fatty infiltration is noted not infrequently. Clinical History.—The mode of invasion is quite diverse, but with few exceptions the onset is either (1) gradual or (2) abrupt, and, as a rule, the health has been previously undermined for a longer or shorter period. (1) Gradual Onset.—(a) Most frequently the disease originates in a manner similar to the origin of ordinary bronchitis, and often, com- bined with the symptoms of broncho-catarrh, are those of pleurisy. Tuberculous bronchial affections often follow certain acute infectious diseases—influenza, typhoid, measles, Avhooping-cough, etc.—and in this form are rarely curable. The physical signs may be negative for some time, and then appear at the apex of the lung. Over a small area there may noAv be slightly impaired resonance on percussion, with harsh broncho-vesicular breath-sounds and Avith or Avithout subcrepitant rales. The expansion, as noted on inspection and palpation,'over the affected spots is more or less defective, Avhile the vocal resonance and fremitus are either increased or unaltered; and the fact that the lesions are more commonly detectable in the suprascapular fossa than anteriorly must be remembered. At this period obvious constitutional disturbances are present (debility, emaciation, fever, etc.). (b) Onset with Pleurisy.—This may be sudden, as in an acute pleu- risy with effusion, but often the latter condition develops insidiously. Of 90 cases of pleurisy with effusion, one-third terminated in chronic phthisis (Bowditch). It may begin as a dry pleurisy at the apex, either anteriorly or posteriorly, or the evidence of pleurisy may be associated with the more common or bronchitic onset. (c) With Gastro-intestinal Symptoms.—There is impaired digestion, and soon the patient becomes anemic, loses flesh, and is debilitated. Later, the first indications of pulmonary tuberculosis develop in the lungs. (d) With i?tdefinite peritoneal symptoms, lasting for months or even years. (e) With Laryngeal Symptoms.—This is a rare form. It begins with hoarseness, more or less aphonia, and considerable cough; there is also a slight muco-purulent expectoration. Laryngoscopic examinations may 19 290 INFECTIOUS DISEASES. defect tuberculosis of the organ, and tubercle bacilli may be found in the sputum before involvement of the lungs is discoverable. (2) Cases with Abrupt Onset.—(a) The most important group under this category is heralded by the symptoms and signs of acute pneumonia, more commonly of the lobular variety. As compared with ordinary pneumonias, these present some peculiar features : the fever is irregular and the expectoration is more abundant, is blood-stained, and contains bacilli. The signs are usually located in the apical region. Resolution may occur, but recovery is not complete, and the condition is likely to pass into chronic phthisis. (b) Onset with Fever.—Chills and fever are apt to arise in all instances in the advanced stage of pulmonary tuberculosis, and these symptoms may also initiate the attack. There is no mistake in diagnosis more commonly made in malarial regions than to ascribe such cases to pal- udism. (c) With Hemoptysis.—This symptom may be the first to invite at- tention to lung-trouble. In the majority of cases the amount of blood lost is considerable, and, less frequently, repeated slight hemorrhages occur. Pulmonary symptoms may be absent, sometimes temporarily, and in rare instances, perhaps, permanently ; but in a great proportion of cases the clinical picture of incipient pulmonary tuberculosis is re- vealed pursuing its accustomed course immediately after the occurrence of the hemorrhage. The physical signs may be latent for a time, and, Avhilst they are usually found to be at the apex, they may assume the guise of a pleurisy in the scapular or infrascapular region. A slight tuberculous lesion is most probably present in these cases before the occurrence of the hemorrhage. The Symptoms are (1) local and (2) general (1) Local.—(a) Pain.—This is absent in many cases of chronic phthisis and in others it may be moderately severe. It is seated usually at the base, laterally or anteriorly, and not rarely there is pain of a lancinating character in the interscapular region in the early stages of the affection. This symptom is of diagnostic worth only after other forms of pain (rheumatic, neuralgic, etc.) have been excluded. The most common cause of pain is pleuritis, Avith or Avithout pleuritic adhe- sions ; it is increased on deep breathing and coughing. Intercostal neuralgia and pleurodynic stitches may also develop in the course of this disease. (b) The Cough.—This may be looked upon as an essential feature, though in a feAv instances it may be slight or even Avanting throughout. Its severity bears no constant relation to the extent of the pulmonary lesions, but rather to the degree of sensitiveness of the patient. It is dry and hacking at the beginning, and, if the larynx be involved, the cough is marked and takes on a hoarse quality. It is most pronounced at certain periods of the day—viz. on lying doAvn at night and on awaking from sleep. Paroxysms may also occur after meals, and these occasionally induce vomiting. The cough is at times distressing and debilitating in its effects. (c) Expectoration.—At the beginning the sputum is scanty and mu- coid, rarely hemorrhagic, or it may be merely streaked with blood; later it may become muco-purulent, and the appearance of small gray CHRONIC TUBERCULOSIS. 291 or grayish-yellow flocculi first suggests the nature of the affection. With the onset of the stage of cavity-formation the sputum becomes more abun- dant and more distinctly purulent, and, after the formation of cavities of any size, airless, opaque, and nummular (coin-shaped) masses are expec- torated. The latter are greenish-gray or greenish-yellow in color, and sink rapidly Avhen discharged into water. They are often mingled with more or less bronchial secretion, and are not entirely characteristic of tuberculous cavities, being sometimes observed in pure bronchitis. They mav even be absent, and the expectoration be merely purulent. The open- ino-" of a fresh cavity may be followed by very free expectoration. The sputum is sometimes fetid, and exceptionally it is horribly offensive, vary- ing greatly in amount in different cases and at different stages of the dis- ease. In certain cases it is absent throughout the greater portion of their course, and is especially apt to be slight in children and old people. In such instances it may be impossible to collect sufficient sputum to ex- amine for bacilli. Microscopic examination discovers alveolar epithelium (particularly in the earlier stages), pus-cells, blood, fat-globules, elastic fibers, and tubercle bacilli, the detection of the latter being the most important factor in the diagnosis. It may be safely stated that the finding of bacilli in the sputum is prima facie evidence of chronic phthisis ; on the other hand, however, their absence in the early stage does not exclude the disease. It is often needful to make repeated and delicate examina- tions of the sputa—a course that will finally bring ample reAvard if the case is one of phthisis. It is also of the utmost importance to select for examination the small grayish masses that are usually to be found, since they early contain the bacilli. "A small amount of the purulent portion of the sputum is spread in a thin and uniform layer on a perfectly clear cover-glass by means of forceps, needles, or the Ohse, which must previously be held a moment in the flame of a Bunsen burner or a spirit lamp, or by pressing a small amount of sputum between tAvo cover-glasses, then sliding them apart. It is then dried in the air, or more quickly by holding the cover-glass with forceps some distance above the flame of a burner or lamp. Finally, it is to be passed three or four times through the flame, and so 'fixed (Musser). The preparation may be stained with carbol fuchsin (basic fuchsin 1, alcohol 10, 5 per cent, solution of carbolic acid 90), either by dropping a few drops of the stain on the smeared side of the cover-glass and holding it above the flame until it steams, or by floating its face doAvn- ward upon a watch-crystal containing the solution. It must then be decolorized either wTith a 10 per cent, solution of nitric acid, alloAving it to remain until the red color has entirely disappeared (about fifteen seconds), and then Avashing and counter-staining writh methylene-blue, or with Gabbett's solution (methylene-blue 2 gm., sulphuric acid 25 c.cm., water 75 c.cm.), in which it must remain until the red color has been replaced by a faint blue (thirty seconds or more). Instead of car- bol-fuchsin, anilin gentian violet may be employed (add a saturated alcoholic solution of gentian violet to a filtered saturated solution of anilin until a metallic luster appears on the surface). The specimen may lie either several hours in a cold solution or a few minutes in one 292 INFECTIOUS DISEASES. that is steaming. Decolorize with the nitric-acid solution and counter- stain Avith rubin or Bismarck broAvn. It is often much simpler to smear the sputum directly upon the slide, and then examine, Avhen stained Avithout the intervention of a cover-glass. A much larger amount of sputum can thus be prepared at a single operation. In the microscopic examination use a-jij-inch (2.11 mm.) oil-immersion lens and Abbe condenser, or, at the least, \- or -|~inch (0.30 cm. or 0.31 cm.) objective. If carbol-fuchsin has been used in staining for the ba- cilli, and methylene-blue as a contrast, the former will be found as red rods in a blue field (background), Avhile if gentian violet has been used, the tubercle bacilli appear as dark blue rods, with all other bodies broAvn, if Bismarck broAvn is used for the contrast stain. There may be visible in the field a few bacilli only, particularly during the early part of the case. In this stage of cavity their number is usually in- creased, and sometimes they are quite numerous. The demonstration of elastic fibers is also an important aid to diag- nosis. Fenwick's method is the following : Boil the sputum with an equal quantity of a solution of caustic soda (gr. xv-^j—0.972-32.0); pour the product into a conical glass and fill Avith cold Avater. The sedi- ment is. subsequently examined with care for elastic fibers. The method of Sir Andrew Clark possesses the advantages of being simple and speedy : " The thick, purulent portions are placed on a glass plate, 15 X 15 cm., and flattened into a thin layer by a second glass plate, 10 X 10 cm. In this compressed grayish layer betAveen the glass slips any fragments of elastic tissue show on a black background as grayish-yellow spots, and can either be examined at once under a low Fig. 26.—Elastic fibers (after Striimpell). power or the uppermost piece of glass is slid along until the fragment is exposed, when it is picked out and placed upon the ordinary micro- scopic slide " (Osier). The form and appearance of the elastic threads differ materially according to their special source. If they come from the alveoli, there is an interlacing of the fibers which may preserve the globular contour of the air-cells. If they come from the blood-vessels, they are single and elongated, or two or three of the fibers may be arranged side by side. Elastic tissue derived from the bronchi presents much the same appearance as Avhen it comes from the vessel-walls. The presence of elastic fibers furnishes incontestable proof that destruction of lung-tissue has taken place. To show that this loss of structure, however, is due to tuberculosis, we must exclude abscess (an CHRONIC TUBERCULOSIS. 293 exceptional event) and gangrene of the lungs—diseases in Avhich it also occurs. Hemoptysis.—This symptom of phthisis will be spoken of under Dis- eases of the Lungs, but its importance as a diagnostic feature of this disease makes special reference to it here absolutely necessary. It is present in the majority of cases, exhibiting, hoAvever, the Avidest vari- ations both in the amount of blood expectorated and in its frequency of occurrence. The sputum may be merely blood-stained or the hemor- rhage may be excessive and prove rapidly fatal, though hemoptysis is rarely the direct cause of death in tuberculosis. Slight hemorrhages are usually produced by mere hyperemia, and are most apt to occur dur- ing the early stages, while severe bleedings are produced by the erosion of a blood-vessel or rupture of a small aneurysm, and are most prone to occur during the stage of cavity. In certain cases hemoptysis is fre- quent. A third or capillary form of hemorrhage may occur in phthisis with cavity-formation, and in this variety, Avhich is of a rather frequent occurrence, the purulent sputum is uniformly stained with blood. It may also be nummular, but presents a reddish-brown or chocolate color. The exciting cause is seldom obvious, though in not a feAv instances ag- gravation of the cough, and in others great mental excitement, would appear to excite bleedings. Slight hemorrhages often, and severe ones rarely, afford more or less relief to the pulmonary condition. On the other hand, severe bleedings usually exert an unfavorable influence, being folloAved by debility and anemia. Moreover, in numerous cases hemoptysis is folloAved by a more rapid extension of the local lesions, with corresponding aggravation of the local and general manifestations. The fact remains, hoAvever, that the effect of severe hemoptysis upon the progress of chronic phthisis is by no means ahvays untoAvard. In a case of my OAvn there occurred periodically copious spontaneous bleed- ings (in spring and fall) for three years, which were as regularly fol- lowed by marked improvement for a period of three or four months. The physical signs of phthisis were absent until after that time, when a small area of consolidation Avas detected near the left apex. The pa- tient Avas a male aged tAventy years, and was sent to the Adirondack region, where the hemorrhage failed to recur and he made a complete recovery. Dyspnea is present, but is not a marked feature, as a rule, despite advanced pulmonary lesions. Perhaps the chief reasons for a lessened demand for oxygen on the part of the system are—first, the slow and gradual manner in which the lesions develop; and second, the pro- nounced bodily wasting. The respirations, however, are moderately increased in rate, averaging from 20 to 30 per minute, and this compen- sates admirably for the diminished breathing-space. The dyspnea may be greatly intensified, however, as the result of intermittent pneumonia, pleurisy, active exertion, or great mental excitement, and toward the close of fatal cases the most intense dyspnea may be manifested. Physical Signs in the Stage of Consolidation.—Inspection gives most important results. The paralytic or phthisical thorax is generally pre- sented to view. It is flat, particularly the upper half; the intercostal spaces are Avide; the ribs slope at a sharp angle from the sternum, mak- 294 INFECTIOUS DISEASES. ing the epigastric angle acute and producing elongation of the chest. The same sharp inclination doAvnward from the vertebral column is observed latterly and posteriorly. The angle of Louis is prominent, and the depressions (supra- and infraclavicular, intercostal, etc.) are deepened, the costal cartilages being often prominent and the sternum, particularly in the lower part, sometimes much depressed or even con- cave (funnel-breast). The scapulae stand out prominently and may be distinctly Avinged. A second type of paralytic thorax is narrow and long. Pulmonary tuberculosis may, hoAvever, arise in chests of appa- rently normal build. With the development of phthisis at the apex the depressions of the side affected are relatively deeper, Avhile the clavicle often stands out more prominently. The paralytic thorax is often a resultant of developed phthisis, and occurs in subjects in Avhich the chest was normal, preceding the invasion of the disease. Finally, both nar- roAving and flattening of the upper parts of the chest may result from great emaciation. Defective expansion is observed early, and usually at the apex of the side first affected ; subsequently this may be more general, and finally bilateral. To note the motions of respiration Avith precision the exam- iner should occupy a position exactly in front of the median line of the patient's body. The difference in the movement of the tAvo sides often becomes more apparent on deep respiration than on quiet breathing, and Avhile at rest the respirations are almost normal, but exertion decidedly increases their frequency. Palpation.—Testing the expansion by palpation gives better rela- tive results than does inspection. To determine the relative movements of the apices the extended hands should be so placed (by allowing them to diverge below) that the tips of the fingers touch the loAver border of the clavicle, and then the patient should be asked to breathe deeply, though slowly. The expansion in the supraclavicular spaces is tested by7 standing behind the patient and using the tips of the fingers, or by allowing the tAvo first fingers of each hand to pass parallel with the clavicles. In this way " lagging " over the apex will be the first symp- tom recognized, and may for some time be the only one. Tactile fremitus is early increased Avith oncoming consolidation, due to the growth of the tubercles, though it is normally more marked at the right than at the left apex. If there be great thickening of the pleura, however, it is more or less diminished, and if there be pleural effusion, it is usually absent. Mensuration.—The difference betAveen the measurement of the chest in inspiration and expiration in any person of average health should be not less than three inches, and a difference below tAvo and a half inches points strongly to tuberculosis. Percussion.—Resonance is deadened more and more as consoli- dation progresses. If the consolidated areas are minute, however, the percussion-note may be unchanged, and as the air-cells surrounding the latter are often emphysematous and relaxed, the note may be somewhat tympanitic. In many cases the tympanitic sound and deadness are intermingled, giving rise to the so-called tympanitic deadened sound. Slight dulness is, as a rule, noted first below the clavicle, though in not a few cases it is first detected upon and above the clavicle. The corre- CHRONIC TUBERCULOSIS. 295 sponding regions of the tAvo sides must be compared during a held inspi- ration, and also during a held expiration. The degree of dulness can sometimes be better estimated by comparing the apical note with that obtained lower down on the same side, allowing for the normal topo- graphic differences of intensity. The latter method is especially applicable to cases in Avhich both apices are involved. Impaired reso- nance may be detected early in the supraspinous fossa, and less frequently in the interscapular space if the subject be not too stout, though slight dulness in the absence of other signs has little diagnostic value. As the lung-tissue becomes airless throughout an area of considerable size it is markedly deadened, until dulness is heard ; finally, Avith extensive consolidation the note may be Avooden and the feeling of resistance be much increased. Auscultation.—The vesicular breathing may be sharpened, OAving to narrowing of the smaller bronchi, but more often perhaps it is dimin- ished by the swelling and secretion. The corresponding regions on the tAvo sides must be compared—first during quiet, and then deep breath- ing, and it should be remembered that prolonged expiration is an early and important diagnostic mark, at first being someAvhat sharpened, and later distinctly bronchial. Tuberculous bronchitis may cause interrupted or jerking inspiration at the apex. If heard elseAvhere, little value is to be given it. With lobular consolidation at different points in the region affected, the conditions favor the transmission of the bronchial sounds, but these are toned doAvn by the remaining intact air-cells; hence there is ''transition " or broncho-vesicular breathing. With com- plete consolidation pure bronchial breathing is audible, and with the latter two forms of breathing crepitant or subcrepitant rales are heard. Sometimes the first rules have a Ioav whistling sound, which accompany the long expiration ; Avith liquefaction they become more moist, are louder (sometimes ringing), and often bubbling, and may be heard on inspiration and expiration. If scanty, they may be audible on inspira- tion only, though they are increased by coughing. If the moist crepi- tant and subcrepitant rales, often due to concurrent bronchitis, be very numerous, the breath-sounds will be obscured, but after free expectora- tion as the result of coughing the exact quality of the breath-sound is appreciable. Pleuritic friction-sounds may be heard, due to accompanying pleuri- tis sicca, and these may be audible before the bronchial rales reveal the disease. Friction-sounds and rales often occur together. Pleuro-peri- cardial friction is present Avhen the " lappet " of lung over the heart is affected, while clicking rales, occasioned by the heart's systole, are audible when the same area is pneumonic. The vocal resonance in- creases Avith the progress of the consolidation, and when the latter is complete bronchophony (rarely pectoriloquy) is present. In the sub- clavian arteries a systolic murmur is not uncommonly heard, the latter being supposed to be due to pressure exerted by the thickened pleura upon these vessels. 296 INFECTIOUS DISEASES. Pig. 27.—1. Small cavity near periphery, with thick relaxed walls, containing secretion and communicating with a bronchus (vide subjoined table). 2. Large parietal cavity, with thin, tense, smooth walls, communicating with a bronchus (vide table). Physical Signs. (a) Percussion-deadness on a strong blow, mere impairment of resonance on a light blow; "Wintrich's inter- rupted change of sound, detectable when patient is upright, but not when recumbent. (b) On auscultation low-pitched cavern- ous (hollow) breathing; gurgling (ringing) rales. (c) Pectoriloquy indistinct, owing to small size of cavity and the con- tained fluid. Physical Signs. (a) Amphoric percussion-resonance, cracked-pot sound, and Wintrich's change of sound. (b) On auscultation, high-pitched am- phoric (musical) respiration and metallic rales. (c) Amphoric (musical) voice and am- phoric whisper. Physical Signs of Cavity.—Inspection shows a more marked retraction and a more decided lack of local motion than during the previous stage. The degree of shrinking is proportional with the extent of fibrous-tissue formation. Palpation corroborates inspection as to lack of motion, and gives increased tactile fremitus if the cavity connects with an open bronchus and if it contain but little secretion. Excessive secretion interferes with conduction of sound. Percussion.—Resonance is generally more or less impaired in con- sequence of the consolidation of the surrounding lung-tissue. The note may be someAvhat tympanitic, but varies Avith the position of the cavities, the amount of fluid secretion contained by them, the condition of their Avails, and the vibratory capacity both of the latter and of the individual thorax. Cavities of the size of a Avalnut situated in the apices usually give a distinctly tympanitic note, Avhile cavities of the same dimensions, or even larger, in the lower portion of the lung do not. The metallic tone is especially noticeable over large cavities with smooth walls. The tympanitic sound may be deadened by closure of the connecting bronchus and by temporary filling of the cavities with secretion, and, again, if they are surrounded by thickened lung-tissue or by a large thickened pleura, there may be impaired resonance or absolute dulness even. Certain special conditions change the tympan- �28726�34322 CHRONIC TUBERCULOSIS. 297 itic sound over a cavity. Thus the note will be louder and exalted in pitch when the mouth is opened wide, and lowered when the mouth is closed (Wintrich's sign), there being dulness Avhen the mouth is closed and tympanitic resonance Avhen the mouth is open. If the cavity com- municates freely Avith the bronchus, it may be necessary to change the position of the patient, and a tympanitic note may change in pitch with change in posture (Gerhardt's change of sound). If the patient changes from the dorsal to the upright position, resonance may give way to more or less flatness, since the fluid contents of the cavity are thus brought into contact with the chest-wall, and, although an almost certain sign of a cavity when present, it is exceedingly rare. The so-called cracked- pot sound is often elicited over large parietal cavities with thin walls, and may be quite intense ; but, since it also occurs in many other patho- logic conditions, its diagnostic significance in this disease is subordi- nate. There may even be normal resonance if the cavity is covered by a layer of unaffected air-cells of considerable thickness. Auscultation over small vomicae Avith lax Avails reveals cavernous (loAv-pitched) breathing, Avhile over large cavities Avith tense walls (if parietal and communicating Avith a tracheo-bronchial column of air) it gives amphoric (higher-pitched) respiration. Moist rales (bubbling and gurgling, according to the consistency of the secretion) may7 be pres- ent, and these correspond in the main to the amphoric breathing, hence being heard most frequently over large, smooth-walled and periph- erally-located cavities. The gurgling and slushing sounds caused by the air bubbling through the secretion in a cavity are ahvays intensified by coughing. The sounds of falling drops (metallic tinkling) may be heard over large vomicae with tense, smooth walls containing thin secretion. Pec- toriloquy and amphoric whispers are the vocal sounds heard over huge cavities, and to the latter should be given the greatest diagnostic sig- nificance. General Symptoms.—(a) Fever.—Whilst the disease is progressing fever is a constant, significant, and, it may be, the earliest, symptom. If a two-hourly record be kept for a few days, from time to time an accurate conception of the course and type of the fever can be formed. In the first and middle stages the highest temperature occurs about 4 or 5 P. M., the lowest about 4 or 5 a. m. The fever may be continuous, remittent, or intermittent, and in a general way these types, in the order named, cor- respond to the stages of tuberculization, softening, and cavity-formation. Modified types, due to the fact that the lesions often and simultaneously represent different stages, are also observed. Apyrexial periods are met with in the early as well as the late stages of chronic phthisis, and indi- cate cessation of the processes of tuberculization and caseation. A continued fever is most apt to be met with during the initial period of phthisis, the evening temperature sometimes registering but a degree higher than the morning. A similar curve may be presented at any later time if acute pneumonia supervene, though it is to be recollected that the remissions in such cases are usually greater than in primary lobar pneu- monia. A remittent fever is more common than the preceding type. It may be present from the start, but is oftener seen in the middle, and less fre- 298 INFECTIOUS DISEASES. quently in the advanced, stages of phthisis. This form of fever points to softening (see Fig. 28). 104 103 102 101 100 99 98 1 A / A /\ A / /\ / \ A / \ / \ \ / \ / A A / \ / \ / \ / 1 A A /\ / \ ' f /\ / \ \ i / i ' , / \ / / ] \ / j , / \ h- h \ i ' \ \ / \ / \ \ \ / \ / / w \ \ \ / \ , ' \ / xt \ \ \/ \ / \ / V V \ \/ \ / \ V V \ / \ \/ \ V \ \ \ Fig. 28.—Temperature-chart of a case of phthisis. Quiescent cavity in right apex, and com- mencing excavation in left apex. Robert G---, aged 21 years; dyer. An intermittent fever is also frequent, and is characteristic of cavity formation, suppuration being invariably associated with the latter process. F 105G —> in° to K _■ V -j L- , t Q. <£> i r —£—zp—I---- —A- 1 A I A 00° t u 39 =• t t < / ' / V i„ i A _iz i /' L _/ V f L I 1 , ° J~ /4_t n _t \ --^-.zz&±zz4-zz-r- 2 ' At- ' \- rv i t ■I \- -J r- i- -j V t A _pj - ^1 4 V 1 V h A 38° 3 / ± d r 1UU t nf t -jt [-l\t r A -, A -C t -i A I ■' t ? 1 \ J \ *h < 99' A I t 3 _A__T----i|t------^ =t—SF---J-J--- p# =Tl .ipi==EEF||EE= - g/l~ "-2-- ~_t 137° 98-------*-----------fj------- ------ ~I=I~~~~~II~J Fig. 29.—Temperature-chart of a case of phthisis. Cavity in left apex, giving cracked-pot sound, AVintrich's sign, etc. George C---, aged 22 years; glass-worker. The temperature may be intermittent from the start, suggesting malaria to the unguarded; but it is due to sepsis, the temperature rising during CHRONIC TUBERCULOSIS. 299 the day, beginning usually shortly before noon, and reaching its maximum at from 5 to 8 p. m. It now falls slowly until about 4 or 5 A. m., and then rapidly reaches the minimum—a subnormal point—usually at from 6 to 10 A. M. For a considerable portion of every twenty-four hours the temperature may be below7 the normal, sometimes dropping as low as 95° F. (35° C). (See Fig. 29.) (b) Night-sweats occur in a large majority of the cases. They may appear during any part of the course of phthisis, though most apt to occur and be most marked during the progress of cavity-formation; they show themselves in the early morning hours simultaneously with the rapid decline in the temperature, and may appear during sleep at any period of the day. They may be light and limited to the neck and upper por- tion of the thorax ; on the other hand, they are often excessive, saturat- ing the bed-clothes and inducing great exhaustion. The drenching sweats are dependent partly upon the fever and partly upon the existing weak- ness, though slight exertion may also engender free perspiration. (c) Emaciation occupies a prominent place in the symptomatology, the muscular and fatty tissues being involved to an equal degree (Strumpell); the extremities and soft parts of the thorax are most affected. It must be remembered that an exalted grade of emaciation may be present at an early period, and in such cases it may be assumed that the thinness of flesh was a precursory state. In nearly all cases an extreme degree of emaciation, reducing the patient to a slightly covered skeleton, is reached before the end. The causes of emaciation are chiefly the persistent fever, the loss of appetite, and the feeble digestive and assimilative poAvers. It is an almost invariable rule that during the afebrile periods, associated as they are with improved appetite and digestion, the patient gains in flesh and strength. (d) The pulse is rarely increased in frequency, is of good volume and regular in rhythm, though of low tension (soft). When suppurative fever sets in the pulse becomes very frequent, small, and compressible, and the capillary pulse is often observed; rarely venous pulsation may be noted in the back of the hands. (e) Anemia is one of the symptoms evidencing impaired nutrition, and seems to appear in certain cases before the more obvious local lesions. The objective changes pointing to anemia are pronounced (pallor of lips, visible mucous membranes, and skin). The blood presents nothing cha- racteristic. In the early stage it may be normal, or in some cases chlo- rotic in type, the hemoglobin being decidedly deficient; later in the dis- ease, when consolidation is advanced, the blood may be wholly normal; but Avhen there is cavity-formation and hectic fever, there is often a very considerable leukocytosis, as many as 50,000 leukocytes per cubic milli- meter having been observed. The differential count shows a great excess of the polynuclear cells. It is not unlikely that the condition is due to secondary infection by the pyogenic micro-organisms, and especially by the streptococcus. General debility is complained of in all cases. It is usually progres- sive and may amount to a feeling of utter exhaustion. Symptoms and Complications presented by Other Organs.—(a) The Heart. —The pulse and the blood-appearances have already been described. With retraction of the upper lobe of the left lung the area of the heart's impulse 300 INFECTIOUS DISEASES. is obviously increased, particularly upward, so that pulsation may be visi- ble in the fourth, third, and even second interspaces, near the sternum while the normal apex beat in the fifth interspace may be wanting. Sys- tolic murmurs both at the apex and the pulmonary orifices are often audi- ble, and occur independently of valvular lesions, though the latter may supervene or may constitute an associated condition. Chronic endocarditis affecting the tricuspid segments is not infrequent in phthisis. (b) Gastro-intestinal Tract.—The tongue may be furred : more often it and the mouth and throat are red, showing increased irritability. The pharynx may be the seat of tuberculous lesions, Avhich may interfere greatly with deglutition, aphthous ulcers being common, while thrush may also appear in the later stages. The appetite is impaired or lost: thirst is annoying, and the symptoms of subacute and chronic gastritis (inter- stitial and parenchymatous) often obtain. With the latter is not infre- quently associated a catarrhal ulceration, and with equal frequency, per- haps, dilatation ; and the stomach may be so irritable that the presence of food, or even coughing, at once excites vomiting: this symptom is most troublesome during the third or last stage of the affection. A study of the gastric secretion gives variable results, there being an early hyper- acidity, while later the secretion is subacid. The causes of gastric symptoms are not clear. The mucosa is the seat of venous engorgement, and may thus occasion the catarrhal changes that are present in many instances. There are not a few cases, how- ever, in which the symptoms are serious without adequate local anatom- ic changes to explain them. The intestinal symptoms are but little less important than the gastric. During the early stage constipation is a frequent condition, and yet few cases run their entire course without manifesting diarrhea. The latter symptom may occur at any time, but is most prone to appear at an ad- vanced period, and may pursue an intermittent course. Occasionally it alternates wTith periods of " hectic fever," and late in the affection a Avatery discharge may develop (colliquative diarrhea). The intestinal lesions are of three sorts : (a) catarrhal, (b) ulcerative, and (c) amyloid. These often arise in the order enumerated, but are not infrequently combined in va- rious ways. Hemorrhoids and anal fistulae are among the common com- plications. (c) Genito-urinary Organs.—There is frequently an albuminuria that may either be of an ordinary febrile nature or due to chronic nephritis (productive and non-productive). Chronic nephritis is usually a late devel- opment, and is associated with a rather marked albuminuria, the presence of tube-casts in the urine, and dropsy. Amyloid changes may also set in toward the close, attended by their characteristic urinary phenomena. As secondary events tuberculous pyelitis and cystitis, with the appearance of pus and rarely blood in the urine, may develop. Hematuria may also result from temporary congestion. The testes may be implicated, and a routine inspection of these organs, as suggested by Osier, should not be neglected. (d) Cutaneous System.—Cyanosis occurs, but, being of a moderate degree, it is often veiled by a decided pallor. The cheeks often wear a "hectic flush," and the skin, late in the affection, is apt to be dry,harsh, and scaly. Among the cutaneous appearances are pigmentary stains over CHRONIC TUBERCULOSIS. 301 the chest (chloasmata phthisicora), and seated in the same regions as Avell as upon the back are frequently seen brown stains (pityriasis versicolor). The hair over the chest often becomes gray; that of the head and beard, long and harsh. The finger-ends are often bulbous (clubbed), Avith in- curved nails, though this is not peculiar to chronic phthisis, and crack- ing of the finger-nails is also often observed. (e) Nervous System.—The mental attitude is characteristically hopeful and buoyant, even in the advanced stages. Hence the patients are read- ily encouraged by the unscrupulous to believe that their condition is improving, despite the steadily unfavorable progress of the disease, and, indeed, they may be in an utterly helpless state, and yet confidently ex- pect to recover. The cerebral symptoms are rarely marked, and the mind, as a rule, is exceptionally clear. Tuberculous meningitis and ine- ningo-encephalitis may develop secondarily, and I have met with cerebro- spinal meningitis in one of my own cases. Osier has seen two cases in strong, robust men " in Avhom the existence of pulmonary phthisis was not discovered until the post-mortem." Focal lesions, due to the presence of tubercles, may produce forms of paralysis (aphasia, hemiplegia, etc.) according to their location. Rarely peripheral neuritis (usually an ex- tensor paralysis of the leg) is observed. Insanity, quite independently of nervous lesions, is a rare complication. (/) Chest-muscles and Mammary Glands.—The former are abnormally irritable, and sometimes even painful on percussion, and the mammary gland is in rare instances hypertrophied, males suffering most; but, as pointed out by Allot, the affection is a chronic non-tuberculous mammitis, and hence a true complication. Diagnosis.—The early recognition of chronic pulmonary tuberculo- sis often tests severely the diagnostic acumen of the physician. The general and local symptoms, including the physical signs, may afford merely a strong suspicion of the existence of phthisis, and in such in- stances repeated examinations of the sputum for the bacilli are impera- tive, and only when they are found is the diagnosis set at rest. Repeated staining of the sputum may be necessary for the detection of tubercle bacilli. It is also desirable to determine Avhether they are constantly present by re-examinations at intervals. There are not a few cases in which the physical signs are clearly obvious, and in which the bacilli are either not at all detectable or only after several examinations: and the fact that a certain diagnosis is made possible only by the demonstration of the bacilli in the sputum in the incipient stage of the affection makes a continued search for these micro-organisms the first duty of the physician in cases presenting suspicious signs and symptoms. An absence of the bacilli, however, does not justify a denial of the existence of phthisis, and is of little negative value. In a certain percentage of cases the careful study of the symptoms and general course of the disease is of paramount importance; and of these symptoms the most valuable are cough, expectoration, fever, progressive emaciation, and the constant presence of certain physical signs situated at the apex on one side (flat- tening of the front of the chest, defective expansion, slight deadening of the percussion-note, and a change in the vesicular murmur, with or with- out adventitious sounds). The diagnostic import of elastic fibers in the sputum is also to be borne in mind. The physician should appreciate 302 INFECTIO US DISEASES. fully his own grave responsibility in all cases of suspected phthisis, and earnestly endeavor to determine the diagnosis early Avhile the condition yet admits of cure. In the more advanced stages of phthisis the diagnosis is rarely dubious or even difficult, and is made usually from the characteristic features-— local and general—Avhich are confirmed by a microscopic examination of the sputum. Differential Diagnosis.—In the very early stage the local condition may be obscured by the general features, and most frequently by the fever, though it may also be by the evidences of anemia or the gastric symptoms, Avith a falling off in the general health. The danger of con- founding these conditions Avith phthisis is slight if the various modes of onset previously described be kept in remembrance. Bronchial catarrh is with great difficulty discriminated from beginning phthisis. If the temperature is elevated from 2 to 5 P. M., and not at all or only slightly above the normal night temperature in the evening, the probabilities are greatly in favor of tuberculosis (Barlow). The condition of the lungs must be carefully compared, since in bronchial catarrh there is no dulness, and moist rales, that vary in intensity from one day to another, are heard equally on both sides. From time to time rales may also be heard at the bases in bronchitis. In phthisis one apex is more involved than the other, the moist sounds not being heard equally low, and after repeated coughs with subsequent deep inspiration the rales are more apt to remain than in ordinary bronchitis. In phthisis, also, there is a gradual loss of flesh and strength—a feature that is absent in bron- chitis. In diagnosing between these affections in doubtful cases it is of the utmost importance to repeatedly examine the sputum for tubercle bacilli. Phthisis in the stage of cavity may be confounded with bronchiectasis. The points of discrimination are, however, given under the latter affection (Diseases of the Lungs). Fibroid Phthisis. Definition.—Fibroid phthisis implies induration followed by con- traction of the affected lung-tissue, due to an increase in the connective- tissue elements. There are cases in which it cannot be distinguished pathologically from chronic pulmonary phthisis, but from a clinical point of view the two affections present distinctive peculiarities. The majority of instances are primarily tuberculous, though manifesting a strong tend- ency to the formation of fibrous tissue—a conservative process; in other instances the fibroid change may be primary, followed by tuberculous infection (vide Pneumonokoniosis). The usual form arises variously as a sequel of other morbid processes, such as— (1) Pneumonias, acute lobar (very rarely) and catarrhal pneumonia (commonly). (2) Pulmonary lesions, such as a tubercle in the stage of consolidation or cavity. (3) Chronic tuberculous pleurisy. (4) Bronchial catarrh from inhalation of irritants (steel-, coal-, or mineral-dust). As stated under the description of pneumonokoniosis FIBROID PHTHISIS. 303 (vide), this condition may be found to be a tuberculous process accom- panied by fibroid change. Pathology.—The process in the beginning is very often localized in one apex, and less frequently in the middle portion of the lung or in the bases. It may remain circumscribed, but more often it extends down- Avard, and gradually invades the entire lung. It is unilateral. Second- ary to the induration and contraction there is dilatation of the bronchi, and rarely bronchiectasis may precede the fibroid induration. The lung-tissue is hard and dense, the alveoli being obliterated. It resists cutting and creaks on pressure, and the section presents a smooth, dry, gray, often marbled aspect, though the fibrous tissue may undergo caseation. Tuberculous lesions may also develop in the opposite lung and in still other organs. The pleura is thickened as a rule, often to a marked degree, and its layers are adherent; the unaffected portions of the lungs frequently be- come emphysematous. The right ventricle is, as a rule, hypertrophied. Symptoms.—These may be briefly stated, since they do not differ from those of cirrhosis of the lung, Avhich is described in the section on Diseases of the Lungs. The onset is extremely insidious: a persistent cough that is apt to occur in severe paroxysms in the mornings, and a purulent expectoration, are for a long period the leading features. If bronchiectasis is present, the sputum may be fetid. Dyspnea is marked, particularly on exertion. Fever is slight or absent, and hence emaciation progresses slowly or may not even be noticeable. The physical signs are obvious, and are identical with those of fibroid induration of the lung (vide infra). The course of this disease is exceedingly long, ranging from ten to twenty or even thirty years, and, as I have before stated, both lungs may become the seat of tuberculous disease. Again, as in chronic pul- monary tuberculosis, prolonged suppuration may lead to amyloid changes in the liver, spleen, kidneys, and intestines. Dropsy, due to secondary dilatation of the right ventricle, often closes the scene. Differential Diagnosis.— Chronic bronchitis is prone to be mis- taken for fibroid phthisis. In the latter disease, however, there are uni- lateral retraction and the signs of consolidation of the apical cavity, all of which symptoms are absent in chronic bronchitis. Complications.—Lobar pneumonia, and less frequently lobular pneumonia, may develop and cause a fatal termination, and doubtless the fact that it is impossible to discriminate these conditions from an acute tuberculous pneumonia has frequently led to confusion as to the exact nature of the cases. Erysipelas may arise in the course of chronic pulmonary tuberculosis, though the proportion of cases is not formidable. Out of 1165 cases of erysipelas, 15 coexisted with pulmonary phthisis.1 Some contend that its occurrence in this disease may be beneficial, but my own observations tend to show that the gravity of both conditions is increased when occurring together. Typhoid fever may rarely be met with in sufferers from chronic phthisis, though I have seen but a single instance come to autopsy. 1" Points in the Etiology and Clinical History of Erysipelas," Journal of the Ameri- can Medical Association, July 2, 1893. 304 INFECTIOUS DISEASES. In another fatal instance the characteristic symptoms of typhoid were present during life, but no post-mortem examination Avas allowed. It is important, however, not to overlook this occasional association of two such common affections. Chronic nephritis and pulmonary tuberculosis are often found in the same subject, and with these arterio-sclerosis is quite commonly combined. Chronic endocarditis, particularly of the tricuspid segments, may also occur in phthisis, and from time to time cases of valvular heart-disease are reported, in which it is evident that passive congestion must have ex- isted for some time before the tuberculous condition developed. The old doctrine of the mutual antagonism between disease of the left heart and pulmonary tuberculosis finds not a little support from these cases, as in a large proportion a very considerable tendency to encapsulation of the lesions exists. Course and Duration.—Both as to course and duration this dis- ease exhibits unusual variations. If not promptly treated during the time in Avhich there is hope of therapeutic and climatic efficiency, it fre- quently progresses with more or less rapidity toward the grave. On the other hand, it is common to observe periods during which the disease is arrested or improved. Generally, the improvement, though followed by an exacerbation, endures for a long time, and permanent cures, even in the advanced stage, are by no means rare. The duration of pulmonary tuberculosis varies exceedingly, though from the collective investigations of different authors and from all the statistics available I find the average duration to be about three years. The late Austin Flint long ago directed attention to the innate tendency of a considerable percentage of the cases to spontaneous recovery—a fact that simply indicates a vic- tory for nature's silent defensive processes in the struggle for existence. In fatal cases death is by (a) gradual asthenia (most frequently), with retention of consciousness until the end approaches. (b) Complicating conditions (bronchitis; pneumonia ; pleurisy ; pneu- mothorax ; amyloid degeneration of the intestines, liver, spleen, kidney; Bright's disease ; diabetes, etc.). (c) Tuberculosis of other organs, particularly the meninges, intestines, and genito-urinary tract. (d) Hemorrhage, due commonly to rupture of an aneurysm in the lung- cavity ; less frequently to erosion of a large vessel. Fatal hemorrhage may, when the vomica is of large size, occur without hemoptysis, as in a case of Roland G. Curtin's at the Philadelphia Hospital. (e) Syncope.—Though of comparatively rare occurrence, there are a number of events that may lead to sudden, fatal syncope—e. g. hemor- rhagic embolism or thrombosis of the artery, pneumo-thorax, thoracen- tesis for pleural effusion, walking about in a moribund state, etc. (/) Asphyxia rarely closes the scene in acute pneumonic phthisis, and very rarely in chronic phthisis complicated with pneumo-thorax, or with a large undiscovered or neglected empyema, or with sero-fibrinous pleurisy. Tuberculosis of the Alimentary Tract. (1) Lips.—Whilst tuberculosis of the lip is quite rare, the possibility of its occurrence must not be forgotten. In a case of my own it assumed, TUBERCULOSIS OF THE ALIMENTARY TRACT. 305 as is usual, the form of a small ulcer, and the diagnosis Avas made by an examination of the labial mucus. It folloAved an accidental lesion of the lip from biting, and Avas not associated, as are most cases, with laryngeal or pulmonary tuberculosis. In diagnosticating the condition chancre and epithelioma must be excluded, the former by the history, and the latter chiefly by microscopic examination for tubercle bacilli. (2) Tongue, Palate, and Tonsil.—The Avork of Orth, Hanan, Schlen- ker, Kruckman, and others has shown that the tonsils, owing to their fre- quent inflammation and the destruction of their mucous membrane, are frequently the point of entrance of the tubercle bacilli, and thus of the infection of neighboring glands. The fact that tuberculosis of the tonsils has repeatedly been found, and often when unsuspected from the gross appearance, and when other lesions of the disease did not exist, points to the not infrequent occurrence of primary tuberculosis in this site. • The infiltrated areas often present small grayish spots, but the appearance of the ulcers is not characteristic, frequently bearing a strong resemblance to epithelioma and to the syphilitic ulcer. The diagnosis demands either inoculative experiments or a microscopic examination of the oral mucus, the latter being oft repeated if necessary. (3) Pharynx and Esophagus.—Both miliary tubercles and ulcerative lesions may rarely arise on the posterior wall of the pharynx by direct extension from laryngo-pulmonary tuberculosis or as the result of second- ary inoculation. The chief symptoms occasioned are the excessive secre- tion of pharyngeal mucus and muco-pus, and painful deglutition. Tuber- culosis of the esophagus is extremely rare. Osier, however, saw a case in his wards in which the ulcer perforated the esophagus and caused puru- lent pleurisy. (4) The Stomach.—Tuberculous lesions appear only exceptionally in the mucosa of the stomach, notAvithstanding the fact that marked gastric symptoms are of frequent occurrence. It should not be forgotten that nausea, vomiting, and other gastric symptoms may be directly due to in- volvement of the larynx. I have been able to find reports of 4 such cases in addition to the 12 collected by Marfan.1 The ulcers may be single (as in Musser's case) or multiple (as in Osier's case). The symptoms are not characteristic, but hematemesis occurring in patients suffering from tuber- culosis of other organs should excite a strong suspicion of the existence of ulcer. Pain coming on soon after meal-time is more marked in tuber- culous ulcer of the stomach than in ordinary gastric lesions. Perforation has taken place in some cases, with its usual dire consequence. (5) Intestines.—The lesions may be (a) primary, or (b) secondary to tubercles of other organs (lungs, peritoneum, etc.). (a) Primary tubercle of the intestines is chiefly met with in children, for the reason that they are more apt to swalloAv the tubercle bacilli with their food, and especially in milk. But though this form of the disorder occurs much less frequently in adults than in children, the intestinal route of infection is, according to my own observation, more common than is generally supposed. Many cases during life present the features of both intestinal and peritoneal tuberculosis, and it is often impossible to deter- mine which of these was the primary condition; and the same difficulty arises when the cases come to autopsy. Yet I have never seen an instance 1 Paris Thesis, 1887. 20 306 INFECTIOUS DISEASES. (post-mortem) in which the peritoneum and mesenteric glands Avere not involved to an equal degree. (b) The secondary variety occurs in more than one-half of the cases of pulmonary tuberculosis, the chief seats of the lesions being the lower part of the ileum, the cecum, and the upper part of the colon. The rectum is also the seat of secondary tuberculosis in a small proportion of the cases of chronic phthisis, and it may, with great rarity, be a primary seat of the affection. The morbid process begins in the solitary glands in Peyer's patches, where at first grayish, firm tubercles groAv and form little prominences. These caseate, becoming yellow in appearance, and then soften and disin- tegrate, producing ulcers. Osier thus describes the characteristics of the tuberculous ulcer: " (a) It is irregular, rarely ovoid or in the long axis, more frequently girdling the bowel; (b) the edges and base are infil- trated, often caseous; (c) the submucosa and muscularis are usually in- volved ; and (d) on the serosa may be seen colonies of young tubercles or a well-marked tuberculous lymphangitis." The cicatrices are extensive and often pigmented, and as they undergo contraction may produce incomplete or even complete stricture of the bowel. At a point corresponding to the seat of the ulcers, local peritonitis invariably develops. The serosa is thickened and adherent, and the ulcer may penetrate through this coat without causing perforative peritonitis, while rarely a fistulous connection is established between different parts of the intestine. The base of the ulcer may show signs of hemorrhage. Symptoms.—In children the symptoms are those of a protracted catarrh of the intestines. Diarrhea may be a prominent feature, though it indicates involvement of the large intestine, Avhich does not occur as a rule until the lesions in the small bowel have reached a rather advanced stage. More often there is constipation, which may be due to peritonitis, and often there is irregular fever, wasting, and a lack of development. These general symptoms of tuberculosis may antedate the local, but they are especially valuable for diagnosis. In adults intestinal tuberculosis generally gives rise to symptoms similar to the above, and when they arise in the course of pulmonary phthisis they are highly significant. If diarrhea be present, it stubbornly resists treatment, and it must not be forgotten that this symptom may also be due either to catarrhal colitis or to amyloid change, both of which processes may be associated with chronic phthisis. Constipation is common and often marked, and local tenderness and colicky pains are complained of frequently. The pulmonary signs, however, may be in abeyance. If the abdominal and general symptoms are such as to excite suspicion of this disease, then a rigid physical examination of the lungs should be made. The chief seat of the lesions may be for a long time in the cecum, or in the appendix, when the symptoms—both local and general—will be those of appendicitis. The diagnosis of primary intestinal tuberculosis is beset Avith special difficulties. Sawyerx has in special instances demonstrated the presence of clusters of tubercle bacilli in the rectal mucus, and in this way the recognition of intestinal tuberculosis at an early date, or before diarrhea 1 Medical News, May 23, 1896. TUBERCULOSIS OF THE SEROUS MEMBRANES. 307 sets in is rendered possible. The mucus is obtained after placing the patient in a position as if to examine for piles, and directing him to bear down as though at stool, by gently removing a small quantity from the everted membrane Avith a sterile loop. It is then spread upon a clean cover-glass and treated exactly as sputum in the ordinary examination. The same method is applicable to cases of secondary intestinal tuberculo- sis, but here the history and associated tuberculous lesions usually serve to remove all doubt. Tuberculosis of the Serous Membranes. General tuberculosis of the serous membranes secondary to pulmonary and intestinal tuberculosis is of common occurrence, and that a primary form of tuberculosis of the serous membranes also occurs is undoubted. Unfortunately, accurate means of discriminating the secondary from the primary form are wanting, since often in the secondary variety the primary lesions in other organs are insignificant. The anatomic alterations resemble those of ordinary inflammation of these structures, plus the presence of nodular tubercles. The latter may be observed, as a rule, only over small, scattered, circumscribed areas, though not infrequently they are both numerous and diffuse (gen- eral miliary deposit). The effusion is in most instances sero-fibrinous, though sometimes it becomes purulent subsequently, and not infrequently is hemorrhagic. Most instances of so-called hemorrhagic pleurisy are due to pleural tuberculosis. Clinically, cases are divisible into (1) acute serous membranous tubercu- losis and (2) chronic tuberculosis. The acute form results from inocula- tion of the peritoneum or pleura, induced by limited foci in the bronchial, tracheal, or mediastinal lymph-glands, or in the Fallopian tubes in women. The chronic type is apt to result from a direct extension of a tuberculous process from some organ adjacent to the pleura or peritoneum, though it may attack the serous membranes primarily. Belonging to this class of diseases are two groups of cases: those attended by sero-fibrinous or sero-purulent effusion and the presence of caseous masses, and those in which there is a tuberculous deposit with increased density and great thickening of the pleural layers, and slight exudation. The pericardium may be similarly involved. (a) Tuberculous meningitis has been described fully in the present section (vide Miliary Tuberculosis). (b) Tuberculous Pleuritis.—This subject will be referred to in the section on Diseases of the Pleura. Its import, however, is such that brief special consideration is demanded, and from a clinical view-point the cases may be grouped under tAvo heads—namely, acute and chronic tuberculous pleurisy. The acute form often has a sudden onset, the initial symptoms being a rigor or repeated fits of chilliness, a stitch-like pain in the side affected, shallow, catching breathing, a cough, and fever. The ushering-in symp- toms sometimes suggest lobar pneumonia, and a fatal termination is not uncommon, though apparent recovery or a transition into chronic tuber- culous pleuritis also occurs. Chronic tubercular pleurisy is vastly more common than the acute 308 INFECTIOUS DISEASES. form, and it is sometimes primary, though more often secondary to pul- monary tuberculosis. In all cases of the latter disease in Avhich the per- iphery of the lung becomes involved the visceral layer of the pleura is invaded. This leads to plastic pleurisy with adhesion, and the membranes contain disseminated tubercles or sero-fibrinous tuberculous pleurisy; but, as above stated, the effusion may be hemorrhagic and may also become purulent. When the tuberculous pulmonary focus perforates the pleural sac, pyopneumothorax is produced. In tuberculous pleurisy, as opposed to simple pleurisy, there is usually an absence of leukocytosis. Symptoms.—The onset is very insidious and often unnoticed. There may be few symptoms, and yet a physical examination reveals a large sero-fibrinous effusion. The cough and other symptoms are fre- quently due to a coexisting tuberculosis of the lungs, but the presence of subcrepitant and dry rales are strongly confirmatory of tuberculous pleu- risy. By and by the evidences of pulmonary tuberculosis are of import- ance, or the supervention of acute general miliary tuberculosis makes clear the nature of the case. The subacute variety with effusion may terminate, after absorption of the exudate, in chronic adhesive pleurisy with great thickening of the membrane. The latter may also originate as a primary proliferative process. TUBERCULOSIS OF THE PERICARDIUM. The morbid lesions are analogous to those of tuberculosis of the pleura. The effusion may be enormous on the one hand or insignificant on the other, and it is often hemorrhagic, Avhile in the chronic form there is marked thickening of the membrane with the deposit of tubercles and cheesy masses. The affection is less common than tuberculosis of the pleura, yet not so rare as was formerly supposed, and occurs in the acute and chronic forms. Acute tuberculous pericarditis is rarely a primary affection, and, as a rule, originates secondarily to pulmonary, pleural, or glandular tubercu- losis. It is especially prone to arise in tuberculosis of the bronchial and mediastinal lymph-glands, and, as the latter condition is frequent in young children, so tuberculosis of the pericardium is relatively frequent at this period, though it may occur at any time of life. Pericardial tuberculosis also results from direct extension from a contiguous focus. The symptoms will be detailed in the discussion of Pericarditis. In the diagnosis of the affection the history and any associated tuberculous pro- cesses detectable must be taken into account, and a point of some diag- nostic value rests in the fact that tuberculous pericarditis does not show the usual inflammatory leukocytosis. Chronic Tuberculous Pericarditis.—This may be a part of the general tuberculosis of the serous membranes, or it may follow the infection of the bronchial and mediastinal glands (most frequently), lungs, pleura, or peritoneum. Undoubtedly, cases of primary origin also occur, but they are exceedingly rare, the neighboring lymph-glands being very generally involved. This form is also dependent upon direct extension from the lungs, the spine, and sternum. From personal observation I am convinced that the cases naturally fall under two heads, when considered clinically: those without effusion, TUBERCULOSIS OF THE SEROUS MEMBRANES. 309 in which the pericardium is adherent; and those Avith more or less effusion. The former are the more frequent, though often entirely latent, the adherent pericardium leading to hypertrophy of the heart, followed sooner or later by dilatation. The signs are therefore those of adherent pericardium, with the occasional difference that the dulness may extend higher up over the sternum, in consequence of the presence of firm, cheesy masses at the base of the heart -and also encircling the aorta. The smaller group of cases (in which the effusion is present) resembles dilata- tion of the heart in its clinical manifestations. I recall one instance of this sort that occurred in a male aged about sixty years at the Episco- pal Hospital, the autopsy revealing extensive pulmonary tuberculosis and chronic tuberculous pericarditis, with the presence of eight ounces of hemorrhagic effusion. TUBERCULOSIS OF THE PERITONEUM. This is dependent upon infection by means of the bacilli circulating with the blood, or upon extension of tuberculous inflammation or ulcera- tion from adjacent organs. Mention has already been made of the fact that the intestines are often invaded by tuberculosis, and that the serosa is quickly involved in such instances. The condition may rarely be pri- mary. This involvement may remain circumscribed and undergo spon- taneous cure if the intestinal lesion cicatrizes, as post-mortem findings fre- quently indicate, but in extensive peritoneal involvement spontaneous resolution is out of the question. These cases may be subdivided into acute and chronic. The very acute cases are those forming a part of acute general miliary tuberculosis, or due to perforation into the peri- toneal sac from adjacent organs, and Adlebert's classification is as follows : (a) the ascitic form, (b) the ulcerous form, and (c) the fibroid form. Though these groups do not present sharp clinical distinctions, the courses they run vary considerably, as do the results of treatment. In the ascitic form the exudate is purulent or sero-purulent, and is often encapsulated. In the ulcerous the tuberculous new-formations, Avhich may be quite large, undergo caseation and ulceration, the latter process being progres- sive, so that it may perforate the Avails of the intestines. This and the ascitic form may be combined. In the third or fibroid form the peritoneal surfaces are adherent. There is little if any exudation; the tubercles may be numerous and diffuse, or may be found only in scattered localized areas, and are often pigmented. The lesions may represent the concluding stage of acute or subacute tuberculous peritonitis. Etiology.—Most cases are produced by extension of tuberculous in- flammation from adjacent organs, and of 107 cases analyzed by Phillips the lungs were involved in 99, the pleura also in 60, and the boAvel in 80. Children are frequent victims to intestinal tuberculosis, and the bacilli often reach the peritoneum through the intestines, as they are also apt to do in adults suffering from chronic phthisis. Extension from the pleura to the peritoneum is frequent (pleuro-peritoneal), but from the peri- cardium it is relatively infrequent. In females the starting-point is very often the Fallopian tubes, and in either sex it may be the appendix. Predisposing Factors.—Age.—During the period from fifteen to forty 310 INFECTIOUS DISEASES. years the incidence is most frequent, though it is not uncommon in chil- dren under ten years, nor between the fortieth and fiftieth years of life. Subsequently, it rapidly decreases in frequency. I agree with Osier in stating that in America negroes are more prone than whites. Sex has a tolerably potent disposing influence. Abdominal surgeons have taught us that the disease occurs more frequently in females than males, owing to the fact that the Fallopian tubes are a favorite seat for primary tuberculous infection. The ratio based upon sex is as 3 to 2 in favor of females. Symptoms.—Some cases develop abruptly with severe symptoms, as fever, marked constitutional disturbance, rapid small pulse, abdominal pain, vomiting, and sometimes diarrhea. The temperature may be quite high (103° to 104° F.—40° C), or it may be only slightly elevated even in the worst cases. There follow quickly such symptoms as anemia, marked emaciation, and a pronounced typhoid condition. The signs of peritoneal effusion (rarely large) are soon in evidence, and are attended sometimes by a suppurative type of temperature, sweats, etc., indicating the presence of pus in the peritoneal sac. A few cases are unattended by ascites, and here nodular masses are palpable, while on auscultation friction-sounds may be audible in the umbilical region. Tympanites, due to intestinal paresis, is common in cases having an acute onset. The acute stage may be absent, the affection then being marked by slight local and general symptoms (low fever, anemia, slight belly-pains, and a sense of distention). The skin is sometimes pigmented, and usu- ally in patches. There are not a few instances in which the affection is latent, and in one case of this sort with ill-defined general symptoms pig- mentation of the skin first directed my attention to the peritoneal con- dition. The physical signs of moderate ascites frequently, and those of en- larged mesenteric glands sometimes, are present. These conditions are often combined in children, constituting the so-called tabes mesenterica. I cannot conceive of the occurrence of this association of symptoms with- out simultaneous involvement of the peritoneum, and doubtless tubercu- losis of the latter membrane and intestines usually coexists. The tuber- culous new growth in the peritoneum may also form a distinct tumor not unlike that produced by glandular enlargement, while the intestinal coils with their now thickened walls are sometimes knotted together so firmly as to simulate a dense new growth. The exudation may be loculated owing to adhesions betAveen peritoneal layers of the intestinal coils, etc., producing a localized tumor varying in size and position. Such saccu- lated exudations most frequently occupy the pelvic or umbilical regions, though they may also be found elsewhere in the abdomen. They may be multiple, and are not infrequently too small to be recognized by the physical signs, being often discovered during laparotomy. On the other hand, they may occupy a large portion of the abdomen. An omental tumor of characteristic elongated form (produced by a shrinking and curling up of this membrane) is demonstrable, its long axis generally taking a transverse direction just above the umbilicus. Gairdner has observed this tumor to disappear by spontaneous resolution in children. The dry, fibrous variety, which is not infrequent, is often latent, and the condition may be general or localized. It is decidedly more frequent TUBERCULOSIS OF THE LIVER. 311 • in adults than in children, though the symptoms are far from character- istic. Among local features are pains, abdominal distention (giving rise to a tympanitic note on percussion), tenderness on pressure, and sometimes a tumor-ridge extending across the upper abdominal region. Among gen- eral symptoms are usually anemia and emaciation, with or without fever. Indeed, the temperature may be subnormal, and these cases may show a tendency to spontaneous recovery. Diagnosis.—Unless tuberculosis of other organs can be demon- strated the diagnosis is often impossible. This is particularly true in cases in which there is no abdominal pain nor tenderness. Fever and the presence of a tumor, especially if the latter be elongated and lies trans- versely in the umbilical region, are important aids; but if tuberculosis of the lungs, pleura, pericardium, appendix, and the tubes, in women, can be excluded, the rectal mucus and the urine should be examined for tu- bercle bacilli. From the acute form several affections must be discrimi- nated : (a) Internal Hernia.—This comes on suddenly; the pain is strictly localized and paroxysmal; stercoraceous vomiting appears in a few hours ; the constipation is absolute, and tympanites is marked, but ascites is absent. (b) Similar symptoms belong to volvulus and to the quick incarcera- tion of loops of intestine under bands of adhesions; on comparison they will be seen to differ from those of acute tuberculous peritonitis. (c) Enteritis is discriminated from acute tuberculous peritonitis by the presence of copious mucous discharges, and by the absence of associated tuberculous lesions, ascites, tumors, and the symptoms of the pronounced typhoid state. Chronic tuberculous peritonitis often closely simulates cancerous perito- nitis, owing to the fact that the elongated omental tumor may be met with in both, associated with ascites, abdominal pain, and slight fever. In carcinoma, however, there is an absence of the tuberculous history and lesions, and the presence, sometimes, of a gradually increasing tumor of primary growth, the slowly oncoming intestinal obstruction from pres- sure, and the cancerous cachexia. Moreover, tuberculous peritonitis occurs more frequently in younger subjects, and is more apt to be inter- rupted by periods of improvement, followed in turn by rather alarming symptoms. Locular exudations must be distinguished from ovarian tumors, and here the history, together with tuberculous lesions elsewhere in the body, the occurrence of febrile attacks, and intestinal disturbance with pain, are of great diagnostic significance. Such cases should be examined by a gynecologist, since, however expert the examiner, when the saccular exu- dations are located in the pelvic region an exploratory laparotomy must often decide the nature of the condition. Finally, it must not be forgot- ten that the vast majority of cases of chronic peritonitis are tuberculous. Tuberculosis of the Liver. The liver was formerly overlooked in many instances of tuberculosis, because the lesions, particularly in acute tuberculosis, are often micro- scopic. In the chronic disseminated variety, however, grosser changes 312 INFECTIO US DISEASES. are observed, the organ being slightly enlarged, pale, and fatty, and pre- senting an irregular surface like that of an orange. On section, the par- enchyma cuts Avith great resistance, being very dense (tuberculous cir- rhosis). Minute gray and larger yellow masses are seen, especially just under the capsule, and small cavities, the result of a breaking down of the cheesy masses and containing pus and bile, are also observed. These changes are most pronounced about the bile-ducts. Etiology.—The liver is implicated in all instances of acute miliary tuberculosis. It is also involved secondarily in chronic tuberculosis of the lungs, pleura, peritoneum, spleen, lymphatics, etc. Symptoms.—This is a common condition, the organ being appreci- ably enlarged and its surface presenting irregular, palpable prominences. The clinical features of perihepatitis and peritonitis are often found in combination. Ascites may be present, but is rare. Tuberculosis of the Genito-urinary System. (1) Tuberculosis Of the Kidneys.—This may be primary or secondary, the secondary form being the more common, and it may be either unilat- eral or bilateral. Infection occurs through the blood in some instances. Pathology.—The process begins in the calices and apices of the pyr- amids (papillw), thence proceeding to the pelvis of the kidney, so that early the condition may be pyonephrosis. The morbid changes then ex- tend to the ureters, and sometimes to the bladder and prostate, and in- stances are even met with in Avhich the process seems to have crept from below upward, starting from the bladder or prostate. The tubercles pass through the usual stages of caseation, necrosis, and suppuration, and de- struction of the renal tissue to a greater or lesser degree occurs, with the formation of cysts containing cheesy material in which lime-salts may be deposited. When the process invades the kidneys through the blood, it may be limited largely to the cortical layer and give rise to nodular tuberculosis with caseous masses, yet Avith little loss of renal substance. There are not a few cases in Avhich the chief lesion is a tuberculous pye- litis. In the latter class the ureters show extensive involvement, such as thickening of the coats with caseation and ulceration of its mucosa; the bladder, deep urethra, and prostate may also be involved. While it is difficult to judge of the relative ages of the lesions in different organs, I cannot escape the conviction that in this group of cases renal tuberculosis is an ascending process and folloAvs uretero-cystic tuberculosis. As before stated, however, most instances are descending. Although both kidneys are finally involved in most instances, the lesions are usually much more advanced in one kidney than in the other, and hence for a considerable period the disease is probably unilateral. Etiology.—Of disposing factors age and sex deserve especial mention, most cases occurring during middle life, though they are by no means rare both at an earlier and a later period. Sex.—The disease is much more frequent in males than in females. As stated, the bacilli reach the kidneys with the blood-stream, producing primary renal tuberculosis, but invasion may also take place through the lymphatics or through direct extension from adjacent structures. Symptoms.—In many cases there are either no renal symptoms or TUBERCULOSIS OF THE GENITO-URINARY SYSTEM. 313 none until a late stage is reached, but the symptoms of pyelitis are usu- ally present. Pyuria may be the only symptom for a long time, and this symptom, according to certain authorities, points directly to cystitis. When the latter condition is present, however, the micturition becomes frequent and there is vesical tenesmus. Pain in the side chiefly affected is complained of, and is sometimes not unlike renal colic^ hematuria is not rare; and a cystoscopic examination may shoAv the blood to be of renal origin (Tuffier). It is useful also in showing the state of the blad- der-mucosa. The demonstration of tubercle bacilli in the urine, especi- ally if arranged in S-shaped groups, is diagnostic (Frisch). When the bacilli cannot be found, inoculation-experiments upon guinea-pigs and rabbits furnish an accurate criterion, though it must not be forgotten that tubercle bacilli may find their Avay into the urine from more distant tuberculous foci. Polyuria is sometimes present, as well as albuminuria; the urine may also sIioav tube-casts (rarely) and pus-cells. Macroscopic cheesy masses are occasionally found. The general features are often marked, but not until the affection be- comes advanced, chills, fever of a suppurative type, emaciation, and in- creasing debility being the chief symptoms. Associated tuberculous lesions, especially of the lungs, are constantly observed. Physical Signs.—Inspection may show a tumor-like prominence on the side chiefly affected, though rarely of large size. Palpation often detects tenderness, and the limits of the organ may be defined by careful firm pressure with the finger-tips. Diagnosis.—It is difficult to discriminate calculous pyelitis. In the latter, hoAvever, the pain is severer, the tumor-mass larger, and the hem- orrhage more frequent than in tuberculous nephritis. The discovery of tubercle bacilli or the demonstration of tuberculosis of the lungs or of other organs would remove all doubt. These tAvo affections may coexist. (2) Tuberculosis of the Ureter and Bladder.—This is almost ahvays secondary to tuberculous disease of the pelvis of the kidney above, or of the deep urethra, testes, or prostate below. When primary, as rarely happens, the bladder is in most instances invaded last. The symptoms are those of chronic cystitis, and in all cases in Avhich no other cause for the latter can be found the primary tuberculous lesion must be sought for and the urine carefully examined for bacilli. The usefulness of the tu- bercle bacillus as a final point in diagnosis is impaired in this situation by the fact of the frequent presence of the smegma bacillus in normal urine. Some observers state that the smegma bacillus can be distinguished by decolorizing with absolute alcohol, which will take place in about tAvo minutes, while Avith the tubercle bacillus a very much longer time is required. Others say this is not sufficient, and that only their methods of culture-growth or inoculation will distinguish them. With the devel- opment of ulcerative lesions hemorrhage is apt to arise. (3) Tuberculosis of the Vesiculse Serainales, Prostate, and Testes.—The prostate gland and testes are frequently invaded in genito-urinary tuber- culosis, and the vesiculse seminales somewhat less frequently. The mor- bid process leads to the formation of cheesy nodules, which may, though comparatively rarely, disintegrate, causing excavations or perforation. Rarely, the tubercle does not pass through the stage of caseation, but merely shows the presence of numerous embryonic cells. 314 INFECTIOUS DISEASES. Etiology.—The condition is usually secondary, but the existence of primary tuberculosis in these organs cannot be denied. Testicular tuber- culosis may begin at any period of life, and is of rather frequent occur- rence in infants. When it occurs in the latter, it is part of a more gen- eral tuberculous infection, and is in many instances undoubtedly congen- ital. In some-cases it may be a late hereditary affection. Symptoms.—In the testicle, tuberculosis, as a rule, induces a pain- less, protracted orchitis, though when cavernous lesions occur the symp- toms are more acute. In prostatic tuberculosis the bladder is highly irri- table, there is great distress felt in the thigh and groin, and micturition is very painful. Catheterization, particularly if the urethra (as is very rarely the case) is the seat of tuberculous ulceration, causes most excruci- ating suffering, and there may be signs of stricture. Rectal palpation detects in the prostate firm nodules varying in size from a pea to a bean, together with enlargement of the organ. Diagnosis.—The diagnosis of tuberculosis of the prostate is easily made from the vesical symptoms, the presence of tuberculosis in other organs, the result of rectal examination, and the detection of bacilli in the urine. Syphilitic involvement of the testicle is sometimes excluded with difficulty; in the latter disease, however, the surface of the swollen organ presents greater irregularities, and is even less painful than in tu- berculosis. The absence of the history of syphilitic infection and the presence of tuberculosis in other organs, particularly in the uro-genital system, are valuable points in the discrimination. Tuberculosis of the Fallopian Tubes, Ovaries, and Uterus. Tuberculosis of the tubes in women is a not infrequent condition, and may be primary. Btiology and Pathology.—The tubes, as a result of infiltration, are thick, hard, and bound down by false membrane. Their ends are generally closed, but the intervening portion is dilated, and contains mucus, pus, and cheesy material. A catarrhal salpingitis is generally in association. Uterine tuberculosis is rare, and its origin is usually attrib- utable to similar involvement of the tubes. The disease is most common during the period of greatest sexual activity, but young children may suffer (vide literature of Hennig), and in them the ovaries and uterus may be implicated without participa- tion of the tubes, as in cases reported by Gusserow. At any period of life the lesions may be microscopic ; they usually, however, excite marked local peritonitis, which may become general, with the development of ascites. The process may extend to the vagina. Diagnosis.—The age, family history, and signs of the tuberculous diathesis must be noted. The disease does not distinguish itself from other tubal tumors by anything characteristic on bimanual palpation. Cases occur with ascites and also without, and in the latter variety plaque- like thickening of the subperitoneal tissue is an aid to diagnosis. The uterine secretions should be examined for bacilli in all obscure cases. Ashton advises an exploratory incision or puncture and examination of the contents of the peritoneum or tubes for bacilli. TUBERCULOSIS OF THE BRAIN. 315 Tuberculosis of the Mammary Glands. This is a rare form of surgical tuberculosis, in which the mammary glands present fistula? and ulcers, with induration of the organ and re- traction of the nipple. The axillary glands are often enlarged. The tuberculous diathesis is usually present, but a positive diagnosis rests crucially upon the finding of the bacilli in the pathologic secretions. A cold tuberculous abscess may occupy the breast. Tuberculosis of the Brain. Pathology.—Tuberculosis of the brain occurs in two forms, one of which, acute tubercular meningitis, has been previously described, while the other is a chronic tuberculous infection, usually localized, of the meninges and cortex, and causing meningo-encephalitis. Very rarely the membranes remain intact. The so-called solitary tubercle is an irregularly round mass, varying in size from a small pea to an apple or even larger. It is generally single, though sometimes there are two, and rarely even three, nodules. The tubercle may be imbedded in, and be contiguous with, the brain-substance, or may be separated from the latter by cysts. The peripheral zone is formed largely of connective tissue, is lighter in color (often translucent), and may contain miliary tubercles, while the central portion, which is cheesy as a rule, may liquefy and thus form a small cavity containing a purulent-looking material. Here, as elsewhere, the tubercles may calcify. They are seen with greatest fre- quency in the inferior portions of the brain—cerebellum, pons, and medulla—and are rare in the cerebral cortex. The new growths may compress the longitudinal sinus, inducing throm- bosis ; they may interfere markedly with the circulation, causing cerebral softening; and, finally, they may excite acute tuberculous meningitis. Tuberculosis of other organs, particularly the lungs, bronchial glands, joints, and bones, is usually found as an associated condition. Btiology.—The disease occurs with especial frequency in young subjects, and, according to the statistics of Pribram, in about three- fourths of the cases before the fifteenth year. The symptom-picture is identical with that of brain-tumor, and hence will be appropriately given under the latter head. Tuberculosis of the Spinal Cord. The lesions are those of solitary tubercle of the brain. It is an ex- tremely rare condition, and almost invariably secondary. (For symptoms, vide Spinal Tumor and Meningitis.) Tuberculosis of the Heart. In acute miliary tuberculosis gray granulations or larger yellow tuber- cles may be found throughout the tissues of the heart. More frequently than was formerly supposed does cardiac tuberculosis also result from chronic tuberculosis of adjacent organs. Illustrative cases have been reported by Townsend and Waldeyer. Constantin Paul has in these 316 INFECTIOUS DISEASES. cases observed tubercles in the Avail of the left auricle, as well as in the infundibulum of the pulmonary artery in several instances. Valvular tuberculosis is, I believe, even more common, though few cases have been reported. Londe and Petit in one instance found the heart much affected, and discovered on the mitral valve several veareta- tions the size of lentils, which showed tubercle bacilli. I have seen two cases—one in which the mitral, and another in Avhich the tricuspid, valve was affected, associated with latent pulmonary and mediastinal tuberculo- sis. Doubtless there are cases in which the valve-lesions form the central and most prominent point in the picture. Tuberculosis of the Arteries and Veins. This may arise consequent upon extension of a tuberculous process into the vessel, as in chronic phthisis. It causes infiltration of the arterial wall, resulting in thrombosis, or the vascular tubercles may caseate and soften, thus leading to hemorrhage. In tuberculous meningitis the arte- rial lesions are conspicuous. The perforation of a vein by an old focus is followed by a distribution to all parts of the body of numerous bacilli and acute miliary tuberculosis. Infection of the arteries may also occur through the blood. In a case of chronic tuberculosis Flexner found a fresh tuberculous groAvth in the aorta which had no connection with the cheesy masses outside the vessel (Osier). General Prognosis.—The prognosis is best reached as in other infectious diseases—namely, by taking into account (a) the severity of the type of the disease ; (b) the presence or absence of frequently associ- ated diseases or complications ; and (c) the numerous circumstances con- nected with individual patients. (a) The Severity of the Disease.—Though there are no accurate cri- teria, we may judge of the severity of the disease by its progress, by the result of proper treatment, and from certain symptoms. If the fever he high, the prostration marked, and the local lesions rapidly advancing, Ave may safely infer that the disease is of aggravated type. With these cer- tain other considerations are closely connected—the stage of the affection and the extent of the local lesions. Thus at an early stage the prognosis is more hopeful than at a late period, and, similarly, when the lesions are strictly localized at one apex it is more hopeful than Avhen they have reached the stage of extensive cavity-formation or are bilateral. As already stated, a certain proportion of the cases manifest an inherent tendency to spontaneous arrest or even cure, and this may occur even after the stage of excavation has supervened. Notwithstanding this truth, however, it is well to make in all undoubted instances of the dis- ease a guarded prognosis. A common error is the mistaking of a tem- porary for a permanent arrest of the tuberculous process, and in the nat- ural history of the affection the fact was emphasized that its course was interrupted by periods of comparative comfort and noticeable improve- ment, followed by sharp exacerbations. (b) Associated Diseases and Complications.—These unfavorably modify the prognosis to a greater or lesser degree, the fatal termination often being hastened by chronic nephritis, by gastric complications, and by intestinal and laryngeal involvement. Some of the accidents of the dis- TREATMENT OF TUBERCULOSIS. 317 ease may also precipitate a fatal result (vide Modes of Death). The sud- den appearance of intercurrent acute pneumonia, whether tuberculous or not, is indicative of danger. Other complications presented by the lungs and other organs have been detailed in the Clinical History. (c) Circumstances connected with Individual Patients.—(1) A feeble, delicate constitution, either acquired or inherent (tuberculous diathesis), increases the gravity of tuberculosis. (2) When the general symptoms shoAV marked improvement, and espe- cially if the fever subsides and the patient gains flesh and strength, the outlook at once brightens. (3) Hygienic Surroundings.—When the hygienic regimen under which the patient lives is of the best, the prospect is more hopeful than when it is faulty. An improved diet often decidedly aids favorable prog- i ress, while a defective one often turns the scales against recovery. Equally influential for good is a pure atmosphere, while, per contra, a vitiated one is most injurious. (4) Age.—In young subjects from five to fifteen years of age tubercu- losis often pursues an acute course and the mortality-rate is exceedingly high. Chronic tuberculosis may occur, however, less frequently, and under appropriate surroundings may lead to recovery. In chronic phthisis "the younger the patient the shorter the duration." I have frequently observed that patients Avho give a history of pleurisy or other phthisical manifestations early in life do not bear chronic phthisis well should it develop at a later period. During old age—a time of life at which tuber- culosis is not uncommon—the disease (especially the pulmonary variety) is usually more or less latent, and, OAving to coexistent emphysema and chronic bronchitis, pursues a slow course.1 (5) The gravity of tuberculosis may be determined Avith some degree of accuracy by the use of creasote in gradually ascending doses. Hence this agent has a value, not only from a diagnostic but from a prognostic view-point. Treatment of Tuberculosis. Prophylaxis.—(1) This embraces thorough and prompt disinfection of the sputum as the best preventive element. To this end the patient must be taught to expectorate at all times into a spittoon or spit-cup which Fig. 30.—Pasteboard spit-cup for receiving infectious sputum. AVhen used the pasteboard can be removed from the steel frame and burned. . contains a proper disinfectant solution, and when the breaking-down stage has arrived portable flasks (e. g. Dettwiler's) containing an antiseptic so- lution must be worn by the patient, even while out of doors. Afterward 1 A physician should not neglect to examine the sputum in suspicious cases for bacilli. 318 INFECTIOUS DISEASES. the sputum is to be destroyed by boiling or burning and the spit-cup sterilized. Paraffin flowers are most desirable for consumptive patients. (2) Isolation.—Isolation stands next to disinfection as a means of limiting the spread of tuberculosis, and after the stage of softening is reached the patient should invariably occupy a separate apartment. Phthisis obeys the laws of infectious diseases, and despite great care the room and bed occupied by the consumptive become in time a source of infection through the drying of the expectoration. Hence, unwashable hangings and upholstered furniture, as Avell as other objects that facilitate the harboring of the bacilli, should be removed from the sick-room. The floor of the apartment should not be carpeted, but may be in part cov- ered with rugs that can be frequently taken up and shaken in the open air. For like reasons, special hospitals for the treatment of the tuber- culous poor are a prime necessity. I quite agree with Flick in recom- , mending that tuberculous patients in the infectious stage of the disease should be retired from occupations in which they can infect others, and the pensioning of those who cannot be maintained in hospitals. (3) Compulsory registration of tuberculous (pulmonary) patients is desirable, since it would serve to emphasize the importance of certain sanitary measures both during and after the course of the case. (4) Government Inspection of Dairies and Slaughter-houses.—This is the serious business of the State, and, since infection through food, espe- cially milk, is quite common in infants, skilled veterinary inspection of dairies is of prime importance. Of the greatest benefit would be the killing of all tuberculous cattle, and of less though decided efficacy the confiscation at the abattoirs of all carcasses that present marked lesions. (5) The popularizing of information relating to the dangers of, and the means of stamping out, this great scourge. This may be in part accomplished by mural placards, stating simple, plain facts about the way in Avhich the disease is spreading. Armaingaud suggests the placing in the homes of the people printed matter in a form suitable for preservation. (6) The Removal of Known Predisposition to the Disease.—The tuber- culous diathesis, Avhether inherited or acquired, must be overcome, if at all, by vigorous measures or by better hygienic living. In attempting to remove the phthisical tendency the physician must place chief reliance upon the most favorable environment attainable. The value of a change of residence—from the city to the country, the seaside, or the mountains, according to circumstances in individual cases—cannot be overestimated. It often renders predisposed persons immune. For some, and particularly young subjects, an equable climate (Southern California or Florida), that will enable them to live an out-door life, is to be preferred. Attention to the food must not be forgotten. Milk is excellent and should be used freely. Daily sponging of the neck and thorax Avith cold Avater is bene- ficial, and appropriate light gymnastics should be instituted if the subject be old enough. In-door occupations are to be forbidden, and the ventila- tion of living- and bed-rooms must be looked after carefully. Flannels are to be worn next to the skin all the year round, for. while it is needful to lead an out-of-door life, we must seek to avoid catarrhal affections, to which these subjects are very prone, and Avhich, it will be recalled, predispose to active infection. Tuberculosis is apt to develop especially in children while convalescing TREATMENT OF TUBERCULOSIS. 319 from acute fevers, and hence during this period every precaution against catching cold must be observed, and the child be strengthened speedily by vigorous feeding, pure air, and tonics. In children predisposition often results from obstructions in the nose and from persistently enlarged tonsils; and whenever these conditions exist they should be promptly re- moved. All local foci of tuberculosis in children—glandular, osseous, and articular—must be attacked surgically. Treatment of the Disease.—The treatment of tuberculosis, re- garded as a parasitic disease, presents two leading indications. One has reference to the destruction of the specific cause, the tubercle bacilli, by the use of antiseptic inhalations or of some parasiticide taken internally. Of the numerous substances used by inhalation, few have given satisfac- tory results, this being largely due to our inability to convey them to the smaller bronchi in a sufficient degree of concentration. They are best adapted to, and most efficacious in, cases in which the larynx is involved. While the antiseptic treatment, both by inhalation and by means of the introduction into the blood of antiseptic substances, is to be carried out, it accomplishes nothing more than the arrest of the growth and de- velopment of the bacilli, and that in an indirect manner. The inhalation of antiseptic substances may be accomplished in various ways—by inhal- ing vapors, by the use of the steam-atomizer, or by some form of "respiration-inhaler." I have long employed the Robinson inhaler, the sponge of which is moistened with a few drops of a mixture made of equal parts of creasote, chloroform, and alcohol, the patient wearing the inhaler nearly all the time when not eating or sleeping. Unfortunately, most patients object to the constant use of this instrument. The chief among other antiseptics thus employed are carbolic acid, terebene and terpin hydrate, turpentine, thymol, iodoform, oil of peppermint, and a spray of a solution of sulphurous acid. These agents may be variously combined. The injection of antiseptics into the diseased areas in the lungs, as recommended by Pepper, has been for the greater part aban- doned. As pointed out by Osier, however, the remarkable results that surgeons have recently obtained in the treatment of joint-tuberculosis by injections of iodoform point to this as a remedy which will probably prove of service when injected directly into the lungs. The most common, because least objectionable, mode of introducing this class of substances is by internal administration. According to the results reported from all quarters of the world, creasote thus employed alone enjoys the confidence of the profession; and in common with nu- merous other observers I have found its continued use to be followed by lessened cough and expectoration, lessened fever, and by a lessening or cessation of the night-sweats, with a gain of strength and weight as the natural consequence. In my own hands its beneficial effects have been manifested at the end of two or three weeks. It must be borne in mind that the dose is to be gradually increased to the point of gastric tolerance, which in my experience usually does not exceed 15 to 20 drops (0.999) three times a day. Larger doses are, however, sometimes tolerated. Following, in the main, the practice of Trudeau, who has used this drug quite as extensively as any other American physician, after reach- ing the point of tolerance I gradually reduce the dose to and maintain it at 5 or 6 drops (0.333), three times daily. Among the best vehicles are 320 INFECTIO US DISEASES. hot milk, hot water, and diluted alcohol. Recently I have ordered it in capsules, which the patient himself fills at the time of using, and have found it a popular and ready mode of administration. When creasote is not Avell borne by the stomach and its inhalation is seriously objected to by the patient, it may be given by enema, the dose being 20 to 30 drops (1.332). in peptonized milk or mixed Avith a little egg-white. It has also been employed hypodermically in a 10 per cent, solution in oil of sweet almonds, the dose of which is 1 dram to 1^ drams (4.0-6.0). Lastly, it has in rare instances been employed by inunction. Guaiacol, particularly in the form of the carbonate, has of late been quite extensively employed in place of creasote, of which it is the chief active principle. It may be administered in pill or capsule, the dose being slightly less than that of creasote. It is well tolerated by the stomach, and is broken up in and reabsorbed from the intestinal canal. Among other remedies prescribed for their supposed parasiticidal effect are arsenic, mercuric chlorid, and alcohol, but they are clearly inferior to creasote in this therapeutic role. Tuberculin was at one time supposed to exert a specific influence upon the tuberculous processes, but this vieAv has been largely abandoned. Its chief value, as Avell as employment at the present day, is as an agent in forming the diagnosis. I am of the opinion that all antiseptics used internally in this disease have for their chief influence a modification of the soil-conditions on which the groAvth and multiplication of the bacilli depend. They are, in truth, of great value in fulfilling the second leading indication of treat- ment, which is to overcome the bodily receptivity for the specific bacillus, or to aid the natural defensive processes in limiting the destructive Avork of the latter. All forms of tuberculosis, hoAvever, may heal spon- taneously in any stage, this being especially true of the local varieties so common in children, affecting the lymph-glands, joints, and bones. A large proportion of pleurisies are tuberculous in nature, and although most sufferers from this disease develop pulmonary tuberculosis later in life, many of them apparently heal without the aid of the physician. This is shown by the old pleuritic lesions that are constantly met with at autopsies in persons dying suddenly of other diseases. Spontaneous recovery is seen oftenest in cases that have not progressed to the stage of cavity-formation. Indeed, in the instances in which vomicae of consider- able size have formed, cicatrization or complete cure is out of the ques- tion, though they may become encapsulated (quiescent). The percentage of cases in which encapsulated and obsolete tuberculous lesions have been observed at the post-mortem table in persons dying of all causes differs Avidely Avith the statistics of different observers. If we consider the cases that are latent from an early period in life, together with those of all ages after childhood, it is doubtless true that in more than 50 per cent. of the human family the bacilli not only gain entrance into the body, but also effect a lodgement. And, since about 14 per cent, of the deaths from all cases can be ascribed to tuberculosis, it follows that unless the conditions are favorable for the growth and development of the bacilli there is manifested a strong tendency to limitation and healing. In removing the diathesis medicines are unquestionably of less value than the hygienic treatment, the latter in the widest sense of the term TREATMENT OF TUBERCULOSIS. 321 aiming to reinforce Nature's efforts at spontaneous recovery, and embra- cing four main elements: (1) Climate; (2) Feeding; (3) Special Reme- dies ; (4) Treatment of Leading Symptoms. (1) Climate.—The all-powTerful influence of environment has already been pointed out. There is no discrepancy in the testimony of clinicians as to the importance of pure air as a means of rendering the soil unfavor- able for the seed. Per contra, patients treated in ill-lighted and ill- ventilated sick-rooms and in hospital Avards are allowed to remain under conditions that are favorable to bacillary growth, and hence also to ex- tension of the morbid process. Experience and observation have shown that certain climates, selected with particular reference not only to the stage of the affection, but more particularly to the individual, stand fore- most as successful modifying influences of the tissue-soil. In any case of tuberculosis that climate is most suitable in Avhich the patient " feels well, eats well, sleeps well, and gains flesh and strength" (Delafield). Until the patient finds such a climate, or if he finds no single climate to produce these results, he should travel from place to place unless special contraindications (excessive debility, etc.) exist. If active tuberculosis has existed, the stay in a suitable climate should not be less than two full years, and if the patient receive benefit from a high altitude, he should remain permanently. The climatic requisites for a consumptive are (a) pureness, (b) equa- bility, and (c) abundant sunshine. Less beneficial, though important, are (d) dryness and (e) altitude. (a) Pureness.—This requirement is of paramount importance, and thus is explained the fact that mountain air and that of the virgin forest are so helpful in phthisis. Forests, and particularly pine-groves, favor atmospheric purification, since they generate ozone, which oxidizes the impurities contained in the air. (b) Equability has reference to the absence of rapid variations of tem- perature. On the Avhole, a relatively low is better than a high tempera- ture, the former being stimulating, and the latter sedative, in effect. It should be pointed out that forests also greatly favor the quality of equa- bility,1 both as to temperature and relative humidity. They tend to maintain an almost unvarying degree of moisture in their vicinity, thus minimizing the diurnal variations of temperature—a point that is of far greater importance than the question of seasonal variations. Forests in- tercept and temper the bleak winds of A\-inter, while by their shade and leaf-surfaces they afford a cooler temperature in summer. (c) Abundance of sunshine is demanded by the consumptive. The advantages of sunshine are obvious from the observations made by Munn2 in the year 1892, when in Denver there was sunshine in 62 per cent, of the possible hours during Avhich it could occur. A dry atmosphere has advantages, but that dryness is not an essential element is shoAvn by the fact that patients often do well at places having comparatively high rela- tive humidity, such as Florida, Southern Georgia, Southern California, and the resorts on the south coast of England. The rarefied atmosphere of high altitudes, on account of its stimulating effect upon the respiratory function, aids in producing good results, but the pulmonary changes in- 1 House-plants as Sanitary Agents ; Sanitary Influence of Forest Growth, p. 312, by the author. 2 Medical News, Aug. 18, 1894. 21 322 INFECTIO US DISEASES. duced (enlargement of the air-cells, Avith augmentation of the size of the chest) make it necessary for patients to remain for the rest of their lives. That it is not an essential factor is shoAvn by the excellent results obtained in the ofttimes purer atmospheres at loAver levels. The essential climatic factors mentioned are found in certain American and European resorts. Of the former, the Adirondack region, Colorado, and XeAv Mexico are especially to be mentioned, combining as they do in Avinter a uniform cold, much sunshine, and purity of atmosphere. A camp- or tent-life in the open air cannot be too strongly advocated. According to my own experience,1 the Adirondacks meet the indications best in early cases or in patients who have strength enough to lead an out- door life, and in whom the breaking-down stage is not too far advanced. Some cases, in the early stage, also do Avell at Thomasville, Ga., Southern California, and in other mild, equable climates. The latter resorts pos- sess the added advantage of affording an opportunity of gaining a liveli- hood. Among foreign resorts. Davos possesses about the same advan- tages as may be met in Colorado, New Mexico, and the Adirondacks, while the resorts in Southern Italy and France are comparable to South- ern California, Southern Georgia, Florida, and the Bermudas in this hemisphere. Good culinary and home comforts are considerations of little less importance than the climate. There is a class of phthisical patients in Avhom the disease progresses rapidly, with the frequent occurrence of hemoptysis, and who, suffering from the debility of the advanced stage, are precluded from the possi- bility of travelling long distances or becoming acclimated. Such patients and persons with weak hearts should not be sent to high altitudes, but to a genial, warm climate with a fair degree of saturation. Briefly, the atmosphere of forest resorts possesses certain unmistakable advantages for this group of sufferers. Hence they should be sent into the neighbor- hood of the nearest forest in a mild latitude Avhere reasonably good food and other comforts of life are obtainable. In this connection the superior value of the highly ozonized and terebinthinized atmosphere of the pine- groves cannot be too strongly emphasized. It is especially serviceable in cases in which the laryngeal or bronchial element is marked. There is also a class of stay-at-homes made up chiefly of the tubercu- lous poor. Easily accessible sanitaria should be provided for these by the larger cities, and, if practicable, choice should be made of a -well- sheltered locality in the Avoodland. Such sanitaria wrould combine the supreme advantages of a uniform temperature and a purified air. Sani- taria for the treatment of pulmonary tuberculosis among the better classes are also needed. The Saranac Sanitarium and Falkenstein, near Frank- furt-on-the-Main, and Gbrbersdorf, are excellent examples, and their reports show encouraging results. Bowditch2 has obtained favorable results from the treatment of 51 cases of incipient pulmonary tuberculosis in the sanitarium at Sharon, near Boston. Attention to every hygienic detail was also given. The sanitaria should take the form of- cottages and pavilions, and should be officered by an intelligent physician. Sola- ria, in connection with city hospitals for advanced cases, would, I am certain, yield gratifying results. Home sanitaria can be readily improvised by stocking living apart- 1 Loc cit., p. 313. 3 Boston Medical and Surgical Journal, July 12, 1894. TREATMENT OF TUBERCULOSIS. 323 ments, preferably those having a southern exposure, with growing plants. The beneficial influences arising from the presence of the latter are ascribable to two functions—the generation of ozone, and transpiration.1 Such a pleasant retreat furnishes a uniform degree of moisture in the air, and is especially adapted to the winter season. During the midsummer months the patient should live out of doors or in the balmy air of a neighboring forest. Home sanitaria are to be thought of when the expense of a sojourn at a resort cannot be afforded. (2) Feeding.—The diet should be both nutritious and generous. Too close attention cannot be bestOAved upon the feeding and upon the condi- tion of the gastro-intestinal tract. Above all, when the remedies pre- scribed interfere in the slightest degree with the function of the stomach they must be stopped. Such disturbances most frequently arise from the use of syrupy cough-mixtures, cod-liver oil, large doses of creasote, and less frequently from the prolonged use of bitter tonics. . Such easily assimilable albuminous articles as milk, eggs, and the lighter forms of meat, together with fats, should be taken freely. The hydrocarbons are urgently needed, but they must be taken Avith care lest they derange the digestive function. The appetite is often poor or even lost in the early stage. When this is the case the patient should keep in the open air or try a brief change of air by going, if it be possi- ble, to the seaside. It is, hoAvever, generally needful to resort to system- atic feeding, giving a small quantity of nourishment, such as milk, meat- juice, egg-white, and the like, at stated intervals. The French method of forced feeding deserves a trial if there be absolute loathing for food. It consists of first washing out the stomach with cold water, and then in- troducing the folloAving mixture thrice daily: 1 liter of milk, an egg, and 100 grams of very finely powdered meat. As a rule, the patient cannot be induced to swallow this, and it then must be poured through a stomach-tube. If begun sufficiently early, the method gives truly bril- liant results. AVhen the temperature is above 100° F. (37.7° C.) the pa- tient should be kept at rest. In a minority of the cases the appetite is ordinarily keen, often as a result of change of air, and usually pursues a relatively favorable course. The following combination will be found useful in assisting the appetite: B/. Sodii bicarb., 3iss (6.0) ; Tr. nucis vomicae, f Siiss (10.0) ; Glycerini, f,5ss (15.0) ; Inf. cascarillse, q. s. ad f|iv (120.0). Sig. 3ij (8.0) t. i. d., in water, fifteen minutes before mealtime. Other simple bitters and mineral acids may be tried, and there are many cases in which the judicious use of stimulants, particularly wines and malt liquors, aids the appetite and digestion materially. The chief indications for the exhibition of alcohol are—loss of appetite, feeble di- gestion, and weak, rapid action of the heart. Occasionally they will tend to aggravate these indications, rather than relieve them, and in this event they should be promptly discontinued. Brandy or whiskey in the form of milk-punch may be given freely in the advanced stage, and more 1 Loc. cit., p. 168. 324 INFECTIOUS DISEASES. especially during the morning hours when the temperature is subnormal. Lavage has helped some of my cases immensely, sometimes curing a com- plicating gastritis. (3) Special Remedies.—These increase the bodily resistance by im- proving the chief nutritive processes, but do not directly affect the tuber- culous lesions; among them cod-liver oil occupies first place. It is use- ful in a certain proportion of the cases, in which it seems to have more than a mere food-value. It is, however, exceedingly difficult to estimate the therapeutic importance of the oil while other measures—dietetic, hy- gienic, etc.—are being brought to bear. It sometimes causes further im- pairment of the appetite and digestion or sets up intestinal disturbances, and under these circumstances its effects are harmful; on the other hand, when Avell borne it may be very properly employed. The commencing dose should be small (3J-4.0, once or twice daily, to be increased after a time t0 3ij—8.0, two or three times daily). It should be taken about meal-time, but whether before or after may be left to the dictation of experience in individual cases. In most instances it is best tolerated after meals. When the pure oil is not well borne, it may be given in combination with an alkali (lime, soda, etc.). Some patients prefer to take it in connection with stimulants, but this should be advised against as long as it can be administered in other ways. Should the oil be found to disagree after it has been used for a considerable length of time, it should be temporarily discontinued. This often happens during the summer months. As a sub- stitute for cod-liver oil, good cream, preferably Devonshire, may be tried (3ij to ^ss-8.0 to 16.0, three times daily), and if taken regularly cream sometimes gives excellent results. The hypophosphites are especially serviceable in a certain proportion of the cases, though there is some difference of opinion in respect to their therapeutic worth. I am in the habit of employing them in cases in Avhich the oil is not tolerated and in which there is a feebleness of intestinal digestion. The commencing dose should be 1 dram (4.0), increased to 2 (8.0) if it is Avell borne. Arsenic is Avarmly advocated for its general influence on this disease, but clinical experience has taught us that it is useful in some cases and not in others. The dose should be small, in order that it may be given for a long period of time without interruption, and it matters little what form is employed. Jacobi speaks highly of arsenic, as well as of digitalis, in tuberculosis in children. The advent of an acute disease may arrest and cure a tuberculous pro- cess. Thus, the symptoms and signs of advanced tuberculosis have disap- peared after an attack of virulent small-pox and acute rheumatism (Harris and Beales). Hysteria also exercises an ameliorating effect upon pulmon- ary tuberculosis, according to the observations of Gibotteau,1 who advises against treatment of the former disease in tuberculous persons. (4) Treatment of Leading Symptoms.—Certain symptoms demand at- tention : (a) Cough.—This is often quite annoying, sometimes interfering with sleep, eating, and digestion, and even inducing vomiting; but it is to be remembered that cough is an essential feature of the disease, and does not claim attention unless it interferes with the above-named functions. The special cause or causes of the coughing should be determined before any 1 The Practitioner, October, 1894. TREATMENT OF TUBERCULOSIS. 325 attempt is made to treat it. It may be attributable to catarrhal irritation of the upper air-passages or throat, when it is best treated by topical applications, Avhich may be made Avith the applicator, or in the form of sprays and inhalations. The following substances may be inhaled : com- pound tincture of benzoin, combined Avith paregoric or carbolic acid ; cre- asote, alcohol, and chloroform, in equal parts. For local applications by means of the spray sedatives and narcotics should be preferred, and a solution of cocain is sometimes most efficient. The cause may be found in pleurisy or pleuritic adhesions, and for this condition counter-irri- tants, as iodin, sinapisms, etc., may be used. Pleuritic coughs often de- mand codein or even morphin in moderate-sized doses. The cough is in most instances occasioned by the tuberculous bronchitis, and to a lesser extent by the vomicae. Cough-mixtures are usually prescribed to meet these indications, but as usually formulated they are apt to disorder the digestive function, and in so far as they have this effect they are positively harmful. Since the relief obtained from their use is due to the sedatives and narcotics which they contain, syrups should be omitted from the com- position. I have come to rely upon creasote by inhalation as the remedy par excellence for tuberculous bronchitis, and combine it with spirits of chloroform and alcohol. To meet the same indication, and particularly when expectoration is copious, preparations of terebene, terpin hydrate, and tar may be resorted to; and when the cough becomes sufficiently distress- ing to urgently demand relief, I employ codein (gr. -|—\—0.008 to 0.016, every three or four hours) in the form of a granule. In the latter stages morphin is allowable, since it is at this time that constant coughing or severe paroxysms of cough, if not restrained, lead to utter exhaustion. Stimulant expectorants may be needful, and when this is the case am- monium carbonate in the infusion of wild-cherry bark is perhaps most efficacious and least apt to disorder the digestion: a few drops of the deodorized tincture of opium or spirits of chloroform may be added. (b) Fever.—Creasote has found a new field of usefulness in the treat- ment of the fever of tuberculosis. In my experience, at all events, the cases in which it has been used, as above indicated, have showTn a greatly diminished febrile movement. Cold or tepid spongings of the body at intervals of one, tAvo, or three hours, according to the intensity of the fever, should be tried. Internal antipyretics are rarely advisable, since during the period of high temperature the cardiac action is much enfeebled; but if urgently called for, the folio wing may be employed: acetanilid (dose gr. ij-iij—0.129-0.194), phenacetin (gr. iij-v—0.194- 0.324). These are to be administered about two hours before the com- mencement of the daily rise in temperature, and repeated every three or four hours if necessary. Other antipyretics worthy of trial are the min- eral acids and zinc oxid, but not quinin, Avhich has utterly failed in my hands. Keeping the patient at rest when the temperature is above 101° F. (38.3° C.) is good practice, though he should be wheeled into the fresh air for as long a time as possible during the day. (c) The Night-sweats.—Among remedies that control the sweats most successfully may be mentioned—atropin (gr. yto~to—0.0005-0.001); zinc oxid (gr. ij-v—0.129-324); sulphuric or gallic acid; muscarin (Tnjij-vj—0.399 of a 1 per cent, solution); agaricin (gr. i--^—0.008- 0.016). Sponging with equal parts of alcohol and tincture of bella- 326 INFECTIOUS DISEASES. donna is very effective, but my OAvn best results have been derived from the use of atropin (gr. y-^-gV—0.0005-0.0007) in combination Avith agaricin (\—0.008). (d) Dysphagia may be a troublesome symptom, especially from in- volvement of the larynx, and it is best met by local applications of a solution of cocain in glycerin and Avater (gr. x to ^j—0.648 to 32.0), thrice daily before meals. In advanced cases I have resorted to hypo- dermic injections of morphin (gr. ■£■—0.008) before meal-time. (e) Gastro-intestinal Disturbances.—In nearly all cases of phthisis dyspeptic symptoms and diarrhea come on sooner or later, and for this gastric disorder nothing is so important as a proper regulation of the diet. Perhaps the medical treatment of the gastric symptoms has been dealt Avith at sufficient length, save that of vomiting, Avnich may come on after meals and constitute a distressing concomitant. Those reme- dies giving the best results may be adduced as follows: cerium oxalate (gr. v-viij—0.324-0.518), in capsules before meals; calomel and soda in fractional doses; hydrocyanic acid (TTtij-iij—0.133-0.199); and chipped ice Avith brandy sprinkled over it, taken at short intervals, but especially shortly before meal-time. (/) Diarrhea.—The most important factor in the treatment of this symptom is a properly restricted dietary. The medical measures that have been and are employed are very numerous, but it will be sufficient to mention only the most useful, which may be used singly or com- bined in various Avays: bismuth (in large doses), acetate of lead, opium, thymol, salol, benzo-naphtol, naphthalin, etc. To the foregoing may be added tAvo formulae : B/. Bismuthi salicylat., .^j (4.0); Pulv. ipecac, et opii, 3ss (2.0). M. et ft. capsules No. xxiv. Sig. Two every four hours. The following acid diarrhea-mixture is excellent; each dose con- taining— B/. Acid, acetici dil., TT(x (0.666); Morphinse acetat., gr. \ (0.008); Plumbi acetat., gr. j-ij (0.0648-0.1296). Complications Avhen they arise must be dealt with according to accepted therapeutic principles. SYPHILIS. Definition.—A chronic infectious disease, due either to inoculation or direct contact Avith a specific virus. It may either be (1) acquired or (2) congenital, and is characterized by three stages, each of which presents special clinical symptoms and pathologic lesions. The con- genital form of the disease is transmitted at the time of procreation either by the sperm virile or by the ovum. SYPHILIS. 327 General Pathology.—(a) Primary Lesion or Chancre.—This ap- pears at the site of inoculation, and is characterized by infiltration of the connective tissue chiefly with round cells, and also by larger epi- thelioid and giant cells. This is folioAved by a shalloAV ulcer of the size of a split pea or larger, of Avhich the base is quite hard, the sclerosis being due partly to cellular infiltration and partly to a marked thick- ening of the intima of the small arteries (acute obliterative arteritis). Adjacent lymphadenitis, more or less marked, is constantly present, and, rarely, all the peripheral lymph-glands in the body are swollen. (b) Secondary Lesions.— Condylomata are the most common. Their favorite sites are the points at Avhich the mucous membrane and the skin are continuous (mouth, anus, etc.); their contour is more or less rounded or oval; their surface readily abraded and usually ulcerated; and their size varies from a pin's head to an inch or more in diam- eter. Like the Hunterian chancre, their periphery is more or less indurated. Secondary lesions also include skin-eruptions and ocular inflammations, etc., but these can only be referred to under later symptomatology. (c) Tertiary Lesions.—These are circumscribed inflammatory prod- ucts (gummata) appearing in the connective tissue, bones, periosteum (''nodes"), skin, muscles, brain, liver, lungs, kidneys, heart, testes, etc. The gummata, though usually sharply circumscribed, may take the form of diffuse infiltrations of the affected parts, and vary greatly in size— from a pin's point to a hen's egg. Usually firm, they may be soft, and, particularly on mucous membranes, tend to disintegrate, forming ulcers. Their color is grayish, and on section they show a caseous semi-opaque center, with a fibrous and more or less translucent periphery. They may occur singly or in groups. Microscopically, the gummata consist of small round cells. The mass thus formed may either be absorbed or persist Avithout change for a considerable period ; but in most instances coagulation-necrosis occurs in the center, due to local anemia, and there is a conversion of the per- ipheral zone into fibrous tissue. The gummata are enveloped in granu- lations and connective tissue, which contracts, forming cicatrices that often contain calcareous masses on their interior. The lesions of certain structures (skin, mucous membranes, bones, and cartilages) often lead to extensive destructive ulceration and sloughing, and these ulcers as they heal also form typical cicatrices. General Etiology.—Bacteriology.—Lustgarten in 1884 described the bacillus of syphilis, which closely simulates that of tuberculosis and the smegma bacillus. It occurs in rod-shaped or curved forms with slightly enlarged ends, and is from 3 to 5p long. From the smegma bacillus it is distinguishable by the carbol-fuchsin test; though demon- strable Avith difficulty in the hard chancre and in secondary lesions, its pathogenic potency is still very doubtful. Inoculation experiments upon lower animals are not possible, since man alone is susceptible. Predisposing Causes.—Since acquired syphilis originates only by in- oculation, it is obvious that a break in the cutaneous or mucous surfaces is essential to infection, such as a slight abrasion, fissure, or laceration, etc., particularly of the genital mucosae. Other surfaces may also be the seat of infection, as the lips, hands, etc. 328 INFECT 10 US DISEASES. Susceptibility to the virus is universal, and no age is exempt, lie- infection is exceedingly rare, but dpes occur; J. William White, how- ever, states that Ave have easy access to more than one hundred pub- lished cases of the reinfection of syphilis. Modes of Infection.—(1) In a great proportion of the cases syphilis is transferred by illicit sexual intercourse, there being, hoAvever, other modes of transmission. (2) Accidental Inoculation.—This is not uncommon, (a) Most fre- quently it is accomplished through the pernicious custom of indiscrim- inate kissing (lip-chancre), and I have personal knoAvledge of not less than 8 instances in Avhich infection has occurred through labial contact. Downie reports 4 cases that occurred in children. (b) The site of inoculation may also be the mouth and tonsils, the virus being conveyed during the Ioav practices of sexual perverts. The Avet-nurse may infect the mouths of suckling babes, or, vice versd, the infant may infect the nipple of the nurse. (c) The obstetric finger may become infected, and Osier mentions one such instance of infection of the back of the hand. Three instances of the sort have come under my OAvn observation, and Fournier gives the details of 40 cases of primary syphilitic infection of the hand. In 30 of these the malady was acquired in medical practice (4 obstetricians, 20 general practitioners, 3 students, and 3 midAvives). The remaining cases were attributable to contact and biting. (d) Humanized vaccine virus may transmit the disease, but this is a rare occurrence (vide Vaccination, p. 230). (e) Accidental infection has, though very rarely, taken place in a variety of other ways—e. g. handling foul rags from the hospital Avard, by bed-clothing, drinking-cups, the pipe, and cigar. Kraft-Ebing found that out of a totality of 3455 cases treated at the University of Christiana during twenty-five years (from 1867 to 1894), 15^- per cent, were of extra-genital origin. The seat of the lesion Avas upon the lips in 51 per cent., in the throat in 20 per cent., and upon the mammary gland in 20 per cent. (3) Hereditary Transmission.—Paternal transmission (through the semen) is much more common than is maternal, the period of greatest danger being immediately after the father has become infected or dur- ing the time of the secondary manifestations. The first-born, if the father be syphilitic, is apt to show well-marked lesions. Appropriate treatment of a syphilitic parent lessens the danger of transmission very materially, however, and in such instances there is little tendency to transmission shown after the third year. On the other hand, a syphi- litic father may beget healthy offspring. Syphilitic children are also common to infected women. In the majority of instances of hereditary transmission, hoAvever, both parents are syphilitic, and under these cir- cumstances the liability to infect the offspring is much augmented. A woman who has become infected after conception may bear a syphilitic child; though the latter may, on the other hand, escape infection, and particularly if the mother has been actively treated. Allusion may here be made to Colles's law—that a Avoman who bears a syphilitic child enjoys, owing to a sort of protective vaccination with the specific virus, perfect immunity, and this in the absence of all signs SYPHILIS. 329 of the affection. Coutts 1 does not believe that a mother may absorb from a syphilitic fetus an antitoxin of syphilis Avhich may render her practically immune to the disease. Clinical History of Acquired Syphilis.—(a) Primary Stage.— The typical initial lesion (chancre) appears about three Aveeks after in- fection, and is followed soon by SAvelling and induration of the nearest lymphatic glands. The primary sore begins as a red papule, which rapidly reaches its maximum, and then undergoes a central necrosis with the formation of a small ulcer. The adjacent structures become hard or cartilage-like—a characteristic to Avhich the lesion owes its name of "hard chancre." Secondary suppuration, either of the pri- mary sore or of the lymph-glands in the vicinity, may take place. A small chancre may often escape detection, especially if it be situated inside the meatus. When situated upon a mucous membrane it is always a chancrous erosion, Avhich may be so mild and of such brief ex- istence as to come and go Avithout the knoAvledge of its bearer. Par- ticularly is this the case in the female. The general symptoms are neg- ative in this stage. (b) Secondary Stage.—This is announced about six weeks after the appearance of the infecting chancre by moderate fever (101°-104° F. —38.3°-40° C), accompanied by languor, headache, bone-pains, im- paired digestion, and a slight degree of prostration. The patient, as a general rule, shows signs of anemia (syphilitic cachexia), and angina, Avith hyperemia of the fauces and hard palate, now appears. There may be minute elevated Avhite patches upon the pharynx; the tonsils may enlarge, and on both shallow ulcers presenting a grayish sharply- defined border appear. They neither excite pain nor spread. There is also an eruption, which is at first usually roseolar and Avidely distributed, coming out abundantly upon the trunk (especially the chest), buttocks, thighs, and forehead. Another early eruption is the papular. The papules are small, hard, and do not ulcerate, while their favorite seats are the scalp, chest, and dorsum of the tongue. The distribution of these early syphilids is symmetric; their outlines are rounded; their color like that of a slice of raw ham (" coppery "); and, as a rule, they excite neither pain nor itching. Other and later-appearing eruptions may be squamous, vesiculo-pap- idar, pustular, and tubercular. These shoAv a tendency to bunch in certain areas, and hence are less diffuse than the afore-mentioned erup- tions. Several sub-varieties, however, may appear simultaneously. The visible mucous membranes (angles of the mouth, tongue, gums, pharynx, vulva, vagina, penis, and around the anus) and the skin may shoAv painful condylomata or ulcers, and especially is this the case in the mouth, Avhere they often stubbornly resist treatment. Recurrences at varying and ever-decreasing intervals are common. Other frequent symptomatic conditions arise during this secondary period, such as iritis, laryngitis (frequently), choroiditis, retinitis, epi- didymitis (more rarely), and alopecia. The hairs of the eyelids and eyebrows may fall off and the finger-nails become brittle. The secondary symptoms last from twro to three months (the usual duration) to a year or more, and are folloAved by a period of apparent 1 " Hunterian Lectures," Lancet, 1896, No. 3789. 330 INFECTIOUS DISEASES. good health lasting for an exceedingly variable interval (from a few months to many years) before the tertiary stage sets in. During the secondary stage the symptoms maybe severe, mild, or even absent. The seArerity of an attack of syphilis depends upon the dose of infectinc virus on the one hand, and upon the condition (both local and general) of the vital functions on the other. This fact explains Avhy a single organ or system, as the brain and cord, is attacked in one instance and some other organ or system in another, and the effect of traumatism in determining the topography of periosteal "nodes" is a good example. (c) Tertiary Stage.—As I have already stated, the secondary period is generally followed by a variable interval of freedom from symptoms, but to this rule there are numerous exceptions, and among not uncom- mon occurrences may be witnessed the appearance of tertiary symptoms during the secondary stage. Belonging to the third stage are certain skin-eruptions, especially the characteristic rupia, Avhich first appears in the form of pustules that break and form ulcers that are covered with dry, laminated crusts "like an oyster-shell." To this stage also belongs psoriasis, especially of the hands and feet. Pustules (tubercular) which do not scale over also appear. These eruptions involve the true skin, and in healing leave scars, but, unlike the secondary cutaneous lesions, they are neither infectious nor contagious, are not, as a rule, symmetric, and are more liable to be attended by itching. True gummata may develop in the skin and subcutaneous tissue, and these break doAvn and form kidney-shaped ulcers which tend to spread in a serpiginous man- ner. On healing (a process that is accomplished Avith difficulty), scars result. Gummata may occur in the mucous membranes, and pass through the stages of ulceration and cicatrization. When situated in the larynx or tratchea their healing is attended Avith narrowing of the organ, and Avhen in the lower bowel or the rectum dysenteric symptoms, folloAved by actual stenosis, may result. In the muscles gummata occur and form small hard tumors. They may also cause periostitis and death of the bones, especially of the nose, palate, and skull; "nodes" are thus formed, which are situated chiefly upon the tibia and the skull in larger or smaller numbers, and also, though less frequently, upon other bones. These are exceedingly pain- ful, particularly at night, and are very tender under the pressing finger. They may be true gummata, but more often, if not absorbed, they either become ossified or undergo fibroid change, Avhile in rarer cases they suppurate. Chronic enlargement of the lymphatics and of the testicle, Avith little tendency to suppuration, may be noticed. The pregnant female is apt to abort or miscarry, either as the result of the action of the syphilitic virus upon the ovum or of the presence of gummatous growths in the placenta. Gummata also occur in the internal organs (visceral syphilis), and of the latter I shall speak presently, taking up separately some of the various organs and systems of the body. Amyloid degeneration is frequently caused by the acquired form, particularly syphilis of the rectum in Avomen, but very rarely by the congenital. Malignant Syphilis.—By this term is meant a virulent and a fatal form of the malady, Avhich is fortunately rare. The various stages manifest themselves early, and especially the tertiary, as on the forty- SYPHILIS. 331 fifth day in a case of Mauriac. The course is rapid and the condition resists all forms of treatment. Roussel narrates a case in Avhich death occurred about one year after the commencement of the disease. Clinical Symptoms of Congenital Syphilis. — These may, though rarely, be identical Avith those of acquired syphilis, if we except the chancre.1 Occasionally the characteristic symptoms are present at birth. On the other hand, in the vast majority of instances they appear between the first and fourth months of life (infra). The symptoms of inherited syphilis may be grouped according to the time of appearance: (1) In the New-born.—There is a lack of physical development. The babe may be greatly emaciated, it has snuffles, and singultus occa- sionally sets in soon after birth. Skin-eruptions are rare, except pem- phigus neonatorum, which appears as bullae on the palms and soles; among exceptional cutaneous phenomena are gummata around the radio- carpal articulations, palmar psoriasis, and a fleeting roseola. LUcers and fissures (rhagades) may be noticed around the outlets of the body (mouth, anus, etc.); the osseous system may show hyperostoses of the long bones; and the liver and spleen are enlarged. Comby reports 8 cases of pseudo-paralysis due to syphilis in the new-born. (2) Early Post-natal Symptoms.—Most subjects of syphilis heredi- taria are born plump and Avithout taint. Romiceano 2 gives the results of his observations of 723 cases of infantile syphilis in which the dis- ease appeared chiefly betAveen the first and fifth months, and only 27 times in all after the sixth month. Rogers's statistics show that among 249 cases, 217 shoAved symptoms before the end of the third month. The first symptom is generally coryza (syphilitic rhinitis), Avhich is be- trayed by a sero-purulent or bloody discharge and a peculiar form of obstructed breathing (snuffles), rendering nursing difficult. The coryza may in some cases be preceded by singultus lasting ten or tAventy days (Carini), and ulcers may form in the nose, leading to necrosis of the bones and producing at last a sunken and deformed nose Avhich is highly significant. The coryza may extend to the middle ear and cause otitis media, A\rith deafness and otorrhea as the chief symptoms. The skull may approach the natiform in shape, and the signs of diaphyso-epiphys- eal inflammation develop. The cutaneous symptoms appear early. The skin has a tawny hue, and an erythematous eruption of the nates and genitals is frequently seen; this is patchy, with well-defined margins, and has the character- istic coppery color. In the same localities papules may appear, Avhile pemphigus may attack the palms and soles. Syphilitic onychia may be present, and the lips and angles of the mouth often show fissures that are of real diagnostic Avorth. Other symptoms are ulcerations of the skin and mucous surfaces, falling of the hair, and a moderate glandular enlargement. Enlargement of the spleen is a frequent characteristic symptom, and White says that the enlargement of the organ when " painless, subacute, persistent, often preceding the eruptions, should be included in the list of significant symptoms." SAvelling of the liver may also be present, but is of little diagnostic import. Syphilitic infants occasionally manifest a hemorrhagic tendency. 1 With prenatal syphilis we are not concerned. 2 La Progres medicate, Paris. 332 INFECTIO US DISEASES. At birth bleeding from the umbilicus may occur; later, into the sub- cutaneous tissue and from the mucous membranes (gastro-intestinal vaginal, nasal, etc.). As pointed out by Osier, these cases must not be confounded with Winckel's disease—an acute infectious hemoglobinuria of the neAv-born. Among nervous symptoms, restlessness, sleeplessness, and a harsh shrill cry Avhich may be almost constant for days together and due most probably to darting pains, are the chief. Anemia and other evidences of syphilitic cachexia soon supervene. (3) Late Symptoms.—The symptoms of syphilis hereditaria tarda may be arranged in groups (Fournier) : (1) Those Indicated by the General Appearance.—There is a retarded general development, as shown by the small stature, undeveloped muscles, the graceful form, and infantile appearance at ages varying from four to tAvelve or more years. The skin has an earthen tint, and the hair may be scanty and late in its appearance on the face and genitals. (2) Skin-cicatrices.—Cutaneous scars, particularly if multiple and extending over a circumscribed area, are important diagnostic signs. Their form is usually round or serpiginous, and their chief location the mouth, nose, soft palate, and lumbo-gluteal regions. (3) Lesions of the Skeleton.—The natiform skull, " with a transverse enlargement, lateral bulgings, and the flattening in the middle," is almost pathognomonic. Asymmetric and hydrocephalic skulls are also to be considered, in many cases, as signs of hereditary syphilis, as is a sunken and deformed nose. The thickened, " sabre-shaped " tibia, due to gummatous periostitis, is capital evidence of the disease, Avhile the chicken-breasted thorax is significant. (4) The testicles show an arrest in development (infantile testicles). This is a sclerotic atrophy. (5) Hutchinson's triad, under which title come (a) the Hutchinson teeth; (b) ear-conditions; and (c) affections of the eye. (a) The Hutchinson Teeth.—The teeth may be late in appearing, and the dental arch may be malformed, the teeth presenting various irregu- larities in form and condition (dental dystrophy). The incisors, especially the superior median of the second dentition, are notched, and show a thinness of the free edge, an atrophy of the summit, and crescent-shaped erosions. The latter are truly pathogno- monic (Fournier). (b) Ear-conditions.—Otorrhea, secondary to naso-pharyngeal catarrh, has already been mentioned, and, in addition, at or about the time of puberty an incurable form of deafness may develop speedily, without the presence of pathologic lesions to explain the same. (c) Affections of the Eye.—These are interstitial keratitis and iritis, affecting both eyes successively. VISCERAL SYPHILIS. 333 Visceral Syphilis. Syphilis of the Brain and Cord.—Pathology.—The most characteristic and not infrequent lesions are the syphilitic neAA7-growths. Their size varies from that of a bean to that of a chestnut, and they present irreg- ular contours. They are usually situated either in the cerebral hemi- spheres or on the pons, and rather superficially, connecting directly or indirectly Avith the dura or pia mater. They may not infrequently orig- inate in the dura mater. In gummata of average size a cut-section shows caseation in spots which are connected and surrounded by firm, translucent, gray or reddish-gray, fibrous tissue; and, according to Gowers, the more irregular surfaces and the irregular caseation serve as important distinctions from tuberculous tumors. When, as is usual, the gummata touch the membranes, meningitis—subacute or chronic, with much thickening—is combined. As I have said, the condition may begin as a gummatous meningitis, while in fewer instances it may start as a gummatous arteritis. On the other hand, a gumma may secondarily involve a blood-vessel for a con- siderable distance, weakening its Avails, with resulting rupture and intra- cranial hemorrhage ; or it may bring about cerebral thrombosis with secondary softening. Histologically " the cerebral gumma differs from other similar bodies chiefly in the presence of very large spider-like cells containing an exag- gerated nucleus and a granular protoplasm which extends into the multi- ple, branching, rigid prolongations" (Wood). The arteries, particularly those of the base, may show syphilitic sclerosis; this renders them thick, hard, opaque-whitish, until their lumen is well-nigh obliterated. Gummatous growths may attack the cord. In a case recently reported by Osier a neAv-growth occupied the cord opposite the root of the third cervical nerve, "and there Avere gummata in the cauda equina." The other gross changes found in connection with cerebral gummata and their secondary lesions (softening, collateral inflammation, etc.) are also ob- served in syphilis of the cord. Etiology.—Cerebral syphilis is usually a late (tertiary) manifestation— appearing from one to thirty years after primary infection. In some recently recorded cases by Lydston and others nervous lesions became evident during the secondary stage of syphilis, even as early as three months after initial infection. It oftenest develops in cases in which the secondary symptoms have been slight, and may occur in those in which both primary and secondary manifestations have been entirely overlooked. Inherited syphilis affects the nervous system less frequently than does the acquired form, but cerebral gummata have been noted at all periods from the time of birth until after puberty. Symptomatology.—Imbecility and idiocy may be due to inherited syphilis, but they are probably too often attributed to this cause. The other features simulate those of the acquired form. The symptoms of the acquired form are with few exceptions referable to three affections : (a) epilepsy, (b) brain-tumor, and (c) paralysis. (a) Epilepsy coming on after the twenty-fifth year is usually due to the ravages of syphilis, and a careful search for traces of scars and 334 INFECTIOUS DISEASES. bone-lesions, etc. should be instituted. The appearance of the disease may be preceded by psychic disturbance, headache, dizziness, and loss of memory. Hysteric manifestations may also be presented, beinu probably provoked by the specific lesions. On the other hand, a pro- tracted torpor which may last for a feAv days or as many Aveeks may develop. In one of my own cases periods of marked mental excite- ment, that persisted for three or four days, alternated with periods of almost complete insensibility of about equal duration. (b) Brain-tumor.—The symptoms pointing to brain-tumor will be dis- cussed under this head in the section on Nervous Diseases. The syph- ilitic nature of the cerebral groAvth cannot be determined with any degree of certainty except in the presence of a clear history of syphilis —congenital or acquired—and the characteristic symptoms or traces of the primary, secondary, or tertiary lesions. In such cases the diagnosis is almost undoubted. It must be remembered that the secondaries are either sometimes absent or go unnoticed, and if the patient has had a primary sore, the presence of the characteristic symptoms of brain-tumor (headache, optic neuritis, convulsions, etc.) make the existence of specific nerve-lesions highly probable. The chancre may also be overlooked or denied, and it is in such instances as the latter that the occurrence of convulsions in persons over thirty should excite suspicion, and lead to a trial of the antisyphilitic treatment for further confirmation. (<•) Paralysis.—This may take the form of hemiplegia (due to cerebral hemorrhage or tumor) or of general paralysis (dementia paralytica). The relation that these affections bear to syphilis vvill be indicated in its appropriate place in this work in the description of Nervous Dis- eases. The fact may here be pointed out that syphilis may induce pre- cisely the same changes met Avith in general paralysis of the insane. The history of syphilitic infection, together Avith symptoms of an atypical type of spinal tumor, points to gumma of the cord. Syphilitic myelitis usually develops within five years after infection, and may pur- sue an acute or subacute course, though oftener it takes the form of chronic myelitis. The latter attacks by preference the lumbo-dorsal section of the cord—a fact corroborated by the character of the symp- toms. The clinical features, hoAvever, are not distinctively syphilitic; neither does the effect of treatment in the sIoav sclerotic form add fresh light as to the specific nature of the trouble, since the process is unin- fluenced by the most vigorous antisyphilitic measures. When the eti- ologic influence of syphilis can be shoAvn, especially in the absence of other causes, the diagnosis of syphilitic myelitis rests upon more certain ground. Acute syphilitic myelitis gives an unfavorable prognosis. The relation betAveen syphilis and spinal meningitis, primary spastic para- plegia, and locomotor ataxia will be more fully dwelt upon under the latter affections. Syphilis of the Liver. In my experience the liver, Avith comparative frequency, bears the stress of visceral syphilis. Pathology.—The lesions may be thus classified: (a) Diffuse Syph- ilitic Hepatitis.—This is met Avith chiefly in congenital cases, though I SYPHILIS OF THE LIVER. 335 have seen an instance in an adult who died of cerebral hemorrhage, the occurrence of Avhich in adult life has been questioned by some. The liver is uniformly enlarged, firm, and resists the cutting knife. Its color is grayish-yelloAV. The microscope shoAvs a marked increase in the connective tissue and a cell-infiltration throughout. From intense, focal cellular infiltration miliary gummata may result; these undergo contraction, diminishing somewhat the size and altering the shape of the organ. (b) Gummata.—These may be seen in congenital cases (chiefly the miliary gummata). As seen in the adult, hepatic gummata are dissem- inated nodules, with the usual central, cheesy mass surrounded by a zone of grayish fibrous tissue and varying in size from a hazelnut to an apple. They form separate tumors, Avhose favorite seat is the convex surface of the organ, especially near to the suspensory ligament. They are usu- ally tertiary lesions, and do not appear until a number of years (tAvo, three, or four) after infection. These so-called syphilomata in the ad- vanced stage contract, and the liver Avill be found smaller than the nor- mal. Deep furrows, due to contracting fibrous bands traverse the organ in different directions and divide it into lobes of various dimen- sions. Gummata frequently undergo fibroid change, but more rarely they soften and liquefy (Wilks). On the other hand, before contraction occurs the liver is increased in size and the gummata form protuberances on its surface. (c) Gummatous Arteritis.—Briefly, this may affect both the portal vein and hepatic artery, though syphilitic endarteritis is situated chiefly in the smaller branches of the latter. (d) Perihepatitis.—Here Glisson's capsule is thickened, owing to aug- mentation of its connective-tissue elements. From the latter there dip into the hepatic tissue cicatricial bands, particularly along the portal canals, which may change someAvhat the shape of the organ. Section shoAvs admirably the pale scar-like tissue. Clinical History.—The affection may exist without symptoms. In the congenital form, however, we have signs of hepatic enlargement, Avith icterus, the spleen being likeAvise large and firm, as a rule. The history and associated lesions are necessary to a certain diagnosis. In the adult syphilis of the liver does not usually attract attention until the gummata interfere with the portal circulation. As they un- dergo contraction they tend to occlude some of the portal branches, or they may, on account of their situation, exert pressure upon the vena porta itself. In either event the evidences (ascites and splenic enlarge- ment) of portal obstruction will develop as in alcoholic cirrhosis. The gastro-intestinal symptoms common to the latter disorder are also pres- ent, and obstructive jaundice may supervene, though it is, compara- tively speaking, rare. Pain, usually localized to some particular spot over the right hypochondrium, is sometimes complained of, and may be quite severe, Avhile pressure over the painful area elicits great tenderness. Physical Examination.—In the early stage, Avhile the organ is enlarged, flattened, irregular protuberances may be detected by the pal- pating fingers. At a more advanced period ascites may interfere Avith palpation, and in such cases an aspiration of the fluid Avill enable one 336 INFECTIOUS DISEASES. to feel the syphilomata. Finally, in the stage of contraction the results of palpation are obviously negative. There is a group of cases in which the clinical picture is that of advanced amyloid disease of the viscera. The liver and spleen are enlarged, the urine is increased in amount and contains albumin and tube-casts, and finally dropsy supervenes. Here secondary amyloid degeneration has occurred. Diagnosis.—This rests upon the etiology, the presence of scars in the throat or on the skin-surface, bone-lesions (especially irregularities of the tibial surfaces), or other evidences of the ravages of the disease, and upon moderately good general health. The causal factors of ordi- nary cirrhosis, alcohol, etc., must be carefully excluded. The most im- portant symptoms are the hemispheric prominences (sometimes sepa- rate) on the surface of the liver, and the localized pain. The grouping of symptoms in this disease bears a close resemblance to those of cancer of the organ, but there are points of dissimilarity which I have contrasted in the subjoined table : Syphilis of the Liver. Cancer. History of heredity or of infection. History of heredity or of primary growth. Occurs congenitally, or, if acquired, at Never congenital. Usually occurs after any age. the age of forty. Often accompanied by symptoms of ter- Often preceded by the primary growth tiary syphilis—alopecia, rupia, syph- in pylorus, uterus, mammary gland, ilitic iritis, etc. etc. Jaundice and ascites are common, espe- Jaundice and ascites are rare. Marked cially the latter. No cachexia. cachexia. The margin, on palpation, is markedly Often the margin reveals the presence of irregular, and neither nodular nor um- umbilicated nodules. bilicated. Recovery may follow, or the affection Always fatal. Duration usually from a may last for years. few months to a year. The course and the results of antisyphilitic treatment are of value from a diagnostic view-point. The course is slow and often interrupted temporarily by improvement, if not arrest of the disease, while appro- priate treatment sometimes leads to recovery, with a complete disappear- ance of the tumor-mass, as occurred in tAvo cases of my OAvn. Syphilis of the Alimentary Tract. The lesions in the mouth have been for the most part considered. In the tongue gummata often develop. A decidedly fissured appearance of the organ and Avhitish scar-like patches upon the surface may be ob- served in syphilis, but have no essential connection with that disease. Gummata also appear on the posterior wall of the pharynx and lead to ulceration, which may cause fatal hemorrhage by erosion of adjacent large blood-vessels (internal carotid, etc.). The Avails of the esophagus may also be invaded, resulting usually in stenosis. The stomach-walls may be infiltrated, though they are rarely ulcer- ated ; syphilitic ulcers, hoAvever, may appear in the intestines, and the condition may lead to perforation and peritonitis. SYPHILIS OF THE LUNGS. 337 Gummatous infiltration of the rectum is a somewhat frequent, severe, and clinically important affection. It is much more common in women than in men, taking place in the " submucosa above the internal sphinc- ter." It has frequently caused a fatal result in persons Avho failed to show post-mortem specific lesions in other viscera, and hence it is to be classed as one of the ravages. The result of the gummatous infiltration is the production of a funnel-shaped stenosis of the rectum which narroAvs from below upward. Above the stenosis, and directly depend- ent upon it, there is dilatation of the rectum and the descending colon. Here may also be found ulcers—some specific, and others the result of mechanical pressure exerted by the fecal accumulations. Symptoms.—The clinical features are for the most part those of a gradually induced stenosis of the rectum. At first there may be hem- orrhages, suggesting internal hemorrhoids. The action of the bowels is irregular, and is folloAved shortly by a tendency to dysenteric diarrhea, Avith pains, tenesmus, and scanty stools containing mucus and pus. Prolapse of the rectal mucosa may occur, and, owing to the presence of small hemorrhoids, the true nature of the case may be overlooked. The disease is most distressing, and leads slowly and gradually to ex- treme emaciation and asthenia. Death may be due to the latter or to some complication (perforative peritonitis, etc.). Diagnosis.—This may be aided by a clear history of associated syphilitic symptoms or of specific lesions, including amyloid degenera- tion. A sure demonstration can only be made by rectal examination. The examining finger feels the sharp edge of the cicatricial ring. Cancer of the rectum can readily be eliminated on account of the absence in syphilis of the "crater-like" ulcer. Syphilis of the Lungs. While undoubted cases occur, syphiJis of the lungs is rare indeed. Pathology.—The cases are pathologically divisible into four forms : (a) Gummy tumors ; (b) Interstitial pneumonia; (c) Brown induration ; (d) Fetal pneumonia. (a) Gummy Tumors.—These appear as yelloAvish-Avhite scattered nodules, varying in size from a cherry-pit to a hen's egg. Their centers are dry and caseous-looking, and their peripheral zones fibrous. They are relatively thicker set near to the root of the lungs. Cicatricial bands may be seen connecting not only the separate nodules, but stretch- ing outAvard to the thickened pleura. Such groAvths may undergo soft- ening and ulceration, thus forming a cavity that rarely attains to large measurements; or, on the other hand, in favorable cases the fibroid changes and cicatrization may lead to recovery. A primary lesion is atrophy of the alveolar walls, with hyaline de- generation of the capillaries (Councilman). Broncho-pneumonia (not distinctively syphilitic) may be associated. (b) Interstitial Pneumonia.—This is a fibrous infiltration, showing a predilection for the right lung. Its chief seat is the root of the lung, Avhence it extends along the bronchi and vessels, and usually involves a part of one or more lobes. Occasionally its starting-point is the pleura, from which the process advances along lines corresponding to the inter- 22 338 INFECTIOUS DISEASES. lobular tissue. Bronchiectasis may be noticed. Gummata may also be associated, or may have been present and been practically obliterated during the process of cicatrization. I have seen an instance in which the merest vestige of gummatous material remained. (c) Brown induration, simulating exactly that Avhich is seen in asso- ciation with organic valvular diseases, may be observed, but it may have no necessary connection Avith syphilis. (d) Fetal Pneumonia (J^irchow's White Hepatization).—This is pecu- liar to the new-born, in Avhich miliary gummata first occur, followed by hepatization of large zones or an entire lung. The chief changes are an infiltration of the alveolar Avails, while the air-cells are filled with desquamated epithelium; on section the tissue presents a grayish-white appearance. Symptoms.—From Avhat has just been stated it is clear that a certain limited number of cases present symptoms and signs that simu- late ordinary ulcerative phthisis, but do not show bacilli in the sputum, and hence have no connection Avith genuine phthisis. There is another group of cases in Avhich the picture presented to view is almost identical with that of fibroid induration though usually giving a distinctly syph- ilitic history. I am not prepared to say that there is an acute syphilitic broncho-pneumonia analogous to acute pneumonic phthisis, though I fail to see any reason why malignant syphilis may not attack the lung and take that form. The symptoms may be too few and too mild to afford ground for suspicion. Diagnosis.—If a suspected case is treated early and accurately, the result may serve to corroborate the diagnosis, which is at first far from being final. Bronchiectasis, dependent upon syphilitic peribronchitis or intersti-, tial pneumonia, cannot be discriminated from other forms of that disease except there be a clear history of infection, and unless associated scars or active syphilitic lesions coexist. Pulmonary tuberculosis cannot be distinguished from pulmonary syphilis Avithout a careful microscopic examination of the sputum. Moreover, it must not be forgotten that luetics often develop ulcerative phthisis, and hence these affections are often combined. Syphilis of the Spleen. Pathologically, syphilis of the spleen is to be classed with the general adenopathy of the disease. According to the statistics of Se"e (relating to hereditary syphilis) and of Avanzini and Schuchter (relating to ac- quired syphilis), in about 25 per cent, of the cases of secondary syphilis hypertrophy of the spleen may be noted. This augmentation begins from two to four weeks after the appearance of the chancre, and gradu- ally increases, persisting throughout the secondary period; it is not, hoAvever, observed during the tertiary stage. It is often accompanied by localized pain—syphilitic pleurodynia (Besnier). Syphilis of the Circulatory System. The Heart.—The pathologic divisions are—(a) Gummata, which attack chiefly the walls of the left ventricle. They are usually encysted. SYPHILIS OF THE ARTERIES, ETC. 339 (b) A Fibro-sclerotic Myocarditis.—The process begins in the peri- vascular tissue and proceeds from the vessel Avails outward (Mracek). It is diffuse, as a rule, and leads to narroAving of the lumina of the cor- onary arteries and their branches or to aneurysmal bulgings, but the pathologic effects of these lesions are seldom detected clinically. Sud- den death may occur. (c) Syphilitic Endocarditis.—The changes are of the fibro-sclerotic variety, and not of the more acute verrucose or Avarty type. The symp- toms to which the lesion gives rise are depicted under Organic Valvular Disease. Syphilis of the Arteries. Tavo forms are recognized : (a) Obliterating Endarteritis.—Here the syphilitic product consists chiefly of proliferated subendothelial tissue, which encroaches more and more upon the lumen of the vessel—a fact to Avhich the disease owes its name. This so-called " Heubner's degen- eration " is not peculiar to syphilis, but, as Osier says, " if, however, there are gummata in other parts, or if there be gummatous periarter- itis in adjacent vessels, the process may be regarded as syphilitic." (b) Gummatous Periarteritis.—This results in larger or smaller nod- ules or ovoid masses that may encircle the artery. Among common seats are the cerebral and coronary vessels, the growth starting in the adventitia and proceeding outAvard. According to the views of syphil- ographers of the present day, it is to be classed with the ravages of the disease, and hence is not due to the syphilitic virus. Syphilis of the arteries has an important etiologic bearing upon atheroma and aneurysm (vide Diseases of the Arteries). Syphilis of the Kidneys. Renal syphilis belongs chiefly to the tertiary stage, though it may appear in the secondary. Pathology.—(a) Amyloid degeneration is a common renal lesion. (b) Granular atrophy (Jaccoud). (c) Gumma. Symptoms.—Except in the case of amyloid degeneration the con- ditions are impossible of correct diagnosis. Wagner describes a special form Avhich he calls acute syphilitic glomerulo-nephritis. Clinically, it is characterized chiefly by hematuria, and ends rapidly with uremia. Syphilis of the Joints. The following division of the affection is made by Hutchinson of London: (1) Synovitis appears during the secondary stage, but soon clears aAvay under appropriate treatment, leaving no traces behind. (2) Perisynovial gummata. (3) Arthritis, due to osseous nodes or gummata in the neighborhood of the joints. (4) True Chronic Synovitis.—This is the most common form of syph- ilitic arthritis. 340 INFECTIOUS DISEASES. (5) Syphilitic chondro-arthritis (Virchow). The last four forms belong to the tertiary lesions. Symptoms.—At the outset it is to be borne in mind that a joint- affection that does not yield to specific treatment is not necessarily non-syphilitic. Perisynovial gumma attacks most frequently the tissues around the knee-joint; it is very chronic in its course and is more commonly seen in Avomen than in men. Arthritis due to osseous nodes has a special diagnostic feature in the severe nocturnal pains. The fourth form of syphilitic arthritis (true chronic) is the most common among the types due to acquired syphilis, while the symmetric synovitis of the knees occurring about puberty is perhaps peculiar to the congenital cases. The latter is apt to follow in- terstitial keratitis, and fortunately clears up rapidly under treatment. Syphilis of the Testicles. The lesions are of two forms: (a) Gummata.—These produce hard, usually nodular, swellings, either single or multiple, and of moderate size, that occupy the substance of the testicle and sometimes the epididymis. (b) Interstitial Orchitis.—This is a fibro-sclerotic change that leads to sIoav, gradual atrophy. Though bilateral, it is usually more marked on one side than the other. Diagnosis.—In gummatous orchitis the SAvelling of the testicle is painless, usually nodular, and feels much like a scirrhous groAvth. Rarely it ulcerates, forming a fungous testicle. The frequency of syph- ilitic involvement of the organ forms a leading factor in the diagnosis. In tuberculous disease the history and associated lesions differ from those of syphilitic orchitis, and the epididymis is generally affected. Atrophied testicles may be due to congenital syphilis. In such in- stances typical scars, eye-affections, and the characteristic physiognomy are usually to be noted. Hydrocele may OAve its origin to the same cause. Atrophy of the testes may lead to impotency and sterility. Such instances are not to be mistaken for the results of metastasis in mumps. General Diagnosis of Syphilis.—Perhaps sufficient has been said regarding the importance of obtaining a correct statement with reference to the primary infection. On failure to find evidence of a genital chancre, an examination for extragenital primary sores must be instituted, and the latter will be found to be by no means rare, even among children. The presence of a scar may betray the previous ex- istence of a chancre in cases in Avhich infection is denied or overlooked by the patient. The secondaries are rarely puzzling, especially when the previous history is complete. There may be complicating eruptions. In Bulk- ley's records of 300 cases, 23 well-recognized affections of the skin were associated with syphilis. In this connection two facts need to be em- phasized : first, that a syphilitic eruption, either macular or papular, may rarely cause troublesome itching; and second, that a patient with a syphilitic eruption may experience itching due to another cause- namely, eczema or scabies. SYPHILIS. 341 Inherited syphilis may be diagnosticated on the appearance in a child under five months of snuffles and the characteristic skin-eruptions. Syphilis hereditaria tarda may be recognized from a retrospective view or from the presence of active lesions and symptoms, or from both of these factors. The recognition of the tertiary manifestations of acquired syphilis embraces these points: 1. The consideration of the fact that obscure cases in general and atypical symptom-groups are often due to the syph- ilitic taint. 2. Direct information or proof, as the result of careful inquiry, to shoAV that the primary and secondary stages (either one or other, or both) have transpired. 3. The evidence presented by the patient and to be obtained by the careful objective examination of the eves (for iritic adhesion, etc.), throat and skin (for scars), bones (for necrosis and nodes), and the testes. 4. Certain symptoms are signif- icant, such as nocturnal pains, paralysis of the single cranial nerves, double deafness Avithout otorrhea, etc. 5. The therapeutic test may aid in doubtful cases. The presence of scars constitutes a most important factor in making a retrospective diagnosis. Recent scars are pigmented, and exhibit a sIoav, progressive clearing up, until, from four to eight years after in- fection, they are wholly decolorized. On the other hand, as pointed out by Hyde, e'czemato-varicose scars remain stationary. These scars are apt to be found on the scalp and on the anterior surfaces of the legs. They may be single or multiple, and may exhibit certain defined shapes (semilunar, dumb-bell, etc.). General Differential Diagnosis.—Numerous affections and conditions— local and general—are liable to be confounded Avith syphilis. Mere allusion to some of these common errors of diagnosis can be made here, while others must be omitted altogether : (a) The primary sore of the lip has been mistaken repeatedly for cancer. The history and symptoms of syphilis, together Avith the ther- apeutic test, must clear up the doubt. (b) Certain skin-eruptions (lichen, psoriasis, papular eczema, etc.) may be mistaken for the eruption of secondary syphilis. J. V. Shoe- maker1 details the differential diagnosis in a recent article, which the reader Avho desires full information may consult. (c) Care must be exercised lest the specific eruptive fevers, especially the papular stage of small-pox, be mistaken for secondary syphilis. (d) The syphilitic arthritis Avhich may develop at the onset of the second stage must be discriminated from rheumatic arthritis—an easy task if only the attention be draAvn to the primary lesion and the cha- racteristic secondaries in cases of the former disease. (e) Syphilis in the tertiary stage may simulate chronic gout or rheu- matism, and unless there is definite evidence of syphilis on the one hand, or typical rheumatic symptoms and history on the other, the diagnosis may remain indefinitely uncertain. The therapeutic test may aid. (/) Periosteal nodes, like those occurring in syphilis, may folloAV vaccination, small-pox, typhus and typhoid fevers. Here the history and associated phenomena furnish reliable data to effect a discrimi- nation. 1 Medical Bulletin, Nov., 1893. 342 INFECTIOUS DISEASES. (g) Carcinoma of the tonsil has often been diagnosed, and the tonsils have been excised when really the seat of a syphilitic lesion. Treatment.—(a) Prophylaxis.—To prevent the transmission of hereditary syphilis infected persons should not marry Avithin three years after the appearance of the primary sore. "Marriage should also be prevented when the patients have not been subjected te a thorough and prolonged treatment" (Porter). If at the end of the third year the patient presents a mucous patch, he must Avait one year longer, and in the meanwhile be actively treated. A fresh outbreak of symptoms in a luetic patient demands immediate and active treatment. Should a healthy mother bear a syphilitic child, she must not be allowed to suckle it. This precaution, though apparently contrary to the principle laid down in Colles's law, is not superfluous, since the mother might be infected by any oozing fissures or condylomata upon the lips or in the mouth of the child if erosions of her nipple were to occur. Wet-nurses should not be employed for syphilitic children, but may be for non-syphilitic, even Avhen the mother is affected. If syphilis appear in the mother during pregnancy, antiluetic treatment should be begun and persisted in even after apparent recovery. After the birth of the child, in such instances the course of treatment should be con- tinued, if the child be nursed by the mother, Avith a view to medicating the milk. As has already been stated, the most frequent mode of infection is irregular and illicit sexual congress, and it follows that absolute moral purity would go further toward the prevention of this Avidespread malady than any sanitary code or legal restrictions. Physicians cannot too strongly advocate continence. Should prostitution be regulated and controlled by the state ? Experience has shoAvn that but a slight con- trol is exercised over the spread of syphilis in countries where system- atic regulation of prostitution is attempted by the state. I am of opinion that the state should maintain some form of sanitary regulation and con- trol, but, unfortunately, to render this efficient demands that prostitutes shall be officially registered. Such a sanitary supervision should consist in the examination of every prostitute at least tAvice a week, including a microscopic examination of the uterine and vaginal secretions, and the sending of every diseased prostitute to a hospital with a special depart- ment for such cases.1 Palmer suggests that the female offender is usually not aware of the existence of a primary sore, Avhile the male is; hence the latter should undergo inspection also. Inspection of prostitutes, however, unless rigid and careful, is absolutely valueless. Chancres are often concealed from view in the vagina or upon the lateral aspect of the os uteri. The maintenance of legal brothels, however, is not here rec- ommended, either from a moral or hygienic standpoint. (b) Medicinal Treatment of Hereditary Syphilis.—For syphilis of the new-born, mercury, either in the form of calomel (gr. y1^-0.0064, t. i. d.) or gray powder (gr. £-0.0324, t. i. d.), is to be employed. These babies must be hand-fed. The issue is almost unexceptionally bad. When the first symptoms appear at the second or third month the above method of treatment is generally successful. Among the poorer classes no objection is made to mercurial inunctions, and these are often 1 The Berlin Commission on the Prevention of Syphilis, Dec. 1, 1892. SYPHILIS. 343 preferable. The ointment may be rubbed into the arm-pits, thighs, or sides of the abdomen, Avhich should be covered Avith a flannel roller. The hygienic details must be attended to, and especially must the parts be kept clean, and the mouth washed after nursing Avith a 3 per cent. solution of boric acid. Syphilis hereditaria tarda is best treated by the use of potassium or sodium iodid. To the iodid may be added mercuric chlorid in suitable doses, though the latter may, as pointed out by Rob- erts, often disagree. In addition to the specific therapy, tonic measures are usually indicated, and Avhen employed are of the highest service. (c) Treatment of Acquired Syphilis.—There is a specific plan of treat- ment which should be commenced as soon as the appearance of the sec- ondaries has set the diagnosis of the given case at rest. This is the use of mercury, and rarely of potassium iodid also. The instances in Avhich the latter alone is to be administered are among the rarest occurrences in medical practice. Fournier's " chronic intermittent treatment" of syphilis—Avhich consists in continuous medication for tAvo or three years with mercury and iodin alternately—is warmly advocated by some syph- ilographers, but the continuous mode is, in the opinion of most specialists, of greater advantage to the patient. Unless mercury disagree or the patient is exceedingly susceptible to its physiologic effects, I use it per- sistently during the secondaries, and later at intervals until the end of tAvo years. It is a protracted course, and a protracted course only, of the specific treatment that suffices if we would obviate the dread ravages that othenvise are so apt to appear. I usually employ the protiodid (gr. |—I—0.008-0.012, three times a day), and later the biniodid (gr. -g1—A_ —0.0021-0.0027, three times a day). Hutchinson recommends the gray powder, given in pill form, combined with Dover's powder (da. gr. j- 0.0648), this pill to be taken from four to six times daily. I can speak from considerable personal experience as to the efficacy of this method. A Avell-known mixture, freely prescribed in many dispensaries, contains mercuric chlorid and potassium iodid in combination. Inunctions of mercurial ointment (3ss-2.0, night and morning) pro- duce excellent results, and it is advisable in cases in Avhich the syphilids yield unsatisfactorily to internal dosage to suspend the latter at inter- vals of six or eight Aveeks and give a course of inunctions. Surely, they often hasten the disappearance of the more obstinate late second- aries, such as psoriasis (palmar), glossitis, etc. White advances the vieAv that in the later stages, Avith the involvement of the deeper tissues, the combined use of inunctions over the affected region Avith potassium iodid internally often seems to have distinct advantages as compared Avith the administration of the " mixed treatment " by the mouth. It is necessary to omit the inunction once in seven or eight days for one day, and to take a Avarm bath to aid in the elimination of the mercury. The hypodermic use of mercury in syphilis is to be adopted only Avhen very prompt action of this agent is desired. Several preparations are used, and whether these are soluble or insoluble is a matter of little mo- ment. The bichlorid takes first place, the dose being gr. \ (0.0162), in 15 to 20 drops of water, twice a week. Calomel probably holds second place (dose, gr. j-0.0648, in 15 drops of glycerin, twice a Aveek). Among other preparations employed are the peptonate of mercury and gray oil. All injections must be made deeply into the muscles. The subcutaneous • 344 INFECTIOUS DISEASES. injection of sterilized serum from the blood of lambs and calves has been successfully practised by Tommasoli. The hypodermic medication in the mercurial treatment of syphilis is not unattended Avith dangers and accidents, though, fortunately, the latter are rare. The method of fumigation has gained favor, particularly in the treat- ment of syphilis, in institutions on the Continent. Lane recommends that calomel (siss—6.0) be put in a china boAvl about half filled with Avater; a spirit lamp is placed under this, and the patient, "sitting above it wrapped in a cloak, has a deposit of mercury settle all over his body as the calomel is sublimed." He should remain Avrapped in the cloak for one hour, take a fumigation once daily, and remain in-doors, From six Aveeks to three months are necessary to effect a cure. If during the mercurial treatment the slightest evidence of salivation arise (tender gums, superficial glossitis, fetid breath, etc.), the adminis- tration of the drug must be interrupted for one Aveek or ten days. The teeth should be cleaned thrice daily. Hygiene plays no mean role in the successful management of syphilis. The diet must be liberal, though green vegetables and fruits are not to be taken ; and alcohol and tobacco are the tAvo great enemies of the luetic. Auxiliary measures, when the disease is associated with other lesions, are important. If syphilis occur in a tuberculous subject, it is of great value to add the potassium iodid to the mercurial, and, if active tubercu- lous lesions are present, cod-liver oil and creasote as Avell. Anemia and debility call for iron and a tonic plan of treatment generally. Attention should be given to the stomach, bowels, kidneys, and other internal organs, as well as to the nervous system. In women the iodids should be suspended during menstruation if the flow of blood is excessive, but not the mercury. Says Mauriac: " During pregnancy specific treatment is Avell tolerated, and often re- quires to be pushed to a point a little short of intoxication for the good of both the mother and the child, close Avatch being kept upon the kid- neys, suspending treatment at the first sign of albumin." (d) Treatment of Tertiary Syphilis.—For most tertiary manifestations, including visceral syphilis, Ave have a therapeutic specific in potassium iodid. This should be used alone, the inunctions of mercury being added if the iodid fails to produce the desired result. I give the potas- sium iodid in a saturated solution, one minim being equal to f grain of the salt. I use gr. x (0.648) t. i. d. at the first dose, and increase the latter 1 grain (0.0648) each day until the manifestations for Avhich it has been prescribed disappear or iodism is induced. It is best given in milk. In cases showing cerebral symptoms it is to be cautiously used, and it is then my custom to combine the iodid with potassium bromid. In hepatic syphilis the mercurials are usually combined with iodids from the start, and particularly calomel if there be ascites or jaundice. In nervous syphilis, especially in the graver forms, I begin with large doses (gr. xx—1.296, three times a day), and augment as above indi- cated. The limit of doses depends upon the effect produced. I have often found sodium iodid to agree better with the stomach than the potassium salt. Most syphilitics tolerate the iodids to a remarkable de- gree ; on the other hand, a few show a marked idiosyncrasy to them. Among unpleasant effects are coryza, conjunctivitis with edema of the • LEPROSY. 345 eyelids, salivation, and certain skin-eruptions (erythema, urticaria, etc.). In this form of syphilis, as in the earlier stages, the specific treatment is made much more effective by attention to certain hygienic measures —fresh air, appropriate diet, bathing, exercise, and rest. LEPROSY. (Lepra.) Definition.—A chronic, contagious disease, caused by the bacillus leprae. It is distinguished by constitutional depression and, pathologi- cally, by tuberculous masses in the muco-cutaneous surfaces, and by changes in the nerves. Historic Note.—In 1889, Morrow stated that in India alone there were certainly not less than 150,000 lepers, Avhile at present it is estimated that there are over 250,000. As in India, so in other regions, especially tropical, leprosy is on the increase, and its geographic dis- tribution probably covers more than one-third of the entire surface of the globe. It is common in Africa, Brazil, in the East, and in NorAvay. In the Sandwich Islands the disease is of comparatively recent origin, and yet of great and increasing prevalence, a leper settlement having been established consisting of more than 11,000 cases. Leprosy is not unknoAvn in America, and in Mexico it has existed ever since the time of Cortes (Morrow). Blanc states that there are 75 to 100 lepers in Louisiana alone. It Avas introduced into California and Oregon by the Chinese, and into Illinois, IoAva, Wisconsin, and Minnesota by Scandi- navian immigrants. It has been imported from the Sandwich Islands to Salt Lake City, and from Normandy to Tracadie on the Gulf of the St. Lawrence, Avhere the "disease is limited to tAvo or three counties Avhich are settled by French Canadians " (Osier). Sporadic cases have been met with in most of the larger American cities. Pathology.—The bacilli groAv and develop in clusters in the tuber- culous nodules in the skin, residing Avithin the epithelioid cells and leu- kocytes. These so-called lepra-cells are probably derived from the lym- phatic vessels or capillaries, having been transformed by the bacilli. Surrounding the granulomatous masses is a layer of connective tissue. The bacilli are also found in the lymphatic glands, the spleen, and liver, but rarely in the blood. The nodular tumors form projections from the skin-surface, and, being poorly supplied Avith blood-vessels, they soon undergo caseation and absorption or are obliterated by dense connective tissue, Avhich leads to the condition knoAvn as fades leontina. The pus- organism generally exercises an influence in causing suppuration Avith ulceration, Avhich may manifest a marked destructive tendency. The changes in the internal organs or in the mucous membrane are identical Avith those above described. Nerve-lesions are induced by the presence of the bacilli Avithin and around the nerves. Here they first set up an irritation Avith hyperes- thesia (neuritis), Avhich leads to atrophy, with degenerative changes and the characteristic symptom, anesthesia. 346 INFECTIOUS DISEASES. Btiology.—Bacteriology.—In 1880, Hansen discovered the bacillus leprae, which has since been proved to be the special agent of the dis- ease. It strongly resembles the tubercle bacillus, but differential stains have been suggested by Unna and others. The British Leprosy Com- mission have shoAvn that the bacillus can be cultivated, but inoculation experiments on animals have not as yet succeeded. Predisposing Causes.—Every one is susceptible to leprosy, but the disease is most frequent between the tAventieth and fortieth years, and is rare in childhood. Sex and latitude have little if any influence. Hereditary transmission probably influences about one-fortieth of the in- stances, according to the careful investigations of Zambaco. As pointed out by Bidenkap, leprosy is often rare in large cities, even though it is quite prevalent in the surrounding rural districts. Modes of Infection.—The disease is doubtless transmitted by contact, but Widal and others, who have studied the disease as it exists in the Hawaiian Islands, think that leprosy is contagious only by inoculation. The effects of the accidental inoculation may either show themselves immediately or a long time may elapse before they are seen. Morrow's view, that, like syphilis, leprosy is generally transferred by sexual in- tercourse, receives abundant support. The possibility of transmission by vaccination must be also admitted. Clinical History.—Two forms are recognized, the tubercular and the anesthetic, while a third or mixed type is described by some authors. Neither of the first two, however, runs its entire course without develop- ing into a third or mixed form. The incubation is usually long (three to five years—Hansen), but it may rarely be a comparatively short period. Vague prodromal symp- toms are present for years, of Avhich the chief are drowsiness, chilliness, irregularly recurring attacks of fever, debility, etc. (1) Tubercular Form.—In the first stage there is a patchy, cutaneous erythema with a slight hyperesthetic elevation of the affected areas. These are oftenest seen on the face or upon the extensor surfaces of the arms and knees. They may vanish after a Avhile and leave the skin pig- mented and anesthetic, and later the pigment may disappear, while white spots of corresponding size remain (lepra alba). When the disease progresses less favorably tuberculous nodules (dusky- red or almost broAvn in color) develop in addition to anesthesia. The small ones soon disappear, while the large ones are either absorbed or break down and ulcerate—changes which, as they advance together with the slow healing process, produce marked deformities. The skin is greatly thickened and presents a scaly surface, and there is loss of sub- stance in certain parts, while others are enormously enlarged (eye- brows, nostrils, lips, etc.). Among the many symptoms pointing to in- volvement of the mucous membrane are ozena, hoarseness or even aphonia, and the signs of inhalation-pneumonia. To the last-named disease, as well as to ulcers extending deeply into the mucosa of the pharynx and larynx, death may often be ascribed. The end may thus be reached amid the evidences of extreme asthenia, if not as the result of gradual failure of strength and energy. (2) Anesthetic Form.—In this variety the local symptoms point usu- ally to implication of the nerves. At the onset there are pain and patchy LEPROSY. 347 hyperesthesia, Avhile minute bullae, due to trophic changes, put in an ap- pearance on the arms and legs. The muscles supplied by the branches of the affected nerve-trunk Avaste, and the superficial nerves feel thick- ened and nodular. Bright-red patches of vaso-motor congestion appear and soon become anesthetic, Avhile the maculae disappear. Anesthesia may proceed Avithout the latter eruption. Dry, yelloAvish-Avhite, scaly patches upon the trunk and extremities are also visible. Early their centers alone are anesthetic, but subsequently the loss of sensation spreads gradually until large areas, as well as healthy portions of the skin, are invaded, as in a case of Dehio's. Trophic alterations reach an extreme degree. Bullae of considerable size appear, and, bursting, leave perforating or destructive ulcers, usu- ally upon the extremities. As the result of absorption, wasting, and necrosis great deformities are produced, such as contractures, exposure of the bones, ankylosis, etc. The hands often take on a claw-like form, and the fingers and toes may disappear (lepra mutilans). Diagnosis.—The early diagnosis rests upon the presence of patchy erythema with hyperesthesia, followed by the development of anesthesia, Avith a disappearance of the macular eruption. Nodular neuritis is pathognomonic of anesthetic leprosy. In the advanced stages of either form confusion could scarcely arise. The nodular form of tubercular syphilis is distinguished by the distribution of the lesions, the history, and the frequent sensory nerve-lesions. Zambaco and others have claimed that syringomyelia and Morvans disease are in most cases but forms of leprosy; but this has been disputed by Hoffman, Schlesinger, Sahli, and others. Syringomyelia depends on lesions of the central nervous system, while leprosy has its nervous lesions in the peripheral nerves; and on this basis the tAvo may be differentiated. The first symptoms in syringomyelia are localized usually in the upper extrem- ities. In leprosy they are generalized, and more often especially affect the lower extremities ; also by the latter disease they are limited often to the area supplied by one nerve, and in the former to that supplied by one segment of the cord. In leprosy the tactile sense is usually lost, in syringomyelia usually not lost, etc. The individuality of Morvans disease is disputed, and it is not impossible that many cases so diag- nosed have been either leprosy or syringomyelia. Prognosis.—Leprosy runs a very chronic course, lasting sometimes tAvo, three, or more decades. The prognosis as to the final issue is hopeless, but the patient may live in comparative comfort for many years before the ravages of the disease cause great mutilation. Treatment.—Here may be mentioned the fact that certain diseases are supposed to exercise a retarding effect on leprosy (pleurisy, pneu- monia, variola, phthisis, etc.). Antagonistic inoculation, however, as practised by Beaven Rake and others, has been practically negative in its effects; and the same is true of the treatment by Koch's tuberculin, which has been tried by Arning, Babes, and others. No specific remedy or agent has been found for this disease. Phillippo, however, found that gurjun oil was serviceable, ulcers being rapidly cured by its appli- cation, Avith few exceptions: the oil may also be applied as an ointment to the swollen parts. Internally, chaulmoogra oil has been employed by Berge and Phillippo with excellent results, the dose being from 1 to 348 INFECTIOUS DISEASES. 2 drams (4.0-8.0). It is sometimes administered in pearls (each con. taining 1TL3 to 5 (0.199-0.333), in ascending doses, until the limit of tolerance is reached. The symptoms must be met as they arise, and the patient placed under the most favorable sanitary conditions. Surgical interference may become necessary in both varieties. Segregation of lepers has been instituted in certain localities Avith encouraging results. GLANDERS. (Farcy.) Definition.—An infectious disease of equine origin, and caused by the bacillus mallei. It is rarely transmitted to man. Tavo leading forms are recognized—true glanders, Avhich attacks the nasal cavities, and farcy, in which the chief lesions are cutaneous. Pathology.—The characteristic lesions are new groAvths (granu- lomata, according to Virchow), Avhich are usually nodular in character, though they may be diffuse. These masses soften and form ulcers Avhen they occur on the nasal mucosa, and abscesses Avhen they are situated subcutaneously. Microscopically, the nodular tumors are composed of cells—lymphoid and epithelioid—together Avith the specific bacillus. Etiology.—The morbid changes above described are caused by a specific organism, the bacillus mallei, Avhich resembles closely the tuber- cle bacillus, though it is a little thicker as Avell as shorter. It is non- motile. It can be readily groAvn, and as readily inoculated into horses, in Avhich it produces the disease Avith every characteristic symptom. Perhaps the simplest method of staining the bacillus mallei " is to treat a cover-glass preparation with Avarm carbol-fuchsin, and then Avash it off Avith a 2 per cent, solution of nitric acid." Modes of Infection.—The virus is, as a rule, transferred directly from the infected animal to man, hence the disease occurs almost invariably among persons Avho come in contact Avith horses (hostlers, coachmen, soldiers, horse-dealers, farmers, etc.). Transmission from man to man has been observed, but rarely. The medium of conveyance is either the pus or the nasal secretions, Avhich may drop upon a Avound in the skin or mucous membrane, however slight, and be absorbed. Males are infi- nitely more liable than females, owing to differences in occupation. Immnnity.—The disease is rare in man, most probably because of almost complete natural immunity. Singer has produced artificial im- munity by intravenous injections of sterilized cultures of the glanders bacillus. Clinical History.—The duration of the incubation period is from three to five days, and rarely longer. Both glanders and farcy may be acute or chronic in their course. (1) Acute Glanders.—At first the signs of inflammation develop at the point of infection, lymphangitis and swelling of the adjacent lymphatic glands being associated. Fever and other evidences of general disturb- ance soon appear, and at the end of tAvo or more days the nasal mucosa GLANDERS. 349 becomes implicated, ulcers forming in the manner previously described, from Avhich a fetid muco-purulent (sometimes blood-streaked) discharge takes place. Nose-bleed is a very common symptom. Usually a little later an eruption comes out on the face, the trunk, and the extremities, particularly about the joints. It is papular, quickly becoming pustular, and the pustules may dry up Avhile fresh papules are developing—a cha- racteristic feature. The face, particularly the nose, now sAvells, and a bluish-brown tumor covered Avith vesicles appears. Implication of adja- cent mucous membranes—conjunctivae, pharynx, mouth, etc.—is usual, and less frequently the bronchial and gastro-intestinal mucous mem- branes are involved. The ulcerative processes may extend until they touch the bones, setting up necrosis. Diagnosis.—Cases have been mistaken for variola, but the history of exposure, mode of onset, the nasal symptoms, and the course of the eruption differ from those of the latter disease. In doubtful instances pure cultures should be made, and inoculated into the rabbit or guinea- pig. Death of the animal usually occurs Avithin tAventy-four hours. (2) Chronic Glanders.—A rare disease Avhich presents rather mild but vague getieral symptoms, such as muscular and arthritic pains, fever at intervals, asthenia, and progressive Avasting, combined Avith the local features of nasal catarrh, Avith a muco-purulent discharge containing blood. Cough may be present. The diagnosis demands the making of pure cultures and of inoculation experiments. (3) Acute Farcy.—In this form the virus is inoculated into the skin, which presents the chief symptoms, the nasal condition being in abey- ance or absent. The primary lesion is of an aggravated type, accompanied by a large crop of cutaneous boils and abscesses, which often follow the lines of the lymphatics. Their favorite seat is in the vicinity of the joints. The constitutional symptoms simulate those of acute pyemia. The diagnosis is reached in the same manner as in preceding forms. (4) Chronic Farcy.—Granulomatous tumors, resulting in abscesses, constitute the chief clinical peculiarity. The abscesses are situated primarily in the subcutaneous tissues, and generally in close proximity to the joints. As a rule, they open spontaneously and discharge in- definitely, first a thick, creamy pus, and later (if they do not heal) a thin fetid material. They sometimes form distinct ulcers, Avhich extend in depth until the tendons and even the bones are involved. The general symptoms simulate those of chronic glanders, the fever- curve being of the hectic type, particularly toAvard the close of the at- tack. About this time emaciation and prostration become extreme. The duration varies from ten to eighteen months, though death often results earlier from some associated disease or constitutional infection. The diagnosis cannot be made without a clear history of contact with an animal knoAvn to be affected Avith the disease, or by the experimental method and artificial cultures. One of the products of the bacillus mallei is so-called " mallein," Avhich has been used by Nocard and others as a diagnositic agent in animals. Its injection into horses suffering from glanders is folloAved by a febrile reaction. Bonoine"l does not con- sider mallein as a reliable diagnostic reagent. Schindelke injected more than six hundred horses with Forth's mallein, and his results show that 1 Riforma medica, Naples, May 25, 1894. 350 INFECTIOUS DISEASES. a reaction of 3.5° F. (2° C.) is an almost positive proof of glanders; a rise exceeding 1.85° F. (1.5° C.) affords a strong presumption; while a rise of 1.25° F. (1° C.) is suspicious.1 Prognosis.—Acute glanders and acute farcy are almost invariably fatal. The chronic forms, hoAvever, and particularly chronic farcy, end in recovery, under appropriate treatment, in nearly one-half the cases. Treatment.—The primary lesion should be dealt Avith surgically, and thorough disinfection followed by cauterization is highly recom- mended. Bayard Holmes advocates the opening of fresh abscesses and the scraping out of old ones under an anesthetic. A supporting plan of treatment, by generous feeding and judicious stimulation, is to be adopted, and the symptoms are to be met as they appear. The product, "mallein," has been recommended as a specific in this disease, but even Bonome", who reports an instance (occurring in a lad of sixteen and a half years) in Avhich recovery folloAved its use, contends that its curative properties have not yet been perfectly demonstrated. ACTINOMYCOSIS. (" Big-jaw,'1'' " Lumpy-jaw,'1'' etc.) Definition.—An infectious disease of cattle, less frequently of man, caused by the ray-fungus (actinomyces), Avhich grows in the tissues, de- veloping a mass Avith secondary chronic inflammation and metastatic growth, as well as a pyemic condition, due to a mixed infection with pyogenic organisms. Historic Note.—In 1877, Bollinger gave the first description of the ray-fungus, which he had observed in the disease known as "big- jaw '" in the ox. It remained, howrever, for Israel of Berlin to discover the fungus in man one year later. In 1879, Ponfick showed clearly that actinomycosis in man and cattle Avas one and the same disease. Murphy, Avho described the first case of actinomycosis hominis in America, states that up to January 1, 1891, there had been reported 250 cases of the disease in man, Avhile up to the present date more than 500 cases have been reported. Pathology.—A macroscopic mass is produced, consisting of a cen- tral fungous mass from which threads of mycelia radiate in all directions, producing the ray form of groAvth. Individual groAvths are of the size of a millet-seed, but their aggregation may result in masses as large a» an orange. They are generally yelloAvish and of tallowy consistence. Projections occur from the surface with club-shaped extremities. Microscopically, the little or single ray-like tumors show straight or wavy branching filaments (supra). Their development is accompanied by the groAvth of dense adjacent connective tissue. In addition, ab- scesses containing yelloAV granules in the pus occur, but these are sec- ondary. The usual lesions are not the same as those described as occurring in beasts. In man the lesions are those of chronic pyemia, and consist of a metastatic abscess-formation. This is probably due to mixed infection, pus-organisms being added to the actinomyces. 1 The American Year-book of Medicine and Surgery, 1896, p. 1013. ACTINOMYCOSIS. 351 Bacteriology.—The organism of the disease probably belongs to the cladothrix variety of fungus, and may be cultivated, though with diffi- culty. The finer threads may readily be stained with anilin colors. The club-shaped projections, however, do not take these stains, so that when examining sections Gram's method may be used. Rabbits and coavs have been successfully inoculated Avith cultures of the actino- myces. Modes of Infection.—Infection generally takes place through the mouth, teeth, and pharynx; and much less frequently the gate of en- trance for the virus is the air-passages or the skin. It is generally introduced Avith the food or drink, and Bostroem, from a study of 32 cases, has come to the conclusion that the poison enters the economy by means of the injected grains of some cereal. It is to be recollected that infection cannot occur through a normal mucous membrane or skin, but that a Avound, hoAvever insignificant, is essential. Clinical History.—(1) Oral Actinomycosis.—The patient often com- plains of toothache, dysphagia, and of difficulty in opening the jaAv. The latter symptom may be owing to induration of adjacent muscles, and is a very characteristic sign (Partsch). At the angle of the jaw a swelling appears which quickly passes into suppuration ; later it opens (first externally, then into the mouth) and discharges pus containing little yellow masses. If not properly treated, extension of the process takes place in a downward direction, and thus in succession the lower jaw, the structures of the neck, the esophagus, clavicle, lungs, heart, and even the abdominal organs, may become involved. The upper jaAv may be the primary seat of infection, and if so the base of the skull may be perforated and the disease attack the meninges and brain. Bollinger has seen primary actinomycosis of the brain. In these instances the extension may take place in the direction of the spinal column, setting up caries. (2) Pulmonary Actinomycosis.—I am satisfied that primary pulmonary actinomycosis is comparatively rare, and that oftener the lungs are in- Araded secondarily to actinomycotic disease elsewhere, especially in the oral cavity. The disease begins with pain in the side, and more often upon the left, due to pleurisy. There are cough and a peculiar (often fetid) expectoration, together Avith general Avasting. A microscopic ex- amination of the sputum, if made Avith care, reveals the actinomyces and furnishes a pathognomonic symptom. In some instances the symptoms are identical Avith those of dissemi- nated tuberculosis (Brigidi), though generally the disease is unilateral. There is irregular fever, due chiefly to suppuration. The physical signs may be those of chronic bronchitis merely, but there are, in not a few cases, extensive destructive changes of variable character (abscess, broncho-pneumonia, etc.) Avhich modify the signs accordingly. In primary pulmonary actinomycosis an extension to adjacent organs, and also metastatic growths and abscesses in various parts of the body, are the rule. (3) Intestinal Actinomycosis.—The condition may be primary or sec- ondary. The organism groAvs upon the mucosa of the intestine and excites a proliferation of the underlying connective-tissue cells, and the formation of submucous nodules. The latter ulcerate, and perforation 352 INFECTIOUS DISEASES. of the serous coat of the boAvel may occur, inducing peritonitis. Peri- cecal abscesses have been formed in like manner. The symptoms point to intestinal catarrh, there being some gastric disturbance, with irregular and recurring attacks of diarrhea. The actinomyces has been detected in the stools. Secondary metastatic groAvths (rarely) and abscesses may arise in other organs (liver, spleen, ovaries, etc.), but it is to be recollected that the primary seat of infec- tion may also be the spleen, liver, or other viscerae. (4) Cutaneous actinomycosis rarely occurs. The skin presents chronic suppurating ulcers Avhich shovv the presence of the ray-fungus, and the condition bears a close resemblance to a lupus patch, as in a case reported by Darier and Gautier. Diagnosis.—This rests solely upon the finding of the actinomyces. The wooden hardness of the tissues beyond the borders of the ulcers or sinuses, the hardness of the neighboring muscles in oral actinomycosis, and the yellow granules in the pus are all significant, but merely cor- roborative. To detect the actinomyces, says Warren, sections may be stained in Ziehl's carbol-fuchsin from fifteen minutes to half an hour, and then decolorized in a 1 per cent, picric-acid solution until the whole section has a yelloAV appearance. Dehydrate and mount. The fungus appears as a brilliant red aster, while the surrounding tissues are yellow. Course and Prognosis.—The course is chronic. Mild cases may recover in from six to nine months or earlier, the oral form being per- haps the most favorable. Schlange, after an analysis of 60 cases of actinomycosis, concludes that pulmonary actinomycosis may terminate in recovery, though rarely. Cases in Avhich a pyemic condition develops generally reach a fatal termination Avithin a comparatively brief period of time. Death usually results from amyloid degeneration and Avasting. Treatment.—This is mainly surgical. The removal of the parts involved and disinfection with acid-sublimate solution are the best meas- ures. Kbttnitz records marked success from incision of the abscesses followed by cauterization with solid silver nitrate. Billroth in a case of abdominal actinomycosis communicating with the bladder effected a cure by the use of fifteen tuberculin injections. Internally, the potas- sium-iodid treatment as first recommended by Thomasseh in 1885 has been attended Avith success in the hands of many observers. The treat- ment is most efficacious when decided iodism is produced. ANTHRAX. (Malignant Pustule; Splenic Fever; Wool-sorter's Disease, etc.) Definition.—An acute, infectious disease, caused by a special ba- cillus and clinically accompanied by the development of a characteristic pustule (boil) and blood-poisoning (external anthrax). The disease like- Avise affects the gastro-intestinal tract and the lungs (internal anthrax). Both forms are derived chiefly from herbivorous animals, it being espe- cially prevalent among sheep and cattle. The existence of anthrax in ANTHRAX. 353 the United States, in Asia, Russia, and parts of Europe has been denied, but it occurs rarely, and Bard has described its ravages in California. Pathology.—Post-mortem rigidity is marked. The blood is dark and thick and coagulates poorly, and in it, particularly in the spleen, as Avell as in the liver, kidney, and lungs, one may find the spores in great numbers. Besides the local lesions of the skin (/. c. ulceration, gangrene, edem- atous infiltration), and besides the degeneration of the heart, kidneys, and liver that is common to the severe and rapid infectious diseases, the especially striking lesion is the constant and great enlargement of the spleen. This may occasionally attain four times the normal size, and rarely it has ruptured. It is ahvays greatly distended Avith blood. In cases in Avhich the intestines are affected the bowel shoAvs hemor- rhagic infiltration and gangrene, and the mesenteric and retroperitoneal glands are enlarged and hemorrhagic. Etiology.—Bacteriology.—The special agent is the bacillus anthra- cis or its toxin, or both. Gratia and Jonne give as the microscopic characteristics of anthrax, as seen in the blood, the following : (1) The anthrax bacillus has the form of a rod of a length varying from 5p to 20//, and in breadth from 1// to 1.5//. It is broken up into short artic- ulations from 1.5// to 2p long, placed end to end like the sections of a tenia, the ends of each articulation being slightly swollen, giving the appearance of a bamboo cane; (2) clear spaces, appearing like a bicon- cave lens, exist betAveen the ends of the articulations, and result from the slight concavity of these ends; (3) a capsule, often distinctly marked, surrounds the rod, seeming to form a protoplasmic support for the individual articulations. These threads of anthrax bacilli stain best with Lbffler's blue. They grow readily on various media (agar, gelatin, potatoes, etc.) into interlacing thread-like filaments Avhich dis- tinctly shoAv spore-formation, the threads assuming the appearance of strings of beads. Toxic substances are developed in the cul- ture-media. Remarkable instances are recorded of the prolonged vitality of anthrax spores in dry or moist earth and in drinking-, sea-, and sewer-water. They resist desiccation, many of the germicides, and boiling Avater even for a few minutes, and facts such as these explain why anthrax is stamped out Avith such difficulty in a locality where once the spores have developed. The latter are not produced within the body either of the inferior animals or man. Inoculations are followed by the production of the pustule of anthrax. The virus (spores) gains entrance into the human body through the skin (slight Avounds, abrasions, or scratches), the intestines (Avith food), or through the lungs (rarely). The sting of insects (mosquitoes, flies) may also transfer the poison to man. Among disposing factors, how- ever, occupation is most influential: persons Avho come into direct con- tact Avith affected animals (hostlers, butchers, shepherds), and Avorkers in factories who handle the hair or hides of such animals, being espe- cially exposed. Immunity.—Pasteur's Avell-known protective inoculation with attenu- ated virus has been extensively practised in anthrax localities with very favorable results. Hankin, by means of albumose, which he separated from cultures, claimed to have produced immunity against the most 23 354 INFECTIOUS DISEASES. virulent anthrax. Peterman, hoAvever, reinvestigated the question of immunity by the albumose of anthrax, and found it to be Avithout pro- tective action, except in the case of cultures on ox-serum, Avhich, when injected in large quantities into the veins, conferred immunity, though only temporarily. Clinical History.—The period of incubation is from one to three davs. Two leading clinical types are distinguished : (1) External Anthrax.—(a) Malignant Pustule.—At the point of infection (the hand, arm, neck, or face, or other exposed part) a small papule first appears, and develops into a vesicle of considerable size with bloody contents. This vesicle breaks, leaving a characteristic dark- bluish or black scab (anthrax), and encircling the primary vesicle an areola of miliary vesicles may be noticed. The base of the original ves- icle now becomes swollen and indurated, and this braAvny edema spreads rapidly to the adjacent tissues until an extensive area is involved. The neighboring lymph-glands may or may not be inflamed; if so, they are apt to be connected with the pustule by red lines corresponding to the lymph-vessels and veins. Severe general disturbances accompany the local disorder in the course of a couple of days, and comprise fever, decided prostration, sweats, splenic enlargement, and delirium tending toward coma. If recovery occur, the edematous SAvelling subsides and the black scab is cast off, sometimes leaving a granulating surface. On the other hand, in unfavorable in- stances collapse develops, and the case ends fatally between the fourth and eighth days. In such instances intestinal symptoms (diarrhea) or nervous phenomena of aggravated type may attend. (b) Anthrax Edema.—In a certain proportion of the cases the sys- temic infection is out of proportion to the local disturbance, the latter consisting of an edematous swelling without the presence of an eschar, The eyelids, lips, tongue, and upper extremities may be the seat of ex- tensive swelling, though there is no change in the color of the skin. This is a dangerous condition, and sometimes results in extensive gangrene. (2) Internal Anthrax.—(a) Intestinal Mycosis.—In this form certain general, indefinite symptoms are the primary features, such as headache, pains in the limbs, anorexia, languor. Soon acute gastro-intestinal symptoms supervene, sometimes preceded by a chill. As a rule, vomit- ing occurs, followed by abdominal pains and diarrhea, and the stools often become bloody. Hemorrhage may also occur from other outlet* Other symptoms, as dyspnea, marked cyanosis, and restlessness, are noted, folloAved sometimes by stupor, general convulsions, or spasms of single muscles or groups of muscles. There is only moderate fever, but the spleen is enlarged, and the pupils may be dilated. Death is preceded by collapse. Interesting epidemic outbreaks of internal anthrax have occurred, due both to drinking-Avater derived from infected wells and also to dis- eased meat. Murisier has related the history of an epidemic in which 200 persons fell ill after eating meat from a certain cow. The animal was quartered by a butcher who had previously slaughtered an ox af- flicted with anthrax, and had not disinfected his instruments; four days after this 25 persons were attacked by the disease. ANTHRAX. 355 (b) Wool-sorter's Disease.—This occurs among the operatives in fac- tories in which imported wool or hair, mostly from Russia and South America, is sorted, and to produce the typical affection the infection must be swallowed or inhaled in the form of dust. Mixed cases, or those showinc both external and internal anthrax, may be met Avith among workers in curled-hair establishments and the like. The onset is sudden, with a chill that is accompanied by pains in the back and legs, prostration, and a sharp rise of temperature to 102° or 103° F. (39.4° C). The local symptoms may either be chiefly pulmonary or gastro-intestinal. The former consist in dyspnea, chest-pains or feelings of constriction, cough, and rarely the physical signs of bronchitis; the latter comprise voniit- ino- and a diarrhea that is folloAved either quickly or after some days by collapse, with marked lividity. Nervous symptoms, delirium, convul- sions, or coma are often prominent, and particularly when death is im- minent ; but a fatal ending may suddenly take place Avhile the mind is unclouded. The usual course ranges from one to five days. (c) Rag-pickers Disease (" Hadernkrankheit "). — This has been identified by Eppinger as the same form of disease as " Avool-sorter's anthrax." It occurs among the rag-sorters in the paper-mills near Graz. Infection occurs in the respiratory tract. The symptoms observed are high fever, folloAved by collapse, with depression of the body-heat, pain- ful and paroxysmal cough, cyanosis, very Aveak heart, together with the signs of pleuritic effusion and consolidation of the lung. Systemic in- fection may ensue. In 8 cases the bacillus of anthrax was isolated. Diagnosis.—The history (occupation, etc.) and the appearance of the malignant pustule in external anthrax leave little room for doubt. The diagnosis, hoAvever, should be confirmed by an examination of the contents of the pustule for the presence of bacilli, and if found they should be cultivated and inoculated upon the guinea-pig or rabbit. The recognition of internal anthrax is more difficult, but the con- dition may be suspected if the more characteristic pulmonary or gastro- intestinal symptoms, together with those of systemic intoxication, de- velop in persons Avhose occupation entails exposure to infection. In these doubtful cases the only safe course is to show the presence of the bacilli in the blood, and, unfortunately, this is generally impossible till death is near at hand. Prognosis.—In external anthrax occurring in healthy persons the disease often pursues a favorable course; moreover, radical surgical measures have decreased the death-rate decidedly. Internal anthrax, hoAvever, is a deadly affection. As regards "wool-sorter's disease," Bell, who first recognized the affection, states that those Avho survive for one Aveek usually recover. Herbivorous animals are more susceptible to anthrax than is man, and in them the mortality-rate is relatively higher—from 70 to 80 per cent. Treatment.—In malignant pustule it has been recommended to destroy the point of infection by caustic or by the hot iron, and then dust Avith poAvdered mercuric chlorid with a view to destroying the mass. It seems to me, hoAvever, that, unless the pustules be small and remain so, removal by excision should be preferred, and Klein and others have reported recoveries after removal of the primary focus of infection. In preventing extension of the brawny edema hypodermic 356 INFECTIOUS DISEASES. injections, several times daily, of a solution of carbolic acid at points a little distance from the site of the pustule have given the best results. Hallopeau recommends that in order to prevent extension the neighbor- ing structures be bathed with a 10 per cent, solution of carbolic acid (first dissolved in alcohol) in oil or glycerin. He applies the same to the surface of the anthrax. Internally, stimulants, antiseptics, and nourishing food constitute our chief reliance. In internal anthrax efforts at treatment avail nothing. Osier wisely recommends active purgatives Avith a vieAv to removing the infecting material, but further than this the internal treatment differs little from that employed in the external form. HYDROPHOBIA. (Rabies.) Definition.—A specific, infectious disease peculiar to carnivora and to a less extent to herbivora, which may be communicated to man by direct inoculation. It is characterized by slight fever, spasm of the larynx and pharynx, delirium, a short stage of paralysis, coma, and, in the great majority of cases, by death. Pathology.—The facies, pharynx, and esophagus may be con- gested, the latter organ being sometimes markedly edematous; pulmon- ary congestion has also been noticed. The mucous membranes may show here and there points of hemorrhage, and Fitz has observed blood- extravasations into the perivascular spaces of the brain. Soft thrombi may fill the cerebral vessels, especially the veins, Avhile the blood has a dark color and its clots lack firmness. The chief lesions are found in the medulla, and particularly in the region of the respiratory center, in which the nuclei of the hypoglossal, pneumogastric, and glosso-pharyngeal nerves are seated. On micro- scopic examination Gowers found the cord in rabies to show merely hyperemia in the gray substance ;x in the medulla, however, he ob- served in addition a cell-infiltration of the perivascular lymph-sheaths and sometimes of the adjacent tissues as well. Small areas infiltrated with leukocytes (miliary abscesses) Avere noted, and scattered through the adjacent tissues Avere seen small round-cells in unusual numbers. Fitz and Shattuck found as the most constant change an infiltration of the adventitia of the veins with small round-cells. Rarely, the kidneys may show cloudy swelling. The cadaver putrefies rather early. Etiology.—No micro-organism is knoAvn to be the special agent of the disease, but that it is of microbic origin cannot reasonably be doubted. The virus is contained chiefly in the saliva, and has been successfully inoculated into other animals both by means of this secre- tion and of the blood of affected animals. Pasteur has found the poison abundantly present in the nerve-centers, and has transferred the disease by taking bits of brain-substance or medulla derived from an infected animal and inoculating them into healthy subjects. 1 Golgi has described important changes observed in the cord structures, but these have not as yet been confirmed by other observers. HYDROPHOBIA. 357 The usual mode of infection in man is through the bite of a rabid animal, and in an immense majority of cases (about 90 per cent.) the dog is the offending party. The cat, wolf, cow, and horse also suffer from the disease, though less frequently than the dog, and in rare in- stances only do they communicate the disease to man. The skunk is also liable, and its bite has often transmitted rabies, especially to per- sons sleeping in the open air or in tents which the animal can enter. The virus gains access to the system through the broken skin, and not through the mucous membranes. Susceptibility to the poison exists in about one-half the instances in which persons are bitten by rabid animals, though in some cases this ap- parent immunity may be owing to slight or even non-infection. Clinical History.—The incubation-period lasts from six Aveeks to three or four months, though in young subjects and in cases in Avhich the infection is severe the symptoms develop earlier. Certain prodro- mal symptoms are manifested as a rule, and generally last only a day or tAvo; I have, hoAvever, seen tAvo instances in Avhich melancholia, due probably to the dread of what might folloAV, showed itself immediately after the reception of the bite and persisted. The usual premonitory symptoms are headache, loss of appetite, sleeplessness, great depression of spirits, and sometimes darting pains that radiate from the seat of the bite. The adjacent lymph-glands may become swollen, and slight difficulty in swalloAving is experienced. FolloAving the invasion are tAvo stages : (1) The Stage of Excitement. —The patient wears an expression of the most intense anxiety. Hyper- esthesia is present and attains to a marked degree, and the special senses exhibit the keenest vigilance, a noise or a draft of air often causing great psychic disturbance or a violent reflex spasmodic contraction of the larynx. Quite early the mere sight of water is dreaded by the pa- tient, and forms a characteristic feature of the disease. This symptom has given the name hydrophobia to the disease, and springs from the fear of inducing a painful spasm of the larynx. The patient has thirst which he cannot assuage. There may be maniacal excitement, and the spasmodic contractions of the larynx may become so strong as to excite urgent dyspnea, Avith the emission of curious sounds. The muscles of the mouth may also exhibit convulsive movements, causing the patient to make snapping sounds ; these, however, are secondary. There is asso- ciated great restlessness, with frequent lateral rolling of the head, and foaming saliva may be ejected from the mouth. The symptoms occur in paroxysms, and during the intervals the patient is generally free from excitement. There is fever as a rule, the temperature ranging from 100° to 102° F. (37.7°-38.8° C.) or over, but it may be absent; the pulse is moderately accelerated and is sometimes irregular, and to- ward the end of this stage the reflex spasms of the respiratory apparatus develop spontaneously. Mental aberrations may set in, and melancholia often leads to suicidal tendencies. (2) The Paralytic Stage.—In the concluding stage the patient passes from a condition of debility into actual unconsciousness or coma, Avith- out spasms. This lasts from twelve to eighteen hours, during which cardiac asthenia rapidly increases, and life soon ends by syncope. In man there is a paralytic form of rabies, but it is rare as compared 358 INFECTIOUS DISEASES. with the delirious or psychic type. Thirty cases have been reported by Gamaleia, and, according to this observer, the paralytic type is apt to folloAV deep and multiple bites. The paralysis begins near the part bitten, and spreads until it becomes general, finally involving the respir- atory centers. In rodents quiet madness (" dumb rabies"), Avithout maniacal excitement, is the rule. The diagnosis is readily made, OAving to the fact that the history of recent infection is usually obtainable. The hyperesthesia, the fear of water, the reflex spasms on attempting to swalloAv, accompanied by dyspnea and great mental agitation, form a very characteristic group oif symptoms. Hysteria may be misleading, since convulsive movements may follow attempts at SAvallowing, but here the previous history suffices to explain the true nature of the case. The name lyssophobia has been given to cases that simulate, but have no relation to, hydrophobia, and Mills has advanced the Avarning that, with hoAvever so suggestive symptoms following a dog-bite, the given case cannot be assumed to be a case of hydrophobia until other possibilities are excluded. It is highly probable that there is a form of hydrophobia which is the result of the wide publicity given to genuine and suspected cases alike. The characteristic symptoms may be present, but they are comparatively mild and the affection does not develop, This so-called pseudo-hydrophobia appears only in neurotic and hys- teric subjects, and runs a longer course than does the disease itself. Recovery is the rule, and yet I feel convinced that even a lyssophobic condition growing out of fear of the disease may cause death. Burr reports an interesting case of the kind that occurred in Osier's clinic, attended, however, with recovery. Prognosis.—Few if any cases of rabies in man recover if the dis- ease be allowed to develop. Preventive measures (efficient and early cauterization, and more especially the Pasteurian antirabic inoculation) have been the means of reducing the frequency of the disease. Treatment.—Prophylaxis.—Upon the reception of a bite thorough disinfection, followed by cauterization of the wound Avith caustic potash, etc., is a measure that can be quickly carried out. The Avound is then to be kept open for a period of four or five Aveeks, and steps taken to carry forward prophylactic inoculation with precision. Preventive inoculation as perfected by Pasteur is a precautionary measure of the utmost importance. This famous investigator, after dis- covering that the virus of the disease could be obtained in a pure state from the central nervous system, showed that its virulence undergoes modification by passage through animals. Thus the potency of the virus is increased by its inoculation from rabbit to rabbit (by placing bits of spinal marrow beneath the dura mater), the period of incubation at the same time groAving shorter, till at last it is but seven days. On the other hand, the virulence is decreased or attenuated as the result of similar experiments upon the monkey. Pasteur also found that if frag- ments of the spinal cord Avere suspended in a dry atmosphere they lost gradually their virulence and finally became inert. From these an emulsion is prepared Avhich is employed in the antirabic inoculations in man. In this way he secured a virus of known and reliable strength, and with this he could readily render the dog refractory by inoculating TETANUS. 359 with very weak virus ; then, by increasing from day to day the virulency of the inoculations, complete immunity was established. Protective inoculation in man was first employed by Pasteur in 1885, and is carried out by injecting the emulsion hypodermically. " The patients are first inoculated with a cord fourteen days old, and the inoc- ulation is repeated daily for nine days, each time with a cord one day fresher. In Avinter the oldest cords used are five days old, and in sum- mer cords that have been drying for four days are also employed. The preceding is the ordinary treatment " (Warren).. For patients who have been bitten on the face, hands, or bare feet, as well as for those who have been bitten long before commencing treat- ment, the special preventive method, the so-called " intensive treatment," is applicable. Briefly, this consists in eliminating some of the inocula- tions of intermediary strengths, thus lessening the number of injections, and also in administering the latter at shorter intervals than in the usual method of treatment. The success of the Pasteur method is almost universally attested, and his own claims, that few persons properly inoc- ulated subsequently suffer from rabies, are generally conceded. The established affection defies all known methods of treatment. Our aim should be to diminish the intensity of the painful spasms and the psychic disturbances. The patient should be isolated from sounds, light, and excitement of every sort. Food, as a rule, must consist of nutrient enemata, though by the local application of cocain the sensi- tiveness of the throat may be diminished sufficiently to enable the patient to take liquid nourishment (Osier). For controlling the spasms chloroform by inhalation is most effective; chloral internally and mor- phin hypodermically may also be tried Avith advantage. The patient's anxiety is best relieved by a cheerful demeanor on the part of the attendants. TETANUS. (Trismus; Lockjaic.) Definition.—An acute, infectious disease caused by the tetanus bacillus. It is characterized by painful spasms, affecting first and chiefly the muscles of the jaw and neck (trismus), and secondly those of the trunk, especially the extensors of the spine and limbs (opisthotonos). The disease may be idiopathic, though more often it is traumatic. In certain institutions and certain localities (e. g. eastern end of Long Island) it occurs endemically, and among new-born children it may pre- vail epidemically (trismus neonatorum). To this latter form the colored race in hot countries (West India Islands, etc.) is especially liable. Pathology.—No constant post-mortem lesions have been found. The majority of authorities contend that the virus acts chiefly upon the nervous centers of the medulla and the cord, where obvious traces of in- flammation (and sometimes of softening of the gray substance of the cord) have been noted. According to Brown-Sequard, the characteristic lesions are consequent upon an ascending neuritis starting from the 360 INFECTIOUS DISEASES. wound, and it is true that the nerves often present traumatic lesions with redness and SAvelling of the neurilemma. Tetanus neonatorum often shows inflammation of the umbilicus. Etiology.—Bacteriology.—In 1885, Nicolaier discovered the bacil- lus of tetanus, and in 1886, Rosenbach first found it in man. It is a long, slender rod, at one end of Avhich appears a SAvelling due to the formation of a spore in that locality, thus giving the organism an ap- pearance like that of a pin or drumstick. The bacilli are easily stained by Abbott's method, and are purely anaerobic. Pure cultures can be made, but with difficulty, since other varieties of bacteria are found in association, and if pure cultures are injected into animals, typical teta- nus folloAvs. Brieger has obtained the poison from sterilized cultures of the bacillus in the pure state, and termed it " tetanin "—a most viru- lent poison in the minutest quantity. The bacilli are most probably limited to the point of infection, and here develop the toxin (a tox- albumin). Modes of Infection.—In the outer world tetanus bacilli are found to be both numerous and Avidely distributed. They abound in the earth (garden-soil in particular), putrefying liquids, manure, in rubbish and dust of streets and houses, etc. The fact that the bacillus of tetanus is anaerobic (cannot grow in the presence of oxygen) explains why tetanus in man is a comparatively rare disease, notwithstanding the widespread dissemination of the parasite, and also why it is most apt to follow punc- tured and contused wounds. It may, though less commonly, follow wounds of any sort. It may be assumed that in the immense majority of the cases an injury, however slight, serves as a gate of entrance for the poison. The locality of the injury is almost always on the extrem- ities, particularly on the hands and the feet; the disease is most common in warm climates; and as regards age it is most common between ten and thirty, if Ave except tetanus neonatorum. Idiopathic tetanus may follow exposure to cold or sleeping on the damp earth, and in tetanus neonatorum the infection may be communicated either by careless nurses or by dirty dressings of the stump, etc. (Papienske). Immunity.—Behring and Kitasato have rendered animals immune by the injection of cultures of the bacillus after the addition of iodin trichlorid to diminish their strength, and this serum has been success- fully used to protect others against tetanus. Clinical History.—The duration of incubation depends upon whether the given case pursues an acute or a chronic course. In acute tetanus it lasts from one to two weeks, while in chronic the first symp- toms usually appear after the second week. In idiopathic tetanus the symptoms generally appear shortly after exposure to the special causes. Symptoms of Acute Tetanus.—(1) Mild prodromal symptoms (languor, headache, etc.) may precede the more intense characteristic phenomena, which develop gradually. At first the patient complains of stiffness and tension in the muscles of mastication and back of the neck, and soon tonic spasm of the masseters renders the facial muscles more or less immobile and locks the jaws (trismus or lockjaw). The rigidity of the cervical muscles is shown by the retraction of, and by attempts at raising, the head. The physiognomy is distinctive; it is immobile, the forehead being often wrinkled and the corners of the mouth retracted, TETANUS. 361 producing a peculiar smile (sardonic grin). Next there is an involve- ment of the muscles of the body, first inducing rigidity of the trunk (orthotonos), and then the spine is bent or bowed and the convexity presents anteriorly (opisthotonos). Lateral arching of the body also occurs, though rarely (pleurosthotonos). The belly-muscles are hard and board-like, and their contractions may throw the body forward (em- prosthotonos). The arms generally remain movable, but the legs may be rigidly extended. The position of the body is one of constant rigid- ity, but from time to time convulsive seizures of variable duration occur, causing most agonizing suffering, thoracic oppression, dyspnea, and more or less cyanosis, due to interference with the respiratory function (especially spasm of the glottis). Sharp lancinating pains occur at the base of the chest and point to contraction of the diaphragm. " Convul- sive dysphagia " (as in hydrophobia) is rarely observed. These parox- ysms may be spontaneous, though more often the spasms are reflex, due to the action of external irritants (generally slight in character). The reflexes are increased. The intellect remains clear. Profuse perspira- tion is a significant symptom. Fever of a moderate degree is generally present. The temperature, however, may suddenly leap to 1,10° or 112° F. (43.3°-44.4° C), form- ing an ominous symptom, these extreme elevations of temperature being probably due to paralysis of the centers that regulate bodily heat. Conversely, fever may be absent throughout the attack, and a post- mortem rise of temperature be seen which lasts for a short period. The pulse is generally quickened, and in the Avorst cases may become very rapid (140 to 160 beats per minute), small, and irregular. The urine may be suppressed or its passage impeded by the muscular contractions. The bowels are constipated. (2) Chronic Tetanus.—The same symptoms are manifested as are seen in the acute form, but the condition does not progress so rapidly. In some instances the symptoms soon become aggravated, to be followed, hoAvever, by periods of decided relief from the painful spasms, so that during the latter the patient's strength can be maintained by means of stimulants, etc. Intervals of partial freedom from the excruciating pains grow longer in favorable cases, until finally the period of convalescence may be reached. Relapses, however, are common. (3) Cephalic tetanus (first described by Rose) usually follows in- juries to the head and particularly to the face. Its most characteristic symptoms are rigidity of the masseter muscles, spasm of the pharyngeal muscles, causing dysphagia, chronic contraction of the muscles of the neck and abdomen (rare), and paralysis of the facial nerve on the same side as the injury. The latter symptom is due to local infection by a toxin. In this form, particularly if the course be chronic, recovery sometimes takes place, occurring in about 25 per cent, of the instances, according to Willard's statistics. Diagnosis.—In view of the usual history, the predominating fea- ture—trismus—together with the early appearance of rigidity at the back of the neck, will, as a rule, render the diagnosis a simple one. Strychnin-poisoning is distinguishable, but often great care is needed in making the distinction. The following points belonging to each may be contrasted: 362 INFECTIOUS DISEASES. Tetanus. Strvchnin-poisoning. History. Reception of a wound, generally followed Ingestion of strychnin, followed iinmedi- by a period of incubation. ately by the symptoms. Mode of Development. Begins with lockjaw; later spreads down- Begins with gastric disturbance or a ward (the arms and hands escaping). tetanic contraction of all the extrem- ities. Symptoms. Reflex spasms not present at the outset. Violent convulsions present from the onset. Rigidity is persistent, except in the Intervals of complete relaxation occur. chronic form. The course is prolonged into days or Course is brief, terminating in death or weeks. recovery. Cultures made from the discharges of Examination of the gastric contents shows the wound show the bacillus tetani. strychnin. Tetany gives rise to a spasm of long duration affecting the extrem- ities (hands in particular) and the larynx, with absolute intermissions; it is also characterized by a peculiar posture. Hydrophobia is discriminated from tetanus by the history of a bite from an animal, by the predominance of the reflex spasm of the respir- atory apparatus, by the intensity of the psychic disturbance, and by the absence of lockjaw and opisthotonos. Course and Prognosis.—In the acute form the course is brief, rarely exceeding ten days, and the prognosis is most unfavorable. Death results from asthenia, heart-failure, or asphyxia (during the paroxysm). According to Richter's statistics, 88 per cent, of military cases are fatal. In idiopathic or rheumatic cases the mortality-rate is under 50 per cent. Chronic tetanus gives a less grave prognosis than does acute. In the new-born recovery is so rare that when it occurs the diagnosis may be called into question. Treatment.—In traumatic cases the wound must be disinfected and thoroughly cauterized. In order to do this effectively, the agents em- ployed must be brought in contact Avith every portion of the wound, so that punctured wounds must first be laid open. Excision of the wound, and even amputation, may be advisable in some cases. The fact that the deadly poison is developed at the site of infection gives to the local measures supreme importance in the treatment of tetanus. The patient should occupy a secluded room with little light and a carefully regulated temperature. A single nurse vvill suffice, and all sources of external irritation should be avoided. A nourishing diet is demanded, and rectal feeding must be instituted as soon as it is found that food cannot be administered per oram, or the food may be intro- duced by means of a small stomach-tube or catheter passed through the nostril. Stimulants should not be spared when the heart's action be- comes quick and feeble. In one of my own cases hypodermic injections of strychnin and digitalis probably saved the patient's life. The spasms are best controlled by chloroform-inhalations, and during the intervals the patient should be kept under the influence of morphin, administered MUSCULAR RHEUMATISM. 363 subcutaneously. Among other remedies that have sometimes been suc- cessfully employed are chloral hydrate and Calabar bean. The former may be exhibited in rectal injection (gr. xl—2.59 at a dose), to be re- peated at intervals of six to eight hours until the spasm is overcome. The heart, however, must be carefully guarded. Rarely, good results have been obtained from the use of potassium bromid, curare, nitrite of amyl, belladonna, and cannabis indica. Tetanus-antitoxin has been recommended for the cure of the disease, and is prepared both in fluid (antitoxin serum) and dry form. The for- mer deteriorates in quality, in consequence of Avhich fact Roux and Vaillard, as Avell as Tizzoni and Cantani, have adopted the method of drying the serum. A dried preparation is also obtainable from Merck and his agents in the form of tubes containing from 4 to 5 grams each; at the time used it may be dissolved in Avater or in glycerin. Of Tiz- zoni's antitoxin 2.25 grams are to be given at the first dose, and 0.6 grams at subsequent doses. Huebner l has studied carefully the im- munizing value of Tizzoni's tetanus-antitoxin, and finds that in the strength recommended by its author it is poAverless to cure cases of tetanus in the human being if grave or if brought under treatment at a late period. Kanthack's and Kneass's 2 recent statistical analysis als$ shoAvs that the question as to its value is still sub judice. INFECTIOUS DISEASES OF UNKNOWN ETIOLOGY. MUSCULAR RHEUMATISM. (Myalgia.) Definition.—A common, painful disease of the muscles and of the structures to which they are attached (fasciae and periosteum), probably due to an attenuated form of the virus of acute articular rheumatism. Leube contends—and very properly, I think—that muscular rheuma- tism is a general disease with local symptoms. The latter may be seated in different parts of the body, and in this way give rise to a number of leading sub-varieties, and it may either accompany acute and chronic rheumatism or it may be experienced as an independent disease. I have also met Avith several instances in which it followed joint-rheumatism, and Leube has seen it precede the latter. This observer noted on one occasion that half the beds in his ward were occupied by patients with this disease, giving evidence of an epidemicity. Certain authors, how- ever, believe that the affection is a neuralgia of the sensory nerves of the muscles. Pathology.—In fatal cases (these are exceedingly rare) the affected muscles shoAv a swelling of the fibers and more or less granular change. In long-standing cases an atrophy of the muscles, due to trophic dis- turbance, may be observed. Etiology.—Among the disposing influences that are most import- ant in the causation of the affection are—(1) The rheumatic diathesis 1 Deutsch. med. Wock, Aug. 16, 1894. 2 Journ. Amer. Med. Assoc, July 18, 1896. 364 INFECTIOUS DISEASES. (appropriate soil); (2) Heredity ; (3) Exposure to cold, damp, and strong air-currents, especially after heavy exercise or during free perspiration- (4) Sex, owing to the more frequent exposure of men Avhile following their occupations; (5) Age. It is met with at all ages, but acute and subacute forms most frequently occur among children and young adults, while the chronic form most frequently affects elderly persons ; (6) Pre- vious attacks increase the susceptibility to the disease, as in acute artic- ular rheumatism. Symptoms.—In the majority of instances the clinical symptoms are local. Out of 200 cases Leube found fever in about one-third, the temperature rarely exceeding 102° F. (38.8° C.) for two days in dura- tion, and far more often remaining normal. In one-sixth of Leube's cases there was a cardiac murmur, that disappeared under treatment in one-half of this number. The most conspicuous local symptom is the pain, Avhich is sometimes sharp, lancinating, and paroxysmal, though it may be deeply seated, dull, and constant, The changes are essentially those of myositis. In the acute form there is often an extensive round- cell infiltration of the connective tissue, Avith swelling and partial de- generation of the muscular fibers and the formation in them of vacuoles, In the chronic form there is a proliferation of the interfascicular con- nective tissue, and the muscle-fibers exhibit slight granulation and in- crease in the number of nuclei. The pathology of this condition is very indefinite. It is aggravated at night in most cases, and also by contraction of the affected muscles, by weather changes, and in acute forms by pressure. In long-continued cases pressure with the broad side of the hand usually affords relief. The duration of the affection is exceedingly variable; it usually ranges from a few hours to several days, but may rarely pursue an apparently endless course. leading Clinical Varieties.—(1) Lumbago (Myalgia Lumbalis).— This is the most common form, ancl may be taken as the type of the myalgias. The onset is sudden, sometimes intensely so, and the lum- bar muscles are exceedingly painful and sensitive. Motion, such as stooping or turning the body or rising from the sitting position, causes intense exacerbations of pain. The affection occurs most frequently in laboring men, its course being brief, as a rule, and recurrences frequent. (2) Pleurodynia.—This term implies involvement of the intercostal muscles, and less frequently of the pectorals and the serratus magnus. It is unilateral, and oftener affects the left than the right side, and causes untold suffering, since it is constantly aggravated by the normal respiratory excursions. The pain is also intensified by pressure, reach- ing, etc., and by movement of the trunk, sneezing, and coughing. Fortunately, it is not a very frequent affection. Similar symptoms may be occasioned by traumatism in Avhich the fibers of the thoracic mus- cles are lacerated, and there is also great danger of confounding pleuro- dynia with costal periostitis and with pleurisy. (3) Torticollis (Myalgia Cervicalis).—Here the muscles, some or all, on one side of the neck, and at times the throat, are implicated. The head is held toward the affected side, so as to relax the group of mus- cles involved, and on attempting to turn it the patient rotates his en- tire body in a pivot-like manner. The complaint is frequent in young persons. MUSCULAR RHEUMATISM. 365 (4) Cephalodynia.—By this term is meant rheumatism of the head- muscles of the scalp and fasciae. It is by no means an infrequent con- dition, and may be either general or local, being sometimes limited to the frontal, temporal, or occipital muscles. The pain is severe and greatly increased on motion of the scalp. (5) Other terms descriptive of localized forms of muscular rheuma- tism are employed: (a) Omodynia (myalgia of the deltoid); (b) Dorso- dipiia (involvement of the muscles of the upper part of the back, etc.); (c) Abdominal rheumatism (myalgia of the muscles of the abdomen); (d) Rheumatic myositis of the extremities. Diagnosis.—This is assured by the etiologic influences and the presence of pain, Avhich is greatly increased by muscular contraction. The presence of fever does not exclude the affection. It differs from neuralgia in that there are no painful points, and in that firm pressure with the broad hand often affords relief. Dermato-myositis must not be confounded Avith muscular rheumatism. Unverricht first distinguished the former from the latter, showing that there are present pain and swelling of the muscles, as in muscular rheumatism, but additionally redness (erythema) and hyperesthesia of the skin, while the joints usu- ally escape. Rovere, hoAvever, reports a case occurring in the course of diabetes mellitus in Avhich there Avas a joint-inflammation resembling that of rheumatism. Of general symptoms, the chief are fever and physical prostration. The spleen is enlarged, and angina and hemor- rhages have been noted. The disease is obviously infectious, probably septic in nature, and occurs in fatal as Avell as in the mild or favorable forms. Dermato-myositis, unlike muscular rheumatism, Avhich is more common among men, is seen more frequently in Avomen, especially servants. The prognosis is good, the disease never directly endangering life, though a person may be more or less incapacitated for work by muscu- lar rheumatism. Treatment.—Severe and acute forms demand the use of opiates internally and anodyne and hot applications externally. When cases are seen early, morphin, administered hypodermically, may serve to relieve the pain and cut short the disease. In acute cases the salicylates and other antirheumatic remedies are to be employed. Hot fomentations give comfort, and the Turkish bath may end the attack if it can be used sufficiently early. The hot-water bag, sponging Avith water as hot as can be borne, or dry heat in the form of bags filled with heated salt or heated hops, Avill all do good service. For the dull pain Avhich is so dis- tressing in some cases of torticollis the affected muscles may be covered Avith flannel, over Avhich a Avarmed flatiron may be passed for a few minutes. This is an efficient expedient. For lumbago acupuncture is highly commended. Needles of from three to four inches (7.5-10 cm.) in length (ordinary bonnet-needles, sterilized, will do) are thrust into the lumbar muscles at the seat of the pain and withdrawn after five or ten minutes (Osier). Blisters have been recommended, but I have tried them frequently without beneficial effects in any case. In subacute and obstinate cases I have recently obtained good results from the use of a 20 per cent, ointment of salicylic acid freely rubbed into the skin. Active friction with anodyne and stimulating liniments (the latter when pain is 366 INFECTIOUS DISEASES. not great) is worthy of trial. Massage and electricity (the constant cur- rent in particular) are sometimes efficient, and in chronic cases potas- sium iodid, guaiacum, and arsenic (the latter in small doses) should be tried. The same measures of prophylaxis are to be adopted as in chronic rheumatism, and the condition of the general health must also be looked to, every endeavor being made to maintain the proper quality of blood and perfect nutrition. OHRONIO ARTICULAR RHEUMATISM. Definition.—An affection of the articular structures which develops slowly and gradually and may be dependent upon the same causes as the preceding forms. Rarely it is a sequence of acute or subacute attacks. Etiology.—(a) Age predisposes to the affection. Though it may ap- pear at any age, the greatest number of cases is furnished by the years from forty to sixty, (b) Sex exerts a slight influence, the disease being observed most frequently among females, (c) External agencies, as pov- erty and occupations Avhich entail exposure to cold and dampness, act as predisposing influences, (d) Heredity may operate to favor its development. Pathology.—The joints, as a rule, do not show pronounced gross lesions, there being some degree of synovial injection and also some, though not much, effusion. Inflammatory thickening of the articular and periarticular structures (capsule, ligaments, sheaths of the tendons, etc.) with contraction, is noted, and is a change which deforms and stif- fens some joints to a certain extent. Superficial erosions of the carti- lages may also be Avitnessed, and, as stated under the Clinical History of Acute Articular Rheumatism, muscular atrophy supervenes in long- standing cases of arthritis. The probable causes of these important changes have been pointed out in connection Avith the latter disease. When the shoulder-joint is the seat of chronic inflammation, this mus- cular atrophy (affecting chiefly the deltoid) reaches its highest degree of development. Symptoms.—The involved joints may not present any markedly visible evidences of disease, and perhaps the most prominent local symp- tom is pain, increased often at night as Avell as by approaching cold or damp weather. Both the larger and smaller joints are involved, though the former to a greater degree, and yet, though usually multiple, the disease may be limited to one joint (knee, hip, shoulder, etc.). The joints are somewhat swollen, at times slightly reddened, tender upon pressure, and their mobility is generally restricted. Pain and stiffness are most marked in the morning hours (after rest), and often largely disappear Avith each returning evening (after use). All the local symp- toms are subject to exacerbations and remissions. A peculiar crepita- tion may be elicited on applying the hand over the affected joints during motion, and eventually ankylosis, with some degree (usually slight) of distortion of the joints, may occur. The general features are usually conspicuous by their absence. No fever is present, and, in most instances, there is no serious impairment of the general health. On the other hand, as the result of constant suffering, a wretched general condition with marked anemia and debility CHRONIC ARTICULAR RHEUMATISM. 367 may finally be reached, such patients often passing sleepless nights and suffering severely from dyspepsia. Chronic endocarditis may develop along with the chronic articular changes—a not uncommon association, though frequently the history of a previous attack of acute rheumatism is also obtainable, to Avhich the endocarditis may be attributed (for the differential diagnosis of this disease vide Arthritis Deformans). Prognosis.—Full recovery is, with but few exceptions, out of the question. A cure may rarely be effected if the case come under appro- priate treatment in the incipient stage. The disease, however, rarely shortens the duration of life, though it may do so by interfering Avith the nutritive processes, the latter effect resulting from loss of sleep (due to pain) and inability to take active exercise. Treatment.—(a) The local measures hold first place. The affected joints should be enveloped in flannel at all times, and underneath the latter may be applied cold cloths, and the Avhole covered Avith oiled silk. On the other hand, sponging the joints frequently with hot Avater also furnishes good results, relieving decidedly the pain and stiffness. Blis- ters have been employed, but I have failed to see any benefit from their use, except in the cases in which effusions w7ere present. In removing the latter they are most efficacious. In the absence of synovial effusion the thermo-cautery is to be preferred to blisters, and for the SAvelling and stiffness massage w7ith passive movement affords excellent results. Massage is also valuable when atrophy of the adjacent muscles exists; and in these so-called " rheumatic paralyses " electricity is an important help. The application to the joints of iodin and stimulating liniments is more or less serviceable. (b) Hygienic Measures.—The diet should be nutritious and ready of digestion, since dietetic errors, Avith their usual baneful consequences, tend to aggravate the arthritic condition. The patient should adopt and continue in moderately active exercise until compelled to omit it on account of the advancing joint-lesions. Cold spongings of the skin-sur- face, followed by active friction, has a good effect in that it lessens cutaneous sensitiveness. (c) Internal remedies do not control the morbid process directly, although arsenic, iodin, potassium iodid, guaiacol, and other agents are much used for this purpose, but their effects are usually limited, and never brilliant. It should be our aim to maintain the general health at a maximum level by the employment not only of the sanitary means before alluded to, but also by tonics (iron, quinin, strychnin, etc.). I have found a course of cod-liver oil, continued for a long period of time, the most serviceable form of internal medication. (d) In general terms hydrotherapy is an important adjuvant to the treatment. The thermal springs Avhose waters are alkaline or contain sulphur, and of which the hot springs of Arkansas and Virginia, and the Rich- field Springs, New York, furnish good examples, have been strongly advocated, and sometimes prove curative in their effects. I have seen excellent results from the methodic use of hot-water baths at a constant temperature (100° to 105° F.—37.7° to 40.5° C), combined with passive motion and careful manipulation of the affected parts. If the latter be adopted, every precaution must be used to avoid exposure to cold or 368 INFECTIOUS DISEASES. draft during and after the baths, which should not be prolonged beyond ten minutes. "WEIL'S DISEASE. (Acute Febrile Jaundice; Fiedler's Disease.) Definition.—An acute febrile disease, probably specific in origin, and characterized by jaundice, remittent fever, and muscular pains. It usually runs a definite course and terminates by lysis. Pathology.—During the comparatively recent studies of the post- mortem lesions occurring in this disease very little has been noted. The liver and spleen are sometimes the seat of an active hyperemia, and occasionally some gastro-intestinal irritation is present. The cortical substance of the kidneys is SAvollen and mottled, and the epithelium of the tubules and glomeruli shows cloudy swelling. Etiology.—The exciting cause of the disease is probably some specific microbic agent, but as yet no bacillus has been finally shown to be responsible for the affection. Jaeger claims that it is due to infection by the bacillus proteus fluorescens. Predisposing Causes.—Among these maybe mentioned the following: (a) Age.—The age of the patient usually varies from twenty to forty years. (b) Occupation.—This seems to have little connection with the cause, though in a certain few cases the disease has been noted as occurring among butchers. (c) Sex and Season.—Most of the recorded cases occurred in males and during the summer months. Symptoms.—The disease is usually ushered in by a chill, followed by fever, headache, and pains in the muscles that may be agonizing. Jaundice usually appears on the second day, and may either be slight or very intense; if it be due to obstruction, the stools are gray-colored, shoAving the absence of bile. The fever is of the remittent type, run- ning from ten to fourteen days and terminating by lysis. Nausea, vomiting, and diarrhea may also occur, but are rare. The liver and spleen are often enlarged, the latter being tender on pressure. The urine is febrile, high-colored, and often shows the presence of albumin, Avith tube-casts, and sometimes blood. In grave (but rare) cases cere- bral symptoms, such as delirium, convulsions, and coma, may occur and prove fatal. Prognosis.—The fatal cases on record are very few, and the prog- nosis, both as to life and recovery, is good. The treatment is purely symptomatic. SCHLAMMFIEBER. (Oderfiecken; Erndtefieber) An epidemic disease that occurred in the basin of the Oder River and its branches near Breslau during the summer of 1S91, supposedly in consequence of the floods of March. It was carefully studied by Muller of Marburg. Nothing is definitely known concerning its pathology or its etiology, save the fact that it prevailed mainly among young persons who worked MALTA FEVER. 369 in the recently flooded districts. It Avas not communicated by contact. Susceptibility to the disease was general, and seemed to be influenced neither by the sanitary surroundings, food, nor by the Avater. The first cases occurred in June, and by October the intensity of the epidemic had passed. The incubation Avas from eight to tAvelve days. Clinically, the disease has not been satisfactorily classified, but Miiller shows the resemblance in certain respects to Weil's disease, Avhich may occur at times Avithout jaundice. He Avould include both in the same group of diseases, and hence it is deemed unnecessary to de- scribe the symptoms of " Oderflecken " separately. FeAv deaths occurred. No special form of treatment has been adopted. MALTA FEVER. (Mediterranean Fever; Rock Fever.) Definition.—An acute, infectious disease, caused most probably by the Micrococcus melitensis, and characterized by periods of remittent fever that are separated by shorter periods of apyrexia. It is endemic in Malta, and from time to time is encountered there, as Avell as at Naples and other Mediterranean ports, in epidemic form. No essential pathologic lesions have been identified with the disease. Hughes1 noted an enlargement of the spleen and of the mesenteric glands, also irregular patches of congestion in the alimentary tract, and grave cases exhibited bronchitis or broncho-pneumonia. Etiology.—The Micrococcus melitensis has been found in the organs tAventy-one times, and is readily recognized morphologically and by cul- ture. Bruce in two cases, and Hughes in four, reproduced the disease in monkeys by the inoculation of pure cultures of the organism. Young persons are most frequently affected. Symptoms.—The incubation-period lasts from five to ten days, and the disease develops gradually like typhoid fever, though it is a distinct affection. Headache, anorexia, languor, and fever (often preceded by slight shiverings) are present, the fever being of the remittent type, though irregular, and lasting one, two, or three weeks. It then dis- appears, to be followed, after an apyrexial period of two or three days, by a relapse, Avith rigors, high fever, and delirium, and sometimes by diarrhea and increased prostration. The relapse frequently lasts from five to six weeks, and then usually gives place to convalescence. At the end of another Aveek or two a second relapse someAvhat similar to the first sets in, with rigors, an intermittent type of fever-curve, ex- treme prostration, and general rheumatoid symptoms. The latter may be so marked as to prohibit voluntary muscular movements of any kind. This most distressing condition may either terminate in recovery or, after the lapse of one or even two months, there may be a repetition of the Avhole group of symptoms. In grave cases the temperature is continuous and death may occur in hyperpyrexia (Hughes). The symptoms and course of the disease re- semble those of malarial fever, but the plasmodium is absent. The spleen is enlarged during the first five or six Aveeks, and then returns to its normal dimensions. 24 1 Annates de I'Institut Pasteur. 370 INFECTIOUS DISEASES. The duration is variable, obstinate cases lasting six months, but the mean length of stay in the hospital is from seventy to ninety days. There is marked anemia in protracted cases. The mortality is about 2 per cent. The treatment is to be directed toward sustaining the strength of the patient by nourishing liquids and stimulants. The fever is unaf- fected by quinin or arsenic, and is to be met by hydrotherapy. Tonics, including iron, are needed to overcome the sequential anemia and debility. FEBRIOULA. (Simple Continued Fever; Ephemeral Fever.) Definition.—A brief febrile attack, unattended Avith definite local lesions, and of varied, often indeterminate, etiology. A true ephemeral fever is one that lasts about twenty-four hours, Avhile the term simple continued fever or febricula is given to cases lasting a longer time—from three to six or more days. The cases are so diversified with reference to their etiology and clinical relations as to make it desirable to group them roughly under several heads: (a) A large group of cases in which a gastro-intestinal disturbance is the only assignable cause. The latter may take the form of indi- gestion due to cold or more often to errors in diet (particularly the use of tainted food-stuffs), accompanied by absorption of toxic substances; or it may consist of the gastro-intestinal catarrh so frequently met with in young children. (b) Undeveloped or abortive forms of the infectious diseases (typhoid, typhus, rheumatism). These affections, particularly during times of epidemic prevalence, may run a brief course Avithout manifesting any of their distinctive characters. In abortive types (particularly of typhoid fever) the invasion-symptoms are apt to be well marked, but the more characteristic features fail to appear. Thus diseases that ordinarily manifest a characteristic eruption (e. g. scarlet fever, measles, erysipelas) may run their course Avithout doing so, or the eruption may escape observation. (c) It may folloAV exposure to the summer sun or excessive heat, or exhaustion of the nervous system. (d) It is not infrequently the result of a slight and unnoticed local- ized inflammation (tonsillitis, bronchitis, lymphadenitis, etc.). (e) The inhalation of sewer-gas or other noxious vapors (such as em- anations from decomposing organic matter) may produce an aberrant form of the fever, and seAver-air has been mentioned elsewhere as a cause of a mild form of sapremia (vide Septicemia). Symptoms.—It is to be remembered at the outset that a single symptom, peculiar to all cases, is the fever. The onset is generally sudden, and especially in ephemeral fever, but it may be gradual; if sudden there is rarely either a chill or vomiting, while in neurotic chil- dren a convulsion may occur. The temperature ascends quickly to 102°-103° F. (39.4° C.) or over, pursues the continued type, and at the end of one, two, or more days subsides abruptly by crisis. There are accompanying symptoms, many of Avhich are due to the fever, such MILK-SICKNESS. 371 as headache, hebetude, mild delirium, flushed countenance, a full rapid pulse, anorexia, constipation, scanty high-colored urine, and, not rarely, herpes labialis. Defervescence may be attended with critical sweats, diarrhea, or a copious flow of urine. Special types (e. g. cerebral, gas- tric) may be observed, due to the predominance of the symptoms pre- sented by individual organs or systems. In another class of cases the access of simple fever may be less sud- den, the maximum level attained being somewhat lower and the attend- ing phenomena less acute and pronounced. * The course is more pro- tracted, though rarely exceeding a Aveek or ten days, and the deferves- cence is not so abrupt. The diagnosis necessitates the exclusion of other acute fevers. The affections from Avhich it is most difficult to distinguish febricula are typhoid fever, scarlet fever, tonsillitis, larval pneumonia, and menin- gitis (in children). In febricula, however, there is an absence of local manifestations and of physical signs pointing to consolidation of the lungs ; characteristic skin-eruptions are also absent. The prognosis is good. Treatment.—FeAv cases require treatment other than rest in bed and liquid nourishment for several days. Cooling drafts internally, and mild forms of hydrotherapy (spongings, ice-caps) externally, are indi- cated. If traceable to gastro-intestinal disturbance, a laxative usually proves beneficial and effective. It should be followed by intestinal antiseptics. Unless it is clear that the given case is non-infectious and non-contagious, isolation of the patient should be ensured. MILK-SICKNESS. Definition.—A peculiar infectious disease, occurring both in man and in the loAver animals, when it is knoAvn as "trembles." The dis- ease is unknowTn east of the Alleghany Mountains, but throughout many of the Western and South-western States it formerly prevailed very ex- tensively, with fatal effect. It has, hoAvever, been almost exterminated as the result of denudation of the forests and the advancing cultivation of the virgin soil. It still prevails in parts of North Carolina (Osier), and until very recent times has been seen in certain parts of Illinois. No peculiar pathologic lesions have been described. Etiology.—It is believed to be due to a special poison derived from the earth, but as yet we are ignorant of its exact nature. Phillips claims to have found a spirillum in the blood. Modes of Infection.—The disease attacks cattle most frequently (espe- cially umveaned calves), horses, sheep, goats, and less often many undo- mesticated animals; wherever trembles prevails among cattle, milk-sick- ness is met with in man. It is thought that the poison is communicated to man in the milk, butter, and cheese, or in the flesh of infected animals. Among disposing factors are the seasons, the disease being most fre- quent in the late summer and autumn. It is most common in adult life. Symptoms.—The period of incubation may be short or long in duration, and prodromata, such as headache, anorexia, languor, and oncoming fatigue, may be noted. These symptoms increase in severity, and are soon eclipsed by the more characteristic features—nausea and 372 INFECTIOI 'V DISK A SES. vomiting, a hot pain in the stomach, and a peculiar fetor of the breath. There is an unquenchable thirst, a swollen, tremulous tongue, and abso- lute constipation. Fever is present, but it is slight, and the surface- temperature is often below the normal. The nervous symptoms include restlessness, merging into mental dulness Avith marked indifference, and the latter condition passing in grave eases into a stupor that may deepen into actual coma. Convulsions may arise or the patient may drop into a fatal typhoid state. The diagnosis rests chiefly upon the history (particularly upon the coexistence of " trembles " in cattle) and the exclusion of other acute intoxications. The prognosis is generally favorable, though a fatal termination due to asthenia may occur Avithin a feAv days of the time of the onset. Treatment.—Prophylaxis consists in the avoidance of those foods that act as bearers of the disease. Apart from the use of supporting measures (appropriate diet and stimulants), we can attend only to the symptomatic indications. Medicated enemata should not be omitted. MILIARY FEVER. (Sweating Sickness.) Definition.—An infectious disease, characterized by copious sweats and a vesicular (miliary) eruption. In certain countries it has prevailed epidemically (France, England, Italy, Germany), and in 1887 a severe epidemic occurred in France. Schaffer! reports the occurrence of a re- cent epidemic in an Austrian province in the spring of 1893, lasting for nearly three months. Out of 5079 persons (the total population of the district), 159 suffered, as follows : 17 men, 14 women, and 128 children. At the present day it seems to be met with only in Picardy, in a few other French provinces, and throughout a limited area in Italy. Neither have definite pathologic lesions nor the specific exciting cause been found. Among predisposing influences the following have been noted: (a) Most epidemies occur in spring and summer; (b) It is more common among Avomen than men, and most frequent during the middle period of life. A large percentage of the entire population of an in- vaded district (usually limited in area) is attacked. The symptoms that characterize miliary fever are fever with its usual accompaniments, irritation of the skin, a sense of oppression in the epigastrium, copious and persistent sweating, followed, on the third or fourth day of the disease, by an eruption of miliary vesicles. The vesicles burst, and within forty-eight hours scaly desquamation is generally completed. In severe types the nervous phenomena (delir- ium, etc.) are grave in character ; hemorrhages may occur, and at times fatal collapse may follow. Relapses are not uncommon. The prognosis is affected largely by the character of the epidemic, the average death-rate being 8 or 9 per cent. Quinin has met with almost universal favor as a remedy, but the expectant plan of treatment is the most appropriate, the symptoms being treated as they arise. 1 Wiener med. Blatter, 1893, No. 32. FO 0 T-A ND-MO UTH DISEASE. 373 FOOT-AND-MOUTH DISEASE. (Epidemic Stomatitis; Aphthous Fever.) Definition.—An acute infection of certain loAver animals (cattle, sheep, pigs, goats, etc.), caused by a micro-organism as yet undiscov- ered. It is characterized by fever, by the appearance of vesicles and ulcers in the mucosa of the mouth, in the furrows about the feet and on the udder, and by the rapid development of asthenia and marked ema- ciation. Though a disease of mild character, its territorial range is so vast as to entail untold loss to European countries. Young animals or sucklings perish in great numbers on account of the deteriorated qual- ity of the milk, Avhich assumes a yellowish-wThite appearance and has a bitter, nauseating taste. During epidemics of foot-and-mouth disease the poison may be trans- ferred to man, in Avhom the disease is known as epidemic stomatitis, the poison generally being transferred by means of the milk. Boiling the latter destroys the virus, but rarely the infection may be transmitted through butter and cheese made from the milk of infected cattle. Com- munication by inoculation (Avhile milking) may also occur. Whether the poison may be introduced into the human body by eating the meat of diseased animals is doubtful. Symptoms.-*-The incubation-period lasts from three to five days. A rigor may mark the onset or merely slight shiverings, folloAved by fever and malaise, and soon vesicles, such as are described under Aph- thous Stomatitis, appear upon the tongue and inner surface of the lips. The mouth is hot, the mucosa reddened and SAvollen, and salivation is present. A form of miliary eruption that may become pustular may also appear on the skin-surface, and particularly on the fingers and hands. Hemorrhages have been observed in severe epidemics. The diagnosis is made with ease if the disease be prevailing at the same time among loAver animals. The peculiar coincidence of the erup- tion in the mouth and extremities, sparing the rest of the body, has not been noticed in any other eruptive disease (Whittaker). Course and Prognosis.—The course is mild and ends in about one week, the disease being very rarely fatal. Treatment.—Prophylaxis requires the use of milk from healthy animals (coavs or goats), together Avith measures looking to the care of the stables and isolation of diseased cattle. For treatment the reader is referred to the article on Aphthous Stomatitis. PART II. CONSTITUTIONAL DISEASES. DIABETES. (Diabetes Mellitus) Definition.—A nutritional affection, attended by an abnormal amount of sugar in the blood, and characterized clinically by persistent glycosuria, by polyuria, and by a progressive loss of flesh and strength. Nature of the Affection.—This is still undetermined. Post-mortem lesions of different organs and structures of the body have been met with in diabetes—a fact that has given rise to a variety of views as to its nature, of which the following are the chief: (1) That it is dependent upon organic disease of the pancreas, espe- cially granular atrophy, or upon marked functional disturbance of this organ. It has been shown experimentally that extirpation of the pan- creas is followed by diabetes, and yet, according to MinkoAvski and Lepine, if a small portion remains glycosuria does not result. On the other hand, Sandmeyer extirpated the pancreas of two dogs, leaving from one-ninth to one-fifth of the organ. The animals became diabetic —one four and the other thirteen months after the operation—and the first dog succumbed two months and the other eight months later. It may safely be assumed that total loss of function ahvays, and par- tial loss sometimes, leads to diabetes. Again, from the observations of Hansemann in the Berlin Pathological Institute and the Augusta Hos- pital, it Avould seem certain that the coincidence of pancreatic disease and diabetes occurs oftener than either diabetes or pancreatic dis- ease alone, and, in truth, oftener than both these separate affections combined. Lepine and Martz have been able to produce a glycolitic ferment by treating the pancreas after their own special method, Avhich need not be detailed here. This ferment is identical with that which is contained in the blood, and in the presence of Avhich glycogen is assim- ilated ; pancreatic diabetes occurs, therefore, when through organic dis- ease or functional disturbance the formation of this ferment is Avholly or even partly arrested. Another source of the glycolitic ferment is the salivary secretion. (2) If the glycogenic function of the liver be interfered with mate- rially, diabetes follows. This may result from organic hepatic disease or the fault may lie solely with the nervous system. Puncture of the floor of the fourth ventricle will also cause glycosuria, and section of the pneumogastric nerve is followed by vaso-motor paralysis of the he- patic vessels, disappearance of glycogen from the liver, and the appear- 374 DIABETES. 375 ance of sugar in the urine. This view explains how central lesions, changes in the cord, and disturbance of the sympathetic system produce diabetes. (3) The so-called alimentary glycosuria has frequently been induced experimentally by Miura and others. It results from the ingestion of more carbohydrates and peptone than can be stored in the liver as gly- cogen, so that some of the latter finds its way into the hepatic vessels with consecutive glycosuria. (4) The administration of phloridzin produces glycosuria both in animals and man. There are two views as to the cause of phloridzin diabetes: (a) that the kidneys, owing to the action of the phloridzin on the renal epithelium, eliminate the sugar from the organism; (b) that an excessive formation of glucose occurs. The condition of the blood in phloridzin glycosuria testifies to the decomposition of proteids rather than to the mere elimination of sugar (Lepine). (5) The Microbic Theory.—Paul Ernst and others have observed all forms of fungi in diabetes, thus showing that the disease is favorable to the development of various micro-organisms, but as yet none have been shown to sustain an etiologic relationship. The rapid succession of cases in a single family led Bose to suspect the contagiousness of the disease in India. (6) Pavy's view regarding diabetes, recently advanced, is that the carbohydrates of the food are converted into fat by the protoplasmic action of cells in the intestinal villi, and enter the system in the same Avay as do fats taken as such. The surplus carbohydrates that escape the action of the cells of the villi are transmuted into glycogen in the liver. The glycogen stored in the liver obviously forms fat also, since this organ has some fat-forming function, and there are thus two barriers preventing the carbohydrate matter entering into the blood, and if either is deranged diabetes may result. It is obvious that no single view explains all the cases of diabetes, and that the glycogen derived from the carbohydrates and proteids of the food (found normally in the liver and in the muscles) may be present in increased proportion, giving rise to glykemia, or be eliminated from the system on the other hand, owing to a great variety of morbid influences. Pathology.—The pancreas in more than one-half the instances shows morbid changes. The most frequent lesion is the granular atrophy of Hansemann, occurring in 36 out of 40 cases of pancreatic diabetes. Fibroid induration of the pancreas is sometimes observed in diabetics, and is due to syphilis. Diffuse cancer of the organ may lead to diabetes, but not readily, Hansemann having observed 2 cases, and I also 2, with- out diabetes. Calculus, Avith atrophy, may or may not be associated with diabetes. Occlusion of the pancreatic duct, atrophy from pressure, and cystic degeneration of the organ may sometimes be combined Avith the disease. Acute necrosis of the organ may rarely lead to glycosuria, but of 100 cases collected by Fitz and Seitz only 2 had diabetes. The liver is often enlarged and the seat of fatty degeneration. Ac- cording to French writers, there is a diabetic cirrhosis of the organ (cirrhose pigmentaire), the pigment being derived from destroyed blood- cells. I have observed an instance in Avhich diabetes coincided with tertiary syphilis affecting the liver. 376 CONSTITUTIONAL DISE. ISES. The Kidneys.—There may be noted a benign, often intermittent, form of albuminuria, and a Avell-marked nephritis, Avith fatty degenera- tion, is often present. The tubal epithelium may shoAv a hyaline change, and the lesions of acute nephritis, Avhich may be the cause of diabetic coma, may be present. Nervous System.—In rare instances organic disease of the medulla (tumors, sclerosis, etc.) is found. Cysts have been met Avith in the Avhite matter of the cerebrum, and perivascular changes have also been described (Osier). Changes in the posterior columns of the cord have been noted, and a peripheral neuritis, simple or multiple, is commonly though not constantly seen. The so-called diabetic tabes is generally supposed to be due to multiple neuritis. Fraser and Bruce post-mor- temized a case of diabetic neuritis Avhich shoAved a zone of degeneration in the optic nerve. Sclerosis and enlargement of the ganglia of the sympathetic system have been noted in a feAv cases. The Lungs.—The commonest lesions in the lungs are gangrene fol- lowing pneumonia (particularly broncho-pneumonia) and the so-called diabetic phthisis. Fatty emboli have been found in the pulmonary vessels. The Heart.—Arterio-sclerosis Avith cardiac hypertrophy is often met with, but does not constitute a peculiar lesion. Marie found pigmentary degeneration of the muscular fibers and sclerosis of the pigmented fibrous tissue. The Skin.—Cutaneous pigmentation, broAvn or even red-black, and more or less uniform, has been reported in 9 cases (Hanot and Chauffard). It is associated with hypertrophic cirrhosis of the liver. The Stomach.—Dilatation and, according to Jacobson, marked catar- rhal changes are common in the early stage. The Blood.—The normal proportion of sugar in the blood (0.15 per cent.) is usually increased, though there is no immediate connection be- tween the percentage of sugar in the blood and in the urine in diabetes. Both in experimental and pathologic diabetes hyperglykemia may be marked, Avith moderate or slight glycosuria, and Lepine has shown that diuretics diminish hyperglykemia by increasing the glycosuria. The blood-plasma contains much fat. It is probable that the albuminoid matters in the blood may produce glucose. Glycogen probably exists in the blood-corpuscles, and not in the plasma, " where it would be destroyed by the diastasic ferment" (Dastre), and it is a normal ele- ment of the blood, apparently belonging to the leukocytes (Huppert and Czerny). The corpuscles show no special alterations. General Etiology.—(a) Heredity is generally believed to exert a predisposing influence, since cases are observed to succeed one another in the same family, (b) Season also exerts an influence, diabetes appear- ing more frequently in the months of March, April, July, and Novem- ber (Davis), (c) The male sex suffers much more frequently than the female. Wegeli, however, found in 107 cases that children of both sexes Avere affected in an equal proportion, (d) Age.—Most cases occur between twenty-five and fifty years. Infantile diabetes is rare, and occurs most frequently about the age of five, though it has been met with under one year, (e) The Hebrew race is especially susceptible. (/) The better classes of society furnish most instances, and particularly DIABETES. 377 that large element composed of neurotic subjects, (g) A nervous shock or strain or prolonged mental anxiety acts as a predisposing cause, (h) Occupation.—The urine of 607 individuals engaged in manual labor that required great muscular and respiratory activity shoAved no sugar in any case; Avhile the urine of 100 individuals engaged in intellectual work of a more or less fatiguing character, but always intense and sed- entary, showed sugar in 10 of the cases in varying proportions (Worms). (i) Obesity predisposes, though usually to the lipogenic form, which is generally a mild variety, (j) Certain chronic diseases—e. g. syphilis, ma- laria, gout—predispose, (k) Pregnancy has a slight though decisive in- fluence. (I) It sometimes follows acute infectious diseases, (m) Local- ity.—Unlike gout, Avhich has been increasing in recent times, diabetes mellitus has been decreasing in America. On the other hand, in cer- tain other countries, particularly in France, diabetics appear to be con- stantly increasing in number, the mortality in Paris having more than doubled from 1883 to 1892, inclusive. The disease is much more fre- quent in cities than in rural districts. Special Etiology.—Under this head may be arranged the folloAving groups of cases: (1) Diabetes due to pancreatic disease. (2) Cases oc- casioned by hepatic disease (organic and functional). (3) Those com- paratively rare instances caused by disease of the brain (tumors, sclerosis, or irritative lesions of the diabetic center) and spinal cord. (4) Diabetes follows traumatism, and especially injuries to the head. Not infre- quently it occurs after injuries to other parts of the body, such as the spine, sacral region, abdomen, etc. In 212 cases of traumatism of the head Higgins and Ogden found 20 cases of glycosuria, though only a small proportion of the cases (2) exhibited a permanent glycosuria from the date of injury. Ebstein,1 after an exhaustive study of 6 of his OAvn cases and of 44 gathered from literature, concludes that there can be no question of the direct causal relation of traumatic neurosis and diabetes. Cases of diabetes may folloAV injury without cerebro-spinal lesions. Clinical History.—For the sake of accuracy and convenience of description the cases Avill be divided into the acute and chronic forms, brief reference being made to special varieties based upon an etiologic classification under Clinical Types. 1. Acute Diabetes Mellitus.—The instances are feAv and the course is, as a rule, rather subacute than acute, manifesting a predilection for the young and middle-aged. The onset is more abrupt than in the chronic form, but the characteristic features do not differ from those of the lat- ter, more common variety. Many of the cases due to pancreatic disease are of this class. 2. Chronic Diabetes.—The symptoms are evolved slowly and gradu- ally, as a rule, and prominent among prodromal conditions is dyspepsia or chronic gastric catarrh. WTe may also note certain nervous disorders, such as headache, mental irritability, moroseness, and insomnia, with or without gastro-intestinal symptoms. In some cases the patient suffers merely from general debility and malaise, and either frequent micturi- tion, polyuria, or unnatural thirst is apt to be noticed. Rarely, dia- betes has an abrupt onset, as after an injury or a sudden severe nervous shock. With the development of the affection the polyuria becomes 1 Deutsche Arch.f. klin. Med., April, 1895. 378 CONSTITUTIONAL DISEASES. marked, as a rule, the thirst great, the appetite keen, and glycosuria appears. In spite of the enormous quantities of food taken, progressive emaciation and debility attend. Leading Symptoms and Complications in Detail.—(1) The Urinary Symptoms.—The daily amount of urine varies from four or five pints te- as many gallons. In very mild cases and in intercurrent febrile attacks it may be slightly, if at all, increased in quantity. Its color is pale, and its specific gravity ranges from 1020 to 1050, rarely being as low as 1015; it has an acid reaction, a SAveetish, aromatic odor, and a dis- tinctly SAveetish taste. Sugar is present, the amount varying from \ of 1 per cent, to 2 per cent, in mild cases, to 5 or even 10 per cent, in severe attacks. The total amount eliminated in the tAventy-four hours varies from five or ten ounces to a pound or more. (For the most satis- factory tests for glucose in the urine vide Glycosuria, Diseases of the Kidney.) Other forms of sugar than glucose (inosite and levulose) may be con- tained in the urine, and glycogen has rarely been found. The urine may also contain fermentation-products (acetone, alcohol, and diacetic acid). Acetone strikes a Burgundy-red color on the addition of the chlorid of iron (vide Acetonuria, Diseases of the Kidney). The urea is greatly increased, Kaufman finding the quantity in the blood of diabetic dogs to be doubled. Uric acid is either normal in quantity or slightly diminished, but a large amount of ammonium is present, indicating an increase of organic acids. The phosphates may also be present in greatly increased proportion (Ralfe), and in such cases the glycosuria may be more or less intermittent. This has been described as a special variety—phosphatic diabetes. Lipuria may be present. Slight albuminuria, often with an intermittent tendency, is common even in the early stages, and is not of grave significance. Well-marked nephritis with its characteristic phenomena may develop, though usually in advanced diabetes; and if albuminuria be marked, the amount of sugar excreted maybe considerably diminished. The development of chronic interstitial nephritis, however, is not a favorable complication, as some have supposed. With or without nephritis, arterio-sclerosis may be observed, and pyelo-nephritis (rarely) and cystitis (not rarely) may appear as complications. As the result of fermentative processes in the bladder gases may form (pneumaturia). Impotence is a not in- frequent, and often an early and a very significant, symptom ; later this condition may improve spontaneously. (2) Digestive Symptoms.— Although a general feature, thirst mav be discussed under this head. This symptom may be most distressing, necessitating the drinking of large quantities of water at frequent inter- vals both by night and by day. The amount of water taken stands in direct relation to the amount eliminated, though not necessarily to the daily amount of sugar excreted. Notwithstanding the fact that the in- creased amount of water is needed to dissolve the sugar, cases of con- firmed diabetes are met Avith in which thirst is not marked and the amount of urine passed but little above the normal. Cases are also encountered in which the amount of urine is large and the percentage of sugar excreted very low. The cause of the unusual thirst is not DIABETES. 379 quite clear, though it is probable that the chief factor is the increased systemic demand for liquids. The appetite is abnormally large and sometimes almost insatiable (bulimia), and there may be an intense craving for carbohydrates. I have, however, met with two instances of Avell-developed diabetes in which the appetite was not inordinate. The cause of the ravenous ap- petite is probably to be found in the defective assimilative processes. Considering the quantity of food consumed, the digestion is often sur- prisingly good, but the association of dyspepsia and diabetes is by no means an uncommon one. As a rule, there is constipation, though brief intervening attacks of diarrhea may occur. The tongue is generally dry, large, often presenting a rough and fissured surface, and it may either be coated or red and glazed. The gums sometimes swell, and may ooze blood. The saliva is scanty and its reaction persistently acid, while the salivary secretion may show sugar on testing. The teeth decay, and aphthous stomatitis or thrush may attack the oral cavity. The liver is frequently somewhat enlarged, though the biliary secre- tion usually is not disturbed; jaundice may, however, arise as a com- plication. Marie has given a description of pigmentary " hypertrophic cirrhosis with diabetes mellitus," of which only 9 undoubted cases have been published. It appears late in adult life, and, in addition to the symptoms of diabetes mellitus, slight ascites, considerable hypertrophy of the liver and spleen, wTith brown or even gray-black cutaneous pig- mentation, are among the chief features noted. There is no true icterus as a rule, but the urine is highly colored and contains bile-pigments. (3) Cutaneous Manifestations.—Diabetic urine, on account of the sugar it contains, has irritant properties, and often produces in the female pruritus vulvae, a most troublesome symptom and one that should always excite suspicion of this disease. In the male, balanitis often occurs, due to the effect of the decomposing urine, and from the same cause the genitals and adjacent cutaneous surfaces may be the seat of eczema. This seems to be more common in women than in men. The skin is usually harsh and dry, though rarely copious perspiration may be observed, and particularly if phthisis be a complication. The hair often falls off, and in one case in my own practice shedding of the nails occurred. Among the commonest of the early cutaneous symptoms are furuncles and boils. Later large carbuncles often appear. Gangrene (especially of the feet) due to arterio-sclerosis is not infrequent, and edema, arising independently of nephritis, is not uncommon. (4) Nervous Symptoms.—Diabetic coma is the most important as it is the most grave symptom, marking a fatal termination in more « than half the cases. It is of most frequent occurrence in instances showing rapid wasting, and is heralded by a fruity odor in the exhaled breath and in the urine. The polyuria and glycosuria lessen, while acetonuria increases as a rule. The cases may be arranged into the fol- lowing clinical groups : Group 1. To this belong abortive forms that terminate in quick re- covery. This process may be repeated several times at intervals, and at last a fatal coma may supervene. Group 2. Perhaps the largest group, in which the diabetic coma fol- 380 CONSTITUTIONA L DISK. 1 .VAX lows some form of exhausting exercise. It may end fatally in a few hours or, though less frequently, in three or four days. Group 3. This is a comparatively small class, and is characterized bv collapse of the circulation (small, rapid, feeble pulse, cyanosis, etc.), leading to coma. It is induced either by over-exercise or by intoxica- tion. I have seen 2 typical instances, but feel that it may be ijues- tioned Avhether most of these cases should be classed as diabetic coma. Group 4. Without previous dyspnea or distress there appear such symptoms as headache and signs of intoxication, and these are followed quickly by deep and fatal coma (Frerichs). Group 5. Here diabetic coma is preluded by symptoms of some localized disorder, such as gastro-enteritis, pharyngitis, pneumonia, gangrene, or carbuncle. The attack sets in Avith headache, delirium, distress, and dyspnea both inspiratory and expiratory. Cyanosis may develop early, and, if so, cardiac failure precedes the coma. The dura- tion is from one to five days. This group, which Avas first described by Frerichs, may have a different onset, and I have seen tAvo cases, one attended by carbuncle, the other Avith gastric symptoms, in Avhich head- ache, dyspnea, and great distress Avere conspicuous by their absence. The coma ended in a speedy death. Group 6. Hirschfeld has recently described a class of cases in which Ave find, in old persons, a moderate glycosuria and coma supervening under the influence of gangrene or carbuncle. The causes of diabetic coma are still obscure. Hirschfeld points to insufficient nutrition from an exclusive meat diet as an important fac- tor. Kussmaul believed diabetes to be due to acetone. Klemperer, after a careful study of 21 cases, concludes, to his OAvn satisfaction, that the condition is not due to an acid-intoxication, and that there probably ex- ists in the blood a toxic substance Avhich produces an increase of acidity ("acetonemia") and coma. In this connection the fact that an in- creased destruction of nitrogenous material may be the cause of fatal coma, not only in diabetes, but also in other complaints (e. g. perni- cious anemia), must be recollected. Again, from the character of many preliminary symptoms diabetic coma must sometimes be of uremic origin, Avhile those cases that follow suppuration and gangrene may be septic in nature. Peripheral neuritis is common. The most frequent form is diabetic tabes, indicated by an absence of the knee-jerks, darting pains, paresis of the extensors of the foot, and by the peculiar gait (steppage). Other symptoms pointing to neuritis may be numbness, tingling, and certain trophic disturbances, such as shedding of the nails and perforating » ulcer of the foot. Neuralgia may be a troublesome symptom, par- ticularly when it is of the symmetrical sciatic type, and it points to neuritis. The same is true of paraplegia, a condition that is sometimes observed. Psychopathia (e. g. irritability of temper, hypochondriasis) may sometimes be present, and temporary hemiplegia has been noted. (5) Special-sense Symptoms.—Not infrequentlv cataract develops. leading to blindness. Its cause is not clear. Transient ptosis and strabismus may also appear, and among other ocular conditions are optic-nerve atrophy, retinitis (often due to associated nephritis), and DIABETES. 381 hemorrhage. Amaurosis is rarely observed. Among the aural symp- toms I would mention otalgia, otitis media, and mastoid disease. (6) Muscular Symptoms.—In diabetics there is a tendency to cramps, especially in the calf of the leg, that does not shoAv itself during the day, but appears during the night and on Avaking in the morning. Unschuld found it present in 33 out of 109 cases. Another variety of cramps that may appear at any hour of the day has been noted in con- nection Avith the so-called " gastric crisis," Avhich may be due to cramps affecting the diaphragm. In these attacks colicky pain in the epigas- trium, with vomiting, and febrile reaction attend. (7) Respiratory System.—Serious pulmonary complications not in- frequently appear in the advanced stages, and often cause death. The most frequent is pulmonary tuberculosis, Avhich has the customary term- ination, and does not differ from the usual form of the disease. A second, quite frequent complication is gangrene, which may either be limited to circumscribed foci or form a general condition. The peculiar and highly offensive odor of the expectoration that is so characteristic of gangrene may be Avanting here. A very serious type of secondary pneumonia sometimes occurs, and may terminate in gangrene. (, i i i 97° I i AFTER EATING AFTER EXERTION AFTER EXCITEMENT Fig. 33.—Pulse- and temperature-chart of a case of chlorosis, showing the effect exerted upon the pulse by eating, exertion, and excitement. 33). Visible undulating pulsations of the carotid vessels are frequent, and a pulsation in the peripheral veins is also observed at times. Phys- ical examination shoAvs the heart to be slightly dilated. Systolic mur- murs, soft and " Avhiffing " in character, are heard at, the base, though in severe cases they may be heard at the apex of the heart also. #ys- tolic blowing murmurs of hemic origin are not infrequently heard over the carotid arteries. More common and characteristic, however, is the venous hum or bruit de diable—the soft continuous murmur heard over the large cervical veins. Thrombosis of the larger veins, or of the fem- oral, or of a cranial sinus, may occur and is always of serious import. Of the nervous manifestations that are often present, neuralgias of the head, mental depression, hyperesthesia of the skin, particularly of the abdomen, gastralgic attacks, and hysteria, are most frequently met with. Tinnitus aurium and anemic amaurosis have been knoAvn to occur. Edema of the ankles is found in perhaps one-third of the cases. The urine is generally pale, free in quantity, and its specific gravity is some- what lowered; and according to recent studies there is a diminished 424 DISEASES OF THE BLOOD AND THE DUCTLESS GLANDS excretion of nitrogen in the form of urea, despite the abnormal destruc- tion of albuminoids. Blood-examination.—The blood floAving from a punctured finger-pulp or ear-tubule is pale, though seldom thin or hydremic, and the paleness is due to a qualitative rather than a quantitative change. There is a disproportionate reduction of the hemoglobin as compared with the number of the red cells. The hemoglobin may range from 50 per cent. to as low as 16 or 17 per cent, in severe cases, the average quantity bein* about 38 or 40 per cent. On the other hand, the number of red corpus- cles is not greatly reduced, and may even be normal. The moderate oligocythemia and marked oligochromemia are almost distinctive of chlorosis: these features, however, may be closely simulated by the chloroanemia of syphilis or early tuberculosis. The average number of red corpusles is from 3,700,000 to 4,000,000 per cubic millimeter of blood, but the count in very severe cases may be as Ioav as 1,900,000, Approximately, the number of red corpuscles is from 70 to 85 per cent. of the normal, while the leukocytes are only slightly increased in num- ber (8000 to 8500 per c.mm.). Microscopically, the red cells are seen to be paler than normal, and someAvhat altered in size and shape. Some are distinctively larger than is usual (macrocytes), but the majority are slightly undersized (microcytes). Irregularity in shape (pokilocytosis) is seen in quite a number of the red cells in the severe cases, and an occasional normoblast (small nucleated red corpuscle) may be noted. Diagnosis.—When the greenish pallor of the face is marked this can often be correctly made at a glance. The blood-examination must be made, however, to completely establish the diagnosis, even when dis- tinctive symptoms are present, such as the shortness of breath, palpita- tion, Aveakness and languor, faintness, amenorrhea, capricious appetite. together Avith a avell-nourished appearance of the body. The bluish- white sclerae and pallid nails are confirmatory Avhen observed, and the physical signs should also be sought for. The primary character of the anemia may be determined in doubtful cases, or in those in which incipient tuberculosis or Bright's disease may be suspected, by exclusion. Here the physical examination of the chest and urinalysis should supplement the blood-examination. Organic dis- ease of the heart may be simulated by the breathlessness, palpitation, vertigo, and edema. According to F. P. Henry, the following blood- variations may be considered in the diagnosis of chlorosis: (1) the red corpuscles may be normal in number and in size, the only change being a deficiency of the hemoglobin; (2) the corpuscles may be normal in number, but diminished in size, Avhile the percentage of hemoglobin is normal; (3) the corpuscles may be diminished in number, with either a diminished, normal, or perhaps an increased percentage of hemoglobin. Prognosis.—This is ahvays favorable, except in those cases in Avhich congenital or developmental anomalies of the vascular system are associated. The discontinuance of proper treatment before a substan- tial cure is effected is often folloAved by a relapse, and even after appar- ent cure one or more recurrences may be Avitnessed before the age of thirty. The average duration of a case of chlorosis is from two to three months. In cases of very severe type, in Avhich the dividing-line CHLOROSIS. 425 between this disease and pernicious anemia may not be marked clearly, the prognosis should be made with due reserve. Treatment.—While the treatment of chlorosis by the administra- tion of iron is Avellnigh specific, the hygienic measures are also import- ant, and particularly in order that relapses may be avoided. Pure air, wholesome food, and plenty of rest and sleep, with reg- ular habits, are prime requisites. Sometimes a change of occupation, even temporary, where confinement may be replaced by an out-door life, fresh air, and sunshine, as in the case of store-girls and mill-operatives, is of great value in bringing about a rapid improvement. Patients in better circumstances may be sent to rural districts, the mountains, or sea-shore. In cases marked by much palpitation, dizziness, and dyspnea, rest in bed for a Aveek or so is often imperative at the outset. As im- provement goes on, however, light and then moderate exercise may be permitted out of doors, and the increasing appetite should be gratified by a generous, easily assimilable diet (milk, meat, eggs, fish, purdes of green vegetables, steAved fruit, apples, etc.). Fats and carbohydrates, however, should generally be aA7oided. Ferruginous mineral waters when procurable may be freely drunk, but coffee, tea, and alcoholics Fig. 34.—Chart of a case of chlorosis, showing the improvement following the administration of iron. Convalescence almost complete ; relapse. Black, red corpuscles; red, hemoglobin; blue, white corpuscles. do more harm than good. The one remedy, par excellence, on both rational and empirical grounds, is a good preparation of iron. This should be given methodically and persistently, until the percentage of 426 DISEASES OF THE BLOOD AND THE DUCTLESS GLANDS. hemoglobin is 90, and then maintained there by continuing the admin- istration of the iron for several Aveeks to prevent a recurrence (Fig. :!4)i Exactly how the iron acts in curing chlorosis has not been definitely proved, but its almost specific action is indubitable. Not all prepara- tions of iron are equally well borne by the stomach, however, and sev- eral changes may be necessary during the course of a given case. Prob- ably the best form for general use is the dried sulphate, usually given together with potassium carbonate in the Avell-knoAvn Blaud's pills—2 grains (0.129) of each to the pill. Starting Avith one pill thrice daily for a Aveek or ten days, the daily dosage is increased until nine pills daily are administered in the third Aveek, and continued for several Aveeks or as long as the case may require. It is very important, meamvhile, that the bowels should be kept soluble by the use of cascara sagrada, salines, and the like. A preliminary course of intestinal antiseptics for a week or so is strongly advised by some authorities, and is worthy of recom- mendation. Beta-naphtol, thymol, guaiacol, and salol are used for this purpose. The hematinic effect of the iron seems to be produced earlier and better Avhen this plan is followed ; and this fact seems to give cor- roborative evidence to Bunge's theory of the absorption of the iron in chlorosis—in a certain class of cases at least. Other iron preparations of value in this disease are the citrate, protoxalate, lactate, carbonate, the succinate, and the reduced iron. The albuminates of iron, so much vaunted for a time, are practically worthless. In severe cases Quincke uses at first a 5 per cent, solution of the ferric citrate, hypodermically (TTLvijss-^ijss—0.5-10.0, daily). The preparation knoAvn as ferratin is also highly recommended by some, and the therapeutic efficacy of gly- cerin extract of bone-marrow in chlorosis is as yet doubtful. Bitter tonics and dilute hydrochloric acid are indicated in a certain number of cases in Avhich indigestion is troublesome. The acid tincture of iron chlorid is sometimes used in such cases. Mild cases often yield to the simple use of remedies for the cure of gastro-intestinal derangement. Adjuvants in the treatment of chlorosis that may be of use are arsenic, manganese, mercuric chlorid, and arsenite of copper in minute doses. PROGRESSIVE PERNICIOUS ANEMIA. (Idiopathic Anemia.) Definition.—A grave blood-disease characterized by a great de- struction of red corpuscles, and a persistent tendency from a bad to a Avorse condition. It usually ends in death, and seldom exhibits causal lesions other than those of the blood or blood-making organs. The term "idiopathic anemia" applied to this disease by Addison, Avhose first clear description of its clinical history has become classical,' is applicable to a proportionately smaller number of cases to-day than during his time. This is OAving to the later discovery (post-mortem) of adequate causes for the pernicious anemia that during life could not be found. Thus, while still a primary essential anemia in most cases, and Avhilst future investigations may show the true Addisonian type of pernicious anemia to be a severe secondary anemia, for descriptive pur- poses it Avill nevertheless be convenient to classify both groups under the title of progressive pernicious anemia in order to describe the PROGRESSIVE PERNICIOUS ANEMIA. 427 invariable tendency of both. Under Diagnosis (vide infra), however, will be found some differential clinical features. Pathology.—As in chlorosis, the subcutaneous fat is rarely dimin- ished, so that emaciation is exceptional. The skin is pale and of a Iemon-yelloAv tint, and most of the tissues and organs are anemic, ex- cept the muscles, which are often decidedly red in color. The fat is usually pale and yelloAvish, and fatty degeneration is one of the most striking changes in this affection. The heart is usually large and flabby, and on section of the ventricular Avails there is a marked pallor, as Avell as a friability, and a fatty change shown by the yelloAV tint. Micro- scopically, the fibers or columns of heart-muscle are seen to be distinctly fatty. The heart-cavities contain very little light-colored blood. Other organs showing the fatty degeneration (of the epithelium) are the liver, kidneys, gastric and intestinal Avails, and the intima of many of the smaller blood-vessels (in patches). This general fatty change is prob- ably directly due to the deficient oxygenation of the tissues and to the anemic blood-supply. OAving to the above degenerative change, and consequent weakening in the vessel-Avails, small extravasations of blood are found in dif- ferent parts. Most frequently these punctiform hemorrhages are seen in the retina and on serous membranes, as on the inner surface of the dura mater, the pericardium, and the pleura. Ecchymoses are also ob- served occasionally on the mucous membranes and on the skin. More or less general edema and dropsical accumulations in the serous cavities are not uncommon. The spleen and liver are seldom and only very slightly enlarged. The lymph-glands are often somewhat swollen and intensely red in color, owing to the unusual number of red corpuscles, some of Avhich are nucleated. A marked and important pathologic feature of pernicious anemia is the presence of abundant deposits of iron-pigment, especially in the liver, but also in the spleen, kidneys, pancreas, and other organs. The fact that the abnormal quantity of iron in the liver is peculiarly distrib- uted about the periphery and middle zone of the lobules is particularly noteworthy, and quite characteristic of pernicious anemia. The origin of this iron is doubtless the enormous destruction of red corpuscles, and that the pigment in the hepatic lobules is ferruginous may be determined by a micro-chemic test with ammonium sulphid, granules of black sul- phid of iron being formed. Of special interest are the lesions found in the bone-marrow on account of its hematopoietic function. This is virtually hypertrophied, and is in many cases deep-red instead of yellow, and more like the hemoblastic marroAv of childhood (H. C. Wood). Indeed, the fat-mar- row of the long bones is often entirely replaced by the red marrow, which makes evident the contrast betAveen it and the icteric pallor of the fatty tissues elseAvhere in the body. Cellular hyperplasia may be seen microscopically in the great number of large and small granular medul- lary cells, and also in the nucleated red cells. An atrophied and polypoid condition of the gastric mucosa, more or less extensively involving the gastric tubules, is noticed in some cases. The sympathetic ganglion cells may also show changes. More constant, hoAvever, is the sclerosis of the posterior columns and, to some extent, 428 DISEASES OF THE BLOOD AND THE DUCTLESS GLANDS. of the lateral columns of the spinal cord: this is especially marked according to Burr, in the cervical swelling. These sclerotic changes are probably secondary either to the blood-state or to minute hemorrhages. Etiology.—There are three etiologic categories into Avhich cases'of pernicious anemia may be grouped: (lj those cases in which no discov- erable cause for the hemolysis (blood-destruction) is ascertained, either during life or after death—i. e. the idiopathic variety of Addison ; (2) those in Avhich an adequate cause is found post-mortem only; (3) thos.- that are plainly traceable, ante-mortem, to some sufficient primary causal condition acting directly or indirectly. (1) As regards the obscure cases of idiopathic anemia—or cachexia— the essential cause of the symptomatic condition is evidently an actively increased hemolysis. The blood-destruction is so great that blood-gen- eration (hemogenesis) is overbalanced. The latter may be normal in power or there may be a congenital or acquired underlying deficiency in hemogenetic poAver ; but in either event the hemolysis far exceeds the hemogenesis in pernicious anemia, the liver being the principal seat of the hemolytic changes—in the final stages, at least. Stengel believes that the hemolysis originates in the gastro-intestinal capillaries, and de- pends upon poisons generated or absorbed from that tract—an auto- intoxication. (2) Apparently causeless cases of progressive pernicious anemia may be found post-mortem to have been caused by (a) obscure malignant dis- ease ; (b) parasites, especially the Anchylostoma duodenalis, and rarely by the Bothriocephalus. Not infrequently, by a careful study of the anamnesis of a patient, aided by modern methods of examination, the cause of pernicious anemia may be detected during life. Atrophy of the stomach and chronic gastritis, Avith polypoid groAvths of the mucosa, may be included in this category. The Bothriocephalus latus may be discovered during life, though more frequently only after death. (3) Certain exhausting causes, operating directly or indirectly, may precede this affection, as severe or prolonged hemorrhages, or diarrhea, fevers, mental shock, profound chlorosis, pregnancy, and parturition. Unfavorable hygienic surroundings and insufficient nourishment, habitually kept up, may also favor the development of the disease; but, as in chlorosis, the most favorable environment is not by any means preventive of its development. Males are more frequently affected than females, and especially does it occur during middle life, though occa- sionally cases are seen in those beloAv tAventy years of age. The disease is Avidely distributed, and, whilst it has been observed to behave almost endemically at times, as in SAvitzerland and Leipsic, no infectious origin has been shoAvn to exist. Symptoms.—Idiopathic pernicious anemia develops so sloAA'ly and insidiously that it is hardly ever possible to fix upon any precise date as the commencement of the disease. The transition from health to pro- gressive pernicious anemia, particularly in persons previously feeble and pale, is usually too gradual to be demonstrable ; though a rapid and acute onset is rare, it may occur in pregnant or puerperal Avomen. Pallor is soon noticed and gradually increases, or Avhen there has been a previous pallor, this becomes more marked. Shortness of breath. and palpitation of the heart, especially on exertion, are complained of; PROGRESSIVE PERNICIOUS ANEMIA. 429 the patient is also easily fatigued, and becomes quite languid. Occa- sional nausea may come on early in those cases in which a previous crastro-iutestinal disturbance has been noted, and headache, vertigo, tin- nitus aurium, and anorexia ensue and grow progressively worse. Gen- eral weakness increases, and occasional attacks of faintness and vomit- in^ supervene. Meamvhile, the skin takes on a bloodless, Avaxy appear- ance, and soon the characteristic lemon-yellow tint appears. The mucous membranes (lips, gums, conjunctivae) are likewise pale and colorless. Prostration in bed gradually becomes almost absolute as the feebleness and flabbiness of the tissue increase. Malleolar edema is sometimes noticable, and ecchymoses—mucous and cutaneous—though not so com- mon as retinal hemorrhages, are seen in profound cases of anemia. Although the intellect is not impaired, except that mental exertion becomes irksome, the tone and manner of speech are feeble, sIoav, and apathetic. As the debility becomes severe the mind wanders, and, to use Addison's words, the patient "falls into a prostrate and half-torpid state, and at length expires." Emaciation is rare, the fat being preserved and sometimes increased in quantity. Pulsation in the large arteries is abnormally visible, and a diffuse, exaggerated cardiac impulse is felt. The pulse early in the case may be strong, and generally it is rapid (100-12(1), soft, and com- pressible, and as full and quick, often, as the water-hammer pulse of aortic regurgitation. Auscultation reveals the constant and character- istic hemic murmurs, best heard at the base of the heart, and the bruit de diable in the A'eins of the neck. There may also be visible pulsations in the latter. Gastro-intestinal symptoms may be the most prominent signs in cases where gastritis polyposa and gastritis atrophica are causal. Diarrhea, dyspepsia, nausea, and vomiting are then present throughout the long course; otherwise, constipation, eructations, and simple anorexia are most common. An ophthalmoscopic examination shoAvs the cause of the anemic amaurosis, in the profound cases of anemia, to be one or more retinal hemorrhages. The liver and spleen are rarely palpable. The bones, and especially the sternum, are sometimes sensitive to pressure. Respiratory Symptoms.—The breathing is accelerated, and the anemic dyspnea may become very pronounced and stertorous, accompanied by a sense of oppression in the chest and a "hunger for air." Near the end pleural and pericardial serous effusions and pulmonary edema tend to appear. The urine is of Ioav specific gravity, and, on account of its pigmenta- tion Avith pathologic urobilin, dark in color. The urobilin is detected both by chemic and spectroscopic examination. In the former the addi- tion of a few drops of an alcoholic solution of zinc chlorid to the urine gives a green fluorescence. Peptonuria is of doubtful significance. Albumin and glucose are absent, but uric acid and urea are both in- creased in amount, the former occasionally and the latter usually. Fever of a moderate degree is commonly, though not invariably, present, the evening temperature sometimes reaching 102° F. (38.8° C). Previous to death the temperature may be subnormal. Nervous Symptoms.—Paresthesia, spastic paralysis of the limbs, and 430 DISEASES OF THE BLOOD AND THE DUCTLESS GLAXDs a loss of control of the sphincters indicate the paralytic tendency of those cases in Avhich sclerosis of the cord occurs. Tabetic symptoms are sometimes marked. Blood-examination.—The blood is usually pale, though sometimes dark and Avatery, and the oligocythemia is distinctive of pernicious anemia. The number of red corpuscles may be reduced to less than 200.000 per c.mm., and is seldom more than 1,000,000; in severe cases about half a million is the usual count. There is ordinarily no increase in the number of leukocytes; on the contrary, they may be somewhat diminished. The percentage of hemoglobin may be approximately pro- portionate to the number of red corpuscles, but more often it is relatively increased, so that the indiA7idual corpuscles are rich in hemoglobin. In other words, although there is a reduction in the total amount of hemo- globin, it is usually not so great as the reduction in the number of ery- throcytes ; therefore, the percentage of hemoglobin is nearly always relatively higher than that of the red globules (see Fig. 35), a condition 100* 90* 80* 70* 60* 50* 40* 30* 20* 10* MONTH JUNE JULY AUGUST 8EPT. MONTH 100* 90* 80* 70* 60* 50* 40* 30* 20* 10* DAY s : s S s ~J » - £ ; t s S £ £ •> - 2 2 S Z s s S; s - ~ * <. a DAY 5,000,000 5,000,000 4,000,000 4,000,000 3,000,000 ^ 3,000,000 i 1 2,000,000 | ~~" \ - - - \ N, 1,000,000 500,000 ^ 500,000 __1 Fig. 35.—Blood-chart of a case of progressive pernicious anemia. Black, red corpuscles; red, hemoglobin. in marked contrast with chlorosis. Macrocytes, microcytes, and poi- kilocytes are abundant, and the macrocytes are supposed to give rise to the relatively larger percentage of hemoglobin. The presence of nu- cleated red corpuscles is also a striking characteristic of pernicious anemia. When normal in size they are known as normoblasts; when very large, as gigantoblasts. In the former, according to Ehrlich, the eccentrically-placed nuclei stain deeply; in the latter the large nuclei stain faintly. The former are typical of those nucleated red globules found in the hematopoietic organ of adults; the latter, of those found in the blood-development of embryonic life. The gigantoblasts are numerous in this disease. There are other and various forms of degen- eration of the red cells, but these are of minor import. There may be an increase in the small lymphocytes at the expense of the polynuclear cells; and, according to Cabot, the presence of large numbers 'of polv- chromophilic red cells has been noted in a series of 50 cases. The blood-plates are generally fewer than normal. The relative proportion of the proteids in the blood-plasma is altered (Adami). Diagnosis. —It is important to determine, if possible, whether the PROGRESSIVE PERNICIOUS ANEMIA. 431 anemia is truly primary (or idiopathic) or secondary. Moreover, the possibility of hidden carcinoma, gastric atrophy, the anchylostoma or other parasite, and incipient tuberculosis should be borne in mind. Intestinal parasites may be inferred from the microscopical examination of the feces after a brisk purge if the eggs of the parasites or the para- sites themselves be found. Atrophic gastritis may be discriminated by examining the viscus and gastric juice by modern methods. The fol- lowing table will permit the elimination of obscure gastric carcinoma: Progressive Pernicious Anemia. Obscure Gastric Carcinoma. The blood shows characteristic changes, Blood shows characteristics of secondary and the red corpuscle count falls to or anemia, and the count does not fall to below 1,000,000 per c.mm. 1,000,000, as a rule. Found earlier in life. Occurs after middle life. Gastric symptoms not so prominent. Gastric symptoms more suggestive. Lemon-tinted skin common. Skin of a pale, muddy-color, or only slightly jaundiced (saffron-yellow). Adipose tissue fairly well preserved. Progressive emaciation. No glandular enlargements palpable. Supraclavicular or inguinal glands may be palpable. No physical signs over stomach. There may be an area of increased re- sistance over the stomach. Examination of gastric contents after Examination of gastric contents shows test-meal usually negative. deficiency or absence of free hydro- chloric acid and presence of lactic acid. Some improvement may be brought about Condition becomes steadily worse until —even cure, though very rarely. death ends the case. From chlorosis the affection may be differentiated easily by the blood- examination. The relative increase in hemoglobin, the presence of gi- gantoblasts and many macrocytes, and the severe oligocythemia are pathognomonic of pernicious anemia, and are in marked contrast to the oligochromemia, and slight, if any, reduction in the number of red globules of chlorosis. Again, the progressive pernicious character of the former and the tendency to hemorrhage should be remembered, as well as the contrasting factors of age and sex in the two affections. Prognosis.—The disease, as a rule, terminates fatally, though not so frequently now as at one time, for obvious reasons. The course of pernicious anemia is usually sIoav and gradual, and may be interrupted by improvement or apparent recovery. Recurrences, hoAvever, are prone to occur, even after intervals of several years, " attacks of anemia" alternating with periods of improvement, accompanied by enlargement of the spleen. Idiopathic anemia is therefore almost hope- less, although a few apparently substantial recoveries have been reported. The duration of the disease is seldom more than a year, and may not be more than two or three months. Death may be caused either by syncope, cerebral hemorrhage (most commonly), or by sIoav asthenia. Treatment.—Hygienic measures must be regarded as of signal im- portance, and rest in bed, together Avith light nutritious food given at short regular intervals, is indicated first of all. Salt-water baths and gentle and systemic massage Avhen the patient is at absolute rest and is not too Aveak, are useful adjuvants. The value of arsenic in progressive pernicious anemia is analogous to that of iron in chlorosis. The best action of the drug will be ob- 432 DISEASES OF THE BLOOD AND THE DUCTLESS GLANDS. tained by the administration of gradually ascending doses of Fowler's solution or of arsenous acid. Beginning Avith four or five drops of the former, three times daily during the first Aveek, and thereafter adding one drop to the dose every day or two up to the point of tolerance, as much as twenty or thirty drops, well diluted, may be taken (see FiUCTLESS GLAXDs. primary diffuse lymphatic tuberculosis, indistinguishable from or mis- taken for Hodgkin's disease. It is not uncommon to find pseudo-leu- kemia developing in a person who immediately preceding the be»innin - of the disease Avas apparently in perfect health. Symptoms.—LTsually the first thing to attract attention is the en- largement of the submaxillary and cervical glands, often on one side of the neck alone. These grow gradually until they may finally appear on both sides as large as a fist, and produce considerable disfigurement. Sometimes several years may elapse before other glandular groups are affected, but, as a rule, it is a matter of months only before the axillary, then the inguinal, and perhaps the internal, glands are inA7aded. The changes vary greatly in rapidity and extent. At first the general health may be but slightly affected. A little constitutional disturbance and some pallor may be complained of, thouirh seldom before the glandular SAvellings are noticed. Then as the disease progresses the paleness increases and all the symptoms of a marked anemia appear—languor, failure of physical strength, beginning emacia- tion, gastro-intestinal derangement, headache, giddiness, palpitation, dyspnea, and edema of the legs. Later, the serous cavities contain MONTH MARCH APRIL MONTH DAY 19 20 21 21 23 2 4 25 26 27 28 29 30 31 1 > 3 4 5 6 7 8 9 10 11 is 13 14 1 5 16 1 7 18 If DAY TIME ME M E M E M Xi EM EUEI E M E M E M E ,EME MEM E M E 4 E M E m|e M E M E M E M E M E M : m e MEM EM E M eJem TIME 105° F. 1 "*10C. ' 1 - 40 104 A 103 '' - / I I / 1 : j I I I / i I.I 1 ] 1 A' 102 I III I I V i' 1 1 1 1 ' 1 0 , 1 1 \; I : ,J i i i n \f\r Viilll J I \ : 1 1 I i : 0 - 38 101 \ 1 I M h / ■ V -l i i\ ii i m \ X / i i : \' 1 1 \ I i II \/ ■ ' " \ II \ 1 V'' V i ■ . ' | . ■ 1 iV 1 II ' . ' \ i 100 j . i '1 M I \ l\ I ' i ' i i 1 \ i I A ■i iii \/\ i \ [ : ' I /+-A- 1 V 111 I 99 1 j 1 1 1 1 1 1 1 1 j / 11 A I \ i , | i i.....r | I : i ' ' | 1 Ml' ; i 1 I lit ll !/■ ' I h 37° 98 "1 i i ii/ \/\ /1 i i i 1 11 1 V 1 —1— u 1 1 1 1 11 97 1 1 _t~~j I'M " 1 1 1 1 1 I I ! - | 1 1 it: -|-r - t'i ! 1 1 1 i i I i ' ' 1 1 1 1 III IE__L +— I 1 1 I_____ Fig. 40.—Temperature-chart of a case of pseudo-leukemia. effusion and there is a tendency to hemorrhages. Epistaxis and metror- rhagia are apt to occur, and petechial spots, especially on the loAver ex- tremities, are not infrequent. The physical signs of anemia—hemic murmurs—are also present. An irregular slight or moderate pyrexia is common to most cases. Fever of a peculiar intermittent type has been observed, the intermissions and paroxysms each lasting for seA-eral days or weeks (see Fig. 40), and the term "chronic relapsing fever" PSE UD O-LE UREMIA. 447 has been applied in consequence. When these pyrexial exacerbations occur the cases generally run a more acute course. The symptoms due to mechanical compression by the lymphomata are varied and numerous, depending upon the number, size, and distri- bution of the tumors. Hundreds of tumors may be present through- out the body, but, unless they press upon the adjacent nerves, the glands are not usually painful. Enlargement of the tracheal and bron- chial glands may cause dysphagia, dyspnea, thoracic pain, disturbed phonation, and venous congestion, by pressure respectively upon the esophagus, trachea, bronchi, thoracic nerves, recurrent laryngeal nerves, superior vena cava, and the jugular veins. The obstruction to respira- tion may become so great as to produce death by suffocation. Conges- tion of the head and upper extremities may be quite marked, and in such cases compensatory dilatation of the superficial veins is observed. Edema of the hand and arm may result from venous obstruction due to the pressure of very large axillary glands. Deafness may be produced by growths within the pharynx. The heart's action may be disturbed by pressure on the pneumogastric, and the heart itself may be dislocated by great gland-tumors Avithin the chest. Under such circumstances the latter may be detected by dulness on percussion over the anterior medi- astinal space. Inequality of the pupils and unilateral SAveating of the face, OAving to glandular pressure upon the cervical sympathetic, may be noticed in some cases. Edema of the feet and legs may be an early indication of enlarged abdominal glands pressing upon the femoral veins. Sharp lancinating pains along the nerves may also be felt. Jaundice is sometimes attrib- uted to pressure upon the bile-duct. Gastro-intestinal disturbances may be troublesome, and are usually7 symptomatic of lymphoid groAvths in the stomach and boAvels. In thin individuals gland-masses may be pal- pable over the abdomen. It has been suggested that the bronzing of the skin sometimes seen in Hodgkin's disease may be due to the pressure of enlarged glands upon the suprarenal capsules. The slightly or mod- erately enlarged spleen can usually be felt just beloAv the ribs, project- ing toward the navel. Pressure-paraplegia and neuralgic pains variously distributed throughout the body should also be mentioned among the nervous manifestations. Tenderness over the spleen and bones may be elicited. An intense pruritus has been complained of, and the skin may be erythematous. Albuminuria is not uncommon; ascites and hydrothorax are late conditions, and occasionally the thyroid and thy- mus glands are involved. The characteristic feature in splenic pseudo- leukemia is the decided enlargement of the spleen Avithout involvement of the lymphatics. The blood shoAvs a moderate diminution in the number of red cor- puscles, and a corresponding diminution in the hemoglobin, the former in most instances numbering from 2,000,000 to 4,000,000 per cubic millimeter. There may be more or less leukocytosis, and sometimes the lymphocytes may preponderate relatively; if the latter be present in great numbers, the blood may shoAV great similarity to that of lym- phatic leukemia. An occasional normoblast may be seen. Diagnosis.—Pseudo-leukemia is more readily confused with tubercu- lous adenitis than any other disease, particularly at the outset. Although 448 DISEASES OF THE BLOOD AND THE DUCTLESS GLANDS. an acute tuberculous adenitis may very closely simulate Hodgkin's dis- ease and render a diagnosis almost impossible, more often the glands of tuberculous adenitis are sloAver in enlarging and extending than in this disease. In fact, extension of the lymphatic enlargements of tuberculo- sis is rarely seen as compared with pseudo-leukemia. Again, tuberculous adenitis is most common in the young, is unilateral rather than circumfer- ential in the neck, and attacks the submaxillary glands oftener than the cervical chains along the sterno-cleido-mastoid. Again, periadenitis. adhesion, and suppuration of the glands occur in tuberculosis. Tubercu- lous foci in other organs may also be found. Intermittent attacks of pyrexia are an indication favoring Hodgkin's disease. In doubtful cases a gland may be removed for microscopic examination. The blood should be examined in order to differentiate from leukemia. Syphilis must be carefully excluded by the history, symptoms, and therapeutic test. Neoplasms of the lymph-glands may sometimes be difficult to distinguish from pseudo-leukemia. Prognosis.—This affection runs an almost invariably fatal course, The variability of the symptoms, of the rate of groAvth, size, and ex- tension of the lymphatic enlargements, and the remissions and exacer- bations of the disease are, however, notable. In some cases the termi- nation may occur in a few months, but usually death ensues after the lapse of two or three years. Recovery is not impossible in the early stages of the disease, but in fully-developed cases the prognosis is absolutely unfavorable. It should be remembered that some instances of Hodgkin's disease seem to merge into a true lymphatic leukemia. Grave indications are the rapid extension of the glandular enlarge- ments, great debility, anemia, emaciation, steadily increasing and con- tinuous pyrexia, thoracic pressure-symptoms, hemorrhages, and marked anasarca. Sometimes the tumors diminish greatly before death. In certain cases general streptococcus infection, hydrothorax, edema of the lungs, mechanical compression, hemorrhage, intercurrent diseases. or such complications as empyema or nephritis, often preceded by coma, may be the immediate cause of death. Treatment.—Local or surgical treatment is of no avail. Hygienic measures and the use of all possible agencies to support the strength of the patient should be resorted to, and the administration of arsenic in gradually ascending doses, as for pernicious anemia and leukemia, should be begun as soon as the diagnosis of pseudo-leukemia is made. The value of arsenic is undoubted in many cases, and FoAvler's solution is very generally used. Phosphorus has also been recommended. In- unctions of ichthyol, iodoform, or green soap may be tried for their psychic effect, and the galvanic current may also be applied topically. Tonics and nutrients may be of temporary service. ANEMIA INFANTUM PSEUDO-LEUK^MICA. Definition.—The above title Avas given by von Jaksch to a form of anemia occurring in childhood that bears certain similarities to leu- kemia, but is Avithout the tendency to a fatal end. It is probably the same class of cases that Italian Avriters have classified under the name of anosmia splenica infettiva dei bambini. ANJEMIA INFANTUM PSEUDO-LEV'KJEMICA. 449 Pathology.—Splenic enlargement is the most striking lesion. The organ is hard and dark red, and perisplenitis may be observed. The histological examination shows a uniform hyperplasia of the tissue, such as is Avitnessed in ordinary splenic hypertrophy due to various conditions. The liver is enlarged in most cases, but presents practically normal ap- pearances on section ; slight enlargement of the lymphatic glands may also occur, though never lymphomatous tumors. Diffuse reddening of marrow has been described. Etiology.—Children under the age of four, and particularly during the second half year of life, are especially prone to this condition. It is equally common in the two sexes, and is most often met Avith in rachitic infants, 16 of 20 cases collected by Monti and Berggriin having exhibited this etiological factor. Hereditary syphilis, intestinal dis- turbances, and other diseases doubtless play a part in the etiology. The disease is a rare affection, occurring very seldom even in the largest children's clinics. Symptoms.—The onset is gradual. The child becomes pale, weak, and often emaciated, and enlargement of the spleen is the most strik- ing feature. Sometimes this reaches such a grade that the left half of the abdomen is practically filled, variations in its size being observed from time to time. Hepatic enlargement is frequently present, but does not correspond to that of the spleen, and the loAver border of the organ is found to be sharp instead of rounded, as is the case in leukemia. Gastro-intestinal disturbances may occur in the course of the disease, and gradually increasing weakness may lead to a fatal end; death may also occur from peritonitis, bronchitis, or pneumonia. Blood.—An examination of the blood will in many cases show an in- ordinate reduction in the number of red corpuscles. Nearly ahvays the number is below 3,000,000. Degeneration of the corpuscles, poly- chromatophilia, and poikilocytosis are seen in the severer cases. Large numbers of nucleated erythrocytes, especially the normoblasts, may be found, and karyokinetic figures are frequently observed in, the nuclei. A marked increase in the number of leukocytes is one of the characteris- tics, the number ranging from 40,000 to over 100,000, and the proportion of the red to the Avhite at times being as Ioav as 12 to 1. Considerable fluctuations in the number of leukocytes may occur from time to time. Von Jaksch insisted that the different forms of leukocytes occur in their usual relative proportions, or that the polymorphous forms are specially increased. Cases have, however, been described in which the mononu- clear elements were particularly increased. The nature of the disease is difficult to determine, though the favor- able termination of many cases, the lesser grade of hepatic enlargement, and the character of the leukocytosis distinguish these cases from leukemia. It is not even certain that it is a special disease-entity, and the evidence is in favor of its being a type of secondary anemia with peculiar features, due perhaps to the constitutional condition and the age of the patient. Diagnosis.—Some points of distinction from leukemia have been referred to above. In addition I would say that the absence of hemor- rhages, purpura, and lymphomatous enlargements, and the presence of abundant nucleated corpuscles showing karyokinesis, together with the existence of rickets, point to a non-leukemic affection. 29 450 DISEASES OF THE BLOOD AND THE DUCTLESS GLANDS. Prognosis.—The disease tends to a progressive increase of thf anemia, but under treatment the majority of cases terminate favorably. Treatment.—Hygienic measures together Avith the administration of remedies directed to the anemia constitute the treatment. CHLOBOMA. OAving to its clinical resemblance to leukemia and pseudo-leukemia a brief reference to this comparatively neAv and rare affection may be made here. Pathologically, it consists of a sarcomatous growth, the pri- mary seat of Avhich is in the periosteum and bone in and about the orbit. The growth shoAvs a pea-green pigmentation. Secondary groAvths may be Avidespread, the metastatic nodules being also green in color, but more circumscribed than are the lymphatic infiltrations of ordinary leukemia. In 2 cases reported recently, 1 by Dock and the other by Ayers,1 the ages were fifteen and seven years respectively. Pain in the orbital region, exophthalmos, and deafness Avere noted early, and severe conjunctival hemorrhages and epistaxis occurred. Rounded elastic SAvellings Avere observed in the temporal and parotid, as well as in the orbital regions, corresponding to the chloromata. The blood Avas pale and Avatery, and leukocytosis Avas present, multinuclear leukocytes being noted. The eosinophiles Avere slightly reduced. The course of the disease—spoken of by French writers as "green cancer "—is rapid, and death usually comes on within a few months. DISEASES OF THE DUCTLESS GLANDS. DISEASE OF THE SUPRARENAL, CAPSULES. ADDISON'S DISEASE. Definition.—A constitutional disease, characterized by a degenera- tion of the suprarenal capsules or semilunar ganglia, a bronzed or pig- mented skin, great bodily and mental asthenia, feeble circulation, and gastro-intestinal irritability. This affection is named in honor of its discoverer, Thomas Addison of Guy's Hospital, London, Avho first described it in a monograph pub- lished in 1855, entitled " The Constitutional and Local Effects of Dis- ease of the Suprarenal Capsules. Pathology.—Addison emphasized the fact that Avhile the supra- renal bodies Avere affected Avith a fibro-caseous alteration in many cases, the anatomical changes were by no means ahvays the same. Both supra- renal capsules are usually diseased at the same time. Tuberculosis is the commonest condition, and is often associated Avith tuberculous lesions in other parts of the body, as in the lungs, bones, and other gland*. Rarely, it seems to be primary, no other evidences of tuberculous infiltra- tion being found. The capsules are enlarged, firm in places, and nodu- 1 Jour. Amer. Med. Assoc, Nov. 7, 1896. ADDISON'S DISEASE. 451 lated on the surface, owing to the caseous masses surrounded by fibrous tissue. Sometimes there is marked cicatricial contraction of the adrenals, and the adjacent structures may be found matted together with the cap- sules. Microscopical examination shows a reticulum of connective tis- sue surrounding a soft cheesy, granular, and fatty detritus, lymphoid cells, and some giant cells. Other morbid processes in the adrenals that are non-tuberculous in nature have also been found associated Avith Ad- dison's disease, such as atrophy of one or both glands from interstitial cirrhosis, carcinoma or sarcoma, and chronic inflammation. Especial attention has recently been given to the condition of the solar plexus and semilunar ganglia of the abdominal sympathetic, and implication of these nervous structures by7 compression, cicatricial con- traction, or by chronic inflammation, is not infrequently discovered, to- gether Avith a degeneration of the nerve-cells. Enlargement of the solitary and agminated follicles of the intestine, and slight enlargement and some softening of the spleen are noted at times; parenchymatous or fatty7 degeneration of the heart, liver, and kidneys has also been noted in some instances. The thymus gland may be found to have remained normal, or even to have enlarged, perhaps. The deposition of pigment is in the same anatomical elements as in the negro—in the lower layers of the rete Malpighii. The pathological connection between the symptomatic phenomena of Addison's disease and the anatomical lesions has not been satisfactorily made out. The experimental evidence regarding the functions of the adrenals is imperfect; but it seems quite probable that some essential "internal secretion," influencing the normal metabolism of the skin and muscles, is diminished or absent in Addison's disease. On the contrary, cases exhibiting the clinical phenomena of this affection have occurred in Avhich no suprarenal morbid processes could be found post mortem. Again, marked changes have been observed in these glands, while dur- ing life no symptoms of the disease had been noted. Hence, it is maintained by some that the abdominal sympathetic nerves and ganglia are directly concerned in producing the clinical manifestations, either by an independent morbid process or by extension from some adjacent organ. Others hold that Avhen both the adrenals and sympathetic ganglia are the seat of pathological changes, the latter directly and the former indirectly lead to Addison's disease. The data are not sufficient, hoAvever, to determine Avhether the principal involvement is nervous or secretory, and to future investigations must be left the decision in regard to this point. Etiology.—This is obscure. It has been held that some infection of the blood from Avithout precedes the suprarenal and nerArous lesions of Addison's disease. A tuberculous diathesis or infection has also been emphasized by some investigators, and a history of injury to the trunk has been noted in several cases. The disease is more common in Europe than in America, though it is rare everywhere. Sixty per cent, of the cases occur in males, and while the disease may affect all ages (it may even be congenital) it is usually found in early or middle life— between fifteen and forty years of age. That Addison's disease is due either to a general neurosis or to disturbed hematopoiesis is merely hypothetic. 452 DISEASES OF THE BLOOD AND THE DUCTLESS GLANDS. Symptoms.—While it does not seldom happen that tuberculosis or carcinoma affects the adrenals, the purest and most typical symptoms of Addison's disease are apparently primary in their development, and not tljose that usually attend the course of the former diseases. The gradual pigmentation of the skin of various parts of the body may be one of the first evidences of the affection. This pigmentation may have either a dusky-yellow, bronze or yellowish-brown, olive, deep or greenish-brown, or even black color. Although sometimes diffuse, the discoloration is not uniform over all parts of the body, but com- mences earlier and becomes deeper especially on the exposed parts and where the normal pigmentation is marked, as the face, neck, backs of the hands, the axillae, abdomen, groins, genital regions, and the areola of the nipples. Pigment-spots, often somewhat bluish in color, are also found on the mucous membranes of the mouth, lips, conjunctiva, and vagina. On the lips the discoloration takes the form of a dark streak, running lengthwise, near the junction of the skin and mucous membrane; or brownish patches or streaks corresponding to points of pressure by the teeth may be noticed. Irregular stains Avith ill-defined borders may also be shoAvn on the skin, corresponding to the lines of pressure ex- erted by garments, strings, suspenders, garters, etc. (Greenhow). White patches of leukoderma may be seen here and there in marked contrast to the pigment-deposits. The constitutional symptoms may exist in a slight degree before the pigmentation first attracts the patient's attention. There is gradual and progressive asthenia Avithout apparent cause, great lassitude and loss of physical and mental energy, breathlessness, palpitation, headache, dizzi- ness, tinnitis aurium, sighing and fatigue, and the functional murmurs that are observed in the anemias. The blood-examination, however, rarely shows any marked reduction of the erythrocytes or hemoglobin; nor is there any leukocytosis. The heart's action is weak and the pulse small and feeble ; attacks of faintness on exertion are common, and coldness and clamminess of the extremities are often complained of. The general nutrition may suffer considerably, though often the fat, particularly of the abdomen, is well preserved. Gastro-intestinal symptoms are usually prominent. There is a loss of appetite, and nausea and vomiting may occur early and either be paroxysmal or persistent. The tongue may be clean, and the gastric disturbances do not seem to follow errors in diet. Diarrhea may be troublesome in the latter stage, and is often associated with intractable vomiting. Neuralgic attacks of either sharp or dull, aching pain are referred to the epigastric, hypochondriac, and lumbar regions in about one-third of the cases. The mind is usually clear until near the last, but mental Aveariness is constant, and, as the later stages of the disease come on, the patient often lies in a somnolent, semi-comatose state. The physiognomy expresses fatigue, dejection, and apathy ; the speech be- comes slow and incoherent, and in many cases the patient passes into delirium. Prostration is profound, the weakness being disproportionate to the general condition. Polyuria is sometimes evident, but albumin is seldom present. The amount of indican is increased, as it is in the urine of all of the cachectic diseases associated with destruction of albuminoids. There ADDISON'S DISEASE. 453 is usually a diminished excretion of urea, but urobilin and uromelanin may be present in abnormal quantity. Tubercle bacilli may be found in the sputum. Diagnosis.—The principal error in diagnosis is in the assumption that the case is one of Addison's disease, simply from the presence of patches of pigmented skin. Other conditions in Avhich the discoloration may simulate that of Addison's disease are the following: (1) Carcinom- atous and tuberculous disease, particularly Avhen seated in the abdomen and when involving the peritoneum ; (2) Hepatic disease, such as the cirrhosis of diabetes, protracted jaundice, chronic congestion, and lith- emia ("liver-spots ") ; (3) Pregnancy, and uterine disease, in which the patchy discolorations (chloasmata) appear principally upon the face; (4) Irritation of lice and dirt and exposure, as in the case of tramps and vagrants ("vagabond's disease"); (5) Tinea versicolor; (6) Melanotic sarcoma; (7) Exophthalmic goiter; (8) Post-eruptive staining of syphilitic eruptions; (9) The administration of silver nitrate for a long time (argyria); (10) Marked brunette complexions and racial admixture. When the pigmentation is scanty, of course the diagnosis is more difficult; but in all cases of pigmentation in which other causes may be excluded the progressive asthenia, unaccountable vomiting and diarrhea, easily compressible pulse, great bodily Aveakness, mental hebetude, and lumbar and epigastric pain render the diagnosis of morbus Addisonii, or melasma suprarenale, justifiable. It is to be remembered that the bronzing of the skin may precede as Avell as folloAV the constitutional symptoms. In the negro the diagnosis of this affection is extremely difficult, both on account of the naturally dark skin and because of the dark dis- colorations of the oral mucous membrane, found even in health in many individuals. Prognosis.—The course of Addison's disease is almost always chronic, though cases have been reported occasionally in Avhich the on- set has been sudden, with febrile phenomena and a comparatively acute course of a few months, or Aveeks even. Usually the disease lasts about one year, although some cases may continue over five or even ten years. Temporary remissions may be observed, but death is inevitable in by far the majority of instances. The termination is gradual, and by profound asthenia, or sometimes by coma, delirium, or convulsions (epileptiform). Treatment.—The hygienic and medicinal treatment must have vir- tually the same objects in vieAv as in the other grave cachectic diseases, and is both sustentative and symptomatic. As quiet a life as possible should be strictly enjoined, owing to the dangers of a sudden and fatal syn- copal attack. Rest in bed is necessary in moderate and advanced cases during a part of the day for the former and constantly for the latter. The diet should be restricted to light nutritive, concentrated, and easily assimilable food, and particularly to the nitrogenous or proteid sub- stances. An absolute milk diet may be necessary in some cases. Iron and arsenic may be administered in the anemic cases, and strychnin, guaiacol carbonate, phosphorus, and the nuclein preparations may also be given, along with bitter tonics. Bismuth and salol may be 454 DISEASES OF THE BLOOD AND THE DUCTLESS GLANDS. of great service in controlling the diarrhea that often occurs. The nausea and vomiting may be relieved by unfermented grape-juice, albumin-water, champagne, cracked ice, cerium oxalate, creasote, and the like. Electricity is often a valuable adjunct in the treatment of the muscular weakness and nervous exhaustion, and even in reducing the pigmentation. Loss of sexual desire and power Avere also restored in a case reported by Flint. It seems quite probable that the administration of the extract of suprarenal capsules Avill prove to be of considerable value in causing marked improvement, if not a permanent cure, in a certain percentage of cases. The therapeutic efficiency of this more or less physiological remedy is still to be proved, but several cases have been reported in which distinctly good results have been obtained. In one instance men- tioned by Osier, in which a glycerin extract of a pig's suprarenal was given at first in doses of half a glass three times a day, improvement Avas noted in the temperature, pulse, weight, and physical and mental vigor from the first week of the treatment, Avhich was continued for three months and a half. Eight months after the treatment Avas begun the patient appeared to be Avell and strong, and attended to business; the pigmentation, hoAvever, Avas not removed. In a recent case of my own this remedy produced like results. For the present, however, too positive a value should not be attributed to the suprarenal extract, owing to the meager data at hand. DISEASES OF THE THYROID GLAND. THYROIDITIS. Definition.—Acute inflammation of the thyroid gland. The gland may either have been previously healthy or the seat of a goitrous en- largement ; when inflammation attacks previously diseased or enlarged thyroid tissue the term strumitis is often used. Pathology.—The gland is swollen, boggy, and the seat either of a single large or of multiple small abscesses; the numerous large blood- vessels are engorged; and hemorrhages, thrombi, and areas of tissue- necrosis are frequently found. Sometimes evidences are seen of the burrowing of the abscess around the trachea and esophagus, and erosion of the laryngeal cartilages and perforation of the respiratory and digest- ive tubes have also been noted. Gangrene of the cervical tissues may follow an intense inflammation. Etiology.—Thyroiditis is seldom primary in origin. It may be caused by traumatism, but usually it is secondary to one of the infectious diseases, such as small-pox, typhus, typhoid fever, or malaria. Rheu- matism has also been given as a cause. Hemorrhages into the substance of a goiter, whether apoplectic or traumatic, may predispose to a strum- itis that may be excited by the introduction of streptococci by an unclean needle, etc. Repeated congestions of the thyroid or a simple acute congestion may also dispose to thyroiditis. Thus, abrupt suppression of the menses and sexual excitement may cause an acute goiter (con- gestion) ; the gland is also found engorged in many pregnant women, and is at such times more susceptible to inflammations. Symptoms.—There are fever, pain, swelling, and suppuration in GOITER. 455 one or the other lobe of the gland. Venous obstruction may be serious and give rise to vertigo, headache, cyanosis, and epistaxis ; and compres- sion of the windpipe by the great SAvelling may cause death before the abscess bursts. Resolution occurs infrequently, especially in the " strum- ous" cases. Indeed, the symptoms of a strumitis are usually more severe, owing to the greater size of the thyroid, a tendency to metas- tasis, and to the burroAving of pus into adjacent tissues leading to per- foration and rupture of the abscess into the trachea or esophagus. Diagnosis.—Thyroiditis must be differentiated from the laryngeal perichondritis that is also seen in the course of infectious diseases, as typhoid fever and small-pox. The higher and more median position and the smaller SAvelling of laryngo-chondritis are distinctive points. Prognosis.—The outcome is usually favorable in all cases in which spontaneous rupture occurs externally or when evacuation of the pus is effected. Strumitis runs a less favorable course for the reasons men- tioned above, and from the fact that the constitutional vitality in such cases is less resistant and the probability of cure is to that degree dimin- ished. Extension of the suppuration into the deeper tissues of the neck is of grave import. Treatment.—This is antiphlogistic and surgical. The pus must be evacuated freely, and sometimes tracheotomy or thyroidectomy may be necessary in order to save life. GOITER. (Bronchocele) Definition.—A chronic hypertrophy and hyperplasia of a portion or the whole of the thyroid gland. It is of obscure origin, involving one or more of the structural tissues, and is subject to various degen- erative changes. Pathology.—Several different varieties are described. In the simple hypertrophic or parenchymatous form there is a hyperplasia of all the original tissue-elements. The follicular form shows an increase of the true glandular elements alone. Fibrous goiter is that variety in Avhich the interstitial tissue or stroma is increased out of all proportion to the hyperplasia of the follicles, which are also involved in a much slighter degree. This variety of goiter may have an inflammatory origin (thyroiditis). In old cases marked sclerosis may be assumed. There is also a vascular variety, in which the blood-vessels are enormously dilated. More commonly the veins are affected; but in the so-called aneurysmal variety the arteries are chiefly involved. The intense venous variety of A7ascular goiter has been de- nominated "cancerous tumor of the thyroid," and the whole gland may in such cases be quite elastic and like spongy erectile tissue. Follicular hyperplasia is often associated with vascular enlargement. The special varieties of goiter due to degenerative changes are the cystic, amyloid, colloid, and calcareous, and of these the first named is the most common. It consists in the development in a large goiter of one or more large or small cysts filled with different kinds of fluid of varying consistency. Sometimes the liquid is colloid or mucinous in nature, and it may be chocolate-colored and contain the residue of hemor- 456 DISEASES OF THE BLOOD AND THE DUCTLESS GLANDS. rhages (cholesterin, fatty7 products, and albumin). Amyloid changes affect principally the vessels; colloid changes are also frequent, while calcareous infiltration is seen in very old fibrous goiters. Inflammation and suppuration of the goitrous gland may ensue. Etiology.—Goiter may occur anyavhere sporadically. Endemically and in its Avorst forms it occurs in the mountainous districts of Europe, Asia, Mexico, and South America, particularly in the Alps, Pyrenees, and Andes. It has also appeared in certain limestone regions, such as New England and Ontario, Canada, Avhere the habitual use of limestone- water for drinking purposes seems to induce the disease. Heredity undoubtedly plays a part in its causation, certain children having been born with goiter. Occasionally it has become epidemic in certain sec- tions of the goitrous districts in Europe where military garrisons have been stationed, thus indicating the possibility of some infectious influ- ence. Women are more liable to goiter than men, and it is more com- mon to find it after ten or tAventy years of age. It has been alleged that pregnancy also influences the development of this condition. Symptoms.—The enlarged thyroid is readily recognized and felt, though the patient may complain of nothing but the disfigurement, ex- cept when the tumor is of sufficient size to cause symptoms of compres- sion. The goiter develops very gradually, and may vary in dimensions from the merest perceptible enlargement to a growth that overhangs the chest and greatly hinders the movements of the head. It may or may not be uniform in its development, and is often more enlarged on the right side and in front than on the left side. It is not infrequently observed to increase in size Avith each succeeding pregnancy and during or after each menstrual flux. The tumor is painless, is not adherent to the overlying skin or to any of the neighboring bones, and rises and falls during the act of SAvalloAving, moving Avith the larynx. The veins covering it are swollen and prominent. It interferes with respiration oftener than Avith deglu- tition, causing dyspnea; alteration or loss of the voice may also ensue. Displacement and distortion of the trachea, the vessels, and other cer- vical tissues may be produced. Large pendulous growths usually cause less serious discomfort than the small encircling tumors that extend dowmvard into the thorax. Headache, somnolence, and marked cere- bral symptoms, such as tetany and convulsions, have been described as due to compression of the carotids. The general health or nutrition seldom fails unless inflammation and suppuration (strumitis) attack the goiter during the course of some in- fectious disease, as not infrequently happens, or in cases in which the thyroid function is abolished, leading to the profound nutritional and cerebral disorders of cretinism in children or myxedema in adults. Dettrich and Osier have each reported an instance of a goitrous growth affecting aberrant portions of thyroid found in the upper region of the pleural cavity, one on the right and one on the left side. Sudden death may ensue in a few cases, either from pressure on the vagi, from a severe intraglandular hemorrhage, or from a hemorrhage into the adjacent cellular tissues. Auscultation often reveals a loud blowing murmur, especially marked in the vascular bronchoceles. Palpation over the tumor often shows ENOPHTHALMIC GOITER. 457 the bossellated surface present in cystic goiter; fluctuation may also be detected in such cases, as Avell as over the abscess of a strumitis. Diagnosis.—Goiter is easily differentiated from other enlargements. The constant location and the character and course of growth of the bronchocele are distinctive. If both lobes of the thyroid are affected, making a symmetric swelling, the diagnosis is almost assured. Bron- chocele is not easily confounded with other cervical tumors, such as lymphadenoma, glandular tuberculosis, carcinoma or abscess of the thy- roid, or sebaceous cysts. A characteristic feature of tumors of the thy- roid is their vertical movement during the act of deglutition. Prognosis.—This is guardedly favorable as to life, but unfavorable as to cure. The course is chronic, but the possibility of a sudden fatal termination should be borne in mind. Treatment.—Prophylaxis should be practised in goitrous districts by the drinking of boiled Avater only, and removal to a non-goitrous region is advisable. The majority of drugs recommended for internal and ex- ternal use have been proved valueless, though in the parenchymatous and follicular forms potassium iodid by the mouth and the vigorous and methodic use of iodin over the tumor have been much lauded. Mer- curial ointment—the red or biniodid especially—has also been recom- mended for local application. Ergot or belladonna in progressively increasing doses may do good in vascular goiters. The younger and softer goiters may also be benefited by electrolysis, needles attached to the negative pole being inserted into the substance of the tumor while a large sponge or clay positive electrode is placed in the vicinity. In the older, fibrous, and degenerated goiters surgical treatment alone may be of service. Injections of iodin, tapping of cysts, incisions of the isthmus, and ligature of the thyroid arteries have been practised among the lesser operations. Thyroidectomy, or a partial extirpation of the thyroid, is the radical and final operation. Recently, the fresh, chopped thymus gland of the sheep, spread on bread, Avas given in 20 cases of follicular and parenchymatous goiter with gratifying results. The pressure-symptoms were relieved and a perceptible diminution in the size of the goiter Avas demonstrated by actual measurements. Complete recovery, in an anatomical sense, hoAv- ever, was realized in two cases only. EXOPHTHALMIC GOITER. (Graves''s Disease; Basedow's Disease.) Definition and Nature.—Although the view cannot be unreservedly accepted, exophthalmic goiter is probably of thyroid origin and is de- pendent upon an abnormal action (or over-action) of the thyroid gland; it is characterized clinically by tachycardia, tremors, enlarged thyroid, and exophthalmos. Among other leading theories the following may be briefly stated: (1) that it is due to disturbed innervation (Buschan); (2) that the seat of the disease resides in the medulla oblongata; (3) that it is an affection of the sympathetic nerves ; and (4) that it is a disease of the central nervous system associated with a chronic intoxication. The theory held by Mbbius, that exophthalmic goiter is attributable primarily to a disturbance of the function of the thyroid (" hyperthyroid- 458 DISEASES OF THE BLOOD AND THE DUCTLESS 'HANDS. ation "), a condition directly opposed to the lack of thyroid function as in myxedema, is amply supported by clinical evidence, the complex symp- tom-group of the former being directly antagonistic to that of the latter disease. Thyroid-feeding, moreover, while it sometimes causes paren- chymatous goiters to disappear rapidly, usually aggravates the symptoms of BasedoAv's disease. Regarding the pathologic changes in the thyroid little is known. Brissaud * found in 25 cases of various chronic diseases changes in the thyroid, and, although the glands in exophthalmic goiter showed no changes peculiar to that disease, yet quantitatively the lesions Avere ahvays such as to make " hyperthyroidation " possible. Etiology.—It is more common in women than men, and, although it has been met with at both extremes of life, it is seen usually in adults. The influence of heredity is undoubted, and several members of a family may suffer, persons that possess a sensitive nervous organization beinc especially prone to the disease. Among direct causes are emotional disturbance, worry, severe acute disease (noted in a recent case of my own), and prolonged mental or phys- ical strain. The disease may also occur as a secondary complication in the course of simple goiter, affections of the nose, and pregnancy; this variety, however, is to be distinguished from the primary or essential form. Symptoms.—The development of the characteristic symptoms is generally gradual, though it may rarely be rapid. In the so-called abor- tive form the symptoms arise somewhat rapidly, but early subside. In acute Basedow's disease the symptoms consist of an excessively rapid action of the heart, incessant vomiting, purging, and marked exophthalmos, Avith or without pronounced cerebral symptoms. J. H. Lloyd's case proved fatal after an illness of three days. In the chronic form heart-hurry is almost constantly a conspicuous early symptom, and not seldom have I found that it precedes for a long period of time the appearance of the remaining characteristic features. The pulse remains at or over 100 beats per minute, and upon unusual ex- ertion or excitement the heart's action becomes violent and irregular, the pulse even reaching 160 or over. Palpitation, often with breathlessness, is a distressing symptom. Cardiac Physical Signs.—Inspection reveals a forcible impulse that is not displaced, though late in the affection it may be much extended in superficial area. The carotids and the abdominal aorta beat more or less violently, and the capillaries and veins of the hands may also pulsate visibly. Palpation detects an increased force of the cardiac impulse. The area of percussion dulness may be somewhat increased, as hyper- trophy and secondary dilatation supervene. On auscultation, blowing murmurs over the heart and the great vessels, as well as an increased accentuation of the valvular sounds, may be audible. Protrusion of the eyeballs (exophthalmos) is usually present, and with rare exceptions follows the tachycardia. The degree of exophthalmos varies greatly from time to time in the same case—a fact that points to an increased amount of blood or lymph in the orbit as its cause. In ad- vanced cases permanent prominence of the balls may be attributable to augmentation of the orbital adipose tissue. On closing the eyes a rim of 1 Mercredi med., No. 34, 1895. EXOPHTHALMIC GOITER. 459 white is visible above and below the cornea, and Graefe's sign, immobility of the upper lid Avhen the eye is turned dowmvard, are two symptoms of great diagnostic importance. Mbbius has called attention to the inability to converge the eyes upon near objects, and Stellwag to an apparent sep- aration of the eyelids, due to spasm or retraction of the upper lid. The pupils and the vision are unaffected. Abnormalities are rarely presented by the optic nerves, and ulceration of the cornea may supervene. The retinal arteries pulsate. The thyroidean enlargement either accompanies or folloAvs the exoph- thalmos, and has for its cause the great dilatation of the vessels, and par- ticularly of the arteries. The enlargement is usually moderate and may be general or partial, the size of the gland exhibiting sudden variations, since it is dependent upon the circulatory disturbance. Inspection may also show visible pulsation ; palpation feels a thrill, and auscultation renders audible a double systolic murmur. The latter sign is probably present in most instances, though not constantly. Muscular tremors form an early symptom ; they are involuntary, and fine in character, numbering about eight to the second (Osier). The cha- racteristic features of neurasthenia appear and gradually increase in intensity. Mental disturbances, particularly- marked depression or great excitability, are common, and even mania (Avhich may prove speedily fatal) or melancholia may be observed. Muscular weakness, either local or general, is pronounced ; the patient becomes anemic and is at last ex- tremely emaciated. The temperature may at intervals be moderately ele- vated, and this symptom may be associated with profuse SAveatings. Among other cutaneous phenomena, though these are for the greater part occasional, are pigmentation (Avhich, in the case of a physician whom I recently saw suffering from Basedow's disease, Avas as pronounced as in typical Addison's disease), scleroderma, urticaria, and circumscribed solid edema. In the advanced stage malleolar edema sets in and may become general. A marked diminution in the cutaneous resistance to the elec- tric current has been noted by Charcot. Vomiting and purging may appear at different times and assume great gravity, and in some cases hemorrhages (epistaxis, hemoptysis, hematemesis) tend to supervene. Albuminuria and an increased amount of urine, with glycosuria, are among the commoner complications. Louise Bryson has maintained that diminution in the chest-expansion is a characteristic sign of exophthalmic goiter, and Patrick,1 who examined 40 cases, found that there was an average diminution, but believed it to be proportionate to the amount of general muscular weakness. Rarely a myxedematous condition is associ- ated ; probably the disease is also remotely related to scleroderma. Diagnosis.—The diagnosis of Graves's disease may be made when tachycardia or delirium cordis and fine, general muscular tremors are present. Exophthalmos and enlargement of the thyroid are often late- appearing symptoms, and are as often temporarily lacking even in fully- developed cases. Rarely, either or both of these signs may be permanently absent. On the other hand, in a feAv cases exophthalmos is the sole cha- racteristic feature for a long time, though it is eventually folloAved by an unmistakable symptom-group. Parenchymatous goiter presents a non- pulsating tumor, and hence is easily distinguishable from the thyroid 1 Deutsche med. Woch., Dec. 20, 1894. 460 DISEASES OF THE BLOOD AND THE DUCTLESS GLANDS. enlargement of Basedow's disease with its additional unequivocal symp. toms. Course and Prognosis.—The chronic form of the disease endures, as a rule, for a few years. A gradual subsidence of the cardinal symp. toms for a long period has been noted, and in such cases complete recov- ery may be claimed. In fully-developed cases the prognosis formerly was almost hopeless, but since the introduction of the operative treatment many cases have been greatly benefited, and others, though constituting a smaller number, have been entirely cured. Treatment.—This is (a) Hygienic, (b) Medicinal, and (c) Operative. (a) Hygienic.—The environment, both physical and mental, should be made as favorable as possible. A change of climate, and especially mod- erate elevation, in cases not too far advanced, bring about beneficial re- sults. Such elevation (3250 feet) produces a sedative effect upon the nervous state that reacts most favorably upon the circulatory organs, while the purity and tonic quality of the air have a general strengthening and restorative effect (Yeo). Among other promising measures maybe mentioned the wet-pack, methodical hydrotherapy with massage, and a continuous galvanic current. The electric treatment should be given a thorough trial over three or four months (Osier). The local use of an ice- bag to the precordium has acted admirably in reducing the heart-hurry in a few cases of my own. I have also observed favorable results from care- fully graduated physical exercise. Rest in bed for a few weeks at a time, at intervals, is often folloAved by improvement, though I have never seen complete cure folloAV this plan of treatment. (b) Medicinal Treatment.—This is probably secondary to the hygenic and operative measures. In two cases of my own, however, recovery fol- lowed the persistent use, for about six months, of the following prescrip- tion : B/. Extr. digitalis, gr. iv (0.259) ; Extr. ergotse (Squibb), 3ss (2.0); Strychninae sulph., gr. ss (0.032) ; Ferri arsenias, gr. ij (0.129). M. et ft. capsulae No. xxiv. Sig. One t. i. d. after meals. In 2 other cases (one, a trained nurse) the use of sodium salicylate (gr. x- 0.648—four times a day) was followed by almost total relief. L. Webster Fox also warmly advocates the latter remedy in this affection. Trachewsky. in Kocher's clinic, found that sodium glycerophosphate (gr. xx—1.296— three or four times a day), had the effect of diminishing the size of the enlarged thyroid glands, and Starrl has also found this remedy of great service in several cases. Other therapeutic agents that have been exten- sively employed, but with doubtful advantage, are aconite, veratrum viride, and belladonna. From all of the clinical testimony at hand I feel con- vinced that thyroid-feeding is contraindicated in the treatment of Basedow s disease, unless a myxedematous condition be associated, when it may prove efficient. From personal observation thyroid extract increases the circu- latory disturbance and excites unpleasant headache. (e) Operative Treatment.—Starr2 has collected 190 cases in which 1 Medical News, April 18, 1896. 2 Lot. cit. MYXEDEMA. 461 anme form of operation was performed. Of these, 74 are reported as com- Srtelv cured, many of them having been watched two to four years hire the result was published; 45 of the cases were improved, and n died immediately after operation. The symptoms preceding the fatal result are sudden hyperpyrexia, with rapid pulse, nervous dis- Ls sweating, cardiac failure, and collapse. The statistics of Kinni- rutt'and of Abram1 (particularly the latter) show less encouraging re- sults from operation, though they warrant the opinion that if cure is not obtained by medical measures, an operation should be undertaken. It is t0 be remembered that under the most favorable circumstances a com- pete cure will not be attained immediately, and frequently not for several Lars I am convinced that removal of the entire gland is not to be ad- vised' since myxedema will likely result. Whether partial removal—one- half to three-fourths of the gland—is to be effected, or mere ligation of the thyroid arteries, must be decided by the surgeon. MYXEDEMA. (Sporadic Cretinism.) Definition.—A general nutritional disorder, consequent upon atro- phy and loss of function of the thyroid gland, and characterized by a myxedematous infiltration of the subcutaneous tissue and a cretinoid PfljCD.6XlEL Three varieties occur, as follows : (1) True myxedema; (2) Cretinism (the absence of thyroid function—congenital, or lost during childhood); (3) Operative myxedema, due to total removal of the glands for surgical reasons or in experiments upon lower animals. Nature of Myxedema Proper of Adults.—Charcot, who gave the name of cachexie pachydermique to this disease, believed it to be of tropho- neurotic origin. Atrophy of the thyroid is pretty constantly present, and the gland may either be converted into a small fibrous mass or be entirely absent, so that the causal relation between myxedema and functional and structural alterations of the thyroid seems to be conclu- sive. Moreover, the therapeutic test of improvement under the admin- istration of thvroid extract sustains this view. It is probable that the active thyroid "supplies some essential secretion which maintains normal metabolism, though this product has not been isolated. Its existence being inferred, however, it has been called thyroidin.2 Others suggest that a substance called thyro-proteid is formed in excess in myxedema owing to a disturbance of glandular function, and this accumulating in the body produces the disease by a toxic action upon the metabolism. Etiology.—The thyroid was destroyed by actinomycosis in a case of myxedema reported recently. Myxedema may also be secondary to exophthalmic goiter, but it is then, as in the case of a simple acute g0lter' only a transient condition. Women are much more frequently aflected than men, and a neurotic condition may precede some cases. 1 he dis- ease may affect several members of a family, and hereditary transmission 1 American Year-Book of Medicine and Surgery, 1897. . „„ -fi_ 'The term "thyroidin" has also been given to a substance possessing specinc therapeutic activities that has been obtained from the thyroid gland ot the sneep oy Baumann. 462 DISEASES OF THE BLOOD AND THE DUCTLESS GLANDS. through the mother has been observed. Pregnancy' may cause a disap- pearance of the myxedematous symptoms (Osier). Symptoms.—The myxedematous condition is most plainlv noted in the face, the skin being SAvollen, but inelastic, rough, dry, and firm. The lines of facial expression are obliterated, and the features are broad, coarse, immobile, and bulky. The physiognomy is stupid, dull, and phlegmatic, and simulates imbecility. The hair falls out, owinc to deficient nutrition, and the general bulk of the body is markedly in- creased. Pressure does not produce pitting, as in true edema. Accord- ing to Ord, the local tumefaction of the skin and subcutaneous tissue is most frequently prominent in the supraclavicular regions. The mucous membranes are also infiltrated, and the teeth may become loosened. The tongue, lips, and nose are thickened, and the voice is monotonous, slow, and has a "leathery tone," " with curious nasal explosions at short in- tervals during speaking." Bodily movements are sIoav, and the gait is heavy and uncertain on account of disturbed co-ordination. Mental perception and thought are also sIoav, and the memory is defective and sIoav to respond. Not infrequently there may be considerable irrita- bility, or hebetude alternating Avith sudden excitability. The patient may become suspicious, and later is subject to delusions and halluci- nations ; or the apathy may pass into a melancholia, ending at last in dementia. Ord mentions ''the aggravation of all symptoms during low climatic temperatures; " and " among the minor or accessory signs may be quoted abnormal subjective sensation, belonging particularly to taste and smell; occipital headache; marked alterations of temper; and a curious persistence of thought and action, overriding all attempts at interruption by friends or observers." The temperature in myxedema is usually either normal or subnormal. Albumin and sugar are occasionally7 found in the urine, but the quantity of nitrogen excreted is small, owing to the diminished metabolism of proteids. Hemorrhages from the nose, gums, and boAvels sometimes occur. Ascites also may be present in some cases, and may simulate ovarian tumor. The thyroid is not palpable, partly because of its atrophy, and partly because of the thickened myxedematous tissues of the neck. The diagnosis is not difficult if one bears in mind the character- istic manifestations described above. Mxedema could hardly be mistaken for acute or chronic nephritis in the absence of pitting, etc., as some have supposed. The prognosis is guardedly favorable in a majority of the cases since the introduction in the treatment of thyroid-feeding. The course of the disease is sIoav and progressive, hoAvever, often lasting from five to fifteen years, and death from intercurrent disease is not uncommon. Treatment.—Until the advent of thyroid-feeding the treatment of myxedema Avas palliative, and usually unsuccessful. A warm and equable climate is very desirable, owing to the sub- normal temperature from which the patients frequently suffer. The various Avarm baths—as the Turkish, Russian, and electric—should be employed for the same reason. Pilocarpin has been recommended, and strychnin and arsenic have been administered for their tonic effect. MYXEDEMA. 463 Since the brilliant results obtained by Murray, hoAvever, the internal use of the thyroid gland of sheep or calves has come into a Avell- deserved favor in the treatment of all cases of myxedema, Avhether of the so-called true form, of sporadic cretinism, or of the cachexia strumipriva. The gland may be given raAv or cooked, in the form of the glycerin extract, or in the dried and poAvdered extract; the last named is sometimes put into tabloid form. If cooked, the gland should be only partially "done." The fresh thyroid is minced and often spread on bread, and from one quarter to half a gland may be taken daily. The glycerin extract is readily made. " Several dozens of thyroids of young sheep or calves are carefully separated from the connective tissue, cut into small pieces about the size of a bean, and then put into a jar and covered Avith glycerin of the best quality7, alloAving 2 c.cm. of glycerin for each lobe of the thyroid used. The mixture is permitted to stand for twenty-four or thirty-six hours, and is then squeezed through a cloth, so. as to get out as much liquid as possible. Of this, 2 c.cm., corresponding to about half a gland, may be given at a dose. If used for hypodermic injection, to a dram (4.0) of the glycerin extract is added half a dram (2.0) of a 1 per cent, solution of carbolic acid in distilled water, of which mixture from 10 to 15 minims (0.66-1.0) may be in- jected three or four times a week."1 It is safest—for reasons that will be pointed out beloAv—to begin with quite small doses, and gradually increase, especially if there is much gastric irritation. Not more than 5 minims (0.333) of the glycerin extract should be given at the start. This dose may be increased grad- ually until 15 or 20 minims (1.0-1.33) are taken three times daily. From 3 to 5 grains (0.194-0.324) of the powdered gland or tabloid form will be a safe commencing dose in adult myxedema: a caution, however, is necessary regarding the various manufactured preparations of the thyroid gland, some of which are impure and even dangerous, owing to the careless handling or fraudulent substitution in order to meet the demand for thyroid extracts on trial in other affections (as obesity and psoriasis). The toleration of thyroid-feeding does not depend upon the volume, but upon the functional activity, of the gland, and this fact, together with the evidences of toxic action reported in some instances of the administration of thyroids to a maximum degree, make it important to urge again—as intimated above—the necessity of small dosage at the beginning of treatment, the most careful and judicious increase in the quantity given, and the closest observation of symptoms indicative of hyperthyroidization. The additional fact of an occasional cumulative action should also be emphasized. Should vomiting, renal pain, tachy- cardia, suffusion of the face, syncope, vertigo, or marked headache supervene, the remedy should be stopped at once. Epileptiform con- vulsions have also occurred. The treatment may be resumed again cautiously, alternating Avith intervals of cessation. Good results are obtained usually Avithin a month, though it is probable that even after all the symptoms have subsided the treatment may have to be continued off and on if the thyroid gland seems to be permanently atrophied. 1 Osier in the Amer. Text-book of Therapeutics, pp. 926, 927. 464 DISEASES OF THE BLOOD AND THE DUCTLESS GLANDS. Cretinism, Sporadic and Endemic.—Here there is a congenital atrophy or absence of the thyroid gland, or an enlargement by the growth of fibrous tissue at the expense of the glandular elements. Cretinism may also develop in early infancy. The patients are off en the children of parents noted for violent emotion and having various neuroses and goiter, and syphilis has also been supposed to have a causative influence. Congenital myxedema is quite common only in regions where goiter is endemic, and hence it is rare in America. A marked sporadic case has, however, been in the Philadelphia Hospital for many years. Symptoms.—Cretins are dAvarfs Avith large heads and faces, thick lips, thick protruding tongues, broad bodies and members, and promi- nent abdomens. The subcutaneous tissues are myxedematous. Umbili- cal hernia has been noted. The mental condition is that of idiocy, and physical growth is retarded and sIoav. Speech is unintelligible or nearly so, and the voice harsh. Walking may never be accomplished, and is always slowly developed. There is anemia, the blood being of a fetal type. Rheumatic symptoms sometimes occur. • Prognosis.—The disease is progressive until about the fifteenth year in those cases developing during early childhood. Congenital cases usually die shortly after birth. At the tAventieth or thirtieth year " the mental and physical characters are those of childhood." Treatment.—Thyroid-feeding has been followed by beneficial results, the checked growth having recommenced and the cretinic aspect having been largely lost. Operative Myxedema, or Cachexia Strumipriva.—Extirpation of the thyroid for surgical reasons has given rise to the gradual production of symptoms and conditions identical either Avith true myxedema or with the cretinoid state. Partial removal of the gland is not followed by cachexia strumipriva, nor is complete thyroidectomy when accessory glands are present elsewhere. The administration of raw or broiled thyroids, or of their various extracts or preparations, must also be employed in this form of myx- edema, and should be continued throughout the rest of the patient's life, perhaps with intervals of withdrawal of the feeding until the im- provement gained begins to lapse. PART IV. DISEASES OF THE RESPIRATORY SYSTEM. I. DISEASES OF THE NOSE. ACUTE RHINITIS. (Acute Nasal Catarrh; Acute Coryza) Definition.—An acute catarrh of the Schneiderian membrane, some- times tending to involve the adjacent sinuses and passages. It is known to the laity as " cold in the head." Etiology.—Its most conspicuous cause is exposure to draughts of air and to the influence of the atmospheric vicissitudes that are espe- cially prevalent during the winter and spring seasons. It often results from the inhalation of irritants (physical, chemical, or biological). It may also display epidemic behavior, and this fact seems to point strongly to its microbic origin. Hence local disturbances of the circulation due to exposure are to be regarded as the accidental means of preparing the soil for bacterial invasion. Acute rhinitis may be also secondary to, or propagated from, inflammations of the faucial mucosa by contiguity. Symptoms.—Sensations of chilliness, succeeded by feverishness (the temperature reaching 100° to 101° F.; 37.7°-38.3° C), frequent sneezing, headache, and a feeling of general ill-health are among the prominent features that attend the development of coryza. Pains in the extremities and back tend to appear only in severe cases. The pulse is frequent, the skin dry and unduly Avarm, thirst is increased, while the appetite is impaired, and constipation often attends. The nasal mucosa is swollen, and thus interferes both Avith the nasal respiration and the senses of smell and taste ; its color is deepened, its surface covered at first with opaque mucus, and later Avith a muco-purulent secretion. Among early symptoms is the discharge of a Avatery, irritating secretion from the nares and a maceration of the epidermis, with resulting abrasions. On account of the SAvelling of the mucosa of the lacrymal ducts the tears noAv down over the cheeks. Adjacent mucous surfaces then become in- volved, giving rise to conjunctivitis, catarrhal pharyngitis, laryngitis, and finally, in the severer types, bronchitis. Naso-labial herpes is not uncommon. As the affection progresses the secretion becomes more abundant and turbid and more or less pyoid. The symptoms due to extension of the catarrhal inflammation vary with the organs or struc- tures involved. The disease runs its course Avithin five or six days, but 30 465 466 DISEASES OF THE RESPIRATORY SYSTEM. the nasal discharge, Avhich gradually diminishes, usually persists for a few days longer. Diagnosis.—In the presence of the above-mentioned symptoms the disease is readily recognized. In Avell-markcd cases, hoAvever, the pos- sibility that an infectious disease may be developing, the beginning of Avhich is characterized by nasal catarrh (measles, influenza, etc.), is to be recollected. Prognosis.—Except in neglected cases, Avhich result in bronchitis, and occur at one or other extreme of life, the disease is free from dan- ger. The nursing infant may have to be fed Avith a spoon temporarily. Treatment.—At the outset a purge, consisting of calomel (gr. ij— 0.129), or a pill of blue mass (gr. v—0.324) at night, followed by a Seidlitz poAvder in the morning, is advisable. To children a dose of castor oil may be given. The early administration of a diaphoretic, such as Dover's poAvder (gr. v-x—0.324-0.648) at night may arrest the complaint, and quinin in a large dose (gr. xij-xv—0.777-0.972) at night may cut short the course of the disease. When the above-mentioned abortive measures fail, the folioAving tablet produces good results: B/. Quinin. sulphat., gr. ijss (0.162); Extr. belladonnse fl., TTIjss (0.099); Sodii salicylatis, gr. xxx (1.944); Camphorae, gr. ijss (0.162). M. et ft. tablet No. x. Sig. One tablet every hour or tAvo. For the fever aconite may be employed, and, if the throat be involved, bryonia may be given in conjunction. Local Treatment.—This aims at soothing as Avell as at reducing the swelling of the Schneiderian membrane. The compound tincture of benzoin forms a soothing inhalation (^ij to a pint—H.O per half liter— of water) when raised nearly to the boiling-point; the vapor is inhaled for ten or fifteen minutes at a time. With a vieAv to reducing the SAvell- ing a solution of cocain (strength 2 to 4 per cent.) may be temporarily used; Mackenzie recommends this admirable combination : Menthol, gr. v (0.324); Pinol ITlv (0.324); Benzoinol, f^j (32.0). In severe cases the patient should be kept in-doors and in an atmosphere of even temperature. CHRONIC RHINITIS. (Chronic Nasal Catarrh.) Two forms are recognized, the hypertrophic and atrophic, and these, though, as a rule, occurring separately, may be found in combination. Pathology.—The morbid changes in hypertrophic rhinitis consist in an enlargement of the loAver turbinated processes, together with red- ness and swelling of the nasal mucosa that may be general or limited CHRONIC RHINITIS. 467 either to the anterior or posterior nares. As the disease progresses the thickening of the membrane increases, until it finally encroaches upon the nasal chambers at every point. In addition to the nasal obstruction there is a hypersecretion of mucus. Opposite changes occur in atrophic rhinitis, such as thinning or atrophy of all the structures, Avith enlarge- ment of the nasal cavities. The nasal mucosa is coated Avith thick, yel- loAvish-green, decomposing crusts, Avhich emit a characteristically fetid odor, and the frontal, ethmoid, or other accessory sinuses may, by an extension of the inflammation from the nasal chambers, be invaded by mucopurulent inflammation. The atrophic process does not affect the glandular structures of the upper third of the nose, and this fact ex- plains the most unpleasant feature of the affection—namely, the hor- rible secretion. Etiology.—Frequently occurring attacks of acute rhinitis may pro- duce the chronic form, and sy7philis and, less commonly, tuberculosis are also among its causes. Abell regards atrophic rhinitis as infectious, claiming that the cause is the bacillus mucosis ozena?, Avhich resembles closely the pneumobacillus, but is distinguishable from it. Symptoms.—(a) In the hypertrophic form nasal respiration is im- peded, OAving to the hypertrophy of the turbinated bodies. The sense of smell is impaired, and there is a discharge of secretion from the nares, particularly the posterior, inducing "haAvking." The diag- nosis is set at rest by a rhino- scopic inspection of the parts. While this is a common affec- tion everyAvhere. it is Avellnigh universal in this country. (b) In chronic atrophic ca- tarrh there is some degree of nasal obstruction, occasioned by the presence of the thick crust, but the most conspicuous symp- tom is the disgusting odor, Avhich makes the patient re- pellent in Society. The sense Fig. 41.— Apparatus for cleansing the nasal passages P n ■ ii- » n, in chronic rhinitis. of smell is lacking. After cleansing the membrane the rhinoscope will show the nasal chambers to be unduly capacious. Treatment.—(1) Chronic Hypertrophic Rhinitis.—The treatment is divisible into general and local. The physician should procure an envi- ronment for his charge most favorable for promoting the general nutrition, which is often below the health-standard. The selection of a suitable climate, then, forms an important part of the management, and a resi- dence in a locality7 that possesses a mild, equable, comparatively dry and pure atmosphere is to be advised and encouraged. Various tonics may then be demanded by the general condition of the patient, and strychnin and electricity are useful in restoring the loss of power in the contractile elements of the intercellular Avails. Local measures are employed to facilitate thorough cleanliness and 1 Zeit. f. Hyg. u. Infektionskrank., Bd. xxi. H. 1. 468 DISEASES OF THE RESPIRATORY SYSTEM. disinfection of the affected parts, though in incipient and mild cases energetic treatment is scarcely needful. The best method of cleansing the nasal passages is by means of the coarse spray (Fig. 41). The apparatus of Lefferts is also to be employed Avhen the secretion is in- spissated or tightly adherent. An excellent combination for use in this manner is the following: B/. Sodii biborat., Sodii bicarb., da. 3j (4.0); Acid, carbolici, gr. viij (0.518); Listerin., l\ (32.0); Aquae destillat., q. s. ad giv (128.0).—M. Sig. Use as a spray three times daily. It is often desirable to use warm or even hot liquids, in which case the application is made by the use of the anterior and posterior nasal syringe. Powders are harmful, and, as the nasal douche is dangerous in unskilled hands, these should both be abandoned. In hypertrophic rhinitis the obstruction to nasal breathing is to be removed, and to accomplish this caustics (chromic, glacial acetic, and nitric acids) are used, of Avhich the most efficacious is chromic acid. This should be applied by means of a pointed glass rod, the application being followed by a sloughing away of the diseased tissues. Among other modes of removing the nasal obstruction that may be mentioned are the galvano-cautery, the thermo-cautery, and the cold-wire snare; these modes, hoAvever, are practised chiefly by the specialist. (2) In atrophic rhinitis a cure is to be despaired of, but the patient can be rendered free from the offensive discharge, and hence to a great degree comfortable. As this is often but an advanced stage of hyper- trophic nasal catarrh, the general treatment is similarly directed: it is therefore Avell to overcome, as far as possible, by a mental stimulus, the depressed mental state due to the fetor. If the diathesis be tuberculous, cod-liver oil, iron, arsenic, and strychnin, together Avith a generous diet, are to be advised. If syphilis is associated, appropriate measures must be instituted. Moreover, since a subject of atrophic rhinitis is a fertile source of atmospheric contamination, his living and sleeping apartments must be highly ventilated. Local Measures.—An antiseptic spray of Seller's or Dobell's solu- tion, and oiling the nasal cavities, are measures to be first tried. If they prove non-efficacious, the crusts may then be removed Avith a cotton applicator coated with a solution of hydrogen peroxid. We may then use a spray of liquid albolene and menthol; this serves not only to lubricate, but to supply moisture, both of which are important thera- peutic indications. Small ulcerations occur in this affection and induce oft-repeated epistaxis ; consequently, an attempt should be made to heal the latter and to obtain an even, moist surface. To accomplish this the method of Clarence C. Rice may be folloAved—i. e. to rub the ulcer- ations thoroughly by means of a cotton-carrier with a small hard pledget of cotton moistened with listerin or borolyptol for a few sec- onds at a time. These antiseptic frictions are made at intervals of two or three days for two or three weeks. AUTUMNAL CATARRH. 469 AUTUMNAL CATARRH. (Hag Asthma ; Hay Fecer.) Bv this term is meant a form of asthma that seems to be dependent upon an idiosyncrasy. It occurs exclusively during the Avarm season, and is caused by the odorous principles given off from certain plants (the pollen of the Anthoxanthum odoratum, of the rose, etc.), by inor- ganic dusts of various sorts, and, occasionally, by psychical influences. In some instances it appears to arise without obvious exposure to a spe- cial irritant. Predisposing Factors.—The male sex suffers more frequently than the female. Age has a slight though decisive influence, more than 33 per cent, of the cases occurring before the twentieth year. The inhab- itants of cities are more liable than those in rural districts, though the air of agricultural regions intensifies the condition. Perfect immunity is enjoyed by the dAvellers in certain climates—chiefly mountainous and marine. Symptoms.—The symptoms are (a) local and (b) general. (a) Local.—Hay fever has an abrupt onset, and the attacks return annually at or about the same time. The invasion is marked by pro- nounced coryzal symptoms, with much sneezing, stoppage of the nasal passages, copious rhinorrhea, the discharge being thin and watery as a rule, and rarely mucopurulent. Suffusion of the eyes, with itching of the lids and free lacrymation are constant features; the decided itch- ing sensation of the palate and pharynx is also at times a very distress- ing symptom. The sense of smell may be lost, and taste and hearing are often impaired. The course as regards the local symptoms is marked by alternate amelioration and aggravation of the symptoms, the exacerbations being due to exposure to the open air, especially in changeable weather. Later the catarrhal process invades the bronchi, and cough and asthmatic seizures appear, these often becoming very distressing. (b) General disturbances are varied, and comprise subjective sensa- tions, such as anorexia, insomnia, lassitude, and chilliness alternating Avith slight feverishness. The course is usually run in from four to six weeks, and cases that occur in the early autumn are usually terminated speedily by the occur- rence of a decided frost. Diagnosis.—The recognition of hay asthma is unattended Avith difficulty, provided that such facts as the time of their occurrence and their annual periodicity are carefully noted. Prognosis.—This is favorable both as to life and length of days, though a permanent cure is among the rarest events in medicine unless permanent removal from the influence of the specific causes can be effected. Treatment.—Whenever possible the patient should travel till he finds a locality in Avhich he ceases to suffer, and subsequently he should there spend the period of annual attack, and by these means escape the exciting causes. The Adirondacks and White Mountains usually bestow immunity. If the patient cannot make the necessary change, the gen- 470 DISEASES OF THE RESPIRATORY SYSTEM. eral nutrition is to be improved by the use of such measures as phos- phorus, strychnin, quinin, and arsenic. Much is to be gained, more- over, by hygienic means, especially a\Toidance of physical and mental overwork and the adoption of a proper mode of life.. The local symptoms demand the topical application of various agents to the nasal chambers. A solution of cocain hydrochlorate (1 per cent.), applied directly to the nasal passages by means of a probe, around the end of Avhich is loosely Avrapped a little absorbent cotton, affords tem- porary relief, and the period of palliation may be very much prolonged by using a 4 per cent, solution of antipyrin immediately after the cocain solution (Gleason). These applications should be made two or three times daily, according to the severity of the individual case. The local symptoms are also greatly benefited by the internal use of atropin, Avhich allays the irritability of the mucous membrane involved and diminishes the rhinorrhea, thus indirectly mitigating the constitutional disturbances and sometimes directly relieving the asthmatic paroxysms. When given internally the dose should not exceed gr. 3-^5- (0.0002), to be repeated every hour till dryness of the throat appears. My own best results have been derived from the hypodermic use of this drug (gr. -^—0.0003) at intervals of three to four hours till the desired effect is produced. Thorough destruction of the vessels and sinuses is also advised (Osier). EPISTAXIS. (Nose-bleed) Etiology.—The causes of nose-bleed are various, and a convenient grouping is the folloAving : (a) Affections of the nasal mucosa (e. g. ulcer, polypi, intense hyperemia). (b) Injuries, either external, as from a bloAv, or internal, as from plugging Avith a foreign body, nose-picking, etc. In this category may also be included epistaxis due to fracture at the base of the skull, (c) Acute infectious fevers, particularly typhoid (at the onset) and influenza, (d) Chronic affections, such as pernicious anemia, leukemia, arteriosclerosis (Avith Avhich cardiac hypertrophy is associated); also the hemorrhagic diathesis or hemophilia, (e) Vica- rious menstruation. (/) Rarefaction of the air. (g) Plethora; here may be mentioned cerebro-congestion Avith intense headache, (h) Severe over-exertion. Symptoms.—Except when due to traumatism the blood usually drops sloAvly from one and occasionally from both nostrils. Rarely, the blood may Aoav as a continuous stream or the nares may present a pro- jecting coagulum. The blood may also gravitate into the pharynx and be coughed up, or it may be sAvalloAved* and vomited. A rhinoscopic examination often reveals the source in cases in which a previous diag- nosis of hemoptysis or hematemesis has been made. The immediate results of nose-bleed are Aveakness and a moderate anemia, but these are not prolonged unless the epistaxis be oft re- peated. Cases arising from fracture at the base of the skull will gen- erally prove fatal. DISEASES OF THE LARYNX. 471 Treatment.—A careful search for a local cause is especially de- manded in cases in Avhich there are frequently recurring attacks. In most cases a spontaneous arrest occurs, but if not, a resort to simple household measures, such as the application of ice to the nose or to the back of the neck, holding the hands up, or the injection of very cold or very hot water into the nares, are to be encouraged. Various astrin- gents (tannic acid, acetate of lead, alum, zinc) may be employed, and a saturated solution of antipyrin is also highly praised. When an ulcerated bleeding point can be reached, there may be applied to it a solution of chromic acid or it may be cauterized by solid silver nitrate. Prolonged pressure applied upon the facial artery as it passes over the inferior maxilla may be efficacious. The late D. Hayes Agnew7 success- fully employed a bougie made of a long strip of the rind of bacon, lt passing it through the nostril and alloAving it to stay there some time." I have little confidence in internal astringent remedies, such as ergot, acetate of lead, or gallic acid, as a means of arresting nose-bleed. The oil of origanum, administered in large doses, has seemed to do good in a feAv of my own cases, but when the.epistaxis tends to prove obsti- nate, the posterior nares should be plugged. II. DISEASES OF THE LARYNX. ACUTE CATARRHAL LARYNGITIS. (Acute Endolaryngitis) Definition.—An acute catarrhal inflammation of the larynx, cha- racterized by cough, hoarseness, and painful deglutition. Pathology.—The anatomic changes present during life are all lacking post mortem. The laryngoscopic appearances will be given among the Clinical Symptoms. Etiology.—Acute laryngitis may be a primary affection—and par- ticularly laryiigitis sicca (Molinie)—but oftener it is associated Avith and secondary to catarrh of the nose and nasopharynx. Wright attributes laryngitis sicca to the coccus of LbAvenburg. Catarrhal laryngitis has for its chief direct causes traumatism, ex- posure to cold and dampness, the inhalation of irritating vapors or gases, rheumatism (rarely), and the corrosive effect of certain poisons and hot fluids. A certain degree of predisposition is engendered by immoderate smoking, particularly by the cigaret-habit, and by the use of concentrated alcoholic drinks. These agencies induce hyperemia of the laryngeal mucosa, which is easily converted into active inflammation. Acute laryngitis is often associated with acute infectious diseases. Symptoms.—There* are tAvo conspicuous symptoms—alteration in the voice (hoarseness) and cough. At first there is merely a huskiness of the voice, but later there may be pronounced hoarseness or even com- plete aphonia. The cough is dry and characteristically painful until secretion is free. In the early stages the patient complains of sensa- 472 DISEASES OF THE RESPIRATORY SYSTEM. tions of tickling or the presence of some small object in the larynx, causing a frequent desire to clear the throat. In severe instances deg- lutition is painful. Edema of the larynx may tend to supervene and cause intense dyspnea, with a feeling of distressing oppression. There is, as a rule, a slightly elevated temperature. Fig. 42.—Method of making a laryngoscopic examination. The patient is placed in front of the operator, on an arm-chair, with the back of the chair high enough to afford his head a comfortable rest, and with the source of the light over the right shoulder. The operator then adjusts the head-mirror (the fixed apparatus), warms the throat- mirror over a light sufficiently to prevent the moisture of the breath from being deposited upon it, and touches the hand with the mirror before passing it into the mouth, so as not to use it too hot. The patient's tongue is then protruded, and by means of a napkin is seized between the thumb and the fore-finger and drawn well forward to lay the fauces open to observation. The throat-mirror is then held in the right hand in the same way as one holds a pen. " Finally, it is introduced into the mouth, its handle being inclined downward and outward, its base being parallel with the dorsum of the tongue; it is then passed backward without altering this relation until the edge of the mirror nearly touches the soft palate, the shaft of the mirror in this move- ment striking the angle of the mouth as a resting-place and fulcrum. The subsequent movement consists in turning the mirror by twisting its shaft between the fingers until it is inclined at an angle of 45 degrees to the line of vision ; then it is carried backward and downward until the uvula rests upon its posterior surface, when it is lifted boldly upward and backward until its lower edge comes entirely into view again and rests firmly against the posterior wall of the pha- rynx. The patient should then be directed to sound in a somewhat high key ' a,' which lifts the larynx and at the same time the epiglottis, and exposes and brings into view the laryngeal cavity " (Bosworth). It is important that the mirror itself should be kept in the median line, with its plane always at right angles with the field of vision, as shown in the illustration. In making a laryngoscopic examination we note any abnormalities of color-appearance (the natural being a rose-pinkish tint), of the outline of the different parts, and the deviations from the symmetrical movements of cords, if any, etc. The laryngeal mirror brings to view a characteristic picture—a swollen, tumefied, and reddened mucosa. These changes affect the vocal cords (whose pearly-white appearance is now lacking) and the ary- epiglottidean folds. It is usual to note also redness and swelling of the epiglottis above and of the trachea beloAv. After secretion has occurred a mucoid covering in streaks or patches is noticeable. CHR ONIC LAR YNGITIS. 473 Diagnosis.—This is easy in the presence of marked hoarseness, dry cough, and the image afforded by the laryngeal mirror (Fig. 42). In very early life the larynx cannot be successfully examined ; still, laryngis- mus stridulus (oAving to the absence of fever, coryza, etc.) could hardly be mistaken, as has been supposed, for acute catarrhal laryngitis. The same is true of membranous laryngitis, if we bear in mind the charac- teristic local features and the more intense constitutional disturbances of the affection. Treatment.—The physician must enjoin against the use of the voice. The very young and the aged should, in severe or even moderate cases, be kept in bed, and should occupy a single apartment in Avhich the at- mosphere is uniformly moist and Avarm, the temperature ranging from 75° to 80° F. (23.8°-26.6° C). Inhalations of moist air or steam are of great service, and I have long been in the habit of recommending the folloAving simple apparatus and method of carrying out this mode of treatment: An ordinary tin cup, small pitcher, or other vessel is filled Avith boiling Avater to which 1 or 2 drams (4.0-8.0) of the com- pound tincture of benzoin have been added; the steam is then collected by inverting over the vessel an ordinary funnel. The patient is alloAved to inhale the steam by placing the mouth over the narrow neck of the funnel above, or a piece of rubber tubing may be attached to the end of the funnel that is uppermost. Steam atomizers admirably meet the necessities of the case; and in the case of children the vapor of benzoin, eucalyptol, and other equally sedative and stimulating substances may be diffused in the air of the sick-room. Concentrated solutions or insufflations of powders are not Avithout harmful influence, and neither the cotton-carrier nor the mop should be allowed to enter the larynx in this affection. The external application of the ice-bag or cold compress tends to mitigate the inflam- matory process and to obviate spasm. The general treatment differs Avith the special stages of the com- plaint. If the case is seen early, a full dose of quinin (gr. xij-xvj— 0.777-1.036) may serve to successfully abort the attack, and, in con- junction Dover's poAvder (gr. v-x—0.324-0.648) may be prescribed. Codein sulphate may be given at prolonged intervals during the attack, and frequently at night, to allay cough ; this remedy may be combined with ipecac, aconite, and liquor ammonii acetatis to facilitate secretion and render the cough humid. If Ave except the abortive measures, the constitutional is wholly inferior to the topical treatment of this variety, though the existence of any particular diathesis may require special in- ternal remedies. CHRONIC LARYNGITIS. (Chronic Endolaryngitis) Pathology.—The laryngeal mucosa is thickened and someAvhat reddened, and erosions amounting to superficial ulcerations are sometimes seen, though they are infrequent. A prominence of the mucous glands, especially of the ventricles and epiglottis, is noticeable. Fine villous 474 DISEASES OF THE RESPIRATORY SYSTEM. projections from, and nodular sAvellings in, the vocal cords are among the rarer morbid changes. Etiology.—Oft-repeated acute attacks frequently cause chronic laryngitis, and the long-continued use of the voice (as in public speak- ing or singing), the inhalation of an atmosphere laden Avith mildly irri- tating impurities (tobacco smoke, etc.), and an immoderate indulgence in alcoholic stimulants, respectively or unitedly, predispose to, if they do not excite, the disorder. Symptoms.—As in the acute form, hoarseness and cough are the tAvo especially prominent symptoms. The former may be so slight as to present merely a rough tone, or it may involve an almost total loss of voice. The cough shoAvs similar variations in severity, sometimes con- sisting of a short hack, and again occurring in spasmodic and ringing paroxysms, due to a sense of tickling in the larynx. There may be a small amount of mucous or muco-purulent expectoration, but for pro- longed periods the cough may be dry and ineffectual. Local pain and discomfort sometimes supervene, and are excited generally by attempts at speaking or singing—events that aggravate all the other symptoms. To complete the diagnosis, the laryngeal mirror is required to show a swollen and slightly red membrane, with a distention of the mucous glands in the immediate vicinity of the epiglottis and ventricles, and occasionally superficial erosions. Prognosis.—This is unpromising as to complete recovery, although it presents no grave dangers. It is incurable in those instances in Avhich the causal influences cannot be removed, and in all cases in Avhich the patient fails to lend hearty co-operation. Treatment.—This is (a) hygienic and (b) medicinal, (a) The sani- tary measures embrace preventives that are directed to the removal of all the etiologic factors, whether merely predisposing or exciting. The voice demands rest and the prohibition of smoking and the use of alco- holics in excess, and the patient must also avoid the close, contaminated air of the croAvded hall, theatre, and like places. In addition, a tonic regimen, with a view to energizing the nutritive processes, is to be en- couraged. In many instances the environment is best arranged with reference to the commonly associated conditions—especially the morbid processes in the nasal and naso-pharyngeal cavities. u A sea-voyage or residence at the sea-shore is, in the large majority of instances, pro- ductive of good, and the effects of surf-bathing are often magic" (Mackenzie). My OAvn practice has been to send subjects of chronic laryngitis to pine-forest resorts at low elevations that afford a pure, equable, and somewhat stimulating atmosphere, and I have found that in many cases the selection of a proper climate constitutes the most im- portant part of the treatment, (b) The medicinal treatment is both local and general. The latter should include creasote, cod-liver oil, and other tonics. Expectorants are of little if any value. The local meas- ures, however, are important. Moderate exposure of the neck and daily ablution Avith cold Avater are to be advised, and attention to the nose and naso-pharyngeal cavity is of prime importance.1 A long list of applications to the larynx from Avithin, including local astringents, disinfectants, and alcoholics, might be enumerated. Of 1 J. C. Wilson's American Text-book of Applied Therapeutics, p. 791. SPASMODIC LARYNGITIS. 475 astringent solutions, hoAvever, the best are tannic acid (1-2 per cent.) or alum (.5-1 per cent.) and zinc sulphate (3-5 per cent.). These may be sprayed into the larynx by means of a compressed-air machine Avith spraying-tubes, although all of the different kinds of inhaling apparatus more commonly used will ansAver the purpose. If the ordinary hand- atomizer be used, the patient should be taught to draw the vapor into the larynx by gentle and frequent acts of respiration. Disinfectants, such as creasote, potassium chlorate (the latter if ulcerations be present) in solutions of suitable strength, may be used in like manner. I can confidently advise as useful alteratives both iodin and silver nitrate, commencing with a Aveak solution of the latter (gr. v-3j—0.324-4.0), and the strength being gradually increased until the maximum strength that can be endured Avithout distress is reached (gr. xx-^ij—1.296-8.0). These topical applications should be made directly Avith a cotton-carrier or brush at intervals of three or four days, preceded by the use of a cleansing spray. Many astringent and sedative lozenges are to be found in the market, but they are only slightly palliative in their effects, and their prolonged use tends to excite gastric disturbance. I am unalter- ably opposed to the insufflation of poAvders, believing that they are capable of augmenting the laryngeal irritation and of adding fresh irritation in adjacent parts, particularly in the tracheo-bronchial tract. SPASMODIC LARYNGITIS. (Laryngismus Stridulus; False Croup.) Definition.—An affection peculiar to children, chiefly of nervous origin, though also, according to Striimpell and others, often associated with acute catarrhal laryngitis. Etiology.—The affection is almost solely limited to children be- tAveen six months and five or more years of age. It is sometimes ex- cited by strong passion or emotion, and it may be associated with tetany. Rachitic subjects are peculiarly liable. The causes of spasmodic croup are in great part those of acute laryngitis. The mode of action of the direct causes is unknown, but the spasm of the adductors that causes the urgent dyspnea is probably reflex and due to peripheral irritation. Symptoms.—Tavo clinical varieties are to be distinguished: (1) that in Avhich the larynx is free from catarrhal inflammation, or the purely nervous type. This is especially characterized by sudden brief attacks of dyspnea, either by day or night (often on aAvakening), that terminate in a high-pitched crowing inspiration (" child-croAving"). The face during the spasm is cyanotic. General convulsions have been noted, but there is neither cough, fever, nor hoarseness. The attacks may be frequently repeated within a single day. (-) Spasm of the larynx, associated with mild catarrhal laryngitis. The attacks generally begin suddenly, about midnight or toAvard morn- ing on awakening from a sound sleep. Positive evidence of the affection is afforded by the croupy, ringing cough, combined Avith the hard, strid- ulus breathing. An approaching spasm may be announced by a harsh 176 DISEASES OF THE RESPIRATORY SYSTEM. cough and slightly stridulous breathing in the sleeping child. During the attack the countenance may be cyanotic and the breathing most dis- tressing, but these and the above-mentioned severer symptoms generally cease abruptly in an hour or two, and the child resumes its slumber. In my experience the attacks have been repeated for tAvo or three nights in succession, and rarely oftener except in the severest cases. Not infre- quently the child manifests the symptoms of mild catarrhal laryngitis between the attacks. A brassy, croupy cough may also attend. Diagnosis.—Membranous laryngitis may be mistaken for spasmodic croup. The development of the dyspnea, however, is more gradual, is without intermission, and without relation to the period of the day. Albuminuria and a false membrane in the throat or nares are usually present in laryngeal diphtheria. Prognosis.—Although the appearance of a paroxysm is alarming, the disease is practically free from danger. Treatment.—1. The treatment of laryngismus stridulus is quite similar to that of infantile convulsions. A warm bath at a temperature Fig. 43.—Croup-kettle in use. Four upright rods (5.7 inches in length) are fastened to the legs of the bedstead by a wire or string. Two side-rods are tied on the uprights, and two end-rods (length dependent on width of bed) rest upon the side-rods, These rods form a complete framework for the sheets to hang upon. Four sheets are required (11-4 size)—three to cover the ends and sides, and one to be placed on top. One side should be completely closed, while the opposite is to be left open for ventilation or to be adjusted according to circumstances. of 98° to 105° F. (36.4°-40.5° C.) is the best means of breaking up the spasm. While in the bath cold sponging of the back and chest is ser- viceable. The finger may be passed into the fauces, and should the epiglottis " become wedged in the chink of the glottis, it must be re- leased by the finger." After the attack active treatment should be di- rected at the discoverable causes, and I have been in the habit of giving TUMORS OF THE LARYNX. 477 small doses of the bromids thrice daily, together with Avarm cod-liver oil inunctions, with striking effect. 2. In spasmodic croup an emetic is to be given at once, the best be- ing a mixture of alum and syrup of ipecac, of Avhich the dose is 3j (4.0), to be followed by irritation of the fauces Avith the finger in order to facilitate emesis. In severe paroxysms a hot bath may be given to aid the emetic. In case the dyspnea is not checked by the above meas- ures, chloral hydrate may be exhibited by enema (gr. ij-v; 0.129- 0.324) or a Avhiff of chloroform may be given. The local application of cold (ice-collar, ice-water cloths) is useful, and sinapisms placed around the throat and over the chest also tend to arrest the spasm. I am con- vinced that the use of steam-inhalations from the so-called croup-kettle (Fig. 43) is of signal service, and should be more widely employed, particularly Avhen it is inconvenient to use the hot-bath. BetAveen the paroxysms the patient should receive a mild laxative, such as calomel or castor oil, and, in addition, the treatment appro- priate in acute catarrhal laryngitis. To prevent recurrences an envi- ronment calculated to increase the nervous tone of the child is to be pro- cured, and it is especially advisable to accustom him to the outer air, though protected by suitable dress and Avithout undue exposure to draughts. TUMORS OF THE LARYNX. These may be either benign (fibroma, myxoma, lipoma, chondroma, adenoma, angioma, cyst) or malignant (sarcoma, carcinoma). Of these, fibroma occurs most frequently, and with an especial frequency in in- fancy. Navratil1 records 42 cases of multiple laryngeal papilloma in children whose larynges were extensively filled. These growths may also occur in chronic laryngitis, and, like other tumors of the larynx, they commonly spring from the vocal cords. Their shape, size, and tendency to pedunculation do not differ from their characteristics when noted else- where in the body. Symptoms.—Small tumors may occupy the larynx without produ- cing symptoms. The first feature then noted is hoarseness, which gradu- ally groAvs worse and may end in complete aphonia. If situated in the upper larynx, cough is common, and when the tumor causes obstruction of the larynx dyspnea supervenes and tends to increase in severity. A mobile growth may cause sudden occlusion of the glottis, exciting orthopnea and threatening asphyxiation. To confirm the diagnosis a laryngoscopic examination is required. The prognosis is favorable in the benign, but unfavorable in the malignant forms. Treatment.—This is altogether surgical, though Delavan states that 3 cases of papilloma have been cured by frequently repeated sprays of absolute alcohol. Curetting is often followed by a recurrence, Avhile laryngo-fissure and thorough removal of the growths restore speech and prevent recurrence. 1 Bed. klin., Woeh., Mar. 9, 1896. 478 DISEASES OF THE RESPIRATORY SYSTEM. EDEMA OF THE LARYNX. Definition.—An infiltration of the mucous membrane of the larynx Avith serum, affecting mainly the region of the epiglottis and of the ary- epiglottic folds. Etiology.—Two chief classes of causes are operative: (1) Those that excite inflammation. The condition may complicate acute laryn- gitis, though oftener it appears in chronic affections of the larynx, and particularly if ulceration be associated (e. g. tuberculosis, syphilis); it may also appear in connection Avith certain infectious diseases, such as erysipelas or diphtheria. The inflammation inducing the edema may extend from adjacent parts, as the neck, pharynx, and other organs. (2) Factors that tend to excite dropsical effusion. These may be gen- eral, as Bright's disease, Avhich may cause a quickly developing edema of the lungs, heart-affections, etc.; or they may be local. Among the latter are enlargements of the cervical and mediastinal lymphatics, aneurysm of the arch of the aorta, thyroid tumors, etc.—i. c. conditions that exercise pressure upon the jugular veins. Symptoms.—In acute cases the initial disturbance is both sudden and severe. There is dyspnea that tends to increase rapidly, accompa- nied by a husky, suppressed voice, with augmenting obstruction. The respiration may become stridulous, but there is no cough. The laryn- goscope reveals marked SAvelling of the epiglottis and of the ary-epi- glottic folds, and rarely the SAvelling occurs in or even wholly beloAv tbe vocal cords. The inserted finger may detect the swollen epiglottis, Avhich may also be seen if the tongue-depressor be used. Diagnosis.—This can be made with ease from the rapidly develop- ing dyspnea soon reaching the climax, the absence of cough and hoarse- ness, and by the use of the laryngoscope. In cases in Avhich the epi- glottis can be felt or seen a laryngoscopic examination is superfluous. The prognosis is decidedly unfavorable except in the event of early operative interference. Treatment.—If of inflammatory origin, the ice-bag should be ap- plied to the larynx, and ice should be alloAved to constantly dissolve in the patient's mouth. Local depletion, preferably by leeching the front of the neck, is also to be tried, and Levy and Laurens l record a case in Avhich a cure followed this measure. If intense dyspnea tends to per- sist, scarification of the edematous parts Avith a curved bistoury, the point of Avhich is covered Avith adhesive plaster, must be promptly insti- tuted, and, if asphyxia threatens, tracheotomy must immediately be per- formed. Dropsical edema demands scarification, and, if relief does not folloAV, tracheotomy. III. DISEASES OF THE BRONCHI. CATARRHAL BRONCHITIS. (Tracheo-bronchitis) Definition.—A catarrhal inflammation of a part or the Avhole of the mucous membrane of the bronchial tubes. The mucosa of the 1 Arch. gen. de. Med., Dec, 1895. ACUTE BRONCHITIS. 479 trachea is also involved to a greater or lesser extent, and hence the term traeheo-bronchitis is quite appropriate, being descriptive of the seat and character of the disease. Involvement of the bronchioles may also take place, but this does not occur Avithout an involvement of the correspond- ing alveolar structure, the condition being then, Avith propriety, termed "broncho-pneumonia." Hence the term 'l capillary bronchitis," Avhich is still often employed to describe the latter condition, is not pertinent. A certain class of cases is met Avith, however, in Avhich the catarrhal inflammation, as the result of doAvmvard extension, implicates the smaller bronchial tubes Avithout involving the bronchioles ; to such the term " capillary bronchitis " might be appropriately given. The disease may be acute or chronic, both of these forms occurring either as a primary or secondary affection. ACUTE BRONCHITIS. Pathology.—The portions of the mucous membrane of the trachea and bronchi that are implicated become reddened and swollen ; they are covered Avith mucus and mingled Avith epithelial cells, and later muco- pus. Some of the smaller bronchial tubes are dilated. The mucous glands are SAvollen. The histological changes may be briefly stated as folloAvs : desquama- tion of the ciliated epithelium, edema and SAvelling of the submucosa, and, in the severer grades, infiltration of the latter with leukocytes. Etiology.—With rare exceptions traeheo-bronchitis is produced by the direct extension of a catarrhal inflammation from the nares, phar- ynx, and larynx. Rarely the bronchi are the seat of primary acute catarrh, and in some of the latter instances the upper air-passages are implicated secondarily, constituting a reversal of the usual direction of extension above referred to. The immediate causes are mechanical, chemical, and biological irri- tants, which act directlyT upon the tracheo-bronchial mucosa; and that bronchitis is frequently due to infection at a time when the resisting poAver of the system is reduced there can be little doubt. The circum- stances disposing to bronchitis are numerous, those pertaining to the in- dividual being—(1) Age, the old and very young being most liable ; (2) Debility; (3) Occupation, as in certain trades that expose to irritating vapors. Among the external conditions are—(1) Climatic factors, par- ticularly variability of temperature and humidity; (2) Seasons of the year. " Catching cold " often results from exposure during the spring and autumn months, Avhen the meteorological elements, humidity and temperature, exhibit greatest variability. These two conditions depend substantially upon the same factors. Acute traeheo-bronchitis arises as a secondary condition in a great variety of diseases, as, for example, the exanthemata and other acute infectious diseases. As shown elsewhere, in certain instances among this large class of diseases the bronchitis is dependent upon the primary infectious process, but in many others it is due either to the inhalation of pathogenic irritants from the throat and higher air-passages or to the retention of bronchial secretions that are apt to accumulate and decom- pose with resulting bronchitis. The accidental inhalation of particles 480 DISEASES OF THE RESPIRATORY SYSTEM. of food and saliva may also lead to secondary bronchitis, or the condi- tion may be secondary to chronic affections (e. g. Bright's disease, chronic valvular disease of the heart). Symptoms.—Bronchitis of the larger tubes, Avhich extends down to about the second division of the bronchi, is spoken of usually as a "cold." In such cases the onset is marked by recurring sensations of chilliness and by coryza, slight sore throat, and hoarseness, while in young and feeble children convulsions may occur early. Mild febrile symp- toms mav appear, the temperature ranging from 101° to 103° F. (38.3° -39.4° C), with slight acceleration of the pulse, and there may be aching in the limbs and lumbar region. With the fully-developed attack substernal soreness, sometimes amounting to pain, is experienced, especially on coughing, and the pain may be referred to the intercostal muscles and the line of insertion of the diaphragm. The respirations are increased in frequency, but there is no dyspnea. There may be thoracic oppression and discomfort until the bronchial secretions become free, and there is a cough which is at first dry and hard. It often man- ifests itself in longer or shorter paroxysms, particularly on lying down and on rising after a full night's sleep. At the end of one, tAvo, or more days the cough is moist and attended with an expectoration Avhich is at first mucoid and scanty, then muco-purulent and free ; later still it is sometimes distinctly purulent. With free expectoration comes relief to the patient. Histologically, the sputum consists mainly of pus-corpuscles with large cells, in which may be seen the so-called my- elin droplets of Virchow and carbon particles. Physical Signs.—Upon laryngoscopic examination the mucous mem- brane of the larynx and trachea may be seen to be reddened and cov- ered by more or less secretion. Inspection and palpation of the chest are negative, except Avhen the finer tubes become implicated or fever is present, in which case the res- pirations may be observed to be slightly accelerated. In children the increased rapidity of the respirations is more common and reaches a higher degree. Bronchial fremitus may sometimes be felt. Percussion yields negative results, save in very rare instances, in Avhich there occurs a decided accumulation of secretion in the tubes, when there may be found impairment of resonance posteriorly below the scapulae. Auscultation usually renders audible a harsh respiratory murmur, and less frequently piping, sibilant, and sonorous rales. In the advanced stage large and medium-sized mucous rales are frequently present, but are by no means always discernible. The rales appear in different seats from time to time, and after coughing may altogether disappear, but only to reappear later. The prognosis varies with the previous constitutional state of the individual. In healthy adults, after a period ranging from a few days to two weeks, the fever subsides, but the cough, though less marked, and the expectoration usually continue for a variable length of time. In old persons and in those greatly debilitated, as well as in those of a gouty or tuberculous diathesis, the cases pursue a more protracted course. There is also in these subjects a tendency on the part of the catarrhal process to extend doAvmvard until the finer tubes are impli- cated. Under these circumstances life may be endangered, and even, ACUTE BRONCHITIS. 481 rarely, terminated. In the old and very young the bronchial secretions are imperfectly expectorated, hence they gravitate to the most depend- ent parts, and tend to induce bronchiectasis. In young children this doAvnAvard extension of the affection, Avith resulting broncho-pneumonia and areas of collapse in consequence of dilatation and occlusion of the bronchioles by muco-pus, is a not uncommon and serious event. The diagnosis is reached without difficulty through the symptoms (slight fever, cough, and expectoration), the acute course, and the physi- cal signs (harsh respiratory murmur, dry followed by moist rales, heard on both sides of the chest). The recognition of the long list of cases that constitute the secondary forms Avill be made easily possible by noting the circumstances under Avhich they arise. Differential Diagnosis.—Bronchitis can readily be separated from pneumonia and from pleurisy with effusion by its history, by its lighter course, and by the different character and general distribution of the physical signs, especially by the absence of the signs of effusion and consolidation. When broncho-pneumonia develops in the course of bronchitis, dys- pnea and fever are increased and the general condition becomes much more grave. There are small patches that yield dulness on percussion, and broncho-vesicular breathing with moist rales can be detected on auscultation. Bronchitis cannot be separated from the early stage of whooping- cough, but Avhen the characteristic cough of the latter is heard all doubt vanishes. The bronchitis of measles before the characteristic eruption appears is distinguished by the red spots upon the anterior half-arches of the soft palate. Localized tuberculosis of the lung and acute miliary tuberculosis are apt to be confounded with bronchitis. The points of difference have been given in the discussion of the former diseases. Treatment.—Not infrequently a "cold " passes through its several stages without rendering the patient ill enough to cause him to seek the advice of a physician, and there are many instances in which but little treatment is required, apart from the usual household measures and pro- tection against cold and damp. If seen early, while the coryza is pres- ent, the attack may often be aborted by the use at bedtime of a Dover's poAvder in combination with quinin (gr. iv-viij—0.259-0.518); this may be seconded by a glass of hot lemonade, Avith or without a portion of whiskey, and either a hot bath or a mustard foot-bath. The folloAv- ing morning a saline laxative should be taken. To children a mild calomel purge followed by a dose of castor oil may be administered. The patient should be kept in a Avarm, moist, equable atmosphere— preferably in-doors—and during this period he should take divided doses of quinin for a day or tAvo. If the above mode of treatment fail or if the patient does not come under observation early, the main objects of treatment should be (a) to render the secretions free, and (b) to hasten the expulsion of the sputum after it has been loosened. The first leading indication is to be met by the use of diaphoretics, diuretics, and relaxants. The subjoined formula combines these classes of agents, and will be found to be highly serviceable: 31 482 DISEASES OF THE RESPIRATORY SYSTEM. B/. Potassii citrat., 3yj (23.3); Liq. ammonii acetat., sv (148.(J); Spt. jeth. nit., 3j (30.0); Yini ipecac, 3ss (2.0); Syr. pruni virg., q. s. ad ^viij (236.0).—M. Sig. 3ss (2.0) in Avater every tAvo hours until the secretions are loosened. If the temperature in anv given case be maintained at a consid- erable elevation, such as 102°-103° F. (38.8°-39.4° C.) or over, tinc- ture of aconite (1UXVJ—1.065) may be added to the above mixture; and if there be present much tickling with distressing cough, due to irrita- bility of the affected mucosa, codein (gr. ij-iij—0.129-0.194) may be added to the same. For the incessant irritative cough Avhich is present in severe forms of catarrh opium alone is really effective. When the above prescription is not productive of free secretion and troublesome cough continues, I employ the folloAving : B/. Ammon. muriat., 3v (20.0); Codeine, gr. iv-vj (0.259-0.388); Spt. junip. co., Iss (16.0); Mist, glycyrrh. comp., ^iiss (80.0); Syr. pruni virg., q. s. ad |iv (120.0).—M. Sig. 3j (4.0) every two hours. Apomorphin is also excellent as a soothing relaxant in doses of gr. To t° to (0-003 to 0.006) every tAvo hours. Mild counter-irritation by means of mustard-paste, followed by the application of iodin once daily, is also helpful. The patient should keep to his room, in which the at- mosphere should be kept moist and of even temperature. The expul- sion of the sputum may demand stimulating expectorants, though rarely. It is to be recollected that when the tracheal secretion becomes copious the period of convalescence is usually reached, and stimulating expec- torants are then entirely unnecessary. When, on the other hand, the cough is no longer dry, and on auscultation the rales are found to be moist, and Avhilst, at the same time, the expectoration is expelled Avith difficulty, or if the bronchitis tends to become chronic, then such stim- ulating expectorants as senega, squills, and ammonium muriate are to be employed. In cases in which expectoration continues to be too abundant terebene, tar syrup, and oil of sandal are to be resorted to, the choice of the special remedy being governed by the requirements of the individual instance. Debility and secondary anemia must be speedily overcome by exhib- iting quinin, bitter tonics, iron, and arsenic, and a suitable change of air often yields prompt and excellent results in protracted cases. The treatment of the various forms of secondary bronchitis will be consid- ered in their appropriate connections in this Avork. Apart from the method above given, of attempting to abort the attack in children, acute bronchitis is in the main to be treated in the same manner as Avhen it occurs in the adult. Opium, hoAvever, is to be used very sparingly, and generally in the form of paregoric. If the secretion is abundant and imperfectly raised, it is well to administer an CHRONIC BRONCHITIS. 483 emetic, such as the Avine of ipecac (3ss-j—2.0-4.0), and repeat in ten minutes if necessary. If dyspnea be urgent and cyanosis be marked in the lips and finger-tips, a prompt emetic is then imperative in order to save life. A child suffering from acute bronchitis should be kept in bed until the fever subsides. The diet during the dry stage should consist of liquid forms of nour- ishment, which should, for the greater part, be taken hot. After the " cold" has been loosened solid food should be resumed. CHRONIC BRONCHITIS. Pathology.—The lesions of chronic bronchitis manifest considerable variety both as regards their nature and extent. The epithelial layer is, in great part, missing, and sometimes the mucous membrane is quite thin. In consequence the longitudinal elastic fibers appear unduly prominent. The mucous glands and the muscular coat undergo atro- phy in long-standing cases, and the bronchial tubes are dilated (bron- chiectasis). In another large group of cases the mucosa is irregularly thickened or infiltrated and granular. Small ulcers corresponding to the mucous follicles are common, and almost constantly emphyrsema develops in consequence of secondary7 changes in the vesicular structure. Etiology.—Chronic bronchitis may either be primary or secondary. The affection is, hoAvever, almost alway7s a secondary one, and, though sometimes the result of repeated attacks of acute bronchitis, it is much more frequently caused by certain chronic complaints and certain diath- eses, such as chronic alcoholism, rheumatism, gout, syphilis, pulmonary tuberculosis, pulmonary emphysema, organic valvular affections of the heart, and chronic Bright's disease. The primary form, Avhich is rare, is the result of exposure to Avet or cold or to the daily inhalation of some irritant that produces and maintains a low grade of catarrhal in- flammation (dust, vapors). When chronic bronchitis folloAvs the acute form, Ave are often able to detect the operation of some favoring cause, as age, climate, and season. It is most common in the aged, though younger persons occasionally suffer, and it occurs by preference during the cold season, often recurring regularly in the cold and variable Aveather of autumn, winter, and spring, and disappearing in summer. Symptoms.—The symptoms are similar to those of acute bron- chitis, though rather less severe. Pain is rarely present, the patient complaining merely of a feeling of substernal constriction. There may be soreness at the base of the chest if the cough be frequent and severe, and occasionally in the epigastrium as a result of traction of the dia- phragm on the ribs. Cough is not a constant accompaniment, hoAvever, but is paroxysmal and varies in severity and frequency7. The degree of the violence of the paroxysm depends upon tAvo factors—the charac- ter of the bronchial secretion and the seat of the catarrhal inflammation. Thus Avhen the expectoration is tenacious and small in quantity, and Avhen the small-sized tubes are affected, cough is most violent. It also varies both Avith the Aveather and the season, as is evident from the fact that there is often an absence of cough in summer, while it returns un- failingly Avith each winter. 484 DISEASES OF THE RESPIRATORY SYSTEM. The expectoration differs widely in different cases. It is sometimes abundant and sero-mucous in character. On the other hand, there are cases of dry cough in Avhich there is little or no expectoration. As a rule, however, it is rather copious, and either muco-purulent or dis- tinctly purulent in character. Fever is usually absent, though there may rarely occur a slight exacerbation at night. The appetite remains good as a rule; the bodily Aveight is also well maintained, and the nutrition may manifest little or no impairment. Physical Signs.—On inspection we usually note undue enlargement of the thorax, Avith a decrease in expansile movements that is due to the associated emphysema. The dyspnea observed is due either to the same cause or to associated asthma. Percussion yields a clear or hyperresonant note. Dulness or im- paired resonance is sometimes met Avith, however, during acute exacer- bations, and especially over the bases, and is due to congestion and edema (Fox). On auscultation rhonchi of various forms and moist rales are heard, their number and size being in proportion to the extent of the swelling of the mucous membrane and the amount and fluidity of the secretory products. The respiratory murmur is somewhat enfeebled, though roughened, and the expiratory sound is prolonged and wheezy. Clinical Varieties.—Special forms, depending largely upon spe- cific causal factors, remain to be described: 1. The commonest variety of chronic bronchitis has been called the "winter cough of the aged," and, as before intimated, is usually accom- panied by emphysema and cardiac disease. For this form the gouty diathesis is often responsible. The cough occurs in paroxysms that are most severe at night, and during the early morning hours it is attended with free expectoration of the secretion that has accumulated during the night. 2. Bronchorrhea.—In this form there may be an abundant bronchial secretion, composed largely of serum (bronchorrhoea serosa), but more frequently perhaps the expectoration is purulent and thin, containing greenish or greenish-yellow masses. It may at times be thick and puru- lent. Dilatation of the tubes and resulting fetid bronchitis may be de- veloped as secondary conditions. 3. Fetid Bronchitis.—In this variety the expectoration emits the characteristic odor of decomposing animal substances. The fetor may indicate gangrene of the lungs, abscesses, bronchiectasis, decomposition of matter within phthisical cavities, or empyema with perforation of the lung. It may, however, occur independently of the above-mentioned conditions, and hence these must be carefully excluded before the diag- nosis of true fetid bronchitis is made. In the latter disease the expec- toration is usually copious, and on standing separates into three layers, of which the uppermost is composed of frothy mucus, the intermediate of a serous liquid, and the lowest of a thick sediment, that presents a granular appearance and is made up chiefly of small yellow masses—the so-called Dittrich's plugs. These plugs are characteristic of fetid bron- chitis, and are the cause of the fetor. On microscopic examination the Dittrich's plugs are seen to be composed of micro-organisms, chief among Avhich is the Leptothrix pulmonalis; they may also contain pus- corpuscles, fat-granules, and crystals of margarin. CHRONIC BRONCHITIS. 485 The condition may be a grave one, and associated with it may be observed ulceration of the bronchial tubes, with dilatation, pneumonia, abscess, gangrene, and rarely metastatic cerebral abscesses. When putrefactive changes take place in the bronchial secretion in the course of chronic bronchitis a new group of symptoms, as a rule, immediately appears. This comprises rigors that occur at irregular intervals and are associated with high fever and increased prostration. Cough and pain in the chest also become aggravated, but these acute symptoms may shortly subside and the usual course of chronic bronchitis be resumed. Even under the latter conditions fetor of the breath and sputum may persist. 4. Dry Catarrh.—The cough is both severe and paroxysmal, and there is little or no expectoration. When expectoration is present the sputum is very tenacious and is expelled Avith great difficulty. An asthmatic disposition is sometimes noticeable in this variety, and emphys- ema is commonly associated. The dry condition of the bronchial mu- cosa is evidenced by sibilant and sonorous rales. This form occurs in old persons, as a rule. 5. Osier has described a form of chronic bronchitis that occurs most frequently in Avomen, and dates its onset from a comparatively early period of life. It does not undermine the general health. The cough is most pronounced in the morning, and is accompanied by a rela- tively small amount of muco-purulent expectoration (giv-vj—120.0- 178.0 daily). An examination of the chest yields negative results. The etiology is as yet uncertain, although the condition seems to proceed from a gouty or tuberculous diathesis in some instances. I have had under observation for several years a young woman, now aged twenty- eight, Avho has from time to time during the last five years suffered from eczema of the face, and in the intervals, when not afflicted with this dis- ease, has manifested the symptoms of the form of chronic bronchitis under discussion. She comes of arthritic stock. Diagnosis.—The diagnosis of chronic bronchitis is rarely difficult. Since it is usually a secondary condition, it is of the utmost importance to determine the nature of the primary affection. An examination of the heart and of the urine should not be overlooked. Pulmonary tuberculosis is to be discriminated from chronic bronchi- tis, and the distinctive points are—(1) A clear tuberculous history. In phthisis there are fever and loss of flesh and strength, Avhile in chronic bronchitis fever is absent and the general health is not impaired. (2) In pulmonary tuberculosis the signs of localized consolidation (usually at one or other apex) appear early, Avhile in chronic bronchitis the vesic- ular structure is not involved. (3) In phthisis the sputum, Avhen examined microscopically, shows the presence of the tubercle bacillus. In acute pulmonary tuberculosis the fever, dyspnea, cyanosis, and in- creased prostration constitute a group of features that should serve to avert the danger of its being confounded with chronic bronchitis. Co- existing pulmonary emphysema is to be recognized by the characteristic symptoms and signs of this complaint. Primary fetid bronchitis must be differentiated, as must also the other conditions previously mentioned, in Avhich the breath as well as the sputum may emit the characteristic fetor. In abscess of the lung the sputum contains shreds of lung- tissue, including elastic fibers, crystals of hematoidin, cholesterin, and 486 DISEASES OF THE RESPIRATORY SYSTEM. amorphous blood-pigment; usually localized dulness and broncho-cav- ernous breathing coexist. In gangrene there are contained in the spu- tum shreds of lung-tissue, but separate elastic fibers are often absent, on account of the presence of a ferment that causes a solution of the elastic tissue (v. Jaksch). Bronchiectasis is usually unilateral, and gives rise to areas of dulness and other physical signs that are confined to limited areas, Avhile in chronic bronchitis the signs are general. Prognosis.—Recovery is the exception, though improvement may frequently be observed. The course of chronic bronchitis is exceedingly protracted, and the danger from the late development of certain compli- cations and sequels, such as emphysema or right-sided cardiac disease, must be constantly borne in mind. Since the disease is generally a secondary affection, the prognosis in most instances depends upon the outlook in the primary disease. Treatment.—The treatment falls naturally under tAvo main heads —(1) Hygienic, and (2) Medicinal. 1. Hygienic.—This has reference, frequently, to the removal of various noxious influences. When the patient cannot make a suitable change of air during the cold season, he must keep his room during in- clement Aveather; he should, hoAvever, be allowed to spend as much time as possible in the open air during clear and pleasant Aveather. The vitiated atmosphere of saloons or public halls is to be avoided. The patient should be carefully clad; he should wear flannels next the skin during all seasons of the year, but his outer clothing need not be unu- sually cumbersome. If the case be of an aggravated type and the cir- cumstances of the patient permit, he should be sent to a warm latitude in the autumn, in order thus to escape the effects of a severe northern Avinter. It is an excellent rule to send patients in whom the bronchial secretions are abundant to a dry, warm climate or to a region whose atmosphere is impregnated with the balsamic vapors of the pine. On the other hand, patients with dry bronchial catarrh are most relieved by an equable, moist, warm climate. Among suitable resorts, those that should be mentioned are the Riviera, Cannes, San Remo, Sicily, and Algiers abroad, and Florida, Southern Georgia, and Southern California at home. Change of air becomes not only a means of relief, but also an effective means of prevention if resorted to at the proper time. Prophylaxis also includes the removal of any diseased conditions that are causally related. The coexistence of cardiac disease, the gouty diathesis, albuminuria, etc. call for the primary treatment of these conditions. The diet should be generous, but not stimulating, and articles easy of digestion should be selected. Wines and liquors are to be avoided unless special indications for their use exist. Special conditions, how- ever (e. g. albuminuria), may render necessary a special dietary. 2. Medicinal.—In this disease medicines are palliative in their effects rather than curative. Relaxing expectorants are to be avoided, owing to their depressing action, and the stimulating expectorants are, in a majority of cases, not only valueless, but hurtful, since they are liable to lessen the appetite and disorder the digestion. When, hoAvever, the sputum is muco-purulent in character and is dislodged with difficulty, expectorants of this class (squills, senega, ammonium muriate) may be BRONCHIECTA SIS. 487 tried. I have obtained good results from the use of the following in cases attended Avith severe paroxysms of cough: B/. 01. eucalypti, 3Jss-3iij (6.0-12.0) ; Codeinge, gr. vj (0.388). M. et ft. capsulge No. xviij. Sig. One every four hours, as required. Occasionally potassium iodid exerts a curative influence, but its use may be limited to cases that are due to the syphilitic, rheumatic, and gouty diatheses. Five or ten grains of the iodid four times daily may be exhibited, and should there be present a syphilitic taint the remedy should be pushed to the limit of tolerance. The balsam of copaiba is sometimes efficacious, several instances in my own experience having yielded to the following combination: B/. Balsami copaibse, 3JH3ij (4.0-8.0); Ammon. muriat., 3ij (8.0); Extr. glycyrrh. pulv., 3j (4.0). Mist, ammoniaci, q. s. ad-f|iij (96.0).—M. Sig. 5\j (8.0) every four hours. Other remedies that possess great value in certain cases are creasote (in ascending doses), turpentine, terebene, tar, the balsams of tolu and Peru, and sandal-wood. H. C. Wood praises sulphuretted hydrogen in cases in Avhich there is profuse expectoration : " From two to four ounces of the saturated watery solution may be administered by the mouth four or five times a day or until the breath has a perceptible odor." If the vital powers are poor, bitter tonics, as iron, quinin, and strychnin, and other measures calculated to invigorate the system, are indicated. When the sputum is excessive in amount, astringents (zinc sulphate and oxid) are sometimes useful. Astringents may also be used with advantage in the form of a spray Avhen the expectoration is too free. On the other hand, sprays from properly selected solutions (e. g. am- monium muriate, gr. v-x ad Ij—0.324-0.648 ad 32.0) are valuable in assisting expectoration. In fetid bronchitis sprays of antiseptic solu- tions are to be used, and the following will be found serviceable: B/. Acidi carbolici, gr. ij-iv (0.129-0.259); Olei eucalypti, mij-iv (0.133-0.266); Aquae, Ij (32.0). Sig. To be inhaled from a steam- or hand-atomizer three or four times daily. Pneumato-therapy has given brilliant results in certain instances, and more particularly in those of asthma and emphysema. BRONCHIECTASIS. Definition.—The universal or circumscribed dilatation of the bron- chial tubes. Pathology.—Two main forms are recognized—the cylindrical or simple, and the saccular, and both of these may be met with in the same 488 DISEASES OF THE RESPIRATORY SYSTEM. lung. Rarely the condition is congenital. It may be general or par- tial, the former variety being ahvays unilateral, the latter sometimes bilateral. In universal bronchiectasis the bronchial tubes, throughout their extent, are the seat of numerous sacculi communicating with one another. These present smooth, shining Avails, except in the most de- pendent parts, where ulcers are sometimes seen. Extreme conditions of dilatation may take the form of huge cysts, which may extend to the periphery of the lung; the lung-tissue lying between the sacculi then becomes cirrhotic as a rule. In partial dilatation the bronchial mucous membrane is implicated, with an occasional narroAving of the lumen. Most commonly these narrowings are cylindrical, though they may be saccular, and rarely fusiform. The partial is much more common than the general variety. Histology.—When the walls of the larger dilatations are examined microscopically, the cylindrical epithelium is seen to be replaced by a pavement epithelium. The elastic and muscular layers are thin, and the fibers are usually separated. Contained in these dilatations are frequently found secretions that may be fetid. Etiology.—The manner in which bronchiectasis is produced may vary, though in the majority of instances the condition doubtless arises from an involvement of the bronchial mucosa that extends to the sub- mucous tissues and leads to muscular, fibrous, and cartilaginous atrophy. These changes render the wall of the tube unable to resist the pressure of the air in violent paroxyms of cough, and, once the process of .dila- tation is commenced, the accumulated secretions tend by their Aveight to further distend the already weakened walls. Thus the elasticity of the latter is impaired, and finally destroyed. The etiological factors show the affection to be secondary as a rule, and are—(1) Chronic bronchitis and emphysema, chronic phthisis (usually Avhen the seat of the dilatation is at the apex), broncho-pneumonia (in children), and compression of a bronchus by a solid tumor or aneurysm. (2) Great thickening of the pleura, especially when associated Avith bronchitis or interstitial pneumonia, with contraction of the lung. (3) Rarely it is a congenital lesion, and is then usually unilateral. Among predisposing conditions are—(a) Age, bronchiectasis being most common in adult or middle life ; and (6) Sex, it being more com- mon in males than females. Symptoms.—There is ahvays cough, and this usually occurs in prolonged and severe paroxysms. The attacks take place most gener- ally after the dilated tubes fill in the morning, and a change of posture may excite them. Accompanying the cough there is profuse expectora- tion, which may amount to a pint or more in tAventy-four hours. The sputum is grayish-brown in color and muco-purulent, emitting a sour or, more frequently, a horribly fetid odor. On standing, the expectoration separates into three strata—the uppermost, of brownish froth ; the mid- dle, of a thin, sero-mucous fluid; and a thick sediment, of cells and granular debris. Examined microscopically, the sputum is seen to be composed chiefly of pus-corpuscles, with which are intermingled Char- cot-Leyden and fatty-acid crystals, the latter being arranged in the form of bundles; also leptothrices, vibrios, and bacteria are found. Elastic fibers may be observed if ulcers be present. BR ONCHIECTASIS. 489 Dyspnea is noted, but is not a prominent symptom, unless some other chronic affections of the chest already coexist or some compli- cation arises. Hemoptysis occcurs rarely, and may be due to the bron- chiectatic lesion. Physical Signs.—These differ in character according to the size, situ- ation, and nature of the dilatation, and also according to the condition of the surrounding lung-tissue. On inspection retraction of the chest-wall may be noted when chronic pleurisy and interstitial pneumonia are associated. The tactile fremitus is usually increased, but may rarely be diminished. The percussion resonance is impaired or even flat, and on auscultation bronchial breath- ing is heard, Avith occasional rales that have a metallic quality. A sac- cular dilatation immediately beneath the pleura may give a tympanitic note, and may also give typical cavernous or amphoric respiration. These signs are generally discoverable at the base of one or other lung. Diagnosis.—Simple dilatation of slight degree may exist without appreciable signs, and in other instances the breathing is broncho-vesic- ular over localized areas, Avith rales displaying increased metallic quality. Saccular Bronchiectasis. Pulmonary Tuberculosis. History of chronic bronchitis, chronic History of cough, hemoptysis, with pro- pleurisy, and interstitial pneumonia, or gressive loss of flesh and strength. of foreign body. Family history. Cough is paroxysmal, and sputum cha- Cough less paroxysmal. Sputum num- racteristic and copious. mular in the stage of cavity. Tubercle bacillus absent. Tubercle bacillus present. Course longer, with little impairment of Course relatively shorter, powers of the the general health. system progressively undermined. Physical Signs. The condition is persistent, but non-pro- Generally progressive, more frequently at gressive. Usually located near base one or other apex. posteriorly. Circumscribed empyema with a fistulous connection with the lung may simulate bronchiectasis. There is often in such cases a clear his- tory of an acute illness with a sudden onset, the symptoms pointing to pleural inflammation; or there is a period of gradually increasing ill- health with thoracic oppression and dyspnea, especially on exertion. In either event the patient suddenly expectorates, at irregular intervals, large quantities of purulent matter. Actinomycosis may also cause conditions that simulate bronchiectasis. The diagnosis may be made by finding granular particles containing the actinomyces in the sputum. Prognosis.—Apart from certain remote dangers (e. g. abscess, gan- grene), these cases pursue a favorable but exceedingly protracted course. Treatment.—The lesion being a permanent one, there is no known remedy that will either abridge or influence the course of the affection. Again, since the cough is protracted and attended with profuse expec- toration, sedatives and ordinary expectorants are contraindicated. For the fetor, antiseptics are to be employed both topically and internally, and a solution of carbolic acid (1-3 per cent.) or thymol (1:1000) is to be used by inhalation. Internally, terebene (1TLv-x—0.333-0.666) in capsules every four hours is valuable; also creasote in increasing 490 DISEASES OF THE RESPIRATORY SYSTEM. doses (tnj—0.066, increasing by tTLj each day, till THyj—0.399—are taken three times daily) is to be persistently employed. Should the above methods prove unavailing, intrathoracic injections of disinfectants are often resorted to with gratifying results. In instances in which the dilatation is situated superficially and is not amenable to therapeutic measures, it may be freely opened and thoroughly drained. BRONCHIAL STENOSIS. Definition.—Narrowing of the bronchus, due either to constriction or to compression. Pathology and Ktiology.—(a) Stenosis due to Constriction.— This form is most frequently occasioned by the presence of foreign bodies; by new growths (polypoid) Avithin the bronchi, or by groAvths without, extending from the lung to the bronchi, and in the case of the smaller bronchi by swelling of the mucosa. The bronchial walls also sometimes become thickened by inflammatory exudates in certain acute and chronic affections, such as syphilis, tuberculosis, and glanders. (b) Stenosis due to Compression.—Compression of one or more bron- chi may be met Avith in a variety of enlargements involving the organs within the thorax, among which are aneurysm, echinococcus cyst, solid tumors, enlarged glands, mediastinal and pulmonary abscesses, and ex- tensive pleural effusion. * Symptoms.—The symptoms do not depend upon the cause of the obstruction, but their extent and character are in proportion to the size of the bronchus affected and the degree of stenosis. Dys- pnea is the most conspicuous symptom, and when this is marked the accessory muscles of respiration are brought into active play, and still the proper filling of the lungs with air is not accomplished. Under these circumstances the air in the lungs becomes rarefied, and instead of normal expansion everywhere the lower part of the sternum and the lower ribs are retracted on inspiration, and expiration is accomplished only with difficulty. Obstruction of the primary bronchus on either side of the chest would naturally be folloAved by inspiratory retraction of the inferior part of the chest-wall and intercostal spaces upon the affected side. It is to be recollected that the movements of the larynx are slight in bronchial stenosis, Avhile they are marked in laryngeal ob- struction. Cough and expectoration are sometimes present, and febrile development of moderate severity is often noted. Physical Signs.—Inspection shows defective respiratory movement upon the side involved. The local tactile fremitus is diminished or absent upon the affected side, owing to the obstruction to the passage of the vibrations of the voice to the pulmonary periphery. The per- cussion-note remains unaltered, though less influenced by forced respira- tion, and particularly expiration, than in health. Pulmonary atelectasis may occur as a secondary event, and is shown by dulness on percussion. The auscidtatory signs consist of a greatly diminished vesicular murmur on inspiration, due to the diminished amount of air entering the air- ASTHMA. 491 cells during inspiration, and the presence of rales, sibilant and sonor- ous in character, at the seat of obstruction. Obstruction of a small bronchus may, hoAvever, be present Avithout appreciable physical signs, OAving to the fact that the surrounding lung-tissue may take on com- pensatory emphysema. Diagnosis.—The nature and site of the affection may be determined by auscultation, and sibilant and sonorous rales will be conspicuous at the point of constriction. A clear history, together Avith a careful in- vestigation of antecedent affections of the thoracic organs leading up to the stenosis, are factors that must furnish the etiological data in indi- vidual cases after the exclusion of foreign bodies as the possible cause. Tracheal or laryngeal stenosis may be eliminated by careful laryngo- scopic examination. Prognosis.—The duration is indefinite, though usually protracted, and most cases yield an unfavorable prognosis. In those instances, however, in Avhich the narroAving is due to foreign bodies the latter may rarely be dislodged and fortunately ejected, thus averting danger to life. Treatment.—The treatment must be addressed to the cause in in- dividual cases. Obviously, the question of the removal of foreign bodies from the bronchi falls Avithin the domain of surgery, though the administration of an emetic has been followed by complete success in certain instances. Obstruction due to stenosis of a main bronchus may be treated by dilatation with bougies, the treatment of course being carried out by a specialist. ASTHMA. (Bronchial Asthma.) Definition.—A chronic affection, characterized mainly by paroxys- mal dyspnea, due to contraction of the muscles of the smaller bronchi. The paroxysmal dyspnea produced by arterial contraction is also termed asthma by many writers. Pathology.—True asthma is a neuropathic disease. In a majority of the cases, however, there is more or less hyperemia of the bronchial mucosa, due to pneumogastric or vasomotor functional disturbances, and also a characteristic exudate of mucin. In a smaller number there may be no lesions Avhatsoever, and the condition is a-pure neurosis, often of reflex origin. Instances that come to autopsy present the morbid changes peculiar to chronic bronchitis, pulmonary emphysema, and right- ventricular hypertrophy with dilatation. Etiology.—There is present either a constitutional peculiarity or a singular susceptibility of the local muscular fibers to spasmodic con- traction, both of which are of unknoAvn nature. The exciting factors are very \rarious, but may be grouped under four heads : (1) Acute Bronchitis.—It must not be forgotten, however, that a bronchitis may be set up by the paroxysms. Curschmann has observed also a local croupous inflammation of the smaller bronchioles in some 492 DISEASES OF THE RESPIRATORY SYSTEM. of his cases, which he describes as bronchiolitis exfoliativa, and Avhich seems to have given rise to the seizures in grave cases. (2) The inhalation of numerous and widely various irritants, as chemical vapors, smoke, fog, dust, and emanations from plants or cer- tain animals. (3) Reflex Causes.—The causal connection between chronic inflam- mations, nasal polypi, and other obstructive affections of the nasal chambers is a subject that is thoroughly appreciated by the specialist. In the same way, gastric disturbances and, as I have observed in a few instances, intestinal irritation are productive of this complaint. (4) Asthma may be secondary to, and most possibly excited by, cardiac disease, emphysema, gout, rheumatism, syphilis, Bright's dis- ease, emotional excitement, and irritating lesions in the region of the medulla. Possibly, some of the latter affections merely constitute pre- disposing factors. In this connection it is to be pointed out that indi- vidual liability to the disease depends upon the special etiologic factor. Predisposing Causes.—Heredity takes first place, and is, when discov- erable, Avell marked ; it is noted in about 50 per cent, of all cases. The complaint is about tAvice as frequent in males as in females, and, if we except hay asthma, it is more prevalent in winter and early spring than during the warm season. Clinical History.—Hyde Salter's collective statistics show that prodromal symptoms appeared in about one-half the instances (in 111 out of 226 cases). They differ widely, but are chiefly nervous in a great proportion of cases, and appear as irritability of temper, either depression or unusual buoyancy of spirits, headache, neuralgia, drowsi- ness, and vertigo. Abundant diuresis and digestive disturbances tend to appear. The attack usually comes on in the night during sleep, and at a definite time. It may develop, however, while aAvake or, again, though rarely, during the day. The onset may be sudden, but perhaps more frequently the patient first experiences a moderate grade of dyspnea and thoracic constriction. This augments with umvonted rapidity, and often attains to an inordinate degree, until the patient feels smothered, sits up, grasps his knees with his hands, or places the palms upon the bed so as to raise the shoulders and thus reinforce the accessory mus- cles of respiration. If the attack be severe, he rushes to an open A\in- doAV Avhen able to leave his bed, or sits on a chair and places his arms on the back of another chair, so as to fix the shoulders and thus give purchase to the auxiliary muscles of respiration while frantically en- deavoring to maintain the act of breathing. The face is pale, anxious, and soon is bedewed with cold perspiration, while the lips, eyelids, and finger-tips are livid, owing to defective oxygenation of the blood. The temperature becomes subnormal and the pulse feeble and rapid. The clinical picture Avears an alarming aspect, but in uncomplicated cases death never supervenes. Physical Signs.—Inspection shows enlargement of the chest, which in the advanced stage becomes barrel-shaped. The reason for this is the presence of an increased amount of air in the thorax with a total inabil- ity to expel it. The respirations are diminished in frequency to 12 or 10 per minute. The natural rhythm is also greatly disturbed, and in- ASTHMA. 493 spiration is seen to be short and gasping, and followed immediately by expiration, which is greatly prolonged. The expansile movement of the chest is very limited, and in inverse ratio to the patient's efforts at breathing. There is lowering of the diaphragm. Palpation is negative in its practical results. Percussion yields a hyper-resonance; in ad- vanced cases with associated emphysema semi-tympanitic resonance is common. On auscultation the inspiration is found to be short and feeble, and the expiration much prolonged and accompanied by a low- toned wheezing sound that may also be audible to onlookers. A great variety of dry rales are heard, chiefly high-pitched, sibilant, and sonor- ous, that are more marked on expiration than inspiration. They also change their character and situation frequently. At the close of the attack moist rales may be heard, and occasionally, Avhen bronchitis complicates asthma, the moist rales may be combined throughout the paroxysms. The duration of the attack is various, ranging from a few minutes to several hours, though rarely it may endure a week or two, with spontaneous remissions during the day (e. g. when chronic bronchitis coexists). Usually it subsides abruptly, with the expectoration of rounded gelatinous masses and, later still, of muco-purulent material. The former, when floated in water, are found to be composed of the so- called Curschmann's spirals (mucous moulds of the smaller tubes), and the spiral character of these small, ball-like pellets may even be detect- able with the naked eye. When examined microscopically their spiral structure is evident. Two forms are recognized: (1) Composed of mucin, arranged spirally; in its meshes may be observed alveolar cells, many of which have undergone fatty degeneration. (2) A perfectly clear and translucent filament that is most probably composed of trans- formed mucin and occupies the center of the coiled spiral of mucin. In the early stage of the attack Curschmann's spirals (Fig. 44) are invariably Fig. 41.—Curschmann's spirals. present in the expectoration, and in many instances Leyden's octahedral crystals are also visible. For a time the latter were supposed, though erro- neously, to excite the paroxysms by means of their irritating character. Similar crystals are found in the semen, as well as in the blood in cer- tain conditions (e. g. leukemia). Miiller, Fink, Leyden, and others have demonstrated extremely large numbers of eosinophile leukocytes in the 494 DISEASES OF THE RESPIRATORY SYSTEM. sputum. Fink and Gabritchewski likeAvise have found a large excess, up to 15 per cent., of eosinophile leukocytes in the blood. V. Noorden and SwercheAvski found the same increase, but only at the times of the attacks. Diagnosis.—A clear history, together Avith the physical signs and a microscopic examination of the sputum, should lead to correct results. The history alone is inadequate to put the physician upon the right track. Laryngeal affections, Avhich give rise to spasm of the glottis and dyspnea, are to be eliminated by the alteration of the voice and the aphonia Avhich are usually present, Avhile the characteristic physical signs of asthma are absent. Again, the dyspnea is inspiratory, not expiratory as in asthma. Emphysema may be confounded Avith asthma, though the frequency with which the two conditions are found conjoined in the same case must be recollected. The distinguishing points will be considered in connec- tion with the former disease. Conrse and Prognosis.—In mild cases of asthma there may be but one or two nocturnal paroxysms, Avith entire freedom from cough and dys- pnea during the following day. On the other hand, in severe cases there is a repetition of the paroxysms from three to five or six nights. Under these circumstances in the intervals (usually corresponding to the period of day) there are slight wheezing and some cough. In long-standing cases asthma leads constantly to the development of chronic bronchitis and emphysema, and in such these affections are invariably combined. The paroxysmal character of the affection is often partly or wholly lost, the patient rarely being entirely free from asthmatic dyspnea, combined with cough and muco-purulent expectoration. The periodicity7 of the attacks varies greatly ; in some it recurs monthly or at even shorter intervals, and in others only annually. There is rarely any danger to life, except when the secondary affection is emphysema and its remote consequence is dilatation of the right ven- tricle ; hut the percentage of cases in which recovery actually takes place is comparatively small, since the affection may reappear long after the paroxysms have ceased to recur in the usual manner. Treatment.—The indications for treatment are—(1) to cut short the paroxysms, and (2) to prevent a recurrence of subsequent attacks. (1) To bring relief during the paroxysms we should ascertain the ex- citing cause, and remove it promptly if possible to do so. In one of my own cases a prolonged paroxysm Avas cut short by a calomel purge fol- lowed by an enema. An overloaded stomach calls for an emetic, and other causal factors are sometimes removable (e. g. congestion of the nasal mucosa, dust, animal and vegetable emanations). If the cause is irremovable, the patient should be kept in a large and freely ventilated apartment, and everything that tends to impede respiration must be re- moved. The choice of posture as affording the greatest relief may usually be left to the patient. To cut short the paroxysms: The particular mode of treatment that will afford most speedy relief differs Avidely in different cases, and not infrequently the patient, as the result of experience, is aware of the rem- edies that are most efficacious for good. As a rule, hoAvever, sedative antispasmodics, relaxants, and stimulants are the classes of medicinal ASTHMA. 495 agents from Avhich a careful selection is to be made; and whilst a great variety of these have been employed, I shall content myself by adducing here only the most valuable and their mode of administration. In the hands of some observers a few whiffs of chloroform have proved highly efficacious, but in my own they have produced only momentary good effects; ether is the safer remedy and may be tried in like manner. In a certain proportion of the cases from four to six drops of amyl nitrite thrown upon cotton-wool or a handkerchief, and inhaled, bring speedy and permanent relief. Of stimulants, coffee is the best: immediately upon the appearance of the paroxysm about one pint of strong coffee is to be taken hot (without cream or sugar), and in this Avay the seizure may sometimes be arrested. Alcohol when given hot and in sufficiently large doses to induce mild intoxication may be found very useful; and by adding to " hot toddy " a dose of spirits of chloroform an efficient combination is the result. The inhalation of the fumes of niter-paper 1 often gives quick, tempo- rary, and, less frequently, permanent relief. When employed, the atmo- sphere of the room occupied by the patient must be well filled with the fumes. Among depressant antispasmodics are belladonna, hyoscyamus, stra- monium, and lobelia, and these seem to be of most value when used in the form of cigarets. The leaves of the plant employed are first steeped in a concentrated solution of potassium nitrate or chlorate, and a trial should be made of different sorts of cigarets or pastilles (which are simi- larly prepared), since all cases are not benefited by the same brand. The inhalation of tobacco-smoke is equally beneficial in a limited number of instances. A large number of cases, despite the use of the measures above indi- cated, exhibit an obstinate tendency, and for their treatment no remedy bears favorable comparison Avith morphin, administered hypodermically, for potency and permanency of its beneficial effects. It is best given in full doses (gr. -|—\—0.0216-0.0324), and may be combined with atropin or cocain. Strychnin also has its warm advocates (Mays and others). The use of opium, oft repeated, has occasionally led to the establishment of the morphin-habit, as in a case that recently came under my obser- vation ; hence it must not be used indiscriminately. I have for a num- ber of years been in the habit of supplementing the action of the first dose of morphin with the folloAving formula : K;. Tr. lobelias, 3J (4.0); Tr. nitro-glycerini (1 %), V(\_xvj (1.06); Sodii bromid., 3v (20.0) ; Vini ipecac, 3v (20.0); Ext. hyoscyami, gr. viij (0.518); Elix. simplicis, q. s. ad siv (128.0).—M. Sig. 3j (4.0) every one or two hours in water. In the protracted cases of old asthmatics, associated with chronic bronchitis and emphysema, the above mixture may be also employed, though sodium iodid (gr. v—0.324) should be substituted for the bromid, and the same dose should be given at intervals of three or four hours. 1 Xiter-paper is prepared by dipping bibulous paper (filter- or blotting-paper) in a solution of saltpeter. 496 DISEASES OF THE RESPIRATORY SYSTEM. (2) In order to prevent subsequent attacks: The history of each case should be carefully inquired into during the intervals, with a vieAv to as- certaining whether any of the numerous causes (bronchitis, gastric disor- ders, dust, emanations from plants) are discoverable; and if so, efforts to re- move them should be instituted. A methodical interrogation of the vari- ous organs of the body and their functions must be carried out, and the therapeutic or hygienic indications presented by them, if any, must be met judiciously. The nasal passages should be examined by a specialist, and any causal conditions found therein are to be promptly removed. If the affection be a pure neurosis or due to bronchitis, a suitable climate may often be found in which the patient will enjoy complete immunity from asthma. The choice of the locality cannot, however, be determined by any known rules. The patient must travel from place to place until he finds the climate that possesses preventive properties in his particular case. To those Avho cannot adopt this plan potassium iodid offers the best hope of relief, though its use must be long continued (gr. x-xx— 0.648-1.296, three times daily). The systematic use of compressed air in the pneumatic cabinet, and also the inhalation of oxygen, are Avorthy of trial. The presence of any conditions of ill-health calls for treatment directed to their removal. There are also certain means of prophylaxis for impending attacks. Thus, if there be premonitory symptoms, the use of such measures as strong coffee or the " hot toddy " above mentioned, Hoffman's anodyne, stramonium or belladonna cigarets, the inhalation of the fumes of niter- paper or of a few drops of amyl nitrite, or the removal of the sources of irritation, may suffice to ward off the attack. FIBRINOUS BRONCHITIS. (Plastic Bronchitis ; Croupous Bronchitis) Definition.—A rare acute or chronic catarrhal affection of the bron- chial mucosa, attended with the production of fibrinous casts that are ex- pectorated in severe paroxysms of cough and dyspnea. These casts, when unfolded, are found to be solid moulds of the bronchial tubes from which they come, being shaped like the branches of a tree, and thus proving that a bronchial tube and its subdivisions had been blocked. When the moulds are large or medium-sized they are hollow, and when from the smaller bronchi they are solid. Pathology.—The pathology is but little understood, but in my own studies I have found the composition of these casts to be identical with that of croupous exudates met with elsewhere, though more dense, per- haps, than the latter. Croupous bronchitis is attended with loss of epi- thelium in the implicated bronchi, as is the case in croupous inflamma- tion wherever it occurs, but the answers to the questions, " Why should the affection be limited to a definite portion of the bronchial tree?" and "Why does it recur from time to time?" are obscure indeed. In fatal cases the lesions of associated or antecedent complaints, such as chronic pleurisy, pneumonia, and pulmonary tuberculosis, have been found. FIBRINOUS BRONCHITIS. 497 Htiology.—What the irritant is that causes the condition is un- known, though streptococci have been found in the moulds and in the mucosa. Some of the predisposing causes, however, have been recog- nized, and are—(1) Sex: it being about twice as frequent in males as in females. (2) Age: though met with at all periods of life, it is relatively more frequent from the twentieth to the fortieth year. (3) Season: the seizures are most common in the spring months. (4) Epidemic influ- ences : Pichini has described a group of instances that occurred in indi- viduals in the same locality. (5) Hereditary influence has been trace- able in a few cases. (6) Other affections, as tuberculosis (quite fre- quently), chronic pleurisy, and certain skin-affections, as herpes, im- petigo, and pemphigus, form antecedent and coexistent conditions. Symptoms.—(a) The acute form is rare. It begins with rigors and fever that are soon followed by urgent dyspnea and severe paroxysms of cough, which are usually attended, soon or late, by the expulsion of fibrinous casts, and sometimes rather profuse hemorrhage. Abundant expectoration usually causes amelioration of the severer symptoms. On the other hand, urgent dyspnea, oppressiveness, and severe cough, with little expectoration, are grave symptoms, often leading to fatal asphyxia. (b) The Chronic Form.—The paroxysms recur at irregular intervals and are less severe than in the acute form, the interim varying from one week to a year or more. In a case observed by myself the patient has experienced a recurrence once annually (on or about May 1st), commen- cing three years ago. Other instances are on record in Avhich the parox- ysms have occurred at regular though much briefer intervals. The cases usually manifest ordinary bronchitic symptoms, with or without fever at the onset. The cough soon becomes troublesome and is paroxysmal in cha- racter. There is expectoration in the form of rounded masses, which, when unravelled, are found to be true moulds of the affected tubes that exhibit a laminated structure. The larger casts (which are of the size of a goose-quill or even larger) may be hollow, while the smaller ones are quite solid. They are of whitish or grayish-white color. When ex- amined microscopically they are seen to consist of a fibrillated base, a few scattered leukocytes and mucous corpuscles, and, rarely, gland- and blood- cells. Occasionally Leyden's crystals and Curschmann's spirals have been found. Not infrequently the sputum is blood-stained, and occasion- ally there is profuse hemorrhage. Physical Signs.—OAving to the obstruction offered by the casts, there is a diminished amount of air entering the corresponding part of the lung. As a necessary result the tactile fremitus, local expansion, and respira- tory murmur are diminished over the affected area. The note on percus- sion over the uninvolved portions of the lung is clear or hyper-resonant, though if the portions of the lung supplied by the affected tubes collapse, there is dulness on percussion. Dislodgement of the casts is followed by a return of the normal respiratory murmur. Diagnosis.—From ordinary bronchitis it is to be distinguished by the presence of the fibrinous casts, which alone are sufficient for a positive diagnosis. The fibrinous moulds met with in diphtheria and pseudo-mem- branous croup, with extension into the bronchi, must also be eliminated. The history and course of the latter will, as a rule, suffice to make a positive discrimination, but if doubt remain a bacteriological examination 32 498 DISEASES OF THE RESPIRATORY SYSTEM. of the membranous casts should be made. If the Klebs-Lbffler bacilli are then found, all doubts as to, its diphtheritic nature are set at rest. Prognosis.—The prognosis in the acute form is quite grave; the chronic variety, though pursuing an exceedingly long course that ranges from five to fifteen years, rarely terminates fatally. Treatment.—This is to be conducted on the same principles as those in simple acute bronchitis. In the acute form an attempt should be made to soften and separate the casts by the topical application of steam, by inhalation, and alkaline sprays (e. g. lime-water). Pilocarpin was em- ployed in one instance under my own observation with apparent good results; it tends to excite free bronchial secretion. Emetics should be resorted to Avithout delay when the signs of cyanosis show themselves. In the chronic form nothing can be accomplished by treatment, dur- ing the intervals between the acute exacerbations, that will tend to obviate a recurrence of the attacks or to mitigate their severity. IV. DISEASES OF THE LUNGS. CIRCULATORY DISTURBANCES IN THE LUNGS. CONGESTION OF THE LUNGS. (Hyperemia of the Lungs.) Definition.—The surcharge of the pulmonary vessels with blood. Two forms are recognized: (1) Active hyperemia, and (2) Passive hy- peremia. ACTIVE HYPEREMIA. Pathology.—The blood-vessels in the bronchial mucosa often appear intensely injected, and the capillaries in the alveolar walls are prominent, while on section a scarlet-colored, frothy liquid flows. The alveolar epi- thelium may become swollen and granular. Etiology.—Active hyperemia is usually a symptomatic condition, though rarely it may arise as a distinct primary affection. Active con- gestion of the lungs exists as an associated condition in many pulmonary affections, as pneumonia, pleurisy, bronchitis, and tuberculosis. On the other hand, active congestion of the lungs may be engendered as an independent affection by the inhalation of hot air, highly irritative sub- stances, as well as by violent physical exercise, the ingestion of large amounts of alcohol, and strong mental emotion. Active hyperemia has, however, little clinical significance. Symptoms.—The capacity of the air-cells is diminished; hence the oxygenation of the blood is markedly interfered with. This embarrass- ment of the function of respiration is compensated for in part by accel- erated breathing, there being a degree of dyspnea proportionate to the extent and intensity of the congestion. There is some cough, accompanied by frothy, bloody expectoration. The physical signs are bilateral, as a rule, and are generally confined CONGESTION OF THE LUNGS. 499 to the bases. Palpation shows increased tactile fremitus. The percussion- note is impaired or, rarely, dull, and it is generally exceedingly difficult to determine the pitch of the note, owing to the fact that both sides are usually involved. On the other hand, Avhen the condition is unilateral and not associated with diseases of the opposite side, the impairment is readily appreciated. The vesicular element of the respiratory sounds is diminished, and the bronchial element relatively increased (broncho-vesic- ular breathing). Less frequently there is bronchial breathing. Diagnosis.—In the presence of the etiologic factors the sudden development of dyspnea, cough, and a frothy, bloody expectoration, and in the absence of fever and the physical signs before enumerated, the diagnosis is easy. Prognosis.—Active hyperemia is frequently folloAved by collateral edema. Its course is brief, and terminates either fatally in a feAv hours, in perfect recovery in a feAv days, or in pneumonia. The condition is therefore ominous. Treatment.—Prompt measures must be instituted in order to arrest the active fluxion. The special causal factors must be actively treated, so as to diminish the quantity of blood in the pulmonary vessels ; dry and Avet cups over the entire seat of congestion must be tried: and in the Avorst cases venesection is demanded. Following the application of the cups, turpentine stupes, sinapisms, and linseed poultices may be em- ployed. I have observed excellent results from the use of veratrum viride combined with saline purgatives. Other cardiac sedatives may also be employed, including nitroglycerin in full doses. PASSIVE HYPEREMIA. Passive, unlike active, hyperemia is always a secondary condition, and is quite common. Two forms are distinguishable : (a) Mechanical, and (b) Hypostatic. (a) Mechanical Hyperemia (Brown Induration).—Pathology.—The pulmonary vessels are distended, the lungs as a Avhole enlarged, and the air-cells crepitate but little, owing in great part to the encroachment upon the air-spaces by the dark venous blood. The lungs are of a reddish-broAvn color and afford increased resistance to efforts at cutting or tearing. On section the reddish-broAvn tint rapidly changes to a vivid red, from oxi- dation of the hemoglobin when exposed to the atmosphere. The process commences at the extreme base, extends upAvard, and may finally become general. The interstitial connective tissue is increased, and is often edem- atous, while the epithelial cells of the alveoli show altered blood-pigment, usually in the form of hemosiderin and responding to the usual tests for iron. Etiology.—Mechanical hyperemia results from the obstruction of the return of blood to the left heart, and among special causative conditions are mitral constriction, mitral regurgitation, dilatation of the right ven- tricle, and certain cerebral injuries and diseases. It may also be a symp- tom of asphyxia, and rarely it arises from pressure of tumors. Symptoms.—The most marked feature is dyspnea, particularly Avhen secondary to organic cardiac diseases with failure of the right ventricle. Cough is common, and an expectoration of frothy serum or blood (hemop- 500 DISEASES OF THE RESPIRATORY SYSTEM. tysis) containing pigmented alveolar epithelial cells, is the most cha- racteristic clinical feature. Diagnosis.—With a clear history, in addition to the dyspnea, cough, and the characteristic expectoration, the recognition of passive hyper- emia of the lungs is a simple matter. The prognosis and treatment will be considered in connection with the causative affections. (b) Hypostatic Hyperemia.—Pathology.—The parts of the lung that are affected are dark in color and the vessels distended with a transudate of blood and serum. In this way the air-cells may become emptied of air (splenization, hypostatic pneumonia), and the resulting condition is in most instances to be regarded as a mild grade of lobular pneumonia. This view is confirmed by the fact that the same etiologic conditions that favor the development of hypostatic congestion also favor to an equal extent the development of hypostatic pneumonia. Etiology.—Feeble cardiac action, as in long-continued fevers, debili- tating chronic affections, and in old persons, combines with a prolonged dorsal position of the body (gravitation thus favoring its development) in producing the condition. This explains why the condition is found usu- ally at the bases of the lungs, and is most marked posteriorly. It is common for the same reason in carcinoma, tuberculosis, paralysis, chronic rheumatism, typhoid fever, etc. Symptoms.—The symptoms are wholly indefinite; indeed, none may be present. Priory has pointed out that old persons in the incipiency of the disease begin to sleep with the mouth open, so as to effect the entrance of more air. Commencing cyanosis may indicate the development of hy- postasis, and a careful physical examination of the lower lobes of the lungs will show increased fremitus, slight dulness, diminished vesicular murmur, and, in the higher grades, bronchial breathing, with liquid bub- bling rales. The prognosis is based upon the character of the underlying affection. Treatment.—This is an affection in which the treatment of causes alone will suffice, save in instances that are secondary to organic heart- affections, in which prompt bleedings are to be advocated. From a pint to a quart of blood should be taken, and I have seen happy results from the employment of this measure in extreme cases. Tapping the right auricle Avhen the blood refuses to flow from an arm vein has also been successfully accomplished by competent surgeons. The patient's posture must be changed from the dorsal to the lateral, and even ventral, and as soon as possible he should be gotten out of bed. PULMONARY EDEMA. (Edema of the Lungs) Definition.—An effusion of serous fluid into the air-vesicles and in- terstitial lung-tissue. Pulmonary edema is scarcely to be regarded as an independent affection, but as a secondary condition, being in most in- stances associated with pulmonary congestion. Pathology.—It consists of a transudation of serum into the alveolar walls, interstitial connective tissue, and air-cells, and rarely the process is limited to the interstitial tissue. Two forms may, for the sake of con- venience, be recognized: PULMONARY EDEMA. 501 (a) Collateral Edema (Inflammatory Edema).—This is usually local in character, circumscribing an area of the lung that is affected by pneu- monia, abscess, or pulmonary infarction, and is the result of a mild in- flammatory process affecting the vessel-walls. When the condition follows hypostatic congestion the terms " hypostatic edema " and " splenization " have been applied. (b) General Pulmonary Edema.—If congestion be not associated, the portions of the lungs involved by this type look pale; when pulmonary congestion or pigmentation of the tissue is present, the lung appears darker than the normal and the serum is blood-tinged. The Aveight of the lung-tissue, owing to the more or less airless condition of the alveoli, is increased, and yet, though heavier than the normal lung, the affected tissue does not sink in water. To the feel it is boggy, and pits on pres- sure, while on section a serous or sero-sanguinolent (if congestion be pres- ent) fluid of Ioav specific gravity, and poorer in albumin than plasma, flows from the cut surface. Edema is most frequently observed at the bases of the lungs, though it may become general, and as a rule the surface of the pleura is moist; hydrothorax may be present. The mode of production of pulmonary edema is not definitely known. Increased fluidity of the blood on the one hand, and increased tension in the pulmonary vessels on the other, seem to be influential factors in many cases. The heightened blood-pressure may be in great part due to a fail- ure of cardiac power, and particularly to failure of the left ventricle (Welch). When weakness of the left is out of proportion to the weak- ness of the right ventricle, we are apt to have the tension in the pulmo- nary capillaries greatly increased, at least until transudation of serum is induced. Edema also occurs as a result of weakness of the right ven- tricle alone, possibly in consequence of the resulting stagnation of the pulmonary circulation. Obstruction to the overflow, such as occurs in weakening of the left ventricle, or even obstruction in the aorta, leads to heightened tension and, secondarily, to paralysis of the right ventricle. The third and most important factor entering into the production of pul- monary edema is the increased permeability of the vascular walls, due to morbid changes that are the result of impairment of their nutrition. This usually arises in connection with toxic and infectious diseases, Avhen the blood also exhibits more or less change, as in cachectic states, uremia, gen- eral septicemia, or some of the infectious diseases. Local edema also occurs in the neighborhood of inflammatory foci, as in pneumonia. Etiology.—Pulmonary edema is secondary to pneumonia and acute and chronic affections, but not with any degree of constancy; nor is it especially liable to be associated with congestion or with Ioav grades of inflammation of the lungs. Among the diseases of which it forms a ter- minal condition are—valvular affections of the heart, fatal forms of anemia, acute and chronic Bright's disease, cerebral lesions (hemorrhage, trauma- tism), and acute infectious fevers Avith failure of cardiac power. Symptoms.—In edema of the lungs the air-space is lessened in di- rect proportion to the amount of serum occupying the alveoli; hence dyspnea is always present and is often a conspicuous symptom. There are cough and bronchorrhea. The sputum is usually abundant and frothy, and is expectorated with difficulty. At times, and especially in the acute forms, it is tenacious and may give rise to alarming laryngeal obstruction. 502 DISEASES OF THE RESPIRATORY SYSTEM. It is blood-stained if congestion be combined. The condition does not give rise to elevation of temperature, except in the inflammatory type, in which fever is constantly present. The pulse is accelerated and feeble, and cyanosis, particularly in cases of collateral edema, usually appears. The extremities are cool and often livid. Physical Signs.—The reasons adduced to explain the dyspnea likeAvise render intelligible the physical signs encountered. There is dulness, though rarely complete, over the areas involved ; the vesicular murmur is feeble or absent, or there may be broncho-vesicular breathing. Since the bron- chioles contain serum, small rales, having a liquid character, are audible with inspiration and at the beginning of the expiration over the seat of the edema. Vocal resonance and tactile fremitus may be present. The diagnosis, Avith a clear history, is based upon the incomplete dulness that is usually bilateral and most marked at the bases, upon the bubbling rales heard over the corresponding area, and upon the absence of any febrile movement, except the latter be due to some underlying affection. Hydrothorax bears some points of resemblance to edema of the lungs, but in this condition the upper level of dulness is movable in con- sequence of change of position of the patient, as is not the case in edema of the lungs. On the other hand, in the latter affection moist rales are present, Avhile they are absent in hydrothorax. Broncho-pneumonia may be mistaken for pulmonary edema, though it has a different mode of onset. It is also accompanied by fever, glairy, tenacious expectoration, and more sharply-localized areas of dulness then appear in edema. The prognosis is governed by the pre-existing condition to which the edema is due. Thus, if secondary to a general dropsy due to renal or cardiac disease, it often destroys life with great rapidity. Inflammatory edema, following lobar pneumonia, is also grave in the extreme. Treatment.—The treatment does not differ materially from that of the associated or causal affections. The conditions on which a pulmonary edema depends must, hoAvever, be sedulously treated, and the limitation of the transudation and the direct removal of the serous effusion from the lungs is of great importance. We should not fail to frequently change the position of the patient's body, so as to prevent the gravitation of blood to the dependent portions of the lungs. I have Avitnessed excellent results from the use of dry cups placed over the thorax, particularly over its posterior and lateral aspects, and renewed at intervals of six to eight hours. The number applied should range from one and a half dozen to three dozen. In aggravated forms that develop quickly prompt venesec- tion is imperatively demanded. This is a measure which, if resorted to at the proper moment, will often rescue the patient from imminent danger. The condition of the heart and kidneys must be carefully investigated, and any indications presented by them for treatment must not go unheeded. HEMOPTYSIS. (Broncho-pulmonary Hemorrhage) Definition.—An expectoration of blood. Its source may be the bronchial mucous membrane (usually the small bronchi), and less fre- quently it comes from eroded vessels in lung-cavities or their walls; rarely from the larynx, trachea, and larger bronchi. When from the bronchial tubes the term bronchorrhagia should be applied. The source HEMOPTYSIS. 503 of the hemorrhage, however, is not ahvays easily demonstrable, even when it has resulted fatally and the lungs are minutely examined. Pathology.—The lesions are often microscopic, and consist for the most part of ruptured capillary blood-vessels, though larger vessels may also become the seat of erosion or rupture. After death the bronchial mucosa is sometimes found to be swollen, bleeds easily, and is of a dark-red color —soon becoming decidedly pale. The lung-tissue proper may look paler than in the sound lung. When hemoptysis occurs in advance of pulmo- nary tuberculosis the lung-cavity may contain a ruptured aneurysm, or mere ulceration of an exposed vessel may be observed. I have witnessed small, dark-red, dense masses in the air-sacs scattered throughout the lung Avhence came the hemorrhage. Doubtless these are blood-coagula, which result from the clotting of the blood after the latter has been carried into the alveoli. Various associated lesions may be observed. Etiology.—(1) Pulmonary Affections.—(a) Pulmonary congestion from Avhatever source may result in hemoptysis, though the amount of blood lost under these circumstances is usually small. There are many causes that excite congestion of the lungs, some of Avhich reside in ad- jacent organs, it being common in organic disease of the heart, and par- ticularly in disease of the mitral segments. That form of pulmonary congestion Avhich is associated with other affections of the lungs, as well as primary active congestion due to inhalation of hot air, irritating substances, and violent physical exercise, may also result in hemor- rhage, (b) Hemorrhagic infarction may lead to slight hemorrhage (vide Pulmonary Infarction). (e) Croupous Pneumonia.—In this disease hemorrhage is caused by the rupture of the capillaries, and the blood, Avhen expectorated, has undergone a change, becoming rusty-colored. (d) Pulmonary Tuberculosis.—This is pre-eminently the most common cause. Hemorrhage may take place early Avhen it originates from a sharply-limited and minute tuberculous focus, and it may also be attrib- utable to congestion. Undoubtedly its exact source is the mucosa of the small bronchi; later it is the direct consequence of the ulceration of an artery or of the rupture of an aneurysmal sac that has its seat in a branch of the pulmonary artery. After the tuberculous cavities have healed or while quiescent, calcareous masses are, from time, to time, expec- torated, together with more or less blood, (e) Ulcers of the Larynx, Trachea, or Bronchi.—Rarely ulcers in adjacent structures erode the larger branches of the pulmonary artery and cause copious and speedily fatal hemorrhages. Osier observed a fatal hemorrhage in a case of chronic bronchitis with emphysema. (/) Fibrinous bronchitis induces hemop- tysis by rupturing the capillaries in the bronchial mucosa at the time of separation of the bronchial casts, (g) Carcinoma of the lung produces frequent expectoration of blood, (h) Gangrene of the lung. (2) Diseases of Other Organs than the Lung.—(a) Affections of the heart act as a cause, and especially advanced mitral disease when it is due to pulmonary congestion. It not infrequently develops during the stage of adequate compensation. In a preponderating proportion of the latter instances the hemorrhage is slight, but it may be profuse and recur at intervals for many years, (b) Aneurysm of the branches of the pulmo- nary artery and of the arch of the aorta (usually with rupture of its coats) is a rare cause of hemoptysis. 504 DISEASES OF THE RESPIRATORY SYSTEM. (3) Certain diseases, such as purpura haemorrhagica, scurvy, anemia, hemophilia, and malignant forms of certain acute infectious diseases (e. g. yellow fever), cause hemoptysis. In this class of cases the hemor- rhages are due either to a diseased condition of the vessel-walls or to blood-changes. (4) Vicarious hemoptysis is not uncommon during menstruation or when amenorrhea is present. Unless occurring at the time of the regular menses it is not to be regarded lightly, and is of the same significance as when taking place in the male. I cannot agree with those authors who contend that hemorrhage from the lungs in women is without the same dire significance as in the opposite sex. (5) Arthritic (Gouty) Endarteritis.—According to Sir Andrew Clarke and others, this is a common cause of recurring hemorrhages in aged per- sons (over fifty years). Symptoms.—Hemoptysis is so commonly a symptom of that most frequent and dread disease, phthisis, as to raise suspicions of the latter in the minds of the patient and physician as soon as it occurs. It is ap- propriate, therefore, to note, first, the features of hemoptysis when depend- ent upon pulmonary tuberculosis, and then to point out its clinical peculiarities when due to other conditions. In incipient pulmonary tuberculosis hemoptysis develops suddenly as a rule, a Avarm, saline taste, lasting but a few moments, generally preced- ing the expectoration of blood. The blood is coughed up, and the bleeding may last only a few minutes or may continue for days, the sputum being apt to remain blood-stained for a longer interval. The immediate effect of the hemorrhage, hoAvever slight, is to alarm the patient, inducing, besides mental agitation, cardiac palpitation and other nervous concomitants. A small hemorrhage is not attended with any other results, but large ones give rise to the symptoms of shock, com- bined with those of symptomatic anemia. When the hemorrhage is large, blood to the amount of a mouthful may be ejected with each cough, and in these instances the effect of the profuse bleeding is evidenced by such symptoms as vertigo, syncope, cold extremities, excessive pallor, perspi- ration, and a rapid, small, feeble pulse. This is followed, if the attack does not prove speedily fatal, by considerable restlessness, and later not infrequently by mild delirium and more or less fever. In comparatively rare instances the same patient has a single hemor- rhage ; more frequently he has several at shorter or longer intervals. Large or small bleedings may precede by weeks, months, or even years any rational symptoms or physical signs of pulmonary tuberculosis. In such instances latent foci of disease may be assumed to have pre-existed. In quantity the hemorrhage varies greatly : there may be less than one ounce ejected or it may amount to a pint or more before the bleeding ceases. In advanced cases in Avhich cavities have formed large vessels may become eroded, followed by copious and dangerous hemorrhage. Fatal hemorrhage may take place into a cavity without the occurrence of hemoptysis, as in a case dissected by Osier at the Philadelphia Hospital. The distinctive characters of the blood discharged are mainly as follows: bright color, very frothy (being mixed with air), and not clotted. A rare exception to the rule may be noted in the case of hemorrhage proceeding from a large cavity, the blood pouring forth in a free, dark stream. HEMOPTYSIS. 505 Physical Signs.—These are, for the most part, negative. Quite com- monly moist bronchial rales are audible on auscultation ; palpation and percussion should not be practised during nor immediately after the hemoptysis. Hemoptysis not Due to Pulmonary Tuberculosis.—(a) In affections of the mitral and aortic valves, especially in mitral stenosis, hemorrhage from the bronchi is not uncommon, and the way in which these lesions lead to pulmonary congestion is explained in the discussion of Organic Affections of the Heart. During the progress of these cases, hemorrhages often occur at considerable intervals; they may either be slight, lasting only a few months, or quite free, extending over periods of a few days or a week. (b) As a rule, in the beginning small hemorrhages occur for several weeks from pressure of an aneurysmal dilatation upon the bronchial mu- cosa, or there may be weeping of blood through the exposed layers of fibrin composing the walls of the sac. The bleeding point can be dis- covered with the laryngscope, Avhen an aneurysm of the innominate or of the aorta impinges upon the trachea. A large and often quickly fatal hemorrhage occurs from rupture into the respiratory tract. (c) "Arthritic hemoptysis" is undoubtedly associated with gouty, degenerative changes in the terminal blood-vessels of the lung, though no coarse pulmonary lesions are induced by the recurring hemorrhages. Though the hemorrhages may occur at intervals for years, as a rule they finally become arrested, and only rarely lead to a fatal issue. I have never observed this form of hemoptysis occurring independently of chronic bronchitis. In emphysema and chronic bronchitis small hemorrhages may occur, and occasionally coagula in the form of casts are formed in the bronchi and afterward ejected. It is probable that the source of the large bleedings that occur under these circumstances is an ulcer in the bronchial mucosa. (d) The hemoptysis that is connected with the menstrual function is of frequent occurrence. I saAV recently a patient in Avhom free bleeding has occurred at intervals of four weeks for a couple of years, with an absence of the menses during the same period of time. In another in- stance, a patient of Dr. Byers, recurring hemorrhages of the lungs took place instead of the regular menstrual discharge for three successive months, and a comparatively rapid form of phthisis was developed. This class of cases must be regarded as grave. (e) The preceding group is to be distinguished from those cases in which trivial bronchial hemorrhages sometimes occur and in delicate, hys- terical females. Though these bleedings are accompanied by cough, it is not uncommon to find, upon careful examination, that the blood comes from the upper air-passages. (/) Hemoptysis may result from severe injuries inflicted upon the thorax, and last for days together. (g) A person may have a single or many recurring attacks of hemop- tysis without assignable cause, if A\re except severe muscular strain or in- tense mental excitement. Although pulmonary tuberculosis does not supervene in instances of this sort, yet not a feAv may be excited by a permanently limited tuberculous focus which may be indeterminable by the usual methods of examination. I have more than once seen a cure 506 DISEASES OF THE RESPIRATORY SYSTEM. result from an active course of treatment Avith creasote and appropriate hygienic measures. In Avell-marked instances of the kind a complete arrest of the trouble resulted from a change of climate. Differential Diagnosis.—A reliable diagnosis necessitates the cer- tain exclusion of hemorrhage from the higher air-passages, pharynx, esophagus, and stomach. In epistaxis the blood may directly enter the naso-pharynx, exciting cough and being discharged as in hemoptysis. A careful examination of the nasal chambers should be made, however, in cases in which the symptoms are suggestive of epistaxis. Bleeding may take place from the gums, from chinks in the pharynx, or from varicose veins. If the seat of the bleeding be the pharynx, the hemorrhage is not free, the blood being commingled with a preponderating proportion of mucus; if from the gums, it may be more copious (as in ptyalism or scurvy), and the hemorrhage then simulates that of pulmonary hemoptysis. An inspection of the mouth will disclose whether or not the gums are the source of the hemorrhage. The distinctive points between hemoptysis and hematemesis will be found in the discussion of the latter affection. Prognosis.—The gravest apprehensions are constantly entertained by sufferers from hemoptysis, but immediately fatal results are of rare occur- rence ; and of this fact the patient should be repeatedly assured by the attending physician. In case, hoAvever, the existence of thoracic aneur- ysm is definitely known, the consequences of hemoptysis are certainly fatal. With reference to the effect of hemoptysis upon tuberculous pulmo- nary disease opinions differ widely ; I am of the belief, however, that prior to the existence of cavities it exerts a favorable rather than an unfavor- able influence upon the course of the disease. On the other hand, in cases in which cavities exist at the time of the occurrence of hemoptysis an opposite effect is observed. The fact that hemoptysis often precedes by prolonged intervals of time the development of pulmonary lesions is an argument in favor of Niemeyer's view, that phthisis is caused by hem- optysis. There can be no doubt, however, that some blood finds its way into the bronchi below the point of bleeding and into the air-cells, setting up in the latter places of irritation and even lobular inflammation. In this way hemorrhages may aid in rendering the tissues more susceptible to tuberculous infection. In cases of profuse hemorrhage, due to aneur- ysm or to the erosion of large branches of the pulmonary artery in phthisical cavities, death may be suddenly induced, and is caused largely by inundation of the lung and the consequent impossibility of respiration. Treatment.—Since the hemorrhage is ascribable to (1) congestion of the bronchial mucosa, (2) erosion of the vascular walls, and (3) blood- changes, obviously the treatment of individual cases must be modified according to the character of the causal condition. In many instances of hemoptysis due to congestion of the bronchial mucosa the hemorrhages are, comparatively speaking, slight; hence, apart from keeping the patient at absolute rest, little treatment is re- quired. If not excessive, they are often salutary in their effect. If free, the physician's aim should be to decrease the power of the heart's contraction, and to accomplish this end the patient should be placed in bed, and not allowed to change his position or to speak above a whisper. The diet should be light, nutritious, and non-stimulating, all hot drinks HEMOPTYSIS. 507 and alcoholics being prohibited. Among cardiac sedatives to be em- ployed Avith a vieAv to reducing the rapidity of the heart's action and low- ering the blood-pressure, if the patient be neither feeble nor anemic, the ice-bag to the precordia is most valuable; if the pulse be full and strong, we may use aconite and other arterial sedatives. Arthur Foxwellx recom- mends venesection in cases in which venous congestion is present, and also lays stress upon measures that confine the blood to the systemic circula- tion—i. e. nutritious food, large doses of the nitrites, hot foot-baths, leeches to the anus, and ligatures applied to the thighs and arms. The pulmonary capillaries may also be effectually depleted by the use of salines, Avhich should be given in full doses. In my OAvn experience dry cupping over the chest has been of the greatest service in cases dependent upon pulmonary congestion. Eating ice and partaking freely of iced drinks are also useful measures. If the attack tends to become prolonged and exhausting, Ave may increase the coagulability of the blood by the use of such remedies as gallic acid, acetate of lead, or calcium chlorid. Hemoptysis is usually accompanied by cough, that constantly disturbs the vascular serenity and excites fresh bleeding. For this symptom opium, and in the worst cases morphin hypodermically, should be freely administered. AVhen hemoptysis is associated with organic disease of the heart, the main indication is to strengthen that organ by bodily rest and quiet and by the use of cardiac tonics, especially digitalis. I have had under ob- servation and treatment for several years a young physician who has been suffering from frequent, marked hemoptysis, due to mitral regurgitation, and in whose case the bleedings are readily controlled by the free use of digitalis. When in thoracic aneurysm or advanced pulmonary tuberculosis the blood is ejected in mouthfuls, Ave may safely infer that erosion of the ves- sel or rupture of the aneurysm has taken place. Here the object is to bring about the formation of a thrombus that will arrest the hemorrhage. Perfect quiet in the horizontal position tends to allay the vascular excite- ment, and the induction of fainting by venesection is a measure worthy of a trial, though efforts at treatment are unpromising. Opium is contra- indicated in the latter class of cases, OAving to the fact that if cough be checked inundation of the bronchial system Avith the blood (the chief danger) will be favored. In all instances of hemoptysis treatment should not cease with cessa- tion of the hemorrhage. A tendency to recurrence is manifested in many cases, and hence measures calculated to avoid this event must be brought into play. The patient should not be alloAved to indulge in a stimulating diet; he should eschew tobacco and alcoholic stimulants, and avoid all physical and mental strain. Every source of bronchial irritation should be carefully avoided, and attacks of bronchitis, however mild, should re- ceive the most careful attention. Moderate exercise is serviceable, as well as a liberal amount of nutritious food. 1 British Medical Journal, 1894, p. 194. 508 DISEASES OF THE RESPIRATORY SYSTEM. PNEUMORRHAGIA. (Pulmonary Apoplexy) Definition.—An escape of blood into the air-cells and interstitial tissue, with or without ulceration of the pulmonary parenchyma. Pathology.—It may be, though rarely, (a) diffuse, when the lung- tissue is ulcerated, as in cerebral apoplexy ; or it may be (b) circum- scribed, as when the blood is effused into the air-cells and the interstitial tissue, with rupture of the parenchyma. The latter form will be consid- ered in the discussion of Pulmonary Infarction. Etiology.—Diffuse pulmonary apoplexy is caused by the rupture of a thoracic aneurysm that has become adherent to the surface of the lung. Its most common cause is traumatism, especially penetrating wounds of the lung, but adult life and the male sex are to be regarded as predisposing factors. The lung-tissue is sometimes the seat of diffuse hemorrhagic infiltration in septico-pyemia and cerebral disease. Symptoms.—These are ill-defined. Profuse hemoptysis, urgent dyspnea, and cyanosis, followed by increased evidences of collapse, together with a clear history, should raise suspicions of the existence of diffuse pneumorrhagia. The physical signs are indicative of extensive consolidation arising suddenly, and not of the nature of the lesion. The prognosis is practically hopeless, and abscess or gangrene may result if these cases recover from the immediate effects of the hemorrhage. Treatment.—Absolute rest of the body in the horizontal position is the one measure that offers a slight prospect of alleviation, for thus the formation of a clot, followed by arrest of the hemorrhage, is encouraged. It is unAvise to use opium to allay the cough, since the action involved assists in ejecting the extravasated blood, which will, in consequence of gravitation and the effect of respiration, submerge speedily so much of the lung-tissue as to hasten the fatal termination. Ergot is not to be given hypodermically, since it raises the blood-pressure in the lesser cir- culation, but the internal and external use of cold has been highly recom- mended. With the onset of collapse cardiac stimulants become absolutely necessary, though many cases are so rapidly progressive as to reach a moribund state before remedial agents can be applied by the physician. PULMONARY EMBOLISM. (Hemorrhagic Infarction; Embolism of the Lungs) Pathology.—Embolic infarctions are firm, airless, brown or black, wedge-shaped masses, with their bases usually at the pleura, which soon becomes lustreless and covered Avith a delicate layer of fibrin. The in- farctions may be single or multiple, and sometimes occupy the greater portion of the lobe; in the majority of cases, however, their size equals that of a walnut. Their most frequent seat is at the back of the lower lobe. The microscope shows the presence of leukocytes and red blood-corpuscles in the air-cells and in the alveolar septa. Collateral congestion and edema are frequent concomitants, and, less frequently, pneumonic consolidation appears. PULMONARY EMBOLISM. 509 Etiology.—The condition is produced by the blocking of the pulmo- nary arteries by an embolus or thrombus. When the circulation in the pulmonary capillaries is feeble, hemorrhagic infarction may be the result of stasis, and this is probably the most frequent form. It is met Avith in connection with diseases of the lungs, and also with mitral stenosis or re- gurgitation. The plug that occludes the blood-vessel may be composed of leukocytes, as in leukocythemia, and the. chief sources of the matter that enters into the emboli are the thrombi in the right side of the heart and in the systemic veins. Infectious emboli, resulting in abscess, Avill be considered in connection with Abscess of the Lungs. Occlusion of a branch of the pulmonary artery cuts off completely the circulation to the territory supplied by that branch, and hemorrhagic infarction occurs as a result, just as elsewhere. Symptoms.—Not all infarctions give rise to symptoms ; on the con- trary, occlusion of a main branch of the pulmonary artery usually ter- minates life speedily. The latter accident occurs not infrequently in con- nection with organic disease of the heart, and if death be not the imme- diate result or if a smaller branch be occluded, the most alarming symp- toms ensue, such as syncope, urgent dyspnea, and convulsions with un- consciousness. The first and most distressing symptom is dyspnea, which is attended by frantic efforts at breathing and by great mental anxiety. Occasionally hemoptysis is an early symptom, and of primary significance if it occur in a patient suffering from mitral disease. If, together with these symptoms, loss of consciousness with convulsions occurs, the diagnosis becomes wellnigh complete. Cough usually supervenes, accom- panied by the expectoration of dark, gelatinous, mucoid masses. Large lymph-cells containing blood-corpuscles are found in the sputum, these giant-cells being most commonly seen in instances of organic cardiac affec- tions. They are supposed to transform the blood-corpuscles into pigment- matter. The physical signs may either be negative—as, for example, when the infarctions are small or deeply located—or they may give information as to the seat and extent of the affected part. When present they are the symptoms of sharply-localized consolidation (increased fremitus, resonance, percussion-dulness, moist rales, and bronchial breathing), and it is not improbable that in many cases the physical signs are due, in great part, to associated conditions, such as bronchitis, edema, or collateral consoli- dation. The appearance of the friction-sound in the course of suspected cases is a great aid in diagnosis. The heart's action becomes enfeebled, the pulse is small and frequent, and the surface of the body is cool and frequently bedewed with cold sweat. Fever may either be present at the onset or absent throughout. The signs of embolic abscesses in the lungs will be elsewhere detailed (vide Pulmonary Abscess). Diagnosis.—To establish the diagnosis of pulmonary embolism there must be a clear history of some etiologic condition, and the sudden appear- ance of such symptoms as dyspnea, cough, bloody expectoration (in par- ticular), chest-pain, loss of consciousness, and convulsions, corroborated by the physical signs of a sharply-defined spot or spots of consolidation. Prognosis.—The prognosis differs with the character of the primary condition. On the Avhole, it is exceedingly grave, though the absorption of an embolism, followed by the disappearance of the urgent symptoms, 510 DISEASES OF THE RESPIRATORY SYSTEM. is not impossible. In case death does not occur soon, infarcts may give rise to abscess or gangrene, the result either of the presence of bacteria in an original embolus or of their entrance through the air-passages. In other cases an infarct may undergo fibroid change and contraction, and may even calcify. Treatment.—Beyond procuring absolute rest of the body and a re- lief from the distressing symptoms, the treatment should be aimed at the affections on which this form of embolism depends. Dyspnea and pain may require the hypodermic use of atropin and morphin, preferably in combination. CHRONIC INTERSTITIAL PNEUMONIA. (Fibroid Induration ; Cirrhosis of the Lung.) Definition.—A chronic exudative inflammation of the lungs, cha- racterized by the formation of fibrous connective tissue. It may occur as a primary or as a secondary affection. Pathology.—Two leading forms of cirrhosis of the lung may be recognized: (a) Local, and (b) Diffuse, though these do not demand sep- arate description. It is a unilateral affection, and the lung of the side involved is much shrunken, its dimensions in some cases being incred- ibly small. I have seen one instance in which the organ measured four inches in its longest and less than three in its shortest diameter. It lies tightly against the spine, and has frequently been overlooked, the heart occupying the affected side, being drawn in that direction during the progress of the disease. The heart is enlarged, chiefly due to hyper- trophy of the right ventricle, and the pulmonary artery is the seat of atheromatous change. The other lung is overdistended (compensatory emphysema), and may encroach upon the mediastinum. Intrapleural and pleuro-pericardial adhesions may be exceedingly firm and thick on the one hand, and only moderately so on the other, though rarely the pleura are intact. The cut surface of the affected lung is hard, dry, airless, shiny, and usually light-gray in color (rarely, reddish-yellow), and the lung- tissue cuts with great resistance. The mouths of the blood-vessels and bronchi, which are often greatly dilated (bronchiectatic), may be observed gaping in the cut section. Cavities may be A\Tholly or in part due to the superaddition of a tuberculous process, though even when the affection is non-tuberculous they may be quite numerous. Phthisical cavities may often be discriminated by their usual situation at the extreme apex. The lung that is unaffected by the fibroid process is also quite often the seat of tuberculous change. Etiology.—The disease is almost invariably secondary, and very generally accompanies prolonged inflammatory and chiefly local changes in the lungs. It may also follow acute inflammatory processes. Ex- amples of localized interstitial pneumonia are seen in connection with pul- monary tuberculosis, emphysema, syphilis, hydatids, and fibroid indura- tion secondary to thickening of the pleura. Diffuse interstitial pneumonia has a variety of causes : (a) It may fol- low acute lobar pneumonia in cases in which resolution is delayed, and CHRONIC INTERSTITIAL PNEUMONIA. 511 here the fibrinous exudate filling the air-cells becomes organized into connective tissue. Fibrous tissue is also substituted for the alveolar walls. The condition is exceedingly rare, and no instance of the sort has fallen under my own observation.' (b) Pneumonia, appearing as a complication in influenza, is very liable to produce chronic interstitial pneumonia. (c) The disease may also result from atelectasis due to compression, as by aneurysms or neoplasms. (d) It most frequently, however, folloAvs broncho-pneumonia in either its acute or subacute form (Charcot). The process starts in the bronchi and extends to the surrounding lung-tissue, till finally an entire lobe, or even an entire lung, may become involved. Tuberculous broncho-pneu- monia also leads to the production of neAv fibrous tissue, but here the pro- cess is a conservative one (vide Pulmonary Tuberculosis), and hence is not to be classed with chronic interstitial pneumonia. (e) The initial lesions may be located in the pleura, and the lung be- come involved as a sequel, and the chief lesions may be located in the adherent pleural membrane, with bands of connective tissue extending into the lung. The bronchi are inflamed and sometimes dilated. Chronic interstitial pneumonia may, however, exist without implication of the pleura, and in view of this fact the primacy of pleural thickenings cannot be granted unqualifiedly when they form a part of the lesions of fibroid induration. The various forms of the disease thus far described arise secondarily. It may also occasionally originate as a primary affection (1) from the inhalation of different forms of dust (vide Pneumonokoniosis). (2) Delafield describes "a special form of lobar pneumonia." lie contends that lobar pneumonia terminates only in resolution or in death, and that this special disease, with its production of newly-formed connective tissue, is from the first a special form of inflammation of the lung. This variety runs a subacute or even chronic course, and terminates by crisis. It is an exudative inflammation, with the formation of new tissue from the onset; but the consolidated areas are not so large as in ordinary pneu- monia, and cut sections lack the granular character of the latter. Symptoms.—The patient suffers from cough, Avhich increases in in- tensity with the progress of the affection. There is a mucous, sero-mu- cous, or rarely bloody expectoration; dyspnea occurs early, and fre- quently is present only on ascending heights; and uneasiness, or even pain, over the side of the chest involved may be experienced. In cases in which the bronchi become dilated the characteristic symptoms of bron- chiectasis are superinduced. The general symptoms consist merely in a loss of flesh and of strength. Fever is altogether absent. Physical Signs.—Inspection.—The chest-wall of the affected side is re- tracted, Avhile the healthy lung is enlarged (compensatory emphysema). The spinal column is curved laterally. The affected side is fixed during respiration, and the heart is displaced by traction toward the affected side. If the left lung be involved, the apex-beat Avill be displaced to the left and slightly upward; if the right, the apex-beat Avill be observed to the right of the sternum. The ribs approximate, thus obliterating the inter- spaces, and the shoulder droops over the shrunken chest-wall. Palpation.—The tactile fremitus is usually increased ; if the pleura be 512 DISEASES OF THE RESPIRATOR!' SYSTEM. much implicated or thickened, hoAvever, fremitus may be decreased. Pal- pation discovers no expansile motion. Percussion.—The percussion-note varies. Dulness is common, owing to consolidation of the lung, but flatness is occasionally met with, and a tympanitic or amphoric note is sometimes elicited over a dilated bronchus. Auscultation.—The breathing is bronchial or more or less sonorous as a rule, and over bronchiectatic cavities it is cavernous or, rarely, amphoric. Near the base it is frequently feeble, distant, and even altogether sup- pressed. Subcrepitant, sonorous, sibilant, or gurgling rales may be audi- ble, and dry, creaking, or leathery friction-sounds may also be heard. Prognosis.—The course of the complaint is exceedingly chronic, and lasts over many years. Death may result from an intercurrent attack of acute pneumonia affecting the other lung. The disease ahvays shortens the duration of life, and less frequently is the direct cause of death. Rarely a fatal issue is due to dilatation of the right heart, followed by tricuspid regurgitation. Treatment.—The condition is incurable. The patient should, how- ever, be placed under the best sanitary conditions, and if practicable he should make a permanent change of climate. A suitable resort should be selected in accordance with the rules indicated in the treatment of Pulmonary Tuberculosis, and every effort should be put forth to improve the general nutrition of the patient. Due attention should be given to the associated bronchitis, as well as to any symptoms that may arise during acute exacerbations. BRONCHO-PNEUMONIA. (Capillary Bronchitis; Catarrhal Pneumonia.) Definition.—An inflammation of the minute bronchi and air-vesi- cles, due either to the extension of inflammation from the capillary bronchi to the air-vesicles or to an inflammatory process set up in ate- lectatic lobules. Pathology.—Macroscopically, the lungs present decided variations in persons Avho have died of broncho-pneumonia. On the pleural sur- face may be noticed purplish or slaty patches, often sunken (atelectasis), intermingled Avith the more elevated patches of healthy lung and gray- ish consolidation, and smoother and more moist than croupous pneu- monia. Similar appearances are presented by the cut surface. On pressure fluid exudes-—edematous from the healthier areas, and gray- ish and puriform from the consolidated areas. The mucosa of the large bronchi may look natural, though frequently it is congested, while the small bronchi usually contain more or less muco-purulent mate- rial. Their walls are greatly thickened, and on section the cut sur- face presents a nodular appearance. Dilatation of the smaller bronchi may be observed, and minute consolidated areas, varying in size from that of a pin's head to that of a pea, may be seen surrounding the thick- ened walls of the bronchi. When, as frequently happens, they become confluent, large areas—an entire lobe and even an entire lung—of lung- BR ONCHO-PNE UMONIA. 513 tissue may become consolidated. The solidified zones are firm to the touch, being destitute of air, and at first they contain blood ; hence their color is a dark-red, but later it presents a grayish hue. The condition is usually bilateral. As a rule, the bronchial glands are SAvollen and in- flamed. In the non-consolidated portions of the lung the air-cells are found to be considerably dilated. The pulmonary pleura is often coated Avith fibrin, but less regularly than in croupous pneumonia. The essential lesion is a productive inflammation of the bronchi and of the immediately surrounding air-spaces. The inflammation is from the first not exudative, but productive; that is, with the formation of neAV tissue (Delafield). This form of inflammation naturally lasts for a longer time than would the exudative, and merges into a chronic pro- ductive inflammation of the lung, it may be Avith subsequent sclerosis or chronic thickening of the pleura. The exudate is ahvays more marked toAvard the center of the process, while the air-cells toAvard the periphery show much less exudate. The latter consists of serum, some mucus, and many SAvollen cells from the alveoli (soon shoAving fatty degeneration), leukocytes, and also red blood-cells in small numbers. Fibrin is seen in small quantity if at all. In deglutition and aspiration pneumonia the leukocytes are in much larger number, and the exudate tends to suppuration, Avhile in the more hemorrhagic forms the red blood-cells are present in larger numbers. Kikodse1 found the blood in broncho-pneumonia to contain an in- creased number of Avhite corpuscles, except in fatal or very severe cases. The cause of this increase appears to be the return into the cir- culation of the corpuscles that have passed into the alveolar spaces; hence it ceases after the fever declines. Among the associated lesions that remain to be mentioned are—(a) Catarrhal inflammation of the mucous membrane of the bronchi; and (b) Exudative inflammation of the air-cells, Avhich become filled with epithelium, fibrin, and pus, Avith resulting consolidation of the lung. The epithelial cells lining the air-sacs, since they7 are more numerous in young children than in adults, form a larger part of the inflammatory exudate in the former than in the latter. Etiology.—(1) A marked predisposing influence is age, the disease being most prevalent amongst young children. In them it may appear in association with measles, whooping-cough, scarlet fever, and diphtheria, but not infrequently it is entirely independent of these diseases. Infants are especially susceptible to the affection, most instances of pneumonia at this period of life being of the lobular form. Other conditions that act as predisposing factors in children are improper exposure to cold, unsanitary surroundings (especially impure air), rickets, and chronic diarrhea. Broncho-pneumonia is also frequent in the aged, often being occasioned by certain debilitating causes and chronic diseases that are common to advancing years. (2) Season.—The affection prevails especially in the Avinter and spring months; particularly is this the case in those forms that are unassociated with the acute infectious group of diseases. (3) It also supervenes as a complication in such acute infectious dis- eases as influenza, typhoid fever, erysipelas, and small-pox, and is of 1 Annual of the Universal Medical Sciences, 1892, vol. i. sec. A. 33 514 DISEASES OF THE RESPIRATORY SYSTEM. serious import. According to my OAvn observations, it is more com- monly met Avith in the diseases above mentioned than is lobar pneumonia. (4) The inhalation of food-particles and other substances often serves to convey the agents of inflammation to the lobules of the lungs. Thus a long-continued recumbent posture disposes the patient to broncho- pneumonia, since it affords a ready entrance to inflammatory irritants. It is, however, in conditions in which the larynx and bronchi have totally or in part lost their sensitiveness—as in coma due to apoplexy, uremia, and allied cerebral states—that retention of bronchial secretions occurs, and that, owing to gravitation, these secretions reach the minute bronchi. Particles of food and drink are also inhaled. Inhalation pneumonia may follow operations upon the nose, mouth, larynx (trache- otomy particularly), and is often secondary to carcinoma of the larynx and esophagus. It is also the pneumonia of new-born children. (5) It must not be forgotten that very frequently broncho-pneumonia is caused by the tubercle bacillus (vide Pulmonary Tuberculosis). A sub- acute type may also occur in the course of vesicular emphysema. (6) The Avork of Weichselbaum has shown the presence of strepto- cocci with the greatest frequency. The pneumococcus has frequently been found, and in a goodly number of cases the staphylococcus aureus (Neumann, Birch-Hirschfeld), while in influenza the specific organism may itself cause broncho-pneumonia (Pfeiffer and others). Numerous other organisms have been found, and it seems a Avell-established fact that various pathogenic bacteria may cause the disease. Symptoms.—Two clinical forms may be distinguished : (a) primary; and (b) secondary. (a) Primary broncho-pneumonia is met with most frequently in adults, and presents, for the great part, the symptoms of an acute bronchitis of severe grade (cough, dyspnea, pain, fever, and prostration). When oc- curring in subjects previously enfeebled the onset may be someAvhat gradual. The cough is attended with a catarrhal expectoration that is glairy and tenacious, and may be tinted with bright-red blood in the form of droplets or points. The fever is moderate, the temperature rang- ing from 101° to 104° F. (38.3°-40° C), and is of irregular type ; in severe cases, hoAvever, continued high temperature may occur. Physical examination gives the same result as in the secondary form (vide infra). The duration is from two to four weeks, the fever terminating by lysis. (b) Secondary broncho-pneumonia is the variety usually met Avith. The symptoms are frequently veiled by those of the primary affection, and, indeed, a moderate grade of lobular pneumonia is frequently unsuspected during life when arising in the course of other grave diseases. It is usually preceded by bronchitis affecting the larger bronchi, and in this common event the first symptom that directs attention to the dis- ease is the sudden increase in the frequency of the respirations, which rise as high as 60 or even 80 per minute. An initial chill is rare. Fever develops suddenly, or, if previously present, increases rapidly. An early symptom is the cough, which is usually hard, harassing, frequently pain- ful, and accompanied by expectoration. The pulse-rate is abnormally fre- quent, and in the later stages may be quite rapid, feeble, and irregular. The type of the fever is similar to that of the primary form. Physical Signs.—At the beginning of the attack the only sign is the BR ONCHO-PNE UMONIA. 515 presence of subcrepitant and sibilant rales, pointing to a general capil- lary bronchitis. Shortly larger or smaller areas of consolidation become manifest. At first rapid breathing, and soon cyanosis, affecting first the lids and conjunctivae, may be observed ; later, the face becomes dusky Fig. 45.—Illustrating broncho-pneumonia. The dark spots represent the consolidated areas; the white dots indicate rales : A, coalescence of two areas of consolidation. and the finger-tips blue. Palpation shows defective expansion and in- creased tactile fremitus over the consolidated areas. The percussion-note is dull or, less frequently, hyperresonant if the area be small. Auscul- tation reveals numerous fine, subcrepitant rales, corresponding to the con- solidated portions. The respiratory murmur may be bronchial, though more often broncho-vesicular. The signs are usually noted in both lungs. Duration.—(1) In children this varies considerably in different cases. Rarely do fatal instances last more than two or three weeks, Avhile they may be as brief as two or three days. On the other hand, cases in which recovery ensues frequently last from six to eight weeks, though in some instances from one to three weeks only. Two special forms demand brief description : (a) The cerebral, in which restlessness, convulsions, and delirium be- 516 DISEASES OF THE RESPIRATORY SYSTEM. come so marked as to overshadoAv entirely the pulmonary symptoms. Not infrequently the onset is characterized by convulsions, high fever, pros- tration, and alternating stupor and delirium. After such symptoms have continued for from two to five days, pulmonary symptoms appear, while the cerebral decline. (b) Other cases may manifest a subacute onset, in Avhich there is ano- rexia and occasional vomiting, with the nervous symptoms before noted. (2) The protracted forms are those in Avhich (a) the symptoms of acute broncho-pneumonia give place to those of a similar though chronic state. The general disturbances may not be marked in some in- stances, but usually there are cough, loss of appetite, or inability to gain in flesh and strength, and the signs of consolidation persist, (b) Those presenting fever of an irregular type, together with decided prostration, in addition to the symptoms of the preceding variety. In many of the latter instances the lesions are tuberculous in nature. In adolescence the cerebral symptoms are not as ay ell marked as in children. Two anomalous varieties are met Avith in practice that demand brief separate description : General Broncho-pneumonia.—The attack develops suddenly and is severe. There are chills, high fever, marked prostration, headache, chest and loin pains, a rapid pulse (soon becoming feeble), rapid and labored respirations, cyanosis, restlessness, delirium, and cough that is at first dry, and followed by mucous, muco-purulent, blood-tinged sputum. The physical signs are defective expansion and an increased tactile fremitus. The percussion-note may be either normal, tympanitic, or dull ; the auscultatory signs are large moist, subcrepitant, crepitant, sib- ilant, and sonorous rales over both lungs, and a harsh or broncho-vesicular respiratory murmur. The affection is very grave. Resembling Tuberculous Broncho-pneumonia.—The symptoms appear slowly, and the case pursues a subacute or even chronic course. Cough, catarrhal expectoration, moderate fever (often of a hectic type), and night- sweats are noted. Physical examination discloses general bronchitis, together with cir- cumscribed areas of consolidated lung-tissue. Resolution may take place at the end of eight or ten weeks, and complete recovery ensue ; when, how- ever, this favorable event does not occur, the case drags on for an indefinite period, and finally terminates fatally. There are no bacilli in the sputum. Diagnosis.—This can be arrived at by considering— (a) The nature of the antecedent affections and their etiologic circum- stances ; (b) The distribution of the consolidated areas in both lungs; (c) The fact that the physical signs of consolidation are subsidiary to those of general bronchitis ; d) The intense dyspnea and cyanosis ; e) The type of the fever, irregular as a rule, and its gradual decline; (/) The frequent long duration. Differential Diagnosis.—Doubtless, lobar pneumonia is constantly mis- taken for broncho-pneumonia, and particularly when, in the latter disease, a large portion of one or both lungs becomes inflamed in consequence of the coalescence of small areas of consolidation. The points of distinc- tion may be tabulated as follows : BRONCHO-PNEUMONIA. 517 Broncho-pneumonia. Lobar Pneumonia. Etiology. Presence of pathogenic organisms * (strep- Presence of the Diplococcus pneumoniae. tococci). Usually secondary to bronchitis and acute Usually a primary disease. infectious diseases (e.g. measles, whoop- ing-cough). Clinical History. Onset gradual. Onset abrupt; previous health generally good. Fever is, in proportion to the extent of Fever is high, of continued type, and inflammation, of irregular type, and falls between the fifth and ninth days . declines by lysis after a variable dura- by crisis. tion. Sputum glairy, tenacious, and in adults Sputum characteristic (rusty or prune- may be blood-tinged. juice). Dyspnea and evidence of carbon-dioxid Respiration panting, but dyspnea and poisoning prominent. cyanosis relatively less marked. Physical signs of general bronchitis Signs of bronchitis generally absent, always marked, and usually preponder- those of lobar consolidation always ating over those of consolidation. preponderating. Consolidation commonly bilateral. Commonly unilateral. Duration indefinite, often extending over Duration definite as a rule, convalescence many weeks. following crisis. Consolidated areas liable to become the Far less likely to become the seat of tu- seat of tuberculous infection. berculous infection. It is also difficult to distinguish tuberculous broncho-pneumonia from the disease under consideration. Indeed, a non-tuberculous broncho-pneu- monia may be located at the apex of the lung and accurately simulate the symptoms and signs of the tuberculous form. The differentiation is to be based upon the presence or absence of the signs of softening, and upon a microscopic examination of the sputum (which in a child may be vomited). The softening in tuberculous pneumonia does not, however, begin very promptly ; but if elastic fibers and tubercle bacilli be found, the diagnosis is at once set at rest. Prognosis.—In broncho-pneumonia the severity and gravity of the symptoms and the extent of the involvement of lung-tissue are propor- tionate to one another; hence it follows that the disease may either be devoid of serious import or it may be fraught Avith great danger to life. Its course is subject to decided fluctuations, the periods of exacerbation in the symptoms often marking the time of the development of the gravest features. Apart from the extent of the lung-tissue involved, how- ever, we must consider especially the condition of the patient at the time of invasion. If the constitution has been previously undermined, as is frequently the case in children, broncho-pneumonia is very apt to be fatal. The disease is less dangerous when it develops in the course of, or follows, measles than when secondary to whooping-cough, influenza, or diphtheria. Wiry, thin children seem to stand broncho-pneumonia better than fat, flabby ones (Osier). Deglutition and inspiration lobular pneu- monia, especially when occurring after operations upon the larynx or 1 The diagnostic value of the discovery of streptococci is not pronounced. Numer- ous other organisms have been found in broncho-pneumonia in their absence, and a sim- ilar organism (Streptococcus pneumoniae, Weichselbaum) has been found in a number of cases of croupous pneumonia. 518 DISEASES OF THE RESPIRATORY SYSTEM. trachea, are frequently fatal. The mortality-rate in this disease varies from 25 to 50 per cent. Treatment.—Prophylaxis.—There are few diseases that can be so effectually prevented as can broncho-pneumonia. In the first place, proper attention to the mouth as Avell as to the position of the patient (which should be changed frequently) during attacks of acute infectious diseases Avill prevent its development in a great proportion of this large class of cases. Adequate protection against exposure to cold during con- valescence from measles, whooping-cough, etc. is also a potent factor in preventing the disease, as is the timely handling of catarrhal affections of the nose, pharynx, larynx, and larger bronchi. Certain sanitary arrangements are of the utmost practical importance.' The sick-room should be Avell ventilated and its atmosphere kept at a uniform temperature—68° to 70° F. (20°-21.1° C). The air of the room should also be well laden with moisture, which may be generated from a croup-kettle or other suitable vessel. Local Measures.—In young children the chest should be enveloped in a jacket-poultice of linseed meal, which should be covered with a layer of oiled silk or waxed paper so as to prevent its growing cool. This should be renewed at intervals of about six hours. After the more active symptoms have subsided the linseed jacket-poultice may be re- placed by one of absorbent cotton, which should also be covered with oiled silk or waxed paper. In older subjects the application of iced poultices to the chest exercises a most favorable influence, not only upon the local inflammation, but also upon the fever and the nervous system. Treatment of the Attack.—In cases in which there is high fever, tub-baths should be employed, the temperature of the Avater at first being about 95° F. (35° C), and then gradually cooled to about 80° F. (26.6° C). The gradually cooled bath or the cold pack may be used tAvo or three times daily. The effects are to reduce temperature, to pro- mote refreshing sleep, and to improve the character of the respiration. This mode of treatment is especially effective in cases that begin ab- ruptly. In such the tincture of aconite or veratrum viride may be em- ployed temporarily. In cases presenting moderate pyrexia cold spong- ings, combined with the use of the ice-bag to the head, may suffice. The folloAving fever-mixture may be employed, though it is not to be regarded as a substitute for the cold-water method of treatment, but is merely supplemental to the latter: Py. Potassii citrat., 3ijss (10.0); Spts. ammon. aromat., f.^ij (8.0); Spts. aether, nitrosi, fsss (16.0); Liq. ammon. acetat., f.liij (96.0); Glycerini, q. s. ad fgiv (128.0).—M. Sig. 3j (4.0) every two hours for a child of five years. In children a mild mercurial purge at the outset is advantageous, and subsequently by the use of salines or glycerin suppositories a daily evacuation of the boAvels is to be secured. The bodily strength is to be maintained by careful, methodical feeding, milk, eggs, albumin, and broths being the best forms of food. The milk should be predigested PULMONARY ATELECTASIS. 519 if there be marked pyrexia, and egg-Avhite may be given in cold Avater with a small amount of sugar or in the form of egg-lemonade. The cough is often Avellnigh constant and very distressing. Fre- quently the use of remedies that promote secretion, combined with a small dose of opium, will, under these circumstances, afford relief. A useful formula is the folloAving: Py. Vini antimonii, 3j (4.0); Spts. reth. nit., gijss (10.0); Tr. opii camph., 3ijss (10.0); Liq. ammon. acetat., q. s. ad ,$ij (64.0).—M. Sig. 3j (4.0) every tAvo hours, diluted, for a child of from three to five years. Dover's poAvder is also of value in relieving the cough. When the expulsion of the sputum is attended Avith great difficulty the preparations of ammonium often meet the indications. Of these the muriate is the most effective, but, unfortunately, this is often objected to, and we must then rely upon the carbonate or the aromatic spirits. The bronchi may contain an abundance of secretion that cannot be expelled, despite the use of the above measures. Under these circumstances an emetic may be given, composed of the wine of ipecac (3j—4.0), combined with alum (gr. xx to xxx—1.296-1.944), and administered to a child every ten or fifteen minutes until emesis occurs. Cardiac stimulants must be employed as soon as the pulse shoAA's signs of failure, and alcohol and strychnin are required in serious cases. The preparations of ammonium owe much of their reputation in this disease to their stimulating properties. These agents when boldly used may suffice to re-establish the cardio-pulmonary circulation, but if they fail in this and cyanosis supervenes, oxygen should be used in addition. Sudden heart-exhaustion may occur, associated Avith mu- cous rales in the larger bronchi and rapidly increasing cyanosis. In such instances prompt relief is to be afforded if Ave would save life. Alternating douching with hot and cold water and electricity should be given a trial. PULMONARY ATELECTASIS. ( Collapse of the Lungs ; Compression of the Lungs.) Definition.—Atelectasis of the lungs is a condition occasioned by the removal of the air from the air-cells—a state directly the opposite of emphysema. The air disappears largely in consequence of the process of absorption. Pathology.—The affected lung-spots sink in Avater, being non-crep- itant. They also present through the pleura a bluish-red tint, and on cross-section a brownish-red color. The surface of the affected areas is smooth and depressed beloAv the level of the adjacent lung-structure. The bronchi supplying the collapsed parts are frequently occluded by inflammatory products, but in all cases, as shown by Legendre and Bailly, they may be inflated by means of a blowpipe. 520 DISEASES OF THE RESPIRATORY SYSTEM. Apart from more or less distention of the pulmonary capillaries Avith blood, there are no histological changes in the atelectatic areas, though they are of firm consistence (splenization, carnification). There can be no longer any doubt as to the entire propriety of the pathological distinction betAveen lobular pneumonia and atelectasis. Etiology.—The condition occurs most frequently in the new-born, and is then due to defective respiration. Thus in children dying soon after birth the lower lobes may be found to be atelectatic. When ac- quired, hoAvever, there are three modes of production : (1) The first step consists in a more or less complete plugging of the smaller bronchi Avith muco-pus and other products of bronchial inflammation. If complete, air can no longer enter on inspiration, and as the contained air gradu- ally becomes absorbed atelectasis is the natural result. This condition is very commonly associated Avith broncho-pneumonia, especially in chil- dren. (2) A frequent mode of origin is through compression of the lungs, resulting from positive intrathoracic pressure, after the normal contractility of the lung has been overcome. Instances of this may be produced by pleural effusion, hydrothorax, pneumothorax, pericardial effusion, great cardiac hypertrophy, a solid tumor, or an aneurysm of the arch. Not infrequently abdominal tumors, excessive meteorism, and ascites make sufficient upAvard pressure against the diaphragm to cause compression of the loAver lobes of the lungs. (3) Conditions that Aveaken and obstruct the inspiration may produce this disease, such as certain brain-affections, paralysis of the pneumogastric, and paralysis of the chest-Avails. Thoracic deformities may produce pulmonary atelectasis, and in extreme grades of kyphoscoliosis the lung occupying the side cor- responding to the convexity of the spinal column is small. Whilst the lung-expansion and the growth of the organ are greatly interfered with, hoAvever, and particularly if the condition arises in youth, true atelec- tasis rarely occurs from this cause, owing to the natural retractility of the lung. Among conditions arising from deformities of the chest is the so-called aplasia of the lungs. Symptoms.—Atelectasis is a secondary condition, and its symp- toms are very generally veiled by those of the primary disease. It arises frequently in the course of broncho-pneumonia, but passes unno- ticed unless it becomes very extensive. Respiration is carried on by the upper and anterior portions of the lungs, and is increased in frequency and labor. The pulse is small, rapid, and feeble; the skin-surface, especially that of the extremities, is cool. The form presenting the most typical symptoms is that occurring in the neAv-born. It is evidenced by shallow, rapid breathing, livid- ity, cold extremities, a faint Avhining cry, drowsiness, and sometimes by evidences of motor irritation, such as muscular tAvitching and con- vulsions. Congenital anomalies of the circulatory organs are asso- ciated. Physical Signs.—When it involves a goodly portion of the lower lobes posteriorly, as frequently happens, there is marked retraction during in- spiration over the loAver portion of the thorax, due partly to external atmospheric pressure, and partly to the contractile efforts of the dia- phragm. Dulness on percussion is revealed, though only when the ate- lectasis is extensive, and the tactile fremitus, though very various, is PULMONARY ATELECTASIS. 521 generally decreased. Localized compensatory emphysema may present semi-tympanitic resonance over small areas of collapse. Auscultation shows a greatly diminished or absent vesicular murmur, and, if the area of collapse be large, bronchial breathing. Among asso- ciated sounds is the subcrepitant rllle, due to broncho-pneumonia, and, indeed, capillary bronchitis and atelectasis are often combined, there being, moreover, no reliable signs that Avill separate them clinically. The aplasia of the lung that is produced by spinal curvature (kypho- scoliosis) richly deserves brief separate description, OAving to its clinical importance. In many instances the chest is more or less tAvisted on its OAvn axis, shortened in the vertical diameter, and thoroughly fixed. Under these circumstances lung-expansion is impossible, and hence res- piration is purely diaphragmatic. In many other patients life may be prolonged for an indefinite period, nothing more being observed than slightly labored breathing. Such persons, however, upon great physi- cal exertion suffer from urgent dyspnea, and the development of an ordi- nary bronchitis may lead to similar results, and even to speedy death. The physical signs are those of localized emphysema, combined Avith those of more or less compression of the lungs. There is an extension of the cardiac dulness to the right, and other evidence of right ventricu- lar enlargement, to which may7 succeed dilatation with the usual clinical events produced by the latter condition. Death is not rarely due to this failure of compensation. Autopsies have shoAvn the lungs to be small and more or less com- pressed, some portions being almost airless. Areas of emphysema of the lungs are often associated. The right ventricle may be found to be hypertrophied merely, or dilatation may also have taken place. Con- genital atelectasis, by keeping up high pulmonary pressure, may lead to a persistence of the ductus Botalli and of the foramen ovale. Diagnosis.—Atelectasis may be distinguished from lobar pneu- monia by the absence of an initial rigor, fever, crepitant rales, and the pain of the latter disease, and by the characteristic inspiratory retrac- tion of the loAver portions of the chest and the smaller areas of dulness. Pleuritic effusion gives a flat percussion-note, the upper level of which varies Avith a change in the position of the patient—a sign that is Avanting in atelectasis. Prognosis.—When the condition is limited to small areas it is rarely serious, but equally seldom does extensive atelectasis lead to recovery. The outlook depends to some extent upon the nature of the associated affections; thus, when it is secondary to whooping-cough and widespread broncho-pneumonia, it is very fatal. Other diseases that may complicate and increase the gravity of the atelectasis are pleurisy and pulmonary tuberculosis. On the other hand, compensating emphysema often coexists, and is to be regarded as salutary in its effects. A\ hen due to compression by pyo-pneumothorax, tumors, and the like, the prognosis is especially gloomy. Treatment.—The treatment corresponds Avith that of the primary disease. Capillary bronchitis, Avhich is so apt to be followed by collapse of the lobules, must receive active treatment, and prophylactic measures are of the utmost practical importance. The patient should be instructed to practise full inspiration at regular intervals ; he should not be alloAved 522 DISEASES 'OF THE RESPIRATORY SYSTEM. to lie continuously in the dorsal decubitus, but should be told to change his position frequently. Another measure that may effectually pre- vent the development of a serious condition is the use of cold shoAver- baths (i. e. a stream of cold water poured over the region of the neck), and this can, in some instances, be depended upon as a curative agency Avhen the condition already exists. Tonics and the judicious use of stimulants, together Avith a nourishing diet, are invariably required. I have also seen good results follow the inhalation of compressed air. In kyphoscoliosis tepid baths are indicated. The heart-condition de- mands careful attention, and cardiac stimulants are to be resorted to at the first loss of compensation or Avhen compensation fails to become established. EMPHYSEMA. Definition.—In general this term implies the presence of air in the interstitial alveolar tissue. As applied to the lungs, however, it relates to an abnormal dilatation of the alveoli, of which two forms are recog- nized : (1) Interlobular; and (2) Vesicular. INTERLOBULAR EMPHYSEMA. This is produced by the rupture of the air-cells, the air contained in the lung escaping into the interlobular connective tissue. Among its causes are—(a) Injuries of the lung (usually by a fractured rib) and perforating wounds of the chest; (b) Violent paroxysms of coughing, as in Avhooping-cough ; and rarely defecation, parturition, and hysterical convulsions. When arising in this Avay its favorite situation is the an- terior margin of the upper lobe. Pathology.—In the interlobular septa immediately beneath the pleura air-bubbles are sometimes seen to be arranged in Avell-defined roAvs. The pulmonary pleura may become detached, and the air-tumors may then become as large as an English Avalnut or even of greater size. Unlike the condition in A7esicular emphysema, these sacs are freely mov- able, and the air may find its way from the root of the lung into the mediastinal connective tissue, and thence into the subcutaneous tissue of the neck and the Avail of the thorax. Rarely these air-sacs perforate the pleura, setting up pneumothorax, with or without pleuritis. Interlobular emphysema is sometimes associated with advanced vesic- ular emphysema. VESICULAR EMPHYSEMA. (Alveolar Ectasis) Definition.—Dilatation or enlargement of the alveoli and infundib- ular passages. Varieties.—The cases are classified into—(1) Compensating, (2) Hypertrophic, and (3) Atrophic forms. HYPERTROPHIC EMPHYSEMA. 523 COMPENSATING EMPHYSEMA. This variety is limited to certain parts of the lung, and arises in consequence of pathologic changes in other parts of the same organ that prevent full expansion of the lung on inspiration. Hence a vica- rious increase in the volume of the air-cells is observed in circumscribed morbid processes such as occur in pulmonary tuberculosis, lobular pneu- monia, cirrhosis, and pleurisy Avith adhesions (particularly Avhen the latter is situated at the inferior border of the lung). An entire lung, unaffected by the primary disease, may be the seat of compensating em- physema Avhen the causal disease invades the Avhole or a greater portion of the other lung, as in cirrhosis, extensive pleurisy with effusion, lobar pneumonia, and pyo-pneumothorax. When, hoAvever, the latter condi- tions are confined to a portion of one lung, the remainder of the same organ becomes distended also. As a rule, this pulmonary change is physiologic and beneficial: only rarely7 secondary atrophy of the Avails of the air-cells develops, Avhen the latter may coalesce. Symptoms are not presented by the lungs in consequence of the changes met with in compensating emphysema. The condition is some- times recognizable by means of the usual physical signs, but even these are not ahvays to be relied upon. Fortunately, its existence may be safely inferred Avhen there is conclusive evidence of the presence of the local causal diseases (broncho-pneumonia, pulmonary tuberculosis, pleur- isy, lobar pneumonia). HYPERTROPHIC EMPHYSEMA. Nature of Emphysema.—The symptoms are dependent upon a loss of elasticity in the lungs, and, the latter condition being the result of overstretching, the contractile energy of the lungs is in great part destroyed; hence they become permanently enlarged. Nor do the em- physematous lungs contract Avhen the thorax is opened, as they do ordi- narily. We may in some cases account for the loss of elasticity in the lungs by the operation of causes that produce an abnormal degree of stretching, either temporarily or constantly; but under these circum- stances emphysema would be developed despite the pre-existence of nor- mal contractility of the lung. In true emphysema, hoAvever, Avhich de- velops at a comparatively early period in life, Ave may safely assume that the retractile energy is defective (probably a congenital condition), and hence in such cases the action of the usual causal factors will speedily engender over-distention, or emphysema may develop even in the ab- sence of the usual causal factors. In these instances there is probably a quantitative as well as qualitative defect in the elastic-tissue element of the lungs. Pathology.—The thorax is enlarged (barrel-shaped), and upon re- moving the sternum the lungs are found to completely fill the mediasti- num, and do not retract as in health. They present a pale, anemic appearance, and may shoAV dark pigmented patches and streaks, Avhile to the feel they appear soft and feathery, though dry. They readily pit on pressure (a leading characteristic). 524 DISEASES OF THE RESPIRATORY SYSTEM. Immediately beneath the pleura enlarged air-cells can be distinguished macroscopically, and air-sacs as large as a walnut or even larger may present irregular projections above the lung-surface. Occasionally they may be so far detached as to be pedunculated. At the anterior borders a series of air-blebs, resembling a frog's lung, may be observed. In these situations, as well as near the root of the lung, distention is usually more marked than elseAvhere. The pleura is also pale, and in patches the pigment may be entirely absent (Virchow's albinism). Upon microscopic examination it is observed that the dilatation starts in the infundibular and alveolar passages. The septa are partially obliterated, the alveolar Avails thinned and, lastly, perforated, Avhile in consequence of these changes the air-cells communicate Avith one another, and thus form larger or smaller air-sacs. The process is an atrophic one, in which the smaller elastic fibers at first disappear, Avhile the larger be- come less prominent and often ruptured. After the latter changes have begun the capillaries likewise disappear, and the epithelium of the air- cells undergoes fatty degeneration, though in the larger bullae a pave- ment layer is retained. The smooth muscular element may also occa- sionally be seen to be hypertrophied (Rindfleisch). The condition from Avhich the clinical phenomena arise is most probably the loss of the capillary blood-vessel system. The bronchial mucous membrane is usually the seat of chronic inflam- mation. It may be roughened and thickened, or the submucous elastic tissue may present prominent longitudinal lines, Avhile the bronchial mucosa is covered with muco-pus. The smaller tubes may be dilated (bronchiectasis), and this condition may be associated Avith hyperplasia of the peribronchial connective tissue. The diaphragm is loAvered and the subjacent viscera correspondingly displaced. The heart is pushed dowmvard and somewhat backAvard, the right side shoAving Avell-marked changes; the cavities are dilated and hy- pertrophied, due to obliteration of the pulmonary circulation ; and in long- standing eases hypertrophy of the left chambers may also develop. The pulmonary artery and its branches may be enlarged and the seat of atheromatous degeneration. The liver, kidneys, and other viscera present the changes that belong to long-continued venous engorgement. Etiology.—The affection is often secondary to, and develops in consequence of, other affections of the lung—notably, chronic bronchitis and whooping-cough. The dry form of chronic bronchitis, in particu- lar, is apt to generate pulmonary emphysema. Under these circum- stances the disease is directly attributable to the mechanical influences to which the alveolar walls are subjected during respiration. This ab- normal strain attends inspiration to some extent, but mainly expiration, owing to the obstruction to the egress of the air in the smaller bronchi, with increased intra-alveolar air-pressure. The increased tension in the air-cells may be accounted for, partly, by the severe and persistent cough, the air being forced during violent coughing into the upper part of the lungs, forcibly expanding them and causing emphysema. Bronchial asthma, on account of the obstruction of the exit of the air from the lungs, produces during the attacks an acute emphysema that may result finally in a condition of permanent over-distention. Certain occupations, such as bloAving Avind-instruments, or those that HYPERTROPHIC EMPHYSEMA. 525 entail severe muscular strain (e. g. blacksmithing), act as predisposing causes, and hence emphysema is of common occurrence among the working classes, and is more common in males than females. The dis- ease is often hereditary, there frequently being several sufferers in the same family. During advanced years the lung-elasticity often dimin- ishes, and as a consequence a disposition to emphysema is engendered. On the other hand, emphysema is not infrequently met Avith in children, and in such there may be a respite during early adult life, with a recur- rence at a later period. An emphysematous tendency also results from congestion of the lungs associated with mitral valvular disease. Clinical History.—In nearly all cases the disease develops insidi- ously7, the svmptoms being gradually added to those of the primary affec- tions (chronic bronchitis, asthma, etc.). When due to the occupation of the patient it's development is also sIoav, and not infrequently its origin dates back to childhood or beyond the recollection of the patient. Rarely it may exhibit a more acute development, as, for example, after Avhoop- ing-cough. The first symptom is a variable degree of dyspnea, and to this may be added temporary cyanosis and cough. The severity of the dyspnea varies Avith the degree of distention of the air-cells, even though addi- tionally aggravated by the coexistence of chronic bronchitis, asthma, etc. In moderate emphysema the dyspnea is only apparent on going up stairs, running, Avalking rapidly, or after a hearty meal; on the other hand, in advanced grades of the affection it is constant, and is intensified by the slightest exertion, even to orthopnea. Speech is inter- fered with, the patient's utterances taking the form of fragmentary sentences or syllables. The labored breathing is shoAvn particularly in expiration, and, as in asthma, in which the alveolar spaces are acutely distended, so in emphysema the rhythm of the respiration is changed. The inspiration is shortened, and the expiration is greatly prolonged and accompanied by Avheezing Avhen chronic bronchitis coexists. In the later stages cyanosis becomes more marked, and is noticeable in proportion to the loss of compensation and interference Avith the car- dio-pulmonary circulation. It often attains to an extreme degree, and the patient's alarming appearance may be in striking contrast with his apparent degree of comfort. In mild forms the cyanotic tint is con- fined to the lips, lobes of the ears, and the extremities. Any increase in the degree of dyspnea after exertion results in an increased blueness of the surface. The cough is dependent upon the presence of chronic bronchitis, and the latter disease is frequently found in combination, particularly during the winter. There is also an expectoration that is identical Avith that of chronic bronchitis, and Avhen this disease reaches an advanced stage the cough persists throughout the year (vide Chronic Bronchitis). In- tercurrent acute attacks of bronchitis are often followed by temporary attacks of asthma; and since chronic bronchitis in its highest grades is met Avith at an advanced period of life, so, as would be expected, the cases of advanced emphysema are also met with at the same period. Osier has described a group of cases occurring in patients " from twenty- five to forty years of age who, winter after winter, have had attacks of intense cyanosis in consequence of an aggravated bronchial catarrh." 526 DISEASES OF THE RESPIRATORY SYSTEM. These patients are short-breathed from infancy, and their condition is attributed to a primary defect of structure in the lung-tissue. General Symptoms.—There is an absence of febrile movement; the pulse is not increased in frequency, though sometimes feeble; and the temperature of the body is generally subnormal. There is a very gradual loss of flesh and strength, and the patient is stoop-shouldered, present- ing a peculiar cachectic appearance—a condition that is in strong con- trast with the dusky appearance of the face, the swollen neck, and the enlarged chest. Finally, other symptoms may be mentioned that are for the most part secondary to hypertrophy, followed by dilatation, of the right ven- tricle. This hypertrophy is the result of pulmonary congestion and obliteration of the pulmonary capillaries induced by the emphysema. Under these circumstances severe attacks of cough occur, attended with extreme dyspnea and lividity, and later the conditions that usually suc- ceed a moderate grade of tricuspid insufficiency supervene, such as con- gestion of various viscera and edema of the feet. Anasarca is rare. Physical Signs.—The shape of the chest is much altered: owing to the increased antero-posterior diameter, it becomes barrel-shaped (Fig. 46), and the sternum bulges, as do also the costal cartilages. The infraclavicular and mam- mary regions are also promi- nent, and give the thorax an abnormally rounded appearance. The episternal notch is deeper than the normal, the clavicles and muscles of the neck are unduly prominent, and the neck itself appears to be shortened, OAving to the elevated position of the clavicles and the ster- num. There is an antero-pos- terior curvature of the spine and a winged condition of the scapulae—changes to which the stooping posture is ascribable. Below, the thorax appears con- tracted. The intercostal spaces are widened and depressed, and a network of dilated venules fre- quently extends laterally above the inferior costal border, but is by no means characteristic of the affection. The movements of the chest are vertical rather than expansile, and the lungs are constantly in a state approaching full expansion; in the lower thoracic and upper abdominal regions there may be observed retraction rather than expansion during the act of inspiration. The respiratory acts, as a whole, are labored, and the diaphragm and ab- dominal muscles are seen working Avith relative violence. The heart's apex-beat is invisible, but marked epigastric pulsation is frequently Fig. 46.—Barrel-shaped chest in emphysema. HYPER TR OPHIC EMPHYSEMA. 527 noticeable. A transverse linear depression across the abdomen, on a level with the loAver ribs, may also be present during inspiration. Ven- ous pulsation may be seen in the neck after failure of the right ventricle has occurred. On palpation the character and direction of the chest-movements may be accurately appreciated. The tactile fremitus is decreased, but not absent. In advanced cases the apex-beat cannot be felt, and even in the earlier stages it becomes more and more enfeebled. OAving to displacement of the heart and engorgement of the right ventricle there is a distinct systolic shock over the ensiform cartilage, and also a pul- sation in the epigastrium. Percussion yields a characteristic hyper-resonance. This may be distinctly " Skodaic " or semi-tympanitic, and in extreme dilatation of the air-cells the tone may be Avoodeny. The area of cardiac dulness, OAving to the fact that the lungs overlap the heart, becomes lessened and finally obliterated ; Avhile the upper limit of liver-dulness, both ante- riorly and posteriorly, is found to be one or two interspaces lower than normal, OAving to the fact that the diaphragm is depressed. The upper level of splenic dulness is also loAvered, and the area of percussion- hyper-resonance extends higher above the clavicle than naturally. On auscultation the inspiration is short and feeble, Avhile the expira- tion is greatly lengthened, the ratio of these sounds as to duration being reversed as compared with the normal. Their pitch is somewhat low- ered, particularly that of expiration; and when rales are present the respiratory murmur (particularly the inspiratory) may be scarcely audible. In well-marked instances of emphysema inspiration and expiration may rarely be of equal length. It is a fact Avorthy of emphasis that the parts of the lungs that are not so markedly emphy- sematous as others give a harsh, exaggerated vesicular murmur, OAving to the great efforts of breathing. Rales of various sorts are frequently audible, due to bronchitis, Avhich, it must be recollected, accompanies emphysema in a majority of instances ; less frequently the auscultatory signs of asthma, pleuritis, and phthisis are encountered. Rarely, rub- bing sounds, that have been attributed to the friction of enlarged air- cells against the pleura, are audible, and Avhen the interlobular variety7 supervenes upon vesicular emphysema a crumpling sound is heard. The so-called " Laennec's rdle," Avhich resembles somewhat the subcrepitant rale, is not infrequently present. The vocal resonance varies from an almost total absence to a greatly increased intensity. The tricuspid in- sufficiency that develops late in this affection is betrayed by its charac- teristic murmur. Diagnosis.—A positive diagnosis may be arrived at from a consid- eration of the history, including such points as heredity, occupation, the long duration of the condition, together Avith the most characteristic symptoms (dyspnea, cyanosis, signs of chronic bronchitis), and from the physical signs. In a case of beginning emphysema, particularly among children, a certain diagnosis is not to be attempted. Differential Diagnosis.—Pneumothorax is the disease most apt to be confounded with emphysema. It develops suddenly, however, Avhile emphysema is of slow development, and. the rational symptoms of pneumothorax are more constant and urgently distressing than those of 528 DISEASES OF THE RESPIRATORY SYSTEM. emphysema. Pneumothorax is unilateral, and gives a purely tympanitic percussion-note, Avhile hypertrophic emphysema is bilateral and its per- cussion-note is hyper-resonant. Auscultation in pneumothorax usually gives amphoric breathing, metallic tinkling, the characteristic suecussion splash, and an absence of the vesicular murmur; all of which symp- toms are very unlike the auscultatory signs of emphysema. Another affection giving rise to dyspnea, cough, and cyanosis is pleurisy with effusion, but the sIoav course, the absence of fever, and the universal hyper-resonance that characterize emphysema do not be- long to pleurisy. The latter affection is usually unilateral, and over its seat a flat percussion-note is obtained. Prognosis.—Hypertrophic emphysema of acute form (e. g. result- ing from whooping-cough) is often curable; but the usual slowlv- generated variety, so far as recovery is concerned, gives a totally un- favorable prognosis. In many cases, however, life is not materially shortened. Temporary improvement is possible Avhen the lesion con- sists merely of a distention of the air-cells, and this is shoAvn by a corresponding improvement in the physical signs. The effect of frequently recurring attacks of bronchitis is only to intensify the symptoms of a disease that is innately progressive. Intercurrent affections, hoAvever, such as pneumonia (lobar and lobular) and pulmo- nary tuberculosis, may prove fatal. Dropsy, following broken compen- sation, is often a late and dangerous complication; other late accidents of the disease are hemoptysis and sudden dilatation of the right heart. Individual circumstances, such as the patient's social condition, the stage of the affection in which he comes under proper treatment, and the degree of care he is willing to exercise, greatly influence the out- come of the case. Treatment.—The treatment is to be directed toward the removal of the causes of emphysema, and chiefly of the chronic bronchitis. From personal observation I am fully convinced of the fact that the progress of the disease can be arrested, and that the condition is some- times improved, by relieving the chronic bronchitis. The iodids (po- tassium, sodium, and ammonium) will sometimes produce effects that are truly remarkable, and the syrup of hydriodic acid may be employed when the iodids are not Avell borne by the stomach. If the occupation of the patient fends to aggravate the disease, it must be forsaken for one that is less harmful. Violent paroxysms of cough also contribute to the production of alveolar distention, and hence must be alleviated promptly. Intercurrent attacks of asthma have a similar effect, and must be relieved as speedily as possible by a resort to appropriate ther- apeutic measures. Attacks of acute bronchitis are to be prevented, if possible, by suitable clothing, by avoidance of exposure to inclement weather, dust, and the vitiated atmosphere of overcrowded halls, churches, and the like; whenever practicable the result can be most successfully obtained by a residence in an equable climate. Since a severe bron- chitis is apt to increase the severity of the emphysematous symptoms, it must be cured as rapidly as possible. As soon as passive congestion, flatulence, and constipation, with other gastro-intestinal symptoms, appear, the diet will demand careful regulation, and especially a restriction in the use of carbohydrates. GANGRENE OF THE LUNGS. 529 The bowels must also be moved regularly with a view to obviating the flatulence and portal engorgement. The heart needs to be carefully Avatched, and as soon as signs of broken compensation appear digitalis and strychnin will be found highly useful. Diuretics and cathartics may also become necessary. The sudden development of urgent dyspnea (or orthopnea) and extreme lividity, especially if associated Avith Aveak cardiac action and a rapid, feeble, irregular pulse, calls for free bleedings, and more than once in the course of my hospital practice have I seen the lives of patients suffering from emphysema saved by timely venesection. Besides meeting the pathologic and symptomatic indications, Ave should aim to assist the patient in expiration, and Gerhardt has sug- gested systematic mechanical compression of the thorax during expira- tion as a useful measure. This external pressure must be made by an attendant, Avho places his hands flat on the loAver lateral portions of the thorax, and the manipulation is to be continued for from ten to fif- teen minutes daily. The results obtained by certain German authors have been encouraging, but in my OAvn hands the method has failed, except in tAvo instances occurring in young adults with yielding chest- walls, in whom it was of the greatest service. The pneumatic treatment, comprising the inhalation of compressed air and the breathing into rarefied air, richly deserves further trial,1 its use having been productive of permanent improvement in a number of cases, as shown by physical examination (including mensuration). SENILE EMPHYSEMA. This variety is in reality a senile atrophy of the lungs, and has been appropriately termed "small-lunged emphysema" by Sir Wm. Jenner. In consequence of the complete atrophy of the alveolar walls, coalition of the air-cells takes place, with the production of large air-sacs. The lungs contain less than the normal volume of air, instead of an abnormal quantity as in true hypertrophic emphysema, and as a result occupy less space in the chest-cavity than do healthy lungs. The pulmonary tissue elements are deeply pigmented. The condition does not produce right ventricular hypertrophy. The Symptoms are negative, although subjects in whom senile em- physema develops may have previously had chronic bronchitis Avith more or less dyspnea. They quite frequently present a withered ap- pearance, and the chest on inspection is seen to be contracted, OAving to the fact that the ribs approximate more closely and take a more oblique direction than in health. Treatment is unavailing. GANGRENE OF THE LUNGS. Pathology.—The affection presents itself in two forms—as a (a) diffuse, and a (b) circumscribed process. (a) The diffuse variety is rare. It may; however, be met with in 1 Waldenburg's portable apparatus is convenient for use. 530 DISEASES OF THE RESPIRATORY SYSTEM. lobar pneumonia, and very rarely in consequence of occlusion of the large branch of the pulmonary artery; it may also be secondary to the circumscribed form. The greater part of the lobe, or even an entire lung, may be involved, the pulmonary parenchyma degenerating into a putrid, greenish-black, pulpy mass, with no obvious line of demarcation. (b) The circumscribed form may involve either one or both lungs, though the right is affected somewhat oftener than the left. To this category belongs the so-called embolic gangrene, the nodules of Avhich have their favorite seat in close proximity to the pulmonary pleura. All etiologic varieties of the circumscribed form more frequently implicate the lower than the upper lobe of the lung, occurring in sharply defined areas, which may either be single or multiple. The affected area first presents a greenish-broAvn appearance; its central portion soon under- goes softening, and a cavity is thus formed whose Avails are ragged and irregular and contain a foul-smelling, dark, greenish liquid. The sur- rounding lung is inflamed, and the air-sacs contain inflammatory prod- ucts (fibrin, epithelium, pus), while the highly-irritating and putrid material sets up an intense bronchitis. These gangrenous foci may in- crease in size by a peripheral extension, and thus the adjacent veins may become plugged Avith infectious thrombi or the vessels may become eroded. Emboli may then be detached from the infectious thrombi, and, entering the circulation, may set up foci of septic inflammation in re- mote organs. A truly remarkable connection exists between circum- scribed gangrene of the lung and cerebral abscess. When the gangren- ous spot is situated near the pleura, simple or gangrenous pleurisy may arise as a complication, or the pulmonary pleura may be perforated and pyo-pneumothorax result. When recovery ensues the cavities formed as the result of the conversion of lung-tissue present a limiting wall of dense connective tissue. Such cavities may remain permanently or may slowly become contracted. Etiology.—Gangrene of the lungs is caused by the bacteria of putre- faction (probably the staphylococcus albus or aureus). The disease is rare, even though the opportunity for inhaling the bacteria that cause it is a constant one. It is only when the lung-tissue has become im- paired or peculiarly altered that the specific bacteria are capable of pro- ducing gangrene. It may occur in several ways : (1) Secondarily to lobar pneumonia, hemorrhagic infarctions, cavities in the lungs, bronchiectasis, wounds of the lung, contusions of the thorax, carcinoma of the esophagus, or to compression or embolism of the pulmonary artery or of the bronchial vessels. (2) As an embolus, derived from a gangrenous area in some other organ of the body, it may lodge in the lung and set up putrefactive changes. (3) Pressure from a thoracic aneurysm may give rise to gangrene. (4) The most important causal factor, however, is the entrance of foreign bodies, especially bits of food, into the bronchi and lungs. Whether or not the specific bacteria of putrefaction enter the lungs Avith the foreign bodies, the latter render the tissue-soil receptive to the former, and once the process has been initiated it is apt to extend itself. There are several ways in Avhich these foreign particles gain entrance into the bronchi and lungs : (a) By a faulty sw allowing of the food ; (b) GANGRENE OF THE LUNGS. 531 By inhalation; (c) By a carcinomatous perforation of the esophagus into the bronchus or into the lung. (5) In the course of debilitated states of the system, as during con- valescence from protracted fever (rarely), and in diabetes mellitus (frequently). Symptoms.—These are local and general, the former alone being diagnostic. Local Symptoms.—There is cough accompanied by an exceedingly fetid expectoration that is usually quite profuse. When abundant, and when expectorated into a conical glass and allowed to stand for a time, it separates into three layers: (a) the uppermost, being frothy, opaque, and of a grayish-yelloAv color; (b) the middle, clear and Avatery; and (c) the lowest, appearing as a greenish-broAvn sedi- mentary layer containing shreds of lung-tissue and sometimes blood. The microscope shows it to consist of numerous elastic fibers, bacteria, fat-crystals, muco-pus, granular matter, and leptothrices. Small quan- tities of blood in the sputum are very common. Kannenburg and Streng have also described ciliated monads as occurring in the sputum. The patient's breath is, as a rule, intensely fetid, even though there be no expectoration, but this fetor of breath may be absent, as in a case of my OAvn (which came to autopsy7), in which the localized gangrenous process had no fistulous connection with the bronchus. It is to be recollected that if any of the large branches of the pulmonary artery be eroded, free and even fatal hemoptysis will result. Physical Signs.—The physical signs are sometimes obscure, as when the areas involved are smaller and deeply situated, and in such instances signs of bronchitis only may be detectable. When large and favorably situated, however, the affected spots usually give signs of consolidation, rapidly folloAved by those of cavity. In addition bronchial rales—usually moist—and coarse cavernous raies are usually audible. It is obvious that when the pleura is implicated the signs of pleurisy are added, and if pneumothorax be present those belonging to the latter condition also. The chief general symptoms are irregular fever, emaciation, and profound prostration. A septic condition of the system is commonly developed, and the patient sinks from exhaustion. Rarely there may be an almost total absence of constitutional disturbances, and such instances terminate in recovery. Diagnosis.—The distinctive feature is the intense fetor both of the sputum and the breath. The physical signs may readily determine the existence of the pulmonary lesion, but it is difficult to eliminate abscess and fetid bronchitis associated with bronchiectasis. The results of a careful examination of the sputum, together Avith the less horribly fetid odor of the breath, in abscess will usually suffice to eliminate the latter affection. In fetid bronchitis the fetor of the breath and sputum is also less marked than in gangrene, Avhile its course is sloAver and more favor- able than that of the latter affection. Prognosis.—The prognosis is always grave, though rarely recovery in circumscribed gangrene of the lungs ensues. The chief dangers are exhaustion and hemorrhage. Improved methods of surgical treatment, hoAvever, have saved life in a feAv instances, and promise to reduce still further the mortality-rate of this serious affection. 532 DISEASES OF THE RESPIRATORY SYSTEM. Treatment.—The leading indications are— (a) The disinfection of the gangrenous focus or foci in the lungs. This may be accomplished by the internal administration of creasote or carbolic acid or by the use of the antiseptic spray. In a recent case the employment of Robinson's inhaler, charged Avith equal parts of creasote, alcohol, and chloroform, gave encouraging results. (b) The patient's nutrition must be maintained, if possible, by a con- centrated liquid diet, administered in fixed quantities and at regular intervals; also by the judicious cultivation of the digestive functions, together with the use of stimulants and tonics. For a description of the surgical treatment of gangrenous cavities of the lungs the reader is referred to special Avorks on surgery. It is the physician's duty, how- ever, to determine Avhether or not the patient's general condition an ill admit of surgical interference, and also to localize as nearly as may be the affected zones for the surgeon's guidance. ABSCESS OF THE LUNGS. (Suppurative Pneumonitis) Pathology.—This affection is characterized by the formation of pus and the degeneration of lung-tissue. It may be (a) a mere infiltra- tion of the blood-vessels, bronchi, or interstitial tissue, but more fre- quently purulent inflammation of the lungs takes the form of (b) an ordinary abscess. In size the abscesses range from that of a walnut to an apple, and I have observed in one case inflammation of the whole of the middle lobe of the right lung. The abscess-walls are irregular and decidedly ragged; and in the case of old lesions there is a dense fibrous Avail; the contents are purulent and rarely necrotic. If the contour of an abscess touches the pleura, empyema is the usual result, though sero- fibrinous pleurisy may rarely follow. Rupture of the abscess into the pleura may also occur. Etiology.—Streptococci are found, though they are not the only direct causes of abscess of the lung. The diplococcus pneumonia? and Friedlander's bacillus have been noted, as well as certain other pyogenic organisms. Predisposition is noted in certain conditions, as (1) during or folloAving the occurrence of inflammation, as in lobar and lobular pneumonia. Suppurative infiltration, however, more frequently arises under these circumstances than abscess, and in the rare instances in which the latter occurs it is apt to be comparatively small and multiple. In all forms of inhalation and deglutition broncho-pneumonia, hoAvever, abscess of the lung is a frequent sequela. (2) Perforation of the lung from without or from adjacent organs, as in carcinoma of the esophagus, abscess of the liver, or suppurating hyda- tid cyst. (3) Infectious emboli, found in connection with septico-pyemia, fre- quently cause metastatic abscesses in the lungs. In a mechanical manner they may produce hemorrhagic infarctions, followed by suppuration, or the latter process may occur independently of the former. The abscesses PNE UMONOKONIOSIS. 533 are usually situated close to the pleura, and are frequently wedge-shaped ; they vary in number from one to several hundred, and in size from a pin's head to an orange. (4) Abscess of the lung may result from imvard extension of a puru- lent pleurisy; and, oppositely, purulent pleurisy may result from an extension of abscess of the lung. (5) As elsewhere stated (vide Pulmonary Tuberculosis), suppuration is quite generally associated Avith chronic pulmonary tuberculosis. Symptoms and Diagnosis.—The examination of the sputum is of the greatest value in the diagnosis of this disease, since, being puru- lent, it usually presents a yellow, or less frequently a greenish- or broAvnish-yelloAv, color. It emits a fetor that is less pronounced than that of either gangrene or putrid bronchitis. Particles of lung-tissue may be visible in the pus, and on microscopic examination of the latter, elastic fibers, the presence of which is of the utmost importance in the diagnosis, may be found in profusion. Next to the investigation of the sputum, the physical signs of cavity are of the greatest assistance in distinguishing abscess of the lung; these, however, are Avanting unless the abscess is of a decided size. By themselves, the signs of cavity7 do not suffice for the recognition of abscess, but Avhen combined Avith the characteristic sputum leave no room for doubt. The history of indi- vidual cases is of considerable importance, as confirming the more characteristic features. Thus antecedent pneumonia or septico-pyemia Avould be strongly corroborative. Prognosis.—The prognosis is often hopeless, as, for example, when the disease is associated Avith pyemic processes in other parts of the body. On the other hand, those rare instances in Avhich it is secondary to pneumonia give a comparatively favorable prognosis. Treatment.—The chief aim in the therapeusis should be to sup- port the system by the administration of tonics, stimulants, and anti- septics, as Avell as by methodical feeding with light and concentrated forms of nourishment. Inhalation of antiseptic sprays (creasote, thy- mol) should be tried. When the abscess is situated near the periphery of the lung, surgical interference is to be advised as soon as the first indications of increasing weakness appear. For the details of the ope- ration of pneumonotomy for pulmonary abscess the reader is referred to special works on surgery. The statistics of Eichhorst,1 showing its favorable results, may, hoAvever, be mentioned, as follows : in 13 opera- tions recovery or improvement Avas noted in 6, while fatal terminations occurred in 7. PNEUMONOKONIOSIS. (Anthracosis, Chalicosis, etc) Definition.—A form of chronic interstitial pneumonia that arises from the inhalation of dust-like particles. Different terms have been applied to the condition according to the nature of the dusts inhaled, the chief among these being—(1) Anthracosis (coal-miner's disease), 1 Specielle pathologic, Bd. 1, S. 519. 534 DISEASES OF THE RESPIRATORY SYSTEM.' due to the inhalation of coal-dust; (2) Chalicosis (stone-cutter's phthi- sis), caused by the inhalation of mineral dusts; and (3) Siderosis, caused by inhaling metallic particles, particularly iron oxid. (1) Anthracosis.—Among dwellers in cities a moderate degree of pigmentation of the lung-tissue Avith coal-dust is the rule, while in those residing in rural districts the condition is decidedly less common. True anthracosis, hoAvever, has reference to such an accumulation of the car- bon particles as can be due only to the inhalation of a well-laden atmo- sphere, or under circumstances when the mucous membrane is unhealthy or without perfect ciliary action. Under such circumstances the normal scavengers of the respiratory organs—the mucous corpuscles lining the trachea, the bronchi, and the alveolar cells—fail to deal successfully Avith the numerous dust-particles that gain entrance along with the inspired air; hence some of the latter pierce the mucosa and reach the lymph-spaces and lymph-vessels. On reaching the bronchial mu- cosa they become enclosed in leukocytes, mucous corpuscles, and alve- olar cells, and are conveyed by the latter to a more remote destination. Arnold shoAvs that after the particles enter the lymph-system they are carried " (a) to the lymph-nodules surrounding the bronchi and blood- vessels ; (b) to the interlobular septa beneath the pleura, where they lodge in and betAveen the tissue-element; and (c) along the larger lymph- channels to the substernal, bronchial, and tracheal glands, in Avhich the stroma-cells in the follicular cord dispose of them permanently and pre- vent them from entering the general circulation." Rarely the carbon particles may find their way into the general circulation; this may occur, as shown by Weigert, when the pigmented bronchial glands be- come adherent to the pulmonary veins, thus giving opportunity for the escape of the carbon granules into the blood. Anthracosis leads, primarily, to chronic bronchitis, to be soon fol- loAved by emphysema; but it must be recollected that extensive anthra- cosis may be present without any other changes in the lung than the presence of carbon particles stored in the protoplasmic cells. The lung- tissue presents great variations in its degree of susceptibility to these foreign particles. Sooner or later, there is usually produced, as the result of their irritant action,1 a proliferation of the connective-tissue elements—i. e. a chronic interstitial inflammation. This fibroid change usually starts in the peribronchial lymph-structures, though the bronchial and tracheal glands are, as a rule, similarly involved at a comparatively early period. The affected lung-tissue is frequently coal-black, dense, and airless. The pneumonokoniotic areas vary greatly in size and numbers, and not infrequently they coalesce, in which case large portions of the lung-tissue may become the seat of fibroid change. The alveolar walls are observed to be much thickened in some instances, and firm pleuritic ad- hesions exist. Bronchiectatic cavities may be present, and later necrotic softening of the indurated areas occurs, leading to the formation of small cavities that contain a dark fluid. When the latter communicate with the bronchi their walls are prone to ulcerate. I have noticed that the process almost invariably terminates in pulmonary tuberculosis, and par- 1 Cohnheim contends that coal particles do not produce irritative changes in the lung, and that the latter are due to irritating substances inhaled with the particles of coal. PNE UMONOKONIOSIS. 535 ticularly is this true of cases that folloAV the inhalation of mineral and vegetable dusts. (2) Chalicosis.—Changes similar to those previously described are in- duced in the pulmonary connective tissue by the inhalation of stone- dust by those who follow certain occupations, such as stone-cutting, knife- and axe-grinding, and millstone-making. The irritating proper- ties of this form of dust cannot be denied, as shoAvn by the great dispo- sition in this subvariety of pneumonokoniosis to the formation of fibrous nodules and diffuse areas of sclerosis in the lungs. The nodules have a gray center and a darker periphery; they are exceedingly dense, and sections are made with much difficulty. The cut surface may present a grayish and distinctly glistening appearance. (3) Siderosis.—This term implies a collection of iron oxid in the lungs, also due to the pursuit of certain occupations (dyeing, iron- smithing, etc.). Cases of much the same nature are caused by the in- halation of vegetable dusts by grain-shovellers, cotton-spinners, cigar- makers, etc. The pathological changes are identical Avith those in anthracosis, though the color-appearance is red instead of black. Symptoms.—Rarely the onset is marked by the symptoms of acute, folloAved by those of chronic, bronchitis; but in a vast majority of in- stances chronic bronchitis gradually develops after long exposure to the action of the exciting cause. The symptoms of emphysema are soon superadded, the patient noAv suffering from dyspnea, and less frequently from asthma. The sputum is diagnostic in anthracosis, being quite dark; in chalicosis a microscopic examination is essential to show the particles of silica; Avhile in siderosis the expectoration presents a red- dish color. Apart from the foreign particles, the sputum is for a long period of years muco-purulent in character, and later it often contains the tubercle bacillus. The physical signs are not distinctive, being identical with those met Avith in chronic bronchitis associated Avith emphysema, and followed by those of interstitial pneumonia, and sometimes by those of cavity. The diagnosis is to be made both from the history and from a gross or microscopic examination of the sputum. It may be confirmed by the invariable presence of the signs of bronchitis and emphysema, as well as by the effect of removal to an atmosphere free from dust. In the later stages the detection of infallible evidences of phthisis only serves to corroborate the early diagnosis of pneumonokoniosis. The prognosis is favorable in hygienic surroundings until the more advanced stage is reached. The condition favors the invasion of new growths (lympho-sarcoma, or cobalt-miner's disease; vide supra). Treatment.—A change of occupation or several hours of exercise in the open air daily for those who are exposed to dust in work-rooms should be advocated. The active treatment is the same as for chronic bronchitis and em- physema from other causes, and is to be appropriately modified when pulmonary tuberculosis develops. 536 DISEASES OF THE RESPIRATORY SYSTEM. NEW GROWTHS OF THE LUNGS. CARCINOMA OF THE LUNG. All varieties of carcinoma have been met with in the lung, but, with rare exceptions, carcinoma of this organ is secondary to similar growths in other parts of the body. To explain its origin it may safely be assumed that the primary new groAvth involves a vein or lymph-channel, and that the latter carries the germ of the disease to the lung. It is also to be recollected that it may result from extension, or by contiguity from neighboring organs (as the esophagus, mamma, pleura, or mediastinum). Etiology.—The causes of primary carcinoma of the lung must be, in the main, identical Avith those of carcinoma in general, and are as yet unknoAvn. Most cases occur in middle-aged persons, and, while sex has no influence upon the appearance of the primary form of the disease, the secondary form is more frequent in the female than in the male. In the female secondary carcinoma of the lung is often preceded by car- cinoma of the breast. We may also regard hereditary influence as a potent predisposing factor. Secondary carcinoma of the lung is most commonly consecutive to primary carcinoma of the bones, and of the digestive and urinary tracts. Pathology.—The pathological varieties of the primary form are scirrhus, encephaloid, and epithelioma, and of these the latter is the most common. Primary carcinoma is usually unilateral, the tumors at- taining to a massive size and frequently involving the greater part of one lung. Their favorite seat is in the upper part of the right lung, though the pleura is quite often invaded by the carcinomatous process. Less frequently there is pleurisy Avith sero-fibrinous exudate, which may be hemorrhagic. Carcinomatous involvement of the cervical, bronchial, and tracheal lymph-glands is quite usual, and rarely even the inguinal glands become implicated. Secondary carcinomata are, as a rule, multiple, and may be miliary in size. They are disseminated Avidely throughout both lungs, though in the rarest instances they may be unilateral. In the softer varieties the central portion of the tumor-mass may undergo fatty degeneration, with subsequent discharge through adjacent .bronchi. Symptoms.—The symptoms of carcinoma of the lung vary accord- ing to the location and extent of the disease. Among the most marked symptoms belongs pain, particularly when the pleura is implicated. As a rule, for a considerable period of time the symptoms of bronchitis obtain, and later the breathing-space is diminished sufficiently to excite dyspnea and cyanosis. With the increase in size of the new groAvth compression of the heart, aorta, and large veins may result, whereupon disturbances of the circulation will arise. The new growth may exert pressure on the esophagus, causing dysphagia; or upon the recurrent laryngeal nerve, causing aphonia and hoarseness; or on the trachea or a main bronchus, followed by the symptoms of stenosis of those organs. There are cough and expectoration, the latter frequently containing blood-corpuscles with mucus, and resembling in appearance currant- jelly; the sputa may also rarely exhibit a grass-green color, due to trans- formation of the blood-pigment. In carcinomatous lungs putrefactive changes sometimes take place, and if so the expectoration and breath SARCOMA OF THE LUNG. 537 emit an offensive odor, while a microscopic examination of the sputum frequently discloses the presence of carcinomatous elements. The well- known cancerous cachexia invariably develops. Physical Signs.—These Avill naturally depend upon the extent and location of the new growth. Inspection.—If the lung-tissue be exten- sively involved, the walls of the thorax become unduly prominent and fixed over the seat of the tumor. Indeed, the tumor may, though rarely, protrude between the ribs. The intercostal spaces are Avidened, and the superficial veins, in vieAv of the fact that they cannot empty themselves into the internal veins, appear engorged; from the same cause edema affecting the thorax, neck, face, and arms may be noted. SAvelling of the lymph-glands in the neck or axilla is often Avitnessed, and is a symptom of high importance. On palpation the tactile fremitus may be found to be diminished or absent. The percussion-note will be flat, since the air-vesicles and smaller bronchi are replaced by the solid groAvth. On auscultation friction-sounds are the rule. The respiratory sounds may be greatly enfeebled or absent; but if the carcinomatous tumor communicates Avith a wide-mouthed bronchus, bronchial breathing may be audible, and the usual physical signs of lung-cavity may be developed. The signs of general bronchitis are present in most instances, being most pronounced in the secondary or disseminated form of the disease; in the latter variety the lung may shrink, forming a condition in Avhich retraction of the chest-walls on the affected side must ensue. If pleurisy Avith effusion occurs as a secondary event, the detection of the charac- teristic cancer-cells in the contents of the pleural cavityT will shoAv the precise nature of the thoracic affection. Diagnosis.—The folloAving symptom-group will pretty well estab- lish a diagnosis: A peculiarly shaped dull area (as Avhen it extends under the sternum), perhaps a marked prominence over the site of the tumor, enlarged and hard lymphatic glands in the A7icinage, and more or less of the compression-symptoms—circulatory, nervous, bronchial, or trachial stenosis. In rarer instances the diagnosis may be made by the occurrence of metastasis to the chest-Avail. Again, the discovery of cancer-tissue in masses accidentally detached gives reliable indication of the disease. The differential diagnosis between pulmonary carcinoma and pul- monary tuberculosis can be made Avith positiveness only by a careful microscopic examination of the sputum. From fibroid induration of the lung it is easily discriminated, OAving to the history and sloAver course of the latter affection. Prognosis.—This is bad, as death may occur suddenly from abun- dant hemorrhage or more frequently from either exhaustion or asphyxia. The duration of the affection varies from six months to a year, or, rarely, even tAvo years. Treatment.—The treatment must be addressed solely to the relief of pain and other subjective symptoms. SARCOMA OF THE LUNG. Primary sarcoma of the lung is rare, but in instances of generalized sarcomatosis the lungs shoAV larger or smaller nodules " in almost every 538 DISEASES OF THE RESPIRATORY SYSTEM. case " (Birch-Hirschfeld), occurring in connection Avith osteo-sarcoma of other organs or in lympho-sarcoma of the cervical glands. Secondary sarcoma, occurring in consequence of invasion of the root of the lung by sarcomatous disease of the post-bronchial glands, is also a not uncommon condition. Neoplasms occurring among the cobalt-miners of Schneeberg were described by Hesse and Tragner as lympho-sarcomata—slowly groAving masses that attained to a large size and gave metastasis to lymph-glands, pleura, liver, and spleen. In a majority of these cases there was an asso- ciated pneumonokoniosis, which had probably predisposed to the new groAvth. HYDATID CYST OF THE LUNG. Hydatids in the lungs may either be primary or secondary, the former variety being exceedingly rare, and the latter somewhat less so. Almost invariably the echinococci are developed in other organs—the liver in particular—and find their Avay to the lungs, either by direct perforation through the diaphragm or by entering through the blood-current. The etiology and pathology will be considered at sufficient length in connection with Hydatid Cysts of the Liver. Symptoms.—The clinical manifestations are quite varied, even though the cyst may entirely conceal itself. It is important to recollect that similar involvement of the liver usually coexists; and in addition to the symptoms of the latter affection there may be pain in the chest, dyspnea, considerable cough, and, rarely, blood-stained expectoration. The physical signs, when present, are as follows: Diminished vocal fremitus, defective expansion, dulness on percussion with an absence of the respiratory murmur, and later signs of cavity-formation may appear. A positive diagnosis of hydatid cyst of the lung can be made only when the scolices, pieces of membrane, and the hooklets of the echinococcus are demonstrable in the sputum. Besides being evacuated into the bronchi, the cysts may rupture into the adjacent serous sacs (pleura, peritoneum, pericardium), or externally, the latter being the most favorable mode of termination. Unless they are discharged early by ulceration into the bronchi or externally, they are apt to excite in- flammation of the adjacent lung-tissue and tubes, accompanied by an active febrile movement and an aggravation of the symptoms before de- tailed : these complicating conditions may assume a dangerous form, or the patient may, if the groAvth attains large dimensions, become asphyx- iated. Prognosis.—The affection is ahvays attended with great danger, and is of more serious import Avhen secondary to involvement of the liver than when primary. Treatment.—When it can be shown that the growths are situated at the periphery of the lung operation should be carefully considered. The physician stands poAverless to do more than to relieve urgent symp- toms in special cases and to support the vital functions. DISEASES OF THE PLEURA. 539 V. DISEASES OF THE PLEURA. PLEURISY. (Pleuritis) Definition.—An inflammation, either local or general, of one or both pleural membranes. The disease, as shoAvn by postmortem exam- inations, is of great frequency. Varieties.—Pleurisy has been variously classified. Etiologically, the distinction betAveen primary and secondary forms of the disease should be made, as Avell as a division into tuberculous, carcinomatous, septic, etc. Pathologically, all cases may be summarized under the following heads : Localized and generalized and dry (plastic) pleurisy and pleurisy Avith effusion (sero-fibrinous, purulent, hemorrhagic). They may also be classified according to their duration into acute, subacute, and chronic pleurisies. I shall describe the following forms, which are based partly upon their etiologic and clinical course, though mainly upon their pathologic manifestations—viz. (a) acute plastic pleurisy ; (b) sero-fibrinous pleurisy; (c) purulent pleurisy (empyema); and (d) chronic adhesive pleurisy. Bacteriology.—In all forms of the disease the immediate causes are various micro-organisms or their irritating chemical products. Con- spicuous among these is the bacillus of tuberculosis, even, though rarely, found in the pleuritic exudate. Inoculation of guinea-pigs Avith the latter by Eichhorst gave positive results in 15 out of 23 cases that Avere considered to be of the primary form. Although rarely containing bac- teria, Netter, Prudden, and others have found in the exudation of fibrino-serous pleurisy the streptococcus pyogenes, the staphylococcus, the typhoid bacillus, and the diplococcus of pneumonia. The micro- organisms most commonly present in emphysema are the micrococcus lanceolatus and the streptococcus, the former especially in the pleurisy associated with pneumonia (in two-thirds of the cases occurring in children—Levy), and the latter in those independent of pneumonia, particularly in adults. Among other bacteria that have been found rarely in the effusion are the colon bacillus, the proteus vulgaris, the gonococcus, Friedlander's bacillus, and various saprophytic bacteria. Except in the case of the pleuritic exudation (usually purulent) in pneu- monia, in Avhich the diplococcus is alone present in about one-half of the cases, the afore-mentioned micro-organisms are generally found in asso- ciation. ACUTE PLASTIC PLEURISY. . (Dry, Fibrinous Pleurisy.) Pathology.—The lesions are usually circumscribed, the part in- flamed being intensely injected. It has lost its natural lustre, and instead has a dull, non-glistening surface "like a tarnished mirror," due to a slight fibrinous exudate. Minute ecchymoses are seen at dif- ferent points. Later the exudate may become more copious, when the 540 DISEASES OF THE RESPIRATORY SYSTEM. pleura presents a rough, shaggy appearance. On account of the fric- tion betAveen the two pleural membranes in high grades of dry plastic pleurisy, the exudate may be very thick, and its color-appearance is then yellowish- or reddish-gray. This sheeting of fibrinous exudate entangles in its meshes numerous embryonic round cells, out of which blood-vessels and connective tissue are developed. The opposing sur- faces of the pleura adhere. Occasionally, in the lighter grades, the disease does not advance to firm adhesion, and in such instances the products of the exudate undergo fatty degeneration and are absorbed. The respiratory movements are but little disturbed in these cases. Etiology.—The affection may be (a) primary or (b) secondary. (a) By the primary form is meant an inflammation of the pleura occur- ring in previously healthy persons. It is exceedingly rare, and doubt- less many instances of true secondary pleurisy are regarded as belong- ing to this category, inasmuch as pleurisy may exist for an indefinite period Avithout exciting noticeable symptoms. Of great etiologic prom- inence is exposure to cold and Avet, and next to this stands mechanical injury. It is more common in men than in Avomen, and especially during the time of active life, on account of the greater degree of ex- posure of the former than the latter sex. In almost all instances a careful search will disclose the existence of some diathesis (tubercu- lous, gouty, rheumatic) that may be properly regarded as the favoring cause. The changeable Aveather of the winter and spring augments the proportion of cases during these seasons as compared with sum- mer and autumn. (b) The secondary for)n of dry plastic pleurisy arises from extension of acute and chronic inflammatory affections of the lungs and other neighboring organs. Hence it frequently follows croupous pneumonia, somewhat less frequently broncho-pneumonia, and more rarely still hemorrhagic infarct, abscesses, and pulmonary carcinoma and gangrene. When pleurisy occurs on the right side it must be recollected that it may have originated in inflammation of the liver. Plastic pleurisy sometimes arises in acute articular rheumatism, to which it may essen- tially belong. It is an almost constant secondary process in chronic pulmonary tuberculosis, and may, though rarely, even constitute the primary lesion (primary tuberculous pleurisy). The disease may appear as a complication in chronic alcoholism and in chronic Bright's disease. Finally, inflammation of other serous membranes, as of the peritoneum and pericardium, by direct extension through the lymphatics of the diaphragm, invade the pleura. Symptoms—The affection may vary in intensity between the ex- tremes of mildness and great severity, though, as a rule, Avell-marked local symptoms attend the onset. Among the latter a sharp " stitch " in the side, that is usually referred to the nipple, is the most prominent. The pleural pain is increased by inspiration as Avell as by voluntary mo- tion of the affected side, and hence the patient assumes a fixed position in which he favors the affected side by leaning toward it. There is a dry, distressing cough that is restrained for obvious reasons, and the respiration is somewhat hurried, painful, and jerking in character until the exudation is poured out, when relief from this and other local symp- toms ensues. ACUTE PLASTIC PLEURISY. 541 The general symptoms are not pronounced, and, save in compara- tively rare instances, do not correspond with the local signs. The tem- perature is not typical, rarely exceeding 103° F. (39.4° C), and more often it is below 101° F. (38.3° C). The pulse is usually small and tense or soft in character, registering from 90 to 120 beats per minute. Not infrequently the cases are so mild as to be attended by few, if any, subjective symptoms. The patient may complain of ill-defined, uneasy sensations in the affected side, but does not discontinue his usual occu- pation. On the other hand, the Avorst cases of acute plastic pleurisy— Avhich, fortunately, are rare—manifest violent symptoms: there is a distinct chill, a speedy development of high fever (104° F.—4.0° C), and profound prostration, and the general and local symptoms are pro- portionately aggravated. The illness then is often a fatal one. Physical Signs.—On inspection the movements of the chest-wall on the affected side are observed to be much restricted, particularly during the first day of the affection. During a later period palpation confirms the results of inspection, Avhile percussion yields a normal note. Aus- cultation renders audible a grazing friction-sound, Avhich, though audi- ble, is most intense at the end of inspiration. With the occurrence of fibrinous exudation palpation detects over the corresponding area a diminution of the tactile fremitus. On percussion there is, as a rule, a slight though variable degree of dulness; and on auscultation the crepitating or rubbing friction-sounds are heard both on inspiration and expiration, being intensified by deep breathing. These sounds frequently endure for a day or two after the other symptoms have disappeared. Very rarely the plastic exudation may be so extensive as to cause compression of the lung, in which instance the breath-sounds may become bronchial in character; and I have known a case of this sort to be mistaken for lobar pneumonia. In addition, the breath-sounds will be feeble and distant. Diagnosis.—By exercising ordinary care the clinician can scarcely mistake other thoracic affections for dry pleurisy, the latter being diag- nosticated to a certainty by the presence of the characteristic friction- murmur. Intercostal neuralgia may present features not unlike those of acute pleurisy. In both affections there is frequently a history of exposure, followed by severe chest-pains that are excited by coughing and deep breathing. In neuralgia, however, there are painful pressure- points, and the pleuritic friction-sound does not occur. Pleurodynia may also give a history very similar to that of acute pleurisy, but the presence of the characteristic physical signs of pleurisy are absent. Prognosis.—The duration of the affection varies from a few days to three weeks, and the immediate outcome is favorable as a rule. It cannot be doubted, however, that a primary attack predisposes to subse- quent attacks, and thus, as a result of repeated seizures, pleural thicken- ing and intrapleural adhesions often arise. Lung-expansion may in this manner be restricted, with the gradual development of interstitial pneu- monia as a consequence. Acute plastic pleurisy is not infrequently a terminal condition in serious forms of illness (e. g. septicopyemia and chronic nephritis). Treatment.—The first object in the treatment is to relieve the pain, and this can best be accomplished by the hypodermic use of mor- 542 DISEASES OF THE RESPIRATORY SYSTEM. phin. The inflammatory process is best controlled by absolute rest in the recumbent posture, allowing the patient to assume that position which gives him most comfort. I am also in the habit of administer- ing moderate-sized doses of quinin (gr. iv—0.259—three times dailv). After the exudation has appeared, the iodids of iron and potassium, in combination, may be employed. Locally, nothing is so effective as cold in the form of the ice-water bag or Leiter's coil, preceded. in robust patients, by the local abstraction of blood (§iij to vj—96.0- 192.0) by leeches. At the end of one week the morphin may usually be discontinued. During convalescence the patient should be instructed to take deep inspirations several times in succession, not less than a dozen times each day, Avith a vieAv to obviating so far as possible the pleural adhesions and other unfavorable consequences. Symptomatic anemia may be present at this time, and should be met by iron given internally. At this time iodin may be used locally Avith great benefit; I have not, however, seen any favorable results from blisters. For the pain which continues in the side after all detectable physical signs have disappeared the use of the constant current over the seat of the pleur- isy for twenty minutes at a time gives almost instantaneous relief (Loomis). SERO-FIBRINOUS PLEURISY (PLEURISY WITH EFFUSION, SUBACUTE PLEURISY). Pathology.—During the first stage of sero-fibrinous pleurisy the changes are the same in character as those met Avith in dry pleurisy. though of severer grade, and usually involving the greater portion of the pleura on the side affected. There is an abundant exudation of serum, and usually the entire pleura becomes coated with a fibrinous exudate, that varies greatly in thickness and arrangement. The latter is thin and smooth in some instances, though more frequently it forms a thick layer, presenting a shaggy surface on the one hand or an irregular, honeycombed surface on the other. Lymph in the form of flocculi is rather abundant in the serous effusion. The interlobu- lar pleural surfaces are also invaded as a rule, in consequence of which they become adherent. The fluid exudate varies greatly in quan- tity (| to 8 pints—4 liters), is often of a citron color, and is, in the ma- jority of instances, clear or slightly turbid. Rarely it is of a dark- brown color. Unless adhesions between the pleural surfaces have previously existed the effusion gravitates to the most dependent portion of the pleural cav- ity. Microscopically, there are found leukocytes, red blood-corpuscles, endothelial cells, threads of fibrin, and, rarely, crystals of cholesterin and uric acid. The composition of the fluid is almost identical with that of blood-serum, and on boiling it is found to be rich in albumin. Spon- taneous coagulation may take place on standing. Changes in the Neighboring Organs.—So long as the normal retrac- tility of the lung is not overcome by the fluid that collects in the pleural cavity, the latter does not produce positive intrathoracic pressure, and hence does not produce displacement of adjacent organs. It may be assumed that until the pleural sac is at least one-half filled with sero- SERO-FIBRINOUS PLEURISY. 543 fibrinous exudate the natural contractility of the lung is not destroyed. At this period there may be a slight displacement of the mediastinum toward the opposite side, due to traction exerted by the normal retrac- tility of the sound lung. Obviously, large effusions must in a mechani- cal manner displace the pleural membranes, thus causing compression of the pulmonary structures lying above the effusion. A very copious effusion may push the lung up and back against the vertebral column and convert it into a small, flat, bloodless, and airless mass (atelectasis). While a total absence of air in the collapsed lung is due chiefly to com- pression by the fluid, to some extent, hoAvever, the air may be absorbed by the vessels or even by the effusion (Striimpell). Together with compression of the lung byr the effusion, pressure is also exerted by the latter against the mediastinum, causing displacement of the heart. The mediastinum also loses the normal traction-force of the lung upon the affected side, and hence the lung on the sound side draAVS the mediastinum toAvard itself by its OAvn retractile energy. Osier shoAvs that even in the most extensive left-sided effusion the heart's apex is not rotated, but that the normal relative position of the apex and base obtain, though the apex is in some instances lifted, and in others the heart lies more transversely. The right chambers of the heart occupy most of the interior of the organ, showing that the displacement of the mediastinum with the pericardium and its contents to the right involves no appreciable tAvisting of the heart itself. DoAvnward displacement of the diaphragm takes place in extensive effusion, and shoAvs itself on the right side by the loAvering of the liver to a variable distance beloAv the inferior costal border; on the left side large effusions produce pressure-displacement of the stomach and the transverse colon, and, to a slighter extent, of the spleen. It must be recollected that adhesions may prevent displacement of any of the adjacent organs. Etiology.—In the present state of our knoAvledge the causal factors are identical in nature Avith those producing dry plastic pleurisy, the pathologic differences being attributable to the differences in the inten- sity of the processes. It is highly probable that the degree of severity is dependent upon the previous condition of the patient, Avhether he be suffering from some other affection or not, and upon the amount of specific poison gaining access to the pleura. The affection may be primary, but is much more often secondary; and this fact may be explained by reference to any of the specific micro-organisms producing the affection. Many of the cases folloAV quickly upon exposure to cold or wet or an injury to the thorax. I thoroughly agree with those authors Avho contend that about three- fourths of the cases of sero-fibrinous pleurisy are induced by tuber- culous infection of the pleura. The tuberculous process may invade the pleura primarily, but more often it is secondary to tuberculosis of the lungs; less frequently, though more often than is generally sup- posed, it is secondary to tuberculous peritonitis. In these instances the tubercle bacilli probably find their way from the peritoneum to the pleura by traversing the lymphatics in the diaphragm. I am con- vinced that a large percentage of apparently primary cases of tubercu- lous pleurisy have their origin in a circumscribed and more or less 544 DISEASES OF THE RESPIRATORY SYSTEM. latent tuberculous focus in the lungs. It is not improbable also that tuberculous processes in other viscera may furnish the tubercle bacilli for secondary pleural infection. Moreover, the fact that many cases of sero-fibrinous pleurisy recover does not disprove their tuberculous nature. The typhoid bacillus of Eberth has also been known to pro- voke pleurisy (Bozzolo, Fernet, and others).1 The affection is not infrequently secondary to acute articular rheu- matism, which is itself most probably a microbic affection. It also arises as a complicating condition in the course of various acute and chronic affections of the chest, as pericarditis and catarrhal pneumonia, and may develop in acute infectious diseases, as typhoid fever or lobar pneumonia. It may occur as a complication in the chronic affections of various viscera (chronic nephritis, cirrhosis and carcinoma of the liver). The predisposing causes are the same as for the dry plastic form. Symptoms.—The description here refers particularly to primary sero-fibrinous pleurisy, and it is important to recollect that when second- ary to other acute and chronic affections characterized by great bodily weakness the pleuritic symptoms may be more or less completely veiled. With few exceptions the onset is insidious, the symptoms being quite mild, but rarely there is a sudden onset with active symptoms (rigor, high fever). In the majority of instances the patient first complains of a stitch-like pain in the side; this is rarely pronounced, but is aggravated upon deep breathing and upon any muscular exertion. Dyspnea soon arises and gradually increases in intensity. Cough may be present or absent, and in some instances is attended by a scanty mucoid expectoration that may rarely be blood-streaked. The constitutional symptoms are of correspondingly sIoav and gradual development. From the commencement of the attack a moderate febrile movement at night may be observed, and the pulse will be found to be frequent, small, and compressible, or, more rarely, tense. At the time of the patient's first visit to his physician he may give a history of having gradually lost flesh and strength for a period of weeks together, though he may not have been obliged to abandon his vocation. He looks pale, his countenance wears an anxious expression, and he is without appetite. These cases frequently drag along from two to four weeks before con- sulting a physician, the local symptoms going unnoticed, and the patient making complaint only of weakness, anorexia, headache, etc. Sometimes the more acute symptoms characterize the period of invasion, and, after lasting a few days, exhibit a decided remission; but at another subsequent period there may be a sudden recurrence of the local and general phenomena, and particularly of the dyspnea. The pleural cavity, which may have been one-half or two-thirds full, now becomes completely filled. Special Symptoms.—Pain.—Chest-pain is an almost constant but not highly characteristic symptom, and, though usually among the earliest symptoms, it may not be present until a few hours or a day after the commencement of the affection. It may be described as a sharp, shoot- ing pain, and is popularly termed a " stitch in the side." It may, how- ever, be tearing or dragging in character. Its intensity is not a safe in- 1 Annual of the Universal Medical Sciences, 1892, vol. ii. p. 12. SERO-FIBRINOUS PLEURISY. 545 dication of the severity of the disease. It is usually referred to a small spot beloAv the nipple or to the mid-axillary region ; exceptionally, how- ever, it is more diffuse, and in my experience it has not infrequently been retrosternal or referred to limited areas beloAv the inferior costal border. When absent it may be excited by coughing, sneezing, deep inspiration, and stooping. AVith the appearance of the effusion the pain diminishes, and, as a rule, soon disappears. Dyspnea.—The respiration is shalloAV, catching in character, and hurried in consequence of the severe pleural pain; in copious effusions, that render one lung almost or wholly functionless, the dyspnea may become intense, even attaining to Avell-marked orthopnea. It reaches its most pronounced form in persons Avho have previously been robust, and in those in Avhom the effusion has developed rapidly. On the other hand, when the pleural sac fills sloAvly dyspnea may be absent, except on exertion. This symptom appears frequently before the effusion takes place, and is then due partly to the fever and partly to the pleuritic pain. FolloAving marked disturbances in the respiration, cyanosis ap- pears and may become quite pronounced. Cough and Expectoration.—Little need be added to A\hat has already been stated. When there is present much expectoration it is most fre- quently due to associated bronchitis or to pulmonary7 tuberculosis; there may, hoAvever, be a total absence of expectoration, and in such instances the exciting cause of the cough is probably the pleuritis. Both the cough and expectoration are apt to be increased during the process of resorption of the exudate as the result of a catarrhal bronchitis that is apt to develop in the re-expanding lung. Fever.—The rise of temperature is not rapid as a rule, nor does it reach a high point (101.5° to 103° F.—38.6°-39.4° C). At the end of a variable period—usually one to three weeks—the temperature falls by lysis, and soon touches the normal. The temperature may be of the continued type in many acute cases. In subacute forms the temperature may rarely rise above 101° F. (38.3° C), or may, finally, assume a hec- tic type. The surface-temperature of the affected side is from one-half to two degrees (.4°-1.6° C.) higher than that of the normal side. Pulse.—The pulse is quickened, beating 100 or-more per minute, and its volume and tension are diminished. Irregularity both of the volume and rhythm of the pulse may also be observed. These pulse- characteristics are to be attributed to the pressure of the effusion upon the heart and great vessels. Gastro-intestinal Symptoms.—Loss of appetite is commonly present, and more rarely nausea and occasional vomiting may be met with at the outset. Constipation is the rule. Renal Symptoms.—The amount of urine is diminished both during exudation and Avhile the exudate remains at the same level. The daily quantity may not exceed eight or ten ounces, but the specific gravity is increased, ranging from 1018 to 1028. An increase in the daily amount of urine excreted is frequently the first sign of commencing absorption of the exudate, and the rapid resorption of the copious effusion may greatly augment the flow of urine to 80 or 100 ounces .(2.5 to 3 liters) daily (Striimpell). The cause of the diminished secretion of urine is, in the main, diminished arterial pressure. 35 546 DISEASES OF THE RESPIRATORY SYSTEM. Physical Signs.—The physical signs of sero-fibrinous pleurisy differ with the amount of effusion present, and also Avith the particular stage of the affection : those of the first stage, hoAvever, are identical with the signs pointed out in connection Avith dry plastic pleurisy, and need not be restated here. We Avill note the physical signs (1) during the stage of effusion, as well as (2) those presented Avhen resorption of the effusion has taken place. (1) Stage of Effusion.—When the pleural sac is only partly filled there is noted, on inspection, but little change in the thoracic contour. The respiratory movements are, however, restricted, OAving to mechani- cal hindrance to the lung-expansion. In the majority of instances the effusion increases until positive intrathoracic pressure and noticeable bulging in the middle and loAver third of the chest-Avail on the affected side take place; the intercostal spaces beloAv are Avidened and more or less nearly effaced. The apex-beat of the heart is displaced, being visible in right-sided pleurisy to the left of the vertical mammary line in the fourth and fifth interspaces, and in left-sided pleurisy to the right of the right mammary line, or even beyond, in the third and fourth in- terspaces. The apex of the heart may take a position behind the ster- num, when no impulse will be visible. Palpation.—The limited movement of the chest is readily appreci- ated on palpation, and in large effusions the chest-wall is practically fixed. The separation of the ribs and the obliteration of the intercostal spaces are easily made out in the same manner. Edema of the chest- wall is rarely present, and fluctuation almost never. An important and early physical sign is the diminished tactile fremitus, Avhich is soon abolished, except in infants, in Avhom it may be excited on crying. This is a less valuable sign in women than in men, owing to the differ- ences in the vocal vibrations in the two sexes. In copious effusions tac- tile fremitus may sometimes be obtained when bands of adhesion, Avhich serve as a medium for the transmission of local fremitus, connect the pulmonary with the costal pleura. The apical impulse can also be readily located by palpation. The displaced spleen or liver can be read- ily felt through the abdominal wall, and must not be mistaken for an actual enlargement of these organs. Mensuration.—It must not be forgotten that in right-handed adults the right side is, normally, slightly larger than the left; and it is only after the effusion is considerable in amount that the cyrtometer shows any alteration in the thoracic contour or an enlargement of the affected side. The tape, however, exhibits the difference in expansive motion of the two sides early, or Avhen there is a moderate amount of fluid. At the end of expiration the circumference of the affected side will be found to be one or two inches greater than that of the left side, Avhile at the end of inspiration the difference Avill be but slight. The cyrtometric tracing also shoAvs a discrepancy betAveen the horizontal outlines of the two sides. Percussion.—At first the percussion-note is impaired, either poste- riorly or in the infra-axillary region, and a little later there is dulness, tending toward flatness (deadness), Avith increasing effusion. The resist- ance to the pleximeter-finger becomes greatly augmented. In cases in which the effusion rises to the fourth rib anteriorly there is dulness over SERO-FIBRINOUS PLEURISY. 547 the fluid above and absolute flatness beloAv. Since both the flatness and dulness are due to the fluid, it is obvious that the upper level of the latter must, Avhenever free, change with the posture of the patient; hence the limit of dulness will be higher in the sitting than in the re- cumbent position. When the pleural sac is filled or Avhen the effusion is confined by adhesions, the latter sign is not obtainable. If the upper level of the fluid reaches the loAver border of the third rib, the percus- sion-note above the line of dulness is tympanitic or vesiculotympanitic (Skoda's resonance). This note is most readily elicited in front, though it may also be present behind and above the level of effusion. In copi- ous exudations the cracked-pot sound may be elicited immediately be- low the clavicle in the usual manner, and " Williams's tracheal tone " may sometimes be obtained in large exudations. This may also be ob- tained near to the spine on the affected side or at a point corresponding to the seat of the compressed lung. When the patient is sitting or in the erect posture, the upper limit of dulness in large effusions is not a horizontal line, but is highest at the spine and falls as Ave proceed to the front, Avhich is its loAvest point. On the other hand, the upper line of dulness in moderate effusions begins "relatively low doAvn in the back, passes upward from the vertebral column, and soon turns upAvard and proceeds obliquely across the back to the axillary region, where it reaches its highest point; thence it advances in a straight line, but with a slight descent, to the sternum" (Ellis). This curved line resembles the italic letter S (Garland). On the right side the flatness is con- tinuous Avith that of the displaced liver; on the left it passes into and may obliterate Traube's semilunar space. Auscultation—The signs of the first stage have already been de- scribed (vide Plastic Pleurisy). With the appearance of the effusion the breath-sounds become Aveak, distant, and have a bronchial quality. Soon the respiratory sounds over the affected side will be entirely ab- sent, except near the upper level of the fluid posteriorly, Avhere distant bronchial breathing and, less frequently, diffuse vocal resonance are audible. The latter sounds may exhibit a metallic or amphoric quality, and may be accompanied by rales (pseudo-cavernous signs). The latter are more frequently met Avith in children than in adults, and often give rise to a false diagnosis. Above the level of the fluid there is broncho- vesicular breathing, and on the opposite side intensified breath-sounds may usually be noted. The effusion-sounds may manifest a nasal or metallic quality, simulating someAvhat the bleating of a goat (Laennec s egophony). This is best obtained near the upper level of the fluid in large effusions, and at or above the angle of the scapula when the effusion is moderate. (2) Stage of Resorption.—With resorption of the fluid there is a de- crease in the size of the affected side, together Avith a return of the nor- mal appearance of the intercostal spaces and the respiratory movements. In many instances there is positive retraction, leading to thoracic defor- mity Avith displacement of neighboring organs toward the affected side; and this retraction may be either general or circumscribed. The infe- rior intercostal spaces are more or less narroAved; the shoulders droop ; the nipple approaches the median line; the spine may be curved, the convexity being directed toward the sound side (quite rarely toward the 548 DISEASES OF THE RESPIRATORY SYSTEM. affected side); and the scapula projects from the chest-Avail on the af- fected side. In children, and even in adults, the lungs and thorax grad- ually expand in order to overcome this chronic deformity. On the other hand, the extensive adhesions betAveen the pleural membranes produce permanent shrinkage of the thorax and displacement of respiration. Palpation.—The tactile fremitus closely folio ays the fluid as it sub- sides from above doAvnward Avithout any extreme degree of thickening of the pleural membranes, though cohesion of their surfaces may pre- vent its return over the loAver segment. The inspiratory movement of the chest-Avail gradually returns, but not to its former limit. Mensuration shoAvs a steady diminution in the size of the side in- volved, which finally becomes smaller than its fellow. Percussion.—The dull or flat note gives way to normal percussion- resonance, proceeding from above doAvnward in a gradual manner; but the latter is not renewed over the loAver portion of the pleural cavity for a long period after the exudation has disappeared. The abnormal areas of flatness due to displacement of organs (liver, spleen, heart) also disappear. Auscultation discloses most important signs during the stage of re- sorption. The breath-signs reappear at first above, and then loAver doAvn, until the base is reached. With commencing subsidence of the fluid the respiratory sounds are feeble and distant, but later they resume their natural distinctness; and partly as a result of the revival of the natural muscular tonicity, and partly in consequence of the disappear- ance of the fluid, the two roughened pleural surfaces come in contact and play upon one another, giving rise to a rubbing, creaking friction- sound on auscultation. These friction-murmurs may persist for months after the effusion has been absorbed. Occasionally the lower portion of the compressed lung remains permanently inexpansile, and usually in such circumstances the upper portion of the lung is the seat of com- pensatory emphysema, which is recognizable by the customary physical signs. By auscultation we may note the return of the heart-sounds to their normal position. Special Clinical Forms of Acute Sero-fihrinous Pleurisy.— The separate varieties are dependent upon the nature of the effusion and the character of the etiologic factors, and in this connection the main clinical features of a few special types may be briefly described. They are as follows: (1) Tuberculous Pleurisy.—This is, in the majority of instances, second- ary to pulmonary tuberculosis. On the other hand, the primary lesions may be situated in the pleural sac and give rise to (1) Acute sero-fibrinous pleurisy (Avith the usual course); (2) Subacute pleurisy (Avith insidious course), leading to tuberculous invasion of the lungs ; and (3) Chronic adhesive pleurisy, in Avhich the course and physical signs correspond Avith those that will be depicted in a special section on Chronic Pleurisy. The morbid lesions are similar to those met with in other forms, plus the specific tubercles, Avhich may be exceedingly numerous (miliary tubercles) on the one hand, or confined to a few circumscribed areas on the other. This variety of pleurisy has* no special etiologic connection with empyema, and the effusion is usually sero-fibrinous and often blood- stained. Brief reference should be made to those instances in Avhich tubercu- SERO-FIBRINOUS PLEURISY. 549 lous pleurisy is folloAved by tuberculous pericarditis or peritonitis, or both. The tAvo latter affections will be considered elseAvhere. Suffice it to state here that tuberculosis of the serous membranes usually pursues a chronic course, lasting a year or more, and exhibits Avidely varying degrees of intensity in its symptoms in different cases, and from time to time in the same sufferer. We must grant that tuberculous pleurisy may pursue a favorable course Avith apparent recovery, though too often, after a variable interval of time, tuberculous symptoms are manifested. (2) Diaphragmatic Pleurisy.—This term is applied to those instances in which the diaphragmatic portion of the pleura is involved, either alone or in part. There occurs an exudate that may be either plastic or sero- fibrinous, though rarely large in amount. The symptoms are acute, and the pain, which is lancinating in character and situated in the epigastric region, is the most prominent feature. Geuneau de Mussy l holds that pain along the tenth rib, extending from the anterior extremity to the sternum and xiphoid cartilage, is pathognomonic. It is increased by deep inspiration and by pressure over the insertion of the diaphragm at the tenth rib, and often abates Avhen effusion takes place. Dyspnea is a marked symptom in most cases, and the patient may be forced to assume a stooping or sitting posture, the respirations being superficial, purely thoracic, and "catching." Cough, nausea, and even vomiting, may occur. In a case under my own care vomiting, due most probably to associated peritonitis, was a troublesome symptom. The constitutional features are quite pronounced, and particularly the fever, Avhich exceeds that met Avith in other forms of pleurisy. The patient's anxietyT is extreme. The effusion may be purulent, and if so bulging of the loAver intercostal spaces, followed by edema, may occur. The physical signs are for the most part negative. (3) Encysted Pleurisy.—This term has reference to effusions that are circumscribed in consequence of adhesions between the pleural mem- branes. There may be tAvo or more pouches, Avith or Avithout communi- cation. This so-called encapsulated pleurisy may occupy any part of the chest, and is exceedingly variable in extent. The symptoms and physical signs are rarely trustAvorthy for diagnosis, but should usually afford ground for suspicion, and hence should lead in every instance to the employment of the exploratory puncture. (4) Interlobar Pleurisy.—This variety is usually secondary to, or associated with, the ordinary type of acute sero-fibrinous pleurisy. The serous surfaces, dipping between the lobes, are involved in the inflam- matory process, and the fluid becomes encapsulated in this position in consequence of interlobular pleural adhesions. It is more frequent on the right than on the left side, and its favorite seat is near the root of the lung, betAveen the upper and middle lobes. Osier2 met with a case folloAving pneumonia in Avhich there Avas betAveen the loAver and upper and middle lobes of the right side an enormous purulent collection that looked at first like a large abscess of the lung. Fistulous connection Avith a bronchus often occurs, and the purulent expectoration that follows may be the first symptom to attract the attention to the process of sup- puration in the thorax. Prior to the occurrence of this accident the patient gives evidence of indisposition Avithout definite symptoms. The 1 Arch. gen. de Med., 1853, vol. xi., quoted by Fox. 2 Practice of Medicine, p. 567. 550 DISEASES OF THE RESPIRATORY SYSTEM. patient may or may not give a clear history of antecedent pleurisy. These cysts contain, as a rule, but a small amount of fluid, and do not cause much bulging of the intercostal spaces. Indeed, in a case of my OAvn at the Philadelphia Hospital there Avas actual retraction, though the aspirating needle shoAved the presence of effusion.1 (5) Hemorrhagic Pleurisy.—By this term is meant an admixture of Fig. 47.—Illustrating pleurisy with effusion: 1, compressed lung-tissue, giving dull tympany on per- cussion ; 2, fluid exudation obliterating intercostal spaces ; 3, depressed liver; 4, displaced heart. blood with the exudate in acute sero-fibrinous pleurisy, in quantities suf- ficient to be detectable by the unaided eye. The condition must be sep- arated from hemothorax. The causes of hemorrhagic pleurisy are—(1) Tuberculous infection, either of the miliary or the chronic (circum- scribed) form, folloAving tuberculous disease of the lung; (2) Carcinoma of the pleura ; (3) Bright's disease, and cirrhosis of the liver ; (4) Ady- namic states of the system associated Avith malignant forms of acute infectious diseases. 1 International Clinics (1894), vol. i. p. 39. SERO-FIBRINOUS PLEURISY. 551 In a certain proportion of the cases no assignable cause can be found, and if the condition be observed for the first time after aspiration, the fact that it may have been engendered by an accidental wound of the lung must be remembered. Diagnosis.—In diagnosticating pleurisy our attention must be directed chiefly to the physical signs. Unfortunately, in vieAv of the fact that the rational symptoms are often ambiguous, a physical explor- ation of the chest is apt to be neglected. The chief difficulties are encountered in distinguishing this affection from conditions in Avhich the lung is either consolidated, retracted, or compressed by solid new growths, etc. Chief among the former is croupous pneumonia, and I have tabulated below the most important distinctions between it and pleurisy. The reader will be further aided by comparing Fig. 47 (Avhich shows the physical conditions in pleurisy) Avith Fig. 17, on page 150, Avhich shows the physical conditions in pneumonia. Pleurisy with Effusion. Primary Lobar Pneumonia. Rational Symptoms. Onset marked by chilliness persisting for A severe rigor, lasting about one hour. a few days. The pain is sharp, " stitch-like," and Acute pain, similar, but soreness more strictly localized. Cough frequent and irritating ; no ex- pectoration. Moderate fever of continuous type ; de- cline by lysis. Systemic prostration of medium sever- ity. Countenance pale and anxious. Herpes does not appear. diffused. Cough accompanied by rusty or bloody expectoration. Intense fever ; decline by crisis from the fifth to the ninth day. Prostration marked. Countenance congested ; mahogany flush, on the cheeks. Herpes quite common. Physical Signs. Inspection. Marked distention of the thorax. Palpation. Diminished or absent tactile fremitus. None. Marked tactile fremitus (absent only when a bronchus is plugged). Percussion. Flatness, with great resistance to the Dulness less complete, less resistance, pleximeter-finger. and sometimes a tympanitic note. Shows displacement of neighboring or- No displacement of neighboring organs, gans. if uncomplicated. If the sac be partly filled, there is a Absent. change in the line of flatness on change of position. Auscultation. Diminished or absent breath-sounds, bronchial breathing frequent, but dif- fused and distant and unaccompanied by rales, as a rule. Vocal resonance diminished or absent. Friction-sound in early and late stages. Aspiration. Yields serum. Harsh bronchial breathing and presence of rales in first and third stages, unless a bronchus be plugged. Bronchophony, unless a bronchus be blocked. No friction-sound, except crepitant rales in the first stage. Yields a few drops of thick blood. 552 DISEASES OF THE RESPIRATORY SYSTEM. Consolidation of the lung, due to tuberculous infection, may be dif- ferentiated from pleurisy with effusion by means of the physical signs contrasted in the foregoing table, by the history of the case, and by the discovery of the tubercle bacillus in the sputum. Hydrothorax presents physical signs that simulate strongly those of pleural effusion. Hydrothorax, hoAvever, gives the history of cardiac or renal disease, is usually bilateral, and is unassociated with a rise in temperature or Avith the pain or friction-sounds peculiar to pleurisy. In obscure instances some of the fluid should be AYithdraAvn and chemi- cally examined. Tumors and cysts of the thorax will give complete dulness, will dis- place the heart, and compress the lung on the affected side, thus caus- ing an absence of the respiratory murmur, etc. But the history of the case, the situation of the dulness (usually over the upper or middle parts of the lung), the absence of uniform distention extending to the base, and the exaggerated tactile fremitus and vocal resonance Avill serve to distinguish these affections from pleurisy with effusion. Echinococcus cyst of the liver, or abscess of this organ, pushing up- ward, will cause retraction or even compression of the lung, and hence will also produce most of the physical signs of pleurisy with effusion. The former affections can be discriminated only by a correct appreciation of the history, by the presence not infrequently of a friction-sound on auscultation, and by the immovable, fixed upper level of dulness. If doubt remains, an exploratory puncture should be made, and the fluid Avithdrawn should be subjected to a chemical, microscopic, and bacterio- logical investigation. An enormous pericardial effusion may be mistaken for a pleural effu- sion on the left side. In the former, hoAvever, there is commonly a his- tory of rheumatism, and dyspnea is the most urgent symptom, while the heart-sounds are greatly enfeebled; moreover, the heart is not dis- placed to the right as in pleural effusion. Again, flat tympany is ob- tained in the posterior portion of the axilla and good pulmonary reson- ance at the base in the postero-lateral region of the chest, differing from the results of percussion in pleurisy Avith effusion. For practical purposes it is desirable to distinguish the tuberculous from the rarer forms of pleurisy. This is sometimes possible by paying due regard to the previous history of the patient, including hereditary taint, by noting certain clinical peculiarities (such as associated dis- ease of other serous membranes and of the lung and bilateral inflam- mation of the pleura), and by the results of an examination of the exudate. In dubious cases the guinea-pig should be inoculated with the exudate, and if the patients are tuberculous positive results may be confidently expected. Duration and Prognosis.—This depends largely upon the cause. The course of acute sero-fibrinous pleurisy is not definite, but is made up of two parts—the febrile folloAved by the non-febrile stage. The fever lasts from one to three Aveeks, and is due to inflammation; it corre- sponds to the period Avhen the effusion occurs, and the appearance of a non-febrile period indicates the subsidence of the inflammatory action. The effusion may be poured out rapidly, and is removed by absorption not less rapidly; more frequently, however, the effusion takes place SER 0-FIBRINO US RLE URIS Y. 553 rather gradually, and the same is true of resolution. Again, large effusions may persist in consequence of a purely mechanical hindrance to resorption; and finally, the course may become subacute or chronic in consequence of the development of empyema. Such facts as these constitute an explanation for the great differences in the duration of the cases. Simple sero-fibrinous pleurisy has a comparatively favorable prognosis. In rare instances, hoAvever, death ensues suddenly, Avith- out adequate lesions to explain its occurrence. Moreover, the fact that a sero-fibrinous effusion may be converted into a purulent one is not to be forgotten. Again, the crippling influence upon the lung- tissue of previous attacks, OAving to resulting adhesions, must be borne in mind, since chronic bronchitis and emphysema are often thus pro- duced. Lastly, it is to be restated that most cases of pleurisy are tuberculous in origin, even though it cannot be denied that complete recovery may take place. Treatment.—In the first stage the treatment is the same as for dry or plastic pleurisy. During the second stage, that of effusion, the objects of treatment are threefold: (1) To limit the extent and intensity of the inflammatory process; (2) To accomplish the removal of the effusion; and (3) To support the strength of the patient. (1) To Limit the Extent and Intensity of the Inflammatory Process.— To this end two classes of agents are employed—namely, (a) Internal, and (b) External. Among the latter are counter-irritants, as sinapisms and iodin, by means of Avhich gentle but constant counter-irritation is to be main- tained. Another agent of great Avorth is cold, applied by means of the ice-bag or ice-water bag, and if the temperature rises to 102° F. (38.8° C.) cool spongings of the surface of the body, together with the use of the ice-cap, will be found highly useful. Roberts recommended keeping the affected structures at complete rest by fixing in a mechanical manner the side affected. For this purpose strips of adhesive plaster must be firmly and evenly applied to the chest, and by this means the pain is relieved and the amount of inflammatory product poured out is greatly limited. The internal remedies embrace quinin, the salicylates, and opium. Opium and quinin are potent in controlling inflammation of serous membranes; the former being given preferably either in the form of suppositories or hypodermically, and the latter in divided doses, in cap- sule, folloAved by a few drops of mineral acid, administering gr. xvj to xx (1.036-1.296) daily.1 I have observed good results from the salicy- lates (3j-ij—4.0-8.0, daily), Avhich have been warmly advocated by Fiedler, Koester,2 and others, as valuable in mitigating or even aborting the inflammation of the pleurae, and thus in limiting the amount of effusion. It must not be forgotten that the effusion is due to an inflam- mation, and not to a simple transudation. The use of mild diaphoretics and diuretics, together Avith repeated small doses of salines, also aids in reducing the inflammation in the pleura. With a subsidence of the inflammatory process the temperature falls, and, when the latter reaches a point near to the normal, our efforts should be directed toward the 1 International Clinics (1892), vol. i., second series. 2 Annual of the Universal Medical Sciences (1893), vol. i. (A-31). 554 DISEASES OF THE RESPIRATORY SYSTEM. fulfilment of the second leading indication, (2) the removal of the effusion. Little is to be accomplished by local means, though iodin, per- sistently employed, sometimes does good. The folloAving ointment may also be tried: B/. Ung. ichthyol. (12 per cent.), Ung. iodini comp., da. 3aj (24.0); Ung. belladonnae, q. s. ad sij (64.0).—M. Sig. Apply tAvice daily. Blisters are not admissible. Mild hydragogue cathartics, and especially the salines, after the Matthew Hay method (i. e. 3ij to §ss—8.0-16.0, in the smallest possible amount of Avater, on rising in the morning), stimulate absorption from the pleural cavities by draining the blood of a certain amount of serum. Unirritating diuretics may also be employed, but I have found no appre- ciable advantage from their use. Free diaphoresis (from the use of pilo- carpin) sometimes assists in the absorption of the exudate, but it should not be employed in the presence of feeble heart-action or marked dis- placement of the organ. Among measures to promote absorption, the best, in my OAvn experience, is the following combination: B/. Potassii iodidi, 3J (4-0); Syr. ferri iodidi, 3ij (8.0); Syr. sarsap. comp., 3j (32.0); Ess. pepsinse, q. s. ad §ij (64.0).—M. Sig. 3j (4.0) every four hours, diluted; the dose to be doubled at the end of four days if well borne by the stomach.1 The patient should be put upon a dry diet in order to increase the plasticity of the blood, Avhich is thus induced to absorb the liquid exu- date from the pleural cavity. The modus operandi of this treatment is different, but the effect aimed at is the same as when saline purgatives are given. The exudation, however, defies all efforts at removal in about 33 per cent, of the cases, and in such the withdraAval of the liquid by aspiration (thoracentesis) must be practised. The indications for thora- centesis arise at two different periods in the course of pleurisy with effusion : (1) During the febrile stage, Avhile efforts are being directed to com- bating the inflammatory process. The object during this stage is to avert imminent danger to life, and not merely to remove the fluid. The conditions demanding immediate thoracentesis are—(a) when one pleural sac is completely filled or when Skoda's resonance extends from the clavicle dowmvard no farther than the second interspace; (b) in double pleurisies, when both sides are half filled, since death may occur from rapid filling of one or the other side; (c) in cases of copious effu- sions, upon the first signs of involvement of the unaffected side, such as moist rales, broncho-vesicular breathing, and impaired resonance; (d) the appearance of serious symptoms, such as orthopnea or syncopal attacks Avith cyanosis; (e) marked displacement of the heart, especially if one or more murmurs develop in the organ. 1 The author has employed this formula in more than 50 cases with very good results. SERO-FIBRINOUS PLEURISY. 555 (2) The indications for aspiration during the second or afebrile period, Avhen the main object is to remove the exudate, are—(a) if no diminution in the quantity of liquid effusion takes place one week after the temperature has reached the normal; (b) in subacute cases, in which there is little, if any, temperature from the beginning; aspira- tion should not then be Avithheld longer than three Aveeks. The operation is free from danger if carried out under antiseptic pre- cautions and if a modern aspirator is employed. The instrument should ahvays be tested before it is used. The patient rests in bed in the semi-re- cumbent posture, the arm of the affected side being brought forAvard with the hand placed on the opposite shoulder, so as to separate the ribs from one another. The point of puncture is in the sixth interspace on the right- hand side and the seventh interspace on the left, in the mid-axilla, or just below the outer angle of the scapula in the seventh right and eighth left interspaces, respectively. An assistant draAvs up the skin from the interspace, Avhile the operator uses the fore finger of his free hand as a director. The needle should be introduced Avith a quick thrust, hug- ging the rib beloAv the interspace, but endeavoring to avoid striking its periosteal covering. The fluid may not be obtained at the first opera- tion, and the reasons for this failure are several. The costal pleura may be excessively thickened, or Ave may meet Avith a much-thickened fibrous band. Again, the fluid may be encapsulated; and, lastly, the needle may become blocked. Under these circumstances repeated trials should be made. The amount of fluid withdrawn at one time should never be large (3xij to xxiv—384.0—768.0), though a relatively larger quantity may be taken during the febrile stage than during the afebrile, since in the latter instance the lung has been compressed for a longer period of time. The fluid is alloAved to drain aAvay slowly, a small needle being used, so as to invite the lung to expand in a gradual manner. If this precaution be not taken, the paretic pulmonary capillaries are apt to become the seat of sudden fresh congestion, followed by edema, and often by a speedily fatal termination. Thoracentesis is to be repeated at intervals of several days if nature does not take up the work of absorption, fol- lowing the first operations. If during the operation incessant cough, dyspnea, a tendency to syncope, marked thoracic constriction, or sudden intense pain be developed, the needle must be Avithdrawn instantly. Thoracentesis should not be resorted to in cases in Avhich croupous pneumonia is associated, and never in very aged and excessively feeble persons. (3) To Support the Strength of the Patient.—The powers of the sys- tem are to be maintained by a nutritious diet, bodily rest, and other hygienic measures. The lighter forms of solid food may be alloAved whenever they are found to agree, and it is important to promote the digestive poAver, should the latter be Aveak, by the administration of suitable remedies. During the stage of convalescence, therefore, tonics (strychnin, quinin, and arsenic) are to be administered. The dietary should be liberal, though composed of Avholesome articles. Gentle exer- cise in the open air is to be encouraged, and massage of the muscles of the affected side tends to re-establish their usual vigor. To bring about the best possible chest-expansion nothing is so good as light gymnastic 556 DISEASES OF THE RESPIRATORY SYSTEM. exercises, together with the methodical practice of deep inspirations for a minute or tAvo at intervals of three or four hours. I am of opinion that the management of the third stage, or that of convalescence, is about the same as that of tuberculosis. EMPYEMA (PURULENT PLEURITIS). Definition.—A suppurative inflammation of the pleura. Pathology.—On opening the pleural sac after death Ave may find a thick, creamy pus, though more frequently it is sero-purulent and sepa- rated into two layers—an upper, clear, greenish-yelloAV serous, and a loAver, thick, purulent layer. In a smaller proportion of cases the exu- date is fibrino-purulent. The odor emitted from the purulent collection is either SAveetish or fetid (e. g. Avhen due to Avounds), and, Avhen the condition is associated with gangrene of the lung or pleura, horribly offensive. Microscopic examination shows that the inflammatory prod- ucts are identical with those of purulent inflammation in general. The pleural membranes are the seat of a more intense inflammation than in acute sero-fibrinous pleurisy, and are greatly thickened (1 to 2 mm.). They present a granular suppurating surface, and both visceral and costal pleurae exhibit perforations, and the latter, quite frequently, erosions. Histologically, the altered membranes consist of new connective tis- sue, new blood-vessels, and numerous leukocytes. Etiology.—The following are the chief circumstances under which empyema arises: (1) As a sequel of the acute, sero-fibrinous variety. However clear the effusion may be, it always contains corpuscular ele- ments, which in the further progress of certain cases undergo coincident increase in numbers until the effusion presents a milky aspect, when it is said to be purulent. Thoracentesis may be responsible for this change, though never if performed under rigid aseptic precautions. (2) In children the effusion early becomes purulent in many instances, and in some cases may be so from the start. (3) Secondary to the acute and chronic infectious diseases (pyemia, scarlatina, pneumonia, tuberculosis, and dysentery most frequently; typhoid fever, measles, whooping-cough rarely). (4) The disease may follow malignant affections of the thoracic organs (lungs, esophagus), or tuberculous pulmonary cavities which perforate into the pleura. (5) Injuries to the chest may set up empyema (fracture of the ribs, stab or other penetrating wounds). Bacteriologic investigation has shown that the organisms most fre- quently present are the micrococcus lanceolatus, streptococcus, staphy- lococcus, and tubercle bacillus. The cases due to pneumococci usually pursue a favorable course. The leptothrix pulmonalis is often found in putrid effusions. Clinical History.—The symptoms vary with the cause. The on- set may be characterized by acute symptoms, such as rigor, followed by high temperature and signal prostration, and in the affected side there may be severe pains, aggravated by deep breathing and bodily move- ments. EMPYEMA. 557 If the exudate becomes gangrenous, a typhoid state develops early, and the case is apt to prove fatal in the course of a few Aveeks. It is quite a common event for the acute symptoms that characterize the in- vasion to be replaced at the end of a Aveek or more by the more obscure rational symptoms of chronic empyema. The latter, hoAvever, may de- velop very insidiously as a secondary affection. The rational symptoms in a Avell-marked case should ahvays excite a suspicion of the "presence of the affection, but cannot set the question of diagnosis at rest. The local symptoms (pain, cough, and expectoration) are of a mild charac- ter ; the dyspnea, hoAvever, that is usually present may be more or less intense. I have on more than one occasion found an utter absence of these symptoms. The general symptoms are those of septic infec- tion—diurnal chills occurring at irregular intervals, folloAved by great paroxysms of fever and profuse SAveating—and such patients lose flesh and become pale and Aveak. The temperature is higher than in pleurisy Avith effusion, and is intermittently, though irregularly, elevated. Peptonuria is a symptom of purulent pleurisy that is not Avithout diagnostic value. It. however, also occurs in suppuration associated with the third stage of pulmonary tuberculosis, and in suppuration due to other causes. While not indicative of empyema, hoAvever, it serves sometimes to eliminate sero-fibrinous pleurisy. The urine also contains indican in excess in the various suppurations, at least from time to time, if not constantly. Blood-examination invariably shoAvs leu- kocytosis. If the pus is not removed artificially, it frequently breaks into the lung, penetrates it, and finally discharges through a bronchus. Pneu- mothorax noAv tends to supervene. Traube contends that necrosis of the pulmonary pleura may alloAv of the soaking of the pus through the spongy lung-tissue into the bronchi, Avithout the establishment of a fis- tulous connection between the latter and the pleural sac, and hence Avithout the formation of pneumothorax. Besides rupture into the lung and external rupture, empyema may perforate through neighbor- ing organs, as the esophagus, pericardium, stomach, and peritoneum. In rare instances the pus burrows along the spine behind the peritoneum and the psoas muscle, reaching, finally, the iliac fossa and simulating psoas or lumbar abscess. Physical Signs.—These are, for the greater part, identical Avith those of pleurisy with effusion. Attention will therefore be called only to such as are more or less distinctive of the affection. Slight edema of the chest-Avail over the seat of effusion, especially in children, is often present, and if the pleural sac be not aspirated, the abscess may point externally and evacuate itself spontaneously. In the latter event a pro- trusion between the ribs shoAvs itself: this may be the seat of fluctua- tion, and present an inflammatory appearance prior to its rupture, with subsequent discharge of its contents. The opening is usually found in the fifth interspace in front, and less frequently in the third and fourth interspaces or beloAv the angle of the scapula behind. The upper level of the fluid does not change so readily on changing the posture of the patient, but requires a longer period of time. Baccelli's sign, or the transmission through a serous exudate of the whispered voice, is sometimes an aid in the discrimination of pleurisy 558 DISEASES OF THE RESPIRATORY SYSTEM. with effusion from empyema. According to my OAvn observation, though it is not invariably propagated by large serous exudations of the pleura, it is yet detectable in a large majority of instances, whilst I have never found it to be obtainable in chronic empyema. Pulsating Pleurisy.—Pulsation synchronous with the cardiac beat in pleural effusion has received various designations (pulsating empyema, empyema necessitatis, pulsating pleurisy). The latter term is the most appropriate one, in vieAv of the fact that its course takes place not only in empyema necessitatis, but also in empyema (Avhich manifests no tend- ency to point externally) and rarely in sero-fibrinous pleurisy. Its etiology is not definitely known. The principal causal factors, hoAvever, seem to be—(1) a copious effusion ; (2) paresis of the inter- costal muscles, inducing relaxation of the thoracic Avail; (3) a someAvhat forcible heart-beat (Henry). The rational symptoms of empyema are present. The physical signs are also identical with those of the latter affection, Avith the pulsation superadded. There are instances in Avhich palpation alone detects the systolic pulse in the pleural effusion. With rare exceptions the effusion occupies the left pleural sac. The pulsation may be limited to two or three interspaces or it may be visible over the entire antero-lateral aspect of the chest; pulsation at the back, however, is rare. Differential Diagnosis.—An absolute distinction between empy- ema and pleurisy with effusion rests solely upon the results of exploratory puncture. For this purpose the needle attached to the ordinary hypo- dermic syringe, or, preferably, the surgeon's exploring needle, may be employed, withdrawing but a very small quantity of the fluid, Avhich should be examined both macroscopically and microscopically. Pulsating pleural effusion simulates closely aneurysm of the thoracic aorta. When pulsation occurs in empyema, however, it is seen to be to the left of the normal course of the aorta: the rational symptoms and usual physical signs of purulent pleural effusion are usually present also, while the vascular symptoms and signs of aneurysm of the aorta (thrill, bruit) are absent. Prognosis.—Empyema is a serious disease, but, obviously, the out- look will be modified by'the special etiology. Spontaneous absorption may occur, though it is extremely rare. The discharge of the contents of the pleural sac through the bronchial tubes is a comparatively favor- able event, some cases in which this occurs recovering, Avhile in others death follows in consequence of the sudden inundation of the bronchi. An empyema may, in rarer cases, empty itself externally with favorable issue (empyema necessitatis). Evacuation of the pleural cavity is often folloAved by a continuous discharge of pus for an indefinite period, but the pus cannot be alloAved to remain Avithin the thoracic cavity Avith im- punity. As a result of the long-continued suppurative process, death may take place by slow asthenia. It must not be forgotten, however, that an unfavorable termination may be, in part at least, ascribable to certain associated affections (phthisis, pericarditis). Among children the outlook is much more favorable than among adults. The prognosis has, hoAvever, been rendered less serious by the application of surgical principles in the treatment of the disease. In all cases in which recovery ensues there is a progressive obliteration of EMPYEMA. 559 the pleural cavity, OAving to adhesions, Avhich finally become universal and lead to marked retraction of the affected side. Treatment.—The treatment of empyema is chiefly surgical. In a child the condition may terminate in recovery without operation, and hence may, at this period of life, be alloAved to run for tAvo or three Aveeks, thoracentesis being resorted to if suffocation be threatened. In an adult, however, if the purulent effusion be copious, aspiration should be per- formed at once as a temporary means of relief. Empyema following pneu- monia may terminate favorably after one or more tappings; but unless contraindicated by an unfavorable general condition of the patient, such as is met Avith in the closing stages of pulmonary tuberculosis, free incision should be made Avithout delay. The pleural sac should be opened in the fifth or sixth interspace to the left of the mammary line, the incision being from 2 to 3 cm. in length. Resection of a rib is advocated by most surgeons, but if the drainage afforded by free incision be complete resection is unnecessary. It is only indicated Avhen, by approximation of the ribs, the free exit of the pus is hindered (Verebeylil). Opinions are divided as regards the value of irrigation of the pleural cavity. When the pus emits an offensive odor irrigation with a disinfecting solution is imperative. Carbolic acid should, however, not be used. In rare instances accidents arise during irrigation (sudden collapse, convulsions), and I have repeatedly observed a dangerous, and in one instance a fatal, collapse as the result of irrigation in children. The careful insertion of a roll of iodoform gauze is a method to be preferred to irrigation, except Avhen the effusion is stinking. For further details in the operative treatment of empyema the reader is referred to text- books on surgery. Every7 effort should be made to favor obliteration of the cavity during post-operative treatment. The indication is to bring about the best possible degree of re-expansion of the compressed lung, and in order to accomplish this the method advised by Ralston James has been practised Avith great success in the surgical Avards of the Johns Hopkins Hospital. The patient daily for a certain length of time, in- creasing gradually with the increase of his strength, transfers a\ ater by air-pressure from one bottle to another. The bottles should be large, holding at least a gallon each, and by an arrangement of tubes, as in the Wolff bottle, an expiratory effort of the patient forces the Avater from one bottle into the other. In this way expansion of the com- pressed lung is systematically practised. The abscess-cavity is gradu- ally closed, partly by the falling in of the chest-Avail and partly by the expansion of the lung.2 In long-standing cases, in which the lung cannot expand on account of thick bands of adhesion, the pleural layers can- not be brought into juxtaposition Avithout more or less sinking in of the chest-wall. This retraction of the thorax is probably hastened by timely resection of one or more ribs, the amount of bone to be removed depending upon the " expansive poAver of the lung and elasticity of the thorax." The duration of empyema is longer than in pleurisy Avith effusion, and the former affection tends to exhaust to a greater degree the poAvers of the system than the latter; hence the physician's attention should be 1 Quoted in Annual of the Universal Med. Sciences, 1892, vol. i. sec. A. 2 Osier's Text-book of Medicine, p. 605. 560 DISEASES OF THE RESPIRATORY SYSTEM. directed chiefly to the support of the vital forces, modified to some extent by the special etiology in the individual cases. CHRONIC PLEURISY (CHRONIC ADHESIVE PLEURISY). Definition.—Chronic inflammation of the pleural layers—(a) with effusion, and (b) without effusion. (a) Chronic Pleurisy with Effusion.—This sub-variety may follow acute sero-fibrinous pleurisy, and less frequently it has an insidious develop- ment. The morbid lesions, including the character of the exudate, may also be identical w7ith those of the acute or subacute forms of the affec- tion. Fibrin and serum are present in varying relative proportions, the latter, however, as a rule, in preponderating proportion Avhen compared with the composition of the exudate in acute pleurisy. The secondary consequences of copious acute effusions also are met with—i. e. displace- ment of adjacent organs (liver, spleen, heart) and unilateral dilata- tion of the chest. When the fluid is either absorbed or removed and the case ends in recovery, marked contraction of the affected side re- sults, since the lung, Avhich is covered by thick, organized bands of adhesion, cannot re-expand. Symptoms.—But for slight dyspnea upon muscular exercise the subjective symptoms are frequently wanting. The pulse is compressible and accelerated, as a rule, and there is a trifling rise of temperature in the evening hours. If the effusion becomes purulent, hectic fever develops, leading to asthenia, and the latter con- dition eventually terminates life. Death may also be due to secondary suppurations (abscess of brain, etc.). In most cases occurring in chil- dren the effusion early changes to pus. The physical signs do not differ from those in acute sero-fibrinous pleurisy. The duration of the cases varies from three months to several years, or intercurrent pulmonary tuberculosis may shorten the course of the affection. (b) Chronic Dry or Adhesive Pleurisy.—(1) This may succeed to the acute or chronic sero-fibrinous pleurisy. If the liquid portion of the exudate is absorbed, the pleural membranes come into more or less close apposition, being separated only by fibrinous elements that become organized into a layer of firm connective tissue. Hence the tAvo layers of the pleura, that are greatly thickened, cannot be separated, OAving to the firmness of the adhesions. Most frequently the autopsy shows the latter condition to be most pronounced at the base, while the lung is found to be compressed and the seat of fibroid change. If it folloAvs the acute form, the extent of retraction is slight, since there are no dense fibrous bands to prevent a fair degree of lung-expansion; if it succeed the chronic form, however, or empyema, the extent of retraction and flattening will be quite marked. The exudate may undergo cal- careous degeneration, and occasionally little pouches of fluid may be found betAveen the false bands. There is a large class of cases that are dry from the onset (idio- pathic dry chronic pleurisy), and this variety may either be a sequel of acute plastic pleurisy or primarily tuberculous. The condition is very commonly met with at autopsy in subjects Avho during life had never presented symptoms of pleurisy with effusion. The plastic exu- date, however slight, invariably tends to become organized, Avith result- CHRONIC PLEURISY. 561 ing fibrinous adhesion of the tAvo layers of the pleura. Most generally the adhesions are circumscribed, and if tuberculous in origin are most frequently apical and often bilateral. Under these circumstances small caseous masses and little tubercles may be found embodied in the some- what thickened pleura. General synechia is, hoAvever, not rare, par- ticularly unilateral. Symptoms.—Definite rational symptoms are rarely present, and the phvsical signs lack uniformity or may be entirely negative. In other cases of a mild grade the main characteristics are restrained mobility of the affected side and feebleness of the respiratory murmur. In rarer cases the weakness of the breath-sounds is out of all proportion to the expansive motion of the chest. In still another category—composed of a considerable number of instances—certain physical signs are quite pronounced. Inspection reveals decided contraction, Avith immobility of the affected side and a compensatory distention of the healthy side. The heart is displaced, and the apex-beat may be missing (e. g. Avhen the heart is draAvn or pushed behind the sternum, or over- lapped by the emphysematous lung). The spinal column is curved, the scapula dislocated, the shoulder ill-shapen and drooping, and the loAver part of the thorax shrunken, while the ribs are obliquely placed and closely approximated, or even overlap one another. The tactile fremitus is decreased or absent over the lower portion of the chest, and there is impaired percussion-resonance or dulness over the same area. The breath-sounds on auscultation are exceedingly feeble, and in some instances an occasional dry, leathery, or creaking friction-sound is audible. Rarely, and particularly if the case be tuberculous, vasomotor symp- toms arise in chronic pleurisy, such as unilateral flushing or sweating of the face, or dilatation of the pupil. Doubtless some of the instances belonging to this affection merge into the pleurogenous type of cirrhosis of the lung, and fatal complica- ting conditions may arise in connection Avith the general circulation. Thus I have observed in one instance enlargement followed by dilatation of the right ventricle, and in turn by general dropsy, with fatal result. Treatment.—In the treatment of this affection tAvo objects must receive especial attention : (1) the removal of any effusion that may be present; and (2) the improvement of the nutrition of the patient. The first indication is presented only by a limited number of the cases, and the rules for meeting it have been stated in the treatment of sero-fibrin- ous pleurisy and empyema ; the second indication is presented by all cases. Careful regulation of the diet is of the utmost importance: it must be generous, with modifications to suit special diatheses (as the gouty or tuberculous), if they be present. Lung-gymnastics are most useful if methodically pursued. The method of Ralston James (pre- viously described) richly deserves a trial in suitable cases. It is to be borne in mind, hoAvever, that in old cases efforts at overcoming the lung-pressure will be unsuccessful. Climato-therapy is advantageous for this class of sufferers, particularly if the slightest tendency toward tuberculosis exists; and in my own experience Ioav, mountainous eleva- tions combined with purity of atmosphere have given the best results. Of medicines little need be said. It is especially important to promote 36 562 DISEASES OF THE RESPIRATORY SYSTEM. the digestive power of the patient to the greatest possible extent. In cases in which the digestive function has been feeble I have observed excellent results from a brief stay at any well-regulated seaside resort or in the country. We may also try, Avith a probability that the effect Avill be beneficial, small doses (3j—4.0) of cod-liver oil, three times daily after meals, or the folloAving formula : B/. Acidi muriat. dil., sijss (10.0); Pepsini pur., 3ij (8.0); Tinct. nucis vom., 3iss (6.0); Glycerini, 3iss (48.0); Aquse, q. s. ad gij (64.0).—M. Sig. 3j (4.0), well diluted, ten minutes after each meal. Intercurrent catarrh of the stomach may sooner or later become a troublesome feature, and in combating it lavage is frequently our most effective measure. PNEUMOTHORAX. (Sero-pneumothorax ; Pyo-pneumothorax) Definition.—A collection of air in the pleural cavity. Since the latter, as a rule, contains at the same time serum or pus, the terms sero- and pyo-pneumothorax are frequently employed to describe the same condition. Pathology.—When the pleural sac is punctured air usually escapes, accompanied sometimes by an audible hissing sound. The pleural sac in pure pneumothorax is greatly distended, and the lung is impacted against the spinal column. Other organs (spleen, heart) are also dis- placed, OAving to positive intrathoracic pressure. The heart is not di- lated, hoAvever, and the relation of its parts is maintained much as in the normal condition (Osier). The air may occupy but a portion of the pleural cavity, on account of previous firm adhesions (circumscribed pneumothorax). The point of perforation, as a rule, can be easily found, and most frequently corresponds to the seat of rupture of the tuberculous cavity or superficial caseous mass. In other instances the cause of pneumothorax cannot be discovered. Inflation of the lung under water may reveal the aperture, Avhich is usually quite small, by the escape of air-bubbles at the seat of puncture. Occasionally a fistulous connection betAveen the pleural sac and the bronchi can be readily traced. Simple pneumothorax is, however, of rare occurrence. The air that gains admission into the pleural sac is laden with micro-organisms, which set up various forms of inflammation, accompanied by equally various exudations. Hence the cavity is usually filled, in part, Avith an effusion that is purulent or sero-purulent, as a rule, and rarely serous or sero-fibrinous. Etiology.—There are both predisposing and exciting causal influ- ences, and among the former are—(a) age ; the condition occurring in PNE UMO THORAX. 563 adults as a rule, though instances are also observed in young children; (b) sex ; males suffer more often than females ; (c) the left side is affected nearly twice as often as the right; (d) emphysema, in which the super- ficial air-sacs are dilated and atrophied, rendering the latter liable to rupture from excessive muscular exertion. The exciting causes are—(1) Perforation of the lung and pulmonary pleura (the most frequent cause), arising in one or other of three Avays —(a) From the rupture of a tuberculous cavity into the pleural cavity. This accident rarely occurs at the apex of the lung, but commonly near the upper border of the loAver or middle lobe; and less frequently near the loAver border of the upper lobe. A caseous focus immediately be- neath the pleura may also, during the process of softening, puncture the pleural sac and invite the entrance of air. From this cause Ave sometimes see pneumothorax developing during a very early7 stage of pulmonary tuberculosis. It cannot occur, hoAvever, except in cases in which previous adhesions have failed to form at the point of perforation. (b) As the result of necrotic processes, in connection Avith certain other lung-affections, as gangrene, broncho-pneumonia, suppurating bronchial glands, abscess, and echinococcus cysts, (c) From rupture of the normal air-sacs in consequence of severe muscular effort (S. West, DeH. Hall). This accident is sometimes ascribable to the violent paroxysms of cough in pertussis. (2) Some cases of empyema, by perforating the visceral pleura, the lungs, and bronchi. (3) Perforations of the pleura in malignant disease and abscess of the esophagus. (4) A peripheral bronchiectasis may open the pleural space and thus establish a communication between it and a bronchus. (5) Pyo-pneumothorax may be of subdiaphragmatic origin, consec- utive to perforation by malignant disease or ulcer of the stomach or colon. (6) Pneumothorax may be occasioned by gases resulting from the decomposition of a pleural exudate. (7) Wounds causing direct or indirect perforative lesions of the lungs. Fractures of the ribs may produce laceration of the visceral pleura, and afford an opportunity for the ingress of air into the pleura] sac. Symptoms.—The earliest symptoms vary according to the cause or causes that produce the condition. When it develops, as it does so often, in the course of pulmonary tuberculosis, the first symptom is a sudden agonizing pain in the side, accompanied by marked dyspnea and frequently cyanosis. The dyspnea is often accompanied by a sense of impending suffocation. The severity of the pain and the degree of op- pression depend largely, hoAvever, upon the amount of air that gains entrance into the pleural sac, the rapidity with which the air escapes into the pleural cavity, and the condition of the latter as regards the presence or absence of previous pleuritic adhesions. If the orifice be large and valvular, the air cannot escape, but rapidly accumulates and forces all the air out of the lung by compression ; the patient then sinks rapidly into collapse from shock, and sudden death ensues. Fortunately, the latter event is rare. The respirations are frequent (60 or more per minute); the pulse is also frequent and feeble, sometimes reduced to a 564 DISEASES OF THE RESPIRATORY SYSTEM. thread; and cold SAveats are not uncommon. The temperature at first is apt to fall one or tAvo degrees beloAv the normal, OAving to sudden col- lapse ; fever, hoAvever, folloAvs almost invariably, and frequently is of the hectic type. Its cause is pleuritis, often of a purulent type, and if this be the case the dyspnea may be due in part to the increased effusion. The patient now also suffers from the grave symptoms of empyema above described. Edema of the hand of the affected side is sometimes present Fig. 48.—1. Air in the pleural sac; 2, fluid exudate at base of pleural sac; 3, compressed portion of lung; 4, displaced heart; 5, depressed spleen; 6, mediastinum pushed toward the right. as an early manifestation, and, as a rule, rapidly disappears (Weil). When pneumothorax develops in the last stages of phthisis acute symp- toms are often entirely absent. Physical Signs.—These are marked (see Fig. 48). Inspection shoAvs marked distention and immobility of the affected side; also some degree of distention with unnatural mobility of the healthy side. Palpation shows the tactile fremitus to be diminished above and greatly diminished or Avholly absent over the effusion below. Edema of PNEUMOTHORAX. 565 the chest-Avail can frequently be made out. The impulse-beat of the heart is found to be feeble and displaced. On percussion a modified tympanitic note (bell-tympany) can usually be elicited over the area corresponding to the contained air, and the ex- cessive tension in the pleural sac, due to the enormous amount of air contained therein, causes an elevation in the pitch of the percussion- note even to dulness. The "cracked-pot sound" is audible Avhen the air in the pleural cavity freely communicates Avith the external air. Wintrich's sign, or a change in the pitch of the percussion-sound Avhen the mouth is open or closed (being raised Avhen the mouth is closed and loAvered Avhen open), may also be observed. In pyo-pneumothorax a flat note is elicited from the base upAvard as far as the fluid extends, and there is a more marked change in the upper level of flatness than in simple pleurisy, on changing the posture of the patient. Modifica- tions in the pitch of the percussion-sound result from an alteration in the form as Avell as in the dimensions of the air-space. OAving to dis- placement of the heart, there is, as a rule, resonance over the normal cardiac region, and particularly when the patient assumes a recum- bent posture. The liver and spleen, according to the side affected, are displaced downAvard to a greater degree than in simple pleural effusion. Auscultation discloses a greatly Aveakened or altogether suppressed respiratory murmur Avhen collapse of the lung is incomplete. Not in- frequently amphoric breathing is audible and bronchial rales possessing a metallic quality are sometimes heard, as well as metallic tinkling on deep inspiration or on coughing. The metallic tinkling is caused fre- quently by drops of fluid falling from above upon the surface of the effusion; less frequently by7 a re-echoing of vibrations of moist bron- chial rales communicated to the air in the pleural chamber. The vocal resonance is enfeebled, as a rule, and evinces the same metal- lic quality. The so-called coin test is a pathognomonic sign, and is elicited in the folloAving manner: An assistant places one coin on the front of the chest and taps it with another Avhile the ear is placed on the thorax posteriorly, Avhere Avill be heard the intensified echo of the coin- sound thus produced. Another most characteristic sign is the so-called Hippocratic succussion, which is elicited by placing one ear upon the patient's chest while the latter's body is shaken, and a distinct splashing sound is heard. Diagnosis.—AVhen the attack is of ordinary severity, pneumo- thorax is diagnosticated by the history of one or other of the causal factors, together with certain physical signs that do not belong to any other affection (coin-sound, succussion-splash). It is only when the air and fluid in the pleural sac are encapsulated that it may become difficult to eliminate (a) a large pulmonary cavity; (b) excessive gaseous distention of the stomach; (c) an abscess below the diaphragm into which air has entered (pyo-pneumothorax subphrenicus); (d) a diaphrag- matic hernia; (e) emphysema; and (/) pleurisy Avith effusion. (a) A Large Pulmonary Cavity.—The "cracked-pot sound" and Wintrich's sign are more frequent in cavity than in pneumothorax, and the former condition does not tend to dislocate the adjacent organs. There is no response to the coin test and an absence of the succussion- 566 DISEASES OF THE RESPIRATORY SYSTEM. splash ; both of which signs are often present, even in circumscribed pyo-pneumothorax. Tabulated, these points of difference are— Pvo-rXEI'MOTHORAX. LARGE PULMONARY C.VVITY. Immobility and bulging of the inter- Immobility, flattening of the chest, and spaces. The apex-beat is usually dis- depression of the interspaces. Apex- placed, beat not displaced. Diminished vocal fremitus. Fremitus usually increased. Tympanitic percussion-note. The effu- Percussion gives tympany or a "cracked- sion sinks to the base, and yields dul- pot sound."' and Wintrich's change of ness, the outline of which changes with sound as a rule. the posture of the patient. Respiratory murmur and vocal resonance Bronchial breathing is heard, and the usually absent. Amphoric breathing vocal resonance is increased. Crack- may be heard if the opening in the ling, gurgling rales, cavernous or am- lung is patulous. Bell-tympany and phoric broathing,and pectoriloquy may Hippocratic succussion - splash are be present. Absence of bell-tympany noted. and succussion-splash. (b) The possibility of excessive gaseous distention of the stomach is to be eliminated by the history of the case and by the happy results af- forded by the application of the therapeutic test, evacuation of the stomach and bowels. (c) Subphrenic Abscess containing Air.—This is exceedingly rare, and occurs relatively oftener on the right than on the left side (Leyden). Its leading causes are ulcers of the stomach or duodenum, folloAved by circumscribed peritonitis, perforation, and abscess, the latter occupying a position immediately beneath the diaphragm and above the liver. The gases that gain admission to the abscess-sac from the intestines force the diaphragm upward, and thus cause retraction or even compression of the lung The symptoms and signs are now identical with those of circum- scribed pyo-pneumothorax, limited to the base; but a knowledge of the steps in the production of subphrenic abscess, the symptoms and history of ulcer of the stomach or intestines, succeeded first by peritonitis and then by symptoms of pyo-pneumothorax on the one hand, and a know- ledge of the etiology of pneumothorax on the other, should lead to a correct inference. (d) Diaphragmatic Hernia.—This either results from a severe injury or is congenital, and the most valuable point of difference betAveen hernia of the diaphragm and pneumothorax is the peculiar cause of the former. The next most valuable point is the fact that the hernial protrusion may return suddenly to its normal position, whereupon the patient Avill be re- lieved ; the condition may then reappear not less suddenly. The third distinctive feature is the presence of rumbling sounds in the protruded boAvel. All other signs and symptoms of one affection may have their counterparts in those of the other. (e) Pneumothorax may be confounded Avith emphysema by the care- less observer; but the latter affection is slow in onset, free from serious shock, is bilateral as a rule, and does not exhibit the distinctive physical signs of pneumothorax (metallic tinkling, coin-sound, succussion-splash). In pleurisy with effusion hyper-resonance may be noted above the fluid, but it lacks the bell-like tympany of pneumothorax. Over the same area there is diffuse, distant, bronchial breathing (at times slightly am- phoric), whilst the metallic tinkling, coin-sound, and succussion-splash are totally wanting. HYDROTHORAX. 567 Prognosis.—This depends solely upon the cause. The cases at- tributed to advanced phthisis usually reach a fatal issue in the course of one, tAvo, or more weeks, and rarely they run a very rapid and fatal course. On the other hand, the pulmonary condition seems to be favor- ably influenced by its occurrence. FolioAving empyema, pneumothorax sometimes takes a favorable course. It is fraught with especial danger when it is the resultant condition of some acute lung-disease (gangrene, abscess, broncho-pneumonia). Treatment.—The leading indication is the alleviation of the pa- tient's sufferings by a prompt resort to morphin, and it often becomes necessary to administer it hypodermically. If the patient's previous strength has been moderately good, the question of operative interfer- ence should be seriously considered, the nature of the surgical proced- ure then depending upon the character of the effusion. If this be sero- fibrinous, aspiration, as in simple pleurisy, must be performed to relieve the urgent dyspnea and the embarrassed cardio-pulmonary circulation ; if purulent, permanent drainage should be procured for the same indi- cations. When pneumothorax develops late in phthisis, radical meas- ures are not to be thought of, and the physician must rely upon aspira- tion (Avhen necessary) to oppose urgent symptoms. We may also tap the air-chamber above the fluid Avith a fine needle, with a view to lessen- ing the excessive tension. Unverricht has recently reported good results from a someAvhat novel mode of treatment. When there is a pulmonary fistula present, he inserts a tube into the pleural sac. This allows free entrance of air, the lung collapses completely, and the fistula has a chance to heal. For the dyspnea, atropin administered hypodermically is valuable; for the feeble cardiac action, alcoholic stimulants, aromatic spirits of ammonia, strychnin, ether, and other cardiac stimulants should be employed. Locally, cutaneous irritants may be applied (turpentine stupes, mustard pastes). HYDROTHORAX. (Dropsy of the Pleura ; Thoracic Dropsy). Definition.—A collection of transuded serum in the pleural cavity. Pathology.—Hydrothorax is, as a rule, a bilateral condition. The transudate is a clear, amber-colored liquid that is free from fibrin, but may contain cholesterin and a few endothelial cells. It has an alkaline reaction, a comparatively Ioav specific gravity (1009 to 1012), and is non- inflammatory. The pleural surfaces are usually smooth, though some- times decidedly pale and edematous. The mechanical effects of hydro- thorax upon the lungs and other thoracic and abdominal viscera are similar to those of the exudates that accompany inflammation of the pleura, though they are rarely so marked as in sero-fibrinous pleurisy. Etiology.—Hydrothorax is a secondary affection, and is usually connected with one or other of the various forms of general dropsy (hemic, renal, cardiac). The cases that are due to blood-impoverish- 568 DISEASES OF THE RESPIRATORY SYSTEM. ment are more numerous than is generally indicated by Avriters upon the subject, and not infrequently is hydrothorax symptomatic of either chronic dysentery, chronic diarrhea, leukemia, pernicious anemia, car- cinoma, malaria, syphilis, or scurvy. Strictly local causes may also induce it, as carcinoma of the pleura, or the compression of the superior vena cava or of the thoracic duct by a tumor. Symptoms.—The subjective symptoms are attributable to the me- chanical effects of the fluid, and the causal affection may have symptoms quite in common; these are dyspnea (often culminating in orthopnea), cyanosis, asthmatic seizures, and a feeble circulation. The general symp- toms arise from the primary affection. Physical Signs.—The physical signs are much the same as in pleurisy Avith effusion—Avith this difference, that they are more often present on both sides of the chest. Hydrothorax is often unilateral, hoAvever, and an enlarged right auricle may be the cause of this condition in some instances. The right side is the one usually affected. I have also ob- served that quite frequently the tAvo sides of the chest exhibit great variations as to the relative amount of fluid contained.1 Prognosis.—This depends upon the nature of the primary disorder that causes the dropsical transudation. Treatment.—The treatment of hydrothorax has intimate relations Avith the indications presented by the underlying affection. If the meas- ures directed toward the removal of the general dropsy, of which hydro- thorax is a part, are unsuccessful, and the amount of transudation in the pleural sac interferes Avith the functions of the heart and lungs, then aspiration must not be too long delayed, and must be repeated as often as occasion demands. NEW GROWTHS OP THE PLEURA. Almost all instances of new groAvths developing in the pleura are secondary to primary carcinoma of the lung, the pleura being invaded by the direct extension of the neoplasm. It may also arise by meta- stasis from carcinoma of the lung, mammary glands, etc. The pleura presents circumscribed areas of thickening, or the growth takes the form of papular projections from its surface, and as these enlarge they become pedunculated. Their size varies from that of a pea to that of an orange. The adjacent pleura is inflamed, often adherent, and much thickened, and an effusion into the pleural cavity is often observed. Primary carcinoma of the pleura is very rare indeed, and E. Wag- ner, who first described it, called it endothelial carcinoma. Most pa- thologists of to-day, however, look upon endothelioma as a variety of sarcoma. It owes its orgin to a proliferation of the endothelial cells of the connective tissue and the lymph-apparatus of the pleura. This in- variably assumes the diffuse form, and by metastasis Ave have involve- ment of the other organs (lungs, lymphatics, liver). Spindle-cell sarcoma of the pleura, as well as the round-cell variety, is occasionally met with. ] For the differential diagnosis between pleurisy and hydrothorax see Pleurisy, p. 552. DISEASES OF THE MEDIASTINUM. 569 Symptoms.—The subjective symptoms are slight in cases in Avhich there is a single circumscribed carcinomatous mass in the pleura; but they are quite severe in the diffuse form, particularly Avhen, as com- monly occurs, it is of a secondary nature. The symptoms are now those of plastic or sero-fibrinous pleurisy, in addition to those of pri- mary carcinoma of the lung, and the former may oftentimes more or less completely overshadoAv the latter. Diagnosis.—The circumstances under which the condition arises often throAV the strongest light upon its nature. The symptoms of sloAvly developing pleurisy, either plastic or sero-fibrinous, folloAving carcinoma of the lung or the breast, and accompanied by the cancerous cachexia, Avould point strongly to the existence of carcinoma of the pleura. Characteristic cancerous elements may also be found by micro- scopic examination of the fluid obtained on exploratory puncture, and this should never be neglected in suspected instances. The difficulties surrounding the diagnosis of primary carcinoma of the pleura are great and usually insurmountable. The cases are very similar in their clinical manifestations to chronic pleurisy with or without effusion. Pain is ahvays a more prominent symptom, hoAvever, than in simple chronic pleurisy-, and this fact, Avhen combined Avith evidences of a cancerous cachexia, should excite strong suspicions. The prognosis is wholly unfavorable, and the treatment merely palliative. DISEASES OF THE MEDIASTINUM. The affections of the mediastinum may be divided into four classes: (a) Inflammation, (b) Tumors, (c) Diseases of the thymus gland, and (d) Mediastinal hemorrhage. (a) Inflammation.—This may affect (1) the glands or (2) the connec- tive tissue. Lymphadenitis of moderate grade is found in association with broncho-pneumonia and the various forms of bronchitis. The con- dition appears in its most pronounced form in the bronchitis of measles, influenza, and whooping-cough, and De Mussy held that enlargement of the glands in the posterior mediastinum is potent in exciting parox- ysms of wThooping-cough. According to De Mussy and Guiteras, these glands Avhen greatly enlarged give rise to dulness in the upper part of the interscapular region or doAvn to the fourth dorsal vertebra in cases of influenza and Avhooping-cough. I have, moreover, been able to con- firm this dictum in cases of influenza, though aAvare of the fact that many authorities consider it questionable. Tuberculous lymphadenitis is elseAvhere described (vide Tuberculosis, page 271). The mediastinal lymph-glands may undergo suppuration in consequence of local specific infection, and, though not recognizable during life, it should be recollected that the condition may lead to perforation into either the esophagus or a bronchus, with serious results. In other instances spontaneous absorp- tion occurs, leaving behind inspissated contents that undergo calcareous change. 570 DISEASES OF THE RESPIRATORY SYSTEM. Abscess of the Mediastinum.—This is of rare occurrence, its most frequent seat being the anterior mediastinum. Of the commoner causes may be mentioned traumatism and the infectious diseases—erysipelas, rheumatism, measles, and small-pox in particular. It may also be the result of an extension of a suppurative process from neighboring struc- tures. Pulmonary tuberculosis is the most potent factor in producing chronic abscess in this situation. Symptoms.—Acute Abscess.—Pain and tenderness in the sternum are the most prominent features, the pain being acute and often of a throbbing character. Cough and dyspnea are usually present. The general features are fever, frequently accompanied by rigors and pro- fuse SAveats and considerable physical prostration. The chief physical sign is dulness upon percussion, usually found anteriorly and increasing gradually Avith the development of the abscess. Later, the tumor may reach the surface of the body, and rarely the sternum is eroded. Pal- pation noAv detects pulsation and fluctuation. The abscess may either find its Avay doAviiAvard into the abdomen, or it may perforate the trachea or the esophagus. In chronic abscess the symptoms bear a closer similarity to those of solid tumors than those in the acute form. Fortunately, chronic abscess quite often results in spontaneous cure, in Avhich case it is in part ab- sorbed, and the remainder of its contents become inspissated. In obscure cases an exploratory7 puncture Avith a small needle may be safely prac- tised, and with definite results, as a rule. Diagnosis.—Abscess must be differentiated from solid mediastinal tumors and aneurysm. The more acute onset and general symptoms of the suppurative process (hectic type of fever, chills, SAveats) and the more rapid course Avill serve to distinguish abscess from aneurysm on the one hand, and solid tumors on the other. Further, the absence of strong expansile pulsation, diastolic shock, and the aneurysmal bruit aid materially in eliminating aneurysm of the arch. The treatment is mainly surgical. (b) Tumors of the Mediastinum.—Two forms only demand practical consideration—carcinoma and sarcoma. Hare's analysis of 520 cases gave the folloAving ratio: of carcinoma, 134; sarcoma, 98; lymphoma, 21; fibroma, 7 ; dermoid cyst, 11; hydatid cyst, 8 ; and feAver cases of ecchondroma, lipoma, and gumma. In 48 of the cases of carcinoma and in 33 of sarcoma the tumor occupied only the anterior mediastinum. It is quite certain, hoAvever, that sarcoma, and not carcinoma, is the com- moner neoplasm of this region. The clinical term " cancer " Avas formerly used promiscuously by many authors, and the pathologic diagnosis Avas then difficult, so that statistics are notoriously fallacious. Upon inves- tigating 25 of the older reports of tk cancer," Pepper and Stengel found in 13 unquestionable evidence that the groAvth Avas sarcoma, Avhile in the remaining 12 they could not, for the greater part, decide to Avhich form the disease belonged. Primary sarcoma may spring from the rem- nant of the thymus gland, from the lymphatic glands, the pleura, or lungs, or from the fibrous tissues of the mediastinum. Primary carcinoma may originate in the esophagus, bronchi, lungs, or rarely in the thymus gland. Secondary mediastinal tumors are most apt to have their seat in the lymphatic glands. Carcinoma is less frequently primary than sar- DISEASES OF THE MEDIASTINUM. 571 coma. Among predisposing causes are sex and age—males being more prone to the affection than females, and the period of chief liability is betAveen the thirtieth and fortieth years. Symptoms.—The earlier symptoms are quite indefinite. The patient complains of slight substernal pains, slight dyspnea, and general languor. Later, Avith the slow increase in the size of the tumor, pressure-symp- toms gradually become more pronounced. The pain may or may not be severe, but is invariably accompanied by a feeling of oppression. Its chief seat is in the upper sternal region, but it may radiate to the sides of the chest and even doAvn the arms (in which case it is due to pressure on the brachial plexus). Dyspnea appears early, is constant, and may become most intense. It is caused by pressure either upon the trachea, upon a primary bronchus, or upon a recurrent laryngeal nerve. Asthmatic seizures may occur before there is constant dyspnea and before the tumor has reached notable size Avithin the chest. Less frequently, and to a less extent, the dyspnea is depend- ent upon dislocation of the heart or upon accompanying hydrothorax due to venous stasis. There is cough, Avhich may be paroxysmal and of a brazen character, and as in aneurysm it may manifest implication of the recurrent laryngeal; for a like reason aphonia may be present. There may be dysphagia from pressure upon the esophagus, though this is rare. If, as may happen, there is an inflammation of the vagus or sympathetic nerve, the rate of the pulse may be affected, and the latter be either sloAved or markedly quickened as a result. Owing to implica- tion of the sympathetic there may be local hyperemias and pupillary changes, and particularly an inequality of the pupils. Rarely, by making external pressure upon the sternum, dilatation of the pupil may be produced. Compression of the superior vena cava or of the subclavian vein may be followed by cyanosis and edema of the parts drained by these vessels, and the early occurrence of venous occlusion and marked dilatation of the superficial veins is quite characteristic. But if the degree of pressure increase slowly, collateral circulation may be established com- pletely. Less frequently the inferior cava may also be pressed upon. Physical Signs.—Inspection.—In advanced cases a swelling, usually someAvhat irregular and often diffuse, appears in the sternal region. The tumor may cause erosion of the sternum, and a little later occupy a position immediately beneath the skin, Osier l being of the opinion that the rapidly-groAving lymphoid tumors, more commonly than others, perforate the chest-wall. I saw a case in which the perforation occurred at the right edge of the sternum, precisely at the point at Avhich aneur- ysms of the ascending arch most frequently appear. In the early stages, however, this prominence is not present. Palpation.—When a tumor is present it may pulsate distinctly, and the hearts apical im- pulse may be detected in various abnormal positions. Tactile fremitus is absent over the seat of the groAvth if the latter be in contact Avith the chest-wall. On percussion dulness is noted, and this is true even in many instances that do not present a visible swelling. The dull area varies in outline with the size and position of the tumor. Auscultation usually reveals 1 Practice of Medicine, p. 579. 572 DISEASES OF THE RESPIRATORY SYSTEM. no sounds over the dull area, except a bruit in rare instances. The heart-sounds are inaudible over the tumor-site as a rule, and the breath- sounds and vocal resonance are feeble or absent. To the above physical signs are frequently added those of pleural effusion. The diagnosis of mediastinal growths is made, if at all, chiefly by exclusion, but it is manifestly impossible before the development of the tumor has progressed to considerable dimensions. Aneurysm is differentiated from solid mediastinal tumors with only slight success in many instances. It is most valuable to note carefully the length of time the condition has lasted, since aneurysm runs a longer course, on the average, than mediastinal tumor, though to this general rule there are many exceptions. The tumor Avhen due to aneurysm communicates a strong, heaving, expansile pulsation—a characteristic that is absent or only feebly manifested in the case of solid mediastinal groAvths. The severe diastolic shock, as noted both on palpation and auscultation in cases of aneurysm, is also absent in solid tumor. The bruit in aneurysm has often a booming quality that does not belong to the bruit of solid growths. Pain is more pronounced in aneurysm. The duration of the disease is rarely less than six, and quite as rarely it is more than eighteen, months. The prognosis is absolutely hopeless, except in the case of benign tumors, which may be removed in some instances. The treatment is directed toward the relief of the most urgent symptoms. Anodynes are required sooner or later, and should not be withheld if indicated. As a routine the preparations of iodin and mer- cury are employed, but, as these are useless, they are unwarranted. Arsenic has sometimes seemed to influence sarcomatous and lymphade- nomatous growths favorably, though only temporarily. (c) Diseases of the Thymus Gland.—Nothing is known definitely concerning the functions of the thymus gland, and the diseases of this organ are Avithout special clinical significance. Tumors may have their origin in the thymus gland, and the organ may become enlarged on ac- count of the presence of true hypertrophy or abscess; these conditions are indistinguishable from mediastinal tumor or abscess as above described. Persons Avho manifest the hemorrhagic diathesis or those who suffer from hemorrhagic affections may also show hemorrhage into the thymus gland —a condition that is identical Avith that produced by hemorrhage into the mediastinum. (d) Mediastinal Hemorrhage.—This term signifies hemorrhage into the mediastinal connective tissue. It oftenest results from the rupture of aneurysms of the arch or of the large vessels within the thorax, or it may be of traumatic origin (wounds, fractures). PART V. DISEASES OF THE CIRCULATORY SYSTEM. I. DISEASES OF THE PERICARDIUM. PERICARDITIS. Definition.—An inflammation of the serous covering of the heart. Varieties.—(a) Plastic, or fibrinous; (b) sero-fibrinous, or subacute; (c) purulent; (d) hemorrhagic ; (e) adhesive. There is also a tuberculous pericarditis Avnich has been described (vide Tuberculosis, page 308). ACUTE PLASTIC OR FIBRINOUS PERICARDITIS. Pathology.—The morbid changes are frequently localized, and less frequently are general. At the onset the membrane is smooth, swollen, and injected, and punctured ecchymotic spots may be visible; soon it presents a grayish, roughened appearance in consequence of a deposition of a thin layer of fibrin. In the severer types the fibrinous deposit in- creases in thickness for a time, and the natural movements of the peri- cardial surfaces upon one another sometimes cause the exudate to assume a honeycombed appearance. Most examples that I have seen, hoAvever, have resembled the roughened surfaces produced by separating tAvo slices of bread that had been thickly buttered; the surfaces are grayish-yellow in color. In the later stages the exudation becomes partly organized, and as the result of friction produced between the opposed surfaces by the incessant action of the heart, the pericardial surface may present a villous appearance; hence the term " hairy heart " which was employed by ancient authors. For like reasons we may see the exudate arranged in the form of little ridges, forming a " tripe-like membrane." Though invariably present, the amount of serous effusion, as the term would in- dicate, is never large in dry or plastic pericarditis. Myocarditis may frequently be found as an associated condition. Etiology.—In each variety of pericarditis there are factors that cause the particular form with such relative frequency as to make it desirable to give its etiology separately, except in the sero-fibrinous and acute plastic types, which have practically the same etiology. The two latter are the more common forms of the disease. Acute plastic peri- carditis frequently occurs in the young and middle-aged, and is only 573 574 DISEASES OF THE CIRCULATORY SYSTEM. rarely a primary process, being secondary to acute articular rheumatism (in more than one-half the cases), to chronic nephritis, and, rarely, to the acute infectious diseases. It may be caused by direct extension of in- flammation from adjacent structures, and in this manner it may be a sequel of simple pleurisy; more frequently the extension occurs from a pneumonia or tuberculous pleurisy, or the condition may complicate neAv groAvths and inflammatory conditions affecting the esophagus and bron- chial glands. It may also be secondary to chronic disease of the aortic valve, the pericardium becoming involved by extension through the Avails of the aorta. Finally, it may be the result of traumatism, and in this connection it should be pointed out that this factor may under certain conditions cause any of the other forms of pericarditis. Bacteriology.—Rudini's experiments have shown that the staphylo- coccus aureus may be a cause of pericarditis, but they have not con- clusively demonstrated that it is the specific cause, as is evidenced by the fact that the disease is sometimes caused by other organisms and found in diseases in Avhich other organisms are active. Moreover, sta- phylococci have not been encountered without demonstrable cause, so that a distinctively specific cause has, as yet, scarcely been proved. Among other organisms, pneumococci, streptococci, and the bacillus coli may be named. Clinical History.—Owing to the fact that acute plastic pericarditis is usually a secondary affection, the symptoms that enable one to recog- nize it are obscured by the disease of which it is a sequel. This is par- • ticularly true of that large class of cases that develop in acute articular rheumatism, in which subjective symptoms are often entirely wanting. It is only in the severest types of this sort that the symptoms referable to the heart are well enough marked to arrest the attention. There may be a feeling of distress or constriction with or Avithout slight pain in the pericardium. During the first stage or prior to the pouring out of the effusion the pain is most marked, extending sometimes into the left arm or the back, and at others to the ensiform cartilage or even to the abdomen. This pain is, rarely, increased by pressure over the pericardium. Palpi- tation and dyspnea may be present, and the pulse is increased in fre- quency and strength, as a rule, except in the later period, when it may be weak and slightly irregular, particularly if the muscular tissue of the heart be involved. There is some fever, but the degree of elevation of temperature perhaps never exceeds 102° F. (38.8° C). In this class of cases the urinary features depend largely upon the character of the lead- ing etiologic factors, though in many instances the urine is scanty, high- colored, and acid in reaction. Physical Signs.—Inspection discloses an increased vigor of the apex- beat. Friction fremitus (due to the rubbing of the altered pericardial layers upon one another) may sometimes be felt during the earlier and later courses of the disease or when the membrane is comparatively dry, and is usually most intense near the base, just to the left of the sternum. Percussion gives negative results. Auscultation usually reveals a double friction-sound over a limited area in the precordia—a characteristic sign, though one on which sole reliance must not be placed in this disease. The friction-rub is caused partly by the exudate and partly by the dry state of the membrane. Its usual seat of maximum pronunciation is in ACUTE PLASTIC OR FIBRINOUS PERICARDITIS. 575 the fourth and fifth interspaces and the adjacent portions of the sternum —/. e. that portion of the heart which is most closely in contact with the front of the chest (Osier). Another favorite point is the cardio-aortic junc- tion. It is usual to hear the rub over small areas, though occasionally it is audible over the whole precordia, and its distinguishing feature is its superficiality, being generated close to the ear. Pressure with the steth- oscope, which approximates the layers, increases its intensity, though if too much force be exerted the murmur may disappear entirely. In like manner the friction-sound is influenced by respiration and change of pos- ture. The quality of the sounds, like their position, exhibits great variability. They are sometimes soft, but most frequently are grat- ing or rubbing, and in the later stages I have noticed that they may have a loud creaking quality, closely simulating the bending of new leather. Though with feAv exceptions they are double, and are primarily produced by the rhythmic movements of the heart, they do not always occur synchronously with the heart-sounds, and usually7 exceed the latter in duration—facts that go to shoAv that the quality, location, or super- ficial area of a given murmur in no Avise indicates the extent of the pathologic process. Complications.—There may be an extension of the inflammatory process to the external surface of the pericardium, either from the deeper pericardial structures or from the pleura, particularly the left. This is a complicated condition termed " external pleural pericarditis " or " medi- astino-pericarditis," in which the mediastinal connective tissue is also, as a rule, involved. It is most frequently secondary to tuberculous pleurisy (tuberculo-mediastino-pericarditis), sometimes also to pleuro-pneumonia, and rarely to simple pleurisy or plastic pericarditis. The recognition of these combined lesions rests chiefly upon the detection of a friction-mur- mur that is partly dependent upon the cardiac and partly upon the respi- ratory movements. These sounds are most distinctly heard along the left edge of the heart. Momentary arrest of breathing suppresses the pleuritic friction-sound, there remaining merely the sounds produced by the rhythmic cardiac action, and even these may be absent. On the other hand, during forced respiration nothing is audible, as a rule, except the strong pleural rub. In normal respiration the inspiratory movements decrease while expiratory movements increase the intensity of the sounds. During inspiration the pulse may become small and slow, owing to the partial occlusion of the aorta, brought about by the traction of fibrous bands of adhesions which pass over the vessel, being at the same time connected with the pleura. When these bands pass from the exterior of the heart-muscle or pleura, they may cause, as first pointed out by Riegel, an absence of the apex-beat during expiration. Instances of this sort are not uncommon. Diagnosis.—Although the presence of a to-and-fro friction-sound is, as a rule, indicative of plastic pericarditis, it is an error to regard it as an infallible sign, since complete calcification of the coronary arteries, as well as excessive dryness of the pericardial surfaces, may rarely produce friction-murmurs. Differential Diagnosis.—The harsh double murmurs due to chronic val- vular lesions can be eliminated if it be recollected that they are more constant, more distinct, and that each has its area of transmission beyond 576 DISEASES OF THE CIRCULATORY SYSTEM. the limits of the precordia. The sitting posture, leaning fonvard, or moderate pressure with the stethoscope, all fail to produce or to increase endocardial murmurs, whether acute or chronic. A double aortic mur- mur is associated with cardiac hypertrophy, the Corrigan pulse, and sys- tolic flushing of the capillaries. Prognosis.—The termination is always favorable as to life. Com- plete resolution does not often occur, but the exudate becomes connective tissue, and agglutinates the two layers of the pericardial sac. The acute may merge into the chronic form, and dry, plastic pericarditis often con- stitutes the first stage of severer grades of the disease. Treatment.—Absolute quiet in the recumbent position should be enjoined. The diet should be composed chiefly of light, easily digested solids, allowing as little drink as is practical, and thus endeavoring to avoid an overfilling of the vessels. With the same object in vieAv, if the patient's strength be good, a half-dozen leeches should be applied over the heart, followed by the use of the ice-bag; the bowels are to be kept soluble by using stewed fruits or saline laxatives if needful. Calomel in doses ranging from gr. ^ to ^ (0.016-0.032) every hour or two, com- bined Avith a little opium to prevent purgation, is serviceable. At the beginning veratrum viride may also be cautiously administered, with a view to dilating the arterioles throughout the rest of the body, and thus virtually " bleeding the patient into his own vessels." Later, digitalis in combination with the iodids of potassium and iron should be substituted for the purpose of absorbing the effused material. Tonics and a change of air may be required during convalescence. SERO-FIBRINOUS PERICARDITIS. Pathology.—The anatomic changes may be grouped into three stages—the first being characterized by a plastic exudation (correspond- ing Avith the lesions in dry, plastic pericarditis, though more pronounced); the second stage, by a variable amount of effusion composed largely of serum. The exudation usually begins about the origin of the great ves- sels springing from the base of the heart, and ultimately forms a thick covering of fibrin, especially on the visceral layer. The quantity of serous effusion may be from 2 to 10 ounces (64.0-320.0), but occasionally it is as much as 3 pints (1^ liters). The admixture of a slight amount of blood- or pus-corpuscles sometimes occurs in this form of the complaint. The third is the stage of absorption in the most favorable cases. Perfect resolution rarely takes place, but, instead, the liquid effusion is alone ab- sorbed, and the lymph causes firm adhesions of the visceral and parietal membranes. If, as sometimes happens, the serum remains, the acute passes into a chronic condition. The muscular tissue of the heart may become involved by an extension of inflammation from the visceral layer which lies in contact with it; it is always the seat of more or less col- lateral edema. The grade of the myocardial inflammation will depend much upon the extent and duration of the pericarditis, though usually it is moderate in the fibrino-serous variety. Etiology.—The disease is most frequently observed to be associated Avith acute rheumatism, Bright's disease, and pulmonary tuberculosis. Respecting the causal relation of acute rheumatism, two facts should be SERO-FIBRINOUS PERICARDITIS. 577 stated—viz. that pericarditis arises as a complication in about one- third of the cases (Bamberger), and that it may rarely precede, by a few days, the articular disturbance. I am of opinion that in excep- tional instances both sero-fibrinous and plastic pericarditis may occur secondarily to the rheumatic dyscrasia Avithout the slightest evidence of arthritis. The disease also occurs in the course of the eruptive fevers, and sometimes as a complicating affection due to extension of inflamma- tion from neighboring parts. Clinical History.—When, as rarely occurs, a primary pericarditis develops, the initial symptoms common to inflammation of other serous membranes manifest themselves, as anorexia, sometimes nausea and vom- iting, chills, fever, increased respiration and pulse-rate, together with local pain. The pain is usually of a dull, aching character, and less fre- quently merely a slight soreness, or it may be absent altogether. Acute pain is experienced only Avhen the pleura is implicated. When pericarditis is secondary to an existing febrile affection there are, in many cases, no subjective symptoms to indicate its presence. In other instances there may be precordial oppression with or without slight pain or a feeling of soreness. Hence the rule should be absolute that in all affections in which pericarditis is likely to arise physical examinations of the heart should be frequently made, and particularly during the height of the disease. Dyspnea comes on simultaneously with the appearance of the effusion and may lead to actual orthopnea. Pressure is exerted upon the left lung if the effusion be large—a fact that explains in part the presence of dyspnea. The cardiac muscle, especially the right ventricle, is also pressed upon by the effusion, thus impeding to a greater or lesser extent the cardio-pulmonary circulation as well as the cardiac diastole. We have here an additional reason why dyspnea occurs, and also why deficient aeration of the blood and a feeble peripheral circulation are found in this complaint. Prior to the occurrence of the effusion the circulation is too actively carried on, the pulse being full and strong. It is clear from the above explanation relative to the mechanical effects of large effusions that during the second stage the pulse is small, feeble, and irreg- ular. When the liquid effusion is not large the heart-action may be ap- parently feeble, while the pulse remains strong—a valuable rational sign. On the other hand, an excessive amount of fluid may cause the radial pulse to become quite small or even to disappear during inspiration (thepulsus paradoxus). Fever is present, as a rule; the temperature is irregularly elevated, ranging from 101° to 103° F. (38.3°-39.4° C). In favorable cases defervescence takes place by lysis. Nervous symp- toms, as headache and mild delirium, often appear, and sometimes give place to stupor or even coma. Physical Signs.—Inspection.—The skin-surface and mucous mem- branes are observed to be pale and more or less cyanotic. The neck- veins are prominent, and sometimes exhibit undulatory movements or pulsations. The face wears an anxious expression ; the respirations are increased, labored, and at times irregular. The decubitus is dorsal; the head and shoulders are elevated, and the patient may be forced to assume the sitting posture. In young subjects precordial prominence, with efface- ment or even bulging of the intercostal spaces, may result from the pres- 37 578 DISEASES OF THE CIRCULATORY SYSTEM. ence of a moderate effusion. In adults, however, a large collection is indispensable for the production of this effect. If the lung be shrunken or if there are pleuritic adhesions, expansion of the pericardium, and hence also bulging, will be prevented. The distended pericardium may depress the diaphragm. Elevation of the left nipple in consequence of marked anterior expansive bulging has been observed. In the first stage the apical beat is intensified, but as the effusion increases (forcing the heart backward and upward) it is displaced in an upw7ard and outward direction, at the same time becoming Aveaker as Avell as more diffused, since with expansion of the sac comes greater mobility of the organ. When the pericardial sac becomes filled the impulse-beat disappears, for the reason that the fluid now completely surrounds the heart and pushes it aAvay from the chest-Avail. Palpation confirms the result of inspection. The apical beat is dif- fused and feeble or lost. When detectable it is found to be displaced upAvard and to the left. Altering the patient's posture changes the seat of the apex-beat (Oppolzer), and if the shock has been lost, turning the patient on his left side or bending his body forward may cause its return. The cardiac impulse disappears earlier when, on account of myocarditis, the systole is greatly enfeebled. On the other hand, old adhesions may retain the apex-beat in contact with the chest-wall, despite the presence of a large accumulation. Hypertrophy of the organ Avould act in a similar manner, though less potently. A friction-rub can be felt occasionally over the base of the heart even when there is a copious effusion present, and, if absorption takes place, the friction fremitus becomes more marked, simulating the first or dry stage. Percussion.—The area of cardiac dulness is greatly increased, and assumes a characteristic triangular form with the base downward and the apex extending up to the third or even second interspace to the left of, though near, the sternum. The lateral border-lines of dulness obviously diverge from above doAvnward, the right passing to a point corresponding with the right edge of the sternum, along which it runs to the seventh rib ; the other to the left, finally intersecting the base-line at the left anterior axillary line. The lower level of the fluid, being continuous with the liver dulness, is not definable. Even in moderate effusions there is flatness in the fifth interspace to the right of the sternum (Rotch). The margins of the lungs surrounding the heart may be retracted and the heart carried forward or dilated, owing to the presence of adhesions; the dull space will then appear larger than is justified by the amount of fluid. Retraction or moderate compression of the lung may, however, give rise to a modified tympanitic resonance to the left of the flat area. Occasionally the lung is attached anteriorly, and then the heart is crowded backward by the effusion, while the area of flatness on percussion is relatively diminished. The triangu- lar shape of the flat space, noted when the patient is in the sitting posture, is to a considerable extent lost and its area diminished when he changes to the supine position or lies on either side, the effusion obeying the laws of gravitation. When the feeble impulse can be felt by the clinician occupying the center only of a dull area, he has good evidence of the existence of pericardial effusion. Auscultation.—The characteristic friction-rub of the first stage has SERO-FIBRINOUS PERICARDITIS. 579 already been described. It may, however, also be audible over the base during the stage of effusion, and ahvays returns, after absorption of the fluid, for a brief period. The heart-sounds grow more and more distant, faint, and muffled, though the second sound, as heard over the extreme base of the organ, may remain clear. Over the area of dull tympany corresponding to the lower antero-lateral portion of the left lung (which, as before pointed out, is more or less compressed) may be heard broncho- vesicular breathing. Course and Duration.—It will appear obvious that the course must vary in individual cases Avith the cause and severity of the special type of infection. Observation has shown that in one class of cases the three stages (dry, effusion, and absorption) are passed through in rapid succes- sion, while in another class each stage is proportionately lengthened. The latter type has been termed "chronic" by some and "subacute " by others. The acute may also be followed by the chronic variety. Usually sero-fibrinous effusions complicating rheumatism are absorbed with rapidity once the process has begun, seldom requiring more than tAvo weeks. When recovery is about to occur the temperature falls by lysis; the dyspnea gradually disappears, and with it the effusion is gradually ab- sorbed. Convalescence is further indicated by a return of the appetite, normal heat of the skin, and a less frequent, full, and regular pulse. In cases that tend to a fatal termination either the fever continues or there is suddenly developed hyperpyrexia, as may happen when pericarditis occurs in the course of acute rheumatism; in such cases the dyspnea is urgent and eyanosis is often marked, with signs of failing circulation. ' Nervous symptoms, as extreme restlessness, insomnia, and active delir- ium, may be present. Under these circumstances death usually ensues at the end of a week or ten days. In a fatal case of acute articular rheumatism which I saw, complicated by pericarditis, Avith hyperpyrexia, death occurred on the sixth day. Rarely acute pleuritis Avith effusion is a complication, and its occurrence usually lengthens the course of the pericarditis and renders the outcome of the latter condition uncertain. When there coexists extensive myocarditis, syncopal attacks often endan- ger the life of the patient. Copious effusion may, by causing pressure upon the recurrent laryngeal nerve, produce paralysis of the vocal appa- ratus ; or, as the result of pressure upon the esophagus, difficult deglu- tition may be a troublesome concomitant. Prognosis.—In sero-fibrinous pericarditis recovery is the rule under favorable conditions. The outlook, however, becomes gloomy Avhen the above-mentioned complications arise, and particularly when there is hyper- pyrexia in connection with acute rheumatism. Occurring as a secondary event in serious acute diseases, as pneumonia, or "in chronic diseases, as Bright's, or organic affections of the heart, the pericarditis often precip- itates a fatal termination. The strong possibility that these cases may only partially recover or assume a chronic form must be recollected in making a prognosis. Diagnosis.—The disease is often overlooked, because unsuspected. Ordinarily the recognition of pericarditis by the characteristic triangular area of percussion-dulness and by the friction-sound is not difficult. Atypical cases or those first seen during the stage of effusion can only be correctly diagnosticated by exclusion. 580 DISEASES OF THE CIRCULATORY SYSTEM. Differential Diagnosis.—Acute pleurisy of the left side may simulate pericarditis Avith copious effusion, and, as before stated, these diseases may coexist. Acute pain, however, belongs to pleurisy alone. In peri- carditis the characteristic physical signs are elicited over the precordia; in pleurisy they are apt to occupy not only the anterior but also the axillary and posterior aspects of the chest; hence the percussion-flatness in pleurisy extends to the left, far beyond the boundary-line of the per- cussion-flatness in pericarditis. The pericardiac friction-sound has a dif- ferent situation usually from the pleuritic, and the latter is heard syn- chronously with the respiratory movements, while the former is intimately related to the time of the cardiac movements. The friction-murmur of pleurisy ceases if the breathing be momentarily suspended. Encapsulated pleural effusions that are limited in area to the antero-lateral portion of the chest are exceedingly difficult of elimination, and especially in the absence of pleuritic friction. In the latter complaint, however, the heart- sounds are clear and the apex-beat often pushed some little distance to the right; on the other hand, in pericarditis the general disturbance is usually greater, while a friction-rub may be detectable over the base. The heart-sounds are distant and muffled. The diagnosis is often aided by a consideration of the previous history and the bearing of any facts thus obtained upon the known etiology of these affections. We encounter intricacies when we attempt to exclude cardiac dilatation, though the fol- lowing brief table will be of assistance in the diagnosis: Pericarditis with Effusion. Cardiac Dilatation. (Previous History) Recent history of gout, acute rheumatism, Usual history of chronic' and valvular acute infectious or septic disease, scur- disease of the heart. vy, chronic nephritis, or tuberculosis. (Clinical History) Fever and slight pain are usually asso- No fever or pain, as a rule. ciated. Nervous symptoms are often present. Absent. (Physical Signs.) Inspection often reveals bulging (more Apex-beat usually visible, wavy, and marked in the young). Apex-beat diffused. pushed up, is feeble, and later absent. Heart's impulse usually absent. Friction- Though feeble, the impulse is palpable. fremitus may be present over the base. Percussion shows a triangular flat area, Dull area varies with chambers dilated; and the boundary-line above changes usually it is coextensive with a wavy on altering the position. There is dull impulse, and does not extend so high tympany in the axillary or subscapular (except in mitral stenosis), and does not region. vary with change of position. No dull tympany. Auscultation shows the first sound distant First sound clear, short, and sharp. No and muffled: the friction-rub is often friction-murmur present, but an endo- double over the base. cardial murmur or murmurs may appear. Treatment.—The management of the first (or dry) stage is identical with that detailed in discussing the plastic variety. During the stage of effusion the patient should be kept at absolute rest in the recumbent pos- ture, and mental excitants should be rigidly prohibited with a view to PURULENT PERICARDITIS. 581 minimizing the labor of the heart. The diet is to consist mainly of easily digested albuminous articles; fluids are not to be given in large amounts, since this tends to overfilling of the vessels, increases the arte- rial tension, and delays absorption. Local Measures.—Flannel should be kept over the precordia, so as to avoid exposure and undue chilling. The ice-bag or Leiter's coils (to be used in the first stage) should be cautiously employed during the second stage, until the temperature has defervesced considerably, thus indicating a sub- sidence of inflammation in the pericardium.1 Subsequently, if absorption does not proceed satisfactorily, blisters may be applied over the pre- cordia, and, should the patient's general condition be markedly asthenic, an ointment containing iodin, lanolin, and ichthyol may be substituted with advantage. The therapeutic measures must be chosen Avith sole reference to the primary disease, which the physician must continue to treat while he attempts by other means to relieve certain symptoms and promote absorption. For example, if the pericarditis be due to rheu- matism, the use of the salicylates must be persevered in, and opium may be added to quiet restlessness and procure relief from pain. In my own experience absorption has been best promoted by the use of the double iodid of potassium and iron or of iron and manganese. These agents are seldom contraindicated unless they are badly borne by the stomach. Diuretics and saline purgatives are not without value, but do good only in the later stages. Depressing measures of Avhatever sort are not to be resorted to unless the circulation be good. If the pulse be small, weak, and rapid, Avith marked cyanosis, stimulants are indicated and are to be given in moderate quantity ; the pulse will then be found to grow stronger and the dyspnea and cyanosis less marked. The nervous symptoms are also benefited as a result of the action of these agents. Strychnin and the salts of ammonium will be found to be useful. Digitalis and strophan- tus are not to be thought of wrhen myocarditis is associated ; at other times they often improve the peripheral circulation and increase the urin- ary secretion. When the breathing becomes greatly embarrassed and the circulation fails, as shoAvn by the feeble, broken, rapid pulse and the cyanotic hue of the lips, eyelids, and finger-tips, cardiocentesis is indicated, and in sero-fibrinous effusion aspiration has, in recent years, given good results if not too long delayed. If the slightest doubt arises as to the character of the fluid, a preliminary puncture with a hypodermic needle should be made. The point for puncturing is the fourth interspace, 1 inch (2.5 cm.) from the parasternal line, or the fifth interspace, 1^ inches (3.7 cm.) from the left edge of the sternum. The operation must be per- formed with the strictest asepsis, and the amount of liquid withdrawn at any one time should not exceed two or three ounces. It would be better to repeat the puncture several times than to remove the pressure too sud- denly from the damaged heart. PURULENT PERICARDITIS. (Empyema of the Pericardium.) Pathology and Etiology.—The condition often follows the sero- fibrinous form. Septic and tuberculous processes involving the pericar- 1 If the pericarditis be secondary to an acute febrile disease, this fact must modify the method here recommended accordingly. 582 DISEASES OF THE CIRCULATORY SYSTEM. dium are also apt to cause purulent effusion, and many of the eases that arise in the course of the acute infectious diseases belong to this category. The membrane is much thickened and presents a gray, granular surface, and the myocardium underlying the visceral layer is softened, fragile, and pale-looking—changes that are in the main due to fatty degeneration. Clinical History.—The local subjective symptoms and physical signs are the same in kind as in the former variety, but the amount of exudation is frequently less. At the onset rigors often occur, and may be repeated at varying intervals. The temperature-curve is of the sup- purative type ; the pulse is small, rapid, and irregular; and physical prostration is pronounced. Purulent pericarditis runs a comparatively rapid and an almost uniformly unfavorable course. Diagnosis.—The chief clinical features are often referable to the primary or causal disease; hence in every instance in which purulent pericarditis is apt to arise a physical exploration of the chest is impera- tive. The purulent character of the effusion cannot readily be ascer- tained, as a rule; but the history of an affection having etiologic im- portance, the observance of rigors, and the presence of the fever-curve peculiar to suppuration would all point strongly to purulent effusion, and should lead to aspiration with the hypodermic needle—a harmless pro- cedure if carefully performed, and one that almost constantly gives relia- ble results. Treatment.—It is within the physician's province to treat the pri- mary disease assiduously, but he should not undertake to treat complica- ting pericardial empyema by the application of therapeutic measures. A surgeon's aid should be invoked. HEMORRHAGIC PERICARDITIS. In purulent pericarditis the effusion may be hemorrhagic, and par- ticularly when it is of tuberculous origin. In non-purulent tuberculous pericarditis also the exudation is apt to be hemorrhagic. In the non- purulent instances that are due to chronic Bright's disease or that occur in the aged the effusion is sometimes blood-stained ; and future ob- servation may show that the hemorrhagic variety is of more frequent occurrence than has hitherto been supposed. Here may be pointed out that even in ordinary serous pericarditis there is apt-to be much more blood than in serous pleuritis. M. T. Ferrier has found 5 examples in 9 collections. This etiologic variety scarcely calls for separate clinical con- sideration. ADHESIVE PERICARDITIS. (Chronic Pericarditis.) Pathology and Btiology.—Chronic pericarditis follows the acute forms, and, as in the case of the latter, it may be partial or general. The effusion may rarely remain as a permanent condition, though not infrequently a clear history of the preceding acute attack is wanting. In most instances the opposed surfaces of the membrane are either univer- sally or over a limited area firmly adherent. The amount of new con- nective tissue present or the degree of thickening of the layers varies greatly, and is dependent upon the type of the primary acute attack. If ADHESIVE PERICARDITIS. 583 the latter is of mild grade—as, for example, in the case of the sero-fibrin- ous variety, complicating rheumatism—then not much thickening is en- countered in the resulting chronic form. Chronic tuberculous pericarditis is not uncommon, and may be pri- mary, though more commonly it is secondary, in its origin. The disease is not invariably preceded by the acute form, but may be chronic from the time of onset. I have noticed that often more or less effusion pre- vails unless artificially removed. The layers become enormously thick- ened, and total obliteration of the sac by agglutination of the surfaces is not infrequent. In the dense exudate that remains after complete absorption of a peri- cardial effusion calcareous depositions occur, forming a bony casing, as it were, which either partially or totally encircles the organ. The external surface of the pericardium may become united either Avith the costal or pulmonary pleura, the chest-wall, or the mediastinal tissues. The myo- cardium is the seat of atrophic and degenerative changes. Symptoms.—Autopsies frequently reveal a chronic adhesive peri- carditis that has not given rise to a single recognizable symptom during life. Hypertrophic dilatation of the chambers usually develops sooner or later, and is due to adhesions that interfere with the free action of the organ as well as with its systole. When present the subjective symptoms point to enfeeblement of the cardiac muscle, as shown by the universal venous stasis. The symptoms of bronchial and gastro-intestinal catarrh are often prominent; rational symptoms indicative of adhesion are, how- ever, scanty and unreliable. The pulse is rapid, of low tension, and irregular, and, though not diagnostic, the pulsus paradoxus has been noted. Physical Signs.—Inspection.—Depression or pitting of the intercostal spaces over the position of the heart may be noticed. Synchronous with the systole there is also a retraction of the chest-w7all in the apical area, and less frequently over the whole precordia, the latter being an unerring sign of universal adhesions. The degree of systolic retraction is slightly influenced by the respiration, inspiration increasing it, and it is best appreciated on palpation Avhile the patient is in the semi-supine position. During the diastole the heart forcibly rebounds, causing the so-called diastolic shock, which is of the utmost diagnostic worth when associated with marked systolic retraction. Though not ahvays visible, it can be readily felt on palpation. Friedrich's sign (the sudden collapse of the jugulars during diastole) may frequently be observed, but I have also noticed this in cardiac dilatation without adhesions. Prior to the onset of dilatation the apex-beat may be forcible and visible over an increased area, indicating hypertrophy; but after the myocardium is weakened (from interference with its nutrition) and dilatation comes on, the impulse-beat is faint or wanting, and in marked systolic retraction may be seen to be vibratory. The fixed position of the apex-beat when the patient is turned over upon his left side is a confirmatory sign of con- siderable value. Percussion.—The area of cardiac dulness is increased, especially upward and to the left, owing to the associated hypertrophy and pleural pericar- dial adhesions, and, since the adhesions between the pleura and the peri- cardium do not allow the lungs to come forward and overlap the heart 584 DISEASES OF THE CIRCULATORY SYSTEM. during inspiration, the upper and left lines of dulness remain fixed (C. J. B. Williams). Auscultation.—When dilatation reaches a high degree the auscultatory signs peculiar to that condition appear. In many cases no murmurs are detectable, but in a third group loud murmurs, quite independent of any value as regards cardiac lesions, are audible; these murmurs may be due to the vortiginous movements in the antero-cardial blood-current occa- sioned by the jogging cardiac action. Finally, it is to be noted espe- cially that chronic adhesive pericarditis may exist without giving rise to any physical signs. Differential Diagnosis.—The condition is apt to be confounded with chronic myocarditis and simple hypertrophic dilatation. As before stated, chronic pericarditis may be associated with effusion, and in such instances it is important to distinguish from the adhesive type if Ave would institute proper treatment. In chronic pericarditis with moderate effusion the seat of the apex-beat is higher and less un- dulatory, and when the amount of effusion is large the impulse is absent and there is bulging. Adhesive pericarditis with hypertrophy causes bulging in young subjects, but the apical beat is retained. In pericar- ditis Avith effusion the upper and left limits of dulness are not stationary, and there is an absence of systolic retraction and diastolic concussion. Course and Prognosis.—The hypertrophy that comes on early in consequence of the obstruction offered to cardiac action is compensatory, and this harmonious balance may be maintained for a long period of time with apparent comfort. After myocardial degeneration, followed by atrophy or dilatation, has occurred, the condition becomes quite serious, and death usually ensues amid signs of extreme cardiac dilatation. The treatment must be ordered chiefly with reference to the nutri- tion of the heart-muscle, following the principles noted in dealing with the management of valvular affections of the heart. If chronic effusion be present early, operative measures are to be warmly advocated. HYDROPERICARDIUM. (Dropsy of the Pericardium) Definition.—A condition in which the pericardium contains a serous transudation, while the membrane itself shows no signs of inflammation. Etiology.—(a) Hydropericardium is usually associated with general cardiac or renal dropsy, of which it forms a component part. Under these circumstances it develops late, and frequently follows hydrothorax, on account of which condition it is liable to be overlooked. It may also occur suddenly in chronic nephritis, and particularly in the scarlatinal variety, (b) It arises not infrequently from local mechanical causes, as the pressure of mediastinal tumors, aneurysm, or thrombosis of the car- diac veins. Symptoms.—No subjective symptoms are present, save perhaps dyspnea, and the diagnosis rests upon the history and the physical signs. None of the latter, however, are particularly significant. They point to HEMOPERICARDIUM—PNEUMOPERICARDIUM. 585 the presence of fluid, and the area of percussion-dulness assumes the same form and exhibits even greater change, Avith alteration of the patient's posture, than in pericarditis. No friction-murmurs are heard and no bulging of the pericardium is observed. It is rare indeed, I have found, to see an excessive amount of serum in the pericardium at the postmortem. The symptoms and signs of hydrothorax generally precede and accompany hydropericardium, and the latter condition tends to intensify the effect of the former. The condition, per se, is rarely of serious import. Osier remarks: "Naturally there are in the pericardial sac a few cubic centi- meters of clear, citron-colored fluid, which probably represents a post- mortem transudate." In rare instances the transudate has a milky appearance (chylo-pericardiuni). The treatment suitable for cases of general dropsy, as a rule, affords relief. In large serous accumulations aspiration should be practised. HEMOPERICARDIUM. By the term " hemopericardium " is meant hemorrhage into the peri- cardial pouch—a rare event. Among the causes are—(a) perforation by aneurysms of the aorta and the coronary arteries into the sac; (b) rupture of the heart, due to injuries or cardiac aneurysms and fibrous formations from myocarditis ; (c) direct injuries, especially stab- and bullet-wounds. The symptoms and course depend greatly upon the nature of the exciting cause. The most frequent factor, rupture of an aneurysm, proves quickly fatal from overcrowding of the heart. In rupture of the heart-muscle there is sometimes a slow outpouring of blood, with a correspondingly slow course, varying from a feAv hours to a couple of days in duration. The physical signs of effusion come on with dy7spnea and failing circula- tion, wThich lead to cardiac exhaustion and death. The blood-stained effusions, before considered, that are met with in certain forms of peri- carditis, are not to be regarded as instances of hemopericardium. PNEUMOPERICARDIUM. (Air in the Pericardium) In this complaint, besides air or gas, there is usually present pus, and less frequently blood ; hence an appropriate term in most instances would be pyo-pneumopericardium. When the pericardium is perforated puru- lent pericarditis results. The causes are the following : (a) wounds ; (b) a fistulous connection between the adjacent air-containing organs and the pericardium as the result of diseased processes, such as pulmonary tuberculosis or empyema; (c) rarely decomposition of liquid pericardial effusions. The symptoms are equivocal. In the main they do not differ from those of pericarditis with effusion, excepting that dyspnea is more intense than in the latter affection. By attention to the physical signs 586 DISEASES OF THE CIRCULATORY SYSTEM. the distinction from pericarditis can rarely be made. In pneumoperi- cardium there is tympanitic percussion-resonance over the precordia, though the fluid, when present, gives rise to a boundary-line of dulness. The change of the patient's posture alters markedly the area of the tym- panitic note. On auscultation may be heard loud, rasping, friction- sounds having a metallic quality, intermingled with churning, splashing noises, or the so-called " water-wheel sounds." I have, however, occa- sionally found the apex-beat and heart-sounds exceedingly feeble. Pneumothorax when encysted in close proximity to the heart, displacing the latter organ, must be eliminated. The latter complaint gives cardiac dulness in the abnormal position and a metallic sound synchronously with the respiratory movements—two signs diagnostic of pneumothorax that are absent in pneumopericardium. The prognosis is grave, death coming on most commonly in a day or two. The admission of air might alone result in a spontaneous cure, as occurs rarely in pneumothorax. The treatment is the same as has been recommended for purulent pericarditis. II. DISEASES OF THE HEART. ENDOCARDITIS. Definition.—Inflammation of the lining membrane of the heart. The process is usually confined to the valves, though the cardiac layer may also be affected. Varieties.—(a) Simple acute endocarditis ; (b) ulcerative endocarditis; (c) chronic endocarditis. The pathologic processes involved in the first two, the acute forms, are identical in nature, though they differ in severity. I have met with two instances that could be referred to neither sub-variety, apparently occupying a middle ground. SIMPLE ACUTE ENDOCARDITIS. (Endocarditis Verrucosa) Pathology.—The disease is characterized by the formation of small vegetations on the segments, varying in size from excrescences that are scarcely visible to those the size of a pea. They are found chiefly on surfaces that are opposed to the blood-current, near the margin of the valve, and " forming a row of bead-like outgrowths." Their seat corre- sponds to the point of maximum contact (Sibson), but the mitral valve is much more commonly affected than the aortic. With the segments the chordae tendinese are sometimes affected, and very rarely the latter are alone involved. The left side of the heart is much more frequently the seat of acute endocarditis than the right, except during fetal life, when the right side is almost exclusively involved. To account for the greater frequency of occurrence on the left side after birth, it has been suggested that freshly oxygenated blood affords the most favorable condition for the multiplication of the micro-organisms that are concerned in the inflamma- tory process. As corroborating this view, the fact is adduced that during SIMPLE ACUTE ENDOCARDITIS. 587 fetal life the blood in the right chamber is the more completely oxygen- ated. It has also been pointed out that before birth the right side, and after birth the left side, is the more active, and that the active side is apt to suffer on account of higher pressure. Obviously, the vegetations form an obstruction to the current of the circulation as it flows through the valvular opening. In the early stage the membrane in the vicinity of these excrescences shows a bright-red color, Avhich has usually disappeared in fatal cases before they come to autopsy. The histologic changes con- sist in a proliferation of the subendothelial tissue (small-celled infiltra- tion), Avhich forms the principal component part of the vegetation. On this basal mass of granulation tissue there is deposited fibrin from the blood, the latter being separable from the former in acute forms of the complaint. Micro-organisms have repeatedly been found in the fibrinous depositions, but the specific causal irritant has not as yet been discovered. In favorable cases either the vegetation is ultimately absorbed or there remains a small indurated mass. When the vegetations are of consider- able size emboli may become detached by the force of the blood-current, and be carried to the vessels of the extremities and to the various viscera, particularly the brain, spleen, and kidneys, giving rise to embolic infarcts. The latter event is frequently observed in cases in which acute endocar- ditis is engrafted upon chronic valvulitis. Simple acute endocarditis may end in the more serious or ulcerative variety. Here the cellular proliferation proceeds actively, leading to necrosis of the newly-formed tissue and to the production of an ulcer. Much more commonly, however, does the simple form terminate in chronic (sclerotic) valvulitis with deformity. Etiology.—The most frequent cause of acute endocarditis is acute articular rheumatism, which complicates the disease in not less than 40 per cent, of the cases. In young subjects suffering from rheumatism the liability to the complaint is particularly pronounced. The severity or mildness of the rheumatic attack does not, however, influence the appear- ance of the cardiac complication. Cases of acute endocarditis of rheu- matic origin are met Avith in which the arthritic phenomena are secondary. It may complicate tonsillitis Avhen the latter is due to or associated with rheumatism. In specific fevers it is also encountered, and found to be common in scarlet fever, but rare in typhoid fever, diphtheria, measles, erysipelas, variola, and varicella. It is not uncommon as a complication in pneumonia and pulmonary tuberculosis, and Osier, as the result of 100 autopsies in cases of pneumonia, found it present in 5 instances, while in 216 postmortems upon phthisical cases it was present in 12 instances.1 It has frequently developed in the more serious forms of chorea, and inter- current acute endocarditis may result from chronic diseases attended with emaciation and general weakness or suppuration, such as ulcerative carci- noma, gleet, gout, chronic Bright's disease, and diabetes. Lastly, acute endocarditis may occur as a secondary event in pre-existing sclerotic endocarditis, Avhen it is termed acute recurrent endocarditis. In chronic endocarditis the liability to the acute form is greatly in- creased by the puerperal state, and also, though to a lesser extent, by pregnancy. It is highly probable that the micro-organisms of inflamma- tion, assisted by the friction between the blood-current and the surfaces 1 Text-book of Medicine, Osier, pp. 628, 629. 588 DISEASES OF THE CIRCULATORY SYSTEM. of the valves, fix themselves upon the latter and there set up the charac- teristic lesions. Indeed, the disease has of late been excited by injecting into the blood the streptococcus pyogenes, staphylococcus aureus, and other micrococci. Frankel and Sanger are of the opinion that the sta- phylococcus pyogenes aureus is the chief specific agent in causing acute endocarditis, but their claim has not as yet been satisfactorily established. Clinical History.—It is only occasionally that definite subjective symptoms, as precordial pain (sometimes extending doAvn the left arm), dyspnea, and cardiac palpitation, are complained of by the patient. In the vast majority of instances the condition is discovered accidentally in the course of an examination of the chest. This being true, not only its frequent occurrence in acute articular rheumatism, but also the possi- bility of its occurrence in the other diseases mentioned under " Etiology," should ever be kept in remembrance. The symptoms of embolism, which will be detailed presently, are rarely observed in this form of endocarditis. The physical signs by which acute endocarditis is recognizable are dependent upon the valvular insufficiencies caused by the morbid lesions previously described. Hence there must be not a small proportion of mild cases, including those in which the valves are not affected, that give rise to no physical signs. On inspection the area of visible impulse may be seen to be increased, though, as a rule, it is normal. The impulse is sometimes forcible and often irregular during the initial period, but later it becomes less distinct and more feeble. Palpation confirms the result of inspection. I have found the impulse to vary at each visit, with a general tendency to lessen in intensity in the later period of the disease. A very weak impulse is indicative of associated myocarditis or of the poisonous effect of a severe type of primary infection. In recurrent endocarditis the apical impulse is often heaving, on account of pre-existing compensatory hypertrophy, and its area is exceedingly variable. A systolic thrill is sometimes felt. On percussion the area of the heart's dulness is found to be almost uniformly normal, except in cases of intense myocardial involvement, Avhen acute dilatation of the chambers may supervene, giving rise to an increased area of percussion-dulness in the transverse direction. In re- current acute endocarditis the area of dulness corresponds to the increased area of the apical beat. Auscultation.—Acute endocarditis is usually attended with a soft blowing, systolic murmur, which, owing to the fact that the mitral seg- ments are the favored seat of the disease, is heard much more frequently at the apex than at the base. The point of maximum intensity of this murmur is often movable, but its area of transmission is usually quite limited. In rheumatic endocarditis this murmur is preceded by a pro- longation of the first sound and the consequent shortening of the interval betAveen the first and second sounds. The murmur is sometimes heralded by a feeble or muffled first sound, with intensification of the second, and sometimes by a pronounced accentuation or roughening of the normal sounds. In acute endocarditis affecting the mitral valves aortic murmurs may coexist, but their true nature is more than doubtful. There is also a short, low-toned, and double systolic murmur over the tricuspid orifice in a small proportion of the cases; this is due most probably to a relative incompetency. When acute endocarditis arises in connection with chronic SIMPLE ACUTE ENDOCARDITIS. 589 valvular disease, the auscultatory signs of the latter are but little changed, and hence a positive diagnosis is not possible. Complications.—There may be developed by direct extension sec- ondary myocarditis, a disease that will receive separate consideration. The diagnosis is based on the physical signs, though it must be re- membered that these are untrustworthy. The points gained by careful inspection and palpation are as significant as those learned by auscultation, as is also the previous history of the patient. The soft belloAvs murmur is often present in acute febrile diseases in Avhich the autopsy fails to reveal the lesions of acute endocarditis. The functional murmurs that arise in the specific fevers, however, are perhaps oftener heard over the aortic area, while those occurring in endocarditis are heard best over the mitral area. Leubel points out that if the dulness is slightly increased to the left, there is fever; in fact, if there is infectious disease present, a diag- nosis must be made of acute insufficiency of the ostium mitralis occurring in the course of acute endocarditis. The distinction between simple acute endocarditis and pericarditis should be categorical, in view of the manifold differences between their signs. But the fact that these two affections may be associated, more especially Avhen they are of rheumatic origin, must be steadily borne in mind, and also that when combined the signs belonging to the endocarditis are not open to observation, owing to the pericardial friction-sound, and later the presence of the effusion. I have found, however, that, fortunately, endocarditis usually precedes pericar- ditis. The murmurs present must be called accidental if the area of car- diac dulness is normal, the second pulmonary sound not accentuated, and if the murmur be heard only at the pulmonary cartilage, or at this point and at the apex, and, at any rate, more distinctly at the pulmonary car- tilage (Leube2). The elimination of old endocarditis or chronic valvular disease—a matter of importance—may be accomplished by attention to the character of the murmur in acute endocarditis, as well as to its limited area of diffusion, and by the absence of the signs of hypertrophy and of accentuation of the second pulmonary sound. A relative insufficiency distinguishes itself by a pure systolic murmur, loud and not invariably uniform, by a weak cardiac impulse, a slight ac- centuation of the second pulmonary sound, and a comparatively small and often irregular pulse. It is met with in excessive dilatation of the left ventricle, in anemia, '* and particularly in certain changes of the valvular muscles, due to myocarditis " (Leube). Prognosis.—The immediate dangers are few, and depend largely upon the primary disease. In many instances, however, acute endocar- ditis initiates permanent lesions of the valves. Treatment.—Prophylaxis.—The prevention of acute endocarditis in rheumatism has been dealt with in discussing the latter disease. No knoAvn direct measures can prevent the development of this condition in the course of the specific fevers, though absolute rest in bed and protection of the body against "cold" may diminish somewhat the tendency to it. The Attack.—The sick-room should be free from draughts, though well ventilated, and flannel is to be applied to the chest. The diet may be liberal, but should be composed chiefly of milk and other light nutritious substances. Stimulants are required in most instances, and 1 Deulsch. Archivf. klin. Med., Nov. 5, 1896. 2 Loc. cit. 590 DISEASES OF THE CIRCULATORY SYSTEM. in abundance should the heart be failing. Digitalis is to be employed cautiously if at all. When the myocardium is involved, its use is not without danger; under these circumstances the drug increases the sufferings of the patient by throAving the inflamed and Aveakened car- diac muscle into firm contractions. The salts of ammo.nium, particu- larly the carbonate, should be given continuously with a viewr to obvi- ating intracardial coagulation of blood; and should the latter accident occur despite all efforts to prevent it, the carbonate, together with strych- nin and alcoholic stimulants, should be freely administered. I am con- vinced that in endocarditis due to acute articular rheumatism it is wise to continue the exhibition of the salicylates, though in moderate doses, pro- vided that the heart is guarded by the use of stimulants. During con- valescence from an acute endocarditis the patient should be kept at rest, so as to minimize the strain upon the affected valves; even after he has apparently recovered, and particularly should the murmur still be present, perfect quiet is to be enjoined for a period of several weeks. ULCERATIVE ENDOCARDITIS. (Maligna)it or Infectious Endocarditis) Malignant endocarditis is variously characterized, though usually either by perforative ulceration, by suppuration of the valves, or by both, giving rise to the physical signs of acute endocarditis. These develop amid the symptoms of a severe type of some primary infectious or septic disease. There is at hand sufficient clinical evidence to Avarrant the assumption that ulcerative endocarditis also occurs, though very rarely, as a primary affection. Pathology.—(a) Valvular Endocarditis.—In its early development the valves are the seat of vegetations (such as are met with in simple acute endocarditis) which later undergo necrosis. The latter process manifests a tendency to spread, destroying more or less of the endo- cardium. In the interior of the vegetations the process of suppuration not infrequently takes place, and the abscesses thus formed rupture and produce various lesions according to their size and situation. The vegetations take on a grayish- or yellowish-green appearance. Histo- logically, they are composed of granulation tissue, veiled by granular and fibrillated fibrin that contains numerous micro-organisms. At the base there is usually developed more or less reactionary inflammation. After rupture the blood-current may enter the abscess-cavity, and, if there be no complete perforation, the endocardium will be pouched out, and an aneurysmal dilatation of the valve will result. Ulcerative lesions are most frequently observed. They may be mere erosions of the endo- cardium, but, as a rule, are penetrating in character and often result in complete perforation. I have seen repeated instances in which the three classes of lesions above depicted were all present. Osier, in an analysis of 209 cases examined by him with a view to ascertaining approximately the relative frequency with which the different parts of the heart were affected, obtained this result: Aortic and mitral valves together, 41; aortic valves alone, 53; mitral valves alone, 77 ; tricuspid in 1'.*, pul- monary valves in 15, and the heart-wall in 33 instances. In 9 instances the right heart alone was involved.1 1 Text-Book of Medicine, p. 631. I TL CERA TIVE END 0 CA RDITIS. 591 (b) Malignant mural endocarditis gives the same set of changes as the valvular form ; indeed, the latter may be combined with the former throughout. It is a comparatively rare condition, as is shown by the foregoing figures of Osier. The ulcerative process may invade the chordae tendineae and the valves, and may perforate the septum or even the ventricular wall itself. The vegetations are detached in small or large masses, and are conveyed by the circulating medium to various distant organs, especially to the spleen and kidneys, less frequently the intestines, meninges of the brain, and the skin. Their site is determined largely by their size, and they may be so large as to plug vessels of the caliber of the external iliac. When found in the lungs they may originate in endo- carditis affecting the right heart. These emboli, containing, as they do, the agents of inflammation, form suppurative infarcts that may be either Avhite or red in color. The detached vegetations are sometimes so laden with irritants as to cause rapid softening of the coats of the vessel at the point where they become arrested, with consequent aneurysmal dilatation directly opposite their seat. As to number, the infarcts vary greatly in different cases; thus there may be only one or tw7o, as in a case in my own knowledge in which the spleen alone contained tAvo small infarcts, or there may be more than a thousand minute abscesses widely scattered throughout the body. Etiology.—It is to be kept in remembrance that the condition is, with few exceptions, most probably a secondary one. The disease, there- fore, arises in consequence of secondary infection, and this explains why the lesions peculiar to simple endocarditis usually precede and accompany those of the ulcerative form. The specific irritant is probably the streptococcus pyogenes (Frankel and Sanger); and if this be true, the diseases in Avhich ulcerative endocarditis occurs as a complication merely furnish the opportunity for the invasion of the streptococcus. The bacillus diphtheria?, however, as wrell as the bacillus coli, the bacillus anthracis, the pneumococcus, the gonococcus, and other organisms, have been found in some cases in the absence of the streptococcus. In purely septic diseases ulcerative endocarditis forms but a part of the serious gen- eral condition. Here the cardiac element serves to facilitate the genera- tion and rapid diffusion of the poison ; and, since the latter is prone to attack the valve-segments, the morbid lesions within the heart not rarely constitute the chief pathologic factor in septico-pyemia. Instances, how- ever, are met with in which the segments present slight changes. The malignant form occurs, in connection with acute articular rheumatism, in about 10 per cent, of the cases in Avhich acute endocarditis appears. Among many other diseases that furnish occasional instances of this serious complication are diphtheria, scarlet fever, typhoid fever, erysip- elas, small-pox, chorea, tuberculosis, and chronic Bright's. In some of these, simple acute endocarditis, it will be remembered, occurs with rela- tive frequency. In lobar pneumonia the ulcerative type is common, occurring almost as frequently as the simple variety, and was found by Osier in 11 out of 23 cases. The septic processes that arise from the puerperal state or from gonorrheal infection may also be complicated with ulcerative endocarditis. Clinical History.—That form of ulcerative endocarditis which is a more or less prominent factor in septic diseases has been considered in 592 DISEASES OF THE CIRCULATORY SYSTEM. connection with septico-pyemia. Malignant endocarditis being usually a secondary event, its clinical features must not be confounded with those of the primary affection in the course of which it occurs. It is, however, often impossible to clearly separate the former from the latter, and the original disease often appears to be but slightly modified. Local symptoms are often entirely Avanting, or, Avhen present, consist merely in slight precordial pain and oppression, and are not sufficiently well pronounced to arrest attention. Subjective symptoms are, hoAvever, connected Avith other organs than the heart, and are due to the irritating effects of emboli that occupy the various organs of the body. Gastro-intes- tinal disturbance, as shoAvn by the occurrence of vomiting and diarrhea, is common. Pain that is ascribable to local peritonitis over the spleen, and sometimes also over the liver, is observed. Hematuria and dimness of vision are also frequent concomitants, and are due to renal and retinal hemorrhages. The urine may be scanty and albuminous. The more gen- eral features that are the result of the local embolic processes and, in part, of the valvular lesions, are serious and for the most part typhoid in character. The onset is usually signalized by a severe rigor that may be repeated at intervals varying from one to several days, and the disease presents an irregularly remittent temperature-curve, often touch- ing a high mark (105° or 106° F.—40.5° or 41.1° C). I saw a case recently in which the febrile movement pursued the continued type for seven weeks. The pulse is rapid and irregular, though frequently be- coming slow within a brief period. The patient rapidly emaciates, and from the earliest development is profoundly prostrated, and nervous symp- toms, as headache, mild delirium, followed by somnolence, and sometimes even coma, appear. Profuse sweating sets in and persists, and as a result the skin may be covered by sudamina. An ecchymotic eruption due to cutaneous emboli is also common, this being often found associated with a papular or a diffused roseolar rash. Physical Signs.—These may be negative as regards the heart. In the majority of instances, however, a systolic murmur is present, which, Avhen associated with other clinical indications that point to this affection, is valuable for diagnosis, and especially so if developed while the patient is under treatment for the primary attack. The second sound is some- times accentuated even when no organic lesions have previously existed. The physical signs of pneumonia and pleuritis (particularly the latter) may not infrequently be noted. Cases occur in which gangrenous in- farcts of the right lung give rise to signs of localized consolidation ; the spleen becomes considerably swollen, as can be easily demonstrated by palpation, and is quite tender as a rule ; and the liver is likewise mode- rately enlarged and slightly sensitive. Cerebral Variety.—In a small though decided percentage of the cases all the clinical features of acute suppurative meningitis are presented, and sometimes to the almost total exclusion of symptoms pointing to the primary disease or to the more typical typhoid form of ulcerative endo- carditis. For a description of the symptoms that characterize the cere- bral form the reader is referred to the discussion of Purulent Meningitis. Recurrent Malignant Endocarditis.—By this term is meant an acute ulcerative endocarditis coming on in the course of chronic valvular dis- ease. As has been pointed out, simple acute recurrent endocarditis is ULCERATIVE ENDOCARDITIS. 593 common, though difficult of recognition. The latter condition, as well as the lesions in chronic valvular disease, predisposes to secondary infec- tion by the streptococcus and other organisms. The onset is usually abrupt and marked by a chill. The patient has fever, which may be quite high (104° F.—40° C, or over), and may present either the irreg- ularly intermittent type or the truly intermittent. The latter is often asso- ciated Avith recurring chills. In either of the above groups the course is apt to be acute. In some cases the character of the pre-existing mur- mur is changed, becoming louder and more decidedly blowing ; in many other instances, however, there is no appreciable alteration in the murmur. The condition may arise suddenly, amid the signs of failing compensa- tion, as in a fatal case reported by Dr. H. P. Loomis,1 in which the patient was semi-conscious, cyanotic, and suffering from intense dys- pnea and general dropsy. It was impossible to diagnosticate the cardiac lesions by the murmur present. Occasionally these severe intercurrent feb- rile attacks end in recovery, and such cases probably belong to the benign form, though closely simulating the malignant in their clinical character. There is a third class of cases that run a subacute or even chronic course, with more moderate elevations of temperature, or, as rarely hap- pens, none at all. Mullin of Hamilton has reported a case that lasted more than a year. Here the other clinical phenomena, especially those referable to the heart, are often scanty and indefinite. Diagnosis.—It is of paramount importance to consider the previous history and all the circumstances under which individual cases occur. These points, together with the symptoms attending the onset and the first three or four days of illness, more particularly the severe rigor, early high temperature, and profound prostration, the sweatings, the various embolic phenomena, and the presence of cardiac symptoms, are often adequate for a positive diagnosis. With a clear history and the presence of the more characteristic general symptoms (in particular, the signs of embolism), a correct diagnosis is possible, even though cardiac murmurs be absent. Instances in which no data can be found to explain the occurrence of the disease are especially puzzling, and these will re- main unrecognized if at the same time the lesions in the heart fail to be manifested by special symptoms. The existence of a chronic valvular affection would, in itself, under the latter circumstances afford strong probability of the presence of recurrent malignant endocarditis if the other significant clinical symptoms above mentioned were present. Differential Diagnosis.—There is a group of cases in which either the history fails to furnish the essential causal factors on the one hand, or there is an absence of definite heart-symptoms on the other ; this group cannot sometimes be separated from cases of typhoid fever. The sub- joined table will, I feel, be found valuable as an aid in eliminating the latter disease from the typhoid form of malignant endocarditis : Ulcerative Endocarditis. Typhoid Fever. Previous or associated disease, as acute Health good before the time of onset of rheumatism or pneumonia. the attack. History of epidemic. Very rarely a primary affection. No Always idiopathic, with a prodromal prodromes observable. stage. 1 Transactions of the New York Pathological Society, 1890. 38 594 DISEASES OF THE CIRCULATORY SYSTEM. Ulcerative Endocarditis. Typhoid Fever. Ushered in suddenly by a severe rigor, Invasion marked by slight recurring which may recur. chilly sensations. (Severe chill very rarely.) The fever rises rapidly. More gradually, in step-like fashion. Profound prostration as early as third Profound prostration not earlier than day. seventh day. The fever is markedly irregular from Less so, especially in the first week. time of onset, as a rule. Embolic symptoms (hemiplegia, etc.) may Extremely rare. appear. Cardiac symptoms, especially loud sys- Sometimes a soft systolic murmur. tolic murmur, often present. The blood usually shows signs of septic The blood shows a decrease in the num- leukocytosis. ber of leukocytes. The cerebral form can only be distinguished from purulent meningitis due to other causes if there be a history of definite causal factors or if there be present distinct cardiac symptoms.1 Prognosis.—Most cases that run an acute course terminate in death, and when supposed instances of malignant endocarditis recover they are usually to be regarded as being of benign character. Subacute or chronic varieties, however, such as are most frequently met with in connection with organic heart-disease, sometimes reach a favorable issue. Treatment.—This is largely supportive. The feeding is to be pushed vigorously, and concentrated forms of liquid food should be given at regular, brief intervals. Arterial stimulants in liberal quantities are also demanded, and in addition quinin and antiseptics may be tried. For the embolic symptoms the salts of ammonium give slight promise of ben- eficial results, and I prefer the carbonate for this purpose. Unfortunately, no known method of treatment is of any positive avail. CHRONIC ENDOCARDITIS. (ChronicInterstitial Endocarditis) Two clinical varieties are met with—one following the acute form, the other beginning as a chronic inflammation. Pathology.—The lesions may be limited to the valvular endocardium (their most common seat), or the mural endocardium may also be involved. In not a few instances the lesions are confined to the edges or bases of the segments, and when seen in the early stages there may frequently be observed merely a slight thickening of the free border of the leaflets; in most cases small prominences appear near their free margins. The endocardium looks opaque and its normal elasticity is lost quite early. When the auriculo-ventricular valves are affected the primary seat of inflammation is the auricular face, but when the semilunar valves are dis- eased the morbid changes begin on the ventricular side and implicate the Aurantian body. Extension of the morbid process to other and all parts of the valvular curtain is common, and it is in cases of this sort that the greatest degree of shrinking and crumpling occurs. The most character- istic lesions consist of inflammation and exudation, Avhich produce cohe- 1 The septic form may simulate malaria in its general course. The points of dis- similarity may be found in the discussion of Septico-pyemia. CHRONIC ENDOCARDITIS. 595 sion of the segments, roughen the surfaces, and lead to the deposit of fibrin upon them. The histologic alterations consist in a proliferation of the endothelial and a round-cell infiltration of the subendothelial connective tissue. Organization of these products of inflammation into connective tissue, with resulting induration and contraction, is the necessary subse- quent pathologic event. In old cases calcification of the diseased struc- ture is frequent. The shrinking shortens the curtains or curls their free edges, and produces insufficiency in either case, since on dropping into the plane of the valvular orifice they fail to close it perfectly. Valves thus deformed may also obstruct the blood-stream. As before mentioned, cohesion of the invaded segments takes place, particularly at their bases, and may extend upward for a considerable distance, leading to constric- tion or stenosis. Involvement of the semilunar (aortic) segments in the ways previously described opposes an obstruction to the outfloAving blood-current on the one hand, and, OAving to the inability of the segments to effect perfect closure of the aortic orifice, alloAvs on the other hand a diastolic reflux of blood into the left ventricle. The aortic ring to which the semilunar segments are normally attached becomes sclerosed, and finally the seat of atheromatous changes, either fatty or calcareous. Again, chronic inflam- mation of the intima of the aorta produces" a similarly thickened condi- tion of this layer in spots, folloAved by atheroma. These changes are most prone to take place in the course of the ascending arch of the aorta or just above the aortic segments. The fact of really vital importance in this connection is that from the aorta and subvalvular ring the diseased processes before described may extend to the coronary arteries. Hence sclerotic and atheromatous alterations are found frequently in association with organic valvular defects. The great clinical significance of the implication of these vessels will be emphasized hereafter. Much less commonly similar lesions are noted at the orifice of the pul- monary artery. A similar involvement of the auriculo-ventricular valves also causes regurgitant and obstructive deformities at the mitral orifice, and in advanced cases the chordae tendineae, and even the papillary muscles, are almost invariably invaded by direct extension from the valves. As these structures undergo marked thickening with subsequent contraction, they become shortened and rigid, causing an actual narroAving of the cardiac orifice. In mitral stenosis during the early stages or in the mildest types a more or less complete ring of vegetations encircles the mitral orifice on its auricular aspect. The margins of the orifice also become hardened and roughened, these changes frequently extending to the valvular curtains and the chordae tendineie. Under such circum- stances the thickened valve could not, during the ventricular diastole, be forced back against the ventricular wall, but would occupy a nearly cen- tral position. OAving to cohesion of the free edges of the valvular struc- tures and to contraction of the chordae tendineae draAving the leaflets toAvard the apex of the heart, the transition from this condition to the formation of a hollow cone (funnel mitral) is accomplished by natural, easy stages. Extensive union of the segments along their free margins may reduce the aperture to a mere button-hole slip (button-hole mitral) as viewed from the auricular aspect. The last two forms of lesions are far less commonly met Avith at the aortic orifice, though they occur rarely in 596 DISEASES OF THE CIRCULATORY SYSTEM. moderate degree; on the other hand, curling of the valvular edges is far more commonly seen at the aortic than at the mitral orifice, if we except the cases that occur in children. The curtains of the thick, rigid valves may also permanently occupy the plane of the orifice, presenting a small ring-like opening (annular mitral). Fatty degeneration leading to the formation of necrotic (atheromatous) ulcers is common ; and calcareous deposits are frequently seen in old cases, either in localized areas or coextensive with the diseased tissue, converting the entire valve into a calcified mass, with loss of the valvular outlines. In chronic mural endocarditis the lesions exhibited are grayish-white, slightly elevated patches that are usually found to invade the underlying muscular structure to a greater or a less extent. Under such conditions of the valves the deposit of fibrin would be greatly favored, and the presence of an ulcerative surface or of a fibrous deposit on the valves affords a ready and satisfactory explanation of the occurrence of embo- lism in these cases. Emboli may also become detached from cardiac thrombi or from thrombi formed in the peripheral veins. For anatomic reasons the favored seats of embolic processes are, as in acute endocar- ditis, the spleen, brain, and kidneys, and irritants that cause acute endo- carditis find here a tissue-soil whose capacity for resistance to invasion is greatly loAvered. Chronic mural endocarditis and chronic myocarditis are, as a rule, due to the extension of the inflammation from the valves, though the ventricular endocardium may be invaded independently of the valvular affection. In one instance of mitral stenosis I observed an enormous calcareous mass partly in the subvalvular tissue and partly in the wall of the ventricle, the segments remaining altogether intact. In advanced stages of most cases of chronic endocarditis myocardial degen- eration occurs. It takes the form of fibroid change or fatty degeneration, or both. Aortic-valve involvement, especially Avhen complicated with ath- eromatous change in the coronary arteries, is most prone to these forms of myocardial disease. Chronic endocarditis may be said to persist until death. The effect of the valvular deficiencies that have been described upon the several cardiac chambers and the muscular structure of the heart will be most advantageously studied Avhen the individual lesions of the segments are considered. Etiology.—There can be no doubt that most cases of organic heart- disease occurring in children and young adults are caused by primary acute rheumatic endocarditis ; and, although the latter affection cannot in truth be said to invariably terminate in chronic endocarditis, it probably does in most instances. This result, in my opinion, is more frequent in children suffering from acute endocarditis than in adults. On the other hand, not a feAv cases of chronic endocarditis originate in a very mild grade of acute valvular inflammation, which may be, though itself mute, reinforced by a rheumatic diathesis. Indeed, acute endocarditis may be the sole expression of rheumatic disease. Not less than one half of all cases of organic val- vular disease are caused by rheumatism, and more than one half of the total number occur between twenty and thirty years of age. Acute endo- carditis complicating other acute infectious diseases than rheumatism (e. g. measles, chorea, pneumonia) may also be followed by the chronic variety ; but it is quite questionable whether this occurs as frequently as in the case of acute endocarditis of rheumatic origin. AORTIC INCOMPETENCY. 597 The second variety, in which slow interstitial changes occur from the beginning, is dependent upon—(a) biologic irritants (e. g. syphilis, malaria, and chronic rheumatism); (b) chemical irritants (uric acid, alcohol, lead); and (c) mechanical influences. Doubtless the influence of repeated strain- ing efforts is the most potent cause of this class of cases. Heavy muscular labor increases constantly the tension in the arterial system, and this acts injuriously upon the valve-segments, setting up a gradual sclerotic change. In like manner, arterial sclerosis and Bright's disease may cause chronic interstitial endocarditis by increasing constantly the vascular tension, though the fact that these affections may in turn result from the action of some of the leading causes of organic heart-disease must also be recol- lected. Trauma has produced in valves previously healthy a sudden, incontestable proof of valvular paresis or laceration, that has persisted in a few well-attested cases. This accident is of course much more fre- quent where the valves have been already diseased, and particularly if they have been the seat of lacerative processes. The predisposing causes of organic valvular disease may be discussed briefly. Hereditary influence, as pointed out by VirchoAv, is especially potent in persons in Avhom there is hypoplasia of the heart and aorta (e. g. in chlorosis). It may be said that any malformation of a valve is certain to throw an undue strain upon certain portions, and hence is likely to be followed by interstitial change. Osier, in 17 cases of bicuspid aortic valve, has reported the segments to be uniformly sclerosed. The cases of supposed hereditary7 transmission are doubtless, however, for the most part, due to the causes before mentioned, and particularly to rheumatism. Age exerts a predisposing influence, its effects, however, varying with the valve implicated. During fetal life this is on the right side of the heart in a vast majority of cases ; during childhood, adolescence, and early adult life, when the infectious diseases and rheumatism are frequent, it is the mitral valve in most instances ; and finallyT, during middle and espe- cially during advanced life the aortic segments are especially involved. I have, however, found aortic disease to be more common in young adults than most Avriters are ready to admit, and that it is favored especially by an occupation involving muscular strain (e. g. blacksmiths, draymen, sol- diers during campaigns). Sex per se has little if any effect, though, OAving to the greater frequency of certain Avell-known causes of valvular disease (chorea and rheumatism) in girls and young Avomen, females are more frequent sufferers than males. AORTIC INCOMPETENCY. (Aortic Insufficiency ; Aortic Regurgitation.) Definition.—The failure of the aortic valves to prevent a return flow of blood into the ventricle, OAving, as a rule, to a diseased condition of the aortic leaflets (sclerosis) that is followed by crumpling and attended Avith contraction, shortening, or curling of the edges, and finally calcification. Pathology.—The aortic orifice may be enlarged (relative insuf- ficiency), and here the normal cusps fail to effect complete closure of the 598 DISEASES OF THE CIRCULATORY SYSTEM. orifice. The flaps of the diseased aortic valves sometimes adhere to the intima of the aorta, and laceration of the semilunar segments, which are the seat of diseased processes (particularly ulceration), is sometimes found post mortem, and may be the chief factor in determining the develop- ment of the condition. This accid( nt may very rarely occur as a result of a severe straining effort in the case of valves previously healthy. Occasionally, also, the chief factor in the production of this valvular lesion is a congenital malformation of the segments whereby they "are rendered very prone to chronic endocarditis in consequence of the undue strain to which they are subjected. The lesions that give rise to stenosis may coexist Avith simple aortic incompetency, and, though the latter con- dition frequently occurs alone, stenosis is quite as often combined with regurgitation. Mechanical Influence of the Lesion.—The reflux current passes from the aorta backAvard through the imperfectly closed semilunar valve into the left ventricle during the diastole of the heart or while the left ventri- cle is being filled by the normal blood-flow from the auricle. It is clear that over-distention of the left ventricle must result at once from two simultaneous influx currents of blood, with a tendency to an increasing dilatation, especially since the lesion itself is steadily progressive. To expel the increased amount of blood from the left ventricle demands in- creased cardiac power, and the over-exertion causes dilatation, followed by a compensatory hypertrophy. Dilatation and hypertrophy of the left ventricle develop pari passu until the left ventricle reaches enormous dimensions, forming the cor bovinum, which weighs 1000 grams or more (30 to 50 ounces). Under these circumstances the arterial system is overfilled at each ventricular systole. In the very early stage the reflux of blood from the aorta into the ventricle tends to lessen the volume of the circulating medium in the arterial tree, but this depleting influence is successfully counterbalanced by the augmented column of blood throAvn from the ventricle during cardiac systole. Hence the requirements for bodily nutrition are, for a longer or shorter time, satisfied. The abnor- mally large amount of blood that is thrown into the arteries with undue force subjects them to increased tension, and as a result arterio-scle- rosis, leading sometimes to atheroma, is commonly developed, and pre- sents its ulterior dangers (aneurysm, apoplexy). The coronary arteries are similarly involved, their caliber being reduced, and particularly at the point of origin. Soon or late the blood-supply to the heart-muscle may become inadequate, and nutritional disturbances now manifest themselves in fatty and fibroid degeneration of the cardiac muscles; these pathologic changes are attended with secondary dilatation, Avhich soon predominates over the hypertrophy. The imperfect blood-supply to the ventricular tissue may be accounted for, in great measure, by the narroAved lumen of the coronary vessels, and also in part by the inelasticity of the walls of the latter and by the inefficiency of the aortic recoil. Furthermore, it is to be recollected that, in obedience to the laws of nature, overuse of any single group of muscles, Avhile productive of marked hypertrophy in the first instance, is followed eventually by atrophy and loss of power. In consequence of the increased tension to which they are constantly sub- jected the mitral leaflets may become the seat of sclerotic endocarditis, and this may lead to the development of mitral insufficiency (usually of A OR TIC INCOMPETENCY. 599 mild grade); or there may be a displacement of the mitral segments in the direction of the auricle, thus creating incompetency at this orifice. There is to be observed in many instances a marked degree of fatty degeneration of the papillary muscles, which also exhibit more or less flattening. Again, secondary dilatation may produce relative insufficiency at the mitral ori- fice. When incompetency has been established here, impeded pulmo- nary and general venous circulation, together with the secondary lesions in the left auricle, pulmonary vessels, and right ventricle that are cha- racteristic of that valvular lesion, are the necessary result. The blood- current through the mitral ring may be retarded, owing to the simultane- ous influx into the left ventricle from the aorta, thus causing pulmonary congestion Avithout organic change in the segments. Special Etiology.—(1) Acute Endocarditis.—Incomplete resolution of the acute form of endocarditis leads to progressive chronic valvular dis- ease. In the young it is caused with comparative frequency by rheu- matic endocarditis. Thus, aortic regurgitation may arise, though rarely, in the course of acute endocarditis, as, for example, when the latter is attended with destructive ulceration. Such instances usually terminate in speedy death. (2) Chronic Infectious Irritants.—I have found syphilis to be a factor (though rarely the sole cause) in a considerable percentage of cases. Aortic regurgitation is a frequent complaint in sailors and soldiers, among whom it is worthy of notice that syphilis is particularly common. (3) Chemical Irritants.—(a) Uric Acid.—In chronic and irregular forms of gout the irritating qualities of uric acid give rise to interstitial endocarditis and arterial sclerosis. It is quite probable that chronic rheumatism has a similar influence, though brought about in a somewhat different manner, (b) By favoring the accumulation of uric acid in the blood, lead-poisoning may be indirectly responsible for the disease, (c) Alcohol by its irritant action may excite chronic valvulitis. (4) Augmented Aortic Tension.—The excessive functional activity of the heart occasioned by the immoderate use of cardiac stimulants (alcohol) tends to raise the blood-pressure above the normal point, and thus sclerotic endocarditis may be developed very slowly. The effect of occupation in causing this disease, by increasing the vascular tension, is more notable than in the case of alcohol, though both of these factors are found not infrequently to be present in the same case. It is undeniably true that strong-bodied men in the middle period of life and those engaged in heavy manual labor are the most frequent sufferers from organic disease of the heart, and that such occupations as demand the repeated putting forth of strong efforts are powerful factors in causing aortic incompetency. (5) From personal observation I feel convinced that chronic endo- carditis (affecting the aortic valves) may be secondary to aortic end- arteritis as the result of direct extension. It must be borne in mind, hoAv- ever, that arterio-sclerosis is also often secondary to chronic valvulitis. (6) Relative insufficiency is caused, in rare instances, by pronounced dilatation of the ascending portion of the arch near to the valve, or by an aneurysm just beyond the aortic orifice. Among the more effective predisposing factors are age and sex. The disease occurs much more often in males than in females, chiefly on 600 DISEASES OF THE CIRCULATORY SYSTEM. account of the fact that a greater percentage of the former than of the latter are engaged in occupations that are causally related to the dis- ease. As to age, a preponderating proportion of the cases arise during advanced middle life, and a comparatively smaller number at a more advanced period than in young adult life. Symptoms.—So long as the hypertrophy of the left ventricle suc- cessfully overcomes the otherwise injurious consequences of the valvular defect the harmonious balance of forces is maintained, and there is an almost entire absence of symptoms. I have observed, moreover, that compensation does not fail so early in young subjects as in those more advanced in years, this being probably due to the fact that the disease is frequently associated with, or secondary to, atheromatous changes at the latter period of life. With the development of marked hypertrophy severe muscular exertion and strong mental excitement will, by excit- ing over-action of the poAverful heart, bring on a train of symptoms, as throbbing headache, vertigo, and tinnitus aurium. The clinical mani- festations of arterial anemia, particularly of the brain, and also those of general arterio-sclerosis, frequently coexist. The patient's counte- nance exhibits pallor, and he complains of headache, flashes of light be- fore the eyes, and dizziness. Dilatation of the peripheral vessels often leads to hot flushes and drenching SAveats. Cases exhibiting the latter symptoms have been mistaken for phthisis. Dizziness is often distress- ing, and is most marked upon rising from the recumbent to the erect posture. Shortness of breath may come on early, but this rarely hap- pens except upon inordinate exertion or great mental excitement—con- ditions that cause strong cardiac action and prohibit the discharge of blood from the left auricle into the left ventricle, thus causing pulmo- nary congestion. Oppression in the precordial region and cardiac pal- pitation are commonly present, as is a dull aching pain; the most con- stant seat of the latter is the precordia, but it radiates not infrequently to the shoulders, and thence doAvn the arms, particularly the left. Gen- uine angina pectoris may be a concomitant. I have also seen a couple of instances of aortic regurgitation in Avhich severe pain was located in the left shoulder-joint, the condition simulating very closely rheumatism, though the latter affection could be readily excluded both as a causal factor and a complication. Following immediately upon failure of compensation the cardio-pul- monary7 circulation is retarded, and there is increased dyspnea, the latter sy7mptom being greatly intensified by undue exertion. There may be cough, and not rarely hemoptysis, though less frequently than in simple mitral disease. Later on, general venous congestion of a moderate grade follows pulmonary congestion, and the dyspnea noAv becomes severe. It is nocturnal, and often compels the patient to assume a semi-erect pos- ture in bed. In the later stages the symptoms are due to mitral incom- petency, folloAved by failure of compensation. Edema of the feet appears, and rarely goes on to general anasarca. In aortic incompetency a higher grade of symptomatic anemia is reached than in any other cardiac lesion —a recent blood-count shoAving 2,800,000 red corpuscles to the c.mm. Hence slight edema of the feet may be due solely or in part to anemia. The intercurrence of acute endocarditis, as evidenced by prostration and A ORTIC INCOMPETENCY. 601 irregular fever, is observed, and not infrequently as a terminal condition. The symptoms of cerebral, splenic, and renal embolism may arise. Prob- ably sudden death ensues, as the result of involvement of the coronary arteries, Avith greater frequency in this than in all other forms of val- vular disease combined; and yet this accident is by no means of fre- quent occurrence. Instances of aortic incompetency, in which nervous phenomena, as peevishness, irritability, or melancholia, manifest them- selves, are too common to be looked upon as mere coincidences. Manv patients are doubtless led to commit suicide because of their cardiac lesion Avhen other and erroneous explanations are given to account for their acts. Physical Signs.—Inspection brings to light an enlarged area of the apex-beat; this is displaced doAvmvard, being visible in the sixth and seventh interspaces and to the left, and most marked betAveen the mammary and anterior axillary lines. The entire precordial zone may be distended, particularly in young subjects, and the systolic pulsation is usually more or less heaving in character. The carotids throb for- cibly, as do the temporals, brachials, and radials, though less vio- lently. These abnormal pulsations are due chiefly to hypertrophy7 of the left ventricle, though frequent factors of lesser influence are asso- ciated—an arterio-sclerosis and a regurgitant blood-stream from the aorta into the left ventricle. The impulse becomes diffused and Avavy with the progressive enfeeblement of the left ventricle, and venous pul- sation due to tricuspid insufficiency may be associated Avith arterio-pul- sation later in the affection. Epigastric throbbing may also be noticed, and on gently rubbing a spot upon the forehead an alternate paling and blushing appear (Quincke's capillary pulse); this may also be noted in the finger-nails. It is not peculiar to aortic insufficiency, hoAvever, and may be observed in cases of decided neurasthenia and in anemia. Very rarely the pulse-Avave is propagated from a capillary to the veins of the hand and back of the foot, giving rise to a visible venous pulsation. L. Webster Fox informs me also that the retinal vessels are seen to pulsate quite commonly in this disease. On palpation a forcible heaving impulse is usually felt. When, hoAv- ever, dilatation predominates over hypertrophy, the impulse is Aveak and undulating. A diastolic thrill just to the left of the mid-sternum may be detected in many instances, and a presystolic thrill is also dis- coverable very7 rarely. The pulse is characteristic ; it is quick, jerking, and full, but, upon striking the finger, recedes abruptly, and is knoAvn as the Corrigan or water-hammer pulse. This sudden collapse of the pulse is most decided Avhen the arm is held in a vertical position. Its distinctive characters are not ahvays appreciable after compen- sation is lost. A glance at the sphygmographic tracing Avill shoAv a sudden rise and fall, Avith absence or delay of the secondary wave (vide Fig. 50). Percussion.—Cardiac dulness is coextensive Avith the impulse, ex- tending doAvmvard to the eighth rib, and to the left as far as. or even beyond, the anterior axillary line. Later, enlargement of the left auricle may cause dulness upAvard and to the left of the sternum. En- largement of the right ventricle causes an increase of dulness to the right. When the dilatation exceeds the hypertrophy the area of dul- G()2 DISEASES OF THE CIRCULATORY SYSTEM. ness Avill be much extended transversely and slightly upAvard, the apex noAv being more rounded.' On auscultation a diastolic murmur becomes audible beloAv and to the left of the aortic cartilage over the mid-sternum, and down along its left edge; this is produced beloAv the aortic valve and in- the left ven- tricle. From the xyphoid it is transmitted to the left as far as the spinal column. It may be heard in the vessels of the neck and, very Fig. 49.—Normal pulse-tracing. rarely, in the radials; occasionally its seat of greatest intensity is at the aortic cartilage, and, rarely, at the apex, as in a case under my oavu care at present. The rhythm of the murmur can be most readily de- Fig. 50.—Pulse-tracing in a case of aortic regurgitation (William Hoffman). termined by ausculting over the base, for while the pulmonic second sound is usually audible at the apex (the murmur appearing to follow it), it is not so Avhen, as sometimes happens, the murmur is quite loud. The first sound is often dull, indefinite, and widely diffused, owing to left ventricular hypertrophy. In quality this murmur is usually soft in character, blowing (long-draAvn), and frequently musical; sometimes, hoAvever, it is someAvhat rough and loud. In most instances a systolic murmur, brief and harsh in character and transmitted into the vessels of the neck, is also discovered over the aortic region (double aortic). The presence of the murmur Avith the first sound is not diagnostic of actual aortic stenosis. It is more often due to a mere roughening of the semilunar segments or of the intima of the aorta. In advanced cases a soft systolic murmur is commonly heard at the apex ; it is readily distinguished from the diastolic murmur by its rhythm, and is occasioned in most instances by a relative mitral incompetency. Still another mur- mur, of rare occurrence, is rolling in character and generally presystolic in time, and may be heard at the apex over a limited surface-area. This may be accounted for by the presence of excessive dilatation of the left 1 A dilated aorta with thickened walls—a condition sometimes associated with aortic regurgitation—may also give rise to abnormal dulness under the manubrium and to the left of the sternum. AORTIC STENOSIS. 603 ventricle, in consequence of Avhich the mitral leaflets must remain free in the blood-stream during the diastole, and here they set up vortiginous movements that cause the presystolic (Flint) murmur. Duroziez dis- covered a double murmur in the arteries (femoral), which is quite fre- quently present, and, in view of its duplex character, possesses con- siderable diagnostic import. Traube has described another arterial phenomenon of interest—a systolic sound in the leg, somewhat resembling a heart-sound, but exceedingly short and sharp. It is probably due to sudden systolic distention of vessels that Avere previously empty. The diagnosis demands the presence of a diastolic murmur, the signs of left ventricular hypertrophy, the peculiar arterial pulsations, and the characteristic water-hammer or Corrigan pulse. The differential diagnosis will be considered in connection with the description of those complaints with Avhich aortic incompetency is apt to be confounded. (See Aneurysm of the Arch, Hypertrophy, Dilatation of the Heart, etc.) AORTIC STENOSIS. Definition.—A narroAving or stricture of the aortic orifice, due to thickening or adhesion of the valve-segments, and causing an obstruc- tion to the flow of blood into the aorta. Simple aortic stenosis may be met Avith, though it is a great rarity. Its development is soon folloAved by more or less valvular incompetency, and hence these affections often coexist. It may be secondary to aortic insufficiency, but only rarely, the conditions in the latter disease being unfavorable to the development of the former. Special Etiology.—Rarely rheumatic endocarditis, and still less frequently other forms of acute endocarditis, cause union of the semi- lunar segments, Avith resulting stenosis. The most common immediate causal factor is a slow sclerosis of the aortic valve, followed by cal- careous deposits. The more or less immobile, rigid valves obviously narrow the aortic orifice and oppose a barrier to the outflowing blood- current from the left ventricle into the aorta. The aortic ring may be the seat of changes similar to those just described, resulting in a moderate grade of stenosis, though the leaflets themselves remain intact. The lesions are most frequently to be regarded as a part of the general process of arterial sclerosis, which is most marked in the region of the thoracic aorta; and sometimes, as Peter contends, they are distinctly secondary to sclerotic changes at the root of the aorta. The coro- nary arteries may be the seat of changes similar to those noted in aortic regurgitation. The condition is also rarely congenital. Males Avho have reached advanced years are especially prone to aortic stenosis, for the reason that atheromatous processes belong peculiarly to that sex and period of life. Mechanical Influence of the Lesion.—To propel the normal volume of blood through the constricted aortic orifice requires increased strength on the part of the left ventricle, and, as a consequence, the latter hyper- trophies. This hypertrophy develops very slowly, and keeps pace with the 604 DISEASES OF THE CIRCULATORY SYSTEM progress of the valvular lesions. The undue ventricular tension sometimes induces more or less sclerotic change in the mitral valves. Hypertrophy of the left ventricle eventually gives way to extreme dilatation, and also to relative mitral incompetency with its unfavorable influence, first upon the pulmonary and, secondly, upon the general venous circulation. Symptoms.—The symptoms date from the commencement of failure of compensation, often many years after the onset of the disease. Their first appearance Avill be found to follow some unusual muscular effort or the operation of some depressing influence, as the too free use of to- bacco or alcohol. They are due to disturbances of circulation arising from a gradual secondary dilatation of the left ventricle, Avhich is now- unable to propel the normal quantity of blood into the arterial tree. Hence anemia, especially of the brain and peripheral parts of the body, becomes pronounced, and is evidenced by such symptoms as syncope, dizziness, headache, and pallor. Since aortic incompetency usually manifests itself secondarily, the clinical features of both affections are sooner or later variously commingled. In cases in Avhich mitral lesions develop they are overcome by compensatory enlargement of the right ventricle: the latter chamber may then become dilated secondarily, in Avhich event tricuspid regurgitation and the symptoms of general venous engorgement appear. As in the case of aortic regurgitation, so in an aortic constriction, slight edema of the feet is common as a terminal symptom; marked dropsy, howeA'er, is uncommon. From the fibrous deposits on the segments, as Avell as from any small clots behind the valves, emboli are apt to become dislodged by the forcible blood-stream and be conveyed to the brain (cerebral embolism), to the spleen (splenic embolism), to the kidneys (renal embolism), or to other organs. Physical Signs.—Inspection.—The apex-beat is gradually displaced doAvnward and to the left, owing to left ventricular hypertrophy. It is, as a rule, slow, forceful, and heaving, but less frequently it may be lack- ing in strength. It may be enfeebled, diminished in area, or even absent, owing to associated emphysema. Palpation discloses the forcible and heaving impulse-beat, unless emphysema be present, Avhen the heart and its movement may be con- cealed and the apex-beat become impalpable. A marked systolic thrill, Fig. 51.—Sphygmogram of aortic stenosis, from a man aged sixty years. Avith the seat of greatest intensity in the aortic region, is quite gener- ally present. I have frequently felt this thrill in the apex region, though not so intensely as at the base. The pulse, in this disease, is small, regular, not compressible, and of normal or slightly lessened fre- quency. The sphygmographic tracing shows sloAvness of the ascending curve and a gradual formation of the descending line (vide Fig. 51). MITRAL INCOMPETENCY. 605 Percussion.—Though there is developed in all cases hypertrophy of the left ventricle, the area of cardiac dulness is almost entirely depend- ent upon the degree of emphysema, if any be present. In the absence of this condition the dulness is increased to the left and doAvnAvard, and especially so Avhen insufficiency of the valve supervenes. Auscultation.—A systolic murmur, harsh in quality, most audible at the aortic cartilage (the second right), and transmitted into the carotids, is present in typical aortic stenosis. When non-compensation is ad- vanced the murmur is neither so rough nor so loud, and quite late it may be missing altogether. As aortic imcompetency is commonly associated, a regurgitant or diastolic murmur is also heard, forming a double or seesaAv murmur, the stenotic bruit more or less completely masking the regurgitant. A soft, bloAving apical murmur (Avith the systole) is not infrequent in the advanced stage or after relative insuf- ficiency of the mitral valves has appeared. The second sound is faint or inaudible on account of the diminished blood-tension in the aorta and the character of the valvular lesion. The diagnosis demands the concurrence of the following signs : a systolic thrill, most marked at the base ; a tense, small, someAvhat sIoav pulse; indications of left ventricular hypertrophy (unless emphysema be present); a rough, loud, systolic murmur at the aortic cartilage and propagated into the vessels of the neck. Differential Diagnosis.—A calcareous plate lying on the intima of the aorta and a markedly^ roughened condition of the aortic segments are conditions frequently mistaken for aortic stenosis, since they give rise to a murmur possessing many of the characteristics of the one above described. These murmurs, hoAvever, are seldom musical, Avhile the murmur of aortic stenosis is often distinctly so; moreover, the second sound is decidedly accentuated, Avhile in aortic stenosis it is faint or absent. In chronic Bright's disease with arterial sclerosis and left ventricular hypertrophy a murmur of maximum intensity may be devel- oped at the base ; but here the urinary symptoms, together with inten- sification of the second sound, are sufficient to establish a positive dis- crimination. In aortic regurgitation a systolic murmur frequently co- exists, but it cannot be reckoned as indicating actual stenosis unless it has a musical quality and unless a systolic thrill can be felt on palpa- tion. In chlorosis and other forms of anemia basic murmurs are con- stant concomitants ; the anemic murmurs are soft and distant, and not harsh ; the intense thrill and hypertrophy are absent also. The venous hum may also be heard in the veins of the neck. MITRAL INCOMPETENCY. (Mitral Regurgitation; Mitral Insufficiency) Definition.—Imperfect closure of the mitral valve due to rupture or contraction of the mitral leaflets. It is also caused by dilatation of the left ventricle and by a diseased condition of the chordae tendinese. Pathology.—This is the most frequent form of organic disease of 606 DISEASES OF THE CIRCULATORY SYSTEM the heart. Thomas G. Ashton,1 from clinical observation of 1012 cases of heart-affection, comprising all the different varieties, found that 54.4 per cent, were instances of mitral regurgitation. The predominating lesions are of three kinds: (a) Acute or chronic endocarditis, leading to contraction and deformity, particularly curling, of the margins of the valve; (b) contraction (shortening) of the chordae tendinese ; and (c) relative insufficiency from excessive dilatation of the left ventricle (the segments being healthy). Adhesion of a segment Avith the Avails of the ventricle occurs rarely, but may result in incompetency. Mechanical Influence of the Lesion.—The mitral leaflets normally close, and prevent the reflux of the blood from the left ventricle into the left auricle with each cardiac systole. Hence incomplete closure of the mitral segments allows a portion of the blood to return into the left auricle during the systole. This regurgitant wave meets and offers an obstacle to the normal blood-current coming simultaneously from the pulmonary veins into the left auricle. It is clear that vortiginous move- ments must result under these circumstances and give rise to a murmur. The double blood-current, entering the left auricle during the systole of the left ventricle, causes over-filling (hence dilatation) of the left auricle, and thus induces compensatory hypertrophy of the left auricle, since its labor has been increased. During the next diastole the abnor- mally large contents of the auricle are passed under increased pressure into the left ventricle, producing over-distention (dilatation) of that chamber. This increased volume of blood in the ventricle is not all expelled into the aorta, but a portion of it returns into the left auricle. Thus the left ventricle, in consequence of its increased labor, becomes hypertrophied as Avell as dilated. Under these circumstances the volume of blood that is poured into the aorta remains about normal, and hence the arterial tension for a longer or shorter period is also normal. Soon the cardio-pulmonary circulation becomes impeded. The blood that returns into the left auricle must, by reason of pressure, offer increased obstruction to the overflow of blood from the pulmonary veins, and the pressure in the latter must, in turn, be similarly increased. The cur- rent of the blood through the pulmonary capillaries and branches of the pulmonary artery is thus retarded, owing to extension of the process of over-filling in a backward direction. The walls of the lung-vessels are the seat of a sclerotic process, and present an abnormal obstacle to the passage of the systolic Avave from the right ventricle to the distal end of the cardio-pulmonary arc; in consequence of this the right ven- tricle becomes dilated and hypertrophied. The abnormally increased tension in the pulmonary vessels is shown by the accentuated pulmonic second sound. Thus the right heart compensates the lesion in the left, though to supply an adequate amount of blood to the peripheral arteries the left ventricle must maintain its proper degree of hypertrophy. As soon as this harmonious balance is disturbed, either as the result of in- crease in the degree of incompetency or of failure of muscular poAver, the progress of the blood from the right auricle to the right ventricle is hindered. Increased pressure in the right auricle produces dilatation of its chamber, Avith subsequent general venous congestion as a natural backward effect (vide Tricuspid Regurgitation). It is now seen that 1 Medical Neics, June 30, 1894. MITRAL INCOMPETENCY. 607 when the right heart fails a lessened amount of blood reaches the left ventricle, and hence an abnormally small amount finds its Avay into the aorta; this fact explains the presence of the low arterial tension late in the disease. Hypertrophy of the left ventricle in this disease has also been attributed in part to the augmented tension in the general capillary vessels that is occasioned by the venous stasis. Special Etiology.—(a) Rheumatic endocarditis is the most fre- quent cause, though mitral regurgitation also results less frequently from acute endocarditis due to other causes, (b) It may7 be a part of a general arteriosclerotic process, this group of cases being caused, not rarely, by syphilis and alcohol, (c) A diseased condition of the columnar cameo.' or chordce tendinece, if it weakens their structures so as to alloAv the free edges of the segments to pass beyond the plane of the orifice, produces mitral insufficiency, (d) It may arise in the course of aortic valvular disease (a secondary mitral affection), and is then excited mainly by undue tension of the blood in the left ventricle. Here the lesion is of a mild grade, as a rule, (e) It is frequently occasioned by enlargement of the left auriculo-ventricular ring, resulting from excessive dilatation of the left ventricle, as in aortic incompetency, aortic stenosis, long-continued fevers, and the graver anemias (relative incompetency). (/) Ulcerative endocarditis, either by7 perforating or producing rupture of the valve-curtains or by destroying the chordae tendineae, may bring about mitral incompetency. Among predisposing factors age and sex are worthy of special mention, the incompetency occurring with greatest relative fre- quency in young adults (from twrenty to thirty years of age, according to Ashton's figures), and someAvhat more commonly in males than females. Symptoms.—During Compensation.—In healthy persons the com- pensatory forces keep pace Avith the valvular lesions for an indefinite and usually lengthy period, during Avhich time there may be an entire absence of symptoms. When present theyT are dependent upon dis- turbances of the cardio-pulmonary circulation that are occasioned by trivial causes, such as excitement, going up stairs, or other forms of active physical exertion. Under these circumstances the force of the regurgi- tant current is increased (by the hypertrophied left ventricle), thus pro- ducing more or less pulmonary congestion that may proceed to edema of the lungs or hemoptysis. The condition is usually a temporary" one, and is attended by dyspnea, palpitation of the heart, a short, hacking cough, and expectoration of a frothy serum that may be blood-stained. The relation existing betAveen the severity of the dyspnea and the degree of active physical exertion is positive and vital. Shortness of breath may be the sole feature during a long period. The rational symptoms rarely warrant a suspicion of the existence of mitral disease until compensation has failed, but the patient's pulse often indicates heart-disease. The face is pale and the features peaked, the eyes, lips, and ears are dusky, and the minute vessels of the cheeks are prominent. Clubbing of the finger-nails is observed most frequently in the yroung. After Failure of Compensation.—Failure of compensation implies failure of the right ventricle to force the normal quantity of blood through the left heart, Avith accompanying congestion of the lungs caused by engorgement of the systemic veins. The latter process begins at the right heart and proceeds toward the periphery, involving 608 DISEASES OF THE CIRCULATORY SYSTEM. the viscera, mucous membranes, and extremities until it is universal. The pulmonic symptoms above detailed are noAv more marked, particu- larly the dyspnea (Avhich may be constant), cough (Avith expectoration of alveolar epithelium containing broAvn pigment-granules), and cardiac palpitation Avith arrhythmia. Pain is rare unless stenosis coexists. General venous engorgement manifests itself by an enlargement of the liver and of the spleen, in the features of gastro-intestinal catarrh, in hemorrhoids, in marked cyanosis of the surface, and in the passage of a scanty albuminous urine containing tube-casts and blood-corpuscles. Dropsy follows, beginning in the feet and progressing upAvard, until finally the trunk and the serous sacs are involved. By stimulation the heart may be reinforced, and all of the unfavorable symptoms disappear in consequence, but this is not for long, as a rule. I have at present under observation a case in Avhich not less than half a dozen instances of broken compensation have occurred at intervals of six to eight months, all of Avhich have been successfully overcome.1 All instances prove fatal, and there comes a time when compensation cannot be re- stored and the end is reached by an uninterrupted doAvnward course. Physical Signs.—Inspection.—The precordia is prominent, particu- larly in children, and the area of the apex-beat is enlarged, later becom- ing diffuse and Avavy. It is carried to the left and doAvnward, corre- sponding with the degree of hypertrophy of the left ventricle. A pul- sating epigastrium is in frequent association, particularly after dilata- tion of the right ventricle appears. With the failure of the right heart also come wavy pulsations in the cervical veins, and occasionally a mild grade of jaundice. Palpation sometimes discovers a thrill at the seat of the apex-beat, that is synchronous Avith the first sound. The impulse during the stage of full compensation is forceful and heaving, but with the beginning of failure of compensation it grows feeble and irregular, and late in the affection is excessively Aveak and arrhythmic. The pulse bears a defi- nite relation to the apical impulse. Thus it is regular and full dur- ing the compensatory period (though at times the tension is slightly loAvered), but becomes small, easily compressible, and exceedingly irreg- ular during the period of broken compensation. The latter pulse- characteristics become especially pronounced near the close. Percussion.—The dull area is increased to the left, extending fre- quently to the anterior axillary line ; and also to the right, frequently from \ to 1 inch (1.2-2.5 cm.) beyond the right sternal margin. Dila- tation of both ventricles exerts a Avidening influence; hence cardiac dulness is increased more laterally than vertically. Auscultation reveals a systolic murmur, Avhich exhibits its greatest intensity at the apex (see Fig. 52). Unquestionably, this murmur is also conducted, though rarely, to the tricuspid and pulmonary valves. Balthazar Foster first called attention to the fact that the murmur of mitral regurgitation may be loudest at the base of the heart and at times audible only in that situation—an occurrence that has since been confirmed by a number of authorities. It is sometimes audible in the recumbent posture and inaudible in the erect. From the apex 1 Neglect of hygienic precautions, and intercurrent complaints of various sorts, often determine the occurrence of failure of compensation. MITRAL INCOMPETENCY. 609 it is transmitted to the left as far as the angle of the scapula, with progressively diminishing clearness. It has a blowing quality, and fre- quently ends in a musical tone. Over the third left costal cartilage, and frequently at the apex, there is heard the accentuated pulmonic second sound, due to the increased tension in the pulmonary vessels that is engendered by the hypertrophy of the right ventricle. Combined murmurs may be heard, and not infrequently a rough, rolling, or rum- bling presystolic murmur is detected. A frequent late occurrence is the secondary dilatation of the right ventricle, causing relative tricuspid insufficiency with its characteristic soft, loAv-pitched, systolic murmur, heard best at the ensiform cartilage. A spurious diastolic murmur may Fig. 52.—1, Seat of greatest intensity; 2, direction of chief transmission ; 3, boundary line of rela- tive dulness; 4, boundary-line of absolute dulness (modified from Sahli). be noted, though rarely, Avhen the sounds are timed with the pulse. This is due to the fact that occasional systoles are too weak to cause a radial pulse. Diagnosis.—In the presence of the following group of features the diagnosis is set at rest: A marked broadening of the area of cardiac dulness; a systolic, apical murmur that is conveyed to the left axilla and may be heard even at the back; and a decided accentuation of the pulmonary sound. Obviously, the latter sound becomes feeble after dilatation of the right ventricle has occurred. A systolic thrill is of the highest diagnostic importance, but is unfortunately absent in perhaps a majority of the cases. Free regurgitation through the mitral orifice may be safely inferred when the following signs are concurrent: 39 610 DISEASES OF THE CIRCULATORY SYSTEM. (a) An absence of the sound of mitral-valve tension, a murmur replacing the first sound; (b) accentuation of the pulmonic second sound; (c) an enlarged area of the left cavity; (d) an enlarged area of the right cavity (Sansom). Differential Diagnosis.—There are two organic lesions of the heart that are sometimes mistaken for mitral incompetency, since both are ac- companied by a systolic murmur—the one aortic stenosis, and the other tricuspid regurgitation. Hoav to distinguish mitral from tricuspid in- competency is a question that will receive due attention Avhen the latter disease is considered. Aortic stenosis generates a systolic murmur, but it is loudest over the base, and is transmitted through the great vessels of the neck; Avhile the mitral systolic is most intense over the apex and is transmitted far to the left. In mitral incompetency the pulmonary second sound is accentuated; in aortic stenosis it is not. In mitral in- competency both ventricles are enlarged, as shoAvn by percussion and other signs; in aortic stenosis the left is chiefly enlarged during almost the entire course. In mitral incompetency a thrill, most marked over the apex-beat, may be felt; in aortic stenosis a thrill, rough and having its chief seat at the base, is common. Other minor points of distinction are furnished by the peculiarities of the pulse, the age of the patient, and other etiologic factors. Functional and other harmless murmurs are often confounded with mitral insufficiency. The considerations on which the greatest depend- ence is to be placed in the differentiation are to be found in the sub- joined table: Mitral Incompetency. Functional and Harmless Murmurs. History. Previous history of rheumatism or other History of causal factors of one or other disease causally related. form of anemia, or of Graves' disease. Frequently there is definite knowledge of No such association. rheumatism and organic heart-disease, in combination in the same individual. Physical Sigiis. Inspection.—Dusky lips, ears, etc.; later Pallor of skin and mucous surfaces com- wavy pulsation in veins of neck. mon. Palpation.—Finger-tips placed over apex- Finger not lifted by the impulse, which beat forcibly lifted. Pulse-tension some- often cannot be felt. Pulse-tension pro- Avhat lowered and not prolonged. Im- longed and arterial pressure increased pulse displaced. generally. Impulse not displaced. Percussion.—Evidence of dilatation of Dilatation of right auricle, but only in both ventricles. about one-half of the cases, giving rise to dulness above or to the right of the right edge of sternum. Auscultation.—A systolic apex-murmur Soft systolic murmur at apex (may be, (often musical), with characteristic area though rarely, transmitted to axilla), of transmission. usually preceded by or associated with a basic systolic murmur and a venous hum in the veins of the neck. To differentiate the murmur of relative mitral incompetency is diffi- cult, though in many instances it can be accomplished Avith reasonable certainty. It rests upon tAvo points : (a) the character of the murmur, MITRAL STENOSIS. 611 which is, as a rule, softer and less intense than that due to valvular lesions; and (b) the antecedent history of the patient. Thus, relative insufficiency of the mitral segments probably exists in patients in the middle period of life, and particularly in those in Avhom the previous history furnishes such etiologic factors as renal disease, svphilis, or alcoholism; or in persons Avho exhibit arterio-sclerosis or organic dis- ease of the aortic valve and an apex-systolic murmur. On the other hand, if the signs of mitral regurgitation occur in a younger subject or in one who has been afflicted Avith acute or subacute rheumatism, it is hardly probable that the mitral-valve segments are the seat of chronic endocarditis of rheumatic origin. Again, if present in chronic renal disease, Avith concurrent symptoms of high arterial tension and of left ventricular hypertrophy—accentuation of the aortic second sound, a mitral systolic murmur—it is to be regarded as being due to relative in- sufficiency. I believe that a rare sequel of mitral incompetency is mitral stenosis, owing to the contraction of the auriculo-ventricular orifice, Avith, in some instances, progressive cohesion of the free edges of the leaflets from the base upAvard. MITRAL STENOSIS. Definition.—Constriction of the left auriculo-ventricular orifice, due either to a thickening or adhesion of the segments. With feAv exceptions adhesions of the free borders of the vahre or of the chordae tendineae obtain. Special Pathology and Etiology.—It is to be recollected that the constriction may be almost inappreciable, and yet that an uneven, roughened surface be presented, producing a murmur as the blood-stream enters the ventricle; on the other hand, a high degree of constriction may be encountered. Thus, in the funnel-shaped form of mitral stenosis the aperture may be so small as scarcely to admit the passage of a goose- quill. When moderate in degree the tip of the index finger is admissi- ble ; in the button-hole form the slit may be so narroAv as not to alloAV an object larger than a shirt-button to pass through it. The funnel vari- ety is common in children, and, in occasional instances, is possibly a congenital condition, Avhile the button-hole variety is comparatively rare in childhood. In adults, however, the funnel-shaped constriction is rare, while the button-hole valve is quite common; in 62 postmortem exam- inations only 3 showred funnel-form contraction (Hayden and Fagge). Mitral stenosis is, as a rule, dependent upon a mild or limited endocar- ditis that is usually of rheumatic origin. It is more common in young adults and in children after the fifth year than in older persons, and it is more frequent in females than in males, for the reason that the affec- tions that are causally related to endocarditis occur more frequently in the former sex (rheumatism, chorea, chlorosis). The endocarditis of measles and scarlatina may also lead to narrowing of the mitral orifice, and I quite agree with Osier in the belief that whooping-cough, owing to the great strain that it imposes upon the heart-valves, may be account- 612 DISEASES OF THE CIRCULATORY SYSTEM. able for certain cases. In adults arterio-sclerosis and chronic nephritis may induce fibroid changes in the mitral leaflets, with resulting stenosis. Mechanical Influence of the Lesion.—On account of the obstruction of the blood-stream at the mitral orifice during diastole, the task of the left ventricle becomes greater than normal, and in consequence of this its walls hypertrophy. They may be found to be one-fourth or even one- half inch (1.2 cm.) in thickness, the normal thickness being only three- tAventieths of an inch (3.7 mm.). Under these circumstances dilatation of the auricle comes on early, and in the later stages it may be extreme, the walls now becoming much thinner than in the normal heart. For a varving period of time the increased power of the heart due to hyper- trophy of the left auricle and that due to an increased resistance to the circulation that is the result of the mitral lesion are exactly balanced. At a comparatively early period, however, the auricle can no longer main- tain this equilibrium ; and then, owing to retardation of the current from the pulmonary veins to the auricle, the vascular tension in the lungs and right ventricle is increased. The right ventricle, in seeking to overcome the obstruction, becomes greatly hypertrophied and dilated, and late in the disease tricuspid incompetency supervenes Avith its usual sequences. The hypertrophy of the latter chamber counterbalances the lesion during the greater part of the period of compensation. For a brief time the left ventricle exhibits no abnormal proportions. Later and at autopsies its cavity is found smaller and its walls thinner than the normal, these conditions being due to its abnormally light labor. The apex of the heart is formed almost exclusively by the greatly enlarged right ven- tricle. If the left ventricle be hypertrophied, it is OAving to the existence of associated mitral incompetency. Symptoms.—The subjective symptoms are scanty and of slight value in forming the diagnosis. During the period of full compensation there may be an entire absence of symptoms except on going up stairs or on attempting some unusual muscular effort, when dyspnea appears. The vegetations previously described are sometimes quite friable, and when so, may be swept from the valves into the circulation and give rise to the phenomena of cerebral embolism (aphasia and hemiplegia). The same conditions may arise, and in the same Avay, from recurring endo- carditis, to which such patients are specially liable. The patient in well-marked cases presents an anemic appearance: a stitch-like pain in the apex-region is frequently present, and active exertion, by overtax- ing the left auricle, induces cardiac palpitation and dyspnea. After failure of compensation the symptoms referable to the pulmo- nary system are almost identical with those manifested in mitral incom- petency. Owing to the pulmonary engorgement the dyspnea is constant, and is increased by over-exertion. After severe or prolonged physical ex- ercise congestion, folloAved by edema of the lungs, may supervene, attended by a copious blood-stained, serous expectoration. True hemoptysis may arise from time to time. The increased tension in the pulmonary vessels being practically constant, sclerosis, followed by atheromatous degenera- tion of their Avails, is a frequent occurrence, and may accidentally result in pulmonary apoplexy. Intercurrent febrile attacks (due usually to re- curring endocarditis) are common, particularly in the later stages, and are attended with marked aggravation of the circulatory disturbances. MITRAL STENOSIS. 613 Among other things, mitral stenosis differs from mitral incompetency in that general anasarca is rare, though enlargement of the liver and other evidences of portal congestion (including ascites) are not wanting. Physical Signs.—Inspection.—The apex-beat is not displaced un- less there be excessive enlargement of the right ventricle or associated hypertrophy of the left. There is usually present a visible pulsation in the second left intercostal space, and sometimes in the third and fourth interspaces, occasioned by increased tension in the pulmonary artery; and there is also a diffuse impulse along the right border of the sternum. Epigastric pulsation is common. A prominence having its seat over the fifth and sixth left costal cartilages and the loAver half of the sternum is observed, particularly in children. After failure of compensation the impulse is feeble and undulates, Avith engorgement and pulsation of the jugular veins. Palpation discovers a presystolic thrill in a great proportion of cases. In certain instances active physical exertion may render this appreciable, or Avhen in the recumbent posture on the left side the ele- vation of the arms may7 accomplish the same result. It is, hoAvever, absent in rare instances before failure of compensation occurs, and more frequently by far after the latter event. This fremitus is best felt over the third and fourth (less frequently the fifth) interspaces, just within the nipple, and during expiration. It commences after the second sound (during the diastole) as a purring fremitus, increasing steadily in volume and intensity, and terminates abruptly Avith the severe shock of the new impulse. The fremitus is pathognomonic, and may be relied upon in the absence of the murmur. The heart's impulse is most forcible over the loAver portion of the sternum and along the right border, being due to the enlarged right ventricle; in a smaller proportion of cases, in the Fig. 53.—Sphygmograms in a case of mitral stenosis treated by extract of convallaria, and sub- sequently by digitalis: A, before treatment, showing the interpolated pulsations; B, after treat- ment (Sansom). fourth and fifth interspaces to the left of the sternum. The radial pulse is small, compressible, and markedly irregular as the propulsive power of the right ventricle diminishes. The sphygmographic tracing is not- ably irregular (vide Fig. 53). Percussion shows an extension of heart-dulness to the right, fre- quently 5 centimeters (2 inches) beyond the sternal margin, as a result of hypertrophy of the right ventricle, and upward as high as the sec- 614 DISEASES OF THE CIRCULATORY SYSTEM. ond rib on either side of the sternum. Increase in the cardiac dulness to the left also occurs not infrequently, and is attributable to excessive enlargement of the right ventricle, though more often of the left ven- tricle in consequence of associated mitral insufficiency. Auscultation reveals a rough, presystolic murmur, Avhich may be characterized as churning or rolling, acquiring increased intensity toward its termination. Its point of greatest pronunciation is just above and about one inch Avithin the normal apex-beat. The area of trans- mission is generally quite limited, not exceeding a couple of inches in any direction. Griffith, however, has shoAvn that the murmur is not seldom widely transmitted. This murmur sometimes exhibits atypical characters : it may be brief and loAV-toned, and may be audible on one occasion and then disappear for a considerable period. After the right ventricle becomes weak the murmur may lose its characteristic sudden termination, or may entirely absent itself either temporarily or per- manently. In most cases the clear, accentuated first sound is retained, even though the murmur disappears. Improvement in the muscular power of the heart as the result of judicious treatment may cause the murmur to reappear, and I have seen such an occurrence in a case asso- ciated with mitral incompetency at the Philadelphia Hospital. For purposes of diagnosis nothing is so vitally important as the time and rhythm of the murmur, and in his examination the observer must there- fore palpate the heart, and not the radial pulse, while practising aus- cultation. The finger as well as the ear will thus become sensible of the systolic shock which replaces the cardiac impulse, and it will be noted that the murmur terminates at the same moment. In cases in which the impulse cannot be felt the finger should be placed over one or other carotid, since here the pulse is practically synchronous with the systole of the ventricle. In the vast majority of the cases the murmur occupies only the latter half of the diastole, though occasionally it is sustained throughout the whole of the long pause. OAving to the pres- ence of right ventricular hypertrophy the pulmonic second sound is greatly accentuated, being distinctly audible at the apex, while the aortic second sound is often absent or only feebly marked. Redupli- cation of the second sound is not rare, and is quite characteristic when it occurs. Secondary Murmurs.—As previously pointed out, the murmur of mitral stenosis may succeed that of mitral incompetency, but this is comparatively rare. Neither does the mitral stenosis follow aortic valvular disease, save in the rarest instances, and in the vast majority of instances it is a primary affection. Secondary murmurs are not un- common, however. Among these the bruit of mitral incompetency is relatively frequent. After compensation is ruptured the murmur of tricuspid insufficiency usually becomes audible at the lower end of the sternum, and persists until the end. At this period the presystolic murmur undergoes certain modifications, as already indicated. Diagnosis.—The distinctive features of mitral stenosis are—(1) A presystolic thrill at the apex. (2) An increase in the precordial dul- ness upward and to the right. (3) A murmur Avhich (a) has its seat above, yet near, the normal apex-beat; (6) is strictly localized; (c) is presystolic in time, terminating abruptly with the systolic shock (sharp TRICUSPID INCOMPETENCY. 615 impulse); and (d) is " churning " in character. (4) A marked accen- tuation of the pulmonic second sound. Differential Diagnosis.—When the murmur of mitral stenosis is very brief, it is difficult to eliminate a mere roughening. In the latter con- dition, however, there is no increase in intensity of the murmurs on ex- ertion or when the arms are uplifted, and there is no right ventricular hypertrophy. From simple mitral stenosis the lesion of mitral incom- petency is easily distinguished by its systolic rhythm, greater area of transmission, and by the soft, more flowing character of its murmur. A combination of the two lesions, however, is a more frequent occur- rence than that of pure mitral stenosis; and under such circumstances it is with great difficulty that the two murmurs are separated. The presence of the systolic murmur is distinguishable by its synchronism with the impulse or carotid pulse, and by its area of transmission to the left as far as the axilla. If noAv the stethoscope be applied just above and to the right of the normal apex, a limited superficial area will be found where a presystolic murmur is distinctly heard. Points can also usually be found where one continuous bruit, covering a portion of the period of diastole and of systole, is audible. The presystolic murmur is sometimes, and especially after failure of compensation, entirely veiled by the systolic. In aortic regurgitation the presence of a presystolic thrill and mur- mur has rarely been recorded, and Fisher, Phear, and others have called attention to their presence in adhesive pericarditis as Avell as in simple dilatation. When, as is usual, a purely diastolic murmur is also present in the aortic area, together with strong correlative evidence of aortic regurgitation, the diagnosis of mitral stenosis must be made with ex- treme caution. TRICUSPID INCOMPETENCY. (Tricuspid Regurgitation) Definition.—An imperfect closure of the tricuspid valve, due either to a dilatation of the right ventricle that is secondary to mitral or lung- disease, or, less frequently, to an inflammatory shortening of the valves. Pathology and Htiology.—As a primary disease tricuspid in- competency is rare. It, however, is not uncommonly due to chronic organic changes, though originating in fetal endocarditis. After birth this variety is most common during childhood, and the frequency of occurrence is in inverse ratio to the age. At any period of life, how- ever, chronic affections of the lungs or organic disease of the left side of the heart may, by augmenting the tension in the right ventricle, pro- duce chronic interstitial changes in the tricuspid segments. These lat- ter, however, are usually of mild grade. I have observed in autopsied cases of chronic bronchitis associated with emphysema, and in pulmonary tuberculosis, that the chief reason why extensive lesions of these valves are seen so rarely is to be found in the fact that dilatation of the right ventricle is soon followed by relative insufficiency, and thus the strain 616 DISEASES OF THE CIRCULATORY SYSTEM. is in great part removed from the valves themselves. And yet, accord- mo- to the statistical studies of Byron Bramwell, the tricuspid valve is implicated in 50 per cent, of all cases of acute endocarditis, notwith- standing the rarity of sclerosis of these segments. He suggests that the acute form frequently results in cure because of the relatively diminished right intraventricular tension. In rare instances one of the leaflets has been ruptured by straining. The relative tricuspid in- sufficiency, produced in a manner analogous to mitral insufficiency, is an exceedingly common secondary condition in affections of the lungs and heart that cause hypertrophy and dilatation of the right ventricle (mitral incompetency and stenosis, emphysema, sclerosis of the lung). Secondary Alterations.—In tricuspid leakage every systole of the right ventricle is accompanied by a reflux of venous blood through the imperfectly closed tricuspid orifice into the auricle, and thence into the veins. This causes venous stasis and gives rise to visible pulsation, and in this manner the engorged pulmonary circulation is relieved to some extent. A necessary unfavorable consequence, however, on account of the reflux current from the right ventricle, is the lessened blood-supply to the pulmonary arteries, even though the latter are found to be en- gorged. The already hypertrophied and dilated right heart noAv under- goes further enlargement in the same manner as in the hypertrophy of the left ventricle following mitral incompetency, though not to the same extent. In mitral incompetency the right ventricle compensates the mitral lesion after failure of the left auricle, but there can be no such effective compensatory reinforcement after failure of the right auricle in tricuspid incompetency, since the right heart is not reanimated by a felloAv as is the left. The blood-stream flowing into the right ventricle during the period of diastole, however, is abnormally large, OAving to moderately increased tension. When the right ventricle fails to main- tain the pulmonary circulation, progressive dilatation of its chamber occurs, with a proportionate thinning of its walls until its dimensions are enormous. Symptoms.—In most instances the indications of the primary or causal affection must be noted, though these are often more or less screened by the more characteristic features of the disease under con- sideration. The symptoms of tricuspid incompetency point to passive congestion of the lungs and engorgement of the systemic veins, and they have been described in connection with mitral lesions. Cardiac dropsy is common, though present in by no means all cases. Frederick Taylorx contends that ascites is absent frequently, because the liver acts as a diverticulum to accommodate the excess of venous blood. Physical Signs.—Inspection.—Venous pulsation,-caused by the back- ward blood-Avave from the right ventricle at each systole, is a path- ognomonic sign. It is confined to the loAver portion of the jugular veins so long as the valve that lies above the jugularis remains closed, but soon this yields, and then the veins seem to pulsate through their entire course Avith each cardiac systole. This is best seen when the patient is in the semi-recumbent posture, and is more marked in the right than in the left side. The subclavian and axillary veins may also be seen to pulsate, but rarely. The veins appear to be everywhere en- 1 Lancet, Nov. 22, 1890, p. 1126. TRICUSPID INCOMPETENCY. 617 gorged, producing a cyanosis that is more noticeable if the breath be held Avhen in full respiration. Tricuspid incompetency may be shown by pressing on the vein with the finger rather firmly, commencing just above the clavicle and passing upAvard, thus emptying it of blood. If, noAv, the right ventricle be capable of producing a return Avave suffi- ciently powerful to overcome the valve in the external jugular, pulsation is seen to take place—also from beloAv—in the vessel slowly and in- creasingly until the vein, as far as the point compressed, becomes filled. The vein fills "by jets synchronous Avith the heart-beat" (Sansom). Again, an impulse may be communicated to the jugulars from the underlying carotid artery; if this be the true explanation in any given case, the light pressure upon the vein beloAv does not arrest the pulsa- tion above, as is the case in tricuspid incompetency7. Not rarely there is noticeable a feeble systolic venous pulse, due to the Aveaker contrac- tion of the right auricle as compared with that of the right ventricle (anadichrotic venous pulse). The area and seat of the apex-beat varv with the nature of the positive affection: in mitral incompetency7, for example, the beat is displaced to the left and dowmvard, Avhile in un- complicated mitral stenosis no appreciable displacement occurs. To the right of the sternum an undulatory pulsation is seen, due to contraction of the right auricle and ventricle, but this is not characteristic, since it may take place in simple mitral stenosis without tricuspid regurgitation. Epigastric pulsation is almost invariably observed. Palpation detects the heaving impulse of the right ventricle in the upper epigastric region. Rhythmic expansile pulsation of the veins of the liver is quite characteristic and is usually detectable. To obtain this sign the patient should lie on the back Avith the arms raised, and the examiner should place the palm of his left hand over the right mid- axillary region, and that of the right hand over the upper abdomi- nal region. He will thus be enabled to feel an expansile pulsation of the liver synchronously with the ventricular systole. This is to be carefully distinguished from mere systolic depression of the organ due to the impulse of an enlarged right ventricle, transmitted through the diaphragm and left lobe of the liver to the epigastrium. Popoff and others have also noted an inequality in the radial pulses in tricuspid regurgitation. This is probably due to the pressure of the enlarged auricle. Percussion.—The extent and form of precordial dulness are variable according to the nature of the causal disease, but a dulness extending far beyond the right edge of the sternum is especially indicative of this lesion. Auscultation.—A systolic murmur having its seat of greatest inten- sity at the base of the ensiform cartilage (vide Fig. 54) is almost con- stantly audible. It is clearly conveyed to the left one inch beyond the lower sternal margin, and to the right and upward for an equal dis- tance beyond the limit of cardiac dulness. It is soft in character, short, and low-toned. Additional murmurs, due to primary lesions, are often heard, and usually at other orifices. The pulmonic second sound is accentuated. Diagnosis.—I believe that the most valuable symptom for diag- nosis is the venous pulse, whether observed clearly in the neck or de- 618 DISEASES OF THE CIRCULATORY SYSTEM. termined positively by bimanual palpation of the liver, as before described. Either of these signs alone suffices. The murmur is gen- erally audible, and Avhen so is a most valuable aid to the diagnosis. The differential diagnosis betAveen mitral and tricuspid regurgitation is easy Avhen either exists alone, if it be remembered that the seat of greatest pronunciation, the area of transmission, and the character of the respective murmurs are Avidely different. But it is sometimes ex- Fig. 54.—1, Seat of greatest pronunciation; 2, chief direction of conveyance; 3, boundary-line of absolute dulness; 4, boundary-line of relative dulness (modified from Sahli). tremely difficult to discern positively a faint tricuspid murmur Avhen it develops secondarily to the more pronounced murmur of mitral incom- petency. If a careful observation of the murmur fails to establish the diagnosis of tricuspid insufficiency, as sometimes is the case, absolute reliance should, in my opinion, be placed upon the venous pulse when present, and the absence of the latter sign should exclude this disease. TRICUSPID STENOSIS. This is a rare condition, occurring as a congenital and an acquired disease with about equal frequency. As a primary, independent dis- ease tricuspid stenosis is very rare, being usually seen in association Avith organic disease of the left side of the heart. The lesions of mitral and tricuspid stenosis are observed to be combined most frequently, PULMONARY INCOMPETENCY. 619 while those of tricuspid stenosis and aortic insufficiency coexist less frequently. The morbid changes are practically identical with those of mitral stenosis, the right auricle becoming dilated, and this being fol- lowed by general venous stasis. The effect of tricuspid stenosis upon the right ventricle is the same as that of mitral stenosis upon the left ventricle. The right ventricle, however, is usually hypertrophied, OAving to the obstruction in the pulmonary circulation that results from the combined valvular deficiencies. Special Etiology.—The fact that mitral and tricuspid stenosis fre- quently have a common cause, acting concurrently, can scarcely be doubted in vieAv of their frequent association and pathologic identity. Hence the statement that rheumatic antecedents are furnished by the history in from 30 to 40 per cent, of the cases of tricuspid stenosis need excite no surprise. As in mitral stenosis, so in tricuspid, sex is a po- tent factor, the statistics of Bedford, Fenwick, and of Leudet (which embrace a total of 160 cases) showing a ratio of 5 to 1 in favor of the female sex. Symptoms.—The symptoms are those of the combined affections. Physical Signs.—Inspection sometimes reveals a feeble venous pulse in the jugulars, due to right auricular systole, and hence presystolic in time. Palpation may detect a presystolic thrill over the body of the right ventricle. Percussion may enable the observer to indicate the enlarged right auricle. Auscultation gives usually an audible pre- systolic rolling murmur, Avhich is best heard over the loAver sternum and along its right border. The above physical signs are to be relied upon in uncombined cases, which are exceedingly rare. On the contrary, it is difficult in the extreme to differentiate the signs of tricuspid stenosis from those of the lesions Avith Avhich it is almost uniformly associated— viz. mitral stenosis and aortic insufficiency. Hence a positive diagnosis of tricuspid stenosis is impossible save in the rarest cases. PULMONARY INCOMPETENCY. (Pulmonary Regurgitation.) This is an exceedingly rare complaint, that results from acute (ma- lignant) or chronic endocarditis after birth; it is also rarely due to a congenital malformation. In the latter form union of two of the seg- ments is often observed ; in the former, the usual sclerotic processes, Avith the occasional adhesion of one or more segments Avith the pulmo- nary artery wall, may be noted. The effect of the lesion is to cause hypertrophy and* dilatation of the right ventricle. The physical signs furnish no diagnostic characteristics. There is developed a diastolic murmur which is most audible in the second pulmonary interspace, and is transmitted to the lower sternal region. This is indistinguishable from the murmur of aortic regurgitation. The water-hammer pulse and marked hypertrophied dilatation of the left ventricle are present in the latter complaint, however, and are absent in pulmonary regurgita- tion. In pulmonary insufficiency, on the other hand, hypertrophy and dilatation of the right ventricle ensue. 620 DISEASES OF THE CIRCULATORY SYSTEM. PULMONARY STENOSIS. A quite frequent form of congenital malformation of the heart is the narroAving of the pulmonary orifice. In the rarest cases it is of post-natal date, and may result in induration, contraction, and fusion of the segments. In one of Osier's cases the orifice " was only two milli- meters in diameter, with vegetations of acute endocarditis on the seg- ments." Even in cases occurring in after-life it is to be borne in mind that the etiologic factors are in all probability chiefly operative during fetal existence. I saw' one case in Avhich the pulmonary artery near the valve was contracted to one-half its normal caliber. Myocarditis with resulting contraction of the conus arteriosus may cause pulmo- nary stenosis, and some of the cases that originate during adolescence and later in life are due to atheromatous change, while others possibly are the result of chronic endocarditis or direct violence. Ulcerative endocarditis is occasionally responsible for the condition. The lesion is compensated by an hypertrophy of the right ventricle, folloAving Avhich dilatation and tricuspid incompetency may appear. Symptoms.—Cyanosis and distention of the systemic veins are observed. Physical Signs.—A systolic thrill may be felt at times over the base. There is considerable enlargement of the right ventricle, as elicited by percussion and palpation, and a systolic murmur of greatest distinct- ness is audible, as a rule, in the second left intercostal space near the sternum or at the junction of the third left costal cartilage with the sternum. It is harsh, superficial, and transmitted a short distance up- ward and to the left. Occasionally this murmur is heard best at the aortic valve, but it is never conveyed to the vessels of the neck, and hence is easily distinguished from the aortic systolic murmur. Its harsh character and loudness would serve to obviate confusion so far as func- tional or anemic murmurs are concerned. The pulmonic second sound is weak, and, not rarely, there is a diastolic murmur of the same cha- racter, indicating pulmonary regurgitation. Sansom holds that disease of the pulmonary artery (contrary to other forms of organic heart-dis- ease) predisposes markedly to pulmonary tuberculosis. I have at pres- ent under my care a tuberculous patient in whom there is a double murmur audible at the pulmonary orifice. COMBINED FORMS OF CARDIAC DISEASES. . Various and frequent combinations of organic lesions occur, and it may be asserted safely that in more than one-half of all the cases com- bined murmurs are exhibited, and that a much higher percentage ap- pears before the fatal termination. As I have already stated, stenosis of an orifice when due to valvular disease is associated with incompetency of the corresponding valve. Thus aortic stenosis is constantly combined with or followed by aortic incompetency, and in like manner mitral stenosis by mitral incompetency. The association may also have refer- ence to lesions at tAvo or more different valves, and according to the CHRONIC VALVULAR DISEASE. 621 elaborate table of F. J. Smith, the relative frequency of the chief mur- murs found in combination is as folloAvs : Aortic diastolic and systolic and mitral systolic, 16.55 per cent. Aortic stenosis and mitral stenosis, 6.12 " Aortic diastolic and mitral systolic, 5.21 " Aortic diastolic and systolic and mitral presystolic and systolic, 3.77 " When two lesions coexist at the same valve, the one may compensate, in part at least, for the other, as, for example, in the case of aortic ste- nosis in association with aortic regurgitation. Here the stenotic deficiency lessens the reflux current from the aorta into the left ventricle during the diastole; hence the latter receives a correspondingly diminished amount of blood. During the contraction of the ventricle undue distention of the aorta is prevented, both on account of the narrowing at the aortic orifice and the relatively lessened contents of the hypertrophied ventri- cle. Similarly, in dominating mitral incompetency an associated mitral stenosis by lowering the strength of the regurgitant current renders the conditions more favorable. Relative insufficiency at the mitral valve, followed by aortic insufficiency, is most probably salutary in its effects, preventing, as it does, over-distention of the left ventricle, and also the over-filling of the arterial tree and the possible rupture of the blood- vessel. On the other hand, mitral incompetency is sometimes second- ary to aortic stenosis ; and when so the latter defect hastens the unfavor- able tendencies in the former. Relative tricuspid incompetency, secondary to mitral disease, usually results in the development of a serious impediment to the systemic ven- ous circulation, and often heralds a speedy fatal issue. It is probable that in advanced mitral disease the occurrence of a slight leakage at the tricuspid valve may be the means of obviating disastrous consequences to the right ventricle in case of undue strain. Physical Signs.—These are confusing, but a systematic analysis often leads to the correct inference. That one of the valvular lesions pre- dominates over all others is a fact of paramount importance for the solu- tion of these cases. The chief lesions can usually be determined by noting the seat, the area of transmission, and the character of the most pronounced murmur; and more important still is the correct timing of any murmur that may be audible. The secondary alterations in the heart frequently coincide with the predominating murmur, and it will therefore be an aid to the observer to recollect the familiar fact that mitral murmurs are often secondary to aortic, and that tricuspid mur- murs point to the coexistence of mitral disease. Unquestionably, a single observation of these cases, however carefully made, is often profit- less, whilst repeated observations may be productive of tangible results. Complications of Valvular Disease.—Most of these have already been spoken of at sufficient length, but to restate them col- lectively in this connection may prove useful to the student and phy- sician. They are—(1) acute endocarditis (including the ulcerative form); (2) acute pericarditis ; (3) pleurisy ; (4) pneumonia ; (5) nephritis, followed by uremia; (6) local or general arterial sclerosis; (7) chronic gastric or intestinal catarrh with intercurrent acute attacks; (8) embolic 622 DISEASES OF THE CIRCULATORY SYSTEM. processes; (9) angina pectoris; (10) edema of the lungs; (11) hypo- chondria and melancholia; (12) rupture of the skin of the extremities in consequence of excessive edema, Avith erysipelatous inflammation; (13) synovitis, a not uncommon complication; fever, swelling of one or more of the joints, and pain are the usual symptoms. The muscles of the extremities may also be involved simultaneously. It is highly probable that these manifestations are to be regarded as being of a rheumatic nature, though they are also met Avith in ulcerative endocar- ditis. (14) Febrile paroxysms occur at varying intervals of time, and are due to a variety of causes, as rheumatism, acute endocarditis, and pericarditis. Ulcerative endocarditis may also occur and be attended with an irregular type of fever. Course and Duration.—When valvular disease consists in rupture of a segment the course is brief and usually proves quickly fatal. Apart from these exceptional instances the duration is measured by months, or more often by years or even decades. Statements applicable to all cases cannot be made, however, owing to the wide differences in different cases. Among the circumstances affecting the duration I Avould men- tion in particular the patient's mode of life, the hygienic conditions under which he lives, his occupation, mental condition, and the severity of the morbid processes. Every experienced physician has doubtless met Avith a small class of cases that have terminated fatally in from six months to a year, having developed in that period all of the serious phenomena and complications of the more chronic forms of organic heart-disease. In the preponderating proportion of cases, however, the course is exceedingly sIoav, and often cases have existed many years before they have finally been recognized. In numerous instances the patient follows his usual avocation, which may even be laborious, for years, and Avithout discomfort. In other instances symptoms, as dysp- nea on exertion, are so slight as not to excite suspicion. Facts such as these render it obvious that the period of compensation is long, though its exact limits are indeterminable. In 12 instances of chronic endocarditis that have developed under my observation (some having lasted ten or tAvelve years) only 3 have reached the stage of broken compensation. The progress after failure of compensation is more definitely known, since frequent opportunities for observation are afforded. At this time the cases also exhibit Avide differences respecting their duration; in my owrn experience they have varied from tAvo to three months to as many years (rarely even longer), depending much on the patient's mode of living. The course may be shortened by severe external injury, intercurrent acute illness (especially febrile disease), vicious habits, straining efforts, and the like. Prognosis.—The detection of a cardiac murmur should not alone lead to a gloomy prognosis. Says Osier : " With the apex-beat in the normal situation and regular in rhythm, the auscultatory phenomena may be practically disregarded." Individual cases require separate and careful consideration. It is well not to advance positive assertions until all the circumstances that may influence the prognosis of any given instance have been Avell Aveighed. Observation of a case for some Aveeks and months enables the physician to speak Avith greater confidence and knowledge concerning the probable outcome; and hence CHRONIC VALVULAR DISEASE. 623 it is the part of prudence to delay giving a positive prognosis for a considerable length of time. Prior to the occurrence of disturbances of compensation the prognosis is measurably favorable. After this pivotal event the prognosis as to life becomes Avholly unfavorable, though the end is not necessarily near at hand. Disturbances of com- pensation that are attended with marked arrhythmia, urgent dyspnea, and general dropsy may, under proper treatment, admit of even complete relief. Later on, hoAvever, restoration of the balance of forces becomes only partial, and finally the above-mentioned symptoms become more pronounced; Cheyne-Stokes' breathing may then develop, and, after a prolonged and distressing struggle for breath, the patient succumbs. Death may also occur suddenly from cardiac paralysis. Among ominous and yet common complications and intercurrent affections may be cited again extensive edema of the lungs, pneumonia, typhoid fever, embolic pro- cesses, ulcerative endocarditis, acute endocarditis, obstinate gastritis, and nephritis. On the contrary, favorable indications are sound general bodily condition, good external conditions (absence of poverty-, hunger, etc.), strong and regular action of the heart, absence of arterio-sclerosis and of rheumatic antecedents, and correct habits of living. Age influences the prognosis to some extent. In children under ten years the lesions are usu- ally somewhat more rapidly progressive than in adults, and the compen- satory hypertrophy is developed with corresponding rapidity ; hence the period of failing compensation is reached earlier. This may be said to be a broad general rule, and I have found that it is one to Avhich there are many exceptions. Among other reasons for the more gloomy prospect when heart-disease occurs in young children are the following: the mitral valve is generally implicated, the liability to rheumatic inter- currences is great, and children, unless carefully controlled, overtax at play the reserve cardiac power Avhen indulging in running and other forms of exercise. After the tAvelfth year the prognosis becomes more favorable. Sex is also a modifying prognostic factor, Avomen bearing valvular lesions better than men, apart from the influence of childbear- ing, though even this is an influence the significance of which has been greatly magnified by many writers. To explain the more favorable out- look in Avomen we have tAvo main facts—viz. a less laborious as Avell as a more quiet life, and a diminished liability to arterio-sclerosis and in- volvement of the coronary vessels. The particular valve involved has some influence on the prognosis. Aortic regurgitation gives, on the whole, the most favorable prognosis, particularly in those cases that begin in early adult life, granting, of course, that the patient regulates Avisely his manner of living. Under such circumstances the lesion may be compensated for many years or even decades. The increased vigor of the left ventricle as compared with the right is conducive to longevity in this disease. After failure of compensation, I admit, the prospect is not as hopeful in aortic regurgi- tation as in mitral regurgitation, since restoration of compensation is not as readily accomplished in the former as in the latter variety. In the lesion under consideration a chief danger arises from associated arterio-sclerosis—a rather frequent occurrence in advanced life—and from implication of the coronary arteries. Much depends upon the condition of the latter vessels. When their lumen is narrowed starva- 624 DISEASES OF THE CIRCULATORY SYSTEM. tion of the heart-muscle quickly ensues, folioAved by myositic degenera- tion. Blocking of one of the branches of the coronary artery is the most frequent cause of sudden death in this affection. In aortic stenosis equally favorable predictions are Avarrantable Avhen the disease is un- complicated. Mitral regurgitation, Avhen a primary lesion, is propitious, except in the very young, and not infrequently the progress of the morbid process is apparently arrested. In a considerable proportion of cases the dis- ease does not materially shorten the life of the sufferer. In a larger percentage, hoAvever, there is special liability to a renewal of the causa- tive affections (e. g. rheumatism) and to pulmonary conditions of serious import, producing exacerbations and permanent aggravations of the disease. The gravity of these intercurrent complaints is also increased by the existence of the cardiac lesion. Failure of compensation at once renders the prognosis decidedly unfavorable. In mitral stenosis com- pensation of the right heart fails somewhat earlier than in mitral insufficiency, and hence the accidents and conditions referable to the lung (diffuse pulmonary apoplexy, edema) are not so long delayed as in the latter disease: this is also true of the later, more serious manifestations. I have learned by experience that mitral stenosis is better borne by Avomen than by men, and better during adolescence and early adult life than during more advanced years. The congenital forms are comparatively benign. It should not be forgotten that mitral stenosis causes sudden death more frequently than any other form of organic disease of the heart except aortic regurgitation. Tricuspid incompetency, Avhether secondary to disease of the lung or of the left side of the heart, is extremely grave. It is usually indicative of dila- tation folloAving hypertrophy of the right ventricle. The vigor of the ventricle, hoAvever, can be re-established, and sometimes repeatedly. Treatment.—This falls naturally into three subdivisions : (1) pro- phylaxis ; (2) management during the stage of compensation ; (3) treat- ment of the stage of non-compensation. (1) Prophylaxis.—It can scarcely be doubted, as shown by the statis- tics of Sibson, that complete rest and protection of the surface during an attack of acute articular rheumatism lessen the average percentage of cases in Avhich acute endocarditis develops. When the latter com- plication occurs in acute rheumatism the patient should keep to his bed for some time after all rheumatic symptoms have disappeared (tAvo to six weeks) or until the improvement in the cardiac condition has ceased absolutely. This precautionary measure will often lessen the extent of the ensuing chronic endocarditis, and also increase the proportion of perfect recoveries. Suitable dietetic and medicinal treatment must necessarily be combined. When the physician is cognizant of hered- itary predisposition to organic heart-disease, or has to deal with the arthritic diathesis (gouty or rheumatic) or the alcoholic habit, he can frequently, by timely advice and hygienic suggestions, direct his pa- tient to adopt measures that Avill obviate the occurrence of valvular disease. All persons predisposed by heredity or otherwise should be told of the probable effect of muscular strain, alcohol, and other excit- ing factors; too often, hoAvever, when he sees his patient for the first time the physician is confronted by an already incurable malady. CHRONIC VALVULAR DISEASE. 625 (2) Management during the Stage of Compensation.—Two main objects are to be accomplished : (a) The avoidance of every agency that tends to aggravate or maintain the lesion or lesions. Under this head the detection and removal of all causal factors is imperative. Thus, if the patient's avocation entails undue muscular effort, it must be aban- doned ; violent exercise, as running up flights of stairs, heavy lifting, or straining at stool, is also dangerous and must be prevented. If alcohol has been a factor, it must be discontinued ; if syphilis, it must be treated specifically. If there be present a rheumatic or gouty taint of the system, it must be overcome as far as possible by special meas- ures. The recognized causes of rheumatism, as fatigue and exposure, must be avoided, particularly if the patient be comparatively young. Mental excitement and strong mental effort injuriously affect the cardiac lesion; therefore tranquillity of mind should be insisted upon, though moderate and systematic mental exercise has no risks for the patient. In the case of children at school careful supervision of their studies as Avell as of their recreative exercises is essential. Fright and sudden emotion must be avoided if possible. The use of tea, coffee, and tobacco should be rigidly prohibited. (b) The diet of the patient demands careful regulation. Only a very moderate amount of food, composed for the most part of readily digested albuminous articles (milk, eggs, the lighter forms of meats, and stewed fruits), is to be taken, since overloading the stomach will disturb the action of the heart; particularly is this true at night. The carbohy- drates may be alloAved only in limited quantities, since they are apt to decompose and form gases that distend the stomach and intestines. For the same reason the coarser and more indigestible food-stuffs should be avoided. Small meals at short intervals is a plan of feeding that I can highly commend. The amount of liquids taken should not exceed the actual requirements of the patient, inasmuch as over-filling of the blood- vessel system increases the work of the already overburdened cardiac forces. Alcoholic beverages should not be used as a rule; but if the patient has been moderate in the use of alcohol, and particularly if he be advanced in years, light wines may be allowred in moderate quantity to aid digestion. Carefully regulated exercise is beneficial, but it must be gentle, and should be taken out of doors. As before intimated, a good general muscular development is an aid of no mean value to the conservative powers of the heart. Oertel, Avith a view to assisting the compensatory forces of the heart, has recommended graduated physical exercise; he advises that patients be instructed first to ascend Ioav ele- vations, and later mountains of a considerable height, the object being to bring about full compensation. Great caution is to be exercised by the physician, hoAvever, since this method has been found to be inapplicable to a large percentage of cases. Cardiac distress, palpitation, and dys- pnea are complained of by this large group of patients if other than the gentlest forms of exercise be undertaken. With respect to exercise, then, the sensations and experiences of each patient must be consulted before the physician can advise judiciously. Woollens should be worn next to the skin during both the Avarm and the cold seasons. The skin should be kept clean by daily sponge baths, and if these be folloAved by friction of the surface, the bodily nutrition will be improved and the 40 626 DISEASES OF THE CIRCULATORY SYSTEM. liability to intercurrent attacks of bronchitis greatly lessened. The boAvels should be moved each day, and usually the use of stewed fruits suffices to accomplish this end; if not, salines, Rochelle or Carlsbad salts, and the bitter waters (Friedrichshall, Hunyadi-Janos) must be brought into requisition. In winter a Avarm climate may prove ad- vantageous, though long journeys are often illy borne, owing to the fatigue induced thereby. If, despite the measures above indicated, the patient becomes anemic or his nutrition is notably impaired, a suit- able change of air,1 or the use of quinin, mineral acids, arsenic, small doses of mercury, and cod-liver oil, is to be recommended. Digitalis should not be employed Avhen compensation can be preserved in other ways. (3) Treatment of the Stage of Non-compensation.—The chief object to be kept in vieAv in this stage is the reinvigoration of the exhausted cardiac muscle, and thus to relieve the impeded circulation. Sudden death may, though rarely, occur from the blocking of a branch of the coronary artery or from acute dilatation. Failure of compensation, however, begins gradually as a rule, the condition often existing without marked or characteristic symptoms; but its early recognition is import- ant from the stand-point of therapy. Increased dyspnea on exertion, and nocturnal seizures of shortness of breath and irregular action of the heart (arrhythmia), are among the earliest clinical features. The latter symptom may have been present before, and particularly during active exercise in mitral disease, but now it is more marked, and may be con- stant. The patient's nutrition often suffers, and he is pale and rather feeble. Absolute quiet, liberal feeding with suitable food, and iron may in a little while restore the impaired cardiac tone. If this treat- ment fails, by the end of a fortnight a small dose of digitalis should also be exhibited (5 minims—0.333—of the tincture three times daily); the latter should be promptly Avithdrawn upon the disappearance of the symptoms. Decided indications of lost compensation are marked dys- pnea and arrhythmia; the canter rhythm ; an irregular, small, compres- sible pulse; and cyanosis, Avith or Avithout the presence of dropsy. To meet the latter serious condition Ave must have recourse to the folloAving means: (a) Absolute rest in bed. This diminishes greatly the work of the heart, and thus enables it to regain largely its former vigor. Rest joined with careful yet liberal feeding and attention to the bowels will often restore disturbed compensation in from one to two weeks. In 3 cases recently treated at the Medico-Chirurgical Hospital this method succeeded admirably. (b) Cardiac stimulants and tonics. Of these, when occasion demands, the most important is digitalis, and this may be tried in any case in which dilatation exists. By stimulating the pneumogastric, by increasing the blood-supply to the heart-muscle, by causing the systole to be more com- plete and the period of diastole to be lengthened, digitalis becomes an in- valuable aid to the nutrition of the cardiac muscles. In addition, the heart contracts more regularly and the blood-pressure in the peripheral circulation is raised. As a result of the use of this drug the tissue-calls 1 Observation and experience have confirmed my belief that sea-air during the warm season and high altitudes at all times are injurious in their effects in valvular disease of the heart. CHRONIC VALVULAR DISEASE. 627 upon the cardiac forces from the outlying portions of the body are satisfied and the reserve energies of the heart-muscles are maintained. In mitral disease the influence of digitalis is most beneficial, the pulse becoming sloAver, of better tension, and more regular as a rule, while the urine increases in amount. The dropsy, Avhen present, often disappears under its employ. In mitral incompetency its good effects are ascribable to the powerful contractions of the left ventricle, whereby the normal blood-stream from the ventricle to the aorta is greatly increased, while the regurgitant current is not proportionately increased, because of the fact that the mitral defect is minute as compared with the aortic. On the contrary, the patient's condition is occasionally aggravated by the drug, because " the leak is increased as much as the normal flow " (Hare). In mitral stenosis digitalis, by lengthening the period of diastole, allows time for the blood to pass from the auricle through the narrowed mitral orifice into the ventricle. Slight toxic effects may sometimes result from digitalis, the pulse becoming thread-like and irregular, the urine scanty, and, as pointed out by Broadbent in connection with mitral stenosis, there may be tAvo heart-beats to one pulse. In aortic regurgitation digitalis exercises as great, if not as wide, an influence as in mitral disease: the theoretic view, however, that by pro- longing the diastole digitalis causes overfilling of the left ventricle rests on too slender a foundation to be regarded as a valid objection to its use. It may, hoAvever, produce excessive hypertrophy if used continu- ously for too long a period. Hence its effects should be carefully noted, and the drug promptly withheld should over-hypertrophy be engendered. In all forms of organic heart-disease, though most frequently in aortic regurgitation, nausea and vomiting sometimes follow the administration of digitalis: when this is the case it should be stopped and other car- diac stimulants substituted, or the dose reduced to the point of toler- ance, when it may be continued if adequate to maintain a proper effect. When secondary dilatation comes on in aortic stenosis, digitalis is needed to increase left ventricular power. The dose is to be calcu- lated according to the degree of existing dilatation. When tricuspid incompetency is secondary to disease of the left heart, striking results are obtained from the use of digitalis; but when it exists alone—e. g. following emphysema or cirrhosis of the lung—digitalis often fails. The cardiac contractions, if they have previously been irregular, may become someAvhat more regular, but the precordial distress will often be increased, while the circulatory disturbance, as evidenced by the objective signs, will remain unrelieved. If dropsy be slight or absent, 10 minims (0.666) of the tincture or 2 to 3 drams (8.0-12.0) of the infusion, three or four times daily, will suffice. If symptoms of decidedly unfavorable import be present, including marked dropsy, the dose should then be larger (of the tincture, minims x to xv—0.666 to 0.999; of the infusion, Sss— 16.0—every two or three hours) for two or three days, when the dose must be diminished or given at longer intervals. Quantitative estimations of the urine should be made during the use of the drug, and if the effect be good the daily amount will often be greatly increased; if bad, there will be a diminution rather than an increase in the amount. Other fav- orable influences and disadvantages have already been adduced. There are not a few patients in whom the symptoms of commencing failure of 628 DISEASES OF THE CIRCULATORY SYSTEM. compensation recur as soon as the drug is discontinued. To such digi- talis may be administered continuously or until toxic symptoms are mani- fested. I believe that the solid preparations (poAvder and extracts) can be taken for longer periods than the liquid forms without exciting unto- ward symptoms. This suggestion should be followed particularly in cases that are seen at long and irregular intervals of time. Evidences of fatty degeneration and atheroma are not contraindications to its use, but are signals for the observance of extreme caution. It should, however, be a rule never to be broken to discontinue the digitalis when the symptoms of disturbed circulation have vanished. When it fails of its effect or is not well borne, and when, as often happens, the arrhythmia is not favor- ably influenced by it, the physician is compelled to resort to other car- diac stimulants. These are numerous, and, whilst their good effects are not comparable to those of digitalis in every respect, some of them seem to meet certain indications that are not met by this drug. Among the more important are nitroglycerin, strophanthus, strychnin, cocain, spar- tein, and caffein. Nitroglycerin in small doses is at the same time a car- diac stimulant and an arterial relaxant, and hence is more often useful in aortic than in mitral valvular disease. In larger doses, when left ven- tricular hypertrophy is excessive, as may occur when general arterio- sclerosis is associated with aortic regurgitation and also (though rarely) aortic stenosis, it is highly useful, widening the blood-paths, and causing less powerful contractions of the heart. Strophanthus should be em- ployed in instances in which digitalis must be interrupted, since the action of these two remedies upon the heart-walls is very similar. The tincture is usually employed, the dose (varying with the indications of each case) being from 4 to 10 minims (0.266-0.666) every three or four hours, and in controlling the irregularity or intermittency of cardiac action it is sometimes better in its influence than digitalis. Many cases of marked arrhythmia will not yield to either when but one is given ; and in such I have occasionally obtained good results from digitalis and stro- phanthus in combination. Caffein citrate is also a good cardiac stimu- lant, but is superior as a diuretic. It should be stated that, rarely, stro- phanthus, like digitalis, does harm rather than good, being sometimes badly borne by the stomach. Under these circumstances I have em- ployed, both in hospital and private practice, the following combination: B/. Caffein. citrat., 3j (4.0); Strychninse sulphat., gr. -|- (0.021); Spartein. sulphat., gr. ij (0.129). Ft. capsulse No. xij. Sig. One every three or four hours. The above prescription is not only a good heart-tonic and stimulant, but also an equally good diuretic. Spartein is a potent diuretic and heart-stim- ulant when employed in doses of gr. ^ to \ (0.010-0.016) every four to six hours, and is especially serviceable in organic heart-affections when dropsy as a symptom and nephritis as a complication exist. Strychnin, when given hypodermically in full dose, gr. -^ to y1^- (0.002-0.004), is the most efficient cardiac stimulant known to medical science. It should be em- ployed in this manner in cases in which there is sudden failure of heart- power with the development of serious symptoms. Given in doses of CHRONIC VALVULAR DISEASE. 629 average size, per or am, its effects in chronic valvular disease are not very striking. Atropin may be advantageously combined with it. When the indications are urgent and the above agents are not avail- able, diffusible stimulants, as ether or ammonium, may be used until more suitable remedies can take effect. Cocain simulates strychnin in its action. The dose is gr. \ (0.016) every four hours, and the drug may be given with digitalis in pill-form. Later, systemic tonics are often de- manded by the anemia and other constitutional indications, and here iron and quinin should be joined with strychnin. Unquestionably, the value of iron in full doses as an aid to the completion of the work of restoring broken compensation has been and is still scarcely appreciated by the profession at large. When iron disagrees, arsenic may be given instead. In many cases of failure of compensation the restoration of the balance of the cardio-systemic circulation can be greatly assisted by withdrawing a portion of the blood-vessel contents; and in other instances the heart cannot be stimulated to regain adequate poAver until the overfilled venous system is depleted and the intracardiac pressure thus reduced. There are twro ways in wThich to attain this end: (a) Venesection.—When the right heart is over-distended, as shown by its very feeble efforts at contraction, and the whole venous system is intensely engorged, as shown by marked cyanosis and orthopnea, bleeding directly from a vein is not only warrantable, but often imperatively de- manded in order to save life. From 16 to 30 ounces (473.0-887.0) may be removed safely, and the heart's action will almost immediately be observed to grow stronger and more regular, and the pulse fuller and of better tension. As before intimated, the form of dilatation of the right ventricle that follows emphysema is disinclined to yield to digitalis. In such instances, following the suggestion of Osier,1 I have obtained bril- liant results from free bleedings. (b) Depletion by purgation affords less pronounced relief to the heart, though it is of the greatest value in cases in which a moderate grade of cyanosis and dropsy exists. As in the case of venesection, a feeble, irregular pulse is not a contraindication to the use of purgatives, since the latter remove directly, a considerable portion of the heart's burden. The purgative to be used will vary with different cases. I select at the outset Rochelle or Epsom salts, employing them after the method of Matthew Hay—i. e. from 1 to 2 ounces (32.0-64.0) of Rochelle or 1 to 1^- ounces (32.0-48.0) of Epsom salts, in concentrated solution, to be given from a half to one hour before breakfast. Watery evacuations (three to six in number daily) usually follow the administration of the saline ; but, unfor- tunately, one meets with many patients in whom it produces symptoms of marked catarrhal irritation. Next to salines, the most satisfactory results have been obtained from the use of elaterium ; I often combine this with podophyllin and belladonna. I have never seen good results from the use of mercurials when the object has been to procure venous de- pletion, but they are of service in dropsy, and particularly in ascites. Schott of Nauheim has introduced a special plan of treatment that is applicable to most forms of valvular disease, simple dilatation, and nervous affections of the organ. Twenty-one baths are given in one month, drop- 1 For illustrative cases from Prof. Osier's wards see article by Leufler, Medical News, July, 1891. 630 DISEASES OF THE CIRCULATORY SYSTEM. ping one every fifth, fourth, third, and second days. The water contains sodium chlorid, calcium chlorid, and carbon dioxid, and the temperature ranges from 82°-95° F. (27.7°-35° C). The first bath lasts seven or eight minutes; the time is then gradually lengthened, the temperature lowered, and the carbon dioxid increased. After the bath the patient is rubbed and allowed to rest for an hour. Artificial Nauheim baths are successfully employed in certain Ameri- can hospitals at the present time. They are prepared as follows: Five pounds of sodium chlorid and eight ounces of calcium chlorid are dissolved in one half bath (30 gals.—114 liters), the temperature of the Avater being 95° F. (35° C). In a few days the water is charged with carbon dioxid by adding sodium bicarbonate (1 lb.—453.6) and HC1 (^- lb.—226.8), the latter just before the bath is taken. The effects are to lower the pulse- rate, to decrease the size of the heart, to stimulate the nerves, and, indi- rectly, the cardiac nutrition. There is also a tendency toward improve- ment of the skin and an increase of the urine. Gentle resistance exercises (consisting of all the more reasonable move- ments that a person naturally makes, and resisted by an attendant) form an important element of the treatment, since they tend to stimulate the muscles and nerves and propel the blood from the congested veins. The Nauheim treatment is not suitable in aortic regurgitation, aneurysm, or fatty degeneration of the heart. Individual symptoms frequently become so conspicuous as to demand special treatment. (1) Dyspnea and Orthopnea.—When these conditions are caused by engorgement of the pulmonary vessels, the cardiac stimulants above detailed usually afford relief. Frequently the patient cannot lie down, in Avhich case a suitable bed-rest often gives immediate comfort and support. For the severe attacks of nocturnal dyspnea (amounting some- times to orthopnea), particularly Avhen accompanied by cardiac palpita- tion, the subjoined formula has proved itself of great benefit: B/. Sodii bromidi, gr. xv (0.972); Tr. opii deod., Vdx-xv (0.666-0.999).—M. Sig. To be taken in one dose at bed-time. In the late stages of heart-disease morphin, given hypodermically, is to be preferred in combating this symptom, and is entirely free from the usual objections to the habitual use of the remedy. Its influence for good is inestimable. Dyspnea may also be produced by associated bronchitis, edema, emphysema, and hydrothorax—conditions that must be treated according to the customary rules. Frequent physical explorations of the chest should not be omitted. Hydrothorax demands aspiration, and this repeatedly in some instances.1 In valvular disease (particularly aortic), OAving probably to coronary arterio-sclerosis, paroxysms of severe dyspnea (cardiac asthma) are apt to arise. These are best overcome by nitroglycerin in combination Avith sodium bromid at bed-time, to be repeated as needful. (2) Cough.—Cough is common after failure of compensation, and is due to bronchitis resulting from stasis in the pulmonary vessels. In 1 When the chambers of the heart are greatly dilated care must be exercised in insert- ing the aspirating needle, lest the left ventricle be entered. CHRONIC VALVULAR DISEASE. 631 mitral disease it may come on before the rupture occurs. Beyond the treatment directed to the causal condition (the cardiac failure) nothing is needed to relieve the cough. It should be remembered, hoAvever, that these subjects are very liable to suffer from catarrhal bronchitis due to cold, and that unless the condition be promptly controlled, the compen- satory poAver of the heart will suffer. (3) Hemorrhage may take place, and generally from the lungs, though it may also proceed from the nose, stomach, bowels, or uterus. In a recent case of double aortic and relative mitral insufficiency attended Avith marked dropsy, rather copious hemorrhages occurred from the boAvel, but Avith apparent relief to the patient. The hemoptysis, Avhich is a rather frequent accompaniment of mitral lesion, is rarely excessive, and is probably ahvays beneficial. I would advise against active treat- ment unless the hemorrhage is actually copious in amount, and would apply this statement with equal force to hemorrhage from other mucous surfaces in connection Avith organic heart-affections. (4) Palpitation may be due to different causes, the recognition of which in each case is important if Ave Avould institute appropriate treat- ment. At times undue hypertrophy maintains a constant throbbing and distress in the precordial region, the former being distinguished by the strength of the impulse and by the full, tense pulse at the wrist. Palpitation is best met by the use of the tincture of aconite, nlj-iv (0.066-0.266) every four hours. With the aconite I frequently asso- ciate the bromids with excellent effect. Unless the patient's discomfort is significant, however, this symptom does not call for active treatment. The administration of a saline purge not infrequently serves to quiet the heart. The patient may suffer from pure nervous palpitation, in which case the diet and the condition of the stomach must be carefully looked to, Avhile for the throbbing the bromids of ammonium and sodium, together with preparations of valerian, are the most reliable. (5) Anginose Pains.—These are seen in aortic incompetency accom- panied by sclerotic vessels, and more especially in mitral stenosis. When dependent upon rigid blood-vessel Avails nitroglycerin should be tried; if the attacks be severe, amyl nitrite by inhalation deserves a trial, and, this failing, morphin and atropin may be employed hypodermically. The latter measures, as a rule, promptly relieve the patient's suffering. Local measures alone are sometimes sufficient when the pain is only moderately intense, and the ice-bag or Leiter's coils may be tried. The sedative effect of a blister (4 by 0 in.—10 by 15 cm.) has more often proved effectual in my experience, though its use should be limited to patients whose general strength is not impaired to a great extent. (6) Pain referred to the stomach, and less frequently to the abdomen also, occasionally assumes prominence and is relieved with great diffi- culty. It is dependent, in part at least, upon obstinate subacute gas- tritis, and I have quite recently seen an instance of the sort verified by autopsy. Among many drugs tested in this case, opium alone gave relief. Usually the pain results from gaseous distention of the stomach and bowels, and is not intense, a mild laxative frequently relieving the pain. Should this fail, however, trial should be made of the carmin- atives in combination with some antiseptic agent, as salol or creasote. (7) Gastric Symptoms.—Soon after compensation is broken the ap- 632 DISEASES OF THE CIRCULATORY SYSTEM. pearance of mild symptoms of catarrh of the stomach may be said to be the rule, and these yield to simple measures in addition to the cardiac stimulants and laxatives already indicated. But there are not a feAv instances in Avhich such symptoms as gastric distress and uneasiness, constant nausea with frequent vomiting, particularly after food, take on an aggravated form. This condition is scarcely amenable to treatment. Such patients cannot, as a rule, take digitalis or strophanthus by the mouth; they sometimes, hoAvever, do Avell on the capsules before adduced composed of strychnin, spartein, and caffein. When the latter cannot be borne I employ hypodermically digital in and strychnin or caffein citrate, the latter being made soluble by the addition of sodium benzoate in solution. Cases of this class reach an early fatal termination, as a rule. The symp- toms may be partly due to gastric catarrh and partly to uremic intoxication. (8) Nervous Symptoms.—Insomnia and internal restlessness are almost constantly present at some period in the course of heart-disease, and notably in the more advanced stages. The restiveness is rendered more distressing on account of hideous dreams and cardiac palpitation on aAvaking. For these phenomena stimulation often answers a better purpose than sedation. Hoffman's anodyne (3j—4.0—Avell diluted), spirits of chloroform (TTlxv—0.999), or ether (3ss—2.0), taken in whis- key (.Ij—32.0) are serviceable. The elixir of ammonium valerianate is also of value when given in full doses. When a hypnotic is required to afford sleep, I prefer sulfonal in combination Avith camphor monobromate or the folloAving poAvder: B/. Sulfonal, gr. xv (0.972); Sodii bromidi, gr. xx (1.296). M. et ft. chart No. 1. Sig. To be taken at 8 p. m. In the later stages there is no objection to the use of morphin hypo- dermically. Headache due to uremia may frequently be a troublesome symptom in connection with sleeplessness, and in such cases morphin is the remedy par excellence ; it is to be supplemented by free purgation and cardiac stimulants. Should the right heart be found flagging, venesection may be practised. (9) Dropsy.—Among the symptoms requiring special treatment in advanced valvular disease dropsy easily assumes the lead. As above pointed out, rest Avith attention to the diet and state of the boAvels will often restore defective compensation even Avhen accompanied by a mod- erate degree of dropsy. In the severe grades of failure of the balancing forces the cardiac stimulants and purgatives before mentioned often suffice to remove the dropsy for a considerable period of time. Later. hoAvever, it becomes obstinate, and refuses to yield to any of the knoAvn methods of treatment. The therapeutic indications, so far as the symp- tom under consideration is concerned, are for the use of diuretics and purgatives. Diaphoretics, particularly the hot-air and vapor baths, are not to be thought of, since they tend to depress the already weakened heart. While describing the action of digitalis as a cardiac stimulant, incidental allusion was also made to its action as a diuretic. In view of the fact that it raises the blood-pressure in the peripheral vessels and capillaries by contracting their walls, and because of its stimulating CHRONIC VALVULAR DISEASE. 633 effect on the heart, digitalis in large doses becomes a most efficient diu- retic in cardiac dropsy. When the renal secretion is not free under its use, or ay hen for some good reason it cannot be taken, I have frequently found that a combination of strychnin, spartein, and caffein (vide supra) will excite free diuresis. Nitroglycerin may also be prescribed, espe- cially in cases presenting evidences of advanced arterio-sclerosis. An unirritating yet highly effective diuretic mixture in these cases is the folloAving: B/. Potassii acetatis, 3j (4.0); Inf. digitalis, gij (64.0).—M. Sig. gss (16.0) every three hours. Purgatives are of the utmost value. Frequently, after a few copious watery evacuations as the result of the action of hydragogue cathartics, a free discharge of urine can be established, when before the latter event it has been impossible. Salines and elaterium, with podophyllin and belladonna, are agents that have been already recommended as purga- tives (to deplete the venous svstem), and these should be first employed in the order named. Compound jalap poAvder may also be combined with the elaterium. A course of calomel, followed by salines until free catharsis is set up, is valuable from time to time. Mercury is especially applicable Avhen the liver is much enlarged and ascites is a marked fea- ture, or Avhen the history of syphilitic infection is obtainable. It may be combined with cardiac stimulants and other diuretics as follows: B/. Pulv. digitalis, Pulv. scillse, da. gr. xij (0.777); Hydrarg. mass., gr. xxiv (1.555); Ext. belladonnae, gr. ss (0.0324). M. et ft. pil. No. xij. Sig. One every three or four hours. When efforts at relieving the dropsy by means of medicines fail, then the most dependent parts of the body, or those most swollen, should be scarified under strict aseptic precautions. Fine silver trocars Avith rubber tubes attached (Southey's tubes) may be inserted and the liquid alloAved to drain off in a gradual manner. Means to Prevent Recurrence of Broken Compensation.—When the compensation has been successfully established, the after-treatment must be prosecuted Avith vigor for at least a year. The cause of the rupture of compensation is most probably fibroid and fatty degeneration of the cardiac muscle, and hence the mere restoration of the compensatory power of the heart does not imply a complete cure of the impaired mus- cular structure of that organ. Much can be done, however, to overcome the tendency to degeneration by the persistent use of certain tonic rem- edies, as iron, cod-liver oil, arsenic, and mercuric chlorid, the latter tAvo in small doses. I have obtained excellent results from the use of the following prescription in these cases: R/. Liq. arsenici chlor., Tfl.xlviij (3.186); Tinct. ferri chlor., gss (16.0); Hydrarg. bichloridi, gr. ss (0.0324); Glycerini, q. s. ad fgiij (96.0).—M. Sig- 3J (4.0) after each meal, well diluted. 634 DISEASES OF THE CIRCULATORY SYSTEM. This preparation may be taken indefinitely Avith occasional brief inter- ruptions. The patient should lead a very quiet life, and follow rigidly all hygienic rules that tend to prevent the production of valvular disease, and avoid Avhatever tends to aggravate in the slightest degree the lesions that may already exist. Appropriate diet, it should be emphasized, is not inferior to appropriate medication in its salutary effect. Should the faintest evidence of failure of the right ventricle manifest itself, the pa- tient must be put to bed immediately, and the foregoing treatment is to be carried out. I am of the opinion that the plan herein advocated not only renders the course of recurring attacks of failing compensation milder, but that, in a considerable proportion of the cases, the much- dreaded recurrence is thus prevented. CARDIAC THROMBOSIS. Pathology.—True cardiac thrombi are seen most frequently on the right side of the heart, in the auricular appendices, and, less commonly, in the right ventricle near the apex. They are of firm consistence, and are tightly adherent to the endocardium, considerable force being re- quired to dislodge them. The color, Avhile generally grayish-broAvn or red, varies Avith the age of the thrombus, being more colorless as it be- comes older. Cardiac thrombi may be pedunculated or sessile, and their contour is, as a rule, more or less rounded. Recklinghausen and others have observed globular masses, the so-called " ball-thrombi," in the auri- cles, without the slightest endocardial attachment. They vary greatly in size, from a mustard-seed to a hen's egg, and sometimes exhibit cal- careous degeneration. Cardiac thrombi may occur singly or in groups of considerable numbers. From the cavity in Avhich they have their primary seat they may project into other chambers of the heart, or from the left ventricle into the aorta for a considerable distance. It is evi- dent that fragments detached by the blood-stream from these cardiac blood-concretions will tend to lodge in various viscera and in the per- ipheral tissues, and set up embolic processes. Examined microscopically, degenerate round cells and detritus are revealed, but pus-cells are not seen. Secondary degenerative changes, and later softening, may take place in the central portions of a thrombus, and these areas may contain a reddish-broAvn liquid. Etiology.—The causes of cardiac thrombosis are to be found chiefly in some previously diseased or injured condition of the endocardium, though sometimes alterations of the blood constitute a factor of consid- erable importance. The condition may occur in the course of both acute and chronic diseases, in which the intracardiac conditions favor the formation of a blood-clot. Hence it is seen in connection with organic diseases of the heart in which the valvular and often the mural endocardium are roughened, and the obstructive and regurgitant lesions at the various valves cause retardation in the blood-current. Chronic obstruction in the lungs may contribute to the result by slowing the cir- culation in the heart. Cardiac thrombosis has been observed in many CARDIAC THROMBOSIS. 635 of the acute affections, and almost invariably there is a loss of endocar- dium, due to inflammatory action (endocarditis) at some point in the cavities of the heart. This becomes the seat of the fibrinous deposit which is subsequently imperfectly organized. Among the most import- ant of these acute primary diseases are rheumatism, diphtheria, lobar pneumonia, and pyemic and puerperal conditions. It may be questioned Avhether, given a healthy endocardium, as contended by some Avriters, slowing of the circulation alone suffices to cause true cardiac thrombi. Symptoms.—These will depend very much upon the rapidity with which the thrombus is formed, as Avell as upon its seat and dimensions. Thrombi invariably lack definiteness, and, as their effects are largely mechanical, signs of obstruction to the cardiac circulation and failure (more or less gradual) of the cardiac muscle are developed. The pulse becomes Aveak, rapid, and irregular; dyspnea, vertigo, and attacks of syncope are frequent; and later cyanosis may appear. It is probable that at times the liquefied products of a clot may be absorbed, producing blood-poisoning. When the thrombus is formed rapidly, all of the symptoms enumerated are suddenly developed and quickly assume a most serious phase. Rarely a valvular orifice, an efferent vessel, or the coronary artery may become blocked and instant death follow. Since the right heart is the most frequent seat for these thrombi, pul- monary embolism, attended Avith its usual symptoms, is a common event. When portions of a clot are broken off and SAvept into the systemic cir- culation, the clinical phenomena of cerebral, splenic, or renal embolism are exhibited. The physical signs consist of a feeble impulse Avith marked arrhyth- mia ; the area of dulness is someAvhat increased to the right, and often upAvard; and the heart-sounds are greatly enfeebled and quite irregular, with marked change in any murmurs that may previously have been audible. In this condition a systolic pulmonary murmur may rarely be engendered. Differential Diagnosis.—It is important to distinguish true car- diac thrombi, such as are above described, from the less dense and usu- ally darker clots that are formed either immediately before or after death. The latter may seldom show an attempt at a very Ioav grade of organization, and may present a someAvhat decolorized appearance, but they do not adhere firmly to the endocardium. Moreover, antemortem and postmortem clots, as the latter may be appropriately termed, have a different causation from true thrombi. For instance, they are apt to form in diseases in Avhich the fibrin-factors of the blood are greatly increased, as in pneumonia. Perhaps a more potent causal element is the progressive weakening of the heart-muscle, resulting in partial ex- pulsion of the contents of the right ventricle; the blood that remains in t,he chamber is merely whipped up, and the deposition of its fibrin must thus be greatly favored. Such heart-clots may be generated if the endocardium be healthy, and cannot be separated positively from true cardiac thrombi by clinical observation. The prognosis is uniformly bad and sudden death may be expected. Treatment.*—Beyond measures calculated to meet the symptomatic indications nothing can be suggested. 636 DISEASES OF THE CIRCULATORY SYSTEM. HYPERTROPHY OF THE HEART. (Hypertrophia Cordis.) Definition.—Hypertrophy is an increase in the muscular structure of the heart, evidenced usually by an increased thickness of its Avails. It is almost invariably associated with dilatation of the chambers. Pathology.—When the tAvo processes—hypertrophy and dilatation —coexist, they cause great enlargement of the organ. To this condition the term '■'■eccentric hypertrophy" has been given. Hypertrophy Avith- out dilatation receives the name " simple hypertrophy," and hypertrophy with diminution in the size of the cavities Avas formerly described as " concentric hypertrophy," but this term should noAv be regarded as ob- solete, inasmuch as the abnormally small chamber is knoAvn to be due to postmortem contraction of a normal or hypertrophied ventricle. The increase in size may affect either the Avhole heart, one chamber on either side, one Avhole side, or but a single cavity (general and partial hypertrophy). The process may also be limited to a minute division of the heart (circumscribed hypertrophy). Owing to its important physio- logic function the left ventricle is more frequently enlarged than the right, and though the auricles are not as often the seat of hypertrophy as the ventricles, the right auricle is more frequently involved than the left. The weight of the normal heart in a man of average size is approxi- mately 9 ounces (255.0); in a woman it is 8 ounces (226.0). In bilateral hypertrophy, however, the weight of the heart may be greatly increased, though wide variations are exhibited; hearts weighing from 15 to 25 ounces (425.0—710.0) are seen in moderate grades of hypertrophy, and those of from 40 to 50 ounces (1134.0-1420.0) in extreme cases (cor bovinum). Measurements showing the thickness of the Avails also indi- cate the degree of hypertrophy1 and the exact seat of the enlargement Avhen not general. Normally, the diameter of the left ventricle is from 8 to 12 mm. (-§-—^ in.); that of the right ventricle, from 5 to 7 mm. (i-j in.); that of the left auricle, about 3 (1 in.), and of the right, 2 mm. (^ in-)- Suffice it to state in this connection that under condi- tions of cardiac hypertrophy the normal thickness of the various cavity- walls is usually doubled, not infrequently trebled, and, rarely, even quadrupled. It must be noted, moreover, that in cases in Avhich there is a concomitant dilatation the Avails may appear thinner than is normal, while the measurement Avill show them to be in reality thickened. The shape of the heart is also altered according to the seat and ex- tent of the hypertrophy. If both ventricles are enlarged, the apex is widened and appears flattened; if only the left ventricle is involved, the apex is lengthened and is more or less pear-shaped; and if the right ventricle alone is hypertrophied (as in pure mitral stenosis), it may form the largest part of the apex, but the latter Avill be less conical than in health. The papillary muscles and columnse carnese are greatly thickened, and, particularly in the eccentric form of hypertrophy, they are often decidedly flattened. In this form the septum frequently shows increased 1 Measurements should not be attempted until the rigor mortis has been overcome by soaking the organ in water. HYPERTROPHY OF THE HEART. 637 thickness—a condition that I have never observed in simple hypertrophy. The muscular trabeculge generally assume greater prominence on the right than on the left side. The muscular structure is usually of a deeper red color and also firmer than normally. The hypertrophied left ventricle can, as a rule, be lacerated readily, while the right, as first pointed out by Rokitansky, may be tough and leathery. As the heart continues to enlarge it sinks loAver in the chest-cavity; this is not, however, OAving to an increase in size alone, but more particularly to an increase in Aveight. In hypertrophy of the heart there is a multiplica- tion of muscular fibers, to which alone the enlargement of its Avails is attributable. Etiology.—Hypertrophy of the left ventricle (sometimes termed general hypertrophy) results from obstructions to the arterial circula- tion of Avhatever sort. These may be classified, according to their seat, into—(1) Lesions of the Heart.—(a) Aortic incompetency and aortic stenosis; (b) Mitral insufficiency ; (c) The fibroid form of myocarditis; (d) Pericardial adhesions, particularly in the young. Late in life the heart may become atrophied. In such cases the rhythmic play of the ventricle is impeded, the adherent pericardium exerts a counter-traction force during the systole, and thus the Avork is increased beyond the capacity of the normal heart: in order to maintain a proper circulation, therefore, the muscle hypertrophies. There is no obstruction either at the orifices or in the arterial tree. In fibrous myocarditis a portion of the muscular tissue is more or less functionless, though compensated for by other healthier portions, while the rhythm of the heart is also greatly disturbed. In valvular disease the augmented tension in the ventricle induces the hypertrophy. (2) Abnormal Conditions of the Blood-vessels.—(a) Narrowing of the aorta—e. g. congenital stenosis, external pressure, and the development of an aneurysm; (b) General arterio-sclerosis, by raising the pressure; (c) Increased arterial pressure, due to the contraction of the peripheral vessels in consequence of the local action of certain chemical and bio- logic irritants (lead, Bright's disease, gout, syphilis). In all of these cases, Avhether the blood-pressure is raised in larger or smaller vessels, increased cardiac action is essential to meet the demands of the system- circulation. Attention should be called to the causes of the so-called "primary idiopathic hypertrophy," in Avhich variety the above-mentioned etiologic factors are absent. The main causal conditions are—(1) Prolonged physical exertion, such as is necessary in certain occupations (black- smiths, locksmiths, draymen, and athletes). (2) Constant over-disten- tion of blood-vessels, as in the case of excessive beer-drinkers (beer- heart), Here the direct action of the alcohol upon the heart-muscle must also be taken into account. (3) Functional disturbances (neuroses), constant over-action of the heart, and even paroxysmal tachycardia— conditions excited by excessive mental excitement or emotion—tea, cof- fee, and alcohol may give rise to primary and general hypertrophy. In the latter category of cases it is the excessively rapid action of the heart that produces the hypertrophy. Hypertrophy of the right ventricle develops secondarily to any condi- tion that offers obstruction to the pulmonary circulation or to the blood- 638 DISEASES OF THE CIRCULATORY SYSTEM. current through the right ventricle. Among them may be mentioned— (1) mitral incompetency and stenosis ; (2) emphysema, or cirrhosis of the lung (producing compression or obliteration of the vessels); (3) right- sided valvular lesions, particularly obstruction at the pulmonary orifice; (4) it is doubtful whether, on account of the normal situation of the right ventricle, pericardial adhesions induce hypertrophy of this chamber, as is sometimes claimed. Hypertrophy of the Auricles.—Hypertrophy with dominant dilatation of the left auricle occurs in mitral disease, and especially in mitral ste- nosis. The right auricle hypertrophies, though not invariably, Avhen the blood-pressure in the pulmonary vessels is pronounced from any cause. Stenosis of the tricuspid orifice is occasionally the sole cause of thicken- ing of the right auricular wall, which also becomes hypertrophied in tricuspid incompetency. Symptoms.—There may be an entire absence of subjective symp- toms, since hypertrophy of the heart may be said, with rare exceptions, to be protective in character. When present, their intensity varies with the degree of the hypertrophy, Avhich is then pronounced, as a rule, and often already attended by incipient dilatation. They may be local en- tirely, though frequently general as Avell. Of the former, precordial fulness and uneasiness are the most conspicuous. They are usually most annoying when the patient is in the recumbent posture, particularly on the left side, and Avhen the hypertrophy is dependent upon nervous causes. Pain and palpitation are seldom complained of except by neur- asthenics and patients suffering from enlargement due to tobacco and excessive muscular exertion. Decided aggravations of the local mani- festations may follow the operation of influences that create a demand for increased cardiac action, such as undue mental emotion or excite- ment, physical exhaustion, active bodily exercise, and gormandizing. The general symptoms, when present, may fluctuate or even intermit. Those most frequently observed are fulness in the head, often amounting to actual headache, tinnitus aurium, carotid pulsations, flushing of the face, flashing of light before the eyes, and often prominent eyeballs. These symptoms are attributable to the increased vigor of the cerebral circulation. Remote Effects.—General or total hypertrophy promotes abnormal fulness of, and increased tension throughout, the arterial tree. Endar- teritis and arterio-sclerosis are, as a consequence, frequent consentane- ous developments in advanced cases, especially when the cause of the enlargement has been increased tension in the peripheral vessels, as in Bright's disease. AVith a circulation too forcibly carried on, as in hy- pertrophy, the sclerotic vessels are overstrained, especially the large ones near the heart, and are apt to rupture. The break often occurs in the brain (apoplexy) or in the lung (pulmonary apoplexy), and hemorrhage from the lungs (hemoptysis), due to left ventricular hypertrophy, is of greater frequency, I believe, than most Avriters are ready to admit. Physical Signs in Left-sided Hypertrophy.—Inspection.—In females and in young children Avith yielding ribs there is seen precordial bulg- ing. The intercostal spaces are much broadened and the visible apex- beat covers a greatly increased area, the extension being doAvnAvard and to the left. The whole body of the patient, and even the bed on Avhich he may be lying, may share visibly in the cardiac impulse. HYPERTROPHY OF THE HEART. 639 Palpation.—In pronounced grades the impulse may be felt as low doAvn as the seventh interspace and as far to the left as the axilla. In simple hypertrophy it is carried doAvnward to the sixth intercostal space and outAvard to a point near the anterior axillary line. The impulse is slow, forcible, and heaving, lifting the fingers of the examiner at each systole. In eccentric hypertrophy (hypertrophy with dilatation), though heaving and forcible, it is somewhat more abrupt, and, partakes of the nature of the impulse in cardiac dilatation. Over the aortic orifice or second interspace, to the right of the sternum, a short diastolic impulse may also be felt occasionally (double impulse). The pulse in pure hypertrophy is full, strong, regular, and of normal rate; it is also pro- longed, OAving to increased tension. In eccentric hypertrophy it is soft, full, and somewhat accelerated. Percussion.—The area of cardiac dulness is enlarged both in its vertical and transverse diameters. Traced upward, dulness may ter- minate in the second interspace, Avhilst to the left it may extend 1 or 2 inches (2.5-5 cm.) beyond the mid-clavicular line. When hypertrophy is of moderate extent, the left limit of dulness corresponds Avith the results of palpation and inspection; but Avhen it is of immoderate ex- tent, the extension of dulness does not keep pace with the systolic im- pulse, Avhich is diffused to points beyond the limits of contact of the heart Avith the thoracic Avail. If concomitant hypertrophy of the right ventricle be present, dulness will also extend to the right for 1 inch (2.5 cm.) or more beyond the right edge of the sternum. Auscultation.—The sounds vary Avith the grade of the morbid pro- cess and the variety7. In simple hypertrophy of marked type a pro- longation of the first sound is ahvays appreciable, and usually it is duller than the normal. The second sound is intensified, clear, and often ringing. The degree of accentuation depends partly upon the vigor of the left ventricle, though chiefly upon the condition of the blood-vessels. Reduplication of the second sound, due to high tension, is common (e. g. in Bright's disease). In dilated hypertrophy the first sound is clearer and more abrupt, Avhile the second sound is less marked or even faint. Modification of the sounds just described occurs Avhen hypertrophy is dependent upon chronic valvular disease. Hypertrophy of the Right Ventricle.—One or more of the causal fac- tors that produce augmented tension in the pulmonary vessels are pres- ent, and, if properly appreciated, will throw light upon the condition. There may be an absence of all symptoms if the hypertrophy exactly balances the result of the obstructive forces, and this state may be main- tained for a long period of time. Undue exertion, hoAvever, soon leads to temporary dyspnea in many cases. When secondary to emphysema or cirrhosis of the lung the symptoms occasioned by the latter diseases, such as cough and dyspnea, may completely veil any symptoms that may be due to the hypertrophy. Discomfort in the cardiac region should, however, arouse suspicions of the existence of the latter con- dition. When dilatation of the ventricle supervenes, as is usual, and the clinical evidences of tricuspid incompetency develop, then pulmo- nary symptoms, due to venous congestion, are prominent; these are bronchial catarrh, shortness of breath, and the like. Later, general cyanosis and edema appear. As pointed out in the discussion of Mitral 640 DISEASES OF THE CIRCULATORY SYSTEM. Stenosis Avith permanently heightened tension and overgrowth of the right ventricle, the lung-vessels become atheromatous and the lung- tissue the seat of brown induration. OAving to the fact that the scle- rotic vessels are easily ruptured, hemoptysis—a not uncommon event after sudden great exertion—is to be expected; intense pulmonary congestion and apoplexy may also be met with in hypertrophy with dominant dilatation. Physical Signs.—These have been in the main detailed in speaking of affections of the mitral valve. Inspection discloses bulging of the sixth and seventh left costal cartilages and of the lower sternum. In the angle betAveen the ensiform cartilage and the seventh rib an epigas- tric impulse may be visible, but more commonly the impulse is in the sixth interspace, close to the left edge of the sternum. It is also very generally seen to the right of the sternum, in the third and fourth interspaces, and particularly is this the case in eccentric hypertrophy, forming a highly characteristic sign. The apex-beat is therefore diffuse, the radial pulse is small, and in dilated hypertrophy it is increased in frequency, and is small and irregular. Percussion shoAvs the extension of cardiac dulness to a point an inch (2.5 cm.) or more beyond the right sternal border. When there is great increase transversely, dilatation is most probably associated and may predominate over hypertrophy. The auscultatory signs are not distinct- ive unless dilatation also exists, when the first sounds are clear and sharp. In simple hypertrophy the first sound is slightly prolonged and lower than in health. Owing to the high vascular tension throughout the lungs the second sound at the pulmonary valve is accentuated, and reduplication of the second sound may occur for the same reason. It must be kept in remembrance that Avhen advanced emphysema is present all the physical signs will be greatly modified, and may even be entirely negative, though the heart be of large size. Under these cir- cumstances venous pulsation in the neck Avould be diagnostic of dilated hypertrophy of the right ventricle. Hypertrophy of the Left Auricle.—This may be assumed to occur in mitral stenosis and incompetency in order to compensate for these lesions : it cannot, however, be recognized positively by physical signs. When the chamber is at the same time extensively dilated, the dulness may be extended upAvard to the left of the sternum, passing over the third and even second interspaces. At this point—the second inter- space—a presystolic wave may now be noticeable. Hypertrophy of the right auricle, associated with dilatation, is per- haps more common than its counterpart on the left side. It is secondary to tricuspid incompetency (rarely stenosis) and enlargement of the right ventricle, and hence has the same etiology as the latter conditions. The physical signs are—systolic jugular-pulsation, sometimes a pre- systolic wavy pulsation over the third and fourth interspaces to the right of the sternum, extension of cardiac dulness to the same interspaces, and other signs of tricuspid regurgitation. Diagnosis.—The recognition of cardiac hypertrophy is possible only by attention to the physical signs. Next to these, in point of diagnostic value, come the causes, which should therefore be diligently searched for; the rational symptoms are least in value, though usually HYPERTROPHY OF THE HEART. 641 corroborative. It is difficult to establish a diagnosis, even approx- imately, Avhen extensive emphysema coexists. As before pointed out, venous pulsation in the neck Avould point indisputably to right ventric- ular hypertrophy. Differential Diagnosis.—Conditions that cause an increase in the pre- cordial area of dulness, except hypertrophy, must be eliminated. (1) Pericardial Effusion.—A careful analysis of the physical signs and the history will suffice. (2) Aneurysm.—In this affection the enlargement is altogether upAvard and to the left or right. This fact, joined with the other evidences of aneurysm, should obviate error. (3) Mediastinal growths also enlarge the dull space mainly upAvard and to the right or left, though the point of cardiac contact may be increased and the heart carried fonvard. (4) Displacement of the heart does not give a heaving impulse nor an increased area of dulness; moreover, it usually furnishes its special cause (pleural effusion). (5) Abnormally narroAv-chested persons present a considerably increased superficial zone of dulness, partly OAving to the position assumed by the lungs and partly (perhaps chiefly) to their imperfect development. Since there is usually an entire absence of all other physical signs of hypertrophy, ordinary caution will exclude the latter complaint. (6) Affections of the Lungs and Pleurce.—Left-sided pleurisy Avith retraction may, by exposing a large part of the anterior surface of the heart, give rise to signs of moderate hypertrophy. The presence of. the former condition, the lack of expansion on deep inspiration, the displacement of the heart to the left and upward, and an absence of the causes of the latter should lead to a correct conclusion. (7) Phthisis and cirrhosis of the lung, Avith or Avithout pleurisy, may in like manner produce apparent enlargement of the heart. It must also be remembered that cirrhosis of the lung is one of the causes of right-sided hypertrophy, and that the latter condi- tion may therefore be present. Prognosis and Course.—The course that will be pursued depends largely upon the stage at which the case has arrived and the character of its special cause. I have repeatedly found postmortem evidence of a moderate grade of hypertrophy in persons who died of other affections, and Avith especial relative frequency in those Avho had constantly fol- loAved manual pursuits. Simple cardiac hypertrophy, being compensa- tory as a rule, exerts in nearly all instances a salutary influence, and if the processes that constitute the causal factors are not steadily pro- gressive, life may not only not be curtailed, but be greatly lengthened by its existence. Even in organic valvular disease of the heart hyper- trophy prolongs life by overcoming the ill effects of the valve-lesion and by maintaining the normal circulatory equilibrium. But since in this class of cases the lesion is progressive despite treatment, a limit is reached sooner or later beyond which the increased vigor on the part of the heart cannot be maintained. The nutritive functions become inade- quate in obedience to a natural law, and muscular degenerations then occur, followed by disturbances of the circulation due to cardiac Aveak- ness and secondary dilatation. It must, hoAvever, be recollected that the heart may at no time, in the course of certain cases, fully compen- sate for the causal condition—e. g. as Avhen a valve ruptures with start- ling suddenness. Failure of the cardiac nutrition at once renders the 41 642 DISEASES OF THE CIRCULATORY SYSTEM. prognosis unfavorable. Serious symptoms, Avidely distributed, that have been previously mentioned as characterizing broken compensation, are certain to arise and gradually prove fatal, though, as a rule, temporary restoration of the cardio-circulatory system is obtainable. Occasionallv, as the result of undue muscular exercise, acute dilatation, folloAved by a speedy termination of life, is observed. I believe that hypertrophy of the left ventricle warrants a more favorable prediction than can be made in hypertrophy of the right, and this for two reasons: first, the increased capacity for Avork of the left ventricle; second, the milder character of the many factors that are productive of left ventricular hypertrophy, as compared Avith those of the right. In special instances, hoAvever, the reverse may obtain, as Avhen left-sided hypertrophy is asso- ciated witji or caused by general arterial degeneration. It may be of advantage to the student and junior physician to recapitulate here a feAv of the chief points that are prognostically favorable as Avell as those that are unfavorable : Favorable Conditions.—(1) When the hypertrophic development fully compensates the causal lesion ; (2) Avhen the causes are removable or more or less amenable to treatment; (3) when the ex- ternal conditions under Avhich the patient lives, his habits, and general nutrition are good. Unfavorable.—(1) When signs of imperfect nutrition of the heart arise; (2) Avhen evidences of advancing cardiac dilatation (dyspnea, rapid, irregular pulse, edema) shoAV themselves; (3) when poverty, poor food, intemperate habits, and an unhygienic environment are all combined; (4) Avhen apparent cardiac vigor suddenly gives place to dilatation and great cardiac Aveakness. The treatment has for its prime objects the establishment of full, and the prevention of failure of, compensation (vide Chronic Valvular Disease). Over-hypertrophy, as indicated by certain cerebral and thoracic symptoms, may result from the exercise of improper notions respecting the treatment of the causative lesions and of organic disease of the heart in particular. It requires careful dietetic and hygienic manage- ment rather than therapeutic activity. Briefly, the diet should be nutritious, but the more concentrated forms of food should be used very sparingly, and the daily quantity should be slightly less than that re- quired in health. It must be non-stimulating, and tea, coffee, alcohol in all forms, and smoking must be prohibited. The physical exercise should be moderate in amount and of the gentlest sort, and if the patient's occupation tends to stimulate the heart, it must be immediately abandoned. A mild saline purge (sij to 3ss—8.0 to 16.0—of Rochelle salts once daily) is quite beneficial. For the relief of the symptoms referring to the head (tinnitus aurium, vertigo, fulness) and to the precordia (weight and discomfort) arterial relaxants are the best, particularly when arterio-sclerosis is causing car- diac overstrain. Among them nitroglycerin in full doses and veratrum viride are most useful, though the efficacy of both may often be enhanced by the addition of the bromids. In cases of nervous origin the bro- mids, Avith preparations of valerian, are the most valuable agents. Nothing, however, is of higher importance than the determination and removal of the cause when possible. After compensation has failed the further treatment is identical with that of cardiac dilatation. DILATATION OF THE HEART. 643 DILATATION OF THE HEART. Definition.—By dilatation of the heart is meant an enlargement of its various cavities. The Avails of the chambers may in consequence be thinner than in health, but much more commonly they are thicker, as in dilatation with hypertrophy. Both hypertrophy and dilatation are rela- tive terms, but the latter has reference to that condition in which the cavities are distended out of proportion to the diameter of their Avails. Varieties.—(1) Dilatation with Hypertrophy.—Here there is a pro- gressive increase in the capacity of the chambers until they attain to large dimensions. The cardiac Avails continue of abnormal thickness, yet the vigor of the divisions affected may be relatively diminished to a remarkable degree, OAving to the Aveakening influence of the degenerative processes that attack the hypertrophied muscles. In eccentric hyper- trophy the heart-cavities are dilated, but the hypertrophied cardiac walls are sufficiently vigorous to meet the demands of the circulation. This condition should not be regarded as identical Avith dilatation with hyper- trophy, but frequently merges into the latter, the size of the cavities noAv being proportionately greater than is the thickness or the functional poAver of their Avails. (2) Dilatation with Thinning of the Heart-walls.—The diminution in the diameter of the cardiac muscles may be slight if the capacity of the chambers involved be only moderately increased. Instances of this sort are sometimes seen to follow prolonged fever (ty7phoid). On the other hand, the process of attenuation may reach a high grade, the greatly thinned cardiac wall being scarcely capable of holding the weight of the contained blood. (3) Dilatation with little or no variation from the normal cardiac wall has also been described by some authors. It is to be observed, hoAvever, that stretching of a cavity Avhose Avails are normal must be attended with thinning of those walls, unless there has been pre-existing hypertrophy. Pathology.—Dilatation with hypertrophy is generally secondary to valve-lesions, and affects more than one cavity7 as a rule. It may happen, as in advanced aortic regurgitation, that all the divisions are dilated. The right ventricle is somewhat more frequently dilated than the left, hoAvever, for reasons previously adduced. The auricles (espe- cially the left) are more frequently expanded than the ventricles; hence of all the chambers the left ventricle is least apt to dilate. The extent of the relative increase in the capacity of the cavities is variable, and often remarkable. As an example of extreme dilatation of a chamber, the left auricle in cases of mitral stenosis may be singled out; I have seen an instance in which this auricle was capable of containing twenty- tAvo ounces of blood. The septum may be seen to bulge Avhen one ven- tricle only is stretched. Extensive dilatation of the chambers produces a dilated condition of the auriculo-ventricular rings, Avhich in turn gives rise to relative incompetency. Other cardiac orifices are found to be similarly dilated. Dombrowski1 has draAvn attention to the fact, first pointed out by Wolf, that the surface of the mitral leaflets greatly ex- ceeds the orifice, and Kirschner and Garcin contend that the anterior 1 "Functional Insufficiency of the Valves of the Left Heart," Revue de Medecine, Sept. 10, 1893. 644 DISEASES OF THE CIRCULATORY SYSTEM. flap alone suffices to close the mitral orifice, "even Avhen the left heart is considerably dilated." DombroAvski believes that functional incom- petency is due, in many cases, "to muscular dilatation, producing a separation of the insertions of the papillary muscles, Avhich in systole cannot approach each other near enough to alloAv the valves to close, the contraction of the papillary muscles only increasing the difficulty." Great dilatation of the left auriculo-ventricular ring is, hoAvever, prob- ablv an important factor in the causation of relative mitral incompetency. The tricuspid valves, being scarcely competent to cover the correspond- ing orifice normally, are unquestionably incompetent when that orifice is considerably dilated. The shape of the heart is altered according to the seat and extent of the dilatation. When all the cavities are dilated the organ assumes a globular form, Avhile dilatation of the ventricles only produces broaden- ing of the apical region. Condition of the Endocardium and Cardiac Muscle.—The muscular tissue generally exhibits degenerations (fibroid, fatty, or parenchyma- tous), but in some cases even microscopic changes are entirely Avanting. Important as is the part played by the ganglia in maintaining the nu- tritive integrity of the heart by supplying nervous force, our knoAvledge of the alterations that may occur in them in this condition is as yet very imperfect. Ott and others have, however, found them to be degenerated. Opacity and patchy roughening of the endocardium are common. Etiology.—Entering into the causation of cardiac dilatation, there are tAvo essential factors: (1) increased endocardial tension; (2) dimin- ished resistance, due to Aveakened cardial Avails. Each of these may be the sole cause, though more often they act together. (1) Increased Endocardial Tension.—It is to be premised that a pri- mary and a secondary form occur, the latter being of greater importance clinically than the former. Primary dilatation occurs from a recent ob- struction to the circulation of considerable magnitude and at any point throughout the blood-vessel system. A good example is afforded by aortic constriction, in which condition the obstruction of the aortic ring engenders dilatation of the left ventricle by raising the intraventricular pressure ; this is, hoAvever, quickly overcome by compensatory hyper- trophy. In the vast majority of these instances, after a long interval of perfect compensation, a nutritive break-down takes place, with ensu- ing secondary dilatation. Other causes of augmented endocardial pressure have been considered in the discussion of Hypertrophy and Chronic Valvular Lesions. In eccentric hypertrophy both dilatation and hypertrophy go hand in hand, until finally the cardiac nutritive funtions fail and dilatation at once predominates (dilatation with hypertrophy). Compensation has noAv been ruptured. Among the exciting factors that may precipitate this accident may be briefly stated—recurrent endocarditis, intercurrent febrile affections which over-stimulate the heart and tend to impair its muscular tissue, general disturbances of nutrition, and, lastly, physical and mental overstrain. Acute primary dilatation may be brought about by sudden, great ex- ertion, as in ascending mountainous elevations. Under these circum- stances the heart palpitates violently, there is epigastric pulsation, and DILATATION OF THE HEART. 645 often pain in the cardiac region—evidences of dilatation of the right ventricle. Although in these cases the heart's reserve capacity for Avork has been exceeded, rest and then quite moderate exercise often restore the conditions to the normal. I have seen acute primary dilatation produced by strong emotion; in such cases sudden contraction of the peripheral vessels occurs, attended Avith arrest of the heart's action ; this soon gives place to violent palpitation and rarely to dilatation. Sudden fright may also, by inducing organic changes, cause acute dilatation. The remarkable endurance of the athlete and the gymnast is in part owing to /the abnormal amount of physiologic cardiac reserve force which they naturally possess, but it is mainly due to the invigorating effect of training. If, hoAvever, the training be not so conducted as to symmetrically develop the entire muscular system, or if the exertion be in excess of the reserve functional power of the heart, then acute dila- tation may suddenly arise. From this accident recovery may, after a time, take place; sometimes, hoAvever, it initiates organic valvular dis- ease, and thus prohibits the further undertaking of unusual feats. The cardiac muscle may be impaired by pericardial adhesions from the ex- tension of fibrous overgroAvth to the adjacent myocardium. Apparently idiopathic eases of cardiac dilatation of indeterminate etiology rarely occur. (2) Diminished Resistance owing to Weakened Cardiac Walls.—The occurrences that weaken the cardiac Avail are numerous, and not a few lead to acute primary dilatation, such as myocarditis due to acute specific fevers (scarlatina, typhoid, typhus). It is especially prone to occur in rheumatic endocarditis and pericarditis. The chronic degen- erations (fatty, fibroid) impair the contractile poAver of the heart. Nu- tritional disturbances of varied origin may induce enfeeblement of the cardiac muscle, such as digestive disorders, ill-ventilation, lack of open- air exercise, and improper or defective food-supply. Dilatation is met Avith also in diseases of the blood (chlorosis, anemia, leukemia). Clinical History.—In acute dilatation the onset is sudden. It is accompanied by such symptoms as dyspnea and cardiac palpitation (both speedily becoming aggravated), and frequently by pain in the precordial region. The physical signs may be incontestable. They are venous pulsation in the neck, a rapid, feeble apex-beat, and a systolic murmur at the tri- cuspid valves, all of Avhich declare the presence of tricuspid regurgitation. Among signs of subsidiary value are a venous turgescence, a marked epigastric pulsation, and a sudden extension of dulness to the right; the pulse is small, irregular, and exceedingly rapid. In the more chronic form, Avhich arises from slowly-acting causes, or in that Avhich accompanies eccentric hypertrophy or folloAvs simple hypertrophy due to left-sided heart- or lung-trouble, the manifestations that characterize the earliest stage are not at all striking. They indicate Aveak heart-Avails, and such chambers are soon unable to expel their contents during systole. Hence with each subsequent diastole the abnormal amount of blood contained in them is increased. From these facts it is readily seen that the essen- tial causal conditions—increased endocardial pressure and Aveakened heart-Avails—are present and active in facilitating the process of dilata- tion, once it has commenced. This blood-stasis, as previously pointed 646 DISEASES OF THE CIRCULATORY SYSTEM. out, often extends from the left heart to the pulmonary vessels, from the latter to the right heart, and finally to the general venous system. Both in the acute and chronic forms, however, failure of the right ventricle more often constitutes or determines rupture of compensation and is the harbinger of serious symptoms. Obviously, the symptoms must be those described as belonging to organic diseases of the heart (tricuspid incom- petency, in particular). Physical Signs.—Inspection in dilatation of the left ventricle shoAvs a diffuse, Aveak, fluttering, and often a distinctly undulating impulse. The apex-beat will shoAV a greatly diminished vigor in its normal area, or there may be no recognizable area of strongest impulse, as in health. Distinct pulsation in the second left interspace is not rare, and is of ventricular origin. Its feebleness and diffuse character are confirmed by palpation. It may be quick and sharp, though ahvays lacking in power. Walsh first made the capital observation—since abundantly corroborated—that the impulse may be visible, yet not palpable. There may be an utter absence of the apex-beat in marked cases. The pulse is small, often rapid, and lacks regularity. Percussion shoAvs a lateral increase in dulness to the left, to or even beyond the mid-clavicular line, upward to the second rib, and downward as far as, though rarely beloAv, the sixth interspace, except perhaps, in rare instances, in dilatation Avith hypertrophy. The lungs in emphysema may to a great extent overlap the heart, with a corresponding diminution in the area of dulness. Dilatation of the right ventricle demands separate consideration so far as the impulse and percussion-dulness are concerned. The normal impulse is largely replaced by the abnormal apex-beat of the right ven- tricle, Avhich advances to the anterior chest-wall. The chief impulse is now seen and feebly felt, as a rule, below the xiphoid cartilage, or, less commonly, to the right or left of the latter. A Avavy pulsation is seen to the left of the sternum, over the fourth, fifth, and sixth interspaces and close to its right edge. If dilatation of the right auricle be asso- ciated, as is often the case, a distinct pulsation also occurs in the third right interspace. Dulness reaches to a point 1 inch (2.5 cm.) or more beyond the right sternal border on a level with the fourth interspace. If both ventricles are extensively dilated, dulness extends bilaterally in a transverse direction. On auscultation variable results are obtained according to the state and diameter of the cardiac walls. When thin and not much disorgan- ized, the first sound is much shorter, sharper, and more ringing than in health. In advanced cases the systolic sounds may be feeble and indef- inite, and sometimes the first closely resembles the second sound, the long pause being shortened (fetal heart-sounds). The canter rhythm, hoAvever, is more common. Irregular and intermittent cardiac action are usual phenomena. The abnormal conditions of the two ventricles often differ, or either ventricle may be implicated alone. Hence sounds may differ in intensity. Reduplication may occur, but is not frequent. Pre-existing organic murmurs obscure the sounds due to dilatation, and, on the other hand, the dilatation may also alter the murmurs (pre- viously audible), and even cause them to disappear, as, for example, in mitral stenosis. Again, dilatation may induce relative incompetency or superadd a murmur, as in cases of chronic valvular disease at the auriculo- DILATATION OF THE HEART. 647 ventricular orifices. It is interesting to recall here that proper treat- ment may remove a murmur due to relative insufficiency, and that this treatment may, in turn, reproduce an organic murmur. Diagnosis.—This is made readily Avhen there is obtainable a clear history, together Avith the folioAving characteristic features : a weak, irreg- ular heart-action ; an extended, Avavy impulse ; a small, vigorless, irreg- ular, and intermittent pulse; often an indistinct apex-beat; an outAvard, upward increase in the percussion-dulness on one or both sides, causing the outline to resemble a square; and a brief, sharp, yet feeble first sound that strikingly resembles the second, which is itself enfeebled. Differential Diagnosis.—Hypertrophy, like dilatation, gives rise to an extended area of impulse and of percussion-dulness; hence by the care- less observer these conditions are sometimes sadly confounded. From dilatations, Avhere the diagnosis rests upon the points above enumerated, hypertrophy is to be distinguished by symptoms of an opposite nature, such as indicate increased vigor on the part of the heart. The latter are—a sIoav, heaving impulse; a slow, full, regular pulse; an increase in the area of dulness, chiefly outAvard and doAvnward; abnormal position of the apex-beat; and the prolonged, dull first and accentuated second sounds. To determine the point at Avhich eccentric hypertrophy ends and dilatation (Avith hypertrophy) begins is often difficult, but a careful discrimination must be attempted, and I have already discussed the ushering-in symptoms of dilatation following hypertrophy (chiefly of the right ventricle) in connection Avith Chronic Valvular Disease. Oc- curring in left ventricular hypertrophy, dilatation first betrays itself by a change in the position of the visible apex-beat and the impulse on pal- pation. Thus, the maximum point of the apex-beat of hypertrophy very early becomes rounded and indefinite, and later is diffuse and Avavy. Its strong, long-draAvn, heaving, yet Avell-defined impulse gives place to the shorter, more sudden shock of commencing dilatation, indicating Aveakness. These signs, together with a reduction in the strength and an increased frequency or irregularity7 of the pulse, shoAv the condition to be dilatation with hypertrophy. The prognosis is bad, as a rule, though it may depend upon the causative factors in numerous instances. Treatment.—This in all essential particulars is identical with the treatment of organic heart-affections after rupture of compensation. The etiology in many cases differs from that of the organic valvular affections of the heart, since, next to rest and cardiac stimulants, the removal of the remote and near causes of the dilatation is the most important part of the treatment. Individual cases frequently present special indications, however, and these must be met according to the usual principles, Avhich may be found in appropriate sections of this work. In cases of non-val- vular origin digitalis and other heart-stimulants may be omitted, though they should be promptly employed if demanded by a recurrence of the symptoms indicating dilatation. When the dilatation has been over- come, careful attention is to be bestoAved upon all the details of the patient's life and sanitary surroundings in order to force his bodily nutrition to the highest point. Every precautionary measure having for its aim the prevention of a recurrence of the dilatation must also be enjoined. 648 DISEASES OF THE CIRCULATORY SYSTEM. MYOCARDITIS. (Carditis) Definition.—An inflammation of the muscle-substance of the heart. It may be acute or chronic. ACUTE MYOCARDITIS. Pathology and Varieties.—(1) Acute Parenchymatous Myocarditis. —This is characterized by a granular degeneration of the muscular fibers of the parenchyma of the organ, with a numerical increase in their nu- clei. The muscle-structure throughout looks pale, is turbid, and very soft. Many cases of a severe type terminate in fatty degeneration. (2) Acute Diffuse Interstitial Myocarditis.—Here the primary altera- tions affect the connective tissue of the myocardium; the histologic changes consist in round-cell infiltration. (3) Acute Circumscribed Myocarditis.—In this variety the degenerative processes result in necrosis of the tissues over large or small areas, with abscess-formation. Though usually multiple, these abscesses vary con- siderably in number, and may rupture either into the various cardiac chambers or into the pericardium. Thus, the purulent contents of the abscess, Avhen there is established a fistulous communication with an endocardial chamber, find their Avay into the blood-stream and are con- veyed to all parts of the arterial system, frequently setting up, here and there, embolic processes of an infectious nature. The blood in turn enters the abscess-cavity, exerting pressure on the Avails, and may either produce an acute aneurysmal dilatation of the heart-Avail or occasion fatal rupture into the pericardium. More frequently, perhaps, the con- nective-tissue wall of the abscess yields gradually during the ventricular diastole, Avhen the cardiac aneurysm is formed Avith corresponding slow- ness. Occurring in the vicinity7 of one of the auriculo-ventricular valves, abscesses may cause mitral or tricuspid incompetency. OAving to their tendency to burro ay, they may perforate the interventricular septum, thus creating a fistulous connection between the tAvo sides of the heart, and resulting in an intermingling of venous and arterial blood. The abscess may become encysted, then caseous, and finally undergoes a calcareous process. Etiology.— The causes of myocarditis are—(a) endo- and pericar- ditis in the course of rheumatism: it is probable that rheumatic myo- carditis may also exist Avithout involvement of the endo- or pericardium; (b) the infectious processes in acute specific fevers; (c) infectious emboli, lodging in the branches of the coronary arteries in connection Avith sep- ticemia, pyemia, and acute ulcerative endocarditis, and commonly termi- nating in abscesses (circumscribed myocarditis). The first tAvo of these causes give rise to acute diffuse interstitial and acute parenchymatous myocarditis as a rule. As compared Avith the female sex, the male suffers much more frequently. Symptoms and Diagnosis.—The symptoms are practically nega- tive. They point to great cardiac enfeeblement, but do not furnish any information beyond exciting a suspicion as to the true nature of the CHRONIC MYOCARDITIS. 649 attack. When cardiac weakness, as shown by a rapid, small, compres- sible, and irregular pulse, and by attacks of cardiac palpitation and syncope, comes on suddenly7 in the course of rheumatism, septicemia, or other causal affections, myocarditis may be suspected. Later, signs of venous stasis appear. The physical signs simulate those of dilatation, and may, indeed, be largely dependent upon the presence of the latter condition. Earlv the action of the heart is tumultuous; the sounds on auscultation are short, sharp, and finally very feeble. Murmurs in myocarditis are not rare, and are not necessarily dependent upon dilatation. Kiehl's work shows the dependence of the valves for their complete closure upon a normal state of the different portions of the heart-muscles, and thus explains these murmurs. Their great variability as to presence or absence is an important point, especially in the diagnosis from murmurs due to endo- cardial changes. The latter usually coexist with an accentuated pul- monary second sound, Avhile the myocardial murmurs usually do not appear, OAving to Aveakness of the right heart. The special conditions rendering the murmurs audible are great dilatation, softening of the papillary muscle, and abscesses near the valves. The recognition of cardiac aneurysm is made possible by the manner of increase in the percussion-dulness (upAvard and toAvard the left) with coextensive pulsation. The symptoms of visceral or cutaneous embolic processes, especially Avhen corroborated by the simultaneous development of a murmur and a septic type of fever, should excite strong suspicion of the existence of circumscribed myocarditis. Prognosis.—The diffuse forms are fatal; the circumscribed form may, however, end in recovery. Myocarditis may terminate life sud- denly if violent or even active exertion be made. The treatment is identical with that indicated for endocarditis and pericarditis—diseases of Avhich myocarditis is often a complication. The effects of digitalis, particularly when myocarditis supervenes upon old heart-lesions, are quite unsatisfactory7. When myocarditis is suspected as an independent condition, absolute rest must be enjoined, the general - nutrition energetically maintained, and the more urgent symptoms relieved. CHRONIC MYOCARDITIS. (Fibrous Myocarditis.) Definition.—A gradually developing inflammation of the cardiac interstitial connective tissue, resulting in induration. Pathology.—The characteristic changes may be diffuse, though most frequently they are confined to certain portions of the muscular structure, the left ventricular wall, the septum, and the papillary muscles being the three favorite seats of the process. This is sometimes of ante- natal development, and then its usual seat is near the apex of the right ventricle. The hardened spots take the form of more or less rounded patches or broad lines. In color they are gray7, grayish-wbite, or gray- ish-yelloAv, the latter tint being due to the intermingling of fibers that have undergone fatty degeneration. Their size is exceedingly variable, some being so minute as to elude detection by the unaided eye, Avhile others measure 1 or 2 inches (2.5-5 cm.) in diameter. Inflamma- 650 DISEASES OF THE CIRCULATORY SYSTEM. tory induration (contraction) of the conns arteriosus of either ventricle causes narroAving of the pulmonary and aortic orifices, with the usual signs and symptoms. Similar changes, by disturbing the functions of the papillary muscles, produce valvular incompetency. Compensatory hypertrophy of the uninvolved portion of the heart is also observed, both the size and Aveight of the organ thus being increased; the hyper- trophic enlargement may frequently be accounted for in part by an associated chronic endocarditis. Sometimes, hoAvever, the hypertrophy is occasioned in great measure by general arterial sclerosis. Dilatation of the ventricles folloAvs soon or late, with fresh and grave disturbances of the circulation. Chronic inflammation usually attacks early the intima of the coro- nary arteries, and leads to thrombosis, Avith the formation of anemic infarcts that subsequently undergo sclerotic changes in the muscle- structure. It is probable that most cases of localized fibrous myocar- ditis have their origin in an obliterating endarteritis. The calloused zone may yield to the endocardial blood-tension, and thus slowly pro- duce saccular dilatation (aneurysm). Microscopically, the affection is characterized by hyperplasia of the interfibrillar connective tissue with subsequent development of neAV fibrous tissue. Fatty degeneration and atrophy of the muscle-fibers (the latter in consequence of compression by the fibroid degenerated tissue) are also observed. Fragmentation of the muscle-fibers has also been observed. This occurs as a postmortem change, and is due to a softening of the interfibrillar substance (the etat segmentairc of Renant). Etiology.—The disease is most commonly traceable to the action of one or more of the following factors: an excess in the use of alcohol or tobacco, lead-poisoning, gout, rheumatism, diabetes, chronic nephritis, malaria, and syphilis. Thus, it may be produced by many infections and chemical irritants, the latter, in most cases, first causing a sclerosis of the coronary arteries, to Avhich the patchy fibroid degeneration is secondary. Some of the causes of acute diffuse interstitial myocarditis may by their more slightly irritant effect (oAving to the minuteness of the close of the specific poison) lead to the subsequent development of the general chronic form (e. g. rheumatism). Certain irritants that usu- ally engender localized lesions of chronic myocarditis may also affect, though less frequently, the entire myocardium, such as syphilis, alcohol, and gout. Chronic myocarditis may also arise in consequence of a direct extension of the infective inflammatory processes in chronic endo- and pericarditis. It may also folloAV injuries of the antero-lateral tho- racic region. Sex and age possess a predisposing effect, the disease being more common in males than in females, and after middle life than before that period. The right ventricle is apt to be the seat of chronic myocarditis during fetal life, if at all. Symptoms.—Extensive indurated myocarditis has been met with postmortem in numerous instances that have been unattended by per- ceptible symptoms during life. In many of these cases the presence of compensatory hypertrophy accounts for the absence of any symptoms, and it may, therefore, be inferred that mild grades that fail to manifest themselves must frequently exist. The symptoms Avhen present are, almost without exception, untrustAvorthy for diagnostic purposes, since CHRONIC MYOCARDITIS. 651 they bear a striking resemblance to those of the organic valvular dis- eases, minus their more characteristic physical signs. Among the earliest phenomena that point merely to failing heart-poAver are dys- pnea, and sometimes also, on exertion, palpitation and a sense of heavi- ness or constriction in the precordia. The patient suffers from marked general debility, and becomes fatigued in consequence of the slightest physical exertion. Mental inertia is the rule, and chronic mania may come on and last to the close. Later, more positive disturbances of the circulation gradually arise, and Avhen the breathing becomes more diffi- cult (cardiac asthma) signs of venous stasis affecting the liver, gastro- intestinal tract, and kidneys, and edema finally appear. Tavo symptoms that are frequently manifested, and not Avithout some diagnostic import, remain to be mentioned: (1) Angina pectoris, Avhich is attributable to the sclerosed condition of the coronary arteries. It occurs in the form of paroxysms of severe pain in the cardiac area, that shoot into the back and doAvn the left arm, accompanied by great anxiety of mind, an anxious countenance, moderate dyspnea, marked precordial pressure, and a feeling of constraint. It is often folloAved by some form of arrhythmia. Cases occasionally occur in Avhich recurring paroxysms of angina pectoris, with or Avithout arrhythmia, are the only phenomena of the disease. (2) Cardiac Arrhythmia.—Brachycardia is associated as a rule, there being a reduction in the pulse-rate to 50 or even 40 beats per minute. With this decreased rate intermittency7 is often combined, and various other forms of disturbed rhythm are also observed, though they are less frequent and less significant. Slowing of the pulse does not, however, prohibit the cardiac palpitation that is especially apt to arise during anginal attacks. Disturbance of the rhythm may, on the other hand, be entirely absent. The pulse is slow, irregular, and of Ioav tension if cardiac atrophy be present. Should fatty degeneration be conjoined, the pulse will be quickened and irregular, and this effect likewise obtains Avhen the patient escapes sudden death and the usual dilatation supervenes. Chronic myocarditis may be the sole cause of the pseudo-apoplectic seizures that often terminate life abruptly. Preceding the unexpected attack the patient, usually advanced in life, may have experienced from time to time slight vertigo, syncope, and oppression. These seizures may also be caused by a heavy meal or intense mental or physical exertion, and may consist in a momentary loss of consciousness, paralytic symp- toms then being usually absent. At other times they last a number of hours, and are accompanied by paralysis which outlasts the coma, as a rule, by a feAv hours only. Convulsive twitchings may be present. During the attack cerebral hemorrhage occurs, and may leave the patient hemiplegic. It is highly characteristic of these pseudo-apoplectic seiz- ures that they tend to recur, sometimes at intervals of a few hours for a day or tAvo, but more frequently at longer intervals during many Aveeks or months. Physical Signs.—The impulse may be feebly heaving (sometimes ab- sent) ; the apex-beat is displaced doAMiAvard and to the left, Avhile the dull area is enlarged correspondingly in the same direction. Quite early the heart-sounds may be clear and strong, but subsequently they 652 DISEASES OF THE CIRCULATORY SYSTEM. become weak and muffled. A contraction of the papillarv muscles and of the chordte tendineae may cause mitral incompetency Avith its customary7 murmur. With the occurrence of dilatation also comes an apical, systolic mur- mur (due to relative incompetency), with a gallop rhythm of the heart. Differential Diagnosis.—(1) Chronic valvular disease can, as a rule, be eliminated prior to the occurrence of secondary dilatation. During this period murmurs do not occur unless the valvular adnexa (the chorda and papillary muscles) are affected. In the latter event the secondary alterations in the heart, the symptoms, and Avhole course of the complaint are the same as in certain chronic valvular lesions. (2) Hypertrophy and Dilatation.—In chronic myocarditis hyper- trophy does not usually reach as high a grade of development as in the majority of the organic valvular complaints and other causal conditions. But after the occurrence of dilatation, folloAving indurated myocarditis, the differential diagnosis between the latter and eccentric hypertrophy is purely conjectural. (3) Fatty overgrowth must be distinguished from fibrous myocarditis, and is met Avith chiefly in brewers, publicans, and butlers. The disease is also found to be specially related to obesity, and sometimes to over- eating and drinking, combined with indolent habits. These subjects suffer more frequently from bronchitis, emphysema, and nocturnal asthma than patients having chronic myocarditis alone. Slight vertigo is com- mon, but true syncopal attacks are rare, according to my observation. In fatty overgrowth the heart-sounds are weak and decidedly muffled throughout; the pulse is weak, though regular as a rule. Marked obesity, however, often obscures the local signs. The prognosis is grave, chronic myocarditis being a fatal disease. Its course and duration, hoAvever, are subject to great variations. Among unfavorable surroundings are certain causal and associated conditions, particularly arterio-sclerosis, chronic interstitial nephritis, and diabetes mellitus. On the other hand, if syphilis has been the cause, hope for temporary improvement, if not for actual cure, may7 be reasonably entertained. Treatment.—The treatment should be managed according; to the considerations pointed out in the treatment of Organic Valvular Dis- ease. Rest of body and mind is imperative. Next to this come the dietetic and hygienic details. Residence in a mild climate in winter and a change to the country or to a moderate elevation in summer are matters of the greatest moment to the welfare of the patient. Those rather frequent cases that present, among other complications, such closely united conditions as arterio-sclerosis, gout, and chronic nephritis sometimes do well while sojourning at certain mineral springs, such as Marienbad, Carlsbad, Kissengen abroad, and Bedford or Saratoga at home. These waters must, hoAvever, be cautiously used. When dilatation arises cardiac stimulants are called for, but must be used with an unusual degree of caution. Strychnin has proved itself to be valuable if perseveringly exhibited, and here, as elseAvhere, digi- talis deserves a trial; its careless administration, hoAvever, may give bad results if the pulse be much retarded or arterial sclerosis coexist. For the angina pectoris morphin, administered hypodermically, is to be pre- DISEASES OF THE CORONARY ARTERIES. 653 ferred. Recurrences of this distressing symptom may be averted by the cautious use of nitroglycerin, the use of Avhich should, however, be limited to cases that seem to be dependent upon arterial degeneration with high tension. Attacks of syncope are most successfully met by the hypodermic use of the diffusible stimulants (ammonia, ether), and at the same time by putting the patient at rest with the head loAvered. DISEASES OF THE CORONARY ARTERIES. It has previously been noted that in pyemia and allied disorders septic emboli may block the branches of the coronary arteries, causing suppurative infarcts (acute circumscribed myocarditis). It has also been shoAvn that one of the chief effects of sclerosis affect- ing the coronary arteries is the production of chronic myocarditis. The fact that the sudden blocking of one coronary artery by an embolus causes instant death should also be emphasized. In numerous instances in which death has occurred suddenly either thrombotic or embolic obstruction has been the only discoverable postmortem lesion. In others the pathologic evidences of local or general atheroma have coex- isted. There is at hand much experimental testimony tending to shoAv that ligation or plugging of the coronary vessels in the loAver animals causes arrhythmia or even an abrupt arrest of cardiac action; a partial or even slight reduction in the lumen of the coronary vessels by diminish- ing the supply of blood to the heart-muscle induces degenerations in the latter. In this connection the anatomic peculiarity of the coronary arteries in that they are end-arteries is to be noted, since it affords a ready interpretation of the notable effects folloAving total or partial occlusion. The blocking of the terminal branches by emboli or by the more gradual formation of thrombi produces the so-called anemic necrosis or white infarct—a condition that richly deserves brief description : Anemic necrosis (anemic infarct) is met Avith most frequently in the left ventricle and septum, Avhich receive their blood from the ante- rior coronary artery. The involved areas are small and circumscribed, and present irregular margins that project slightly above the surface. Rarely the infarct is wedge-shaped. Its color is grayish-white or gray- ish-red, while the central portion is often distinctly white and firm; less frequently it breaks doAvn into a soft detrital mass (myomalacia cordis). When softening does not occur the fibers in the affected area lose their nuclei, becoming first hyaline and subsequently sclerotic. The chief histologic changes are of tAvo sorts: (a) the striae of the muscle-fibers are lost, the latter becoming granular and breaking doAvn; and (b) the fibers assume a homogeneous hyaline appearance, the nuclei having dis- appeared. The symptomatic consequences of the lesions are often obscure and unreliable. Sudden death may take place, and rarely this accident may be due to rupture of the heart. Weak and irregular action of the heart, evidences of embarrassed circulation (especially in the cardio- 654 DISEASES OF THE CIRCULATORY SYSTEM. pulmonary area, as shoAvn by cough and dyspnea), and finally angina pectoris, are among the chief features observed. Death may ensue in the first attack, but more often the patient survives the first and has repeated subsequent seizures. The paroxysms are presumed to be due to sudden occlusion of a branch of the coronary artery, but it should be stated that occasionally in fatal instances of true angina pectoris a total absence of lesions, including emboli, has been noted. DEGENERATIONS OF THE HEART. (a) Fatty.—The term "fatty heart" includes two pathologically dis- tinct affections : (1) Fatty degeneration, in which the cardiac muscle- fibers have been converted into fat; and (2) Fatty overgrowth, in which an abnormal quantity of fat is deposited in and about the heart. PATTY DEGENERATION. Pathology.—The condition may be either general or localized. Its most frequent seat is in the left ventricle, the papillary muscles and trabecules, first appearing as yelloAvish spots or stripes beneath the en- docardium. The affected portions are light yellow or yellowish-brown (faded leaf) in color, due to an associated brown atrophy; they are also soft and friable, and are easily lacerated. The heart is enlarged, and often decidedly so if the process be general, and its walls lack firmness. The microscope reveals characteristic changes: the striae and nuclei begin to fade, oil-drops and granules appear in tlie fibers, and finally the latter are occupied throughout by minute globules. Etiology.—Fatty degeneration has already been mentioned as occurring in both the primary and secondary forms of cardiac hyper- trophy. It is found also in association Avith fatty change in other organs in severe forms of primary and secondary anemias. It is most commonly encountered, hoAvever, in the cachectic states produced by such chronic diseases as carcinoma and phthisis, and in the course of acute infectious diseases of intense type, all of which may produce the condition. In poisoning by arsenic and phosphorus and in pernicious anemia it advances to a high grade. The various lesions of the coronary arteries previously considered bear a special causal relation. Predisposing causes are—(a) age—it being most common after forty years of age; (b) sex—it occurs someAvhat more frequently in men than in women, notAvithstanding the fact that there are predisposing influ- ences at work in the latter that do not obtain in the male sex, such as childbirth and amenorrhea; and, lastly, (c) Avhatever may be its apparent etiology, it is invariably preceded by a defective nutritive supply to the muscle-cells: this may be dependent on mechanical causes, such as narrowing of the lumen of the coronary vessels, or upon impairment of the oxygen-carrying poAver of the blood, as in the anemias. Symptoms.—The disease may exist in an advanced form without FATTY DEGENERATION OF THE HEART. 655 noticeable symptoms, though the conditions under Avhich it is most liable to occur often afford premises for suspicions; only rarely is anything more tangible offered than this. The evidences of cardiac enfeeblement are usually present, but in pernicious anemia the pulse may even be full and regular. Dilatation is apt to supervene early, OAving to the weakened state of the heart; and hence it is probable that many of the symptoms that have been ascribed to the fatty change are in reality due to secondary dilatation. Among these are palpitation, dyspnea, a small, irregular, and someAvhat quickened pulse, and cool and clammy extremities. The heart-sounds are Aveak, as a rule, and the action of the heart often irregular; later the physical signs of dilatation are almost invariablv present, and, as a rule, are progressively intensified. Sometimes sud- den, great physical exertion produces equally sudden dilatation, Avhere- upon a canter rhythm and an apical systolic murmur speedily develop. In most instances, hoAvever, the symptoms are more gradually brought to light. Breathlessness on exertion is often a striking feature, and syn- copal attacks are sometimes troublesome. The pulse, in consequence of irritation of the inhibitory center in the medulla, often becomes greatly retarded, dropping from the normal rate to 30 or 40 beats per minute, and, in rare cases, to 10 or 12 beats. The fatty arcus senilis is devoid of diagnostic value. There are frequent attacks of cardiac asthma in the mornings, and these are apt to be accompanied at intervals by angina pectoris. Disturbances of the intellect, sometimes taking the form of maniacal delusions, may come on and persist for Aveeks or even months. Pseudo-apoplectic attacks, such as have been described in connection Avith Chronic Myocarditis, are also concomitants that point to dis- turbance of the cerebral circulation. Cheyne-Stokes breathing is among the later manifestations, and I have noticed that these symptoms often occur together, rather than separately, in a given case. The diagnosis is sadly obscure. The history (of the utmost im- portance), the age of the patient, and the symptoms of cardiac Aveakness and subsequent dilatation, together with retardation of the pulse, apo- plectic attacks, and Cheyne-Stokes breathing, in the absence of prece- dent hypertrophy merely justify a probable diagnosis. With a clear history and the presence of the more significant symptoms, including the signs of dilatation following hypertrophy, fatty changes may be inferred Avith some degree of assurance, and yet even this state of affairs should not lead to a positive statement of opinion. The prognosis is as varied as the etiology. Death may come quickly, though oftener the end is reached in a gradual manner, the signs and symptoms of advanced dilatation closing the scene. Treatment.—The cause in each individual case should be deter- mined Avith as much precision as possible, and when ascertained a bold attempt should be made to remove it. This course often places the patient in the most favorable position for the successful treatment of the cardiac condition; and the method embraces many hygienic and dietetic considerations that assist in improving the nutrition of the cardiac tissue—one of the cardinal aims of a proper system of treatment. An- emia in one form or other plays an important role in the majority of the cases, and the particular variety present in each instance must deter- 656 DISEASES OF THE CIRCULATORY SYSTEM mine the character of the remedies to be employed. In that large cate- gory of cases occurring in certain cachexias (cancerous, tuberculous) the following formula has given gratifying results: B/. Acidi arsenosi, gr. j (0.0648); Ferri sulph. exsic, gr. xxx (2.0); Strychnines sulph., gr. j (0.0648); Quininae sulph., 3j ("^-O); Papoid, gr. xxx (2.0). M. et ft. capsulae No. xxx. Sig. One after meal-time. A frequent, irregular pulse and other signs of cardiac failure indicate commencing dilatation, and under these circumstances digitalis should be employed in small doses. When used Avith perseverance it is of the greatest service in many cases of this sort, and in the form of the poAv- der or the aqueous extract it may be conveniently combined with the above prescription. For the treatment of the more serious evidences of failure of the circulation the reader is referred to the discussion of the organic valvular diseases. I believe that gentle indulgence in physical exercise and light gym- nastics is beneficial, since it tends to invigorate the heart-muscle; it is to be increased in proportion to the manifest improvement in the patient's condition. It sometimes happens, however, that even gentle exercise is badly borne, and it should then be discontinued. I have been in the habit of advising daily inhalations of oxygen gas in this class of cases Avith good results. Recourse to massage is also in the line of sound practice, but the sittings should not exceed half an hour in duration at the start. The more prominent symptoms may require special measures. The syncopal and anginal attacks are to be handled in the manner indicated for the same symptoms in chronic myocarditis. For the pseudo-apoplectic attacks rest in the recumbent posture, with the head slightly elevated, is useful. Therapeutic agents, as digitalis, ammonia, and ether, may be used hypodermically to stimulate the heart; it is also good practice to Avithdraw from 12 to 24 ounces (355.0-710.0) of blood directly from a vein. If the arteries be hard and tense, nitro- glycerin is of service. A strictly horizontal posture and the application of ice to the pre- cordial region often quickly terminate the attacks of cardiac asthma, and spartein sulphate, with nitroglycerin, is Avorthy of a trial. Hot toddy and other diffusible stimulants are valuable adjuvants. Should these remedies fail, hypodermic treatment by morphin is then to be adopted. PATTY OVERGROWTH. Pathology.—The characteristic change consists in a marked in- crease in the normal fat, particularly in the auriculo-ventricular fur- roAvs. This over-production of fat takes place to a greater or lesser extent in every obese person, and may become so excessive as to form a complete enveloping mantle measuring an inch or more in thickness. In these extreme grades the muscular fibers of the organ may, from too great pressure, undergo atrophy and thus become Aveakened. Dilatation FATTY OVERGROWTH OF THE HEART. 657 often supervenes, and it is quite probable that in most cases the symp- toms, when present, date from the time of its occurrence. In the ca- chexias of carcinoma and phthisis the general atrophy of old age, fatty overgrowth, and fatty degeneration coexist. The diagnosis rests upon the presence of marked obesity combined with cardiac enfeeblement. Treatment.—I wish to warmly advocate the system of treatment introduced by Oertel, as I have seen excellent results from its faithful employment. It should not be resorted to in chronic valvular disease, especially in cases that have passed into the stage of broken compen- sation, nor should it be used if the arteries are markedly atheromatous. Oertel's method comprises three parts: (1) The reduction of the amount of liquid taken Avith the meals and during the intervals, the total for each day being 36 ounces (1064.0). Frequent bathing (includ- ing the Turkish bath in suitable instances) and pilocarpin are employed to promote free diaphoresis. (2) The diet is composed largely of proteids, as follows: Morning.— A cup of coffee or tea, Avith a little milk—about 6 ounces (178.0) alto- gether; bread, 3 ounces (93.0). Noon.— Three to 4 ounces (90.0-120.0) of soup ; 7 to 8 ounces (218.0- 248.0) of roast beef, veal, game, or poultry, salad or a light vegetable, a little fish; 1 ounce (32.0) of bread or farinaceous pudding; 3 to 6 ounces (93.0-186.0) of fruit for dessert. No liquids at this meal, as a rule, but in hot weather 6 ounces (178.0) of light wine may be taken. Afternoon.—Six ounces (178.0) of coffee or tea, with as much water. An ounce of bread as an indulgence. Evening.—One or two soft-boiled eggs, 1 ounce (32.0) of bread, per- haps a small slice of cheese, salad, and fruit; 6 to 8 ounces (178.0- 236.0) of wine, with 4 or 5 ounces (120.0-148.0) of water (Yeo). (3) Graduated exercise up inclines of various grades. The distance to be undertaken each day is to be carefully specified and frequently, though gradually, increased. A like plan is to be pursued with refer- ence to the degree of inclination. This is the most important part of the system, since it directly invigorates the heart-muscles. (b) Brown Atrophy.—A form of degeneration in which accumulations of yelloAvish-brown pigment-granules occur in the muscular fibers. The color exhibited by the heart-muscle is a reddish-broAvn, and in pro- nounced cases a dark-red brown. Brown atrophy is most commonly seen in the hearts of the aged, though also quite often in cases of chronic valvular disease that have reached an advanced period before the time of the fatal issue. (c) Calcareous Degeneration (Calcification).—Calcareous infiltration of the muscular fibers of the myocardium has been noted, though very rarely. Somewhat more common are the bony callosities that result from the inspissation and calcification of the purulent contents of former myocardial abscesses (vide Circumscribed Myocarditis). (d) Amyloid Degeneration.—This form of degeneration is rarely met with. It is limited to the blood-vessels and interstitial connective tis- sue, the muscular fibers escaping, and its causes are the same as those of amyloid degeneration of other viscera. 42 658 DISEASES OF THE CIRCULATORY SYSTEM. (e) Hyaline Degeneration.—This is sometimes seen in association with amyloid change. It also occurs independently in prolonged fevers (hyaline transformation of Zenker). The fibers are SAvollen, translu- cent, and homogeneous, and their stria? almost entirely disappear. CARDIAC ANEURYSM. (Aneurysm of the Heart.) A cardiac aneurysm may, in the first place, involve the Avhole diameter of the myocardium (aneurysm of the Avails).1 Secondly, it may merely implicate the valves, together Avith a feAv myocardial fibers (valvular aneurysm). Aneurysm of the Walls.—This is not of frequent occurrence. Its most common seat, however, is the Avail of the left ventricle near the apex; it is quite generally a sequel to chronic myocarditis, which, as before stated, occurs oftenest at this point. Anything that produces a decided localized weakness of the ventricular parietes (other forms of degeneration and endocardial and pericardial inflammations) may, hoAv- ever, lead to its development. In size cardiac aneurysms are exceed- ingly variable, and may either be very small, or as large as the average- sized head of an adult. As to form, two types should be recognized: (a) an equable dilatation of a part of the ventricular Avail, and (b) the sacculated form, Avhich communicates Avith the chamber by a compar- atively small orifice. Layers of fibrin are often found in these aneur- ysmal dilatations as an indication of Nature's attempt at a cure, and occasionally they may completely efface the sac Avhen the attempt is successful. In most aneurysms non-laminated blood-clots are also found. It must not be forgotten that, once an aneurysmal distention has begun, a straining effort may cause a sudden great increase of the dimensions or even rupture it. The structures adjacent to the gradu- ally formed aneurysm exhibit fibroid overgroAvth and other kinds of degeneration, these changes being secondary and most probably con- servative processes. Diagnosis.—Aneurysm of the myocardium has no characteristic features. Usually the symptoms and local signs of chronic myocarditis or dilatation are more or less conspicuous, but the presence of the aneurysm is not even suspected unless certain physical signs develop in the course of the former complaints. These are—a pulsating prom- inence in the apex-region that may even perforate the chest-Avail, and a coextensive dulness. The abnormal area of dulness is best appreciated early by stethoscopic percussion, but unless peculiarly circumscribed the condition cannot be distinguished from hypertrophy or dilatation. The course of these cases is unfavorable, death ensuing (rarely) from rupture of the sac or (more frequently) from gradual cardiac exhaustion. Valvular aneurysms sometimes arise in acute ulcerative endocarditis, Avhich destroys the segmented endocardium and permits of dilatation as the result of the intracardial blood-pressure. They occur with much 1 Of 87 cases collected by Pelvet, 57 were in this situation, and of 90 collected by Legg, 59. RUPTURE OF THE HEART. 659 greater frequency on the aortic than on the mitral valves. They are spheroid in shape, and project into the left ventricle Avhen found at the aortic segments, and into the left auricle Avhen at the mitral. Though usually single, they are multiple in a feAv instances. Rupture of these aneurysms is common, Avith the subsequent development of extensive valvular incompetency. They cannot be diagnosticated during life. RUPTURE OF THE HEART. This rare and serious accident may either be complete or partial. The term partial rupture implies laceration of the trabeculae ventriculi, whereby the chordae tendineae are liberated, or, more seldom, of the papillary muscle. The muscular structure may be involved to a slight extent. Valvular incompetency is the consequence of partial rupture. Complete rupture consists in a solution of continuity of the total diam- eter of the myocardium. Pathology.—The chief seat of rupture is the anterior wall of the left ventricle, though it may also occur in the right ventricle and in the auricles, but Avith great rarity. The rent runs parallel with the mus- cular fibers, and is to a certain extent the result of laceration, though chiefly of a separation, of the fibers. The fissural communication pre- sents irregular edges, and at autopsy is seen to contain blood-clots ; the pericardial sac is also occupied by coagula, often in great numbers. If pericardial adhesions have previously7 obliterated the cavity, the es- caped blood-clots may occupy the pleural cavity. Histologic examina- tion of the muscle-structure surrounding the fissure shoAvs the charac- teristic, changes of fatty and other forms of degeneration. Etiology.—Both predisposing and exciting causes may be at Avork. The former are the more important and always obtain, and, named in the order of their frequency of occurrence, the predisposing factors are disease of the coronary arteries (thrombotic and infectious embolic pro- cesses which produce anemic necrosis and abscesses), fatty7 degeneration,1 chronic myocarditis, parietal tumors, and parasites in the heart-Avail. The influence of age as a predisposing factor has not been determined ; rupture of the heart usually occurs after the sixtieth year has been passed, hoAvever, for the reason that the myocardiac changes that cause it belong to that period of life. Males suffer someAvhat more frequently than females. The exciting cause is, as a rule, some form of muscular exer- tion, though it may occur spontaneously during sleep. Symptoms.—In the majority of instances rupture of the heart re- sults in sudden death. Sometimes, however, the patient survives the accident for several hours or even for as many days. The symptoms are those of internal bleeding, in addition to pain that may be agonizing and is referred to the heart. The body-temperature falls, the skin-sur- face becomes pale and cool, and it may be covered Avith cold perspiration, Avhile the pulse grows small, very frequent, and finally almost vanishes. Occasionally gastro-intestinal symptoms and syncope tending to convul- 1 According to Quain's statistics, about 75 per cent, of the cases are due to this cause. 660 DISEASES OF THE CIRCULATORY SYSTEM. sions appear in consequence of the irritation of the vagus centers due to cerebral anemia. The physical signs of cardiac failure rapidly develop, and, if the leak be not too large, those of pericardial effusion more gradually. Diagnosis.—A certain diagnosis is rarely possible. Heart-anguish, rapidlv progressive cardiac failure, the evidences of internal hemor- rhage, and the speedy7 development of the signs of pericardial effusion should, hoAvever, ahvays excite a strong suspicion of rupture, and in many cases suffice for a correct inference. The prognosis is hopeless. AVhen immediately fatal, death is the direct result of heart-shock ; when delayed, the sad issue takes place in consequence of anemia of the brain or of compression of the heart by the blood that pours into the pericardial cavity. Treatment.—Prophylaxis is of the utmost importance. In all conditions of the cardiac parietes in Avhich this accident is liable to occur the physician should not fail to give ample Avarning of the dangers con- nected Avith muscular strain of Avhatever sort. If rupture has occurred or is suspected to have taken place, the patient must be put at complete rest in the horizontal position. Full doses of morphin should be given hypodermically, and the ice-bag locally applied. Warmth to the ex- tremities may be useful, but applied to the heart-region can be only harmful. The use of pure cardiac stimulants Avill be attended with in- creased bleeding from the rent, but agents that relax the peripheral arterioles, such as nitroglycerin, may be employed with a vieAv to dimin- ishing the heart's labor without diminishing its power. Should the rup- ture be partial and the hemorrhage slight, the patient's life may be pro- longed, or even saved, by keeping him at absolute rest for a long period or until Nature effects recovery. MINOR AFFECTIONS OF THE HEART. (a) New Growths.—Primary carcinoma or sarcoma is rare indeed. Metastatic groAvths occur, but are very rarely sufficiently large (except perhaps the colloid variety) to be detected by physical examination, or to give rise to symptoms. Very large tumors may, by interfering with cardiac nutrition, weaken the heart-muscle, but this must be an extremely rare occurrence. The separation of portions of the tumor may, if of considerable size, block one of the valvular orifices and cause sudden death, or more minute portions, becoming released, may give rise to embolism in distant parts. Tuberculosis and syphilis have been con- sidered elsewhere. (b) Parasites.—Four forms may invade the heart-muscle—the taenia echinococcus, actinomyces, cysticercus cellulosae, and the pentastomum denticulatum. The former two are alone productive of mischievous re- sults. The echinococcus groAvths may attain to considerable dimensions and are often multiple; they are secondary to echinococcus-cysts in other organs. Their effects are produced in a purely mechanical man- ner unless fragments become detached, when they may excite embolic NEUROSES OF THE HEART. 661 ' lesions at different points in remote organs. Embolic abscesses have occasionally been observed, appearing like degenerations due to the actinomyces fungus. (c) Misplacement (Transposition of the Heart).—During intra-uterine life the heart (and rarely all the other thoracic and abdominal viscera) may either be transposed to the right side of the thorax, or the fetal position—in the median line—may be retained. The sternum may be missing in Avhole or in part, and the heart, which now lies immediately beneath the skin, can be seen and felt as a throbbing tumor. Recently a man of about forty years applied at the Medico-Chirurgical Hospital in whom the loAver half of the sternum Avas absent; his heart occupied a position in the median line directly underneath the skin, Avhere its strong pulsations could be felt. The patient Avas of the opinion that the condi- tion was congenital, and stated that it had given him no inconvenience. Very exceptionally7 other anomalous positions are acquired during ante-natal development, and the heart may become displaced upward in the chest-cavity even to the neck or dowmvard into the abdominal cavity. (d) Floating Heart.—The structures that serve to maintain the heart in its normal anatomic relations may become Aveakened or unduly lax, in consequence of which the organ may exhibit increased motility. III. NEUROSES OF THE HEART. PALPITATION. Definition.—A more or less rapid action of the heart that is per- ceptible to the patient, and usually accompanied by an increased force of the cardiac contractions or a disturbance of the rhythm, and often also by precordial distress, anxiety, and dyspnea. Etiology.—Chronic valve-disease and other organic affections of the heart seldom produce palpitation, numerous conditions outside of the organ being more frequently related causatively. Among these are—(1) Mental excitement, depression or emotion; (2) Anemia (from the local irritant action of the altered blood-state); (3) The acute in- fectious diseases, in which the toxins in the blood irritate the cardiac accelerating nerves; (4) Dyspepsia, even in robust-appearing persons (as in the gouty7) Avho willingly or unAvillingly commit dietetic errors. Special articles of diet may excite over-action (e. g. straAvberries, shell- fish), the palpitation thus arising from reflex irritation being de- pendent upon gastric catarrh. (5) The use, and more especially the abuse, of tea, coffee, alcohol, and tobacco. These agents are injurious largely through their effects upon the nerves. (6) The female sex mani- fests a greater disposition to the complaint than the male, especially about the period of puberty and the menopause. In the male it is most common at or after the middle period of life, a time Avhen the effects of the work and worry of life showT themselves. (7) Disturbances of the ovaries and other pelvic organs may induce palpitation reflexly. Symptomatology.—Cardiac over-action may, though rarely, be 662 DISEASES OF THE CIRCULATORY SYSTEM. constant, but, as a rule, it displays a definitely paroxysmal character. The onset is sudden, and immediately preceding the attack there are often a blanching of the face and a slowing of the cardiac action, symp- toms due to the momentary inhibitory effect of the nerve-affections that cause the "palpitation." The patient's perception of increased force and rapidity of the heart's action is the essential symptom. Great mental anxiety is common, and more or less dyspnea, and the latter symptom may assume curious phases. In a recent case, occurring in my own practice, the patient Avould attempt at intervals of three to five minutes a forcible, long-draAvn inspiration, Avhich would sometimes suc- cessfully relieve his respiratory difficulties for a few minutes; at other times repeated efforts of the sort would prove ineffectual. Physical Signs.—Inspection shows the impulse to be someAvhat diffuse and forcible. Visible throbbing of the superficial vessels is also common. The finger-tips easily appreciate the increased strength of the impulse. At the wrist the pulse, though strong and full, as a rule is rapid, the rate varying from 120 to 160 per minute. Percussion may shoAv the area of cardiac dulness to be enlarged, while auscultation reveals louder sounds than the normal. The attack is usually of brief duration—but a feAv minutes, though sometimes it may last for hours or days. Attention should here be called to the irritable heart described by DaCosta—a form of palpitation common among young soldiers during the late Civil War. It was caused partly by mental excitement and partly by inordinate muscular exertion. A minor part in its production avus also played by the diarrhea that Avas so often present. The leading symptoms were palpitation, a very frequent pulse, dyspnea, and cardiac pain of varying intensity. Differential Diagnosis.—Nervous palpitation must be distin- guished from the comparatively rare cases in Avhich the heart contracts rapidly, but does not excite subjective sensations. Some of the latter instances of increased frequency are to be looked upon as physiologic, while others are due to exhaustion from ovenvork and dyscrasial debility. They do not constitute cases of palpitation, since they are unperceived by the patient, but are in reality cases of tachycardia. Palpitation due to chronic valve-disease should also be differentiated from the purely nervous form. Here chief reliance is to be placed upon the presence of a murmur and other physical signs during the intervals between the attacks. Anemic murmurs are sometimes present, and must not be confounded with those of organic nature. Prognosis.—The condition is free from real danger to life. Most authors, however, are agreed that cardiac hypertrophy may be a sequel. Treatment.—The chief indications for treatment are—(1) The arrest of the paroxysm. The patient must be put at absolute rest in bed in a large, well-ventilated, darkened chamber, and his clothing loosened so that the respiration is unimpeded. Pressure upon the vagus in the neck or upon special points on the abdominal parietes (the ovarian region in particular) sometimes arrests the attack promptly. In my own hands the best results have been obtained from the application of the ice-bag to the precordial region. If this does not succeed in cutting short the paroxysm in the course of a couple of hours, the ice-bag should be removed every third hour. In conjunction with this measure the TACHYCARDIA. 663 patient should be told to take large draughts of cold water or to SAvallow bits of ice. On the other hand, I have observed a feAv instances which were speedily relieved by the ingestion of hot and someAvhat stimulating drinks. It is, however, not possible to formulate general rules that will be applicable to all cases, and there are rare instances in which the local application of ice cannot be borne. Among the many therapeutic measures that have been employed, none have gained enduring professional favor save the use of morphin, which has given quite constantly good results, and particularlv when administered hypodermically. However, before employing morphin, other sedatives and narcotics should be tried, such as the bromids (in large doses), hyoscyamus, hyoscin, and camphor monobromate. In neur- asthenic and hysteric subjects the bromids and the preparations of vale- rian are highly serviceable. The tincture of valerian or the elixir of valerian ammoniate may be used, and I have found the following cap- sule of great utility: B/. Zinci valerianat., gr. x (0.648); Strychnin* sulph., gr. £ (0.0216); Ext. sumbul., gr. x (0.648); Ext. hyoscyami, gr. v (0.324); M. et ft. capsulae No. x. Sig. One after meal-time. If a special article of diet or an overloaded state of the stomach is the cause, an emetic may be given and the attack thus speedily con- trolled. (2) To prevent a recurrence of the paroxysms, the causal conditions, some of Avhich may long antedate the occurrence of palpitation, must be removed, if this be possible. All exciting factors must also be avoided. The use of tea, coffee, and tobacco must be discontinued, and alcohol should be allowed only in small amounts. The general health must be consid- ered, and anemia, chlorosis, neurasthenia, or hysteria must each receive appropriate treatment when present. When cardiac palpitation occurs in neurasthenia and hysteria the Weir Mitchell rest-cure should be advised, its results often being strikingly good if rigidly practised. Galvanism of the pneumogastric is sometimes useful, the positive pole being placed under the angle of the jaw, and the negative lower down, over each side of the neck. The removal of certain local conditions that sustain a causal relation, as gastric catarrh or intestinal parasitic diseases, is a question that must not be overlooked. If the heart be weak, digitalis may be exhibited for a long time in small doses, and it may in some cases be combined advantageously with iron, arsenic, and strychnin. TACHYCARDIA. (Tachycardia Paroxysmalis; Synchopexia ; Rapid Heart.) Definition.—A rapid movement of the heart occurring in parox- ysms of variable duration, and directly dependent upon either paralysis of the pneumogastric or stimulation of the sympathetic nerves. It is 664 DISEASES OF THE CIRCULATORY SYSTEM. not dependent upon chronic valvular disease, nor upon other gross organic lesions, nor is it generally accompanied by notable subjective sensations. Martius believes that the condition is attributable to sud- den dilatation. Pathology and Htiology.—It occurs as a physiologic condition in a certain proportion of the human family; in such cases the pulse, may range from 90 to 100 beats per minute or over. Certain individuals can increase the pulse-rate by their own volition. The pathologic forms are divisible into—(1) Essential or neurotic tachycardia, and (2) Symptom- atic tachycardia. (1) Neurotic Tachycardia.—The causes of this variety are identical Avith many of those that excite palpitation. Thus, among disposing fac- tors are hysteria, anemia, neurasthenia, chlorosis, and toxic agencies (tea, coffee, tobacco, the poisons of febrile conditions). Violent exercise, intense mental agitation, fright, grief, and other forms of shock are the chief determining influences. Not a feAv cases are obscure as to their etiology. (2) Symptomatic Tachycardia.—The lesions that induce this form are —(a) Central, and (b) peripheral. In the former group are especially to be placed tumors, clots (due to hemorrhage), and softening of the me- dulla and cord; and in the latter, tumors, aneurysms, enlarged lymph- glands (which paralyze the vagus by exerting pressure upon it either in the neck or thorax), and neuritis, affecting the pneumogastric nerve. The latter lesion may be associated with polyneuritis (alcoholic or infec- tious). Rapid heart is sometimes due to reflex irritation from gastric, intestinal, arterial, uterine, and ovarian affections. Symptoms.—The clinical picture in most instances of the com- plaint is made up of recurring paroxysms of heart-hurry (paroxysmal tachycardia). These attacks come on Avith great suddenness, and, as a rule, Avithout prodromes or forebodings. If the latter occur, they con- sist of vertigo, tinnitus, and a sense of impending danger, and some- times persist to the end of the attack. With the onset of the parox- ysms the cardiac movements leap to 150, 175, 200, and 250, or even JaAAA/WwvAAAAAAAaA/VSAT^^ Fig. 55.—Radial pulse during an attack of paroxysmal tachycardia. to 300, beats per minute. The pulse is feeble, small, readily compress- ible as a rule, and sometimes irregular (Fig. 55). Rarely it is full, strong, and of good tension. The respiration may or may not be in- creased in frequency, but dyspnea is not common. Actual thoracic con- striction and smothering are seldom witnessed in genuine tachycardia. At first pale, the skin soon becomes flushed, and the countenance may wear an anxious expression ; but unless " palpitation " is associated there are no symptoms present that denote an intense degree of suffer- ing. In many cases the patient is not conscious of palpitation, or there may be a sense of slowing of the heart, Avhen in reality the cardiac con- BRACHYCARDIA. 665 tractions may be increased to 200 or more ; this is typical tachycardia. In a chlorotic girl I found that the pulse-rate increased to 200 beats, and lasted for a feAv minutes at each visit to my office. During the intervals betAveen the visits the pulse Avas apparently normal in fre- quency. II. C. Wood reports a truly remarkable case occurring in a physician in his eighty-seventh year, Avho has had attacks at intervals since his thirty-seventh year. Following a sudden onset, the pulse rises quickly to 200 beats per minute. The attacks can be averted by the taking of ice-water or strong coffee. Physical Signs.—A diffuse, rapid, and sometimes irregular impulse may be observed on inspection and palpation, but seldom is there an enlargement of the heart. The sounds are slightly modified, the first being accentuated, and the second aortic greatly diminished in intensity, OAving to the lessened amount of blood throAvn into the aorta with each ventricular systole ; the intensity of the second pulmonic, however, may be increased. An apical systolic murmur is occasionally audible. The carotids pulsate, and on auscultating over them a murmur is sometimes heard. The duration of these recurring cardiac paroxysms Araries from one to tAvo or more decades. Diagnosis.—I Avould restate the fact that a high pulse-rate (200 or over a minute) and an absence or only a slight sense of palpitation or rapid heart-action are the distinctive features of true tachycardia. In palpitation (previously considered) the pulse-rate is not usually so high as in tachycardia, while the associated phenomena of dyspnea, precor- dial constrictions, smothering, and painful anxiety are correspondingly more pronounced. Prognosis.—In the majority of cases no serious impairment of the general health follows, though the course is exceedingly chronic and recoveries are comparatively rare. When symptomatic tachycardia is due to lesions that are removable, it is often curable, though not invari- ably so. In sufferers who are advanced in years, hoAvever, the cerebral vessels may rupture at the onset of an attack or sudden death from cardiac paralysis may ensue. Bouveret analyzed a number of cases, 4 of Avhich proved suddenly fatal in consequence of heart-failure. The treatment is to be conducted on precisely the same lines as those advanced for ''Palpitation" (vide p. 662). BRACHYCARDIA. (Bradycardia) Definition.—SloAvness of the pulse. The condition may be physio- logic, the rate of the pulse being sometimes 60 or less, and very rarely as Ioav as 40 per minute during perfect health. All cases of pathologic brachycardia fall naturally and conveniently into tAvo groups: (1) those that are secondary to other complaints (symp- tomatic brachycardia); and (2) those that are due to, or associated with, a neurosis. Pathology and Etiology.—Symptomatic Brachycardia.—(a) Aris- ing during convalescence from acute infectious diseases, especially pneu- 66Q DISEASES OF THE CIRCULATORY SYSTEM. monia, typhoid, diphtheria, erysipelas, and acute rheumatism. Accord- ing to Riegel, who analyzed 1047 cases in Avhich the pulse-rate was less than 60, the acute fevers must be awarded the first place among the causal factors. I have met with 3 cases of diphtheria in Avhich the pulse in convalescence fell to 30 a minute. That such instances are, as Traube contends, due to exhaustion is true of some cases, but not of all, and doubtless there are other changes in a certain proportion. The sloAving of the pulse that is observed after premature or full-time delivery is sim- ilarly produced, (b) The second place belongs easily to gastro-intestinal and hepatic disorders (chronic gastro-intestinal catarrh, ulcer, or carci- noma of the stomach), (c) Brachycardia occurs in diseases of the circu- latory system—in coronary disease, fibroid and fatty myocardial change, most frequently; and chronic valvular disease much less frequently, if we except aortic stenosis, (d) Pulmonary complaints (emphysema and asthma), (e) Toxic agencies, as in jaundice, blood-poisoning, al- coholism, the unAvonted use of tea, coffee, tobacco, and a feAv drugs (e. g. digitalis, strophanthus). (/) Certain constitutional affections (anemia, chlorosis, diabetes), (g) Rarely skin-diseases and affections of the sexual organs are accompanied by brachycardia. In various organic nerve-affections (apoplexy, meningitis, epilepsy, tumors of the cerebrum, and the medulla in particular, injuries and diseases of the cervical por- tion of the cord). In such cases the brachycardia is due chiefly to direct or reflex irritation of the center or of the peripheral portion of the vagus system. Indeed, brachycardia is produced in one or other of these ways, whatever may be the nature or seat of the primary condition, except in those cases in which it is brought about by exhaustion of the automatic motor apparatus of the heart. (2) Brachycardia associated with a neurosis may be found to be marked in epilepsy, less so in hysteria, melancholia, mania, and gen- eral paresis of the insane. It precedes palpitation. Symptoms.—The sole characteristic symptom is the slow action of the heart, and this may either be temporary or permanent. If paroxys- mal, both the onset and termination are apt to be sudden. A slow emerg- ence is, however, more common than a sIoav beginning, though a small group of prodromes appears, comprising vertigo, tinnitus, and a sense of impending danger. During the paroxysm the patient may repeatedly suffer from syncopal attacks or become unconscious for hours at a time; physical prostration may also be marked, and especially when secondary to chronic valve-disease. The pulse is weak and small, and the beats per minute vary from 50, 40, 30, 20, to 10, or even 8. When the con- dition arises in the course of organic valve-lesions the cardiac contrac- tions, as a general rule, may be increased in power, though greatly reduced in frequency. Thus, I observed this occurrence in a patient under my care at the Philadelphia Hospital suffering from a double mitral lesion and aortic constriction. The pulse fell from 70 to 28 per minute, but the systole Avas more powerful than before brachycardia Avas developed. The pulse at the wrist does not shoAv the rate of cardiac contractions (when the heart is weak), since the latter do not always emit a pulse-wave that can be detected at the wrist; hence the heart- action must be noted by auscultation, and the rate compared with that of the peripheral pulse. The impulse and the heart-sounds are feeble. ARRHYTHMIA. 667 Diagnosis.—A pulse beloAv 48 beats per minute, with correspond- ing sloAvness of the systole, suffices for a positive diagnosis. The prognosis is governed by the cause, being very grave in cerebral and advanced cardiac diseases. When fatal, sudden death is the rule. Treatment.—Rest in the lying posture, particularly if the condition has come on in organic heart-disease, and such remedies as atropin, strychnin, caffein, nitroglycerin (in small doses), and ammonia are to be given a trial. If the ventricular contractions are very feeble and not beloAv 30, small doses of digitalis Avill be found useful, though the effect must be closely Avatched. In the intervals betAveen the attacks the gen- eral health must be improved and the causal states eradicated. ARRHYTHMIA. (Irregidar Heart- and Pulse-beat) (1) The irregularity may affect only the volume and force of the pulse. Here the intervals betAveen the beats are equal, but in regard to fulness and strength the beats are unequal. Instances of irregularity in the volume and strength of heart-beats may give rise to the condition known as pulsus alternans (Traube), in which fuller and stronger pulse- beats regularly alternate with those of lesser volume and strength (see • Fig. 56). (2) Irregularity in Time.—(a) Intermittent heart-beat. This Fig. 56.—Pulsus bigeminus alternans (Eichhorst). is but an exaggerated degree of the first variety, and signifies a missed or dropped beat. This occurs at irregular intervals in most of the cases, though sometimes a cyclical irregularity is observed—i. e. every four, six, eight, or ten beats being marked by an intermittence. (b) Twin- pulse (coupled beats, allorrhythmia). When two beats follow each other quickly (the diastole being shortened), and the next two not so quickly (the diastole being lengthened), we have produced the pulsus bigeminus. The first and second beats may be of equal strength, but often the second is relatively feeble. This is best determined by auscultation of the heart, since the second systolic contraction (of the ventricle) may indeed be so weak as not to give rise to a palpable beat at the Avrist. I have frequently observed the pulsus bigeminus in mitral disease. With 668 DISEASES OF THE CIRCULATORY SYSTEM respect to the diastole, the pulsations may be in blocks of three (pulsus trigeminus), or even of four (pulsus quadrigeminus). (3) Combined irregularity of time and volume. Whilst the forms of irregularity above described should be distinguished from one another whenever possible, vet this is sometimes unattainable, particularly in the last stages of val- vular disease and in the acute infectious diseases—conditions in Avhich the heart-muscle fails in consequence of degenerative changes. (4) The paradoxical pulse of Kussmaul also consists in irregularity of volume, strength, and time, though not indicative of so great peril as the preced- ing. It is dependent upon the act of inspiration—" normal as well as forced"—the beats during respiration being more rapid, though weaker, than during expiration. This is met with in chronic adhesive pericarditis, in cases of pressure upon the root of the aorta by bands, in pleuro-peri- carditis, and in a very weak heart. (5) Delirium cordis is a term very appropriately given to great irregularity and inequality of the pulse-beats. It is seen in extreme dilatation and advanced exophthalmic goiter. (6) Embrocardia or Fetal Heart-rhythm.—There is a shortening of the long pause with a striking similarity of the first and second sounds, as in the fetal heart. I have already pointed this out in connection w7ith dilatation, though it also sometimes attends the advanced stages of grave fevers. (7) Cantering Rhythm (bruit de galop).—The sounds simulate the triple footfall of a horse at canter. The interpolated sound is due to a redupli- cation of the second, though rarely it is the first that is doubled instead. The third sound, hoAvever, may occur at any period of the diastole. The condition is developed frequently in the hypertrophy of arterio-sclerosis and Bright's disease, in profound anemias, and in the myocarditis of certain acute infectious diseases. Etiology.—Baumgarten's classification of the causes of arrhythmia (quoted by Osier) is the best, and is here given : (1) Those due to central—cerebral—causes, either organic disease, as in hemorrhage or concussion, or more commonly psychical influences. (2) Reflex influences, such as produce the cardiac irregularity in dys- pepsia and diseases of the liver, lungs, and kidneys. (3) Toxic influences. Tobacco, coffee, and tea are common causes of arrhythmia. Various drugs, as digitalis, belladonna, and aconite, may also induce it. (4) Changes in the heart itself, (a) In the cardiac ganglia. Fatty, pigmentary, and sclerotic changes have been described in cases of this sort, and these may have an important influence in producing disturb- ances in the rhythm, but as yet we do not know their exact significance. They may be present in cases that have not presented arrhythmia, (b) Mural changes are common in conditions of this kind. Simple dilata- tion, fatty degeneration, and sclerosis are most commonly present, the two latter being usually associated with sclerosis of the coronary arteries.1 Symptoms.—Arrhythmia, particularly when functional or of reflex origin, may exist for years together, without associated symptoms refer- able to the heart, and hence is often discovered accidentally. When it is combined with palpitation or extreme Aveakness or dilatation of the organ, it is apt to arrest not only the attention of the observer in many instances, but that of the patient also. 1 Transactions of the Association of American Physicians, vol. iii. ANGINA PECTORIS. 669 Physical Signs.—In given cases the cause Avill be found to govern the character of the physical signs, Avhich are often scanty or sometimes practically wanting. Those usually present have been indicated in speaking of the different varieties. Diagnosis.—Palpation and auscultation of the heart while examin- ing the pulse are matters that should never be neglected if reliable results are to be obtained. It is especially in this class of cases that the sphyg- mograph renders invaluable aid. Sphygmogranis will often shoAv the kind and degree of arrhythmia Avhen all other means of examination have failed, and also distinguish marked dierotism from irregularity. It is important to differentiate functional arrhythmia or that of reflex origin from arrhythmia due to more or less grave myocardial disease. This can be accomplished only by a careful exclusion of the varied eti- ologic factors that produce the functional form, and by a careful revieAV of the cardiac symptoms. The prognosis is as variable as is the causation of the complaint. A gentleman Avith whom I am well acquainted Avas rejected by a leading life-insurance company twenty years ago on account of occasional inter- mittence and irregularity of the heart, though he is still in active busi- ness life and apparently in vigorous health. When the myocardium becomes involved, either secondarily to chronic valvular or coronary disease or in association with the acute infectious diseases, the prospect is gloomy ; but when it folloAvs the action of mental influences and remains as a permanent condition, or when it is due to other causes outside of the heart itself, the course pursued is, on the whole, much more favorable. Treatment.—There are many cases of the more benign form in which little, if anything, can be accomplished save to benefit the patient's general health, and this. I take it, is of paramount importance. Removal of the causal forces, as tea, coffee, alcohol, indigestible food-stuffs, con- ditions acting in a reflex manner, must be executed promptly. When the condition is due to changes in the heart-structure, cardiac in addition to the general tonics should be prescribed. I prefer strychnin, arsenic, and the dried sulphate of iron in combination as being both local and general in their effect. If the arrhythmia be due to excessive cardiac dilatation, digitalis should be employed. In purely functional cases, in which there is a predominating neurotic element, not infrequently the subjoined formula has been useful in my hands : R/. Ferri valerianatis, Zinci valerianatis, ad. gr. xxx (1.94); Strych. sulph., gr. j (0.0648); Pulv. digitalis, gr. viij (0.518). Ft. capsular No. xxx. Sig. Take one after meal-time. ANGINA PECTORIS. (Stenocardia, Breast-pang.) Definition.—A paroxysm of violent precordial pain extending into the neck, back, and arms, and at times attended by a sense of impending 670 DISEASES OF THE CIRCULATORY SYSTEM. death. It scarcely deserves to be classified as a separate disease, bein^ merely symptomatic of several cardiac lesions already described. Pathology.—Concerning the nature of angina, we possess few, if any, positive data. Many theories have been advanced, but to adduce them here could serve no useful purpose, and conclusive postmortem evi- dence in support of the various theories that have been and are advocated is, as yet, wanting. Neither does any single hypothesis fit the group of symp- toms so constantly observed in cases of angina. It is to be recollected, however, that it is a neurosis affecting the cardiac sensory filaments that are given off chiefly from the pneumogastric, and in many cases the vasomotor apparatus is also involved. Nothnagel has described a form distinct from the above in which the vasomotor apparatus is chiefly in- volved (angina pectoris vasomotoria). Htiology.—Cases of angina unassociated with arterial sclerosis, hypertrophy, or aortic regurgitation are rarely encountered. Hence it is quite probable that certain cardio-vascular lesions in some way, as yet undetermined, dispose to the disease under discussion. This vieAv also receives some degree of color from the fact that angina usually occurs after the fortieth year, and principally in the male sex. The determining factors of the attack are undue exertion and mental emotion. Symptoms.—The paroxysm begins quite suddenly during the action of one or other exciting cause. The suffering is excruciating and of a grip-like character, affecting the entire chest and rendering the body mo- tionless. The pain radiates most frequently to the left shoulder, though also at times to the right, and thence to the back, neck, and doAvn the arms to the fingers. Coldness and numbness of the fingers or in the precordial area may be present. Not less agonizing than the pain is the awful sense of impending death. The countenance is frequently pale, and may assume a leaden hue, and is usually bathed in cold perspiration. The respirations are exceedingly shalloAv or even temporarily arrested, and the patient's anxiety is extreme. The heart's action may be regular, and the arterial tension, as shown by the pulse, is generally increased. The duration of the paroxysm varies from a feAv seconds to a minute or tAvo, and after the pain is over gaseous eructations, vomiting, or the dis- charge of a large amount of clear urine may occur. With the cessation of the attack comes instant relief from the cardiac symptoms. On mak- ing a careful examination of the heart subsequent to the seizure there may be an utter absence of signs, and, though there is weakness, this soon disappears. The attacks may recur at intervals varying from a feAv days to many years. I have usually found that cases associated with aortic regurgitation give the shortest intervening periods as a rule. In angina vasomotoria the pain in the heart-region is preceded for a few minutes by pallor of the face, coldness and stiffness of the limbs, due to spasm of the peripheral vessels. The painful paroxysms are less severe than in the form above described. Pseudo-angina.—This is also a paroxysmal affection, occurring usually in hysterical females, though occasionally also seen in neurasthenic males. Its symptomatology is given below. Diagnosis.—The characteristic events are a sudden, most intense pain in the substernal and left parasternal regions, with marked constric- tion of the chest, the peculiar manner of radiation of the pain, and the ANGINA PECTORIS. 671 sense of impending death. Less diagnostic, though of considerable value, are the brevity of the attack, the sudden onset and cessation of the pain, the age and sex, and the anxious, moistened features. There are also lighter forms in Avhich one or more of the diagnostic phenomena, above described are absent. If they occur between the ages of forty and sixty years in persons in whom either arterial sclerosis or aortic regurgitation is present, this disease should be thought of; and after the exclusion of certain com- plaints in Avhich paroxysmal pain is prominent, such as gastralgia and locomotor ataxia, the diagnosis of angina becomes reasonably positive. The distinction between true and pseudo-angina pectoris is not always easily drawn, but the most important points for discrimination may be found in the tabulated statements below : Axgina Pectoris. Pseudo-axgina. Etiology indeterminate, though generally The causes are—hysteria, neurasthenia. associated with arterio-sclerosis (in- toxic agents, and reflex irritations. eluding coronary disease) or aortic regurgitation. Occurs after the fortieth year, usually in Occurs at any age (over six years), and males. usually in females. Paroxysms, provoked by exertion or men- Paroxysms arise spontaneously, are peri- tal emotion, are rarely periodic and noc- odic and often nocturnal. turnal. Pain intensely severe, and constricting, Less intense pain, more diffused over the its chief center being to the back of the thoracic region : sensation of cardiac mid-sternum and toward the left. distention. Duration of attack from a few seconds to From a half to several hours. one or two minutes. Patient silent and body fixed. Restlessness and emotional symptoms of causal conditions associated. Arterial tension increased as a rule. Usually not increased. Prognosis unfavorable. Entirely favorable. The vasomotor form of angina must not be confounded with pseudo- angina, Avhich is infinitely more common. The prognosis is bad, yet uncertain. I recall two instances that occurred ten and tAvelve years ago respectively: the first attacks were survived with no recurrence up to the present, and neither case presented any evidence of cardio-vascular disease. When the arteries are sclerosed (particularly the coronaries) life is often suddenly terminated during the course of the attack. Occasionally the sufferer dies of syncope. The nature of the causal and associated lesions must, therefore, be considered in making a prediction. In the vasomotor angina of Nothnagel the out- look is less grave, while in pseudo-angina it is always bright. Treatment.—Prevention of the attacks in persons who are subject to them is of the most importance. In order to do this all known excit- ing factors are to be rigidly avoided. The patient should be instructed to carry constantly in a convenient pocket such agents as nitroglycerin and amyl nitrite, beads or perles (strength 3 to 5 drops), and also how to use them with judicious care immediately upon the first indication of an approaching paroxysm. The treatment of the attack must be prompt and energetic, though carefully conducted, amyl nitrite being inhaled at once from a handker- chief in doses of 3 to 5 drops according to the severity of the attack. The patient should then be placed in a cool apartment free from disturbing 672 DISEASES OF THE CIRCULATORY SYSTEM. sounds. Locally, the use of the ice-bag may prove efficacious and should be tried at first. There are cases, hoAvever, in which hot applications (hot cloths or sinapisms) give better results than cold. If the pain is not controlled promptly by this method, the nitrite should be reinforced by the hypodermic injection of morphin (gr. -|—0.0216) combined with atro- pin (gr. Tttq—0.0005). This rarely fails of bringing speedy relief, and is best suited to those instances in which there is no increase of arterial tension. In cases exhibiting high arterial tension, to the treatment advo- cated above may be added the tincture of nitroglycerin, employed hypo- dermically (dose TTlj—0.066—to be repeated once in a minute if the pain continue). During the intervals betAveen the attacks the aim should be not only to obviate the action of the exciting causes, but also to overcome any dis- posing influences that may exist. Obviously, then, the nature of the causal conditions, hoAvever remote, will govern the treatment. In cases in which the arterial tension is habitually exalted nitroglycerin in in- creasing doses is to be used perseveringly, beginning with 1TLJ (0.066) and increasing by TTLJ (0.066) every five or six days until the physiologic effects are produced. Sodium nitrite may be employed similarly, the dose, being gr. j-iij (0.0648-0.184) three or four times daily. Marked arterial sclerosis, particularly if there be a syphilitic history, is more favorably influenced by a long course of potassium iodid than by any other remedy. It may be prescribed in doses ranging from gr. v to xx (0.324- 1.296) three times a day. When, as happens in aortic regurgitation, the hypertrophy of the left ventricle is excessive, the use of the following formula is effective: B/. Tr. aconiti rad., Wxlviij (3.10); Sodii bromidi, §ss (16.0); Elix. simplicis, q. s. ad giij (96.0).—M. Sig. 3j (4.0) t. i. d. It may be omitted at the end of every two weeks for two or three days. The presence of a gouty diathesis would call for special treatment. In the vasomotor form amyl nitrite and nitroglycerin are most valuable. Externally, hot foot-baths, followed by friction of the extremities, are also of the highest utility. The treatment of pseudo-angina must be directed to the cause of the complaint—the neurotic condition. IV. CONGENITAL AFFECTIONS OF THE HEART. These result from two leading causes : (1) Arrested development, and (2) Fetal endocarditis. Occasionally, both these factors are operative. (1) Arrested development may produce a great variety of anomalies, some of which may be briefly enumerated: (a) Acardia, absence of the organ, (b) Cor biloculare, or reptilian heart, in which the septum be- tAveen the auricles and ventricles is absent, thus reducing the number of chambers to two. This is an instance of reversion to a lower type, (c) CONGENITAL AFFECTIONS OF THE HEART. 673 Absence of the interventricular septum, the heart consisting of three chambers (cor triloculare). More frequently there is a mere perforation in or an incomplete development of the septum, and this is usually situ- ated in the upper portion. Obstruction of the pulmonary orifice or of the conus arteriosus of the right ventricle are frequently conjoined con- ditions. ((/) Patency, or incomplete closure of the foramen ovale. Per- sistence of the foramen is, in the majority of cases, associated with ob- struction of the pulmonary valve, though it may be solitary, (e) An anomaly known as ectopia cordis deserves mention. This is a condition in which the sternum is usually divided vertically, and the heart is either entirely exposed or beating just beneath the skin in the cardiac, thoracic, or abdominal region. In this connection another and the most common form of malposition may be added—namely, dextrocardia. Here the heart occupies the right side, with reversion of the arch and displacement of the descending aorta to the right of the spinal column. Transposition of other viscera is usually associated. (/) Anomalies of the valves.—There may be either a numerical increase or decrease of the cardiac valves, par- ticularly the segments of the semilunar valves of the aortic and pulmo- nary orifices. Supernumerary segments are usually rudimentary, and at the pulmonary valve one, two, or more are most commonly seen. A de- crease in the number of segments is also most frequently observed at the arterial orifices, the aortic and pulmonic semilunar valves then being composed of two segments (bicuspid). This condition may be due to de- fective development on the one hand, or to endocarditis with resulting cohesion of segments on the other. (2) Fetal endocarditis leads to valvular deficiencies in a manner sim- ilar to Avhat occurs during the whole post-natal period. The valve- lesions originating during fetal life are most frequently situated on the right side, probably for the reasons that the ante-natal circulation is more actively carried on in the right than in the left heart, and that the former receives the oxygenated blood from the placenta. They may7 occur at the pulmonic, the aortic, or the auriculo-ventricular orifices. The changes are of the slow sclerotic form as a rule, and their character is determined largely by the antecedent anomalies that predispose to them. The leaflets present smooth, thickened, and contracted borders. Union of the mitral segments is common, and the chordae tendinere are often thickened and contracted. The small rounded bodies that are normally present on the mitral and tricuspid segments (nodules of Albini) must not be confounded with pathologic verrucosities. The most frequent congenital valvular lesion is stenosis of the pulmo- nary orifice as the result of chronic endocarditis. Rarely, it is due directly to defective development, and perhaps more rarely still to endo- carditis verrucosa. Pulmonic constriction of ante-natal origin may be an associated lesion in other forms of valvular disease in the young adult. With stenosis at the pulmonary orifice, there usually coexist stenosis of the conus arteriosus of the right ventricle, an open foramen ovale, and a patent ductus arteriosus; according to Peacock, " in 86 per cent, of the patients with congenital heart-disease living beyond the twelfth year the lesion is at this orifice." Atresia of the pulmonary orifice occurs, though less frequently than stenosis. At the tricuspid orifice there may be stenosis or contraction of the 43 674 DISEASES OF THE CIRCULATORY SYSTEM. valves, producing either obstruction or regurgitation. Similar lesions of the aortic orifice are infrequent. Congenital mitral disease also occurs, but only exceptionally; it is then usually associated with tricuspid stenosis. Boys are somewhat more liable to congenital affections of the heart than girls. Symptoms.—Though the precise nature of the anomaly differs widely in different cases, there is one almost constant and strikingly dis- tinctive symptom in congenital heart-disease—the cyanosis. The tint of skin observed is variable, being at one time a general duskiness, at an- other a deep violet, and rarely almost black. This coloration is most noticeable about the lips and mucous membrane of the mouth, the nos- trils, conjunctivae, the fingers, toes, and lobules of the ears, and as a rule is general, though it may be a local condition. The tint may grow less distinct, and even almost vanish, Avhen the child is in perfect repose or sleeping ; excitants or efforts at coughing, hoAvever, increase the in- tensity of the discoloration. The cyanotic hue comes on almost invari- ably during the first week of life. The fingers present a decidedly clubbed appearance, and the nails are thickened and curved like the claws of certain animals. The temperature is subnormal, Avhile the ex- tremities are cool to the feel. Dyspnea on exertion and cough are usual concomitants. Cyanosis may be due to numerous causes that may act either singly or more often concurrently. The leading factors are an ex- tensive intermingling of venous and arterial blood, obstructive to the flow of the venous blood-stream to the lungs or through the latter organs —a condition usually resulting in cyanosis in consequence of deficient ox- idation of the blood. Physical Signs.—In the very young the impulse is feeble (with an ab- sence of a palpable thrill), the percussion-dulness is increased, especially to the right, and a loud systolic murmur is audible at the pulmonary ori- fice. When the auriculo-ventricular valves are the seat of endocarditis the murmur may be apical. In pure pulmonary stenosis the second sound is feeble. In older children the area of dulness is only slightly extended, partic- ularly to the left, while the murmurs heard are loud and often musical. It is interesting to note that in rare instances cerebral abscess is an associated condition. Differential Diagnosis.—The distinction betAveen congenital and acquired lesions in children may be assisted by a reference to certain points tabulated beloAv : Coxgexital Lesions. History of almost constant cyanosis, be- ginning in the first week after birth. Slight enlargement of the heart. It is of the right ventricle, chiefly non-progres- sive. Loud and musical murmurs present, au- dible over upper third of sternum, with small area of transmission upward and to the left; second sound weak. Deficient bodily development. Mental faculties in abeyance. Acquired Lesions. Not so; history of endocarditis or of rheumatism or other complaints in which endocarditis occurs as a com- plication. Enlargement marked, frequently involv- ing the left ventricle, and progressive. Audible over apex or base ; definite large areas of transmission. Second sound frequently accentuated. Bodily development good, as a rule. Mental faculties normal. DISEASES OF THE ARTERIES. 675 Prognosis.—The prognosis is exceedingly grave. Many succumb within a few days after birth, more than one-half before the expiration of one year, and not less than three-fourths before the end of the third year. Few survive the first decade of life, and feAver still reach full adolescence. Among the forms giving the most favorable prognosis are pulmonary stenosis, especially Avhen of moderate grade, and defective auricular and ventricular septa. In those instances in which life is spared in the first weeks after birth there is a disposition to affections of the lungs (phthisis, hemoptysis), nerve-complaints (convulsions), cerebral hemorrhages, etc. Treatment.—The treatment is, in the main, hygienic. The body must be warmly clad, flannels being worn next the skin, and every source of cold should be carefully guarded against. The diet is to be judiciously arranged, yet liberal, preference being given to the carbohydrates. Gentle exercise when it can be taken is valuable, as are also daily spongings of the surface followed by friction. Special therapeutic indications may arise, and must be met in accordance with general principles, while tonics, such as iron, arsenic, quinin, nux vomica, and cod-liver oil, are frequently applicable. V. DISEASES OF THE ARTERIES. ACUTE AORTITIS. Pathology.—The morbid changes coincide with those noted in acute endocarditis, including the ulcerative variety. Aneurysmal dilatation, or even rupture of the aortic coats, may be observed as a sequel. Utiology.—The causes are not clear, but the condition most generally follows many of the acute infectious diseases (typhoid fever, pneumonia). Infectious emboli have been discovered to be causal irritants. Symptoms.—The symptoms are local and general. Of the former, diffuse thoracic pain (sometimes severe and throbbing, though more often slight), with more or less substernal tenderness under pressure and cardiac palpitation, are the chief. Among the general symptoms a moderate feb- rile movement is almost constant. In a certain percentage of cases em- bolism is betrayed by the usual signs, as rigors, accompanied by a steep temperature-curve. These forms are analogous to the malignant variety of endocarditis. A cardiac murmur may be heard over the upper part of the sternum. Diagnosis.—All that the best clinicians can do is to establish a probable diagnosis even in the presence of the most frankly expressed features of the affection. From acute endocarditis aortitis is to be dis- criminated by its diffuse and severe pain and by the higher seat of its murmur wrhen present. The prognosis is serious, owing to the greater liability to infectious emboli and the possibility of aortic rupture. The treatment is to be conducted on the same general plan as in acute endocarditis. 676 DISEASES OF THE CIRCULATORY SYSTEM. ARTERIAL SCLEROSIS. (Arteriosclerosis; Arterio-capillary Fibrosis; Endarteritis Chronica Deformans; Atheroma?) Definition.—An overgrowth of the connective tissue of the arterial coats (chiefly and primarily of the intima), followed by calcareous deposi- tions. The process may, though seldom, extend to the veins. Pathology.—The most frequent seat of the sclerotic process is the aorta, and the next most common the coronary arteries. Other vessels implicated are the arteries of the brain, the temporals, radials, brachials, ulnars, femorals, and iliacs. On the other hand, certain arteries, as the gastric, hepatic, and mesenteric, are rarely affected. Tavo forms may be recognized : (a) the circumscribed, and (b) the diffuse. (a) Circumscribed Arterio-sclerosis.—Naturally, the intima presents a smooth internal surface, but when atheromatous changes occur it shoAvs localized areas of thickening. These patchy prominences are often hemi- spheric in outline, yellowish-white in color, and their favorite seats are the orifices of the branches. They increase in depth and superficial area, and on reaching an advanced stage their interior disintegrates into granular material (atheromatous abscess). In circumscribed or nodular atheroma the microscope discloses the fact that the middle and external coats are the primary seat of the changes, which consist of localized infiltrations. These lesions weaken the media and adventitia, and then (as shown by Thoma) compensatory processes are set up in the intima which lead to the formation of the so-called atheromatous button. The latter consists in a hyperplasia of the intima with a deposit of round cells, AA'hich causes a gradual increase in thickness; in this Avay the groAving weakness of the middle and outer coats is com- pensated. When the prominences in the intima undergo softening or liquefaction, rapid dilatation of the affected vessels is apt to occur. The same accident may arise early, or before the intima has reinforced the other layers by its increased thickness and strength. (b) Diffuse Arterio-sclerosis.—In this form the morbid process is dis- tributed throughout the greater part of the arterial system, the nodular or circumscribed form being usually combined with it in the aorta. Dila- tation of the aorta and of its branches commonly coexist. Apart from the yellowish, translucent, elevated areas, the intima may be smooth and the naked-eye appearances almost normal. The coats, however, and par- ticularly the intima, are very much thickened. Microscopic examination brings to light an extensive proliferation of the sub endothelial connective tissue and a hyaline transformation of the entire media, particularly in the larger vessels. The muscular fibers and elastic tissue have in advanced cases almost totally disappeared. Necrotic degeneration of the media, especially in the smaller arteries, is also observed, and calcareous deposits, causing rigidity of the walls, occur among the later changes. This is particularly true of the so-called senile arterio-sclerosis. Atheromatous abscesses that burst from atheromatous ulcers are likeAvise common pathologic events in the aged. There may be associated atrophy of the heart, liver, and kidneys, due to a lack of nutritive supply in consequence of the narrowed tissues of the vessels. More commonly, however, in this, and constantly in circumscribed and diffuse sclerosis, the heart is moder- ARTERIAL SCLEROSIS. 677 ately hypertrophied. When coronary disease is associated, fibrous myo- carditis and sclerosis of the aortic flaps may be found associated. The kidneys may also become sclerotic—a condition which will be described hereafter (vide Diseases of the Kidneys). Sclerosis of the pulmonary artery, previously referred to in the dis- cussion of the Diseases of the Heart, exhibits all the changes observed in connection with atheroma of the systemic arteries, including aneurysmal dilatation of the trunk and rarely of the main branches. From the ter- minal tributaries the process may extend to the capillaries, and even to the pulmonary veins (angio-sclerosis). The effect of arterio-sclerosis upon the physiologic functions of the vessel-Avails, and the pathologic and clinical results are of the utmost im- portance. The elastic coat is destroyed, and hence the Avails cannot bear the blood-pressure as well as in health. This predisposes to dilatation of the vessels (aneurysm). Another result of extensive atheromatous degeneration of the vessels is an increase in the resistance to the blood-current, and a consequent elevation of the arterial pressure. Furthermore, the loss of elasticitv in the coats of the medium-sized and smaller arteries removes an important factor in the propulsion of the blood. The left ventricle, in consequence of this fact, almost invariably becomes hypertrophied in cases of extensive arterio-sclerosis, provided the general nutrition of the patient is still well maintained (Striimpell). The reduction of the lumen of the vessel, owing to the thickening of the intima, must lessen the blood-supply to the various viscera, and thus in part are explained such secondary affections as fibrous myocarditis, cirrhosis of the kidneys, and cerebral softening. Sclerosis of the veins (phlebo-sclerosis) has rarely been observed as a sequel to arterio-sclerosis. It is, however, not infrequently found in asso- ciation with hepatic cirrhosis and mitral disease when the portal system and pulmonary veins are involved. It is occasioned by increased intra- venous pressure. Microscopically, thickening of the intima and atrophic degenerative changes in the media are commonly observed. Calcification and hyaline degeneration of the layers also occur, and I have observed them in one of my own cases. Moderate dilatation is not exceptional. Etiology.—The diffuse form has, in part, a special etiology. It may appear in the young, though rarely; I have met with a case in the Medico-Chirurgical Hospital in a man aged twenty-four years. It is, howrever, most frequent in the middle-aged who are able-bodied and in the aged. In old persons atheroma is often physiologic and characterizes the natural involution-period of life. Heredity may play no inconspicuous part in arterio-sclerosis dependent upon the age. This fact furnishes, to some extent at least, the reason why senile changes in the arteries occur at a much earlier period of life in some instances, and even throughout whole families, than in others. Negroes are more liable than whites to this form of atheroma, and males than females, though it is more frequent in the latter sex than the circumscribed variety. Muscular overstrain, Avhich augments the blood-pressure while at the same time obstructing the peripheral circulation, is a leading factor. The general causes of arterial sclerosis are—(1) Biologic irritants, 678 DISEASES OF THE CIRCULATORY SYSTEM. as the specific micro-organisms of malaria, rheumatism, and syphilis. (2) Chemical irritants (chronic alcoholism, lead-poisoning, uric acid in gout). The above toxic agents produce their effects partly by their direct irritant action, and partly by increasing the resistance in the peripheral vessels and thus raising the arterial pressure. Syphilis, saturnine-poison- ing, and chronic rheumatism may produce the affection in young subjects. (3) Bright's Disease.—It must be admitted that there is a class of cases in Avhich arterio-sclerosis is secondary to Bright's disease, but when found in association the former is more frequently the primary disease than the latter. The chief causes of chronic nephritis are also capable of setting up atheroma, and hence it must not be forgotten that the tAvo diseases may develop independently of one another, and yet simultaneously, in conse- quence of the action of a common cause. (4) Constant over-filling of the blood-vessels, resulting from excesses in eating and drinking, in the opinion of certain authors also causes arterio-sclerosis. A predisposing effect is exerted by advancing years and by the sex, more males being affected than females; it must be recollected, however, that males are more often subjected to the influence of the leading causal factors than females. The main causes of sclerosis of the pulmonary artery are mitral disease and emphysema. Clinical History.—The disease may exist for years without becom- ing apparent, or it may be discovered incidentally at autopsy while pal- pating the arteries during the course of an examination for some sup- posed local visceral affection. The accessible peripheral vessels (radial, temporal, femoral, and brachial) should be carefully felt when the pres- ence of the disease is suspected. The walls of the affected artery feel hard, and the pulse, owing to increased tension, is incompressible ; as a result of this rigidity of the arterial Avails the degree of vascular tension is difficult of estimation. In marked cases the sensation is similar to that perceived when grasping a goose's neck, and in such instances the pulse- wave may not be detectable on palpation. Again, the tension may be high, and yet sclerosis of the vessel-wall be slight or absent. When doubt arises as to whether or not sclerosis exists, the pulse should be pal- pated by means of two fingers. If now, while compression of the pulse is made with the index finger, the middle finger detects a pulse-wave, arterio-sclerosis is present. On account of the loss of elasticity of the vascular walls the pulse is retarded, and the sphygmogram shows a short sloping ascent, a wide top, and a slow, gradual descent, Avith almost an effacement of the dicrotic notch. The opposition of the increased resistance to the circulating medium (due to the rigid vessel-wall) in the outlying portions of the body calls forth a correspondingly increased cardiac action, and thus hypertrophy of the left ventricle is engendered, with its customary symptoms and physi- cal signs, including the ringing, accentuated second sound. The balance of the cardio-vascular forces may thus be maintained for a long period of time, during which the health of the patient often remains unimpaired. It happens sometimes that hypertrophy preponderates and veils com- pletely the symptoms of arterio-sclerosis. In elderly persons suffering from atheroma the first sound is often surprisingly feeble. Myocardial degenerations frequently come on in the later stages, Avhen dilatation of the left ventricle, accompanied by a mitral systolic murmur and marked ARTERIAL SCLEROSIS. 679 rapidity of the pulse, may supervene. The aorta may be so dilated as to give rise to an abnormal area of dulness in the upper sternal region. Palpitation, dyspnea on exertion, a feeling of precordial constriction, and light febrile attacks are not uncommon. Angina pectoris is an infrequent symptom except in coronary atheroma. It cannot be stated absolutely that involvement of the external arteries implies a serious involvement of the aorta and its main branches. On the other hand, the circumscribed variety is not attended with charac- teristic alteration of the pulse. The pathologic, and more particularly the clinical, events above described may be more pronounced at one por- tion of the body than at others, and this fact has given rise to several distinct or special types (apart from the general or cardio-vascular form first depicted) according to the seat of the most marked symptoms and lesions. Among the latter I Avould mention the (a) cerebral, (b) pulmo- nary, (c) renal, and (d) peripheral types. (a) Cerebral Type.—In the milder grades of this type such symptoms as headache, tinnitus, vertigo, syncopal attacks, and local palsies are variously blended as a rule. I have had under my care for two years a case of marked arterio-sclerosis in a man aged eighty years in whom tin- nitus aurium and vertigo, with mild melancholia, are the only constant symptoms; on tAvo occasions temporary aphasia was superadded. Especially in the aged, the condition is apt to lead to thrombosis or cerebral embolism, small emboli being detached from the aortic area and conveyed to the brain, with the development subsequently of the symp- toms of anemic softening of the latter. The loss of elasticity of the vessel-walls in atheroma renders them more liable to rupture than normal arteries, while the tension is much increased. Under these circumstances the danger from apoplexy is quite obvious. (b) Pulmonary atheroma is considered in its clinical relations in con- nection with the diseases of the heart and lungs. (c) The renal type includes those instances of kidney-lesion that are associated with or follow general arterio-sclerosis. The condition is essen- tially an atrophic nephritis, due to the diminution of the blood-supply to the organs in consequence of the narrowed lumen of the renal arteries. The reader is referred to the discussion of Nephritis for the symptom- atology of this variety. (d) In the peripheral type the arteries leading to the extremities be- come obliterated to such an extent as to cause starvation of the tissue, with resulting gangrene. Diagnosis.—Hardened arteries, increased arterial tension, left ven- tricular hypertrophy, and marked accentuation of the aortic second sound form a grouping of clinical characters that leaves no doubt as to the diag- nosis. Not infrequently it is the occurrence of apoplexy, acute cardiac dilatation, or of some other such accident that leads to the discovery of general arterial sclerosis. To differentiate the murmur of dilatation of the left ventricle follow- ing the hypertrophy of this disease from organic valvular lesions is only possible by the history or the results of treatment. The systolic mur- mur over the aortic area in atheroma may suggest aortic stenosis. In such cases, hoAvever, the second sound is loud, and the pulse more voluminous than in aortic constriction (vide Aortic Stenosis). 680 DISEASES OF THE CIRCULATORY SYSTEM. Prognosis.—Arterio-capillary fibrosis is an exceedingly chronic, though usually a progressive disease, and frequently it terminates life. The axiom that a man is as old as his arteries has been borne out by the test of extensive clinical observation. The condition may prove fatal either with great suddenness, as Avhen it occasions apoplexy, or Avith un- wonted slowness. Very rarely the aorta ruptures at the seat of an athe- romatous ulcer, causing instant death. Treatment.—Though the progress of the disease cannot in most in- stances be successfully stayed, it can be retarded frequently by correcting aggravating habits and by removing the influence of ascertainable causes. Any degree of syphilitic taint that may be present should be assailed immediately by a liberal use of the iodids. The diet must be simple and free from stimulating properties; skim-milk is excellent, particularly if renal symptoms be manifested. Perhaps no other agent is so generally serviceable in all cases as potassium iodid, which should be administered continuously in doses ranging from gr. x-xx (0.648-1.296) three times daily. For the increased arterial tension nitroglycerin or the other nitrites should be employed. The former should be given in increasing doses until an impression has been made upon the blood-pressure, after Avhich this effect should merely be maintained. For the local aortic symptoms (fever, pain) absolute rest, a liquid and unirritating diet, and a small blister are most efficacious, together with internal minute doses of calomel, quinin, and potassium iodid. ANEURYSM. Definition.—A true aneurysm is a circumscribed dilatation of an artery, formed of one or more of its coats. Classified according to their form, aneurysms are—(1) sacculated, (2) cylindric, and (3) fusiform. They are termed axial when the complete circumference of the vessel participates in this dilatation, and peripheral when a single sac is confined to the side of the vascular duct. Miliary aneurysms occur along the course of the cerebral vessels, and are so termed on account of their minute size. On the other hand, they may attain the size of the human skull. A false aneurysm is one that, owing to laceration of the internal coat, dissects betAveen the layers of the vessel-wall. For its seat it usually selects the aorta, and may traverse its entire length. An arterio-venous aneurysm arises from a direct fistulous connection between an artery and a vein (aneurysmal varix), or an aneurysmal sac may intervene (varicose aneurysm). Pathology and Etiology.—The wall of the aneurysm is quite often the seat of arterio-sclerosis, and its power to resist the blood-stream is thus reduced. The media probably Aveakens first in most cases, and extreme atrophy of both the intima and media is not uncommon in the later stages, so that the wall of the sac is often formed almost exclusively of the adventitia. The intima or media may become lacerated, and finally the external coat yields; this results in rupture unless the adherent neighboring structures compensate for the natural wall. ANEURYSM. 681 The blood in the aneurysmal sac is partly fluid and is composed of old and new thrombi. The latter when comparatively recent may be soft, and when old may be firm or even calcified, yellowish in color, and ad- herent to the wall. With the progressive enlargement of the aneurysm surrounding organs are apt to be compressed and their functions disturbed, and pressure upon the bony walls of the thorax (ribs, vertebrae) results in their atrophy and final disappearance. Other remote pathologic con- sequences will be referred to in connection with the clinical history. Among recognized causes are—(1) Arterio-sclerosis.—It follows that the same conditions that originate the latter must also tend to bring about aneurysms. Chief among these is syphilis. Less potent, though still active, are gout and alcoholic excesses. (2) Sudden Great Strain.—Though this may not be productive of aneurysm, except some previous local impairment of the arterial Avails has been present, yet it must be granted that a sudden strain is powerful in producing aneurysm when com- paratively slight antecedent changes have existed. In this Avay only can the fact that most instances of aneurysm occur during the period of greatest activity, or from thirty to fifty years, be accounted for. (3) Embolic plugging of a vessel, if complete, may cause aneurysmal dilata- tion on the proximal side of the point of obstruction. The development of aneurysm may under these circumstances be facilitated by the mechani- cal effects of the embolus, which may be of calcareous hardness, as ^vhen it comes from diseased heart-valves. Infectious emboli set up inflamma- tion and softening. (4) Mycotic Aneurysms.—That aneurysms sometimes owe their existence to mycotic origin was first pointed out by Osier, who found an abundant growth of micrococci in the aneurysmal sacs. They are met with in ulcerative endocarditis, and are often small and usually multiple. (5) Age and Sex.—Aneurysms are most frequent between the thirtieth and the fiftieth years, this being the period of greatest physical exertion. After the fiftieth year cases occur Avith someAvhat diminished frequency, whilst under thirty years they are quite rare. The male sex is more frequently affected than the female, and chiefly for the reason that arterio-sclerosis, sudden strain, and other leading factors that engender the disease are more apt to be operative in the former sex. ANEURYSM OF THE THORACIC AORTA. (Aneurysma Aortce.) The thoracic portion of the aorta is involved in about 75 per cent. of the cases, and the abdominal aorta and its branches furnish about 25 per cent. Within the thorax nearly 60 per cent, of the cases originate in the ascending portion of the aorta, Avhile nearly 30 per cent, are seated upon its arch (Lyman). Symptoms.—Intrathoracic aneurysms may exist, particularly if they are small, Avithout symptoms or noticeable physical signs. When they attain to any considerable dimensions, however, they usually excite characteristic signs and distressing symptoms, the latter being the results of direct pressure, and hence varying with the seat and direction of the progressive enlargement. In a few instances truly diagnostic symptoms are present in the absence of a detectable tumor or physical signs. Finally, the more characteristic features—the tumor inclusive—may be 682 DISEASES OF THE CIRCULATORY SYSTEM. more or less nearly intermittent. It is important to note the condition of the neighboring organs upon which pressure is exerted by the growing aneurysm, as Avell as the symptoms and signs thus occasioned. Aneurysms of the ascending portion of the arch usually compress the vena cava, causing distention of the veins of the head and arms, though in a pro- portionately small number of cases the subclavian may be the only vein compressed, with resulting enlargement and edema of the right arm. The largest aneurysms may even compress the inferior vena cava, causing edema of the lower extremities. The heart is displaced outward toward the left pleura, usually forward and upAvard, and rarely causing erosion of the ribs and sternum. The right recurrent laryngeal nerve may be implicated, giving rise to dvspnea and aphonia. Pain is a constant feature. AVhen a tumor appears, it occupies the upper two or three intercostal spaces near the right border of the sternum. Aneurysms of the transverse portion of the aorta, when they attain any considerable size, cause the most intense symptoms, owing to the relatively shorter antero-posterior diameter of the chest at this point, in consequence of Avhich greater compression of the neighboring tissues takes place. By protruding backward they may exert pressure upon the trachea, causing paroxysmal cough and dyspnea, or on the esophagus, causing dysphagia; these are common events. The pressure may fall also €upon the bronchus, inducing dyspnea, bronchorrhea, and dilatation, the latter in turn sometimes leading to circumscribed abscess. The left recurrent laryngeal nerve may be implicated, with resulting aphonia. Upward extension of the aneurysmal process, with involvement of the coats of the carotid and subclavian on the left side, or of the innominate and carotid on the right, may occur. The sympathetic nerves in the cer- vical region may be irritated, causing dilatation, or they may be para- lyzed, causing contraction, of the pupils. Compression of the thoracic duct may occur with resulting rapid emaciation. A tumor may appear in the jugular fossa. The aneurysm may groAv forward, in which event it lies directly behind the manubrium, Avhich from the pressure becomes eroded and may finally disappear in part. In aneurysms involving the transverse portion of the arch lateral pressure in either direction is also effected, causing recession and compression of the lungs. When the descending portion of the arch is affected, the pressure is ex- erted upon the spinal column to the right, and upon the tissues as far as the shoulder-blade to the left. As a consequence of destruction and ab- sorption of the vertebrae compression of the spinal cord may ensue, and is an intensely painful process. Pressure may be made upon the esophagus, causing dysphagia, or upon the left bronchus, causing bronchiectasis, Avith its usual sequelae (bronchorrhea, fetid bronchitis, gangrene of the lung). The sac may in consequence of the sIoav ulcerative process that attends its progress, rupture eventually into the bronchus or the esophagus, with sudden death as the result. Frequently repeated small hemorrhages, due to weepings from the thinned walls, may precede the fatal rupture. I saw a case of aneurysm of the transverse portion in Avhich rupture into the esophagus resulted from a sudden though not severe exertion, with instan- taneous death. When the tumor has reached the subcutaneous tissue and bulges ex- ANEURYSM. 683 ternally, the skin covering it becomes tense and shining, and with in- creased pressure the surface becomes reddened and finally necrotic. The necrosed area is bedecked with a dry brown scab, Avhich later is thrown off, leaving an oozing surface. Rupture soon follows. Among the symptoms that demand special description pain stands primarily, being the first and most constant. It is of two kinds : (a) Due to direct pressure upon and stretching of the nerves. When aneurysm is developed suddenly, a sharp, excruciating pain is felt in the upper sternal region, accompanied by a feeling of "something giving way." In consequence of the stretching of the nerves a constant pain is expe- rienced that is subject to exacerbations Avhen the intra-aneurysmal pressure is raised. Pressure against the bony structures causes erosion, and usually produces a continuous boring pain. In a recent case of aneurysm shown in clinic at the Medico-Chirurgical College, how- ever, a tumor that had eroded the right half of the sternum, and of the size of a goose's egg, had given rise to no, suffering Avhatever. In latent aneurysm there is an absence of pain until the growth terminates life. Anginose attacks sometimes occur Avhen the sac has its seat near to the heart, (b) Reflected pains of a neuralgic character may be excited by aneurysm. This is true, in particular, of aneurysms situated in the transverse portion of the aorta, in which instances pain is frequently felt in the region of the neck and occiput and down the left arm. When the growth is situated along the course of the descending aorta, intercostal neuralgia may be excited, and it is probable that pain of this sort is due to pressure upon the nerve-trunks. Cough.—The cough is paroxysmal, and frequently has a peculiar brazen, ringing character that points to its laryngeal seat. Pressure upon the AA'indpipe excites a paroxysmal dry cough. Compression of a bronchus may lead to bronchiectasis, and the cough then occurs only in long and severe paroxysms which recur at intervals of a day or even longer, and are attended with copious, thick, ropy expectoration (vide Bronchiectasis). Dyspnea is a conspicuous symptom in aneurysm of the transverse por- tion of the aorta. It arises (a) most frequently in consequence of pres- sure upon the recurrent laryngeal nerve, (b) direct pressure on the trachea, and (c) from pressure on the left bronchus. Marked stridor may accom- pany the first variety. Paralysis of the vocal bands is occasioned by compression of the recur- rent laryngeals, particularly the left, while a slight degree of compression or irritation of the same nerve causes spasm of the vocal cords. The symptoms indicating the presence of these conditions are hoarseness, cough, and aphonia respectively. The laryngoscope should be employed, since paralysis of one of the abductors may be present without giving rise to appreciable symptoms. Hemorrhage may occur as a slow oozing, either from the point of com- pression in the trachea or externally; in either case the amount of blood lost is small. Profuse bleedings (often producing sudden death) take place in consequence of rupture of the sac into the lung, the bronchus, or the trachea. Deglutition may be difficult, owing to compression of the esophagus. When an aneurysm has been diagnosticated or even suspected, the esoph- 684 DISEASES OF THE CIRCULATORY SYSTEM. ageal sound should not be passed for purposes of exploration, on account of danger of rupture of the sac. Compression and irritation of the sympathetic system of nerves cause pupillary changes that have already been mentioned. With dilatation of the pupil there may be observed pallor of one side of the face, due to stimulation of the vaso-dilator fibers ; on the other hand, with contraction of the pupil (due to paralysis of the dilator fibers) there is hyperemia of one side of the face and unilateral sweating. Clubbing of the fingers and incurvation of the nails are not rarely met with in thoracic aneurysm. Physical Signs.—Inspection.—Visible pulsation is one of the earliest appreciable signs. It is most frequently observed at the right side of the sternum, above the level of the third rib (second interspace), and much less frequently on the left side over a corresponding area. In aneurysm of the transverse portion pulsation may be seen at the episternal notch, though an impulse here may also be due to nervous palpitation, and have no connection Avith aneurysmal groAvths. The pulsation may occur in the absence of the slightest bulging ; when associated with swelling, however, its diagnostic value is infinitely greater. Involvement of the innominate artery produces pulsation in the neck above the sterno-clavicular junction, or less commonly above the sternum. Corresponding to the site of visible impulse, there is, sooner or later, bulging in most instances. It may, however, be so slight as to elude de- tection unless the keenest observation be practised, and in not a few instances the tumor itself is invisible from the front of the body, but is recognizable looking from behind or from either side. Again, on alloAV- ing the light to fall obliquely upon the chest slight prominences may be brought to view that would otherwise be inappreciable. When the aneurysm is situated in the ascending part of the arch, the most frequent seat of the bulging—which varies in size from a hen's egg to a cocoanut—is over the first and second right interspaces near to, and frequently involving, a portion of the sternum ; when seated just beyond the aortic orifice, a pulsating prominence may occupy the third interspace along the left sternal border; situated in the transverse section of the aorta, bulging of the upper part of the sternum is a frequent event, or a projection into the cervical fossa may occur, though with comparative rarity. In the descending portion the swelling, when present, is in the second and third left interspaces near to the sternum, or very rarely in the left scapular zone. The skin over the tumors has been described. The apex-beat is displaced downward and outward, chiefly from pressure, though to a lesser extent also from hypertrophy (functional). Palpation.—The protrusion presents a more or less yielding and elastic mass, and when superficially seated fluctuation may be obtainable. The degree, and the rhythmic expansile character of the pulsation are to be noted, and also the fact that there is an alternate contraction and dilatation of the sac in every direction—a distinctive feature. If the aneurysm is largely concealed, bimanual palpation should be employed, the palm of one hand being placed over the spine and that of the other over the sternum. In an inconsiderable number of cases aneurysmal pulsation is only yielded when the finger-tips are used, and quite rarely only at the end of expiration. A diastolic shock is often ANEURYSM. 685 perceived, and forms a physical sign of no little value. A distinct sys- tolic shock, sometimes accompanied by a purring fremitus, can also be felt over the aneurysmal sac. Percussion.—If the growth be deep-seated, percussion may give neg- ative results; when, however, the tumor causes bulging or comes in con- tact with the chest-wall, a proportionate area of flatness is presented. The abnormal field of dulness may be the only symptom present, as in an instance of suspected aneurysm that recently came under mv care. Aneurysms of the ascending arch give flatness to the right of the ster- num ; those of the transverse arch, over the upper part of the sternum and to the left; while those of the descending portion are revealed by a flat area betAveen the spine and the left scapula. With flatness of the percussion-note there is a sense of increased resistance. The shape of the flat area is to be noted at the end of both inspiration and expiration. Auscultatory percussion (practised after the method of Sansom and Ewart) quite often gives valuable results. Auscultation.—Since murmurs owe their origin, in great part, 'to the presence of fibrin in the sac, they may often be absent, and this even in the case of large aneurysms. When, as is usual, a murmur is present, it is systolic in rhythm, heard with greatest intensity over the flat area or body of the tumor, and is transmitted in the direction of the blood-stream, being, therefore, distinctly audible in the vessels of the neck and along the course of the aorta. The chief characteristic of this murmur is its booming quality. Aortic regurgitation may be considered as associated with aneurysm near the aortic ring when a double murmur is heard. In a few instances the diastolic bruit is alone detectable. A much intensified, ringing sec- ond sound is present (unless marked aortic regurgitation coexists), and is a sign of the utmost significance for diagnosis. The Peripheral Arteries.—The pulse in the vessels beyond the aneurysm is slowed. Hence the two radial pulses may exhibit differences in time. The volume of the pulse beyond the aneurysm is also lessened, and in cases Pig. 57.—Sphygmogram of a case of aneurysm of the left subclavian artery (Foster). of aneurysm of the abdominal aorta or the femorals it may be obliter- ated. Such differences as these will not only point to the existence of thoracic aneurysm, but also may indicate its seat. Thus, if there be dilatation of the transverse arch with no implication of the innominate, the pulse at the right wrist is strong and almost simultaneous with the cardiac impulse, while that on the left side is small, weak, and more re- tarded. If the reverse be true, then the aneurysm may be near to or in- volve the innominate. The sphygmogram exhibits a slanting up-stroke with obliteration of the secondary wave (Fig. 57), though its characters are by no means constant. 686 DISEASES OF THE CIRCULATORY SYSTEM. Tracheal Tugging.—This sign may be practised while the patient is sitting or standing Avith the chin slightly elevated. The cricoid cartilage is then grasped between the thumb and forefinger and pushed gently up- ward so as to stretch the trachea. The patient must at the same time be told to cease breathing momentarily, when, if this sign be present, there will be a doAvnward dragging or tugging at each systole. The trans- mitted pulsations from the cervical vessels synchronous with the tug- ging must not be confounded with the up-and-down movement of the trachea. A new method of eliciting tracheal tugging, first suggested by Ewart,1 has been pretty widely adopted, and possesses the advantage of ensuring greater delicacy of touch than the old. He stands behind the patient, supporting the head of the latter against his body, and the cricoid is then grasped firmly betAveen the tips of the forefingers. The method is in other respects similar to that previously describe*d. Diagnosis.—In the presence of the following points the existence of thoracic aneurysm may be confidently inferred : (1) Antecedent arterio- sclerosis (Avith the appropriate causes of the latter); (2) History of other etiologic factors, as age (between thirty and forty-five years) and occu- pation (such as entail unusual muscular strain); (3) Pressure-symp- toms, as pain, dyspnea, aphonia, cough (either laryngeal or bronchial), bronchorrhea, dysphagia, edema, vasomotor disturbances ; (4) Physical signs of a pulsating tumor (including the abnormal area of dulness, sys- tolic murmurs, the systolic and diastolic shock, and tracheal tugging) somewhere along the course of the arch or its great branches, with or without differences in the volume and time of radial or carotid pulses. There are, however, several classes of cases Avhich offer difficulties that are sometimes insurmountable: (a) Those in which the aneurysm is small and deep-seated. Here the symptoms and physical signs are indefinite. There may be thoracic oppression, in Avhich pain may radiate to the left shoulder, and mild pressure-symptoms—a group of suspicious features merely—sometimes appear. I have under my observation noAv a patient suffering from aneurysm of the ascending aorta in which for a long time left-sided intercostal neuralgia was the only symptom, (b) Aneurysm of the transverse arch, in which the pressure-symptoms are more or less pro- nounced, but Avith no physical signs. In such, a clear history suffices to complete the diagnosis. Pressure-symptoms, on the other hand, without etiologic factors are just as likely to be due to other causes, (c) Those cases in which the more characteristic features are manifested intermit- tently. The distinction between the latter two groups and the conditions with which they are apt to be confused will be pointed out incidentally in connection with the differential diagnosis. Extremely obscure are many of the cases in which the only symptoms manifested point to irritation of the trachea or bronchial tubes, with par- oxysmal cough, bronchorrhea, and sometimes the signs of bronchiectasis. In a recent case of this sort tracheoscopic examination revealed com- pression of the windpipe, making clear the nature of the affection. In still another instance, in which laryngeal dyspnea and cough, Avith bron- chorrhea, were the only symptoms, a laryngoscopic examination determined the diagnosis,, in that it brought to view bilateral paralysis of the abduc- 1 British Medical Journal, March 19, 1892. ANEURYSM. 687 tors of the vocal bands. Subsequent events proved its correctness Avhen the characteristic physical signs appeared. Differential Diagnosis.—The affections from which intrathoracic aneur- ysm must be distinguished in cases presenting a complexity of features are pulsating empyema, abnormal pulsation of the aorta, and solid tumors. Of the latter, those simulating aneurysm are carcinoma, sarcoma, and en-« larged lymph-glands. These mediastinal tumors may duplicate all of the pressure-symptoms, though they are less apt to cause bulging, and less apt still to excite abnormal pulsation; when pulsation is noted it is observed to be quick, and not heaving and expansile as in aneurysm. Solid growths also lack the characteristic shock—both systolic and diastolic—of aneur- ysm. The cardio-vascular symptoms are usually Avanting in the case of solid tumors, especially cardiac hypertrophy, accentuation of the second sound, tracheal tugging, and the difference between the radial pulses. Carcinoma of the mediastinum usually gives a history of the disease in other parts of the body, with enlargement of the axillary or other super- ficial lymphatic structures, and later the characteristic cachexia, this being particularly marked in carcinoma of the esophagus. Abnormal pulsation in the aorta is noted in neurotic subjects, mostly females, and in aortic regurgitation; less frequently it is associated with retraction of the right lung, with spinal curvature, and with displacement of the aorta. In the case of the latter two conditions a careful considera- tion of the causal states and the absence of the characteristic physical signs Avould lead to a correct diagnosis. Aortic regurgitation is frequently associated with aneurysm of the arch, and in its course there is developed, not infrequently, a dilatation of the ascending portion of the aorta. The diagnosis of aneurysm of the arch of the aorta should not be made, even when all the characteristic physical signs of aortic regurgitation are present in any given case, unless the signs of the pulsating tumor above the heart be unmistakable. Dynamic pulsation of a neurotic origin is seen and felt in the episternal notch, as a rule, and a correct appreciation of the nervous element, whether inherited or acquired, will prevent the observer from committing an error. Pulsating empyema can only be confounded with large aneurysmal groAvths, and, as pointed out by Wilson, it does not have the same definite relation to the central long axis of the body as do aneurysms. The abnormal area of dulness is situated at the base of the lung in empyema, and usually extends over a larger superficial area or is less circumscribed than in aneurysm. In empyema, moreover, the pulsation is not expansile, but is caused by pressure on the respiratory movements. Auscultation in empyema renders audible neither a bruit nor the double shock of aneurysm; the pressure-symptoms and pulse-characters are also entirely wanting;. Pulmonary tuberculosis may be mistaken for thoracic aneurysm. When an aneurysm compresses a bronchus, bronchiectasis, attended Avith cough, bronchorrhea, fever, and emaciation, may be the result; but in phthisis the fever and emaciation are more pronounced, tubercle bacilli are pres- ent, Avhilst the characteristic cardio-vascular signs of aneurysm are absent. Prognosis.—The existence of aneurysm without producing any symptoms, as well as the possible occurrence of perforation and conse- quent speedy death, must be recollected. At least, some of the features 688 DISEASES OF THE CIRCULATORY SYSTEM. previously adduced may be present in aneurysm for a long period of time (even years), when sudden death may ensue. In other instances the end is approached in a very gradual manner, and cases in Avhich rup- ture does not supervene sometimes pursue the general course of chronic valvular affections of the heart. The fact that aortic regurgitation may t coexist has been referred to; in such cases there may develop at any time failure of compensation, with its usual serious phenomena. The condition ends in death as a rule, and the immediate causes of the fatal issue are as follows: (1) Rupture of the aneurysm, followed by hemorrhage into any of the adjacent cavities or organs (pericardium, heart, large vessels, mediastinum, trachea, a bronchus, esophagus, lungs, pleura, spinal canal); it may, though rarely, rupture externally, in which case slight hemor- rhages occur and life may last for Aveeks; (2) Gradual asthenia; (3) Direct pressure; (4) Independent diseases, either primary or secondary to, and induced by, the aneurysm. Treatment.—There are two chief indications around which all others center in the management of this disease—first, the promotion of coagu- lation of the blood, and secondly, the contraction of the sac. The clotting of the blood within the growth may be greatly favored by retarding the blood-current. Nothing so well accomplishes this object as absolute rest in the recumbent posture. This cannot ahvays be rigidly enforced, but muscular exertion must be minimized, and mental application and emo- tional excitement must also be avoided; stimulants, arterial and nervous, are to be escheAved for like reasons. Palpitation of the heart, when present, is best allayed by the local use of the ice-bag. The coagulability of the blood is also increased by removing as far as possible the liquid portion of the diet. The measures already indicated tend to lessen the volume of blood and the intra-aneurysmal pressure, thus inviting contraction of the sac as Avell as coagulation of its contents. Among medicinal agents, ergot and potassium iodid have been employed, the latter Avith good effects. The exact manner in which the iodid produces its favorable results in these cases is unknown, though most probably it acts upon the vascular Avails, and hence Avould be most efficacious when the disease is of syphilitic origin; this vieAv accords with my own personal experience. I would advise against the internal use of ergot, which can have little to recom- mend it, and the prolonged use of which maybe attended Avith unpleasant effects. Langenbeck and others have obtained good results from the direct injection into the sac of the aqueous extract of ergotin dissolved in water or glycerin, every day or two. When employed in this manner ergotin induces contraction of the smooth muscles in the Avail of the aneurysm. The injection of chemical substances, as the tincture of the chlorid of iron, for their effect in promoting coagulation of the blood is not free from dangerous consequences, and in my opinion the risk of engendering embolism of the peripheral vessels Avith detached fragments of the clot should not be assumed. Other observers have resorted to the use of horse-hair, fine wire, fine catgut, slender watch-springs, with a view to coagulating the blood as it comes in contact with these foreign bodies. Combined with the insertion of Avire the use of electrolysis is a method that has been warmly advocated (Loreta). A piece of fine, slender wire, several feet in length, is passed directly ANEURYSM. 689 from a spool through a hypodermic needle, so that the Avire curls up within. This is now attached to the positive pole, while the negative is connected with a surface pad placed over the abdomen or with an insulated needle inserted into the sac, and the current is then passed through. It is import- ant to test the strength of the current beforehand by inserting the needle attached to the positive pole into the white of an egg and observing its power to coagulate albumin. Each application of the current should last from one to two hours. This plan of treatment has in some instances given striking results, though a more extended trial is needed before its true value can be estimated. The author saw a case that was successfully treated in this manner, the solidification of the sac being apparently com- plete. Knerr and Rosenstein have also reported cures from the employ- ment of this method. It is not, however, without serious dangers (hemor- rhage and embolism). After the same method galvano-puncture has long been resorted to, and in the hands of some clinicians with encouraging results. The cases that receive most benefit from the above measures belong to the saccular vari- ety ; this is also true of the special plan first commended by Tufnell, which is especially applicable in the earlier stages. Tufnell's method is founded upon two main principles—absolute rest in the recumbent posture, and a much-restricted, dry diet. With physical rest a quiet mental state should be conjoined. The diet is as follows : Breakfast, 2 ounces (64.0) of bread and butter and 2 ounces (64.0) of milk ; for dinner, 2 or 3 ounces (64.0- 96.0) of meat and 3 or 4 ounces (96.0-128.0) of milk or claret; for supper, 2 ounces (64.0) of bread and 2 ounces (64.0) of milk. The chief advantages growing out of this method are the lessened number and decreased force of the heart-beats in consequence of the posture and bodily rest, and the diminution of the blood-volume in consequence of the dietetic restrictions. It should be persevered in for several months. When, as often happens, the plan cannot be rigidly enforced, the great benefit to the patient of quiet of mind and body and a suitable, though less exclusive, diet should not be lost sight of. His bowels should be regulated, and he should be told not to strain while at stool. A. E. Wright has particularly insisted upon the value of calcium salts in increasing the coagulability of the blood (gr. x to xv—0.648 to 0.972, t. i. d., may be given). A number of investigators have confirmed Wright's findings, but others have met with contrary results. Special Symptoms.—Pain is often relieved by potassium iodid. When marked arterial sclerosis is present I have seen relief from pain afforded by the internal use of nitroglycerin (TTLj to ij—0.066 to 0.133, three or four times a day). In the later stages morphin should be given to allay suffering. When there is bulging the pain may be assuaged by the local use of the ice-bag or by a belladonna plaster. Dyspnea and great venous congestion are to be met by free bleedings from a vein, and tracheotomy may be required if the dyspnea be shown to be due to bilateral paralysis of the abductors. In dyspnea arising from pressure on the trachea or bronchus, however, tracheotomy Avould be a valueless expedient. When the aneurysm forms a large external tumor the application of an elastic bandage to the chest may be both agreeable and advantageous, as in a case referred to by Osier. 44 690 DISEASES OF THE CIRCULATORY SYSTEM. ANEURYSM OF THE ABDOMINAL AORTA. The vicinity of the celiac axis is the favorite seat of abdominal aneur- ysm, which is by no means as common a condition as intrathoracic aneur- ysm, though not rare. It may assume a fusiform or saccular nature, and is sometimes, though rarely, multiple. Symptoms.—The tumor may grow backward, but more frequently its growth is in a forward direction. Projecting from the posterior wall, it usually erodes the vertebrae, and compression of the cord is apt to take place, producing paraplegia, preceded by tingling and numbness of the legs. Pain is the leading symptom. It may be neuralgic or of a boring or gnawing character, due to destruction of the bone. Rarely, the aneurysm perforates the diaphragm, and finally ruptures into the lungs or pleura, causing death quickly. Arising from the anterior wall, it may early form a well-defined tumor. It may, however, when situated high up or near the diaphragm, conceal itself until it has attained a comparatively large size, as in a case recently under my care at the Medico-Chirurgical Hospital. Vomiting and gastralgic seizures may be troublesome, and the fact that embolism of the superior mesenteric artery may occur and give rise to severe colicky pains must be recollected. Jaundice has been observed. Physical Signs.—Epigastric pulsation may be visible, and occasionally an epigastric swelling. The palpating hand detects a heaving, expansile pulsation that may be accompanied by a thrill. When the tumor hugs the diaphragm, the pulsation may be double. The femoral pulse is diminished in volume and delayed. If the growth be large, an abnormal area of dulness may be present on percussion. In most instances a soft bruit is audible on auscultation. The diastolic murmur and shock of intra- thoracic aneurysm are quite usually absent. Diagnosis.—A certain diagnosis demands the presence of a definite growth that is seizable and has a heaving, expansile pulsation. Mere pulsation attended Avith a thrill and a systolic murmur may be simulated by other conditions. Differential Diagnosis.—A throbbing aorta, as met with in neurotic females and in anemia (particularly in instances of the traumatic form), is not infrequently distinguished from aneurysm of the abdominal aorta with great difficulty. It does not, however, present a tumor that can be grasped, and which possesses an expansile, heaving pulsation, as is true in the case of aneurysms that are at all recognizable. When solid growths lie upon the aorta the latter may manifest pulsa- tion, a thrill, and a systolic murmur, but the very general absence of pulsation, owing to the fact that the tumor falls forward when the patient is placed in the knee-elbow position, suffices usually to differentiate the condition from genuine aneurysm. Again, expansile pulsation is not evinced by a solid growth. The prognosis is very gloomy. Very rarely, however, nature effects a cure if the conditions be favorable. " Death may result from (a) the complete obliteration of the lumen by clots; (b) compression-paraplegia; (c) rupture either into the pleura, retroperitoneal tissues, peritoneum, the intestines, or, very commonly, into the duodenum ; (d) embolism of the su- perior mesenteric artery, producing infarction of the intestines" (Osier). ANEURYSM. 691 Treatment.—Apart from the measures indicated for thoracic aneur- ysm, there is one means of cure that may be tried if the growth be Ioav down—viz. pressure. This must be maintained for twenty-four hours at least under an anesthetic. It is best to make steady pressure on the proximal portion of the vessel, and unless practised with great care the sac will be damaged and death ensue. ANEURYSM OF THE PULMONARY ARTERY. Dilatation of the pulmonary artery is of frequent occurrence in affections that oppose obstruction to the lesser circulation (e. g. mitral disease, emphysema, phthisis). Very rarely extreme dilatation of the vessel is followed by semilunar incompetence, when a diastolic murmur at the pulmonary orifice (second left interspace) becomes audible. Aneurysms involving the pulmonary artery are quite rare: such as occur are small and of the saccular and fusiform varieties. The symptoms resemble those of intrathoracic aneurysm, though they are rarely well marked, owing to the fact that they remain of small size as a rule. Physical Signs.—Pulsation (and, rarely, a small tumor) is detectable in the second left interspace. Palpation may also render appreciable a thrill and a diastolic shock. Coextensive with the area of pulsation there may be dulness on percussion, and over the second interspace to the left of the sternum a loud superficial systolic murmur is heard on auscul- tation, together Avith a diastolic shock. Before attaining to a large size, these aneurysms usually rupture into the heart itself. The prognosis is altogether unfavorable, the treatment having refer- ence to the principles that are appropriate in thoracic aneurysm. The coronary arteries may be the seat of aneurysm, though exception- ally. The condition arises in consequence of weak points (due to arterio- sclerosis) in the course of the vessels, and is unrecognizable during life. ANEURYSM OF THE CELIAC AXIS. This condition is sometimes observed in combination with aneurysm of the upper portion of the abdominal aorta. ANEURYSM OF THE SPLENIC ARTERY. This branch of the celiac axis is occasionally the seat of aneurysmal dilatation. It may be single or multiple, and, whilst it is small as a rule, may in rare cases be quite large. The Symptoms are indefinite, but distressing. Deep-seated abdomi- nal pain, which shows a tendency to radiation, forms, with vomiting, and rarely hematemesis, the main features. By careful percussion a tumor may be mapped out in the left hypochondriac region, the dulness merging with that of the spleen and the left lobe of the liver. Usually, pulsation, and, rarely, a tumor, can be felt, and a systolic murmur is often, though not invariably, heard. The condition must not be confounded Avith gastric ulcer. ANEURYSM OF THE HEPATIC ARTERY. This is exceedingly rare, the total number of cases on record being about 20. II. B. Schmidt has recently reported a case associated Avith 692 DISEASES OF THE CIRCULATORY SYSTEM. symptoms of gall-stones, in which, as shown by the autopsy, death Avas caused by rupture of the sac into the bile-ducts. Schmidt found records of but 5 cases of this mode of termination. Osier and Ross have reported an instance associated with multiple hepatic abscesses. The symptoms are, in the main, colicky pains, vomiting, hemateme- sis, and obstructive jaundice. A tumor is rarely discernible, though an abnormal area of pulsation is relatively more frequent. The recognition of the condition during life is entirely conjectural. Aneurysm of the superior mesenteric artery is of rare occurrence. Pain in the epigastric and lumbar regions, and a demonstrable tumor near to or directly over the median line of the abdomen, are the symptoms dis- played. Detached fragments of the clot may produce embolism of the terminal branches of the mesenteric arteries. The condition terminates usually in rupture into the peritoneal cavity. Aneurysm of the inferior mesenteric artery runs a course similar to that of the superior mesenteric, but is so rare as to possess little or no clinical interest. Aneurysm of the Renal Arteries.—Small multiple dilatations are occa- sionally seen, but large ones are of great rarity. They are prone to rupture into the retroperitoneal cavity. ARTERIO-VENOUS ANEURYSM. Definition.—An artificial communication between an artery and a vein. A sac may intervene between the two vessels (varicose aneurysm) or there may be a direct fistulous communication without an intervening sac (aneurysmal varix). In varicose aneurysm the sac is developed from the structures that mark the boundaries of the communicating duct. The majority of cases are caused by the simultaneous wounding of an artery and a vein during venesection. Hence their most frequent seat is at the bend of the elbow. Pepper and Griffith have analyzed the records of 29 cases in Avhich the ascending portion of the aortic arch had opened into the vena cava. Symptoms.—The symptoms are to a large extent aneurysmal, and in addition there appear in rapid sequence great SAvelling of the veins, cyanosis, and edema of the upper portion of the body. A continuous thrill and buzzing murmur, with systolic intensification, are the chief physical signs. In the treatment of thoracic arterio-venous aneurysm the same gen- eral plan is to be pursued as advised in the purely arterial variety. The management of both forms belongs to the domain of surgery. CONGENITAL ANEURYSM. This condition arises because of a defective ante-natal development of the elastic coat. It is often multiple, and the tumors are, as a rule, small, in size ranging from that of a pea to a hazelnut. The most common situations for these growths are the coronary and pulmonary arteries. To Eppinger belongs the credit for having pointed out the fact that the aneurysmal walls consist only of the adventitia and intima. The condi- tion may be met with in children, and rarely in adults. PART VI. DISEASES OF THE DIGESTIVE SYSTEM. I. DISEASES OF THE MOUTH. STOMATITIS. CATARRHAL STOMATITIS. (Stomatitis Erythematosa) Definition.—A simple, acute inflammation of the buccal mucous membrane. It is more commonly met with in children than in adults. Etiology.—As a primary affection its causes are mainly mechanical and chemical irritation, such as the presence in the mouth of hard and sharp bodies, dental caries, acids, hot or cold food, condiments, tobacco, certain drugs (as mercury), eruption of teeth, and bad feeding, par- ticularly in illy-nourished children. It is the result often of a neglect of the mouth-toilet, leading to the decomposition of accumulated bits of food and mucus and to the production of fungous and bacterial irrita- tion. Secondarily, catarrhal stomatitis may be associated with certain of the eruptive fevers (scarlet fever, measles, typhoid), also Avith gastro- enteric derangements, and may follow, by direct inflammatory extension, upon ulcerative tonsillitis, pharyngitis, and the like. Symptoms.—The local symptoms of this affection are those usually seen in an inflammation of a mucous membrane—redness, heat, SAvell- ing, and dryness, soon followed by increased secretion and soreness. The lips and gums only, or the membrane of the Avhole mouth, may be inflamed, and the SAvollen lips, cheeks, and furred tongue may be indented by teeth-marks. Enlarged and reddened papillae on the tongue and minute vesicles inside the cheeks and lips from projecting mucous follicles are sometimes seen. These, later, may terminate in simple small ulcers. A craving for cold drinks is nearly ahvays noted, as Avell as distress and even pain on suckling, mastication, or touching Avith the inspecting finger, and there is a disagreeable taste due to the perverted buccal secretions. Chemical examination of the dribbling saliva shoAvs an acid reaction, Avith the presence, microscopically, of an excess of des- quamated pavement epithelium that has undergone partial fatty degen- eration. Leukocytes, micrococci, the leptothrix buccalis, and the re- mains of food may also be seen (Striimpell). Aside from restlessness and the symptoms common to slight febrile disturbances, the constitu- tional condition is rarely disturbed, except Avhen the stomatitis is sec- 693 694 DISEASES OF THE DIGESTIVE SYSTEM. ondary either to inflammations loAver doAvn in the digestive tract, or to the specific infectious fevers. The course of the disease is usually acute, and the duration about one week. The differential diagnosis of catarrhal stomatitis is easily made by inspection of the membrane. The prognosis, though favorable, Avill vary as to time and severity according to the cause. Treatment.—After proper attention to the hygienic surroundings of the patient and the removal of all irritant influences, the treatment is mainly local. The first indications are to cleanse the mouth and allay the pain, and these may be met by the use of cool solutions of boric acid, sodium bicarbonate, or potassium chlorate, 5 and 10 grains (0.324 and 0.648) respectively to the ounce (32.0) of glycerin and rose-water, as mouth-Avashes, or for swabbing in the case of infants. When iced drinks are ungrateful and the inflammation is more intense and protracted, the use of hot milk and lime-Avater, mucilaginous decoctions, and sedative and antiseptic sprays of 1 or 2 per cent, solutions of cocain or carbolic acid are often beneficial; or mild astringents may be needed, as \ to 1 per cent, solutions of silver nitrate, alum (5 to 10 grains—0.324 to 0.648 —to the ounce—32.0—of honey), and glycerite of tannin (2 drams to the ounce—8.0 to 32.0—of Avater), especially if there is a tendency to chronicity of the trouble, as in topers and inveterate smokers. Tender and spongy gums may be relieved by the application of equal parts of the tinctures of myrrh and rhatany on a camel's-hair brush (Striimpell). General symptoms as they arise must be met by the remedies rationally indicated. Small doses of aconite or potassium citrate for the pyrexia, with a minimum dose of bromid for irritability and sleeplessness, may be all that is required. The internal use of potassium chlorate in chil- dren is not to be recommended in this affection, both because of its deleterious action upon the kidneys, and also because it seems to be unnecessary (Forchheimer; Backader). Sometimes an associated gastro-intestinal catarrh needs correction by the use of laxatives. The administration of bland foods and mild ferruginous tonics should be continued throughout convalescence. APHTHOUS STOMATITIS. (Follicular Stomatitis ; Stomatitis Aphthosa.) Definition.—A variety of catarrhal stomatitis that is characterized by the eruption of one or more vesicles upon the edges of the tongue, the cheek, or the lips, rapidly passing into small round, or oval discrete spots that are slightly raised and surrounded by yelloAvish-Avhite bases with narroAv red areolae. Etiology.—Though more common in children betAveen the ages of tAvo and six years, they are by no means rare in adults. Predisposing influences may be found in the seasons (spring and autumn), malnutri- tion, tuberculosis, dentition, persistent gastro-enteric disorders, anemia, and the acute exanthemata. The exciting causes are supposed to be certain deleterious substances, bacterial or toxic, though no special par- asite has yet been isolated. A PHTHO US STOMA TITIS. 695 Symptoms.—The herpetic vesicles soon rupture, leaving the aphthous ulcers as described above. They are found singly, or at times as many as twenty in number, pin-head to split-pea in size, inside the lips, espe- cially near the frenum, along the tongue-edges, and sometimes inside the cheeks near the edges of the back teeth. They are exquisitely tender, so that almost any motion of the affected parts causes sharp burning pain ; nourishment is therefore difficult. Patches of catarrhal stomatitis, and even of gingivitis, are seen adjacent to the aphthous spots. There is an increased flow of the secretions of the mouth, and the breath is heavy, though not offensive. General symptoms, as slight fever, anorexia, and furred tongue, constipation or diarrhea, and irrita- bility, are usually present, Avith the additional symptoms of any associated disease that may coexist. Gastro-intestinal affections, though often associated Avith aphthous stomatitis, are most probably due to the common cause, and are not necessarily the cause of the stomatitis in these in- stances. In some of the specific infectious fevers many aphthae may appear and tend to run together; these form large irregular ulcers, and give rise to the confluent form of stomatitis aphthosa. The special form known as Bednars aphthos, occurring in young marantic babes, is a rare condition in America. Large Avhite patches are seen on both halves of the posterior part of the hard palate near the alveolar processes, and these may cause large ulcers and involve the bone. Pressure of the tongue upon the thin mucous membrane during nursing, or some other such form of traumatic irritation, appears to act as the cause. Recovery from this type is rare. The average duration of the ordinary discrete aphthous eruption is from four to seven days ; in very ill-nourished and poorly cared-for cases the appearance of successive crops of aphthae will prolong the distress. Diagnosis.—This is based upon the characteristic appearance of the ulcers and the degree of soreness. Aphthae must be differentiated sometimes from thrush, and the distinguishing features will be dwelt upon in the description of the latter affection. Herpes of the mouth, so called, and aphthous vesicles are probably identical in most cases ; and the pres- ence on the lips of herpetic vesicles in some of the grave constitutional diseases indicates simply the severity of the common cause of the aphthae. Prognosis.—The discrete form is mild, and favorable in its course toward recovery; confluent aphthae is more troublesome, and folloAvs a prolonged course on account of the general debility induced by the associated disease (Starr). In certain adults, as well as in children, the affection is apt to recur; relapses are also frequent in those having weak digestive and imperfect assimilative functions. Treatment.—It is first necessary to remove all irritating influences, and in order to minimize the intense pain of the aphthous spots the blandest liquids and the softest foods that are consistent with the sus- tenance of the patient are imperative. Absolute cleanliness of both the foods and the vehicles of administration, especially in bottle-fed children, is not less important than the thorough cleansing of the mouth, par- ticularly after taking nourishment. Local applications are of obvious value. Demulcents, as mucilage of sumac, or of marshmallow, with boric acid (gr. v to gj—0.324 to 32.0), sodium bicarbonate (gr. v-x to I]— 0.324-0.648 to 32.0), carbolic acid, or potassium permanganate (gr. iv 696 DISEASES OF THE DIGESTIVE SYSTEM. t0 gj—0.259 to 32.0), are invariably useful. Swab-applications of Avine of opium (iriv to Ij—0.333 to 32.0) or of cocain (4 per cent, solution) may be necessary when the pain is intense, and prior to taking food. To promote the healing of the ulcers a very light touch with the silver-nitrate stick or solution (gr. x-xxx to 3j—0.648-1.94 to 32.0) is often beneficial. Much favor is deservedly given also to potassium chlorate in solution (gr. x to 3J—0.648 to 32.0), or applied in the dry poAvdered form. In the confluent aphthous ulcer the use of sodium salicylate (3J to Ij—4.0 to 32.0) has been recommended, Avhile an ethereal solution of iodoform (^ij to 3j—8.0 to 32.0) has been advised by J. Lewis Smith. For bleeding and spongy gums the mild astringents mentioned in the treatment of catarrhal stomatitis are indicated. Stronger astrin- gents may answer for application to sluggish ulcers; thus copper sul- phate, either solid or in solution (gr. x to §j—0.648 to 32.0), and zinc sulphate (gr. xv to §j—0.972 to 32.0) are useful. Potassium chlorate acts as a specific in ulcers of the mouth, and is eliminated by the buccal secretions, which keep the ulcerated surfaces constantly bathed with the drug, so that its internal use is to be recommended, though in very small doses in children, being given Avell diluted, as in the folioAving formula: B/. Potassii chlorat., gr. xxiv (1.55); Tinct. myrrhae, gtt. x (0.666); Syr. acaciae, f^ij (64.0); Aquae dest., q. s. ad fgiij (96.0).—M. Sig. Teaspoonful every three hours for a child three years of age. Constitutional symptoms are to be combated on general principles and require careful attention. Remedies directed to the correction of digestive derangements and to the stimulation of assimilation are also often required. Good food and ferruginous tonics are frequently necessary. MEMBRANOUS STOMATITIS. (Stomatitis Crouposa) Definition.—In this form of stomatitis the inflammation is more intense and more extended in area than in the aphthous form, being also attended with the formation of a false membrane, Avhich, when separated from the subjacent mucous surface, leaves a deeper and larger ulcer than does aphthous stomatitis. The pathology of these membranous patches, which are very sel- dom confined to the mouth alone, is embraced in the article on Diph- theria. If in the latter disease the typical false (diphtheritic) mem- brane is removed, it leaves a deeper ulcer than does the removal of a croupous membrane, in which the coagulation-necrosis involves the more superficial layers. In cases in which necrosis of the upper layers of the oral mucosa folloAvs from the application of caustics, the coagula- tion-process extends inAvard from the surface, forming yellowish-Avhite patches of dead tissue, Avhich, on separation, leave an ulcer (Allchin). Membranous stomatitis may also be due to gonorrheal or syphilitic in- fection of the new-born. The etiology of membranous stomatitis is, then, either specific (diphtheritic,) or non-specific, due to chemical or physical irritants. ULCERATIVE OR FETID STOMATITIS. 697 The account of the local symptoms and treatment is also included in the description of the causal diseases. ULCERATIVE OR FETID STOMATITIS. (Stomatitis Ulcerosa.) Definition.—A specific ulcerative inflammation of the buccal mu- cous membrane and gums, attended Avith marked fetor of the breath, and having a tendency to extend Avidely and deeply. Etiology.—The predisposing causes of this malady are principally as follows: Childhood, after the commencement of the first dentition, and usually betAveen the ages of three and eight years; damp Aveather, especially during spring and autumn ; unhygienic surroundings, partic- ularly the lack of pure air, of good and abundant food and clothing, and the added detriments to health for which neglect and filth, specific in- fectious diseases, uncleanliness of the mouth, caries and loosening of the teeth, and congenital heart-disease (DuckAvorth) are responsible. An endemic type of this affection has been observed among soldiers in camps and barracks, among children in crowded eleemosynary institu- tions, and in jails, and may be accounted for by unsanitary conditions affecting communities alike; its epidemic and contagious character like- wise points to a microbic origin. The specific exciting cause, it has been held, corresponds to the hoof-and-mouth disease of cattle, the poison being conveyed in milk. Payne suggests the identity of the virus with that of impetigo contagiosa. The careless administration of mercury, especially to susceptible adults, may also be followed by a severe mer- curial stomatitis that is typically ulcerative. Scurvy (scorbutic stoma- titis) and the persistent use of lead and phosphorus are also excitants of this disease. Clinical Symptoms.—Locally, the disease starts, as a rule, at the edges of the gums opposite the loAver incisor teeth, gradually spreading baekAvard and to the adjoining portions of the lips and cheeks. The gingival mucous membrane is deeply red and SAvollen ; the gums soon become spongy, bleed easily, and break doAvn into thick, soft, grayish sloughs, Avhich leave deep and ragged ulcers surrounding the necks of the teeth. The latter even become loosened, and in protracted cases the alveolar periosteum may become inflamed and cause necrosis of the bone. Profuse salivation, a foul breath (that once earned for the con- dition the term of " putrid sore mouth "), occasional slight hemorrhages from the gums, and excessive discomfort, or even pain, on mastication are nearly always present. The tongue is coated, SAvollen, and tooth- marked ; aphthae are sometimes seen, and the submaxillary glands are generally SAvollen. The general symptoms attending this ailment are those of a lowered state of vitality, produced by an unhygienic envi- ronment, or cachexia, or severe illness primary to it, Avith, usually, mod- erate fever. Nausea and vomiting or an offensive diarrhea may super- vene as the result of swallowing the putrid discharges. Course and Duration.—Though acute in its course, the highly debilitating character of the disease may tend to make it chronic, espe- cially Avhen there is alveolar necrosis and a neglect of proper treat- ment. Ordinarily, with careful management, convalescence may be 698 DISEASES OF THE DIGESTIVE SYSTEM. established in from four days to a week. Goodhart regards the occa- sional termination of the pyrexia by lysis, Avith an accompanying im- provement of the local symptoms in such cases at least, as suggestive of the specific nature of ulcerative stomatitis. Diagnosis.—Upon examining the mouth and noting the character- istic ulceration, the fetid breath and saliva, and the cachectic appear- ance, the disease is usually recognized, and should not be confounded with the dark, extensive, gangrenous sloughs of noma. The prognosis is favorable in typical cases, though less so in marasmic and neglected cases and Avhen cancrum oris or necrosis of the jaw are superadded; in such cases recurrence, chronicity, deformity, and even death, may take place. Treatment.—It is well in nearly all ill-nourished, uncleanly-kept, and sickly children, as well as in cases in which mercury is to be admin- istered for any length of time, to prescribe mouth-washes of potassium chlorate (gr. xv to Ij—0.972-32.0), in order to prevent the occurrence of mercurial or ulcerative stomatitis. The hygienic treatment of ulcer- ative stomatitis is important. On account of the contagiousness of the disease cases occurring in a family or in institutions should be isolated, and fresh air, light nourishment, and cleanliness are sine qud non of recovery. The local treatment is virtually a specific one in the use of potassium-chlorate Avashes (gr. x-xx to Ij—0.648-1.296 to 32.0— of rose-Avater or demulcent), aided by the internal administration of the same salt in small doses. For the disagreeable fetid odor the alter- nate use of antiseptic washes is indicated. Solutions of carbolic acid or potassium permanganate, in strength equal to or slightly over that indicated in the treatment of aphthae, or hydrogen peroxid (3J-iij to Ij ; 4.0-12.0 to 32.0), or listerin and Avater (equal parts), are useful. Pencilling the spongy gums with such astringents as tincture of rhatany, silver nitrate (gr. x to Ij—0.648-32.0), alum, and also Avith tannic-acid solutions, may be necessary. Loosened teeth should not be disturbed, as they may groAv firm Avith convalescence, though surgical interference may be required in cases of necrosis of the alveolar process. Until the patient has regained considerable vigor the use of mild antiseptic mouth- washes should be continued regularly, so as to effect thorough cleanliness and rid the oral cavity of lurking germs. Careful attention to the teeth is ahvays requisite. During the height of the disease constitutional treatment may have to be directed toAvard stimulating the languid and loAvered vitality. For this purpose either Avhiskey or brandy, in half or one teaspoonful doses in milk, is extremely useful; the elixir of cinchona, with some vegetable salt of iron, as the citrate or tartrate, also forms a useful combination. When there is pyrexia or a diminished urinary secretion the internal use of potassium chlorate is dangerous and must be cautiously employed. The folloAving prescription is tonic and almost specific, and may be recommended : B/. Potassii chloratis, gr. xlviij (3.11); Acidi hydrochlor. dil., fsj (4.0); Syrupi, fevj (24.0); Aquae destillat., q. s. ad fliij (96.0).—M. Sig. Teaspoonful diluted, every tAvo hours for a child three years old (Starr). PARASITIC STOMATITIS. 699 The prolonged use of tonics and cod-liver-oil emulsion with lime- salts in scrofulous, rachitic, and scorbutic subjects must be carried on in order to prevent relapses of ulcerative stomatitis. PARASITIC STOMATITIS. (Thrush; Stomatitis Mycosa) Definition.—A specific, contagious fungous disease, characterized by the rapid formation upon the oral mucous surfaces of small, whitish, soft, and lightly adherent spots or flakes, tending to coalesce and spread throughout the entire buccal cavity. Etiology.—Predisposing causes are—infancy with its concomitant disorders of the gastro-intestinal tract (especially when unhygienic sur- roundings and a consequently impaired vitality and malnutrition prevail), also congenital syphilis, tuberculosis, and the exanthemata. The dis- ease may attack adults and complicate the typhoid and cachectic states, as in the final stages of low fevers, carcinoma, chronic tuberculosis, and diabetes. The growth of thrush-patches is due, specifically, to the sac- charomyces albicans (formerly oidium albicans). It is a characteristic of this fungus to develop from round or oval spores in the formation of long- branching mycelium filaments, from the ends of Avhich a multiplication of ovoid torulae-cells takes place by the process of simple budding. These mycelia exhibit a tendency to penetrate the deeper layers of the mucosa of the mouth and also into the mucous glands (Starr). Since the growth of this organism requires both an altered condition of the mucous membrane and an acid medium, the primary or exciting cause of thrush is to be found in whatever produces such a favorable nidus. Most important in this connection is uncleanliness, particularly in the case of poorly-nourished and bottle-fed children. The development of catarrhal stomatitis and the acid fermentation of remnants of food (especially of saccharine substances), which prevent the nutrition'of the mucosa and acidify the normally alkaline oral secretions, are common causes of thrush. The further groAvth of the fungous patches also contributes to the acid state of the already abnormal buccal fluids. The fact that the spores of thrush may be transferred to other cases by bottle-tips, spoons, and ill-kept feeding-bottles is well recognized as an explanation for the occasional endemic character of the malady. Symptoms.—Any marked local symptoms are due rather to the coexisting stomatitis than to the thrush itself (Allchin). There will be some soreness, heat, persistent dryness, and lividity of the mucous mem- brane. Thrush-spots, slightly raised above the surface, begin to appear on the tongue, and grow into patches that may coalesce and spread to the cheeks, lips, and hard palate: they may even invade the tonsils, pharynx, and esophagus, and, rarely, the true vocal cords, the stomach, and cecum (Parrot). At first pearly-white in color, the curd-like flakes may become yellow and even broAvn, OAving to slight hemorrhages caused by the irritation. Though early adherent, in a few days they become loose, and when brushed off leave a smooth surface ; when complicating some serious gastro-intestinal disease or dyscrasia, however, their attach- ment is deeper, and the deposit may sometimes appear in successive crops. A microscopic examination of the thrush-patches shows inter- 700 DISEASES OF THE DIGESTIVE SYSTEM. lacing, irregular, and branched mycelial threads, spores, occasional bacilli, and leptothrix-filaments imbedded in a mass of granular debris and fetid particles. The buccal fluids are acid in reaction. The gen- eral symptoms depend upon the associated disease, and are usually those of wasting, artificially-nourished children having digestive troubles or a constitutional taint. Diagnosis.—This may be accurately made upon the discovery of the fungus by microscopic examination. Only very rarely are portions of the thrush-organism found in the false membrane of diphtheritic stomatitis. Milk curds may be readily removed, and are not necessarily associated Avith the stomatitis accompanying thrush or the grave sys- temic states. The only important point of differential diagnosis arises in the case of aphthce. The folloAving table will express the main points upon which a safe discrimination may be based: Parasitic Stomatitis (Thrush). Aphthous Stomatitis. Dryness of the mouth. Salivation. Whitish, raised spots or patches with no An ulcer with a yellowish-white, de- red areola ; these are easily removed, pressed base, surrounded by a red are- leaving no ulcer and causing no bleed- ola. The base is removed with diffi- jng. ' culty by forceps, and bleeding results. Spots are numerous. Usually few in number and discrete. Begins in the form of minute spots. Not so ; ulcers appear, preceded by the formation of herpetic vesicles. Ulcers not painful. Discomfort depends Ulcers exquisitely tender. on the associated stomatitis. The characteristic thrush-fungus is al- No specific micro-organism determined, ways present in the deposit, and can be though probably present. seen with the microscope. Prognosis.—This is favorable as regards the thrush alone, but, occurring in marantic children and cachectic adults, its appearance is of grave significance, and it is even suggested by some that it portends a speedy death. Treatment.—Prophylaxis is of great moment, since it is much easier to keep the mouth clean and the secretions normal, and to attend to proper food, and thus avoid creating a soil for the growth of the vegetable parasite, than it is to prevent absolutely the entrance of thrush-spores. Efforts directed toward preventing acidity are especially indicated. This is to be done by the use of mild alkaline mouth-washes, as soda- water and lime-water. The dietary should be carefully looked after, and should exclude sugars and all starchy food; the addition of lime- w7ater to the milk (about one part to four) is a desirable precaution to take, particularly Avith children. Cleansing the feeding-apparatus and the mouth after each feeding is essential, both in the prevention of the formation, and in decreasing the further groAvth, of thrush Avhen pres- ent. The local treatment consists in the use of alkaline and antiseptic applications, preferably by means of the spray. Solutions of boric acid or sodium hyposulphite (sj—4.0—of either to Ij—32.0—of Avater, Avith the addition of a little glycerin), potassium permanganate, or hydro- gen peroxid, are useful. Syrupy excipients are to be excluded. Potas- sium chlorate may exert a beneficial effect in those cases in Avhich stom- atitis is associated, as may also pencilling with a solution of silver nitrate (gr. v to Ij—0.324 to 32.0) over the inflamed mucosa. GANGRENOUS STOMATITIS. 701 When esophageal obstruction exists it may be necessary to gently force a rubber tube through the mass of thrush-deposit in order to give nourishment (Forchheimer). Medicinal treatment embraces the administration of nourishing and easily digestible food, occasional stimulation, and the correction of gastro-intestinal disorders. Attention must also be paid to the pri- mary affections to Avhich the thrush is superadded. Iron, cod-liver oil, and acid and bitter tonics in palatable form are usually indicated in debilitated subjects, along with general hygienic measures. The inter- nal use of small doses, frequently repeated, of calomel or mercuric chlorid may also be tried for a possible specific effect in combating thrush. LA PERLECHE. This contagious disease is confined to the angles of the mouth. It was first described in 1886 as prevalent among the children of Limousin in France by Lemaistre. It was found that the drinking-water in that locality contained cocci similar to the spherobacteria that infested the epithelial thickenings, and that these were probably conveyed to human beings by drinking-vessels. Little elevations and fissures, said to resemble those of congenital syphilis, were seen around the oral angles. The latter Avere the seat of smarting pain, particularly on opening the mouth sud- denly or too far, and caused the patient to lick (perlicher) them con- stantly. The disease seemed to be entirely local, and lasted from two to three w7eeks. Alum and copper-sulphate solutions Avere most useful. GANGRENOUS STOMATITIS. (Noma; Cancrum Oris.) Definition.—A rapidly-spreading gangrenous affection of the cheek and gums, of rare occurrence, usually asymmetric, and ending fatally in most cases. Pathology.—In addition to the necrotic changes in the cheeks, the process may extend to the jaws and lips. The blood-vessels contain thrombi, thus preventing hemorrhage from the sphacelus. The submaxil- lary and cervical glands may be slightly enlarged and soft. Blood-changes of an uncertain character have been noted. Hemorrhagic infarctions, aspiration broncho-pneumonia, or gangrene by inhalation of gangrenous particles or metastasis, may be met in the lungs. Wharton has described an associated membranous form of colitis, and a metastatic infiltration of the cardiac muscle and purulent pericarditis may also be seen post- mortem. Klementorosky met Avith a peculiar and fatal form of gangrene limited to the gums of babes and occurring a feAv days after birth. Etiology.—Predisposing Causes.—This uncommon affection attacks girls more frequently than boys, usually betAveen the ages of tAvo and five years; it appears to be endemic in Ioav, moist countries, as Holland, though apparently it is not contagious. Sickly and ill-nourished chil- dren suffering from the effects of overcrowding and previous disease are especially liable to noma. Most often, hoAvever, it is secondary to measles; it may also follow scarlet fever, typhoid, small-pox, or less fre- quently pertussis. Boydon reported a case associated Avith erysipelas 702 DISEASES OF THE DIGESTIVE SYSTEM. in an adult. The causative influence of mercurialization and ulcerative stomatitis has been overrated. The primary exciting cause of cancrum oris is probably microbic, and Lingard has found " long thread-like groAvths made up of small bacilli at the line of extension of the necrotic patch." Symptoms.—The mucous membrane of one cheek, near the corner of the mouth, is usually first affected, a dark, ragged, sloughing ulcer appearing and spreading insidiously for tAvo or three days before the substance of the cheek is involved. A hard and sensitive nodule may then be felt by grasping the cheek betAveen the thumb and finger on placing the one Avithin the mouth over the ulcer and the other outside. BraAvny induration of the skin over this nodule soon becomes manifest, and then there appear collateral edema and an unctuous-looking, deeply livid, gangrenous spot, soon becoming bullous and leaving a black eschar. Perforation of the cheek may occur on the third day, though usually not until a week has passed. There is an ichorous dis- charge of shreds of gangrenous tissue from the unhealthy Avound. The fetor of the breath is almost intolerable and characteristically gangren- ous. The necrosis may extend over one-half the face of the side affected, and may involve the gums and jaAvs, but seldom does it attack the opposite side of the face. The general symptoms of such a grave mal- ady may be slight at a very early period, but with the formation of the eschar they become rapidly severe and typhoid in type. Great prostra- tion, delirium, pyrexia (104° F.—40° C.), diarrhea, and edema of the feet are common. The course is actively acute; the duration rarely extends beyond two weeks. Complications.—Septic lobular pneumonia may occur from aspira- tion of gangrenous particles; colitis and gangrene of the genitalia in females (noma pudendce) are also seen. In those very rare cases that recover granulations form, the gangrenous edges become clean, and cicatrization, Avith great disfigurement of the face and even restricted jaAV-motion, is then apt to folloAV. Diagnosis.—The disease Avhen fully established is easily diagnosed by its characteristic origin, the gangrenous ulcer-nodule, the eschar-for- mation, and perforation, associated with a previous history of measles or other acute infectious fever of childhood. The offensive fetid odor and severe constitutional depression are also of great value. Differential Diagnosis.—From anthrax it differs in that the latter affection is more common in adults, Avith a history of contagion, and in the fact that malignant pustule starts on the exterior of the cheek, and perhaps in a previous abrasion in the skin. The discovery of the bacillus anthracis in the blood and discharges is conclusive, tfh-eratire stomatitis of a severe and neglected type may be confounded with can- crum oris, but in the former the destruction of tissue is mainly of the gums and alveoli, the cheeks being simply ulcerated and no extensive sloughing taking place; the breath, though fetid, is not gangrenous, and the oral discharge, though sometimes bloody, is not mixed with shreds of gangrenous tissue (Starr). Finally, the course of ulcerative stomatitis is less severe, a fatal termination being extremely rare. Prognosis.—Noma is seldom recovered from, the mortality being about 80 to 90 per cent. (Bogel). When recovery does take place the MERCURIAL STOMATITIS. 703 development of ectropion, facial deformity, and local disability, with a protracted convalescence, render life burdensome. Treatment.—This embraces the prevention of gangrenous stoma- titis by means of a proper management of the diseases that are knoAvn to cause it; careful hygiene and the avoidance of mercurialization will also be of undoubted use. The primary indication in the local treat- ment is the arrest of the gangrenous process, thus causing, if possible, a healthy reaction on the part of the surrounding tissues. All dead sloughs should be cut away before using escharotics, and Avith this end in vieAv some recommend the prompt application of strong caustics, as fuming nitric acid, the acid nitrate of mercury, solid zinc chlorid, silver nitrate, carbolic acid, a concentrated solution of perchlorid of iron, Vienna paste, and the actual cautery. For the protection of the healthy parts and for efficiency the Paquelin or the galvanic cautery is prob- ably best. Anesthesia is requisite for such strong measures. Milder applications, however, seem to be quite adequate in some cases. Thus, bismuth subnitrate, potassium chlorate, and aristol, or the following for- mula by Dr. Coates, may7 be tried: R^. Cupri sulph., 3ij (8.0); Pulv. cinchonae, Iss (16.0); Aquae, q. s. ad fliv (128.0).—M. It is essential, for the prevention of septic infection to ensure cleanli- ness of the wound and of the mouth, and to promote the separation of the sloughs. To effect the former Ave employ mild antiseptic washes of carbolic acid, hydrogen peroxid, Labarraque's solution, potassium per- manganate, etc.; for the latter and for the diminution of the fetor, anti- septic charcoal poultices containing boric or salicylic acid are useful. Mild antiseptic and astringent lotions of boric acid, zinc sulphate (gr. ij to Ij—0.129 to 32.0), or balsamic ointments Avith vaselin, may aid in healing the granulating surfaces in favorable cases. The internal treat- ment must be directed toward sustaining the strength of the patient by the administration of the most nourishing food, stimulants, and tonics, especially quinin, iron, and strychnin. Rectal feeding may be neces- sary. Plastic operations are sometimes needful after recovery to miti- gate oral disabilities or facial deformities resulting from cicatricial adhe- sions and contractions. MERCURIAL STOMATITIS. (Mercurial Ptyalism) Definition.—An inflammation of the mouth and salivary glands, caused by the excessive use of mercury; it is rarely seen as a result of the therapeutic use of other drugs. Etiology.—Predisposing causes are dyscrasia and occupation, mainly. The peculiar individual susceptibility of these subjects to dyscrasia will not permit the use of even minimum doses of mercury Avithout serious and almost immediate symptoms of ptyalism. This is also seen in barometer-makers, mirror-silverers, chemists, and others who handle mercury in their daily work. The exciting cause of ptya- lism is the ingestion, inhalation, or cutaneous absorption of mercury. 704 DISEASES OF THE DIGESTIVE SYSTEM. Symptoms.—A metallic taste in the mouth is first noticed by the patient. Soon the gums become '"touched"—/. c red, SAvollen, tender to the touch, and sore during the act of mastication. A marked secre- tion and flow of saliva, with a fetid breath and SAvollen tongue, folloAV. Very rarely in this disease the affection passes into an ulcerative stoma- titis, and causes loosening of the teeth and necrosis of the maxilla. General symptoms, as constitutional depression, anorexia, diarrhea, mental anxiety, and nervousness, may supervene. The recognition of the foregoing causal factors—predisposing and exciting—renders the diagnosis easy. The prognosis is favorable, and, although the local symptoms may be harassing, recovery is attainable Avithin a few Aveeks as a rule. Treatment.—The toxic action of mercury in the production of ptyalism can be avoided by a knoAvledge of individual susceptibility and by the local and internal use of potassium chlorate. Upon the first appearance of the symptoms there must be a prompt withdrawal of the mercurial influence, and a change of occupation if that be the predis- posing cause. Locally, soothing, alkaline, and mildly antiseptic mouth- washes, as in the treatment of catarrhal stomatitis, may be all that is necessary. For the fetid breath solutions of boric acid or potassium chlorate may be used. Ulcers may be brushed with silver-nitrate solu- tion. The internal treatment should be directed toward keeping the bowels soluble; in addition, alkaline mineral waters may be used, and in severe cases potassium chlorate in 5- to 10-grain (0.324-0.648) doses. Atropin (gr. y^—0.0006) and opium have been recommended to de- crease the excessive salivary secretion and to allay pain, and hot baths will aid the treatment materially. In severe cases the resulting debility and anemia should be met by the use of highly nourishing liquid foods and by tonics. Osier points out that the condition of the teeth knoAvn as erosion, which sometimes folloAvs infantile stomatitis, and especially the mercurial form, is to be discriminated from the deformed teeth of congenital syph- ilis. In the former the first permanent molars, and then the incisors, are observed to have small pits or discolored and eroded spots, due to a morbid deficiency in enamel-formation. The notched and irregular teeth of hereditary syphilis in children (Hutchinson) are sufficiently distinctive. II. DISEASES OF THE TONGUE. GLOSSITIS. ACUTE GLOSSITIS. (Glossitis Acuta) Definition.—An acute parenchymatous inflammation of the tongue, sometimes ending in abscess. Etiology.—Predisposing causes are supposed to be an impaired gen- eral health and exposure to cold, humid weather. The exciting causes CHRONIC SUPERFICIAL GLOSSITIS. 705 are most frequently the stings and bites of insects, or burns, scalds, and the action of corrosives. I believe that many cases folloAV slight in- juries to the tongue that alloAV of the introduction of inflammatory poisons or microbes. Symptoms.—These come on rapidly and Avith more or less local severity and danger. The tongue becomes much SAvollen, and may even protrude beyond the lips. It is very tender and painful, and coated with a thick, soft yelloAvish-Avhite fur, and it may also be dry, cracked, and ulcerated. Catarrhal stomatitis is often associated, salivation is usually profuse, and talking, SAvalloAving, and even breathing, are ren- dered difficult and distressing. Dyspnea, even to suffocation, may be imminent. The cervical and sublingual glands may be SAvollen, mode- rate fever is ahvays present, and the obstruction to breathing and admin- istration of nutriment may assume a dangerous aspect. The inflammation reaches its height in about three or four days, tending to subside almost entirely about the seventh day. Not rarely the inflammatory infiltration passes into suppuration Avith the formation of a circumscribed abscess of variable size in one-half of the tongue; fluctuation may not, however, be obtainable, spontaneous rupture being sometimes the first indication of abscess. The prognosis is favorable, except that serious obstruction is likely to remain. Treatment.—When the case is seen quite early and during the congestive stage, the topical use of ice, allowed to sloAvly dissolve in the mouth, may be both grateful and of service in preventing the swelling. Mucilaginous mouth-washes, containing some mild antiseptic, as sodium borate with sodium bicarbonate (gr. v-xx to Ij—0.324-1.296 to 32.0), should also be employed. A brisk saline purge, given early, will aid in reducing the inflammation, and should the tongue become alarm- ingly SAvollen, deep scarification and the use of half a dozen leeches be- tween the hyoid bone and the jaw-angles may be of decided service. Steam-atomization, medicated Avith the compound tincture of benzoin or ammonium chlorid (sj to Ij—4.0 to 32.0), favors resolution (Cohen). Abscesses must be incised and washed out with antiseptic solutions. Tracheotomy is rarely called for to relieve the dyspnea. Rectal ali- mentation Avith predigested foods may be necessary, and during con- valescence ferruginous tonics in glycerin and bland foods should be con- tinued for some time, in order to prevent chronic inflammation and thickening. Any local source of irritation, as from carious or sharp teeth, should be removed. CHRONIC SUPERFICIAL GLOSSITIS. Definition.—A chronic inflammation of the mucosa of the tongue. Etiology.—This disease is often preceded by several acute attacks, the habitual use of tobacco, both in smoking and cheAving, and of strong spirituous liquors being mainly productive of the original affection. The frequent use of irritating foods is also a prominent factor in some instances. Symptoms.—The surface of the tongue is continually sensitive and more or less reddened. Often there are seen ovoid patches of various size, smooth and shiny, on account of the loss of papillse, and separated 45 706 DISEASES OF THE DIGESTIVE SYSTEM. by furroAvs that extend to the depth of the mucosa itself. The tongue may also be slightly furrowed in intervening spaces, especially at the base. The general health is someAvhat deteriorated. Diagnosis.—This rests upon the history of the case and upon the results of examination of the organ. The prognosis is favorable as to alleviation, but guarded as to cure. Treatment.—The blandest dietary must be insisted on, as Avell as absolute abstention from the causal irritants, exacerbations being prone to occur. The local use of demulcents and of mildly alkaline and anti- septic lotions, such as Seller's tablets in solution, and of solutions of chromic acid or silver nitrate (gr. v-x to Ij—0.324-0.648 to 32.0) in glycerin or honey, applied once or twice daily by gentle brushing, is to be recommended. General tonics and the avoidance of irritating drinks will be indicated. GLOSSITIS DESICCANS. A rare disease, chronic in nature and of unknown causation. It is characterized by "the gradual development upon the surface of the tongue of a number of deep fissures and indentations, giving the organ an uneven and ragged look. The pain is due to the frequent presence of excoriations and ulcers in these fissures " (Striimpell). The prognosis of the affection is favorable as regards any danger. The treatment is hygienic, consisting of cleanliness of the mouth and the use of disinfect- ant mouth-lotions, together Avith the topical use of alterative or astrin- gent applications, as silver nitrate or chromic acid, to any ulceration. LINGUAL PSORIASIS (TYLOSIS LINGU.E). In this disease there are small regular areas of hyperplasia of the glossal epithelium, eventually causing a map-like appearance of the sur- face of the tongue—"lingua geographica." The trouble is obscure in its etiology and persists for years. Seldom is there any discomfort asso- ciated, although mental anxiety or hypochondriasis may develop. LEUKOPLAKIA ORIS (BUCCAL PSORIASIS). In this affection the mucous membrane of the mouth and tongue may be involved. On the lateral borders of the tongue white or bluish-white scar-like spots or patches, often slightly notched, make their appearance. Some of these pass away to be replaced by others, and the affection pro- gresses despite all attempts to cure it. The true cause is unknoAvn, but it has been suggested that some irritant, as the use of a pipe, may account for the condition. The malady has, hoAvever, been seen in women. A syphilitic taint is said to especially predispose to the dis- ease (Striimpell). The affection must be carefully diagnosed from the oral manifestations of syphilis, if for no other reason than to relieve the mind of a morbidly anxious patient. Excepting some pain con- nected Avith possible ulceration, there are no annoying symptoms, and the treatment further than that suggested for glossitis desiccans is usually of no value. DISEASES OF THE SALIVARY GLANDS. 707 In children a similar tongue-affection has been named " wandering rash." The Avhitish patches are circinate and enlarge peripherally, forming rings of epithelial hyperplasia, within Avhich is a red, glossy center " devoid of filiform papillse, though the fungiform remain " (All- chin). The affection is regarded as a tropho-neurosis. ANGINA LUDOVICI. (Ludwig's Angina.) Definition.—A rare acute phlegmonous inflammation of the floor of the mouth. Etiology.—The condition may be idiopathic, but more often it is secondary to specific infectious diseases, as scarlet fever and diphtheria. Undoubtedly it is directly caused by a streptococcus and by an extension of the infection from adjacent glands (Osier). Symptoms.—These are intense at the outset, and begin Avith swell- ing in the region of the submaxillary gland, Avith a rapid involvement of the cellular tissue of the floor of the mouth as Avell as of the anterior portion of the neck. Pain is marked, and this, Avith the acute SAvelling, renders articulation, mastication, and deglutition extremely difficult. Compression or edema of the larynx may often cause dangerous dyspnea. The constitutional disturbance is usually febrile, and may either approach the typhoid type or may be septic. The condition generally terminates either in abscess or extensive sloughing (cynanche gangrcenosa), and only rarely does resolution take place. The diagnosis is easily made when complicating a specific fever. The prognosis is ahvays guarded, since death sometimes occurs. Relapses are likeAvise apt to follow in Aveakly and strumous subjects. Treatment.—The most that can be done is to sustain the strength of the patient and secure prompt surgical interference when the process has reached the point of beginning suppuration or gangrene. Trache- otomy may be demanded if asphyxia threatens life. III. DISEASES OF THE SALIVARY GLANDS. HYPERSECRETION. (Ptyalism.) Definition.—An abnormal increase in the secretion of saliva. Etiology.—Salivation as an idiopathic affection is rare, and as such is considered to be a neurosis. Thus, it has been seen in emotional children of from tAvo to eight years of age, though apparently in perfect health. According to Bohn, the secretion in these cases is mostly in- creased during active exercise, is reduced on lying doAvn, and absent during sleep. Spontaneous recovery takes place in a feAv years. As a deuteropathic disease ptyalism may be the result of oral disease (e. g. noma, ulcerative stomatitis), and also of gastro-enteric, pancreatic, 708 DISEASES OF THE DIGESTIVE SYSTEM. uterine (as gestation), centric (as diseases or tumors of the medulla or of the facial nerve), toxic, systemic (as small-pox, the use of mercury, iodids, pilocarpin, tobacco), and hydrophobic irritation and disease. Diagnosis.—It should be pointed out that a failure in sAvalloAving the normal quantity of saliva may cause dribbling from the mouth and simulate true hypersecretion. The prognosis is favorable in itself, but dependent on the gravity of the cause. Treatment.—The causes are to be removed and the general health toned up. For stomatitic salivation potassium chlorate is first in rank as an internal and local remedy. Iron and arsenic are valuable in neur- otic cases, and the bromids or hyoscin may be of supplemental use. Atropin (gr. -^iro t0 Too— °-0003 to 0.0006) and belladonna are almost uniformly successful in idiopathic as Avell as in central ptyalism. XEROSTOMA. (Aptyalism; " Dry Mouth.') Definition.—A morbid suppression or arrest of the salivary and buccal secretions. Etiology.—Most of the cases of dryness of the mouth have been observed in women in conjunction with nervous or sudden mental phe- nomena, and only as a temporary condition. Centric involvement con- nected Avith the secretion of saliva is probable in some cases (Hadden). Much more commonly xerostoma is an effect of the febrile state, of mouth-breathing (due to nasal obstruction), and of diabetes. Symptoms.—Apart from the sensation of dryness, mastication, deglutition, and articulation are difficult. The local appearances show a glazed, shiny, red, and sometimes cracked condition of the tongue and labial and palatine mucous membrane. The absence of saliva may per- mit the remnants of food to collect around the gums and harden (Osier). The diagnosis is made on inspection, the prognosis depending on the removability of the cause, and rightfully being guarded on account of the frequent obstinacy of the trouble. Treatment.—Attention to the systemic condition, Avhether diseased or merely debilitated, is requisite. Small doses of potassium iodid and pilocarpin (gr. -^—0.003) in gelatin lamellae or in lozenge form, allowed to dissolve in the mouth Avith the aid of a sip of Avater, have been pro- ductive of relief. In cases of obscure or of centric origin the galvanic current should be tried. SYMPTOMATIC PAROTITIS. (Parotid Bubo.) Definition.—A secondary inflammation of the parotid gland, gen- erally due to septic infection, usually unilateral, and tending to suppu- ration. Etiology.—Not being a primary affection, the causes giving rise to DISEASES OF THE TONSILS. 709 it may be mentioned as folloAvs: (a) Acute infectious fevers, as typhoid, typhus, pneumonitis, pyemia, erysipelas; (b) Injury or disease of the abdomen or pelvis (Stephen Paget), especially Avhen associated Avith the genito-urinary tract, as mild traumatisms or derangement of the testes or ovaries, the use of a pessary, or even menstruation or pregnancy; gastric ulcer may be accompanied by it; (c) Peripheral neuritis with facial paralysis (Gowers). Most of the cases are probably septic and indicative of an unfavor- able course in the progress of the associated disease, and especially of the fevers mentioned. The symptoms, diagnosis, and treatment of the parotitis itself fall more properly under the scope of surgery. IV. DISEASES OF THE TONSILS. ACUTE TONSILLITIS. Definition.—An acute inflammation of the tonsil or tonsils, affect- ing either the mucous membrane, the follicles, or the parenchyma, and ending either in resolution, suppuration, or chronic enlargement. Pathology.—In the superficial variety of acute tonsillitis the mu- cosa is simply red, SAvollen, and sometimes covered with a thin, soft exu- date of muco-pus. The tonsil itself may also be SAvollen. In follicular tonsillitis the lacunae become filled Avith a cheesy exudate which often protrudes from the tonsillar crypts; epithelial and pus-cells, cellular debris, and occasional cholesterin-crystals are found in these cheesy masses. In older, darker-hued masses an offensive odor is given off, and numerous micrococci and bacteria are found. In adults, calcareous infiltration of the cheesy little masses may be met Avith. Parenchyma- tous tonsillitis is shoAvn by a greater enlargement of the tonsil, due to a marked infiltration of all the tissues. Suppuration in the tonsil is frequent, the follicles usually bursting and uniting in abscess-forma- tion. Pus may burroAv into the cellular tissue surrounding the tonsil, and find its Avay even down to the clavicle. The herpetic or ulcero-mem- branous form of tonsillitis described by Rilliet and Barthez, DaCosta, and others, in Avhich an eruption of herpetic vesicles on the tonsils is folloAved by their rupture and the formation of a lightly adherent, membranous covering, is rarely met with. It is said to complicate superficial or ca- tarrhal tonsillitis (Allchin). In necrotic tonsillitis (Striimpell) a grayish- white adherent necrotic membrane is observed, that is limited by the in- flamed membrane surrounding the mucosa covering the tonsils, Avhich are moderately swollen. After the removal of the slough a dirty and often deep ulcer remains. Etiology.—Predisposing causes are age, sex, temperament, and atmospheric conditions. The disease is more common in youth and in early adult life than during infancy, although enlarged tonsils are fre- quently met Avith at this period of life also. Boys and young men ap- pear to be attacked more often than the opposite sex. An individual susceptibility is most distinct in lymphatic and strumous constitutions; 710 DISEASES OF THE DIGESTIVE SYSTEM. this may be simply hereditary, or in certain cases it is aggravated by or tends to recur especially in the rheumatic diathesis. It is certain also that one attack of acute tonsillitis predisposes to subsequent ones, par- ticularly Avhen the first attack has left some enlargement or hypertrophy of the tonsils. Sudden, rapid, and extreme climatic changes, and the special local and atmospheric conditions sometimes seen in connection with outbreaks of scarlet fever, measles, and diphtheria, have an un- doubted influence predisposing to epidemic tonsillitis. The exciting causes of acute tonsillitis are most commonly the follow- ing : (a) exposure to cold and dampness, or talking in a cold, moist at- mosphere ; (b) exposure and talking in an overheated atmosphere viti- ated with smoke or other poisonous and irritating vapors or gases; (c) bad drainage, sewer-gases; (d) specific infectious fevers, as scarlatina, measles, and erysipelas; (e) irritation from hard and sharp foreign bodies or chemical irritants; (/) the presence of microbes. Clinical Symptoms.—Three principal varieties of acute tonsillitis occur clinically, the symptoms of Avhich will be described under their respective headings: (a) Acute Catarrhal or Superficial Tonsillitis.—This form is often associated Avith acute pharyngitis. The earliest local symptoms are pain and difficulty in SAvallowing, the former often becoming quite acute and radiating to the ear and lymphatics at the angle of the jaw, where ten- derness on pressure may also be elicited. In speaking a nasal twang is often noticed. During the laborious act of swalloAving the sensation of a lump in the throat, especially when the mouth is dry, is commonly complained of. Simple stomatitis, with its discomforts, may be associated, and rarely there is a slight cough Avith the painful expectoration of a sticky mucus which accumulates in the throat (BroAvne). There may be salivation, and usually there is a bad taste in the mouth, with fetor of the breath. Inspection shoAvs the tonsil to be red and swollen. Though dry and glazed at first, the surfaces soon become covered Avith a thin exudate of muco-pus, Avhich is easily detached by brushing, gargling, or "hawking" the throat. There is usually some accompanying red- ness, and also a tumefaction of the uvula and faucial pillars. The con- stitutional symptoms of simple erythematous tonsillitis at the outset are mildly febrile. The attacks usually come on rapidly, and last but a feAv days, subsidence taking place rapidly also. Otitis media may folloAV the extension of the tonsillar inflammation, and acute pharyngitis is a more common complication; endocarditis and pericarditis rarely also occur. (b) Acute Lacunar or Follicular Tonsillitis.—In this form, Avhich is quite common in children, not only the mucous membrane lining the crypts is inflamed, but that covering the surface of the tonsils also, giv- ing rise to more or less associated catarrhal tonsillitis. The local sub- jective symptoms in this disease are pain, tenderness, and difficult deg- lutition, the counterparts of those of the preceding form. The tonsils are seen to be covered Avith small, slightly prominent, whitish-yellow spots or patches of a characteristic creamy exudate corresponding to the position of the crypts and numbering from tAvo to eight or ten or more. These little masses or plugs may be pressed out of the follicles with a spatula. A predominance of pus-cocci and cells may rarely forerun the further formation of little follicular abscesses, and even of slight erosions ACUTE TONSILLITIS. 711 and ulceration of the mouths of the lacunae. Unlike simple catarrhal tonsillitis—at least in so far as simultaneous involvement is concerned (Cohen)—both tonsils are usually affected in this trouble, though one to a greater degree than the other. The Avhole tonsil is considerably sayoI- len, and in severe cases the cervical lymph-glands also. The constitu- tional symptoms of follicular tonsillitis may be quite severe. The disease may be ushered in with a pronounced chill, headache, aching of the back and limbs, marked anorexia, a heavy deposit of urates, and in- somnia, along Avith a rapid rise in the temperature to 103° or 104° F. (39.4°-40° C.)—in children as high as 105° F. (40.5° C). The gen- eral depression may be so great as to simulate adynamia. Though sud- den in its onset and rapid and often intensely acute in its progress, the disease seldom lasts more than five or eight days. Follicular abscesses, febrile albuminuria (Hais-BroAvn), may appear and complicate the case, Avhile chronic swelling of the tonsils, desiccation, and bacterial degen- eration of the lacunar masses may be sequelae. The latter give rise to an offensive odor Avhen crushed, and often cause hypochondriac patients needless anxiety by being mistaken for tuberculous deposits. The re- tained follicular exudates may undergo calcification, and may be expec- torated along Avith concretions or chalk-plugs. (c) Acute Parenchymatous Tonsillitis (Tonsillar Abscess or Quinsy). —In this form of tonsillitis, Avhich occurs most often during adolescence and early adult life, the symptoms reach the most pronounced and severe types. The stroma is inflamed and the tendency is toAvard suppuration. Local Symptoms.—Complaint is first made of dryness of the throat, Avith painful and difficult deglutition. The pain is a prominent subjec- tive sign, and may be referred to one or both ears according as one or both tonsils are inflamed. The secretion of a viscid mucus soon takes place, and as the tonsillar SAvelling increases the husky voice of sore- throat and difficult articulation supervene; in cases of aggravated SAvelling dyspnea may often appear later. On examining the tonsils they are found to be greatly enlarged, deeply reddened, and edematous. The surrounding soft parts, the faucial arches, pillars, and the uvula, also manifest a deep congestion. The swollen tonsils may cause a bulging forward of the anterior pillars of the fauces, and push the often elongated and edematous (jelly-like) uvula to one side; or if both tonsils are affected, they may grasp or push it fonvard. In severe cases the tonsils may meet in the median line. They are firm to the touch. Patches showing follicular tonsillitis are not infrequently seen associated Avith the trouble. The submaxillary glands may be engorged, and open- ing the mouth is often performed with difficulty; it is usually only par- tial, on account of the fixation of the jaw. In a few days, perhaps, softening and fluctuation may be detected in the tonsils, and spontaneous rupture and discharge of the pus may occur, Avith almost instant relief to the patient. Suppuration and tonsillar abscess are not ahvays the termination, hoAvever, of parenchymatous inflammation, resolution sometimes taking place in the milder cases. The abscess may open in one or more places, and rupture during sleep may rarely cause suffocation by the entrance of pus into the larynx. The tonsil may regain its original size in a few days after the discharge of pus, and all the symptoms subside. The constitutional phenomena 712 DISEASES OF THE DIGESTIVE SYSTEM. of parenchymatous tonsillitis are usually severe from the start, even in children, and more so than in the follicular form (Mackenzie). The tem- perature rises to 104° or 105° F. (40° or 40.5° C.), and the pulse-beats may reach 130 per minute. The usual symptoms accompanying inflam- matory fever are marked. There may be delirium, and the symptoms generally increase until the abscess bursts or is opened, Avhen the con- stitutional as Avell as the local disturbance rapidly abates. Course, Duration, and Terminations.—Though often severely acute in its course, quinsy seldom goes on to rupture in children, usually end- ing in resolution in from three to five days. If both tonsils are inflamed, only one suppurates as a rule, or but one at a time. The duration of an attack ending in tonsillar abscess is about eight or ten days in adults. Complications and Sequela'.—The tonsillar suppuration may invade the cellular tissue betAveen the tonsil and the pterygoid muscles; a peri- tonsillar abscess may then result that may open even above the clavicle. Deep involvement of the tonsil may also cause ulceration into the in- ternal carotid or internal maxillary arteries, and fatal hemorrhage occur, though these accidents are, fortunately, rare. Edema of the larynx is also an infrequent complication. French Avriters, as Guble, Germain See, and others, have reported cases of paralysis of the soft palate and pharynx following inflammatory throat-diseases. On subsidence of the tonsillar inflammation the trouble becomes evident in the difficult SAval- lowing and partial regurgitation of liquids and solids into the nasal passages, and in the nasal intonation of the voice. A frequent sequel, especially in those predisposed by heredity, is chronic enlargement of the tonsils. (d) Necrotic Tonsillitis.—This affection is considered by Striimpell to be in some instances entirely distinct from diphtheria in its etiology, although he admits that quite frequently it is simply a mild form of the latter disease, and that often it is impossible to distinguish betAveen the local appearances of the tAvo conditions: these have been referred to under the heading of Morbid Anatomy. The constitutional disturbances are severe, especially in children, though they seldom last longer than a week, and are followed by a rapid convalescence. The cervical glands are not SAvollen to the same extent as in diphtheria. The occurrence later of palatal and pharyngeal paralysis in a supposed case of necrotic tonsillitis would point to its true diphtheritic origin. Diagnosis.—The appearance of the several forms of acute tonsil- litis, associated Avith the clinical history of each case, should enable a ready diagnosis to be made in the majority of cases. A difficulty may, however, arise in discriminating follicular tonsillitis from diphtheria, especially Avhen the pseudo-membranous exudate of the latter is limited to the tonsils. The appended table gives the important points of differ- entiation between these diseases': Follicular Tonsillitis. A soft, pultaceous, yellowish-white de- posit occurs in spots or patches situated over the mouth of the follicles, with areas of redness intervening. The exudate is easily removed, leaving a smooth surface. Diphtheria. A tough, ashy-gray, continuous, and uni- form pseudo-membranous deposit cov- ers the tonsils. Very adherent, and can be torn off in strips only, leaving a bleeding erosion. ACUTE TONSILLITIS. 713 Follicular Tonsillitis. Diphtheria. The deposit is limited to the tonsils (im- The pillars of the fauces and uvula are portant). involved as well. If the creamy deposits unite to form a Removal of the membrane is followed by continuous layer, removal is either not re-formation within twelve to twenty- followed by re-formation, or very late. four hours. May have high temperature, but lasting Persistent elevation of the temperature; only a day or two. Albuminuria ex- more or less albuminuria is common. tremely rare, if present at all. Cervical lymphatic glands seldom or Usually markedly swollen glands. slightly swollen. Complications rare and mild. Complications frequent and grave. Cellular detritus,-bacteria, etc. in deposit. Fibrinous exudate, etc. containing the Klebs-Lbffler bacillus. Cases seen early, Avith severe constitutional symptoms and red and swollen tonsils having no deposit, may give rise to the question whether simple angina or scarlet fever is to follow. In such cases the latter dis- ease may be excluded by a negative history of exposure to contagion, by the absence of a very high pulse-rate, and by the non-appearance of the scarlatinal eruption. Necrotic tonsillitis may be discriminated from the lacunar variety in the same manner as diphtheria—i. e. by its local manifestations, a full description of which has already been given under the heading of Morbid Anatomy. The prognosis is good as regards life, and favorable as regards complete recovery. The occurrence of either fatal hemorrhage or asphyxia in cpdnsy is extremely rare. In debilitated and strumous in- dividuals relapses are prone to occur, and successive acute attacks of tonsillitis tend to cause permanent hypertrophy of the tonsils. In cases of necrotic tonsillitis, especially during the earlier periods, the prog- nosis should always be guarded. Treatment.—Particularly in the lacunar and necrotic forms of ton- sillitis the patient should be kept apart from others as much as possible, since both types appear to be contagious to a certain degree ; or, if other persons in the house are subject to a common source of infection —not human—their frequent nearness to a given case only serves to augment their OAvn liability to similar attacks. Individual susceptibility to frequent attacks of sore throat may be lessened by systematic cold bathing of the neck. Constitutional and local rest is a first and con- stant requisite. Efforts at swallowing and talking should be reduced to a minimum, and in marked cases of follicular or suppurative tonsil- litis rest in bed is often sought without direction. Bland nourishing liquids, as milk, broths, and the like, should constitute the only nutri- ment during the stadium of the tonsillar inflammation. Earlv in the case a free evacuation of the boAvels should be obtained, and small doses of calomel (gr. \-\—0.008.-0.010, repeated hourly until about gr. 1 —0.0648—has been taken), followed by a Seidlitz powder or Rochelle salts in hot water, will be effective in most cases. In severe cases of quinsy relief from the pain is urgently called for, and either a Dover's poAvder or a hypodermic injection of morphin (gr. -g--4;—0.010-0.016) and atropin (gr. y-^j-—0.0006) will probably suffice for their relief. A high temperature must be combated by small doses of aconite, fre- quently repeated: this drug has been much used in the follicular ton- 714 DISEASES OF THE DIGESTIVE SYSTEM. sillitis of children. Quinin, in solution Avith dilute sulphuric acid, is also often given. The administration of sodium salicylate or benzoate, of salol, or of the ammoniated tincture of guaiac in 1-dram (4.0) doses (Sajous), seems to lessen the duration and severity of tonsillitis, and even to cure some cases of the lacunar form within forty-eight hours and Avithout local applications. The tincture of the chlorid of iron in glycerin (4 or 5 drops to the dram—4.0—given every two hours) is regarded by Bos- Avorth as almost specific at the commencement of an attack of acute follicular tonsillitis. During convalescence semi-liquid and soft, light foods may be alloAved gradually; and bitter tonics and iron are to be administered if there are depression and anemia. The folloAving is a favorite prescription : Py. Strychninae sulph., gr. ss (0.032); Syr. acaciae, Iss (16.0); Liq. ferri et ammon. acetat., q. s. ad §iij (96.0).—M. Sig. 3j (4.0) t. i. d., in Avater, after meals. If the case is seen quite early during congestion, the use of cold is of great value in giving local relief and in shortening the attack. Ice may be sucked, and flannel dipped in ice-Avater and wrung out may be applied around the neck, or an ice-bag used. Lozenges of guaiac (gr. ij—0.129) or the ammoniated tincture in 1-dram (4.0) doses in milk, and used as a gargle, are indicated early, and, according to Sajous, seldom fail to control or arrest the inflammation. Equal parts of the tincture of the chlorid of iron, glycerin, and Avater, applied gently with a camel's- hair brush, have long been used locally on the surfaces of the tonsils, and with marked benefit. Alkaline and mild antiseptic solutions, used as gargles or sprays (preferably the latter), are generally useful. Thus, Dobell's solution, or Seller's tablets dissolved in water, or borax and thymol, or carbolic acid, or potassium permanganate in Aveak solution, may be serviceable. Mild counter-irritation at the angle of the jaw by means of iodin or slightly irritating embrocations is helpful. Early scarification of the tonsils as a depletory measure, and painting Avith cocain (10 per cent.) sometimes bring about quick resolution. Astringent sprays containing alum or silver nitrate are often effica- cious after a day or two. When the case is first seen and fully devel- oped, the atomization of a warm solution of cocain (4 to 8 per cent.) or lime-Avater, Avith the external application of heat by means of poultices, is indicated. Should gargling be possible, nothing is better than hot water or milk. If, in parenchymatous tonsillitis, fluctuation be detected or suppuration be even suspected of commencing, the prompt use of the bistoury (the blade being guarded by wrapping with cotton or adhesive plaster), with the production of free bleeding or the discharge of pus, Avill give great satisfaction and relief. The patient's head, especially if it be a child, should be tilted forward during the operation, so as to allow most of the blood and pus to pass into the mouth. "When incision of the tonsil fails to bring pus, it has been advised to puncture through the anterior pillar, where pus may be formed in the cellular tissue in front of or behind the tonsil. When the tonsillar enlargement threatens life through suffocation, CHRONIC TONSILLITIS. 715 excision of the tonsils, laryngotomy, tracheotomy, or intubation may have to be performed. CHRONIC TONSILLITIS. (Hypertrophied Tonsils; Adenoid Vegetations) Definition.—Enlargement of the tonsils (faucial and pharyngeal), due to chronic inflammation or hypertrophy, and usually associated Avith or causing a perverted local and systemic condition. Pathology.—The faucial tonsils show a true chronic hypertrophy of the lymphoid and fibrous elements. According to the hyperplasia of the latter the organs will be smaller and more indurated. They may be rough on the surface from " distended lacunae or ruptured follicles " (Berkley Robinson), the latter being in a state of chronic inflammatory thickening, and shoAving caseous degeneration of their contents. The groAvths in the vault of the pharynx are adenomatous papillomata; they are either sessile or pedunculated, and are fleshy in appearance and con- sistence and very vascular. They range in size from a grain of wheat to an almond-kernel (Allen), and project from the pharyngeal vault, lying in the depression posterior to and on a line Avith the fossa of the Eustachian tube (Rosenmliller's fossa). " Hypertrophy of the pharyn- geal adenoid tissue may also be present Avithout great enlargement of the tonsils proper" (Osier). A congestive type of nasal catarrh in adults often accompanies, or is the result of, neglected adenoid growths and hypertrophied tonsils that date from childhood. Chronic pharyn- gitis is also not infrequently associated. Etiology.—The predisposing causes of chronic hypertrophy of the tonsils are—(a) heredity, especially in the scrofulous and syphilitic diath- eses ; (b) age, most frequently betAveen five and fifteen years; (c) sex, boys appear to be affected more frequently; (d) hygienic surroundings. The exciting causes are usually previous attacks of acute tonsillitis, either simple or that Avhich is symptomatic of diphtheria or scarlatina. According to Harrison Allen, adenoid groAvths from the normal lymph- oid tissue of the vault of the pharynx (pharyngeal tonsils) may be con- genital, and are "in some way associated Avith the canal which is found in early fetal life penetrating the brain-case and uniting the anterior part of the pituitary body to the lining membrane of the pharynx." Symptoms.—Local.—With slight or even moderate tonsillar en- largement there may be feAv or no symptoms attributable to it. There may be simply an increased secretion of mucus, and a susceptibility to fresh anginal attacks or to severe tonsillar manifestations in diphtheritic or scarlatinal attacks. The first symptom to attract the attention is the direct effect of naso- pharyngeal obstruction—i. e. oral respiration. This mouth-breathing is visibly labored and abnormally audible, and is especially marked at night, the child's respiration being noisy, snorting, and irregular. Sleep is disturbed by paroxysms of dyspnea, sometimes due, perhaps, to reflex spasm of the glottis. Nightmare folloAvs as a result of imperfect aera- 716 DISEASES OF THE DIGESTIVE SYSTEM. tion of the blood which supplies the brain on account of the obstruction to perfect respiration. The act of swalloAving is rendered difficult bv the faucial obstruction, and is often painful, OAving to the superadded acute tonsillar trouble that is so liable to occur in the hypertrophied glands. Indirect results of chronic tonsillar enlargement are a laryngeal stridor and a croupy cough. Sometimes asthmatic attacks coexist, and seem also to be due to the hypertrophy. An excessive secretion of mucus in the pharynx is a common symptom, and causes haAvking in subjects past young childhood. The hearing is often impaired, and tinnitus aurium is complained of, being the result of pressure of the groAvths against the orifice of the Eustachian tube or of clogging of the tube with mucus, due to the extension of inflammation from the naso- pharynx. Absolute deafness may result, and the senses of taste and smell are likeAvise diminished or perverted. The signs of chronic tonsillar enlarge- ment and pharyngeal adenoid growths are interesting and important. Inspection of the fauces will show the tonsils bulging as tAvo lumps cov- ered Avith thick mucus, or the latter may ooze around the uvula from the pharynx. In mouth-breathers of long standing the superior dental arch is narrowed and the hard palate is highly arched. The breath is fetid, OAving to the cheesy, inspissated exudate in the tonsillar crypts. In very old cases a tonsillar calculus may be felt, and is the result of cal- cification of the secretion. The facial expression is characteristically stupid and pathetic; the disposition is dull, irritable, and stubborn; the lips are thick, and a vacant stare is in the eyes. Speech is slow, phonation nasal in quality, and articulation of the nasal consonants n and m, I and o, is changed or muffled. Stammering is not rarely associated with tonsillar hypertrophy. The anterior nares may be dilated and present a pinched appearance above their openings. The prolonged interference with normal respiration gives rise to a peculiar chest-conformation, simulating that of rickets (chicken-breast). The ribs are prominent anteriorly, and there is a marked forAvard angle at the manubrio-gladiolar junction, as well as a grooved depression at the ensiform cartilage. Depressions between the widely-separated ribs exist anteriorly also. Posteriorly, and at the base of the chest in par- ticular, the intercostal spaces are practically absent on account of the closeness of the ribs. The upper part of the chest is very narroAv and the shoulder-bones quite prominent; the antero-posterior diameters of the thorax are less than normal; the sides are unusually curved. On percussion the hepatic area of dulness is diminished on the chest- wall, but increased downward and to the left. The first cardiac sound is weak. On inspiration there is a retraction of the intercostal spaces in the lower and lateral thoracic regions. The lymphatic glands of the neck may be moderately swollen. The general symptoms of tonsillar hypertrophy are more marked when the growths exist in the pharyngeal vault alone. Developmental processes in children, such as dentition, and at puberty, particularly when the voice-changes are looked for, are often retarded or perverted. Anemia, headache, especially during study, cardiac palpitation, enuresis, and habit-chorea of the facial muscles, may be associated Avith general CHRONIC TONSILLITIS. 717 capriciousness, mental dulness, indisposition to intellectual exertion, drowsiness, and sullen irritability. The term aprosexia has been given to the loss of power to concentrate the mind for any length of time that is so characteristic of these cases. Diagnosis.—Inspection of the fauces will reveal enlarged tonsils. It should be borne in mind, hoAvever, that the act of gagging often causes the tonsils to rotate forward and inward, making them appear larger really than is the case. Adenoid groAvths of the pharyngeal vault may exist without tonsillar enlargement, and can be detected by posterior rhinoscopy or by the insertion of the finger into the naso- pharynx ; the vegetations may7 thus be felt blocking the vault. Differential Diagnosis.—It is important not to attribute the obstruc- tive symptoms to nasal hypertrophies or atresia or to malignant growths in the naso-pharyngeal space. The latter are infrequent at the ages at which chronic tonsillar enlargement of the fauces and pharynx is most apt to occur—i. e. early in life. Again, palpation of sarcomatous or carcinomatous groAvths gives marked differences in consistence, and there are usually spontaneous hemorrhages and local pain in attendance upon these neoplasms. " Thumb-suckers " differ from mouth-breathers in that in the former the incisors are inclined forAvard and cause slight protrusion beneath the upper lip; the dental arch is flat. In mouth- breathers, however, the incisors are vertical or nearly so, or incline so as to overlap each other; the dental arch is high and curved (H. Allen). Retropharyngeal abscess may be confounded with tonsillar enlargement, especially in children. But in this disease the attacks of dyspnea, the dysphagia, and the local distress are more marked. Again, in the pharyngeal disease the swelling is in the median line, pushing the soft palate forAvard perhaps, and on palpation it may give a sense of elas- ticity or fluctuation to the finger. Slight fever may also be present. Prognosis.—Tonsillar hypertrophy is not a severe disease as re- gards life. There is, however, an increased liability to contract colds, recurrences of follicular tonsillitis, attacks of diphtheria, and severe scarlatinal angina. The prognosis in acute respiratory affections asso- ciated Avith chronic tonsillar enlargement is always more or less grave. Adenoid groAvths, even Avhen neglected, tend to lessen in size after puberty, with a subsidence of local and reflex symptoms. After removal the growths, as a rule, do not return. Treatment.—The old-fashioned use of astringent applications is probably useless when there is any marked chronic enlargement of the tonsils, and active surgical treatment alone is to be recommended for the condition. The use of absorbents and caustics, either externally or by parenchymatous injection, is also of doubtful value, and is objection- able on account of the necessarily protracted and painful course of treatment. There are no more satisfactory means of doing radical good in cases of this kind than the galvano-cautery, scarification, and the removal of the tonsils Avith the tonsillotome, snare, or bistoury. In offensive fol- licular disease applications of chromic acid may give good results. Ade- noid growths may be removed by means of the finger, curet, or forceps. Constitutional treatment is often necessary in improving the nutrition of the patient. Good food, a change of air, systematic bathing, prudent 718 DISEASES OF THE DIGESTIVE SYSTEM. habits, careful dress, and medicinal tonics and alteratives, as cod-liver oil, iodid of iron-, and the hypophosphites, are usually indicated. V. DISEASES OF THE PHARYNX. PHARYNGITIS. ACUTE PHARYNGITIS. (Pharyngitis Acuta Simplex.) Definition.—An acute catarrhal inflammation of the mucous mem- brane of the pharynx. Pathology.—The mucous membrane is congested diffusely or in patches, and there may be an inflammatory exudate in, and a consequent SAvelling of, the submucosa and the contained glandular structures. The surface of the membrane is more or less coated Avith a viscid muco-pus. Etiology.—Predisposing causes are—age, it being more frequent in adolescence and young adult life; a depraved constitution ; digestive disorders; and a rheumatic, gouty, or scrofulous diathesis. The usual exciting cause is exposure to cold or sudden changes of temperature and climate and to irritating vapors. An acute naso-pharyngeal catarrh, by bathing the pharyngeal mucosa with its irritating secretions, may set up the trouble. " Epidemic pharyngitis " is probably a manifesta- tion of influenza. Acute simple pharyngitis may be a complication of scarlatina, measles, and small-pox (exanthematous pharyngitis) and of erysipelas (erysipelatous pharyngitis); in the latter disease, moreover, it may become gangrenous or suppurative. Symptoms.—Locally, the affection is ushered in Avith a feeling of dryness and soreness, especially on swallowing. With the production of the muco-purulent secretion a tickling sensation provokes hawking or a slight " throat cough" and efforts at exspuition. The catarrhal pro- cess may extend to the larynx and cause some hoarseness, or to the Eustachian tube, causing dulness of hearing. Movements of the neck are painful and stiff, particularly if there is, as is often the case, slight involvement of the lymph-glands. Inspection of the throat sIioavs the pharynx, often the posterior pillars of the fauces and the soft palate, and even the anterior pillars and tonsillar surfaces, to be deeply red- dened and tumefied; the coursing veins are enlarged, and particles of a yellowish-Avhite secretion appear here and there. Sometimes the phar- yngeal follicles become subject to acute inflammation, and appear as elevated, discrete, shiny spots (herpetic pharyngitis—Mackenzie). At the onset of this affection there may be chilliness, folloAved by slight fever, headache, an accelerated pulse, a dry skin, and anorexia. The pharyngeal symptoms seldom last more than from three to five days, Avhen resolution takes place, some tenderness of the pharynx, hoAvever, remaining for a time. Diagnosis.—On examination of the throat there should neither be any difficulty in diagnosing the affection nor any likelihood of confound- ing the affection Avith simple tonsillitis. MEMBRANOUS PHARYNGITIS. 719 The prognosis is ahvays favorable. In weakly patients, hoAvever, there is a liability to subsequent attacks. Treatment.—In the early stages sucking of small pieces of ice does much to allay the congestion and irritability. A spray of cocain or menthol in albolene (2 per cent.) may also be used, followed by a 4 per cent, solution of antipyrin ; Dobell's solution is ahvays to be recommended for its alkaline, sedative, and antiseptic action. SAvabbing the pharynx Avith a silver-nitrate solution (gr. xl to the ounce—2.59 to 32.0) is, according to Sajous. of great benefit. When the disease is Avell established relief is often obtainable by medicated steam-inhalation, as Avith the compound tincture of benzoin. In rheumatic cases lozenges of guaiac (gr. iij—0.194) are useful. The sipping of hot milk in Avhich sodium bicarbonate has been dissolved is very soothing to the inflamed mucosa. The general treatment embraces measures directed at the fever and the diathetic condition. A hot foot-bath and a calomel purge, Avith belladonna, acetanilid, or aconite for the fever and pain, and sodium salicylate (gr. lx-lxxx—4.0-5.1—in the twenty-four hours), may be re- quired. The diet, of course, during the height of the attack, should either be liquid or semi-solid. Persons susceptible to repeated attacks must exercise caution in regard to exposure to severe cold and Aveather-changes, irritating vapors, and the like. Daily cold sponge-baths may be used to harden the skin. Tonic, nutrient treatment is also frequently called for. MEMBRANOUS PHARYNGITIS. (Pharyngitis Crouposa) Definition.—An acute superficial inflammation of the pharyngeal mucosa, characterized by the formation of a whitish false membrane, due usually to the streptococcus. Etiology.—The principal causes of this form of pharyngitis are exposure of persons in debilitated health to cold or an impure or a septic atmosphere, particularly during epidemics of such diseases as scarlatina. Symptoms.—The local and general symptoms are those of ordinary sore throat, though of a more severe type. Diagnosis.—The pseudo-membrane is thin, of a yellowish-Avhite color, and appears in small patches over the pharynx ; it is easily de- tached, and is thus distinguished from diphtheria, with Avhich alone it might be confounded. The presence of small vesicles or ulcers and the absence of grave constitutional disturbances are also features in this affection that serve to differentiate it from diphtheritic pharyngitis. The prognosis is favorable. Treatment.—Local applications of solutions of hydrogen peroxid or potassium permanganate (gr. x to the ounce—0.648 to 32.0) are very satisfactory. For the painful dysphagia the sedative and soothing rem- edies suggested for simple acute pharyngitis may be used. Internally, sodium benzoate (gr. v-xv—0.324-0.972) in glycerin, elixir of calisaya, and salol have each been recommended. Tonic treatment is nearly ahvays needed. 720 DISEASES OF THE DIGESTIVE SYSTEM. CHRONIC PHARYNGITIS. Definition.—-A chronic inflammation of the mucous membrane of the pharynx. It may consist of either a hypertrophic or an atrophic involvement of the follicles, or both processes may coexist. Varieties.—(a) Chronic naso-pharyngeal catarrh ; (b) chronic hyper- trophic pharyngitis or naso-pharyngitis (pharyngitis sicca); (c) follicular or granular pharyngitis. The last named is probably the result of, and nearly always is associated Avith, chronic simple (or hypertrophic) pha- ryngeal (or naso-pharyngeal) catarrh. Pathology.—The mucous membrane in simple chronic pharyngitis is either reddened, thickened, and viscid (hypertrophic form), or pale, thin, and dry (atrophic form); in both instances dilated and tortuous veins are prominently shown. In the follicular variety the pharyngeal mucous glands are SAvollen into little red, glistening nodules studding the congested membrane. The enlarged follicles are due to a hyperplasia of lymphoid cells and an accumulation of retained dried-up secretions. Etiology.—A protracted impairment of the general health, espe- cially in those Avho over-exert mentally and are of sedentary habits, is a common predisposing cause of chronic pharyngitis. Repeated acute attacks may precede the affection, or it may develop subacutely and almost imperceptibly. It is most common in adolescent and middle life. The exciting causes are frequent and prolonged over-use and strain of the voice in clergymen, singers, teachers, army-officers, and street- venders ; irritation from tobacco-smoke, chemical vapors, and continued exposure to cold air; and perhaps the persistent swalloAving of very hot or cold foods, stimulants, or spicy articles. Symptoms.—In all varieties of chronic pharyngitis the local dis- comfort is often very slight, and more annoying than painful, except Avhen an exacerbation takes place. It is a particularly uncomfortable condition in those whose occupation requires more or less constant use of the voice. There is a sensation of dryness and tickling or burning in the throat and the desire to clear the throat of sticky mucus by hawking or a short cough. These symptoms are usually Avorse on rising in the morning, especially if some unfavorable influence has been ex- erted during the night previous, the throat being dry and a viscid secre- tion having collected. SwalloAving is seldom interfered Avith. If the larynx is somewhat affected by extension of the pharyngeal inflammation, hoarseness and a dry, hacking cough are produced. After using the voice there is a sense of fatigue, with huskiness and quite often some irritability. The local appearances of chronic pharyngitis vary according to the form of the affection present in the case. In chronic catarrh of the pharynx a considerable collection of muco-pus is seen adhering to the mucosa and extending doAvnward from the posterior nares. The senses of hearing and taste may be impaired. The uvula is frequently elong- ated, and its tip may rest on the base of the tongue. A nasal intona- tion of the voice is sometimes provoked. The posterior nares as seen by the rhinal mirror are often stopped up by foul secretions or by hypertrophy of the nasal mucous membrane. Headache and attacks of vertigo may occur. ACUTE INFECTIOUS PHLEGMON OF THE THROAT. 721 Chronic hypertrophic pharyngitis and follicular pharyngitis (" clergy- man's sore throat ") are commonly associated. The thickened, reddened, pimply, vein-coursed appearance of the mucosa is characteristic. The follicles may be seen sometimes as polypoid elevations, and the pharyn- geal tonsil may be found by the finger to be enlarged (Kblliker). In the dry, atrophic pharyngitis that occurs more often in later life, and as a sequel of the simple chronic or follicular variety, a pale, smooth, relaxed, lustrous, and often quite painful membrane is observed. The general symptoms are usually those of a weak, debilitated, nerv- ous constitution, though in mild cases the general health may be unim- paired. In atrophic pharyngitis considerable cachexia may be present. Diagnosis.—Care should be exercised in discriminating the variety of chronic pharyngitis present in any given case, so that the treatment may be planned accordingly. Careful and repeated inspection of the throat must render the diagnosis easy unless ulceration has taken place: in such cases a tuberculous or syphilitic sore throat must be eliminated by the superficial character of the ulcers, by their ready response to proper treatment, by the history of the case as to specificity, and by the ab- sence of marked pain or constitutional or pulmonary symptoms pointing to tuberculosis. Prognosis.—This should be guarded as to cure, on account of the stubborn resistance to treatment and the difficulty in removing unfavor- able influences. Acute exacerbations are liable to recur unless rigid prudence and caution are practised at all times in avoiding the cause of the trouble. Treatment.—The local use of astringent and alkaline antiseptic sprays or of the nasal douche is usually recommended, but has only a palliative effect. Silver-nitrate cauterization may be tried. The only effectual means, hoAvever, of curing the follicular or hypertrophic variety is that used by most throat-specialists—namely, the wire galvano- or actual cautery. Applications of silver nitrate (gr. x to the ounce—0.648 to 32.0) and the internal use of the oleoresin of cubebs have been recom- mended for the atrophic pharyngitis. Insufflation of powdered tannin or alum is also of service. Systemic disturbances need attention according as they present them- selves. Mineral baths are sometimes of great benefit, and tonics are usually indicated. It is of prime importance that all irritating causal factors be removed or avoided before any favorable results can be hoped for from local applications. Tobacco-smokers and topers must deny themselves their habitual luxuries. Krause and Heryng recom- mend with favor curetting and the application of lactic acid to super- ficial tuberculous ulcers. ACUTE INFECTIOUS PHLEGMON OF THE THROAT. Definition.—An inflammation of the pharyngeal mucosa that passes rapidly into a suppurative process. Its etiology is not definitely known. I have met with no cases except in my hospital wards, though they doubtless occur in general medical practice. The clinical features have been described by Senator. The symptoms are sudden in their onset and quite intense. They 46 722 DISEASES OF THE DIGESTIVE SYSTEM. are severe soreness of the throat, dysphagia, and hoarseness, as a rule: in advanced cases there has been difficult respiration. Inspection shows the pharynx to be deeply injected and the seat of marked inflammatory edema, the neck appearing greatly SAvollen as well. The general dis- turbance is correspondingly severe. The treatment is Avholly symptomatic. RETROPHARYNGEAL ABSCESS. Definition and Pathology.—A suppurative inflammation of the connective tissue lying anterior to the cervical spinal column. The disease is rare, though it is relatively most common before two years of age. It is usually a primary affection, occurring Avithout assignable cause, but a certain proportion of instances are doubtless caused by caries of the cervical vertebrae. It may rarely be secondary to any of the specific fevers. The symptoms are pain in swallowing, impeded respiration, soon becoming stertorous in character, the dyspnea meanwhile constantly in- creasing. There may be cough, and the voice may present abnormal characteristics. The signs of stenosis finally declare themselves with considerable violence, and an examination of the pharynx usually serves to make the diagnosis positive; the projecting tumor is visible, and the palpating finger readily detects fluctuation. In infants, hoAvever, this procedure may be attended Avith great difficulty. The course of the disease may be acute, lasting one or tw7o weeks; more frequently, however, it is subacute (rarely chronic), as, for example, Avhen it is due to caries of the vertebrae. The prognosis is favorable in all cases that are early and properly diagnosticated. If unrecognized until the later stages have been run, suffocation may ensue, or in the event of spontaneous rupture pus may pour into the larynx and cause death by asphyxia. Treatment.—As soon as fluctuation is detected the abscess should be freely opened, and preferably, as a rule, through the mouth by means of a guarded bistoury. The throat, after the abscess is thoroughly evacuated, should be Avashed out Avith some mild antiseptic solution (salicylic acid 2 per cent, or boracic acid 2 per cent.). When pointing occurs at the side of the neck, as sometimes happens, the incision should be made through the skin in that locality. Constitutional indications are to be fulfilled in accordance with general principles, and the strength of the patient is to be maintained by a highly nutritious dietary. VI. DISEASES OF THE ESOPHAGUS. ESOPHAGITIS. ACUTE ESOPHAGITIS. Definition.—An acute inflammation affecting either the mucous membrane or submucous tissues of the esophagus, or both. Pathology.—The ordinary morbid changes of an acute esophagitis DISEASES OF THE ESOPHAGUS. 723 are those of a simple catarrhal inflammation of the mucosa. It is rather characteristic of the condition that there is no increased secretion, a sponginess and rapid desquamation of the epithelium taking place in- stead, and causing a granular appearance of the membrane. Occasion- ally the mucous glands are swollen, and may break down, Avith the for- mation of small follicular ulcers. Catarrhal erosions may also be seen here and there. A croupous or diphtheritic exudate is seldom found in the lower portion of the esophagus, and small-pox pustules are rarely, if ever, seen. A diffuse or circumscribed purulent inflammation of the submucosa may dissect up the mucous membrane so as to consid- erably diminish the esophageal caliber; pus is usually discharged into the tube. In severe cases of poisoning (corrosive esophagitis) sloughing may extend into the muscular layer, and may produce a foul, dark, hem- orrhagic mass. A fibrinous cast of the gullet has been vomited up by an hysteric Avoman (Birch-Hirschfeld). Etiology.—The causes of acute esophagitis, other than traumatic, are rare. Under the latter are included the mechanical, thermal, and chemical irritants, such as the presence of foreign bodies and the swal- loAving of hot liquids, corrosive poisons, "concentrated lye," mineral acids, and arsenic. The condition may also be the result of the follow- ing : (a) an extension of catarrhal inflammation of the pharynx; (b) specific infectious fevers, as typhoid, typhus, and pneumonitis; (c) diph- theria (pseudo-membranous esophagitis) by the extension of pharyngeal diphtheria; (d) small-pox, giving rise to a pustular inflammation of the gullet; (e) local disease, as carcinoma of the esophagus, glandular or vertebral abscess, or laryngeal perichondritis (Striimpell). Symptoms.—Pain during deglutition may be referred to the region of the esophagus, and a steady, dull pain may exist beneath the sternum. Dysphagia and regurgitation of food may be caused by spasm in severe cases. Mucus, blood, and pus may be discharged later. The absence or mildness of pain is not a true indication of the gravity and extent of esophageal inflammation. Sequela?,.—Simple catarrhal or follicular ulcers may7 appear, and the necrotic form of the disease may be folloAved by suppurating ulcers, which, if healing takes place, may7 cause cicatricial stenosis. Diagnosis.—This may be based upon the localization of pain, especially during deglutition; upon the pain occasioned by the passage of the esophageal sound; and upon the mucus, blood, or pus adherent to its bulb on withdraAA'al, provided carcinoma at the cardiac orifice of the stomach can be excluded. The expulsion of a pseudo-membrane (diphtheritic) from the gullet should be differentiated from esophago- mycosis (thrush), especially in children. The diagnosis of the particu- lar form of esophagitis will depend upon the facts elicited relating to the etiology. The prognosis is good in mild cases, and should be guarded in those associated Avith grave disease. Death may occur in either the purulent or necrotic form. Treatment.—This is entirely symptomatic, and in severe cases is of little value. A soft, bland diet, preferably of milk, may be borne in ordinary instances; if not, rectal alimentation should be resorted to. For the mild cases swallowing of bits of ice, and later of Avarm demul- 724 DISEASES OF THE DIGESTIVE SYSTEM. cent drinks, should be recommended. In cases of marked pain and esophageal spasm relief may be afforded by a hypodermic injection of morphin and atropin. CHRONIC ESOPHAGITIS. Chronic catarrh of the gullet may result from continued irritation by the causes of the acute form, and also from passive congestion due to hepatic cirrhosis, chronic cardiac or renal disease. The last-named con- ditions may also cause varicose esophageal veins, and fatal hemorrhage may result therefrom. The increased mucous secretion may cause eruc- tations and nausea. Postmortem evidence of esophagitis, either acute or chronic, is found with extreme rarity. ULCER OF THE ESOPHAGUS. This is a consequence of a simple or follicular catarrh of the gullet or of gangrene. " Catarrhal erosions " and follicular ulcers may occur in numbers, and necrotic ulcers may occur in bedridden persons opposite the cricoid cartilage. The extensive purulent ulceration following the separation of necrotic sloughs may heal and cause contraction and marked stenosis of the tube. Ulcers simulating those occurring in the stomach (ulceres ex digestione) may sometimes be found at the loAver end of the esophagus. Postmortem digestion, however, must not be mis- taken for peptic ulceration. There may be pain or localized points of tenderness on the passage of the esophageal bougie, with some pus and blood on the bulb after its withdrawal. Rest from swallowing should be secured as far as possible. The sipping of hot milk may be sooth- ing, and the slow swallowing of mild boric-acid and sodium-bicarbonate solutions, or of glycozone, may be tried with benefit. CARCINOMA OF THE ESOPHAGUS. This is the most frequent affection of the tube, and, as it is the com- monest cause of stenosis, it is important from a diagnostic standpoint. Pathology.—Carcinoma of the esophagus is primary and of an epi- theliomatous nature, the mucous membrane here being composed of pave- ment-cells. The new growth affects the mucosa first, and then, increasing in size and causing ulceration, it may involve the entire circumference of the tube with a ring-like mass. This may either be hard, dense, and fibrous, or soft and jelly-like. The esophageal lumen is markedly dimin- ished as a rule, although disintegrating ulceration or "flat" carcinoma may encroach upon the caliber but very little. There may be a diffuse dilatation of the esophagus above the growth, as Avell as an hypertrophy of the circular muscular fibers. The cancerous tumor is found most commonly in the middle and lower thirds of the esophagus. CARCINOMA OF THE ESOPHAGUS. 725 Etiology.—The predisposing causes of esophageal carcinoma are age and sex, males past forty years of age being the usual subjects of this neoplasm. The exciting causes are of uncertain origin. It has been alleged that various forms of protracted irritation of the mucous mem- brane may cause the development of carcinoma; and especially has this point been maintained in connection Avith the frequent occurrence of carcinoma of the gullet in topers. It is also believed by some that as gastric carcinoma may develop from the scars of old ulcers, a like con- dition in the esophagus may act as a nucleus for a carcinomatous groAvth in that structure also. Symptoms.—Dysphagia is the earliest symptom of esophageal car- cinoma Avith beginning stenosis of the tube. This gradually and steadily increases, so that liquids alone can be SAvalloAved, and later regurgitation even of liquid foods takes place. There may be considerable pain in some cases. The ejecta may contain cancerous fragments, blood, and mucus. The dysphagic symptoms may subside spontaneously, OAving to the disinte- gration and ulceration of the groAvth, or the dysphagia may be so slight as to be masked by the prominent symptoms of hepatic or pulmonary carcinoma and gangrene secondary to a very flat esophageal carcinoma. Or, Avithout secondary manifestations of such a groAvth, the esophageal symptoms may rarely be latent. The cervical glands may be enlarged. The most important general symptom of esophageal carcinoma, as of this malignant growth elseAvhere, is the progressive emaciation, which increases Avith the stenosis and obstruction to the entrance of nourish- ment into the stomach. Though seemingly anemic, the patient's blood may contain an excessive number of corpuscles in a given bulk. This is due to inspissation from failure to absorb water and food into the body. Course, Duration, and Termination.—The disease is chronic, becoming progressively Avorse, and is often beset Avith grave complica- tions (vide infra). It seldom lasts longer than one and a half years, and the duration of medullary carcinoma of the gullet is usually much shorter. A fatal ending is inevitable, by inanition and exhaustion, or as the result of metastasis and secondary complications. Complications.—These folloAV extension of the cancerous growth to neighboring parts. Thus, involvement of the larynx, trachea, and bronchi has been noted. The cancerous ulcer may also perforate the pleura, the pericardium, or the aorta or its branches, and cause fatal hemorrhage. The vertebrae have been eroded, and compression of the cord, with resulting paraplegia, may take place. Paralysis of the vocal cords may be the effect of pressure by the groAvth upon the recurrent laryngeal nerve; most frequently pulmonary gangrene is due to perforation of the lung or to the inspiration of can- cerous and decomposing particles that have been regurgitated. Diagnosis.—As the dysphagia is a symptom of paramount im- portance in the diagnosis of esophageal carcinoma, all other causes of the symptoms must be excluded. Thus, enlarged tonsils, pharyngeal tumors, pressure from without by cervical intrathoracic tumors, as aneur- ysm, or by displacement of the sternal end of the clavicle, and the presence of foreign bodies or cicatricial strictures of the gullet,—all fig- ure in the production of difficult deglutition. The history of the case, 726 DISEASES OF THE DIGESTIVE SYSTEM. the age of the patient, the progressive emaciation (cancerous cachexia), and the obstinately increasing dysphagia will enable us to exclude the other affections named. In using the esophageal bougie for diagnostic purposes great care should be exercised, as an aneurysm may thus be ruptured or a deeply ulcerated carcinoma perforated. The AvithdraAval of cancerous tissue upon the bulb will decide the case. The esophago- scope may be useful in certain cases, but requires great care and special skill. The prognosis is hopeless, and the supervention of grave compli- cations or pulmonary gangrene renders the chances of an early demise very probable. Treatment.—This is essentially symptomatic and sustentative. If feeding by the mouth is difficult on account of the extreme stenosis, although permitting the passage of an esophageal tube, the latter may be used for the passage of liquid nourishment. Rectal feeding may later become imperative. The mechanical treatment of the cancerous stricture by the passage of the graduated esophageal bougie is seldom of any avail, although temporary improvement may perhaps be obtained. Soft, disintegrating, and ulcerating carcinoma should thus be treated, though with the absence of any force Avhatsoever, lest perforation take place. The performance of esophagostomy may prolong life in some cases. RUPTURE OF THE ESOPHAGUS. The first recorded case of this rare condition occurred under the ob- servation of Boerhaave in 1724 in the person of the Baron Wassemar. Pathology.—Softening, together with a great friability, of the esophageal Avails may be found, this probably being the effect produced by the solvent action of the gastric juice upon the mucous membrane at a time when the local circulation is disturbed and the vitality of the tissues thus lessened. The postmortem evidence of this accident consists of a longitudinal (as a rule) tear about 5 cm. (2 inches) in length, and situated in the lower half of the esophagus. Food and air may be found to have es- caped into the left pleural cavity, and unless death occur at an early date signs of secondary purulent inflammation will probably be noticed. Postmortem digestion of the esophagus is more common (Osier). The perforation is often quite large, and is located in the posterior wall of the tube. Etiology.—Softening of the walls of the gullet (esophago-malacia) is suggested by Zenker as a condition that ahvays precedes spontane- ous rupture, so called. The exciting cause is believed to be violent and persistent vomiting after a particularly heavy meal or during acute alcoholism. Symptoms.—These come on suddenly or soon after a full meal, and commence with nausea and very severe vomiting, accompanied by great pain and rapid and extreme collapse of the Avhole body, due to the shock. A cutaneous emphysema of the neck and chest is manifested soon after the rupture. NEUROSES OF THE ESOPHAGUS. 727 The diagnosis, if made at all, must rest upon the clinical history. Death usually takes place in a few hours, or days at the most, and the prognosis is necessarily hopeless. The treatment is equally so in the present status of surgery. Pain, if excruciating, should be dulled by the hypodermic administration of morphin. NEUROSES OF THE ESOPHAGUS. MUSCULAR SPASM. (Esophagismus) Definition.—A spasmodic contraction of the muscular layer of the esophagus. Etiology.—It is almost always a secondary affection, met with not infrequently in hysteria, hydrophobia, and rarely in chorea and epilepsy. I have seen one instance of the idiopathic form of the disease in a female possessing a highly neurotic constitution. In this case the esophageal bougie could be passed only with a great deal of difficulty during the spasm: Avhen this relaxed, the bougie glided into the stomach without meeting with any noticeable resistance. It has usually been observed in aged males, and especially in those suffering from hypochondriasis. It may be due to reflex causes, originating, for example, in the uterus; thus, in some cases, it occurs only during the pregnant state. Symptoms.—The chief subjective characteristic is dysphagia. Al- though liquids can be SAvallowed, solids, as a rule, cannot. Post-sternal pain is sometimes noticed, and choking signs are quite common. In the hysteric variety emotional disturbances are found among the prodromata, and most probably bear a causal relation. Diagnosis.—The etiologic factors must be carefully weighed in connection Avith the symptoms and the valuable testimony gained by the use of the sound. The bougie on reaching the constriction is rather tightly gripped, though gentle pressure soon causes it to relax. After the subjective symptoms and spasm are over the sound passes without the slightest difficulty, providing a point of the greatest diagnostic import. The elderly hypochondriac is, as before stated, liable to develop a similar condition, which must not be confounded Avith true cancerous stricture. The prognosis is good. The treatment is directed to the disease on Avhich the condition is found to depend, and this must receive careful attention. The sound should be used as previously indicated under the discussion of Esopha- geal Stricture. Its passage has often been followed by speedy and per- manent cures. PARALYSIS OF THE ESOPHAGUS.1 In extensive bulbar paralysis, when adjacent parts are involved, we may infer the existence of esophageal implication, though there be no 1 For remarks on the treatment of this complaint the reader is referred to section on Nervous Diseases. 728 DISEASES OF THE DIGESTIVE SYSTEM. objective evidence to adduce in confirmation. Doubtless the esophagus rarely shares in post-diphtheritic paralysis also. Dysphagia is the lead- ing symptom. An invaluable peculiarity belonging to diphtheritic paralysis is the fact that solids are more readily swalloAved than liquids. DILATATION OF THE ESOPHAGUS Pathology and Etiology.—Diffuse dilatation of the esophagus is usually secondary to stricture at or near the cardiac orifice. In accord- ance with the common law of compensation, the first effect of the stenosis is to engender hypertrophy of the muscular layer above it Avith a view of overcoming the resistance caused by the obstruction. The w7all of the esophagus becomes thickened, and the tube is generally somewhat nar- roAved, above the seat of the stenosis; but finally, as a result of degen- erative changes, the muscular coat weakens, the esophagus dilates, and food accumulates above the stricture—a condition that, once begun, progresses. Congenital dilatation, in which the whole extent of the tube partici- pates, has also been met with, though such a condition is rare indeed. It sometimes results from fatty degeneration of the muscular Avail, and a predisposition to the complaint may be acquired as the result of injury or prior inflammation. Symptoms.—The essential symptom is chronic dysphagia. When dilatation folloAvs stenosis the patient often locates the point at Avhich the food lodges in the esophagus. Most of the ingesta are regurgitated several hours after eating, and this process is often attended by more or less severe strangling. The esophageal sound comes upon the stricture, and is either gripped firmly or totally resisted; in the latter event the bulb can be moved about above this point with abnormal freedom. In the rare cases of spindle-shaped dilatation without stenosis the sound usually detects no obstacle on its way into the stomach. A sac is occasionally formed, however, as the result of localized bulging of the paralyzed wall, in which food may collect or the exploring sound may catch, thus lead- ing to erroneous inferences. Dysphagia is present, though it pre- sents peculiarities, in that the food may either pass down very slowly until it reaches the stomach, or it may find its Avay down for some dis- tance and then lodge in the shallow pouch, as above described. In the latter event the food may be gulped up from time to time. If the sound can be easily introduced into the stomach, Ave may safely eliminate stricture as the cause of the dilatation. The prognosis is good as long as sufficient food can be gotten into the stomach for the support of life. Treatment.—The chief object in the treatment of this condition is to keep the patient well nourished. If sufficient food cannot be swal- lowed, a Symond's tube should be inserted and nourishment given through it; and when this mode of feeding is no longer feasible, the physician has to choose betAveen gastrostomy and rectal feeding. There can be no doubt that by means of nutrient enemata nutrition may be ESOPHA GEAL DIVER TIC UL I'M. 729 fairly well maintained for a considerable period of time, but not indef- initely, as these cases would seem to demand. In the hands of a com- petent surgeon, on the other hand, gastrostomy is often fruitful of brilliant results. Galvanism has been recommended on high authority, but I cannot speak from personal experience in its use. Local lesions, Avhen present, must be dealt with in accordance Avith the rules govern- ing the treatment of the several causal conditions. ESOPHAGEAL DIVERTICULUM. (Pharyngocele) Definition.—A circumscribed sac in the Avail of the esophagus. Pathology and Etiology.—Two varieties are met with, which Zenker has termed pressure and traction diverticula ; the latter are rare. Diverticula that occur at or near the inferior constrictor, and more par- ticularly the larger ones, are congenital in origin. When acquired they are the result of a localized lesion in the muscular coat, through Avhich the mucous membrane bulges like a hernia. This is owing to repeated slight pressure occasioned by the passage of food. When once such a process is started, various factors tend to continually enlarge the pouch. Chief among these are the morsels of food that find lodgement and naturally tend to augment the size of the diverticulum by dragging it doAvnward. The sac may finally7 attain a diameter of not less than 4 inches (10 cm.). Its situation is nearly always on the posterior Avail at the pharyngo-esophageal junction, and its form is usually saccular or pear-shaped. Most instances have been met Avith in males after middle life. The cause of the Aveakened area at which the diverticulum occurs is to be found sometimes in injury, but more frequently in an antecedent inflammation. Histologic changes are observed only in the mucous and submucous layers, these anatomic elements together forming the pouch. Traction diverticula are produced by the fringe of tissues that often becomes adherent to the upper aspect of the esophagus, and from their mode of occurrence they will obviously be more or less funnel-shaped. Their dimensions are small. They are more common in children than in adults, for the reason that in the former, more frequently than in the latter, do the bronchial glands suppurate, Avith subsequent cicatrization. This circumstance affords an explanation of the fact that traction diver- ticula are usually seated on the anterior Avail of the esophagus, near the bifurcation of the trachea. Clinical History.—Traction diverticula do not, as a rule, give rise to clinical symptoms. Exceptionally, however, as the result of the mechanical irritation caused by bits of food that are retained in these funnels, ulceration may occur and be followed by perforation of their apices. In this manner the main bronchi are often perforated (causing pneumonia and pulmonary gangrene), also the pleura (causing empyema), and, more rarely, the pericardium (causing suppurative pericarditis). Pressure diverticula when small cannot be recognized, owing to the 730 DISEASES OF THE DIGESTIVE SYSTEM. absence of signs and symptoms. When they attain considerable size, however, they are often attended Avith severe symptoms. The earliest clinical manifestation is difficulty in SAvallowing ; some of the food enters the sac, and, if allowed to remain, undergoes putrefactive decomposition, causing fetor of the breath. From time to time, and especially on at- tempting to swallow, the partly or wholly filled condition of the pouch excites nausea and vomiting, associated with prolonged strangling; this results in the ejection of a portion of the accumulated contents. After such an attack the patient is unable, temporarily, to SAvallow food, and in consequence of the limited amount of food taken signs of inanition soon appear; this may finally become extreme, and is sometimes the immediate cause of death. The appearance of a pear-shaped swelling in the side of the neck has been observed. As the tumor enlarges it displaces the larynx and presses upon the enlarged vessels—more rarely upon the superior laryngeal nerve, giving rise to dyspnea and distressing fits of coughing. Diagnosis.—A leading point in the differentiation of this affection is the enlargement of the sac after meals (not all the food passing into the stomach), and its disappearance after being emptied. Another valuable discriminating sign is the effect of compression by the hand in causing the contents (" air and sodden food ") to Aoav back into the mouth. In those instances in which the tumor is absent, Avhile the symptoms point to the disease under consideration, we may demonstrate its existence by the use of the esophageal sound. If the sound passes into the sac, its descent will soon be arrested. If, however, the instru- ment fails to enter the mouth of the pouch, it readily glides into the stomach. An elboAved sound, bent at an obtuse angle near the tip, is especially useful in such cases. It may be inserted in different direc- tions, so as to avoid entrance into the sac. Prognosis.—The outlook is unfavorable in the absence of operative treatment, though modern surgery gives promise of curing a certain proportion of cases. Wheeler has operated successfully in one instance at least. The physician may prolong life by directing attention to the nutrition of the patient, but he cannot hope to promote a cure. If the patient cannot SAvallow an adequate amount of nourishment, he may be successfully fed for an indefinite period through a tube, which he him- self should be allowed to pass. When sufficient food cannot be intro- duced by this method to maintain the poAvers of the patient, rectal feed- ing should be instituted. If excision of the diverticulum be deemed impracticable by the surgeon, then the establishment of a gastric fistula is worthy of extended trial in cases in Avhich the above-mentioned modes of feeding have failed. STRICTURE OF THE ESOPHAGUS. Etiology.—A stricture of the esophagus may be due either to (a) Congenital narrowing (exceedingly rare); (b) Squamous epithelioma, usually producing an annular constriction; (c) Rarely to polypi pro- truding from the mucosa, which almost occlude the lumen of the tube; STRICTURE OF THE ESOPHAGUS. 731 (d) Rarely to specific inflammation, as syphilis and tuberculosis; (e) Simple stricture generally results from the ingestion of corrosive fluids, which cause extensive sloughing of the mucosa, followed by cicatricial contraction. < Clinical History.—The symptoms vary with the special cause and with the degree of stenosis. The first and most prominent indication of narrowing of the gullet is a very sloAvly increasing dysphagia. The patient for a long time complains of a sense of pressure at a certain sub- sternal point on sAvalloAving solid food, or, more rarely, an apparently healthy person will suddenly experience painful pressure in attempting to swalloAV a larger quantity of food than usual. By and by even fluids cause dysphagia, and the patient observes that the time required for the food to reach the stomach is lengthened. The impediment to the act of SAvallowing is not due alone to mechanical stenosis, but partly to the Aveakness of the muscular coat, sometimes owing to its partial destruc- tion, and in exceptional cases partly to spasmodic contraction. When due to carcinoma, difficult deglutition is, as a rule, the only symptom complained of. When occasioned by corrosive fluids or traumatism, pain is prominent from the onset. Above the seat of stricture the esophagus is often dilated and con- tains accumulations of the ingesta. The latter, together Avith consider- able mucus, are regurgitated three or four hours after meals, and Ave may be certain that the materials thus ejected do not come from the stomach if they are alkaline in reaction. The leading clinical features are the gradually increasing debility and emaciation, finally reaching an extreme degree. Diagnosis.—HoAvever characteristic the symptoms may be, the bougie should invariably be passed before pronouncing a positive diag- nosis. By this means Ave ascertain the degree and the seat of the stric- ture. To begin Avith, a medium-sized gum-elastic bougie (No. 16 Eng- lish scale) should be employed, after Avarming it and lubricating with glycerin. Its use should be preceded by a cocain-spray to prevent spasm. The patient should occupy a low seat, Avith his head supported by an assistant from in front of the operator. The head should be only slightly throAvn backAvard. The forefinger of the left hand should then be passed back over the tongue until it touches the epiglottis, and the bougie inserted along it Avith the right hand, thus avoiding the error of passing it into the naso-pharynx or the larynx. When the bougie reaches the cricoid cartilage it is sometimes gripped pretty firmly even in a healthy person—a fact that is ahvays to be remembered. No force should be applied. The instrument may pass the constriction with a jerk, or it may not only be gripped, but distinctly arrested, when a smaller bougie should be tried. By moving the instrument upAvard gently Ave may detect sometimes several strictures lying one above an- other. To locate the obstacle, the distance from the teeth to the point of stricture is measured on the instrument, and the results compared Avith the normal measurements, which are as follows: from the teeth to the cricoid cartilage, 7 inches (17.7 cm.); to the left bronchus, 11 inches, (27.8 cm.); and to the opening into the diaphragm, 15 inches (37.9 cm.). Auscultation of the esophagus has been practised, but the clinical indications afforded are of little practical value. The stethoscope is 732 DISEASES OF THE DIGESTIVE SYSTEM. placed to the left of the spine, and the patient takes a mouthful of Avater, Avhen, if a stricture be present, a splashing, cooing sound Avill be heard at the seat of the stricture instead of the normal esophageal bruit. Differential Diagnosis.—It is important to determine not only the ex- istence of a stricture, but also the diseased underlying process, since without this knoAvledge rational methods of treatment cannot be in- stituted. First and foremost, Ave must exclude those affections that simulate simple and malignant stricture, in certain of which the in- troduction of the sound would be attended with grave dangers. Com- pression of the esophagus by enlarged or accessory thyroids, aortic aneurysms, vertebral abscess, enlarged lymphatic glands, and occasion- ally pericardial effusions, may produce dysphagia, and on passing the bougie resistance is offered at the seat of the external pressure. As a rule, the extent of the stenosis is moderate. If the narroAving be due to aneurysm—"(a) rhythmic movement is sometimes communicated to the free end of the sound introduced as far as the stenosis." Careful physical examination will often reveal the presence of an aneurysm or other pressing tumor, and should never be neglected. A passage of the sound in cases of aneurysm has even caused rupture of the sac and death, (o) Spasm of the esophagus or paralysis (the latter rarely) may closely resemble true stenosis. These neurotic forms are almost exclu- sively met with in young hysteric females; on the other hand, malig- nant strictures are found almost solely in males over forty years; while in simple stricture there is usually a definite history and certain etiologic factors. To discriminate between simple and malignant stricture is not diffi- cult, as a rule. When a clear history of gumma, of tuberculous disease, or of injury (from corrosive liquids) is obtainable, the presence of a simple stricture may be safely inferred after eliminating the affections previously mentioned. In the absence of etiologic data pointing to the simple form, cases occurring in the male after forty years of age may be looked upon as malignant. Prognosis.—In forming a prognostic opinion the chief factor to be considered is the nature of the stricture. Practically, so long as the stenosis is dilatable, the prognosis is not unfavorable provided sufficient nourishment can be taken ; moreover, not a few cases of simple stricture are curable. The majority, however, come to a fatal termination finally, death resulting from exhaustion. Treatment.—The chief object of the treatment is to gradually and methodically dilate the stricture in a mechanical manner. The flexible English bougie above mentioned is the best for the purpose, commencing Avith one of good size; conical ivory bougies, having a flexible Avhalebone handle, may also be used, though, being quite hard, they are apt to inflict injuries unless used cautiously. It is sometimes necessary, on account of the tightness of the stricture, to begin with a catgut sound. The method of introducing these instruments has already been given. They should be used once daily, and often can be passed successfully by the patient himself. At intervals of three or four days trials of bougies of larger size should be made. I have seen truly remarkable results from this treatment when carried forward systemati- cally in cases due to cicatricial contraction, the patients increasing in DISEASES OF THE STOMACH. 733 bodily weight and strength. In annular constrictions of a malignant type, however, the same plan of treatment is productive of temporary benefit only. The diet deserves most careful attention. When the stenosis is so pronounced as to prohibit sufficient food being swallowed, a Symonds tube should be passed into the stomach, and through it liquid food is introduced. Concentrated forms of nourishment, as raAV eggs, bovinin, and the various infants' foods, may also prove useful, and may be ad- ministered with milk. So long as an adequate amount of food (semi- solid or liquid) can be easily introduced into the stomach, the amount given should be sufficient to fully meet all the demands of perfect nutrition. When the passage of the bougie is no longer possible relief may be secured in one of two ay ays : (1) rectal feeding; (2) gastrostomy, if the seat of the stricture be near the stomach, and esophagostomy if at the upper portion of the gullet. I have recently witnessed favorable re- sults from gastrostomy in a case of simple stricture operated upon by Laplace. It is important that the patient should thoroughly masticate the food before introducing it into the stomach. Before resorting to operative procedures, however, careful trial should be made of rectal feeding, since life may be prolonged for an indefinite period by this means. Various forms of nutritious enemata and other points regard- ing rectal alimentation will be found in the Treatment of Gastric Ulcer. VII. DISEASES OF THE STOMACH. METHODS OF DIAGNOSIS. EXAMINATION OF THE GASTRIC FUNCTIONS. Secretory Function.—When food enters the stomach the glands im- mediately begin to secrete their various juices, and continue to do so until the food has passed into the duodenum. During the later stages of gastric digestion the activity of the secretory function of the stomach diminishes, and to obtain accurate knowledge of any pathologic condition of the organ, examinations of the gastric contents must be made under conditions as nearly like the physiologic as possible. Reliable results cannot, therefore, be obtained from an examination of ordinary vomita, but the contents of the stomach must be procured at a definite period after a so-called test-meal (vide infra). Numerous test-meals have been offered to the profession, but those that I have found most satisfactory are " the test-breakfast of Ewald and Boas" and "the test-dinner of Leube-Riegel." The former being simpler and easier of preparation than the latter, it is the oftenest used. The Ewald-Boas test-breakfast consists of one or tAvo rolls (50-70 gm.) and one cup of tea or Avater (300-400 c.c). I constantly advise the use of one roll and a glass of Avater. About an hour after this meal has been taken the contents of the stomach are to be withdraAvn, and at such a time HC1 should be the only acid present. 734 DISEASES OF THE DIGESTIVE SYSTEM. The Leube-Riegel test-dinner consists of a large plate of soup (300- 400 c.c), a large piece of beefsteak (150-200 gm.), and some potatoes (about 50 gm.) or a roll—practically, a large plate of soup, a piece of meat (preferably beefsteak), and a roll of bread. The examination is to be made about three and a half to four hours after the meal. To obtain the contents of the stomach we should use a soft, flexible- rubber tube Avith an end-opening, or, better still, with several additional openings on the sides, and it should be marked at a point 23.5 to 2f>.5 inches (58-64 cm.) from the end introduced, this helping the examiner to determine Avhether it has entered the fundus. The tube is moistened Avith water and the end carried back to the pharynx; the patient is noAv asked to SAvalloAY, and the tube is gently pushed doAvn the esophagus, these acts being repeated until the tube reaches the stomach. An ordi- nary Politzer bag is noAv attached to the tube (EAvald), or a Boas aspi- rator (Avhich consists of a rubber bulb having a soft-rubber tube at one extremity with clamps). If the Politzer bag be employed, it is com- pressed and alloAved to re-expand, the contents being thus withdraAvn into the bag. There are cases in which it is safer to empty the stomach by siphonage. This is readily accomplished by using a long tube and exerting gentle pressure on the abdomen to start the current. The method I have most frequently used is that of " expression," as folloAvs: The patient is asked to take a deep inspiration, and then to contract his abdominal muscles as in the act of having a stool: in this way the contents are quickly expelled through the stomach-tube above described. These should be first examined microscopically to detect any residue from previous meals, such as meat and the like, and the quantity obtained should be 20 to 40 c.c After filtering the gastric contents thus obtained they are variously tested. Among qualitative tests the following are important: To determine the reaction, ordinary litmus-paper is used ; if acid, the blue turns red. The presence of free acids is determined—(a) By Congo-red, a solu- tion of Avhich is turned blue by the addition of liquids containing free acids. The use of Congo-paper (prepared by dipping ordinary filter- paper in Congo-red solution) is the easiest method. (b) Tropeolin O. O.—Alcoholic solutions of tropeolin are turned by the addition of liquids containing free acids to a brownish-red, deep red, or deep mahogany-broAvn, according to the amount of acids present. Tropeolin-paper (filter-paper immersed for some time in an alcoholic so- lution) may be used, but must not be kept too long. Free HCl.— G'unzburg's test—phloroglucin gr. xxx (2.0), vanillin gr. xv (1.0), absolute alcohol 3j (30 c.c). To two or three drops of this reagent add an equal number of the gastric filtrate in a porcelain dish, and sloAvly7 evaporate to dryness over a flame; and if free HCl is present, a rose-red tint appears along the edges. BloAving at the edge will hasten the reaction. The great delicacy of this test is conclusively shown by its availability Avhen HCl is present in the proportion of 1 to 20,000. There are no recognized interfering conditions. Boas' Resorcin Test.—Resublimed resorcin 5 parts, white sugar 3 parts, and diluted alcohol 100 parts. The method of procedure is the same as in Giinzburg's test, and a purple-red color appears. More EXAMINATION OF THE STOMACH. 735 caution is required in evaporating, but this method will also detect the presence of free HCl in the proportion of about 1: 20,000. Lactic Acid.— Uff'elmann's test. The reagent should ahvays be freshly made, as folio ays : To 10 or 15 c.c of a 2 per cent, aqueous solution of carbolic acid add 1 or 2 drops of neutral ferric chlorid, Avhen an amethyst-blue color will appear. To 1 or 2 c.c. of the mixture add a few drops of the filtrate, and if lactic acid is present it changes to a canary-yelloAV color. Certain substances that are often found in the stomach, as alcohol, sugar, and various salts, especially the phos- phates, may give a coloration simulating that of lactic acid. These sources of error may be overcome by shaking 5 or 10 c.c. of the fil- trate Avith double the quantity of ether, and, after alloAving the ether to separate and pouring it off", more is added, the Avhole shaken, and the Avashing is repeated. The ether is then decanted and evaporated almost to dryness in a Avater-bath. To the residue about 1 c.c. of Avater is added, and to this an equal quantity of the Uffelmann reagent from a pipette; if a canary-yellow now appears, positive proof of the presence of lactic acid is afforded. Boas and others have experimentally shoAvn to their OAvn satisfaction that the presence of lactic acid in the gastric contents during the first stage of digestion (formerly believed to be physiologic) has pathologic significance. Boas also found that ordinary bread contains lactic acid, and hence he has abandoned the usual test- meal, so far as the determination of this acid is concerned, and adopted a thin gruel made by adding to a quart of water flavored Avith salt half an ounce of oatmeal-flour. Boas states that no lactic acid is present in the filtrate several hours after this test-meal, except in cases of carci- noma of the stomach. The use of this test-meal for usual clinical purposes is now generally held to be superfluous. Lactic acid in the stomach-contents occurs with fermentation-stagnation from either ob- struction or deficient motility. A more reliable test for lactic acid than the foregoing is that of Boas, as folloAvs: Digest the filtrate several times with ether to remove the fatty acids; add a feAv drops of phosphoric acid and boil. Transfer the mixture to a distillate flask ; add H2S04 and Mg02; heat, and lactic acid Avill be distilled over. This can be conducted into a strongly alka- line solution of iodin and potassium iodid. The presence of lactic acid is then shoAvn by the production of iodoform, Avhich can be recognized by its odor and by the precipitate that is formed. Fatty or Volatile Acids.—Heat to boiling a feAv c.c. of the filtrate in a test-tube, over the mouth of Avhich place a strip of moistened blue litmus-paper; the presence of fatty acids will change the paper to red. Acetic Acid.—In large quantities this acid is detected by its odor, and in smaller quantities its presence is determined by neutralizing with sodium carbonate the watery residue of the ethereal extract, and adding neutral ferric chlorid, when a blood-red color will be struck. Quantitative estimation of certain constituents is desirable. Total Acidity.—To 10 c.c. of the filtrate add 1 or 2 drops of a 1 per cent, alcoholic solution of phenophthalein, and as many cubic centimeters of a decinormal solution of sodium hydrate are added slowly from a buret until the reddish color that appears fails to disappear on shaking. The number of cubic centimeters of the decinormal solution normally required 736 DISEASES OF THE DIGESTIVE SYSTEM. ranges from 4 to 6 ; hence, if these be multiplied by 10, Ave have 40 to 60 as the percentage of acidity. Under pathologic conditions these num- bers may be either higher or lower. This total represents both free and combined acids. If no organic acids be present, the above figures Avill represent the percentage of HCl. The latter is also reckoned thus: If it required 5 c.c. of the decinormal solution of sodium hydrate to be added to 10 c.c. of the filtrate to get the red color (alkalinity) Avith the phenophthalein, Ave say the acidity is 50, and multiplied by 0-003,(>4(> - 0.1823 per cent, of hydrochloric acid. It should be stated that the normal range of percentage is from 0.14 to 0.24. Estimation of Free HCl.—Mintz's method: To 10 c.c. of the filtrate add a decinormal solution of sodium hydrate from a buret until no re- action is given with Giinzburg's reagent. The number of c.c. of the decinormal solution used, multiplied by 10 and then by 0.003,646, gives the percentage of free hydrochloric acid. Estimation of Lactic Acid.—If the volatile acids are present, they should be removed by boiling. Take the total acidity of 10 c.c. of the filtrate; then to a second 10 c.c. add 25 to 30 c.c. of ether; shake well, alloAv the ether and filtrate to separate, remove the ether, and again add 25 to 30 c.c. of ether ; shake, and repeat the process. Next obtain the acidity of the watery solution, and the difference betAveen this and the total acidity, multiplied by 10X0.09, will give approxi- mately the amount of lactic acid. In the gastric digestion of the albuminoids (proteolysis) the proteids are converted into peptone. Although commenced in the stomach, this function is dependent in greater part upon the action of the pancreatic ferment in the small intestines. Among the substances earliest engen- dered by this process are the albumoses (propeptone), Avhose separation may be thus effected: Add a small quantity of a saturated solution of sodium chlorid to an equal amount of gastric filtrate, and if it becomes cloudy propeptone is present, the degree of the cloudiness indicating the amount present. If the mixture does not become turbid, add a few drops of acetic acid, when it will become so in the presence of this sub- stance, however slight the quantity. If heated, the solution becomes clear, and if allowed to cool, the propeptone precipitates and may be obtained by filtration. In a later stage of the process of albumin-digestion peptone is pro- duced and its detection is easy. To a small quantity of the filtrate (the propeptone having been removed) add enough sodium or potassium hy- drate to render the solution alkaline; then add a few drops of a 1 per cent, solution of cupric sulphate, and, if peptone be present, a purplish color is presented. The Test for Pepsin.—In a test-tube containing 5 c.c. of filtrate add a small piece of egg-albumin, and keep at a temperature of about 100° F.; if present, the albumin disappears in from two to six hours. If hydrochloric acid is absent from the filtrate, it is necessary to add a few drops of the dilute acid. It should be pointed out that laboratory attempts to estimate the rate of albumin-digestion are unreliable. Rennet Ferment.—To 5 or 10 c.c. of raw milk add a few drops of the gastric filtrate, and keep it at a temperature of about 100° F.; if rennet EXAMINATION OF THE STOMACH. 737 is present, coagulation into a single cake occurs in from a feAv minutes to an hour or more. Rennet Zymogen (which is converted into rennet ferment in the pres- ence of an acid).—To 5 c.c. of gastric filtrate add enough sodium car- bonate or sodium hydrate to make it slightly alkaline ; then add calcium chlorid (1-2 c.c. of a 2 per cent, solution); then mix with an equal quan- tity of milk, and, if zymogen is present, coagulation occurs as in the case of rennet ferment. Both rennet ferment and rennet zymogen may be assumed to be present Avhen HCl has previously been found. Starchy Derivatives.—To a small quantity of gastric filtrate add 1 or 2 drops of Lugol's solution; the presence of dextrin gives a blue reaction—erythrodextrin purple, achrobdextrin, grape-sugar, and malt- ose (intermediate substances)—showing a yellowish color. If there is a mixture of these starchy derivatives, as Avhen the digestion of starches proceeds naturally, the first few drops of Lugol's solution may produce no color-reaction, or it may be taken up by the dextrose or maltose, Avhile the addition of more of Lugol's solution Avill give a purple (if erythro- dextrin be present) or a blue color, due to starch. Indeed, if a minute quantity of the solution strikes a blue or purple tinge, conversion of starch into maltose has been abnormally tardy. I believe this is oftenest due to hyperacidity, though it may also more rarely be due to a defective ptyaline-supply.1 The Tests for the Motor Function.—More important than the secret- ory is the motor function of the stomach. There are three recognized tests: The oldest method is that of Leube. It consists in washing out the stomach from six to seven hours after a large meal, preferably consisting of beef-soup (13 oz.), beefsteak (6J oz.), bread (IJ oz.), and water (6J oz.), or from two to two and a half hours after EAvald's test-breakfast. Normally, the stomach should be empty Avithin these periods of time, so that if a residue remains it denotes a lack in the motor force. Salol Test of Ewald and Sievers.—Salol being composed of phenol and salicylic acid, it is not acted upon in an acid medium; therefore, when introduced into the stomach it remains a stable compound, and is only broken up in the intestine by the action of the pancreatic juice. The salicylic acid is absorbed into the blood and eliminated through the urine, in which it can be detected by adding a feAv drops of neutral ferric chlorid, a violet color appearing. The patient is given 15 grains (1 gm.) of salol in two thin gelatin capsules; the bladder is emp- tied, and the patient told to urinate every half hour for tAvo hours. Normally, it requires from three-fourths to an hour for the salicyluric acid to appear in the urine, but Avhen the motor function of the stomach is much impaired it may require tAvo or more hours. In order to detect the earliest traces of the eliminated salicyluric acid, Ewald and Einhorn have suggested moistening a piece of filter-paper with the urine, and then allowing a drop of neutral ferric chlorid solution to come in con- tact with it, the edges of the drop showing a violet color in the presence of the slightest traces. The varying reaction of the intestinal contents 1 The tests for the estimation of the combined acids, of some of the fatty acids, and of many of the products of proteolysis are complicated and unnecessary in an ordinary clini- cal examination. 47 738 DISEASES OF THE DIGESTIVE SYSTEM. renders the salol test very unreliable. Sometimes in healthy individuals the decomposition of the salol is retarded, and to overeome this objection Huber has suggested the determination of the precise time when the salicyluric acid no longer appears in the urine. He found that normally it required from tAventy-four to thirty hours. If, then, the reaction out- lasts this period, it shoAvs peristalsis or the motor function to be unduly tardy. Leube's test is much more reliable. Klemperer s Oil-test.—The stomach is thoroughly Avashed, and 3J ounces (100 c.c.) of olive oil are poured into it through the tube. Two hours later the remaining oil is withdraAvn by aspiration. As the stom- ach-Avall does not absorb oil, the difference betAveen the original amount and that Avithdrawn shoAvs the condition of the motility. Klemperer states that at this time the residue should not exceed 20 to 40 c.c. This test is also unreliable. To Test the Absorptive Power.—The method described by Penzoldt has been almost universally adopted: A capsule containing grains 11 (0.1), of potassium iodid is given to the patient, care being taken that the capsule is first carefully Aviped. The iodid is absorbed from the stomach and appears in the saliva, which is to be examined for the pres- ence of iodin. For this purpose strips of starch-paper (filter-paper moistened in a solution of starch and dried) are used; they are moist- ened Avith the saliva of the patient, and the moistened areas treated with a drop of fuming nitric acid. As soon as the iodin enters the saliva, the characteristic reaction for starch is struck—a blue color. Normally, this reaction occurs in from ten to fifteen minutes ; under abnormal con- ditions it may be delayed for half an hour or more. Rarely it fails to occur. This test cannot be strongly depended upon. PHYSICAL OR EXTERNAL EXAMINATION. This implies the well-known physical signs—inspection, palpation, percussion, succussion or splashing, and auscultation. Inspection.—(a) General.—This may give an idea of the nature of the illness as Avell as its severity by noting Avhether the patient appears to belong to a neurotic group, the general health often being good, or whether the patient is emaciated, or has with the latter the cachexia of a malignant groAvth. In diseases of the stomach attention should be di- rected to the mouth, and especially to the teeth, because the latter are often of causal importance in many gastric ailments. Dental affections often prevent the possibility of curing the various chronic diseases of the stomach. (b) Local Inspection.—In patients with thin and relaxed abdominal walls the contour of the stomach can be plainly noted; especially is this the case in very large, dilated stomachs or in those that have been dis- placed. The examiner is greatly aided by inflating the stomach with air or gas. The former is to be preferred, for the reason that the supply is easily regulated; he is enabled to Avatch the different steps of the dis- tention, and after the examination is completed the air is allowed to escape through the tube. For this purpose an ordinary stomach-tube is most convenient, and its passage is to be effected in the same Avay as in removing the gastric contents. A double bulb-attachment is connected EXAMINATION OF THE STOMACH. 739 with the external end of the tube, by means of Avhich air is readily forced into the stomach (Runeberg's method). Frerichs' method is sometimes used. It consists in administering 3j (4.0) of tartaric acid, dissolved in half a glassful of Avater, and im- mediately afterAvard 3j (4.0) of sodium bicarbonate, dissolved in the same amount of water. Effervescence noAv occurs, Avith a progressive visible distention of the organ. The chief objection to this method is the fact that either too much or too little distention is obtained. The inflated stomach presents a circumscribed protuberance, usually in the epigastric, and also in the umbilical region if the organ is dis- located or dilated. The air may find its way into the intestine, produ- cing a visible change in the contour of the abdomen. Tumors and other abdominal enlargements may also be recognized, and an idea obtained as to Avhich organ is involved, after making due alloAvances for displacement, as in gastroptosis and pyloric carcinoma. Exaggerated peristaltic Avaves mayT also be noticeable in the upper portion of the abdomen, usually Avhen associated Avith the stomach, and in the loAver portion if it is in the small intestine. Peristalsis is increased from various causes—inflation of the stomach, external tapping, neuroses, pyloric obstruction, and the like. The value of the gastroscope in inspecting the interior of the stom- ach is, I think, doubtful. Gastro-diaphany (illumination of the stomach) is sometimes useful in showing the fundus extending to a loAver level (at the navel) than is indicated by percussion. The Rbntgen rays (skiag- raphy) already enable us to detect non-penetrable foreign bodies in the stomach, and bid fair to distinguish aneurysms, gall-stones, and the like in the interior of the body. Palpation.—This elicits at times more trustworthy information than inspection. The patient should be in the recumbent position, the lower limbs partially flexed on the abdomen and the head low. The examiner should stand at the right side of the patient and use the right hand, which should be Avarm. With the palmar surface down gentle pressure should be made with the fingers and the ulnar side of the hand. If the abdominal wall is tense, it is best to distract the attention of the patient from the examination by talking to him. In this manner Ave can corroborate the inspection as to the size, shape, and position of the stomach, and can detect morbid growths and determine their consistency and movability. Caution must be exercised to differentiate betAveen normal and abnormal conditions, and opportunities should not be ne- glected by the physician to equip himself in delicacy of palpation by practice upon a normal abdomen. Deep palpation elicits the degree of sensitiveness, tenderness, or pain, AA'hether circumscribed as in ulcer or diffuse as in generalized inflammatory states (enterocolitis, peritonitis). In some instances relief from pain may be noted on pressure Avith the broad hand in neuroses. Variations in the degree of tension and of resistance are found and prove valuable aids. With Boas's algesimeter we are enabled to detect the amount of pressure necessary to be exerted over a given area to cause pain, by reading the number of kilograms from a scale. In some instances this is a serviceable instrument, but in ulcer, when palpation must be done 740 DISEASES OF THE DIGESTIVE SYSTEM. with the greatest gentleness, it would not be a very safe procedure as compared with the soft hand—nature's OAvn instrument. Percussion.—The patient is placed in the recumbent position; the examiner uses his fingers and endeavors to discriminate the slightest differences in the note, and percusses lightly. If the stomach is empty or partially filled with gas, it gives a loAver tympanitic sound than the colon, Avhich is also often filled Avith gas. To ascertain the size and position of the stomach by percussion the process should begin at the symphysis pubis and folioav the median line upAvard. The upper border of the stomach is at the ensiform cartilage, the loAver about tAvo fingers' breadth (3 cm.) above the umbilicus; hence, if the latter is beloAv the umbilicus and the upper border in the normal position, it denotes an enlarged stomach. If the upper margin is some distance below the ensiform, displacement of the organ is indicated. It is Avell to trace the limits of resonance of the stomach and of any areas of dulness met with, so that their size and position may be graph- ically represented. The differences in the percussion-note over the stomach and colon may be gi^atly exaggerated by inflating the former. Runeberg's method is to be jJSreferred. By employing light percussion the limits of the stomach can noAv be easily and accurately defined, unless the transverse colon be at the same time greatly distended Avith gas. In such instances Dehio's modification of Piorry's method is to be resorted to. It consists in giving about 1 liter (1 quart) of Avater in fractional doses while the patient is standing; one-quarter of the liter is swalloAved and percussion practised, Avhen a dull note will be obtained over the most dependent portion of the stomach. A second quantity of equal amount is given and a re-examination made, and so on, the object being to ascertain to Avhat point the loAver border sinks on the addition of more fluid. Boas holds that this method tests effectively the tone of the stomach, and that a marked descent of the lower border after each addition of water is indubitable evidence that there exists weakness or atony of its walls. If a neoplasm originates posterior to the stomach or colon, inflation of the latter may cause the previous circumscribed dulness to disappear. By striking the abdomen in the epigastric region splashing-sounds may be produced. This sign is of diagnostic value in dilatation of the stomach, though its absence does not contradict the presence of the dilatation. Again, if the splashing-sound is obtained in a fasting stom- ach, it may give a clue to some abnormal condition. In many instances, however, the stomach may contain large quantities of fluid and no splashing-sound be obtained. Caution should be exercised lest the splashing-sound sometimes produced in the transverse colon be mistaken for that originating in the stomach ; in the former the sound is usually associated with diarrhea, Avhile in the latter constipation usually obtains. Auscultation.—Various sounds are heard, none of Avhich are pathog- nomonic of any diseased condition. Succussion-sounds are produced by shaking the patient, and, if the stomach is dilated and contains fluid, the sounds may be audible some distance from the patient. The patient can sometimes engender similar sounds by voluntary contraction of the abdominal muscles. Various murmurs are heard in the act of deglutition—one Avhen the food passes MALPOSITION OF THE STOMACH. 741 from the pharynx into the esophagus; Ewald has described two, both heard at the cardiac extremity of the stomach; the first is a hissing murmur, the second a splashing or sprinkling. The heart-sounds are heard over an inflated stomach, and have a clear, metallic quality. Sizzling sounds are audible when fermentation occurs ; also after giv- ing a Seidlitz powder. MALPOSITION OF THE STOMACH. The stomach may occupy a truly vertical position in consequence of the persistence of the normal infantile condition or of improper cloth- ing, as long-continued pressure from corsets and the like. Unless an angular condition of the duodenum, causing obstruction to the outflow of the gastric contents, folloAved by dilatation of the stomach, be en- gendered, the malposition is of little or no clinical significance. Trans- position of the stomach, with the organ occupying the right hypochon- drium, is rarely met with in association with transposition of other viscera. GASTROPTOSIS. Definition.—DoAvmvard displacement of the stomach. The lesser curvature of the organ lies about midway between the ensiform cartilage and the umbilicus, and the greater curvature near the symphysis pubis. Etiology.—So far as our present knoAvledge extends, the conditions and circumstances contributing mostly to the origin and development of gastroptosis are—(a) Age and sex. Meinert of Dresden found among girls of fourteen years gastroptosis in 80 per cent., and among the women Avho presented themselves at his private clinic in 90 per cent. According to my own observation, gastroptosis is not as frequent among American girls and women as among the Germans. " Dislocation occurs in about 5 per cent, of the male population of Dresden." (b) Improper clothing, particularly tight lacing, (c) Dislocation of the right kidney. This operates potently, and prolapse of other abdominal organs may occasionally constitute the chief point of departure. (d) Repeated pregnancies, inducing a relaxed state of the abdominal Avail, (e) Mus- cular strain and local injury, by diminishing the tonicity of the gastro- hepatic omentum. (/) Abnormalities of the chest-formation (kyphosis); great meteorism, and enlargement of the abdominal organs, especially of the spleen and liver. Certain chronic diseases may be active-—e. g. chlorosis, tuberculosis. Symptoms.—Malposition of the stomach may exist Avithout symp- toms, but in most instances it produces functional disturbances of clin- ical importance. The latter are due, first, to the difficulty that the stomach experiences in emptying its contents. Soon functional dis- orders arise in consequence of gastric atony, and later there is apt to be a greatly diminished gastric secretion, associated Avith a nervous dys- peptic condition. Especially to be emphasized is the fact that the stom- ach may be of natural or of diminished size (as the primary result of the compression of the corsets—Fleiner), or it may be dilated—a not 742 DISEASES OF THE DIGESTIVE SYSTEM. uncommon event that often colors the clinical picture in a peculiar man- ner. Constipation due to defective peristalsis, and colicky pains due to spasm of the intestinal muscles, are important features. Physical examination of the inflated stomach * permits the accurate demonstration of gastroptosis. The percussion-note now indicates the position of the organ. It is to be borne in mind that the cardiac end remains fixed at the tAvelfth dorsal vertebra, while the pylorus moves dowmvard and to the left: this will explain Avhy the epigastrium is free of gastric tympany. Succussion splashing-sounds may be heard if atony, Avith retained gastric contents, obtains. The differentiation of gastrop- tosis from dilatation of the stomach is also accomplished by the method of inflation, since this makes plain the course and position of the lesser curvature and of the pylorus. The prognosis is not bad, being much the same as in nervous dys- pepsia ; it is modified in some cases by the presence of special causal agencies, and in others by the occurrence of certain complications, as dilatation of the stomach. The treatment has relation to the removal of all causes that favor the condition and to the associated functional disturbances. Nervines and nutrients are especially to be employed. DILATATION OF THE STOMACH. The condition is to be subdivided, clinically, into acute and chronic forms. The normal capacity of the stomach varies within rather wide limits, though the maximum normal capacity, according to Ewald, does not exceed 1600 c.c. (1.5 quarts); enlargements above this capacity may then be said to fall under the heading of dilatation. Pathology and Etiology.—The chief factor in the production of chronic dilatation is pyloric stenosis. This is usually due (a) to such diseases of the stomach as carcinoma, ulcer (occasionally), hypertrophic thickening of the pylorus, or the thickening and induration consequent on the action of corrosive poisons; (b) to the external compression aris- ing from carcinoma of the liver, pancreas, or gall-bladder, from the omental lymph-glands, and not infrequently from a displaced right kidney, or from large gall-stones; (c) congenital pyloric stenosis and adhesions about the pylorus may also act as causes of dilatation. Obviously, in all such instances increased force is necessary to pro- pel the food from the stomach into the duodenum, thus leading gradually to a hypertrophy of the muscular fibers; this is noted in an especial degree in the immediate vicinity of the pylorus. So long as this hyper- trophied state of the muscular layer compensates for the obstructive lesion no pathologic dilatation can occur. Just as soon, hoAvever, as the muscles prove to be inadequate on account of secondary degenera- tive changes, accumulation of the undigested food in the stomach en- sues. This tendency for the contents of the stomach to accumulate is 1 Inflation may be accomplished by the use of effervescent mixtures or by the intro- duction of atmospheric air (vide ante). DILATATION OF THE STOMACH. 743 very much augmented by the increasing Aveakness of the muscle on the one hand and the increasing degree of stenosis on the other. A further step in the anatomic alteration is the development of a chronic gastric catarrh in consequence of the chemical and mechanical effect of the un- digested food, the latter inevitably undergoing fermentative aud putre- factive changes from prolonged retention. The degree of dilatation is, to some extent, augmented byT the generation of excessive amounts of gases under these abnormal conditions, as Avell as by the great Aveight of the accumulated gastric contents. When produced in this manner the stomach attains enormous dimensions, and one instance has been re- corded in Avhich it Avas capable of containing 90 pounds of fluid (Loomis). Dilatation is usually general, though there may be mere diverticula cor- responding to the seats of ulcers or to erosions of the walls. Dilatation may also occur independently of pyloric stenosis, though this class of cases is not so large as the preceding, nor does the condi- tion attain so pronounced a degree. In this variety of dilatation there is atony of the muscular coats, due to various and dissimilar causes : (a) repeated over-strain of the muscular layer, due to over-filling of the organ Avith food and drink, is a comparatively7 frequent cause, and one met with in diabetics and in those who habitually drink large quantities of beer; (b) chronic gastric catarrh frequently Aveakens the muscle, and more especially Avhen associated Avith an over-indulgence in food and drink ; (c) fatty and other forms of degeneration or nutritional disturb- ances associated Avith certain constitutional diseases (particularly carci- noma, anemia, and tuberculosis); (d) congenital weakness of the mus- cular coat; (e) impaired innervation, leading to imperfect peristalsis and consequent dilatation; (f) omental hernias (Bamberger) that drag down the stomach ; (g) fibrous bands, by binding the stomach to other organs, will occasionally cause slight dilatation. Acute dilatation has for its chief causes—(a) specific fevers, pro- ducing parenchymatous degeneration of the muscular coats ; (b) the acute parahrtic distention of Fagge, Avho ascribed the condition prima- rily to chronic catarrhal inflammation ; (c) the drinking of large quan- tities of effervescing liquids; (d) Boas and Rosenheim have recently reported cases of acute dilatation folloAving shock. Clinical History.—Since the diseases causing dilatation are numer- ous and diverse, the clinical history presents great variations. Associated with the symptoms of dilatation are usually those of the causal affections, and the latter sometimes overshadow the former. Among the earlier symptoms, increased hunger and thirst are frequently observed, partly due most probably to the general condition of inanition. The thirst is also due, according to Von Weinig, to the fact that the stomach does not readily absorb water, and the pyloric obstruction prevents the passage of water into the intestines. Vomiting occurs at intervals of several days, the matter ejected amounting to from 1 to 3 gallons (4-12 liters). The clinical characters of the vomitus are strikingly peculiar. Occasionally the vomiting occurs more or less regularly some hours after feeding. The ejecta are, as a rule, excessively acid, emitting a sour odor, and on micro- scopic examination they shoAv bacteria, sarcinge, and torulse in great num- bers. The vomitus undergoes fermentative changes very rapidly, and usually emits disagreeable odors that are due to sulphuretted and phos- 744 DISEASES OF THE DIGESTIVE SYSTEM. phureted hydrogen. It consists of acetic, butyric, and lactic acids and partially decomposed food, and on standing separates into three layers— an upper layer of brownish froth, a middle one of grayish-broAvn fluid, and a loAver one composed of remnants of food. The acid contents of the stomach may be regurgitated, causing pyrosis. Eructations of foul gases are also common, and certain general symptoms almost invariably ensue. Progressive emaciation naturally follows, sometimes becoming extreme. A characteristic symptom is muscular cramp affecting the calves of the legs and sometimes spreading to the flexors of the arms and the abdominal muscles ; Kussmaul attributes this to an abnormal dryness of the muscular tissue. It is similar to the cramps in cholera. Owing to the fact that but a small amount of liquid reaches the intestines, and also to the im- paired absorption from the stomach, there are constipation and scanty urine, the latter usually being alkaline in reaction. Loss of conscious- ness has been met with, and tetany has also rarely been observed. In two instances in which lavage Avas employed in the treatment of dilata- tion tetany folloAved, lasting three-quarters of an hour; death followed about seven hours after the beginning of the attack in both instances. A striking instance is reported by J. T. Whitcomb in which nearly all the muscles of the body, including those of the esophagus, appeared to be in a tetanic condition. Dreschfield calls attention to dilatation of the epigastric veins in both inguinal regions as an evidence of dilatation of the stomach ; he has observed it in more than 60 cases, and refers to compression of tributaries of the portal vein by the dilated and displaced stomach as the supposed cause of the condition. Physical Signs.—Inspection reveals a rounded prominence just above the umbilicus in the supine and just below the umbilicus in the standing posture. In the epigastric region there is sometimes a noticeable de- pression. Obviously, then, the abdomen is unsymmetric in appearance. The outlines of the stomach may be made distinct by the patient taking an effervescing draught, and may sometimes be readily seen, particularly the greater curvature, " passing obliquely from the tip of the tenth rib on the left side toward the pubes, and then curving upward to the right costal margin" (Osier). Sometimes peristalsis is visible through the abdominal walls, and rarely the peristaltic waves are seen passing from right to left. These movements may be excited mechanically by various manipulations. Palpation.—The increased resistance of the Avails of the stomach and their peculiar elasticity aid us in mapping out the contour of the stomach with more precision by palpation than by inspection alone. The movements of the organ can be plainly felt, frequently lead- ing up to a pyloric mass. A highly characteristic sign is the loud splash- ing sound obtained by tapping the region of the stomach with the finger- tips of both hands alternately. The patient may produce, and maintain for a considerable period, similar splashing sounds by breathing rapidly and forcing doAvn the diaphragm at the same time. His own bodily movements may provoke them. Percussion furnishes subsidiary evidence as compared with palpation. The examiner should first percuss the empty, and then the filled stomach, if he would obtain reliable aid from this sign. When empty, an increased area of tympanitic resonance will be obtained, extending from above downward to a point several inches below the umbilicus. If now water amounting to 1 quart (1 liter) be in- DILATATION OF THE STOMACH. 745 troduced into the organ, and, in consequence, a line of dulness at or below the navel be noted where tympanitic resonance had been found, we have good evidence of the existence of dilatation. The posture of the patient should next be changed, when it will be found that the line of dulness has also altered. Frerichs' plan of expanding the stomach with carbon dioxid, and also Runeberg's method (vide Physical Examination), may be employed as aids to mapping out the limits of the organ. Auscul- tation reveals little that is of diagnostic value. The transmitted sounds heard over the stomach have a metallic ring. I have confirmed the observation by Franck and others, Avho claimed to have heard pecu- liar gurgling sounds produced by the heart's action and systolic in rhythm. Fluids swallowed by the patient may be heard dropping into the dilated stomach, and succussion-sounds may be elicited by shaking his body. Measurements made by introducing a probang into the stom- ach until it reaches the greater curvature are valuable only when the degree of dilatation is considerable, on account of the obvious chances of error. In health the instrument passes about 60 cm. (24 inches), reach- ing a point more or less nearly on a level with the umbilicus, while under conditions of extreme dilatation it may be introduced 70 cm. (28 inches). Diagnosis.—The diagnosis embraces, first and foremost, the recog- nition of the special causes. The unmistakable clinical manifestations are the characters of the vomitus and the peculiar manner of recurrence of the vomiting. These, together with the physical signs and a knoAv- ledge of the causal condition in the individual case, are adequate for a positive diagnosis. Differential Diagnosis.—The condition is most apt to be confounded with ascites or over-distent ion, and in the female, though rarely, Avith ovarian cyst. In dilatation of the intestines the gastric symptoms of dilatation of the stomach are wanting; moreover, the physical signs are dissimilar. The splashing sounds on manipulation, the line of dulness beloAv the umbilicus after filling the stomach, and other signs so signifi- cant of gastric dilatation are absent in over-distention of the intestines. In addition, we should make trial of the salol test, though this is now considered of little value (vide Chemical Examination). In dilatation of the stomach salicylic acid appears in the urine two or three hours after salol has been taken, while in health as early as from one-half to one hour. From dilatation of the stomach we may discriminate ascites by the history and by the characteristic gastric symptoms belonging to the former affection. In dilatation the abdomen is asymmetric, the pro- jecting prominence being in the vicinity of or just below the umbilicus. In ascites the lower portion of the abdomen is chiefly distended, and on assuming the recumbent posture the abdominal area becomes broad- ened and flattened. On palpation fluctuation may be elicited in the hypogastric and iliac regions. Megalogastria, or simple " big stomach," is distinguished by its absence of symptoms, and especially by the fact that the food is passed into the intestines as quickly as in health. Gastroptosis is easily distinguished from gastric dilatation (vide article on Gastroptosis). Acute Gastric Dilatation.—Acute dilatation of the stomach has a sudden onset, and gives rise to all of the above-mentioned physical signs. 746 DISEASES OF THE DIGESTIVE SYSTEM. In this type of the disease, however, vomiting is more frequent and severe than in the chronic form. Cyanosis is a common symptom, and pain often a prominent one. The patient frequently passes into a condi- tion of collapse that may prove speedily fatal. Acute dilatation may arise in the course of chronic cases, or may be primary. When it occurs independently of the chronic variety, it is often recovered from in the course of two or three days. Prognosis.—The prognosis in the acute form is uncertain, though the majority of cases recover; the condition may, however, tend to merge into the chronic form. Chronic dilatation offers a bad prognosis, most instances being utterly incurable. Obviously, it depends greatly upon the causal conditions. A resort to surgical interference sometimes gives promise of a more favor- able subsequent course in cases of cicatricial stenosis. Cases of dilata- tion that are not secondary to pyloric obstruction, however, give a more favorable prognosis on the whole. Treatment.—One of the chief aims of the physician should be to lessen the labor of the muscular coat and to prevent the* continual neces- sity of passing the contents of the stomach into the intestines. This is to be accomplished by careful attention to the character and amount of food taken and by frequent cleansing of the stomach. It is neces- sary to thoroughly empty the organ by lavage, this being repeated daily. A thorough and safe manner of washing out the stomach is by means of the soft Nelaton catheter, its introduction being unat- tended by injurious local effects. Perhaps the best way in which to thoroughly empty the stomach is by the use of the stomach- tube, as will be detailed under Chronic Gastritis. Recently this has been replaced by the siphon apparatus as a simpler and more con- venient mechanism than the former, and one not so likely to be at- tended Avith harmful effects, though perhaps less efficacious. The long course of these conditions renders it desirable that the patient should, Avhenever possible, be taught to wash out his own stomach. On account of the fermentative and putrefactive changes going on in the ingesta it is necessary to use weak antiseptic solutions for this purpose, suita- ble ones being a 3 per cent, solution of boracic acid or a 1 per cent. solution of salicylic acid. Subsequently warm water alone may be em- ployed. The diet should be composed chiefly of fluids, given in small quantities and at stated intervals. If the pyloric obstruction be not too far advanced, tender meats, eggs, and other easily digested albuminous articles of food may be allowed in moderate quantities. Since gastric digestion and absorption are very often markedly impaired, it is well also to include those substances that are readily digested and assimilated after leaving the stomach, though the latter must be given in a fluid state. Too much care and attention cannot be bestoAved upon the question of the adaptation of the diet to the condition of the patient. In no other man- ner can we bring such marked relief from disagreeable gastric symptoms as by a suitable dietary, and in no other manner can the general nutrition of the patient be so markedly improved. The weakened condition of the muscle-walls is due to over-strain and to degenerative processes; hence, after having removed as much of the labor throAvn upon it as possible, we should attempt to overcome its paretic state by the employ- ACUTE CATARRHAL GASTRITIS. 747 ment of such agents as strychnin and electricity. For the associated catarrhal state the remedies recommended under Chronic Gastric Catarrh may be employed. Since some of the more annoying symptoms and remote evil conse- quences are directly attributable to the fact that too small a proportion of the gastric contents finds its Avay into the intestines, we should compensate for this deficiency of intestinal fluid by rectal injections of a Aveak solu- tion (gr. v to sj—0.324 to 32.0) of sodium chlorid, not less than one pint of this solution being injected twice daily. In addition, nutrient enemata should be employed Avhen, despite proper regulation of the dietary, loss of flesh and strength continue. In consequence of the marked anemia and extreme emaciation frequently present in this affection tonics are in- dicated, and more particularly iron, which may be administered hypo- dermically in the form of the albuminate. Finally, it may be necessary to resort to surgical measures. INFLAMMATORY DISEASES OF THE STOMACH. ACUTE CATARRHAL GASTRITIS. (Acute Gastric Catarrh.) Definition.—An acute catarrhal inflammation of the mucous mem- brane of the stomach, attended Avith more or less severe local and con- stitutional symptoms. Pathology.—The postmortem evidences of an acute inflammation of the gastric mucosa are distinctive only of the graver forms, since the' latter alone usually terminate fatally. Observations upon cases of gas- tric fistula, hoAvever, have shoAvn that in the milder grades of acute gas- tric catarrh the morbid appearances are similar to those characteristic of acute catarrhal inflammations of the portions of mucous membrane normally exposed to view. Thus, at first there are small irregular patches of redness, slight swelling, dryness, and ecchymosis. Later, serum effused from the congested vessels, and mixed Avith an increased quantity of mucus, escaped leukocytes, and desquamated epithelium, is present. Hemorrhagic erosions may be seen ; the mucous membrane is noAv thickly swollen, softened, and covered Avith a tenacious muco- pus, which, from an increase in the number of leukocytes in a more intense inflammation, may pass into a purulent exudate. Infiltration and SAvelling of the solitary lymph-follicles are frequent; these some- times form minute abscesses that burst and result in follicular ulcers. The gastric tubules may be filled Avith a granular debris of epithelial cells that have undergone albuminous infiltration (cloudy SAvelling) and fatty degeneration. Etiology.—The predisposing causes of acute gastric catarrh em- brace those various impairments of the system in which the normal func- tional activity of the stomach is altered or diminished. These are seen as the result of (a) improper hygienic surroundings; (b) malnutrition; (c) the various anemias ; (d) in gouty and rheumatic subjects; (e) in the 748 DISEASES OF THE DIGESTIVE SYSTEM. tuberculous, cancerous, and malarial dyscrasia1; (/) associated with chronic passive hyperemia of the stomach due to emphysema of the lungs, cirrhosis of the liver, and renal and cardiac diseases ; (g) in sickly and delicate children, in convalescents from acute diseases, and in ener- vated chronic invalids, (h) Persons having chronic gastric catarrh are predisposed to superadded attacks of the acute disorder. The direct causes are mainly (1) dietetic. These include the ingestion of too much indigestible food ; food that is too hot or too cold ; very sour and highly seasoned articles; the too free use of condiments; and espe- cially the eating of decomposed canned goods and tainted meats. In cases due to the latter the fermentative and putrefactive agents (acetic, lactic, and butyric acids, and the ptomains) are the immediate causes of the catarrhal inflammation and tend to produce the constitutional disturb- ances, sometimes typhoid or septic in nature, that give rise to the so- called "gastric fever." The term " crapulous gastritis" has been ap- plied to those cases due to gluttonous meals. (2) Excessive indulgence in spirituous liquors is a common cause of acute catarrh of the stomach. (3) Acute infectious fevers, as measles, typhus fever, and scarlatina, provoke the disorder ("-erythematous gastritis"), as do also remittent and intermittent fevers, especially Avhen of the pernicious variety. (4) Certain drugs, as the salicylates and iodids, sometimes act as causative agents. (5) The influence of cold as an exciting factor of this disease has very probably been overestimated. (6) Since the publication of the observations by Klebs, Frankel, and others the mycotic origin of the condition cannot any longer be doubted. It has long been known that the larvae of certain insects may produce gastritis. Clinical History.—The symptoms of the ordinary or milder vari- ety of acute gastric catarrh are embraced in the description of the " sub- acute gastritis "or " acute dyspepsia " of some Avriters. Soon after eat- ing there are uneasiness, fulness, pressure, distress, and, perhaps, a dull pain referred to the epigastrium. Thirst is common, also nausea, eruc- tations of gas or liquid, and, less often, vomiting. The vomitus con- sists of undigested food, considerable mucus, and fluid constituents that are sometimes bile-stained. The tongue is coated. The general condi-, tion of the patient remains unimpaired, and the average duration is less than twenty-four hours. In severer cases the symptoms before stated are intensified, and particularly the nausea and vomiting. Physical exploration discloses slight prominence of the epigastric area, with more or less tenderness on palpation. The tongue is dry and heavily coated, the breath unpleasant as a rule, the patient complaining of a flat or bit- ter taste in the mouth. Constitutional symptoms appear early, and the onset is often marked by rigor and a febrile reaction, the temperature rising to 102° F. or even 103° F. (38.8°-39.4° C). Herpes may appear on the lips and skin—a fact that points to the infectious nature of this complaint. The pulse is usually accelerated, and there are indisposition to exertion, headache, dulness, and other nervous symptoms. An ery- thematous cutaneous eruption is often present, and particularly in febrile cases in children. That the marked disturbances of the general health are due to the toxic effects of the products of fermentation and decom- position is quite probable. Complications.—Constipation is a comparatively frequent compli- ACUTE CATARRHAL GASTRITIS. 749 cation, and diarrhea a comparatively infrequent one. Either coinci- dently or by direct extension the duodenum is similarly affected, and in some instances jaundice becomes an accompanying feature. The duration of this variety of the disease rarely exceeds four or five days. Diagnosis.—The diagnosis of the lighter, afebrile forms of the dis- order is not attended with the slightest difficulty. On the other hand, the diagnosis in cases in Avhich Avell-marked local and general symptoms appear is not easy. The definite etiology, the vomiting, the pain or tenderness, the sudden rise of temperature, and the equally sudden fall at the end of a few days, are almost unequivocal. Differential Diagnosis.—The absence of prodromata, of rose spots, of the peculiar temperature-range, and of enlargment of the spleen serve to distinguish this complaint from typhoid fever. The instances of in- determinate etiology may present a clinical picture not to be differen- tiated from certain infectious diseases. Here a careful analysis of the local symptoms and signs will usually lead to a correct conclusion, despite the apparently complete identity of the general disturbances. Close ob- servation of the behavior of any given obscure case for a couple of days will usually enable the physician to arrive at a correct diagnosis. In children headache and vomiting are symptoms often so well marked as to create a striking resemblance to tubercular meningitis, but the latter can be discriminated by the history and longer duration. In children acute gastritis Avith an erythematous rash is often mistaken for scarlet fever. The final elimination of the latter disease is usually easy, hoAv- ever, in consequence of the absence of angina, of the typical tongue, the hard and very rapid pulse, and the peculiar desquamation affecting the hair and the nails. Prognosis.—Quite generally the prognosis is good. When, as sometimes happens, however, the disease is purely secondary, the prog- nosis must depend largely upon the primary affection. I have found that many persons suffer from repeated attacks of gastric catarrh, each rendering them more liable than previously to subsequent attacks. Treatment.—Our chief aim should be to remove the cause and then to give the stomach complete rest. Hence, Avhenever the disease is dis- tinctly traceable to errors of diet, emetics of the blandest sort should be employed; large draughts of warm water usually suffice, but lavage is to be preferred in some cases. This should be followed by a purge made up as follows: R> Hydrarg. chlorid. mit., gr. j (0.0648); Sodii bicarb., gr. xviij (1.16); Sacchari lactis, gr. xij (0.777). M. et ft. chart. No. vj. Sig. One, dry on the tongue, every hour; the last to be folloAved in two hours by a wineglassful of Hunyadi Janos or other saline laxative. The stomach must now have absolute rest for about twenty-four hours, Avhen pancreatized milk or milk boiled with lime-water may be given at stated intervals. If nausea and continued vomiting prohibit the use of milk by the mouth, I resort to rectal alimentation early, and particularly in children. Certain symptoms, as nausea, pain, and rest- 750 DISEASES OF THE DIGESTIVE SYSTEM. lessness, demand as early relief as possible, and can be most success- fully met by the use of morphin in small doses hypodermically at inter- vals of tAvelve hours. When constant nausea is the symptom chiefly complained of, I have found creasote combined with bismuth or cocain in small doses to be highly serviceable. Convalescence is usually unin- terrupted, and is soon complete. When protracted it is often on account of the too early return to solid articles of diet or the too early use of bitter tonics. The mineral acids should first be administered, aa ell di- luted, after the local symptoms have in a great measure subsided, and to these the bitter vegetable tonics are later to be gradually7 added. Locally, I employ sinapisms at the beginning of severe types of the affection, and follow these Avith warm linseed poultices lightly applied to the entire epigastric and hypochondriac regions. TOXIC GASTRITIS. Pathology and etiology.—This is an intense form of acute gas- tritis, produced by the ingestion of irritant and corrosive poisons, among the former being such agents as phosphorus, antimony, and arsenic, and among- the latter concentrated mineral acids and strong alkalies. When caused by the non-corrosive poisons intense hyperemia and tumefaction, leading to desquamative changes in the glandular structure, ensue. AVhen excited by corrosive substances necrosis of the mucous membrane mav occur, leading even to an involvement of all the coats of the stom- ach-Avalls, and terminating in perforative peritonitis. The lesions may be of various grades of severity, and are either strictly localized or more or less general. Symptoms.—The symptoms vary someAvhat with the nature of the special poison, though they are usually quite violent. Incessant vomit- ing, great pain in the epigastric region, and, later, diarrhea, and exces- sive thirst, together Avith such symptoms as intense burning pains in the mouth and throat and dysphagia, are the most characteristic signs. The vomitus contains mucus, sometimes blood, and rarely shreds of mucous membrane. The physical examination reveals a marked disten- tion of the abdomen, which is also, as a rule, very painful on pressure over the epigastric region. The general condition of the patient soon becomes one of profound prostration; the skin-surface is cold and clammy, and the pulse and respiration are greatly7 hurried, terminating at times in fatal collapse Avithin a few hours. Sometimes a marked febrile movement precedes the development of the symptoms of collapse. The temperature may reach 104° F. (40° C.); the pulse ranges from 100 to 130; and the urine may be scanty, containing a slight amount of albumin or red blood-corpuscles. As a sequel we may have symp- toms of gastric ulcer or of esophageal stricture. Diagnosis.—The diagnosis rests upon the history of the ingestion of some toxic material, upon the character of the symptoms (referable not only to the stomach, but also to the mouth and to the pharynx), and upon the results of the inspection of the mouth, pharynx, and the mat- ters vomited. A chemical examination of the latter may be necessary. Prognosis.—This depends upon the nature of the poison and its dose. When free emesis occurs early the prognosis is thereby rendered ACUTE SUPPURATIVE GASTRITIS. 751 more favorable, since under these circumstances both the local and con- stitutional effects are mitigated. Among unfavorable symptoms may be mentioned the development of signs of collapse or of peritonitis. Treatment.—To ascertain, in the first place, the special cause of the gastritis, and when this is found to administer the proper antidote to that poison, are measures of prime importance. The stomach should be Avashed out with ay arm water containing some demulcent substance and a small proportion of the appropriate antidote. While lavage may be resorted to, it must be cautiously undertaken. Subsequently meas- ures should be employed to combat the active local inflammation. Ex- ternally, leeches, folloAved by the ice-bag, have proved to be the best agents in my own hands ; internally, opium, bismuth, and demulcents, Avith bits of ice, are most useful. Rectal alimentation should form the sole method of feeding so long as the signs of severe inflammation along the upper alimentary tract are present. The indications presented by the general conditions Avill vary Avith the general effects of the peculiar poison in each case. DIPHTHERITIC GASTRITIS. This form of gastritis is ahvays a secondary condition, though it is not, as has often been stated by others, ahvays caused by a direct extension of the diphtheritic membrane from the pharynx doAvn through the esopha- gus to the stomach. It arises more frequently in the course of some other acute infectious malady, as pneumonia, scarlet fever, or small-pox. Though it is regarded as a rare disease, the fact that it is unrecognizable during life renders it certain that the affection is sometimes overlooked. I have seen two instances associated with croupous inflammation of the intestines, both occurring in greatly debilitated children. Osier saw a case which occurred as a secondary process in pneumonia. ACUTE SUPPURATIVE GASTRITIS. (Phlegmonous Gastritis.) Definition.—An acute suppurative inflammation of the submucosa. Pathology and Etiology.—Phlegmonous gastritis is confessedly a rare, and almost invariably a secondary, disease. I have observed pathologic evidences of its presence, however, in two cases that came to autopsy, both patients having died of sepsis. In general, the eti- ology is obscure. It may very rarely originate spontaneously; it may also follow an injury, though more commonly it is merely a symptom of a general septic process or a complicating condition of an acute infectious malady. Tavo forms are described—namely, a diffuse puru- lent infiltration and a circumscribed form. The morbid process begins in the submucous layer, and then spreads in various directions, involv- ing soon the muscular and serous coats on the exterior and the mucous coat on the interior. The limited variety results in the formation of true abscesses, that may attain considerable size and rupture either into the peritoneal cavity or into the stomach. Symptoms.—There may or may not be an initial rigor. Whether the case is ushered in by a chill or not, however, the temperature soon 752 DISEASES OF THE DIGESTIVE SYSTEM. rises to 103° or 104° F. (40° C.), and subsequently pursues an irreg- ular course. The symptoms of the typhoid state supervene, and are usually associated Avith the symptoms of the primary affection. Hence the clinical picture is greatly diversified. For a variable period prior to the fatal issue the patient passes into coma. The local symptoms and physical signs are rarely diagnostic. There is a constantly increasing epigastric pain; emesis also appears, the vomita often containing a notable quantity of pus-cells. The physical signs reveal but little in most instances, and vary Avith the form of the complaint. Inspection shows in the diffuse form a con- siderably distended abdomen. On pressure the stomach is found to be quite tender. In the limited variety the gastric abscess sometimes gives rise to the physical signs of a tumor, and a localized prominence may be seen over the seat of the abscess; the tenderness to the pressing finger may be confined to the same area. Palpation has served to elicit fluctuation and to define the limits of the tumor, the latter sometimes attaining the size of a cocoanut; on percussion either dulness or a muffled tympanitic resonance is elicited, according to the size of the tumor. Diagnosis.—The diffuse variety cannot, as a rule, be positively distinguished from certain other gastric affections. The detection of pus-cells is, hoAvever, of the utmost diagnostic value. Gastric abscess, on the other hand, is often recognizable, since the physician has not only the history to aid him, but also the physical signs, which may demonstrate the presence of a fluctuating tumor. Conrse and Prognosis.—The majority of cases reach a fatal ter- mination Avithin one Aveek, and those that do not terminate in death thus early merge into a subacute or even chronic course. They present such symptoms as local pain, chills, and fever, and death results, sooner or later, either from exhaustion or such complications as peritonitis and metastatic abscess Avith jaundice. Treatment.—The treatment in the diffuse form is, at best, only palliative. In the circumscribed variety the aid of the surgeon should be invoked as soon as a probable diagnosis has been made. CHRONIC CATARRHAL GASTRITIS. (Chronic Catarrh of the Stomach; Chronic Catarrhal Dyspepsia.) Definition.—A chronic catarrhal inflammation of the gastric mu- cous membrane, presenting various degrees of intensity and embracing the symptoms that are more or less characteristic of widely different clinical forms of gastric derangement. Pathology.—The anatomic changes are most marked near the py- lorus, Avhere the mucous membrane often presents a distinctly Avrinkled, mammillated appearance. The mucous membrane looks either red or gray (the hitter hue being due to pigmentation), and is pretty generally covered by tenacious mucus, mingled with detached epithelium. Ewald describes the histologic changes thus: " The minute anatomy shoAvs the picture of a parenchymatous and an interstitial inflammation. The gland-cells are in part eroded or shoAv cloudy, granular SAvelling or atro- phy. The distinction betAveen the ' haupt' and ' beleg ' cells cannot be recognized, and in many places, particularly in the pyloric region, the CHRONIC CATARRHAL GASTRITIS. 753 tubes have lost their regular form and show in many places an atypical branching like the fingers of a glove. Individual glands are cut off to- ward the fundus, but appear at the border of the submucosa as cysts, partly empty, with a smooth membrane, partly filled Avith remnants of hyaline and refractile epithelium. An abundant small-celled infiltration presses apart the tubules, and is particularly marked toAvard the surface of the mucosa, and from the submucosa extensions of the connective tissue may be seen passing between the glands. The mucoid transformation of the cells of the tubules is a striking feature in the process and may ex- tend to the very fundus of the glands." Hemorrhagic abrasions may be found in cases due to cardiac disease or to portal engorgement. If the catarrh is of long duration, further anatomic changes occur. Superficial ulcers may form, usually in the pyloric region or along the lesser curva- ture, varying in size from a few lines to an inch or more in diameter, and nearly circular in shape. Long-standing cases also present sclerotic changes of the mucous membrane. Of these, two forms are distinguished. In the one variety the mucous membrane is perfectly smooth and atro- phied; the glands are displaced, narrowed, and shortened, while the gap thus formed is more or less filled with connective tissue. There is a thinning of the stomach-Avail, with enlargement of its cavity. The other form presents a hyperplasia of the mucous membrane, the gland- ular structure, and the submucous layer, sometimes resulting in enormous thickening of the stomach-walls, with great diminution in the size of its cavity. I have seen one instance in which the stomach held less than a half pint at the autopsy. Etiology.—It is evident that the factors which produce acute gastric catarrh will, if long continued, produce a chronic condition. The latter has many causes, all of which act either as mechanical, chemical, or bio- logic irritants, and fall naturally into the following classes : (a) Errors of diet (referring more particularly to improper articles of food), its variety, and preparation; excessive alimentation ; the habit of eating at irregu- lar intervals or with undue haste, and thus not allowing time for perfect mastication of the food, (b) The immoderate use of alcohol doubtless stands second in order of importance. Those persons Avho habitually indulge in alcoholic beverages to excess are prone to an irregular mode of life, and this of itself tends to produce debilitated states of the sys- tem that lead to digestive disturbances and reinforce the baneful effects of the excessive use of alcohol. Such patients are apt to suffer from the more active forms of the complaint, and, at shorter or longer intervals of time, from genuine acute gastritis (vide Etiology of Acute Gastric Catarrh). In the same category should be mentioned other gastric irri- tants, as the excessive use of tobacco and the prolonged use of tonics and purgatives, (c) Functional derangements of the stomach some- times merge into the disease under consideration. This is especially true of that form in which there is a deficiency in the gastric juice. Under these circumstances fermentative and putrefactive changes set in, and the products thus generated become sources of chronic irritation. (d) Local mechanical influences may offer resistance or obstruction to the outflow of venous blood from the stomach to the right heart. These consist in portal congestions, either passive or more or less active accord- ing to their special causation. In this class of cases chronic gastric 48 754 DISEASES OF THE DIGESTIVE SYSTEM. catarrh is a secondary process in chronic affections of the liver, heart, and lungs, (e) Such constitutional conditions as gout, chronic rheuma- tism, chronic tuberculosis, Bright's disease, diabetes, anemia, chlorosis. chronic malaria, syphilis, and chronic forms of skin-disease. The ex- planation of the peculiar liability of these conditions to catarrh of the stomach lies in the obstruction offered to the passage of blood through the hepatic and cardio-pulmonary circulation. This is true in an especial degree in chlorosis, anemia, chronic tuberculosis, and malaria; in gout. chronic Bright's disease, and syphilis it is probably due largely to the action of chemico-vital irritants in the circulating medium. Clinical History.—The local symptoms bear a striking resemblance to those of other forms of gastric disturbance. They vary greatly in severity, though never entirely absent, as in the case of purely functional disorders. Deficient secretion of the gastric juice, due to the anatomic changes in the gastric tubules, is a potent factor in the production of the symptoms directly referable to the stomach. It is the function of hydrochloric acid, normally present in the gastric secretions, to destroy the ferment-producing spores; hence Avhen, OAving to lack of free HCl, the latter are not destroyed, deleterious products of fermentation are the result, these in turn aggravating and prolonging the course of the affection. Recent investigations go to shoAv that deficient motor poAver is more important than a deficiency in the secretions in bringing about the clinical phenomena of the disease. The presence of an inordinate amount of mucus which is alkaline in reaction neutralizes in part the HCl; it may also more or less completely cover the ingesta, thus pre- venting the gastric secretions from reaching them, and lengthening, at the same time, the period of digestion. Among the earlier symptoms directly attributable to the gastric lesions are anorexia (though at times the appetite may be moderately good or even keen); fulness and distress; burning sensations and dull pain in the epigastric region; eructations of gas, which may be either offensive or odorless, during and immediately after meals; regurgitation of fluid, either acid (heartburn), due to the presence of organic or hydro- chloric acid, or a bitter form of peptones. These symptoms are usually increased in intensity after meals. The tongue frequently appears broad and flabby, and almost constantly the edges and tip are someAvhat red- dened, whilst the papillae are enlarged. Occasionally it is small, with enlarged and red papillae, or it may look healthy. A bad or, at times, a persistently bitter, taste in the mouth and great thirst may be com- plained of. There is often a profuse secretion of saliva, but the mouth may be dry. Nausea is common, and is most marked in the morning hours; it is frequent before or after meals, and often vomiting oc- curs, either immediately after meals or a couple of hours later. The vomitus will vary someAvhat Avith the time of the occurrence of emesis. Usually it consists of food in the first stages of digestion, mixed Avith large quantities of mucus. In alcoholic catarrh morning vomiting occurs quite commonly, and consists of a watery fluid composed of saliva and mucus. This class of sufferers from chronic gastritis not infrequently exhibits well-marked evidences of salivation. I have repeatedly found the material vomited in chronic gastric catarrh to be acid in reaction, unless, as occasionally happens, the vomiting takes place several hours CHRONIC CATARRHAL GASTRITIS. 755 after eating, Avhen it is sometimes faintly alkaline or neutral. The acidity of the vomitus is not due solely to the presence of HCl, but partly and sometimes largely to acid salts or the weaker acids (lactic, butyric) resulting from the abnormal processes of fermentation pre- viously mentioned. Microscopic examination sometimes reveals the presence of sarcinae ventriculi, yeast fungi, and numerous bacterial organisms. The relations of these low forms of life to the pathologic processes going on in the stomach are not Avell understood, except in the case of the yeast fungus, Avhich is concerned Avith the process of fermentation. The sarcinse ventriculi may, hoAvever, exercise a causative influence, since certain cases yield readily to the antiseptic method of treatment. An examination of the contents of the stomach for purposes of diag- nosis according to the methods laid doAvn in the preliminary section (vide p. 733) should not be neglected. In simple chronic gastric catarrh the hydrochloric acid is found to be diminished, and sometimes, though not as a rule, lactic, butyric, and acetic acids are present. In aggra- vated forms this result may be modified by the presence of the organic acids and by a great relative diminution in HCl. In many cases of chronic catarrhal gastritis there is an abundance of mucus, and an excess of hydrochloric acid may be met Avith in proliferative gastritis. On the other hand, in atrophic gastritis there is little or no mucus in the gastric contents, Avhile there is a great diminution or an absence of HCl and of the digestive ferment. Ewald has subdivided all cases into three varieties: (a) Simple gastritis, in which the fasting stomach contains only a small quantity7 of slimy fluid, while after the test-break- fast the HCl is diminished in quantity, and lactic acids and the fatty acids are usually present, (b) Mucous gastritis, in Avhich class the acidity is ahvays slight and the condition is distinguished from simple gastritis by the large amount of mucus present, (c) Atrophy. Here the fasting stomach is always empty, Avhile after the test-breakfast HCl, pepsin, and the curdling ferments are Avholly wanting. The absorbent and motile powers of the stomach are both more or less diminished, and are determined by the potassium iodid and salol tests respectively. Physical Signs.—Sometimes there may be observed an undue disten- tion of the stomach, the prominence being more marked toward the left. On making firm pressure over the epigastric region tenderness is often elicited. This is not present in the early stages, nor constantly later in well-marked cases, since the degree of inflammatory action is subject to great oscillation. When tenderness is found over a considerable portion of the epigastrium in the absence of a new growth, it is of great diag- nostic value. It is to be recollected, however, that resistance may be felt when the stomach is thickened in chronic interstitial gastritis. Dilata- tion of the organ may be indicated by splashing sounds, and the latter may be elicited in the absence of gastrectasis at a time when the stomach should contain no food. On percussion there are discoverable alterations in the size of the organ. Among the general or indirect symptoms manifested the nervous phe- nomena are of first importance. So prominent are they in the clinical 756 DISEASES OF THE DIGESTIVE SYSTEM. picture ofttimes as to lead the incautious physician to the conclusion that his patient is suffering from some primary disease of the brain or nerves. The nervous derangements have been attributed solely to morbid sympa- thetic disturbances; it is quite probable, however, that we should ascribe a share of the morbid influence to the absorption of toxic materials from the stomach and intestines. Headache is frequently complained of; it is generally frontal, though also occipital, and tends to appear before meals. The so-called sick headache more rarely occurs. Indisposition to mental or physical exertion, vertigo, depression of spirits, and well-marked hypo- chondriasis are common concomitants. Patients complain of Avakeful- ness and disturbed dreams, though drowsy after meal-time. There is a sympathetic disturbance of the cardiac rhythm, and sometimes dyspnea, owing to the same cause. The urine is often highly colored, scanty, and deposits an abundant uratic sediment; occasionally, however, it is of low specific gravity, rather copious in amount and pale in color, owing to the influence of phosphates. This condition is found in cases in which the nervous element is notably prominent. Complications.—The intestines often become involved, and usually by direct extension. Implication of the duodenum may lead to jaundice and to obstinate constipation, though only moderate constipation is the rule in catarrh of the stomach. When the process extends to the large intestines diarrhea develops. Alternating constipation and diarrhea are often observed. The nutritive system is, in confirmed cases, seriously implicated, as shown by the anemia (of the pernicious type in some cases), emaciation, and general debility present. It is particularly in examples of combined intestinal and gastric catarrh that we observe the most notable impairment of the general health, and the reason of this will be clear when it is recollected that under these circumstances all the digestive fluids are lessened in amount. The gases generated in the stomach often find their way into the intestinal canal, giving rise to tym- panitic distention, and sometimes to colicky pain. In not a feAv instances the gastric catarrh extends upward to the oral cavity. Under such circumstances the tongue is large and heavily coated, with impressions of the teeth upon its edges. Since the mucous membranes are unhealthy, there is produced an abnormal condition of the secretions that renders the breath foul and causes thirst. Certain skin-eruptions, as eczema, lichen, and urticaria, are common concomitants of this disease. By some authors these disorders of the skin are supposed to be caused by the catarrh of the stomach. I have frequently observed, however, that when present their improvement has been followed by an aggravation of the gastric symptoms, and vice versd. A sequel of the disease is dilata- tion of the stomach, but I believe this to be less frequent than was for- merly supposed. The course of chronic gastric catarrh is long, the average duration being considerably more than one year. Its duration may be much abridged by early recognition and proper treatment of the condi- tion. The symptoms at first intermit and are mild, but later are persistent. Diagnosis.—A positive diagnosis may be based on a clear etiology, the presence of persistent symptoms and signs of chronic disturbance of digestion, upon defective motor poAver, a diminished amount of HCl, an abundance of mucus in the gastric contents, and deficient absorptive power. The points of difference betAveen the more serious affections of CHRONIC CATARRHAL GASTRITIS. 757 the stomach (carcinoma, ulcer, and dilatation) and chronic gastric catarrh will be detailed when the former diseases are considered. As I have said, Ewald makes three leading forms of the complaint, based on the results obtained from an analysis of the contents of the stomach, but I have found his classification not satisfactory in practice. Prognosis.—Chronic catarrh of the stomach may be said not to manifest an innate lethal tendency. It, however, predisposes to, as well as aggravates, the symptoms of existing forms of acute and serious forms of chronic diseases, especially organic affections of the stomach. The prognosis depends considerably upon the stage in which the disease is when first met with, since the condition is amenable to treatment only when not too far advanced. The prognosis is rendered someAvhat more grave by the presence of certain complications previously mentioned. I have seen one case that proved fatal in consequence of stricture of the pylorus. Hematemesis has caused death rarely. Treatment.—It must never be forgotten as far as possible to search for and remove the causal affections in every case. When associated with grave forms of cardiac, hepatic, or renal disease these must receive care- ful attention primarily. The masticating apparatus must be looked after by the physician, who must also instruct his patient in the art of eating slowly, so that insaliva- tion of the food is thoroughly effected. Too often the quantity of ali- ments consumed is beyond the needs of the bodily functions, and the method of preparing the same faulty7—defects to be early corrected. Such patients should eat oftener than in health, taking four or five meals in the twenty-four hours. The physician must with untiring diligence attend to every dietetic, sanitary, and therapeutic detail. The major portion of the treatment has relation to— (1) The Diet.—In the matter of arranging the dietary in separate cases the general condition and peculiarities of the individual must be taken into account. The Avise physican will be guided to some extent by the dictates of his patient's experience, and will not fail to avail himself of any information obtainable upon this head. In severe cases an exclu- sive milk diet for a period of two to four weeks often gives the best re- sults. The daily amount requisite to meet the demands of the vital functions is 4 to 8 pints. Of this, 5 to 8 ounces are to be taken slowly every two hours during the day. The beginning amount, hoAvever, must occasion- ally be smaller—2 to 3 ounces—to be gradually increased. A pinch of salt or from 1 to 1 ounce of lime-water may be added to each feeding, or the milk may be diluted with Vichy. The milk should not be taken iced, but warmed or at the temperature of the room. Boiled milk is objection- able. The stools are to be watched for curds, and when the digestive capacity is exceeded the amount of the nutrient should be lessened and other articles cautiously added. When whole milk cannot be digested on account of an actual loathing for it, skimmed or partly skimmed milk or buttermilk should be substi- tuted. If the latter cannot be utilized in proper amount, animal broths, together with some of the artificial foods (panopeptone, liquid peptonoids), may be added. As tolerance for a liberal amount of milk becomes estab- lished the appetite is no longer satisfied, and then I begin to add the light solids in a gradual manner ; for example, white meat of chicken or 758 DISEASES OF THE DIGESTIVE SYSTEM. game (except tame ducks and turkey), stale or tAvice-baked bread, milk or dry-toast or zAveiback, soft-boiled eggs, oysters, fish, and, later, Ham- burg steaks, stewed SAveatbread, and the like. For dessert, junket or cus- tards, SAveetened with saccharin, are well borne as a rule. Subsequently, farinaceous articles, if thoroughly cooked (except oatmeal), and certain plain vegetables, may be allowed, but their effects"must be minutely ob- served. The former are to be eschewed in cases in which acid-fermenta- tion or flatulency is a prominent feature. Among the latter, rice, spin- ach, lettuce, and macaroni (steAved in milk) are to be selected. Peas and beans, if green and succulent, may be tried, but if ripe are to be dis- carded. The only form of fat permissible is good butter. Stewed fruits are often well borne and tend to overcome constipation. In cases in which the latter symptom obtains Graham bread and green soft vegetables are also indicated and often are readily digested. In light cases and in those of moderate severity, particularly if the cause of the complaint is removable, the dietary need not be rigid at the start. Indeed, to minimize the saccharine articles and starches and to avoid the coarser vegetables, hot bread, pastries, and the like, is all that is required. In the case of confirmed dyspeptics the following articles are to be scrupulously avoided: very fat meats, fat fish-foods, condiments, certain fruits (strawberries, bananas), hot bread, saccharine articles of diet and farinacea, potatoes, particularly swreet potatoes, and other coarser vegetables. Of drinks, the best during meal-time is simple hot water, to which a little milk may be added, or a single coffee-cup of weak tea. Occasion- ally cocoa is allowable, but ordinary chocolate, coffee, and strong tea are harmful. Too much liquid should not be taken during a meal, since it dilutes the gastric secretion to a deleterious extent, and cold drinks are to be interdicted during the same period. I have never observed any unfavorable effects from the moderate use of ice-water betAveen meals. Alcohol, and particularly concentrated spirituous liquors, exert an irri- tating effect, and hence in cases of chronic catarrhal gastritis should be absolutely forbidden. (2) Hygienic measures are of signal value in this disease. Of these the most important are forms of fresh-air exercise, as bicycling, walking, boating, and horseback-riding. Suitable indoor apparatus for physical exercise is now easily obtainable at little cost, and therefore open-air exercise may be supplemented by the latter. Physical exercise must be carefully supervised, so as to avoid the deleterious effects of over-exertion. I am convinced of the superior advantage of travel, including a sea- voyage, and an appropriate change of air—for example, to the seaside or mountains—particularly for the large class of self-centered and low- spirited dyspeptic patients. A cold sponge-bath, followed by brisk fric- tion of the skin, is to be advised. An abdominal bandage, made of wool- len or silk material and constantly worn, tends to increase the patient's comfort. (3) Medicinal Treatment.—Saline laxatives, as Rochelle salts or Carlsbad salts, taken fasting in hot Avater, are advantageous, since they serve to regulate the boAvels, to deplete the engorged gastro-intestinal vessels, as well as to rinse the stomach. Hunyadi Janos or Carlsbad mineral waters may be substituted. Their efficacy is much enhanced in CHRONIC CATARRHAL GASTRITIS. 759 cases in which gastro-duodenal catarrh is associated with portal congestion, when the alkaline carbonates are administered simultaneously. Further than this, little is needed in the majority of instances. The use in- ternally of antiseptics, combined with alteratives and mild astringents, is often beneficial. I can speak most positively in favor of the fol- lowing pill: R> Argenti nitratis, gr. iv (0.259); Ext. hyoscyami, gr. viij (0.518). M. et ft. pil. No. xvj. Sig. One about one hour before each meal, the stomach being first prepared by rinsing with a 2 per cent, solution of borax in water. The silver nitrate is to be continued for a period of five to eight weeks, with interruptions of several days at the end of three weeks. In the fermentative form of chronic gastric catarrh the hyperacidity is, in reality, often dependent upon the lack of free HCl; hence this agent should be supplied. It is best administered immediately after meals, the dose being not less than 10 minims (0.666), well diluted, and this may be repeated in the course of ten or fifteen minutes in obstinate cases; it may be combined advantageously with pepsin (gr. v-x—0.324-0.648) or pan- creatin (gr. x—0.648). Pancreatin is better associated with sodium bi- carbonate in the form of a tablet containing each gr. ij (0.129). Of these tAvo or three may be administered fifteen to thirty minutes after meal-time. Care is to be taken to use only the best articles of pepsin and pancreatin. When hyperacidity exists, diastase and ptyalin may be exhibited, but I have failed to obtain encouraging results from their employ. This class of cases represents an aggravated or advanced form of the disease (atrophic stage), and demands prolonged and varied treat- ment. At the end of the digestive process it is well to thoroughly irri- gate the stomach (lavage), and more particularly if evidences of dilatation be present. The stomach may also be cleansed and prepared for the re- ception of the next meal in a very agreeable manner by having the patient sip a 2 per cent, solution of borax in warm water or a 2 per cent. solution of sodium chlorid half an hour before meals; indeed, the con- tinued use of simple hot water for the same purpose has, in my hands, often given excellent results. With it must, of course, be combined the saline laxatives and the restricted diet. Not less than 1 pint of water, hot as it can be taken by the patient, should be sipped at each sitting. To assist the appetites of these patients and to stimulate the secretory function a few drops (not more than 5) of the tincture of nux vomica may be given fifteen minutes before meals, with gr. ij-iij (0.129-0.194) of so- dium bicarbonate. These indications are also fulfilled by lavage once daily or bi-daily (if the patient be feeble). If hyperacidity, due to the organic acids, persists despite the measures already recommended, we may combine bismuth subnitrate with magnesia and a few grains of charcoal, this being administered when the stomach is empty. We may also check fermenta- tion by the exhibition of salicylic acid (gr. v—0.324) thrice daily or cre- asote (gr. -|—0.0324) thrice daily. Germain See has recently found stron- tium bromid (3ss to 3j ; 2.0-4.0) to be of great value in cases in which gaseous fermentation with hyperacidity is combined with permanent ten- 760 DISEASES OF THE DIGESTIVE SYSTEM. derness. Happy results often follow a course at some spa if the patient be under the charge of a competent physician during his sojourn. The robust or plethoric should go to Carlsbad, Ems, and Kissingen abroad, and to Saratoga in this country, using more especially the Hawthorne water. The anemic should go to Franzenbad or the spa near Brussels, and in this country to the iron springs at Bedford, Pennsylvania. A course of the alkaline mineral waters may be successfully taken at home in many instances, though patients are much more apt to obey the phy- sician's injunctions as to diet, exercise, and the like Avhen at a spa than when at home. These waters do not simply act as purgatives, but also as antacids. It has been experimentally shown that sodium chlorid, so- dium carbonate, as well as carbon dioxid, promote the secretion of the gastric juice. In the more chronic cases belonging to this class or those that have resisted other forms of treatment intestinal complications are usually found. Here the alkaline waters are to be alternated with calomel in small doses, prescribed thus : R> Hydrarg. chloridi mitis, gr. ij (0.129); Sodii bicarb., 3J (4.0); Sacchari lactis, 3ss (2.0). M. et ft. chart. No. xij. Sig. One, dry on the tongue, four times daily. I have been in the habit of continuing the use of these powders for several days to one week, then returning to the alkaline waters for two weeks, and so on. In the mucous variety of gastric catarrh additional indications for treatment are presented. The chief aim should be to limit, as far as possible, the production of mucus and to cleanse thoroughly the stomach prior to each meal, thus preparing the organ for the reception and better digestion of food. Here, again, at least one pint of hot water, contain- ing the substances before mentioned, should be sipped half an hour before each meal. This mode of cleansing the stomach is usually successful; if unsuccessful, however, it should be supplemented by lavage once daily, using the same solutions as above indicated, though in larger quantities. The siphon is also highly useful in cases of this sort in Avhich stricture of the pylorus is suspected and when the food is retained in the stomach much longer than the normal period of digestion. This frequently happens, for the reason that the mucous covering which the food receives not only prevents it from being acted upon by the gastric juice, but also renders absorption tardy. The therapy of this form of chronic gastritis requires, in addition to what has before been given, the more potent astringents for the purpose of arresting hypersecretion of mucus. The best way to use these agents is topically. The stomach may be washed out (at bed-time or early in the mornings) with a 2 per cent, solution of alum or a 1 per cent, solution of tannic acid ; antiseptic solutions are employed in like manner, a 2 per cent, solution of salicylic acid being especially efficacious. If lavage cannot be practised, such astringents as catechu, cerium oxalate, and silver nitrate, with small doses of opium (vide supra), should be tried. For use internally one of the very best remedies is atropin sulphate. Certain symptoms belonging to all varieties of the affection may demand GASTRIC ULCER. 761 relief. These must be met in accordance with general principles. Vom- iting, which is at times a distressing symptom, is best allayed by small doses of resorcin or creasote in combination with cerium oxalate. As soon as the morbid irritability of the stomach has been reduced mild forms of bitter tonics, with a view to imparting vigor to the digestive organs, may be cautiously employed. Their too early use is very apt to aggravate existing symptoms, or even to reproduce such as have already disappeared. Iron is often indicated during convalescence. GASTRIC ULCER. (Simple or Round Ulcer of the Stomach.) Definition.—An ulcer presenting sharp borders, with a tendency to extend in depth, generally without collateral inflammation, giving rise, usually, to one or more characteristic symptoms, as pain, vomiting, and hematemesis. Rarely it is entirely latent. Pathology.—The gross anatomic characteristics and peculiarities may be briefly considered seriatim, (a) In shape it is usually round or oval. It rarely happens that there are several ulcers, and these may form larger ones having irregular borders. They are at first superficial, though their floor (when seen at autopsy) is below the mucous membrane, owing to a tendency to extend in depth. This characteristic has given rise to the term "perforating ulcer." Thus, the ulcer has for its base, very frequently, the muscular or serous coats, but sometimes, and not rarely, the ulcerative process extends through the walls of the stomach, in which case adhesions form between the stomach and the adjacent vis- cera, one or other of the latter organs occupying the base of the ulcer. Almost always the walls slope inward, giving rise to the characteristic funnel-shape. The edges may, however, be sharp and abrupt. The floor of the ulcer is quite generally clean, and rarely may present a hemor- rhagic aspect. A recent ulcer presents clean-cut edges, that are not the seat of collateral inflammatory edema, though an old ulcer often presents somewhat thickened margins, (b) In size it is quite variable. The majority of the ulcers are not larger than a dime; others may measure as much as 10 cm. (4 inches) in their greatest diameter. The edges are almost invariably formed from the coalescence of two or more smaller ones, (c) The position is most frequently near the pylorus on the poste- rior wall, and particularly in the vicinity of the lesser curvature.1 For- tunately, they occupy the anterior surface but rarely, this being a danger- ous situation, as will presently be explained. The ulcer often heals by cicatrization. The resulting scar is pale and stellate, and there is puckering of the surrounding mucous membrane. If the ulcer has not extended deeper than the mucous membrane, granu- lation-tissue develops from the edges and base; this tissue slowly con- 1 Of 793 cases collected by Welch from hospital statistics, 288 were on the lesser curvature, 235 on the posterior wall, 95 at the pylorus, 69 on the anterior wall, 50 at the cardia, 29 at the fundus, 27 on the greater curvature. The duodenal ulcer is usually sit- uated just outside the ring in the first portion of the gut (Osier, page 369). 762 DISEASES OF THE DIGESTIVE SYSTEM. tracts, uniting the margins and leaving a comparatively smooth scar. On the other hand, if the ulcer be large and involve the muscular and serous coats, stricture of the pylorus, folloAved by dilatation, may re- sult. The stomach may present an hour-glass shape, due to the con- traction of a girdle ulcer in the central part of the organ. Nearly all gastric ulcers Avould perforate the coats were it not for the development of a local peritonitis which establishes adhesions between the correspond- ing portion of the stomach and adjacent structures. The ulcers being usually situated on the posterior Avail, the surface of the pancreas forms the point of attachment most frequently, though the stomach may also become adherent to the left lobe of the liver, the spleen, omentum, diaphragm, or the transverse colon. The organs with which the stom- ach becomes agglutinated may be penetrated by the ulcerative process, resulting in suppurative inflammation; or fistulous connections of the stomach with the transverse colon, the pleura, the pericardium, lungs, gall- bladder, and the duodenum may thus be established. Of these, gastro- colic fistula? are the most common. Osier states that there are two instances on record in which the ulcer perforated the left ventricle. Penetration of the ulcer through the posterior gastric wall opens the lesser perito- neal cavity, in which case the base remains limited, producing a condi- tion known as subphrenic pyo-pneumothorax. When the anterior surface of the stomach, which has no anatomic relations with other organs favor- able for the establishment of protective adhesions, is perforated, general infectious peritonitis rapidly supervenes if a fatal end be not reached im- mediately. Intense hyperemia or the erosion of small vessels gives rise to small or moderate hemorrhages. If the ulcer penetrate one of the larger vessels, as happens not rarely, then profuse and even fatal hema- temesis is the result. This accident is doubtless frequently prevented by the development of a " protective thrombosis." In several instances small aneurysms have been found at the bases of the ulcers (Douglas, Powell, Welch). Etiology.—Since gastric ulcer was first accurately described by Cru- veilhier many and widely various theories as to its mode of origin have been promulgated. Whilst there is to-day no universally accepted view of its pathogenesis, yet there are two points that may be regarded as definitely settled: (a) that the ulcer is due to a self-digestion of a cir- cumscribed portion of the stomach ; (b) that the alkalinity of the part digested has been previously7 reduced. Among the conditions lessening the supply of alkaline arterial blood, which, as is Avell knoAvn, prevents the stomach from being digested in health, the chief are embolism and thrombosis of the nutrient artery of the part, the infarct thus produced being annihilated by the gastric secretions (Virchow). This vieAv receives confirmation from the fact that many instances of gastric ulcer have been observed in connection with disease of the cardio-vascular system. Op- posed to this view are the experiments by Panum and Cohnheim, which show that ulcers produced artificially by occluding the arterioles with em- boli tend to heal rapidly. Without stopping to detail all the other theories that have been propounded to explain their mode of development, I will mention only a few additional, and probably predisposing, causes. Most influential among them stands, doubtless, hyperacidity of the gastric juice —a condition almost universally present in this disease; although the GASTRIC ULCER. 763 ulcers may not result primarily from the presence of an excess of acid, it is quite probable that further extension of the ulcerative process may be due to this factor. Peter assumes the cause of simple ulcer to be gas- tritis, and it cannot be gainsaid that the former is often met with in con- nection with the latter disease. On the other hand, Stockton holds the disease to be a neurosis. It is well known that the affection is often sec- ondary in chlorosis, anemia, and oftener still in amenorrhea. The fact that in all the different forms of anemia there is a diminished alkalinity of the blood is of great interest in this connection. Obviously, then, ulcer of the stomach occurs more frequently in females than in males. It is most common betAveen seventeen and thirty-five years; it is rare in young children, though Gorgart saw an instance in a child thirty hours after birth, and less rare in those past middle life. It is more frequent in the poor than in the rich: occupation has also a noticeable influence, and I have personally seen a number of instances in weavers. It is also prone to attack servants, cooks, and needlewomen among females, and shoe- makers and tailors among males. Injuries of the immediate vicinity of the epigastrium have been often followed by gastric ulcer, but these have, as a rule, healed rapidly, and are not to be classed as " peptic " ulcers. Clinical History.—In typical cases of gastric ulcer the clinical symptoms are almost positively diagnostic. The earliest symptoms point, very frequently, to chronic or subacute gastric catarrh, these being fol- lowed, soon or late, by those that are characteristic, as pain, vomiting, and hematemesis. Of these, pain is most constantly present, and pre- sents certain peculiarities that demand rather elaborate mention. It is commonly dull, at times burning, and is associated usually with great oppression. These symptoms are doubtless often due to coexisting catarrhal gastritis. The character of pain that is most diagnostic is an intense gnawing, burning, or boring in the epigastrium, more or less periodic and strictly localized in a circumscribed area. These par- oxysms usually come on almost immediately after eating, occasionally one or two hours later, and disappear quite promptly when the stomach is emptied either by vomiting or by its contents passing into the duodenum. From the time of its occurrence, the quality, and strict localization of the pain, it may safely be assumed that it is due to direct irritation, set up by the food, of the sensory fibers occupying the base of the ulcer. In addition, there are paroxysms of diffuse pain (gastralgia) that are often strictly intermittent, though not necessarily excited by the partaking of food. This pain is due to a sympathetic nervous disturbance or reflected irritation. Finally, sharp, intense, lancinating pains, that are caused by local or general peritonitis, may appear suddenly, ceasing only with the death of the patient. We often meet with the four kinds of pain above described in a single case, though they vary in relative intensity in different cases. The pain in round gastric ulcer is greatly modified by numerous conditions, all of which are largely under human control. The effect of taking food has been already referred to, though it should be added that, obviously, undigestible, imperfectly masticated, highly- spiced food, sweet and hot substances, cause the paroxysms to be more intense than less irritating articles of diet. Rest diminishes the severity of the pain in that it prevents traction on the ulcer. Certain postures may aggravate it, and, though not a trustworthy guide, we may often de- 764 DISEASES OF THE DIGESTIVE SYSTEM. termine the situation of the ulcer by the effect of posture after taking solid food. The severity of the pain is often increased by bodily fatigue or even moderate exercise, and, to a greater degree, by special emotional influences. The situation of the pain when strictly localized is of the utmost importance in diagnosis. I have found it invariably from one to two inches below the ensiform cartilage, though it has been observed in the umbilical and hypochondriac regions. It is absent in one-half of all cases. Vomiting, next to pain, is the most frequent symptom, but unless the vomitus contains blood, which is present in less than 50 per cent, of all the cases, it has little diagnostic value. Nausea and eructations of acid or food often precede or accompany the emesis. Vomiting usually occurs about tAvo hours after eating, and is often coincident with the height of the paroxysm of pain, which the vomiting relieves as a rule. The vom- itus, as first shown by Riegel, usually contains an increased proportion of HCl. Hematemesis is a symptom of unequalled clinical significance. On it alone frequently rests a positive diagnosis. When the hemorrhage is con- siderable, pure blood, more or less clotted, may be ejected, this being highly characteristic of gastric ulcer. Frequently, however, the blood oozes gradually into the stomach and mingles with the gastric juice, and in consequence the oxyhemoglobin of the blood is converted into hematin, the vomitus presenting the appearance of coffee-grounds. On microscopic examination under these circumstances only larger or smaller pigment- masses can be seen, and no blood-corpuscles.1 Vomiting of blood may recur at intervals of a few hours or on each successive day. The amount also varies within the widest limits according to the size of the vessel eroded. Some of the effused blood passes through the pylorus, escaping with the feces and giving to the latter a tarry, black appearance. A few cases have been reported in which all the blood was evacuated with the stools except that which was absorbed from the alimentary tract. Either as the result of a single copious hemorrhage or of repeated smaller hemorrhages a pronounced anemia is produced, the objective signs and the cerebral and cardiac manifestations of the latter disease at once be- coming evident. As a rule, however, the evidences of anemia are only moderately well marked, and to assume that the anemia is due solely to the hemorrhages would probably be an error. A slight rise of temper- ature is often observed under these circumstances; this is to be regarded as the so-called anemic fever. Beneficial effects often follow hematemesis. The pain and the most unpleasant local symptoms have been frequently observed to disappear after its cessation—a circumstance that, as Striim- pell observes, may be owing in part to the extreme caution of the patient thereafter. Not infrequently convalescence sets in almost immediately. Physical signs are few and slight. On palpation tenderness is found, though not in all cases. The spot of localized agonizing pain before alluded to is often excessively tender on pressure—a valuable sign. The true gastralgic attacks, so common in gastric ulcer, are at times relieved by making firm pressure Avith the broad hand over the epigastrium. Near the pyloric end of the stomach palpable tumors may be felt, due to the 1 The blood, however, can be identified by chemical tests and the spectroscopic appear- ance of the hematin. GASTRIC ULCER. 765 thickened floor of the ulcer. When these indurated masses become ad- herent to adjacent organs—the pancreas, for example—epigastric tumors of considerable size may be felt, suggesting the presence of carcinoma. General symptoms often do not appear until late in the disease, the patient continuing to look as well as usual. Anemia is usually noted first, to be followed by debility and emaciation ; the degree of the general disturbances is in direct proportion to the severity and duration of the causes producing them—namely, the coexisting catarrh, hemorrhages, pain, and vomiting. In some instances the cachexia is pronounced, and the face, on account of the prolonged suffering, assumes a drawn, hag- gard appearance. Other Clinical Forms.—These have been subdivided into numerous types, some of which merge into one another and cannot be separated clinically. The following atypical forms should be distinguished: (a) Latent ulcers, whose existence is not suspected during life, but which are revealed, should they come to autopsy, as open ulcers or cicatrices, (b) An explosive form, in which the ulcer may or may not give rise to gastric disturbances prior to the occurrence of perforative peritonitis, (c) A re- current form, described by Welch- thus : "In this the symptoms of gastric ulcer disappear, and then follow intervals, often of considerable duration, in Avhich there is apparent cure, but the symptoms return, especially after some indiscretion in the mode of living. This intermittent course may continue for many years. In these cases it is probable either that fresh ulcers form or that the cicatrix of an old ulcer becomes ulcer- ated." Perforation of the ulcer is a serious event, and one that almost always quickly proves fatal, occurring as a complication in any of the types be- fore described. This accident may, however, though exceptionally, be followed by recovery. In these instances the peritonitis remains lim- ited, either on account of rapidly formed adhesions or on account of the ulcer opening into the lesser peritoneal cavity. The symptoms of this complication will be given in the proper place. General Course.—This presents wide variations in different cases. It may be, though seldom, limited to a few hours, as in the explosive form. Innately, the disease is an exceedingly chronic one, often lasting several, and sometimes ten or fifteen, years. Its duration in curable cases may be lessened by proper treatment. Recovery may be incom- plete, and the scar resulting from the healing process may give rise to true attacks of gastralgia. Again, if the cicatrices be situated at the pyloric orifice, dilatation will almost invariably develop. Diagnosis.—The typical cases in which the characteristic symp- toms above mentioned are conspicuous are easy of diagnosis. Hemor- rhages occurring with gastralgic attacks are almost pathognomonic. A considerable proportion, hoAvever, offer great difficulties. Without the presence of hematemesis, for example, a positive diagnosis should not be made, and yet this symptom does not appear in 50 per cent, of all cases. In the absence of hemorrhage we may, hoAvever, infer the altogether probable existence of ulcer if there be a history of the more important etiologic factors; if there be gastralgia, hyperacidity, local pain, and tenderness; and, particularly, if the latter symptoms be excited or greatly aggravated by the taking of food. The long course and liability 766 DISEASES OF THE DIGESTIVE SYSTEM. to remission, to be folloAved by exacerbations of the symptoms, are strongly confirmatory. Differential Diagnosis.—This disease may be mistaken for gastralgia. chronic gastritis, the passage of gall-stones, cirrhosis of the liver, and carcinoma of the stomach. The differentiation of the latter complaint Avill be given later, (a) In certain cases of cirrhosis of the liver hema- temesis is met Avith, but here there is absence of all the other character- istic symptoms of ulcer, and the presence of a group of symptoms and physical signs pointing to disease of the liver, (b) Hepatic colic simu- lates, though not closely, ulcer of the stomach. The sudden onset, the longer duration of the attack of pain, its sudden complete cessation, the presence of jaundice and certain physical signs presented by the liver, suffice to distinguish this affection from gastric ulcer, (c) Chronic gas- tric catarrh with hematemesis simulates ulcer of the stomach in many particulars. The great diminution in the proportionate amount of hydrochloric acid found in chronic gastric catarrh and the increased amount in gastric ulcer are facts that Avill help materially in discrimina- ting these two diseases. When they are associated Avith one another my observation teaches that there is an excess of HCl present; hence a proportionately diminished amount of HCl probably argues against the presence of ulcer. The vomiting in ulcer is combined Avith severe par- oxysms of pain; not so in chronic gastritis, and the vomit in the former contains larger quantities of blood than in the latter disease, (d) Doubt- less ulcer of the stomach has often been mistaken for neurotic gastralgia, and the discrimination cannot ahvays be accomplished to a certainty. Their chief differential points may be conveniently arranged thus: Gastric Ulcer. The paroxysms of pain usually come on at a definite period after eating. Eating rarely relieves pain. Tenderness on pressure over a certain limited area in the epigastrium. Pressure usually aggravates, and only occasionally relieves patient during paroxysm of pain—not during the in- tervals between seizures. In the intervals between the attacks gas- tric disturbances, more or less severe, are present; also tender point fre- quently. Hematemesis present in nearly one-half of the cases. General health often much impaired, par- ticularly late in the affection. History of certain occupations, anemia, chlorosis, amenorrhea, tuberculosis, and diseases of the heart common. Most frequent from fifteen to thirty-five years of age. Physical signs of a mass may be present. Dilatation may coexist in the late stage. Hyperacidity of gastric juice usually present. Improvement follows rest and regulation of diet. , Gastralgia. Paroxysms more frequent when the stom- ach is empty than soon after meals. Eating usually brings relief. Tender spot absent. General hyperes- thesia of the skin often present. Pressure almost always relieves the pain. In the intervals between attacks no gas- tric disturbances present, as a rule. Hematemesis absent. General health less affected than in ulcer. History of neurasthenia, neuralgia, and hysteria common. Most frequent before or near the meno- pause (in the female). Signs of tumor always absent. Dilatation never present. Hyperacidity present only in certain forms (supra). Regulation of diet has no effect. GASTRIC ULCER. 767 The prognosis is obviously uncertain. The average mortality is about 25 per cent. Such grave complications as free bleedings and peri- tonitis have been discussed sufficiently in the Clinical History. Among thoracic complications, pneumonia, tuberculosis, and left-sided perfor- ative empyema are those most frequently encountered. They all render recovery almost positively hopeless. The possibility that the resulting scar may cause persistent gastralgia, and the probability that a cicatrix surrounding the Avhole or any part of the py4orus may cause obstruction at this orifice, folloAved by dilatation, must .be kept in remembrance. Carcinoma may7 develop in the floor of an old ulcer in subjects who, on account of a predisposition, furnish a suitable soil. Treatment.—The treatment of gastric ulcer embraces three lead- ing objects: (1) Of paramount importance is absolute rest for the stom- ach. This is to be accomplished by maintaining the recumbent posture in bed, on the one hand, and by rectal feeding, wholly or partly, on the other. This mode of alimentation vs ill be discussed presently. . Perfect rest constitutes the best-knoAvn safeguard against those serious accidents that intervene suddenly in the course of this affection. It also ensures more rapid cicatrization than any other single agent. The process of repair is very sIoav under the most favorable circumstances; hence the patient should be informed at the outset that from four to six months, at least, must be spent in bed. (2) The careful regulation of the diet. It is not possible for the stomach, when the seat of ulcer, to digest the normal amount of nitrogenous food Avithout being injuriously affected thereby. Those articles of diet should be employed that are digested and assimilated chiefly in the intestinal tract. But, though the patient is fed by the mouth, this should be supplemented by rectal feeding almost from the beginning. By7 pursuing this combined method and giving per rectum but a limited amount of albuminous food the vital forces can more effectually be supported. Failure to cure cases of gas- tric ulcer is often due to the fact that but little nourishment is supplied to the system, the patient's general strength being alloAved to become exhausted quite early. Frequently the stomach is so irritable as to render it exceedingly difficult to introduce into it even a fractional part of the amount of food necessary to support life properly ; arid in all cases that I have seen the amount of food that could be taken by the mouth was really inadequate, considering the dietetic requirements of the disease. Should nutrient enemata not be well borne, they may be discontinued until the unpleasant symptoms have subsided, and then resumed immediately. By giving only a portion of the food in this manner rectal feeding may be continued for a long period without dis- agreeable intestinal symptoms. The following dietary will be found use- ful: At 7 A. M. give 100 c.cm. (3iij) of Leube's beef-solution; at 11 a. m., 200 c.cm. (lyj) of pancreatized milk-gruel;l at 3 p. m., 200 c.cm. (3yj) of peptonized milk or skimmed milk or buttermilk ; and at 7 p. m., 200 c.cm. (§Arj) of pancreatized milk-gruel; in addition, the folloAving by rectal injection : at 8 A. m., 6 ounces of pancreatized milk-gruel, Avith \ ounce of bovinin and 10 drops of tincture of opium, this to be repeated at 2 p. M. and 8 p. m. If the nutrient enemata must be discontinued for a time, the 1 The milk-gruel is prepared with wheaten flour or arrowroot, mixed with an equal quantity of milk. 768 DISEASES OF THE DIGESTIVE SYSTEM. regular diet must be increased proportionately. If, on the other hand, the stomach rejects the above-mentioned food, then the feeding must be, for a time, exclusively rectal; this is quite practicable if the proper choice be made of nutrient preparations. In addition to the substances before mentioned we may employ from 4 to 6 ounces (150-200 c.cm.) of Leube's beef-solution, or the same amount of defibrinated blood or pan- creatized milk with brandy. DaCosta reported recently a number of instances that were cured by a diet of ice-cream. It has been recom- mended to employ lavage, when the stomach is exceedingly irritable, but the use of the stomach-tube is liable to damage the ulcer even in the most careful hands. The good effects from washing out the stom- ach for uncontrollable vomiting and pain have, however, been frequently witnessed. It may often be satisfactorily accomplished by the use, in- ternally, of 1 pint (^ liter) of warm water containing a few grains of sodium chlorid or bicarbonate, sipped slowly when the stomach is com- paratively empty. If at the expiration of two months the condition of the patient in- dicates that the reparative process is far advanced, then well-boiled rice, stale bread, and potatoes may be allowed; and later eggs, oysters, fish, and sago, the patient not being allowed to assume ordinary solid diet for at least six months. (3) The medicinal treatment, which is altogether subsidiary to the dietetic, has reference to two ends: (a) Promotion of the healing process. We cannot be certain that any remedial agents at our command can accomplish this object, and yet it is our duty to attempt it. Of the efficacy of alkaline remedies in this disease we are thoroughly convinced; in neutralizing the hyperacidity of the gastric secretions they fulfil an important indication, since the excess of HCl must have an unfavorable effect upon the ulcer. Of these, sodium bi- carbonate (in full doses) or the alkaline purgative mineral waters, as Carlsbad, Kissingen, Hunyadi Janos, are most useful. The Carls- bad salts are also highly beneficial. They may be prepared artificially as follows: sodium sulphate, 50 parts ; sodium bicarbonate, 6 parts; sodium chlorid, 3 parts—of which a teaspoonful may be taken in hot water, fasting, in the morning. The preparations of bismuth may be given in combination with antiseptics, which latter are especially to be recommended. Fleiner's method of giving 10 gm. of bismuth in 200 gm. of warm water on an empty stomach, and then allowing the patient to drink several swallows of water, and afterward placing him in the horizontal position with the hips elevated for about an hour, has yielded gratifying results. About 200 gm. of bismuth administered in the above manner usually suffice to effect a cure (Savelieff). Sil- ver nitrate has long enjoyed an enviable reputation in this disease. For the chronic gastric catarrh Avhich is very generally associated with ulcer, silver nitrate, as before stated, is most efficient, and may be com- bined with small doses of opium or hyoscyamus. The previous general condition of the patient is frequently unfavorable to the successful heal- ing of the ulcers, and to combat the anemia and chlorosis that are often present Ave may employ iron and arsenic. The albuminate of iron has been Avarmly recommended, and small doses of Fowler's solution of arsenic are generally well borne by the stomach; the former may also be given hypodermically. When organic cardiac diseases are concom- CARCINOMA OF THE STOMACH. 769 itants they should receive careful attention, and the recognition and treatment of all associated diseases must not be overlooked if the phy- sician Avould obtain good results. (b) The relief of urgent symptoms. The preceding measures re- lating to the diet and treatment, and particularly small doses of the extract of opium combined with silver nitrate, often relieve the pain. Mild counter-irritation is also of service, but warm poultices should not be employed if hematemesis be present in however slight a degree. The application of cold to the epigastrium in the form of an ice-bag some- times alleviates the pain, though quite as often it fails to benefit. For the severe gastralgic attacks morphin administered hypodermically, at varying intervals, is demanded. Gerhardt prescribes three or four drops of liquor ferri chloridi in a Avineglassful of Avater. Vomiting, Avhen not excessive, will be allayed by the use of the agents already mentioned, and bismuth, creasote, silver nitrate, and opium are especially useful; chipped ice, with a small amount of brandy throAvn over it, is also of value. When obstinate the following remedies, in small doses, may be tried separately : cerium oxalate, potassium bromid, tincture of iodin, cocain, chloral, and hydrocyanic acid. For the hematemesis the application of a broad, flat ice-bag, together with the use of ergot hypodermically, will usually suffice. If the signs of peritonitis due to perforation should develop, the measures to be promptly instituted are—opium to relieve the intense pain, saline purgatives in small doses and at short intervals until free purgation results, and the flat ice-bag locally. It would be well at the earliest moment to call a progressive surgeon to the case. CARCINOMA OP THE STOMACH. Pathology.—Next to the uterus, the stomach is the most favored seat of carcinoma. In a total of over 30,000 cases studied by Welch, 21.4 per cent, were found to show involvement of this organ. With refer- ence to the parts of the organ most frequently attacked, Welch analyzed 1300 cases with the following results: pyloric region, 791; lesser curva- ture, 148 ; cardia, 104 ; posterior Avail, 68 ; greater curvature, 34 ; ante- rior wall, 30; fundus, 19. The forms of gastric carcinoma noted are columnar epithelial (including colloid) and the glandular carcinomata (embracing encephaloid and scirrhous). The epitheliomata grow from the lining epithelium whilst the encephaloid and scirrhous are new growths from the glandular epithelium proper. The last two forms are therefore similar in structure, the differences possibly being due to variations in their growth (rapid in the encephaloid and slow in the scir- rhous variety), and to the consequent varying proportion between fibrous tissue and cells; the encephaloid cancers are thus soft, and readily break down on their surface, forming large ulcers that have a clean floor, while the scirrhous cancers are hard and firm. Columnar epitheliomata are frequent, and are situated at the pyloric end of the stomach, where the glands are formed of a single layer of columnar cells on a basement mem- 49 770 DISEASES OF THE DIGESTIVE SYSTEM. brane. They are often the seat of colloid degeneration. Squamous epi- theliomata occur only at the cardiac end, at the esophageal opening. All the varieties mentioned are prone to produce secondary new groAvths in adjacent organs, the scirrhous, however, manifesting a less marked tend- ency to metastasis than the others. They occur either as circumscribed tumors or as a diffuse infiltration, and in the immediate vicinity of the gastric carcinoma there is a marked thickening of the muscular coat and other tissue-elements. Etiology.—The factors bearing upon the etiology of gastric carcino- ma may all be regarded as predisposing causes. Of these age is the most potent. Of 2038 cases examined by Welch Avith reference to this point, 75 per cent, occurred between the fortieth and seventieth years, 24.5 per cent, between forty and fifty years, and 30.4 per cent. betAveen fifty and sixty years. It is an exceedingly rare affection in very young persons. Heredity stands next to age as a causal factor, though it is far less influ- ential. Welch analyzed 1744 cases, and found that a family history of car- cinoma Avas present in about 14 per cent. Sex has little if any influence. The extent to which gastric carcinoma is dependent upon previous disease of the stomach is not definitely determined, but in persons that are predis- posed to the affection by reason of age or heredity, the cicatrix of an old ulcer or a pre-existing chronic catarrh of the stomach may become addi- tional causative factors of no mean importance. Striimpell has called renewed attention to the probable relation between gastric ulcer and gas- tric carcinoma, citing in confirmation the interesting discovery by Hauser of atypical groAvths of epithelium in the scars of gastric ulcers. Schmidt also has recently found the same cell-degenerations around both cancerous and ulcerous growths. Clinical History.—Prior to the development of gastric carcinoma the symptoms of catarrhal dyspepsia may be present for a variable period of time. The onset is often, comparatively speaking, abrupt. It may, however, be insidious, and be marked more by the evidences of failing general health and strength than by distinct local subjective symptoms. Anorexia is commonly present, though occasionally the appetite re- mains unimpaired. A sense of oppression, rarely amounting to true cardialgia, and frequent eructations, come on soon after eating. In many cases but little pain is complained of, whilst in a lesser number pain is a prominent symptom throughout the entire course of the affec- tion. Its character is very often described as lancinating, less often as burning or gnawing; the latter form of pain is due, most probably, to associated and secondary ulcers. The pain is often referred to the shoulders and the back or loins. Vomiting is infrequent, excepting in the more advanced stages of the disease, when it is almost con- stantly present to a greater or less degree. During the early stages it is due to the catarrhal irritation, later to obstruction. When the latter is at the cardiac orifice, the pain occurs at once after eating; Avhen at the pylorus, it appears several hours after meals. Vomiting may also be caused by the occurrence of fermentation in large accumulations in the stomach. The vomitus has feAv, if any, of the physical characteristics noted in simple ulcer of the stomach. Free hematemesis is very rare; when, however, the surface of the new growth ulcerates, there is almost invariably an occasional sIoav oozing of blood into the stomach. It is CARCINOMA OF THE STOMACH. 771 here acted upon by the altered gastric juice, and the black hematin re- sulting from the transformation of the red hemoglobin gives rise to the well-known " coffee-ground " vomit of carcinoma of the stomach.1 It is to be recollected, in this connection, that the chocolate-colored appear- ance of the vomitus is not found alone in carcinoma of the stomach, but may also occur in non-malignant disease and under other abnormal con- ditions of the gastric contents. The chemical examination of the gastric contents is of prime diagnostic importance, showing as it does the almost constant absence of free HCl. Riegel has recently given emphasis to the fact that the presence of free HCl, supposing the examinations to be properly made (by the use of the color test) and sufficiently often re- peated, speaks almost positively against carcinoma. In not one of 154 artificial digestive experiments Avas albumin digested in this disease. Rare cases do, hoAvever, occur in Avhich free HCl is present, as when carcinoma of the stomach is secondary to an ulcer, the free acid in these conditions being usually increased. More important than the latter small class of cases are those instances, not of carcinoma of the stomach, in Avhich free HCl is absent; these are carcinoma of the esophagus, extensive amyloid disease, advanced cases of renal disease, and the febrile state. Riegel also noted the absence of free HCl in carcinoma of the duodenum. Two leading views are held concerning the cause of the failure to find HCl: (1) That it is due to inflammatory degeneration of the mucous membrane, commencing as a catarrhal inflammation and advancing to interstitial change and atrophy7 (Rosenheim's vieiv); (2) that the absence of the acid is due not so much to non-secretion as to its combination Avith some substance arising from the carcinoma (Riegel's vieiv). Lac- tic acid occurs in the stomach in carcinoma more often than in any other condition, owing to the presence of the tAvo essential conditions— an absence of the antifermentative (HCl) and the stagnation of food. The microscopic appearances of the Aromitus are in some Avays identical with those observed in gastric ulcer, and if it be examined speedily, red blood-corpuscles may rarely be seen. The microscope also, very occa- sionally, reveals pieces and bits of cancer-tissue, and Kaufmann, Ham- merschlag, and others emphasize the frequency of long bacilli. It has been claimed that sarcinse are present, but Oppler says that they never occur Avhen HCl is present, and Riegel says that they are very infre- quent. Chronic interstitial gastritis and atrophy of the mucosa may, among other conditions, shoAv symptoms in addition to the absence of HCl. Physical examination often discloses the presence of a tumor. In- spection may reveal an irregular tumor, particularly if the patient be much emaciated. When dilatation exists the outlines of the organ may be seen. On palpation the neAv groAvth, in a majority of cases, may be felt through the abdominal Avails, though often not clearly, as a hard, nodular, and sometimes movable mass. Though this generally appears in the epigastrium, it must be recollected that it depends upon the part 1 Teichmann's test for hematin crystals may be employed as follows: Place a drop of the" coffee-ground" material upon the slide and add a few crystals of sodium chlorid. Then introduce a few drops of acetic acid beneath the cover-glass, and on warming hema- tin crystals will form. 772 DISEASES OF THE DIGESTIVE SYSTEM. involved; also that a tumor united Avith the Avail of the stomach fre- quently changes the position of the organ ; hence the mass may be felt outside the normal boundaries of the stomach. The displacement is usually in the doAvmvard direction owing to dilatation, and the tumor may be found on a level with the umbilicus or even lower still. Less frequently, on account of its mobility, it is discovered in such unlooked- for situations as the right or left hypochondriac region. The varying degree of fulness of the stomach will obviously alter the position of the tumor. When situated at the cardia it is beyond reach of palpation; when attached to the lesser curvature of the stomach or the posterior wall, it is rarely to be felt unless it be of large size. The new groAvth cannot be definitely made out Avhen it assumes the form of a diffuse in- filtration, though it offers increased resistance to the palpating fingers and exhibits more or less tenderness on pressure. Usually the patient lies in the dorsal decubitus during the examination, with the limbs drawn up, being instructed at the same time to breathe regularly Avhile opening the mouth. The detection of a tumor Avhen in an unfavorable situation may be facilitated by shifting the patient's position from the dorsal to the lateral, the standing, or the knee-elbow position respect- ively ; at the same time one or two tumblers of some carbonated Avater should be given, with a view to distending the stomach and bringing the tumor within reach. Pulsations are frequently communicated from the aorta to the palpating hand through the tumor. If the growth is situated at the lesser curvature, a deep inspiration will often cause the tumor to fall lower, and thus become accessible to palpation. Percussion over the seat of the new growth causes a muffled tympanitic resonance; superficial percussion, hoAvever, frequently gives absolute dulness. The presence of metastatic new groAvths in the liver and enlarge- ments of the supraclavicular or inguinal lymph-glands are of value in the diagnosis. In one instance that I saAv in the Philadelphia Hospital a nodule the size of a walnut protruded from the umbilicus, leading to the suspicion that gastric carcinoma might be present, though the gen- eral symptoms pointed strongly to chronic gastric catarrh at the time. Subsequently, however, a round and someAvhat nodulated mass, situated near the pyloric end of the stomach, could be readily grasped. In sev- eral instances in which the lymph-glands in the groins and the supra- clavicular spaces Avere the seat of enlargement a probable diagnosis of abdominal carcinoma was made in the absence of positive symptoms and physical signs, and the diagnosis was borne out at the autopsies. General Symptoms.—Quite early in the disease such evidences of gen- eral nutritional disturbance as loss of flesh and anemia may be observed, and, obviously, cases attended Avith constant anorexia and vomiting will earliest manifest the Avasting processes. Almost from the beginning the face gradually assumes the cachectic appearance which, in the advanced stages, becomes so characteristic of gastric carcinoma. Anemia soon becomes a prominent feature. There is a Avaxy pallor of countenance, and the cerebral symptoms, as Avell as the peculiar cardiac murmurs of anemia appear. The blood frequently presents peculiarities that bear a resemblance to those seen in pernicious anemia, and sometimes there is a marked poikilocytosis. Welch has recorded an instance in which the ratio of Avhite to red blood-corpuscles was 1 to 20, but the blood-count CARCINOMA OF THE STOMACH. 773 and the estimation of hemoglobin rarely show the marked reduction in the number of corpuscles that is seen in progressive pernicious anemia; leukocytosis is also much more frequent. There is an absence of a post- digestive increase in the number of leukocytes in carcinoma that does not occur in other gastric diseases. " When any degree of anemia is presented nucleated red corpuscles may be found in dry and stained specimens, and this method of examination may be of much service Avhen an actual blood-count is impossible. The condition is, hoAvever, an anemia with Avasting, and the layer of panniculus is not retained as in the ordinary forms of pernicious anemia" (Osier). The causes of the profound anemia met Avith in this affection are not quite plain, since frequently it becomes pronounced before the nutritional disturbances (shoAvn by a loss of flesh) have become marked. The fact that metastatic cancer has been found to be abundant in the marrow of the bones is significant in this connection, as pointing to the probable interference, in some instances, with the blood-producing function of the bone-marrow. In advanced cases moderate edema of the ankles and of the backs of the hands is frequently observed, and is probably dependent upon excessive anemia. The temperature at first shows no abnormalities, as a rule, though after the cachexia has become decided it is often subnormal. Sudden elevations of temperature (103° to 104° F.—40° C), preceded by rigors and folloAved by profuse SAveating, are rarely observed. The explanation of their occurrence is to be found in the fact that suppura- tion sometimes takes place in the bases of the cancerous ulcers. The mind almost invariably remains clear to the last, though delirium may occur near the close. Complications.—Intestinal symptoms are frequently observed, and constipation in particular is quite common. It is apt to alternate Avith diarrhea toward the close of the disease, or diarrhea may in the later stages become a permanent and obstinate symptom. Some of the com- plicating conditions have reference to the secondary neAV growths. When, as frequently happens, the liver is implicated, jaundice is not uncommon, being associated with signs of hepatic enlargement. In- deed, so prominent may be the symptoms and physical signs referable to secondary carcinoma of the liver as to entirely mask the more or less latent forms of carcinoma of the stomach. The mesenteric and retro- peritoneal lymph-glands or the lungs may be the seat of secondary car- cinoma, though in these situations it rarely gives rise to characteristic symptoms. Occasionally the new growths spread to the peritoneum and sometimes give rise to ascites. As has been stated under Pathology, per- foration may rarely occur, and we then have the pronounced and rapidly supervening symptoms of diffuse peritonitis. Fistulous communications between the stomach and the transverse colon or the small intestine— the latter rarely—may also occur. Nervous symptoms may be regarded as complicating conditions, and sometimes hasten the fatal termination; the patient becomes somnolent or, rarely, even comatose ; the breath- ing is difficult and the respiration deep and labored. This mode of termination I noted in one of my own cases. Traces of albumin, and in the later stages tube-casts, may be present in the urine. An in- creased quantity of indican has frequently been noted; acetone and dia- cetic acid are present in rare instances. 774 DISEASES OF THE DIGESTIVE SYSTEM. Atypical Forms.—The disease rarely is entirely latent, and most often in persons previously much enfeebled and in the aged. In other instances the more prominent above-mentioned symptoms, and particu- larly the characteristic pain, are lacking; hence it frequently happens that the presence of cancerous tumors in the stomach is not suspected until accidentally discovered, the symptoms being attributed to less grave conditions. In still other instances the development of a pro- nounced anemia and of the cancerous cachexia alone furnish ground for suspicion; when these are associated with dyspeptic symptoms, hoAv- ever slight, they should lead to a careful physical examination of the stomach as well as a chemical examination of its contents. General Course and Duration.—The course of gastric carcinoma is invariably toward a fatal issue, death usually taking place before the expiration of tAvo years. The average duration of the disease probably does not exceed one year. According to my own observation, when it occurs in emaciated persons it pursues a slower course than when occurring in apparently robust and fleshy individuals. No case of re- covery from carcinoma of the stomach is recorded. Diagnosis.—A positive diagnosis of gastric carcinoma is easily made when a tumor is demonstrable. It is, hoAvever, possible to diag- nosticate the disease in the absence of a palpable new growth. The history, the presence of such characteristic symptoms as pain, coffee- ground vomit, the existence of dilatation of stomach, the constant absence of free hydrochloric acid, the constant presence of lactic acid after the Boas test-meal,—all occurring in an elderly person, together with marked anemia and emaciation, are sufficient to Avarrant a diag- nosis. It is needful, however, to exclude the diseases other than gastric carcinoma in Avhich the absence of free hydrochloric acid has been noted. If these points be carefully considered, there are few instances in Avhich the diagnosis cannot be made with reasonable certainty. Of course all corroborative evidence must also be taken into account. Differential Diagnosis.—A gastric carcinoma presenting a discernible mass is liable to be mistaken for a cicatrized ulcer, for carcinoma of the pancreas, of the tranverse colon, duodenum, omentum, and the left lobe of the liver, as well as for aneurysm of the abdominal aorta. The aneur- ysmal tumor, however, is smooth, and is not nodular like the cancer- ous growth; moreover, it gives rise to an expansile impulse, and not to the heaving impulse of a solid growth. In aneurysm the characteristic gastric symptoms, the peculiar cachexia, emaciation, and marked ane- mia that belong to carcinoma are wanting. In pancreatic carcinoma the tumor is ahvays fixed; there is an absence of the coffee-ground appear- ance of the vomit and of dilatation, and free HCl is present in the gas- tric contents. Further than this, fat may be present in the stools and sugar and fat in the urine. Carcinoma of the transverse colon and omen- tum will be excluded by the presence of such significant symptoms as gastric hemorrhage and the consequent hematemesis, by a chocolate- colored appearance of the vomitus, and the permanent absence of HCl. In this connection tAvo facts should be re-stated : (1) That in carcinoma of the duodenum free HCl has been found to be absent from the gastric contents ; (2) that in carcinoma following gastric ulcer free HCl may rarely be present. The points of difference between carcinoma of the CARCINOMA OF THE STOMACH. 775 stomach and of the left lobe of the liver will be referred to under the latter head. Simple round ulcer of the stomach may in cicatrizing give rise to a small tumor, followed by pyloric stenosis and secondary dilatation—an exact counterpart of the course of gastric carcinoma. Under such cir- cumstances the clinical picture is at first apparently identical with that of pyloric carcinoma, though it presents a feAv distinguishing features. Great reliance should be placed on the age of the patient, the presence of HCl in the gastric secretions, the grave gastric disturbances Avith hematemesis, together with the longer duration of ulcer (more than two or three years), Avhich is almost pathognomonic of the latter disease. Simple gastric ulcer and chronic gastritis are often confounded with carcinoma of the stomach. The facts of greatest value in the discrimi- nation of these three affections are so well presented by DaCosta that they are, in the main, here subjoined: Chronic Gastritis. Not confined to any age. More common in middle- aged or elderly people. Pain at the epigastrium somewhat augmented by food; soreness is also present. Both are con- stant, although compar- atively slight. Symptoms of indigestion marked. Sometimes vomiting. No hemorrhage, or but tri- fling hemorrhage; at most blood-streaks in vomited matter. Bowels constipated. Xo fever. Not much emaciation; no cachectic appearance. Disease may be relieved or cured; is often of very long duration. Gastric Ulcer. May occur in middle-aged persons, but is most fre- quent in young adults, especially women. Pain at the epigastrium much augmented by food ; subsides when this is digested : paroxysms of pain, not lancinating ; strictly localized soreness to touch in epigastrium ; sometimes a painful spot over lower dorsal verte- brae. Intermissions in the pain of considerable length are frequent. Symptoms of indigestion sometimes very slight. Vomiting may be present or absent. Abundant hemorrhage from the stomach com- Bowels may or may not be constipated; usually are. No fever. Frequently extreme pallor and debility. Duration uncertain; may get well, may run on rapidly to perforation; on the other hand, may last for years. Gastric Carcinoma. Most common in elderly people; rarely occurs in persons under forty years of age. Pain frequently of a radi- ating kind, often parox- ysmal, not infrequently severe and lancinating, but not of necessity asso- ciated with soreness. Lit- tle or not at all affected by food, ^ain rarely remits ; ne\7er intermits for any considerable time. Symptoms of indigestion marked. Anorexia; ex- treme acidity of stomach. Vomiting a very frequent symptom. Hemorrhage not very abun- dant, but frequently oc- casioning coffee-ground- looking vomit. Bowels obstinately consti- pated. Intercurrent attacks of slight fever may occur; but temperature often subnormal. Gradual and progressive loss of flesh, and debility; and at times, with the cachexia, hypertrophy of the peripheral lymphatic glands, especially above the clavicles. Average duration one year; may be shorter, but sel- dom longer. 776 DISEASES OF THE DIGESTIVE SYSTEM. No tumor. Rarely a tumor. Generally a tumor. Contents of stomach al- Hydrochloric acid in excess No hydrochloric acid in most always contain free in contents of stomach. contents of stomach. hydrochloric acid. No dropsy. No dropsy. Edema of ankles often met with. No lactic or fatty acids after No lactic or fatty acids after Lactic acid present after the rigid Boas test-meal. the rigid Boas test-meal. Boas's test-meal. Treatment.—The diet should receive careful attention, and it Avill be necessary to adapt it to the peculiarities of the individual case. In general terms, articles of food that are digested and assimilated in the intestines should be employed. After well-marked evidences of pyloric obstruction appear Ave may add greatly to the comfort of the patient by limiting the dietary to liquids, and by predigesting them if they are not otherwise well borne. Should the stomach reject all food, rectal alimen- tation should be promptly instituted. The medicinal treatment of gas- tric carcinoma is altogether symptomatic, no remedy with any poAver over the lesion having been found. The more troublesome symptoms —namely, pain, vomiting, and constipation—are to be met on general principles. Should free hematemesis occur, it should be treated as pre- viously indicated under Gastric LUcer. The claims that have been ad- vanced in favor of arsenic and other preparations as possessing poAver to control the progress of gastric carcinoma have not been confirmed by any extended experience. If dilatation coexists, it is to be managed in accordance with the recommendations found under that heading. Sur- gical treatment may also be called into service. HEMATEMESIS. Hematemesis is a symptom that occurs in widely different diseases and conditions. Inasmuch as it is due to various causes in diseases other than those of the stomach, it is hardly to be properly classed among gas- tric affections, and, at all events, is not entitled to more than a brief separate description. Etiology.—Among the causes of hematemesis are—1. Injury to the stomach; 2. Diseases of its coats (carcinoma and ulcer); 3. A me- chanical impediment to the portal circulation; 4. Vicarious menstruation; 5. Alterations in the blood; 6. A disease of some neighboring organ, such as carcinoma of the pancreas, may perforate the gastric coats and open its vessels. Symptoms and Diagnosis.—If the fact that it is always a symp- tom, and not the disease itself, be recollected, the importance of recogniz- ing its special causal condition in each instance will be obvious. The manner of its occurrence and the characteristics presented by the blood often give a clue to its nature and origin. Thus, we have seen that the clinical signs in hematemesis due to carcinoma and ulcer of the stomach vary greatly, being almost peculiar to each. This fact must, however, be weighed with the history and symptoms of the case in which it may occur; in this manner, and in this manner only, can errors be avoided. A process of exclusion is the best way to reach a decision. If a careful inquiry determines the absence of morbid lesions of the stomach, such as NEUROSES OF THE STOMACH. 777 carcinoma, ulcer, or chronic gastritis, then the other organs of the abdo- men, and more particularly the liver, must be examined. If this and the heart be found to be healthy, attention should then be turned toward the state of the blood, since the presence of any specific fever may readily account for the hematemesis. Should the blood present nothing abnor- mal, it may be found that the menstrual or other habitual discharge has become suppressed. Differential Diagnosis.—It is to be recollected that the source of the blood may be other than the stomach. Rarely, an abdominal aneurysm bursts into the stomach ; occasionally, too, a thoracic aneurysm opens into the esophagus, whence the blood speedily finds its way into the stomach. A careful consideration of the history and of the attending symptoms, together with a thorough physical examination, will, after excluding the various conditions causing true gastric hemorrhage, lead to a correct inter- pretation of the phenomena. Blood coming from the throat, tonsils, mouth, or the respiratory organs, including the nose, is sometimes swal- lowed, and aftenvard ejected by vomiting. To discriminate from this condition it is only necessary to make an examination of the lungs and elicit most carefully the history. It must also be recollected that hys- teric females and malingerers have been known to SAvallow the blood of animals and other dark fluids, and vomit them subsequently. The vom- itus may resemble dark blood in appearance when stained by bile or iron or after a free indulgence in wine. The diagnosis between hematemesis and hemoptysis is sometimes attended with difficulty, and the points of contrast have therefore been placed side by side in the following table: Hematemesis. Hemoptysis. The history points to gastric, splenic, he- History of cough and other symptoms patic, or cardiac disease. points to pulmonary or cardiac disease. A feeling of uneasiness, and sometimes A feeling of weight and uneasiness in of nausea or faintness, precedes the the chest, a saline taste, and a tickling hemorrhage. in the throat precede the hemorrhage. The blood is ejected by vomiting; violent The blood is raised by coughing, though, vomiting may excite cough. if it be swallowed, vomiting may follow. The blood is either clotted or fluid and The blood is bright-red, frothy, in small dark; it may be mingled with rem- coagula, and alkaline in reaction. nants of food, and is acid in reaction. Prognosis.—Hematemesis, except it be due to rupture of an aneur- ysm, rarely presents a hopeless prognosis. In cases of splenic enlarge- ment, hepatic cirrhosis, or gastric ulcer it may prove fatal, either as the direct consequence of loss of blood or more gradually as the result of anemia and debility, induced by the bleeding. The treatment has been detailed in the discussion of Gastric Ulcer. NEUROSES OF THE STOMACH. NERVOUS DYSPEPSIA. Definition.—A functional disorder of the stomach, usually charac- terized by regularly (and sometimes irregularly) recurring attacks of gastric disturbance, followed by almost complete freedom from symptoms. The explanation of the symptoms is found in the well-knoAvn effect of 778 DISEASES OF THE DIGESTIVE SYSTEM. certain nervous influences upon the digestive function, and the term ner- vous dyspepsia embraces all the forms of gastric neuroses to be hereafter described. There are no local lesions detectable. Etiology.—The vast majority of cases occur in highly emotional and hysteric persons, under such exciting conditions as great anxiety, violent passion, anticipation of pleasure; in short, any startling news or sudden excitement may cause it. The condition is most commonly met with in healthy-looking, ruddy-cheeked subjects, though it may also occur in the weak and pale-faced. The symptoms follow immediately upon the action of the exciting cause. A small percentage of instances are due to hypochondriasis. Symptoms.—In the ordinary form the gastric secretions are normal, and the stomach is found empty after a test-meal within the physiologic time- limit. There is anorexia, which occasionally alternates with a voracious appetite. After meals the patient complains of distress and oppression in the epigastrium; eructations, and an occasional regurgitation of the acid liquid or solid contents of the stomach, with heartburn, will also be noted. Vomiting is not rare, and occurs independently both of the time of eating and of the character of the food. Gastric peristalsis is some- times so well marked as to be readily felt and even visible through the stomach-Avail. Kussmaul has called special attention to this symptom, which, I believe, belongs largely to nervous dyspepsia, though I shall refer to it separately under the designation of peristaltic unrest (vide p. 782). In every instance it is dependent upon the excitement of sensibility. The increased peristaltic waves, especially under emotion, excite cooing, gurg- ling sounds that are a source of great annoyance to the patient. Peri- stalsis, in which the movement occurs from right to left, has also been observed, and under these circumstances fecal vomiting may occur. The physical examination sometimes reveals abdominal distention and hyperesthesia of the surface, but no localized tenderness, pressure with the broad hand usually affording relief from pain. Nervous phenomena always exist, and their correct interpretation is of the utmost importance in the diagnosis. The presence of headache, vertigo, numbness, should be noted, and also a coolness of the extremities during the exacerbations to which the disease is liable. The mental condition is unstable and illy regulated, and this fact furnishes a satisfactory explanation of the opera- tion of the etiologic factors. The general health is in many instances not noticeably impaired; in others, particularly in those subject to frequent vomiting and complete anorexia, the general nutrition suffers considerably. Complications.—The bowels are often constipated, are apt to be distended with gas, and may be the seat of an abnormal peristalsis that is transmitted directly from the stomach. Nervous dyspepsia with hypochondriasis forms a group of cases in which the hypochondriasis may sustain a causal relation; it may be sec- ondary to the gastric disturbances, however. In either event it is apt to become pronounced after the gastric symptoms have lasted a long time. The symptoms other than the nervous phenomena are quite similar to those previously described. Diagnosis.—The course of nervous dyspepsia, in all of its clinical varieties, is chronic, and it not infrequently terminates in chronic catarrh of the stomach. The diagnosis is based on the following points: (a) The NEUROSES OF THE STOMACH. 779 etiologic factors. Here it is important to ascertain the particular mental influence that produces the gastric symptoms, taking also into considera- tion any well-recognized predisposing causes, (b) The course of the com- plaint and the absence of some of the physical signs and symptoms that Avould point positively to anatomic lesions of the stomach. When there is a catarrhal process, the symptoms become more pronounced immediately after taking food; this is not so, however, in the disease under considera- tion. The influence of the ingestion of indigestible substances upon sym- pathetic dyspepsia is often to relieve, or is of neutral effect, whereas in catarrhal indigestion it decidedly aggravates the condition. The dull pain after eating and the tenderness on pressure are usually more marked in the catarrhal variety than in the nervous type. The symptoms of the latter intermit from time to time, while they are more constantly present in chronic catarrh. The analysis of the contents of the stomach by means of the stomach-tube will also assist in the diagnosis. The gastric contents in cases of nervous dyspepsia are usually about normal, though any ab- normality (even to complete achlorhydria) may occasionally be present. Prognosis.—If there be an absence of any inherited predisposition, and if the cause is removable, complete recovery may be prognosticated. In a neurotic constitution, however, the tendency to recurrence, even after a decided improvement has taken place, is very strong. The most un- promising cases are those in which the causative mental influences are irremovable, though as to life the prognosis is not unfavorable. The patient himself is always of the opinion that he is suffering from a serious and incurable affection. Treatment.—Every causal factor must be recognized and removed if possible. If we fail to accomplish this end, our efforts at cure will be unsuccessful. The dietary should be generous and composed of highly nutritious articles of food, and to convince the patient that his stomach is capable of digesting a full meal is the first duty7 of the physician, though the task is confessedly difficult. So soon as the patient realizes the truth in reference to his digestive capacity his sufferings are largely at an end. It is the nervous system that demands especial attention, and the internal treatment of the stomach is merely placeboic. Nerve-tonics combined with nerve-stimulants are often serviceable, and the following prescription will be found to be adapted to a certain proportion of cases: Ify. Quininse valerianate Zinci valerianat., Ext. sumbul, aa. gr. xxx (2.0); Strychninse sulphat., gr. j (0.0648). M. et ft. pil. No. xxx. Sig. One after each meal. Should the patient be anemic, iron and arsenic should be added to the above pill. A change of air from the city to the country, the moun- tains, or the sea-coast is usually followed by improvement. In some manner the patient must be extricated from the old surroundings under the influence of which the disease was started and has continued. Sea air has seemed to me to be more serviceable than mountain air in these cases, though I believe it to be an axiom in climatic therapeutics that the latter confers more lasting benefits than the former. These patients are 780 DISEASES OF THE DIGESTIVE SYSTEM. often averse to taking exercise, but so great is the value of this sanitary measure that it should never be overlooked. Walking and the lighter gymnastics are especially useful. Cold sponging of the surface, followed by friction to the skin, should be practised daily for its effect upon the skin-circulation and the nervous system. Occasional lavage, hot and cold douches, electricity (intra- and extra-gastric), and gastric massage, may all be tried, and may prove of distinct advantage. In highly neurotic and hysteric females, as well as in those in whom nervous vomiting is a prominent symptom, the S. Weir Mitchell treatment is often attended with good results. The hypochondriac form is often intractable. Strych- nin, however, if perseveringly used, and if coupled with a change of air, often proves beneficial. One of the most obstinate examples of this nature that I have ever seen occurred in a retired merchant living in Philadel- phia. This man was finally cured in consequence of his own suggestion, resulting in his removal to the country and engaging in farming on a small scale. NEUROSES OF SECRETION. HYPERCHLORHYDRIA. (Hyperacidity.) Definition.—An augmentation of the secretory function of the stomach during the digestive period, resulting in the presence of an ex- cessive amount of hydrochloric acid. Htiology.—Hyperacidity is common during digestion, and its cessa- tion in most instances is due to some one of the psychologic influences men- tioned under Nervous Dyspepsia (grief, great anxiety). Less frequently, it is induced by mental over-taxation, and it is often met with among the professional classes. Highly-seasoned foods and alcoholic stimulants may sometimes occasion the condition. Symptoms.—Hyperchlorhydria may be continuous, though more often it is discontinuous and lasts from a few hours to several days. After the periodic form has lasted a long time it may gradually become a permanent condition. The patient at first complains of uneasiness in the epigastrium one or two hours after meals. Later, this amounts to pain of moderate intensity, and soon folloAvs every meal after a like interval. The duration of the pain is from one to three hours. Acid eructations are frequently noted. The increase of hydrochloric acid interferes with the digestion of starches, and thus tends to increase the pain. On the other hand, hoAvever, a diet composed of albuminoids often affords relief, and the salts of the alkalies also ease the pain. Associated nervous symptoms (headache, dizziness) are often observed, though the bodily nutrition is usually well maintained. Palpation of the epigastrium may show a diffused tenderness. Evidences of moderate dilatation of the stomach sometimes appear, and splashing sounds may be detectable. Diagnosis.—Though the diagnosis of hyperacidity is made probable by the above-mentioned symptoms, it is rendered certain only by a re- peated analysis of the gastric contents. The findings, according to Ein- horn, are—(1) On examination of the stomach in the fasting condition, the organ either is found empty or contains only a few cubic centimeters of juice; (2) one hour after Ewald's test-breakfast the hyperacidity is greatly increased, owing to the great amount of free HCl. NEUROSES OF SECRETION. 781 Gastric ulcer must be eliminated. In this disease the pain is aggra- vated immediately after eating, and is not relieved by albuminous food, nor by large doses of alkalies as in hyperchlorhydria. In ulcer, more- over, the pain often leads to vomiting, and severe, painful attacks fre- quently occur at night. Gastro-succorrhcea (Reichmann); Gastroxynsis (Rossbach).—In this affection there is an increase of hydrochloric acid, either constantly or intermittently, Avhen no food is present. An epigastric gnaAving pain and nausea appear in the full bloom of health. The nausea soon results in the vomiting of enormous quantities of gastric contents. The appetite is lost, but the thirst is excessive, and the amount of drink taken and of liquid vomited are proportional. During the night or in the early morning hours the patient commonly vomits large amounts of a clear or bile-tinted liquid containing hydrochloric acid and the gastric ferments in excess. This may be folloAved by persistent vom- iting, attended with much retching. After a lapse of a few hours the ejection of a large quantity of highly acid liquid may be repeated. The pain often becomes intense, headache is common, and a tendency to col- lapse is usually marked. The attacks last, as a rule, about two or three days, when they quite abruptly give place to apparent good health. Recurrence at the end of periods ranging from a few months to a year or more are common. The diagnosis is made upon the presence of the clinical symptoms and course, as well as upon the results of oft-repeated analyses of the vomitus. Gastric ulcer and certain organic spinal and cerebral nervous affections, in which there is excessive gastric secretion, must be excluded before an absolute diagnosis can be made. Gastro-succorrhcea Continua Chronica.—Reichmann first described a condition characterized by a constant secretion of gastric juice, either in the absence or presence of food. The symptoms are much the same as those in hyperacidity, but tend to become continuous, so that the vomiting finally becomes a daily occurrence. In the fasting state a highly acid secretion that contains no food-particles flows through the tube from the stomach. Albuminoids are rapidly and starches sloAvly digested by these patients, as is shoAvn by an examination of the gas- tric contents three or four hours after the Leube-Riegel's test-meal (one plate of soup—400 c.c.—a large portion of meat, some potatoes, and a roll). The disease is quite rare, and must not be confounded with the organic diseases to which continuous gastric succorrhea may be second- ary and upon which it is dependent. Indeed, Schreiber, Boas, and others believe that this is almost always a symptom of gastric atony or gastric ulcer. Leube has described a neurosis in which there is a constant sub- acidity of the secretion. During the digestive process the percentage of hydrochloric acid is low. I believe this condition to be rare as a pure neurosis; it is, hoAvever, of frequent occurrence as a symptom of such organic gastric affections as chronic catarrh and the like. The prognosis in the foregoing affections is not bad as to life, and not infrequently a cure, even, can be effected. Treatment.—The dietary embraces only nitrogenous articles of food, while the medicinal treatment should, in addition to meeting the general 782 DISEASES OF THE DIGESTIVE SYSTEM. neurotic condition, consist of full doses of sodium bicarbonate. Lavage daily, before the chief meal, is also sometimes beneficial. NEUROSES OP MOTILITY. INCREASED PERISTALSIS OF THE STOMACH. Gastric peristalsis is increased in various conditions, which will be considered seriatim, though briefly. (a) Belching and Eructations.—These may be of nervous origin, and are met with generally in hysteric subjects, and less frequently in neurasthenics. The air is swallowed, and then expelled Avith more or less noise, owing to an increased contractility of the stomach. The gas is odorless, and differs in this point from the gases of fermentative dys- pepsia. Epigastric distress and distention often arise, and certain nervous phenomena, as anxiety or palpitation, may coexist. It must not be forgotten, moreover, that in hysteric subjects the belching may be from the esophagus alone. (b) Pyrosis means regurgitation of the acid contents of the stomach into the esophagus and mouth, causing intense burning sensations. The stomach-contents are not necessarily hyperacid. (c) Rumination (Merycism).—A rare affection in Avhich the food is re- gurgitated into the mouth, the cud chewed, and again swallowed after the fashion of ruminants. (d) Nervous Vomiting.—This is a reflex neurosis that may affect persons of any age, though most frequently it is seen in adult females with an hysteric tendency. Without previous nausea, and independ- ently of the character of the food taken, the contents of the stomach are readily expelled or, more correctly speaking, regurgitated into the mouth, and then expectorated. Though this usually takes place after meals, it may occur Avithout reference to meal-time—a feature that indi- cates its nervous origin. The attacks of vomiting are separated by longer or shorter intervals of excellent health. Periodic vomiting may also occur independently of hysteria or other nervous affections, as pointed out by Leube. The course is rarely unfavorable, though exceptional instances have proved fatal. (e) Peristaltic unrest (Kussmaul), or spasm of the stomach, has been referred to under Nervous Dyspepsia. It has also been observed in com- pensatory hypertrophy of the stomach-wrall following pyloric stricture. In a case of gastric carcinoma in my own care the supermotility of the stomach caused an almost immediate expulsion of the gastric contents, and even of the rigid test-meal at certain times. Treatment.—To the regimenal management, including a hygienic mode of living, the attention of the physician should be primarily di- rected. The medicinal treatment is to be aimed at the causal or primary nervous affection. The valerianates and the bromids (the latter continued over a period of two or three months) often do good service. DIMINISHED PERISTALSIS OF THE STOMACH. (Atony.) (a) Pyloric Relaxation or Incompetency.—This is a rare neurosis that allows the partially digested gastric contents to pass the portals of the NEUROSES OF SENSATION. 783 stomach prematurely. It likewise permits the regurgitation of the con- tents of the duodenum into the stomach. Its recognition is possible upon inflating the stomach, when gas may be seen to pass into the intestines, and also (even Avith greater certainty) upon the regurgitation of intestinal contents into the stomach. (b) Cardiac Relaxation.—This condition leads to eructations and re- gurgitations, and when these are of aggravated form they impair the general nutrition. Ordinarily this state of affairs runs for years without marked ill-effects. (c) Atonic Dyspepsia (Atony).—This may occur as a neurosis, though oftener it is secondary to chronic gastritis. It implies hypomotility or insufficiency. The chyme is retained in the stomach beyond the natural time-limit. There is an epigastric oppression with a distention of the organ during digestion that tends to become permanent. There are eruc- tations of gas, an impaired appetite, and often constipation. The stom- ach is found empty in the morning, and six or seven hours after Leube's test-meal it contains some chyme. In the absence of pyloric stricture the hypomotility may be shoAvn by the administration of salol (see Methods of Diagnosis). Treatment.—The diet is to be regulated as in chronic gastric catarrh. It is rarely necessary to restrict the solids to the same extent as in the latter affection, but the quantity of fluids should be lessened. The patient must be taught to eat slowly and masticate thoroughly. His hygienic standard of living must be high, and he must not be allowed to over-use his mental faculties. Exercise in the open air and cold baths, properly regulated, are potent for good. Of medicines, strychnin stands first, and I have found the following formula of great service: Rj. Tr. nucis vomicae, feijss (10.0); Inf. cascarillse, q. s. ad f^iv (128.0).—M. Sig. 3ij (8.0) three times daily. Electricity is also indicated, and it is in these cases that intragastric faradization has given excellent results. The constipation is to be over- come by an appropriate dietary (green vegetables, Graham bread, an abundance of fruit). The fluid extract of cascara sagrada may be em- ployed if dietetic means fail. NEUROSES OF SENSATION. CARDIALGIA. (Gastralgia; Gastrodynia) Definition.—Severe paroxysmal pain in the epigastrium in the ab- sence of gastric lesions. There are two other forms of this disease that are clinically identical with gastralgia, the one occurring in ulcer and carcinoma of the stomach, and the other in certain chronic nervous diseases, forming the so-called gastric crises, Avhich Avill be considered hereafter. Etiology.—There may be a history of an inherited predisposition to neuroses of various sorts. Such conditions as anemia, exhaustion from 784 DISEASES OF THE DIGESTIVE SYSTEM. repeated hemorrhages, excessive venery, and lack of nourishment also predispose to this affection. The female sex is more liable than the male, and in the former it appears to be dependent upon disturbances of the menstrual function or quite frequently upon hysteric conditions. It is sometimes excited, in those predisposed, by reflex irritation, by deep grief, worry, and great anxiety. Hypochondriasis and hyperacidity are also among its frequent causes. Symptoms.—These are sudden in their onset as a rule, and quite characteristic. Occasionally the attack is preceded by anorexia, or it may begin with a sense of oppression and distention in the epigastrium, lasting for a few minutes. In any event, the onset of the attack proper is marked by agonizing pains in the epigastrium, that dart through to the back, and at times also pass around the lower ribs. The seizure lasts from a feAv minutes to an hour or two, and terminates with eructations of gas, or, less frequently, with vomiting. From the nature of the causative factors it is obvious that the gastralgic seizures are in no wise dependent upon the character of the food taken ; hence the fact that they occur more frequently when the stomach is empty need occasion no surprise. Firm pressure over the epigastrium relieves the pain. Nervous phenomena, varying with the etiology of individual cases, are constant attendants, but cannot be detailed here. A distinct clinical variety is found associated with that form of nervous dyspepsia in which an excess of acid is secreted (vide Hypersecretion); this occurs at varying intervals. Many purely functional nervous disturbances are thus subject to the law of periodicity. I believe that a very small percentage of cases are caused by malaria, since I have met with two such cases in a distinctly malarial district, both of which yielded readily to quinin. The disease took on a des- ultory, periodic character, and was associated with other malarial symptoms. Diagnosis.—The history, together with the characteristic symptoms of the gastralgic attacks and their time of occurrence, and also the ab- sence of any local causes, will render a positive diagnosis easy in most in- stances. To discriminate this condition from gastric ulcer is sometimes difficult, but stress has been laid upon the differential points in the description of the latter condition. Prognosis.—This depends entirely upon the causal condition. The disease itself has no intrinsic fatal tendency. Treatment.—This is to be subdivided into (a) the treatment of the attack ; (b) the management of the intervals between the seizures. The pain is, as a rule, sufficiently intense to demand morphin, which is best administered hypodermically in combination with atropin. This should not, however, be repeated unless urgently needed. In mild attacks the constant or the faradic current often affords prompt relief. Under these circumstances counter-irritation, together with the use internally of Hoffman's anodyne or chloroform in small doses oft repeated, sometimes suffices to relieve the pain. (b) The Management of the Intervals.—Here the physician's efforts should be directed to the detection of the causes and their removal by ap- propriate means. In hysteric females I have obtained good results from the prolonged use of the valerianates, combining with them iron and arsenic, thus: HYPERESTHESIA OF THE STOMACH—ANOREXIA. 785 R^. Zinci valerianat., gr. xviij (1.16); Quininse valerianat., gr. xxvij (1.74); Ferri arseniat., gr. ij (0.129). M. et ft. pil. No. xviij. Sig. One after each meal. A change of air is often highly serviceable, and should be advised whenever financial considerations permit. These patients are constantly in a more or less exhausted, anemic, and run-down condition, and a tonic plan of treatment is always indicated. The return of the attacks in ma- larial gastralgia may be prevented by the timely use of quinin and arsenic. In the intervals between the attacks digestion, as before stated, proceeds normally, and the stomach therefore requires no treatment. Constipation, if present, is a condition demanding relief, not, however, by the use of purgatives, but by such means as massage, a suitable diet, enemata, or laxative suppositories. The physician must so regulate the sanitary par- ticulars of the patient's daily life as to put him in the best possible con- dition to improve the general nutritive processes. HYPERESTHESIA OF THE STOMACH. This is met with in functional and organic diseases, as well as in chronic gastric catarrh and other affections of the stomach. Again, it may occur as a neurosis, most frequently in chlorotic girls and women. There is an increased gastric sensibility, so that the mildest irritant pro- duces painful sensations that may be either gnaAving or burning in cha- racter. A feeling of fulness and nausea are among the common features of the complaint. Food and certain articles that are not easily digestible may afford relief, and, oppositely, fasting or restriction of diet may aggra- vate the condition. The complaint, however, is often aggravated during digestion, particularly after excessive indulgence in certain kinds of food (crabs, lobsters, oysters, straAvberries). Cutaneous symptoms, as erythema and urticaria, may appear. Hypochondriasis is often associated. The above symptoms are dependent upon an individual idiosyncrasy. Treatment.—At first a restriction of the diet to soft and liquid arti- cles should be tried, and later a cautious return to solid food is to be made. Of medicaments, the bromids, given for a period of two or three months, have given the best results in my own hands. For the chlorotic type iron in the form of Blaud's pill, in ascending doses, is the best treatment. ANOREXIA. This consists merely in a loss of appetite, and occurs in many organic gastric disorders. It may also be a primary gastric neurosis, the latter being often associated with gastric hyperesthesia. Anorexia sometimes leads to a repugnance to food and a degree of abstinence that may induce grave nutritional disturbance. Among exciting causes mental shock of any sort ranks first. In other instances the patient may experience hunger, but on attempting to eat anorexia quickly develops. The recog- nition of anorexia as a primary neurosis of the stomach is difficult in the extreme after the general nutrition has become seriously impaired. 50 786 DISEASES OF THE DIGESTIVE SYSTEM. Chronic dyspepsia, phthisis, and other diseases associated Avith emaciation and debility must be excluded before the diagnosis is established. HYPEROREXIA. (Excessive Appetite.) This may either be symptomatic of other affections (c. g. diabetes melli- tus) or it may be of nervous origin. It may also be paroxysmal (bulimia). The patient complains of burning sensations in the epigastric region and of an insatiable hunger. The symptoms of neurasthenia and hysteria are often in association. The local and general symptoms are relieved by food. Hyperorexia may become permanent (polyphagia) and induce great debility. It may also accompany other nervous disorders, as affections of the brain, exophthalmos, and migraine. Pica is the term applied to the craving for substances not used as food (slate-pencils, dirt, chalk). Malacia represents the desire for highly spiced dishes (mustard, salads, pickles, fruits). The above conditions are met with in neurasthenia, chronic gastric affections, and chlorosis. VIII. DISEASES OF THE INTESTINES. METHODS OF DIAGNOSIS. Examination of the Feces.—Although the results are in most cases unsatisfactory, an examination of the feces should not be neg- lected, especially in the more serious affections of the intestine. This embraces—(a) a macroscopic ; (b) a microscopic; (c) a chemical; and (d) a bacteriologic examination. (a) The macroscopic appearances often suffice. A thorough inspec- tion of the stools, a matter too often omitted, furnishes valuable points in regard to the presence or absence of coarse parasites, fragments of tumor, foreign bodies, concretions, blood, bile, pigment, fat, pus, mucus, undigested meat, and the like. The shape, color, and consistence of the stools must be noted, and it is to be remembered that in these particulars, as Avell as regards their frequency, they exhibit a considerable range of normal variations, according to individual peculiarities, the character of food taken, and so on. It is to be recollected that normal stools contain fat in varying amounts, for the reason that only a limited quantity can be emulsified and taken up from the intestine. The naked eye may, at times, detect its presence from the "peculiar silvery appearance" of the feces. Fat in the stools (steatorrhea) is often pathologic, and the separate affec- tions in Avhich it is met Avith will be considered hereafter. The dejecta present a shining, tallowy appearance, either throughout or in circum- scribed spots. Again, the fat may occur in the form of oil floating on the surface of liquid stools. Mucus is also visible, either as slimy or jelly-like masses, or as shreds and granules (sago-grains). Diarrheal DISEASES OF THE INTESTINES. 787 stools should be examined macroscopically Avith great care, and the same may be said of constipational dejections. The latter often assume a rounded form (sheep's dung) on account of their delay in the large bowel. They may attain to the size of a small orange, and may be, though rarely, enveloped in mucus or blood-streaked. Their color is dark. On the other hand, the stools may be colorless in cases in Avhich the bile-ducts are occluded; these usually contain a large proportion of fat, though not invariably. The effect of certain drugs upon the color of the stools is to be borne in mind. When blood is intimately min- gled Avith the feces, they have a reddish, dark- or blackish-broAvn (tarry) color, according to the quantity and the time alloAved for decom- position in the intestine. Blood, either clotted or fluid, may also be passed in a pure state. Its source is usually the loAver part of the bowel, though, Avhen peristalsis is greatly augmented, it may come from the small intestine, as in typhoid fever. Pus may occasionally be recog- nized macroscopically. "For the detection of small concretions the stools should be passed through a sieve; large concretions are easily recognizable. I generally add some ether previously, in order to some- what overcome the bad odor " (EAvald). (b) Microscopic Examination.—Diarrheal stools can be examined as discharged, but to solid and mushy dejections a solution of common salt Q- per cent.) should be added and all hard masses thoroughly broken up. Different portions of the stools are to be selected for micro- scopic examination. By the use of the microscope Ave are enabled to detect parasites and their eggs in the intestinal contents; also mucus in the form of shining, vitreous, homogeneous, or whitish masses; and in the interior of the latter bacteria, various crystals, and intestinal epi- thelium may be seen. Remnants of vegetable food may simulate mucous islets, but the former strike a blue color on the application of the potassium- iodid test. Microscopically, diarrheal stools shoAv undigested muscle- fibers, fat-crystals, vegetable cells, starchy granules, and innumerable bacteria. On microscopic examination of the dejections in constipation Ave find "a copious detritus of broAvn or black color, usually numerous colorless or slightly tinged triple phosphates (phosphate of ammonium and magnesium crystallizing in the form of a coffin-lid), or, more sparse, crystals of neutral phosphate of lime. Seldom do we meet with the rhomboid plates of cholesterin, Avhich are recognized in that they are colored from a reddish-broAvn to violet by dilute sulphuric acid (1 : 5), and become blue or green on the further addition of a solution of iodid. Needle-shaped crystals of fat, single and also in the forms of tufts, are frequently met with. Bile-pigment cannot be detected. Undigested rem- nants of food are only sparsely present, OAving to the long detention of the fecal matter in the boAvel. Epithelium from the mucous membrane, pus-cells, and blood-corpuscles, unless they come from the passage of the fecal mass through the anus (in Avhich case they are simply adherent to the external surface of the scybala and are but little changed), are greatly altered; they are fatty, degenerated, shrunken, and hardly recognizable. "The micro-organisms are numerous, in lively motion, but have no specific significance " (Ewald). (c) Chemical Examination.—The presence of bile-pigment is easily detected by the Gmelin reaction. The stools must, if needful, be ren- 788 DISEASES OF THE DIGESTIVE SYSTEM. dered fluid by the addition of Avater, then filtered, and the filtrate alloAved to dry. At the margin of the drop the characteristic green color will appear. Urobilin strikes a red color. The stools in diarrhea may contain ferments capable of digesting albuminoids. The fatty acids are distinguished from fatty soaps by the solubility of the former in ether. To detect a very small amount of blood that may be intimately mixed Avith the feces the test of Fr. Miiller and Weber gives the most reliable results. Solid or mushy stools are first rubbed up Avith water and filtered.* A portion of the filtrate of liquid feces is added to 5 cubic centimeters of glacial acetic acid and ether, and the Avhole Avell shaken. The ether generally settles clear, but if it does not a few drops of absolute alchohol are to be added. The presence of blood (hematin acetate) is shown by a reddish-brown tint given to the layer of ether. (d) A bacterial examination of the intestinal contents, and particu- larly of any mucus or muco-pus that may be discharged, may decide the diagnosis of certain intestinal disorders (tuberculosis, amebic dysentery). For the method of carrying on these investigations the reader is referred to special Avorks on diagnosis and bacteriology. Physical or External Examination.—Inspection.—A few of the points of greatest diagnostic importance only can be given here. Localized prominences are to be noted over the abdomen, though the fact should be remembered that these may be simulated by localized contractions of the various abdominal muscles. The influence of respi- ration on these circumscribed bulgings is also to be observed. In the absence of unusual tension of the abdominal w7alls it is of great value to inflate the large intestine with air per rectum, and to note the progres- sive distention of the intestinal coils as a means of detecting obstruct- ing lesions in the boAvel; the position and mobility of a tumor should also be noted. It is often of marked aid to inspect the mucosa of the large intestine, as far as may be, by the use of approved specula (Sims, Fergusson, Cusco, as modified by Ricord). Palpation.—This is the most important method employed in the diagnosis. The patient should occupy the dorsal decubitus, Avith the head raised, the thighs drawn up, and the mouth open, so as to relax the abdominal muscles. Something may be gained in this direction by dis- tracting the patient's attention. I have found that placing the patient in the lateral decubitus, Avith the thighs flexed on the abdomen, has en- abled me to determine better than in any other manner the degree of mobility of certain tumors. The examiner should not fail to remember the knee-elboAv position in cases in Avhich it is desired to palpate the parts occupying the bottom of the pelvic cavity and all deep-seated, movable groAvths. In certain cases relaxation of the abdominal muscles is only obtainable by bringing the patient under the influence of an an- esthetic, and I do not hesitate to do this in cases in Avhich a correct diagnosis is highly important. In palpating the abdomen for abnormal conditions Ave must keep in mind steadily the relations of the different parts of the intestines, and also the fact that the latter may vary con- siderably in position—a fact particularly true of the transverse colon (vide Enteroptosis). In this connection EAvald's statement " that abnor- mally situated organs or neoplasms of parts other than the intestines ENTEROPTOSIS. 789 Avill, under the pressure of the intestines filled Avith air or Avater, return to the position that the organ normally occupies," should be emphasized. He continues: " Tumors of the kidneys or spleen will be pressed up under the diaphragm, tumors of the liver and of the stomach will be forced upAvard, and those of the large omentum toAvard the front and downAvard, while retroperitoneal tumors of the pancreas, of the spinal column, or of the pelvis will remain fixed." The palpation of pathologic conditions of the intestines will be con- sidered in connection Avith the separate intestinal affections. Percussion detects a fluid effusion either in the general peritoneal cav- ity, the position varying Avith the position of the body, or in circumscribed localities; the latter must not be confounded Avith areas of dulness that are occasioned by splenic and hepatic enlargements, solid neAv-growths, or abscesses. Air in the peritoneal cavity (meteorisrnus peritonei) gen- erally gives a pure tympanitic note, though if the tension be very strong, a non-tympanitic tone is elicited. These sounds are general, even ex- tending up to the fifth or fourth rib, and hence they cover the regions of the spleen and liver. The best results when the abdomen is not tense, hoAvever, are obtained after inflation of the large intestine Avith air, since the presence of neA\-groAvths, of dislocated viscera, and the relation of the large to the small intestine can thus be accurately determined. Ausadtation.—Noises are often audible either at a distance or by means of a stethoscope applied to the abdomen. They are sometimes occasioned by the natural peristaltic movements or by certain voluntary or involuntary spasms of the abdominal muscle. Again, a large amount of air and gas in the intestine may excite sounds. These are heard most frequently in the ileo-cecal region. I have repeatedly confirmed the observation of EAvald, Avho frequently found in those suffering Avith chronic intestinal indigestion a SAvashing or splashing noise, sounding as though air and Avater Avere being forced through a narroAv space in the ileo-cecal region. These sounds may rarely be found in healthy persons. Similar noises sometimes have their seat in the descending colon, particularly if the bowrel is unnaturally dilated by air or fluid. They are often audible prior to an evacuation in cases of colitis. Noises may also originate in the transverse colon, and to discriminate these it is necessary to empty the stomach if we would avoid confusion with iden- tical gastric sounds. Direct auscultation of the intestines renders aud- ible the peristaltic movements, and the absence of the latter indicates paralysis of the intestine, which may be local or general. Friction- sounds tend to appear, and are audible when inflammatory exudates are present. When obstruction of the large intestine is suspected, ausculta- tion should be practised Avhile air is being forced into the rectum, in- asmuch as the degree of permeability can be thus determined. Metallic tinkling and amphoric noises may be audible, particularly on making auscultatory percussion, but these are Avithout real diagnostic value. ENTEROPTOSIS. Definition.—The descent of the intestines from their normal position. The condition occurs coincidently Avith gastroptosis, neph- 790 DISEASES OF THE DIGESTIVE SYSTEM. roptosis. and prolapse of other viscera, constituting splanchnoptosis (Glenard's disease). Etiology.—It is linked Avith gastroptosis and other forms of ptosis by common etiologic influences, such as sex (being most common in females), tight-lacing, traumatism, muscular strain, numerous pregnan- cies, rapid emaciation, and probably the wrong use of cathartics. Either the small intestine alone or the large, or both, may be involved. Pro- lapse of the colon (coloptosis) is the more common, and, according to C. Meinert, is even more frequent than gastroptosis. Lying immediately above the symphysis pubis, it is sometimes elongated and tortuous— " S- or M-shaped." Symptoms.—The condition, even when pronounced, may exist Avithout svmptoms. On the other hand, in the majority of instances the intestinal, gastric, and other bodily functions are disturbed, and yet enteroptosis is usually overlooked. Chief among the intestinal symp- toms is excessive flatulence; not rarely, also, there is membranous enteritis, the latter probably being due to the flexures that produce an arrest of fecal masses, and this in.turn causing inflammation (Boas). Constipation generally prevails, and sometimes alternates with diarrhea. The symptoms of gastroptosis and nephroptosis are often associated; they are loss of flesh and nervous symptoms, and the latter may simu- late those of neurasthenia or hysteria. The diagnosis is made upon the afore-mentioned points and upon the results of a careful physical examination. The position of the colon may be determined by inflation Avith air or gas. Again, after the injec- tion of Avater (f^viss-ixss—200-300 c.cm.) a splashing sound is audible; this is double the amount of Avater required in the normal condition. Glenard has pointed out that a transverse cord (which he believes to be the colon) can be felt in the upper part of the abdomen. Boas and Ziemssen assert that this cord is the pancreas, rendered palpable by the sinking of the stomach. Treatment.—The bowels must be moved regularly, the tonicity of the abdominal Avails must be increased by electricity, massage, and hydro- therapy, and in strongly nervous cases the treatment of neurasthenia, including the Weir Mitchell rest-cure, must be instituted. Supporting bandages have been found serviceable. The medicinal treatment aims at meeting certain symptomatic indications, such as flatulence and fer- mentation. INTESTINAL CATARRH. (Catarrhal Enteritis; Muco-cnteritis.) Definition.—A catarrhal inflammation of the mucous membrane of the whole or of any anatomic division of the intestinal tract. It may be either acute or chronic, primary or secondary. The chronic variety oc- curs less frequently than its counterpart, chronic gastritis, particularly in adult life. Pathology.—The morbid lesions of the acute variety do not differ INTESTINAL CATARRH. 791 essentially from those met Avith in catarrhal inflammation of any other mucous membrane. The first stage is characterized by swelling and dry- ness of the mucosa; this is soon folloAved by a copious secretion of mucus, and more rarely of pus, which bathes the membrane more or less com- pletely. After an abundant secretion is poured out the membrane appears rather pale, though the tips of the valvulse conniventes in the small in- testines may appear reddened. The solitary and agminated glands, as well as Peyer's patches, stand out prominently, owing to their corrugated condition. Quite often the apices of the solitary glands undergo a ne- crotic change, thus forming follicular ulcers. The remainder of the mucous membrane may also be the seat of rather extensive areas of superficial erosion, though this must not be confounded with postmortem softening of the epithelium. Postmortem softening of the mucosa, with swelling and even desquamation of the epithelium, is commonly seen at the autopsy. In chronic intestinal catarrh the mucosa presents a slaty hue, with a more or less dark pigmentation of the villi and follicles; it is in most instances thickened, OAving to an increase in its connective-tissue elements. In a smaller number of cases it is thinned, particularly in the intestinal catarrh of children, on account of atrophic changes affecting chiefly the glandular and muscular layers. Roughening of the inner surface of the bowel, due to projecting glands, is frequent in those forms of chronic intestinal catarrh that are attended with thickening of the coats. Polypoid cysts may develop in long-standing cases. Etiology.—The primary form is produced by (a) local irritants, either mechanical or toxemic, that find their way into the intestinal canal. The chief source of these excitants is an unsuitable dietary, and especially is this the case in children. It is readily seen from this fact why the stomach and the intestines are often simultaneously involved in a catarrhal process, (b) Over-eating may be productive of the disease, though this often excites diarrhea by merely increasing intestinal peristalsis, (c) Idiosyncrasy has a positive influence, the ingestion of certain substances not difficult of digestion being invariably folloAved by this affection in individuals thus predisposed, (d) Toxic substances, Avhether in the form of tainted food-stuffs (spoiled meats, ice-cream, beer) or inorganic poisons (mineral acids, caustic alkalies, mercury, arsenic) or irritating cathartics, often produce intestinal catarrh, (e) Impure water. (/) At- mospheric changes, particularly a prolonged high or a sudden fall of tem- perature, the latter being especially apt to cause it in children, (g) An excess or a lack of biliary secretion. Two functions of the bile (its anti- septic properties and its power to stimulate peristalsis) must not be for- gotten : the one explains how a paucity of this secretion favors the abnormal processes of fermentation that are capable of exciting catarrh, and the other makes plain the possibility of a bilious diarrhea being due to an excessive hepatic secretion. It is not clear, however, that the latter condition is attended with an actual catarrhal process. The same is true of diarrhea due to fright, excitement, or other nervous influence. Secondary or complicating forms are caused—(a) By direct extension from adjacent organs (e. g. gastritis, peritonitis, hernia, and invagina- tion) ; (b) By general infectious processes (septicemia, pyemia, typhoid fever, dysentery, cholera, tuberculosis, pneumonia). The chronic forms are met with—(a) In certain cachectic states (car- 792 DISEASES OF THE DIGESTIVE SYSTEM. cinoma, chronic malaria, chronic Bright's disease, Addison's disease, and profound anemia); (b) In connection Avith disturbances of the circulation, particularly such as produce stasis in the terminal branches of the portal system of vessels : among the chief diseases that tend to prevent the return of venous blood from the intestines are chronic heart-affections, diseases of the liver (especially cirrhosis), and emphysema; (c) Severe cases of chronic diarrhea, supposed to be due to the protozoon balantidium, have been reported recently. The evidence to shoAv that the morbid lesions of this disease are of parasitic origin is exceedingly strong. In a case reported by Ortmann, in which the balantidia Avere readily discov- ered in the discharged mucus, treatment was of no avail until means Avere employed that destroyed and caused their disappearance ; the patient then made a good recovery. Among predisposing causes is the age, and, though it occurs at all ages, children are particularly liable to the disease. Unfavorable hygienic surroundings, especially Avhen a high temperature prevails, and epidemic and endemic conditions, have a strong predisposing influence also. Clinical History.—From a purely clinical standpoint we recognize not only acute and chronic forms of enteritis, but also a few important varieties based upon their general and local anatomic regions. The simple acute form of general catarrh of the intestines (muco- enteritis) has for its two most characteristic symptoms slight griping or colicky pains in the abdomen (sometimes absent), that are followed soon by diarrheal stools. The discharges consist, at first, of feculent masses, and later of a watery, highly irritating fluid. Diarrhea is due partly to increased peristalsis and partly to the abnormal irritability of the intes- tinal mucous membrane. Active peristalsis of the intestines may (vide ante) be of purely nervous origin, and produce a diarrhea that is to be distinguished from that due to catarrh. The causes that produce the catarrh also produce the undue peristaltic movements—a fact of great clinical importance. If it be true, as physiology teaches, that the stools, owing to the absorption of the watery portions of the food, are normally formed in the large intestines, then catarrh of the small intestines alone cannot excite diarrhea, though it may be attended with increased peristal- sis. On the other hand, in acute colitis diarrhea is conspicuous, and forms the most important clinical symptom. The vigorous peristalsis also accounts for the gurgling and rumbling sounds (borborygmi) that are often felt and heard by the patient himself. These peculiar noises, if pronounced, point to isolated catarrh of the small intestines. The stools vary in number from two to ten or more, being increased in frequency after taking food; gases are also formed, causing tympanites. The thin stools either present a bright-yellow or a yellowish-brown color and emit offensive odors. Occasionally they are greenish in color from the pres- ence of considerable quantities of bile-pigment or from bacterial action. In advanced cases of considerable severity there is painful tenesmus; the stools are often small and contain mucus and blood, becoming dysenteric in character, especially when the colon is chiefly affected. A microscopic examination reveals large masses of epithelium and mucus, as well as fungi of many different descriptions, and isolated leuko- cytes, crystals of calcium phosphate, oxalates, remnants of food (starch- granules, fat, vegetable and muscular fibers). Flakes of yellowish-brown INTESTINAL CATARRH. 793 mucus and large pieces of epithelium may often be seen with the naked eye. The stools give an alkaline reaction, except in cases of acute en- teritis in children, when it may be acid (Von Jaksch). The physical examination reveals on inspection slight tympanitic dis- tention as a rule. Palpation elicits considerable sensitiveness in the ma- jority of cases, though during the colicky pains pressure with the palm of the hand often affords relief. Fluctuation may be detected if the intes- tines contain much fluid. Percussion gives an exaggerated tympanitic resonance, varying, however, with the fulness of the bowel. Nausea may be present, and the appetite is often greatly impaired. There is marked thirst and the tongue is dry and furred. The general symptoms are often entirely wanting, save for a slight feeling of weakness due to the diarrheal discharges. Severe forms of infectious origin often disturb the general health considerably. The patient is languid, and prostration is prominent; he suffers much from headache, and pyrexia is common, the temperature often reaching 100°- 103° F. (37.7°-39.4° C). The higher temperatures are seen among children. Additional evidences of a systemic affection are sometimes observed, such as painful enlargements of certain joints and severe muscular pains. Complications. — The symptoms of gastric catarrh (vomiting, nausea, and pain immediately after feeding) are often associated with those of enteric catarrh ; the combination is then spoken of as gastro- enteritis. Special Forms.—Though the anatomic limits in the more or less local forms of intestinal catarrh cannot be made out definitely, yet the different clinical pictures observed often enable us to fix the location of the disease with considerable accuracy; it is important, moreover, from the standpoint of the treatment, to accomplish this whenever possible. The following may be briefly described: (a) Duodenal catarrh (duodenitis), in Avhich form constipation, often obstinate, is present in the place of diarrhea, the colon not being af- fected ; merely local pain, tenderness on palpation, and uneasiness are complained of. These symptoms may frequently be overshadowed by those referable to the stomach when gastric catarrh coexists (gastro-duo- denitis). AVithout the presence of jaundice, due to the occlusion of the common bile-duct in consequence of the swelling of the duodenal mucous membrane, the diagnosis of this affection mu,st remain highly doubtful; but, fortunately, this symptom is frequently observed. (b) Localized catarrh of the jejunum and ileum cannot, as yet, be diagnosticated correctly. The condition is often found to be a more or less prominent feature in general enteric catarrh, in which complaint diarrhea is a prominent symptom. The existence of this special variety may be safely inferred when certain enteric symptoms are combined Avith marked gastric disturbance. Under these circumstances the symptoms indicative of inflammation of the small intestines are rumbling noises (borborygmi), colicky pain, SAvelling, and slight tenderness over the abdomen in the vicinity of the umbilicus or over other regions occupied by the small intestines. Finally, an examination of the stools furnishes valuable points for differential diagnosis. It must be kept in remem- brance that in catarrh of the small intestines the stools may be quite 794 DISEASES OF THE DIGESTIVE SYSTEM. solid, despite the increased peristalsis caused by the catarrhal process (vide ante). More frequently, Avhen the ileum is the seat of catarrh the colon is also implicated, this combination being attended with diar- rhea, even if it be of minor severity. The thin stools "contain food- remnants, that point indubitably to implication of the small intestine." As the result of increased peristalsis of the small intestines their con- tents are passed into the large boAvel with undue rapidity; hence the latter contains undigested food-constituents and other substances that are normally found in the small intestines. These pass from the rec- tum unchanged. They are mainly starch, fat, and masses of meat-fiber, the latter of Avhich may be of sufficient size to be seen by the naked eye. This would be pathognomonic evidence of the form of catarrh in ques- tion if it were not true that increased peristalsis of the small intestines, due to other conditions, as anemia, extreme nervousness, and fever-con- ditions, that are not seen in ileo-jejunal catarrh, causes the same fecal peculiarities. In health the contents of the small intestines give the characteristic color-reaction for bile-pigment, Avhilst the contents of the large boAvel and the stools do not. In intestinal catarrh, with increased peristalsis of the small and large intestines, there is, hoAvever, quite often a large admixture of undecomposed bile-pigment (Striimpell) that responds to Gmelin's test,1 a fact of considerable value in diagnosing catarrh of this portion of the intestinal canal. Nothnagel has called forcible attention to the fact that round bile-stained stools and small pigmented masses of mucus are met with, and are highly characteristic of the diarrhea that marks catarrh of the small intestines. (c) Colitis.—The joint appearance of abdominal pain and diarrhea is almost pathognomonic of this condition. These symptoms, in the ab- sence of the more prominent and above-mentioned clinical features that have special reference to inflammation of the small intestines, point to the fact that the large intestines are the chief seat of the disease. Physical examination is only partially confirmatory of the rational symptoms. The chief sign is tenderness on palpation over the track of the colon. An ocular examination of the stools furnishes important prac- tical results. They may contain blood and mucus, and the latter often in masses large enough to be readily visible to the naked eye; it is not intimately mixed with the feces, as in catarrh of the small intestines, but forms separate masses, The feces are often of the consistence of soup. " If the catarrh affects the loAver portion of the large -intestine chiefly, it may be that the intestinal contents are already formed " in firm lumps, Avhich may sometimes be wholly or partly enclosed in a layer of mucus (Striimpell). Such general symptoms as loss of flesh, Aveakness, and salloAvness of the skin are often observed. Simple diarrhea, lasting but a feAv days, as a rule, is to be classed Avith catarrh of the large intestines, since these affections imply increased peristalsis of the large bowel. It is not always easy, however, to discriminate diarrhea due to purely functional influences or to catarrh of the rest of the intestinal tract. 1 This consists in bringing a few drops of nitric acid in contact with the intestinal contents, when the characteristic play of colors appears. 'See also Methods of Diagnosis, pp. 786-789.) INTESTINAL CATARRH. 795 (d) Proctitis, or inflammation of the rectum, is characterized by painful tenesmus and by the presence of large quantities of mucus and pus, particularly in the dejections. The disease may be primary, though more often it is secondary to morbid lesions either in organs that are adjacent to or in the rectum itself. Chronic intestinal catarrh may, comparatively rarely, be a primary disease, developing gradually, it may also be secondary (vide Pathol- ogy) at times to one or more attacks of acute intestinal catarrh. Gen- erally there are no other local symptoms to call attention to the condi- tion than chronic diarrhea. More rarely there are in addition colicky pain and tenderness over the abdomen. The diarrhea often alternates Avith constipation, and this is most apt to be the case when the disease is of idiopathic origin and affects only the large intestine (Nothnagel). Constipation is constant in those cases in Avhich atrophic alterations occur in the glandular and muscular coats, as well as in those in Avhich the lesions are in the small intestines. When constipation is not pres- ent the stools are thin, pale, sometimes fermented, emitting offensive odors, and vary greatly in number and quantity. There is com- monly present visible mucus, OAving to the fact that the most frequent seat of the disease is the large intestine. When the small boAvels are also implicated, food-remnants are found in the dejections (lienteric diarrhea). That form of diarrhea occurring in organic diseases of the heart, liver, and lungs demands brief special mention. Here the serum of the blood is made to exude into the intestines, owing to mechanical obstruction to the return of the venous blood, and this results in a liquefaction of the feces. The stools are apt to be most copious and numerous during the morning hours. Sometimes an irresistible desire to evacuate the boAvels seizes the patient as soon as his feet strike the floor on rising in the morning; two or more serous discharges follow each other at short intervals. Subsequently, all dis- charges cease until the folloAving morning, when the same symptoms are repeated. The general nutrition suffers visibly in chronic enteritis, and emaciation eventually becomes pronounced. I have also noticed slight pyrexia, especially in the evening hours. Differential Diagnosis.—Among the diseases likely to be con- founded w7ith acute catarrh of the intestines are typhoid fever, dysentery (diseases in Avhich diarrhea is a cardinal symptom), peritonitis, and colic. The chief differential features betAveen simple colic and enteric catarrh may be contrasted thus : Enteric Catarrh. Colic. Diarrhea is constant. Constipation is present. Fever may be slight or marked. No fever. Pain is griping, and is then followed by Pain is colicky, more severe, and is not the stool. followed by diarrheal discharges. Tenderness in the intervals between pains. No sensitiveness on palpation. From peritonitis Ave may readily distinguish catarrh of the intestines by the more intense pain and tenderness, by the constipation, the greater tympany, the constitutional disturbance, and more especially by the anxious face, thoracic respiration, and immobility of the patient, all of Avhich characterize the former disease. When the characteristic 796 DISEASES OF THE DIGESTIVE SYSTEM. symptoms of typhoid fever (the typical temperature-curve, SAvelling of tne spleen, and eruption) and dysentery (scanty, frequent stools and tenesmus) are present, they are easily separable from enteric catarrh. In children, however, the diagnosis betAveen typhoid fever and simple catarrh of the boAvels offers considerable difficulty ; but the temperature- record, if carefully kept, the enlargement of the spleen, and the charac- teristic eruption, when taken jointly, will Avarrant the diagnosis of typhoid fever. In diagnosticating chronic intestinal catarrh we may have difficulty in eliminating lardaceous disease of the bowels and ulceration ; the man- ner of doing this in case of the latter condition will be pointed out here- after. Amyloid degeneration, however, is a general disease, affecting primarily other organs than the bowel, and hence lardaceous diarrhea is ahvays preceded by the clinical indications of the disease in other parts of the body. The condition also gives a definite etiology as a rule. Prognosis.—The prognosis in uncomplicated cases is favorable, though the possibility of a merging into the chronic form must be borne in mind. Occurring in weakly subjects, especially at the extremes of life, and in the course of debilitating affections, acute catarrh of the intestines may become a source of danger to life. Its duration varies much—from three to ten days or more—according as the type of the in- dividual case is mild or severe. The prognosis in the chronic forms is moderately good as to life, though as to cure it is not so, the disease often lasting for many years together, or as long as the chronic conditions producing it remain un- removed. It sometimes exhausts the system of those suffering from serious causal affections of a chronic nature, and occasionally it ulti- mately proves fatal. The prognosis will depend largely upon the charac- ter of the etiologic affection, but intestinal catarrh invariably renders the prospects of the latter more gloomy. Treatment.—Respecting the treatment of this affection the vieAVS of the profession have undergone many changes, even within recent years ; hence it may be reasonably inferred that our present therapeutic methods are by no means satisfactory. Hygienic and Dietetic Management.—If the cause be some error of diet, all injurious articles must be rigidly prohibited. In the milder cases due to this cause a mild purgative, followed by proper dietetic treatment, is all that is required. Albuminous food in liquid form, such as skimmed milk, weak broths, and even semi-animal articles of diet, as eggs, oysters, sweet milk Avith seltzer, are usually well borne. In the severe forms predigested liquid foods only should be alloAved. AVhen the chief seat of the disease is in the large intestine, we may allow easily digested starches and certain green vegetables (arrow-root, sago, lettuce, water-cress); the coarser vegetables, all fats, and most fruits should be withdraAvn absolutely. Rest in bed is especially beneficial in that it serves to keep the abdomen Avarm and mitigates the pain and diarrhea, and, in short, cures the disease. Sinapisms should be ap- plied at the outset until the skin is reddened, succeeded by light linseed poultices until the local sensitiveness has, in a great measure, subsided; after this a flannel band may be applied. The local abstraction of blood by a few leeches, applied to the abdomen or anus, is beneficial in the INTESTINAL CA TARRH 797 early stages in severe types of enteric catarrh, provided the patient's strength is good. Medicinal Treatment.—It is sound practice to prescribe a mild ca- thartic (castor oil, calomel, or rhubarb, folloAved by a saline) Avith a view to getting rid of irritating intestinal contents. In my OAvn hands a second dose of some gentle purgative has been folloAved by happy re- sults. HoAvever, should improvement folloAV the action of the first measure, a repetition should not be advised. If the chief tenderness be localized in the right iliac fossa, corre- sponding to the course of the colon, a simple enema, sloAvly given, Avill stimulate the boAvel sufficiently and cleanse it more effectually than a cathartic. Subsequently, chief reliance is to be placed on intestinal antiseptics and astringents, though it must be recollected that the selec- tion of internal remedies must, in part, be influenced by the etiologic indications. For instance, if the cause has been exposure to cold or wet, besides the efforts directed at the local condition diaphoretics and febrifuge mixtures are serviceable. I have found the following com- bination to be of benefit in controlling the inflammatory action : R. Salol, * 3ss (2.0); Creasoti, ITlx (0.666); Bismuthi salicylat., 3j (4.0). M. et ft. capsulee No. xx. Sig. One every three hours. If pain be troublesome, opium or phenacetin may be combined with the above formula, or the folloAving may be employed: R. Argenti nitrat., gr. ij (0.129); Ext. opii, gr. iss (0.097). M. et ft. pil. No. xij. Sig. One every three or four hours. In many instances the secretions of the intestinal tube are decreased for a considerable period after the most active symptoms have been subdued. Here Ave must supplement the natural juices of the bowel, as folloAvs: 1^. Pancreatin, Sodii bicarb., M. et ft. chart. No. xij. Sig. One an hour after meals. In cases in which the large intestine is chiefly affected, and Avhen the condition does not yield to internal medicines, treatment per rectum should be employed. If colicky pain be severe, morphin (gr. ^—0.008) should be given hypodermically in addition to the measures before sug- gested. If the diarrhea shows no tendency to abate after forty-eight hours of the general treatment above outlined, large doses of bismuth (gr. xxx to lx—2.0 to 4.0) every three or four hours should be tried. In my OAvn hands lead acetate (gr. ij—0.129), with the extract of opium (gr. I—0.008) in pill-form, has proved a most efficient combination. AVhen there is reason to suspect that the main lesion is in the large bowel, small enemas of starch-water (3ij—64.0), with laudanum (lit xx 30 (4-0); 3ij (8.0). 798 DISEASES OF THE DIGESTIVE SYSTEM. -xxx—1.33-2.0), every four to six hours, are efficacious. The thirst is best relieved by chipped ice in small quantities or by carbonic acid and Apollinaris Avaters. For distressing flatulence Ave may prescribe the alkaline carbonates, or spirits of ammonia, and some carminative. In chronic catarrh of the intestines the local treatment is of para- mount importance. Daily irrigation of the boAvel Avith a weak solution of some antiseptic agent, as salicylic acid (gr. v-5J—0.324-32.0), boracic acid (gr. x-^j—0.648-32.0), creolin (m v-^—0.324-32.0), or Avith some such astringent as tannin (gr. v-gj—0.324—32.0), or finally Avith an alterative, such as silver nitrate (gr. ^-.ij—0.010-32.0), will be found to be beneficial. The latter solution is a most excellent remedy, but sometimes excites pain if used in excessive doses. To obviate this, I have often used a mild antiseptic or astringent Avith the foregoing, giv- ing them on alternate days, and thus obtained most happy results. The only appliance needful is a fountain syringe with a soft-rubber end- piece, which should be gently introduced for a considerable distance into the bowel. The fluid used should be warmed to 90° F. (32.20C), and the quantity administered at each sitting should be not less than 2 to 3 pints (1-1.5 liters) ; this should be allowed to flow in slowly. The patient should, as a rule, assume the dorsal decubitus, though if the fluid is to be carried as high up as possible, the knee-elboAv position may be assumed or the patient may be placed on the left side Avith the hips elevated. The same careful attention must be paid to hygienic details, and especially to the diet, as is directed in the acute form. In addition, flan- nel should be worn next the skin both in winter and summer. If the strength will admit of it, cold baths are useful. A stay at a suitable spa (Saratoga, Bedford, Virginia Springs, Carls- bad. Kissingen) often produces most satisfactory results. Among internal agents, zinc oxid (gr. v to x—0.324-0.648—t. i. d.), silver nitrate, lead acetate, and alum, given with tonics, such as strych- nia, arsenic, and iron, are especially to be recommended. The management of this troublesome malady depends upon the in- dications furnished by the causal chronic affections. No method of treatment can succeed, hoAvever, that is not carried out systematically and over long periods of time. DIARRHEAS OF CHILDREN. ACUTE GASTRO-INTESTINAL CATARRH. (Acute Gastro-enteric Infection; Summer Diarrhea: Gastro-enteritis; Cholera Infan- tum ; Mycotic Diarrhea.) Definition.—This is the usual intestinal trouble that prevails during the warm summer months. It usually takes the form of an epidemic, and its course is manifested by a sudden onset, high fever, irritability of the stomach, frequent Avatery evacuations, symptoms of nerve-involve- ment, and possible collapse in young children. This form of diarrhea DIARRHEAS OF CHILDREN. 799 usually folloAvs an attack of acute indigestion, in which it very fre- quently has its origin. Acute gastro-intestinal catarrh stands midAvay betAveen acute indigestion and ileo-colitis. Btiology.—Two important conditions seem to be necessary to influ- ence the disease—temperature and diet. Nearly all the fatal cases occur in the artificially fed, and a general and Avell-recognized belief associates special danger Avith the second summer of children. Out of nearly 2000 fatal cases collected by Holt, only 3 per cent, were exclusively breast-fed. Generally speaking, the disease has its origin in some irregularities in artificial feeding. Heat is an important ele- ment in the continuation of the disorder when once commenced. The death-curve begins to rise in May, increases during June, climbs to the highest point in July, and very greatly declines during August and September. High temperature must not, hoAvever, be regarded as the sole or direct agent, but only one of several factors. Bacteriology.—Ballard believes the cause to be a micro-organism (not yet isolated) that is constantly present in the superficial layers of the earth; it enters the food, and develops under favorable conditions— either inside or outside of the body—a virulent poison, or ptomain, that gives rise to the symptoms seen in the disease. This unknoAvn micro-organism is supposed to play the same part in producing the dis- ease as the comma bacillus in Asiatic cholera. Baginsky, experimenting with the micro-organisms formed in the stools of infants suffering from diarrhea, failed to find any that could be regarded as specific or pathogenic, but found many saprophytic or non- pathogenic bacteria ; he inclines to the belief that the decomposition- products formed by these different varieties of micro-organisms are the toxic substances that give rise to the disease. Meinert, Avhile believing that micro-organisms and their resulting ptomains may give rise to an intestinal catarrh, believes that the acute forms of summer diarrhea are produced directly by the action of a high temperature—i. e. a sort of heat-stroke, having nothing to do Avith micro-organisms or ptomain-poisoning. Although no pathogenic organisms have been isolated, this does not disprove their existence; and, on the other hand, Ave are not yet in a position to accept the conclusion that summer diarrhea is a definite parasitic disease, like Asiatic cholera or scarlet fever. A high atmo- spheric temperature continuing for days and nights favors the develop- ment of all forms of saprophytic organisms that groAv in all kinds of food, animal and vegetable, and under favorable conditions produce poisons such as muscarin, which when taken into the stomach gives rise to fever, depression, and collapse. The proteus class of bacteria are most frequent, and are most likely to possess pathogenic properties, according to Barker, who has made a very complete study of the subject. AAlth him are in accord the opin- ions of Jeffris and Baginsky. Pathology.—A catarrhal swelling of the mucosa of the large and small bowel is present; the mucosa itself is pink in color from capillary congestion. Peyer's patches are enlarged. The whole intestinal tube shoAvs an early stage of inflammation (ileo-colitis). In addition to the inflammation, there is most likely some involvement of the sympathetic 800 DISEASES OF THE DIGESTIVE SYSTEM. nerves, leading to dilatation of the capillaries and transudation of serum into the intestine, and to alterations of the pulse, temperature, and respiration. Its nature is paralytic, and closely resembles in its results experimental sections of the sympathetic nerves. The changes in the other organs are slight. Broncho-pneumonia frequently occurs. The spleen is very often swollen, the brain is anemic, and the kidneys are usually congested. Symptoms.—Clinically, Ave recognize two forms of acute en- teric infection : (1) acute dyspeptic diarrhea, and (2) cholera infantum. (1) Simple Gastro-intestinal Catarrh (Acute Dyspeptic Diarrhea).— The child may appear in its normal condition, Avith merely an increase in the number of stools, Avith or Avithout fever; restlessness is usual at night. This condition may continue for tAvo or three days, Avhen the stools become more frequent and offensive, containing undigested food and curds. The odor by this time is very pronounced—penetrating and adhering to the clothes and room for a long time. Frequently the disease has a sudden onset, Avith vomiting, griping pains, and fever which may quickly rise to 104°, 105°, or 106° F. (40°-41.° C). Con- vulsions may be the commencement of the attack. The abdomen is sensitive and SAvollen, and the child lies with its legs flexed on the stomach. The stools consist of grayish or greenish-yellow feces (mixed with gas, curds, portions of undigested food), and some fluid. In children two years of age and older the stools may contain unripe fruit or very large curds from excessive drinking of milk. Relapses are frequent, and during hot Aveather the frequency of the attacks may lead to the commencement of a severe entero-colitis. In delicate children a severe attack, especially if it is accompanied by convulsions, may prove fatal. From the fact that the general symp- toms may be few, the case is often allowed to go on for several days, under the impression that the child is " only teething." (2) Cholera Infantum.—The initial symptoms are sudden. The child voids immense stools, at first fecal, if no preceding diarrhea have been present. Soon they become watery, light yellow or greenish in color; frequently they are so thin and colorless as to pass through the napkin without leaving a stain. At times they contain a few yelloAV or greenish flocculi or a mass of mucus, and in all cases they are odor- less. Very often the stools are broAvn and liquid, Avith a small quan- tity of fecal matter, having a peculiar musty odor that clings to the napkin and child for days. The number of stools per diem may vary from six to thirty, and a most remarkable feature is the fact that they are evacuated with considerable force. The stomach becomes irritable, refusing everything ; even ice is re- jected as soon as swallowed. The appetite is, of course, entirely lost; intense thirst prevails, the little patient drinking at every chance and following the receding glass Avith eager eyes. The tongue, moist at first, soon becomes dry and pasty; the abdomen is collapsed. The temperature is always high—105° or even 108° F. (40.5°-42.2° C); and the pulse small and very frequent—130 to 180 beats per minute. The breathing is shallow and irregular, and the eyes anxious and staring, but soon becoming dull. The urine diminishes in quantity daily. With this array of symptoms there is a striking and appalling change DIARRHEAS OF CHILDREN. 801 in the child's general appearance. AVithin a few hours smiling, perhaps plump and rosy, it can now scarcely be recognized; the face has become pale and pinched, the eyes and cheeks sunken, the eyelids and lips wide apart from loss of muscular control, the muscles flabby, the bones prominent, and the skin greenish or cadaverous, hanging in loose folds from the wasted frame, all the fat having melted from the body. Collapse comes on soon : the hands, feet, nose, and breath become cool, the respirations more unequal, and there are drowsiness and utter apathy. When life is near its close, vomiting stops, the whole surface be- coming cool and clammy as the patient sinks into a state of coma, with injected eyes and contracted pupils. At last the end is reached quickly, preceded perhaps by a slight convulsion. The duration of the dis- ease is short; it may prove fatal in from one to four days. Diagnosis.—This is readily made. There is no other intestinal trouble in children to mislead one. The character of the stools, the ex- treme irritability of the stomach, the disturbed respiratory rhythm, high temperature, intense thirst, constant vomiting, frequent Avatery stools, and collapse soon coming on, tell the true story. The prognosis is very unfavorable. Treatment.—The treatment of acute gastro-intestinal catarrh di- vides itself into hygienic, dietetic, and medicinal measures. If a child is attacked in the city during the summer and does not yield to treat- ment in two or three days, it should be sent to the country or seashore. In the case of a child under two years this is absolutely imperative. Fresh air is important in all diarrheal disorders in summer both in country and city, and all cases should be kept out of doors as much of the time as possible. Children should be kept quiet—not permitted to walk, even if able. Bathing is soothing and beneficial in that it en- sures cleanliness and, what is very important, reduces the temperature. Dietetic treatment is of great importance. It should be remembered that digestion is arrested in the early stage, hence all food must be with- held ; to give food at this stage is to do harm. Thirst may be controlled by ice- or albumin-water, toast-water, or gum-Avater, Avith a little brandy. Medicinal Treatment.—The first step is directed against the acute indigestion and the active putrefaction going on in the intestinal tube. The indication, therefore, is to empty thoroughly the whole alimentary tract as soon as possible, and no other treatment must be thought of until this end has been accomplished. Whenever vomiting persists the stom- ach should be washed out; usually one washing is sufficient. In older children emetics will favor complete emptying of the stomach, but are never to be given to infants under two years. For the intestine calomel and soda may be used ; for the colon Ave may use, in addition, irrigation : this is advisable in all cases, as it hastens the effect of the cathartic and removes at once much irritating and offensive material. Opium should not be used until the whole intestinal tube is clean, and then cautiously. Spirits of chloroform, or camphor, is a better remedy for the pain than opium in any form. In older children the hypodermic injection of mor- phin and atropin in appropriate doses most frequently controls the Avhole train of symptoms. Treatment of Cholera Infantum.—In this, form of infection of the intestinal tract we are likely to forget that Ave are called upon to treat 51 802 DISEASES OF THE DIGESTIVE SYSTEM. a case of acute poisoning. The toxic material acts both poAverfully and quickly as a cardiac and systemic depressant. It also acts toxically upon the nerve-centers, and paralyzes the vaso-motor nerves. According to Holt, the leading indications are—(a) to empty the stomach and intes- tines ; (b) to supply the body with fluid to offset the great loss by vomit- ing and purging; (c) to counteract the effect of the poison on the heart and the nervous system ; (d) to reduce temperature ; and (e) to treat the svmptoms as they arise. In the first condition thorough stomach and intestinal cleansing is absolutely necessary. Moreover, Ave cannot depend on emetics or purgatives to arrest pain and to limit the effect of the poison on the nervous system ; a hypodermic injection of atropin and morphin is essential. Morphin must be given Avith discrimination to young chil- dren, especially when the vomiting and purging are slight; it is espe- cially contraindicated Avhen stupor or collapse seems near. Small doses repeated are better than larger single doses. Holt gives gr. T^ (0.0006) of morphin, with gr. -g^ (0.00008) of atropin, as the first dose in a child one year old. In supplying fluid to the exhausted tissues it is useless to attempt to give them by the mouth, or even by the rectum, as by both avenues it Avould be rejected. An injection into the cellular tissues of the buttocks, back, or thighs of a saline solution (40 grains—2.59—of common salt to a pint of sterilized Avater) is the best way to meet the drain. One pint (half liter) may be used every twenty-four hours, and larger quantities may often be used with advantage. Baths must be given to control temperature, and ice-bags should be placed to the head. Ice-Avater injections will aid in the control of temperature, and ice-sup- positories act efficiently when the water is not retained. Stimulants may be given hypodermically. During the active stage nothing should be allowed by the mouth except iced brandy or champagne. CELIAC DISEASE. (Diarrhoea Alba; Diarrhoea Chylosa.) Definition.—A form of intestinal catarrh marked by copious fetid and frothy discharges resembling gruel. Pathology.—Although ulcers have been noted in the intestine, the pathology of the disease is not known. Says Osier: This affection re- sembles somewhat the disease in adults knoAvn as " hill diarrhea " or the " Avhite flux " of India, Avith which psilosis or sprue, another tropical disorder, is considered identical by some writers. Btiology.—The disease is limited chiefly to children from one to five years old, though it has no connection Avith an inherited tendency. The filaria sanguinis hominis has been found in the feces in cases of diarrhoea chylosa. Symptoms.—The disease is of sIoav development, and the character- istic feature consists of copious diarrheal (though not Avatery) stools, re- sembling gruel or oatmeal-porridge. These are also frothy (frog-spawn), and horribly fetid. The physical signs consist of a moderate distention of the abdomen and a boggy sensation that is imparted to the palpating finger. The general features may be summated in gradually increasing emaciation, debility, and.pallor. The course is prolonged, and terminates fatally as a rule. CROUPOUS OR DIPHTHERITIC ENTERITIS. 803 The treatment is purely symptomatic, unless the presence of para- sites be suspected, when large antiseptic enemata should be sloAvly administered in a methodic manner at intervals of a day. PHLEGMONOUS ENTERITIS. This is a suppurative inflammation of the submucous layer of the intestines. It is among the rarest of grave maladies, especially as an irrelative disease. It may be diffuse or take the form of a circumscribed abscess. Rarely it occurs as a complicating condition in septico-pyemia and in malignant types of the exanthemata, resulting in the formation of abscesses that have their seat usually in the duodenum. Phlegmon- ous enteritis may be secondary to strangulated hernia or intussusception. The stomach may be similarly affected at the same time. Symptoms.—The local signs simulate closely those of peritonitis, and the position assumed by the patient is identical with that seen in the latter disease. Among the symptoms vomiting is prominent, though not diagnostic; it is always severe, and may become stercoraceous. Pain and tenesmus, when due to obstruction, are intense. Rigors more or less severe have been observed. The temperature is high, and its curve is someAvhat typical of the fever of suppuration. The disease is very fatal, and Avhen it is about to terminate unfavorably the patient passes from a condition of extreme prostration to one of utter collapse. Treatment.—The physician's task is confined to an attempt to sup- port the powers of the patient and to relieve his inordinate suffering. The surgeon's aid should be invoked early in cases of obstruction. CROUPOUS OR DIPHTHERITIC ENTERITIS. Definition.—An intense inflammation of the intestinal mucosa, ac- companied by a croupous exudate; it occurs in connection with widely various conditions and diseases. It has been definitely shoAvn that if from any cause the epithelial covering is destroyed, the same agents that are productive of croup may set up inflammation in the part. Pathology.—There are two sets of morbid lesions to be distin- guished : (1) The first and most important class exhibits a croupous deposit varying greatly in thickness and in superficial area. Its color is variable, being sometimes of a grayish or grayish-white hue, though more frequently perhaps grayish-yellow. I have almost invariably seen these lesions in the colon, while other observers have seen them in the cecum and small intestines. (2) In the second group the solitary folli- cles alone are inflamed, and the diphtheritic deposit is merely coexten- sive Avith their mouths. The etiologic factors may be (a) mechanical irritants (impacted feces, enteroliths, gall-stones); (b) chemical irritants (ammonia, acids, mercury, arsenic); (c) the condition may be secondary to acute infectious diseases and certain chronic complaints (Bright's disease, pyemia, carcinoma). 804 DISEASES OF THE DIGESTIVE SYSTEM. Symptoms.—AVhen mechanical irritants give rise to symptoms, they do not differ from those due to stercoral ulcers, and there is no way of recognizing the croupous deposits unless they be discharged per rectum and are detected in the stools. In cases that arise from the action of irri- tant poisons vomiting and purging are well marked and the dejections contain blood-stained mucus. We cannot be certain about the presence of croupous deposits in toxic cases unless they be found in the dis- charges. AArhen phlegmonous enteritis occurs as a complicating condi- tion in infectious diseases, the symptoms are almost completely veiled. The symptomatology of the follicular variety cannot be separated clini- cally from that of follicular ulceration. The treatment is that of the indications presented by the causal conditions or affections in the course of Avhich it occurs. CHOLERA MORBUS. (Cholera Nostras.) Definition.—A self-limiting disease, characterized by a brief course and by serous vomiting and purging, colicky pains, and often muscular cramps. Pathology.—No constant anatomic changes have been noted. So far as observed, they are analogous to those seen in acute gastroenteri- tis, though cases have terminated fatally in which no morbid lesions were detectable at the postmortem examination. Etiology.—Among predisposing causes, the age and the season exert the most prominent influence. The condition may appear in sub- jects under tAvo years, when the term " cholera infantum " is employed,1 though it is more often met with in older children and adults. It is almost invariably seen during the heated term, from the latter part of June to September, being rarely met Avith at other seasons, and it is especially prevalent during the month of August. Bad hygienic environments, foul air in particular, have a noticeable effect, and, though not as yet absolutely proved, it may be safely inferred from the clinical history and the usual course of the affection that it is of microbic origin. Among other factors are improper food, particularly unripe fruit, cucum- bers, egg-plant, and exposure to cold and wet. Various organisms (especially the Finkler and Prior spirillum) have been found present. No one variety, however, has been definitely found to be the cause of the condition. Virulent specimens of the bacillus coli communis, and even of the streptococcus, have been noted. Clinical History.—The symptoms are those of an intense gastro- enteric catarrh. The onset is often sudden, and is marked by abdominal pain, vomiting, and diarrhea. At first the vomitus consists of food, and later of a mixture of bile and mucus. The dejections are fecal in cha- racter at the onset, though they soon become watery, and may resemble the rice-Avater stools of Asiatic cholera. 1 This affection is described separately (vide p. 798). CHOLERA MORBUS. 805 Physical examination reveals only tenderness on pressure over the abdomen, particularly the epigastric region. General symptoms are not Avanting. Cramps in the calves are com- mon. The thermometer may register a high temperature, though it varies greatly, ranging from 100° to 106° F. (37.7° to 41.1° C). The skin-surface, however, and more particularly that of the extremities, feels cool, and OAving to this fact the rectal temperature should be re- corded. The pulse, as the case progresses, becomes rapid and feeble. The face is pale or even cyanotic, the features looking pinched. The extremities lose their plumpness, and the patient usually appears pros- trated and mentally dull. The urine is apt to be scant, high-colored, and sometimes albuminous, and thirst is extreme. Often the picture of general collapse is soon developed. Differential Diagnosis.—The local and general symptoms of cholera morbus resemble so closely those of true Asiatic cholera as to place the greatest difficulty in the way of a differential diagnosis. The dissimilarity betAveen these affections lies partly in the fact that no con- nection can be established betAveen isolated cases of cholera morbus and cases of true Asiatic cholera Avhen the latter disease is not epidemic. During a cholera epidemic the distinction between them is made without difficulty (see Diagnosis of Asiatic Cholera). Prognosis and Duration.—The duration of the disease varies from three or four hours to two days. It is rarely fatal, though in persons suffering from such chronic affections as Bright's or cardiac disease, and also in the aged, the prognosis is only guardedly favorable. It is said to be more unfavorable Avhen cholera and dysentery prevail (Loomis). A pronounced algid state should not be looked upon as free from danger. I remember tAvo cases attended with profound collapse that recovered, but in Avhich a condition of marked neurasthenia, indigestion, and func- tional heart-disturbance formed a series of sequelae that lasted for several months. Nearly all cases, hoAvever, recover without sequelae. Treatment.—The diet must be rigorously restricted, and predi- gested milk and animal broths are to be prepared as lightly as possible until convalescence has been fairly entered upon. The comfort of the patient, as Avell as the cure of the disease, is much enhanced by keeping the patient at absolute rest. Local measures are useful in combating pain and vomiting. A large mustard-paste applied to the stomach and abdomen, folloAved by linseed-poultices that are to be worn constantly, has a strong influence in accomplishing the relief of the symptoms before mentioned. If indigestible substances have been taken prior to the attack, prompt though mild laxatives are to be given at the begin- ning of the treatment. For the excessive thirst chipped ice, over Avhich a little brandy has been sprinkled, is effective. For controlling the pain, the nausea, and the diarrhea in this disease we have a remedy par-excellence in the hypodermic administration of morphin. The dose should vary (gr. \ to \—0.016 to 0.032) according to the severity of the symptoms, and I have rarely found it necessary to give a second dose. Not only are the pain and diarrhea subdued, but the peripheral circulation is also re-established. It has also been recommended to ad- minister opium by the mouth for these symptoms in the form of the solid extract or laudanum, but the results are infinitely more brilliant 806 DISEASES OF THE DIGESTIVE SYSTEM. when the drug is employed subcutaneously. The other points in the treatment of this affection are identical with those discussed under the treatment of Gastric and Enteric Catarrh. INTESTINAL INFARCTION. A few instances of occlusion of the superior mesenteric artery by an embolus have been recorded recently. The condition produces hemor- rhagic infarction of the small intestines, and is marked by grave and usually fatal symptoms. Its causes are sometimes obscure. The cases that have come to autopsy have shown intense congestion, Avith a SAvollen, blood-infiltrated state of the jejunum and ileum. Osier has seen three instances : in one there were numerous vegetations on the mitral valves from which the embolus was probably derived; in another the superior mesentery was plugged at its orifice; and in the third the artery was blocked by a portion of the fibrous clot of an aneurysm of the aorta near the diaphragm. The symptoms are urgent. Quite often diarrhea is present from the first, the dejections sometimes becoming blood-tinged. Soon, however the characteristically grave symptoms of intestinal obstruction supervene—viz. great pain, vomiting, and consti- pation, with excessive tympanitic distention of the abdomen. The con- dition cannot be recognized from the symptoms and physical signs on account of their close resemblance to the various forms of obstruction, yet its probable existence may be inferred in the presence of one of the known causal conditions. INTESTINAL ULCERS. DUODENAL ULCER. Definition.—A small, round perforating ulcer of the duodenum, and a counterpart of the gastric ulcer (vide p. 761). Pathology.—The morbid characteristics are so nearly identical in appearance and nature Avith those of peptic ulcer of the stomach that they scarcely demand a separate presentation. The seat of the ulcer is with feAv exceptions above the orifice of the common bile-duct. When these ulcers heal the resulting cicatrix produces stenosis, which in turn leads to dilatation of that portion of the duodenum back of it, and finally of the stomach also. Progressive cicatricial contraction may completely close the ductus communis, and in like manner the pancreatic duct or the portal vein may be occluded. Protective adhesive inflammation between the duodenum and the adjacent parts (pancreas, gall-blad- der, liver) often prevents complete perforation of the duodenal wall: when perforation does occur, hoAvever, the peritoneal cavity may be opened, causing peritonitis, or a fistulous communication may be estab- lished with the gall-bladder, liver, or pancreas. Rarely the direction of INTESTINAL ULCERS. 807 an abscess resulting from perforation is outward, pointing at the seventh intercostal space. In cases in Avhich the posterior Avail of the duodenum has been perforated the abscesses burrow through the mediastinum into the tissues of the neck and open posteriorly near the shoulder-blade (Loomis). The concurrence of a gastric and a duodenal ulcer is not infrequent. Etiology.—Though the duodenal ulcer has, as a rule, the same mode of origin as the gastric ulcer, the fact should be prominently mentioned here that extensive burns of the skin-surface of the body are quite prone to be followed by a perforating ulcer of the duodenum, Avhile gastric ulcers are seldom caused in this manner. To explain this form of ulcera- tion of the duodenum is difficult. It is quite probable, hoAvever, as in other forms of duodenal and gastric ulcers, that the circulation is arrested by an embolus (from decomposing masses of blood) at some point in the mucous membrane, the acid gastric juices subsequently digesting the part that is thus deprived of its blood-supply. In confirmation of this view Ave may mention the facts that these ulcers are rarely situated beloAv the point of entrance of the ductus communis into the duodenum, and that the contents of the portion of the duodenum above the mouth of the common bile-duct are identical Avith those of the stomach, the acid secretion remaining unchanged until it becomes mixed with the biliary and pancreatic secretions. Sir AVilliam Gull suggests that the situation of the ulcer depends someAvhat upon the fact that the portion chiefly im- plicated is so much more fixed than the rest of the organ that one can imagine its surface becoming abraded during peristaltic movements. The influence of sex and age as causal factors is notable and in striking contrast Avith their import in gastric ulcer. In the latter dis- ease most instances occur among young females, while in duodenal ulceration they occur, as a rule, in males betAveen the thirtieth and fortieth years. Of 64 cases collected by Kraus, only 6 sufferers Avere females. In view of the fact that the pathology of gastric and duodenal ulcers is the same, these differences respecting their etiology are inex- plicable. The ratio of cases of gastric and duodenal ulcers, hoAvever, is about as 30 to 1 in favor of the former. Clinical History.—Perhaps no real distinction between the symp- toms of gastric ulcer and those of its analogue affecting the duodenum can be said to exist in most instances. A probable diagnosis of ulcer- ation of the duodenum has, however, been repeatedly made, and some- times verified by the subsequent autopsy. Inasmuch as the essential symptom in ulceration of the duodenum—viz. melena—occurs not in- frequently without the presence of marked gastric symptoms, there is great danger that the disease under consideration will be mistaken for other affections of the intestine in which this is also a prominent symptom. Under like circumstances, if duodenal ulcer be classed with gastric ulcer, there is great danger that the true nature of many cases will be overlooked. The difference in the symptomatology in the two forms of ulceration is owing solely to the difference in locality, implying a differ- ence in nervous and blood supply. The distinctive diagnostic features of this disease may be shown by presenting its leading symptoms beside those characteristic of gastric ulcer: 808 DISEASES OF THE DIGESTIVE SYSTEM. Duodenal Ulcer. Usually occurs between 30 and 40 years, except when due to external burns. Males are more frequent sufferers than females, in the proportion of 10 to 1. Onset marked by intestinal hemorrhage, which may recur at intervals of vary- ing duration. The melena may be preceded by or ac- companied by hematemesis, though not generally. Blood in the discharges often is bright red, profuse, sometimes dark, and tarry from the action of acid chyme when slight, though less marked than when from the stomach. Pain may come on late, two to four hours after meals; more often it is absent. It is localized in the right hy- pochondriac region. Gastric crises of much greater violence and without reference to time of tak- ing food. Hemorrhage from the bowels is apt to occur at time of crises. Vomiting less frequent. Jaundice occasionally present from oc- clusion of bile-duct. Less marked improvement after diet has been regulated. Painful point is either in the same area to the right or is absent altogether. Gastric Ulcer. May occur at any age after childhood. Females are the chief sufferers. Gastric hemorrhage is preceded by other gastric symptoms, as a rule; it is apt to be more severe. Blood may appear in the stools, usually after hematemesis. The blood in the dejections is dark and tarry from the action of the gastric juices. Pain paroxysmal, greatly influenced by taking food ; often relieved by vom- iting. Pain sharply localized in the epigastric region, about two inches be- low the ensiform cartilage. Gastric crises coming on soon after tak- ing food. Vomiting and hematemesis apt to occur at culmination of crises. Jaundice absent. Usually a marked improvement follows regulation of diet. Boas claims to have discovered a painful point over the tenth and twelfth ver- tebrae, on the left side. Of the symptoms mentioned under Duodenal Ulcer, the intestinal bleedings and violent crises (in which the pain is referred to the right hypochondrium, and comes on from two to four hours after meals) are the most diagnostic. While hemorrhage is the leading single symptom in this complaint, we must not, in attempting to estimate its significance in any case, neglect to eliminate hemorrhoids, carcinoma, tuberculosis, dysentery, and finally the hemorrhagic diathesis,—all conditions in which melena occurs as a cardinal symptom. Recently many cases have been reported in which there was an entire absence of symptoms until per- foration occurred, followed by rapidly fatal suppurative peritonitis. In regard to these accidents we may refer to what is said in the description of the latter disease (infra). The signs of dilatation of the stomach, for reasons before stated, sometimes follow the healing of these ulcers, associated usually with chronic gastro-duodenal catarrh, the latter being due to mechanical causes. Rarely, stenosis of the ductus communis takes place as the result of duodenal ulcer; it is caused more fre- quently by tumors that either compress or occlude the lumen of the bowel. The symptoms presented differ widely from those due to ste- nosis above the duct, the most characteristic being the continual back- ward flow of bile into the stomach, sometimes attended by constant vomiting of biliary secretions. As in the case of gastric ulcer, in the duodenal form there is at times so much thickening about the base of INTESTINAL ULCERS. 809 the ulcer as to give rise to the signs of tumor. This is especially true of those instances in which the base of the ulcer becomes attached to adjacent organs; in such cases the resemblance to malignant disease becomes striking. Prognosis.—The risk to life is greater than in gastric ulcer, since there is less tendency to cicatrization. Treatment.—The suggestions made in the treatment of gastric ulcer are entirely applicable to the duodenal form also. Follicular ulcers have already been described under Catarrhal Enteritis (vide p. 791), and they have a similar pathology and etiology. AVhen present in goodly numbers they give rise to a symptom peculiarly their OAvn, and hence may be dignified by a separate though brief mention. The symptoms of the condition arising in the course of chronic enteritis often escape observation for a long time. The most characteristic man- ifestation is the appearance in the stools of conical-shaped masses of mucus resembling "boiled sago." Marked Aveakness and emaciation rapidly ensue. Among children the disease is common and assumes an aggravated form, the little sufferers quite frequently reaching their end as the result of inanition. An unfavorable termination may be due to perforation followed by suppurative peritonitis. The treatment coin- cides Avith that of chronic enteritis. Stercoral ulcers are the result of the mechanical effect of hard fecal scybala (often enteroliths, due to a deposit of lime-salts) upon the intes- tinal mucous membrane. They occupy the sides or tops of the normal folds in the colon. Symptoms.—There is, as a rule, a clear history of chronic constipa- tion, though the physician may, notwithstanding, be called on account of the presence of diarrhea; this is caused by the retained hardened feces Avorking their way into the rectum. A digital exploration will now clear up the diagnosis. There are tenesmus and colicky pain in the abdomen, the latter symptom being also complained of Avhen no diarrhea is present. The pain often occurs in severe paroxysms that may be attended with the discharge of thready or flaky mucus, pus, and sometimes blood. Physical Examination.—Palpation may in rare instances reveal the presence of a sausage-shaped tumor and sharply localized tenderness over the seats of ulcers. Enteroliths may lie in the intestines for years together, or they may finally be discharged with the stools. The ulceration that is thus caused often passes unrecognized. The prognosis is good if the condition be not overlooked. The treatment consists in thoroughly evacuating the bowels by salines and simple enemata, persistently used. Subsequently these cases are to be managed in the same manner as other non-specific ulcers of the bowels. Simple ulcerative colitis is a not uncommon complaint, and one that is frequently associated with chronic intestinal catarrh. The ulcers may be quite extensive, removing the greater portion of the mucous 810 DISEASES OF THE DIGESTIVE SYSTEM. membrane, though in several instances I have observed cases at the Episcopal Hospital that were superficial; these were confined almost solely to the mucosa. The muscular layer of the gut was greatly hyper- trophied and its lumen increased in every instance. The non-ulcerated portions of the mucosa looked, in part, quite pale, and in part quite dark. Polypoid growths have been observed situated between the ulcers. The etiology is obscure. The disease is met with most frequently in persons past middle life, and it is quite probable that chronic enteritis sustains a causal relation. Those Avhose constitutions have been enfee- bled by previous disease or an unfortunate hygienic environment are the chief sufferers. Symptoms.—The clinical features are ill defined at the onset, and are often erroneously ascribed to indigestion. Diarrhea (lienteric in character) is its most prominent symptom, and with it constipation may alternate. Pus and blood are absent with the rarest exceptions. The general health soon suffers greatly, the patient becoming weak and emaciated. The course of the disease shoAvs it to be of the subacute type, tending in most cases to become chronic. The diagnosis, apart from a consideration of the symptoms above men- tioned, requires the elimination of dysentery—an easy task as a rule. Prognosis.—This is unfavorable during the earlier stages in the aged. The strong innate tendency of the disease to become chronic must be considered. The treatment embraces (a) a careful regulation of the diet, consist- ing in a restriction of the patient to liquids and semi-solids during the acute stage; (b) the administration of a gentle laxative, followed by antiseptics and astringents (bismuth gr. xxx—2.0—combined with salol gr. v—0.324—every four hours); (c) the more serviceable local measures in the form of enemata, among the best being silver nitrate (gr. \ ad sj —0.016 to 32.0) or creolin (2 per cent.). Solitary Ulcers.—" Two instances of ulcer of the cecum, both with perforation, have come under my observation, and in one instance a simple ulcer of the colon perforated and led to fatal peritonitis " (Osier). The diffuse catarrhal ulcer is inseparable from acute enteritis; the cancerous ulcer is alluded to under the latter head. APPENDICITIS. Definition.—A catarrhal, ulcerative, or interstitial inflammation of the appendix vermiformis. It must be confessed that the disease, according to our present vieAvs, is rather a surgical than a medical con- dition, particularly from the standpoint of treatment. Knowing from personal experience and observation, hoAvever, that general physicians are annually meeting Avith cases of appendicitis, its prompt clinical rec- ognition by the latter is not only a matter of interest, but also of great practical importance for two reasons : First, in order that surgical inter- APPENDICITIS. 811 vention can be instituted at the proper moment; and secondly, because appendicitis is the leading serious disease of the intestinal tract. The term "appendicitis" includes the affections typhlitis (inflamma- tion of the cecum) and perityphlitis (a similar involvment of the connec- tive tissue behind the cecum), for the reason that with feAv exceptions Avhen the symptoms of the latter affections are presented the ap- pendix vermiformis is the part primarily affected. To the physicians and surgeons of America belongs the credit of having first established the truly important rank of appendicitis.1 Anatomical.—AVithout any knoAvn function the human appendix vermiformis represents the remains of the enormous cecum of inferior animals, especially rodents and herbivora. Clado asserts that the ver- miform appendix is kept in position by two folds of peritoneum, a meso-appendix, which is attached to the iliac fossa, and a second fold, perpendicular to the first, Avhich is attached to the posterior portion of the small intestine.2 A lymphatic gland generally occupies the angle formed by the appendix, cecum, and the small gut; this receives all the lymphatic vessels of the appendix. The size of the latter varies greatly. Ferguson,3 after measuring 200 appendices, gave as the aver- age length 4i inches (11.4 cm.), and as the diameter, that of a No. 9 English sound—about a quarter of an inch (0.62 cm.). Berry's studies, which are partly based upon personal examination of 100 bodies, and partly upon comparison of his OAvn results Avith those obtained by other investigators, gives the average length in. all the observations as 9.2 centimeters (3.6 inches). The caliber is ordinarily of the size of a goose-quill. Very exceptionally, as in a case reported by Swan, there is a congenital absence of the appendix. Its two fibro-muscular coats (external longi- tudinal and internal circular) are thick; its mucous membrane contains lymphoid elements in abundance. The blood-supply is derived from the ileo-colic artery at the valve, a single branch running to the end of the appendix. Shortly after middle life the cavity of the appendix becomes obliterated. Its blind extremity points most frequently toward the spleen. The appendix may lie behind the cecum, and sometimes partly to its inner side, its tip almost touching the liver or the gall-bladder. In not a feAv instances it dips downAvard, passing over the brim of the pelvis. There is no adjacent organ to which it may not become adherent, and in rare instances it is twisted like a loop around the small gut, causing constriction or even strangulation. Osier mentions one case in Avhich the appendix, with the cecum, entered the inguinal canal, curved upon itself, re-entered the abdomen, and was adherent to the wall of an abscess-cavity just to the right of the promontory of the sacrum. Pathology.—Three pathologic varieties are recognized: (1) Catarrhal or Obliterative Appendicitis.—This may be acute or chronic. The term " catarrhal inflammation " is still retained, though scarcely applicable, since, as a rule, appendicular inflammation tends to spread quickly to all the coats, including the serosa. Obliterative ap- 1 The following names will long be connected with this disease: Pepper, Fitz, Mc- Burney, Porter, Willard Parker, Weir, Sand, Bull, Warren, Keen, Morton, Price, J. William White, Deaver, Senn. and many others. 2 Sajous1 Annual, vol. i., 1893. 3 "Some Points regarding the Appendix Vermiformis," American Journal of Medical Sciences, Jan., 1891. 812 DISEASES OF THE DIGESTIVE SYSTEM. pendicitis is descriptive and in every Avay preferable. The meclianism of the inflammation is briefly as follows: The mesentery being too short, the exit is too small, and in consequence of swelling of the coats (especially the mucous) the venous return is greatly impeded, then the arterial, followed often by abscess-formation. In the female a branch is supposed to be furnished by the ovarian artery, making a more perfect blood-supply. The appearances are, in the beginning, identical with those of catarrhal inflammations elsewhere in the bowel. AVithin twenty-four hours all the layers are swollen, Avith marked cellular infiltration, causing the appendix to become firm and often rigid. The mucosa may be de- nuded of its epithelium and present a granular surface. The external coat (serosa) is usually hyperemic, and not uncommonly the seat of fresh or old adhesions. The tube may become completely obliterated by pressure, resulting in a union betAveen the granular surfaces, in this manner rendering subsequent attacks impossible (Hawkins). It is in cases in Avhich this fortunate result is not reached, hoAvever, that acute appendicitis leads to the chronic form with relapses. Two additional terminations may be observed: First, an obliteration of the lumen may occur near the valve, in which case the appendix becomes dilated, and sometimes enormously so (cystic). The contained liquid may be either serous or purulent. Second, obliterative appendicitis may lead directly to ulceration of the mucous membrane, and often in the absence of a fecal concretion or foreign body. Again, the cystic appendix may ulcerate, with or without perforation. Obviously, the more marked the stenosis of the appendix the less favorable the conditions for natural drainage, and the greater the liability to recurrences of attacks of appendicitis. This variety then may end in resolution, complete oblit- eration, stenosis, or ulceration, and the latter sometimes in perforation. (2) Ulcerative Inflammation.—Like the preceding, this variety may be acute or chronic. It may be a sequel of the obliterative form, and often accompanies chronic obliterative appendicitis. More commonly, however, it is seen in connection with concretions, and less frequently with foreign bodies. By no means invariably, hoAvever, does the pres- ence of these substances excite ulceration of the appendix. Micro- organisms play an important role in this variety (vide Etiology). The submucosa or muscularis usually forms the base of the ulcer. The ter- mination may be in healing, Avith tendency to stricture. AVhen obliter- ation is complete, dilatation beyond the seat of the latter may ensue. Again, the ulcer may extend in depth until perforation occurs. (3) Interstitial or Parietal Inflammation.—This may be preceded by the obliterative or the ulcerative form, which may be followed by anemic necrosis and sloughing. Concretions or foreign bodies are often found, though specific bacteria are of greater etiologic importance. The gravest, most common, and hence the most important lesions are the gangrenous, which are usually limited to a circumscribed part of the tube. Interstitial inflammation has a single termination—perforation—and leads to appen- dicular peritonitis of a virulent and infectious type. It may be that neither necrosis nor gangrene may supervene. AVhen perforation occurs, one or more openings, ranging in size from one to several millimeters, may be observed, while the remainder of the appen- dix may present no abnormalities; more often, however, it is blood- APPENDICITIS. 813 injected and swollen. The appendix may slough en masse. The histo- pathologic changes may be characterized by intense cellular exudation, necrosis, or purulent inflammation. The muscular coat is hypertrophied; the arteries show obliterating endarteritis. Consequences of Perforation.—A common result of all forms of appen- dicitis is a localized peritonitis, and this is a constant effect of the severer forms, either leading to (a) circumscribed peritonitis or to an (b) acute diffuse peritonitis. (a) Circumscribed Peritonitis.—At first the surface of the peritoneum is opaque and velvety. Soon a fibrinous exudation covers the appendic- ular peritoneum, and quickly establishes adhesions betAveen the appendix and the adjacent parts (abdominal wall, intestinal coils). The process may not proceed any further. Generally, hoAvever, it is soon followed by a serous or sero-fibrinous exudation, which becomes sero- or fibrino-puru- lent, and often forms the so-called perityphlitic abscess. The seat of the abscess is ahvays near the tube, and is as varying as the position of the appendix ; its size is also extremely variable, as it sometimes contains enormous amounts of pus. Among the most common locations are— McBurney's point, the vicinity of the cecum, the coils of the small in- testines (near the umbilicus), and, more rarely, in the pelvis below. The pus contained in the abscess is rarely thick, grayish-yellow in color, and emits a fecal odor; more commonly it is thin, turbid, dark-gray or greenish in color, and has an extremely fetid or even gangrenous odor. The process of gangrenous sphacelation en masse is often completed after the limiting wall of adhesion has formed, when the entire appendix is found free in the pus-cavity. The abscess may be subperitoneal, as Avhen perforation occurs into the retro-cecal connective tissue, and the term " iliac abscess " was formerly applied to these extra-peritoneal purulent collections. They are rare, hoAvever, since the early operation has been employed. Their situation and dimensions depend upon the direction taken by the ap- pendix. The latter may pass downAvard, and the pus is then apt to accumulate in the lower part of the iliac fossa, and may point and finally burst in the neighborhood of Poupart's ligament, with subse- quent recovery. Occasionally under these circumstances a fistula remains for an indefinite period of time. The appendix may touch various abdominal structures, and the pus in following the line of least resistance may cause spontaneous rupture into the rectum, bladder, or the vagina Avhen it points inward; and into the perinephric region or into the pleural cavity (through the diaphragm) when it points upward; or even into the cecum or colon. The contents of the abscess may also find their way through the abdominal wall in the vicinity of the umbil- icus. The psoas muscle may conduct the abscess downward, and it may then point at the hip-joint or gain the gluteal regions or the scro- tum, producing the so-called " scrotal appendicitis." The appendix has also been found in a hernial sac. Among the rare lesions to be noted are erosion of one of the arteries of the iliac region (causing fatal hemorrhage) and pylephlebitis. From the thrombi in the mesenteric veins in the latter condition infectious emboli may be conveyed to the liver, giving rise to hepatic abscess; this occurred in a case of my own at the Episcopal Hospital, Philadelphia. The abscess may also be due 814 DISEASES OF THE DIGESTIVE SYSTEM. to an extension of the thrombo-phlebitis of the mesenteric veins that lead from the appendix to the portal vein. Thrombosis of the iliac veins with edema of the corresponding leg may also arise, and these veins may, during the process of healing, become compressed, with a resulting edema of the leg, as I have Avitnessed in tAvo cases. It rarely happens that suppurative processes are both extra- and intra- peritoneal. (b) Acute Diffuse Peritonitis.—This folloAvs perforation when previ- ous adhesions have not taken place or when, having formed, they yield. Generalized peritonitis may also follow the circumscribed form, the lesions being propagated to the entire membrane by direct extension. The morbid changes are those mentioned in the description of Acute Peritonitis. Since the early operation has been employed peritonitis has been the result, usually, of direct perforation before a limiting Avail of adhesion has been formed. Etiology.—Predisposing Causes.—(a) Doubtless there are congenital structural defects that aid in the production of appendicitis. Among them are unnatural length, location, and arrangement of the organ, and peculiarities in the development of its mesentery. These factors tend to obliterate the lumen of the canal by producing kinks and tAvists, thus favoring the collection of material Avithin the appendix, (b) Stric- tures, particularly near the cecal end of the tube, and adhesions due to old inflammation, especially peritonitis, operate in the same manner as the preceding, only with greater poAver. (c) Fecal concretions are the main cause in nearly one half, and foreign bodies in considerably less than one quarter, of all cases. The calculi form in the appendix itself (Rochaz). The foreign bodies are very various, and consist of seeds. Avorms, beans, gall-stones, pills, bristles, and, more rarely, pointed bodies, as fish-bones or pins. The presence of fecal concretions and foreign bodies is often tolerated by the appendix without symptoms or local pathologic changes; hence they are looked upon rather as a pre- disposing than as an exciting cause of appendicitis, (d) Ulcers (tuber- culous, typhoid, and, rarely, actinomycotic) may also produce this affec- tion, (e) Straining Efforts and Traumatism.—Not uncommonly ex- cessive muscular exertion, traumatism, or jarring of the body as in jumping, act as favoring causes. (/) Age.—The disease is especially frequent in young adults betAveen the fifteenth and thirtieth years. It is not very infrequent in childhood, however, after the third year, and it has even been seen in persons over seventy years of age. (g) Sex.—Appendicitis attacks males oftener than females; this fact has been ascribed to a supposed inferiority in the appendicular blood-supply in the male (vide supra), (h) Gastro-intestinal Disturbance.—Indis- cretions in the diet may precede a primary attack, and are of paramount etiologic importance in the recurrent forms of the malady, (i) Heredity. —That this plays no mean role in many cases of appendicitis I have long felt convinced. There may exist the same family tendency to in- flammation of the lymphoid follicles of the appendix as to a like involvement of the lymphoid structures elseAvhere in the body—e. g. the tonsils. This serves as the explanation of those cases in which rheumatism and uric-acidemia seem to act as causal agents, (j) Evi- dence to show that influenza and other affections may cause appendicitis APPENDICITIS. 815 is not Avanting. (k) It is not improbable that poor blood-supply is, after all, the leading predisposing factor, and torsion and the like the active cause. Bacteriology.—AVhile it is true that in many instances there is no apparent exciting cause, yet there are excellent grounds for ascribing specific pathogenic properties to certain micro-organisms. The com- bined results of several experimentalists tend to shoAV that no special organism plays an exclusive role in this disease, but the studies of Hodenpyl indicate that the bacillus coli communis is the bacterium most generally present: it is well known, moreover, that this bacillus becomes pathogenic when it escapes into tissues in Avhich it does not naturally belong. Barbacci emphasizes the etiologic importance of the passage of the intestinal contents into the peritoneal cavity—i. e. the chemical factor. Of other specific bacteria, those of typhoid and tuberculosis are not uncommonly found to be present. The streptococcus pyogenes may also be found to produce the most virulent infection, and the staphylococ- cus pyogenes aureus, the proteus, and other specific organisms have been found. The great frequency of appendicitis is rendered appreciable by the numerous favoring factors (including the congenital conditions) act- ing upon the appendix, Avhich naturally has an exceedingly low vitality ; also by the constant presence of one or more organisms that are knoAvn to become pathogenic in the presence of a slight lesion. Clinical History.—Doubtless many cases are overlooked because of the extreme mildness of the symptoms. These are often attributed to intestinal indigestion or to a "cold," to Avhich the patient pays little attention unless he displays unusual susceptibility. The onset of acute appendicitis may be sIoav and gradual, but oftener it is quite sudden. A clear history of some obvious cause (an error in diet or muscular effort) may be obtainable. Again, preceding the onset of the definite symptoms and extending over a day or two, there may have been certain prodromes, as impaired appetite, nausea, consti- pation, or diarrhea. In slow cases the local and general symptoms are at first slight, but gradually increase in severity as the different stages of the disease are evolved. Indeed, in the latter class the patient may go about his customary duties during the attack with ill-defined rational symptoms, while in reality suffering from periappendicular abscess. These patients run two serious dangers—first, spontaneous rupture of the abscess into the peritoneal cavity may occur; and secondly, the sIoav septic absorption may suddenly overwhelm the system. As a rule, the sudden cases develop in seeming perfect health, and are sometimes heralded by a rigor or chilliness. The characteristic features of the invasion are abdominal pain, fever, tenderness over McBurney's point, circumscribed resistance, gastric dis- turbances, and, as a rule, constipation. The pain varies in intensity from a mere feeling of soreness to that of the most agonizing suffering. It may be paroxysmal, though oftener it is constant, with moderate exacerba- tions. Severe pain points to an involvement of the peritoneum and signalizes a danger of perforation. At first the pain may be referred to any point in the abdomen; later it becomes more distinctly localized in the ileo-cecal region. Elevation of Temperature.—The exacerbations may at first touch 816 DISEASES OF THE DIGESTIVE SYSTEM. 102°, 103°, or even 105° F. (38.8°-40.5° C), and particularly in chil- dren ; more commonly they range from 100° to 102° F. (37.7°-38.8° C). The degree of fever is unreliable, however, as a criterion of the severity of the case, since the worst cases may have a subnormal temperature throughout. M £ M E M E M E M E M E M E M e M E M E M E M E M E M E BOWELS - - ~ " " URINE OAiLY AMOUNT F. 101° 100° 99° 98° 97° -> DATE z 9. < A /' £ / ^ Hi \ t v I \ A / s, A / A / / \ / V I 1 \ , L / V \ , A / V \ A / L/ '\ J V / / n f -. i . . MG A 'ERA TUF E! |12 13 14 15 16 17 18 19 20 21 22 23 24 25 Fig. 58.—Temperature-chart of a case of appendicitis. M. M---, aged thirty-five years; motor- man. Laparotomy, by Prof. E. Laplace, disclosed catarrhal appendicitis with adhesions. An elevation of temperature, however trivial, is most significant, pointing as it does to inflammation as the cause of the local symptoms. The pulse-rate is somewhat higher than the elevation of temperature would lead one to expect, and in bad cases the pulse is usually much quickened. Sometimes, however, it remains at 80 to 90 per minute, and may be full and soft, even though the patient be practically moribund. Fixed tenderness is practically constant on pressure over a limited area, midway on a line betAveen the anterior superior iliac spine and the umbilicus (McBurney's point), and is a most valuable sign. The seat of the tenderness may rarely be found at other points, depend- ing upon the location of the appendix. I have twice observed it in the lumbar, once in the right hypochondriac region, and once below the usual point, in the right iliac fossa. It has also been found in the umbilical and left iliac regions, in the pelvis, and in the groin. In several instances, although I have found it elsewhere in the early stage, it has shifted to McBurney's point later. On the other hand, it may move from the usual position in cases that are alloAved to drag on. When the sensitive area is at McBurney's point, as is the rule, the gentlest pressure often suffices to elicit exquisite tenderness, but Avhen it is situated elsewhere firmer pressure Avith the finger-tips is usually required. Deep pressure ahvays reveals localized tenderness at some point in the abdomen if the case is one of appendicitis. Palpation also detects an abnormal tenseness of the right rectus abdominis muscle. On or about the second day a circumscribed induration manifests itself, followed soon by a fulness and swelling tending to obliterate the depres- APPENDICITIS. 817 sions above and in front of the anterior iliac spine. The position of the indurated area varies according to the location of the appendix, but is usually found at or in the vicinity of McBurney's point. Sometimes a resistant mass of the shape and size of an enlarged appendix is palpable. In such cases peritoneal exudation has not as yet occurred to any great extent. In some cases the induration is diffuse at first, but assumes the usual circumscribed form later; it may, moreover, be so deeply seated as not to be appreciable. The degree of tenseness of the tAvo recti mus- cles—right and left—should be compared, though an absence of tension of the right rectus does not, I feel certain, eliminate the possibility of appendicitis. The results of percussion furnish no certain guide. As a rule, the note on light percussion differs from that on the opposite side; on deep percussion a dull tympany or a circumscribed area of dul- ness can be outlined. This deadness may be due in great part to the presence of fecal matter in the adjacent coils of intestine. While at the start the abdomen may be flattened or even retracted, tympanitic dis- tention afterward appears, particularly in the cecal region, giving rise to exaggerated tympany on percussion. Less characteristic, though still of diagnostic Avorth, are certain other symptoms. At the beginning vomiting usually occurs, unless there be diarrhea, and is attended by more or less nausea; it may con- tinue throughout the course of the attack. In most cases, hoAvever, after a feAv fits of vomiting the symptom disappears, though it may recur if errors in diet be committed or if peritonitis supervene. During the attack constipation is the rule, though diarrhea, which sometimes precedes appendicitis, may also occur at a late stage as a septic symp- tom. There is anorexia, and the tongue is coated. The decubitus is dorsal, Avith the right leg flexed. Frequent micturition (early) and re- tention of urine (later) are not uncommon, the urine having a deep color-tint, and sometimes containing albumin. The case may follow a mild course, terminating in resolution with recovery; or it may be of a severe type and develop perforation, Avith the formation of abscess or diffuse peritonitis. As graphically stated by Fitz, it is impossible to obtain statistical evidence on a large scale of the relative frequency of these alternatives, and hence the frequency of treatment of appendicitis by abdominal section. From all available data, however, it would appear that in more than one-half of the cases the course is light and favorable. If not operated upon early, the fever may continue for three to five days, and then subside, Avith simultaneous abatement of the severe local and general symptoms and Avith the establishment of convalescence. The same amelioration of the symptoms may be brought about by early free purgation, either as the result of salines or, rarely, spontaneously. In these instances resolution takes place even after invasion of the peri- toneum. Small abscesses may be absorbed, and usually in cases ter- minating in resolution perforation has not occurred. Infection of the peritoneal membrane directly through the appendix is not uncommon. In severe attacks perforation may occur, with the development of localized peritoneal abscess or generalized peritonitis (vide Pathology), and it must be remembered that cases that begin gradually may also show a tendency toward perforation. A\Then this event occurs early in 52 818 DISEASES OF THE DIGESTIVE SYSTEM. the course of a severe attack or after a protracted mild appendicitis, the symptoms of local or general peritonitis are superadded. If early, the symptoms pointing to peritonitis are intense; the abdomen swells quickly, and is exquisitely tender, though the physical signs of a tumor are ab- sent. The temperature often falls, and the characteristic vomiting and circulatory collapse appear. Often the generalization of the peritonitis is marked by less violent symptoms. Starting from the seat of circum- scribed inflammation, the pain and tenderness propagate themselves noticeably from day to day until every portion of the peritoneum has been invaded. Besides progressive augmentation in the local features, including the pain, there is a gradual failure in cardiac poAver, as shown by the condition of the pulse ; vomiting also returns, and at last becomes fecal. Death results from asthenia, and sometimes suddenly when un- anticipated. If perforation occurs later, sufficient time has been allowed usually for the inflammation to become circumscribed, in Avhich case the localized abscess is generally intra-peritoneal; it may, however, rarely be extra-peritoneal. The local symptoms intensify, the pain becomes excruciating, and the spot of tenderness may rapidly extend itself in all directions, particularly doAvnAvard. Vomiting sets in, and may become troublesome, and constipation is absolute, not even gas escaping from the rectum. Retention of urine is common. Physical Signs.—Inspection shoAvs distention of the belly, the affected area being especially prominent, with an obliteration of the natural de- pression in the right iliac region. Palpation discovers induration and great tension that soon yield to pressure (doughy), and edema of the skin. If the abscess is superficially seated, fluctuation may be appre- ciated on bimanual palpation. Deep-seated tumors are not uncommon, however, and then fluctuation is detected with difficulty or not at all. An examination per rectum, with a view to determining whether the abscess has gained the pelvis, is highly important. Counter-pressure above Avith the free hand aids materially. In doubtful cases bimanual pelvic examination should not be neglected. Percussion reveals dulness if the abscess be superficial. A tympanitic note, however, is often elici- ted, due either to an intervening coil of intestine or to the gas contained in the sac of the abscess. If active peritonitis and septicemia do not develop, the constitutional as well as the local symptoms may abate, and the patient leave his bed, carrying Avith him, however, the abscess. The latter may point some- where in the right loAver quadrant of the abdomen or in the lumbar region. There is also a strong tendency toAvard spontaneous rupture into the rectum, bladder, vagina, or cecum. Often, preceding the dis- charge of pus into these organs, the latter display marked irritability, particularly the rectum and bladder. There is ahvays the danger that the contents of the abscess may find their way into the general perito- neal cavity. The symptoms of hepatic abscess may develop at an ad- vanced stage. The pus may traverse the abdomen in the upward direc- tion until it touches the diaphragm, Avhen the symptoms of subphrenic abscess may be manifested. Extension through the diaphragm may now occur, causing pleurisy or pericarditis, and a pleuro-fecal fistula may thus be established. The general symptoms undergo a modification, due to the suppurative APPENDICITIS. 819 process. Rigors or a decided chilliness may occur. Diarrhea often succeeds to previous constipation, and drenching SAveats to a dry skin. Improvement and even spontaneous cure may ensue if spontaneous rup- ture into one of the outlets of the body should occur. The fever (Fig, M E M E M E M E M E M E M E M E M E M E M E M E M E M E M E M E M E BOWELS NO. OF MOVEMENTS " ~ ~ - - - " " ~ ~ - - - URINE DAILY AMOUNT F. 105° 104° 103° 102 101" loo -9'/ -9if -97 -DATE I : :s ^ "O £ O. < - EVE N nl s- _E VI 3E R-t rT URE! 25 26 27 28 29 30 31 1 1 2 3 4 & 6 7 8 9 10 Fig. 59.—Temperature-chart of a case of appendicitis. R. C---, aged nineteen years; carriage- builder. A peritoneal abscess was found, while the appendix was becoming gangrenous. 59) may be either remittent or intermittent, and if the localized inflam- matory process be active, the usual pronounced features of septicemia are predominant in the clinical picture. The latter specially grave con- dition often drifts into an extreme typhoid state Avith a hopeless course. Diagnosis.—Typical cases of appendicitis are readily diagnosti- cated. Their recognition rests upon a few cardinal symptoms—viz. the acute development of severe pain in the right iliac fossa, coming on in a person previously healthy and usually under forty years of age ; appendicular tenderness, unilateral induration, fever, vomiting, and con- stipation, or, more rarely, diarrhea. Atypical cases, hoAvever, may offer great difficulty, at least at an early stage in primary attacks. Often the pain is, for a time, referred to a circumscribed area far removed from the usual site of the appendix, and rarely it continues without a change of situation throughout the attack. In the latter case the local lesions may occupy the usual, though oftener they have an unusual, position. Thus, when the pain is referred " due east," or to the left iliac fossa, Avith 820 DISEASES OF THE DIGESTIVE SYSTEM. bilateral induration, the appendix will be found in the pelvis (Deaver). In such instances a rectal and a bimanual vaginal examination are im- perative. It should be an unvarying rule in all cases of severe abdom- inal pain to palpate Avith the finger-tip every square inch of the abdomen if necessary, to find the localized tenderness when it is not found at McBurney's point. The degree of tenderness sustains a close relation- ship to the severity of the local inflammation as long as the condition remains strictly localized, but this relationship is lost Avhen generaliza- tion occurs. With the appearance of a circumscribed induration and of the intense local tenderness and pain it is reasonably sure that per- foration either has occurred or is impending. Perforation, hoAvever, may occur Avithout local induration, and even after subsidence of the acute pain and excessive tenderness. Gangrenous appendicitis is most deceptive. The very acute symptoms, including the fever, may disap- pear, and unless the physician be upon his guard the patient Avill be considered convalescent and be allowed to go about. Rupture of the abscess noAv occurs unexpectedly into the peritoneal cavity, intestines, or some other direction, or a large-sized abscess develops Avith the usual signs and symptoms. Differential Diagnosis.— Typhlitis, and especially the Massing of Feces in the Cecum.—These are truly rare conditions. According to McBurney, 99 per cent, of all typhlitic abscesses are of appendicular origin, and of 400 autopsies by Einhorn 91 per cent, had this origin. Ball and others have performed laparotomy for ulcerative cecitis, but this condition cannot be recognized during life. Stercoral typhlitis is discriminated from true appendicitis by the precedent constipation, which may become absolute, by the dragging character of the pain, the late-appearing fever, and chiefly by the physical signs, which indicate the presence of a superficial, sausage-shaped tumor that is often doughy and extends vertically from a point near the right costal border " south- ward " through the ileo-cecal region. Percussion elicits dulness over the seat of the tumor. The localized tenderness and circumscribed resist- ance of acute appendicitis are wanting, and a thorough emptying of the large intestine usually cures stercoral typhlitis.1 Renal Colic.—The absence of fever and of a localized spot of ten- derness and induration, and the presence of hematuria are points that distinguish this affection. Indigestion.—Digestive disturbances, and particularly pain and vom- iting, accompany appendicitis. AVhen they occur independently of ap- pendicitis, however, they can be relieved, and the appendicular region remains free from fixed pain, tenderness, or tumor. Acute Inflammation of the Gall-bladder, with Distention.—This gives rise to a superficial, mobile, pear-shaped tumor, with or without jaun- dice—features not met with in appendicitis. Osier, hoAvever, mentions a case of the sort in Avhich the diagnosis was undetermined until lapa- rotomy was performed. Perinephric Abscess.—AVithout a clear history of chronic renal dis- ease or of nephro-lithiasis the differentiation cannot be made except by exploratory incision. 1 It is highly probable that the term " stercoral typhlitis " is synonymous with chronic appendicitis with retained feces in the cecum. APPENDICITIS. 821 Carcinoma of the Large Intestine.—This discriminates itself by its peculiar and more chronic history. Acute Peritonitis, due to Ovariatt or Tubal Disease.—To eliminate these conditions the results of a careful bimanual pelvic examination and a clear antecedent history are demanded in many instances. Right ovaritis, OAving to the presence of pain, tenderness in the right iliac fossa, and fever, often closely simulates appendicitis. In the former tenderness is less pronounced, and the organs of utero-gestation manifest certain disturbances of function. A pelvic examination will now com- plete the discrimination. Extra-uterine Pregnancy.—In this condition the menstrual history furnishes important information. There is, in addition, profound col- lapse, due to hemorrhage, Avhen rupture of the adhesions occurs. Ele- vation of temperature is absent. The localized tenderness and in- creased resistance are loAver in the pelvis than in appendicitis. Acute Tuberculous Peritonitis.—As in appendicitis, so in tuberculous peritonitis, pain, tenderness, and fever are present, but in the latter the onset is more gradual, and the signs of tumor and increased resistance in the right iliac fossa are absent. Movable dulness may be present in the tuberculous affection, and not in appendicitis until the peritonitis has become generalized. The lungs are generally implicated in tuberculous peritonitis. Acute Intestinal Obstruction.—AVhen this is due to intussusception there may be signs of a tumor, but not at McBurney's point; the ten- derness over the site of the mass is less intense, Avhile the frequent bloody discharges that are seen in this condition, accompanied by tenes- mus, do not characterize appendicitis. When obstruction is caused by strangulation stercoraceous vomiting is apt to occur, and is absent in appendicitis. Pain, local tenderness, and, not uncommonly, signs of a tumor appear, but elsewhere than at McBurney's point. Some of these instances, however, remain obscure till the diagnosis is set at rest by the surgeon's knife. Hip-joint Disease.—In both hip-joint disease and appendicitis the dorsal decubitus with flexed leg is noted. If the patient be anesthet- ized, however, full extension of the leg and a normal condition of the hip-joint are easily demonstrable in appendicitis. Typhoid Fever.—Mild cases of appendicitis with accompanying diar- rhea bear a close superficial resemblance to typhoid fever. In the latter affection, however, the onset is more gradual and the fever-type more continuous than in appendicitis. In typhoid the stools are someAvhat peculiar, the spleen is SAvollen, there is dulness of intellect, bronchitis and the characteristic eruption attend,—all features that are absent in appendicitis. The diazo-reaction, if present, would strengthen the diag- nosis of typhoid, and a response to Widal's test Avould be conclusive. In appendicitis the local features, and in typhoid the general, are pre- dominant. Dietl's Crises.—In a case of movable kidney Avhich I saw recently 'all the symptoms pointed to appendicitis. An operation was about to be performed when a sudden subsidence in the abdominal SAvelling and local induration occurred. The kidney Avas subsequently detected in an abnormal location (vide Mobility of the Kidney). 822 DISEASES OF THE DIGESTIVE SYSTEM. CHRONIC APPENDICITIS. (Relapsing Appendicitis.) Relapses occur in nearly one-half the total number of persons Avho have suffered from a primary attack of appendicitis. In most of these cases there is constantly present a slight local discomfort during the in- terval ; in a small percentage, hoAvever, there is an entire freedom from uneasiness. The local symptoms in those having had an antecedent peritonitis are more pronounced than in the first attack, but after a number of recurrences the symptoms are likely to be less severe with each subsequent attack. The most constant symptom between attacks is a subacute form of pain that is liable to manifest acute exacerbations with slight fever. Physical fatigue, a strain, and errors in diet causing gastro-intestinal disorder are very likely to induce a relapsing appendi- citis. Chronic appendicitis strongly favors the retention of fecal mat- ter in the cecum, thus forming so-called stercoral typhlitis. This asso- ciation was formerly mistaken for primary typhlitis. The characteristics on which the diagnosis is based during the attack are similar to those detailed under Acute Appendicitis; the course is, however, somewhat more condensed than that of the acute form. In the intervals between the attacks the appendix can be readily ap- preciated on palpation, the method employed by Edebohls being prefer- able: "The patient lies upon his back with the examiner at his side; the latter places his right hand upon the patient's abdomen over the right rectus muscle, opposite the anterior superior spine of the ilium, and presses the left hand upon the right, so that no force is used by the right hand and the tactile sense of its fingers is left undisturbed. The hands are drawn slowly outward, allowing the contents of the abdo- men to slip from underneath them. The coils of intestine can be felt as they escape from under the hand as it presses against the posterior abdominal wall."1 In this way the appendix may be felt as an elon- gated tumor of the size and shape of the little finger. If there be only a slight exudation present, the appendix often appears to be immediately beneath the abdominal Avail. It may, however, be deep-seated, even though the exudation with adhesions be absent. Both pain and tender- ness are pronounced, and particularly if pus be present. The results of chronic appendicitis upon the general health and nu- trition of the patient are quite noticeable, and tend to augment as time passes, if the attacks be frequent or the intervals betAveen them groAv shorter. The chief symptoms are those of a nervous type; emaciation and debility are also observed. The associated nervous symptoms are those of neurasthenia. These patients often become introspective and exceedingly irritable, the mental condition being accounted for, to a great extent, by the consciousness that there is ever the danger of a fresh attack Avith serious possibilities. Differential Diagnosis.—Carcinoma of the Cecum.—This presents many points of similarity to chronic appendicitis. I have under my care at present a lady aged sixty years suffering from chronic appendicitis, whose case had been diagnosticated as carcinoma of the cecum, and for a considerable time my own vieAv coincided Avith that of my predecessor. 1 B. Farquhar Curtis: Twentieth Century Practice of Medicine, vol. viii. RECURRENT APPENDICITIS. 823 The occurrence from time to time, however, of relapses, during Avhich the feces Avere massed in the cecum and fever arose, soon indicated the correct diagnosis. Besides the absence of periodic attacks of fever, the general features—loss of flesh and strength, anemia—are more steadily and rapidly progressive in carcinoma of the cecum. The history of the mode of onset also aids in the distinction. Pain, tenderness, and a re- sistant tumor are common to both affections. Hypochondriasis and Hysteria.—Hypochondriasis and hysteria may lead to the manifestation of morbid feelings simulating those of appendi- citis. Such cases may shoAv merely a greatly exaggerated uneasiness, or such an increase of sensibility as to cause the patient to complain of pain in the right iliac fossa. In addition, there may be localized ten- derness. I recently Avitnessed the removal of the normal appendix from an hysteric female in Avhose family tAvo genuine cases of appendicitis had occurred not long previously. Hypochondriasis and hysteria dis- tinguish themselves by the antecedent history and by the absence of a tumor-mass and of increased resistance ; there is also an absence of localized tenderness if the patient's attention be withdraAvn. In such subjects oxaluria is not infrequent, and it is possible that irritation of the right ureter by the passage of crystals of calcic oxalate, as men- tioned by Cabot, may explain the localizing of the discomfort (Wood and Fitz ). I recently saw a case of this sort in a neurasthenic med- ical student. RECURRENT APPENDICITIS. AVhen successive attacks occur in the same individual at intervals varying from several months to a year or more, each neAV attack is spoken of as a recurrent appendicitis. Severe attacks may succeed light ones, or, conversely, mild recurrent may follow severe preceding attacks. I recall several cases in Avhich rudimentary appendicitis (indi- cated merely by colicky pain) occurred, and lasted from a few hours to a day or tAvo. Often the illness is too trivial to lead the patient to con- sult a doctor. An absolute diagnosis demands, besides the subjective symptom, pain, the presence of localized tenderness (with or without induration), and elevation of the temperature. In several subjects of recurrent appendicitis formerly under m}7 care the last attack occurred three or four years ago. That each new attack may be the last is ahvays to be remembered. Prognosis.—In forming the prognosis in a given case of appendi- citis the same rules may be folioAved as in the case of acute infectious diseases, since to the latter category this affection probably belongs. To estimate the severity of the type of infection, hoAvever, is not a simple matter. Unlike many of the acute infectious diseases, the height of the temperature and, to a lesser degree, the rate of the pulse are un- reliable guides in appendicitis. Broadly speaking, hoAvever, in the severer forms the local process exhibits a strong tendency to spread ; the temperature and pulse are relatively high, and tend to rise Avith the progress of the affection. These are the cases that suppurate or result in perforative peritonitis (often rapidly spreading) and in pericecal abscesses. They are among the gravest of known conditions. Of this 1 The Practice of Medicine, p. 886. 824 DISEASES OF THE DIGESTIVE SYSTEM. fatal group of cases not less than 68 per cent, die before the eighth day. The development o\ fulminant peritonitis or of a peritoneal abscess after perforation is attended by a falling temperature, though subsequently the latter may mount high or become markedly irregular. On the other hand, in the mild types that are included in the name catarrhal appendicitis recovery is the unvarying rule. These lighter cases often lead to adhesive peritonitis—a circumstance that strength- ens the vieAv that they are of an infectious nature. The temperature is only moderately elevated as a rule, and the pulse-rate correspond- ingly quickened. Both pulse and temperature indicate marked im- provement on the third or fourth day, Avhile the pain and localized tenderness disappear. In this connection the deceptiveness of gan- grenous cases must be recollected (vide supra, Diagnosis). The com- plications that are most likely to arise and other points of prognos- tic significance have been fully stated in the Clinical History. The general mortality of appendicitis is about 14 per cent. (Fitz). Im- proved methods, chiefly surgical, of dealing Avith the disease have, however, greatly reduced its death-rate. The prognosis in chronic appendicitis is most uncertain; after the patient has survived several attacks it is on the whole more favorable. Treatment of Appendicitis.—AVhether imminent danger of per- foration exists or not, the physician Avho is called to a case of appendi- citis should request the services of a competent surgeon. Few surgeons subscribe to the doctrine that all cases require operation, but, since it may become necessary to operate at any hour of the affection, the latter should help to settle the important question, " AVhen is operative inter- ference demanded in the individual case ?" The physician Avho does not pursue the course above recommended falls short of his duty, both toward the patient and toAvard the surgeon on Avhose skill he relies to safely re- move the source of danger. It may be that a surgeon's fears are some- times groundless, but I am convinced that there is much truth in the state- ment that physicians too often invoke the aid of the surgeon when the patient is beyond hope of recovery. Surely, in a disease that so often baffles both physician and surgeon, suddenly developing, as it sometimes does, a fatal virulence without previous unfavorable symptoms, they should stand guard together from the moment the case is diagnosticated or appendicitis is strongly suspected. With rare exceptions, I think surgical interference should be recom- mended. The indication for immediate operation is undoubted in all cases of acute appendicitis, Avhether marked by sudden and severe or mild invasion-symptoms, if seen at the beginning of the attack. Obvi- ously, the conditions are less favorable for operation after a case has progressed to the beginning of abscess-formation—i. e. from the third to the fifth day of the illness. It is at this period that the peritoneal in- flammation tends to circumscribe itself by the formation of adhesions, which are, however, not yet strong. Hence, as Richardson has graph- ically stated, it is "• too late for an early operation, and too early for a safe late operation," since there is great risk of infecting the general peri- toneal cavity. AAThether it is Avise to alloAv the appendix to remain after adhesions have been formed in some cases, and to merely drain, cleanse, APPENDICITIS. 825 and pack the cavity, cannot be discussed here. The very mild attacks that develop in the course of chronic appendicitis after numerous previ- ous and improperly treated seizures need not excite alarm. Under such circumstances operation should be undertaken between attacks, when the mortality is practically nil. On the other hand, in cases that have been allowed to drag on until general peritonitis has set in, with threat- ened or actual collapse, the operative treatment might as well be aban- doned. Finally, the most ardent advocate of immediate operative treat- ment is sometimes compelled to rest satisfied Avith medical measures. Such cases are those in Avhich there are associated chronic affections (advanced diabetes, Bright's disease), not to speak of those in which the patient refuses to submit to an operation. General Management.—The patient should be kept in bed in a quiet, well-ventilated apartment, and in no affection is the value of absolute rest in the treatment of inflammation greater than in appendicitis. The diet should be liquid and nutritious, consisting chiefly of pancreatized milk and concentrated broths. All articles of food that tend to undergo fermentative changes, and all carbonated drinks, should be prohibited, since they increase meteorism. The patient should be under- rather than over-fed. At the start, and particularly if a sausage-shaped tumor be present, intestinal irrigation, oft-repeated Avith a view to removing the fecal matter, must be carried forward assiduously. Saline laxatives (Rochelle salts, 3ij—8.0—every hour or two, preceded by a dose of castor oil or a few fractional doses of calomel) are to be administered until the evidence of their action upon the bowels has been definitely noted. There almost never exists a contraindication to the use of saline aperients at the onset of the attack, and they constitute the best known means of obviating, as Avell as limiting, the spread of peritonitis by de- pleting the portal system and emptying the bowels. If commenced early, they may be continued throughout in doses sufficient to produce two or more daily eA7acuations. In the event of a development of evidences of peritonitis Avith pus-formation, salines should be pushed vigorously, unless an operation can be promptly performed. I am aware that many authors advocate Avithholding purgatives when indications of suppuration appear, but I have yet to see a case in which perforation has followed an active saline treatment. I avoid the use of high enemata in progressive cases, since they are more apt than salines to induce rupture of the sac. As regards the use of opium professional opinion is not united, though a general tendency toward the limitation of its use to the mini- mum amount necessary to alleviate pain is happily noticeable; unless demanded by excessive suffering it had better be omitted altogether. When necessary, it is best administered hypodermically in the form of morphin (gr. jL—\—0.0054-0.0081). The greatest objection to the use of opium is its effect in veiling the symptoms that assist the physician in forming a judgment as to the peculiarities in the case. Local Measures.—The suspended ice-bag is an excellent means of combating the pain, and often obviates the necessity of an internal use of opium. Instead of the ice-bag, cloths wet in cold Avater may be applied and changed every few minutes. In the early stage a few leeches may be beneficial in their effect upon the local inflammation. Blisters, however, are rarely advisable, and are particularly objection- 826 DISEASES OF THE DIGESTIVE SYSTEM. able should the patient afterward be submitted to an operation. Mild forms of counter-irritants (mustard-paste) are preferable, though these also render the skin and underlying tissues hard and leathery. Management of Convalescence.—The patient should not be alloAved to leave his bed for several days after the disappearance of all symp- toms ; even the mildest forms of exercise should not be undertaken for at least one Aveek subsequent to getting out of bed. During convales- cence the diet must be carefully guarded, and the bowrels, at all hazards, kept in a soluble condition. It is questionable whether drugs will aid in the absorption of the exudate or assist in resolution. Gentle and per- sistent counter-irritation Avith preparations of iodin Avill be found useful. INTESTINAL OBSTRUCTION. (Ileus) Definition.—An acute or chronic, complete or partial, occlusion of the intestinal canal. Pathology and Etiology.—The causes of intestinal obstruction may be divided, at once most simply and practically, into the (1) acute and (2) chronic forms. In the former variety the narrowing or closure develops very suddenly or rapidly, and usually in the small bowel; in the latter, the large bowel is commonly affected by pathologic conditions that develop slowly and gradually and narrow its lumen; the latter conditions usually occur in persons of advanced years. Acute.—(a) Strangulation.—In the order of frequency, this is first among the causes of acute intestinal obstruction. It is produced most often by bands of adhesion, the result of a former recent or remote peri- tonitis, and is most commonly situated in the right iliac fossa. Incar- ceration of the boAvel from flexions and adhesions not rarely follows upon abdominal section for the treatment of pelvic disease in women. The usually free end of Meckel's diverticulum is sometimes attached to the abdominal Avail, and may thus cause constriction of a loop of boAvel. This diverticulum is the remains of the fetal omphalo-mesen- teric duct, and arises from the ileum about half a meter (1.64 ft.) from the ileo-cecal valve. A similar constricting band is formed by a cord representing one or more of the obliterated omphalo-mesenteric vessels. The adhesive attachment of the free end of the appendix vermiformis may also form an opening through which the bowel may be caught. Internal strangulation (hernia) may be the result of forcing a portion of bowel through a slit in the omentum or mesentery, or into peritoneal diverticula and openings, such as the duodenojejunal fossa (Frcitz's retro-peritoneal hernia) or the foramen of Winslow. Diaphragmatic hernise are not of extreme rarity, and may be either of congenital or traumatic origin. Most cases of intestinal strangulation occur in males during early adult life. (b) Intussusception.—Invagination is the descending " telescoping of one section of the bowel into another," probably caused by a circum- scribed, irregular peristalsis of the intestine. The effect of the latter state in producing invagination may be either a thrusting forward of INTESTINA L OBSTR UCTION. 827 the receiving portion by a contraction of the longitudinal muscular coat (Xothnagel), or a thrusting imvard and doAvmvard of the portion imme- diately above by means of an increased or spasmodic peristaltic action. Thus, a cylindric or sausage-shaped tumor results, varying from a half inch to over a foot (1.3-30 cm.) in length. The layers met Avith in intussusception are the outer or receiving, called the intussuscipiens, the middle or returning layer, and the inner, called the intussusceptum. The seat of invagination is most commonly at the ileo-cecal valve, though it is often found in either the ileum or colon alone. Sometimes the in- tussusception occurs and is detected in the rectum. A lateral or partial invagination, more or less chronic, may also occur, due to the attachment of a tumor Avithin the boAvel. The intussuscepted portion of intestine is usually the seat of perito- neal adhesions and considerable tumefaction, so that in pronounced cases the parts are so firmly agglutinated that reduction is Avellnigh impossi- ble. The engorgement may pass into an intense local inflammation, Avith final necrosis and sloughing, and even the discharge per rectum of the invaginated portion; or a fatal termination may be ushered in by perforation of the boAvel. Intussusception occurs most frequently by far in children prior to ten years of age, in Avhom also the disease is more acute than in adults. Males are more subject to invagination than are females. Invagination is asserted to be an occasional consequence of the ope- ration of circular enterorrhaphy and of lateral anastomosis by plates (Robinson).1 (c) Volvulus.—TAvists of the intestine are met Avith most commonly at the sigmoid flexure of the colon. An unusually long or relaxed mes- entery predisposes to the condition, so that the axis of tAvisting may either consist of the mesentery itself or frequently of the boAvel. Not rarely the pedicle of the volvulus contains both a tAvist and a sharp bend in the boAvel, causing complete acute strangulation. The latter condition may be pronounced in such cases, or at least be hastened, by the accumu- lation of the intestinal gas and of masses of feces, or by boAvel-adhesions to an adjacent stump of omentum (Nieberding). The passive reactive pressure of the coils of intestine and of the abdominal Avails tends also to further confine the enormously dilated and tAvisted loop of bowel to its abdominal state. Knots may be formed by the association of loops of the ileum Avith each other or about the pedicle of a tAvisted cecum. Here, again, males betAveen forty and sixty years of age have been observed to be especially the subjects of volvulus. Chronic.—(a) Fecal Impaction.—Intestinal Concretions.—Accumula- tion of feces (coprostasis) is a common cause of intestinal obstruction, the impaction taking place usually in the cecum or sigmoid flexure. Though not infrequent in children, fecal obstruction is more common in adults (particularly in females), in the hysteric, the demented, and the hypochondriac. Congenital dilatation of the colon may predispose to coprostasis, and an acquired dilatation, Avhich in some cases becomes enormous, is often the result of paresis of a portion of boAvel caused by over-distention for a long period of time. The retained fecal masses may become hard, but for some time permit the passage of soft or liquid 1 Med. Record, Aug. 13, 1892. 828 DISEASES OF THE DIGESTIVE SYSTEM. material through the interstices of the accumulation, until finallv either complete obstruction takes place or the condition is relieved. So severe may the obstruction prove in some cases as to result in inflammation, ulceration, and even perforation of the bowel. Among other causes of obstruction due to abnormal contents may be mentioned enteroliths. These are intestinal concretions formed of various nuclei, as gall-stones, hardened feces, phosphates of lime and magnesia, various foreign substances, and organic derivatives. Balls of tangled ascarides may mass sufficiently to cause obstruction. Gall-stones not infrequently become impacted in the duodeno-jejunal or ileo-cecal regions after ulceration through the duct, except in the case of very small stones, which enlarge subsequently by accretion. Foreign bodies, as pins, buttons, coins, fruit-stones, may also cause obstruction of the bowel. It is stated that even insoluble mineral medicines, as bismuth or magnesia, have caused obstruction by accu- mulation in the intestines. (b) Tuuiors.—Tumors cause a form of chronic obstruction that may at any time develop suddenly into the acute type. They may do so either as—(1) new growths in the wall of the intestine itself, or by (2) com- pression and traction from without. Again, the intestinal neoplasms may be malignant or benign in nature. Carcinoma of the bowel is at once the most frequent and important of these. It may be either cir- cumscribed and annular, causing a gradual narrowing of the boAvel- lumen, or a diffused infiltration of the intestinal wall, commencing either in the mucosa or in its glands (cylindric epithelioma). Its most common seat of growth is the large bowel, about the sigmoid flexure. The mesenteric and retroperitoneal glands are usually secondarily affected. Ulceration of the bowel and catarrhal inflammation of the mucous membrane above the carcinoma may coexist late in life. Sarcoma usually attacks the small bowel, starting beneath the mucosa, and is of the recurrent variety. Regional infection of the mesenteric and retroperitoneal glands (Lobstein s cancer) is also a usual consequence of sarcoma. It may occur in children or in young adults. Benign tumors may be polypoid, adenomatous, fibromatous, and lipomatous. Intestinal obstruction due to compression or traction may be caused by tumors (omental) or by adhesions of the pelvic viscera. (c) Cicatricial strictures cause chronic intestinal obstruction, as after the healing of various ulcers, the cicatrices of which slowly contract. Cicatricial stenosis of the colon is commonly due to the cicatrization of dysenteric ulcers. In the rectum the stenosis is usually a result of a syphilitic lesion. Tuberculous and, very rarely, typhoid ulceration may be followed by stricture of the small intestine. (d) Congenital stricture is rare, and is more purely surgical than the preceding cases. It is often an occlusion or an imperforate condition of the anus (atresia ani), and is only mentionable in this connection. (e) Paresis of Peristalsis.—This condition—called also adynamic ob- struction—while it is a functional affection, is held to be either a cir- cumscribed or diffuse paresis of the intestinal muscular coat. It is caused by some such inflammatory disturbance as enteritis or peritonitis, or even by the manipulations employed in prolonged abdominal sections. In such cases the obstruction is due to an accumulation of feces and INTESTINAL OBSTRUCTION. 829 gases in the paretic portion of the boAvel, causing marked tympanites, vomiting, and constipation. Special Pathology.—The pathologic changes that accompany nearly every form of intestinal obstruction are briefly stated as follows: Accumulative dilatation—Avith hypertrophy in chronic cases—of the intestine above the seat of disorder, and an emptiness, narrowing, and even atrophy beloAv the obstruction. The affected Avails of the boAvel are inflamed, and there is a surrounding acute or chronic peritonitis. Catarrhal and sometimes diphtheritic inflammation of the mucosa may develop. Gangrene, ulceration, and perforation of the bowel, Avith resulting generalized peritonitis, may also ensue. Symptoms.—Acute Obstruction.—There is suddenly developed ab- dominal pain that may follow some abrupt or severe exertion. Early vomiting and absolute constipation are also conspicuous and important symptoms. If the obstruction is high in the small bowel, distressing hiccough and eructations may precede the vomiting. Except for the possible discharge of the intestinal contents below the seat of obstruc- tion, the constipation is usually complete and obstinate. Accompanying the latter condition there is tympanites, Avhich is most marked in ob- struction of the colon. Intermittent and colicky at first (partial obstruction—Treves), the pain soon becomes agonizing and constant. Aromiting, also, alternating with painful retching, is more constant and severe after several hours. The material at first ejected is gastric and mucous; it then becomes bilious, and finally is characteristically ster- coraceous, due, most probably, to the putrid decomposition of stagnated contents above the obstruction. The constitutional symptoms develop early, are intensely threatening to life, and cause rapid and profound depression and collapse. The pinched and pallid features, cool and moist skin, Hippocratic expression, rapid and feeble pulse, the usually subnormal temperature, shalloAV and accelerated breathing, marked thirst, scanty urine, great anxiety and prostration,—all indicate the gravity and danger of the condition. The physical examination will discover a SAvollen, extremely tender, and tympanitic belly. Exaggerated peristalsis of the intestine above the obstruction may be visible on the surface of the abdomen. Bor- borygmi, gurgling, and splashing may be heard on auscultation. Chronic Obstruction.—The symptoms are more dependent upon the special causes operating than in acute obstruction. The fact that early in the case only partial obliteration of the intestinal lumen may be rightly inferred in many of the chronic forms of obstruction has given rise to the discriminating term of intestinal constriction. In gen- eral, the clinical history is one of increasing and intractable constipa- tion, sometimes alternating with diarrhea, due to catarrhal inflammation of the mucosa above the obstruction. Paroxysms of colicky pain and, later, augmenting tympanites, vomiting, and prostration, attend. These symptoms may merge suddenly into those of the acute form of obstruction. The boAvel-movements in chronic obstruction are irregular, infrequent, slight, and sometimes accompanied by pain and tenesmus. The stools consist often of small, hard, ribbon-like, or scybalous masses, and may contain blood and mucus. AVhen the stenosis is in the small intestine, the constipation is less apt to occur on account of the fluidity of the 830 DISEASES OF THE DIGESTIVE SYSTEM. contents. Sometimes, and particularly in old people, the rectum be- comes distended Avith hardened accumulations of feces; there is in such cases a constant feeling of fulness and a harassing desire to defecate, but the attempts thereat are ineffectual. The pain of fecal impaction may be due either to colitis or to peritonitis, and may be referred to the regions of the cecum or sigmoid flexure. In malignant and in cicatricial stenosis there are a prolonged and variable history of constipation, occasional vomiting, localized pain, meteorism, and, in cancerous cases, the development of the characteris- tic cachexia and the progressive emaciation. Physical Examination.—Inspection shows the abdomen to be dis- 'tencled from meteorism, the movements, and contour even, of the coils of intestine in active peristalsis above the seat of stricture being evi- dent. A tumor or the throbbing aorta (excited, perhaps, by pressure of the distended bowel or growth) may be palpated. Tympany and borborygmous noises may also be noted. Diagnosis.—Locality of the Obstruction.—Given the symptoms of a sudden, severe, and exacerbating pain in the abdomen; of marked, and later feculent, vomiting; of absolute constipation and of tympanites and profound, early, systemic depression,—a diagnosis of acute intestinal obstruction may be easily made. The determination of the seat of trouble, however, is often very difficult. First may be mentioned the differential diagnosis betAveen obstruction occurring in the small and in the large intestine. It may be noted of the former that vomiting occurs early, is scanty, and later feculent, while in the latter there is less vom- iting and the vomitus is seldom feculent. Again, in obstruction of the small gut the distention is both less marked and higher situated, Avhile in that of the large gut tympanites is often quite marked, is more cen- tral, is associated Avith tenesmus, and sometimes Avith mucus and blood. If the cause of obstruction be a tumor or stricture, the locality may be successfully palpated or the lower limit of the active coils of hypertro- phied intestine may be defined. In stenosis of the duodenum or jejunum, OAving to the stagnation and decomposition of albuminous substances, the products of Avhich (indol and phenol) are absorbed and partly excreted by the urine, use may be made of the discovery of increased amounts of indican in the urine for diagnostic purposes. On the other hand, in stenosis of the large intestine the urinary test may be negative, since the albuminous elements of the intestinal contents are absorbed before they reach the stenosed portion of boAvel, where stagnation and putrefaction can take place. Examination per rectum with the finger or Avith the rectal tube, by means of liquid distention or gaseous inflation of the colon, may enable us to determine the seat of obstruction in certain cases. The detection of a deeply-seated incarcerated hernia (in the abdominal fossae and pouches, diaphragm, or obturator foramen) is often made only postmortem. Nature of the Obstruction.—This is even more difficult of discovery than the preceding. The following causes of obstruction with their differentiation may be referred to in attempting a diagnosis: Strangu- lation often affords a previous history of peritonitis or abdominal sec- tion or of recurrent attacks of abdominal pain, occurring mostly in young adults. Early fecaloid vomiting is common. INTESTINA L OBSTR UCTION. 831 Intussusception usually gives a negative previous history. The sud- denness of the attack, without appreciable cause, occurring in a child, and associated with colicky pain, tenesmus, and the presence of mucus and bloody stools, and of an elongated cylindric tumor in the right iliac or umbilical regions, however, render this condition easy of diag- nosis in some instances. It is to be noted that absolute constipation and meteorism here are unusual. The intussusception may be felt in the rectum. In volvulus it may be helpful to elicit a history of former constipa- tion and flatulence, Avith evidences of atony of the boAvel, in persons of advanced years, along Avith marked abdominal tympany, tenderness over a distended coil, Avhich may perhaps be outlined (AVahl), a rigid abdomen, and sometimes dyspnea from great gaseous distention. The history in cases of fecal obstruction is nearly always one of obstinate, habitual constipation, and occurs especially in females and neurotic subjects. The onset is gradual; pain is less acute ; and tym- pany and fecal vomiting are less prominent and late in appearance. Fecal masses in the colon and rectum may be palpated, and even in- dented, particularly in the cecal and sigmoid flexures. Dulness is present on percussion, Avith slight tenderness over the tumor. Obstruction due to large enteroliths or foreign bodies may be only surmised; especially is this true when symptoms of appendicitis arise. Biliary calculi may give a history of previous attacks of hepatic colic and jaundice. In the chronic obstructive form of stricture of the bowel due to cica- trices or neoplasmata the history of dysentery, tuberculosis, sarcoma, or carcinoma should be considered. The detection of an irregular tumor and the cancerous cachexia point to malignancy. In obstruction caused by intestinal paresis there is generally a history of a previous enteritis, peritonitis, or celiotomy. The abdomen is smooth, though tympanitic throughout, and there is no perceptible peristalsis. Not rarely it Avill be of therapeutic as well as of diagnostic import- ance to ascertain whether an attack of acute obstruction is primary, or whether it is the terminal exacerbation of a chronic condition, such as carcinoma of the bowel. Here a study of the past history of the patient, as well of the present signs of a probable nature, will afford considerable aid. Differential Diagnosis.—Acute intestinal obstruction must be discrim- inated from acute generalized peritonitis. Acute Generalized Peritonitis. Acute Intestinal Obstruction. Etiology. There is a history of causal conditions or There is a history of previous chronic diseases (ulcer, appendicitis, pelvic in- obstruction or hernia. (The age of fection). the patient if it be intussusception.) Symptoms. An early and considerable rise of temper- No early rise (except in volvulus), but ature ; later variable or may be absent. later with advent of peritonitis. Pain more continuous and diffuse. Pain in short paroxysms and localized. A'omiting is characteristic, but not ster- Vomiting becomes characteristically ster- coraceous. coraceous. Collapse occurs later. Earlier onset of collapse. Slight increase of indican in the urine. Excessive indicanuria, particularly when the small intestine is obstructed. 832 DISEASES OF THE DIGESTIVE SYSTEM. Physical Signs. Distention of the abdomen is usually Less marked (sometimes partial), unless general and marked. the obstruction be situated in the lower segment. Visible peristaltic waves absent. Present and pronounced when the seat of obstruction is low. Tenderness general. Tenderness localized. Signs of effusion appear. Less common, due to secondary perito- nitis. Auscultation negative. Loud gurgling and splashing sounds au- dible on auscultation. Prognosis hopeless. Not so if operated upon early. It must "also be differentiated from acute enteritis, in Avhich (particu- larly Avhen due to toxic minerals) there is more apt to be diarrhea Avith considerable mucus and blood, an elevated temperature, intense gastric pain, associated Avith traces of the poison in the vomitus, as Avell as Avith its effects on the oral mucous membrane, and an absence of marked tympanites and fecal vomiting. There are also localized pain, tender- ness, and tumor, or there may be collapse. The various forms of abdominal colic, as enteralgia, hepatalgia, and nephralgia, should not be mistaken for acute intestinal obstruction after considering the history of the cases, the character and locality of the pain, and the absence of such symptoms as obstinate constipation, fecal vomiting, early collapse, intense local pain and tenderness. Course, Complications, and Prognosis.—A case of acute ob- struction usually terminates Avithin from two to seven days. The chronic form may last weeks, and even months, with progressive emaciation and anemia, until the superaddition of more or less acute symptoms, lasting from ten to fourteen days. As a rule, the prognosis is Avholly unfavor- able, and especially in the acute cases. The chronic forms, due to fecal or other impaction, often recover with the discharge of the disturbing intestinal contents. Life may be prolonged by surgical interference in certain cases if they are taken in their inception. Complications that may occur, as secondary peritonitis, gangrene, perforation, septico-pyemia, and enteritis, are all grave, and only tend to hasten the dissolution. Treatment.—Whilst the treatment of intestinal obstruction is sooner or later essentially surgical, attention to the medical aspect is frequently of prime importance. The first indications for therapeutic interference in acute obstruction are presented by the pain and the incessant vomiting. The former is to be met by hypodermic injections of morphin, which at the same time tend to arrest the excessive peri- stalsis. For the vomiting no other measures are comparable to gastric lavage and starvation. It is well in most cases to withhold food for some hours to prevent retching and aggravation of the condition. The lavage is strongly advised by Kussmaul, Avho claims that both the tension above the seat of stricture and the inordinate peristalsis are thus greatly diminished and, exceptionally, cured. It may be repeated every six hours. A diagnosis of intestinal obstruction having been made with- out having learned the cause or character of the obstruction, cathartics should absolutely not be given. If it has been determined that fecal impaction is the trouble, it is still prudent to avoid purgatives until the CARCINOMA OF THE INTESTINE. 833 main mass has been moved, as in many cases there are both paresis and inflammation at the seat of impaction, so that this class of agents would thus be useless, if not harmful. High rectal injections, copious, steady, and regularly repeated, are to be practised, using for this purpose pre- ferably "a warm saline solution of olive oil" (particularly if scybala be present) administered Avhile the patient is in an inverted position by means of a fountain syringe, so that the flow is readily controllable. The abdomen should be methodically kneaded (a valuable adjunct in the procedure) and the patient at times well shaken. This method of treatment, by hydrostatic pressure, can and must be carried forward Avithout undue violence, and if it be unsuccessful, the intestines are to be inflated from a large india-rubber bag Avith air or hydrogen gas (Senn), of Avhich tAvo to three gallons may be cautiously introduced. Thorough manipulation of the abdomen from beloAv upward, particularly if it be a case of intussusception, may be combined. In the latter con- dition inflation, early and perseveringly applied, cures the majority of instances. In cases of intussusception or strangulation of the bowels these efforts should be continued for tAventy-four hours, when, if the condition is not relieved, immediate operation is to be encouraged and advised. Although the statistics of Fitz show the mortality in cases without operation to be loAver (69 per cent.) than Avith operation (83 per cent.), I am convinced from personal observation that the less favor- able results from abdominal section Avould not obtain if it Avere per- formed in due time. To relieve the excruciating tympanites the plunging of a fine trocar and cannula into the intensely distended bowel, as in case of volvulus, may be required. In chronic obstruction the treatment of the underlying or etiologic conditions and various complications is to be conducted on general prin- ciples. Additionally, the patient's dietary is to be arranged with care, and the boAvels moved with unfailing regularity, by the use of unirri- tating laxatives and enemata. During the periods of threatening com- plete occlusion, Avith pain, the methods advocated above for acute ob- struction are appropriate. If total obstruction persist despite medical treatment, surgical treatment—enterectomy, enterotomy, or other opera- tion, as the circumstances of individual cases may dictate—is required. The after-treatment consists in keeping the bowels active and regular by habit, diet, and an aperient pill if needed. Massage and electricity to the abdomen are found useful at this time. CARCINOMA OP THE INTESTINE. (Carcinoma Intestinalis) Carcinoma of the intestine is perhaps the commonest cause of chronic intestinal obstruction. The stenosis is usually partial, and is due both to compression and to direct invasion of the lumen of the bowel by the growth. Primary intestinal carcinoma is rare in comparison with the occurrence of gastric carcinoma. 53 834 DISEASES OF THE DIGESTIVE SYSTEM. Pathology.—A\rhen carcinoma attacks the intestine it is usually in the form of a cylindric-celled epithelioma, although it may assume the various forms as found in carcinoma of the stomach—namely, scirrhous, medullary, and colloid. The growth may be annular or semipolypoid, or it may occur as a diffuse nodular infiltration of the bowel-walls. Ulcera- tion of the surface of the carcinoma may take place, and the glandular structures of the abdominal cavity sometimes reveal metastatic groAvths. The most frequent seat of intestinal carcinoma is the rectum, and next in order of frequency are the sigmoid flexure, the transverse and descend- ing colon, the papilla duodenalis, the ascending colon, and the lower and middle portions of the ileum. The bowel is dilated above the constric- tion, and is usually filled with an accumulation of fecal matter. The muscular coat is hypertrophied. Below the narrowing the intestine may be small and atrophied. Etiology.—Heredity and advanced age are of chief importance as predisposing causes. AVhether or not antecedent intestinal ulceration may afford a probable nidus for carcinomatous growths is scarcely be- yond conjecture. Symptoms.—A description of the course of rectal carcinoma be- longs more properly to surgical works. The chief symptoms are pro- gressively increasing distress and radiating pain in the rectum; these occur, at first, during defecation only, but later almost constantly. There may be diarrhea alternating with constipation, and the feces often con- tain blood and mucus. Gradual bodily wasting and increasing mental anxiety are associated. Paralysis of the anal sphincter and consequent incontinence may ensue. The symptoms of carcinoma of the bowel above the rectum are often vague, and vary according to the portion involved by the neoplasm. With or without an appreciable tumor in the abdomen the clinical his- tory is usually that of chronic obstipation of the intestines. There are irregular attacks of sharp, colicky pains, especially a few hours after eating, distressing defecation, obstinate constipation, perhaps alternating with diarrhea, sometimes vomiting, which may be feculent, and not rarely slight meteorism. The special symptoms of carcinoma of the papilla of Vater are vomiting, jaundice, and colic. The progressive emaciation and debility of the patient are marked. In advanced cases of stenosis the feces are passed in small, compressed lumps resembling sheep's dung. Physical Examination.—Inspection of the abdomen may show the presence of a tumor produced by the carcinomatous growth along the line of the sigmoid flexure or colon ; peristalsis may be seen above the site of the carcinoma, communicating its movements to the abdominal walls. Palpation may be resorted to in order to confirm the above, and the growth is then frequently found to be nodulated. Percussion may give either dulness or a muffled tympany over the tumor and for some distance above, on account of accumulated masses of feces. This area of impaired intestinal tympany may be sharply defined by a clear tym- panitic note elicited over the empty boAvel beloAv the groAvth. Diagnosis.—This may rest, in some cases, upon heredity, the age, the evidences of the cancerous cachexia, sharp, radiating abdominal pains, bloody stools, and the detection of a more or less firm and nod- ular tumor. CARCINOMA OF THE INTESTINE. 835 Differential Diagnosis.—(a) Carcinoma of the boAvel above the rectum needs to be discriminated from other abdominal tumors. The presence of the folloAving may render the diagnosis of carcinoma during life Avell- nigh impossible: sarcomata, fibromata, myomata, adenomata, and cys- tomata, all of which may produce symptoms of obstruction like those due to carcinomatous growths. The cancerous cachexia may be simu- lated by other conditions. The advanced age of the patient and the distressingly rapid and downward progress of the disease Avill, hoAvever, point toAvard malignancy. Fecal tumors, enteroliths, and foreign bodies may need to be excluded also. Fecal masses have been mistaken for carcinoma, and when it is recollected that such may exist above and overshadow the presence of carcinoma of the intestine, the difficulty in differentiating the two is quite obvious. (b) The portion of the boivel involved by the neoplastic growth is also difficult of definite diagnosis, except when it occurs in the rectum, Avhen the digital and visual examination of the parts, supplemented, it may be, by microscopy, are sufficient. The locality of the tumor as detected by palpation, associated Avith special symptoms, is of value in arriving at a diagnosis of the diseased portion of bowel. Thus, a hard, nodular mass felt in the low7er epigastric or upper umbilical region, and increas- ing gastric dilatation, Avith marked and persistent jaundice, Avould indi- cate probable carcinoma of the duodenum, with complete or partial closure of the common bile-duct. It is apparent, hoAvever, that carci- noma of the pylorus, of the left lobe of the liver, or of the omentum or mesenteric glands, or a thickened cecum might all be easily confounded with carcinoma of the boAvel at various adjacent parts of its course. The injection of fluid into the bowrel may be resorted to in locating the probable situation of the groAvth. Thus, if obstruction from carcinoma exists in the sigmoid flexure, liquid will be arrested there and the rec- tum distended, Avhile, if the stenosis be high up in the large or small intestine, the colon will be found comparatively emptied of feces and will be distended with the injected liquid. The history of the case and a careful exclusion of factors not common to carcinoma, presumably in the locality under observation, together with repeated physical ex- aminations, must all be brought to bear in arriving at a diagnosis. Course and Complications.—Carcinoma of the intestine some- times runs a rapid course, and, symptomatically at least, lasts but a few months or even weeks; in the scirrhous variety, however, the disease may last two or three years. Intestinal carcinoma may perforate the boAvel and cause fatal puru- lent peritonitis, and carcinoma of the rectum may perforate and invade the vagina and bladder, causing purulent vaginitis and cystitis. Or, owing to extreme distention by fecal accumulation betAveen a cancerous stricture of the sigmoid flexure, for instance, and the resistant ileo-cecal valve, rupture of the colon, folloAved by a terminal peritonitis, may result. Extension of the groAvth into surrounding tissues, Avith ulceration, may lead to cellulitis, phlebitis, and pyemia. The prognosis is almost hopeless. Treatment.—This, from a strictly medical standpoint, is simply palliative. The diet should be highly nourishing and easily assimilable, but Avhen the symptoms of acute obstruction supervene the administra- 836 DISEASES OF THE DIGESTIVE SYSTEM. tion of food by the mouth is contraindicated. Attention to the state of the boAvels by the use of enemata, or of the aloin, strychnin, and bella- donna pill is necessary in most cases. Opium or cannabis indica for the pain, and stimulants for the depression, may also be serviceable. Lavage of the stomach gives decided relief Avhen decomposing mat- ters tend to cause regurgitation on account of the damming back of accumulated food-detritus. Carcinoma of the boAvel may be treated surgically by colotomy, ex- cision, lateral anastomosis of the bowel, enterostomy, and, if the groAvth be situated in the rectum, by extirpation by means of sacral resection (Kraske's operation). HABITUAL CONSTIPATION. (Costiveness) Definition.—Chronic fecal retention, habitual infrequency, irregu- larity, difficulty, or insufficiency of the evacuations of the bowels. Although constipation is a symptom, and although habitual consti- pation is frequently a symptom of chronic disease, the causal elements of the latter may be so indefinite and obscure that the former takes on all the individual importance of a functional affection. I describe habit- ual constipation, therefore, as a disease suigeneris ("idiopathic"). Etiology.—In the majority of cases habitual constipation is the direct effect of a lack of expulsive or peristaltic poAver, and also of a deficiency of the hepatic and intestinal secretions. Tavo sets of causes operate to bring about these conditions of abnormal defecation: General Causes.—(a) Temperament: it has been observed often that people of a nervous and "bilious" or motive temperament, of the dark type—brunets with a predominating nervo-muscular susceptibility— are much troubled with inherent constipation. Anemic brunets—per- sons having pale skin and dark hair combined—are particularly so affected, although alternating periods of diarrhea may supervene, owing to the hydremic state of the blood. "Torpid liver" and "sluggish boAvels " are commonly held to be synonymous with these physical cha- racteristics, (b) Habit: a sedentary life conduces to secretive inactivity. Thus, a lazy life, in which the calls of nature are irregularly attended to or habitually neglected, leads to frequent over-distention of the rectum and paresis, a common cause of chronic constipation. Again, the femi- nine false modesty (so called) that prompts a postponement and suppres- sion of the desire to defecate in public places, as well as the habitual, hurried performance of the act in illy-kept, uncomfortable, and unsani- tary closets,—all these tend to obtund the sensibility of the bowel to fecal masses in the rectum. The accumulation of these fecal masses causes paralytic over-distention, their hardening into scybala, and diffi- culty of expulsion, (c) General bodily weakness, and diseases, as neur- asthenia, hysteria, anemic brain- and spinal-cord affections (causing inhibitory disturbances of the intestinal nerve-supply), acute fevers, hepatic disorders, especially the presence of jaundice, and the habitual HABITUAL CONSTIPATION 837 dependence upon and use of purgatives, (d) Diet: the constant use of concentrated articles of food, as meats, in which little residual mat- ter is left to stimulate the bowel to peristalsis. On the other hand, a very coarse diet may leave such an excess of residue as to cause fecal impaction, (e) Abundant and prolonged diuresis and diaphoresis, by causing loss of fluids, also may induce chronic constipation. Local Causes.—(a) Atony of the abdominal muscles from obesity or, in females, as a result of many pregnancies, (b) Atony of the large bowel (the sigmoid flexure in particular) from chronic colitis, (c) Pres- sure by tumors, (d) The presence of intestinal stenosis from external or internal constriction, (e) Congenital stricture or giant growth of the colon, Avith coprostasis (as in Formad's case) (Functional Neuroses of the Intestines, vide p. 844). Symptoms.—In cases in which there is no adequate cause for habit- ual constipation other than a constitutional and perhaps an inherent pe- culiarity there may be the appearance of perfect health. Nothing is complained of save the fact that an evacuation of the boAvels occurs too infrequently. It should be borne in mind here, however, that the term " constipation " is, individually speaking, almost wholly a relative one— i. e. one person may enjoy good health with but one evacuation every other day, another Avith tAvo passages per diem, Avhile still another must have one stool a day, ccetcris paribus, to feel perfectly Avell. The last is usually considered an average normal state Avith most people. Persons such as are instanced above, in apparently good health, but observing that they have to defecate less often than many others, sometimes groAv anxious, worried, and even hypochondriac, until assured that they are not truly constipated if enjoying perfect physical ease. Symptoms of habitual constipation may be direct or reflex. Direct or local troubles are seen in the feeling of fulness, weight, and pressure in the perineum and abdomen. Flatulence, colicky pains, and alterna- ting diarrhea occur not infrequently. The hurried and inattentive per- formance of defecation gives rise to the so-called " cumulative constipa- tion," in Avhich the accumulated feces are but partially evacuated with the movement, and the rectum consequently is not emptied. A sense of fulness then remains, and complete relief is not felt in these cases. Reflex and general symptoms are malaise, languor, hebetude, irrita- bility of temper, headache, facial flushing, palpitation, cold extremities, anorexia, vertiginous attacks, paresthesia, menstrual distress in women, sleeplessness, and bad dreams. Pressure on the sacral and visceral nerves may cause neuralgias. The tongue is coated. Palpation of the abdomen often shows the presence of doughy-like fecal tumors at the cecum or at the hepatic, splenic, and sigmoid flexures, or of bologna- like masses at intervening places. In marked cases attacks of nausea and vomiting, Avith diarrhea, may ensue; fever may also be present, and typhoid fever even may be simulated (Meigs). Complications and Sequelae.—Hemorrhoids, ulcerative colitis, perforation, and enteritis may be associated with chronic constipation. Not rarely do Ave have as results dilatation of the colon or sacculation, Avith the presence, in old people mainly, of enteroliths (calcified scyb- ala); also intestinal obstruction and typhlitis, or cerebral hemorrhage or hernia from violent straining efforts. 838 DISEASES OF THE DIGESTIVE SYSTEM. Diagnosis.—Bearing in mind the relativity of constipation in dif- ferent individuals, the diagnosis is read at sight. The detection of the causes is not difficult, though sometimes tedious. Hypochondriasis or melancholia should be carefully placed either as precedent to or conse- quent upon chronic constipation, the nervous condition often acting to produce the latter, and vice versd. The prognosis is usually favorable, but should be guarded. Treatment.—Hygienic.—Causative factors must, of course, be re- moved, modified, or lessened. Systematic regularity as to time and frequency and sufficiency of movements of the boAvels should be en- joined upon and practised by the patient. Exercise is of signal value, and particularly horseback riding or gymnastic motions that bring the ab- dominal muscles into play. Attention to the calls of nature should be esteemed a duty, and proper time and heed must ahvays be given to the completeness of defecation. Young girls especially should be in- structed in this regard. The wholesale SAvallowing of cathartics is to be vigorously combated. The dietetic regimen, if properly looked after, often avails much in relieving this affection, and foods calculated to be easily digestible, but leaving a moderate residue after digestion, are to be recommended. Such are bread made of unbolted flour, plenty of vegetables and fruits, butter, and such laxative articles as figs or honey. A glass of cold water taken regularly at bed-time and in the morning before breakfast is efficacious and a point of common knoAvledge. Remedial.—The methods and means offered for the cure of chronic constipation number legion. From the little aperient pill or " peristaltic persuader " to the cannon-ball rolled externally along the course of the large boAvel is made up such a list of drugs and measures as to leave un- tenable any plea of lack of resource that may be advanced. Drugs occupy a subordinate part in the treatment of habitual constipation. Indeed, their use should be restricted mainly to those periods when the boAvels become unusually obstinate and Avhen a more or less free movement is urgently needed. That the constant use of laxative and purgative drugs tends to a confirmation of the condition, and its ulti- mate resistance to the action of cathartics Avhen circumstances will have required their use, is familiarly knoAvn. I have found of value, especially in lithemic and dyspeptic subjects, the laxative bitter waters, as Hunyadi Janos, Kissingen, Friedrichshall, and Carlsbad. Drugs employed to unload a filled bowel may at times be used spar- ingly and in the smallest adequate quantities; the mildest forms should be selected. Since the constipation is only temporarily relieved by catharsis, the frequent use of strong purgatives in large doses only tends to render the bowel accustomed to their use; it then gradually becomes irresponsive to the most drastic drugs. Among those laxatives and cathartics most commonly used may be mentioned aloes, rhubarb, Rochelle and Epsom salts, compound licorice poAvder, castor oil, jalap, senna, mercury, colocynth, and podophyllin. Important adjuncts in combination with one or more of the above are the extract of nux vomica (or strychnin) and the extracts of belladonna, hyoscyamus, and physostigma. The much-used aloes, strychnin, and belladonna pill can be used for a considerable length of time in the hope HABITUAL CONSTIPATION 839 of stimulating a normal intestinal and sphincteric activity, and thus in- ducing even a cure in some cases. The formula may be made up as follows: B/. Aloin., gr. iij-v (0.194-0.324); Strychninae sulphat., gr. ^-1 (0.0216-0.0324); Extr. belladonna, gr. ij—ijss (0.129-0162). M. et div. in pil. No. xx. Sig. One pill at bedtime. Sulphur in confection, along Avith the official pill of aloes and iron, has been recommended for the habitual constipation of anemia. In senile atony of the bowel, Avith much flatulence, a laxative pill having in combination asafetida or capsicum is often beneficial. The subjoined formulge are also rationally and empirically service- able in chronic constipation : B/. Ext. cascar. sagrad., 3ss (2.0); Ext. nucis vomicae, gr. iv (0.259); Ext. physostigmat., gr. iij (0.194); Ext. belladonna, gr. ij (0.129). M. et ft. in pil. No. xx. Sig. One at night, or night and morning. (Aloes, gr. j (0.0648), or podophyllin, gr. TV-| (0.005-0.0108) may be substituted for cascara in the foregoing formula.) Or, B/. Ext. colocynth. comp., gr. xxx-xl (1.94-2.59); Ext. hyoscyami, gr. x-xx (0.648-1.29); Ext. nucis vomic, gr. iv (0.259); Ext. gentianae, gr. xx (1.29). M. et ft. in pil. No. xx. Sig. As above. The mechanical means of relieving habitual constipation, as by enemata, are injurious if long continued, by reason of their irritating effect on the rectal and colonic mucous membrane, as well as on account of their tendency to become incompetent. At times, Avhen the stomach is weak or irritable, a loaded bowel may be relieved by an ordinary enema of soap and water or by one containing ^ to 1 ounce (16.0- 32.0) of castor oil, with 1 or 2 drams (4.0-8.0) of oil of turpentine if there be some flatulence. Glycerin enemata, containing from ^ to 2 ounces (16.0-64.0) of the agent, may be used. Suppositories of soap, molasses candy, or glycerin are included in the armamentarium. Mas- sage also claims an important part in the relief of habitual constipation. It acts by stimulating the peristalsis and the abdominal muscles, and should be employed at set times in the day preceding a desired evacu- ation of the bowels. The hand of the masseur, or that of the trained patient even, when systematically used in this way, may be effectual AA'hen all other means have failed. The regular rolling of a metal ball along the course of the greater gut may be mentioned for its novelty as well as for its undoubted efficacy. The application of the faradic cur- rent to the abdominal walls or galvanization of the lumbo-abdominal 840 DISEASES OF THE DIGESTIVE SYSTEM. circuit deserves proper trial in many cases. Hydro-therapeutic meas- ures, or cold sponging and baths, are nearly always useful adjuncts in the treatment of this often stubborn affection. DILATATION OF THE COLON. (Ectasia of the Colon.) This is usually a chronic condition, though not rarely it is acute. It may also be general, but in the majority of cases it is confined to the colon, and particularly to the sigmoid flexure. The postmortem findings are those of hypertrophic dilatation of the bowel, and rarely (as in a case of Rolleston and Hay w7ard ) ulcerative and catarrhal lesions of the in- testinal mucosa are noted. The sigmoid flexure is prone to become di- lated in subjects in whom it is congenitally elongated. Mya2 believes that the condition is due to a faulty development and not to fetal dis- ease. The most distinctive features are constipation, Avhich generally dates from infancy, and great abdominal distention. In the case of Rolleston and HayAvard peristaltic waves ay ere visible upon the surface. The condition may fluctuate, constipation alternating Avith regular daily movements, and the distention changing to a normal softness of the ab- dominal parietes in some instances. I have recently seen a case of this kind in a male aged tAventy-seven, in Avhom the affection had commenced in infancy. In the treatment of the constipation resulting from congeni- tal ectasia of the colon, lavage of the intestine with a very long tube is superior to laxatives or purgatives. NEUROSES OP THE INTESTINE. As in the case of the stomach, these embrace derangements of (a) secretion, (b) sensation, and (c) motion. (a) SECRETORY DISTURBANCES. Unquestionably the intestinal secretion may, through a purely ner- vous influence, be augmented. This manifests itself most frequently in the primary morbid secretion of mucus (mucous colic) and in membranous enteritis. Moreover, the fact that an actual catarrh of the intestinal mucosa may supervene as a secondary event is undeniable. MEMBRANOUS ENTERITIS. (Enteritis Membranacea) Definition.—A peculiar pathologic condition, chiefly of the large intestine, attended by a morbid secretion of mucus. Pathology.—In the truly primary form there are no morbid lesions 1 British Medical Journal, May 30, 1896. 2 Lo Sperimentale, 1894, fasc. iii. p. 215. NEUROSES OF THE INTESTINE. 841 discoverable in the mucosa. Osier states that the membrane is due to a derangement of the functions of the mucous glands the nature of which is unknoAvn. My own vieAv is that this is a secretory neurosis, and that the catarrhal process may develop as a secondary event. Etiology.—Sex has a decided influence; according to AY. A. Ed- wards, not less than 80 per cent, of all cases occurring in adults are noted in women. Hysteric females and those of a highlv neurotic con- stitution are the most frequent victims of the disease, AA-hich is rare in children. Symptoms.—I have found the condition to be invariably associ- ated Avith a decidedly constipated habit—a fact that may, in part, ex- plain its occurrence, since time is thus allowed for the formation of the membrane. The most important clinical feature is the passage, at vary- ing interA-als, of long, ribbon-like threads of mucus or of more or less perfect casts of the gut, the act being attended Avith tenesmus and severe colicky pains. The composition of the stools has been thoroughly in- vestigated by M. Rothmann and 0. Rothmann and C. Ruge. They " consist of a uniformly turbid ground-substance, which, on the addition of acetic acid, becomes opaque and striped. It is interspersed with a cellular detritus, consisting partly of strongly refractile granules and partly of cellular elements, desquamated epithelial cells, round cells, and peculiar glossy flakes. There are also found cholesterin-crystals, needles of fatty acids, triple phosphates, remnants of undigested food, pigment- granules, many bacteria, and occasional red and Avhite corpuscles." The individual paroxysms vary in duration from one to ten days or more. In one case observed by me the attacks lasted about tAvo days, recurring regularly at the end of every three months. Ordinarily the recurrence is after a shorter interval. Diagnosis.—It is important to make a microscopic examination of the pieces of membrane. If, Avhen thus examined, mucus, cylindric- celled epithelium, a feAv round cells, and the other elements already mentioned are found present, the diagnosis of mucous enteritis is un- doubted. It is to be recollected, however, that membranes are not passed with every attack. Course and Prognosis.—The disease pursues a very chronic course and lasts for many years. The bodily nutrition suffers consider- ably if the attacks are frequent and severe, though, as a rule, this does not occur until a late stage in the affection. The risk to life, it is need- less to say, is slight. (b) SENSORY DISTURBANCES. It may be noted here that the sensory nerves of the intestines, as well as the inhibitory and vaso-motor dilators, are traceable to the splanchnics. Increased sensibility of the sensory nerves produces— ENTERALGIA. (Neuralgia of the Intestine.) Etiology.—This is commonly met with in hysteric, neurasthenic, and anemic subjects. It occurs as a reflex neurosis, as in the case of 842 DISEASES OF THE DIGESTIVE SYSTEM. cold, gout, and irritative lesions of the pelvic organs (kidneys, liver). Enteralgia is symptomatic of many local affections and conditions that induce direct irritation of the sensory nerve-filaments of the in- testine ; among these are inflammation of the mucosa, foreign bodies, gall-stones, abnormal distention with gas, and enteroliths. Under these circumstances the condition is associated with increased activity of the motor nerves or heightened contraction of the muscularis, forming true intestinal colic. In lead colic it is probable that the lead acts directly upon the nerves or their ganglionic cells. I have repeatedly observed the action of certain exciting causes, and particularly of nervous shocks. Symptoms.—Enteralgia may develop very suddenly, but oftener it sets in less abruptly, and is then attended Avith eructations of gas, ex- pulsion of flatus, and the like. In the fully-developed attack the pain may attain to great violence, causing the patient to "bend double" or even faint, and its character is variously described as boring, tearing, or cutting. The pain may be confined to a circumscribed spot or may be diffuse. The attacks are sometimes brief, or they may be character- ized by a sudden subsidence. At other times they last for days or per- haps weeks, and then subside gradually. Recurrences are common, but the intervals betAveen the attacks vary extremely in duration. Hypogastric neuralgia is a term applied to neuralgia affecting the sensory nerves lying in the most dependent segments of the intestine. Here the nerve-fibers entering into the hemorrhoidal plexus are involved. It is caused chiefly by tabes, by hemorrhoids, and by the neurotic state so common to females. This form of neuralgia has its seat in the hypo- gastric region, and is accompanied by a distressing sensation of pressure in the rectum and bladder, and by an irresistible desire to go to stool; pains also radiate to the sacrum, thighs, and perineum. Diagnosis.—The various organic diseases and conditions mentioned under Etiology, in the course of which colic is a common symptom, must be separated from the true neurotic enteralgia. The former are distin- guished from the latter by a group of symptoms peculiar to themselves (fever, aggravation of the pain upon pressure, vomiting, constipation, or diarrhea), and by the usual definite causes furnished by the history. Renal and hepatic colic bear a superficial similarity to enteralgia. The former conditions, however, are distinguished first by the seat and direction of the pain, and secondly by the appearance of jaundice in hepatic colic and of hematuria in renal colic. Rheumatism of the abdominal muscles is easily eliminated, since it is generally combined Avith rheumatism in other parts of the body; the pain is also greatly increased upon throAving the muscles into contraction, as in stooping or rising; finally, it vanishes in response to the action of the salicylates. DIMINISHED INTESTINAL SENSIBILITY. This implies diminished peristalsis or constipation. A greater or less degree of anesthesia of the bowel attends, with a loss of desire to go to stool and an accumulation of feces in the rectum. This is a usual concomitant in many diseases of the brain and cord, with which paraly- sis is associated. Motor innervation may remain intact, and when atony NEUROSES OF THE INTESTINE. 843 of the intestine is absent spontaneous movements of the bowels occur; when atony is present, however, to a marked degree (motor paralysis), the feces must be artificially removed. (c) DISTURBANCES OP MOTILITY. AVhen the contractility of the muscularis is increased from purely nervous causes the result is— NERVOUS DIARRHEA. This condition presents no morbid lesions. The increased contrac- tility results from an exaggerated irritability of the motor nerves of the boAvels. It may also result from morbid processes in the central nervous system and in other organs of the body; in short, the condition may be a reflex one. Examples of this sort are caused by tabes, by gastric disturbances, as after certain foods and drinks, by dentition, and the like. Most cases, hoAvever, are encountered in persons having an abnormally irrita- ble nervous organization—i. e. the neurasthenic and hysteric classes. In such the effect of mental excitement, of fright, and similar pyschic influences is to induce diarrheal evacuations. Symptoms.—The stools vary in number from two or three to tAventy-four or more daily. In rare instances they are soft—not truly diarrheal—and formed, yet they may be quite frequent. Blood and mucus, pus, and other morphologic elements are absent from the de- jections. It is characteristic of nervous diarrhea that the stools follow one another in rapid succession, usually during the morning hours, and then discontinue for the greater part of the day. The bodily nutrition is often well preserved. In the diagnosis organic affections of the bowel are to be carefully eliminated. ENTEROSPASM. (Spasm of the Intestine.) By this term is meant a concurrent spasm of both the longitudinal and circular muscular fibers, usually inducing spasmodic constipation, and sometimes total, though temporary, occlusion of the bowel. Its causes are similar to those of nervous diarrhea, and the condition is clinically related to enteralgia. Neither pain nor constipation, how- ever, is a constant feature. The stools may assume the form of a rib- bon or of large rounded masses (sheep's dung), but they are not pathog- nomonic. They may also be covered with mucus. Evyald distinguishes between an idiopathic and a secondary or symptomatic spasm, the lat- ter being a concomitant of basilar meningitis and of chronic lead- poisoning. Another variety affects the rectum (proctospasm), and is generally secondary to some other rectal affection, as fissure of the anus; it may, however, occur as a neurosis in the hysteric and nervous class of subjects. The diagnosis of true functional enterospasm can only be made after all organic causes that may produce spasm of the boAvel have been excluded. 844 DISEASES OF THE DIGESTIVE SYSTEM. CONSTIPATION. This is a common condition as a functional neurosis. It is due to an abnormality of function of the intestinal nerves that leads to a Aveak- ened peristaltic action, and is met Avith in hysteria, neurasthenia, and in those suffering from the various forms of psychoses. Central nervous affections often manifest atony of the intestine as a symptom ; hence this form is not a disease sui generis. Cases of this class do not respond to any variety of cathartics, Avhether these act upon the small or large intestine (Ewald). Paralysis of the external sphincters is a common concomitant in a great variety of local (catarrhal) and central nervous diseases. Under these circumstances the act of defecation may be purely reflex, OAving to loss of control of the voluntary muscles ; or it may be voluntary, ex- cept Avhen the person affected is not upon his guard, or during mental excitement, micturition, sneezing, and like influences, the latter condi- tion being a mere Aveakness. Treatment of Intestinal Neuroses.—A suitable change of en- vironment, including an appropriate arrangement of the dietary, is of primary importance, and is uniformly applicable in this class of sufferers. Further, the treatment of special cases has peculiar reference to the character of the nervous derangement. After making an accurate diag- nosis a search for the factors of the greatest etiologic importance should be made, and these must then be vigorously assailed. In the secretory neuroses an associated membranous enteritis must be corrected, the digestion must be improved if faulty, and the obstinate constipation overcome. For the latter symptom enemata containing ox- gall, either alone or in combination with salines, are especially service- able. Kussmaul and Fleiner have obtained the best results from reg- ular large oil-enemata administered once or twice daily. During the painful attacks simple enemata, repeated every couple of hours, Avill sometimes bring speedy relief by facilitating the removal of the scybala, and will assist natures efforts at separating the adherent membranes. Pain must be relieved by morphin. In the sensory disturbances in Avhich the activity of the sensory nerves is increased (enteralgia and hypogastric neuralgia) the treatment may be considered under two headings : first, the relief of the neuralgic pains ; and secondly, the correction of the causes or conditions on which the enteralgia depends. If the pain be severe, opium or morphin may be required. Especially good as an antispasmodic is codein, Avhich may suffice in all save the severer cases. The object should be to give the minimum amount of the opiate that will meet the necessities of the case, with a vieAv to obviating a resultant constipation. In hypogastric neuralgia I have found suppositories containing opium to be little short of magical in their effects. In cases in which there is constipation due to diminished sensibility, with a loss of motor innervation (atony of the bowel), the feces must be artificially removed unless the underlying condition can be successfully overcome. It is especially important that the environment—physical and psychic—be so regulated as to bring about an improvement in the gen- DISEASES OF THE LIVER. 845 eral condition of the patient. It may become necessary to employ tonic preparations of strychnin, iron, or arsenic. The treatment of nervous diarrhea involves the same principles, so far as the indication presented by the peculiar nervous organization is concerned, as in the sensory and secretory neuroses. It is especially important to prevent the operation of the direct causes—fright, mental excitement. Astringents and intestinal antiseptics are not called for, unless the bodily nutrition be affected thereby. Enterospasm is to be met by the same remedies that are used to control enteralgia. IX. DISEASES OF THE LIVER. ANOMALIES IN SHAPE AND POSITION. Altered Shape.—Occasionally malformations of the liver are met with that materially alter the shape of the organ, either primarily when the result of disease, or secondarily from pressure of adjacent structures. Of the latter class the most important cause is tight-lacing, met with almost exclusively in Avomen and producing the so-called " corset liver." The lower part of the right lobe of the liver is usually the part affected ; the hepatic parenchyma is atrophied, OAving to continued compression, and shows deep grooves that correspond to the position of the lower ribs. The connective-tissue capsule and the peritoneal coat are both thickened at this point, the smaller blood-vessels often being entirely obliterated. In marked cases the right loAver lobe may become con- verted into a dense fibrous band, Avith only a vestige of the former liver- structure remaining. Among other acquired causes of anomalies in the shape of the liver may be mentioned deformities of the vertebrae and ribs, or tumors of the ribs or adjacent structures (the pylorus, omen- tum) pressing against the liver. Diagnosis.—Rarely, clinical symptoms are present. "A constant sensation of pressure and pulling is felt in the hepatic region, and sometimes, as a result of venous stasis, there is a temporary but decided SAvelling of the isolated portion, and, possibly, violent pain and indica- tions of irritation of the peritoneum, such as Aromiting and an approach to collapse. Jaundice is rare in consequence of this deformity" (Striim- pell). The danger of this condition lies in a possible mistaking it for an abdominal tumor (Pepper), amyloid disease, passive congestion, or new growths of the organ (Striimpell). Primary alterations in the shape of the organ may be due to active or passive congestion, hereditary syphilis, hypertrophic or atrophic cir- rhosis, acute yellow atrophy, carcinoma, abscess, or hydatid cyst. The accompanying symptoms would, of course, be those of the disease caus- ing the deformity. Anomalies of position are not infrequently met with, the organ being displaced upward, downward, or laterally. The most common cause of lateral displacement is found in an abnormal lengthening of the suspen- sory ligament. The organ may occupy the epigastric region or be dis- 846 DISEASES OF THE DIGESTIVE SYSTEM. placed into the loAver part of the abdominal cavity, but a change in the posture of the patient or external pressure is often sufficient to replace the liver in its normal position. The symptoms (if present at all) con- sist of a dragging sensation, often amounting to pain that may be severe and referred to the right shoulder. On physical examination palpation may reveal a fissure betAveen the right and left lobes, together with a movable tumor presenting the size and normal outlines of the liver, which by manipulation may be returned to the right hypochondriac region. Percussion gives tympany over the normal area of liver-dulness, which changes to flatness when the organ is pressed or falls into its natural position. Displacement upward may result from gastric or intestinal distention, marked ascites, or an abdominal tumor; Avhile dowmvard displacement may be due to a mediastinal tumor, an emphysematous lung, or a pleural effusion. Diagnosis.—Among the conditions likely to be confounded Avith movable liver may be mentioned carcinoma of the omentum or of the pylorus, dermoid cysts, tumors of the ovary and uterus, hydro- or pyo- nephrosis, tumors of the kidney, and chronic proliferative peritonitis. By a careful study of the symptomatology, and in the absence of the normal physical signs over the hepatic area, the differential diagnosis can usually be firmly established, although marked fatty degeneration or atrophic cirrhosis may coexist with any of the above conditions and cause marked diminution in the area of hepatic dulness. The treatment of movable liver is merely palliative, and consists in the application of a suitable bandage for preventing the displacement. JAUNDICE. (Icterus) Definition.—A condition in Avhich the tissues and secretions are stained Avith bile-pigments. Jaundice is not a disease, but a symptom. The various theories of the origin of so-called hematogenous jaundice have been, I take it, successfully overthrown by the investigations of Stadelmann, Hunter, and others. All forms are due to obstruction either in the larger or smaller ducts (hepatogenous). Hepatogenous or obstructive jaundice is more commonly seen in— (1) Inflammatory swelling of the duodenum or of the lining membrane of the duct, which is by far the most common factor in its causation, and demands separate consideration (vide infra, Catarrhal Jaundice); (2) Foreign bodies Avithin the ducts, as gall-stones or parasites; (3) Stric- ture or obliteration of the duct; (4) Tumors Avithin the duct or ob- structing its orifice; (5) Pressure on the duct from Avithout, as by a tumor of the liver, stomach, pancreas, or omentum; also by fecal ac- cumulations, displaced organs, a pregnant uterus, enlarged glands in the fissure of the liver, and, more rarely, by abdominal aneurysm; (6) Low- ered blood-pressure in the vessels of the liver favoring resorption of bile, as in simple icterus of the neAv-born (Frerichs). CATARRHAL JAUNDICE. 847 CATARRHAL JAUNDICE. (Hepatogenous Jaundice; Icterus Catarrhalis; Duodeno-cholangitis; Inflammation of the Common Bile-duct) Definition.—A condition characterized by a discoloration of the tis- sues from retention and absorption of bile and resulting from a catarrhal inflammation of the lining membrane of the ducts, more especially the larger, and of the duodenum. Pathology.—On examining a liver and gall-bladder in situ in a case of catarrhal jaundice the former is usually found enlarged, lighter in color than normally, and of a distinct icteroid tint. In Avell-marked cases the smaller ducts are distended throughout the hepatic parenchyma, and on making a longitudinal section drops of bile can be collected on the edge of the section-knife. The gall-bladder is found distended with bile, and on firm pressure a tough plug of mucus is usually expelled from the common duct into the duodenum, after which bile flows into the intestine freely. The mucous membrane lining the ductus communis is SAvollen and inflamed, and the catarrhal process may extend to the cystic, and in some cases to the hepatic, duct. As a rule, that portion of the common duct lying in the intestinal Avail is more frequently and more deeply involved. If the disease becomes chronic, a formation of connective tissue occurs, owing to the irritation caused by the retained secretion, and atrophy of the liver-cells, with biliary cirrhosis, may result. Suppuration is exceed- ingly rare in this affection. Etiology.—As simple catarrhal jaundice results in a majority of cases from extension of inflammation due to gastro-duodenal catarrh, the chief predisposing causes may be mentioned as follows: (a) Exposure to cold and wet; (b) The use of improper foods, under Avhich heading may also be comprised faulty cooking, improper mastication, irregular meals; (c) The excessive or prolonged use of such irritants as tea, coffee, or alcohol; (d) Prolonged anxiety and mental or physical overwork; (e) Certain acute diseases, as pneumonia, relapsing fever, typhoid fever, and malaria; (/) Portal obstruction, occurring in chronic heart- or kidney-disease; (g) More rarely it has occurred in epidemic form. Symptoms.—(a) Icterus, or tinting of the body-surface, is often the first symptom noticed in this condition, appearing usually on the forehead and neck and gradually spreading over the entire body. The conjunctiva? also early become discolored, and the general hue, though variable, is generally a bright lemon-yelloAV. In chronic ca- tarrhal jaundice the color is apt to change to a bronzed or deep- green tint. (b) Secretions and Excretions.—The urine and SAveat are often found to contain bile-pigment, the patient's linen frequently being discolored. In extreme cases the urine may be dark-green in color, Avhile in those of average severity it is of a lighter or deeper greenish-yelloAv hue. The shaken specimen foams, and the froth has a yelloAV color-tint. Often the presence of bile is detected before any noticeable coloring of the conjunctivae occurs. In cases of intense or long-standing jaundice albumin and tube-casts may be present, and the latter may 848 DISEASES OF THE DIGESTIVE SYSTEM. be bile-stained.1 Hyaline casts are often found in cases of moderate intensity. The boAvels are constipated, and the stools are pale-drab or slate- colored ; they are usually very fetid. Diarrhea, hoAvever, may be pres- ent, OAving to the production of irritating substances and decomposition. The tears, saliva, and milk are rarely stained Avith bile-pigment. The expectoration also is rarely tinted, unless pneumonia or some form of pulmonary infiltration coexists. (c) Circulation.—The pulse, although not appreciably altered in vol- ume or tension, is usually sIoav (often 30 or even 20 beats per minute), though this is not an unfavorable symptom. (d) The temperature is usually normal, although slight elevations may occur (100°-101° F.—37.7°-38.3° C). (e) Gastro-hepatic Symptoms.—Among the first symptoms noticed in catarrhal jaundice may be those of dyspepsia—viz. anorexia, a sense of fulness after eating Avith flatulence, acid eructations, nausea and vomiting, accompanied by a dull, heavy pain over the hepatic area, with some tenderness on pressure. These often develop insidiously, and may be present several days before the appearance of the jaundice. More rarely they occur suddenly Avith a severe rigor or chill, violent head- ache, and vomiting—e. g. in the epidemic form. (/) Cutaneous Phenomena.—Pruritus or itching often becomes a troublesome symptom, being more common, however, in the chronic forms. Lichen, urticaria, furuncles, and SAveatings (diffused and local- ized) may develop, the latter being often limited to the skin covering the abdomen and the palms of the hands. A peculiar disease of the skin called xanthelasma or bita higoidea may also occur. It consists of bright-yelloAV spots, slightly elevated, appearing on the eyelids, and rarely on other parts of the body. In the more severe forms spots of ecchymosis, and in some instances profuse hemorrhages, may occur into the skin and mucous membranes. These are usually associated with other symptoms of a grave type. (g) Nervous Symptoms.—Headache and vertigo are common; irri- tability of temper, despondency, and Avakefulness or mental dulness almost equally so. AVith the oncoming of darkness vision may grow indistinct (hemeralopia) or it may attain unnatural clearness (nyc- talopia). Rarely, objects look yellow (xanthopsia). The nervous phe- nomena observed in catarrhal jaundice are attributable to the effects of the bile-acids. In certain cases, hoAvever, associated with destruc- tion of the hepatic substance, as in acute yellow atrophy, carcinoma, cirrhosis, and fatty degeneration, grave cerebral symptoms (acute delirium, convulsions, and coma) may develop suddenly and prove fatal. This class of symptoms has been named acholia, cholemia, or cholesteremia (the latter OAving to the mistaken supposition that cho- lesterin is the poisonous product). The true nature of the toxic agent in the blood is unknown. In some fatal terminations of this charac- 1 Tests for Bile.—Gmelin's test, or the play of colors, consists in bringing a few drops of urine in contact with the same quantity of commercial nitric acid on a plain white slab, whereupon various shades of yellow, green, red, and violet are produced. RosenbacKs test is made by filtering the suspected urine and touching the filter-paper with a drop of nitric acid. If bile be present, a green circle will form at the point of contact. (See also Choluria, p. 944.) CA TA RRHA L J AITNDICE. 849 ter death Avas due directly to a renal complication rather than to the primary affection. The physical signs in a case of simple catarrhal jaundice show on palpation and percussion an increase in the hepatic area, the loAver bor- der of the liver projecting in some instances several fingers' breadths below the ribs. Rarely, the distended gall-bladder projects below the loAver lobe of the liver, as when there is complete obstruction near or at the duodenum, and then it can be distinctly palpated. Diagnosis.—The etiology (errors in hygiene and diet), a history of previously existing gastro-intestinal catarrh, the age of the patient (young adult life), and the appearance of the jaundice unaccompanied by pain or general emaciation, together Avith an absence of symptoms pointing to cirrhosis, carcinoma, or acute yellow atrophy, form a cha- racteristic grouping of clinical indications. Duration and Prognosis.—The duration of catarrhal jaundice varies from two to eight Aveeks. If the symptoms continue longer than tAvo months, grave doubts may be entertained as to the case being one of simple jaundice. The prognosis is guardedly favorable. A rise of tem- perature usually indicates mischief (Pepper), while hemorrhages of the skin and mucous membranes always influence the prognosis unfavorably. Treatment.—The diet and hygiene are the first considerations in the treatment. Systematic bathing (Turkish or Russian baths, under super- vision), regulated hours of sleep, and moderate exercise in the open air, all exert a beneficial effect. Rich, highly seasoned foods, rich pastries, fats, and sweets, are to be interdicted ; starchy foods, lean meats, bread, soups (containing no fat), and green vegetables may, however, be used in moderation. Skimmed-milk, butter-milk, and alkaline drinks (Arichy and Saratoga mineral waters) may be used freely, while sour wines, lem- onades, and tamarind-water are -allowable. The free use of pure water often does good by increasing the flow of bile and by dislodging plugs of mucus that may obstruct the duodenum and the common duct. Gerhardt and Kraus have recommended the faradic current, applied over the region of the gall-bladder ; manipulation has also been tried with a view to removing the obstruction in the common duct. Neither of these methods has met with success. The first therapeutic indication is to keep the bowels freely soluble by the use of saline aperients, as Hunyadi water or Carlsbad salts (-| to 1 teaspoonful in hot water before meals). The latter remedies tend to lessen the catarrhal inflammation by depleting the mucous membranes. In obstinate constipation calomel, rhubarb, the extract of colocynth, or castor oil may be employed. Prevost and Binet believe that calomel is in part converted in the economy into mercuric chlorid, which stimu- lates the biliary secretion. Conspicuous among other remedies may be mentioned the alkalies, sodium bicarbonate, salicylate, and phosphate, which tend to increase the flow of bile and render it less thick ; hydrochloric acid (which, accord- ing to Ewald, by aiding digestion prevents the formation and conseqiTent absorption of toxic substances), in combination with the bitter tonics— gentian, quassia, and nux vomica; ammonium chlorid, which sometimes proves beneficial; and silver nitrate (gr. -|— \—0.008-0.016, three times daily). 54 850 DISEASES OF THE DIGESTIVE SYSTEM. Injections of cold water (60°-70° F.—lf).5°-21.1° C), daily, in quantities of 1 or 2 quarts (1-2 liters), are highly recommended as promoting the secretion of bile ; while lavage, practised daily and over a protracted period of time (one to two months), has proved highly bene- ficial, especially when gastro-duodenal catarrh has existed. This treat- ment was advocated by Krull, but has given negative results in the hands of Osier and Burney Yeo. Itching.—This troublesome symptom may often be relieved by the ex- ternal application of a solution of borax or sodium bicarbonate (|ss-Oj— 16.0-512.0), or of menthol and alcohol (gr. x-gj—0.648-32.0). Inter- nally, large doses of the bromids (gr. xx-xxx—1.29-1.94, at bedtime) or the continued use of pilocarpin (gr. -^ to \—0.005 to 0.008, two or three times a day), as recommended by Witkowski, are worthy of a trial. Flatulence may often be relieved by preventing fermentation. To this end it is important to regulate the diet, avoiding starches and sugars as far as possible. Ox-gall and sodium chlorate (gr. v—0.324—of the latter three times a day) are sometimes useful in checking the formation of gas. Charcoal tablets, bismuth subnitrate or salicylate, and beta- naphtol are also useful in checking fermentation. Diarrhea.—Occasionally attacks of diarrhea alternate with constipa- tion in catarrhal jaundice, and when present demand treatment. As they are usually due to fermentation, salol and creasote (Hiss—0.033), combined with the bismuth salts (subgallate, subnitrate, subcarbonate, or salicylate), are usually efficacious ; they are administered before meals. Headache is caused by the circulation in the blood of some toxic prin- ciple, due to the absorption of bile ; it is often persistent and annoying, although rarely acute in character. Temporary relief may sometimes be obtained as the result of free sweating induced by means of the hot bath or hot pack. Of drugs, caffein citrate, acetanilid, camphor monobromate, and phenacetin, either singly or in combination, may be recommended. In the other forms of hepatogenous jaundice permanent relief can only be afforded by removing the obstruction in the biliary channels, and thus permitting the normal outflow of bile. AA7hen the obstruction is due to mechanical causes (biliary calculi, tumors pressing on the duct) the treatment is chiefly surgical, and con- sists in their removal (vide Cholelithiasis). OTHER FORMS OF JAUNDICE. Modern experiments, as I have said (vide p. 846), tend to show that the so-called hematogenous jaundice is ahvays hepatogenous—i. e. the blood-dyscrasia probably exerts a toxic influence on the liver-cells; and there may at the same time be a more rapid blood-destruction in the liver (Neumeyer, Stadelmann, et al.). Among the more common causes of jaundice not purely catarrhal in origin are the following : (a) Certain fevers, as yellow fever, relapsing fever, (b) Grave forms of anemia, as pernicious anemia and chlorosis, (c) Certain poisons, as in pyemia, septicemia, shock, snake-bite, chloroform- and ether-poisoning; also in poisoning by phosphorus, arsenic, mercury, and other minerals. The pathology of these forms of jaundice differs essentially in the BILIARY CALCULI. 851 individual cases according to the cause, and will be considered under the different diseases mentioned in the etiology. Symptoms.—In the ordinary forms the symptoms are less marked than in the catarrhal variety. The skin presents in many instances only a slight lemon-yelloAv tint. The normal pigments of the urine are usually increased in amount, while bile-pigments may be entirely absent. Finally, the stools are not characteristic, as in the catarrhal form, and may be even dark in color. This occurs in cases in which the extra- hepatic bile-ducts are only partially obstructed or the cause is solely intra-hepatic. In the severe forms of this variety of jaundice, as in that produced by acute yelloAV atrophy of the liver, symptoms of cholemia (described under the Symptoms of Catarrhal Jaundice) are apt to develop. The prognosis and treatment depend entirely upon the cause. BILIARY CALCULI. (Gall-stones; Cholelithiasis.) Definition.—Concretions formed in the gall-bladder, due to an altered physiologic function or pathologic change; they vary in their composition and consist for the most part of bile-elements, and often set up characteristic disturbances (cholelithiasis). Etiology.—As a result of biliary retention increased consistency and a concentration of bile occurs, and certain constituents that were before held in solution are thrown down. Among the most common predisposing causes may be mentioned the following: (a) Female sex, especially between the ages of forty and sixty. Durand-Fardel's sta- tistics (1868) shoAv that out of 230 cases, 142 were Avomen and 88 men. Senac's statistics, out of a total of 311 individuals give 227 women (Dujardin-Beaumetz). (b) Irregular meals and an excessive diet of starches and fats, combined Avith a sedentary life, are strong predispos- ing factors, (c) According to Harley, gall-stones and biliary concre- tions of all kinds are frequently hereditary. Among other, and perhaps minor, causes may be mentioned constipation, tight-lacing, pregnancy, chronic obstruction to the flow of bile (as from tumors pressing from Avithout on the ducts, or catarrh of the ducts), and, more rarely, the rachitic and lithic-acid diathesis. Composition and Appearance.—Water comprises from 2 to 5 per cent, of the composition of gall-stones, the chief solid constituent being cholesterin, and the remainder being composed of bile-pigment and salts (lime, potash, soda, and perhaps traces of iron and copper). Pigment-lime may be, though rarely, the main constituent. In size they vary from the smallest particle of sand to that of a goose-egg. Harley records a case in Avhich a pyriform cholesterin-calculus was discovered in the feces; in a dry state it Aveighed 400 grains (26.0) and measured 2\ inches (5.6 cm.) in length and l-j1^ inches (2.7 cm.) in diameter. Fagge reports a calculus weighing, in a dry state, 462 grains 852 DISEASES OF THE DIGESTIVE SYSTEM. (30.0). The color varies from Avhite or light-yelloAv to that of a dark- green (as in pigment-lime calculi), and may present any variation betAveen these tAvo extremes. The nucleus often consists of cholesterin, the outer layer being usually the harder, and made up, for the most part, of lime-salts. The center of the nucleus generally consists of desquamated epithelium or dried mucus, and on cross-section concentric laminae are usually developed. The cholesterin gall-stones cut like wax, are Avhite, and the cut section presents a crystalline appearance. ' Other forms are apt to be brittle. The surfaces may be smooth, stri- ated, or hollowed out, solitary calculi being usually round or ovoid, while multiple stones often present smooth facets, due to the massing together of the calculi (Dujardin-Beaumetz). They are usually olive- shaped, but may be pyramidal, cylindric, lenticular, pisiform, cubic, finger-shaped, or olivary. Their seat is usually the gall-bladder, but they may be found anyAvhere along the biliary passages. Symptoms.—There may be no subjective symptoms of biliary cal- culi unless the stone becomes impacted in the hepatic, cystic, or com- mon duct. Thus, Naunyn states that "the gall-bladder will tolerate large numbers for an indefinite period of time, postmortem examinations shoAving that they are present in 25 per cent, of all Avomen over sixty years of age ;" and I quite agree with him in his estimate. The passage of a calculus through the duct will give rise to hepatic colic, whereas a permanent blocking of the duct will cause symptoms of chronic obstruc- tion, followed in many cases by those of ulceration and perforation, with the establishment of a biliary fistula. Hepatic Colic.—AVhen a gall-stone becomes impacted in a bile-duct the patient experiences agonizing pain (tearing, cutting, or lancinating in character) in the right hypochondriac region, radiating to the right shoulder, and accompanied often by profuse SAveating, vomiting, and a feeble running pulse. The most common seat of the pain is two to three inches to the right of the median line and about an equal distance beloAv the ensiform cartilage. Less frequently it is in the region of the gall-bladder. This happens in cases in Avhich the gall-stone is impacted in the cystic duct, and may be in greater part due to distention of the gall-bladder. In some instances the pain is so severe as to produce syncope. Hepatic colic, however, may occur independently of the passage of biliary calculi, as from inflammation of the gall-bladder. On the other hand, large calculi have been found in the dejecta Avithout having excited hepatic colic. I recently saw an instance of this kind in which the gall-stone was of the size of an English walnut. A rigor or chill often precedes the attack, Avhich is usually accompanied by mod- erate fever, the temperature reaching 101°-102° F. (38.3°-38.8° C). If the stone passes through the duct Avithout becoming impacted, jaun- dice and pain may either be only slight or entirely absent. When, how- ever, occlusion of the common duct occurs, the jaundice becomes intense. This symptom, hoAvever, may be present, though less marked, before the gall-stones reach the ductus communis. Jaundice occurs in about 50 per cent, of the cases (Fitz), and it sets in from eight to twenty-four hours after the onset of the attack of pain. Physical examination reveals on inspection a slight prominence in the hepatic area, and on palpation the edge of the liver can often be distinctly felt below the costal margin— BILIARY CALCULI. 853 at times as low as the umbilical level. The enlarged liver is sensitive on pressure, and particularly the gall-bladder, which can be palpated in not a few cases. If the latter viscus contains many calculi, crepitation may be noticeable to the palpating fingers, and a friction-sound may be distinguished on auscultation. The SAvollen organ, after the cessation of the colic, subsides Avith truly remarkable rapidity. Recurrences of the painful attacks after varying intervals of time are common. Finally, the gall-stone is expelled and the colic ceases to return. Multiple stones, however, may be passed. Rupture of the duct, followed by fatal peritonitis, has been known to occur. Attacks of biliary colic are of variable duration, lasting from a few hours to a feAv days, and in some instances one or more Aveeks. Sudden cessation of the pain is usually followed by rapid disappearance of the jaundice (Avhen present) and the discovery of the stone in the feces. Examination of the urine after the paroxysm reveals bile and an abundance of uric acid and urates. The pulse often becomes slowed. The prognosis of biliary calculi as regards life is good, but as re- gards recovery only guardedly favorable. Attacks of biliary colic usually terminate favorably, although cardiac distress with palpitation may occur and form a serious complication. Fatal syncope has also been known to occur, and fatal intussusception has followed the impaction of gall- stones in the region of the ileo-cecal valve. If evidences of an infec- tious inflammation arise, the outlook is then more serious. Diagnosis.—The diagnosis of gall-stones is sometimes extremely difficult on account of the obscure clinical symptoms and the entire ab- sence of physical signs. When, however, the calculus becomes impacted in the duct, symptoms of biliary colic usually appear, characterized by intense pain in the epigastrium and right hypochondriac region, radiat- ing to the back and right shoulder. There is also fever, vomiting, and in one-half the instances jaundice and the finding of the stone in the dejecta. Differential Diagnosis.— Gastralgia usually occurs in individuals with neurotic tendencies, and is characterized by severe paroxysmal pains in the epigastrium, extending to the back and base of the chest. It occurs often when the stomach is empty and is relieved by eating. Firm press- ure over the epigastrium often alleviates the pain temporarily, and the absence of fever, jaundice, stones in the dejecta, and the negative urinal- ysis, together with the history of former attacks, would tend to differenti- ate it from hepatic colic. Renal Colic.—The pain in this condition, which is often as acute as that of biliary colic, starts in the flank of the affected side and is trans- mitted down the ureter. The testicle and inner side of the thigh are very painful, the former being often retracted. Micturition is frequent and sometimes painful, and the urine is scanty in amount and often mixed with blood. Intense pain may also be felt in the back and abdomen, although it is usually localized in the affected side. This grouping of symptoms is wholly unlike that characterizing biliary colic. Intestinal Colic.—In this variety the pain is of a boring or twisting character, usually centering about the umbilicus. It is relieved by firm pressure. Abdominal distention is often present, and relief comes with the passing of flatus. Usually there is a history of an indiscretion in 854 DISEASES OF THE DIGESTIVE SYSTEM. diet. AVhen due to lead-poisoning, the history, the blue line on the gums, and the presence of wrist-drop would tend to confirm the diagnosis. Reflex colic, due to uterine or ovarian disease, may also occur. The recurrence of the attacks, together with other symptoms pointing to dis- ease of these organs and the exclusion of all other causes, Avould tend to establish the identity of the condition. In all forms of colic, if the pain be very severe symptoms of shock may develop, indicated by vomiting, cold, clammy skin, pale and pinched features, and a rapid running pulse. CHRONIC OBSTRUCTION OF THE DUCTS BY GALL-STONES. The obstruction may exist in the ductus choledochus, in the cystic duct, or in both. 1. Obstruction of the Common Duct.—Pathology.—The result of the irritation produced by the presence of the stone is a catarrhal pro- cess (cholangitis) that may either remain chronic or terminate in suppu- ration (suppurative cholangitis). In a case of simple obstruction the gall- bladder is often moderately enlarged, though rarely extending below the lower border of the liver. The common duct is greatly distended, the stone being usually located near its termination; it is distinctly felt just beneath the mucous membrane of the descending duodenum. Occasion- ally two or more calculi are present, completely obliterating the canal. The hepatic duct and its branches are greatly dilated, and often contain thin, colorless mucus, the membrane lining the ducts being smooth and clear. The liver in these cases is firmer in consistency than normal, showing some increase in the connective-tissue elements, though cirrhotic changes are rare. Moderate enlargement of the organ usually exists, but progressive atrophy may occur. AVhen suppuration has occurred the mucous membrane is greatly swollen and reddened, and in some instances shows erosions or ulceration. The process often extends through the hepatic and cystic ducts into the liver and gall-bladder, giving rise to localized abscesses in the former and to empyema of the latter. In some instances the gall-bladder has been perforated and abscesses have formed between the liver and stomach. Diverticula are sometimes found post- mortem, containing biliary calculi. Symptoms.—Chronic obstruction by gall-stones, with coexisting ca- tarrhal inflammation, is characterized by a distinctive group of symp- toms, among the most prominent of Avhich are— Jaundice.—This may be constant and very intense, or intermittent and slight, depending upon the amount of obstruction present. In some cases it disappears entirely for several months, and then recurs with vary- ing intensity (ball-valve action of the stone). Itching is, as a rule, a most distressing feature. Pain, occurring in paroxysmal attacks and referred to the region of the liver. This is accompanied by fever that may reach a high degree (102°-103° F.—38.8°-39.4° C), also by chills and sweating, resem- bling somewhat the paroxysms of malaria. Painful points in the right side posteriorly may be annoying ; these are either constant or par- oxysmal. The chills are often intense, and may present a quotidian, tertian, or CHRONIC OBSTRUCTION OF THE DUCTS BY GALL-STONES. 855 quartan form. The temperature of the intervals is normal. The peculiar exacerbations of temperature Avere first described by Charcot, and to them has been given the name of Charcot's intermittent fever. Many theories have been advanced as to its cause, and Murchison writes: "These paroxysms may be more or less periodic, and may extend over several months, without necessarily indicating pyemic hepatitis, the pa- tient ultimately recovering." He further states that they are probably due to simple irritation by a stone, and are analogous to febrile paroxysms produced in passing a catheter along the urethra. Charcot believes the etiologic factor to be a septic poison, bacterial in origin and the result of chemical changes in the bile. Various micro-organisms have been de- tected in the bile in such cases (bacterium coli commune, streptococcus pyogenes, et al). Gastric Disturbances.—These may be so severe during the paroxysm as to excite alarm. Intense pain is complained of in the epigastrium, accompanied often by persistent nausea and vomiting, which, however, usually subsides at the close of the paroxysm, while the jaundice at this time deepens. The attack may persist for years without progressive fail- ure of health. When, however, suppurative cholangitis occurs the prognosis becomes grave and recovery is unknown. The paroxysms occur more frequently, the fever merging into a remittent rather than an intermittent type. Grave constitutional symptoms, indicating septico-pyemia, are present, the duration is shorter, and the case rapidly tends to a fatal issue. The attacks of colicky pain occur and the jaundice, but the latter symptom is less intense than in the catarrhal form. Hepatic enlargement, on the other hand, is more marked than in the latter variety. 2. Obstruction of the Cystic Duct.—This almost invariably causes distention of the gall-bladder (dropsy of the gall-bladder), which may be felt distinctly beloAv the loAver edge of the liver as a pyriform, fluctuating tumor. If obstruction of the cystic duct alone occurs, jaun- dice may be entirely absent, the bile in the distended tissues being re- placed by a thin, mucoid fluid. This is more apt to exist as the obstruc- tion becomes more chronic. In some instances the distention is so great as to reach below the umbilicus, and the dilated viscus has even been mistaken for an ovarian tumor. Osier records a case in Avhich 18 oz. (556.0) of fluid were removed from the gall-bladder. The contents are neutral or alkaline in reaction, albumin being often present in abun- dance. Catarrhal inflammation of the gall-bladder is often associated, causing pain and sensitiveness in the region of the organ. The pain may be severe and simulate biliary colic or appendicitis. The examiner can feel an elastic, gourd-shaped tumor closely connected with the liver, movable in respiration in the vertical, and also, under the influence of the palpating fingers, in the lateral, direction. If the obstruction persist for a length of time, calcification or atrophy of the bladder are common sequelae. In the former calcareous plates may be deposited in the mucosa, or the wall may be the seat of calca- reous infiltration, converting the viscus into a hard, stone-like body that is gritty on section. When atrophy occurs the organ shrinks into a small fibroid mass the size of a cherry, Avhich on section is often found to con- tain a stone. Complete obliteration of the cavity may occur. 856 DISEASES OF THE DIGESTIVE SYSTEM. Among rarer sequelae of chronic obstruction may be mentioned—(a) Empyema of the Gall-bladder.—AVhen this takes place the organ be- comes greatly distended, and has been known to contain as much as a pint of purulent material. The symptoms of suppurativa cholecystitis simulate those of purulent cholangitis, and are often preceded by those of catarrh of the gall-bladder and ducts. Perforation may occur, giving rise to circumscribed periportal abscesses or to generalized peritonitis. (b) Acute Phlegmonous Cystitis.—This is of very rare occurrence, cha- racterized clinically by pain and tenderness in the hepatic region, rigors and high fever, and intense prostration. It often proves fatal as the result of peritonitis from perforation. More Remote Effects of Gall-stones.—These will be spoken of under three headings: 1. Stricture of the duct, resulting from ulceration and cicatrization produced by the passage of a stone. 2. Intestinal obstruction, due to impaction of gall-stones. 3. Biliary fistulae resulting from perforations. 1. Stricture of the Duct.—Obliteration of the common duct may re- sult from the passage of a gall-stone, giving rise to ulceration and cica- trization, or the stone may become impacted and lead to adhesions and permanent closure of the duct below it (Murchison). AVhen due to ulceration the seat of the stricture is usually Ioav down in the common duct.1 Symptoms.—The symptoms are those of chronic obstructive jaundice (Osier). In many cases there will be an antecedent history of the passage of gall-stones. In all cases in which the symptoms of gall-stones are folloAved by permanent jaundice without pain it may be suspected either that the calculus has become firmly impacted or that it has produced organic stricture or closure of the duct. 2. Intestinal Obstruction from Impaction of Gall-stones.—The ileum is commonly the seat of obstruction by gall-stones, that may give rise to intussusception or cause ulceration and gangrene of the boAvel with per- foration and fatal peritonitis. The latter event, however, occurs more frequently when the biliary concretions are situated in the cecum. Rarely they are found in the appendix, causing, as other foreign bodies, inflam- matory changes, followed by ulceration and in many cases by perforation and death. Cases of impaction in the rectum of several biliary calculi have been recorded. I have recently seen a case with Dr. R. Bruce Burns. Symptoms.—If the impaction occurs in the small intestine, the abdo- men becomes tympanitic and tender on pressure. The contents of the stomach are first vomited, followed by bile and stercoraceous matter. Obstinate constipation persists, and symptoms of peritonitis develop and continue until either the impaction disappears or death ensues. Ileus, the result of biliary concretions, is common in females of advanced age. The history of previous acute attacks would tend to confirm the diagnosis. The pain is intense and vomiting severe and persistent. The duration of the last attack is often short, terminating fatally in a few hours. 1 In vol. ix. pp. 22 and 130, Pathologic Transactions, two cases are recorded in which the strictures were exactly similar to those of the urethra, one being situated in the hepatic duct of the left lobe and the other in the common duct. TREATMENT IN CHOLELITHIASIS. 857 3. Perforation may occur with the establishment of fistulous com- munications between the gall-bladder and stomach, intestinal canal, blad- der, vagina, lungs, abdominal parietes, or portal vein. Fistulae between the gall-bladder and stomach are rare, though cases are recorded by Oppolzer, Frerichs, Cruveilhier, Murchison, and others. Cruveilhier states that vomited gall-stones necessarily reach the stomach through fistulous tracts, as the passage from the duodenum through the pyloric orifice would be impossible. Fistulae into the duodenum are of much more common occurrence, ulceration taking place usually in the fundus of the gall-bladder and in the descending or third portion of the duodenum: 39 cases are recorded of fistulous communication with the colon (Osier). I have reported a fortieth case,1 which prior to reaching a fatal issue had developed wide- spread septico-pyemic lesions. In 6 of 9 cases reported by Murchison carcinoma of the gall-bladder was present. Fistulae into the urinary passages may occur, 2 authenticated cases being reported. The distended gall-bladder may come in contact with the urinary viscus, or the stone may perforate into the pelvis of the kidney and pass through the ureter into the bladder. Fistulous openings through the abdominal parietes are the most com- mon of all fistulae, the place of exit of the biliary concretions being usually in the region of the gall-bladder or at the umbilicus, to which (according to Murchison) it may be directed by the suspensory ligament of the liver. As many as 600 stones have been removed from the gall- bladder in this manner. They vary greatly in size, being often as large as a goose-egg. Advanced life and female sex are said to be predis- posing causes. Murchison records 5, and Courvoisier's statistics shoAv 184 cases, in 78 of which recovery took place. Fistulae into the pleura, bronchi, and vagina have been recorded, but are extremely rare. Courvoisier records 24 cases of fistulae into the lungs, only 7 of which terminated in recovery. Fauconneau, Dufoesne, Frerichs, Bristowe, and Murchison mention cases of fistulae into the portal vein, with the presence of biliary concretions in the latter. Treatment.—The indications for treatment in cholelithiasis are (a) to remove the cause; (b) to relieve the paroxysms of hepatic colic; and (c) to adopt palliative or radical measures for the removal of the gall- stones. Preventive Treatment.—In this, as in the treatment of jaundice, diet and hygiene play an important part. The former should be as simple as possible, consisting largely of skimmed-milk, lean meat, eggs, fruit, and green vegetables. Fatty foods, sugars, starches, and pastries are to be strongly interdicted. All foods should be thoroughly masticated, so as to digest easily, and meals should be taken at regular intervals. Syste- matic exercise in the open air is of signal value, as it stimulates the flow of bile. Punkhauer strongly recommends horseback-riding, believing this to be efficient in removing obstructions in the common duct. Among the drugs mostly used in the treatment of this condition I would advise the following: Sodium sulphate, combined with the extract of taraxacum (Harley); ox-gall (Dubney), in 5- to 10-gr. (0.324-0.648) 1 Clinical Lecture, International Clinics, vol. ii. third series, p. 27. S58 DISEASES OF THE DIGESTIVE SYSTEM. doses, three times daily (to relieve flatulency and stimulate the biliary secretion); sodium salicylate (gr. x to xv—0.648 to 0.972, three times daily) ; and sodium chlorate (gr. iv to vj—0.259 to 0.388) three times a day (Schiff). The boAvels should be kept freely soluble, constipation being carefully avoided. In my own experience a dram (4.0) of sodium phosphate or of Rochelle salts in concentrated solution in the morning on rising has yielded excellent results. Other laxatives whose use is to be advised and encouraged are cascara sagrada, podophyllin, and rhubarb. Treatment of the Paroxysm of Biliary Colic.—At the very onset of an attack of hepatic colic the prompt exhibition of morphin or of codein may greatly mitigate an attack. The former may be given hypodermi- cally in |- to -j-gr. (0.008-0.016) doses every hour until relief follows; the latter is exhibited by the mouth in doses of 1 gr. (0.0648) every hour. Inhalations of chloroform, Avith morphin hypodermically, the former being continued until the latter has taken effect, may be regarded as the typical treatment during an attack. Hot baths and hot applications (Avith counter-irritation) over the liver are valuable aids in the treatment of hepatic colic, being given at a tem- perature of 98° to 100° F. (36.6° to 37.7° C), and continued for twenty minutes if endurable, so as to effect relaxation. If cardiac depression results and the pulse becomes Aveak, the baths should be discontinued. Hot flaxseed-poultices, cloths wrung out of hot water, hot hop-bags, or turpentine stupes may be applied over the hepatic region until the attack subsides. Ice-poultices have been advised by Buchetan. If shock or syncope should develop, the body-temperature must be maintained by hot bottles or bricks placed in contact with the surface of the body, together with strychnin (gr. -A^—0.0021), atropin (gr. jj^ — 0.00042), and brandy (1 dram—4.0) hypodermically. Nausea and vomiting may be reduced by 15-drop doses of spirits of chloroform every half hour; also by brandy and soda-Avater or cham- pagne. In mild cases sodium salicylate (gr. viij-xv—0.518-0.972 in twenty- four hours), recommended by Prevost and Binet, or codein (gr. j), with phenacetin (gr. x), every few hours gives relief. The free use of olive oil or glycerin in hepatic colic has been folloAved by a beneficial effect (Rosenberg, Goodhart). The former is given in quantities of 4 to 6 oz. (128.0-192.0) by the mouth every three or four hours, nausea being pre- vented by concealing the taste with lemon-juice ; the latter, recommended by Ferrand, is given in doses ranging from 1 to 2 tablespoonfuls, repeated in the same length of time. Both remedies are supposed to do good by increasing the flow of bile, thus forcing the stone outward toward the bowel. Treatment for Removal of Gall-stones.—The palliative treatment consists in the administration of agents that tend to increase the Aoav of bile. The free use of pure Avater by the mouth, together Avith copious rectal injections daily of cold water, has been found effective. It may be rendered alkaline by sodium bicarbonate or borate in a 3 per cent. solution. A course of alkaline treatment at some of the more noted mineral springs (Bedford, Vichy, Carlsbad) is often attended with good re- CARCINOMA OF THE BILE-DUCTS. 859 suits. Perhaps the three best cholagogues that may be mentioned are sodium phosphate, sodium cholate, and ox-gall; all of these aid the biliary flow. Olive oil and glycerin (2 tablespoonfuls of the former to 1 of the latter) three or four times daily also increase the secretion of bile. Cholagogues are quoted by some authorities to be contraindicated when intermittent hepatic fever and tenderness are present on pressure over the liver, but the fact is to be remembered that both symptoms may occur Avithout ulceration having taken place. Agents to dissolve the stone have been tried at various times, among them being Durande's method (turpentine and ether), but, so far, all such methods of treatment have been unsuccessful. Of the various surgical measures for the removal of gall-stones the fol- lowing are the chief: (a) Removal of the stone from the common duct (choledochotomy); (b) Removal of the stone from the cystic duct (cho- lecystotomy); (c) Establishing a fistulous opening betAveen the gall-blad- der and the bowel (cholecystenterostomy); (d) Extirpation of the gall- bladder (cholecystectomy), the latter operation giving a mortality of 17 per cent., according to Murphy's statistics. CARCINOMA OF THE BELE-DUCTS. The biliary passages may be the seat of carcinoma, which may occur primarily and exist over a long period of time without being recognized. Pathology.—The gall-bladder, as the result of obstruction of the duct, is often greatly distended, measuring as much as 7 inches (17.7 cm.) in length (in a case reported by Harley) from the entrance of the duct to the fundus, and being filled with a cloudy liquid, somewhat resembling barley-water, that contains flakes of epithelium, granular matter, and particles of inspissated bile. The reaction is usually alka- line, the specific gravity varying from 1010 to 1015. The mucous mem- brane lining the interior may present a red, granular appearance. If the growth be near the duodenal orifice, the common and cystic ducts are often greatly distended, and the dilatation may extend into the hepatic ducts and their branches. The liver may be enlarged, and in some in- stances presents the secondary nodules that are characteristic of the disease. Etiology.—The causes of carcinoma of the bile-ducts are the same here as elsewhere, and among these the mechanical or inflammatory theory of Virchow must be accepted. Tight-lacing and mechanical irritation by gall-stones are followed in many instances by cancerous degeneration; Osier states that " biliary calculi are present in at least seven-eighths of all cases." Among other factors, heredity and age (after forty) play an important part. Although carcinoma of the liver undoubtedly occurs more frequently in males, Musser found that out of 100 cases of carci- noma of the ducts 75 were females; in the same number of cases col- lected by Courvoisier 83 occurred in males. 860 DISEASES OF THE DIGESTIVE SYSTEM. Symptoms.—The signs and symptoms, according to Harley, present nothing characteristic to distinguish them from other causes of obstruction in the ducts. On palpation in the early stages the gall-bladder is found moderately enlarged, but later it rapidly undergoes diminution in size. Jaundice becomes very intense, and remains permanent. Throughout the course of the disease all the symptoms referable to chronic obstruction of the duct by gall-stones (paroxysmal pain, gastric disturbance, rise of temperature, Charcot's fever) may develop. Examination of the urine and feces reveals the presence of bile-pigment in the former and its entire absence or a greatly diminished amount in the latter. Ascites not rarely occurs during the later stages, with the involvement of surrounding organs by contiguity, as well as with the appearance of secondary nodules in the liver and the development of cachexia. Diagnosis.—Carcinoma of the biliary ducts cannot always be detected by physical examination. Distinct evidence of chronic obstruction of the duct, as persistent and intense jaundice (which occurs in three-fourths of the cases), the development of cachexia and the absence of cancerous in- volvement of other organs, however, will tend to characterize it. Often a hard tumor-mass is present in the region of the gall-bladder, and it should be recollected that this is oftener a seat of the primary affection than the liver. An assured diagnosis of carcinoma of the gall-bladder, however, is often impossible. Prognosis.—The prognosis of carcinoma of the bile-ducts is, like that of other organs, absolutely fatal, though the course of the disease is not so rapid as that of carcinoma elsewhere until secondary involvement of the liver occurs. Treatment.—The treatment is merely palliative. Operative meas- ures are rarely justifiable, since the disease is rarely recognized before the liver becomes involved. As seven-eighths of the cases follow obstruc- tion of the duct by gall-stones, the preventive treatment of the latter should be carefully observed whenever symptoms of disordered liver-func- tion manifest themselves. The treatment of the pain, anemia, and emaciation will be described in the discussion of Carcinoma of the Liver (vide p. 896). STENOSIS OP THE BILE-DUCTS. Stenosis, or narrowing of the duct, may result from any of the follow- ing causes : (a) Round-worms in the duct; (b) Foreign bodies, as seeds; (c) Ulceration and cicatrization following the passage of gall-stones; (d) Pressure from without, as from tumors (carcinoma chiefly) of the head of the pancreas and pylorus ; (e) Abdominal tumors; (/) Aneurysm of the abdominal aorta or of the celiac axis; (g) Secondary enlargement of the lymphatics of the liver; (A) More rarely in man than in the lower animals distoma hepaticum or liver-flukes and echinococci; (i) Adhesions due to chronic peritonitis. Pathology.—If the stenosis is of recent origin, the liver is enlarged STENOSIS OF THE BILE-DUCTS. 861 and shows more or less congestion, with some increase of the connective- tissue elements. The substance is firmer than normal, the color varying from an olive-green to a deep bronze. The biliary passages are dilated, and in some instances filled Avith bile. " It is not uncommon to find the ducts larger than the middle finger, and many instances are on record where the dilatation has been even greater than this " (Murchison). If, however, the obstruction be of long standing, the presence of the dilated ducts and the increase of connective tissue cause secondary atrophy of the hepatic cells, with a diminution in the size of the organ. Symptoms.—The symptoms vary greatly according to the cause of the stenosis, but in the main they are those of chronic obstruction of the duct—viz. paroxysmal pain in the region of the liver, referred to the right shoulder; jaundice of varying intensity, but gradually deepening after each attack ; and gastric disturbance, with ague-like paroxysms (fever and sweating), the latter being most frequently met Avith in occlu- sion from gall-stones. Diagnosis.—The pathognomonic symptoms determining the nature of the stenosis are very often wanting, and the diagnosis is rendered cor- respondingly difficult. " Great and progressive enlargement of the liver, with jaundice and moderate continued fever, is more commonly met with in cancer" (Osier). When the condition is due to lumbricoid worms, reflex symptoms usually appear in the intestinal canal, as pruritus of the nose and anus, grinding of the teeth during sleep, and convulsions. In carcinoma of the head of the pancreas or the pylorus pressing on the ducts the growth may be detected by palpation, together with a rec- ognition of other more or less characteristic features (vide infra, p. 908), and the rapid course of the disease. Abdominal aneurysm may give rise to obstruction of the duct without being evidenced by physical signs. Usually, however, when the saccula- tion presses against the bile-duct, the throbbing in the epigastrium, the tumor (Avhich can often be grasped), and the expansile pulsation on pal- pation will tend to establish the cause of the obstruction. AVhen due to cancerous nodules in the liver there is usually a history of primary carcinoma of the stomach, mammary gland, rectum, or of one of the pelvic viscera. Osier records a case in which jaundice (thought to have been Catarrhal in origin) developed seven weeks previously. On careful examination " a small nodule was detected at the umbilicus, which on removal proved to be scirrhus." AVhen the stenosis is due to ulceration following the passage of gall- stones, the history of biliary colic and of the presence of calculi in the dejecta, and the paroxysmal pain with jaundice and intermittent fever, will serve to establish the cause. If the fever be of the continued type and the liver uniformly enlarged, with the development of jaundice, the case is probably one of hypertro- phic cirrhosis; whereas if the enlargement be progressive and nodules can be detected on palpation in addition to the appearance of cachexia, carcinoma is undoubtedly present. Physical signs aid but little in the diagnosis, as obstruction of the common duct is usually unattended by any great enlargement of the gall- bladder. 862 DISEASES OF THE DIGESTIVE SYSTEM. In many cases only by remembering the various causes and eliminating them carefully, one by one, can the diagnosis be positively made. Prognosis.—It may be said of the prognosis, as of the symptoms, that both vary according to the cause of the stenosis. Generally speak- ing, the prognosis is rather grave, since many of the causal conditions are fatal. If the obstruction is due to cicatricial contraction, the prog- nosis is guardedly favorable as to life, but hopeless as to recovery. If the obstruction is permanent, the prognosis is absolutely hopeless. Treatment.—The treatment of occlusion of the bile-ducts varies according as it is due to cicatricial contraction following ulceration or to foreign bodies (seeds or lumbricoid worms), or to gall-stones or tumors pressing upon or involving the ducts or adjacent organs (pancreas, pylorus). If the stenosis folloAvs ulceration in the duct, and is sufficient to cause almost complete occlusion with biliary retention, the operation of cholecystenterostomy may become necessary in order to prevent dila- tation of the gall-bladder with resorption of bile. Foreign bodies in the duct may be removed by free purging, aided by the liberal use of alkaline mineral waters. In critical cases the operation of cholecystotomy has been practised. Gall-stones form the most frequent cause of stenosis, and the treat- ment, both for the prevention and removal of calculi, has already been described in the discussion of Biliary Calculi (vide p. 857). ICTERUS NEONATORUM. Definition.—Jaundice occurring in the new-born. This may be either pathologic or physiologic—a slight tinting of the skin occurring quite commonly in the new-born. Pathology.—The morbid anatomy of the pathologic form varies with the cause of the jaundice. The secretion of bile, like the secretion of urine, begins long before birth, and Zweifel has found bile-pigment and bile-acids in the contents of the intestines of a three-months' fetus. Hence children may be born laboring under an attack of well-marked jaundice. In well-marked cases of pathologic jaundice the skin presents a deep greenish-yellow hue, the conjunctivae being markedly discolored and the mucous membrane of the lips pale and anemic. The internal tissues (intestines, liver) are also stained with bile-pigment. Htiology.—Of the physiologic forms, the following are the main causes : 1. The ductus venosus may remain patulous, allowing some of the portal blood, containing bile, to flow into the systemic circulation (Quincke). 2. Diminished pressure in the portal vessels from ligation of the umbilical vein causes increased tension in the hepatic capillaries and absorption of bile. Pathologic Icterus.—The causes are the following: (a) Congenital stricture or absence of the duct; (b) Syphilitic disease of the liver; (c) Septic processes set up by infection through the umbilical vein. Symptoms.—In physiologic jaundice the skin is tinted greenish- VASCULAR (CIRCULATORY) AFFECTIONS OF THE LIVER. 863 yellow, resembling somewhat that of chlorosis. The mucous membranes are pale and the conjunctivae pearly-white. The pulse is feeble and some- times rapid. Auscultation over the base of the heart often reveals a soft systolic murmur transmitted to the vessels of the neck and associated Avith a venous hum. According to Murchison, false or physiologic jaundice differs from the true or pathologic form in that—1. The conjunctivas are of a natural color; 2. The urine is free from bile-pigment; 3. The yel- low color gradually fades from the skin after a feAv days; 4. The child is quite well and the bowels are acting properly. In pathologic jaundice the skin and conjunctivae are more or less in- tensely icteroid, the urine is loaded with bile-pigment, while the feces are of the pipe-clay variety. Hemorrhage from the cord may occur and de- struction of life may be rapidly accomplished, or the condition may last for some weeks without serious impairment of the general health, with final recovery. Treatment.—In the milder cases calomel in minute doses, combined with lactopeptin and sodium bicarbonate, can be recommended. In ma- lignant cases treatment is of no avail. VASCULAR (CIRCULATORY) AFFECTIONS OF THE LIVER. ANEMIA. The physical symptoms of this condition are absolutely nil, and its existence only discoverable postmortem. Its most common causes are those of general anemia, fatty and amyloid degeneration. HYPEREMIA. Definition.—An excess of blood in the liver. This may he of two varieties : (a) active and (b) passive, the latter being the more common. ACUTE HYPEREMIA. (Active Congestion.) Definition.—An excess of arterial blood in the liver. Etiology.—Among the common causes are rich living, sedentary habits, alcoholism, traumatism, acute infectious diseases (typhus, typhoid), and pernicious malaria. The condition may also be vicarious, due to a sudden cessation of menstruation or of hemorrhage in other parts of the body. A physiologic condition is the temporary hyperemia that occurs during the ingestion of a full meal. Symptoms.—There are no symptoms characteristic of this condition; those present in the different cases are varied and referable to disturb- ances of other viscera, as in coexisting cardiac hypertrophy or gastro-in- testinal catarrh. Often, however, there is a sense of fulness and distress in the right hypochondrium after eating, with tenderness on palpation over the lowTer margin of the organ. Prognosis and Course.—It is impossible to make any definite state- ment as to the course and prognosis of active hyperemia, these depending 864 DISEASES OF THE DIGESTIVE SYSTEM. wholly upon the cause of the affection. When due to errors of diet and hygiene the condition is easily remedied; the prognosis of hyperemia accompanying hepatic cirrhosis, however, is decidedly grave. PASSIVE HYPEREMIA. (Passive Congestion.) Definition.—An increase of venous blood in the liver. Pathology.—The organ is enlarged in size and changed to a deep- red color, its substance being firmer than normal. The center of the lobule (the area of the hepatic vein) becomes deeply pigmented, the pe- riphery (occupied by the portal vein) being lighter in color, sometimes owing to fatty infiltration. Because of its mottled appearance this has received the name of the "nutmeg liver." In long-standing passive congestion there is an increase of connective tissue, due to a proliferation of round-cells, causing atrophy of the parenchyma. The blood in the central capillaries becomes altered, the capillaries themselves are distended, and brown pigment is deposited about the center of the lobules. The organ becomes very much darker in color, and to this condition the name " cyanotic induration" or "cardiac liver" has been given. Later, contraction of the connective tissue occurs, causing a diminution in the size of the organ, and forming the so-called "atrophic nutmeg liver." Etiology.—The causes that lead to passive hyperemia are both local and general. Among local causes may be mentioned the following: 1. Pressure over the portal area from without, as from a tumor or cyst. 2. Disease of the walls of the veins, as in syphilitic phlebitis. 3. Coagulation of the blood in the veins (thrombosis). Among the general causes are— 1. Chronic valvular disease affecting the right side. Passive hyper- emia is also common in mitral disease. 2. Pulmonary emphysema and cirrhosis of the lung. 3. Intrathoracic tumors, which by their mechanical action cause an increased pressure in the efferent branches of the hepatic veins. Symptoms.—Often the patient experiences a sensation of fulness and weight in the region of the liver that amounts in some instances to actual pain. Jaundice is usually present, but varies in intensity, and is due to obstruction of the smaller ducts by the distention of the hepatic venules. Hematemesis is not rare, and symptoms of gastro-intestinal disturbance are usually present. In marked cases the stools are clay- colored, showing the absence of bile ; the urine is loaded with bile-pig- ment; and jaundice deepens with the development of ascites or anasarca from portal obstruction. On palpation the organ is tender and increased in size, extending in some instances fully a hand's breadth below the costal margin. In marked cases the whole organ pulsates, owing to the regurgitation of blood into the hepatic veins. This symptom is best elicited by placing one hand on the ensiform cartilage, while the other presses against the liver below the right lower border of the ribs. Diagnosis.—The diagnosis of passive congestion, per se, is often very difficult, but when secondary to heart- and lung-diseases it is ren- dered more plain. DISEASES OF THE PORTAL VEIN. 865 The prognosis and treatment depend wholly upon the causal factors. DISEASES OF THE PORTAL VEIN. THROMBOSIS AND EMBOLISM. Thrombi are rare occurrences in the portal vein. Among the causes that lead to their occurrence, however, may be mentioned—(a) Trauma- tism ; (b) cirrhosis; (c) carcinoma of the liver, involving the portal area; (d) pressure from without, as in proliferative peritonitis involving the gastro-hepatic omentum, abscesses, enlarged glands, or impacted calculi pressing on the veins; (e) obstruction of the blood-current, as by foreign bodies or by a roughened venous Avail; (/) slowing of the circulation due to splenic diseases, such as marasmus. Pathology.—In the early stages the clot presents a grayish-red or yellowish appearance, and on loosening it is found to adhere more or less closely to the inner coat of the vein. Later it becomes a mass of small white fibrin tightly adherent to the sides of the blood-vessel, which itself undergoes fibroid change, giving rise to the so-called adhesive pylephle- bitis. Organized thrombi are rarely found, except in the smaller branches of the portal area. If the thrombus obstruct the vessel, collateral circu- lation may be established for years, as in a case recorded by Osier. Septic softening, however, is a very common result, and most frequent of all is pylephlebitis. If a parietal or channelled thrombus be formed, partial or complete circulation may be re-established and recovery take place. Hem- orrhagic infarction may take place, but is very rare. Symptoms.—Symptoms may be almost lacking in portal obstruction, or the condition may simulate cirrhosis of the liver. In ordinary cases the symptoms are very slight, the hepatic circulation, as shown by Cohn- heim and Litton, being " sufficient for the nourishment of the liver and secretion of the bile " (Henry). If the occlusion be complete, edema followed by the rapid development of ascites may occur. In such cases loss of strength is persistent and progressive, and death may result from exhaustion. Hemorrhages due to venous stasis may occur from the nose, stomach, and intestines. Jaundice and diarrhea occur frequently, the former being the result of obstruction to the biliary passages from the same causes that produce the thrombosis or the diminished pressure in the portal area. On palpation the liver is found slightly enlarged and tender on pressure, and projecting below the lower margin of the ribs; the spleen is also enlarged. Percussion also reveals enlargement over the splenic area. If ascites is present, percus- sion will reveal dulness in the flanks, changing with the position of the patient; and on gently tapping one side of the belly-wall, with the hand on the opposite side, a wave of fluctuation will be felt. Diagnosis.—The diagnosis of portal thrombosis is often extremely difficult. "A suggestive symptom, hoAvever, is sudden onset of the most intense engorgement of the branches of the portal system " (Osier). Sequelos.—If the emboli are septic in origin, an abscess, with all its accompanying symptoms, will be the result. Hemorrhagic infarction 55 866 DISEASES OF THE DIGESTIVE SYSTEM. may occur, but is very rare, since a free anastomosis exists between the lobular plexuses and the hepatic artery. " Pylethrombosis may be regarded as probable if no other possible cause of the portal obstruction seems likely, and if we are able to discover a cause for thrombosis, like a former attack of circumscribed peritonitis" (Striimpell). The prognosis is always unfavorable, although certain cases have been demonstrated by autopsy to have improved temporarily. Course and Duration.—Nothing definite can be stated in regard to the course and duration of this affection, since these depend entirely upon the cause. Treatment.—The symptoms resulting from portal congestion, due to thrombi in the portal vein, are those described under Cirrhosis of the Liver, and the treatment is identical with that of interstitial hepatitis. In rare instances septic emboli give rise to abscesses that are usually multiple; when these occur the treatment is purely symptomatic. SUPPURATIVE PYLEPHLEBITIS. Definition.—A purulent inflammation of the portal vein or its branches. Pathology.—If noted in the early stages, the coats of the portal vein are distended and thickened, and the connective tissue surrounding the portal area is infiltrated and the seat of minute ecchymoses. The inflammation usually originates in the smaller veins of the portal system or in the hepatic branches of the vein itself; the main trunk is attacked least often. Numerous thrombi are found obstructing the vein and its branches, which finally undergo suppuration. From these, emboli enter the circulation and are carried to all parts of the liver, forming meta- static abscesses. In advanced cases the whole organ (especially the pe- ripheral parts) becomes infiltrated with pockets of pus, that communicate with the portal vein or its branches, and extend in some instances into the mesenteric or gastric veins. A single large abscess may be present, but multiple abscesses are the rule. The contents may be very fetid and bile-stained, or, as in many instances, they may be composed of thick, creamy laudable pus. From this focus of suppuration embolic abscesses may extend to the lungs, brain, kidneys, and joints. The macroscopic appearance, with the organ in situ, is sometimes practically normal. The liver may present a uniform enlargement, the surface being of normal color and the capsule non-adherent. More com- monly, however, the cortex presents a mottled appearance, and numerous yellowish-white spots are seen beneath the capsule. Etiology.—The most frequent source of purulent pylephlebitis is perityphlitic abscess. Rarely the disease arises idiopathically. Among other causes are the following : (a) A secondary (becoming a general) pyemia, (b) Ulceration of the intestines, occurring in dysentery and, more rarely, in typhoid fever, (c) Gastric ulcer, (d) Pelvic ab- scess ; abscess of the spleen, (e) Specific infection through the umbili- cus, occurring in the new-born. Symptoms.—The symptoms vary according as to whether the case remains one of suppurative pylephlebitis or terminates in hepatic ab- SUPPURATIVE PYLEPHLEBITIS. 867 scess. If the condition is part of a general pyemia, the symptoms refer- able to the liver may be almost negative. The liver is usually enlarged, and tender on pressure, the enlargement being most marked when an he- patic abscess exists. Though pain is present, in many cases it is not a marked feature; it is frequently referred to the epigastrium, and may radiate laterally or downward. Percussion in the left axillary line shoAvs splenic enlargement, and the organ can in some instances be felt beloAv the costal margin, constituting the "acute splenic tumor" of septico- pyemia. The fever is of an irregular septic type, the elevation in temperature is accompanied by rigors or chills and followed by profuse sweating. Other febrile symptoms, as headache, anorexia, and scanty, high-colored urine, are present. Jaundice of varying intensity is present, although usually it is not pronounced, the complexion being merely doughy or muddy. Diarrhea is not an infrequent symptom of this condition, and the dejecta sometimes contain blood as a result of the venous engorge- ment. Nausea and vomiting are often marked. As the case advances the pulse becomes rapid and small, and a low form of delirium develops; this is followed by stupor, coma, and death. Duration and Prognosis.—The duration of suppurative pylephle- bitis is usually from one to three or four Aveeks or longer. The prognosis is absolutely fatal. Diagnosis.—The diagnosis of suppurative pylephlebitis is sometimes extremely difficult, unless the case is complicated by hepatic abscess, as enlargement of the liver is not constant in the former condition. The etiology, septic temperature, enlargement of the spleen, jaundice, and pain in the region of the liver would all, however, point to this affection. The differential diagnosis of hepatic abscess will be spoken of later. Treatment.—Unfortunately, the treatment of suppurative pylephle- bitis can only be palliative. Surgical measures are rarely curative, unless the abscess is single and localized and shows signs of pointing. Free stimulation should be begun early, and should be persisted in throughout the course of the disease. Nausea and vomiting may often be relieved or controlled by pellets of cracked ice, brandy, and soda-Avater or champagne. One-drop doses of wine of ipecac every half hour until relieved, or the antiemetics, as cre- asote (X(l\—0.033—every half hour combined with bismuth subnitrate gr. v—0.324) or cerium oxalate (gr. \—0.016—every two hours), often check the gastric irritability. The pain in suppurative pylephlebitis is often acute, and demands the free use of morphin, either hypodermically or by the mouth. If much nausea exists, suppositories containing the extract of opium may be given at intervals. As the disease is almost invariably fatal, opium or its alka- loids may be given liberally. Fever may be controlled by repeated cold spongings or by the cold pack (68° F.—20° C), aided oy large doses of quinin and salol. As the pyrexia is pyemic in character, hoAvever, drugs have little or no effect in reducing the temperature. Delirium, Avhich, Avith the rise of temperature, usually becomes aggra- vated toward evening, can best be subdued by applying an ice-cap to the head; this may also be reinforced by motor and sensory depressants, 868 DISEASES OF THE DIGESTIVE SYSTEM. as chloral hydrate and the bromids. In Avell-marked cases hypodermic injections of hyoscin hydrobromate (gr. y^-g—0.0006—every two hours until relieved) may be necessary. STENOSIS. Obstruction of the portal vein may be due, as before mentioned, to (a) thrombosis; (b) cicatricial contraction from cirrhosis or syphilis of the liver; and (c) tumors pressing on the portal area. The first cause is the more common, chiefly because mechanical obstruction, by causing a stasis of the blood-current, induces the formation of a thrombus. The Symptoms of portal stenosis may be nil; if the stenosis occurs slowly, the hepatic artery furnishes sufficient blood to carry on the func- tions of the liver, the compensatory circulation being established by means of the systemic vessels. If due to thrombosis, the symptoms of portal engorgement appear suddenly with the development of edema and ascites. The liver is rarely enlarged in this condition. Prognosis.—This depends wholly upon the cause of the affection. Thrombi in the portal vein often give rise to a suppurative pylephlebitis, terminating in hepatic abscess; tumors are rarely accessible; whereas fibroid conditions of the liver causing cicatricial contraction are incurable. As a rule, the prognosis may be said to be guardedly unfavorable. AFFECTIONS OF THE HEPATIC BLOOD-VESSELS. Osler records a case of stenosis of the hepatic veins that was asso- ciated with fibroid obliteration of the inferior vena cava, with a greatly enlarged and cirrhotic liver. Among other affections of the hepatic veins are (a) Emboli, orig- inating from a thrombus in the right auricle, and (b) Dilatation, from stasis of the blood-current flowing to the right heart, due to enlarge- ment of the latter. Affections of the hepatic arteries are exceedingly rare, but may occur in one of the folloAving forms: (a) Aneurysm.—Only 10 or 12 cases of aneurysm have been reported, (b) Hypertrophy and Dilatation.—These may occur in connection with general hepatic cirrhosis, the cicatricial bands obstructing the lumen of the artery, and causing thickening in some places, and ampullae, or sac-like dilatations, in others, (e) Sclerosis. —This may form a part of a general arterio-sclerosis, though it occurs oftener in connection with cirrhosis or syphilitic hepatitis. ATROPHY AND HYPERTROPHY OF THE LIVER. (a) Atrophy.—Simple atrophy of the liver may result from pressure (corset-liver), syphilis, advanced cirrhosis, senility, and from the toxic HEPATIC INFILTRATIONS AND DEGENERATIONS. 869 action of phosphorus, arsenic, or chloroform—all factors that induce rapid fatty degeneration with cell-destruction. (b) Hypertrophy is of two kinds—(1) true and (2) false. (1) True hypertrophy may be subdivided into simple and numerical (hyperplasia), the latter referring to an increase in the number of the parenchymatous cells, and not, necessarily, implying an increase in the size of the organ. The two causes of simple hypertrophy are active and passive conges- tion. Among the causes of numerical hypertrophy may be mentioned the following: Leukemia, hypertrophic cirrhosis, atrophic cirrhosis (hyper- plasia), syphilis, diabetes, and malaria. (2) Pseudo- or false hypertrophy occurs in amyloid and fatty infiltra- tion, carcinoma, and abscess, and consists in an increase in the tissues least concerned in the function of the organ. HEPATIC INFILTRATIONS AND DEGENERATIONS. AMYLOID INFILTRATION. (Waxy, Lardaceous, Bacony, or Albuminoid Infiltration; Amyloid Disease.) Definition.—A deposit in the hepatic connective tissues of a peculiar substance having some of the reactions of, and resembling, starch. A physiologic example of amyloid infiltration may be found in the corpora amylacece of the prostate gland, in which there is a concentric arrange- ment somewhat resembling a starch-granule. Pathology.—The organ is larger than normally and of firmer con- sistence. The edges are rounded and not well defined, and the surface is of a light color, presenting in some instances a mottled appearance. On section the surface presents a grayish-brown, glistening appearance, which Avhen scraped fails to exude oil-droplets, as in the fatty liver. On microscopic examination the connective-tissue trabeculae and the intima and media of the capillary walls (the starting-points) are chiefly affected, the lumen of the latter being lessened; this decreases the blood- supply to the liver, and often directly induces fatty degeneration. The hepatic cells may be atrophied and show evidences of fatty change. Amyloid material is structureless, and appears in small cloudy masses under the microscope. Chemically, it contains small amounts of potassium and phosphorus and an excess of sodium and chlorin. Etiology.—Amyloid infiltration may occur primarily in the liver, but it is often a part of a general infiltration, affecting especially the spleen (sago spleen) and kidneys. It is also found in some syphilitic scars and in certain tumors and old thrombi. Dickinson believes that the deposition of amyloid material is due to a decrease in the alkalinity of the fluid of the body, the pus (in cases of long suppuration) having removed a large quantity of the natural potas- sium salts. In malarial cachexia, however, such losses could not have occurred. " Amyloid infiltration is not uncommon in scrofulous, tuberculous, and rickety children " (Harley). It is a frequent sequel to long-standing 870 DISEASES OF THE DIGESTIVE SYSTEM. and exhausting suppurating and cachectic affections, as necrosis of the bones, hip-joint disease, and pyelitis; especially is this the case Avhen they occur in an hereditary tuberculous or syphilitic constitution (Har- ley). Amyloid disease may also complicate chronic malaria. Tests and Characteristics of Amyloid Material.—Although of animal origin, amyloid matter is closely related to a vegetable albuminoid starch. It is, however, sIoav to decompose, and is not acted on by weak acids and alkalies, whereas strong alkalies dissolve it. Iodin gives a blue color upon the addition of sulphuric acid. Lugol's solution (the aqueous solu- tion of iodin and potassium iodid) gives a brown tint to amyloid liver- substance and stains ordinary hepatic tissues a yellow color. Gentian- violet givesa reddish or pinkish hue to amyloid substance, while normal tissue is stained blue. The following is taken from Harley's Comparative Table of Amyloid Tests : Starch. Amyloid. Cholesterin. Water. Ether. Heat. Sulphuric acid. Iodin. Dissolves on boil- Dissolves on boil- Unchanged. ing. Insoluble. Dries up. Chars. Becomes blue. Sulphate of indigo. ing. Insoluble. Dissolves. Dries up. Melts. Swells up, reddish- Becomes green, brown. blue, etc. Blue color with H2- Remains un- S04, which is de- changed. stroyed by excess. . Amyloid tissue soaked in it be- comes a brilliant blue, while with ordinary liver-tis- sues the blue fades to a pale green. Symptoms.—When amyloid disease occurs in children the subjects are poorly developed and puny, the complexion is, as a rule, muddy or salloAV, and the abdomen usually prominent. Occasionally the skin is exceedingly transparent. Various gastro-intestinal symptoms are present, prominent among which are marked constipation and a capricious appe- tite. Mental phenomena, as impairment of memory and inability to con- centrate, are not unusual in this disease. The physical signs show an increase in the area of hepatic dulness; the edges of the organ extend below the costal margin and have a rounded outline. Sometimes, how- ever, the edge, even in a very great enlargement, is sharp and large. Wilks speaks of an amyloid liver weighing 14 lbs.—6.35 kgms. (Osier). In rare instances the liver is reduced in size. Pain about the hepatic region is a rare symptom. The spleen is usually enlarged from coexist- ent amyloid infiltration. The urine often contains albumin (globulin is nearly always present) and waxy tube-casts ; it is of high specific gravity, is usually scanty, and dark colored. Diagnosis.—The foregoing symptoms and physical signs, in con- junction with an ordinarily clear etiology, are sufficient to establish the diagnosis. Treatment.—As amyloid disease is almost invariably a secondary FATTY INFILTRATION OF THE LIVER. 871 condition, the treatment must be directed to the removal of the primary cause, whether syphilis, tuberculosis, or rickets. The diet should consist of nitrogenous or animal substances, with a minimum amount of fatty or farinaceous foods. French rolls and bran- or gluten-bread are alloAvable, together with lean meat and green vegetables. Stimulants are to be strictly avoided. Moderate exercise, Avith the judicious use of Turkish (hot-air) and Russian (hot-vapor) baths, is also of great value. Many drugs are mentioned in the treatment of this disease, among the more important being the ammonium salts (the chlorid, gr. v to x__ 0.324 to 0.648—three or four times a day), and other alkalies, together with tonics and laxatives. When syphilis has been clearly established as an etiologic factor of the disease, the tincture of iodin in 10-to 15-minim (0.666-0.999) doses, well diluted, has been recommended to be given three or four times daily. Cod-liver oil as a nutritive has been tried with good effect. Of tonics, the dilute mineral acids, given in moderate doses over a long period of time, have probably achieved the best results. FATTY INFILTRATION. Definition.—A deposit of fat in the hepatic tissues due to the in- gestion of fats and albuminates. Pathology.—The infiltration occurs often in localized areas, and may be so intense that the organ when cut presents a shiny, oily ap- pearance. The liver is often evenly enlarged, and may weigh twelve to fifteen pounds. The edges are rounded and the substance less firm than normally. Portions of the liver-substance float in water, being of Ioav specific gravity. The color is light-yellow or grayish. On micro- scopic examination the protoplasm of the cell is seen to be pushed to one side by the fat-droplets, Avhich tend to coalesce. When the fat is removed the cells resume their normal outline and appearance. Etiology.—(a) Fatty infiltration may form part of a general obesity or it may folloAV excessive over-eating or sedentary habits, (b) It often occurs in wasting diseases, as carcinoma, syphilis, chronic malaria, and tuberculosis, and it often accompanies fatty degeneration. Symptoms.—The subjective symptoms of fatty infiltration may be entirely wanting, since the function of the liver is not impaired to any extent. When they are present progressive anemia and debility are noted, and are accompanied by nervous irritability and insomnia. In marked cases the cardiac rhythm is disturbed, causing a feeble and irregular impulse. The physical signs are usually well defined, and the area of hepatic dulness is uniformly increased, extending in some instances as low as the umbilicus. The enlargement, however, is not as great as in amyloid disease. Diagnosis.—Fatty infiltration of the liver, Avhen well developed, is not apt to be mistaken for any other affection of this organ. The occurrence of general obesity, together with an entire absence of symp- toms of obstruction to the portal vessels or bile-ducts or of other evi- dences of fatty degeneration (particularly feeble heart-sounds), will help to distinguish it from this latter condition. The etiologic factors above mentioned will also aid in the differentiation. 872 DISEASES OF THE DIGESTIVE SYSTEM. Prognosis.—This is decidedly favorable, as the function of the liver in many instances is not impaired in the slightest degree. Treatment.—As the disease is of gradual development and long duration, a modification of the diet constitutes the first essential of the treatment. That prescribed under the Treatment of Amyloid Liver is admirably suited to this affection. Saccharine and farinaceous articles of food (potatoes, oatmeal, and sweetmeats) must be eschewed. Wheat- bread must be partaken of sparingly, and in its place gluten- and bran-bread or crusts of French rolls should be used. Fish, lean meats, fresh vegetables, and fruits are also allowable. Alcoholic beverages must be interdicted. Graduated daily exercise and Turkish or Russian baths, judiciously used, are important factors in the treatment. Medicinally, the salts of the alkalies are highly recommended: sodium sulphate (in dram—4.0— doses, taken on an empty stomach) and ammonium carbonate (gr. xv to xxx—1.0 to 2.0—in twenty-four hours). FATTY DEGENERATION OF THE LIVER. Definition.—A conversion of the albuminates of the cells into fat; it is characterized anatomically by a destruction of the liver-substance, with atrophy of the organ, and clinically by biliary, gastro-intestinal, cardiac, and renal symptoms. Pathology.—On examining a liver that is the seat of marked fatty degeneration the organ is found smaller than normally, and the sub- stance is light yellow in color, soft, pliable, and easily torn. On section the relation betAveen the interlobular connective tissue and the acini is lost, the latter being replaced by fat-cells and oil-droplets. Scattered areas of pigmentation may be observed throughout the organ. Microscopically, the cells lose their shape and become globular; the nuclei tend to coalesce, and finally disappear, together with the cell-wall, giving rise to compound globule-cells, which do not tend to coalesce and are stained black by osmic acid. Crystals, granular debris, Lener's spheres, cholesterin, tyrosin, and phosphatic crystals are also found in this form of granular change. Etiology.—The following are among the recognized causes of the affection: (a) The excessive use of beer or alcoholic liquors, (b) It may be a sequence of amyloid disease, and hence result from any of the causes of the latter, (c) Diminution of the oxygen-supply to the tissues, occurring in phosphorus-, chloroform-, or arsenic-poisoning and in certain wasting diseases (carcinoma, phthisis, and chronic dysentery), (d) It may occur as a complication in the grave anemias and in acute infectious diseases ; also as a part of the pathology of acute yellow atrophy of the liver. Symptoms.—I feel convinced that partial or mild cases of fatty de- generation of the liver present no morbid symptoms of diagnostic import. Pain, jaundice, and ascites may occur separately or conjointly, but form the exception rather than the rule. The severe forms are characterized PERIHEPA TITIS. 873 by the symptoms seen in phosphorus-poisoning and acute yellow atrophy to the discussion of Avhich the reader is referred. ' Complications.—The disease may be complicated with fatty change in the kidneys. Under these circumstances the urine is diminished in amount, of low specific gravity, and contains an abundance of albumin fatty or oily casts, and crystals of cholesterin, leucin, and tyrosin In marked cases there is a very feeble and irregular cardiac impulse, accom- panied by attacks of vertigo and syncope, the latter symptom indicating beginning degeneration of the cardiac muscle. Edema of the lower ex- tremities and anasarca may occur as complications of this condition. The physical signs elicited by palpation and percussion show increas- ing diminution m the size of the liver as the disease advances. Diagnosis.—The chief diagnostic points of fatty degeneration may be summated thus: (a) A history of alcoholism, of poisoning by drugs (arsenic, phosphorus, or chloroform), or of an acute infectious disease (acute yellow atrophy); (b) Grave general symptoms, as albuminuria, edema, ascites, cardiac failure, terminating often in acholia or cholemia ; (c) Progressive diminution in the size of the organ. When these occur conjointly the diagnosis is established beyond a doubt. Prognosis.—The prognosis is entirely dependent upon the cause. If due to an excessive use of stimulants, the process, if recognized early, may be arrested ; if associated with acute yellow atrophy or other infec- tious disease, the prognosis is absolutely hopeless. Treatment.—The indications for treatment may be divided into the dietetic, hygienic, and medicinal. The same precautions regarding diet should be observed as in fatty infiltration. An open-air existence, short of injurious exposure, aided by hot salt-water, Turkish, or Russian baths, under restriction, is sure to improve the general condition of the patient. The medicinal treatment varies according to the cause of the disease. If due to grave anemia, iron (tinct. ferri chlorid. or syrup, ferri. iodid.) may be given in ascending doses. Poisoning by drugs"that produce fatty degeneration of the liver is to be combated by their respective antidotes. Gastro-intestinal disturbances, if coexistent, demand appropriate treat- ment. For the latter Frerichs recommends highly the salts of the alka- lies (sodium sulphate in dram—4.0—doses taken on an empty stomach and ammonium carbonate). Ascites and cardiac asthenia, when occurring as complications, must be met by suitable measures. PERIHEPATITIS. ACUTE PERIHEPATITIS. (Pyo-pneumothorax Subphrenicus.) Definition.—An inflammation, either suppurative or fibrinous, of the peritoneal covering of the liver and the corresponding portion of the diaphragm. Pathology.—The morbid changes may consist in a purely plastic inflammation, the serous layers being thickened, opaque, and covered with a fibrinous exudate leading to adhesion. In the majority of cases, 874 DISEASES OF THE DIGESTIVE SYSTEM. hoAvever, the inflammatory product is chiefly purulent, and is ribboned by fibrous bands so as to form circumscribed areas, filled with pus, lying betAveen the liver and the diaphragm; this constitutes the subphrenic abscess. The latter is found more commonly to the right than to the left of the suspensory ligament. It may contain much pus (1 quart—1 liter—or even more), Avhich in most cases is mixed Avith air or gas de- rived from the gastro-intestinal canal. Rarely, bilirubin-crystals are found, betraying the presence of bile. If the latter be present in large amount, the pus assumes an ocher-yellow hue. Etiology.—The fibrinous variety may result from the direct exten- sion of one or other of the acute forms of inflammation of the liver (ab- scess, hydatid cyst), from a pleurisy spreading along the lymphatics in the diaphragm, or from traumatism—particularly a blow. The suppura- tive form (pyo-pneumothorax subphrenicus, Leyden) may be caused in the same manner as the former, but far oftener—in more than one-half of the instances—it follows perforation of a gastric ulcer, and at times follows perforation by a duodenal or colonic ulcer. Appendicitis and penetrating Avounds are not infrequent causes. Perihepatitis is a grave complicating event in carcinoma (of the stomach, esophagus, and intes- tines), lobar pneumonia, and purulent pleuritis. Symptoms.—Those of the acute fibrinous variety are scanty, and often are either altogether missing or are too vague to admit of correct interpretation. The coappearance, however, of severe pain, increased on deep breathing, and tenderness over a circumscribed area either in the right hypochondrium or the epigastrium, after the action of some knoAvn cause or the occurrence of one of the causal affections, is a symp- tom of great clinical import. A friction-sound may at times be heard below the seventh rib in the mammiilary and the ninth rib in the axil- lary line, or over the epigastrium, as in tAvo cases in my own practice. It is of short duration, and is limited usually to the end of inspira- tion. It must be recollected that plastic pleurisy may be an associated condition. In suppurative perihepatitis the symptoms are sometimes screened by those characterizing the special causative complaint, but in my experi- ence, in cases due to perforation—the most common cause—the onset is rapid and severe, and is marked by acute pain referred to a circumscribed spot in the hepatic region, great tenderness, rapid, embarrassed, and painful respiration (owing to implication of the diaphragm), by vomiting (often bilious, though at times hemorrhagic) or nausea, and by faint jaundice in some cases. Shortly the general features of circumscribed peritoneal abscess also appear—rigors, irregular fever, sweats, and pro- gressive prostration and emaciation. Physical Signs.—Inspection discloses bulging of the right hypo- chondrium and often of the epigastrium. The same regions are immo- bile, but this is best appreciated by palpation. The anterior edge of the liver is felt even as low as the umbilical level. Percussion reveals a variable increase of hepatic dulness upAvard, sometimes touching the fourth rib. The upper level of the fluid is movable on changing the po- sition of the patient, and this is particularly striking if air or gas is con- tained in the abscess ; the presence of the latter also causes a zone of tympanitic resonance above the dull area, while overlying the latter CHR ONIC PERIHEPA TITIS. 875 there is the semi-tympanitic area of the retracted lung. Auscultation reveals an absence of breath-sounds and of the vocal resonance over the dull and tympanitic areas, Avhile the respiratory sounds over the dis- placed lung are broncho-vesicular. Diagnosis.—Acute suppurative perihepatitis often remains unrecog- nized during life. It may be confounded Avith empyema of the right side, but the tAvo conditions have different modes of development. Perihepatitis is preceded and accompanied by abdominal symptoms; empyema mani- fests thoracic symptoms—e. g. cough and pleuritic pain. At a later stage the exaggerated respiratory murmur above the dull area, the slighter cardiac displacement toAvard the left, and the greater hepatic displacement downward in suppurative perihepatitis aid in the differen- tiation. The introduction of the trocar in the seventh or eighth inter- costal space in the mid-axillary line may also be helpful, especially if the exudate be found to contain bile-pigment. PfuhVs sign—the more ready escape of the fluid during inspiration on aspiration of abscesses below the diaphragm—may not be without value. The points narrated above may likewise serve to separate pyo-pneumothorax from suppurative perihepatitis (see also Pneumothorax, p. 565). Course and Prognosis.—In the milder or fibrinous variety the outlook is favorable and the course is brief. On the other hand, the suppurative type due to perforation, if not early brought under proper surgical treatment, often terminates unfavorably by gradual asthenia. Rarely the pus is resorbed, or it may find an outlet through the lungs, abdominal walls, or other avenue, folloAved by slow recovery. The treatment is the same as for localized peritonitis. The first evidence of the presence of pus is the signal for appropriate surgical interference—evacuation and drainage. CHRONIC PERIHEPATITIS. (Zuckergussleber) This affection is a chronic inflammation of the perihepatic fibrous membrane, which becomes opaque and thickened. Contraction of this capsule ensues, with compression of the liver and atrophy to even one-half the size of the normal organ (as in a case reported by Rumpfl), and par- tial or total occlusion of the vessel and bile-ducts. Perhaps these changes are most marked in cases that follow acute suppurative perihepatitis. Genuine instances show no hyperplasia of the interstitial connective tis- sue; hence the condition is closely related pathologically to " Glissonian cirrhosis" (vide p. 886). The main causes of chronic perihepatitis are great and protracted local pressure, as from a corset, and certain occupations. It may rep- resent a portion of a more general chronic inflammation of the serosae. Finally, I am of the belief that syphilis is the leading single cause, and have discovered no other factor present in two cases that yielded to antisyphilitic treatment. The diagnosis is generally problematic. Of special clinical worth are the etiology, pain in the right hypochondriac region—particularly in cases due to syphilis—absence of the signs of stasis of the gastro- intestinal tract, and the very protracted course. 1 Deutsch. Arch, f klin. Med., March 13, 1895. 876 DISEASES OF THE DIGESTIVE SYSTE3I. The treatment is purely palliative, apart from the effort to remove the special cause, Avhether this be syphilis, occupation, or other influ- ential factor. ABSCESS OF THE LIVER. (Hepatic Abscess; Suppurative Hepatitis.) Definition.—A circumscribed collection of pus in the hepatic parenchyma. Pathology.—If examined in situ, a liver that is the seat of ab- scess-formation is usually found to be symmetrically enlarged, and on careful palpation one or more areas of fluctuation (either deep or super- ficial, according to the location of the abscess) may be detected. If single, its position is usually in the right lobe near the convexity of the organ (70 per cent, of cases). The tissue surrounding the abscess-wall is usually deeply injected, the wall itself in acute cases being poorly defined, but grayish in color, irregular and shreddy, and composed of necrotic liver-cells, pus-corpuscles, and often amebae. In chronic cases it becomes greatly thickened and often cartilaginous in appearance. Microscopically, the hepatic cells are altered in shape and devoid of nuclei; they undergo rapid degeneration. A round-celled infiltration occurs about the blood-vessels, their walls being filled with small emboli containing innumerable staphylococci and streptococci. As the sup- purative process continues liquefaction-necrosis occurs, resulting in complete destruction of the hepatic parenchyma. The amount of fluid contained in a liver-abscess may exceed 2 or 3 quarts-(2-3 liters), and its color varies from grayish-white to a creamy, reddish-brown. The collection in some instances resembles healthy pus. I have spoken of the methods of infection and of some of the different varieties of hepatic abscess in the discussion of Dysentery (see p. 96). Various odors are described, depending largely on the extent of bac- terial invasion and the degree of necrosis. In this connection it may be said that in amebic dysentery, with abscess of the liver as a compli- cation, the abscess is often single (involving more often the right lobe), Avhereas other forms due to septic infection give rise to multiple abscesses. In the latter instances the surface of the organ presents many small yellow areas beneath the capsule, varying from 5 to 15 mm. (^—f inches) in diameter. Usually, in such cases infection has taken place through the portal circulation, and on section the appearances of a suppurative pyle- phlebitis present themselves. If thrombi have formed in the portal tributaries, localized necrotic areas are the result, but more often the invasion affects the whole portal system, the liver being riddled with abscesses. If the abscess is secondary to obstruction by gall-stones or inspissated bile, the ducts are greatly distended and the gall-bladder is filled with pus mixed with bile. Etiology.—Idiopathic abscess of the liver is rare even in tropical climates. The affection, even when excited by mechanical causes, as traumatism or obstruction by gall-stones, is invariably septic in cha- ABSCESS OF THE LIVER. 877 racter, and the infecting material reaches the interior through the hepatic vessels or the biliary passages. Septic emboli enter the liver by means of the vascular system through the hepatic artery or portal vein, the latter being the more common channel of transmission. Gastric ulcers, or the ulceration occurring in dysentery, typhoid fever, typhlitis, or appendicitis, may be followed by a purulent portal pylephlebitis, resulting in abscess-formation. In gen- eral pyemic processes or in bone-suppurations of long standing the germs enter the venous circulation, traverse the intralobular pulmonary plex- uses, and enter the liver through the hepatic artery. Suppurating Avounds of the head are not uncommonly folloAved by abscess of the liver. Because of obstruction of the common duct by gall-stones, either from pressure-necrosis or OAving to the decomposition of accumulated bile, germs may enter the liver and cause abscess-formation through the medium of the bile-ducts. In such cases gastro-hepatic disturbances usually make their appearance before the symptoms of abscess develop. The most common method of infection, hoAvever, is through the portal vein. Among other causes may be mentioned foreign bodies travelling up the ducts, as parasites, round-Avorms, liver-flukes; also, more rarely, suppuro-perforation by mechanical irritants (needles, fish-bones, and the like), and suppuration occurring in the course of an hydatid cyst. Symptoms.—In a typical case of hepatic abscess the most promi- nent symptoms are—hectic temperature, pain, tenderness, and enlarge- ment of the organ, and often slight jaundice, although it must not be forgotten that any or all of these may be absent during the development of an abscess. The multiple abscesses occurring in pyemic conditions, which are frequently diagnosed Avhen in view upon the postmortem table, form an instance of this. To facilitate the subject I shall consider the more important symp- toms seriatim: Pain is circumscribed to the hepatic region, and radi- ates to the right shoulder in conjunction Avith the other symptoms and physical signs; it is very characteristic, although not pathognomonic of hepatic abscess. In the earlier stages this symptom is not pronounced unless the abscess or abscesses lie superficially. It is usually of a dull, boring character, differing in severity Avith the patient's position; it is usually aggravated by pressure over the costal margin and by lying on the left side, this tending to drag the liver by its own weight from its normal position. Luschka explains the radiation of pain to the right shoulder by stating that filaments of the phrenic nerves that distribute themselves in the suspensory ligament and Glisson's capsule are irri- tated. The phrenic arises from the third, fourth, and fifth cervical nerves, and, as the fourth supplies sensation to the right shoulder, the impression is thus transmitted through the central nervous system. In acute cases accompanied by rapid destruction of the hepatic tis- sues the temperature usually rises rapidly, reaching 103° or 104° F. (39.4°-40° C.) in the course of from twenty-four to thirty-six hours. Its course, however, is irregular and intermittent, and it may be hectic in character; just as often it resembles a tertian or quartan intermittent or a remittent temperature. Rigors or decided chills frequently accompany the rise of temperature, and during the decline profuse sweatings may take place, thus simulating to a certain extent the symptoms of malarial 878 DISEASES OF THE DIGESTIVE SYSTEM. fever. In chronic abscess of the liver pyrexia may be entirely absent. The pulse is usually rapid in proportion to the temperature. Less commonly the temperature may remain continuously high, with slight morning and evening exacerbations and remissions. The physical signs in a case of hepatic abscess are always present to a greater or less degree, and are often pathognomonic. Inspection may reveal nothing during the entire course of the dis- ease, although in cases accompanied by intense congestion in Avhich the abscess involves the anterior surface of the right lobe, bulging of the ribs on that side will occur, with a marked prominence in the hypo- chondriac region extending three or more finger-breadths below the costal margin. Palpation confirms inspection and reveals tenderness on pressure below the costal margin in the mammary line. The liver, if projecting below the edge of the ribs, is usually enlarged uniformly, unless the abscess involves the surface of the margin. As the upper right lobe is more often involved, especially in a large single abscess, the increase in size is in an upAvard direction, thus rendering palpation negative. In rare instances the abscess gives rise to fluctuation on palpation, and if the peritoneum be inflamed and adherent a friction fremitus may be detected. Percussion.—The area of hepatic dulness may be increased uni- formly, but it is usually most marked upward and to the right, in some instances reaching at the anterior axillary line to the fifth rib, and pos- teriorly to the level of the angle of the scapula. The increase of per- cussion dulness upAvard and to the right may also differentiate abscess from other affections of the liver, in which the enlargement usually extends in a doAvnward direction. General Symptoms.—The skin is pale and shoAvs slight icterus, the conjunctivae being often bile-stained; intense jaundice, however, is rare. Progressive loss of flesh and strength, with gastro-intestinal dis- turbance (fulness in the epigastrium, flatulence, Avater-brash, nausea, and occasional vomiting), are common symptoms at the onset. The boAvels are variable, and constipation usually alternates with diarrhea, the stools in some cases containing the ameba coli. Ascites may develop from pressure on the inferior vena cavae, but these cases are rare. The spleen may undergo active hyperplasia in acute abscess-formation. Pul- monary symptoms are not uncommonly present; they are due to com- pression of the base of the lung by the abscess pressing upon the dia- phragm. In fatal cases certain nervous symptoms (muttering delirium, cephalalgia, and subsultus tendinum) make their appearance, and are fol- lowed by stupor and coma. Complications and Sequelae.—The abscess may perforate into the pleural cavity (pyothorax), bronchi, lungs, intestinal tract, stomach, pericardium, peritoneal cavity, or externally through the abdominal Avail, giving rise to various symptoms. If rupture occurs into the intestinal tract, sudden diarrhea, Avith the discharge of large quantities of pus, takes place; there is then an amelioration of the pain, fever, and other symptoms. If the rupture is into the lung, the physical signs will reveal the sudden development of Aveak, tubular breathing over the base, with increased tactile fremitus and percussion-dulness, together ABSCESS OF THE LIVER. 879 with the occurrence of profuse expectoration. In cases spoken of by Budd and Osier the sputum ay as of a reddish-broAvn color, resembling anchovy sauce, while Reese and Lafleur found the ameba coli in the bronchial discharge. Rupture in the abdominal cavity gives rise to the rapid development of a purulent peritonitis that is often fatal. Rarely, the abscess is emptied into the pericardium, giving rise to fatal acute pericarditis. Septic emboli have been knoAvn to lodge in the circle of Willis, producing fatal brain-abscess. Diagnosis.—The clinical symptoms of hepatic abscess are of diag- nostic importance only Avhen taken in the aggregate, since the pain, fever, enlargement, and even hectic symptoms, occur singly in other conditions unaccompanied by suppuration. The chief points in the establishment of the diagnosis of the affection may be summed up as follows: Residence in tropical countries, the previous existence of typhoid or dysenteric ulceration (or other gastro-intestinal inflamma- tion), enlargement of the liver, Avith pain and tenderness on pressure, and in some instances fluctuation on palpation. Lastly, aspiration may succeed in revealing pus-corpuscles, hepatic cells, staphylococci and streptococci, the ameba, and bile-pigment, Avhich when found are path- ognomonic ; if the abscess be secondary to an echinococcus cyst, the presence of hooklets will be detected. Differential Diagnosis.—Hepatic abscess may be misdiagnosed for empyema, malarial fever, and hepatic calculi. Empyema.—The mode of onset and the physical signs peculiar to this condition, if studied carefully, are entirely different from those of abscess. In empyema there may be the history of a perforating wound of the chest, the rupture of an emphysematous or tuberculous cavity, or the pre-existence of a sero-fibrinous pleurisy; Avhereas hepatic abscess may be preceded by an attack of amebic dysentery or intestinal ulcera- tion, or it may follow the impaction of biliary calculi. In both there may be the occurrence of a hectic temperature, Avith chills and sweating; but in empyema cough and dyspnea are prominent, and, if the pleural cavity communicates Avith a bronchus, profuse muco-purulent expectora- tion containing pus-cells, staphylococci, streptococci, and in many cases elastic tissue and tubercle bacilli. Rarely, an abscess of the liver pene- trates the diaphragm, and, entering the bronchi, is expectorated. The recognition of hepatic abscess under these circumstances is to be based mainly upon clear evidence of the affection prior to the occurrence of perforation and copious purulent expectoration. The detection of the amoeba coli in the sputum alone Avould set the diagnosis at rest. The contents of hepatic abscess obtained by aspiration consist of the micro- organisms of suppuration, and in addition broken-down liver-cells, bile- pigment, and in some cases the amoeba coli. Inspection in empyema reveals bulging of the intercostal spaces on that side, while percussion gives absolute flatness over the base of the chest, rising posteriorly and changing with the change from a dorsal to a sitting position. Above the area of flatness we find either a normal pulmonary note or hyper- resonance. In abscess of the liver the lung is very slightly displaced upAvard, being often bound to the diaphragm by adhesions, and the line of percussion-dulness in the right hypochondriac region does not change with the decubitus of the patient. DISEASES OF THE DIGESTIVE SYSTEM. Hepatic Abscess. Malaria. History of traumatism, dysentery, intes- History of previous attacks. Residence tinal ulceration, or residence in tropi- in warm, damp climates among the cal countries. lowlands. Hectic character of the temperature— Regularly recurrent rise of the tempera- high every evening and low every ture (intermittent or remittent, quotid- morning; irregular chills, followed by ian, tertian, quartan, or septinarian), fevers and sweatings. and the rise occurring during the chill, followed by profuse sweating; chills more often in morning. An irregular, fluctuating tumor or multi- The spleen is enlarged; also there is a pie nodules in the liver ; no splenic en- yellow-brown coloration of the skin, largement; rapid emaciation, with or more or less marked; and, in long- without jaundice, but no cachexia. standing cases, the occurrence of ca- chexia. Blood shows simple anemia, and in The presence of the hematozoa of Laveran marked cases disintegration of red and free pigment in the blood. blood-cells, but an absence of micro- organisms. Abscess-contents consist of the staphylo- Absent. cocci, streptococci, pus-cells, and, in some instances, amebae. Impacted Calculi.—In this condition attacks of hepatic colic are often first noticed, folloAved by jaundice, and, if impaction be not absolute, by the occurrence of stones in the feces. In abscess the pain is not parox- ysmal, but dull and boring in character, increasing in severity as the disease progresses. In chronic impaction occasional attacks of fever (not hectic in character), jaundice, dull pain over the hepatic area, dis- tention of the gall-bladder (Avhich in some instances can be palpated), and clay-colored feces, constitute the principal symptoms. In abscess of the liver jaundice is comparatively rare, the temperature is often hectic in character, and, unless the abscess rupture into the gastro-in- testinal tract, the stools contain nothing abnormal. In some instances biliary abscesses may follow impacted calculi, or perforation may occur into the peritoneal cavity, with rapid development of peritonitis, which may prove fatal. Among the conditions that are liable to be mistaken for hepatic ab- scess may be mentioned carcinoma, hypertrophic cirrhosis, and hydatid cyst, the differential diagnosis of which will be spoken of under these diseases. Prognosis.—The prognosis of hepatic abscess is very unfavorable, the disease generally progressing to a rapidly fatal termination. Prompt evacuation of the abscess Avhen its location can be detected may be suc- cessfully performed. The mortality ranges from 50 to 60 per cent. In rare cases the walls of the abscess become calcified and the disease re- mains latent. The single large abscess that most often follows dysentery offers the best opportunity for surgical measures. Treatment.—Barring operation, the treatment of abscess of the liver is purely symptomatic, being in many instances identical with that of septico-pyemia. The temperature often responds to repeated spong- ings with cool Avater (65° F.—18.3° C). For the pain mustard-poul- tices, the turpentine stupe, or hot fomentations over the hepatic area, in conjunction with full internal doses of opium, prove beneficial. Full and free stimulation and the free exhibition of quinin as soon as the ACUTE YELLOW ATROPHY. 881 condition is detected both support the system and control, in a measure, the pyemic process. If the abscess be single and localized, prompt evacuation should be resorted to. ACUTE YELLOW ATROPHY. (Malignant Jaundice; Icterus Gravis.) Definition.—An acute and probably infectious disease, character- ized by a rapid destruction of the parenchyma of the liver and by a diminution in the size of the organ; also by jaundice, hemorrhage, and grave cerebral phenomena. Pathology.—Macroscopically, in a case of acute yellow atrophy the liver is seen to be much reduced in size, weighing but 15 or 20 ounces (480.0-640.0), instead of its normal weight (50 oz.—1.6 kgms.). The capsule is shrivelled and the Avhole organ is of a pulpy consistence, and changed in appearance from a mahogany-broAvn to a light-yelloAv color, due to rapid fatty degeneration. On section the cut surface often pre- sents areas of red and yellow discoloration, the so-called " red atrophy " and " yellow atrophy," the former being a later stage of the latter. The red appearance is due to an excess of blood in the capillaries, Avith free pigment that has been liberated by destruction of the red blood-cells. Microscopic examination reveals a widespread destruction of the hepatic cells. The nuclei have disappeared, and the cell-Avail contains a num- ber of fat-globules of various sizes containing free pigment. In ad- vanced cases, accompanied by total disintegration of the cells, fat-drop- lets, granular debris, cholesterin-plates, leucin spheres, tyrosin needles (first discovered by Frerichs, both in the cells and in the blood-vessels), and crystals of bilirubin may be found. The common duct is patulous and the gall-bladder is usually empty. In AAell-marked cases both the heart and kidneys shoAV evidences of fatty degeneration, the kidneys often showing ecchymotic areas. The spleen is greatly enlarged from active congestion, giving rise to the so- called "acute splenic tumor." The splenic substance is soft and easily torn, and on section the organ often drips blood. The skin and mucous membranes may be the seat of numerous ecchymoses, and dropsy of the pericardial and other serous cavities is frequently noted. The blood is dark and fluid, and under the microscope is seen to contain disintegrated red corpuscles, with crystals of leucin and tyrosin. Etiology.—The causes of acute yelloAV atrophy are both primary and secondary. Primary or idiopathic acute yellow atrophy is a rare and an invariably fatal condition. Among the secondary predisposing causes may be mentioned age (fifteen to thirty-five years), female sex, pregnancy, and the occurrence of certain fevers (puerperal fever, typhoid, septicemia, malaria). Acute phosphorus-poisoning is almost invariably followed by acute yellow atrophy. The disease rarely accompanies cirrhosis of the liver, and may follow a debauch. In some instances an endemic form is assumed, but the exciting cause is thus far unknown. Although certain investigators claim to have discovered micrococci in the hepatic vessels, 56 882 DISEASES OF THE DIGESTIVE SYSTEM. they have not yet been able to prove them to be the pathogenic germs of the disease. Symptoms.—The clinical history in a case of acute yelloAV atrophy varies considerably in the early stages of the disease, the graver symp- toms of the later stage alone being pathognomonic. The attack is usually ushered in by headache, malaise, anorexia, nausea and vomiting, moderate fever, and after a variable length of time (usually a few days) jaundice appears. Physical examination at this time shows the area of hepatic dulness to be normal or only slightly increased. After a period varying from a few days to two or three weeks grave nervous and cerebral symp- toms present themselves, as restlessness and violent headache, folloAved by delirium, which often becomes maniacal. Convulsions then appear, and are succeeded by stupor and coma, the latter occurring usually within forty-eight hours from the onset of the period of cerebral excitement. Often coarse tremors are noticed in the voluntary muscles, and with the onset of the second stage the jaundice usually deepens. The temperature often remains normal until just before death, when it may rise one or two degrees. The pulse is much diminished both in volume and tension, and is rapid in proportion to the temperature. The tongue at the onset is covered with a light coating, most marked on the dorsum and around the tip and edges. Later, it changes to a thick yel- low color and becomes dry and fissured, like that of typhoid fever. Vomiting appears usually during the premonitory stage and often be- comes intense; the vomit consists at first simply of the gastric contents, which later in the disease become mixed with blood (hematemesis). Hem- orrhages also frequently occur into the skin (ecchymoses) and from the mucous membranes, giving rise to epistaxis, hematuria, melena, hemop- tysis, and menorrhagia. These are supposed to be the result of a diape- desis of corpuscles due to the altered blood-pressure and to a diminished power of resistance in the muscular coats of the arterioles caused by degeneration. The urine in acute yellow atrophy is often scanty in amount, high col- ored, and shows an increase in specific gravity (1028-1032). The urea is greatly diminished, but bile-pigments and albumin, tube-casts, leucin, and tyrosin are found both on chemical and microscopic examination. The latter can be easily demonstrated by allowing a drop of the urine to evaporate on a cover-glass and examining under the microscope. Striim- pell regards the diminution in the quantity of urea, Avith the appearance of leucin and tyrosin, as a significant fact in view of the theory supported by Meissner and von Schroder, who claim that urea is manufactured by the liver. Among other products found in the urine worthy of mention are creatinin and sarcolactic acid, which, however, have no clinical importance. The patient is usually constipated, and the stools are clay-colored in appearance, being devoid of bile-pigment. When hemorrhage from the bowels occurs the dejecta are dark-colored, owing to the presence of al- tered blood. The physical signs reveal tenderness over the hepatic region, often amounting to actual pain, though this is rarely severe or lancinating. During the second stage, in extreme cases, the edges of the organ cannot be palpated under the costal margin. Percussion, moreover, shoAvs a THE LIVER IN PHOSPHORUS-POISONING. 883 great diminution in the size of the liver, the area of dulness in a case recorded by Harley extending over but 1 inch (2.5 cm.) in the mammary line and 1\ inches (3.1 cm.), measured perpendicularly, in the mid-axil- lary line. The left lobe is often the first to show physical signs of atrophy, per- cussion giving tympany instead of flatness in the upper epigastric region. As the atrophy continues the tympany extends below the seventh rib from above and advances upward from the costal margin, leaving but a small circumscribed area of hepatic dulness. The atrophy is usually progress- ive until death occurs, although favorable cases have been recorded in which the liver increased in size perceptibly during recovery (Harley, p. 260). When occurring in pregnant females the affection is likely to be complicated by abortion or miscarriage. Diagnosis.—The symptoms of acute yelloAV atrophy of the liver, and especially those occurring during the second stage of the disease, are usually so characteristic as to leave little doubt concerning the diagnosis. The occurrence of gradually increasing jaundice, grave delirium, hem- orrhages into the skin and mucous membranes, and the presence of an immense amount of bile, Avith leucin and tyrosin, in the urine, all com- bine to form a typical clinical picture. In hypertrophic cirrhosis the onset is more gradual. There is gener- ally a previous history of alcoholism, and the condition is often accom- panied by jaundice, vomiting, hemorrhages (from passive congestion), and delirium. Examination of the urine, hoAvever, fails to reveal leucin and tyrosin, fever is rarely present, and the physical signs often show an enormous increase in the area of hepatic dulness. The differential diagnosis betAveen this disease and phosphorus- poisoning is given under the latter condition (vide infra). The prognosis is almost invariably fatal, since every case of true yellow atrophy is associated Avith a destruction of liver-cells that is accompanied by acute toxemia. Treatment.—As yet no specific treatment has been discovered, all remedies used being directed to the relief of symptomatic indications. The gastro-intestinal system should be relieved at the onset by divided doses of calomel. For the vomiting cracked ice, Avith 1-minim (0.066) doses of the wine of ipecac repeated every half hour or divided doses of opium, may be given. Marked nervous phenomena with delirium I have seen controlled by cool baths and the ice-cap, together with cam- phor, chloral, or other antispasmodics used internally. Free stimulation should be begun early and persisted in throughout the course of the disease. THE LIVER IN PHOSPHORUS-POISONING. Following the ingestion of a dose of phosphorus varying from gr. \ to gr. 1 (0.008-0.0648) symptoms of poisoning manifest themselves (Taylor, Wormley) as follows: After a period of time varying from three to twelve hours a sense of wretchedness, nausea, abdominal pain (not intense), and often vomiting, 884 DISEASES OF THE DIGESTIVE SYSTEM. occur. The vomit consists of the gastric contents, with bile, and during the first few hours it may contain phosphorus, Avhich gives it a luminous appearance in the dark. After the second or third day the vomiting usually ceases with the appearance of jaundice, Avhich may become intense as the process con- tinues. Later in the course of the case emesis recommences, the vomita consisting of altered blood, giving rise to the so-called "black vomit." At this stage nervous symptoms usually manifest themselves (headache, insomnia, vertigo, and delirium, Avith convulsions and coma in fatal cases), death closing the scene usually in from thirty-six to forty- eight hours. The boAvels are constipated, although attacks of diarrhea may super- vene, the evacuations being in some instances phosphorescent. Fever is irregular and usually is not marked, the temperature swing- ing from 99° to 101° F. (37.2°-38.3° C). In fatal cases the temper- ature may become subnormal just before death. The urine is scanty, of high specific gravity, and contains bile, bile- acids, albumin, sarcolactic acid, and in rare cases leucin and tyrosin (Wood). Renal epithelium and free fat-globules have also been found. When occurring in pregnant Avomen abortion or miscarriage invariably folloAvs. Physical examination reveals a liver uniformly enlarged and tender on pressure. In protracted cases atrophy of the organ may rarely occur. Pathology.—On opening the abdominal cavity in a case of phos- phorus-poisoning the liver is seen to extend beloAv the costal margin, its surface being lighter in color than normal and mottled in appearance, and its substance softer in consistence and friable. The cut section presents marked evidences of fatty degeneration, the acini being lighter in color than the interlobular tissue. Portions of the hepatic parenchyma are deeply bile-stained, and on scraping the cut surface bile- and fat-globules will be found on the edge of the knife. The gall-bladder may be either full or empty. Microscopically, disin- tegrated liver-cells, fat-globules, granular debris, biliary coloring-matter, leucin-spheres, cholesterin-plates, and tyrosin-needles are noted. The gastric mucosa is found thickened, opaque, and yellow-white in appearance, due, as pointed out by Virchow, to a universal gastro-adeni- tis, and not to the local action of the poison. Ulcerative or erosive gastritis is very rare in phosphorus-poisoning. The kidneys may shoAV beginning atrophy, the epithelium in the cortices undergoing granular and fatty degeneration, Avith final destruc- tion of the cells. The blood is dark, fluid, and not easily coagulable. Concato found that during life the Avhite corpuscles are increased in number, and that the red are changed in shape and smaller than normal (Wood). Pete- chiae and ecchymoses frequently appear in all parts of the body, and occur oftenest in the mediastinum and serous membranes. Bollinger records a fatal case in Avhich a hemorrhagic effusion Avas discovered between the membranes and the spinal cord. Diagnosis.—The diagnosis of acute phosphorus-poisoning is always extremely difficult and often impossible. The disease with which it is CIRRHOSIS OF THE LIVER. 885 most apt to become confounded is acute yellow atrophy of the liver. The differential points may be summated as folloAvs: Acute Phosphorus-poisoning. There is a history of accidental ingestion of poison (friction-match heads, rat- poison). The onset is sudden; violent nausea, vomiting, and pain over the region of the liver. Jaundice appears on -the second or third day. Nervous symptoms appear late in the disease—always preceded by jaundice. The vomit and stools are phosphorescent. Black vomit precedes death. Temporary arrest of symptoms between the occurrence of jaundice and black vomit. Sarcolactic acid is present in the urine, and rarely leucin and tyrosin. Prognosis and Duration.—The prognosis in phosphorus-poison- ing is bad, as small a dose as gr. | (0.008) of white phosphorus having caused death (Wormley). The duration is usually from one to six days, although the symptoms have been knoAvn to persist for twelve days be- fore death. In violent cases the end may come within tAventy-four hours. Treatment.—The initial plan of treatment is by causing emesis to free the system of the poison that still remains undigested. For this purpose copper sulphate (gr. x—0.648) in divided doses (gr. ij or iij— 0.129 or 0.194—every five minutes) should be given until free vomiting occurs. As copper sulphate is a chemical antidote, forming with phos- phorus black copper phosphid, it should be continued in less frequently repeated doses (gr. ij—0.129—every half hour) and guarded by morphin to prevent vomiting. If emetics by the. mouth fail to afford relief, apo- morphin muriate (gr. \—0.0129), hypodermically, may be resorted to. The free evacuation of the stomach should be followed by the adminis- tration of the French oil of turpentine. Wood recommends that 1 part be given to every 100th part of the poison ingested. Ordinary turpen- tine is useless, but combined with mucilage of acacia 2 fluidrams (8.0) of French oil of turpentine may be given every fifteen minutes until 1 ounce (32.0) has been taken. Alkalies (magnesia) have been given, but are practically valueless. Free purgation should be effected if possible by Rochelle salts or mag- nesium citrate. Demulcent oils are never allowable, as they dissolve the phosphorus and hold it in solution. After absorption of the poison and degeneration of the tissues have taken place all known remedies are futile. CIRRHOSIS OP THE LIVER. (Sclerosis of the Liver; Nutmeg Liver; Gin-drinker's Liver; Interstitial Hepatitis.) Definition.—A chronic disease of the liver, characterized by an excess of connective tissue, with atrophy of the liver-cells. It presents various biliary, gastro-intestinal, circulatory, and cerebral symptoms. Acute Yellow Atrophy. There is often an endemic history. A slow onset—malaise, slight fever, with nausea and vomiting ; jaundice is a be- ginning symptom. Nervous symptoms may appear early, often before the occurrence of jaundice. Black vomit occurs early and persists throughout. Progressive march of symptoms with no remission. Leucin and tyrosin are common in the urine. 886 DISEASES OF THE DIGESTIVE SYSTEM. Pathology.—There are tAvo leading forms, pathologically: (a) the atrophic and (b) the hypertrophic. In the atrophic form the capsule is thickened, though the organ is greatly reduced in size and altered in shape. Foxwell's recent studies, however, shoAv that, as a matter of fact, the alcoholic (indurative) liver is more frequently enlarged than decreased in size. This accords Avith my experience also. Strands of grayish-white interstitial tissue may be seen surrounding yellowish areas of hepatic structure that are elevated above the surface and look not un- like hob-nails ; hence the term "hob-nailed liver." The substance is much firmer than normally, resists the cutting knife, and a cut-section presents a granular appearance. Microscopically, the connective tissue is most abundant about the acini; the liver-cells surrounding the hepatic veins are atrophied from pressure and undergo fatty degeneration. Sieveking in a microscopic examination of 20 Avell-marked cases of atrophic cirrhosis, chiefly alco- holic, found that the proliferated connective tissue infiltrated the liver- substance in an irregular manner. In some parts the newly-developed connective tissue was inter-acinous, and in others intra-acinous; only Avhen the connective tissue encircled separate cells or small groups of cells did atrophy occur. He therefore regards the proliferation of con- nective tissue as a primary change, and the atrophy as secondary. On the other hand, Weigert and his disciples contend that atrophy is often the primary change, and connective-tissue production the secondary— filling the gap, so to speak. The biliary canaliculi are apparently in- creased in number, consisting for the most part of toavs of liver-cells that are caught in the newly-formed connective tissue. As the cirrhotic pro- cess continues the minute portal veins are pressed upon, causing obstruc- tion to the portal circulation, Avith the development of ascites. This form of cirrhosis was first described by Laennec. Hypertrophic.—On examining the liver in situ during hypertrophic cirrhosis the organ is found enlarged (sometimes enormously), the lower border projecting several fingers' breadths below the ribs. The margin of the organ is Avell defined, the substance firmer than normal, and it cuts Avith difficulty. The organ is lighter in color than in health, and pre- sents a yellow or mottled-green appearance. On treating a section Avith compound iodin solution (Lugol's) the color changes to that of a deep mahogany-red. The acini are darker in hue than the interstitial tissue. Microscopically, the peripheral portions of the acini are first seen to be the seat of a round-cell infiltration, with the formation of embryonal tissue; later, the interlobular connective tissue undergoes hyperplasia, causing obstruction of the biliary ducts with retention of bile and sub- sequent atrophy of the liver-cells. Tavo other varieties may here be mentioned: (1) That characterized by marked fatty degeneration of the hepatic parenchyma and resembling fatty liver, except in the excessive amount of neAvly-formed connective tissue. The organ either maintains its normal size or is enlarged; its consistence is increased and section is difficult. It presents both macro- and microscopically the appearance seen in fatty infiltration. (2) Capsular or Glissonian cirrhosis, or perihepatitis, in which the CIRRHOSIS OF THE LIVER. 887 organ is surrounded by a dense white fibrinous membrane which con- tracts, reducing the size of the liver and altering its shape (vide Chronic Perihepatitis, p. 875). Associated Avith this form of the disease sclerotic kidneys, arterio- sclerosis, chronic gastritis, and fatty degeneration of the heart are often found at autopsy. .Etiology.—Among the more important factors in the causation of all forms of cirrhosis are: Male Sex and Middle Life.—The disease is most common in men about the age of forty, although cases have been known to occur in children. D'Espine records a case of hypertrophic cirrhosis in a child of six and a half years; Jacoby, a case in a child of four years; Gilbert and Fournier report 7 cases of biliary cirrhosis in children, the majority of which, in addition to the usual symptoms, shoAved enlargement of the spleen. In children the affection is usually either of syphilitic origin or follows the infectious fevers, notably scarlet fever (vide also Syphilis, p. 334). Alcoholism is said to be responsible for at least 50 per cent, of all cases, and Freyhan found this causal factor operative in nearly all of his cases. Clinical history tends to prove that the stronger the alco- holic beverage and the larger the quantity consumed the more quickly cirrhosis occurs. Spicy foods are, according to some, classed as predis- posing agents. Tiraboschi records a case that had long been induced by the use of spicy foods and by over-eating. In many cases ptomains, the products of mal-assimilation through faulty digestion, are supposed to be the exciting cause. Certain chronic diseases (syphilis, rickets, diabetes, gout, malaria, carcinoma, tuberculosis) that favor the formation of connective tissue are apt to be complicated by cirrhosis. Hanot and Roix state that these cases are preceded by protracted gastro-intestinal derangement, and that the sclerotic process extends to the acini, but does not affect the biliary passages. Passive congestion, secondary to chronic cardiac lesions or to obstruc- tive lung-disease, not infrequently gives rise to hepatic cirrhosis. Here venous stasis produces a chronic inflammation Avith the formation of con- nective tissue. Primary inflammation or chronic obstruction of the bile-ducts is not infrequently followed by cirrhosis of the liver. Symptoms.—Atrophic Cirrhosis.—The symptoms of this variety of cirrhosis may present nothing characteristic as long as the sclerotic pro- cess does not interfere with the bile-passages or the portal circulation. Among the prodromal symptoms, a gradual loss of flesh, anorexia, con- stipation, a coated tongue, slight jaundice, dyspepsia, and occasionally hematemesis, are to be mentioned. As the obstruction becomes more marked, the mucous membrane of the gastro-intestinal tract "becomes more and more swollen and con- gested, and gives rise to augmenting nausea and vomiting (most marked in the morning), and hemorrhages from the stomach (hematemesis) and intestines (melena), Avhich may be frequent and profuse, but are rarely fatal. Severe hemorrhages may also occur from enlarged, varicose esophageal veins. Owing to the establishment of a compensatory circulation the super- 888 DISEASES OF THE DIGESTIVE SYSTEM. ficial epigastric and internal mammary veins enlarge, forming about the umbilicus the so-called " caput medusa." Hemorrhoids also are not uncommon, and are due to passive conges- tion of the inferior hemorrhoidal veins. As the disease progresses the general emaciation becomes more marked. The face assumes a pinched expression, the tip of the nose having a purple tint from distended veins; the eyes are sunken, the cheeks holloAv, and the skin presents a salloAv tint. Failure of the compensatory circulation gives rise to edema and ascites, and the latter causes in many instances hydroperitoneum, leading to enormous distention of the abdomen. Later in the disease toxemic symptoms may develop, due to some poisonous product in the blood, the exact nature of which is unknown; these are violent head- ache, followed by wild, noisy delirium, convulsions, stupor, and coma. They not uncommonly occur Avithout jaundice, and have been mistaken for uremia. Fever is usually absent throughout the course of the disease, but may rarely be present, and reach 100°-102° F. (37.7°-38.8° C). Examination of the urine shows it to be of increased specific gravity, loaded Avith urates, and containing bile. In a small proportion of cases it is slightly albuminous, and contains casts, though out of 28 urinal- yses in cases of cirrhosis Henry discovered the presence of albumin in but one. The amount of urea is constantly diminished, owing to the disturbance of the urea-forming function of the liver. An excess of indoxyl sulphate in the urine is a frequent occurrence. The physical examination in a typical case of atrophic cirrhosis re- veals a distention of the abdomen ; there may be also an extreme enlarge- ment of the superficial veins over the surface of the body, and an icteroid tint of the skin. Palpation of the liver and spleen may be greatly interfered with by the large amount of peritoneal fluid present. On AvithdraAval of the latter, hoAvever, the spleen is found greatly enlarged and extending in some instances to the epigastric region. The liver may shoAv slight enlargement in the beginning of the dis- ease, but it soon atrophies, and in emaciated subjects Avith lax abdominal walls its finely granular or nodular edge can be felt above the margin of the ribs. Percussion shoAvs its vertical diameter, which normally extends from the sixth interspace to the costal margin, and averages about 4 inches (10 cm.), diminished, especially toward the median line. Posterior dul- ness begins lower than normally. Hypertrophic Cirrhosis.—In this variety of the disease there is usu- ally a distinct history of alcoholism. The liver often shows moderate enlargement before subjective symptoms are noticed, and the latter may be practically absent until late in the course of the disease ; they then resemble in a marked degree those of acute yellow atrophy, with a rap- idly fatal termination. Nausea, vomiting, epigastric distress, and ten- derness over the hepatic area are often the first symptoms observed. Jaundice is more common than in the atrophic form, often appearing early and persisting throughout the course of the disease ; it may be in- tense. These symptoms may persist for months or even years: as the obstruction increases, hoAvever, the portal circulation becomes engorged, CIRRHOSIS OF THE LIVER. 889 and gives rise to hemorrhoids, and in some cases to hematemesis, epis- taxis, and melena due to passive congestion. Splenic enlargement occurs in this variety of cirrhosis, but ascites is rare. The urine in the hypertrophic form may shoAv an increase in the amount of urates, and albumin and tube-casts may be present if the kid- neys are involved. The presence of leucin and tyrosin is not constant. Late in the disease the increase in the size of the liver becomes more apparent, because of the general emaciation of the subject. Jaundice deepens, the venous stasis becomes more marked over the surface of the body, and sometimes petechia develop in the skin. Delirium, convul- sions, stupor, and coma are not uncommon symptoms of the later stages of the disease. The temperature ranges usually from 102° to 104° F. (38.8°-40° C), although fever may sometimes be absent throughout the course of the case. Physical examination shows a moderate and, in some cases, a uniform enlargement of the organ ; the loAver border is felt distinctly outlined beloAv the costal margin, its edge being rounded and in some instances finely granular. The substance is firmer than normally, the increase in density being.due to the neAvly-formed connective tissue. On making deep pressure tenderness may be elicited. Percussion shows an increased area of hepatic dulness, most marked anteriorly toward the median line and extending below the costal mar- gin. The fatty or Glissonian cirrhosis, when avell marked, presents the same symptoms as the atrophic variety. Among the more common com- plications are chronic interstitial nephritis, cardiac hypertrophy, hemor- rhages from the mucous membranes, chronic pachymeningitis, and tu- berculous peritonitis, the latter being not infrequently associated Avith cirrhosis. Diagnosis.—At the very onset the diagnosis is rendered obscure, and often impossible, by the absence of characteristic symptoms. A history of alcoholism, hoAvever, or of long-standing diseases that favor the growth of connective tissue (gout, syphilis, chronic rheumatism), together with the development of ascites, edema, and progressive en- largement of the liver (in the hypertrophic form), and the negative signs elicited by careful examination of the heart, lungs, and kidneys, make the diagnosis of cirrhosis reasonably positive. Among the more important affections to be differentiated from this disease are the following: carcinoma of the liver, abscess, hydatid cyst, and chronic peritonitis with effusion. Cirrhosis. Carcinoma of the Liver. History of alcoholism or of long-standing Hereditary history. diseases. Occurs in middle adult life (twenty-five Usually occurs after forty years of age. to fifty years). Occurs as a primary affection. Often occurs as a secondary growth. Jaundice is slight or intense, according Anemia is present, and also the develop- to the variety ; there is no cachexia. ment of a typical cachexia. Tenderness is marked. The case runs a There is more pain, with rapid emacia- slow course, usually lasting many tion. The case terminates usually years. within one year. Enlargement is regular in the hypertro- The liver is irregularly enlarged, and phic form; there are no umbilications. contains umbilicated nodules. (See Fig. 60.) 890 DISEASES OF THE DIGESTIVE SYSTEM. Cirrhosis. History of alcoholism or chronic disease. Occurs idiopathically. Fever, jaundice, and ascites may be pres- ent singly or together. Anemia and emaciation slowly progres- sive. Enlargement or atrophy of the liver ac- cording to variety of cirrhosis. No fluctuation or thrill. Aspiration is negative. Hydatid Cyst. History of ingestion of the embryo of tenia echinococcus with improper food. Simultaneous occurrence in colonies or in others in the vicinity. No fever, pain, jaundice, or ascites. Emaciation not marked. On palpation an irregular, fluctuating tumor is felt over the hepatic area, giving an "hydatid thrill." Aspiration gives a clear, serous fluid, rich in chlorids, and containing hooklets. Fig. 60.—Showing approximate enlargement of the liver corresponding to the different dis- eases described in the text (after Rindfleisch): I, position of the diaphragm to the maximum enlargement (carcinoma); II, II, normal situation of the diaphragm; II, III, relative dulness; IV, border of the liver in cirrhosis; V, border in health; VI, lower border of the fatty liver; VII, of the amyloid liver; VIII, of carcinoma, leukemia, and adenoma. Cirrhosis. History of irritants (alcohol) or chronic processes (tuberculosis or gout), form- ing a growth of connective tissue. Usually a slow course. There is tender- ness, but no pain. Hectic symptoms absent. Moderate fever appears late in the disease. Runs a slow course, lasting months or years. Abscess of the Liver. History of dysentery, traumatism, or pyemia. Acute course, severe pain. Hectic symptoms appear early (fever, chills, and sweating). Runs an acute course, lasting a few weeks. CIRRHOSIS OF THE LIVER. 891 Cirrhosis (continued). Abscess of the Liver (continued). Slow enlargement, often regular, or Rapid development of *a fluctuating slightly nodulated. No fluctuation. tumor in the hepatic area. Aspiration is negative. The aspirating needle reveals the pres- ence of pus. Prognosis.—Atrophic Cirrhosis.—The prognosis of this form of cirrhosis is decidedly unfavorable, the function of the liver-cells having been impaired or destroyed by contraction of the neAvly-formed connec- tive tissue. In rare cases the symptoms abate, OAving to the establish- ment of a compensatory circulation, and may remain in abeyance for months or years. The duration varies usually from a feAv weeks to five or six months after the symptoms of portal obstruction appear. Hypertrophic Cirrhosis.—Because of the frequently definite history of alcoholism in this variety the prognosis may be said to be more favor- able than in the atrophic form if the disease be recognized in its early stages and the source of irritation removed. Even after the occurrence of jaundice, hematemesis, and toxic symptoms, under appropriate treat- ment patients have been knoAvn to enjoy comparative health for years. Treatment.—The prophylactic treatment, if the disease be early recognized, consists in improving the general health of the patient and in removing, if possible, the cause of the affection. Rest, graduated exercise, systematic bathing, and regular hours for eating and sleeping should be inaugurated and strictly adhered to. Alcohol, strong coffee, spices, and gastro-intestinal irritants of every nature must be inter- dicted. The diet should be simple and easily digestible. An exclusive milk diet has been highly recommended (Semmola). The medicinal treatment is largely symptomatic, no remedy having been discovered to prevent the formation of, or remove, the newly-formed connective tissue. The chief object is to deplete the portal system and prevent, if possible, the occurrence of ascites. The bowels should be kept freely open by the use of saline purgatives (concentrated solution of Epsom salts), elaterium, or compound jalap powder. The skin is to be kept active by means of Turkish or Russian baths (under supervision), and in extreme cases by the steam bath or hot pack, employed just short of the point of exhaustion. The kidneys should also be kept active by the hydragogue diuretics (as potassium acetate), squills, digitalis in the form of the infusion, or Niemeyer's pill. Jendrassik recommends calomel as an efficient diuretic (gr. iij—0.194—t. i. d. until diuresis begins). Klemperer and others have also recently recommended urea as an efficient diuretic, and from 20 to 30 grains (1.29-1.94) may be given in solution. Urea acts best after paracentesis. If the case be syphilitic in origin, potassium iodid should be exhibited in ascending doses. Ascites, Avhen it appears, calls for free and thorough diuresis, diapho- resis, and catharsis, and if not relieved in the course of a feAv days tap- ping should be resorted to. Cases are recorded in Avhich, after early tapping Avith free depletion, the course of the disease has been appa- rently checked for months or even years. The operation of paracentesis abdominis, if performed under strict antiseptic precautions, is free from danger. The bladder having been emp- tied, a spot over the linea alba about 3 inches (7.5 cm.) above the sym- 892 DISEASES OF THE DIGESTIVE SYSTEM. physis pubis is anesthetized (preferably Avith a compress of cracked ice and salt), and a trocar is quickly thrust through the abdominal Avail for a distance of about 1 inch (2.5 cm.). The distance is determined by the fore-finger, Avhich is placed at the desired distance from the point of the cannula before its insertion. The patient must be in a sitting or semi-reclining position, so as to allow the ascitic fluid to collect by grav- ity in the loAver part of the abdominal cavity. A tube having been attached to the cannula to convey the liquid to a receptacle, the trocar is Avithdrawn, the fluid alloAved to run out, the cannula removed, and the Avound closed by antiseptic gauze or a pledget of cotton. Turlington's balsam is then smeared over the site of puncture, and the abdominal binder, Avhich has been previously applied, is tightened. The operation should not be repeated until orthopnea begins to develop, as absorption may occur after the first tapping. Complications, as cardiac hypertrophy, tuberculous peritonitis, or chronic meningitis, demand appropriate treatment; this is described in full in the discussion of the respective diseases. CARCINOMA OF THE LIVER. Definition.—A malignant growth of the liver, occurring usually after the age of forty, and characterized by pain, progressive emaciation, cachexia, and the appearance of a nodular mass in the hepatic paren- chyma. It may be primary or secondary, though the former variety is very rare as compared with the latter. Pathology.—Histologically, the cells are not distinctive, being iden- tical with those of carcinoma elseAvhere; they are epithelial in charac- ter, having a small vesicular nucleus and much protoplasm. They are altered greatly by pressure, and vary in shape, being hexagonal, poly- hedral, or amorphous. Large giant-cells and spots of pigment knoAvn as " broAvnish granules" are not uncommonly found in the cancerous mass. The so-called colloid cancers are nearly ahvays mucoid, and the cells have undergone a mucoid change; the stroma of connective tis- sue surrounding the cancer-nests in some instances undergoes hyaline or myxomatous degeneration. In other instances the interstitial tra- becular completely surround the epithelial nests, Avhich are separated by a basement membrane ; to this variety the name of adeno-carcinoma has been given. When examined microscopically, medullary cancer, either in a large mass (primary) or in secondary nodules scattered throughout the organ, is the most common variety found in the liver. On examining a liver that is the seat of carcinoma, one of tAvo conditions usually presents itself: First, the organ may be apparently normal with the exception of one lobe (usually the right), which contains a dense Avhitish groAvth of firm consistence, being distinct and sharply defined from the surrounding liver-tissue. On section the tumor is often of uniform density, bluish- white in appearance, and exudes a milk-white fluid known as " cancer- juice," Avhich, Avhen examined microscopically, is found to contain large, nucleated, and irregularly-shaped cells containing free granular matter. The center of the tumor may have undergone liquefaction-necrosis, with the formation of a cyst, or it may be the seat of an abscess. Various CARCINOMA OF THE LIVER. 893 smaller nodules may be scattered throughout the organ by metastasis from the primary groAvth. The second and most common condition is that found on examining a liver which is the seat of secondary carcinoma, the primary lesion being situated in the mammary glands, pylorus, or the cervix uteri. Numerous nodules are scattered throughout, and can usually be seen projecting beneath the capsule, those superficially situ- ated having received the name of "■Farre's tubercles." In the center of these nodules characteristic pits or umbilications are often present, caused sometimes by contraction of the interstitial trabeculse and some- times by a central softening. On section they are usually grayish-Avhite in color and of firm consistence, although cysts, hemorrhages, pus-cav- ities, or areas of hyaline and fatty degeneration are often found. The cells are identical with those of the primary groAvth, and are composed for the most part of cylindric epithelium. In rare instances carcinoma occurs simultaneously Avith cirrhosis in the same liver, the organ presenting an uneven, nodular appearance, and being slightly increased in size and of firmer consistence than normal. When examined in situ the external appearance does not differ materi- ally from that of cirrhotic liver, but on section the Avhole organ is found to be infiltrated with various-sized cancer-nodules surrounded by bands of cicatricial tissue. In some cases the excess of connective tissue and the amount of contraction are extreme, and the size and weight are reduced below the normal. Etiology.—Among the more important predisposing factors may be mentioned— (a) Age.—The disease seldom occurs before thirty-five or forty years of age, although cases have been knoAvn to occur in children. Descroi- zilles reports the case of a child eleven years old Avho died with a tumor in the right hypochondriac and iliac region, the autopsy revealing a liver studded with cancerous nodules, the nature of Avhich was demonstrated microscopically; the small intestine was also the seat of cancerous infiltration. (b) Sex.—Men are more often the victims of carcinoma of the liver than women. When occurring in the latter it is often secondary to car- cinoma of the uterus or mammary gland. (c) Heredity is said to be the cause of hepatic carcinoma in at least 20 per cent, of all cases, and is one of the strongest arguments in sup- port of the diathetic theory of the disease. (d) Mechanical Obstruction.—Primary carcinoma of the gall-bladder and bile-ducts not infrequently follows chronic obstruction by gall- stones. Symptoms.—There may either be almost no symptoms of carci- noma involving the liver, or its manifestations may be intense and varied according to the extent and location of the groAvth or groAvths. Associ- ated gastric symptoms, Avhich increase as the disease advances, usually attend. A more or less marked cachexia may be the first noticeable feature. The chief symptoms may be considered in detail, as follows: (a) Jaundice.—Discoloration of the skin and tissues is often by no means intense, and may be entirely absent. Harley states that true icterus Avas present in only 6 out of 100 cases seen by him, though feAv observers agree with him in his extreme view as to the rarity of this 894 DISEASES OF THE DIGESTIVE SYSTEM. symptom. The reason given for its lack of intensity is that in the great majority of cases the groAvth is situated in the right lobe of the liver, and neither compresses the bile-ducts nor destroys the secretory cells of the liver. (b) Pain is usually present to a marked degree, though it also may be entirely wanting. It is dull and boring in character, and localized generally in the right hypochondriac region. In some instances (as in the case of impacted biliary calculi) it may radiate to the right shoulder and the scapular region. It usually appears as the hepatic enlargement progresses, although cases of enormous-sized cancerous tumors of the liver have been known to occur Avithout pain. The character and loca- tion of the pain are of diagnostic importance, and Avill be spoken of under the differential diagnosis. (c) Ascites.—When the cancerous growth compresses the portal ves- sels, and also in cases of cirrhosis Avith carcinoma, obstruction to the portal circulation occurs, and results in the development of ascites. This may cause distention of the abdominal cavity to such an extent as to occlude the physical signs of hepatic enlargement. The cancerous groAvth may invade the peritoneum and cause an effusion. This symp- tom, however, is not frequent, at least two-thirds of all cases terminating without the appearance of ascites. (d) Fever is usually absent until the later stages of the disease. It may then appear and rise to hyperpyrexia (105° F.—40.5° C), but it is usually moderate in degree, irregular, and intermittent in type. (e) Cachexia.—In every case of carcinoma, at some stage of the dis- ease, cachexia develops; when pronounced, it is almost pathognomonic. (/) Cerebral Symptoms.—These may be absent throughout. In the advanced stages, however, the deleterious products in the blood, due to the perverted functions of the liver and the toxemic condition of the patient, often produce such striking symptoms as violent headache, mental hebetube, or delirium (less frequently) which may be maniacal in character. These symptoms resemble those of cholemia (vide Hepatic Cirrhosis, p. 885). The patient may die in sudden coma. Physical Signs.—Inspection often reveals enlargement of the super- ficial veins over the abdomen, and a prominence in the upper epigastric and hepatic regions, varying with the degree of enlargement, may also be seen. In the nodular form and late in the disease, Avhen emaciation has become extreme, elevations that are movable Avith respiration can be noticed beneath the skin. On palpation the organ can be distinctly felt projecting below the costal margin and extending in some instances to a point beloAv the level of the umbilicus. During deep inspiration the liver can be felt to move doAvnward, and during expiration upward, the organ being under the influence of the diaphragmatic excursions. In emaciated subjects the cancer-nodules are readily appreciable, and in some instances the central pits or depressions are palpable, forming a pathognomonic sign. Cancerous infiltration of the anterior margin is most easily felt, and in any enormous enlargement of the organ I have frequently detected them on the posterior surface as well. Rarely the liver is found to be uniformly large. Palpation may also show splenic enlargement, due to passive congestion. CARCINOMA OF THE LIVER. 895 Percussion shows flatness, extending in many cases in both an up- Avard and a doAvnward direction. In primary carcinoma (usually found in the right lobe) the area of hepatic dulness is increased irregularly dowmvard and generally to the right. On the other hand, in second- ary groAvths (usually massive) the nodules are oftener distributed equally throughout the liver. In such cases the area of dulness may extend across the epigastrium to the left hypochondriac region, the heart and other viscera being now displaced. Posteriorly, dulness may extend upward on a level with the fourth rib, and anteriorly doAvnward to the iliac fossa. The organ may noAv weigh from 15 to 20 lbs. (6.5-9 kgms.), while the weight of cancerous livers in ordinary cases varies between 3 and 6 lbs. (1.3-2.6 kgms.). Diagnosis.—In forming a positive diagnosis the family tendency, the history of primary carcinoma elseAvhere in the body, the age of the patient, the localization of the pain in the right hypochondrium, the cachexia, and the progressive enlargement of the liver, Avith the charac- teristic umbilicated nodules, are the most reliable points. The appear- ance of jaundice or ascites, or both, is confirmatory. Differential Diagnosis.—Among affections of other organs that are likely to be mistaken for carcinoma of the liver may be mentioned— (1) carcinoma of the pylorus ; and (2) carcinoma of the colon and omen- turn. The chief diseases of the liver itself apt to be diagnosed as car- cinoma are—(a) abscess, (b) syphilis, (c) benign growths (adenomata, angiomata), (d) hydatid cysts, and (e) hypertrophic cirrhosis. (1) Carcinoma of the Pylorus.—In carcinoma of the pylorus the phys- ical examination frequently shows a hard nodular tumor that is most plainly outlined in the epigastric region. In a typical case, on deep inspi- ration, the tumor is pressed downward by the liver, but is not pulled up- Avard by forced expiration, as in hepatic carcinoma. In many instances, however, adhesions bind the stomach firmly to the under surface of the liver, Avhich may be the seat of secondary involvement. The absence of early nausea and vomiting and the presence of jaundice, as well as the negative results from an examination of the gastric contents, would tend to eliminate pyloric carcinoma. (2) Carcinoma of the Colon and Omentum.—Secondary carcinoma of the intestine affects most frequently the sigmoid flexure. The symptoms of intestinal obstruction arise, constipation being followed by attacks of serous diarrhea due to irritation, and later by the presence of blood in the stools. In carcinoma of the liver, on the other hand, the bile-ducts may be obstructed, causing clay-colored stools, but otherwise the dejecta are normal; the seat of the nodular enlargement and pain is located in the right hypochondrium. Jaundice and ascites are absent in carcinoma of the colon. The tumor, if palpable, in the latter condition is more movable and is less under the influence of the diaphragm. It does not give an absolutely flat percussion-note, as does hepatic carcinoma. Car- cinoma of the omentum is usually secondary. The absence of small mov- able tumors in the umbilical, lumbar, or hypogastric regions, ranging in size from that of a pea to a walnut, aids in the elimination of carcinoma of the omentum. As the latter affection advances the abdomen be- comes distended and painful to the touch, the boAvels are obstinately constipated, and the physical signs reveal the presence of an effusion 896 DISEASES OF THE DIGESTIVE SYSTEM. Avhich, Avhen aspirated, is generally serous, but sometimes bloody. Mi- croscopic examination may possibly reveal the presence of cancer-cells, though their recognition is difficult. The liver, unless primarily in- volved, is not enlarged, and cachexia does not usually appear until late in the course of the disease. From hepatic abscess the points of differentiation are— Carcinoma of the Liver. Hepatic Abscess. Is often hereditary. There is a history There is a history of traumatism or of in- of a primary growth. testinal ulceration, as in dysentery. Occurs usually after the age of forty. Occurs at any age. Jaundice is rare. Jaundice is sometimes present. Fever is absent or slight. Hectic temperature, chills, and sweating. Cachexia is present and almost pathog- Anemia may be present, but never ca- nomonic. chexia. Pain is dull and boring in character, and Pain is sharp, lancinating, and paroxys- more constant. mal. A nodular, umbilicated tumor or tumors A fluctuating tumor may sometimes be may be detected. detected below the costal margin. The enlargement is downward. The enlargement usually upward. The duration is a few months to one year. The duration is usually a few weeks. Microscopic examination reveals disinte- The microscope reveals pus, liver-cells, grated liver-cells, cancer-nests, and in staphylococci and streptococci, and in some cases the micro-organisms of sup- some cases the ameba coli. puration. Benign Growths (Adenomata, Angiomata).—Occasionally growths are detected in the liver, and may occur at any age; Avhen these are present at or about the age of forty, they may be mistaken for carci- noma. The absence, hoAvever, of a primary growth in some one of the other viscera, together Avith the duration of the groAvth and the absence of cancerous cachexia, would tend to differentiate them from cancerous involvement. An examination of the blood may be of service, leuko- cytes being more common in carcinoma. The diagnosis betAveen hepatic carcinoma and hypertrophic cirrho- sis, hydatid cyst of the liver and syphilis, has been spoken of in the dis- cussion of the latter diseases. The prognosis is invariably fatal, the disease terminating rapidly in from a feAv months to a year. The most rapid course is run by sec- ondary carcinoma of the organ. Treatment.—The treatment is purely symptomatic. An easily digested, nutritious diet should be given, together with active stimulation to support the system. The pain may be relieved by the free use of morphin, given by the mouth, rectum, or hypodermically. For the nausea and vomiting that are apt to supervene the carbonated waters, cracked ice Avith champagne, or repeated doses of creasote (beechAvood), dilute hydrocyanic acid, or wine of ipecac (2 minims—0.133—every hour until relieved) may be given. If violent delirium should occur during the later stages of the disease, cold compresses to the forehead or vertex, and bromids and chloral hydrate given in rectal enemata, may prove efficient. OTHER NEW GROWTHS IN THE LIVER. (a) Angioma, Adenoma, and Cyst. Occasionally, benign growths occur in the liver, and often with an DISEASES OF THE SPLEEN. 897 absence of symptoms unless their increase in size gives rise to mechan- ical obstruction. One of the most common of these is angioma, Avhich is often found in the livers of old people. Angiomata consist of tortu- ous and dilated capillaries in the hepatic connective tissue; they rarely attain to a size larger than a crab-apple, and usually cause no symp- toms. Although most common in adults, they have been known to occur in children. Adenomata and cystomata may also occur in the liver. They are both benign growths. The former is of the tubular variety, consisting of connective-tissue nests lined Avith cylindric epithelial cells. Yon Berg- man removed a portion of a tuberous adenoma of the liver with perfect recovery and non-recurrence of the groAvth. (b) Sarcoma. Of the many varieties of sarcomata, those occurring most commonly in the liver are the small and large round-celled and the melanotic vari- ety, the latter often being secondary to sarcoma of the choroid coat of the eye. These grow rapidly, causing a Avidespread destruction of the liver-structure, with a change in the size and shape of the organ that is often demonstrable by palpation. E. R. Axtell reports a case in which at the postmortem the upper two-thirds of the liver revealed an entire absence of hepatic structure, and consisted of three tumor-masses which, on microscopic examination, were found to be small round-celled sar- comata. On section the tumor is seen to be of firmer consistence than the surrounding liver-tissue, and presents a dark, grayish-white, striated appearance. If the growth be of the pigmented variety, patches of a deep black or of different shades of pigment may be scattered through- out the mass. Metastasis is rapid and widespread, as is shoAvn by the fact that other organs are invariably found involved at the time of the groAvth and development of the sarcoma in the liver. Codd of Birming- ham describes a case of melano-sarcoma of the liver in which growths were also found in the heart, pancreas, right kidney, and right lung, and Holsti reports a similar case in Avhich the omentum, peritoneum, and myocardium were involved. The symptoms are those of mechanical obstruction, and consist of gastro-intestinal disturbances due to passive congestion, edema, and ascites. Anemia and emaciation may become marked late in the disease, but cachexia does not develop. The diagnosis can often be made from the primary groAvth (melano- sarcoma of the skin or sarcomata of the lymphatic glands) and from the rapid development of the tumor. The prognosis is, of course, absolutely fatal, and the treatment merely palliative. X. DISEASES OF THE SPLEEN. Diseases of the spleen are mostly secondary to other diseases, the consideration of Avhich embraces an appropriate description of the as- sociated splenic disorders. The intimate relation between the spleen 57 898 DISEASES OF THE DIGESTIVE SYSTEM. and blood accounts for the frequency Avith Avhich this organ is involved in many of the blood-diseases. DISLOCATION OF THE SPLEEN. (Floating Spleen.) Etiology.—This may be due to the increased Aveight of an enlarged spleen, to tight-lacing, relaxation of the ligaments, and traumatism; sometimes the cause is unknown. Symptoms.—The symptoms are vague and are the result of pressure by the wandering and mobile spleen. By physical examination we dis- cover with the touch the spleen as a mobile tumor pendant from the left hypochondrium; the tumor is superficial, blunt-edged, and notched on its anterior border, and may be replaced by the hand nearly in its nor- mal position. On percussion over the splenic area the normal dulness is found to be absent. In the diagnosis it is important to distinguish between floating spleen and simple enlargement, as well as between the former and mov- able kidney. The prognosis is guarded as to cure, though favorable as to life. The treatment must be mechanically supportive, consisting of pads and bands. Splenectomy for dislocated spleen has been successful in a majority of the cases in which it has been performed. SPLENIC HYPEREMIA. Acute or active hyperemia may be found as the result of the acute infectious diseases, giving rise to the acute splenic tumor, or as the result of amenorrhea, or of injuries and inflammation (circumscribed hyper- emia). The organ is uniformly enlarged (except in the last-named cases), and is darker in color and softer in consistence ; the capsule also is tense. This condition merges insensibly into acute splenitis. Chronic or passive hyperemia is due to some mechanical obstruction of the portal circulation caused by tumors, cardiac, hepatic, and pulmo- nary disease, and pylephlebitis. The spleen is enlarged, firm, dark-red in color, and the capsule is somewhat thickened. The symptoms are vague, and may consist of simply a sense of weight, fulness, and pressure, and some tenderness in the left hypochondrium. In cases of extravasation of blood and rupture of the spleen the symp- toms of intestinal perforation, hemorrhage, and collapse may supervene. On physical examination the edge of the spleen may be palpated be- low the margin of the ribs. The percussion-dulness is increased in area, especially downward and forward, and may encroach upon the slightly-curved umbilico-axillary "resonant line." The detection of acute or chronic splenic hyperemia, as manifested in enlargement of the organ, is often of invaluable aid in the diagnosis of the causative disease. The prognosis and treatment are embraced in those of the disease causing the congestion. SPLENITIS. 899 SPLENITIS. Definition.—This term comprises acute and chronic (hypertrophic) proliferative splenitis and suppurative inflammation. Pathology.—Next to the kidneys, the spleen is the favorite seat of metastatic inflammation and embolic infarction. Splenitis, due to a benign embolus originating in the left side of the heart or from the aorta above the splenic arteries, is usually circumscribed to a zone of sero-hemorrhagic infiltration about the resultant infarct. The latter is hemorrhagic at first, and later becomes particolored or mixed, and is of a yellow color, OAving to partial fatty degeneration ; still later it may become whitish and remain as a wedge-shaped (the base being periph- eral), cheesy (necrotic softening), or even calcareous mass or as a fibrous cicatrix. Infection of the infarcts by pus-micrococci leads to the devel- opment of small abscesses, and the trabeculse surrounding the latter may give way until several abscesses or one large pus-sac may be formed. Perisplenitis generally folloAvs, and sometimes with adhesions attached to adjacent holloAv organs, as the stomach and colon, through Avhich the perforating abscess may discharge its purulent contents. An unfor- tunate termination is the bursting of the abscess into the peritoneal cavity; a more fortunate ending results in an external opening. In acute splenic tumor there is an active congestion, with round-cell infil- tration and some proliferation of the splenic cells. The spleen is mod- erately enlarged, dark, soft, pulpy, and friable. In cases of intense vascular engorgement, as in the acute splenic tumor of severe typhoid fever, intermittent fever, and epilepsy (during the paroxysm), hemorrhagic extravasation may occur, and there may finally be even a rupture of the capsule and a passage of the blood into the peritoneal caA'ity. In chronic splenic tumor there is a persistent hyperplasia of the splenic cells, and frequently also of the trabecular cells, minus the acute engorgement. Cirrhosis of the spleen (chronic interstitial splenitis) differs characteristically from that of other organs (as the liver and kidneys) in that there is enlargement instead of con- traction. Added to the increase in the size of the spleen, there are in both forms of chronic splenitis thickening of the capsule, patches often of old perisplenitis, and a slaty color of the tissues, Avith more or less pigmentation. Etiology.—The disease probably never starts primarily in the spleen itself. Acute proliferative or hyperplastic splenitis (acute splenic tumor) is seen as the result of the acute infectious diseases (typhoid, typhus, relapsing, and malarial fevers). Chronic proliferative splenitis occurs as the so-called chronic splenic tumor in connection with chronic malarial infection, splenic anemia, chronic passive congestion of the spleen, and leukocythemia. The leukemic spleen represents a some- what different form of chronic proliferative splenitis from the ordinary forms. Acute suppurative splenitis, or abscess, is usually secondary to infectious (pyogenic) emboli, as in ulcerative endocarditis and pyemia. Again, as the result of simple valvulitis or aortic thrombosis, not infre- quently embolic infarction of the spleen may be found, Avhich may soften and break doAvn in abscess-formation from subsequent infection. Abscess 900 DISEASES OF THE DIGESTIVE SYSTEM. of the spleen may also follow traumatism or the perforation of a gastric ulcer and the extension of adjacent suppurative*processes. Symptoms.—These are indefinite or absent in most cases. Usually there is no pain or tenderness unless perisplenitis exists. Considerable enlargement of the spleen may be attended Avith a sense of aveight, ten- sion, or distress in the left hypochondrium, and perhaps by slight dys- pnea. Any suppurative fever present will most probably be disassociated from the idea of abscess of the spleen, provided the local signs of pus be absent. Sudden pain appearing in the gastric region, followed by the vomiting of pus and blood, in the course of an infectious disease, Avith splenic enlargement, may be due to the rupture of an abscess of the spleen. Ascites may also be present. The physical examination may reveal some bulging on inspection, and a fluctuating tumor may be palpated. The enlargement may be sufficient to enable the examiner to feel the notch in the spleen, and also the anterior and loAver borders, reaching even to the umbilicus and to a level Avith the pelvic brim. The percussion-dulness is correspond- ingly increased. Diagnosis.—This may be made from a consideration of the physi- cal signs in conjunction with a study of the primary disease. In cases in which pus is suspected an exploratory puncture may clear the diag- nosis. The splenic inflammation is rather an aid to diagnosis than a condition essentially needful of recognition in itself, by reason of its almost invariably secondary nature. Acute suppurative splenitis might be mistaken for gastric or pancre- atic disease, but the previous history in the former, as contrasted with that of the latter affection, conjoined with the local symptoms that are more or less characteristic of the organ involved, will generally furnish an accurate means of differentiation. The huge enlargements of chronic splenitis may be confounded Avith hepatic, renal, omental, or ovarian growths. Here a careful, discrimina- ting observation of the constitutional state and of the physical signs is requisite for a diagnosis; even then it is often puzzling and difficult to attain. Care must be taken that splenic enlargement be not assumed when a large pleural effusion on the left side is causing the depressed lower border of the organ to be felt. Finally, fecal accumulation in the splenic flexure of the colon may be mistaken for moderate enlarge- ment of the spleen. The former gives an irregular, doughy tumor, tympanites, vomiting, and a history of constipation alternating some- times with diarrhea; there is no increase in the splenic area of dulness. Prognosis.—This will depend upon the primary systemic condition in most cases. Abscess of the spleen is always a very grave complica- tion, the main danger consisting of rupture and fatal peritonitis. Even in acute splenic tumor of a violent type there may be a hemorrhagic ex- travasation so severe as to burst the capsule. Chronic splenitides are not in themselves grave disorders. Treatment.—This is to be directed mainly at the causative condi- tion. Quinin and arsenic are often useful in the malarial form, and the chalybeates, iodids, and ergot have been recommended for the various chronic splenic enlargements. Abscess must be treated by splenotomy and drainage. Splenectomy may be useful in certain cases of simple RUPTURE OF THE SPLEEN. 901 hypertrophy, but records shoAv only about 20 per cent, of recoveries from the operation. The state of the patient must be Avell considered. Splenectomy is probably never justifiable in leukemic enlargement. AMYLOID DEGENERATION OP THE SPLEEN. (Sago Spleen.) This occurs as a part of the cachectic condition attending amyloid or Avaxy degeneration of other organs (liver and kidneys). The con- dition develops in the course of cases of prolonged and Avasting dis- charges (phthisis, empyema, suppurative ostitis, syphilis, chronic peri- tonitis, chronic entero-colitis). The spleen is, as a rule, greatly enlarged, putty-like, and rotund. The capsule is tense and glistening. There are two forms of Avaxy degeneration—namely, the so-called " sago " spleen and the diffuse waxy or lardaceous spleen. In the former the Mal- pighian bodies are chiefly affected and appear on section like sago- granules ; in the latter the Avhole splenic pulp, and even the trabecule, are more or less degenerated, and on section the spleen appears pale, smooth, and homogeneous. This may be but a late stage of the "sago" spleen. The symptoins are those of general cachexia, and the diagnosis rests upon the detection of an enlargement of the organ associated Avith evi- dences of amyloid disease in other organs. The prognosis is unfavorable, and the treatment does not differ from that indicated for the underlying and causative disease. MORBID GROWTHS OF THE SPLEEN. The principal morbid growths of the spleen are the granulomata, as tubercles and syphilitic gummata; also secondary carcinoma, sarcoma, and hydatid and other cysts. These affections of the spleen are all of rare occurrence, and are not readily, if at all, discoverable during life. They are of no clinical or therapeutic interest apart from the general or primary disease. It may be stated that carcinoma of the spleen is always secondary ; it may be diagnosticated by a physical examination, shoAving the organ to be en- larged, with the unmistakable signs of the primary carcinoma, as of the stomach. Secondary sarcoma is more common, and is recognized by an irregular enlargement and the presence of a primary tumor. Syphilitic gummata of the spleen are often associated with amyloid degeneration and enlargement. RUPTURE OF THE SPLEEN. This may occur as the result of an intense hyperemic engorgement, both in splenitis from the rupture of an abscess and from traumatism. In the acute splenic tumor of typhoid fever, in malaria, and during an epileptic paroxysm, rupture of the capsule has been known to occur on 902 DISEASES OF THE DIGESTIVE SYSTEM. account of the extravasation of blood. The symptoms are usually mis- taken for those of intestinal perforation Avith internal hemorrhage. The treatment is palliative. XL DISEASES OF THE PANCREAS. ACUTE PANCREATITIS. Investigations of late years have rendered it probable that this disease is not so rare an occurrence as was formerly presumed, when it Avas not so readily recognized, owing partly to insufficient clinical and pathologic data, and partly to an indifference as to its existence. HEMORRHAGIC PANCREATITIS. Pathology.—The pancreas is enlarged, usually firm, and somewhat chocolate-colored. Irregular areas shoAv the circumscribed as Avell as the diffused form of hemorrhagic infiltration of the interstitial fat-tissue, with thrombosis of the pancreatic veins in some cases (Day). There is also a cellular or fibrino-cellular exudation between the lobules of the glands. The adjacent tissues may also be found to be hemorrhagic, as the mesentery, mesocolon, omentum, and perinephric tissues. The gall- bladder may contain biliary concretions. The gastro-intestinal mucosa may be hyperemic, ecchymotic, or in a slightly catarrhal state. Evi- dences of a localized peritonitis (peripancreatitis) are not frequent, though they should be looked for. Disseminated fat-necrosis is quite commonly associated Avith hem- orrhagic pancreatitis. Small areas of a peculiar substance, ranging from the size of a miliary tubercle to that of a pea or even larger, are found scattered in the fatty interlobular pancreatic tissue, in the omen- tum, mesentery, and sometimes in the abdominal panniculus or fat. They are opaque-Avhite, and slightly firmer (tallow-like) than the sur- rounding fatty tissue. They contain fatty acids in combination with lime or lime-salts. Bacteria are sometimes found in and near the patches of necrosis, but the precise relation that this more or less inflammatory degeneration bears to pancreatic disease has yet to be determined. Mention should be made here of the fact that as the result of the in- fectious fevers Ave find the pancreas shoAving diffuse, parenchymatous, and granular degenerative changes. Chiari has also recently pointed out the fact that postmortem digestion is very frequent in the pancreas. Ktiology.—Most of the cases reported have occurred in men, and in persons past fifty years of age. An especial predisposition to the disease seems to be the result of cases of severe and obstinate dyspepsia (gastro-duodenal), alcoholism, gall-stones (Fitz), and traumatism. Hem- orrhage into the pancreas of either traumatic or unknown origin may lead to subsequent pancreatic inflammation. A prolonged course of mercury has seemed to have a causal influence; the condition has also folloAved glycosuria. It is seen occasionally postmortem in cases of acute tuberculosis, of the specific fevers, and of septico-pyemia. Symptoms.—The onset is sudden and violent. It is character- HEMORRHA GIC PA NCREA TITIS. 903 ized by excruciating, deep-seated pain, usually in the epigastrium or betAveen the xiphoid and umbilicus. There are also nausea and severe retching and vomiting, constipation, and speedy collapse, ending fatally Avithin a feAv days (second to the fourth—Fitz). Fever is generally slight, though it may be absent. Dyspnea and a rapid, feeble pulse, with jactitation and marked anxiousness or an afebrile delirium, may perhaps be present. In some cases there may be diarrhea, with thin and watery stools containing free fat. Instances may be repeated in which, OAving to the coincident presence of gall-stones, there may be jaundice and colicky pains over the right hypochondrium. The jaun- dice, however, may sometimes be due to a considerable SAvelling of the head of the pancreas, Avhich presses upon the common bile-duct. Tym- panites occurs in a majority of the cases. Hiccough and albuminuria have also been noted. The pain in this disease, as Avell as the profound collapse, may be due either to a circumscribed peritonitis or to pressure upon the solar plexus. Diagnosis.—This is at all times difficult, since many or all of the symptoms enumerated may be present in other affections. A careful inquiry into the previous history is important. The sudden develop- ment of an intense, deep-seated pain in the epigastrium, followed by vo nut ing, collapse, abdominal distention, with circumscribed resistance in the epigastrium, and the presence of constipation and slight fever, should point strongly to hemorrhagic pancreatitis. The detection of free fat in the dejections, and the discovery of scattered points of tenderness, when they occur, are also of corroborative significance. Differential Diagnosis.—The temperature is apt to be higher and the pain and .tenderness less localized and more constant in peritonitis. Fecal vomiting would indicate obstruction of the bowel. Here also we may determine the patency ot the bowel by injection or inflation. Intestinal obstruction is of comparatively rare occurrence in the epigastrium, where the pain and distention of acute pancreatitis are localized; there are likely to be present more marked and general tympany and a circum- scribed distention of the intestinal coils. In perforating gastric or duodenal ulcer there is a history of pain after eating, hemorrhages from the digestive tract, and of anemia or chlorosis occurring more commonly in the young female. Corrosive poisons may be excluded by the history of the case and by an examination of the mouth and vomitus. Hepatic colic may also be excluded; the pain in this condition is intermittent, and referred more to the right side than in pancreatitis. There are also "an early collapse and an absence of jaundice in the pancreatitis, as a rule. Acute gastro-duodenitis is characterized by fever, by a history of injudicious eating, followed by mild inflammatory symptoms within a few hours, and by an absence of the sudden prostration and collapse so com- mon to hemorrhagic inflammation of the pancreas. Prognosis.—Acute hemorrhagic pancreatitis in most cases ends in death. It is but fair to state, however, that in view of the ease with which the disease may be overlooked it is quite possible that certain cases of a less severe type may often recover; in these the recovery has been said to follow an entirely different affection. Osier reports a case diag- nosticated as one of intestinal obstruction in which abdominal section was 904 DISEASES OF THE DIGESTIVE SYSTEM. performed. There was no obstruction found, but disease of the pancreas and fat-necrosis Avere definitely noted, and recovery followed the section. Treatment.—This must needs be merely palliative and symptomatic. The treatment as for shock by the use of external heat and of Avarm saline solutions (by injection), hypodermics of morphin, atropin, strych- nin, and of diffusible stimulants may probably be of some avail. suppurative pancreatitis. Pathology.—The suppuration may be diffuse, with numerous small abscesses, or a single abscess may exist in the head or body of the pan- creas, which may be considerably enlarged and the glandular structure extensively destroyed. The abscess may communicate with peripancreatic areas of suppuration, or it may evacuate either into various organs (stom- ach, duodenum, peritoneal cavity) or externally. Pylephlebitis and hepatic abscess or pyemia may follow. A disseminated fat-necrosis is not found so frequently as in hemorrhagic pancreatitis. Htiology.—Most of the cases collected have occurred in adult males prior to fifty years of age. Intemperance, debauchery, gluttony, and various dietetic errors enter into the previous history of suppurative inflammation of the gland. Symptoms.—These may be acute, subacute, or chronic. Acute cases occur less frequently than the latter, there being a marked tendency of the disease to chronicity. Acute suppurative pancreatitis usually begins suddenly, with severe epigastric pain, vomiting, hiccough, chills, and an irregular pyemic temperature, progressive tympanites (at times limited to the left half of the abdomen), and perhaps acute splenic enlargement. Constipation may be followed later by diarrhea, and slight jaundice may appear. Prostration is generally great, and death may set in within one week from the onset. Not seldom, however, the course is prolonged to three or four weeks, the symptoms persisting with progressive emaciation and final exhaustion. Rupture of the circumscribed peritoneal abscess, evidenced by copious dejections in which the sloughing pancreas has been found, and rapid diminution in the size of the abdomen, may take place. Again, the onset may be less severe, and yet the case progresses steadily downward with little pain, slight suppurative fever, anorexia, anemia, and gradually increasing debility, lasting for months or even a year, and ending in anasarca and death. A pancreatic swelling is rarely palpable. Diagnosis.—A limitation of the pain and tympany to the epigas- trium, irregular fever, and the constitutional indications of suppuration are probably all that can be relied upon in arriving at a diagnosis. In fact, the diagnosis is hardly made antemortem. The differentiation from circumscribed peritonitis, perforative gastric or duodenal ulcer, and acute obstruction of the bowel is the same as in the case of hemorrhagic pancreatitis (vide ante). The prognosis is fatal and the treatment palliative. GANGRENOUS PANCREATITIS. Pathology.—The pancreas may be found in various stages of necro- sis, depending upon the duration of the disease. It may be a dark-brown, CHRONIC PANCREATITIS. 905 flabby, soft, friable, shreddy, and putrid mass, with areas of hemorrhagic infiltration and yelloAV softening, and surrounded by a dirty-greenish, thin, purulent, and ichorous fluid. In cases lasting for from three to seven weeks the gland may be found completely sequestrated, lying in the omental cavity as a small, thin, brownish-black, shreddy, and foul-smell- ing detritus, soaked in a dark-colored, ichorous, and purulent fluid. The peri- and para-pancreatic tissues are usually involved Avith acute peritonitis. Splenic thrombo-phlebitis is commonly associated, and, as in the hemor- rhagic, so in the gangrenous pancreatitis, disseminated fat-necrosis is fre- quently seen. The sloughed pancreas may be discharged into the intestine. Etiology.—Males and females seem to be equally liable to this variety of pancreatitis, and persons past thirty years of age are most commonly affected. Hemorrhagic pancreatitis is the most frequent ante- cedent of the gangrenous form. The disease may result also from perfor- ative inflammation of the gastro-intestinal or biliary tract, or from the simple extension of a catarrhal inflammation of those tracts into the pancreatic duct (Fitz). Symptoms.—These are essentially the same as those of hemorrhagic pancreatitis. The course may last longer, hoAvever, so that death may not occur until the second or fourth week, preceded by symptoms of collapse. CHRONIC PANCREATITIS. Pathology.—The pancreas is indurated from an increased develop- ment of interstitial fibrous tissue. The secreting glandular substance may be nearly obliterated, or at least considerably changed, and, owing to occluding pressure upon the duct of Wirsung, small pancreatic cysts may be formed. Interstitial hemorrhages and peripancreatic adhesions may be present. In chronic suppurative pancreatitis there may either be several small circumscribed abscesses or one large pyogenic cyst. The pus is often found to have undergone cheesy changes or calcareous infil- tration. Etiology.—Chronic pancreatitis may be due either to one or to sev- eral attacks of the acute disease. Chronic inflammation of the pancreatic duct—often secondary to gastro-duodenal catarrh—is the most frequent cause. Persistent inflammations of contiguous structures, frequent irri- tation from biliary calculi, and the causes of cirrhotic changes in other organs (chronic alcoholism, syphilis) probably also lead to this disease. The condition may be limited to a part of the organ. Symptoms and Diagnosis.—The symptoms are hardly indicative of the disease. For a long time the symptoms of chronic gastric catarrh, frequently attended by diarrhea, may compose the clinical picture. Later there may be paroxysms of deep epigastric pain, and slight fever, with great anxiety and faintness, occurring at irregular intervals. Some ascites and occasional jaundice, due to pressure, may be observed. The detection of free fat in the dejections (without jaundice), and the occur- rence of glycosuria and lipuria, would be of distinct diagnostic value. 906 DISEASES OF THE DIGESTIVE SYSTEM. The presence of glycosuria in this variety of pancreatitis probably indi- cates an extreme degree of destruction of this gland (Fitz). A cachectic, emaciated appearance may be associated. Circumscribed resistance on palpation in the pancreatic area has been noted. Evidences of hepatic cirrhosis or of chronic renal and arterial disease may be present, and are likely to overshadow the pancreatic lesions. The prognosis is grave. It is to be recollected, however, that the greater portion of the gland may become functionless, as the result of progressive fibrous change, without much impairment of the general health or the production of permanent (fatal) glycosuria. Treatment.—The major treatment is dietetic. Fats and starches, since they demand the pancreatic ferment for their conversion, are to be interdicted, or, if permitted, are to be, so far as may be, artificially di- gested by the administration of tablets of pancreatin and soda (gr. v-x— 0.324-0.648) fifteen or twenty minutes after meals. Malt diastase, com- bined with alkalies, should also be tried. Becher has found that car- bonated waters stimulate pancreatic secretion in dogs, and hence their use may be advised. According to the result of Abelmann's experiments, minced pancreas promotes the digestion of fats. PANCREATIC HEMORRHAGE. (Pancreatic Apoplexy.) It is only in recent years that this fatal affection has been clearly iso- lated and defined, and mainly through the observations of Zenker, Draper, and especially Fitz. Profuse hemorrhages within and around the pancreas are seen postmortem. Pathology.—The pancreas may or may not be enlarged ; it may also be soft and friable. The hemorrhage is apt to occur into circumscribed areas of the gland, the interstitial and subperitoneal tissues both usually being the seat of hemorrhagic infiltration of a dark-purple color. Con- siderable blood may be found in the omentum, transverse mesocolon, in the retroperitoneal fat-tissue, and surrounding the kidney even. Fatty infiltration and degeneration of portions of the pancreas may occasionally coexist. Miliary aneurysms have not been found, but hemorrhages into the adjacent mucous surfaces have been detected in some cases. Etiology.—Slight hemorrhages into the pancreas may be found that are secondary to excessive chronic passive congestion or to hemophilic or purpuric cases, and they may be met with in acute infective diseases. These have, however, no clinical import. The precise cause or causes of marked hemorrhage into the pancreas are not known. Most cases have occurred in adults past forty years of age in whom the previous health was unusually good. Traumatism, or some obscure local vascular weak- ness, superinduced by alcoholic habits or a rich diet in an atheromatous person; or, possibly, some corrosive action of the panceratic secretion in certain destitute states, may operate as causes. Symptoms.—The patient may have been in apparently robust health when the attack comes on Avith sudden and startling gravity. The most prominent early symptom is intense pain, located in the epigastric region CARCINOMA OF THE PANCREAS. 907 or in the lower chest, together with a sense of constriction. Nausea and vomiting may be associated, and the latter is usually obstinate and gives only temporary relief. Tympanites may also occur. There are early and constant general evidences of internal bleeding—an anxious countenance, restlessness, depression, yawning, pallor, cold sweat, a lowered surface- temperature, and a small, rapid, and weak pulse. Prostration and syn- cope follow, and death ends the case in from half an hour to twenty-four hours. According to Zenker, death is caused by reflex paralysis of the heart, due either to some coincident vascular affection, or to pressure, perhaps upon the solar plexus and semilunar ganglion (pancreatic apo- plexy). The diagnosis is rarely made; but given the suddenly-developed signs of a concealed internal hemorrhage, with pain referred distinctly to the epigastrium, and vomiting and rapid collapse, a probable diagnosis may be made. Treatment.—This consists in relieving the pain by opiates and in overcoming the collapsed condition by free stimulation. CARCINOMA OF THE PANCREAS. Pathology.—Primary carcinoma is the more frequent variety. It is of the scirrhous form in most cases, and usually involves the head of the gland, which may attain to the size of a child's head. Not rarely the adjacent organs are found affected, either by direct or metastatic exten- sion of the disease or by the pressure of the growth; the liver, perito- neum, stomach, portal vessels, bile-ducts, ureters, and aorta may thus be involved. The pancreatic duct may be occluded, so as to form retention- cysts. Adjacent organs are often adherent to the cancerous pancreas. Etiology.—Men past forty years of age are most liable to carci- noma of the pancreas, though it has been met with even in the new-born. Mirallie* has collected 113 cases of primary carcinoma of this viscus (Fitz). Symptoms.—These are scarcely ever sufficient to indicate the dis- ease with any certainty. There are usually a stubborn dyspepsia, a progressive loss of flesh and strength, anemia, and a dull, or sometimes neuralgic, epigastric pain. Nocturnal paroxysms of pain are common, and are often accompanied by signs of collapse. In some cases vomiting and diarrhea are present. The stools may be light in color, greasy, and may contain blood! There may also be found an abundance of undigested muscular fibers in the stools in the absence of diarrhea; this is an incon- testable proof of faulty pancreatic digestion. Among the pressure-effects due to carcinomatous enlargement of the head of the pancreas there may, not rarely, be jaundice (due to pressure upon the common duct), which persists and " is associated with an enlargement of the liver and gall- bladder." Ascites may appear from pressure on the portal vein. Chyl- ous ascites, from pressure upon the thoracic duct, has been observed in 2 cases. The inferior vena cava may be compressed, causing dropsy of the lower half of the body ; also the duodenum, followed by gastrectasis or by signs of intestinal obstruction. Fitz points out that carcinoma of the tail 908 DISEASES OF THE DIGESTIVE SYSTEM. of the pancreas may be a cause of hydronephrosis of the left kidney from pressure upon the ureter. Marasmus and the cachexia groAv from bad to worse, and emaciation may become so extreme as to permit of a satisfac- tory palpation of the tumor, Avhich occupies a position near the median line above the umbilicus. Very often, however, the growth is too deep- seated to be felt, being palpable in about one-third of the cases only. Glycosuria may be associated. Diagnosis.—Carcinoma of the pancreas is probably present in a given case in which there are rapid and progressive emaciation, deep- seated epigastric pain, muscular fibers in the stools, without diarrhea, but with late jaundice and enlargement of the gall-bladder, and the detection of a deeply-situated, fixed, and firm tumor in the region of the gland. The quantity of indican in the urine is diminished. Aortic abdominal aneurysm may be mistaken for carcinoma of the pancreas because of the transmission of the aortic pulsation to the tumor. But in aneurysm the impulse is expansile instead of to and fro, and the contact is neither so sharp nor so sudden; moreover, the cancerous cachexia is absent in aneurysm, and the history of the case may be clearly indicative. It is sometimes difficult to differentiate a malignant tumor of the pan- creas from carcinoma of the pylorus, of the stomach, or of the transverse colon or omentum; the following points will help in the differentiation of the former two : Carcinoma of the Pancreas. Carcinoma of the Pylorus. The tumor is deep-seated and fixed ; later The tumor is more freely movable, and it becomes slightly movable. It is not is usually associated with dilatation of associated with gastric dilatation. the stomach. Symptoms of chronic dyspepsia manifest There are more marked gastric symptoms. themselves. The vomitus is bilious ; does not contain " There is coffee-ground " vomitus. It is blood ; often is that of gastrectasis. seldom bilious. HCl is present, while there is an absence HCl is absent from the gastric contents; of lactic acid. lactic acid is present. The stools contain undigested muscle- Usually the bowels are constipated, with fibers. There is an absence of pan- occasional diarrhea. The stools are creatic secretions. The urine may con- black after a hemorrhage. The urine tain sugar. does not contain sugar. There is usually jaundice; sometimes Usually there is no jaundice or ascites. ascites is present. Inflation of the stomach shows the absence Inflation shows the presence of a pyloric of a pyloric growth. tumor. The course is more acute. Death may The course is more chronic, and second- occur within a few weeks or months. ary growths appear in the liver. Neoplastic growths of the transverse colon are also more often super- ficial, and are movable and definable with the palpating fingers. There are symptoms of intestinal obstruction here, and inflation of the colon will show the relation of the tumor to the gut. In carcinoma of the colon the urine generally contains an increased amount of indican. Obstructive jaundice due to gall-stones may be mistaken for pancre- atic carcinoma; but in the latter affection the jaundice develops more gradually, may be less marked, and is permanent, while that of chole- lithiasis is transient. In hepatic colic the onset is sudden and the pain PANCREATIC CYST. 909 is severe and colicky, or is reflected to the right and posteriorly, with equally sudden relief. A discussion of the prognosis and treatment of carcinoma of the pancreas is obviously unnecessary. PANCREATIC CYST. Pathology.—Pancreatic cysts may be single or multiple, and large or small. When large they develop chiefly to the left of the median line. Sometimes a cystic pancreas may have the appearance of a bunch of grapes, or a single cyst may be so large as to simulate an ovarian cys- toma, and may contain as much as several quarts of fluid. The contents may at first consist simply of retained pancreatic juice, and usually the liquid is dark-gray or dark-brown, alkaline, and hemorrhagic or albumin- ous. The specific gravity is from 1010 to 1024. Atrophy of the pan- creas may ensue. Examined microscopically, the contents reveal leuko- cytes, red blood-corpuscles, oil-drops, fatty degeneration of the epithelium, and crystals of fatty acids and cholesterin. Etiology.—Cysts of the pancreas may be due to occlusion of the pancreatic duct or its branches by compression from within or without the gland. They may also be due to tumors, to impaction of biliary or pancreatic calculi, to cirrhosis or angular displacements of the gland, or to the obstructive swelling from extension of catarrh of the bowel (Krecke). Many cases have been traced distinctly to traumatism. Lloyd suggests that the cysts that follow local injury are in reality instances of encysted peritonitis involving the lesser omentum or that portion of the latter covering the pancreas. Cysts of the pancreas usually occur in adults, though rarely they may be congenital. Sex is without influence. Symptoms.—The symptoms are those of pressure, and in part are the result of an absence of the pancreatic secretion. Pain may be ab- sent, or it may occur as colicky paroxysms, referred either to the epigas- trium, the left hypochondrium, or even the left shoulder. Jaundice and ascites are present in large tumors. Vomiting, constipation, or fatty diarrhea, with undigested muscular fibers in the dejecta, or clay-colored, pasty, and offensive stools, may be present. Albumin and sugar may be found in the urine. Emaciation is not infrequent. Intestinal hemor- rhage may occur and recur. A late and constant symptom is a feeling of pressure in the epigastrium. On physical examination a smooth, elastic, lobulated tumor is discov- ered in the region of the pancreas if the growth is moderate in size. Sometimes a very large cyst develops in a remarkably short space of time—i. e. in a few weeks. When very large in size fluctuation is easily elicited. It may be slightly movable in the grasp and during inspiration. It usually presents between the stomach and transverse colon an area of dulness, and unless the tumor be of large size it is surrounded by tym- panitic resonance of deeper timber above than below. Auscultation may reveal a murmur caused by compression of the aorta. When the cyst attains enormous dimensions the usual mechanical pressure-effects are produced. Diagnosis.—The diagnosis rests on the typical physical signs—the 910 DISEASES OF THE DIGESTIVE SYSTEM. discovery on palpation of a smooth, elastic, lobulated, or rounded tumor that is slightly movable, and on percussion of a dull area that is not con- tinuous above with the spleen- and liver-dulness. Resort has been had to filling the stomach with air and the colon with water (after puro-ino-), and thus proving by palpation the deep-seated situation (behind the stomach) of the tumor. The supposed cyst may be aspirated, and if pancreatic fluid be obtained, it will digest albumins and emulsify fats. This test is not wholly reliable, however. A pancreatic cyst may be mistaken for an ovarian cyst, for renal tumors (cysts), dropsy of the gall- bladder, and retroperitoneal sarcoma (Lobstein's cancer). The differ- entiation is extremely difficult, and must be made by a oomprehensive and careful study of all the points in the case. The prognosis is good under proper treatment, which would seem to be incision and drainage. PANCREATIC CALCULI. Pathology.—These are grayish-white, rounded concretions, consist- ing of calcium carbonate or phosphate, with a nucleus of inspissated mucus in most instances. The calculi may be fine as dust or as large as an almond. Among their remote pathologic effects are fistulous com- munications with the colon, peritoneal cavity, and stomach. Atrophy of the organ is frequently, and carcinoma rarely, associated. Etiology.—Pancreatic calculi presuppose a catarrhal condition of the pancreatic duct, with retention of secretion, anomalies of the pancre- atic secretion, or the presence of cysts or some other form of obstruction of the pancreatic duct. The symptoms are developed when, during the passage of the stones along the duct to the duodenum, the latter excite inflammation. In con- sequence, paroxysms of pain occur (pancreatic colic) that are usually attributed to gall-stones, and Ave are often unable to differentiate the two conditions. The radiation of pain along the lower left costal border to the back rather than to the right side, and possibly the detection of free fat in the stools, or glycosuria, may aid markedly in the diagnosis. Jaundice is usually absent in pancreatic colic. Moreover, the finding of characteristic calculi in the stools is entirely confirmatory. Soon or late emaciation may become marked in calculi of the pancreas. The prognosis is mainly dependent upon the associated lesions and upon certain sequelse—pancreatic cysts and chronic pancreatitis. The indications for treatment do not differ materially from those of hepatic colic. XII. DISEASES OF THE PERITONEUM. ACUTE PERITONITIS. Definition.—An acute inflammation of the peritoneum. The con- dition may be primary or secondary. Clinically, two varieties—general and circumscribed—are recognized, while, pathologically, the disease is classified according to the nature of the exudate. DISEASES OF THE PERITONEUM 911 Anatomic and Physiologic Peculiarities.—The surface area of the peritoneum is quite extensive, being almost equal to that of the skin. Fluids of all sorts are rapidly absorbed by the peritoneum, and thus, if they be poisonous, constitutional infection is speedily propagated. Pathology.—Upon opening the abdomen in acute general peritonitis vascular injection both of the serous covering of the intestine and of the parietal layer is observed. Even in the most recent cases the coils of intestine may be feebly glued together by lymph, while in those of longer duration the adhesions are quite firm. As in the analogous inflammation of the pleurae or pericardium, we distinguish the folloAving forms patho- logically : (a) A plastic or fibrinous, in which there may be also a small amount of serum present, (b) Sero-fibrinous (comparatively infrequent), chiefly characterized by an abundance of sero-fibrinous fluid. Addition- ally, the coagulated fibrin forms a covering for the parietal and visceral layers of the peritoneum, (c) Purulent (most frequent). The amount of inflammatory exudate varies greatly, and is frequently enormous, ex- ceeding 30 liters (quarts). Not rarely putrefactive decomposition of the pus occurs, especially in perforative and puerperal peritonitis, giving rise to a thin fluid that is grayish-green in color, is sometimes distinctly sani- ous, and emits a gangrenous odor. Offensive gases are present Avith rela- tive frequency. These may come from the intestinal canal, following the track of perforations, or they may be due to decomposition of the puru- lent exudate, (d) Hemorrhagic. This form is common in cases that are of a cancerous or tuberculous nature, though it also occurs in acute gen- eral peritonitis of traumatic origin. Tuberculous peritonitis is considered separately. In severe types of the disease the intestines are the seat of morbid changes. Their walls are often thickened on account of inflamma- tory edema, while at the same time their muscular coat is also Aveakened —even to absolute paralysis—allowing of a greater or less degree of tympanitic distention of the bowel. The different pathologic varieties above described may be limited to definite portions of the peritoneal sac, when they are termed " encapsu- lated " or localized acute peritonitis (vide supra). In localized purulent peritonitis, further extension of the process is arrested by the rapid forma- tion of circumscribed adhesions due to the exudation of lymph; there are also undoubted instances of circumscribed, aplastic peritoneal ab- scesses. The milder forms of limited plastic and sero-fibrinous perito- nitis pursue a slower course than the purulent variety, and as commonly lead to the development of firm adhesions (adhesive peritonitis). Since the histologic changes in acute peritonitis do not differ from those ob- served in other inflammations of serous membranes, the reader is referred to the section on Pleurisy for their consideration. Etiology.—The irritants causing acute peritonitis may be—(a) Or- ganized inflammatory agents (organic irritants). These may be specific and non-specific. Among the non-specific agents are the pyogenic bac- teria. Grawitz has shown that the latter can only cause peritonitis under certain conditions; they excite the disease when injected into the perito- neal cavity or when poured out from the diseased or injured membrane more rapidly than the peritoneal tissue can dispose of them ; also when the epithelial layer has from any cause been removed. Absorption may be interfered with, while the pyogenic micrococci continue to enter from the 912 DISEASES OF THE DIGESTIVE SYSTEM. bowel or other viscera in great numbers. Unfortunately, the clinical practitioner often meets with cases of peritonitis in which these pyogenic organisms are the only positive agents. These essential conditions obtain when the membrane is Avounded by the perforation of gastric and intestinal ulcers, and also in perforation of the gall-bladder, in rupture of the liver, kidneys, and spleen, when the latter are the seat of abscesses, and, with uncommon frequency, in appendicitides with purulent inflammation in the ovaries, and in the Fallopian tubes. " There are instances in Avhich peritonitis has followed rupture of an apparently normal Craafian follicle " (Osier). It has been experimentally shown that non-specific organisms that are non-pyogenic are incapable of causing peritonitis unless the serosa is injured. Death may result from the injection into the peritoneal sac of putrid liquid if the dose be large enough, but it is practically the same whether the fluid is injected into the blood-stream at once or allowed to find its way into the peritoneal cavity, and the result follows nearly as quickly in the one case as in the other " (Moullin). The rapid absorption of liquid substances gives full opportunity for the phagocytic action of the white blood-corpuscles. Among specific organic irritants the tubercle bacillus deserves especial mention, though, as before intimated, a discus- sion of its characteristics is not in place here. The streptococcus pyog- enes is probably responsible not only for many cases of puerperal perito- nitis, but also for many of the post-operative variety. More frequently than the streptococcus, however, has the staphylococcus pyogenes aureus (or albus) been found in such instances. The bacterium coli commune (always present in the intestinal tract) is most frequently the leading factor in peritonitis of intestinal origin, and, I believe, also in that form following operations upon the appendix. Occasionally other organisms, as the pneumococcus, the bacillus of Fried- lander, or the bacillus pyocyaneus, have been found. Osier saAv a case in which the ameba coli was found in the thin, fibrous peritoneal effusion. Patients have been known to die of septicemia after operations on the abdomen (secondary infection), without any detectable evidence of peri- tonitis. (b) Chemical Irritants.—These are rather numerous and varied, though all produce their effect in one of two ways. First and most frequently, the irritant acts upon the membrane, exciting an exudation of lymph. In this instance constitutional intoxication is secondary. Secondly, the chemical irritant may be quickly absorbed and produce systemic intoxica- tion immediately. (c) Mechanical irritants, as, for example, a hernia, which may produce a localized peritonitis. (d) Peritonitis may be due to a direct extension of inflammation from the intestinal tract or other adjacent organs. In the majority of instances this variety is protective in character and results in local adhesions. I have seen a few undoubted instances of peritonitis secondary to pleurisy in which the irritants presumably found their way from the pleura to the peritoneum along the course of the lymphatics in the diaphragm. (e) The disease very rarely occurs idiopathic ally: somewhat more fre- quently it appears as a rheumatic condition, and then it is usually attrib- uted to exposure to cold or wet. These so-called idiopathic cases are probably instances of cryptogenetic infection. As in other inflamma- ACUTE PERITONITIS. 913 tions of serous membranes, so peritonitis may be secondary to chronic Bright's disease. In such cases the special irritants reach the membrane either from the intestinal canal or through the general circulation. Clinical History.—The symptoms are both of a local and a general nature. In sthenic cases of perforative peritonitis they occur simul- taneously with great severity and suddenness. On the other hand, in asthenic cases, such as occur frequently in those already afflicted Avith some serious disease that is apt to result in perforation (for example, typhoid fever), both the local and constitutional symptoms are more or less masked by the disturbances due to the primary affection. Again, circumscribed abscesses of the peritoneum often lead to diffuse suppura- tive peritonitis, and the change may take place so insidiously as to defy detection. These anomalies from the typical onset and course of the disease are by no means exceptional, and should ever be distinctly borne in mind by the physician. Local Symptoms.—Among these, pain is the chief. At the commence- ment its seat of greatest intensity corresponds, in most instances, with the seat of origin. Hence the character of the causal disease is often betrayed by the location of the chief pain. For instance, if this ap- pears in the region of the stomach and is referred to the back or shoul- ders, we would think of gastric ulcer; if in the ileo-cecal region, of ap- pendicular disease; and so on. It follows that quite commonly the severest pain is in the lower half of the abdomen. It is almost constant, increases in severity, and finally becomes general and excruciating ; it is also much increased by deep respirations, by pressure, and by bodily movements. It remits, but does not intermit, though it may be slight in asthenic cases. Here the patient is excessively weak, while his sen- sibilities are greatly blunted. Gastro-intestinal symptoms are prominent, more particularly vomiting, which occurs early and is apt to recur with relative frequency. It may follow the taking of food, though, in my OAvn experience, it has more frequently taken place spontaneously; the vomitus then consists of a watery liquid greenish in color and contain- ing mucus. In rare instances the matter vomited is a dark-brown liquid. Vomiting may sometimes be absent, however, owing to the presence of marked asthenia or coma. Eructations are common, and constipation is usually present. On the other hand, there may either be diarrhea throughout the disease or this symptom may often precede the constipation. Constipation is due chiefly to a weakened condi- tion of the muscular coat of the intestine, while the diarrhea is to be ascribed to an increased peristalsis due to intestinal catarrh. The apex of the heart is elevated ; the tongue at first is furred and moist, and later it is dry, brown, and often fissured. Constitutional Symptoms.—At the onset the patient in asthenic cases is seized with a rigor that may be repeated. The shock sustained by the nervous system in acute peritonitis is most intense: the temper- ature rises immediately, though it does not, as a rule, attain to a high point, and it frequently presents a curve more or less characteristic of suppuration. The rectal temperature is often relatively high; the respirations are shallow and much accelerated, ranging from thirty to forty per minute. We have, as factors to account for this increased frequency, (a) a crowding upward of the diaphragm, (b) the greatly en- 58 914 DISEASES OF THE DIGESTIVE SYSTEM. feebled heart, and (c) the pain occasioned by throwing the diaphragm into action. The heart early becomes excessively weak, and, as would be expected, the pulse is rapid, small, and soft. The pulse toAvard the close becomes exceedingly frequent (130 to 150 beats per minute) and is almost imperceptible ; during the early stages the pulse ranges from 100 to 130. Other evidences of more or less marked circulatory col- lapse soon manifest themselves. The patient Avears an anxious facial expression, the eyes are sunken, the features pinched and cool, the lips cyanotic, and the extremities are likewise cold and someAvhat livid. The patient invariably assumes the supine position, with the loAver extrem- ities drawn up, so as to lessen the tension of the abdominal muscles, and thus to secure the greatest possible comfort. The urine is scanty, high- colored, and contains indican. There may be a retention of urine, though more often, perhaps, micturition is more frequent than in normal health. Marked nerA7ous symptoms do not appear; indeed, the mind usually remains quite clear to the close. Moderate delirium, however, which sometimes gives Avay to mild stupor, is met Avith occasionally. In connection with these facts it should be pointed out that in the asthenic form of acute peritonitis the constitutional features differ from those above described. The temperature is usually subnormal (except in the rectum), the pulse is exceedingly feeble and running, and the signs of collapse are well marked from the onset. Physical Signs.—Inspection reveals the gradually increasing abdom- inal distention, that frequently becomes excessive if the intestinal walls are more or less completely paralyzed. Often the amount of effusion soon becomes large, when the abdomen appears widened. The degree of distention bears a definite relation to the severity of the inflammatory process, and is in inverse ratio to the development of the abdominal muscles. Thus, when the latter are poorly developed or greatly relaxed the expansion is enormous. On the other hand, when they are strong the muscles are apt to be quite tense, permitting of a relatively slight enlargement; the abdomen may even show a small concavity, in which case the walls are of a board-like hardness. The cardiac apex-beat is displaced upward and outward, occupying the fourth interspace. Palpation elicits extreme tenderness, more particularly in the vicinity of the umbilicus. In not a few instances of acute peritonitis have I been able to detect a distinct friction-rub. Percussion gives everywhere an exaggerated tympanitic note. There is often an absence of liver- dulness in the mammary line, and rarely also it is absent in the mid- axillary line. In pneumo-peritoneum, resulting from perforation of the gut or stomach, we often meet with an absence of liver-dulness, especially when a large purulent effusion coexists. It is to be remembered, how- ever, that a great diminution in, or even the total effacement of, the dull area may be caused by coils of intestine forcing their way up between the anterior surface of the organ and the inner surface of the abdominal wall. Owing to the fact that the diaphragm is pushed up, both the upper and loAver lines of hepatic dulness, when present, are correspond- ingly higher than normal. To the left we find the loAver level of cardiac dulness as high as the fifth rib, the heart being pushed upward in ad- vance of the diaphragm. Splenic dulness is quite often obliterated. By means of percussion, sooner or later, fluid effusions are usually LOCALIZED OR PARTIAL PERITONITIS. 915 detectable in asthenic cases. On the other hand, there may be in mark- edly asthenic cases a very slight amount of liquid exudation, that is often too small to admit of detection. When the effusion is considerable in quantity there is dulness on percussion over the most dependent parts; Avhen tympanitic distention is excessive, however, even a copious effusion may be so effectually hidden as to elude discovery in this Avay. I have already reported one such instance.1 On account of the painful character of the illness the patient's position cannot, in the majority of instances, be changed. When, however, the decubitus can be altered the line of dulness will be found to be movable, but the degree of mo- bility varies exceedingly, depending upon the extent of the peritoneal adhesions present. The effused material is partly contained in pouches, giving rise to areas of circumscribed dulness, and these must not be mistaken for the lesions of a localized peritonitis. Course and Prognosis.—Asthenic forms of peritonitis are perhaps invariably fatal. Though the local symptoms and signs are not marked, the characteristic evidences of collapse appear almost immediately and grow in intensity to the end. The duration in sthenic cases rarely ex- ceeds one or tAvo days: in asthenic cases it is longer, lasting from four or five to six or eight days. Death sometimes occurs quite suddenly, owing to cardiac exhaustion or paralysis. Although most instances are dynamic in the early stages, acute diffuse peritonitis assumes a markedly adynamic form in the later stages, the cases terminating in fatal collapse. The clinical peculiarities and the course of an individual case are greatly influenced by the etiology. Acute general peritonitis arising from per- forative appendicitis, from perforation of a gastric ulcer, or from exter- nal injuries is usually of a severe type and proves quickly fatal. Prompt operative interference, hoAvever, is poAverful in saving life in a small per- centage of the latter class. When the disease is traceable to rheumatism or exposure recovery may take place. A case occurred in my' own prac- tice in which acute sero-fibrinous peritonitis Avith considerable effusion was associated with acute articular rheumatism and organic lesions of the aortic segments; the patient recovered. Acute general peritonitis may not infrequently merge into a chronic condition; this, however, will receive separate consideration in its proper place. LOCALIZED OR PARTIAL PERITONITIS. (Circumscribed Peritonitis.) This is a localized form of inflammation of the peritoneum that is coextensive only Avith the serous covering of single organs, and involves a limited portion of the membrane. Hence, to the various forms of cir- cumscribed peritonitis such terms as perihepatitis, perisplenitis, peri- nephritis are applied. The condition is found in its most important form in appendicitis, but the points that are characteristic of localiza- tion in this disease have been mentioned elseAvhere (vide Appendicitis, p. 817). Local peritonitis may also be caused by a carcinomatous growth. Pyo-pneumothorax subphrenicus is the term applied to a circum- scribed peritoneal abscess containing air, situated between the liver and 1 International Medical Clinics, vol. iii. second series, p. 82. 916 DISEASES OF THE DIGESTIVE SYSTEM. diaphragm. The condition is described under the heading Acute Peri- hepatitis (p. 873). Local pelvic peritonitis (perimetritis) is the most frequent variety, and is secondary, as a rule, to inflammation about the uterus, Fallopian tubes, and ovaries. Its consideration, however, must be left to special works on gynecology. I/OCal Symptoms.—The local clinical features do not differ from those described under the diffuse form, but their area of distribution is more or less strictly limited to definite regions. By eliciting the physical signs with care, fluid collections are sometimes demonstrable. The constitutional symptoms are likeAvise similar in character, though less marked than those belonging to the diffuse variety. There may be rigors, and pyemic symptoms appear, together with the temperature- curve peculiar to this condition. The danger of involvement of the general peritoneal cavity as the result either of rupture or of an exten- sion of septic inflammation is a constant menace. When the peritonitis remains localized these cases may pursue a subacute or even a chronic course, though in most instances the constitutional disturbance becomes grave at last. Diagnosis.—In attempting to diagnosticate acute generalized peri- tonitis it is of great importance for the clinician to keep in remembrance the sthenic and asthenic forms of the affection. The character and gravity of the symptoms, both general and local, are such as to render the diagnosis of the sthenic form entirely easy. Especially valuable features are the constant pain, the marked tympany, the excessive ten- derness under pressure, and the vomiting at intervals of a greenish fluid material. Of equal importance are the serious general disturbance previously depicted, and in particular the cool, sharpened features and the ever-increasing weakness and rapidity of the pulse. These clinical manifestations clearly foreshadow cardiac exhaustion or fatal collapse. When the cases are not seen until the advanced stage has arrived, how- ever, the diagnosis presents many difficulties. Nothing is noAv more important than the consideration of the history from the time of onset, also of the previous history, with a view to determining the point of origin and the probable cause of the disease (usually some such primary disease as appendicitis or gastric ulcer). The smaller number of cases belonging to the adynamic type are from the start extremely difficult of diagnosis. Here a history of the causal factor, the presence of moderate tenderness, and augmented ten- sion of the abdomen, with profound collapse, would point strongly to this condition. It must, hoAvever, be confessed that a positive opinion is often unwarranted, owing to the absence of such clinical indications as have been before mentioned. Differential Diagnosis.—Hysteric peritonitis (so called) simulates in every leading particular the genuine form so closely as to make the dis- tinction an insurmountable difficulty, unless there be present other hys- teric manifestations. In my experience the tenderness has been out of proportion to the gravity of the constitutional disturbance. The patient often complains bitterly before the abdomen has been touched; on the other hand, Avhen his attention has been otherwise engaged firm and prolonged pressure can be made. LOCALIZED OR PARTIAL PERITONITIS. 917 Acute generalized peritonitis occasionally supervenes on typhoid fever. In such cases it is caused either by perforation of the intestine or by a direct extension of inflammation from a deep typhoid ulcer. If con- sciousness be retained, sudden severe pain, tenderness folioAved by ex- cessive tympany, and signs of collapse Avill establish the diagnosis. Peritonitis, however, develops more often in those grave cases of typhoid that are attended Avith coma, marked meteorism, and profound adynamia, and under such conditions it often remains unrecognized (vide typhoid Fever, p. 35). In acute enteric catarrh the meteorism and sensitiveness under press- ure are usually less pronounced; the disease also lacks the marked con- stitutional symptoms of acute peritonitis. The pain is colicky, is cha- racterized by exacerbations, and even intermits in entero-colitis, Avhile it is constant in peritonitis. The pain in acute enteric catarrh is often folloAved by diarrheal stools. Intestinal colic is distinguished from peritonitis by the flatulence, the borborygmi, and the wandering pain in the absence of all other phe- nomena. Rheumatism of the abdominal muscles excites pain, A\hich, however, is superficially located (the disease being an affection of the muscular layer), and is frequently associated Avith rheumatism in other parts of the body. There may also be a clear history of previous rheumatic attacks. Tubal pregnancy (after rupture) has also been confounded with acute peritonitis, but its differential diagnosis is fully discussed and must be looked for in special Avorks on gynecology and obstetrics. Rupture of an abdominal aneurysm and embolism of the superior mesenteric artery are also conditions that give rise to peritonitic symp- toms—meteorism, recurrent vomiting, and collapse—all appearing with explosive violence. Acute generalized peritonitis in its symptomatology bears a close resemblance to acute intestinal obstruction, and the discriminating points have already been tabulated (vide p. 831). Prognosis.—General suppurative peritonitis is almost invariably fatal. Under the present improved methods of dealing with the affec- tion, hoAvever, it may be confidently expected that the mortality-rate Avill be lessened in the near future. Perforative and puerperal periton- itis offer the most unfavorable prognosis, while that form due to extension of inflammation promises the most favorable outcome. In localized forms of the disease timely operative interference has saved many lives. Death may be caused either by the primary shock or by cardiac exhaustion. Sequela?.—If recovery should take place, the inevitable result is the formation of adhesions and fibrous bands, the contraction of Avhich may cause constriction of the bowels, bile-ducts, and other structures. Treatment.—Hygienic and Dietetic.—The patient should be placed in the position that will give him most comfort, and should be kept ab- solutely undisturbed. The sick-room should be of good size and Avell ventilated; the temperature should be kept at from 65° to 70° F. (18.3°-21.1° C). The diet demands careful attention. Pancreatized milk in accurate dosage (aiv-vj—128.0-192.0—every tAvo hours) should be administered, and if the stomach Avill not bear the introduction of 918 DISEASES OF THE DIGESTIVE SYSTEM. nourishment, recourse should be had to rectal alimentation. Other pre- digested liquid food-stuffs, as meat-juices, may also be alloAved. Medicinal.—Formerly the opium method of treatment, first insti- tuted by the late Alonzo Clarke, was the one folloAved by the bulk of the profession. His plan was to administer -|- gr. (0.0324) of mor- phin or its equivalent (gr. ij—0.129) of opium, and repeat the dose every tAvo hours until the respirations Avere lowered to ten or twelve per minute. The pupils Avere then observed to be contracted, the pulse from 76 to 80, the pain relieved, and peristalsis arrested. This latter effect was obtained, even though in the case of some patients larger doses of opium than here indicated were necessary; in others smaller doses sufficed. The bowels were absolutely let alone. It is explained that in favorable cases the bowels moved spontaneously at the end of one week, and that the patient then entered upon convalescence. This method of treatment is at present adhered to only by the ultra-conserv- ative element of the profession. Among those authors who recommend opium as the most efficient measure in the treatment of this disease many still advise against the immoderate dosage previously so generally administered, but employ just enough to keep the patient Avell under the influence of the drug. The leading mode of treatment to-day consists in the use of saline purgatives, exhibited in divided doses in concentrated solution (3J-ij— 4.0-8.0—every two or three hours) until several copious serous dis- charges occur daily ; this effect is to be maintained until the local con- dition shows decided improvement. Purgatives do good Avhen given in this manner by causing a rapid exosmosis of serum from the blood-ves- sels of the intestines, by removing the collateral edema, and by indi- rectly relieving the congestion of the peritoneum, thus promoting a rapid absorption through the latter membrane. By increasing the peri- staltic movement they also diminish the danger of peritoneal adhesions. The remedies to be selected will depend upon two primary considera- tions : first, the etiology of the individual case (Avhether a communica- tion has or has not been established between the peritoneal cavity and the boAvel), or an intra-peritoneal abscess or abscess-cavity in one of the abdominal viscera ; and secondly, the type of the case, Avhether sthenic or asthenic. If perforation is knoAvn to have taken place or the occur- rence of this accident is strongly suspected, a prompt laparotomy, fol- lowed by the free use of salines, is the proper treatment. After the primce vice have been looked after by the surgeon, salines, for the reasons before stated, are to be used with a free hand. For a like- reason they are most serviceable in peritonitis due to extension of the inflammation, and also in the puerperal form. If the patient be robust, with a full, tense pulse, he may begin the treatment by the use of mercury, the best preparation being calomel, exhibited in fractional doses (gr. ss— 0.0324—every hour) until its purgative action is obtained ; this is to be folloAved by the salines. The object of the calomel treatment is to de- fibrinate the exudation as Avell as the blood of the patient. Indications demanding the opium treatment do not often present themselves. When, however, the vital forces are profoundly depressed, as shoAvn by the symptoms of collapse, and there is not even a reasonable suspicion of perforation, then opium should be tried, but not in the heroic doses CHRONIC PERITONITIS. 919 formerly advocated. Enough only should be given to obtain the physi- ologic effect of the drug in a moderate degree. Again, if the evidences of perforation into the general peritoneal cavity are complete and com- petent surgical skill is not at hand, large doses of morphin are imper- ative, with a view to relieving pain, keeping the patient at absolute rest, and sustaining the heart against the exhausting effect of shock. The bowels should noAv be relieved by simple large enemata. Local Treatment.—At the onset, if the patient be strong, from twenty to thirty leeches are to be applied to the abdomen. In cases in which meteoric distention is not great I have also made repeated trial of the folloAving ointment with gratifying results : B/. Ung. ichthyol., 3j (32.0); Ung. belladonnae, §ss (16.0); Ung. hydrarg., q. s. ad gij (64.0).—M. Sig. Apply t. i. d. In order to relieve the tympany turpentine stupes are serviceable. I have also had moderately good results from the use of the long rectal tube (soft esophageal) in treating the same symptom. Injections con- taining turpentine should be tried, as in the following combination : B/. Turpentine, 3ij ( 8.0); Ox-gall, 3ij ( 8.0); Milk of asafetida, §iv (128.0); Warm water, Jvj (192.0). Puncturing the abdomen Avith a hypodermic needle in order to re- lieve tympany, as recommended by Loomis, may also be resorted to, though I have had no personal experience with this measure. Pain.—No matter what general plan of treatment is pursued, the pain must be relieved by opium in some form. Thirst is to be relieved by chipped ice, over which a little brandy may be sprinkled. The vomiting is best treated by carbonated water exhibited in small quan- tities, or by iced champagne similarly administered. One-drop doses of creasote are also of value. CHRONIC PERITONITIS. Definition.—Chronic inflammation of the peritoneum. Pathology and Etiology.—The anatomic characters presented by different cases are greatly varied, though for convenience of study they may be considered under two divisions (as in the acute form): 1. Local; 2. General. The latter may be (a) Adhesive, when the peritoneal layers are inseparable and indistinguishable, with an obvious thicken- ing, and the intestinal coils are everywhere seen to be grown together. The cause is usually a previous acute attack, and, doubtless with great relative frequency, the condition is produced by the acute progressive form (Mikulicz), which is localized at the start. Rheumatism is also an occasional factor, and a mild variety of adhesive peritonitis, confined, as 920 DISEASES OF THE DIGESTIVE SYSTEM. a rule, to small circumscribed areas, may be engendered by the trocar used for tapping in ascites. (b) Proliferative Peritonitis.—" The essential anatomic feature is great thickening of the peritoneal layers, usually without much adhesion" (Osier). It has been found to be associated Avith cirrhosis of the stom- ach, liver, and other abdominal organs. The amount of liquid effusion, varying in composition from serum to pus, is usually moderate, and it may, owing to adhesions, be loculated. The omentum is sometimes rolled up in the form of a massive cord, with its long axis in the trans- verse direction. In an autopsied case of chronic peritonitis apparently secondary to hepatic cirrhosis I observed in the thickened membrane numerous small hard nodules that were at the time regarded as being tuberculous in nature. It is to be pointed out, hoAvever, that a number of cases of pseudo-tuberculosis have been recently reported. In several of these an operative incision was followed by recovery, and this Avas put doAvn as a cure of tuberculous peritonitis till the microscope showed the nodules to be fibrous. Among etiologic factors chronic alcoholism stands first. In one case that I saw, acute followed by chronic rheumatism seemed to be the only assignable cause. The condition is sometimes secondary to chronic nephritis. (c) Cancerous Peritonitis.—Quite often in connection Avith cancerous growths in the peritoneum a Avell-marked peritonitis is evident. There may be a liquid exudation, which is apt to be bloody and chylous. (d) Chronic Tuberculous Peritonitis.—This is the most important vari- ety. The inflammatory lesions are quite pronounced, as a rule, and lead to marked thickening of the layers—changes that are to the naked eye identical in appearance with those noted under the preceding forms, but which on histologic examination show the presence of tubercles and caseous degeneration. The amount of liquid effusion varies within wide limits, and is usually blood-stained. The frequent association of hepatic cirrhosis with tuberculous peritonitis should be remarked. From tuber- culous peritonitis, tuberculosis of the peritoneum is also to be distin- guished clinically; the latter may be acute or chronic, and the lesions consist in the deposit of various sized tubercles Avithout much collateral inflammation. Acute and chronic tuberculosis of the peritoneum have received due consideration in their appropriate place (p. 309). (e) " Chronic Hemorrhagic Peritonitis."—This term should be limited in its application to that form first described by Yirchow, in which the peritoneum is at intervals partly covered by a membrane of neAv con- nective tissue that alternates, as it were, Avith layers of hemorrhagic extravasation. A similar condition results from the frequent use of the trocar for ascites. Chronic Localized Peritonitis.—This is of frequent occurrence, and is confined most commonly to the serous covering of the spleen, liver, and certain portions of the bowel, particularly of the appendix. The condi- tion results in the formation of firm adhesions, with matting of the in- testinal coils and fibrous bands. It is usually the sequel of localized acute peritonitis occurring in connection with inflammatory diseases of the different abdominal organs. Symptoms of the General Forms.—Whether chronic peritonitis follows the acute form or not, it always develops insidiously. Most cases CHRONIC PERITONITIS. 921 remain quite obscure, and not a few are totally devoid of clinical mani- festations. When the latter are present, however, the patient complains of disturbances of the alimentary tract, and especially of constipation. On the other hand, diarrhea is observed in tuberculous peritonitis from associated intestinal ulceration. Rarely pressure on the common duct or portal vein gives rise to obstructive jaundice or ascites, as the case may be. I saw an instance recently in which compression of the veins leading to the lower extremities caused unilateral edema. Subjective abdominal sensations, as uneasiness, oppression, heat, and pain (often colicky in character) are experienced. Sometimes pain is entirely absent. General symptoms appear, though they are feebly marked as a rule. An irregular fever, hectic in type, is occasionally observed. Later, in- creasing general Aveakness and emaciation become rather prominent clinical features. Some of these phenomena, however, may be due to associated affections. When the peritonitis is tuberculous we frequently see clinical evidence of the causal disease in other parts of the economy (vide Tuberculous Peritonitis, p. 309). Physical Signs.—Inspection usually shows the belly to be slightly, though unequally, enlarged. As in acute peritonitis, so here, we find the belly flat, or even concave occasionally, with great tension of its Avails. Fluctuation is sometimes obtainable over limited areas only, since the fluid is not free, but encapsulated. The coiled-up and shrunken omentum may be palpable as a sausage-shaped mass, and thick bands of adhesion may also not rarely be felt, in different places, as hard, un- even masses simulating neoplasmata. The percussion-dulness varies con- siderably Avith the amount of effusion, its arrangement, the degree of peritoneal thickening, as well as Avith the character and locality of the fibrous bands. It follows that in some cases irregular areas of tym- panitic percussion-resonance and of dulness are to be found side by side scattered over the abdomen. Obviously, too, changing the patient's posture would not give movable dulness, owing to sacculation of the fluid. A marked sense of resistance is experienced on percussion over the dull area. Friction-fremitus can sometimes be elicited, and less fre- quently friction-sounds also during forced breathing. Symptoms of Chronic I/Ocal Peritonitis.—This condition is often entirely latent. When not so, the most characteristic indication is constant pain, distinctly colicky in nature and often quite intense. The physical signs are negative, as a rule. Very rarely a resistant, ill- defined mass, corresponding with the seat of greatest pain, can be felt. A fibrous band may be so arranged as to form a snare through which a knuckle of bowel may pass, with resulting strangulation. Fitz's analy- sis of 295 cases showed 63 to be caused in this way. Diagnosis.—That form of chronic peritonitis (serous or granular) most frequently seen in females at the commencement of puberty is hard to discriminate from tuberculous peritonitis, since the latter may be more or less latent. Tuberculous peritonitis is attended with fever, more pain and tenderness, and there is a more rapid accumulation of the exudate. Again, the general features, debility and loss of flesh, progress more rapidly than in granular peritonitis. The detection of conclusive evidence of the disease in persons closely related, or on phys- 922 DISEASES OF THE DIGESTIVE SYSTEM. ical examination of associated pulmonary or pleural lesions, would ren- der the diagnosis of tuberculous peritonitis almost certain. In obscure cases the guinea-pig should be inoculated with the exudate (see Pleu- risy, p. 539). Course and Prognosis.—The milder varieties of simple chronic peritonitis may, though very rarely, reach a favorable issue. In cases belonging to this category the disease takes a chronic course, and leads gradually to a condition of extreme debility, even if it does not, as is usually the case, materially shorten life. Tuberculous peritonitis has, until recently, been regarded as being almost uniformly fatal at the end of several months. Cures that must be attributed to the surgeon's Avork, hoAvever, are at present by no means uncommon. Rarely spontaneous cures also occur, particularly among children, in whom the disease is less serious than in adults. Treatment.—The patient should be enabled to enjoy the benefit of good sanitary surroundings. Close attention is to be paid to the diet, the coarser vegetables and sAveets being prohibited, since they increase the pain by exciting the production of gas. A change of air has im- proved the condition in several instances occurring in my own practice. The usual constipation may be relieved by simple enemata or by the use internally of the fluid extract of cascara sagrada. Tonics and alter- atives, the latter with a vieAv to promoting the absorption of the exudate, may also be employed, and I would recommend especially for this pur- pose the double iodids, as in the formula given in the discussion of Pleurisy (vide p. 554). In the early stages some degree of relief, or even a curative effect, may be secured by local means, as the application of equal parts of belladonna and iodin ointments until mild counter- irritation is produced. Ichthyol ointment is also serviceable. After all, however, little is to be gained from therapeutic measures, and it is to surgery that we must look for fresh triumphs in the treatment of this truly distressing complaint. Cases of chronic localized peritonitis with adhesions have been operated upon successfully by W. E. Ashton, H. A. Kelly, and others. Instances of chronic generalized peritonitis, Avhether tuberculous or not, in which the fluid effusion reaccumulates rapidly after repeated tappings, also furnish adequate indications for operative procedures. ASCITES. (Hydrops Peritoncei; Dropsy of the Peritoneum) Definition.—An accumulation of serum in the peritoneal cavity, resulting from stasis in the branches of the portal vein. Pathology.—The quantity of liquid contained in the peritoneal cavity is quite variable, though it often amounts to several gallons. It is clear and transparent, or slightly opalescent, especially on standing, and the specific gravity ranges from 1010 to 1014. In color it often has a faint lemon-yellow tint; it may, however, be either distinctly yellow, brownish (in cirrhosis), bile-stained (as when jaundice is present), or slightly blood-stained. In reaction it is usually alkaline; very rarely it is either acid or neutral. ASCITES. .923 The ascitic fluid usually contains much albumin, resembling in this respect blood-serum, as Avould be expected from its source. The per- centage of albumin may be approximately ascertained by noting the specific gravity of the fluid by the urinometer. Thus, in true ascites the specific gravity ranges from 1010 to 1014, and the variation in the percentage of albumin is from 1 to 2. In effusions due to peritonitis the percentage of albumin ranges higher (2.5-6 per cent.); hence the specific gravity ranges correspondingly higher (1015-1024). The standing specimen may show to the unaided eye a minute coagulum of fibrin. In the loAvest layer of the fluid the microscope discloses leu- kocytes, red blood-corpuscles (in abundance when ascites is due to gen- eral venous stasis), fat-cells, endothelium, and cholesterin-crystals. In ascites the microscopic appearances of the peritoneum are usually normal, while in instances of peritonitis the membrane, including the subperito- neal fibrous tissue, is opaque and slightly thickened. In the so-called chylous ascites the fluid resembles milk, owing to the presence of molecular fat. This condition may be associated with a collection of milky fluid in the left pleural sac Avhen there is thrombosis of the subclavian vein at the point at Avhich the thoracic duct enters. The term ascites adiposus is applied to a milky fluid in the peritoneal sac Avhich shows the presence of large and small fat-globules to the ex- clusion of other morphologic elements. In true ascites of long standing the abdominal, and to a lesser degree the thoracic organs, become atrophied from the great and prolonged pres- sure exerted by the dropsical fluid. The heart is often considerably elevated. Etiology.—Among the chief causal factors are those that hinder or arrest the return of venous blood from the peritoneal membrane, as the following: (a) Pressure upon the branches of the portal vein within the liver, due to contraction of surrounding tissues, as in hepatic cirrhosis, syphilis of the liver, and cancerous infiltration, (b) Numerous conditions in the course of which pressure may be made upon the portal vein external to the liver, as enlargement of the glands in the fissure, carcinoma, hydatids, or abscesses connected with the liver. Tumors of any adjacent organs (e. g. pancreas) may produce it, and rarely also secondary contraction in perihepatitis, (c) Thrombosis of the portal vein. (d) Pressure upon the inferior vena cava after it receives the hepatic trunk (Roberts), or upon the latter itself, or the lymphatics, (e) The portal circulation is also impeded in chronic pulmonary affections (cir- rhosis and emphysema) and organic heart-diseases. (/) A neAv groAvth in the peritoneum may compress the smaller veins lying in the membrane or the root of the mesentery, (g) Diminished resistance of the Avails of the portal vessels due to chronic affections that diminish the albumin- ous constituents of the blood and impair the nutrition of the peritoneum, as Bright's disease, carcinoma, syphilis, chronic malaria, (h) Chylous ascites is caused either by a leakage of the lacteals (due to ulceration, injuries, or the presence of filarige) or by the obstruction of the thoracic duct (due to thrombosis, cicatrices, compression), (i) Adipose ascites has for its direct cause fatty cellular degeneration, such as is found in carcinoma, tuberculous, and other forms of chronic peritonitis. Leyden has recently (1897) described an ameboid organism observed in the ascitic fluid in 2 cases. 924 DISEASES OF THE DIGESTIVE SYSTEM. Symptoms.—Slight peritoneal dropsy gives rise neither to symp- toms nor to abnormal physical signs. When the sac contains 1 quart (1 liter) of fluid or over, however, the first subjective symptoms that are due to the mechanical effect of the fluid appear. They are a sense of weight and fulness with slight uneasiness. As the proportion of trans- uded serum becomes gradually increased these symptoms become more pronounced. There may in addition be a dragging pain in the loins, gastro-intestinal disturbance (meteorism, constipation), and dyspnea (oAving to the resistance opposed to the descent of the diaphragm, resulting in compression of the lungs). The latter symptom is much increased upon exertion or on assuming the recumbent posture. Since the heart is displaced upward, an embarrassment of its action (rapidity and irregularity) Avould be expected. Syncope is not infrequent for similar reasons. Frequent micturition from pressure upon the bladder is common, and the kidneys, OAving to compression of the renal vessels, secrete an albuminous urine, Avhich is greatly lessened in amount. Physical Signs.—After the serum has collected in considerable amount the physical signs afford characteristic evidence of the condition. From inspection we learn many valuable points : (a) The belly is uniformly prominent (the degree depending upon the amount of serum present), giving a rounded form. Changing the posture of the patient shifts the point of greatest pouching, (b) The skin is seen to be tense, smooth, and shining, and sometimes shows linege albicantes ; the umbilicus com- monly bulges forward; less frequently it is obliterated, and the surface- veins are often enlarged, (c) The thorax appears small, except at the base, where it is distended, and the ensiform cartilage is sometimes abruptly curled up. (d) The respirations are hurried and are of the thoracic type, the abdominal movements being slight or entirely Avant- ing. As soon as the belly-walls become moderately tense fluctuation is readily obtainable. It is to be elicited by placing the palm of the left hand vertically upon one side of the abdomen, and then, Avith the fin- ger-tips of the right hand, tapping lightly the opposite side; impulses thus sent through the fluid will be distinctly felt by the hand in contact Avith the abdomen. When the dropsical fluid is small in quantity the physical signs should be practised with the patient in the erect posture during the examination. Percussion gives dulness, even to flatness, over all of that portion of the abdominal cavity occupied by the fluid. The upper level of dulness is not represented by straight transverse lines, but presents a concavity that is pointed toward the head. The dulness is extremely movable, shifting as the patient's position is changed. When the decubitus is supine the flanks and the lower por- tion of the abdomen give dulness on percussion, whilst over the anterior portion there is normal tympany. Again, if the patient be made to lie on either side, the opposite or uppermost flank will be found clear, the ascitic fluid always gravitating to the most dependent portion of the sac. Encapsulation of the fluid does not take place unless the case is complicated with peritoneal adhesions. In mapping out the limits of dulness, if the layer of liquid be thin the pleximeter finger should not be pressed too firmly upon the surface, otherwise the liquid will be dis- placed and a clear note elicited. Moreover, to obtain reliable results under these circumstances the gentlest percussion only is alloAvable. A ASCITES. 925 very large quantity of fluid even may occupy the abdominal cavity, and yet emit no dulness, owing to extreme tympanitic distention of the in- testines, as occurred in a case reported by myself.1 When the colon is thoroughly emptied tympanitic resonance may be elicited over the cecum and descending colon, despite the presence of considerable ascitic fluid. In the cardiac region there is often percussion-resonance as high as the fourth rib, and occasionally a murmur may be heard at the base. Diagnosis.—In order to arrive at a positive diagnosis a clear his- tory of one or the other of the known causative conditions is requisite, joined with distinct evidence of the presence of fluid—viz. fluctuation and movable dulness. Differential Diagnosis.—Ascites is most apt to be mistaken for an ovarian cyst. The accompanying table presents the chief differenti- ating points: Ascites. Ovarian Cyst. Clinical History. General health is bad prior to the ap- General health is good before the devel- pearance of the enlargement. opment of the tumor ; failure of health afterward. History of disease of liver, lungs, heart, Frequent history of dysmenorrhea, neg- kidneys, or other organ. ative as to organic affections. Swelling begins below and gradually ex- Swelling is unilateral at first, gradually tends higher ; more noticeable when becoming more central. sitting than in the standing posture. Physical Signs. Enlargement is symmetric, the abdomen Enlargement is asymmetric or irregular, being rounded and most prominent unless the tumor be very large, when about the umbilicus ; in the supine it may fill the entire abdomen. The posture the abdomen flattens, with lat- greatest circumference is below the eral bulging ; the umbilicus is often umbilicus, which never bulges. pouched and thin. Fluctuation is general from side to side Fluctuation is circumscribed, correspond- and in a vertical direction. ing to the limits of the tumor. No aortic pulsation felt. Aortic pulsation is sometimes evident. Vaginal examination often shows the Vaginal examination shows the uterus to uterus to be movable. A pouch may be displaced. A cyst may be felt and project into the vagina, but no cyst is outlined in the pelvis. detectable. AVhen standing, the upper line of dul- When standing, the upper line of dulness ness is concave. is uniform or convex. In the supine position the flanks are In the supine position dulness is still in especially dull, with tympany in front. front and the flanks are resonant. Dulness is movable according as the po- The area of dulness is not varied by sition is altered. change of posture. Character of the Fluid. Ascitic fluid has a specific gravity of Ovarian fluid has a specific gravity of 1010-1014, and is usually clear. It is 1018-1054. It is of a thick, turbid of a pale straw-color. character, and the color is variable. It should be recollected that large cysts may spring from other ab- dominal organs than the ovaries, as the pancreas and liver ; the elimi- nation of these latter conditions, however, does not, as a rule, offer marked difficulty. Ascites must be distinguished in practice from the 1 International Medical Clinics, vol. iii. second series, p. 88. 926 DISEASES OF THE DIGESTIVE SYSTEM. exudation due to chronic peritonitis, and the points of differentiation have been arranged thus : Ascites. Chronic Peritonitis. A previous history of organic disease of There is a previous history of acute peri- the liver, heart, kidneys, or other organ tonitis, tuberculosis, or inflammatory is obtainable. diseases of the female pelvic organs; sometimes a history of injury. No pain is experienced. Pain is a prominent symptom. The abdomen is symmetrically enlarged. Abdomen is irregularly prominent, and rarely flat. Fluctuation is general in the transverse Fluctuation is often limited to circum- or vertical directions. scribed areas due to loculation of fluid. Palpation detects no hard masses of ir- Palpation often detects resistant, uneven regular prominence. prominences. Dulness is always movable upon altering Dulness often not changeable on varying the position of the patient. the position, owing to adhesions. The fluid consists of serum with few mor- The fluid is either sero-fibrinous, sero- phologic elements. It is limpid, with purulent, or milky in nature. It is a specific gravity of 1010-1014, and is often viscid, and its specific gravity is pale straw-yellow in color, often with 1018-1024. The color varies. a greenish tinge. Over-filling of the bladder has also been confounded with ascites, and this organ has been tapped under the mistaken notion that the condition was one of dropsy of the peritoneum. If, however, the precaution be taken to catheterize the patient before tapping for supposed ascites, the error cannot, as it should not, occur. Prognosis.—The duration of ascites may be for many months or even years. In most instances the prognosis is unfavorable, though modified by the character of the causal condition in individual cases. The immediate cause of death may be either syncope, asphyxia, pul- monary atelectasis from compression of the bases of the lungs by the diaphragm, or it may be the causal disease. Treatment.—Dietetic.—The diet should be largely nitrogenous, light, nutritious, and given at frequent intervals with a view to main- taining the normal proportion of albuminous material in the blood. Medicinal.—By means of therapeutic measures Ave should aim to accomplish two things: First, the improvement or cure of the original disease; and secondly, to relieve the chief symptoms by removing the ascitic fluid on which they depend. Though the causative affection is usually chronic and incurable, every effort should be made to remove or mitigate its pernicious activity in accordance Avith the principles laid down in appropriate portions of this work. Of medicines used to re- move the transudation, hydragogue cathartics are most potent for good, and particularly Avhen the ascites is due to cardiac or renal disease. Calomel and jalap in combination, or salines in full doses, administered after the Matthew Hay method, should be tried. Diuretics are also recommended, and English authors greatly praise copaiba and its resin as being among the best. The bitartrate and other salts of potash, either alone or in combination with juniper and digitalis, are of signal value. Equally important with the exhibition of the above remedies is the use of tonics to promote the general nutrition of the patient. I have reported one instance, occurring at the Philadelphia Hospital, in which a cure was effected perhaps solely as the result of the exhibition of NEW GROWTHS IN THE PERITONEUM. 927 measures intended to assist the nutritive processes. In ascites due to cirrhosis of the liver recourse should be had to paracentesis abdominis, not as a last resort only, but "as a systematic method of treatment" (Roberts). A single tapping may be sufficient, though rarely is this the case. No valid objection, however, can be urged against a repetition of the measure from time to time, and at least until the collateral circu- lation is established. A favorable result is obtained relatively often, and especially when, at the same time, the general nutrition receives careful attention. In cases in which the transuded serum has rapidly re-formed after its removal by tapping, Southey's tubes, by means of which permanent drainage is secured, have been used with good result. NEW GROWTHS IN THE PERITONEUM. The most frequent and important of the neAV growths of the perito- neum are (a) carcinoma and (b) tuberculous deposit and tuberculous peritonitis, the latter two having been already considered. CARCINOMA OF THE PERITONEUM. There occur the usual varieties—scirrhous, encephaloid, and colloid —the latter most frequently involving the omentum. Primary carci- noma of the peritoneum is rare. Primary endothelioma, hoAvever, is occasionally met Avith. It resembles true carcinoma in macroscopic as well as in microscopic appearances, though it is in reality to be ranked with the sarcomata on account of its origin. Carcinoma of the perito- neum is almost ahvays secondary to carcinoma of the stomach, liver, or pelvic organs. The peritoneum may either be the seat of numerous small round miliary tumors, or, less frequently, of larger and distinctly nodular masses, the most extensive development being presented by the colloid variety. Cancerous peritonitis is commonly found to be an asso- ciated condition, and the retro-peritoneal lymph-glands not infrequently show cancerous development. Etiology.—More cases occur in the female sex than in the male. Age has also a potent influence, most cases appearing late in life. Symptoms.—When primary, carcinoma of the peritoneum is ob- scure during the early part of its course. Local pain and discomfort are complained of, and clinical evidences of the cancerous cachexia develop early, but these symptoms are not at first striking enough to be entirely characteristic. Later, however, the nodules can often be plainly felt (unless the liquid effusion be too marked), and the ascites, loss of flesh, weakness, and anemia are now sufficiently developed for diagnosis. In the colloid variety ascites is often absent, the abdominal cavity being the seat of a large, semi-solid, non-fluctuating mass. The secondary form usually follows carcinoma of the stomach or the ovaries, and the cachexia will have been developed before the peritoneum is secondarily involved in consequence of the presence of the primary growth. Hence, any symptoms referable to the general abdominal cav- 928 DISEASES OF THE DIGESTIVE SYSTEM. ity are strongly suspicious. Among other constitutional symptoms, apart from those already mentioned, is fever (rarely absent), which may be due in small measure to the anemia, though in a greater measure to the associated peritonitis. Physical Signs.—The abdomen protrudes if effusion be present or if the carcinoma be of the colloid form, though this cannot be set down as a uniform rule. Even when the tumor is large, dropsy of the peri- toneum sometimes makes its detection impossible. On practising palpa- tion after tapping, hoAvever, the nodules can be easily made out, either extending from side to side or being more or less localized and not adherent to underlying structures. Differential Diagnosis.—It will be remembered that an oblong tumor lying in a transverse position below the stomach is met Avith in certain forms of chronic peritonitis. This offers the same physical signs that are presented by cases of peritoneal carcinoma, unless the tumor- masses in the latter affection be of considerable size. Carcinoma, Iioav- ever, is most apt to occur in persons past middle life, Avhile nodular tuberculous peritonitis appears almost exclusively in children and young adults. Evidences of tuberculous disease elsewhere, past or present, and particularly suppuration about the umbilicus, would point to tuber- culous peritonitis. Moreover, in all forms of abdominal carcinoma the inguinal glands are apt to be indurated and enlarged. Proliferative peritonitis usually gives a histbry of chronic alcoholism. The differen- tiation of hydatid cysts of the peritoneum from carcinoma depends upon the history of the case, the presence of hydatid fremitus, the finding of the hooklets in the fluid, the less rapid growth of the tumor, and the lessened amount of pain, fever, and cachexia in the latter disease. Carcinoma of the intestine may simulate somewhat the disease under consideration, but the signs of increasing stenosis, as evidenced by the colicky pain, the discharge of blood and pus with the stools, and the ribbon-like character of the feces, will serve to separate the condi- tions. Retro-peritoneal tumors (sarcomata) are discriminated Avith the greatest difficulty. Tumors of the peritoneum, however, whether of the omentum or mesentery, are movable, while those behind the peritoneum are immovably fixed. Omental tumors lie in front of the intestines (as can be shown by kiflation of the bowel); mesenteric new growths some- times have a coil of intestine in front of them. On the other hand, retro-peritoneal tumors are always crossed by loops of intestine. Peri- toneal tumors (particularly the omental) follow the movements of respi- ration, while the retro-peritoneal remain immobile. The latter always cross to some extent the central long axis of the body, while the former may be confined to one or the other side. The prognosis is always unfavorable. Treatment can accomplish nothing beyond a more or less com- plete relief from the distressing symptoms. PART VII. DISEASES OF THE URINARY SYSTEM. I. DISEASES OF THE KIDNEY. MOBILITY OF THE KIDNEY. (Movable Kidney; Floating Kidney; Wandering Kidney; Ren Mobilis; Nephroptosis) Definition.—A distinction is made between two common varieties of mobile kidney, according to the degree of displacement, as folloAvs: (1) Movable kidney, the upper end of which can be felt during deep inspiration, and which can be pushed down in the retro-peritoneal space to the level of the umbilicus; (2) Floating kidney, which is freely mov- able below or beyond this point—i. e. possessing a larger arc of mobility. In the so-called palpable kidney the lower edge of the organ can barely be felt on deep pressure. Etiology.—Although an anomalous position of the kidney is usu- ally acquired, it may be congenital; in such cases the condition may be due to relaxation of the perinephric (peritoneal) tissues, the kidney thus having a mesonephron and floating freely about in the abdominal cavity. An abnormally long renal artery may also predispose to the develop- ment of a movable kidney. Emaciation with a marked wasting of the fatty capsule in which the kidney is imbedded is a frequent underlying cause of movable kidney. Women are oftener affected than men, and relaxations from multiple pregnancies, tight-lacing and girdling, and traumatism (falls, heavy lifting, and the like) have frequently caused displacement and mobility of the kidney. Heavy tumors of the organ, the pressure of adjacent tumors (as of the liver), and the traction of hernias may likewise cause the condition. In enteroptosis, or Gle'nard's disease, in which there is a downward displacement of all the viscera, mobility of the kidney is often asso- ciated. Although either kidney, or even both kidneys, may be abnor- mally mobile, the right one is usually affected, probably owing to its anatomic position and to its relation with the liver above. Sometimes a floating kidney becomes fixed by peritoneal adhesions in an abnormal position, as in the right iliac fossa; an instance of this occurred in a seaman, under my care, admitted to the Medico-Chirurgical Hospital 59 929 930 DISEASES OF THE URINARY SYSTEM. of Philadelphia. In this case the dislocation of the kidney Avas appa- rently caused Avhile on shipboard by a prolonged and intense straining at stool after taking a large dose of castor oil. Symptoms.—Movable kidney may exist without any symptoms whatever. It may be discovered accidentally by physical examination, and not infrequently it is found postnwrton in a similar manner, no history of trouble having been elicited during life. The symptoms of movable kidney are local, reflex, and general, the local and reflex symptoms being the most prominent in the average case. The reflex symptoms, though usually abdominal, may become general. The local symptoms are most marked in extreme mobility of the kidney (floating kidney), while in moderate mobility the reflex symptoms usually predominate over the local. Most frequently there is a troublesome dragging pain, or a sense of weight or pressure in the loins or abdomen, especially after long Avalking or standing or hard labor; this may, at times, be referred to the sacral region. Sometimes the pain may be quite sharp and colicky in nature. Pain in the kidney itself is seldom complained of, and then only in those comparatively rare conditions in which congestion is produced by pres- sure or traction upon the renal veins, obstruction of the ureter, or the like. The patient himself sometimes recognizes the kidney as a tumor, tender and distressing, as in a case under my own care. Reflex gastro-intestinal disturbances are common. Indigestion is usually complained of, and occasionally nausea and vomiting are noted. Dilatation of the stomach may possibly be caused by a dislocated kidney pressing upon the duodenum, but the association of the two conditions is probably coincident rather than causative. Pressure-jaundice is also an unusual concomitant of the floating kidney. Cardiac palpitation, constipation, flatulence, and edema of the lower extremities (from pres- sure on the inferior vena cava) may attend, and disturbances of the pelvic viscera have also been noted occasionally (dysmenorrhea, abortion, and irritable bladder). Some cases of displaced kidney are characterized by sudden and severe attacks of nephralgic or gastralgic pain, chills, fever, nausea and vomiting, and general collapse. These attacks are often periodic, occurring sometimes at the menstrual period, and are known as " Dietl's crises" or "incarceration symptoms." They may be excited, also, by a too free indulgence in eating and drinking, as in a case reported by Osier. It is most probable, as Dietl himself sug- gested, that these cases are due to a twisting or bending of the renal vessels or of the ureter, or, perhaps, to circumscribed inflammation of the mobile kidney. An acute hydronephrosis may thus develop, Avith diminished diuresis. The urine is concentrated, and may contain uric acid or oxalates in excess. After three or four days, as the attack subsides, micturition becomes free, the swollen and sensitive kidney becoming movable once more. When produced by movable kidney the attacks of hydronephrosis may occur intermittently (vide Hydro- nephrosis). Floating kidney associated Avith Gle'nard's disease (enteroptosis, splanchnoptosis), in which the transverse colon, pancreas, stomach, intestines, and other viscera are prolapsed, owing to looseness and weakness of the visceral attachments, gives rise to symptoms similar to MOBILITY OF THE KIDNEY. 931 those stated above, only Avith the addition of greater discomfort and nutritive and nervous disturbances. The general symptoms of movable kidney are those of " nervousness " neurasthenia, or hysteria. Mental anxiety, leading to melancholia, some- times follows the discovery by the patient of a movable abdominal tumor, which is persistently believed to be a u cancer." Cephalalgia, backache^ mental irritability, paresthesias, neuralgias, nervous dyspepsia, and vari- ous hysteric manifestations may arise and prove a perpetual annoyance. In those less frequent instances in Avhich men are affected Avith mobile kidney hypochondriasis may develop. The physical signs of movable or floating kidney are highly import- ant and diagnostic. Palpation, especially bimanual, as by Israel's method of counter-pressure (the left hand being placed over the lumbar region, the right next the skin in front, manipulating the abdomen from above dowmvard), may detect a firm, movable tumor of renal size and shape in either flank (usually the right) just beloAv the ribs (movable kidney), or in the inguinal or umbilical regions (floating kidney). Though comparatively easy to outline, the tumor is nevertheless hard to grasp; it is often, however, readily pushed into place. Deep breath- ing may affect a palpable or movable kidney, but has no effect upon one that freely Avanders about the abdomen (floating kidney). Pulsation of the renal artery may be felt in the last-named cases. Inspection and percussion of the lumbar region in movable kidney are uncertain, and therefore unreliable. Visible depression here is rarer than a visible tumor anteriorly; the latter, hoAvever, is not common, although it is occasionally noted in cases of marked Avandering of the kidney, as to the inguinal region. I have noted increased tympany over the affected side in several cases as compared Avith the same area on the opposite side. A diagnosis is possible only after a careful and thorough physical examination. When this is made, an abnormally mobile kidney is usually discoA'ered Avithout difficulty. The size and shape of the organ, its right-sided position, and its mobility, associated with a train of local, reflex, or general nervous disturbances, especially in a thin, emaciated woman, are quite distinctive. A standing (preferably bending forward with the hand resting on a table) or knee-elbow posture is sometimes more favorable than the recumbent position for determining a movable kidney, and a lax abdomen greatly facilitates the physical exploration. Floating kidney is of course more easily diagnosticated than the movable type, and partly because of the fact that in instances of the latter, tumors of the gall-bladder especially, and wandering spleen must first be excluded. The absence of a well-defined splenic notch, the presence of pulsation of the renal artery, and an unchanged area of splenic dulness will assist in the diagnosis; in addition there is the fact that Avandering spleen is a comparatively rare affection. Tumors of the gall-bladder, as Henry Morris has shown, are fre- quently mistaken for movable kidney, and occasionally the opposite error is made; sometimes, indeed, both conditions may exist. They are both common to women; the right kidney is much more often movable than the left; they both may present as tumors in the right hypochon- driac and umbilical regions ; they are more or less movable, firm, smooth, 932 DISEASES OF THE URINARY SYSTEM. slightly tender, round or oval in shape, Avith variable percussion-signs, and dyspeptic symptoms ; and either may give rise to paroxysms of severe colic, or to jaundice. Jaundice, hoAvever, is probably rare in movable kidney, Avhile emaciation and general nervous disorders are more com- mon ; the floating tumor is also less easily palpated than the cholecystic, and may vary in size (hydronephrosis), the diminution being accompanied by a marked increase in the Aoav of urine. If the gall-bladder be filled with calculi, the consistence is firmer than that of the kidney, and fre- mitus may be felt. Moveover, the movements of the gall-bladder are usually lateral Avithin a short arc of a circle, the center of Avhich is a point beneath the edge of the right lobe of the liver; Avhile those of floating or movable kidney may be either vertical, oblique, or lateral in arcs of a much larger radius. Again, tumors of the gall-bladder descend Avith inspiration, as is not the case Avith Avandering kidney. In some cases it may be necessary to distinguish betAveen the attacks of pain knoAvn as " Dietl's crises " and renal, hepatic, or intestinal colic, acute intestinal obstruction, and appendicitis; the symptoms peculiar to these conditions must then be considered in forming a diagnosis. Tumors of the ovaries and boAvel are rarely confounded with wander- ing kidney. Prognosis.—In uncomplicated cases life is never endangered, and a cure may be effected in a large majority of cases in Avhich suitable com- bined medical and surgical treatment is pursued. The general nervous symptoms are usually very obstinate, but after relief is afforded from the local and reflex symptoms, whether by tentative or operative means, they subside or cease altogether. Treatment.—Since emaciation and loss of perirenal fat is a fre- quent cause of wandering kidney, it is often advisable to resort to meas- ures that will tend to increase the weight and fat of the body. The "rest-cure," with its forced feeding, may be all that is necessary in highly nervous subjects having but a slightly movable kidney. In all cases more or less prolonged intervals of rest (lying down) throughout the day aid markedly in ameliorating the symptoms. Other hygienic measures, as the avoidance of over-exertion, extreme bodily movements, straining—as at stool—and so forth, should also be enjoined. Trusses, kidney-pads, and bandages, I have recently been convinced, avail nothing. A transverse, oval, and concave abdominal shield, how- ever, if placed between the umbilicus and the symphysis, and sustained from- the sacral region by a pad connecting the shield with springs (or by an inelastic material passing over the hips, as recommended by Schatz) will give comfort, support, and ease. In severe cases of renal displacement, in which recurring attacks of hydronephrosis, strangula- tion-crises, profound nervous and mental disturbances, or other grave renal complications occur, some such surgical procedure as nephrorraphy may be necessary. This often proves an effectual cure, although occa- sionally the anehorage may be torn loose by a sudden or severe physical effort. Total extirpation of the kidney (nephrectomy) is justifiable only in the gravest cases and after other means have failed. The hypodermic injection of morphin and atropin and the external application of heat are indicated in the crises of Dietl. PASSIVE HYPEREMIA OF THE KIDNEY. 933 CIRCULATORY DISORDERS OP THE KIDNEYS. ACTIVE HYPEREMIA. (Acute or Active Congestion.) Definition.—An acute, temporary engorgement of the vessels of the kidneys, Avith little or no exudation. Pathology.—The kidney is swollen, deep-red in color, and en- gorged Avith blood, which Aoavs freely on section. Microscopically, in severe congestion there may be seen cloudy SAvelling of the cortical epithelium. Etiology.—Acute renal congestion is due mainly to the action of irritants present in the circulation, as in the acute infectious (especially the eruptive) fevers. The stimulating diuretics and certain poisonous drugs, as copaiba, squills, cantharides, potassium chlorate, and car- bolic acid, also sudden contraction of the peripheral blood-vessels by exposure to cold Avhile the body is overheated, act as causes. When prolonged the congestion passes into an acute nephritis. It may be caused in one kidney as a result of the nephrectomy of its felloAv. Cer- tain ill-defined centric and peripheral nervous influences and neuroses are held by some to cause an active hyperemia of the kidneys through a vasomotor paralysis of the renal arteries. Symptoms.—There may be a dull pain in the lumbar region, Avith a slight elevation of the temperature and pulse-rate. The urine either is scanty, or, as in cantharides-poisoning, it may be altogether sup- pressed. It is dark, the specific gravity is increased, and it contains some free blood, a trace of albumin, and a few hyaline tube-casts. Diagnosis.—The absence of a marked quantity of albumin, of the numerous and various casts, of dropsy, and of uremic symptoms distin- guishes active hyperemia from acute nephritis. The prognosis is quite favorable upon the removal of the cause. It must be borne in mind that a frequent repetition of the attacks may lead to a nephritis. Treatment.—Absolute rest and a liquid diet should be ordered. Cupping over the loins or the use of hot fomentations should be prac- tised. The free use of water and other diluents or mucilaginous drinks should be encouraged. Saline laxatives to freely open the bowels, and the use of hot air or a hot pack to promote SAveating, are important aids in relieving the congested kidneys. PASSIVE HYPEREMIA. (Chronic or Passive Congestion.) Definition.—A chronic venous engorgement of the renal vessels, generally secondary to diseases of certain other viscera. Pathology.—There is in the later stages a characteristic condition of the kidneys called "cyanotic induration." Earlier in the case the organs are enlarged, firm, and of a dark, bluish-red color. The capsule is usually non-adherent. On section the medullary substance is seen to be darker red than the cortex and coarsely fibrous in appearance. Micro- 934 DISEASES OF THE URINARY SYSTEM. scopic examination shoAvs the capillaries (both glomerular and medullary) somewhat dilated and the Avails thickened. The epithelium may either be unchanged or a little cloudy and SAvollen, or, later, even fatty ; the interstitial tissue may be slightly increased, especially beneath the cap- sule of the kidney. Etiology.—Most commonly the renal congestion is a part of a gen- eral venous engorgement due to chronic cardiac, pulmonary, or hepatic disease. It is found in mitral valvular disease Avith ruptured compen- sation of the heart; in pulmonary emphysema, fibroid phthisis, and chronic adhesive pleurisy ; and in cirrhosis of the liver. The " cardiac kidney" is the commonest variety. Less frequent causes of congested kidneys are tumors, the pregnant uterus, and ascites, all of which bring about the condition through pressure upon the renal veins. Only rarely may passive renal congestion be due to thrombosis of the ascending vena cava or of the renal veins. Symptoms.—These are accompanied by those due to the primary diseases that are manifested in the general venous congestion, as edema of the loAver extremities. There may be a sensation of weight in the loins. The urine is diminished in quantity, of a higher specific grav- ity, and darker in color ; it contains a little albumin, some blood-cor- puscles, and a feAv hyaline casts and epithelial cells, depending upon the chronicity and intensity of the congestion. Urates may be deposited in the standing urine. Diagnosis.—From nephritis passive renal congestion may be differ- entiated by the comparative absence of albumin, casts, dropsy, and uremia, and by the undiminished quantity of urea. Prognosis.—This depends upon the primary cause. Chronic con- gestion may pass into chronic nephritis. Treatment.—Rest and a light and easily assimilable diet, together with cardiac tonics and diuretics, are indicated. The infusion of dig- italis serves a good purpose by increasing the quantity of urine and clearing it of albumin. Basham's mixture is a useful adjuvant. EMBOLIC INFARCTIONS. Anemic and hemorrhagic infarctions of the kidney are of pathologic rather than of clinical significance. Cicatrices may result from these infarctions, giving rise to the "embolic contracted kidney." Very rarely the sudden appearance of a slight amount of blood in the urine, associated with cardiac disease and possibly Avith a sudden severe pain over the loin, may point to hemorrhagic infarction. SPECIAL PATHOLOGIC STATES OP THE URINE. HEMATURIA. Definition.—The presence of blood in the urine. Etiology.—(1) Local or renal causes of hematuria include conges- tion, acute inflammation of the kidneys, and acute exacerbations of chronic nephritis, embolic hemorrhagic infarction, renal calculi and HEMATURIA. 935 pyelitis, tuberculosis, traumatism, and parasites (the filaria sanguinis hominis and distoma haematobium (Bilharz). (2) Affections of the Urinary Tract.—In the ureter, calculi or lacera- tions due to traumatism, as in protracted and complicated abdominal sections; in the bladder, calculi, malignant tumors, acute cystitis, ulce- ration and rupture of varicose veins at the vesical neck; and in the urethra, gonorrhea, calculi, parasites, and traumatism,—may all cause hematuria. (3) General Diseases.—Acute specific fevers and certain blood-dys- crasise (purpura, scurvy, hemophilia, malaria, and leukemia) may produce hematuria. Malarial hematuria in mild form is an uncommon feature of paludism in the Middle States of this country, and may occur after the manner of intermittent malarial paroxysms. That due to the renal congestion of chronic heart-, lung-, or liver-disease, is not a marked condition, and is not of frequent occurrence. Senator describes an interesting and unusual form of hematuria that is sometimes seen in young persons Avhose health may be quite fair, the blood often appearing paroxysmally and without apparent cause (''renal hemophilia"). Hematuria may be also a manifestation of vicarious menstruation. Endemic hematuria, so called, is that variety found in some of the tropical regions where the distoma haematobium (a trematode Avorm) abounds. Diagnosis.—This has for its object the discovery (1) of blood in the urine, and (2) of the source of the hemorrhage. Bloody urine varies in color according to the quantity of blood present, to its condi- tion (coagulability), disposition, and the length of time present in the urine. A light reddish tinge may indicate a slight quantity of blood. A dark coagulum may be at the bottom as a sediment, with small clots floating above in a deep-red, turbid layer, above which, again, the urine may shoAv but the slightest tint of red. Or the urine may have a smoky- red or chocolate-hued appearance. Microscopically, the blood-corpuscles are readily discovered, establishing the diagnosis from hemoglobinuria, in which condition they are absent. When red corpuscles are associated with tube-casts, renal hemorrhage may be positively diagnosed. In ammoniacal urine or in urine of low specific gravity the corpuscles are very pale and shadoAvy (dissolved hemoglobin). After remaining in ordinarily acid and diluted urine they lose their disk-like shape and swell into spheres of a smaller diameter. Urine containing blood always shoAvs the presence of albumin. Chemically, the blood-pigment may be detected by Heller's test, Avhich consists in adding liquor potassse, boiling the urine, and observ- ing the flakes of precipitating phosphates, which become reddish-yellow or brown from the hematin-crystals as they fall. The guaiacum test is also used. The spectroscope is sometimes employed to discover the bands produced by the blood coloring-matter. The source of the blood in hematuria is of great diagnostic and therapeutic importance. In renal hemorrhage the blood is thoroughly mixed with the urine, giving a uniformly red or brown color, as in hemorrhagic nephritis. Blood-casts and leukocytes may also be found. The disease causing hematuria may be traced sometimes by a study of the 936 DISEASES OF THE URINARY SYSTEM. urine; thus, in cases of valvular cardiac disease the sudden appearance of hematuria would indicate infarction of the kidney. The discovery of a few red blood-corpuscles in a concentrated urine Avould point to renal congestion. In profuse renal hemorrhages clots representing moulds of the renal pelves and of the ureters may be discharged. Blood from the ureters is usually moulded in clots in the shape of curved cylinders, and appears like small dark worms in the urine. Casts from the ureters are often secondary to hemorrhages; in such cases the hematuria may alternate with the passage of clear urine, owing to temporary hemorrhages or to the blocking of the ureter on the dis- eased side. (See also Fibrinuria.) Cystic hemorrhages may be quite copious. The blood and urine are not intimately mixed, and large clots settle on standing. The first por- tions of urine discharged may not be bloody, while the last portion may consist of pure blood; again, on washing out the bladder blood-tinged urine comes away, while this is not the case if the hemorrhage comes from the higher portions of the urinary passage. Finally, urethral blood is discharged in advance of the urine, and either comes away freely or may be " milked out" independently of urination. The endoscope has been used successfully to determine the source of the hemorrhage. It is especially useful in women. It is also possible with this instrument to determine Avhich kidney is affected. HEMOGLOBINURIA. Definition.—The presence of blood-pigments, especially methemo- globin, in the urine. Etiology.—The direct cause of hemoglobinuria is a condition of the blood in Avhich, as a result of the dissolution of the red corpuscles, the hemoglobin is set free and is excreted by the kidneys. (1) The causes of the hemolysis are principally toxic, and include the following: (a) Poisons (carbolic and pyrogallic acids, potassium chlo- rate, naphtol, phosphorus, arseniuretted hydrogen, and carbon dioxid). (b) The ingestion of poisonous fungi or of tainted edible mushrooms (Helvetia cesculenta). (c) The poisons of certain infectious diseases (scarlatina, typhus and typhoid fevers, yelloAV fever, syphilis, scurvy, purpura), (d) Extensive burns, the absorption of hemorrhagic effusions, and the transfusion of animal blood, (e) Rarely it may be due to ex- posure to cold and to violent physical exertion. (/) Finally, there is the so-called epidemic hemoglobinuria (Winckel's disease) that occurs in the new-born. (2) Paroxysmal hemoglobinuria, a rare and interesting variety, may occur without any apparent cause in persons enjoying otherwise good health. It appears thus distinctly as an independent disease. Some of these cases, however, have been attributed to a peculiar susceptibility to cold (generally or locally applied) and to marked exertion; especially is this the case in adult Avnite males. It is held by some to be a manifestation of Raynaud's disease, and by others to be the result of syphilis. (3) It appears as a symptom of malaria (which acts like the other infec- ALBUMINURIA. 937 tious diseases) in the southern part of this country, where the pernicious varieties of malarial toxemia are most common. This is termed malig- nant malarial hemoglobinuria. In Africa it is called black-water fever. Symptoms.—These are generally the symptoms of the condition that accompanies hemoglobinuria. In paroxysmal hemoglobinuria the attacks are usually sudden, brief in duration, and sometimes intermit- tent, especially when of malarial origin. Jaundice may be an associ- ated symptom. The hemoglobinuria seldom lasts for more than tAvo days, though very grave cases take on the aspect of a pernicious mala- rial attack. There may be lumbar pains, chills and fever, and gastric disturbances. Urticaria and purpura have also been noted, as has anemia in cases in Avhich frequent attacks have taken place. Diagnosis.—This is made by an examination of the urine. Macro- scopically, it is of a red-brown color, slightly turbid, with a reddish- brown or brownish-black sediment. The reaction is usually acid, and the specific gravity slightly loAvered. The microscopic features that distinguish hemoglobinuria from hematuria are variable. In the former condition feAv or no red corpuscles are present, and the few that may be seen are usually colorless (" shadows ") or fragmentary. Small flakes or granules of disintegrated hemoglobin are found, and are brownish-black in color. There may be also brown-tinged casts and epithelium. Chemically, the urine is found to contain albumin, for the discovery of which Heller's and the "guaiac" tests for blood-pigment may be tried. The former has been described in the preceding discussion of Hematuria. The guaiac test consists in overlaying Avith urine a mixture of the tincture of guaiac and hydrogen peroxid or the oil of turpentine (equal parts). When the blood-coloring matter is present, an indigo-blue ring is formed above a Avhite resinous deposit. When shaken a lighter blue color develops throughout the contents. By means of the spectroscope the three absorption-bands of methemoglobin may be seen (red, green, and yelloAv). The blood-serum in. hemo- globinuria may be someAvhat red-tinged on account of the dissolved hemoglobin. The hemoglobinuria is further marked by the aplasticity of the red corpuscles, by their pallor, by poikilocytosis, and by the presence of the irregular flakes of hemoglobin. The prognosis of hemoglobinuria depends upon the cause. It is favorable in the ordinary paroxysmal form. Malignant malarial hemo- globinuria, however, is often fatal. The treatment consists primarily in rest in bed. The application of dry cold to the loins is useful, and the hypodermic injection of ergotin is to be recommended for trial. Internally, such hemostatics as the extract of hamamelis virginica, the extract of hydrastis canadensis, gallic acid, lead acetate, ergot, and opium may be used. Hemoglobinuria is rather intractable. During the paroxysms ex- ternal warmth is needed, along with hot drinks to encourage perspira- tion. In malarial cases quinin, and in syphilitic the iodids, should be administered. ALBUMINURIA. Definition.—The presence of albumin in the urine. Pathology and Etiology.—The immediate cause is the escape of <»38 DISEASES OF THE URINARY SYSTEM. the normal blood-constituents, serum-albumin and serum-globulin, from the vessels into the renal tubules. This transudation of albumin indi- cates either a transient and slight or a permanent and grave nutritional disturbance of either the epithelium lining the glomeruli or of that of the contained tufts of capillaries, or, possibly, of the membrana propria or the epithelium of the uriniferous tubules. These changes induce and offer an abnormal perviousness to the albumin of the blood. The principal causes of albuminuria are—(1) Those associated with definite lesions of the kidney ; nephritis, acute and chronic ; renal con- gestions, active and passive (the latter being secondary to chronic liver-, heart-, and lung-disease, pregnancy, or tumors); and certain toxemias. Among the last-named are included scarlet fever (scarlatinal nephritis) and gout. Other causes are—amyloid and fatty degeneration of the kidney, suppurative nephritis, and renal tumors (cystic kidney). Albuminuria occurs also in conditions in Avhich (2) the renal lesions are either slight or undemonstrable: (a) Thus, it is present in blood- changes, as in chronic lead-, mercury-, and arsenic-poisoning, scurvy, purpura, syphilis, leukemia, or extreme anemia, and in cases in which urobilin or bile-pigment and sugar (glucose) circulate in the blood. Again, slight albuminuria may be present in pregnancy (kidney of pregnancy), in saccharin diabetes, and after etherization. In certain affections of the nervous system albumin is found in small quantity, as after an epileptic paroxysm, in tetanus, injuries to the head, apoplexy, and exophthalmic goiter. (b) The so-called accidental or spurious albuminuria is due to the presence of pus or blood; in such cases the condition is not a true renal albuminuria, since it is commonly associated with cystitis, pyelitis, urethritis, or is the result of hemorrhage from the pelvis of the kidney, from the ureters, bladder, or urethra. (c) Febrile albuminuria is of rather frequent occurrence in diseases accompanied by pyrexia, especially Avhen long continued. Among these are typhoid fever, small-pox, yellow fever, diphtheria, and even follic- ular tonsillitis and pneumonitis. The renal changes in these cases are scarcely more than a transitory cloudy SAvelling in the glomeruli, which, together with the albuminuria, rarely lasts longer than the fever. (d) Other forms of albuminuria have been styled physiologic or func- tional, dietetic, intermittent, and cyclic ; in these no definite lesions of the kidney are found, and are denied by some to exist. Recent observ- ers are inclined to believe that trivial, non-progressive renal changes occur in these cases. Slight albuminuria certainly does occur in some cases after a heavy meal rich in albumin, after marked and prolonged muscular exertion, intense emotion, and cold bathing. (e) Cyclic albuminuria has come to be of greater interest and import- ance in later years, particularly as it bears upon the prognosis and upon life-insurance risks. In this variety there is a periodic appearance and absence of albumin in the urine. The albuminuric paroxysms are very variable, recurring usually after meals or on exertion, but generally being absent during rest at night or early in the morning. The albu- min is present in but small quantity, and only rarely are casts (hyaline) found. The urinary features are otherwise normal, and the accompany- ing signs and symptoms common to nephritis are absent. Cyclic albu- ALBUMINURIA. 939 minuria is most common in adolescent anemic males, of poor nutrition, neuralgic, often neurotic, and even hysteric. Under careful manage- ment these cases ordinarily recover. There is, hoAvever, a class of cases in which the albuminuria is persistent, though but a mere trace of albu- min may be detected, and neither can tube-casts be found nor are symp- toms complained of. As a rule, however, an insidious degeneration of kidney-structure may manifest itself many years later, an urgent con- dition sometimes developing. Diagnosis.—This rests upon the discovery of albumin by means of any one or more of the reliable tests shortly to be described. Since albuminuria is no more synonymous Avith nephritis than is glycosuria or polyuria Avith diabetes mellitus, it becomes important and necessary, both for prognostic and therapeutic reasons, to differentiate between the so-called functional albuminuria, the cyclic variety, and those associated with coarse and definite anatomic lesions of the kidney. Differential Diagnosis.—Inquiry and careful inference concerning the etiology of a given case must be made. Renal albuminuria is persistent and of considerable quantity, except in chronic interstitial nephritis. Tube-casts are usually present. Functional albuminuria is slight and inconstant. Tube-casts are either absent or exceedingly feAv in num- ber in the latter. Again, in the former variety general symptoms, as dropsy, cardiac hypertrophy, anemia, and uremic prodromes, are pres- ent. It is true that slight edema is sometimes found in cyclic albumi- nuria, but this is probably due to the marked anemia that is so often seen. In this variety of the mild albuminurias also there may be at times a considerable quantity of albumin, due to the presence of pus or blood, the microscopic elements of Avhich, when found, of course settle the question as to the origin of the albuminuria. When the quantity of albumin is disproportionately large in spurious albuminuria, a suspicion of coexisting renal albuminuria should be aroused (Striimpell). Tests for Albumin.—Tayo samples of urine, one of the morning before any food is taken, and one of the evening before the patient retires, should be examined. Care should be taken that there be no contamina- tion of the urine Avith the menstrual, leukorrheal, or urethral discharges. The smallest quantity can be detected only by its coagulum rendering the urine turbid; hence any turbidity present before the given test is made should be removed by filtration, unless this turbidity be due to urates, when a little warming of the tube will render the urine clear. (1) Boiling Test.—This is the commonest and perhaps the most reli- able practical test for albumin. The tube is filled about tA\o-thirds full of urine. If alkaline or neutral in reaction, a drop of acetic or nitric acid is added; an excess of acid must be carefully avoided, lest the albumin (if present) be converted into a non-coagulable form. The tube, held aslant, is then applied to the flame, and sloAvly revolved with the fingers, so that the upper portion of the column of urine is brought to the boiling-point. A comparison of this Avith the lower portion of the urine is made. Any turbidity is due to albumin or phosphates. If albumin, adding a few drops of nitric acid will increase and thicken the coagulum; if phosphate, the opaqueness will be cleared at once. (2) Heller's Nitric-acid Test.—This is easily performed, and is both delicate and satisfactory. About 1 c.cm. of nitric acid is poured into a 940 DISEASES OF THE URINARY SYSTEM. tube, and some urine is allowed to Aoav sIoavIv from a pipet and settle upon the acid. The presence of albumin is indicated by a Avhite ring at the point of contact of the tAvo liquids. Uric acid, urates, and certain urinary coloring-matters form a pink or deep-red ring or zone; this forms, as a rule, above the juncture of the acid and urine. Hemialbu- mose also gives a Avhite zone, but does not respond to the boiling test as does serum-albumin. (3) Johnson s Picric-acid Test.—To filtered urine in a test-tube are slowly added a few drops of a saturated Avatery solution of picric acid. Immediate turbidity indicates albumin. Some authorities prefer that a dram or tAvo (4.0-8.0) of the yellow fluid be placed gently on the surface of the urine, Avhen, if albumin is present, a white zone at once is appa- rent, together with a haziness that spreads doAvnward Avith the diffusion of the liquids. Heating emphasizes the evidence of the test, Avhich is extremely sensitive. (4) Roberts' nitric-magnesium test is also very delicate. It consists in using the folloAving mixture, just as in Heller's test: one volume of concentrated nitric acid, added to five volumes of a saturated solution of magnesium sulphate. (5) Trichloracetic-acid Test.—This will discover minute traces of albumin, but has the disadvantage that it responds to nucleo-albumin as well as to serum-albumin. A feAv crystals may be dropped into the urine, or a saturated solution may be used after the "contact method," Avhen, if albumin be present, a white coagulum forms. This and the Geisler test-papers (Vierordt) constitute portable and handy tests. (6) The acetic-acid and potassium-ferrocyanid test is also valuable and minutely sensitive. The urine is first made decidedly acid Avith acetic acid. A feAv drops of a freshly prepared solution of potassium ferrocyanid are then added, and if either albumin or hemialbumose be present, it will be precipitated. (7) Quantitative Test—Esbach's Albuminometer.—This consists in using a graduated test-tube, into Avhich definite amounts of urine and a reagent composed of 10 parts of picric acid, 20 of citric acid, and enough water to make 1000 parts are carefully mixed by reversing several times the stoppered tube. After allowing this to stand about tAventy-four hours, the height of the precipitated albumin is read off on an etched scale, Avhich will indicate approximately the parts per thousand. Not less than 0.5 parts per thousand can be estimated correctly, however. Should there be a hematuria, if the percentage of albumin by Esbach's method, divided into the number of red cells per cubic centimeter of urine, is less than 30,000, it suggests a purely hematuric albuminuria; if greater, it suggests an independent albuminuria (Goldberg). Prognosis.—Etiologic considerations bear heavily in this matter. Functional abuminuria is of favorable import, as a rule. The febrile, hemic, cyclic, and paroxysmal varieties usually clear up Avith convales- cence and with advancing years (in the latter case). The persistence of albumin in these cases, hoAvever, even in slight amounts or at vari- able periods, should cause suspicion, since there must be some glome- rular renal change to account for the disorder, the tendency of which is to progress steadily and insidiously. Especially is this true Avhen there is associated a gradually increasing arterial tension. The presence of INDICANURIA. 941 tube-casts is conclusive of structural change in the kidneys, marked by degenerations and by exudative and productive inflammation, either acute or chronic. PEPTONURIA AND ALBUMOSURIA. True peptone (Kiihne) has never been demonstrated in the urine. The so-called peptones discovered by Devoto's and other methods are really ulbumoses, and the term albumosuria should be substituted for pep- tonuria. These albumoses (proto-, deutero-, hemi-) are found in acute suppurations or Avhen resolution of inflammatory effusions is going on, as in lobar pneumonia. They may be found also in acute rheumatism, scorbutus, and in certain forms of metallic and ptomain or bacterial poisoning. Albumosuria may be suspected when, after negative results with the boiling and nitric-acid tests, cold acetic acid produces a cloudi- ness. This suspicion may be confirmed by the biuret test, as follows: Any albumin that is present must first be coagulated and removed. Then, after placing some Fehling's solution in a test-tube, an equal quantity of urine is allowed to come in contact with it, when, if albu- moses be in the latter, a rose-pink zone or halo appears at or near the point of contact. Hemialbumose is formed in the urine in osteomalacia, in chronic suppurations, and in sarcomatous disease of the spinal cord, though the clinical or diagnostic significance of the substance has not been fully determined as yet. INDICANURIA. Definition.—The presence of a pathologic quantity of indican in the urine. Indican occurs in the urine in health in very small quantities as a colorless compound, and is, chemically speaking, indoxyl-potassium sulphate. Pathology and Etiology.—Indican is increased abnormally in the urine by any disorder Avhereby large quantities of albuminous mat- ters are decomposed. Thus, it occurs in intestinal obstruction, especi- ally Avhen the caliber of the small bowel is diminished from any cause so as to produce a stagnation of the contents and a consequent decom- position from bacterial action. Under such circumstances indol and phenol are formed. The former, being absorbed and oxidized into in- doxyl, finally appears in the urine in combination with potassium sul- phate. Acute peritonitis, obstinate and chronic constipation, wasting diseases, and cachectic conditions in which there is a considerable de- struction of albuminoids (as in Addison's disease, neoplasmata, cholera Asiatica, and empyema) usually have an associated indicanuria. An increase of the aromatic sulphates in general, or an increase in pro- portion to the fixed sulphates, is especially significant of intestinal pu- trefactive processes. Since the pancreatic secretion peptonizes the pro- teids from which arise leucin and tyrosin, and these in turn are decom- posed into skatol, indol, and phenol, it is stated (Piseuti) that any ob- struction preventing the Aoay of the pancreatic juice into the bowel 942 DISEASES OF THE URINARY SYSTEM. would be reflected in a diminished quantity of indican in the urine. On the other hand, any epigastric tumor suspected of pressing upon the small intestines Avould be accompanied Avith indicanuria. Diagnosis.—This depends upon the demonstration of indican by adding strong oxidizing agents, Avhich decompose this product and set the indigo or pigment free. At times sufficient oxidation of the indican has taken place in the urine before any chemical test is applied, so that a bluish tinge is given thereto. This may be seen in urine that has been standing for some time, the sediment giving a bluish reflection, or there may be a blue-turbid film on the surface. In the urine of indican- uria, moreover, Avhere putrefaction is marked, a pronounced blue-black color may be present. Tests.—Jaffe's well-knoAvn test consists in mixing equal volumes of urine and hydrochloric acid, and then adding, drop by drop, a concen- trated solution of chlorinated lime, shaking the tube after each ad- dition. A strong indigo-blue color appears if there is much indican. A good modified test is the use of fuming nitro-hydrochloric acid and urine (equal parts) and a saturated solution of chlorinated potash, used as in the above method. A blue-black cloud or ring appears beloAv the surface. If a few drops of chloroform are then added and the mix- ture is agitated slightly, a blue color settles at the bottom, owing to the chloroform carrying with it the oxidized indican. PYURIA. Definition.—The presence of pus in the urine. Etiology.—Pyuria is due to (1) suppurative inflammation along some portion of the genito-urinary tract, or (2) to the rupture of adjacent ab- scesses into the tract. According to the source of the pus the urinary manifestations differ in a more or less characteristic manner. Pyelitis and Pyelo-nephritis.—Pus from the pelvis of the kidney may be due to calculous, tuberculous, or other irritation. It is associated at times Avith the "railed" or transitional epithelium usually seen early in the case. In pyelo-nephritis casts may indicate renal involvement, although it should be borne in mind that in abscess of the kidney pus may be discharged continuously Avithout the appearance of any casts in the urine Avhatsoever. One such case came to necropsy under the ob- servation of H. S. Anders, in Avhich small uratic calculi Avere dis- charged noAv and then for several years. Later, several larger stones were removed from the bladder by Willard by suprapubic cystotomy, in the hope that by drainage and irrigation of the bladder the marked pyuria might subside or cease. The abdominal opening healed in a feAv months, and, Avhilst bladder-symptoms were absent after removal of the calculi, pyuria persisted. Death having occurred suddenly from coro- nary-artery disease and interstitial myocarditis, it was found postmortem that a large abscess occupied the loAver third of the left kidney, Avhich Avas filled Avith small, dark, and irregularly-shaped calculi. A thick pyogenic membrane surrounded the purulent and calculous contents. No casts were found at any time during life, though repeated exami- nations were made, and, remarkable as it seems, renal symptoms Avere altogether absent. CHYLURIA. 943 The pyuria is sometimes intermittent, one ureter becoming tempor- arily occluded (on the side of the disease), the clear, normal urine from the healthy kidney passing until the ureteral obstruction is relieved, when pus again appears. Purulent urine from the kidney is usually acid in reaction, except Avhen the pyelo-nephritis is secondary to cystitis, when it is more apt to be alkaline and to contain a decided quantity of mucus. Cystitis.—Pyuria in this affection is fetid in most cases. Bladder- symptoms are marked. The urine is alkaline, and a stringy, tenacious muco-pus comes with the last portions. Triple phosphates are "often found. The pus and urine are not so intimately mixed as in pyelonephritis. Urethritis.—The pus is in small quantities, is passed in advance of the urine, and can be "milked out" from the male urethra. There is usually a history of gonorrheal infection, and the gonococcus may be demonstrated in most cases. Rupture of contiguous abscesses into the urinary tract is accompanied usually Avith a sudden discharge of a large quantity of pus in the urine, preceded by symptoms of abscess elseAvhere, as in the pelvis or right iliac fossa (suppurative appendicitis) or perinephritic abscess. The pyuria disappears as abruptly as it came on, or lasts but a few days, lessening gradually until there is a complete cessation. The strongylus gigas in the pelvis of the kidney causes pyuria as Avell as hematuria. Diagnosis.—Pus gives a greenish-yellow or yellowish-Avhite tinge to the urine and sediment, the latter very often becoming very tenacious or jelly-like from the presence of mucus. It may resemble a phosphatic precipitate, as in cystitis; the latter, hoAvever, is Avhite, lighter, more gran- ular, and not so thick or tenacious. Microscopically, a positive diagnosis is made by the discovery of pus-corpuscles (or leukocytes) Avith their granular protoplasm, which has the faculty of clearing up and shoAving one or more nuclei upon the addition of acetic acid. The corpuscles are either more or less swollen and clear, or opaque, granular, or even nucleated, according to their number, the length of time in the urine, and the degree of alkalinity or acidity of the latter. The greater the change in the urine, the more marked the change in the corpuscles. A few phosphatic crystals may be seen, and epithelium more or less cha- racteristic of the seat of suppuration is present. Chemically, there is slight albuminuria, a marked amount of albumin usually indicating renal disease. Nephritis may be diagnosed in con- nection with pyuria by the discovery of casts. On the addition of liquor potassse to urine containing pus the latter is converted into a clear gelatinoid substance; mucus, on the other hand, becomes thin and flocculent. Mucus may also be distinguished from pus by its failure to react to cold nitric acid, whilst the albumin of purulent fluid coagulates. CHYLURIA. Definition.—The presence of chyle in the urine. Etiology.—This interesting condition may be either parasitic or non-parasitic in origin. The former type is more common in the tropics, and is caused by an engorgement and rupture of the bladder or renal lymph-vessels, due to obstruction of the larger branches of the thoracic duct or in the duct itself, by the filaria sanguinis hominis (vide Filaria- 944 DISEASES OF THE URINARY SYSTEM. sis). The latter form, the pathology of which is not definitely knoAvn, is occasionally found in temperate regions. It is held to follow injuries to the lymphatic ducts, and may be associated with pregnancy. Diagnosis.—The urine is increased in quantity, and has a milky turbidity (galacturia) due to the emulsified fat. After standing for a time a light coagulum settles to the bottom and a creamy pellicle of fat rises to the surface. The sediment contains also the fibrin of the chyle. Some- times as much as 2 or 3 per cent, of fat is present (lipuria); this may be tested by agitating a portion of the urine Avith ether, whereupon the turbidity disappears. Owing to the serum-albumin in the chyle, the various tests for that substance Avould show traces of its presence in chyluria, Hematuria may be associated with chyluria, especially in parasitic cases, in Avhich case the blood comes from ruptured veins and tinges the urine accordingly. Microscopically, chyle-containing urine resembles milk in its millions of fine granules and fat-droplets. Prognosis.—Chyluria is intermittent in its appearance, correspond- ing to the times of rupture of the vesical lymphatics, and may last for years. The prognosis of non-parasitic chyluria is good as to life, but unfavorable as to cure. CHOLURIA. Definition.—The presence of bile-pigment in the urine. Etiology.—Choluria may be caused by any disease, local or general, in Avhich jaundice is a symptom. Diagnosis.—Bile-stained urine has a color varying from a green- ish-yellow to a brownish-green or brown-black, resembling porter. When shaken its foam assumes a characteristic yellow or greenish-yellow color. White filter-paper dipped in the urine is stained yellow. Tests.—The chloroform test consists in adding this substance to the urine and allowing it to settle to the bottom of the tube. If bile or pigment be present, the gravitated chloroform Avill be colored yellow. Gmelin's test is most commonly employed, though it is not the most delicate. A feAv drops of urine and nitric acid are allowed to run together on a white porcelain plate; if bile-pigment (bilirubin) be con- tained in the urine, a play of colors ensues, the green predominating, fol- loAved by the blue, violet, and red, each shade representing a new form of pigment. The first color noticed (green) corresponds to the biliver- din or normal bile-pigment of herbaceous animals. This oxidation of bilirubin into biliverdin is better accomplished by nitric acid containing a little nitrous acid. Hence, the test may be improved by adding enough fuming nitric to ordinary nitric acid to form a yellow trace of the nitrous acid. This may be placed in a test-tube or wine-glass, and some of the urine added gently from a pipet. Bile-pigment will be indicated by successive rings of green, blue, violet, and red from above downward; this occurs, however, only when the bile-pigment is present in consider- able quantities. Rosenbach's test is a modification of Gmelin's, and is more distinct. The urine is first filtered, and a drop or two of the nitric-nitrous acid is then poured upon the filter-paper, when the characteristic colored rings will appear if bile be present. According to Penzoldt, the Gmelin- Rosenbach test is made more distinct by acidulating the filtrate with URORILINURIA—GL YCOS URIA. 945 acetic acid and pouring a thin layer into a white shallow dish. The acetic acid assumes a greenish-yelloAV, and later a green, or even a blue- green, shade if bile be in the urine. This reaction is quickened or in- tensified by the application of heat to the liquids. In the 3Iarechal-Rosin test a mixture of one part of the tincture of iodin and ten parts of alcohol is spread in a deep layer over the suspected urine in a test-tube or glass. A grass-green ring forms at the point of contact in choluria. Bile-acids.—These are principally the glycocholic and taurocholic acids. Traces are found in normal urine, and their clinical significance or diagnostic importance, as far as is known, is practically nil. When testing for bile-acids the Stranburger modification of Petten- kofer's method may be used, as follows: " After isolation cane-sugar is added to the extract, which is then filtered. A drop or two of strong sulphuric acid is spread on the dried filter; a violet or purple color appears " (Musser). Other constituents of the urine in choluria of long standing are slight quantities of albumin and icteric or yelloAV bile-stained hyaline or finely-granular casts. A point in differential diagnosis should be noted in connection with the fact that certain drugs, as rhubarb and santonin, when given intern- ally, may produce a discoloration of the urine similar to that caused by the presence of bile. On agitation, however, there will be no yellow foam and no reaction to the tests for bile, while the addition of liquor potassa? causes a red color. UROBILINURIA. Definition.—The presence of pathologic quantities of urobilin in the urine. Urobilin is the principal coloring-matter of the urine, and hence is present in normal urine in small quantity. It is derived from hematoidin or bilirubin as a product of the reduction of these substances in the tissues and blood-vessels. When present in large quantities urobilin gives to the urine a red- brown color. This is seen in fevers, varying in depth of shade accord- ing to the degree of pyrexia; also in diseases of the liver, after hemor- rhagic effusions (due to resorption), in the hemorrhagic diathesis, and in progressive pernicious anemia. When deposited in the tissues it gives rise to a form of jaundice— in Avhich there is a brownish discoloration of the skin—called urobilin- icterus. Diagnosis.—The presence of urobilin is best detected by a spectro- scopic examination. A marked absorption-band betAveen Frauenhofer's lines (f and b), fading off from the green into the blue, is characteristic. Chemically, the addition of a few drops of a watery solution of zinc chlorid to the urine will cause the peculiar red-green fluorescence of urobilin to appear. GLYCOSURIA. Definition.—The presence of sugar (glucose) in the urine. Nor- mally, a trace of sugar is present in the blood (glykemia), but it may be doubted whether any is excreted in the urine in health, except after 60 946 DISEASES OF THE URINARY SYSTEM. the ingestion of an excess of food rich in saccharine or starchy sub- stances. Uric acid may give the same reactions as glucose in the urine. Etiology.—The causes of glycosuria may be enumerated as follows: (1) Diabetes mellitus—the most common. (2) Certain diseases, like gout (intermittent glycosuria), cholera, typhoid, typhus, and scarlet fevers, whooping-cough, diphtheria, malaria (paroxysmal glycosuria), tetanus, phthisis, hepatic cirrhosis, and organic nervous diseases, espe- cially those affecting the medulla and involving the floor of the fourth ventricle. Glycosuria may also result from psychic causes, as excessive mental exertion, extreme emotional activity (grief, Avorry, and shock), from injuries, as cerebral concussion and hemorrhage, and fracture of the skull, from apoplexy, cerebro-spinal meningitis, and after epileptic parox- ysms. (3) Pregnancy. (4) Certain toxic agents cause a transient gly- cosuria, among these being carbon monoxid, morphin, hydrocyanic acid, amyl nitrite, curare, chloral, alcohol, mercury, arsenic, turpentine, phlo- ridzin, and various coal-tar derivatives, as salicylic acid and salol. This source of glycosuria has been experimentally demonstrated in dogs by Paul Gibier of the NeAv York Pasteur Institute. (5) Obesity may cause a temporary glycosuria (lipogenic). (6) Pancreatic disease (chronic in- terstitial pancreatitis and, less commonly, pancreatic calculi, carcinoma, and cysts). (7) Glycosuria may occur in exophthalmic goiter, and, ac- cording to Lyman, may be present for a short time in (8) diabetes insip- idus. (9) Heredity probably plays a part in predisposing to glycosuria in certain cases, particularly in the permanent affection. (10) Dietetic glycosuria may at times be noted. Diagnosis.—The daily quantity of the urine of typical glycosuria— i. e. when masking saccharine diabetes—is greatly increased (60 fluid- ounces—2 liters—and over per diem); it is of high specific gravity (1025 and over), of a clear, pale-yellow color, a "ripe-fruit" odor, a sweetish taste, and an acid reaction that is intensified on standing, owing to the fermentation of the sugar. Albuminuria is not infrequently associated Avith glycosuria, and the albumin should be removed before testing de- cisively for sugar. Again, since urine of high color, heavy density, and marked acidity often contains uric acid, and since this substance, as already pointed out, responds to the sugar tests, care must be exercised lest a false conclusion be drawn. Tests.—The most important of these depend mainly upon the pe- culiar property of glucose in reducing the blue oxid of copper to the orange or red suboxid. It must be remembered that other metallic sub- stances are similarly decomposed. (1) Fehling's Test.—Two solutions are used, equal parts being mixed to form the Fehling's solution, as folloAvs : Solution I. contains 34.64 gm. of cupric sulphate, dissolved in enough water to make 500 c.cm. Solution II.: 173 gm. of Rochelle salt are dissolved in 480 c.cm. of sodium hydroxid (sp. gr. 1.14); this is then diluted with water up to 500 c.c. Application: Dilute 1 c.c. of Fehling's solution (about 10 drops of each of the above solutions) Avith about 1 dram (4 c.c.) of water in a test-tube, and heat to the boiling-point. If the clear blue color re- mains, the solution is ready for use; should it change color, however, the solution is unfit for use and should be discarded. The suspected GLYCOSURIA. 947 urine is added, drop by drop, heating occasionally, when, if glucose be present, the blue color will be discharged by a yellow turbidity, which increases until finally a deep-yelloAv or orange red precipitate falls. Bluish-white flakes and a greenish discoloration of the mixture simply indicate cupric hydroxid, and not glucose. This test serves for the detection of .001 per cent, of glucose (Wormley). (2) Trommers Test.—To about 5 c.c. of urine in the tube add one-third or one-half its volume of potassium or sodium hydroxid, and then, drop by drop, add a 10 per cent, solution of cupric sul- phate. If a bluish-white precipitate falls, either filter or agitate the liquid until it assumes a slight and uniform turbidity ; then heat, and, if sugar be present, a yelloAV or red deposit of cuprous oxid falls: .01 per cent, of glucose may be detected in this way. Besides uric acid, there are certain other substances Avhich Avhen present in urine make the copper tests fallacious by reducing the cupric to cuprous oxid. Among these are mucin, lactose, pyrocatechin, hydrochinon, bile-pigments, glycosuric acid, the products of elimina- tion after the ingestion of chloral (urochloric acid), and benzoic and salicylic acids. (3) Bottger's Bismuth Test.—This may be performed as a counter to the copper tests. Albumin, however, interferes Avith the test on account of the contained sulphur, which forms a black bismuth sulphid : hence, if present, it must first be removed. This may be done by acidulating the urine with acetic or nitric acid, boiling, and then filtering. Bott- ger's test is then made by adding to the non-albuminous urine or to the filtrate from one-half to an equal quantity of liquor potassae and a few grains of .bismuth subnitrate. Boil for several minutes, and if glucose be present black metallic bismuth will be precipitated. (4) Nylander's reagent may be employed. This consists of 2 parts of basic bismuth nitrate and 4 parts of sodium tartrate to 100 parts of an 8 per cent, solution of caustic soda. One part of the reagent is boiled Avith 10 parts of the urine for a feAv minutes, when a change from the original to a broAvn or black color will indicate the presence of glu- cose. This test is quite distinct, but has the fallacy that is common to all the bismuth tests, of forming a black precipitate with the sulphur compounds. (5) Fermentation Test.—Though not ahvays convenient to apply, this is, nevertheless, a most reliable test. It depends upon the action of yeast in breaking up glucose into alcohol and carbonic-acid gas (carbon dioxid). It is performed easily by adding a small piece of compressed yeast to the urine in a test-tube, inverting the latter in a dish of the same, and standing aside for tAvelve to twenty-four hours, the temper- ature being kept at about 80° to 100° F. (26.6°-37.7° C). The evo- lution of gas resulting from the fermentation of the sugar takes place, with a consequent reduction of the specific gravity of the urine. The yeast may be tested simultaneously for its purity and strength by pla- cing one portion in a test-tube containing about two-thirds mercury and filling Avith normal urine, and a similar portion in a second tube with mercury and a thin, watery solution of sugar or glucose; the fermenta- tion test of the suspected urine may be made at the same time, and all three tubes inverted over a dish of mercury. Obviously, the first 948 DISEASES OF THE URINARY SYSTEM. tube should not shoAV the presence of carbon dioxid if the yeast Avas free from sugar ; but the second tube should show this gas to be present or the yeast was inert. Other tests, such as Moore's liquor-potasscv-and-boiling test, Johnson's picric-acid test, and the phenyl-hydrazin test, are more intricate and in no Avay more reliable. The quantitative estimation of sugar may be made Avith Fehling's solution in two parts, as recommended above for the qualitative test. This method is based upon the fact that the cupric oxid of 1 c.c. of Fehling's solution will be reduced by not less than 0.005 gm. of glucose. Place 1 c.c. of the solution in a test-tube and dilute Avith 4 c.c. of water (5 c.c. dil. sol.). Heat to the boiling-point, and add 1 c.c. of urine, and heat the liquid again. If reduction has taken place, 0.005 gm.—0.5 per cent, or more—glucose is present; if no reduction has occurred, less than 0.5 per cent, is present. If 2 c.c. urine are used before the color of the Fehling solution is discharged, there will be 0.25 per cent, glucose. If J c.c. is used, 1 per cent, is present. If Y1^ c.c. urine is all that is required (about 2 drops), then 5.0 per cent, of glucose is present. , Roberts' differential-density method depends upon a loss in the specific gravity of the urine, due to the fermentation of glucose. Ac- cording to Roberts, each degree in specific gravity lost is equivalent to 1 grain of glucose in 1 imperial fluidounce (437.5 gr.) of urine, or one degree represents 0.23 per cent, glucose. (See works on Urinalysis.) Circumpolarization.—Finally, sugar may be determined by the sac- charimeter or polariscope. Glucose polarizes light to the right. The percentage may be calculated by reading the vernier scale indipating the degree of reflection, and multiplying the number read by the factor of the apparatus used, after making any required corrections. ACETONURIA, DIACETONURIA, AND OXYBUTYRIA. Acetonuna, diacetonuria, and oxybutyria are so closely allied with glycosuria, and especially with diabetic coma (acetonemia), that they may be considered together. In the first-named condition the urine contains acetone; in the second, diacetic or aceto-acetic acid; and in the last, oxybutyric acid. Diacetic and oxybutyric acids are products of the decomposition of acetone, and hence the importance previously ascribed to the latter, Avhen detected in the urine of diabetics, has given place to the tAvo former, the oxidation of which yield acetone. Acetonuria may exist to a minute degree in health, the acetone being a product of the normal metamorphosis of albumin. It may be present also in—(1) diabetes ; (2) carcinoma; (3) febrile conditions; (4) inanition; (5) psychoses; and (6) auto-intoxication. Urine that con- tains acetone in pathologic quantities has a fruity (apple-like) odor or one resembling that of chloroform. Tests.—(1) Gerhardt's original test consisted in the addition of a few drops of the tincture of the chlorid of iron, which produced a Burgundy- red color with acetone, or rather with the aceto-acetic acid. (2) Nitro-prussid Test.—To a fluidounce (32.0) of the urine add a dram or two (4.0-8.0) of a solution of sodium nitro-prussid (gr. v. to 3j LITHURIA. 949 —0.324 to 32.0) and a few drops of strong aqua ammoniae. On stand- ing a rose-violet color appears. According to Legal, proportionately smaller quantities of urine and the reagent may be used, and strong liquor potassae. A bright-red color develops, and fades rapidly, but upon adding acetic acid this changes to purple or violet-red (Vierordt). This is a better test. (3) Perhaps the most accurate and, at the same time, satisfactory test for acetone is the following : Distil the urine Avith a little phosphoric acid, and add to the distillate a feAv drops of sodium hydroxid and of Lugol's solution. If acetone be present, yellow crystals of iodoform will form, Avith the characteristic odor. Diacetonuria and oxybutyria never occur normally. They are often associated Avith acetonuria in diabetes, and sometimes in fever, or occur as an independent disease (V. Jaksch). Moreover, it is believed that diacetic and oxybutyric acids are the causes of diabetic coma, and not acetone, as was held formerly. Stadelmann affirms that of like value Avith the recognition of oxybutyric acid in diabetes is the deter- mination of a marked and increasing amount of ammonia in the urine (1 gram—gr. xa7—and more per diem), as indicating the imminence of diabetic coma. Diacetonuria is found to occur in certain acute diseases of children, accompanied Avith convulsions. Tests.—The presence of diacetic acid is demonstrated by the chlorid- of-iron reaction, as in the case of acetone, except that the urine is boiled previously. This is done to avoid fallacy, since in unboiled urine acetic, formic, and oxybutyric acids may strike a Burgundy-red also; in urine that has been previously boiled these do not react, while the diacetic acid does, if present. Diacetic acid is usually present simultaneously with acetone. If a portion of the urine is mixed Avith sulphuric acid and extracted wTith ether, diacetic acid may be inferred to be present if the extract shoAvs a chlorid-of-iron reaction that fades Avithin tAventy- four hours (V. Jaksch). LITHURIA. Definition.—A persistent excess of uric (lithic) acid and urates (lithates) in the urine. Normal urine contains about 0.4 part of uric acid to 1000 parts of urine (about gr. x—0.648—per diem), or it exists in the proportion of about 1 to 45 of urea, the principal solid constituent. The evidence of recent experimentation is in favor of the vieAv that uric acid is derived wholly or almost wholly from a metabolic solution of leukocytes and nuclear substances generally, and that uric-acid formation is not to be regarded as an "unfinished product" in the old sense. Etiology.—The causes of lithuria, as seen in certain conditions in which this metabolic change occurs, may be put down to be chiefly as follows: (1) Lithemia (uricemia; uric- or lithic-acid or gouty diathesis); (2) gout and rheumatism; (3) fever; (4) leukemia and pernicious an- emia ; (5) pulmonary affections in which the interchange of gases is in- terfered with ; (6) a highly nitrogenous diet. Certain other conditions of the urine may diminish its power of dissolving the uric acid shortly after voidance, and may cause a deposit that should not be mistaken for 950 DISEASES OF THE URINARY SYSTEM. an excess. Such are—(a) temporary increase in the quantity of uric aoid from an over-indulgence in nitrogenous food; (b) temporary high acidity; (c) deficiency in mineral salts. Diagnosis.—The urine has a high specific gravity, a deep red-yel- low color, and a marked acid reaction, although, rarely, uric acid is formed in neutral or alkaline urine (Vierordt). On standing the uric acid is deposited in yelloAvish-red or "Cayenne pepper" grains, com- posed of microscopic uric-acid crystals. Chemically pure uric acid is colorless, but that deposited from urine has ahvays this yellowish-red appearance both to the naked eye and under the microscope. Exami- nation Avith the latter shows a great variety of rhombic prisms—" whet- stone-shaped," "crosses," "lozenges," and other many-shaped and sized crystals—single and in agglomerations. Test.—The murexid reaction may be obtained by evaporating a little urine in a watch-glass or porcelain dish, adding a few drops of strong nitric acid, and heating to dryness again; this is alloAved to cool, and a drop of liquor ammonias added, when a beautiful purple shade of murexid will appear if uric acid be present. Urates.—These are increased in pathologic conditions that give rise to uric acid in excess, and are usually present with the latter in some quantity. It is not rare, however, in healthy individuals for a deposit of urates to occur in concentrated urine exposed to a cool atmosphere. Urates appear also in the scanty urine due to the profuse perspiration and diarrhea of renal congestion, in fever, from renal calculi, and after a meal rich in albuminous elements. Urates occur principally as acid sodium urate, calcium urate, and ammonium urate. They appear macroscopically as a flesh-colored or "brick-dust" (lateritious) sediment; this is usually abundant and very finely granular in appearance, while the urine above is cloudy. It is quite characteristic that upon heating such urine it becomes clear, the urates being completely dissolved. Microscopically, the sodium and calcium salts of uric acid occur as needle- or dumb-bell-like crystals or as fine, dark, amorphous granules. Ammonium urate is found in alka- line urine, often Avith triple phosphates Avhen some putrescence has en- sued. It is seen in dark-brown or green spiculated spherules; these are sometimes called "hedge-hog" or "thorn-apple" crystals. On the addition of a drop of hydrochloric acid under the cover-glass uric-acid crystals may be seen to develop. OXALURIA. Definition.—A persistent excess of calcium oxalate in the urine. A feAv crystals may occur in normal urine that has been standing for a long time. Transient oxaluria may folloAV the ingestion of sub-acid fruits, as pears, or of vegetables containing oxalates, as rhubarb, tomatoes, sorrel, and caulifloAver. Oxaluria has been described by some English physicians as an inde- pendent disease or special diathesis in which marked dyspepsia and hypochondriasis or neurasthenia are associated. The condition is better explained, probably, as one of a disturbed metabolism—particularly of PHOSPHATURIA. 951 the fats and carbohydrates—in which the oxaluria and the nervous symptoms are manifestations analogous to the lithuria and the irregular gouty symptoms of lithemia. Oxalates and lithates are not infrequently found together in the urine of those subject to the gouty habit. Oxa- luria is also present in wasting diseases, as in tuberculosis, diabetes mellitus, and in the cancerous cachexia; it may appear in catarrhal jaun- dice, spermatorrhea, also with the "mulberry calculi," and in general paresis of the insane. Diagnosis.—Oxalate-of-lime crystals appear in the urine in two forms—most commonly as minute, regular, highly-refracting octahedra, or, more rarely, as hour-glass- and dumb-bell-shaped crystals. The octahedral crystals have two crossed axes, giving a star or enve- lope-like appearance. Oxalates sometimes give a glittering and scintil- lating effect to floating mucus in urine that has undergone fermentation. PHOSPHATURIA. Definition.—A persistent excess of phosphates in the urine. Phosphoric-acid salts may be precipitated in normal urine that has become temporarily alkaline. These acid sodium and potassium phos- phates in normal acid urine are derived from the alkaline phosphates (neutral sodium and potassium phosphates) of the blood. In normal urine 1.2 parts alkaline phosphates per 1000 and 0.8 part earthy phos- phates are appreciable. Conditions that produce an alkaline fermentation of the urine cause a deposit either of amorphous earthy phosphates or of crystalline phos- phates. They are also found in the decomposing urine of chronic cys- titis, of phosphatic vesical calculi, of paralysis, and in undue retention of urine. In this alkalinity, due to the ammoniacal fermentation of urea, ammonium carbonate reacts with the phosphates of magnesium to form the triple ammonio-magnesia phosphatic crystals, the commonest variety of phosphaturia. Here the phosphates are deposited before or immediately after the urine is passed, giving a milky appearance to the last portion. Deposits of phosphates, and especially of triple phos- phates, by no means, however, indicate an actual phosphaturia. This must be determined by chemical analysis. Amorphous carbonate of lime in small quantity may be present also if the urine is strongly alkaline and ammoniacal (Beale). The calcium phosphates are generally more abundant than the magnesian, and may be found in cases of ner- vous or atonic dyspepsia, neurasthenia, melancholia, and other debili- tated conditions. Whether or not a marked precipitate of phosphates means an excess to the detriment of nervous tissue alone has not been determined precisely as yet. Obviously, however, a certain portion of phosphates is supplied by food and the rest of the body, owing to defec- tive assimilation and metabolism. A quantitative estimation of the daily output of phosphates shows a decided increase in the quantity in wasting diseases, as tuberculosis, leukemia, chronic articular rheumatism, and acute yelloAV atrophy of the liver. The phosphoric acid is not increased, however. The so-called "phosphatic diabetes" is characterized by polyuria, excessive phospha- turia, thirst, emaciation, and nervous disturbances (Tessier). 952 DISEASES OF THE URINARY SYSTEM. Diagnosis.—Phosphatic urine has usually a stale, ammoniacal odor, a Avhitish turbidity, and a copious light-colored granular sediment falls on standing. Microscopically, the calcium phosphate crystals ap- pear singly as " knife-blade," " arrow-head," or " slender wedge-shape," or in stellate clusters. Acetic acid dissolves them. The ammonio-mag- nesian phosphate crystals are transparent rhombic or triangular prisms, large and small—" coffin-lid-shaped." These also are soluble in acetic acid ; oxalate-of-lime crystals are not so. On heating phosphatic urine an increased cloudiness is produced that simulates albumin, but on acidifying, as with a drop of nitric acid, this is cleared up at once. LEUCINURIA AND TYROSINURIA. Definition.—The presence of leucin and tyrosin in the urine. These are strictly pathologic substances, and are usually found together. They are products of the decomposition of albumin, intermediary to the formation of urea, and are most apt to be found in the urine, along with biliary matters, in certain hepatic conditions. Etiology.—The principal causes of leucinuria and tyrosinuria are acute yelloAV atrophy of the liver, acute phosphorus-poisoning (in both of which fatty degeneration of the liver is pathologically conspicuous), specific infectious diseases, as typhoid fever, small-pox, and yelloAV fever, and pernicious anemia. Diagnosis.—Of the tAvo substances, leucin is the more soluble, and hence is rarely found in the urinary sediment. Tyrosin, on the other hand, may be discovered sometimes as a fine greenish-yelloAv deposit. Bile-pigment may be found not infrequently in urine containing leucin and tyrosin. A trace of albumin also may be present, while the urea is, as a rule, markedly diminished. Leucin and tyrosin may be de- tected by evaporating a few drops of urine on a glass slide and examin- ing microscopically. Leucin appears in the form of slightly glistening, greenish-yellow spheres that may show radiating lines and concentric rings. Tyrosin is recognized by the slender tufts of fine, needle-like crystals arranged in star- or cross-like fashion. If the residuum after evaporation be heated Avith a drop of nitric acid, slowly evaporated to dryness, and then touched Avith a drop of sodium hydroxid, the leucin, if present, will assume a yellowish-brown hue. Tyrosin becomes red in color when boiled with Millon's reagent of mercurous nitrate, or it is demonstrated by a violet color Avhen carefully warmed with a little sulphuric acid, and then treated Avith a drop of the solution of phenic chlorid. CYSTINURIA. Definition.—The presence of an excess of cystin in the urine. Cystin in minute quantity may be found sometimes in normal urine. It contains sulphur. The causes of cystinuria have not been well made out, though hereditary influences seem to have an important bearing on the etiology ; in Avhat manner they act, however, is not known. On account of the insolubility of cystin any marked quantity would be deposited in UREA IN URINE. 953 the urine. Cystin calculi sometimes result, though cystinuria may ex- ist without the presence of a cystin calculus. Brieger points out a probable significance in the discovery of the associated presence of ptomains with cystinuria. Thus, in certain infec- tious diseases, as intestinal mycosis, a ptomain-cystinic product is sup- posed to be formed, then to be absorbed, and finally decomposed in the urine, thus setting free the cystin. Cystitis may be caused by the action of the ptomains. Diagnosis.—The sediment is light, and not very unlike that of the amorphous urates. It is not dissolved by heat, however, though soluble in ammonia. Under the microscope cystin occurs in the form of thin, transparent, hexagonal crystals. Care should be exercised in forming a diagnosis of cystinuria that a contamination with iodoform be excluded, since the microscopic appearance of that substance is similar to that of cystin. On account of the sulphur contained in cystin, a test may be employed by Avhich hydrogen sulphid is liberated, as by boiling the sus- pected urine with a solution of lead oxid and sodium hydroxid, black lead sulphid resulting from the reaction if cystin be present. VARIOUS OTHER CONDITIONS. Urea.—This occurs in solution in the normal urine as a product of the perfect decomposition of the nitrogenous elements of food and tis- sues. In 1000 parts of urine about 20 parts are constituted of urea (2 per cent, equh-alent to about gr. 450—30.0—daily). The quantity of urea is increased in the urine after the ingestion of a considerable quan- tity of proteid food ; sometimes after exertion; in acute inflammation and in fevers—either relatively or absolutely, as in pneumonitis; in diabetes and other morbid conditions in which metabolism is accom- panied by an increase in the tissue-waste. In febrile states its excretion increases or diminishes with the exacerbations and remissions of tem- perature respectively. Urea is pathologically diminished in quantity in all forms of nephri- tis, and markedly so in uremia ; in organic liver-diseases, as acute yellow atrophy; in cachectic and anemic states; and in dropsy, inanition, and allied conditions. The quantitative estimation of urea may be made according to one or more of several methods : Fowler's hypochlorite test (with Labarraque's solution) is perhaps the most practical for ordinary clinical purposes; the hypobromite and Liebig's methods, both requiring special apparatus, are better adapted for the laboratory.1 Fowler's method is based upon the loss of specific gravity upon the liberation of the nitrogen of the urea. The mean specific gravity of a mixture of 1 part of urine and 7 parts of the solution of sodium hypochlorite is taken Avhile quiescent, and is then subtracted from the specific gravity of the mixture taken after agitation several times during about two hours. The difference which is due to the liberation of the nitrogen (as is shown by the effer- vescence), multiplied by the factor 0.77, gives the approximate percent- age of urea in the urine. This test, however, has a considerable range of error. See works on Urinalysis. 954 DISEASES OF THE URINARY SYSTEM. Urine evaporated to a syrupy consistence and then treated Avith nitric acid shoAvs crystalline quadratic plates of urea nitrate. Chlorids.—About 10 parts of the chlorids of sodium and potassium in 1000 parts of urine are excreted daily. They are increased in the urine after muscular exertion, during the resorption of mechanical or inflammatory transudations and exudations, and in intermittent fevers, OAving to the destruction of the red corpuscles. Pathologic diminution in the quantity of chlorids occurs in fevers, in the nephritides, in cachectic conditions, and especially in such diseases as pneumonitis, pleuritis, and rheumatism. In the last-named class the chlorids diminish as exudation continues, and may even totally disap- pear from the urine in extensive pneumonic consolidations, to reappear again Avith the resorption of the exudate. Test.—The chlorids may be detected, after first removing any albu- min that may be present, by acidulating with a few drops of nitric acid (to keep the phosphates in solution), and by then adding, drop by drop, a strong solution of argentic nitrate. According to the abundance of the resultant white, curdy precipitate of argentic chlorid a rough esti- mate may be made of the total quantity of chlorids in the urine. Lipuria is a term applied to the presence of fat in the urine. It may result from the steady use of cod-liver oil or of fatty food, or it may be found in pyonephrosis (Ebstein); in phosphorus-poisoning; in pro- longed suppuration; in the lipemia of diabetes mellitus; in the "large white kidney" with fatty degeneration of chronic Bright's disease; in beer-drinkers ; and in chyluria. Fatty urine becomes clear upon agitat- ing after the addition of ether. Lipaciduria, or urine containing volatile fatty acids (acetic, butyric, and propionic), is as yet without diagnostic significance. Melanuria, or urine containing the pigment melanin, is found in cases of melanotic sarcoma. The urine is dark, either just after being voided or after some exposure and oxidation. Hematoporphyrinuria (Urospectrin).—This term implies the presence of hematoporphyrin (iron-free hematin) in the urine. It occurs after long-continued use (even in small doses—Miiller) of certain coal-tar products, particularly sulfonal and trional. Among the symptoms in poisoning from these substances is a cherry-colored or dark blue-red urine, the abnormal appearance of the latter being due to the presence of hematoporphyrin resulting from the destruction of the red blood-cor- puscles. The urine is always quite acid. According to Garod, hemato- porphyrin is a scanty though constant ingredient of normal urine. He extracts it by adding 100 c.cm. of urine to 20 c.cm. of a 10 per cent, solu- tion of sodium hydroxid. This precipitates the phosphates, which are Avashed Avith water and redissolved with rectified spirits. After acidula- tion Avith hydrochloric acid the solution shoAvs spectroscopically bands of acid hematoporphyrin. The treatment consists in the prompt with- drawal of these drugs and the free administration of alkalies. Pneumatinuria, or gas-formation in the bladder, rarely occurs. Heyse' records a case of myelitis in which this condition was present. Fibrinuria.—In certain conditions of the genito-urinary tract, partic- 1 Zeit.f. klin. Med., 1894, xxiv. p. 130, quoted in The American Year-Book of Medicine and Surgery for 1896. THE NEPHRITIDES. 955 ularly pyelitis and ureteritis, fibrinous (and mucous) casts are found in the urine. Fibrinuria may follow nephro-lithiasis, as in a case recorded by v. Jaksch. Bacterinuria.—There are probably few specimens of urine that do not contain bacteria. Engel has found a great variety of organisms in the nephritides, one of which (a micrococcus of characteristic growth and properties) was present in 17 out of 31 cases, hence regarded by him as the specific cause of some of the cases in this category of diseases. This organism was found in mild types of nephritis, and Engel believes it to be responsible for many instances of the sort beginning as mild forms of " bacterial albuminuria." Lactosuria.—Lactose is found in the urine of some puerperse. Inosituria.—Inosite occurs in the urine in diabetes insipidus. Alkaptonuria.—Alkaptone is an obscure substance (so called by Bredeker) that is sometimes found in the urine of phthisical cases, or at times in that of patients Avithout any apparent local or general dis- ease. On exposure the urine darkens in color; also upon the addition of liquor potassae. It gives the sugar-reaction Avith Fehling's solution (Osier). Urine as affected by the administration of various drugs—as carbolic acid, salol, antipyrin, and potassium iodid—responds to certain chemical tests, for the study of Avhich the reader is referred to works on urinal- ysis and clinical diagnosis. THE NEPHRITIDES. Befoke considering the several varieties of nephritis, and especially the clinical history peculiar to each variety, it may be well to first de- scribe certain general manifestations of renal disease—Avhether degen- erative, exudative, or productive lesions are predominant—that are more or less common to all. Reference to these symptoms under the different forms of nephritis will, it is hoped, thus make possible a clearer appre- hension of their significance and value, as well as render unnecessary any further elaboration. One of these pathologic conditions has already been described—viz. (1) Albuminuria. It remains, then, to speak of (2) the Morphologic constituents of the urine in nephritis, (3) Edema (anasarca, dropsy), and (4) Uremia. THE MORPHOLOGIC CONSTITUENTS OP THE URINE IN RENAL DISEASE : CASTS, EPITHELIUM, ETC. 1. Tube-casts.—These are undoubtedly the most important morpho- logic elements in the urine of a nephritic. Albuminuria is coincident- ally present, and the occurrence together of these two pathologic con- stituents furnishes indisputable evidence of renal disease. According to the nature and quantity of the casts also may be determined the cha- racter and variety of the affection of the kidneys in most instances. Casts, as their name implies, are simply cylindric bodies moulded in 956 DISEASES OF THE URINARY SYSTEM. the renal tubules, and composed essentially of the coagulable substances in the serum exuded from the blood-vessels. The coagula of the tubules are mostly albuminous. Other morphologic elements may be mixed Avith casts, such as epithelium, red blood-cells, pus-cells, and the granu- lar matter and fat-droplets due to degeneration of the renal epithelium. Singly, the casts are invisible to the naked eye, but in acute nephritis they may be so abundant as to form a cloudy sediment near the bottom of the urine-containing glass. (a) Microscopically, the unmixed or hyaline cast—the commonest— appears either long or short and narroAv or broad, of a clear, transparent, homogeneous substance, delicate in outline, and often showing ends with a cheesy—or wax-like—fracture. They may be straight or slightly curved and tortuous, Avith fine short transverse lines here and there at the borders of the cast. Rarely, a cast may be found equal to a milli- meter in length. The so-called narrow casts are about equal in width to the diameter of a leukocyte, while the medium or broad casts are from three to four times this size. They will take either the carmin or gentian-violet stain. Hyaline casts are usually associated with other varieties of casts in nephritis, though in fevers, congestion of the kid- neys, chronic interstitial nephritis, and in amyloid kidney they may occur unassociated with other forms of casts (Vierordt). (b) Granular casts are nothing more than hyaline casts with fine or coarse granules superadded. The granules represent minute, opaque particles of urates, albumin, fat, cellular debris, and even bacteria (bacterial casts). It should be remembered, however, that granular casts may be simulated by casts of coagulated albumin covered Avith particles of hematoidin, especially in acute nephritis. The hematoidin can be recognized, hoAvever, by the broAvn-yellow coloration. (c) Epithelial casts are hyaline casts covered with renal epithelium, or composed entirely of an epithelial conglomeration, indicating an acute desquamative nephritis. The opaque, spheric renal cells should not be confounded with swollen leukocytes. Again, the epithelial cells themselves may show evidence of granular or fatty change. (d) Blood-casts consist of coagula of red corpuscles shaped in the renal tubules, or they may be composed of soft hyaline (mucous) casts, having red blood-cells imbedded in them. These are present in renal hemorrhage and in acute hemorrhagic nephritis. (e) Waxy casts are similar in appearance to hyaline casts, though better defined, broader as a rule, and of an opaque, slightly yelloAvish tint. They often show broken ends. It has been suggested that they may be the products of a metamorphosis of hyaline casts because of their occurrence in various forms of nephritis, and since they do not merely indicate amyloid disease of the kidney as Avas formerly held. They may, hoAvever, sometimes show the amyloid reaction with iodin and potassium iodid, and are always suggestive of serious renal disease. (/) Fatty casts are such as have left upon and in them fat-droplets or granules, which, if abundant, are indicative of fatty degeneration of the kidney. Cells shoAving granulation from fatty change may be seen simultaneously. Rolled casts (made by sliding a cover-glass over a specimen of urine) of urates, cells, and debris should not be mistaken by beginners for DROPSY OF RENAL DISEASE. 957 genuine tube-casts. The same may be said of mucous cylindroids and foreign substances. Nephritis may exist when the casts are ahvays to be found, varying in numbers only, Avhile albuminuria may be incon- stant or intermittent. 2. Epithelium.—Renal cells are found in the urine of those forms of nephritis that are characterized by a catarrhal or desquamative and exudative process in the tubules. Epithelial cells from the kidney are polygonal or spheric in contour, Avith an indistinct cell-Avail; they have a large oval nucleus, and are either abundantly granular or show a fatty change. These cells are about the size of the white corpuscle. 3. Leukocytes.—Only Avhen attached to casts can it be positively affirmed that leukocytes are of renal origin (Striimpell). 4. Red Blood-corpuscles (vide Hematuria, p. 934).—In acute hem- orrhagic nephritis and in severe renal congestion free red blood-cor- puscles are generally to be found. 5. Fat-globules and granular, fatty-degenerated cells are seen espe- cially in the subacute and chronic forms of nephritis Avith fatty degen- eration of the proliferated epithelium, or in the fatty stage of large white kidney. DROPSY OF RENAL DISEASE. Since, as in other conditions, renal dropsy or edema is an abnormal accumulation of watery fluid transuded from the blood-vessels into the cellular tissues and lymph-spaces, the question arises, " What is the rationale of its development in nephritis ? " On the ground that the renal secretion consists principally of Avater, and that in most forms of nephritis the urine is diminished, it was formerly held that the dropsy was due to the saturation of the tissues Avith the Avater that Avas not excreted by the kidneys. This theory is not fully tenable, hoAvever, for there are some cases of edema unaccompanied by any diminution in the daily quantity of urine; on the other hand, certain instances of renal disease in Avhich there is a state of almost anuria show no evidence of dropsy whatever. Indeed, it has been suggested (Striimpell) that edema is the cause rather than the result of a diminished elimination of water by the kidneys, this vieAv corresponding in part with Cohnheim's assertion that the increased transudation is due to changes in or injury to the endothelium, increasing the perviousness of the blood-vessels. The failure of any one theory as advanced above to explain the etiology and pathology of edema has justified the proposal of another and un- doubtedly a more plausible one by Landerer—viz. that the relaxation of the tissues (Avhich may be caused by the increased transudation of stasis, or by hyponutrition from hydremia), and their consequent loss of elas- ticity, prevent that forcing of the lymph into circulation that exists in the normal state, and as a result a watery infiltration of the tissues is permitted. The loss of elasticity or power of resistance in edematous tissues is quite apparent under the skin, and affords a positive means of diagnosis in the pitting produced by the pressing finger. The dropsy of the nephritides may be either slight or marked, local or general (anasarca), and sudden or slow in onset. It is purely renal in origin perhaps only in acute Bright's disease or in the earlier stages of chronic Bright's disease. In all forms of chronic nephritis the dropsy 958 DISEASES OF THE URINARY SYSTEM. may be due, in part, to the venous stasis of cardiac incompetency. In chronic interstitial nephritis, especially, edema is slight, and usually is the result of weakness and dilatation of the heart, increasing pari passu Avith the latter. Mention may be made here of those rare cases of dropsy that simulate Bright's disease in which no satisfactory causative lesion is apparent or discoverable, and also of those cases, rarer still perhaps, that have a peculiar family or congenital origin. The recognition of edema is made possible both by inspection and palpation. Renal dropsy is manifested first by puffiness of the skin of the face, and especially of the eyelids. At other places Avhere there is loose subcutaneous cellular tissue, and in particular where the parts are dependent, dropsy is most apt to be seen early, as under the malleoli of the ankles, the dorsum of the foot, and the scrotum. Later, the limbs and the lower part of the back become swollen, and even the whole body is involved in severe cases. The skin has a peculiar waxy pallor and a glossy appearance. When evident vascular or cardiac changes exist, so as to permit of increased dropsy from engorgement, as in cirrhotic kidney, a cyanotic or muddy color of the skin may prevail. Dropsy is most constant and most persistently decided in the large Avhite kidney of subacute or chronic nephritis; it is most uncommon and irregular in chronic interstitial nephritis (red granular and contracted kidney). The familiar pitting on pressure over edematous tissues is a true indication of fluid under the skin. There is also a doughy or putty- like consistence.- In very marked cases of dropsy the deeper parts, such as the muscles, become affected. The serous cavities also in general anasarca show evidences of effusion, and thus give rise to hydro-thorax, hydro-peritoneum, and hydro-pericardium. Less frequently there may be edema of the larynx, uvula, conjunctiva, and other mucous membranes. Edema of the brain, either local or general, may be the cause of grave uremic symptoms in chronic nephritis, or of unilateral convulsions or paralysis and apoplectic seizures. The dropsical liquid is chemically similar to a diluted blood-serum. A minute quantity of albumin and urea is present. UREMIA. Definition.—Uremia is the term applied to a group of manifestations, mainly nervous and either acute or chronic, resulting from a toxemia due to the retention in the body of certain products of urinary or renal origin. Strictly speaking, uremia means simply blood containing excrementitious urinary substances. Although most common in Bright's disease, uremia may arise also in other diseases, as in gout (gouty kidney), scarlet fever (scarlatinal nephri- tis), typhus fever, yellow fever, and cholera, in which the kidneys and blood may be seriously affected. Kidneys Avhich, on account of marked structural changes, fail to eliminate the normal quantity of urates and solid constituents are directly or indirectly responsible for an association of the morbid conditions knoAvn as uremia. Our present knowledge of the pathology and etiology of uremia, as of renal edema, is based solely upon theoretic vieAvs. The theory that attributes uremic symptoms to the retention of the excretory prod- UREMIA. 959 ucts appears to have the strongest proofs to support it; but the positive nature of these substances, or which is the most toxic, or Avhether several are concerned in the causation or not, remains to be determined. Since the urea and uric acid have been found in increased quantities in the blood of uremic patients, and since these products are diminished in the urine of nephritis, they also were at first supposed to be the cause. Am- monium carbonate, it was alleged by Frerichs, operated in the same man- ner after it accumulated in the blood in sufficient quantity as a result of the decomposition of the urea by a ferment. Not only some of the solid urinary constituents accumulate in the blood in uremia, but the water also is only partly eliminated, and its presence in the blood renders the latter hydremic and of lower specific gravity. It is true, hoAvever, that, notwithstanding the fact that most cases of uremia may be traced to a marked simultaneous diminution in the quantity of urine passed, there remain still certain instances of renal disease in which uremic symptoms appear without any perceptible dimi- nution of the urinary secretion. Again, and even more frequent perhaps, are those perplexing cases of anuria noAv and then reported in which no uremic symptoms appear. In the latter instances it is probable that the elimination of products normally excreted by the kidneys may be accom- plished through other channels, as by the skin and bowels ; in the for- mer it is still likely that the solid urinary constituents are retained, even with an undiminished quantity of water excreted. Traube's theory of the cause of uremia, particularly of the nervous or cerebral manifestations, was that it is an acute edema of the brain—local or general—with cerebral anemia. This Avould seem to explain certain cases of nephritis, as already mentioned, in Avhich a fair amount of urine and solid constituents is passed ; also cases of anuria due to urethral ob- struction in which no uremic symptoms appear; and certain cerebral disturbances. But with our present knoAvledge of the chemico-pathology and of the clinical cause of the uremia of nephritis in all its forms there seems to be no doubt that most cases are caused by the toxemia produced by the retention of the mass of excrementitious substances that is due to an abatement of the renal functions. Delafield, however, attributes the sudden violent motor symptoms of acute uremia to a contraction of the arteries from some unknown cause other than blood-contamination. The Symptoms of uremia may be either acute or chronic in onset, severity, and course. In acute uremia the severest nervous symptoms come on suddenly; they last but a comparatively short time, and termi- nate fatally, with convulsions and coma, dyspnea, feeble cardiac action and pulse, fever, and pulmonary edema. These acute symptoms, however, are not infrequently preceded by mild uremic prodromes, as headache, somno- lence, nausea, malaise, slight dyspnea, and uneasiness. Chronic uremia is characterized by the absence of the marked symp- toms referred to above, the milder manifestations alone appearing and lasting over a considerable length of time. Here the general prostration, the feeble cardiac and arterial states, the occasional stupor and delirium, transient dimness of vision, anorexia and nausea, irregularly hurried breathings, and muscular twitchings, indicate the grave condition of the patient. To gain a more thorough knowledge of this interesting and 960 DISEASES OF THE URINARY SYSTEM. serious complication of renal disease a divisional study of the symptom- atology is necessary. Cerebral Symptoms.—These vary from a slight headache, tremors, and the restlessness of anxiety to the most violent maniacal delirium and con- vulsions ; from somnolence and mental stupor to profound coma; and from the slightest visual disturbances to complete amaurosis. The onset of a.noisy delirium, and less commonly of a marked mania, is often quite abrupt, and may be the first manifestation of Bright's disease in an in- dividual. Delusional insanity (folie Brightique) is seen in some cases. Melancholia and the delusion of persecution, with suicidal and homicidal tendencies, may thus occur. The most characteristic symptom of uremia, hoAvever, is the convulsion (uremic eclampsia). Uremic convulsions are epileptiform in type, although they may be either unilateral or local—of the Jacksonian form of epilepsy. They are supposed to be due to a local or general edema of the brain, and are probably allied to the apoplexia serosa of early writers (Osier). The convulsions of uremia may come on suddenly or may be preceded by headache, vertigo, dropsy, nausea, and vomiting. As in the epileptiform convulsion, after the early tonic rigidity there may follow at short intervals the clonic spasm, with cyanosis, fever, and contracted arteries, and the intervening periods of unconsciousness, shallow or noisy respiration, and slow, hard pulse. Coma may come on gradually as well as during the convulsive attacks. It may be preceded by headache, apathy, and insomnia, and continue progressively to deepen for a long time. A typhoid state not infre- quently accompanies uremic coma. The temperature is usually low- ered, and moderate dilatation or contraction of the pupils may be evidenced. Uremic Amaurosis.—Blindness may follow uremic convulsions, or, rarely, it may come on without motor disturbances. It is of purely centric origin (the cortex of the occipital lobe), and its duration is short, lasting but a few days in most instances. Uremic deafness, which is probably also of centric origin, is a less common manifestation. Other nervous phenomena, as hemiplegia, monoplegia (from cerebral or spinal congestion or edema), contractures, aphasia, pruritus, paresthesiae, and cramps in the calf-muscles are not so frequent in occurrence. Circulatory Disturbances.—The pulse is moderately slow, tense, and full in uremia, but with the onset of acute and severe symptoms, as con- vulsions, it usually becomes accelerated, small, and feeble. The heart's action is labored and feeble. Respiratory Symptoms.—Renal dyspnea, which is sometimes called " uremic " or " renal asthma," is a marked, rather constant, and often an early symptom of uremia. The respirations are deep and often stertorous in coma, or they may be irregular, accelerated, and shallow, sometimes assuming the Cheyne-Stokes type. Dyspneic attacks are especially apt to occur at night. In chronic uremia slight dyspnea may be continuous for a long time. Again, alternating paroxysmal exacerbations may arise. The uremic dyspnea is probably due in most cases to the toxemia affecting the respiratory nervous centers. It may, however, be the result of cardiac weakness or of dropsy or pulmonary edema. Gastro-intestinal Symptoms.—Uremic stomatitis is generally seen. The breath is foul, the tongue, lips, and gums are red, swollen, and pain- UREMIA. 961 ful, and the saliva is increased. Uremic vomiting is also usually of cen- tric origin, though it may be provoked by the irritation of the gastric mucosa, caused by the vicarious elimination of the urea and the decom- position of the latter into irritating ammonium carbonate. The vomiting may come on suddenly and be persistent. Uncontrollable hiccough and sometimes uremic diarrhea may be associated. The irritant action of the ammonium carbonate on the intestinal mucous membrane may produce a catarrhal or diphtheritic inflammation. Uremic diarrhea may also exist apart from any marked gastric disturbances. General Symptoms.—The skin of the face is usually pale in uremic coma. Urea may be excreted by the sweat-glands, and may be seen as minute glistening crystals in some of the cutaneous furrows after the evaporation of a free SAveat. The skin is often harsh and dry, as in chronic interstitial nephritis. Uremic pruritus is probably the result of the peripheral irritation of the cutaneous nerves by crystals of urea. The temperature is generally lowered, but uremic fever frequently accompanies the convulsions or they may be preceded by "uremic chills." In some cases the temperature rises to 105°-107° F. (40.5°-41.6° C.) just before death, whilst in other cases, characterized by a profound and lasting coma that deepens into collapse, the temperature may be so low as 91° or 93° F. (32.7°-33.8° C). There is not infrequently an ammoniacal odor about a uremic patient. The urine is diminished in quantity, is generally highly albuminous, and deficient in urea. A previous dropsy is sometimes markedly reduced upon the appearance of acute uremic symptoms. Duration and Prognosis.—Acute uremia is manifested by coma and convulsions, seldom lasting more than a few days. Chronic uremia, in which milder nervous symptoms, nausea and vomiting, and dyspnea are more prominent, may persist, however, for many weeks. While a grave condition, uremia, even in its most acute and violent forms, is not at once necessarily fatal, for under proper treatment—as by venesection, for instance, followed by judicious hygienic measures—life may be con- siderably prolonged. Sooner or later, however, barring a possible death from some intercurrent affection, the kidney-lesions are of such a nature as to preclude the likelihood of anything but a fatal result. Diagnosis.—Uremia may be recognized by the history, the marked arterial tension, and the accentuated second sound of the heart; also by the albuminuria (the urine has to be withdraAvn), the temperature, and the odor of the breath. The presence of dropsy in some cases is a valu- able indication of the nephritic origin of uremic manifestations. Differential Diagnosis.—Uremic unconsciousness coming on suddenly, as in chronic interstitial nephritis, may simulate alcoholism, cerebral hemorrhage (apoplexy), cerebral tumor, or meningitis. The points of dissimilarity between the first two conditions and uremia are here tabu- lated (after Herrick): Cerebral Hemorrhage. Alcoholic Narcosis. Uremia. Pupils unequal or dilated. Pupils contracted or di- Pupils generally dilated; lated ; eyes injected. albuminuric retinitis. Stertorous, puffy breath- No stertorous breathing. Sharp, hissing stertor. ing, and napping cheek. No odor. Odor of alcohol. No odor, unless urinous. 61 962 DISEASES OF THE URINARY SYSTEM. Cerebral Hemorrhage. Paralysis ; hemiplegia. Unconsciousness absolute. Pulse slow and strong or irregular ; arteries often atheromatous. Coma sudden and deep. Convulsions late ; may be unilateral. Urine generally negative. Apoplectic habit; heart may show hypertrophy. Alcoholic Narcosis. No paralysis, usually. May be aroused. Pulse frequent and feeble. Coma gradual. No convulsions. Urine generally negative. Red face and nose, heart often weak, dilated, my- ocarditic. Uremia. No paralysis. May or may not be aroused. Pulse at first strong, later weak and rapid ; tension strong; arterio-scle- rosis. Coma gradual or sudden. Preceded by general con- vulsions, headache, etc. Urine albuminous. Edema and pallor ; heart hypertrophied. In meningitis the mode of onset, the rigidity of the neck, incoherence or mild delirium, photophobia, and pronounced fever point to the distinction. Uremic coma must also be differentiated from opium-poisoning and diabetic coma. Chronic uremia must not be confounded with the asthenic state of typhoid fever and acute miliary tuberculosis. In opium-poisoning the pupils are contracted and do not respond to light. Again, in opium- poisoning the respirations are slow, deep, and full, and the patient may answer rationally when aroused. In uremic coma, it will be remembered, consciousness is abolished. In diabetic coma the history must be learned, the harsh, dry skin and emaciation noted, and especially are the ethereal odor and the Burgundy-red reaction of the urine (acetone) with the tincture of the chlorid of iron to be observed; sugar is also present. The prognosis is grave, but guarded; it is even favorable in many cases, so far as immediate results are concerned. Treatment.—This will be detailed in the discussion of the various forms of nephritis. Suffice it to say that the supreme indication is the prompt elimination of the poisons in the blood. When diaphoresis and catharsis fail either in promptness or efficiency, venesection should be em- ployed ; the latter measure is also probably the most reliable in urgent cases of uremic convulsions or coma. Bozzoli recommends the subcutaneous injection of sterilized serum because of the gratifying results secured in a number of cases of uremia. AMYLOID KIDNEY. Definition.—Amyloid (waxy or lardaceous) degeneration of the kid- neys ; it is usually coexistent with a similar degeneration of other viscera. Pathology.—Macroscopically, the amyloid kidney appears pale, greenish or yellowish-white, and uniformly enlarged, and the surface is smooth, glistening, and often mottled, owing to the prominence of the stellate veins. It has a doughy consistence. On section a homo- geneous, anemic, or " bacon-like " surface presents itself, particularly in the cortical region. The cortex is wider than normal; the pyramids may be red in color and slightly infiltrated ; and the glomeruli may show an infiltration by the glistening, translucent amyloid (albuminoid) mate- AMYLOID KIDNEY. 963 rial. On the application of Lugol's solution of iodin to the amyloid areas a mahogany-brown color is produced. Brushing over the amyloid substance with a solution of iodin, and then with dilute sulphuric acid, gives a blue or violet tint. Similarly used, a 1 per cent, solution of methyl-violet strikes a red color. The capsule of the kidney is not adherent. Microscopically, the amyloid change is generally found in the early stages to affect the Avails of the capillaries of the Malpighian tufts. The Avails are swollen with the homogeneous material and the vessel-lumen is diminished or obliterated. The straight uriniferous tubules are also infil- trated later perhaps, the deposit occurring primarily in the membranae propriae. A diffuse nephritis is nearly ahvays an associated condition, the so-called pure amyloid kidney, Avith normal renal tissue other than that above mentioned, being relatively infrequent. Fatty degeneration of the epithelium, glomerulites or waxy glomeruli, and a thickening of BoAvman's capsule are common in markedly amyloid kidneys. In ad- vanced cases most of the secretory structure becomes atrophied. Amy- loid infiltration of the smaller granular kidney is less common than of the large white kidney, with intense parenchymatous changes. Hypertrophy of the heart is not ahvays present in amyloid disease of the kidneys. Amyloid infiltration of other organs, however, as of the liver and spleen, is usually associated with waxy kidneys. Etiology.—The causes of amyloid kidney are those of the amyloid change affecting (either simultaneously or nearly so) other organs, as the spleen, liver, and intestines. Commonly, amyloid disease is marked also in the other solid organs named above ; it is secondary to wasting diseases, cachexiae, and the like. Perhaps the most frequent cause of the waxy kidney is tuberculosis, espe- cially of the lungs ("chronic ulcerative phthisis"): tuberculosis of the intestines also is often associated and aggravates the amyloid infiltration. Next in order are the prolonged suppurations, particularly of the bones, as in osteitis of the vertebrae and hips (usually tuberculous). Chronic empyema, intestinal ulcers, vesico-vaginal fistulae, and other purulent affections, chronic in nature also, have the same etiologic effect. Amyloid kidney is often present in syphilis, especially in the tertiary stage, when ulceration of the mucous surfaces and of the bones is present. Rarely, gout, malaria, and chronic valvular endocarditis with insufficiency seem to produce amyloid disease. Symptoms.—These vary greatly according to the extent to Avhich the amyloid degeneration has encroached upon the normal kidney-struc- ture, and may be overshadowed partially or completely by those of the dominant causal affection. The urine is pale yellow, clear, and variable in quantity, and the amount passed in twenty-four hours is sometimes normal or may be slightly diminished. More frequently, perhaps, it is increased, and espe- cially in marked or advanced cases. The specific gravity is apt to be low (1015-1005), and there is seldom any sediment. Serum-albumin and globulin may both be present in the urine, but a highly significant condition, and one that is seemingly diagnostic, is the high proportion of globulin as compared with the serum-albumin (Sal- kowski, Senator). Tube-casts may be found, but their presence may be 964 DISEASES OF THE URINARY SYSTEM. only temporary ; they are usually wide hyaline or fatty and granular, and are feAv in number. The amyloid reaction may be elicited "with the hyaline casts; sometimes symptoms referable to the kidney are rare in comparison with those of the nephritides. Dropsy is not invariably pres- ent, and when present is but moderate in degree and generally in the legs only. It is proportionately prominent with the increase in the anemia, circulatory depression, and wasting of flesh and strength. These latter manifestations, constituting a cachectic appearance, are quite commonly observed in amyloid kidney. The associated enlargement and the firm, sharp outlines of the liver and spleen are of diagnostic significance. Marked diarrhea may be due to coexisting amyloid infiltration of the intestines or to tuberculous intes- tinal ulcers, and is often seen in advanced cases. Diagnosis.—-This can seldom be made upon the urinary manifesta- tions alone. Important and often necessary adjuncts are the histories of causation and of the associated symptoms and physical signs. Thus, there will be evidenced in most cases tuberculosis, chronic bone-suppura- tions, or syphilis, while coexisting hepatic and splenic enlargements, wast- ing, and cachexia are usually present. In any of the diseased conditions mentioned amyloid kidney may be diagnosticated with reasonable cer- tainty upon the development of an increased quantity of pale clear urine of low specific gravity and containing a large amount of albumin, or even with slight albuminuria. From parenchymatous nephritis amyloid kidney is to be differentiated by the history, by the more marked and generally distributed dropsy, and by the albuminuric retinitis that characterize the former. In chronic interstitial nephritis there are less marked albuminuria and dropsy, and there are present arterio-sclerosis, cardiac hypertrophy, and a pronounced tendency toward uremic symptoms. Prognosis.—This varies with the cause. Incipient bone-disease or tuberculosis, with only slight evidences of amyloid change in the kidneys, may be controlled. As a rule, however, the structural alterations are so far advanced, and the constitutional powers of resistance so much ener- vated, before the amyloid infiltration can be distinctly apprehended that in the majority of instances the prognosis is entirely unfavorable. In decided cases death ensues in from several weeks to as many months. Treatment.—This also depends upon the causal affection. Hygienic and dietetic measures are always useful, however, with a view to improving the general nutrition. The iodid of iron has been recommended as an alterative, and easily assimilable and palatable fats and tonics may also be tried. Tuberculous cases require creasote or allied preparations ; syph- ilitics require mercurials and iodids; while malarial subjects do best under the systematic use of arsenic, iron, and quinin. NEPHROLITHIASIS. (Renal Calculi; Pyelitis Calculosa; Renal Colic; Gravel.) Definition.—A condition characterized by the formation of fine or coarse concretions in the kidney-substance or in the renal pelvis by the precipitation of certain of the solid urinary constituents. NEPHR OLITHIA SIS. 965 Varieties.—According to their size, renal concretions are variously termed—(1) Renal sand, of which the particles are fine and pulverized; (2) Renal gravel, consisting of coarse grains or even of pea-sized concre- tions ; (3) Renal stone, or calculus, Avhen larger masses than the preceding exist, either more or less rounded or as stony casts or moulds of the pelvis of the kidney, its infundibula, and calyces (dendritic or coral calculi). According to their composition, the chemical varieties of renal concre- tions are—(1) Uric-acid calculi, the most frequent in occurrence. Urates are often associated in the calculus with uric acid, thus producing strati- fication. These concretions may occur as sand, gravel, or large stones ; they are usually quite hard, reddish-brown or black in color, and have a smooth though irregularly-shaped surface. The fracture is crystalline, and in the larger calculi often shows the alternating layers of uric acid and urates. Pure uratic stones may occur in children. (2) Calcium-oxalate concretions occur more rarely in the kidney. They constitute the so-called "mulberry calculi," from a fancied resemblance to the mulberry, owing to their dark-brown or black color and very irreg- ular and nodulated or prickly appearance. They are also quite dense; lamination, however, is not common, although they are sometimes formed about a uric-acid nucleus. (3) Phosphatic calculi of the kidney are still less common than the oxalate, but they are more common in the bladder. They may consist of calcic phosphate or ammonio-magnesic phosphate, and may possibly be associated with calcic carbonate. Phosphatic salts are most often depos- ited secondarily about uric-acid or oxalate calculi in the alkaline urine of a cystitis set up by the irritation of the true renal stones. Phosphatic calculi are grayish-white in color and are comparatively soft. (4) Renal stones composed of cystin, xanthin, carbonate of lime, fatty or saponaceous matters (urostealith), indigo, and fibrin, though of extreme rarity, have been occasionally reported. Cystin calculi have a pale-yellow color and a Avaxy luster. Pathology.—The anatomic changes of the kidney vary with the degree and persistence of the irritation, the size of the calculi, and their passage or retention. Sometimes numerous granular and pea-sized con- cretions are found in the renal pelvis, with desquamated epithelium and a turbid urine. Interesting cases are those in which a dendritic stone occupies a great portion of the atrophied kidney-substance, as well as the entire pelvis of the organ. In one of my OAvn patients the left kidney was, apparently, nearly twice the normal size, owing to the presence of a large coral-calculus (uric acid and urates), connected by an isthmus with a rounded stone in the inferior portion quite as large as a large Avalnut. The pelvis of the right kidney also contained a dendritic calculus. Secondary Lesions.—Perhaps the most usual result of renal concre- tions is a pyelitis : this may be simple catarrhal, diphtheritic, or purulent, with or Avithout hemorrhages, depending upon the intensity of the mechan- ical irritation. A pyelo-nephritis may follow in severe cases, as may even a general suppuration (pyonephrosis) or perinephric abscess and perfora- tions. Renal pus-cavities are sometimes found postmortem containing numerous small stones. Hydronephrosis is another important pathologic sequel, in which the cause is to be attributed to the blocking of the ureter by an erstwhile passing stone or by the closing of the aperture of 966 DISEASES OF THE URINARY SYSTEM. a ureter from within the pelvis. Pressure-necrosis and perforation may thus be induced. Owing to the prolonged pressure of a dendritic calculus, there is commonly a distinct and marked atrophy of the renal parenchyma, resulting in chronic diffuse nephritis Avith little or no exudation. Etiology.—The definite causation and the exact manner of formation of renal concretions are still unestablished. We may infer not a little, hoAvever, Avith some good reason, since the predisposing causes are rather distinct. Thus, in children and in advanced life the occurrence of calculi is most common, the uratic variety being most frequent in the former and the uric acid in the latter. Men are subject to nephrolithiasis more often than are women. The uric- or lithic-acid state (lithemia), gout, and the various influences that induce these conditions, as an excessive meat (proteid) diet or a sedentary life, seem to predispose to stone. Heredity probably plays a part also in many cases. Broadly speaking, any habit of the system that encourages the pre- cipitation of insoluble abnormal ingredients or of normal ingredients in excess, owing to chemical changes in the urine, tends to the formation of calculi. It should, however, be provisionally stated that the primary cause of calculus-formation is the presence of some solid substance in the urinary tract that affords a nucleus about which the successive layers of crystals may deposit and adhere, such as bits of mucus, epithelial shreds, parasitic ova, bacteria, blood-clots, and tube-casts. It is generally believed that the requisite conditions for the formation of an uric-acid renal calculus are—a highly-acid urine, an excess of uric acid, and a low percentage of salines. Symptoms.—These may be slight, progressive, and chronic, or they may be intensely acute and comparatively short in duration, though sub- ject to repetition—i. e. renal colic. It is not unusual for patients to pass uric-acid sand and gravel for years without much complaint. A sudden blocking of a ureter, hoAvever, or a slowly-passing stone of dis- tending dimensions produces great agony at times. A smooth, snugly- fitting dendritic calculus in the pelvis may not cause any symptoms for years until the destruction of tissue by its weight and mechanical irritation ensues ; there is then a progressive failure of health, a constantly increas- ing pain in the back, occasional hematuria, tenderness on pressure over the diseased kidney, both anteriorly (deep) and posteriorly, and finally uremia and death. The characteristic symptoms of stone in the kidney appear as an attack of renal colic. This happens when a calculus in its passage down the ureter acts as a mechanical irritant, or when it is caught and stopped in the passage. The large "gravel" or pea-sized and more or less rough stones usually cause the attack, which comes on, as a rule, quite suddenly, although it may be preceded by a chill and some general uneasiness or by slight pain in the region of the kidney. It may be excited by a sud- den muscular effort. The pain is tearing in character, and rapidly reaches an agonizing maximum of severity, starting from the lumbar re- gion and extending down along the ureter into the groin, and often into the testicle and inner side of the thigh. The paroxysm may appear in the form of a diffuse abdominal and lumbar pain in some instances. There is local tenderness on pressure, and nausea and repeated vomitings are frequent. The patient is often collapsed, and perspiration, a rapid, small, NEPHR OLITHIASIS. 967 and feeble pulse, trembling, anxiety, bodily twistings about, convulsions even, and syncope may ensue. There may be moderate fever. The urine is scanty or may be suppressed for a time, and is often bloody. Frequent and painful attempts at urination are made, with the passage of but a feAv drops at a time, owing perhaps, in part at least, to a reflex spasm of the vesical sphincter (vesical tenesmus). The presence of pus and of pelvic epithelium in the urine indicates a pyelitis. When a large quantity of clear urine is passed, as sometimes happens, it may be looked upon as having come from a healthy kidney. The paroxysm of renal colic ends when the impacted stone passes out of the ureter. This may occur within a few hours or it may take several days; in instances of the latter type the attacks of renal colic may be intermittent. Recovery is not always complete immediately upon the evacuation of the stone. The previously retracted testicle may be painful and swollen for a little while, and there are apt to be an aching and a soreness over the affected kidney and ureter. In certain severe cases of mechanical irritation the symptoms of pye- litis, pyelo-nephritis with abscess, or hydronephrosis may be superadded. Anuria and uremia result from simultaneous obstructive suppression of the urine upon both sides. Nephrolithiasis as a chronic affection may exist for many years, with recurring paroxysms of renal colic. Between the latter the patient may be entirely comfortable, save perhaps an occasional burning in the urethra on micturition, owing to a highly-concentrated, acid urine or to the pass- age of minute uric-acid granules. There are apt to be pain and tenderness over the kidney containing a large imbedded stone. A smoky-hued urine, due to slight hematuria, is also sometimes present in long-standing cases of renal calculus, particularly after exertion. A renal intermittent fever, simulating malarial paroxysms, may occur in nephrolithiasis, and is analogous to the hepatic intermittent fever of cholelithiasis. Pyelitis—simple or purulent—with late involvement of the kidney- parenchyma (pyelo-nephritis) is a frequent concomitant of chronic nephro- lithiasis. The presence of pus in the urine is constant, with an absence of renal epithelium in cases of an abscess-cavity of the kidney. In ordi- nary pyelitis the pyuria is often intermittent. The general health of patients with nephrolithiasis is, as a rule, re- markably good. Anorexia is not only seldom present, but such persons are habitually free and good livers. Persistent headaches with nausea, however, should warn one of uremia. Splenic and hepatic enlargement may be found with prolonged suppurative pyelo-nephritis, indicating amyloid disease. Diagnosis.—This resolves itself into a study of the diagnostic cha- racters of (a) the attacks of renal colic, (b) of the underlying systemic condition in general, and (c) the renal condition in particular that renders these attacks possible. The latter can be discovered only by a careful and continuous study of the clinical history and urinary manifestations as outlined in previous paragraphs. Nephrolithiasis may be positively diagnosed in a case in which, after sudden, agonizing, colicky pain, referred to either lumbar region and 968 DISEASES OF THE URINARY SYSTEM. radiating down the ureteral course to the testicle, a concretion is found to have passed with the urine. It is therefore necessary in a suspected case of renal colic to pour the urine through a fine sieve as soon as passed. Differential Diagnosis.—Renal colic must not be taken for biliary or intestinal colic. The antecedent history is of great value in arriving at a diagnosis. In biliary colic there may be jaundice, and pain referred to the upper rather than to the lower abdominal zone, both of which symp- toms are absent in renal colic ; Avhile in the latter the disturbance of mic- turition and the character of the urine, especially the hematuria, are characteristic. In intestinal colic the griping pain is usually most intense in the um- bilical region, is often relieved by pressure, and is associated with tym- panites and constipation; it has usually a dietetic origin, while the renal and urinary symptoms are absent. The exclusion of lumbodynia and lumbo-abdominal neuralgia is not so difficult. The differentiation of the varieties of calculi from the symptoms is not positive. It has been sug- gested, however, that the oxalate stones usually cause the sharpest pains and the hematuria. Prognosis.—This should always be guarded, owing to the possible dangers and complications that frequently attend nephrolithiasis in all of its forms. Thus the passage of gravel without marked symptoms tends to persist or recur—in both events an unfavorable tendency, since subsequent formations are apt to be larger and cause serious symptoms. An attack of renal colic may itself be fatal. Large latent calculi (den- dritic), of long standing, are nearly always incurable, and in most in- stances lead to such grave complications as pyelo-nephritis, pyo- and hydronephrosis, perinephric abscess, and uremia. Treatment.—Paroxysms of renal colic call for prompt relief. This is best afforded by hypodermic injections of morphin and atropin, coupled with hot baths or fomentations applied to the loins. The free use of hot drinks, as lemonade, soda, or plain water, is also helpful in promoting the passage of the stone. Cases of excessive suffering re- quire the inhalation of chloroform. The treatment of the nephrolithiasis without or between attacks of renal colic is most important. First to be considered are the hygienic and dietetic measures, for in mild and uncomplicated cases much can be done to prevent the aggravation of the disorder, and at least the forma- tion of larger concretions may be delayed. When the tendency is to uric-acid gravel (the commonest variety), the patient should live a reg- ular, calm, steady, and temperate life. Exercise should be so managed that it may be taken rather moderately in the open air, and Avith a view to preventing additional weight in persons of fair nutrition and to pro- moting a reduction of weight in the obese. In short, the exercise should be sufficient to thoroughly use up all nitrogenous food, so that the formation and elimination of urea may be increased to normal and the quantity of uric acid diminished. Hence a clinical study of the percentage of urea in the urine is advisable (vide, p. 953). Over-indulgence in food, particularly in red meats (liver, sweetbread, and similar nuclear food), should be prohibited, owing to the ready for- mation of uric acid from the latter. Alcohol should be taken seldom, or, better, not at all. On the other hand, since the urine is apt to be NEPHROLITHIASIS. 969 scanty and highly acid, the patient should be encouraged to drink freely of plain and alkaline waters, artificial and natural. The value of various pure spring-waters as diluents is undoubted, the Buffalo, Londonderry, and Otterburn Lithia, the Saratoga, Bedford, and Poland waters, all being distinguished for their purity. More marked and more generally useful for their alkalinity are the Carlsbad, Vichy, and carbon- ated waters. In cases characterized by occasional hematuria the Rock- bridge alum-water may be tried. Plain soda-water and lemonade may be used as adjuvants. The medicinal treatment of nephrolithiasis is aimed to secure a sol- vent and disintegrating action upon the stones ; it is symptomatic. It is extremely doubtful whether stones once formed in the pelvis of the kid- ney and remaining there are ever dissolved, though certain drugs would seem to have had an eroding effect in some instances, and they are to be recommended as useful in preventing the formation of new deposits. Lithium citrate or carbonate in 5-grain (0.324) doses in tablet form, three or four times daily, has been generally employed for the purpose. Sodium phosphate and the vegetable salts of potash, as the citrate, acetate, and tartrate, are useful. Much water, especially the carbonated, should be drunk, along with doses of the above, in order to facilitate the solvent action, and in this way relieve, in a measure, the local distress and pain. Recently piperazin has been brought forward as an uric-acid-calculus solvent by some clinicians, and that it has an action such as is claimed for it has been proved beyond a doubt in certain cases. Whilst it de- serves a further trial in nephrolithiasis, it is too much, however, to ex- pect to look for positive and successful results in every case. It is pre- scribed usually in 5-grain (0.324) tablets three or four times daily, with much water. Recently, Von Noorden has recommended calcium carbonate (gr. x- xv—0.648-0.972—or more thrice daily). The theory is that the calcium unites with the acid phosphates in the intestines, and thus reduces the deuterophosphates in the urine, leaving the protophosphates to dissolve the uric acid. He reports excellent clinical results. The reaction of the urine must be tested at stated intervals and kept faintly acid. Should the urine become alkaline, the alkaline treatment must be suspended for a Avhile, or a secondary deposit of phosphates about the uric-acid stone may be induced. Nagging lumbar pains may be re- lieved by occasional doses of such analgesics as phenacetin, belladonna, hyoscyamus, codein, and indirectly by the sweet spirits of niter, buchu, and uva ursi. Renal hemorrhage may be controlled effectually by the use of the fluid extract of ergot, or by alum in 10- or 15-grain (0.648 or 0.972) doses, or by gallic acid in 20- or 30-grain (1.29-1.94) doses. Efforts to acidify the urine are indicated when the calculus happens to be composed of phosphates or of calcium carbonate. This is more difficult of accomplishment than when it is necessary to reduce the acidity. Saccharin in 2- or 3-grain (0.129-0.194), and benzoic and boric acids in 5- to 15-grain (0.324-0.972) doses, in capsules, seem to be most useful for this purpose. The question of surgical interference must be decided in not a few cases ; thus, it may be briefly stated that in protracted and obstinate cases of calculous renal disorder, with persistent local pain, a gradually 970 DISEASES OF THE URINARY SYSTEM. decreasing capacity for work, and evidences of severe pyelitis, pyelo- nephritis, or, worse, of perinephric abscess, the surgeon must operate. In the simplest cases a nephrotomy or nephrolithotomy may be performed and the stone removed. Where the renal structure is much damaged it may be necessary to do a nephrectomy. To avoid the increased perils of the latter operation, however, it were better that a nephrotomy were done as early as consistent with the diagnosis of incarcerated pelvic stone and the condition of the patient. ACUTE NEPHRITIS. (Acute Brighfs Disease; Acute Diffuse Nephritis; Acute Parenchymatous Nephritis; Exudative, Catarrhal, Tubal, Desquamative, and Glomerulo-nephritis of Acute Course.) Definition.—An acute inflammation of the kidneys, more or less diffuse in nature. It may be either of a mild, severe, or grave cha- racter. Delafield describes three varieties of acute renal inflammation under the common synonym of acute Bright's disease, as follows : (1) acute degeneration of the kidneys, (2) acute exudative nephritis, and (3) acute productive nephritis. This division is of etiologic and pathologic import- ance and interest, rather than of clinical necessity or practical value. Pathology. —The anatomic changes in, and the appearances of, the kidneys vary considerably in different cases according to the degree of involvement. From the very mild to the gravest cases of nephritis there is an intermediate series of continuously more marked pathologic changes in the renal tissues. These depend greatly on the amount of poisonous material circulating in the kidneys and eliminated by them, as well as upon the intensity and duration of its noxious action. In the mildest cases the microscopic appearances of the kidneys may present nothing distinctly abnormal. As a rule, however, the organs are slightly enlarged, swollen, and somewhat softened. These conditions are more evident when the interstitial exudation is abundant and when in- flammatory edema is evident. The kidneys may be reddened and con- gested and appear bloody on section, or they may be pale and mottled. In examples of the former, hemorrhages may be formed beneath the cap- sule (acute hemorrhagic nephritis), though it is more common to see red patches of hyperemia alternating with opaque, whitish portions on both the outer and cut-surfaces of the kidneys. The cortex especially is swollen, turbid, and pale, or slightly congested in the mildest cases, and is deeply mottled (red and pale glomeruli) or hyperemic in severe in- stances. The pyramids usually shoAv an intense redness. The surfaces are smooth and the capsule non-adherent. Microscopically, alterations may be discovered that are not visible to the naked eye in the very mild cases referred to above. There is simply a cloudy SAvelling or a granular (parenchymatous) degeneration of the epithelium of the Malpighian tufts, Bowman's capsule, and of the cortical uriniferous tubules. This is not true acute nephritis, hoAvever, in the absence of exudative changes in the interstitial tissue. The acute paren- ACUTE NEPHRITIS. 971 chymatous degeneration may be almost exclusively limited to the glome- ruli, as in some cases of scarlatina, and hence the term glomerulo-nephri- tis. The cells are swollen, opaque, and irregular in shape, while the cell-contents are granular (albuminoid or fatty) and the muscles are either SAvollen or absent. A further advance in the process is seen in the death of the cells that is due either to coagulation-necrosis or disintegration, desquamation of the cells, and hyaline degeneration of masses of them in the tubules. Acute degenerative changes are frequently found in the acute infectious diseases or when inorganic poisons have been introduced into the body. In phosphorus-poisoning actual fatty degeneration of the epithelium may be found, this either proceeding from the cloudy swelling or developing independently. A rapid necrosis of cells is also met Avith in severe cases. True acute nephritis is not only characterized by changes of the renal epithelium (the parenchyma), but the inflammatory exudate (serum, leu- kocytes, and erythrocytes) is found between the tubules. The kidneys show different stages of the process in different portions. In some places there is only a slight cellular infiltration of the intertubular tissues; in others, besides the desquamation of necrotic epithelial cells and the pres- ence of hyaline casts in the tubules, the interstitial tissue is swollen by the coagulated sero-fibrinous exudate, abundant leukocytes, and some red blood-corpuscles. It should be stated that the inflammatory exudate col- lects also in the Malpighian bodies and tubules. The epithelium lining the latter, especially the convoluted portion, is often flattened, and the tubules themselves may be dilated and choked with degenerated cells, or, more frequently in the straight tubules, with hyaline casts. The white blood-cells that are found infiltrating the stroma of the kidney are not usually equally diffused, but are collected in foci in the cortex. The glomerular epithelium of the capsule, and especially that covering the outside of the capillaries of the tufts, is swollen and opaque, and the outlines of the individual capillaries are lost. In most cases of diffuse exudative nephritis new epithelium appears, and a restoration of the glomerular function takes place. In the productive variety of acute diffuse nephritis, however, according to Delafield, certain lesions are more permanent in character from the first in the glomeruli and stroma, and hence the increased gravity of the disease. The additional changes that are here superadded to the usual exudative condition are—(a) a growth of the cells lining the capsules to such a degree as to form a mass that compresses the tuft, " and leading finally to obliteration of the vessels and fibroid glomeruli; " (b) a growth of the connective tissue parallel to, and surrounding, one or more arteries having thickened walls, and form- ing more or less numerous and regular strips or wedges in the cortex. In the more intensely acute cases the new tissue between the tubules is largely cellular; in those of a subacute type it is relatively dense and fibrous. Anasarca and pleural, pericardial, and peritoneal dropsy are also found in those dying of acute Bright's disease. Cerebral edema, meningitis, and lobar pneumonia are to be mentioned as complicating conditions that are sometimes seen postmortem. Etiology.—Acute nephritis may occur at any time of life, though it more often makes its appearance before than after middle life. Males are 972 DISEASES OF THE URINARY SYSTEM. more susceptible than females, and particularly Avhen engaged in occupa- tions requiring exposure to cold and wet. The habitual use of alcoholics also is generally a predisposing cause of acute Bright's disease. The principal exciting causes of acute diffuse nephritis are the folloAv- ing : (1) Those acting on the skin, as cold and dampness, extensive burns, and chronic skin-diseases. In many cases it is difficult to estimate whether the influence of alcoholic intemperance predominates or the exposure in- cident to it. Thus, acute intoxication from beer-drinking itself may cause an attack of acute nephritis, but it is likely that in most instances the direct exciting cause is cold acting upon the individual in his ex- posed and maudlin condition. The disease may also be attributed at times to exposure to cold and wet irrespective of alcoholic indulgence. It may be presumed with reason that in such cases there is some inherent or acquired Aveakness or a susceptibility of the kidneys, rendering them the weak links in the visceral or systemic chain. (2) Biologic Toxic Agents.—These embrace the poisons of the acute infectious diseases, though in the majority of cases scarlet fever is the primary affection. Nephritis may supervene during the height of scarla- tina, but more often it occurs in the second or third week of convales- cence. Other infectious fevers may also cause acute nephritis (small- pox, typhus, typhoid, relapsing fever, cholera, diphtheria, yellow fever, measles, chicken-pox, erysipelas, septico-pyemia, acute lobar pneumonia, cerebro-spinal meningitis, dysentery, acute articular rheumatism, and tuberculosis: syphilis is rarely a cause). Acute infectious nephritis may also occur as a primary disorder, and the brunt of the affection may fall either upon the kidney, rather than upon any other part, or upon the organism as a whole, as in the fevers. Mannaberg, among others, has described such cases, and demonstrated streptococci in the urine. (3) Chemical Toxic Agents.—Among the principal irritants of this class are turpentine, cantharides, carbolic and salicylic acids, iodoform, the mineral acids, potassium chlorate, and such inorganic poisons as phos- phorus, lead, arsenic, and mercury. The excessive ingestion of highly- acid, spiced, or adulterated foods (as from salicylic acid and lead chromate) may in certain individuals cause acute renal inflammation. (4) Pregnancy.—Here the nephritis (gravidarum) comes on in prim- iparae, usually in the last months of pregnancy. It is probably caused by renal engorgement due to mechanical pressure, as well as to nutritive dis- turbances in the kidney, owing to the altered blood-condition. (5) Finally, latent and insidious chronic nephritis may be the cause of an onset of a manifest acute nephritis. Symptoms.—The onset varies with the cause of the nephritis, though generally it is rather sudden. Chilliness, nausea and vomiting, pain in the back, and, Avithin twenty-four hours, dropsy, are seen in some cases. Children may be seized with convulsions (uremic), and adults are not less liable to them in severe attacks. Fever may be present, although it is neither constant nor high. The characteristic symptom is the early appearance of edematous puffiness of the eyelids and face, with pallor of the skin. Soon (and sometimes at first, even) a swelling is noticed about the ankles and legs, and in marked cases the Avhole body becomes drop- sical, so that pitting on pressure may be observed pretty much all over the bodily surface. In such instances the scrotum and penis or the ACUTE NEPHRITIS. 973 labia may become enormously distended, the skin having almost a trans- lucent appearance. Local symptoms, as pain and tenderness in the lumbar region, are often wanting and are never marked. There may be a desire to mictu- rate often, accompanied by slight burning and vesical tenesmus, due to the concentrated urine. In very severe dropsy the tense, dry skin, as of the limbs, may be sensitive or even painful to the pressing finger. Movements of the body are often difficult, painful, and distressing in marked anasarca. Intense headache and backache may precede the on- set of uremia. In mild cases the renal condition may be overlooked unless a urinary examination is made. Prostration may be unnoticed, and the patient feel nothing more than a general malaise. The characteristics of the urine in acute nephritis are all-important. The total quantity passed in twenty-four hours is diminished, and may be very scanty, sometimes amounting to not more than from 5 to 25 ounces (150-740 c.c). Suppression occurs in some cases of toxic origin, when an acute degeneration or necrosis of the renal epithelium takes place, and in the most severe exudative inflammations. The specific gravity is in- creased to 1025 or more early in the case ; later it may be as low as 1010 or 1015. The color is darker than normally, and is usually smoky-red or reddish-brown, according to the amount of blood passed. If the ab- normal morphologic constituents are present in great quantity, a more or less abundant flocculent sediment appears on standing. Microscopically, some red blood-corpuscles and renal epithelium are found, along with the characteristic hyaline, blood, and epithelial tube- casts. Chemically the urine is acid, and on boiling a thick, curdy pre- cipitate of albumin forms. The percentage of the latter by weight varies from 4; to 1 per cent. The urea is diminished. Other symptoms may develop during the course of acute Bright's dis- ease. If great general edema is present, physical signs of hydrothorax, ascites, and hydropericardium may be elicited. The first-mentioned con- dition is bilateral and causes dyspnea ; the second increases the dyspnea by pressing the diaphragm upward; and the last impairs the heart's action. Striimpell describes a form of pneumonia—a " stiff inflammatory edema"—midway between lobar pneumonia and broncho-pneumonia, that sometimes develops in severe cases of acute nephritis. Edema of the conjunctivae, soft palate, and larynx may also occur. The pulse is often hard and tense, and, though slow at first, it may become accelerated later. Cardiac hypertrophy of a slight degree may be detected. The aortic second sound is accentuated. Epistaxis is an occasional symptom, and subconjunctival hemorrhages are sometimes seen as a result of uremic convulsions that may not have been witnessed. A very constant symptom is the dry, anemic skin. Uremic manifestations may ensue at any time during the course of the disease. They appear early in the most severe cases, with intense headache and backache, vom- iting, and convulsions. The clinical course in other cases differs somewhat from the above, which may be considered as the common form resulting from exposure. Acute nephritis occurring as a complication of the infectious fevers, except scarlatina, may be characterized by the very slight degree, or even by 974 DISEASES OF THE URINARY SYSTEM. the absence, of dropsy. Albuminuria, hematuria, anemia, and uremia supervene in the graver affections. In scarlatinal nephritis, hoAvever, ana- sarca is common, and slight edema at least is quite constant. In mild affec- tions simply a little albumin and a few hyaline casts reveal the paren- chymatous degeneration. In cases of degenerative nephritis due to min- eral poisoning the subsidence of the acute toxic symptoms may be fol- loAved by the typhoid condition, marked by prostration, muscular twitch- ings, stupor, coma, and death. In the so-called nephro-typhoid condition, Avhere typhoid fever begins with pronounced symptoms of acute nephritis, hematuria may be marked. The nephritis of pregnancy is usually grad- ual in its onset. The albumin increases in amount from month to month, and reaches a high percentage during the eighth and ninth months. Some hyaline casts are found, but othenvise there are few morphologic elements, and erythrocytes rarely appear in the urine. Danger of eclampsia is constant until the child is delivered, but recovery is rapid after the birth of the child in uncomplicated cases. That variety of acute (productive) nephritis in Avhich there is a tend- ency to the formation of patches or wedges of fibrous tissue is charac- terized by higher fever, by cerebral and circulatory disturbances of a typhoid nature, and by anemia, dropsy, and a highly albuminous urine, even though blood may be absent and casts may be few. The dropsy is most apparent in the legs. Dyspnea, vomiting, diarrhea, and a progres- sive and rapid loss of flesh and strength ensue until convulsions or coma end in death. Milder cases, lasting from two to four Aveeks, apparently get Avell, albumin and casts persisting, however, until, after an interval of weeks or months, another and similar attack occurs. In short, the first acute attack is liable to chronic repetition until a fatal one takes place. Diagnosis.—The condition cannot be overlooked Avhen the urine is carefully examined both chemically and microscopically. The dreaded eclampsia gravidarum can, however, be recognized only by repeated urinary examination, especially during the last months of pregnancy. Acute Bright's disease should be suspected, and the urine examined in every case shoAving pallor of the skin and puffy eyelids, Avhether general prostration of the health is apparent or not. The characteristic symp- toms of acute exudative nephritis, as commonly seen Avhen the condition is due to cold or occurs in scarlet fever, are the following: headache, restlessness, muscular tAvitching, nausea and vomiting, a tense pulse, moderate fever, dropsy, and anemia. Tube-casts and albuminuria are constant. It should be borne in mind that slight albuminuria occurring in the course of pregnancy or during any of the fevers, without casts, is not a true nephritis, although the latter may be a more or less remote consequence of the glandular degeneration of the renal epithelium asso- ciated Avith the febrile albuminuria. In addition to the presence of albu- min and hyaline and cell-casts, hoAvever, a diminished quantity of sooty- looking urine and the discovery of red and Avhite blood-corpuscles will render the diagnosis positive. The history of the case and the causal factors are also to be taken into consideration. Prognosis.—The duration of ordinary exudative nephritis follow- ing exposure to cold and wet varies from a few days to three, four, or six Aveeks. The albuminuria steadily decreases, and Avith the casts finally disappears, Avhile the daily quantity of lighter urine increases, ACUTE NEPHRITIS. 975 as does the daily excretion of urea. The prognosis depends much upon the primary disease or causative condition, and also upon the intensity and character of the renal inflammation. Scarlatinal nephritis is less likely to be recovered from than nephritis due to exposure to cold after alcoholic excesses. The acute parenchymatous degeneration that accom- panies typhoid fever, diphtheria, and other infectious fevers, as well as pregnancy, is usually a mild affection and recovery takes place easily. But in acute yelloAV atrophy, yelloAV fever, cholera, and in severe phos- phorus- or mercurial poisoning death may occur from the intense and Avidespread necrosis of renal epithelium. In favorable cases of ordinary exudative nephritis the dropsy and albuminuria gradually diminish, Avhile the color of the skin and the quantity of urine and urea increase, so that in the course of from three to four or six Aveeks recoverv is established. After the disappearance of the dropsy the albumin may persist for some time, and then slowly disappear; but rarely, in unfavor- able cases, even when dropsy has disappeared, albuminuria may continue and the affection become a chronic parenchymatous nephritis. Serious and often dangerous symptoms of acute nephritis are—severe general edema, dropsical effusions into the serous sacs (as hydrothorax), uremia (especially when beginning Avith cerebral manifestations, as coma or convulsions), and finally inflammation of the internal organs, as pleu- ritis, pneumonitis, pericarditis, peritonitis, and meningitis. In the ab- sence of uremia recovery in cases of marked general dropsy is quite common. Suppression of urine, hoAvever, lasting more than twenty-four or forty-eight hours, is usually a fatal symptom. The prognosis is un- favorable also in cases in which the nephritis has a productive character. Life may, on the other hand, be prolonged for several years. Treatment.—I shall not include here the management of the pri- mary affection of Avhich the nephritis may be either a complication or consequence. Since the renal function is diminished by the congestion and inflam- mation, the first object in the treatment is to relieve these conditions and thus restore the excretory function. The single or combined use of diaphoretics and cathartics is practised, therefore, not that the skin and boAvels should be made to perform the Avork normally done by the kidneys, but in order to restore the functional equilibrium by the anti- phlogistic effect produced. Absolute rest in a Avarm bed and in a warm room is of primary im- portance. Woollen underwear and blankets should be provided, so as to promote a constant free action of the sweat-glands. These hygienic measures should be carried out both in the mild and in the severer cases. Bland liquid foods only should be alloAved in the diet, and the patient should be encouraged to drink freely of water (plain, distilled, or car- bonated), lemonade, skimmed milk, or buttermilk ; these are especially valuable when hot. Later, thin meat-broths may be allowed, although a strict milk diet is better. Local bloodletting, as by leeches or cupping over the loins, is seldom needed; in rare cases, however, Avhen much pain is complained of, they may be useful, although hot fomentations may be more so. Diminution of the edema and the elimination of urea and other urinary constituents that may be retained in acute nephritis are best obtained by exciting a 976 DISEASES OF THE URINARY SYSTEM. profuse perspiration. This vicarious action of the skin, as before stated, also relieves the congestion of the kidneys. The hot-air or hot-A\ater bath and the hot Avet-pack are also used to accomplish these results, and in most cases the last-named method suffices. It is easily applied by Avringing a blanket out of hot water, wrapping the patient in it, and then Avith a dry blanket, and finally a rubber-cloth cover, surrounding all. This furnishes a steam-bath in which the patient may remain until copious sweating has lasted an hour or so, according to the condition, Children suffering from scarlatinal nephritis may be treated thus, or quite readily also by immersion in hot water, for tAventy, thirty, or forty minutes; the skin should then be lightly dried, and the child wrapped in Avarm sheets or blankets and Avarmly covered in bed. Hot vapor or air may be generated alongside the bed, and transferred under the raised or cradled bed-clothes by means of a tin funnel and pipe. The sweating Avill be aided by the drinking of hot lemonade or soda-Avater or of Avater containing spirit of Mindererus. Should the skin fail to respond to these measures, as in uremia, perspiration may be started by a hypo- dermic injection of pilocarpin (gr. -| to ^—0.008 to 0.0108), after which it Avill continue to pour out on the application of heat. The heart and pulse should be Avatched after the injection of pilocarpin, as serious col- lapse sometimes attends its use. The sweatings should be repeated until the dropsy disappears and as often as the patient's strength will permit. A useful adjunct to the above is the administration of hydragogues, as the saline cathartics, elaterium, and compound jalap poAvder. Elaterium extract (gr. ^—\—0.0108-0.0162) is prompt in action, and magnesium or sodium sulphate (3j—4.0), given in hot concentrated solution every hour, or a calomel purge, may be recommended. It may be necessary to aid in relieving the tension and distress of extreme edema by multi- ple punctures or by the use of a small trocar and cannula, with a drain- age-tube (Southey) attached to the latter after the trocar is Avithdrawn. Aspiration must be performed if either hydro-thorax, hydro-pericardium, or ascites assumes serious proportions. Half-ounce (16.0) doses of the spirit of Mindererus (liq. ammon. acetat.) in water may be added to the diaphoretic treatment; this, combined Avith aconite, aids in controlling the fever that may be present and in preventing the vaso-constriction that is often premonitory of uremic symptoms. Uremic convulsions that do not soon yield to prompt diaphoresis and catharsis should be treated by venesection. As much as a pint or two (.5-1 liter) of blood may be Avithdrawn and life saved thereby. Some- times chloroform-inhalations are needed to subdue the very violent con- vulsive seizures, as in eclampsia. Their return may be prevented by rectal injections of potassium bromid and chloral, consisting of 1 dram (4.0) of the former and -§- dram (2.0) of the latter. Nausea and vomiting may be controlled by the use of cracked ice, minute doses of cocain, dilute hydrocyanic or hydrochloric acid, bis- muth, and by the addition of soda- or lime-water to the milk. Contraction of the arteries with increased tension and beginning muscular tAvitchings call for the use of nitroglycerin, chloral hydrate, or, possibly, morphin. Diuretics other than the simple diluent drinks mentioned have very little use in the therapy of acute diffuse nephritis, at least early in the CHRONIC NEPHRITIS. 977 disease. Later, as adjuvants to the diuretic properties of water, potas- sium bitartrate or acetate, sodium benzoate, and stimulants to aid cardiac depression at the same time, or caffein citrate and the infusion of digi- talis, may be given Avell diluted. During convalescence care must be exercised that the patient does not catch cold. The diet must not be increased to solids too sud- denly nor too rapidly, and particularly in the matter of meats. Light watery vegetables, fruits, and cereals may be gradually added to the diet-list, although milk should be mainly used. Ferruginous tonics are indicated for the anemia, and Basham's mixture is an admirable preparation at this stage. A change of locality to a warmer, drier, and more equable climate, and careful habits of dress, diet, and exercise, are necessary in cases of recovery from the very serious forms of nephritis, in which the renal parenchyma is shown by the persistence of slight albuminuria at inter- vals to have been somewhat damaged. CHRONIC NEPHRITIS (EXUDATIVE). (Chronic Brighfs Disease; Chronic Parenchymatous Nephritis; Chronic Diffuse Nephritis with Exudation ; Chronic Tubal and Chronic Desquamative Nephri- tis; Chronic Glomerulo-nephritis; Large White Kidney; Secondary or Fatty and Contracted Kidney.) Definition.—A chronic diffuse inflammation of the kidneys, at- tended with epithelial degeneration, exudation from the blood-vessels, and permanent connective-tissue changes in the stroma. According to Delafield, this is the chronic productive (or diffuse) nephritis with exu- dation—one of two varieties of chronic Bright's disease. Pathology.—Although there are several types of pathologic kidney in this disease, and many individual cases in which anatomic differences are noted, the changes of structure are essentially the same, and the variations depend upon the causation and duration of the nephritis. The first type of kidney to be mentioned is the large white kidney (Avithout waxy degeneration). It is either enlarged or normal in size, and pale or yellowish in color. The surface is smooth, and the capsule is easily stripped off. On section the cortex is broader than normally, yellowish-white throughout, or it may present opaque yellowish or whit- ish areas with mottlings of red. The pyramids are congested in some cases. Microscopically, the following changes are commonly observed: the renal epithelium is SAvollen, hyaline, granular, or fatty, and more or less disintegrated or flattened; the glomeruli are enlarged from the growth of the capsule-cells and of the cells covering the capillaries, and in some cases, owing to the connective-tissue thickening of the capsule, the tuft of capillaries is found to be atrophied. The interstitial tissue shoAvs some thickening of the arterial walls and a moderate growth of connective tissue in patches around the glomeruli and tubules ; the latter contain hyaline and granular casts. The small white kidney, or secondary contracted kidney, in most in- 62 978 DISEASES OF THE URINARY SYSTEM. stances is probably a later stage of the preceding, in which the degen- eration of epithelium is more advanced and the groAvth of connective tissue and resultant cicatricial contraction are prominent features. The kidneys are about normal in size (shrinkage of the large Avhite kidney). the surface is slightly granulated, and the capsule is proportionately ad- herent. While this kidney is usually grayish or yelloAvish in color (pale, granular kidney), there may be some mottling due to red spots. The consistence is firmer than that of the large Avhite kidney. The cut- surface shoAvs yellowish-wThite foci of the fatty degenerated epithelium in the someAvhat narroAved cortex, and hence the term that is sometimes used of "small, granular, fatty kidney." Under the microscope Ave find extensive degeneration and disintegration of the epithelium of the glomeruli and convoluted tubules, Avith atrophy of the parenchyma, and a corresponding increase of the interstitial connective tissue. Waxy degeneration may be associated. Another variety is the large red or variegated kidney of chronic hem- orrhagic nephritis. The organs are usually enlarged, SAvollen, red, and congested-looking or mottled, and frequently " bumpy" or slightly bossellated. The capsule is slightly adherent to the depressions between the bosses. Red spots, due to small hemorrhages, may be noticed on both the outer and cut-surfaces of the kidney. The section shows also congested portions and gray or yellow spots corresponding to the anemic and fatty degenerated portions. Small cortical hemorrhagic areas or striations, brownish-red in color, are distinctive of the kidney. The microscopic appearances are those of the large Avhite kidney plus those of acute nephritis—viz. granular and fatty degeneration, proliferation of epithelium, thickened glomeruli-capsules, atrophied capillary tufts, and a groAvth of interstitial fibrous tissue in some places. In others there are inflammatory edema and cellular infiltration of the intertubular tissue, and dilated tufts of capillaries Avith surrounding cellular hyper- plasia. This variety of chronic nephritis is frequently found in inebriates. Etiology.—The disease may follow either the acute diffuse nephri- tis, as of scarlet fever or pregnancy, or simple chronic congestion and chronic degeneration of the kidneys. More often it arises insidiously, in a subacute manner and Avithout any previous acute manifestation. Males are more frequently subject to this form of chronic Bright's disease than females. Children affected with the disease have usually had scarlatinal nephritis. Young adults are more commonly affected, however, with the usual variety, developing subacutely. Drinkers of beer and other malt and alcoholic intoxicants seem to be liable to the disease. It is not improbable that some toxic or infectious agency, acting sloAA7ly and persistently, may in the insidious cases be the cause of the nephritis, although manifestations elsewhere may be absent. It has been observed in certain individuals living in malarial regions. Persons working under exposure to cold and wet, or those living in humid and low, marshy localities, are more liable to this renal malady than those who are better protected from climatic vicissitudes. Tuberculosis, syphilis, and chronic suppuration may give rise to this so-called " parenchymatous " form of chronic Bright's disease, and it is usually combined Avith amyloid disease (Avaxy degeneration). Symptoms.—There may be a persistence, in a lesser degree, of the CHRONIC NEPHRITIS. 979 symptoms of an acute parenchymatous nephritis, particularly the anemia, dropsy, and the albuminuria, until the affection becomes chronic. In most cases, however, the disease develops sloAvly and gradually, in a subacute manner, though the earlier symptoms seldom indicate any renal derangement. There may be simply a general impairment of health and strength, loss of appetite, nausea, and attacks of indigestion, headache, dulness, and perhaps some pallor. Soon there is puffiness of the eyelids or SAvelling of the feet or ankles, or both, and the com- plexion takes on a blanched appearance. The edema gradually extends up the legs, and is often Avorse as the day grows, Avhile on rising in the morning it may be found to have disappeared during the night's rest and recumbency. The quantity of urine is diminished in the majority of cases, though in the later stages it may be nearly or quite normal, and even slightly increased in long-standing instances of pale contracted kidney or when absorption of the dropsy is taking place. Superadded acute nephritis may cause a very scanty or a suppressed secretion of urine. The specific gravity is, of course, increased in scanty urine, and vice versd. Albuminuria is often quite marked. The amount of albumin may be from one-fourth to three-fourths of the Aolume of the urine, or from 1 to 3 per cent, by weight, so that the daily loss of albumin may be considerable. The urea is much diminished. The color of the urine is turbid, sometimes smoky-yelloAv, and urates, casts, red and Avhite blood-cells, epithelial cells, granular debris, and fatty granular cells are found in the usually abundant sediment. The tube-casts are of different varieties, but narroAv or broad hyaline, fatty granular, and epithelial casts are commonly observed. The edema is prominent and persistent. It gradually extends all over the body, so that pitting can be obtained on the limbs, chest, abdo- men, and back. The loose subcutaneous tissues, as of the penis, scrotum, and eyelids, are particularly distended. In chronic hemorrhagic nephri- tis, only, the edema may be absent or very slight. The pasty, pallid complexion and anasarca are most characteristic of chronic exudative nephritis, especially with large Avhite kidney. The dropsy may be mod- erate and about stationary for several months; then, despite all treat- ment, it becomes insidiously worse, death ensuing in a month or two. Dropsy of the serous sacs, with its attendant distressing symptoms, may be present in serious cases, and edema of the larynx and lungs may come on suddenly and cause death. Dyspnea may be toxic and nervous, as well as mechanical or cardiac in origin. Cardiac dyspnea, due to failure of the heart's action as seen in many cases, is usually worse on lying down. It may be provoked by vaso-constriction, and is then a danger-signal of uremia. Catarrhal bronchitis may be associated Avith cough and expectoration. The heart is often affected with moderate hypertrophy of the left ventricle, and later by dilatation and Aveakness of both ventricles. The aortic second sound is accentuated and the pulse-tension increased. Uremic symptoms are frequently manifested, except the convulsions which are common to chronic nephritis without exudation. Headache, vertigo, sleeplessness, nausea and vomiting, diarrhea, and stupor, coma, or delirium, may develop and precede a fatal termination. Albuminuric neuro-retinitis, as evidenced by dimness of vision and 980 DISEASES OF THE URINARY SYSTEM. field-defects, occurs in quite a number of cases. The skin of the legs becomes subject to a red eczematous eruption in some cases of great dropsical distention. In the absence of complicating inflammations, such as pericarditis, endocarditis, pneumonitis, and ulcerative colitis, which are rare, the temperature is practically normal. The course of chronic exudative nephritis may either continue from bad to Avorse, until death ends all in a year or tAvo, or anemia, dropsy, and albuminuria may attack one who for years previous has had apparent good health, after a first attack the second proving fatal within a few months. Again, some patients, having a little pallor, slightly diminished urine of high specific gravity, with albumin, may complain of nothing for years, until decided attacks, lasting for several months, may occur at intervals, during which the dropsy, dyspnea, etc. may be absent, although some albuminuria persists. The average duration of the disease varies from one and a half to three years. Diagnosis.—The diagnosis of the disease itself is not difficult, but of the stage or the variety of kidney it is almost impossible to tell cor- rectly in some instances. The urinary examination, coupled with the symptoms of dropsy and anemia, is sufficiently diagnostic of chronic diffuse nephritis (with exudation). In cases of large white kidney the urine passed is less in quantity and of higher specific gravity than in the small, pale, and contracted kidney. Edema is usually greater in the former also, while in the latter cardio-vascular changes are more marked, as shoAvn by the physical signs and the hard pulse. The transition of the disease from the earlier to the later stage may be thus noted. The existence of hemorrhagic kidney may be inferred from the chronic congestion of the kidney and alcohol- ism and the presence of marked red blood-corpuscles and blood-casts in the urine. The duration of the latter form of chronic nephritis may be somewhat longer (eight months to tAvo years) than that of the large Avhite kidney (six to eighteen months), but it is shorter than the second- ary, contracted kidney, which lasts from one and a half to three or even five years. The casts in the latter may also be narrower and more darkly granular than in the large white kidney. Chronic parenchymatous is distinguished from chronic interstitial nephritis by the folloAving points of difference: Chronic Parenchymatous Nephritis. Occurs in early or middle life. There is a previous history of an acute attack of scarlet fever, or perhaps of acute alcoholism. The onset is gradual or markedly mani- fest. Dropsy is a constant symptom. Vascular changes and cerebral symptoms are comparatively uncommon. Marked albuminuria, with tube-casts. Urine but little increased in quantity, often diminished; specific gravity is increased or slightly diminished. Anemia occurs earlier and is more dis- tinct. Chronic Interstitial Nephritis. Occurs later in life. A previous history of gout, chronic lead- poisoning, syphilis, excessive eating and drinking (spirits), nerve-strain; otherwise often negative. The onset is very slow, insidious, and in- definite. Dropsy is rare. Arterio-sclerosis, cardiac hypertrophy, and cerebral symptoms are common. Very slight albuminuria and few casts. Urine of very low specific gravity, and excessive in quantity. Anemia slowly progressive and less marked. CHRONIC NEPHRITIS. 981 Chronic Parenchymatous Nephritis. Chronic Interstitial Nephritis. Uremic symptoms are generally less se- Uremic symptoms are, generally severe vere—amaurosis, vomiting, diarrhea, —coma and convulsions, great dyspnea. headache. Runs a shorter course—from two to six Has a more chronic course—seven to or seven years. thirty years. Prognosis.—This is invariably bad as to cure, though life may be prolonged in certain cases. In severe cases death may take place in from three months to a year, either from uremia, dropsy, cardiac dilatation, or complications. Cases of a year's duration almost never recover, and, a fortiori, those in which advanced secondary contraction of the kidney may be inferred are incurable, and may soon terminate fatally. Com- plete recoveries from the disease, particularly in children that have had scarlet fever, may occur but rarely. The prognosis depends greatly on the quantity of urine passed in the twenty-four hours, and upon the amount and persistency of the albumin, as well as upon the degree of cardio-vascular and retinal changes. It should be remembered that acute attacks may supervene, and that relapses may occur in apparently favor- able cases. Treatment.—The indications for treatment are similar to those in acute nephritis. The dropsy and uremia must be treated symptomatically, and the diet is of importance. Skimmed milk and buttermilk should be depended on as.much as possible when dropsy is pronounced. When dropsy is slight, more solid food, white meats, vegetables, and fruits, and an out-door life, should be recommended. Residence in a warm, dry climate may aid in prolonging life. Wool- lens should be worn next to the skin, and prolonged, sudden, and severe exercise should be forbidden. The infusion of digitalis may be needed in cardiac weakness, or nitro- glycerin for contracted and tense arteries with a tendency to uremic twitchings. Unirritating diuretics and Basham's mixture for the anemia are useful. Strontium lactate in doses of from 15 to 20 grains (0.972- 1.29), three or four times daily, may be tried in some cases. CHRONIC NEPHRITIS (NON-EXUDATIVE). (Chronic Interstitial Nephritis; Chronic Bright's Disease; Primary, or Genuine, Contracted Kidney; Cirrhotic Kidney; Red Granular Kidney; Renal Arterio- sclerosis ; Chronic Productive (Diffuse) Nephritis without Exudation (Delafield); Gouty Kidney.) Definition.—A chronic diffuse inflammation of the kidneys, attended with a growth of connective tissue in the stroma, degeneration and atrophy of the renal parenchyma, and marked change in the cardio- vascular system. Pathology.—In genuine primary contraction of the kidneys there is a reduction in size and weight about equal in both organs. They may be only one-half or one-third the size of normal kidneys, and the two kidneys together may not weigh over two ounces. They are often 982 DISEASES OF THE URINARY SYSTEM. found imbedded in thick adipose tissue, the capsule being thick, opaque, and very adherent, so that on stripping it off it brings aAvay portions of the renal cortex. The outer surface of the kidney is red, irregularly granular, or finely nodular, and occasional small cysts are sometimes present. The consistence is firm, dense, and resistant to the knife. Ex- amination of the cut-surface shoAvs a thin atrophied cortex, and dark, reddish streaks alternating with pale portions. The pyramids are also diminished, and darker than the cortex. In the gouty contracted kidney the pyramids show fine striations of sodium urate or of uric acid, or crys- tals representing uric-acid infarctions. Microscopically, the essential changes are an increased production of connective tissue, especially in the cortical substance, and a more or less proportionate degeneration and atrophy of the renal parenchyma, the destruction of which is due to the circulation of noxious agents, but which is replaced by cicatricial fibrous tissue (Weigert). The new tissue is not uniformly distributed in the cortex, but occurs in irregular masses around the shrunken glomeruli or between the tubules. The distribution of connective tissue in the pyramids is more diffuse. Many of the glomeruli are quite small and fibrous in advanced cases, while in the earlier cases the cells of the tufts and capsules are swollen and multiplied, and a small-celled infiltration is seen around the glom- eruli and tubules. Later this infiltration of cells becomes fibrillated and ends in thickening. Glomerular atrophy is due partly to the changes in and growth of the capillary and intra-capillary cells, as well as of those around the tufts; partly also to capsular thickening and hyaline or waxy degeneration; and partly to the thickening and occlusion of arterioles. The tubules show marked changes. Some are included in masses of connective tissue, so that there is compression-atrophy and even total oblit- eration of the lumen. In other instances the intertubular connective tissue constricts the tubules in certain places, so that the lumen is else- where increased. This dilatation is especially prominent in the granules seen on the outer surface of the kidney, and, owing to the damming back of urine in some of the tubules thus obstructed, little cysts are visible to the naked eye here and there. The epithelium lining these tubules shows granular, fatty, or Avaxy degeneration, and may be either flattened, cuboid, or SAvollen. The tubes may contain granular or fatty debris and tube-casts. An important change in most cases is the groAvth of fibrous tissue in the walls of the arteries, causing sclerosis. This affects the intima (end- arteritis), the media, and adventitia, all of which are thickened by the hyperplasia of connective-tissue elements. The arteries and capillaries are thus nrostly occluded by the obliterating endarteritis or by their con- version into masses of connective tissue. Waxy or hyaline degeneration is seen also (vide Arterio-sclerosis). These arterio-capillary changes may in some cases be the primary condition that leads to granular and con- tracted kidneys, and may represent the renal effects of a general arterio- sclerosis or fibrosis. An almost constant accompaniment of chronic, non-exudative, produc- tive nephritis is cardiac hypertrophy. The degree of the latter depends upon the extent of the renal, and also of the general arterial, degener- CHRONIC NEPHRITIS. 983 ation and sclerosis. The whole heart may become so large that the term cor bovinum has been fittingly applied to it. In moderate enlarge- ments the left ventricle only is hypertrophied. Complicating lesions of chronic Bright's disease that may be men- tioned are cerebral hemorrhage, cirrhosis of the liver, pulmonary em- physema, chronic endocarditis, chronic endarteritis, pericarditis, bron- chitis, and gastric catarrh. Etiology.—The cause of the very slow primary, diffuse degenera- tion, atrophy, and fibroid contraction of the kidneys is sometimes quite obscure, (a) In some cases it Avould seem to be "only an anticipation of the gradual changes Avhich take place in the organ in extreme old age " (Osier)—the " senile kidney." (b) Heredity undoubtedly plays a part in the causation of certain cases, even to the third or fourth gene- ration, (c) Age and Sex.—The disease is more common in males than in females, and it usually begins near middle life; it is seldom manifested symptomatically until about fifty or sixty years of age, and is therefore an affection of advanced life, (d) Individuals having a special tendency to sclerotic degeneration of the arteries, from whatever injurious influ- ence, Avhether chemico-toxic or parasitic, are more liable to chronic in- terstitial nephritis, although the prolonged irritation of such deleterious agents may give rise to the disease in those whose cellular nutrition is usually not defective. Thus, the folloAving causes have been attributed to the disease : alcoholism, uric acid, and lead, giving rise to chronic poisoning. Chronic syphilis and chronic malaria probably also are caus- ative factors, (e) Habitual overeating and drinking, OAving to the imper- fect metabolism of the substances ingested, causes a constant excretion of irritating products by the kidney, and no doubt frequently causes granular atrophy and sclerosis of the organ. The continuous and even moderate use of alcohol for many years, especially of spirituous liquors, is a widespread cause of the disease. It is equally likely that the ex- cessive use of red meats in the diet leads to the production of the uric acid that induces the renal disorder (uricemia-lithemia) by deranging the function of the liver (Murchison). (/) Allied to the above is gout, which causes chronic Bright's disease—in England perhaps more than in this country, where lithemia and nervous dyspepsia are more common. (g) According to Striimpell, severe acute articular rheumatism is some- times folloAved by contracted kidney, (h) Chronic Bright's disease with renal sclerosis is favored in origin and development by the anxieties, worries, and high nervous tension connected with modern business ac- tivity and "social functions," the latter particularly acting their part among elderly ladies. Associated with these are usually over-indul- gence in rich foods and Avines and sedentary habits, (i) The cold, moist climate of New England and the Middle States would seem, ac- cording to Purdy, to predispose to contracted kidney. A chronic pro- ductive nephritis without exudation, though not the true "contracted and red granular " kidney, may be caused by hydronephrosis, chronic pyelitis, and chronic congestion of the kidney, as from heart-disease. Symptoms.—These may be latent for years, Avhile the morbid pro- ductive changes in the kidneys are sloAvly effected. The first symptoms may not appear until late in life, although the kidneys may be in an advanced stage of degeneration. Or some complicating or intercurrent 984 DISEASES OF THE URINARY SYSTEM. affection may set in, as pneumonia or pericarditis, and cause the de- velopment of grave or fatal renal symptoms. More commonly, hoAV- ever, there is an attack of uremia, Avith headache, stupor, or convulsions, dyspnea, nausea and vomiting, and a tense pulse. This attack may be recovered from. Then there is an interval of variable duration, during Avhich the health is more or less impaired, and lassitude, drowsiness, disordered digestion, headache, failing vision, dyspnea, and frequent micturition are complained of. This is folloAved by another uremic attack, severer than the first, or perhaps fatal; if not fatal, the general health is still more reduced, and confinement to the house or bed is necessary, until the vital forces can no longer compensate for the destruc- tion of the renal parenchyma. Spasmodic dyspnea (uremic-cardiac) is sometimes the first manifesta- tion of contracted kidney. The gradual onset of periods of uncon- trollable droAvsiness during the day is often marked. An attack of hemiplegia may also be the first indication of renal disease. Sometimes progressive loss of flesh and strength, Avith a dry, harsh, wrinkled skin, may be from the beginning the only clinical features of the affection until death results from sheer feebleness and emaciation. The complex- ity and variability of the symptoms make it best to describe them under the heads of the various systems: Urinary System.—The daily quantity of urine is usually increased so much that patients are troubled Avith a desire to urinate frequently, not only during the day, but tAvo or three times during the night. This complaint may be aggravated by the hyperacidity of the urine and the irritability of the prostate (especially in advanced age) that are so often associated Avith cases of renal cirrhosis. The urine voided during the twenty-four hours may measure several quarts (2 to 4 liters) in well- marked cases of the disease. Early in the attack, Avhen the incipient degeneration and destruction of the parenchymatous cells is taking place, the quantity of urine may be slightly decreased ; but as the " blood-flow to the parts that remain must, ccvtcris paribus, be as great as it would have been to the Avhole of the organs if they had been in- tact," excessive pressure is brought to bear Avithin the capillaries by the compensating hypertrophy of the heart, and the secretion of the urine, especially of the watery elements, becomes more active. The polyuria may give rise to a suspicion of diabetes. The urine is clear and pale- yelloAv in color, the specific gravity being seldom above 1010 or 1012, and it may be as low as 1002 or 1005. Albumin is found only in traces or it may be absent altogether (glomerular atrophy), especially in urine voided in the early morning. The urea is diminished, as in all forms of Bright's disease, and there is little or no sediment. A very careful microscopic examination may reveal a few, usually narrow, hya- line or granular casts, perhaps some leukocytes, and rarely a feAv ery- throcytes. In the later stages of the disease or upon the supervention of an uremic exacerbation or of a complicating inflammation the urine may be decreased, the albumin increased, and numerous casts be discovered in a more apparent urinary sediment. Hematuria is rare. Circulatory System.—The physical signs of cardiac hypertrophy (of the left ventricle in particular) are present. Symptoms referable to the heart are absent, unless dilatation and feebleness, sudden arterial con- CHRONIC NEPHRITIS. 985 traction, cardiac complications, or endocarditis occur. Inspection and palpation of the hypertrophied heart show an apex-beat displaced down- ward and to the left, and an increased, heaving, and rather circumscribed apical impulse. These signs may be less evident both in cases of coex- isting emphysema and later Avhen dilatation may eclipse the hypertrophy. The left border of the deep cardiac dulness extends outside the nipple- line in the fifth or sixth interspace. The first sound of the heart is loud, and may be duplicated. A distinctive auscultatory sign is the accentuation of the aortic second sound, indicating increased vascular tension ; it may have a metallic quality in some cases. A mitral sys- tolic murmur may also develop, owing to relative insufficiency. The pulse is increased in tension, and is hard, incompressible, and persistent, the duration of each pulse-wa\Te being increased (pulsus tar- dus). The radial artery itself—and this is true of most of the palpable arteries—feels hard, thickened, and often tortuous, on account of the arterio-sclerosis. As soon as compensation of the heart fails, symptoms of breathlessness (especially on exertion), palpitation, and the like appear, and sometimes in paroxysmal attacks ("cardiac asthma"). The resultant stasis gives rise to transudation into the lungs (bron- chorrhea-pulmonary edema), and later to edema of the extremities. Respiratory System.—Epistaxis may be a serious symptom. Sudden edema of the larynx may also occur, and is always grave. Transuda- tions into the pleural sac (hydrothorax), as well as into the lungs (vide supra), may precede death. Dyspnea, which is either cardiac or uremic, is usually worse at night, and a true orthopnea, together Avith Cheyne-Stokes breathing, may be observed toAvard the end of the pa- tient's life and in association with uremic stupor and coma. Nervous System.—Symptoms referable to the nervous system are very important, since they are usually indicative of grave uremia. Cephal- algia is frequent, and neuralgic pains throughout the body, and insom- nia, may be complained of. Later great drowsiness is often a premo- nition of uremic coma. Convulsions may be preceded by muscular twitchings, which should attract attention to the imminent danger of the former. Cerebral apoplexy with hemiplegia may be the first symptom of contracted kidney. It is especially apt to occur in cases of marked hardening and weakening of the arteries. There may be an hemorrhagic pachymeningitis, as well as a hemorrhage into the brain-substance. The hemiplegia may persist until death, or it may disappear in a short time, and be followed by subsequent attacks at in- tervals. Formication, numbness, and pallor of one or more fingers (the so-called "dead finger") is believed by Dieulafoy to be sometimes the earliest symptoms of chronic Bright's disease. Of the special senses, nephritic retinitis is often the earliest evidence of chronic Bright's disease. The patient may or may not have had slight dimness of vision (mistiness) prior to the ophthalmoscopic exami- nation. The loss of vision affects both eyes, and is usually partial (am- blyopia). Sudden and complete blindness may come on in grave cases —uremic amaurosis—the condition being due to a neuro-retinitis. The optic papilla is SAvollen, and surrounded by retinal hemorrhages or by Avhite dots and streaks (" feather-splashes "). Tinnitus aurium, deafness, and vertigo are not uncommon. 986 DISEASES OF THE URINARY SYSTEM. Digestive System.—Anorexia, nausea, and annoying dyspepsia are often complained of. Severe vomiting may usher in an uremic attack. Catarrhal gastritis may exist for some time, the tongue being coated and the breath heavy and urinous. Uremic diarrhea may also occur. The Skin.—Edema is usually absent in renal sclerosis; Avhen it does occur, hoAvever (as in the ankles and limbs), it is due to dilatation and failure of the heart. The skin is dry, and minute lustrous scales of urea may be seen around some of the pores. A certain degree of pallor is noticed, and often the skin has a cyanotic tinge. Pruritus and trouble- some eczema are frequently present, and muscular cramps, occurring especially in the calves of the legs and at night, may also be associated. The general nutrition gradually fails, so that in advanced cases the debility and emaciation are extreme. It is important to bear in mind the fact that uremia may come on at any time during the course of the disease, and that it may be the first symptomatic manifestation ; also that it may either be sudden and severe in its onset (acute uremia) or mild, insidious, and gradual (chronic uremia). Moderate fever may attend an uremic attack, or the tempera- ture may be normal; in chronic uremia, with prostration, coma, delir- ium, and feeble pulse, it may be even subnormal. Among the complications that may occur in the red, granular, and contracted kidney are the following: pneumonia, either lobar or lobu- lar ; pleuritis, pericarditis, laryngitis, bronchitis, gastritis, enteritis, peritonitis, meningitis, endocarditis, emphysema, phthisis, and hepatic cirrhosis. Diagnosis.—This depends in great part upon the physical, chemi- cal, and histologic examination of the urine. Both the morning and evening urine should be examined repeatedly for albumin and casts, since one examination—and especially that of the morning urine—may give negative results, owing both to the scarcity of these two pathologic elements and to the fact that albumin may be altogether absent in some instances. The mere discovery of a trace of albumin or of a few casts is not ahvays positive evidence of chronic Bright's disease, as both may exist in other conditions. But the age, habits, and symp- toms of the patient must be studied in connection with frequent urinary examinations; and a persistent slight albuminuria, with casts, and the passage daily of large quantities of clear, pale urine of Ioav specific gravity, afford sufficient grounds for making the diagnosis. Contracted kidney should be suspected in all cases in Avhich, during middle life, either one or more of the folioAving symptoms and signs may be noticed: frequent headache, congestive disorders, repeated epistaxis, vertigo, dimness of vision, impaired strength, dyspneic attacks, gastro- intestinal dyspepsia, noises in the ear, itching of the skin, cramps in the calves, muscular tAvitchings, groAving mental dulness, increasing pulse- tension, and a rigidity and tortuosity of the temporal and radial arteries. Sudden coma, convulsions, amaurosis, apoplexy, vomiting, or dyspnea in persons in the middle period of life, Avith or without a history of polyu- ria, should create the suspicion of chronic Bright's disease. It will be found in such cases that there has been a diminution in the urinary flow before the attack. Persons of lithemic, gouty, rheumatic, or alcoholic habits, or in Avhom lead-toxemia is discoverable, Avith evidences of car- CHRONIC NEPHRITIS. 987 diac hypertrophy, an accentuated aortic second sound, and a hard pulse, are often readily diagnosed as subjects of contracted kidney when a fur- ther examination of the urine is made. * The diagnosis may be very difficult, however, in cases in which the first examination of the patient is made during a sudden uremic or apo- plectic attack. Catheterization should be done if necessary, and the detection of albuminuria Avill then clear the diagnosis. In order to differentiate between primary renal affection Avith second- ary cardiac hypertrophy and primary heart-disease with a secondary con- gested kidney occurring late in the case, the general features, course, symptoms, and signs must be carefully and judiciously balanced. Prom- inent cardio-vascular changes Avould indicate an arterio-sclerotic kidney, rather than the primary granular and contracted kidney of toxic origin, though even here the diagnosis is often as difficult as it is unnecessary from a therapeutic standpoint. Prognosis.—The duration of chronic interstitial nephritis varies. In uncomplicated cases it may last for five, ten, twTenty, or possibly thirty years. Complications or intercurrent affections may, hoAvever, shorten the duration very much, or the existence of the condition may be un- known, as frequently happens, Avhen the postmortem examination shoAvs the characteristic kidneys in one Avho during life had no symptoms indi- cating renal disease, and Avhose death Avas caused by some intercurrent disease. Chronic Bright's disease with contracted kidneys destroys life sooner or later unless the patient dies from some intercurrent disease. The gradual destruction of the renal parenchyma and its replacement by scar-tissue cause irreparable damage to the organs. On the other hand, the fact that the process is usually a slow one and its duration long is compatible Avith the preservation of life for many years, and with comparative comfort, even, in many instances. The prognosis in a given case depends very much upon the general constitutional condition, the cardio-vascular state, and the presence or absence of uremia and inflam- matory complications. Cardiac dilatation and insufficiency indicate a not far distant end. Convulsive and apoplectic seizures are often fatal, and hemorrhages, persistent vomiting, and diarrhea, retinitis nephritica, coma, and delirium render the prognosis as to further systemic toler- ance of the degenerated kidneys exceedingly grave. Treatment.—An early recognition of the disease and the steadfast practice of careful hygienic measures will prevent, to a considerable degree, the advance of the cirrhotic changes. Noxious substances enter- ing into the etiology of the affection must be avoided and removed as far as possible. The formation of uric acid must be reduced by dietetic management, alcoholics must be interdicted, and lead—when the cause of the condition—must be kept from further poisoning the system by a change of occupation. By diminishing these irritants the heart and blood-vessels are also conserved—a point of vital importance. The hygienic treatment must embrace a regulation of all the habits of body and modes of life. The patient must be treated, and not his malady, since that is incurable. A dietary that is suitable for each in- dividual case must be made out, and on general principles. Saundby's rule is a good guide: "Eat very sparingly of butcher's meat; avoid malt liquors, spirits, and strong wines." An exclusive milk diet may 988 DISEASES OF THE URINARY SYSTEM. be necessary for short periods when gastric irritation is present, but in such a chronic disease undue Aveakness would result from a restriction to milk alone. A light, nourishing diet is therefore to be recommended, and lean meat may be alloAved once daily in favorable cases. Vege- tables, greens, fruits, and light, Avell-cooked farinaceous articles may also be partaken of, and tea, coffee, and cocoa may be drunk. The use of natural mineral Avaters aids in the renal circulation and keeps the kidneys flushed. In general a mixed diet Avill be of advantage; the nitrogenous and carbohydrate elements (sugars and starches) are used in limited amounts, while pure fats and fruits (raAv or cooked) are to be recommended. Stout persons and those leading sedentary lives should have less food than those taking exercise, and gastric disorder requires the elimination of all but soft, bland foods, or a liquid diet until diges- tion is restored. Extremes of bodily, mental, and emotional activity should be avoided, and physical exercise should be moderate, regular, and taken in the open air, provided the latter be warm and dry. Men- tal labor should never be excessive, nor should the patient be subjected to the vicissitudes of worry, anxiety, or competitive tension. Venereal excitement and indulgence of any kind tending to unbalance the self- control or disturb the equanimity, cheerfulness, and contentment should be strictly forbidden and guarded against. A change of residence to a Avarm, mild, and dry climate is often of service in prolonging life. The variability and humidity of temperate climates, particularly during the Avinter months, aggravate this disease, while a sea-voyage or a sojourn at some southern European resort may be very beneficial to one who can afford it. The indications for medicinal treatment are principally as folloAvs: The bowels should be kept free by the aid of laxatives or laxative alka- line mineral waters. Papoid, peptenzyme, and other digestants, with bitter tonics, are useful in some cases in Avhich a furred tongue and indi- gestion are troublesome. Acids or alkalies, according to special indica- tions, may also be used simultaneously. An increased vascular tension (vaso-constriction), such as to place a serious strain upon the heart; the other extreme, of a very Ioav tension that induces dropsy ; and compli- cations, usually uremic (convulsions, dyspnea, headache), also call for therapeutic assistance. High tension is to be met by the cautious use of nitroglycerin in gradually ascending doses, beginning Avith 1 minim (0.066) three or four times daily, until all danger of rupture of the ves- sels seems to be past. Headache, vertigo, and the so-called renal asth- ma (dyspnea) are also often relieved by this drug. Loav tension, Avith signs of cardiac dilatation, scanty albuminous urine, and edema, requires heart-tonics and stimulants, in conjunction Avith purgatives. Digitalis (preferably in infusion) has good effects, especially when combined Avith strychnin nitrate or Avith caffein citrate. Calomel and the salines should be given for the dropsy. Uremic symptoms should be treated as in acute Bright's disease by causing profuse SAveating and free catharsis, and in some cases by phle- botomy. Inhalation of amyl nitrite or chloroform, or, Avhat is often a useful and necessary measure, the hypodermic injection of morphin (gr. ^—0.0108), may be tried in convulsions, severe headache, or dyspnea. Contracted kidney of a probable malarial or syphilitic origin may be PYELITIS. 989 benefited someAvhat by the use of arsenic and the iodids respectively; but no drugs can possibly restore the destroyed renal parenchyma or transform connective-tissue cells into secreting kidney-cells. PYELITIS. (Pyelo-nephritis; Pyonephrosis.) Definition.—Inflammation of the pelvis of the kidney. The com- pound terms above (in italics) represent an inflammation of the kidney- structure as a result of, and combined with, pyelitis. Pathology.—In the mildest varieties of pyelitis (the catarrhal) the morbid changes consist simply of a reddened, SAvollen, and turbid mucous membrane, covered with an exudation of viscid muco-pus and desqua- mated epithelium. Ecchymoses are sometimes seen. The urine in the pelvis of the kidney is also turbid from the admixed pus-corpuscles and pelvic epithelium. In calculous pyelitis, OAving to prolonged and severe irritation, purulent inflammation and ulceration prevail, and the kidney- structure is also involved by extension (pyelo-nephritis). Renal ab- scesses are thus formed, and small dark calculi are frequently found mingled with the pus in quite a number of small abscess-cavities; or perhaps, as noted before (vide Nephrolithiasis), one large abscess-cavity may replace the destroyed renal parenchyma (pyonephrosis). A diphtheritic inflammation, Avith the formation of a false membrane and sloughing of the pelvis, sometimes folloAvs the severe infections of the specific fevers. Marked hemorrhagic areas may be seen also. In tuberculous pyelitis there is usually an association of nephritis with areas of tuberculous softening and ulceration, and later pyonephrosis. In very chronic and sluggish cases the pyelitis may be followed by an infiltration of the kidney-structure with cheesy or putty-like masses that may become the seat of calcification. Persistent obstruction leading to pyelitis is associated with dilatation of the pelvis from retention of urine or of pus (pyonephrosis). This in turn, from prolonged pressure, causes the marked atrophy of the secret- ing structure of the kidney that is seen in such cases. There is also an increase in the interstitial tissue and secondary contraction. The so-called surgical kidney is found when an acute bilateral pye- litis, folloAving a severe cystitis, has excited an acute suppurative in- flammation of the kidney. Acute suppurative or interstitial inflamma- tion of the kidney due to metastatic or miliary abscesses is considered under the heading Pyemia (vide p. 199). Etiology.—Pyelitis rarely is primary or independent in origin, as after exposure to cold and wet. The secondary causes of pyelitis are as folloAvs: (1) renal calculi (the most frequent); (2) extension upward of urethritis, cystitis, or ureteritis; (3) retention of decomposed urine in the pelvis of the kidney ; (4) renal affections, as tubercle, carcino- ma, and acute nephritis; (5) specific fevers; (6) foreign bodies, other than stone in the pelvis ; (7) irritating diuretics. To point out briefly certain additional facts bearing upon the above in the order named, it 990 DISEASES OF THE URINARY SYSTEM. should be mentioned that calculous pyelitis may result from the irrita- tion of the constant presence and passage of small stones ("gravel "), or even of uric-acid " sand," as well as from the large dendritic concre- tions that send offshoots into the calyces. Extensions of inflammation to the pelvis from lower portions of the urinary tract may occur in pro- tracted cases of such affections as gonorrheal urethritis aud puerperal and calculous cystitis. Obstructive pyelitis sometimes folloAvs the im- paction of renal calculi or of other foreign bodies in the ureter Avhen there is pre-existing inflammation of the tract, or Avhen, as usually hap- pens, there is chemical irritation from the decomposition of the accumu- lated urine. There may be obstruction in the bladder and urethra, as from enlarged prostatic tumors, stricture, phimosis, and paralysis of the sphincter vesicse, or as in paraplegia. LTnder the consideration of tuber- culosis and carcinoma of the kidney is included the involvement of the pelvis by these conditions. Infectious pyelitis may also result from small-pox, diphtheria, typhus and typhoid fevers, and scarlatina, and it depends upon the irritating effect of certain substances eliminated by the kidneys. It is usually associated with more or less nephritis (pyelo- nephritis). Parasites, such as the echinococcus (hydatids), distoma, strongylus, and filaria, may give rise to pyelitis. Cantharides", cubebs, copaiba, turpentine, and diabetic urine even, may in rare instances also excite a pyelitis. Symptoms.—These are frequently overshadowed by those of the primary condition that causes the pyelitis: they are varied also for the same reason. The clinical manifestations of a simple catarrhal pyelitis are slight pain and tenderness in the region of the affected kidney or kidneys, mild fever, Avith a turbid urine of acid reaction, shoAving a few pus-cells, a little mucus, rarely some red blood-corpuscles, and a trace of albumin. In the severer varieties, as in calculous pyelitis, especially Avhen there are attacks of renal colic, the urine frequently show's to the naked eye the presence of blood and a marked amount of pus, some mucus, and the transitional caudate epithelial cells from the middle layers of the mucosa. The presence of the latter, hoAvever, is not constant, hence its absence does not exclude the existence of a pyelitis, since some of the most destructive forms of the affection, as the acute or chronic suppurative or the pyelo-nephritic, may be unaccompanied by the presence of the pelvic epithelium in the urine. This holds still more true in the case of true pyonephrosis, in Avhich the kidney usually becomes one large abscess. In severe pyelitis the pain is often acute, coursing down the ureters. The fever is moderate, and there are present the common symptoms de- scribed under Nephrolithiasis (vide p. 966). The fever in purulent pyelitis (pyonephrosis) and pyelo-nephritis takes on a hectic or typhoid type. Paroxysms of rigors or chills, fol- loAved by a rapid rise in temperature and ending in perspiration, may be observed, or there may be marked prostration and feebleness of cir- culation, delirium, and stupor. The temperature-curve runs an irregu- lar course, Avith marked remissions, in cases of a pyemic nature. In obstructive pyelitis the urine sometimes flows freely and nor- mally for a Avhile, until the developing pain over the inflamed kidney PYELITIS. 991 ends in relief by the expulsion of the obstacle and the passage of puru- lent urine. This alternation of normal with pyoid urine is indicative of a unilateral pyelitis. Ammoniacal urine is met with in cysto-pyelitis. Albuminuria is de- cidedly shown according to the degree of pyuria. In chronic suppurative pyelitis or pyelo-nephritis the pyuria is vari- able both in quantity and constancy. Intermittent pyuria may be due to the temporary blocking of the ureter by a stone (vide Obstructive Pyelitis). The pus is seldom mixed Avith epithelium in chronic purulent pyelitis. The associated intermittent fever may be like that of tubercu- lous pyelitis, and marked prostration, anemia, and emaciation are con- comitants. Evidences of amyloid change may be revealed in long-stand- ing, chronic cases. The term ammoniemia has been applied to that complexus of nervous symptoms that is supposed to arise from the decomposition and absorption of urinary substances. These symptoms may be similar to the manifesta- tions of diabetic coma. Distinct enlargement and fluctuation of the diseased kidney may be determined in some cases of pyonephrosis. This may also be inter- mittent, being detectable while there is obstruction to the flow of pus, and vice versd. According to A. H. Smith, at the menstrual periods pyelitis may be subject to marked exacerbations, simulating renal colic. In chronic pyelitis with atrophy of the kidney the onset of uremia may terminate the case. Granular kidney alone may have been simulated by the passage of an increased quantity of urine of proportionately low specific gravity. Diagnosis.—This embraces the discrimination from other affections, and the possible detection of the variety—etiologically considered—of the pyelitis. It is most important to pay attention to the clinical history of any case with a vieAv to the discovery of the cause; also the urinary con- dition must be carefully studied. In the very nature of this affection it is often impossible to exclude other affections of the urinary tract, as nephritis, cystitis, and urethritis. Any severe inflammation of the tract in which the lower portion is known to be affected is generally associated with pyelitis or pyelo-nephritis, from the well-knoAATn tendency to exten- sion by continuity. Epithelium from the pelvis of the kidney cannot be distinguished from transitional bladder-cells; but, given the indications of a pyelitis, its cal- culous cause is at once made clear upon the passage of the characteristic uratic or oxalatic concretions. It may happen that the urine from one kidney is prevented from flowing by the impaction of a stone in the ureter. The urine may noAv flow clear from the other and vicariously acting kidney until, the stone having given way, it suddenly increases in quantity and changes in character, owing to the return of the mor- phologic elements of the pyelitis (corpuscles, desquamated epithelium, crystals, and de'bris). In women catheterization of the ureters and renal pelves, as described and practised by Pawlik and Kelly, is a most certain method of deter- mining in doubtful cases from which side the purulent urine arises. Pal- pation of the ureters through the lateral and anterior fornix of the vagina 992 DISEASES OF THE URINARY SYSTEM. will sometimes reveal thickening and tenderness in cysto-pyelitis, and ureteral distention sometimes may be felt in pyelitis calculosa. Vierordt mentions having seen in some cases of pyelo-nephritis pecu- liar hyaline casts " split like a pair of trousers." Casts and albumin are usually present Avhen the kidney-structure is involved by extension of the pyelitis, while marked pain in the region of the kidney indicates predom- inant pyelitis, though it does not exclude the possibility of coexisting nephritis. Marked vesical irritability points to associated cystitis, but in intense pyelitis with much pus and an acid urine vesical tenesmus may also be troublesome. Tuberculous can be discriminated from calculous pyelitis, possibly, only by the detection of the tubercle bacilli in the pus. The presence of a fluctuating tumor in the lumbar region is significant enough of pus, but it may be difficult to determine whether it is due to pyonephrosis or perinephric abscesses, although pyuria and the previous history of pyelitis, as well as the more circumscribed and less edematous character of the swelling of the former, are important distinguishing points. The hemorrhagic pyelitis of Senator, Delafield, and others, described as occurring in milder forms, and particularly in girls of neurotic types, may be distinguished by the intermittent hematuria and the occasional lumbar pain, lasting but a few days or a week, and followed uniformly by recovery. Digestive disturbances may be prominent in these cases. Much difficulty is sometimes experienced in diagnosticating pyelitis when coexistent with cystitis—pyelo-cystitis. These infections will not be confounded, however, when it is recollected that their histories differ, acid pus being usually present in the former, and evidences of ammoniacal decomposition in the latter (with alkalinity). There is also pain in one lumbar region in the former, and in the bladder in the latter. Prognosis.—Renal complications always make the pyelitis a serious affection. Catarrhal cases recover. Calculous pyelitis tends toward chronicity. Pyelo-nephritis and pyonephrosis are apt to end fatally from exhaustion or uremia. Perforation and the discharge of pus into the peri- toneal cavity, pleural sac, intestine, and bronchi even, may precede death. The gravity of all cases of pyelitis depends upon the causes and upon the tendency to consecutive suppuration. Treatment.—This varies according to the cause: the latter needs to be removed, its effects counteracted, and its return avoided. The treatment of calculous pyelitis is essentially the treatment of nephro- lithiasis. Primary inflammation of the lower portions of the urinary tract must be combated; causes of retention of decomposed urine, as an urethral stricture or enlarged prostate, must be diminished; infectious fevers must be judiciously handled and irritating diuretics Avithheld. Local measures are of value in all forms of pyelitis. Hot-water bags, fomentations, poultices, and dry cupping are often of great service. Internally, the use of diluents is to be recommended, especially the alkaline mineral waters, flaxseed tea, barley-Avater, skimmed and butter- milk, and lemonade. Potassium citrate, uva ursi, buchu, and pareira brava are some- times selected for their soothing properties. But, practically, none of the remedies named nor any other drug is of any avail when suppu- ration is once established. Irrigation by means of Kelly's ureteral HYDR ONEPHR OSIS. 993 catheter may be practised with good results in females. In chronic pyelitis salol and the oils of turpentine, sandalwood, juniper, copaiba, and erigeron have been used for their stimulating and alterative effects upon the mucous membrane. Surgical intervention is necessary in severe purulent pyelitis, pyelo-nephritis, and pyonephrosis. HYDRONEPHROSIS. Definition.—An obstructive accumulation of urinary fluid in the pelvis and calyces of the kidney; it may cause dilatation, pyelitis, or inflammation and atrophy of the renal structure. Pathology.—Hydronephrosis is usually unilateral. The pathologic changes consist of a dilatation of the pelvis of the kidney, associated Avith a degree of atrophy of the renal tissue depending upon the degree and persistence of the pressure. The accumulated fluid causes flatten- ing and atrophy of the papillae, and gradually of the tubules and glom- eruli, as the dilatation and distention increase, until in extreme cases remnants only of the renal structure remain in the Avails of the hydro- nephrotic cyst. The mucous membrane lining the pelvis and calyces first becomes thinned, and later thickened, by the groAvth of connective tissue, thus forming the dense sac-Avail. There is also a growth of con- nective tissue in the renal parenchyma, medullary and cortical, a chronic nephritis Avith degeneration and atrophy of the renal cells being set up. A nephrydrotic cyst may be very large, containing as much as several gallons of liquid. Sometimes in medium-sized sacs the external appear- ance of the Avails may be lobulated; the interior, hoAvever, usually shows only partial septa projecting from the wall into the cavity of the sac. The smaller sacs partially enclosed by the membranous septa probably represent the dilated calyces. According to the seat of obstruction one or both ureters may also be dilated. If one kidney is affected, its fellow is often hypertrophied. The fluid contained in the sac varies in composition, but usually is a clear, thin, yellowish, Avatery urine. The specific gravity is low, and the reaction is often slightly alkaline. Traces of albumin, urea, uric acid, and salts are found. Turbidity may be present, OAving to admix- ture with pus, blood, or epithelium, but only in instances in Avhich pre- vious inflammatory conditions, as a calculous pyelitis, or subsequent complications of like nature have existed. Etiology.—Hydronephrosis—or, better," nephrydrosis—is in most instances secondarily produced by diseases—congenital or acquired— that cause occlusion of the ureter. It is, therefore, rather an associated abnormal condition than a distinct disease in itself. Probably from 20 to 35 per cent, of cases are congenital (Roberts). In these cases the causal condition is one of stricture, due to obstruction caused by a de- fective development or malformation in the urinary passage of one or both sides, usually the latter. Thus, there may be a valve-like formation or a very acute insertion of the ureter into the kidney. The dilatation has occasionally become so great in the fetus as to cause considerable mechanical difficulty during labor. 63 994 DISEASES OF THE URINARY SYSTEM. Among adults, women are more often subject to hydronephrosis than men, and especially women who have borne children. The condition may be bilateral, as from a stricture Ioav down and due to gonorrheal urethritis, but more often it is unilateral. The causes of these acquired cases are as follows: (1) Impacted calculi in the ureter or renal pelvis. (2) Disease of the ureteral Avails, as inflammatory thickening and cica- tricial stenosis from ulcers. (3) Flexion and tAvisting of the ureter, as from movable kidney. (4) Pressure upon the ureter from Avithout, as by tumors and constricting bands (pelvic adhesions). The gravid and retrodisplaced uterus, uterine and ovarian neoplasms, and similar con- ditions causing compression or traction and obliteration of the lumen of the ureter, are found in this class. (5) Diseases and tumors of the bladder that involve the ureteral orifices, particularly carcinoma, or that cause retention, as prostatic enlargement. (6) Urethral stricture. Symptoms.—These depend someAvhat upon the cause and extent of the hydronephrosis. Marked bilateral disease, Avhen congenital, may render the fetus inviable. The unilateral variety may be overlooked for years, and no symptoms may point to the trouble until a tumor can be made out by inspection and palpation, or until the ureter of the re- maining kidney may become obstructed and symptoms of uremia super- vene. The latter are more apt to come on, and earlier too, in double hydronephrosis. Locally, the patient may complain of frequent and severe pains that shoot about the affected loin and downward toward the thigh. Sensa- tions of Aveight and a dragging discomfort are common. Anorexia, nausea and vomiting, eructations, and irregularity of bowel-action are associated sometimes. In large hydronephrotic cysts a continuous dull, aching pain only may be felt, or, as is not infrequently the case, the tumor may be absolutely painless. Obstinate constipation may result from compression of the colon, or in moderate enlargements diarrhea may occur from the pressure-irritation. Usually a SAvelling is detected in the region of the affected kidney. It gradually increases in size, and in marked enlargements distinct bulging may be visible in the hypochondriac and lumbar regions. Pal- pation reveals a rounded, firm, yet someAvhat elastic and sometimes fluc- tuating tumor. There may be slight tenderness. Dulness on percussion is found over the mass, except Avhere the colon overlies it, Avhen tym- pany is elicited; this is a characteristic sign of kidney-tumors. Mod- erate enlargements generally do not descend during inspiration. There may, however, be exceptions to this rule. The intermittent form of hydronephrosis (Landau) is interesting from the variations that occur in the size of the tumors. A marked diminu- tion is coincident with a more or less sudden increase in the quantity of urine passed, and, on the other hand, as the tumor gradually enlarges the flow of urine decreases. These cases are in most instances due to movable kidney. Colicky pains often usher in the periods of greatest distention preceding the sudden increase in the Aoav of clear urine. This variety of the affection occurs most frequently in Avomen that have borne children. The general symptoms scarcely amount to more than a certain loss of flesh incident to the associated Avorry and anxiety. The filling of the nephrydrotic cyst, the distention, and the pain and HYDRONEPHROSIS. 995 discharge, with subsidence of the tumor, recur Avith variable frequency. According to Osier: " Among the circumstances liable to cause them are sudden and violent exercise, the jarring and jolting of ridino- and driving, any fatigue, mental emotions, and errors in diet." The tumor may continue to develop in size for several days after the pain has dis- appeared. The latter may last from several hours to a day. During the intervals, and after the urine has increased in quantity, gradually or quickly, the patient feels tolerably comfortable, and this sometimes for Aveeks or months. For obvious reasons the tumor is rather mobile in intermittent hydronephrosis. The occurrence of chills, fever, and sweats, nausea and vomiting, abdominal distention, and rapid pulse usually indicates suppuration, and pyonephrosis may be the consequence. The urine will then be cloudy and reveal pus, following both discharge and aspiration. A lowered specific gravity and the presence of albumin will be noted Avhen a chronic nephritis has been set up. Increased arterial tension and symp- toms of acute febrile or chronic afebrile uremia may be added. Hydronephrosis paraplegica is a form of the disease in Avhich para- plegia develops as a complication. The course of nephrydrosis is usually chronic, with variations and exacerbations depending upon the cause of the affection. Diagnosis.—This is obviously very difficult in cases in Avhich the accumulation of liquid is small. Characteristic signs are the gradual development of a tumor in either flank, as described above, Avith dimi- nution in the urinary flow, followed by a more or less sudden free dis- charge and the subsidence of the tumor, Avith recurrences (as in the in- termittent variety). When these do not occur and the tumor continu- ously enlarges, aspiration may be practised to determine whether the mass is solid or liquid ; the nature of the latter may also thus be ascer- tained, whether urinary or not. Ureteral catheterization will determine which is the dry side. The history of the case and the detection of some causative occlusion will point to the diagnosis. Differential Diagnosis.—The nephrydrotic sac must be distinguished by exclusion from an ovarian cyst, cystic kidney, and tumors of the spleen, liver, and gall-bladder. Very large cysts may be mistaken for ascites. Assurance of the presence of the colon over the tumor is diagnostic, and a chemical examination of the fluid obtained by the use of the ex- ploring needle will suffice in most cases. It should be remembered, hoAvever, that a slight amount of urea is sometimes found in ov7arian cystic fluid. The presence of pus-cells in abundance in the aspirated fluid, with symptoms of suppuration, is significant of pyonephrosis. Prognosis.—This is generally unfavorable, though in unilateral hydronephrosis evidences of compensation on the part of the unaffected kidney should render the case guardedly favorable, particularly if the cause be a movable kidney. The bilateral affection is always grave, owing to the danger of uremia. Infection of the cyst Avith pus-organ- isms is usually a fatal complication. Recovery may ensue in rare in- stances in which a spontaneous discharge of the liquid takes place. Rup- ture of the sac is unlikely. Treatment.—The removal of the cause is seldom feasible. Symp- 996 DISEASES OF THE URINARY SYSTEM. tomatic treatment only is required in mild cases, though sometimes gen- tle massage over the sac, properly directed and cautiously applied (to avoid rupture), may cause a reduction in the size of the tumor. Most often surgical measures only are of use. These embrace puncture and aspiration, incision (nephrotomy) and drainage, nephrorrhaphy, ne- phrectomy, and the formation of a renal fistula. These procedures, hoAV- ever, are undertaken only Avhen successive reaccumulations of the fluid follow those measures first mentioned. PERINEPHRIC ABSCESS. (Perinephritis) Definition.—Suppurative inflammation of the connective tissue surrounding the kidney. Pathology.—The suppuration attacks either the lax adipose tissue or the fatty capsule in Avhich the kidney is imbedded and the adjacent retroperitoneal tissue. The starting-point of suppuration is usually be- hind the kidney. There may be several small abscesses at first, but more often a single large abscess is found. The walls may be soft and shreddy, or in more chronic cases thickened and fibrous. A bulging externally over the affected lumbar region is not infrequent, particularly in large and extensive accumulations of pus. The latter has a tendency at a given point to burroAv into the surrounding tissues, and especially doAvnward toward the iliac fossa, pointing in the groin near Poupart's ligament. It may extend backward and open upon the skin-surface. Sometimes the pus perforates the diaphragm and discharges through the pleural cavity and lungs, or the colon, vagina, bladder, or peritoneum may be perforated. The pus is occasionally quite offensive, and may be ichorous from an admixture of infiltrated urine. Perirenal abscess due to calculous pyonephrosis may contain calculi that have ulcerated through pelvic or renal Avails. Thickening of the juxtaposed peri- toneum is often found. In certain cases of perinephritis, which usually gave no symptoms during life, the postmortem examination has revealed fibrous adhesions and a firm and thickened and fatty capsule, stripped with difficulty from the true capsule of the kidney. Etiology.—Perirenal abscesses, when not traumatic in origin, de- velop most frequently as a result of purulent pyelo-nephritis or pyo- nephrosis. Hence they are usually secondary. Other primary condi- tions that may cause perirenal suppuration are the following : extension of inflammation from the ureter or pelvis of the kidney; from a pelvic abscess ; from appendiceal or hepatic abscesses; and from spinal caries (psoas abscess) and empyema. Sometimes tuberculous processes in the kidney and suppurating new groAvths, as carcinoma and cysts (includ- ing the echinococcus), are complicated by perirenal abscess. More rarely such severe infectious diseases as typhus fever, small-pox, and pyemia lead to purulent perinephritis. Finally, there are cases for which no cause is discoverable. CYSTIC KIDNEY. 997 Symptoms.—Subjectively, there is noted a dull, throbbing pain over the affected region that is increased by motion; sometimes, when the abscess is large and presses on the large nerve-trunks, the pains may become shooting in character and be felt in the leg on the same side. Numbness may also be felt. Pain and tenderness on palpation are com- mon. The patient is prostrated, weak, and often quite emaciated, and flexure of the thigh on the affected side is frequent. The characteristic fever of suppuration is present in the deeply remitting or intermitting type, Avith alternating chills and debilitating sweats. Pus is found in the urine only when the kidney is involved. Sooner or later evidences of a tumor are seen; the areas can be palpated, and a gradual bulging in the lumbar area, increasing sloAvly, Avith smoothness and glistening of the skin and pitting (edema), may be observed. Fluctuation is fre- quently apparent in advanced cases, and in favorable cases signs of " pointing " appear. Diagnosis.—Should the abscess tend to burrow downward, the condition may be somewrhat obscure on account of the absence of dis- tinct local symptoms. Indeed, involvement of the psoas may give rise to symptoms of coxitis, as pain referred to the knee-joint. The diag- nosis is usually easy, and Avhen in doubt as to Avhether the tumor is an abscess or an hydronephrosis or solid mass, the exploring needle should be used. Differential Diagnosis.—An important point in differentiating peri- nephric abscess from suppurative pyelitis or pyelo-nephritis alone is the fact that in the latter the quantity of urine is usually diminished, Avhilst in the former there is less apt to be any interference with the renal secretion. Again, Avhilst in the latter the urine usually contains blood and pus, in the former the urine is free from blood, though not necessarily from pus, and casts are also absent here. Prognosis.—This is guardedly favorable if the abscess points ex- ternally in the lumbar area. Of course rupture into the peritoneal cavity, bladder, bow7el, and groin is ahvays a serious occurrence. The treatment is essentially surgical, and consists in free incision and drainage. CYSTIC KIDNEY. (Renal Cyst) Pathology.—Congenital cystic kidneys are in reality collections of cysts, varying in size from a pea to a marble, and separated from each other by septa of compressed renal or fibrous tissue. Either one, or fre- quently both, kidneys may be affected with Avhat is sometimes termed congenital cystic degeneration of the kidneys. There is considerable en- largement of the organs, and during intra-uterine life they may attain a size so enormous as to render parturition extremely difficult and danger- ous. The fetus is usually non-viable, though in mild cases the affection may be tolerated for some years after birth. The cystic fluid may be either clear or turbid, a reddish-yellow or a dark-broAvn in color, acid 998 DISEASES OF THE URINARY SYSTEM. in reaction, and holds in solution urinary salts, blood, cholesterin, and sometimes uric acid and urea. A single layer of flattened epithelial cells lines the cyst-walls. The cysts themselves seem to be dilatations of the renal tubules and of Bowman's capsules, due, in some instances, to an obliteration of the tubules of the papillae or to stenosis of some portion of the urinary tract. The cystic kidneys usually met Avith in adult life (acquired) are of several varieties: (1) One or perhaps a few cysts may be present, larger usually than those in the congenital cystic kidney, which seem to cause no interference with the normal renal functions. Sometimes a reddish- brown colloid material is contained in these cysts. (2) Small and often quite minute cysts frequently accompany the chronic nephritic kidney that is small, contracted, and cirrhotic. These result from dilated tubules and capsules when the former are narrowed by the hyperplasia of fibrous tissue. (3) Cystic kidneys in adults may have the pathologic characteristics of the congenital variety—a mere conglomeration of cysts containing a clear or colored serum or a cloudy, dark, thick, and colloid liquid. This condition is sometimes associated with similar cystic disease of the liver and spleen. It may be a late manifestation of mild congenital disease. The kidneys have been found converted into cysts in cases in which the presence of calculi (uric acid) in the tubules has probably started the the cystic degeneration. (4) Solitary cystic adenoma occurs rarely. It is in the form of a globular tumor projecting from the surface (usually the anterior) of the kidnev. It may be as large as an orange, and may be enclosed in a dis- tinct capsule. On section the mass is found to be composed of various- sized cysts separated by septa of fibrous tissue lined with cuboid or columnar epithelium. The remainder of the kidney appears to be quite healthy. Etiology.—Cystic disease of the kidneys is either congenital or acquired. The former is probably commoner than the latter condition, and may persist for a while in extra-uterine life, Avhile the acquired variety may be of unknown origin or secondary to chronic interstitial nephritis or to urinary calculi in the renal tubules. The direct cause of intra-uterine renal cysts is not definitely knoAvn, but they are probably developmental rather than pathologic, since other defects of embryonic groAvth are frequently associated Avith the disease. Symptoms.—These may be absent in adults until the sudden de- velopment of uremia. Ordinarily, the clinical picture is similar to that of chronic interstitial nephritis. There is an increase in the quantity of urine, Avhich is of low specific gravity. Slight albuminuria may be present. On palpation a large, rounded, and sponge-like mass may be felt in either hypochondrium or on both sides. Cardiac hypertrophy and increased arterial tension, as in chronic cirrhosis, are also fre- quently met with in cystic degeneration of the kidneys. The diagnosis can only be made upon the presence of the above symptoms and the discovery of the clear physical signs of the tumor. It should be pointed out that a possible complication of perinephric abscess, due to rupture of one or more of the cysts (as has occurred—Osier), would of course render a diagnosis Avellnigh impossible. NEW GROWTHS OF THE KIDNEY. 999 Prognosis.—Bilateral cystic disease of the kidney must eventually prove fatal, owing to the sudden onset of uremia or cardiac failure. Solitary cysts give a tolerably favorable outlook under proper surgical interference. Treatment.—The unilocular cysts just referred to above may be removed, capsule and all, and the kidney sutured. Bilateral disease cannot be operated upon for obvious reasons; unilateral cystic degen- eration may be treated by nephrectomy, Avith narrow chances of success. NEW GROWTHS OF THE KIDNEY. The most common tumors of the kidney are those belonging to the class of adenomata (benign) and those that are either sarcomatous or car- cinomatous (malignant). Adenomata may be congenital or acquired. They grow in the cortex of the kidney in the form of small nodular masses, Avhich in some cases may increase to a considerable size before any symptoms are pro- duced. A cystic growth may be combined with adenoma (cystic ade- noma), and lymphadenoma is also occasionally seen as a secondary growth. Other benign tumors that may affect the kidney are angioma, fibroma, and lipoma. Very large vascular adenomata may become malignant. Sarcoma and carcinoma may be either primary or secondary. Sarcoma is frequently congenital in origin, and may have an admixture of striped muscular tissue. The presence of the latter in the kidney points to developmental disturbances during embryonic life as the cause of a variety of tumor knoAvn as rhabdomyoma. Alveolar sarcoma is also met with. Renal carcinoma is probably of less frequent occurrence than sar- coma ; it may, however, be found in children as Avell as in aged persons, the two extremes of life. Carcinoma of the kidney is usually of the soft medullary or encephaloid variety, and as a primary affection it was thought to be of comparatively frequent occurrence, especially in early life. There is at least some doubt, hoAvever, connected with the sup- posed carcinomata of children. Both sexes are subject to the disease. Secondary carcinoma of the kidney, although probably more frequent than the primary form, is seldom of clinical importance. Renal carci- noma may occur as a diffuse infiltration or in nodular masses, one kid- ney usually being affected in primary carcinoma. The tumor sometimes reaches an enormous size, and instances are recorded in which nearly the whole abdomen has been filled, and in which the growth weighed as much as 31 lbs. (14 kgms., Roberts). Rhabdomyomata do not, as a rule, attain a very large size, though sarcomata may grow quite large. Softening and hemorrhage Avithin these malignant groAvths may occur. The pelvis of the kidney may be invaded, and metastatic areas may form in the liver or the lungs, though this occurs in the case of primary renal carcinoma less readily than from carcinoma in other organs. Me- tastatic growths arise most likely through involvement of the renal vein. 1000 DISEASES OF THE URINARY SYSTEM. The renal parenchyma is either partially or wholly destroyed, trhe pyr- amids being attacked later than the cortex. Symptoms.—Lumbar pain on the affected side is often an early symptom, and may persist throughout the course of the disease. It may be paroxysmal, and be felt extending doAvn the thigh, or it may be dull, dragging, and limited in character. Pain is not, hoAvever, a con- stant symptom in a certain proportion of the cases. Hematuria may occur early or late, and often appears before any tumor is palpable. The blood may be in a fluid state or in clots, the latter not seldom taking the form of pelvic or urethral casts, the passage of Avhich may give rise to colicky pains. Casts of the ureter sometimes resemble lumbricoid Avorms. The hemorrhage may be excessive and cause marked weakness and a symptomatic anemia, superadded to the cancerous anemia that is usually present; on the other hand, it may be so slight as to be discoverable only microscopically. It recurs at irreg- ular intervals of days or weeks. Large clots may accumulate in the bladder and cause vesical irritability. The urine from the healthy kid- ney may be quite normal, and may be secured for observation by ureteral catheterization. . Cancer-cells or tissue-fragments of the neoplasm very rarely appear in the urine, at least so as to be distinctly recognizable as such. Anorexia, nausea and vomiting, progressive loss of flesh and strength, increasing pallor, and the concomitant symptoms of the can- cerous cachexia are seen to develop. Physical Signs.—These may not be sufficient to reveal the presence of the tumor for some time after the above symptoms have been observed. The appearance of a palpable tumor in either flank is a definite aid to diagnosis. It is felt betAveen the ribs and pelvis latero-anteriorly, and at first, when small and on the right side, it may be movable. Both sarcoma and carcinoma of the kidney may assume enormous sizes. The tumor feels dense and hard (except rapidly-groAving tumors, as encepha- loid), either smooth or lobulated, and, Avhen not too large, may retain the natural position and form of the kidney. The growth extends downward and inward, and in the very large malignant renal tumors of childhood the abdomen shows considerable enlargement, along with an abnormal pulsation and a prominence of the veins. Usually the tumor does not move with respiration. Percussion gives dulness over the mass, although in small and moderately large tumors the overlying colon may cause a tympanitic note to be heard. Neighboring organs, as the liver and spleen, may be found by palpation and percussion to be displaced by the renal tumor. Diagnosis.—The presence of a tumor, Avhen not too large and dis- tinctly occupying the lumbar and lower lateral abdominal region, to- gether with hematuria, pain of a local nature, and progressive failure of nutrition, may be looked upon as diagnostic of a malignant type of renal tumor. The relation of the colon to the tumor and immovability of the latter during respiration are also diagnostic. When the tumor is very large and adhesions have formed, as in cancerous kidney, it may be mistaken for other conditions. Differential Diagnosis.—Affections such as hydronephrosis, pyone- phrosis, cystic kidney, hydatids, ovarian, splenic, and hepatic tumors, and (particularly in children) retroperitoneal sarcoma must be differentiated DISEASES OF THE BLADDER. 1001 from renal growths. Careful bimanual palpation will aid in the diagno- sis, but the exclusion of other lumbar enlargements must be made by close attention to the history and to the development and course of the symptoms. Hematuria alone, in aged persons, is suggestive of carcinoma when no tangible cause for the presence of the blood is at hand. Hepatic and splenic tumors are usually movable during deep breathing, whilst renal tumors are not so. In cases of hepatic growths also the area of dulness extends higher, Avhilst in renal growths on the right side a tym- panitic area generally lies betAveen the liver and the tumor. The cha- racteristic notch and edge of the spleen, and the absence of the overlying colon-tympany, are points that distinguish splenic enlargements from those of the left kidney. Pelvic growths (ovarian and uterine) enlarge from below upAvard, and are readily detected by vaginal examination. In children Lbbstein's cancer (retroperitoneal sarcoma), if very large, is easily mistaken for a renal tumor, except that it is usually more cen- trally situated and more firmly fixed. Prognosis and Treatment.—The termination in cases of renal carci- noma is inevitably fatal, and children succumb more quickly than adults. The disease may last from a feAv months to sometimes a year or two. If the kidney be removed while the growth is still small, the prog- nosis is fairly good; but if large or if metastatic tumors have formed, the prognosis is ahvays bad. The treatment, aside from early surgical measures, is entirely symptomatic and supportive, and obviously it is unsuccessful. Renal colic, excessive hematuria, and a gradually loAvered vitality may be met by the use of palliatives, tonics, and by a nutritious and easily digestible diet. Nuclein may be tried hypodermically or by the mouth. II. DISEASES OF THE BLADDER. CYSTITIS. Definition.—Inflammation of the mucous membrane of the bladder. It may be either acute or chronic, the latter being clinically the much more frequent condition. ACUTE CYSTITIS. Pathology.—Cystoscopic examination performed according to PaAv- lik's or Kelly's method, hereafter to be described, reveals an intensely hyperemic condition of the vesical mucosa, which is puffy, edematous, and of a bright-red color; this may be more intense at points, especi- ally in the vicinity of the trigone. The membrane is bathed in a thick, tenacious muco-pus, and here and there may be noted denuded areas, and the exfoliated epithelium often hanging in shreds from the bladder- wall ; overlying these denuded patches hemorrhagic effusions may be observed. In the severer grades of the disease the intense general hy- peremia causes a disappearance of the blood-vessels that are to be seen in the normal condition. Occasionally small patches of ulceration, due to abscess-formation (phlegmonous cystitis), may be observed, and in 1002 DISEASES OF THE URINARY SYSTEM. rare and fatal instances the entire bladder-wall is involved in a necrotic process. Etiology.—Cases of acute cystitis may be grouped according to their origin into four main classes, as folloAvs : (1) Catarrhal.—Like other mucosae, the vesical epithelium is very re- sponsive to systemic circulatory disturbances. Thus, sudden exposure to extremes of cold or heat or violent atmospheric changes, thereby abruptly suppressing the action of the skin, may be potent influences in the etiology of the disease. An intense acute catarrhal inflammation may folioav retention of the urine in the bladder, with or without its subsequent decomposition; it may also be the result of pressure from an enlarged prostate or other tumor, and may follow cystocele, urethral stricture, or paresis of the bladder-wall. In simple over-distention of the bladder, with the accumulation of a gallon (4 liters) or more of urine, the so-called acute exfoliative cystitis may result, in which the entire mucous membrane of the bladder may be shed, and the patient shortly manifest all the symptoms of grave uremic intoxication. The prolonged retention of urine is folloAved by decomposition of the fluid, and this by its irritant action ahvays excites a cystitis that soon assumes the chronic type. (2) Septic.—This may result either from the direct introduction of pus-producing germs into the bladder or from the systemic transmission of these micro-organisms to the organ. This is known as the bacterial origin of cystitis, Under the first class may be mentioned the passage of a dirty catheter or sound; this is the great cause of cystitis in puerperal women, and in men who are the subjects of minor grades of urethral stricture, and Avho have been subjected to gradual dilatation by means of bougies. Gonorrheal cystitis is also to be included under this heading. There is a condition known as febrile cystitis, which consti- tutes the second class of septic cases. This comprises the vesical in- flammation that is present in the various febrile conditions, and which is probably a direct result of the presence in the urine of the causal bacilli or their toxins (Fitz). Thus, in all of the infectious diseases and fevers (typhoid and the other exanthemata, rheumatism, diphtheria, tuberculosis) there is noted a cystitis of varying degrees of severity that can be accounted for only by the local irritant action of the spe- cific germ of the associated disease. The so-called gouty cystitis, Avhich is often present in lithemic individuals, and which is due to the irri- tating and concentrated urine, may also be here included. (3) Toxic.—Certain drugs when introduced into the system manifest an intense antipathy for the vesical mucosa, and promptly excite a severe grade of acute cystitis. Prominent among these may be mentioned cantharides and other irritants of the urinary tract—cubebs, copaiba, and sinapis. (4) Traumatic and Irritant.—Traumatic inflammation of the bladder follows the improper and careless use of the catheter, sound, or other instrument; the presence in the bladder of calculi or other foreign bodies; and the pressure of the fetus in parturition, or of large masses of impacted feces. Irritation with consecutive inflammation may result from the extension of an inflammatory process from sur- rounding structures either by continuity or contiguity of tissue. Thus, ACUTE CYSTITIS. 1003 a cystitis may folloAV a urethritis—gonorrheal or otherwise ; it may re- sult from an extension doAvnward of a ureteritis, or it may be conse- quent upon a vaginitis, a malignant neoplasm of an adjacent viscus, a salpingitis, pelvic peritonitis, or pelvic abscess in the immediate vicinity of the bladder, as in the vesico-uterine pouch, the inflammation extend- ing by an involvement of contiguous tissue. Symptoms.—The symptoms of acute cystitis are very manifest. Pain, vesical irritability, vesical and rectal tenesmus, frequency of mic- turition, fever, and urinary changes are all pronounced. Prominent among these is pain, Avhich may be most intense and is the earliest and most persistent manifestation of the disease. Its seat is the suprapubic region, whence it may radiate to the sacral region, the perineum, the end of the penis, or the upper portion of the thighs ; it is most con- stant, but is worst just before micturition, by which it may be alleviated. It is considerably relieved by the recumbent posture, and is aggravated by pressure over the bladder. As the inflammatory process diminishes the pain gradually disappears, and the entire attack may subside in a few days or a week. With the pain, and probably ranking second in severity, is the rec- tal and vesical tenesmus, or strangury. There is an almost constant de- sire to urinate, the patient sitting upon the urinal, it may be, for hours. The urine may be opaque or highly-colored. It is often bloody (in very acute cases the vesical contents may consist of a small quantity of pure blood only), is of a specific gravity varying from 1005 to 1030 (in the febrile cases), and contains pus-corpuscles in abundance, mucous flakes in large quantities, shreds of disintegrated and exfoliated epithelium (blad- der) ; also numerous micro-organisms (streptococci, staphylococci, gono- cocci, proteus vulgaris, bacilli of tuberculosis, and very commonly the bacillus coli communis). Its reaction may be either acid or alkaline; if alkaline, it contains ammonium urate, amorphous phosphates, and triple phosphates (crystalline) as a rule. More or less albumin will be noted, and on standing a dense sediment forms in the bottom of the flask, composed of all the foregoing substances, as shoAvn by chemical and microscopic examination. The total quantity of urine voided in the twenty-four hours may be normal in amount or even slightly in ex- cess of the normal. On the other hand, if exfoliation of the mucous membrane takes place, there may occur partial or even total suppression of the urine. Fever, with or without an initial rigor, persists through- out the attack, but is not of a severe type, save in the septic and ma- lignant (diphtheritic) forms of the disease, Avhen it may reach 103°-105° F. (39.4°-40.5° C). Abscesses may form, and betray themselves by localized pain, ten- derness, and, in some cases, by a circumscribed induration. These may rupture into the bladder, folloAved by the free escape of pus from the urethra and by relief (temporary as a rule) from urgent symptoms, or they may spread to the peritoneum and induce peritonitis, which, if not promptly treated by surgical measures, may prove fatal by gradual asthenia. In the variety associated with extreme exfoliation of the vesical mucosa grave uremic manifestations follow. These include all the features of the typhoid state (dry, black tongue; mild delirium; ner- 1004 DISEASES OF THE URINARY SYSTEM. vous and muscular twitching; headache; gastric disturbances; and coma). There is also some degree of malaise and anorexia. It must not be forgotten that acute cystitis may represent an acute exacerbation in the chronic form, and at times may assume a severe type of the disease. Diagnosis.—Cystitis should be readily recognized from the history of the case and the frequency of the two almost pathognomonic symp- toms—suprapubic pain and vesical tenesmus. An examination of the urine will reveal the characteristic clinical features. Cystitis may be confounded with acute nephritis or pyelo-nephritis, but a careful study of the clinical manifestations and, if need be, the catheterization of the ureters after vesical irrigation, will reveal the true condition. The presence of tube-casts in the urine would indicate renal involvement. The percentage of albumin is usually much larger in nephritis than in irritability of the bladder. The differentiation between cystitis and vesical irritability will be noted under the latter condition. The prognosis of the milder grades of cystitis is good; the septic and malignant (diphtheritic) cases offer a much graver outlook. Exten- sion of the process upward toward the kidneys is always serious. Treatment.—The treatment of acute cystitis includes prophylactic, hygienic, and medicinal measures. Prophylactic.—Most important is the prevention of the disease, and this includes, in addition to the usual care of the body, the observance of thorough asepsis Avhenever it becomes obligatory to introduce an instrument (catheter, sound) into the bladder. Hygienic.—The cause of the disease, if evident (calculus, external pressure), should be sought and removed. The patient should at once be placed absolutely at rest in the recumbent posture. The value of this injunction will be most clearly understood when it is stated that in the erect position the intra-vesical pressure is three times that in the dorsal position. The simple observance of this law will do much toAvard relieving the sufferings of the patient. The diet must be regulated, and all irritating, highly seasoned articles of food must be interdicted. Alcohol in any form is prohibited. If it can be enforced, during the early stages of the disease an absolute milk diet will be most bene- ficial. The patient should be instructed to drink freely of water and other diluent drinks, Avhereby an internal irrigation of the bladder may be secured and much of the irritating substance removed. The free action of the skin may be secured by friction and Avarm bathing. Medicinal.—The drugs to be employed are the saline laxatives and the various mild diuretics and urinary alterants. The reaction of the urine will indicate the variety of alterant to be employed. If it be acid, alkaline waters are serviceable, as the soda-preparations, Vichy, or the potassium salts. In alkaline conditions of the urine probably the most valuable drugs are benzoic and boracic acid and salol. Benzoic acid is best administered in the form of ammonium benzoate, Avhich may be given in 10-grain (0.648) doses thrice daily in the compound infusion of buchu. Hot applications and hot local bathing (sitz-baths) will do much to relieve the pain and tenesmus; if these be severe, a rectal sup- pository of opium and belladonna or an enema of chloral hydrate will generally give prompt relief. Tincture of cannabis indica, administered CHRONIC CYSTITIS. 1005 internally, may answer if opium be contraindicated. Under such a course as the preceding a cure may be expected Avithin eight or ten days. CHRONIC CYSTITIS. , Pathology.—The vesical mucosa is not so hyperemic as in the acute variety, but is of a peculiar muddy or grayish-blue (slate) color, dotted here and there Avith patches of erosion or of actual ulceration. The muco-pus that bathes its surface is not so apt to be hemorrhagic as in the acute form of the disease, although slight hemorrhages may and do occur. Owing to the sIoav course and long duration of the disease there follows an immense thickening of the bladder-wall from hyperplasia of its constituents, conjoined Avith more or less edema of the tissues. The result is a contraction of the Avail Avith a proportionate diminution in the vesical capacity. The mucosa may become, as it were, polypoid in spots, and there may folloAV obliteration or partial obstruction of the ureteral orifices, with consequent dilatation of the ureters and renal pelves from a damming back of the secretion. The urinary changes are about as in the acute form, save that the reaction is always alkaline and the amount of mucus and pus is proportionately greater. Etiology.—Chronic inflammation of the bladder may be the result of a neglected or oft-repeated acute attack. It may occur from the persistent action of an exciting cause, as the presence of some irritating substance (calculus) in the bladder, or of some excitant external to that viscus, as a localized inflammation or a displaced uterus. Again, the inflammation of the bladder may be chronic from the beginning; espe- cially is this true of the tuberculous variety and of that due to neoplas- mata of the organ. The Symptoms and diagnosis differ but slightly from those of acute cystitis. It may, hoAvever, be pointed out that the pain and tenes- mus are less intense. Oppositely, the amount of albumin in the urine is comparatively large. The same remark applies to the quantity of mucus and pus (vide Pathology); indeed, the last-named ingredient often forms a thick gelatinous mass in the standing urine that tends to adhere to the receptacle. Chronic cystitis is accompanied by debility and emaciation, Avhich, however, are of sIoav development. The prognosis is ahvays serious, and the course of the disease is at the best protracted. Treatment.—Very generally, the treatment set down for the acute disease will not answer in the chronic form. Undoubtedly, there will follow more or less amelioration of the symptoms, but the tendency is toAvard a prolonged chronicity. In such cases, after the removal of the ascertainable causes so far as practicable, we are compelled to resort to local treatment of the bladder. This includes—(1) Vesical irrigation; (2) Topical applications; (3) Permanent drainage of the bladder. Vesical irrigation is secured by means of an aseptic soft-rubber catheter Avhich is connected Avith a graduated glass funnel: a siphonage is produced by the alternate elevation and depression of the funnel, which contains the irrigating fluid. The latter may consist of plain sterilized (boiled) water, sterile normal salt-solution (40-60 gr. to the pint—2.59-4.0 per ^ liter), or a weak solution of mercuric chlorid (1: 1006 DISEASES OF THE URINARY SYSTEM. 50,000-100,000). The irrigation should be done slowly, and not more than twice or thrice daily in severe cases, and much less frequently in ordinary cases, according to the exigencies of the condition. Vesical medication may be secured by means of the funnel after irri- gation, the medicating substances being dissolved in a pint of water and allowed to flow slowly in and out of the bladder. The drugs that may be used in this manner are silver nitrate or zinc sulphate (1-5 gr. to the ounce—0.0648-0.324 to 32.0) or a saturated solution of boric acid. If the salts of zinc or silver are used, not more than an ounce of the solu- tion should be allowed to enter the bladder, and much less than this amount will generally suffice. In cases in which there exist patches of ulceration the application must be made directly to these areas through the endoscope or cystoscope (PaAvlik, Kelly). In Avomen this may be readily done by placing the patient in the exaggerated lithotomy or knee-chest posture, dilating the urethra, and introducing the cystoscope, through which a reflected light is thrown upon the distended bladder- Avall. Stronger solutions may noAv be employed, as silver nitrate, 20- 30 gr. (1.29-1.94) to the ounce. This application should be folloAved by a slight irrigation of the bladder. When this local medication fails to effect a cure, permanent drainage of the bladder must be secured—in the male by a suprapubic or perineal incision, and in the female by the establishment of a vesico-vaginal fis- tula. This places the bladder absolutely at rest, and gives the inflamed mucosa a chance to heal under proper medication. ' As to internal remedies, various agents that possess a local stimulating effect upon the genito-urinary tract are advised by most authors, but I think little is to be gained from their employment as compared with the results achievable from topical treatment. Most efficacious among inter- nal remedies are—oil of sandalwood, terebene, buchu (fluid extract), and the oil of copaiba. If disinfection of the bladder in loco is not practi- cable, antiseptics should be given internally, combined with those stated above. Salol and potassium chlorate are excellent for this purpose. NEOPLASMS OP THE BLADDER. Primary new-growths of the bladder are exceedingly rare, occur- ring, however, with greater frequency in males in about the proportion of 3 to 1; they may be either benign or malignant. On the other hand, secondary neoplasmata, particularly carcinomata, are relatively common. The most frequent variety of new-growth encountered is carcinoma, par- ticularly the so-called villous or papillomatous carcinoma, Williamsl find- ing in 20 women affected with bladder-tumor, carcinoma in 16. Other growths are sarcomatous, fibromatous, and papillomatous in nature. The Symptoms are the same for all varieties, and include, first and most commonly, hemorrhage (which is both persistent and free), together with pain, frequency of micturition, and occasionally the discharge of detached fragments of the growth. In carcinomatous cases of advanced 1 Brit. Med. Journ., 1889. NEUROSES OF THE BLADDER. 1007 standing cachexia will be marked. Examination by means of the cysto- scope will reveal the nature of the complaint. In the case of secondary growths the primary tumor may often be detected. The prognosis, of course, will depend upon the nature of the growth. The treatment is purely surgical, and comprises enucleation of the tumor either by means of the snare, or after a vesical section. VESICAL HEMORRHAGE. ( Vesical Hemorrhoids) Hemorrhage of the bladder has been mentioned as a symptom of various affections, both general and local, among the former being leu- kemia and malarial hematuria, and among the latter nephrolithiasis and tuberculosis and carcinoma of the bladder. It is also a prominent mani- festation in stone in the bladder, and not infrequently appears in preg- nancy (late). Independently of the operation of all of the above-men- tioned etiologic factors, hemorrhage has been known to occur from the bladder, and recent precise methods of exploring the viscus (endoscopic examination) have shown it to be due to a hemorrhoidal state of the ves- sels. The hemorrhage may be profuse, and, rarely, even fatal in its effects. The diagnosis is based in part upon the absence of the more obvi- ous causes of hematuria and the presence of free bleedings, but chiefly upon the result of a careful cystoscopic exploration of the bladder. The prognosis, so far as my experience extends, is eminently favor- able, though a few fatal cases have been reported. Treatment.—This is mainly local. The bladder may be irrigated with an astringent solution (1 per cent, tannic acid, -1- per cent, alum), and this may be alternated with an antiseptic solution (3 per cent, boric acid, 1 per cent, salicylic acid). I have recently observed a case in which recovery followed the internal admission of the extract, hamamelis fluid. (3J-4.0), t. i. d. NEUROSES OF THE BLADDER. IRRITABILITY OF THE BLADDER. Definition.—By this term is meant a condition of the bladder in which there exists an hyperesthesia of the organ, especially of the neck— that portion surrounding the urethral and ureteral orifices (vesical trigone) —without the presence of any tangible cause therefor. This must be dis- tinguished from the irritability that is associated with true organic dis- ease of the bladder itself, as in the presence of calculi, tumors, or fissure of the neck, or with disease of the surrounding structures. 1008 DISEASES OF THE URINARY SYSTEM. Pathology.—There are no pathologic features to be noted. A cysto- scopic examination of the bladder may reveal a slight increase in the vas- cularity of the mucous membrane, but the condition, in most instances at least, must be regarded as a true neurosis. The condition of irritable bladder in women, which has previously been held to be a purely func- tional derangement, is noAv regarded by Dacheux and Zuckerkandl as a localized hyperemia, especially at the bas fond, and less often at the beginning of the urethra.1 Etiology.—While in many instances no well-defined causal relations can be determined, it is very generally true that the patients who are the subjects of vesical irritability are individuals of a neurotic temperament, very often manifesting strong hysteric tendencies. They present the cha- racteristic features of this unfortunate group. They are generally illy- nourished, fretful, irritable, peevish, suffering almost constantly from vague neuralgic attacks in different portions of the body (cephalalgia, tic douloureux, lumbo-sacral pain), and in a chronic condition of physical prostration. Frequently they eventually develop a true hypochondriasis or melancholia. In others there may be found a history of extreme men- tal and physical tire, overwork, business anxiety, over-indulgence in ven- ery, menstrual irregularity, dysmenorrhea, ovarian or uterine disorders, long-continued gastro-intestinal disturbance (dyspepsia), improper hy- gienic surroundings, improper regimen, indulgence in late hours, and a general lack of will-power. It must, however, be remembered that sub- jects of chronic malarial intoxication very often manifest all the symp- toms of vesical irritability, marked, it may be, by a feature of more or less periodicity. This has been termed by some malarial fever of the urethra and bladder. Lithemic individuals also are very prone to develop a pro- nounced vesical irritability, the affection in them probably resulting from the local action of the highly concentrated and irritating urine. The con- dition must commonly, however, be regarded as belonging essentially to the large group of neuroses. In a certain percentage of cases the bladder-trouble is a reflex mani- festation of some disease of an adjacent organ, as the urethra, ureter, va- gina, rectum, anus, or the internal organs of generation. These are not, however, to be looked upon as cases of true neurotic vesical irritability. Symptoms.—The symptoms of irritable bladder are mainly extreme painfulness and frequency of micturition, associated with marked vesical and rectal tenesmus. The dysuria is not always or altogether relieved by micturition; indeed, the pain may be just as severe, or even worse after, than before, the voiding of the urine. Especially is this true when there coexists a more or less spasmodic muscular action of the bladder-walls, the hypersensitive mucosa then being squeezed, and the patient suffering at times to such an extent as to be throAvn almost into a state of collapse. There is usually a sense of weight or pressure in the pubic region, which is largely relieved when the patient assumes the recumbent posture. Uri- nation is often performed spasmodically, or there may be a spasm of the urethra and neck of the bladder resulting in an utter inability to perform the act. The urine may be normal in appearance and amount. Very often it is increased in quantity (hysteric polyuria), and at times the op- posite may be true and more or less suppression be noted. In lithemic 1 The American Year-Book of Medicine and Surgery, 1897, p. 576. NEUROSES OF THE BLADDER. 1009 cases the urinary characteristics already mentioned under that condition will be present (vide p. 401). Diagnosis.—Very frequently will simple vesical irritability be con- founded with true cystitis. The points of differentiation, however, are as follows: Irritable Bladder. Cystitis. The patient is of a neurotic tempera- May occur in any individual, irrespective ment, and generally gives no history of temperament. It frequently follows of organic bladder-disease nor of ope- cathenzation, sounding, or other trau- rations upon the bladder. matism. Pain is severe, and often worse after mic- The pain is usually much relieved by turition. micturition. The constitutional symptoms are those of The constitutional symptoms are not nervous depression. marked, save in grave cases. Never results fatally. May result fatally. The urine does not present any marked There are always present marked and alteration in its physical or chemical characteristic alterations in the physi- qualities. It may shoAv hyperacidity, cal and chemical qualities of the urine. or extreme concentration, or dilution. The appearance of the mucosa is negative Cystoscopic exploration reveals the angry in true neurosis. and diseased mucosa, and may show the cause (calculus, tumor). The duration is always protracted. The duration of acute attacks may be short. Prognosis.—Good as regards life; doubtful as regards the ultimate cure of the patient. Treatment.—Since the condition is largely one of neurotic origin, the attention of the physician must be directed mainly toward a bet- terment of the state of the nervous system. Absolute rest, physical and mental, must be insisted upon, and the patient must be subjected to a course of strict moral suasion whenever this may be deemed necessary. Any cause of reflex irritation must be removed, and a careful search should be instituted for some such condition as cervical stenosis, uterine displacements, anal fissure, hemorrhoids, stricture of the rectum, vaginitis, urethritis, tuberculous infection of Skene's glands of the urethra, chronic gastro-intestinal catarrh, and the like. The habits of the patient must be inquired into, and late hours, the eating of improper and unwholesome articles of food, masturbation, or the reading of sensational and trashy literature corrected. In many instances the pronounced neurasthenic condition demands a course, more or less protracted, of the Weir-Mitchell rest-treatment (vide Neurasthenia, p. 1177). The urine should be care- fully examined for lithemic and other pathologic features, and by an ap- propriate course of treatment it should be rendered as bland and unirri- tating as possible. Large draughts of diluent drinks may be of benefit, and if these be combined with the prolonged administration of nerve- sedatives and antispasmodics, a marked amelioration of the patient's con- dition may be secured. In cases associated with spasmodic muscular con- traction it may become necessary to employ an occasional suppository of opium and belladonna, or an enema of chloral hydrate. Change of air and scene, regulation of the diet, the institution of a proper course of gymnastics, mental and physical, and the observance of a happy and cheerful atmosphere will generally do much to improve the patient's con- 64 1010 DISEASES OF THE URINARY SYSTEM. dition. The administration of tonics (strychnin, iron) and the prevention of constipation are very essential. Especially must it be remembered that in all these cases of simple vesical irritability physical exploration of the bladder is absolutely contraindicated. The patients mind must be directed away from the bladder in order to secure good results. NEUROSES OF MICTURITION. 1. Incontinence of Urine (Enuresis).—An inability to retain the urine. This may arise from a number of causes. Frequently it is the result of some lesion of the spinal cord involving the sphincteric cen- ter of the bladder; this is known as paralytic incontinence, and is to be recognized by a constant dribbling, alternating with spurts of urine when voluntary or involuntary muscular action is brought into play, as in the act of coughing, sneezing, or bending forward of the body. It may be the result of a general bodily weakness or after prostrating diseases (typhoid, late stages of pulmonary tuberculosis). Again, it may result from some local condition in the bladder or urethra. Here may be mentioned paralysis of the urethra from over-dilatation or from traumatism, or that due to pressure of the fetal head in a prolonged labor; imperfect vesical innervation ; over-distention of the bladder, producing a paresis of its walls; or from some temporary obstruction at the urethra or base of the bladder, such as a tumor or a sharply retroflexed uterus. It may be a result of over-distention of the bladder, with partial paral- ysis of the sphincter, the bladder remaining overfilled, while there is a constant escape of a few drops of urine (incontinence of retention). It may follow some local causes of irritation, as the presence of vesical cal- culi, pressure from an anteflexed uterus upon the fundus of the bladder, cystitis, and parasites. The condition known as spasmodic incontinence is that due to an over-action of the compressor muscle of the bladder, as a consequence of which there is a diminution of the vesical capacity, the urine being forcibly and involuntarily ejected at irregular intervals. Finally, nocturnal enuresis is that variety which is so common in young, delicate, and often neurotic children: this is usually noticed in the early hours of sleep, and is often the result of some local irritation acting upon a hypersensitive organism, such as the presence of ascarides, an elongated prepuce, contraction of the urethral meatus, or masturbation. Nocturnal incontinence may be a manifestation of nocturnal epilepsy or of incipient cerebral or spinal disease (Fitz). The constant escape of urine in the paretic cases is apt to result in extensive excoriation of the parts. The treatment varies according to the cause. The enuresis of chil- dren, if left alone, will eventually cure itself as the age and strength of the patient increases, though obvious exciting causes, if present, should be removed if not impracticable. Good hygiene, systematic evacuation of the bladder, plenty of out-of-door exercise, a change to the seashore or mountains, an abundance of suitable and strengthening food with a mini- mum of water, and the administration of tonics (iron, cod-liver oil, and strychnin), will generally effect a cure. Excellent results often follow the administration of minute doses of atropin or tincture of belladonna. A favorite formula of my own in cases possessing a hypersensitive nervous organization has long been as follows : NEUROSES OF MICTURITION. 1011 ty. Tr. belladonnas, 3ss-j ( 2.0-4.0); Sodii brom., gij ( 8.0); Ac. hydrobrom. dil., gijss ( 10.0); Ext. ergotse fl., gij ( 8.0); Glycerini, gj ( 4.0); Elix. simplicis, q. s. ad 3iv (128.0). M. et Sig. 3j (4.0) three or four times a day for a child of five years. In very delicate or feeble children suffering from enuresis I substitute a motor tonic and stimulant (tr. nucis vom.) for the bromids or nerve- sedatives. Spasmodic action of the vesical compressor may be relieved by the cautious use of the motor depressants, while its converse, paresis, de- mands the exhibition of full doses of strychnin or tincture of nux vomica. The judicious and careful use of the catheter, followed by the adminis- tration of strychnin, will promptly effect a cure in the incontinence of retention. Any local cause of vesical irritation must be removed. Gal- vanism in the paretic cases, applied both to the bladder and to the urethra, may be of service, and in the female Sanger suggests massage of the urethra. Should excoriation occur, bland ointments, as of zinc oxid and lanolin, should be used. 2. Retention.—Nervous retention of the urine is occasionally encountered in hysteric and highly neurotic individuals. Its most common manifesta- tion is an inability to urinate in the presence of others. It is also occa- sionally noted after childbirth, when it may be due to nervous reaction, to edema and tortuosity of the urethra, or to a temporary inability of the bladder-walls to contract upon their contents, thereby permitting a longer retention of the vesical contents, and even favoring over-disten- tion of the organ. If the urine be allowed to remain for too long a period in the bladder, fermentative changes follow and a secondary cys- titis will result. Under these circumstances an exfoliation of a portion or even of the entire bladder-epithelium may be noted. The treatment consists in the administration of strychnin and other nerve-tonics, in building up the general constitution, and in affording a change of air and recreation. In that variety following childbirth the patient should be urged to make voluntary efforts at micturition, and these may be seconded by the firm application of an abdominal binder and compress. The sound of running water, as when pouring water from a pitcher into the basin, often causes a contraction of the bladder and excites the flow of urine. It may become necessary, the foregoing meth- ods failing, to resort to catheterization, the usual antiseptic precautions being observed. PART VIII. DISEASES OF THE NERVOUS SYSTEM. While the following is only an outline of the anatomy and physi- ology of the nervous system, a certain amount of knowledge of the sub- ject is essential to a thorough appreciation of the lesions thereof. Embryologically, the earliest trace of the nervous system appears as the so-called medullary furrow on the dorsal surface of the embryo. This rapidly deepens into a groove, and is soon converted into the me- dullary canal by the closing over and union of the dorsal edges. At first its ectodermal lining is composed of cells of similar character. Soon, however, a differentiation takes place, forming a layer of radially disposed columnar cells lying next to the medullary canal, while more ex- ternally, small round-cells are to be seen situated between the columnar Outer border (layer). White substance (longitudinal fibers). Germ-cells Central canal Inner border- (layer Spongioblasts Neuroblasts Anterior roots Fig. 61— Transve*3e section through the spinal cord of a vertebrate embryo; X 550 (after W. His.). cells (see Fig. 61). The former are called spongioblasts, and give rise to the neuroglia or " spider " cells ; the latter, the neuroblasts or germ-cells, as they have been termed, give rise to the nerve-cells and fibers. The spinal ganglia arise from an accumulation of ectodermic cells 1012 DISEASES OF THE NERVOUS SYSTEM. 1013 (the neural crests) lying on either side of the posterior part of the medul- lary canal (see Fig. 62). With the growth of the cerebro-spinal axis the spider cells become more or less irregularly scattered through both white and gray matter, serving, in part at least, as sustentacular tissue. It is quite possible also that they may functionate in some other manner. From their ecto- dermal origin and close relationship with the neurogenetic tract, also from their peculiarly branched form, they cannot be regarded as mere con- nective tissue. The rest of the supporting framework of the nervous system is composed of connective-tissue trabecule derived from the pia. In the gray matter the ground reticulum consists of collaterals, terminal axons, and nerve-fibers. Many of the nerve-fibers become invested with a medullary sheath or the white substance of Schwann, a derivative of the mesoblast; the time at which this occurs varies in different fibers, but is constant for each group. This fact was taken advantage of by Flechsig, who perceived that he could thereby study the course of the fibers. It has been ob- served that the white matter appears first in those tracts that are imme- diate prolongations of peripheral nerves, and later in those connected with the brain-centers. Thus has been described the development of both the cells and fibers, the predominance of one or other of which in a certain area constitutes the gray or white matter respectively. Nervous tissue is, therefore, seen to consist of nerve-cells and fibers with a supporting framework of neuroglia and connective-tissue trabecular. The nerve-cell consists of a cell-body, protoplasmic processes (den- drites) with their lateral buds or spines, and the axis-cylinder or axon 1014 DISEASES OF THE NERVOUS SYSTEM. with its collaterals. To this composite body Waldeyer has given the name neuron. The cell-body consists of a more or less granular protoplasmic mass having a nucleus and a nucleolus. The cytoplasm is prolonged into one or, more commonly, several, processes, from which fact has arisen the custom of describing these cells as unipolar, bipolar, or multipolar (vide Fig. 63). The protoplasmic processes probably form the path of afferent nerve- impulses, while the axon is the efferent path; hence the terms proposed by Cajal—viz. centripetal or cellulipetal for the former, and centrifugal or cellulifugal for the latter. The axis-cylinder processes are delicate filaments that terminate in arborizations, and give off collateral branches that in turn end similarly to the main axis. The ganglion-cells tend to collect in certain centers Fig. 64.—Section of spinal cord (after Dana), showing complete subdivision of white columns into— (DPy, direct pyramidal tract. AFC, anterior funda- mental column. Lateral columns. f Column of Goll. Posteriorcolumn, j StrTm-zon^oSsauer's I column. f LFC, lateral fundamental column. LL, lateral limiting layer. CPyT, crossed pyramidal tract. CT, direct cerebellar tract. ALT, antero-lateral ascending tract. f ARZ, anterior root-zone. ! MRZ, middle root-zone. I OZ, oval zone. I PRZ, posterior root-zone. of the cerebro-spinal axis, as in the horns of the cord, Clarke's column, and the brain-cortex. They vary in size, and have a direct relation with the length of their axis-cylinder processes ; hence we find the largest in the anterior horns of the cord and the paracentral lobule. The neurons are never found in actual contact in any part of their distribution, but are merely contiguous. The axis-cylinders and their collaterals terminate in a latticework arrangement or arborization that is always found in relation with the dendrites of another neuron. A nervous impulse originates in a cell- body, passes out through the axon, and is then distributed to another neuron or series of neurons by means of the tufts of the collaterals or the terminal arborization of the axon in relation with the dendrites. In 1852, Waller discovered that section of a nerve is followed by degeneration in the direction in which impulses are conveyed; hence the DISEASES OF THE NERVOUS SYSTEM. 1015 term " Wallerian degeneration." The columns or tracts that have been mapped out in the cord may be seen in the accompanying diagram (Fig. 64). In the antero-lateral portion are found the anterior or uncrossed pyramidal column, the antero-lateral column of Gowers, the cerebellar column, and the crossed pyramidal column. In the posterior region are seen the column of Goll and the column of Burdach. The rest of the white matter forms the so-called ground-bundles. In the area comprising the anterior and lateral columns both ascend- ing and descending fibers are found. The columns that transmit ascending impulses are—1. The direct lateral cerebellar column. 2. The antero-lateral ascending column of Gowers. 3. The antero-lateral ground-bundle or fundamental column. 4. The columns of Goll and Burdach. Descending impulses are transmitted chiefly by way of the direct and crossed pyramidal tracts and the antero-lateral descending tract. The ventro-lateral or dorso-lateral tract—i. e. the direct lateral cerebellar tract of Flechsig—takes origin in the cells of the column of Clarke, and first appears in the lower dorsal region, runs up the cord, into and through the restiform body, to the cerebellum. Gowers' tract, or the antero-lateral ascending column, is first seen in the lumbar cord, and arises from some of the cells of the posterior horn. It then crosses to the other side of the cord through the posterior commissure and runs up and terminates in the region of the lateral nucleus. The antero-lateral ground-bundle, or fundamental column, is made up of commissural fibers that connect different levels of the cord; also of fibers that pass through the anterior commissure from the gray matter of the opposite half of the cord; and of obliquely-coursing fibers derived from the anterior root. The direct and crossed pyramidal columns constitute the great motor path by which fibers descend from the cortex and end in the motor nuclei of the cranial and spinal nerves—in the latter case in the multipolar gan- glion-cells of the anterior horns. Their origin is in the motor region of the cerebral cortex—i. e. the ascending frontal and parietal regions, the paracentral lobule, and the posterior part of the inferior frontal convolu- tion ; they then bend in the form of rays, as do fibers from all parts of the cerebral cortex (known collectively as the corona radiata), to enter the internal capsule. This may be described as a wedge, bounded in front and to the inner side by the caudate nucleus and the optic thalamus, and on the outer side by the lenticular nucleus. All of the fibers of the corona radiata do not pass through the internal capsule, some being lost in the gray matter of the basal ganglia, while others take origin in the ganglia. The angularity of the internal capsule is due to the position of the lenticular nucleus, the angle being known as the genu or knee, the part anterior to it as the anterior limb, and the pos- terior portion as the posterior limb. Through the anterior limb course the fibers from the frontal region ; in the region of the genu are the fibers for the muscles of the face and tongue; and in the posterior limb, the motor fibers to the extremities, also the sensory or tegmental fibers, and at its posterior end the fibers of the optic radiation. The crusta consists of fibers that pass through the pons and enter the medulla, constituting its pyramidal tracts. 1016 DISEASES OF THE NERVOUS SYSTEM. The tegmental fibers are continuous through the longitudinal fibers of the pons with those derived from the formatio reticularis of the medulla. This is formed by fibers from the superior cerebellar peduncles, the olivary body, and the posterior and lateral columns of the cord, which are rein- forced in their upward course by fibers derived from the quadrigeminal and geniculate bodies. Tracing the pyramidal fibers through the medulla, they will be found to divide into two unequal portions at its lower part. The larger decussates at this point (the region of the first and second cervical nerves), constitut- ing the decussation of the pyramids ; it then crosses to the posterior part of the lateral column of the opposite side, in which it runs as the crossed pyramidal tract. In their course these fibers give off collaterals at right angles to them- selves. These pass into the gray matter, and terminate in arborizations about the root-cells of the anterior horn of the same side. The main axes end in the same manner. As these main fibers with their collaterals pass into the gray matter at various levels of the cord, the tract becomes more and more attenuated, and terminates finally in the lumbar enlargement of the cord in the neighborhood of the third or fourth sacral nerve. The smaller division of the medullary pyramids passes directly into the anterior region of the cord without decussating, and is known as the direct pyramidal tract, or the column of Tiirck. In its course it gives off collaterals at right angles. These pass through the anterior commissure at different levels of the cord, and end in relation with cells of the anterior horn of the oppo- site side. The main fibers terminate precisely in the same manner. Thus it will be observed that the fibers of the column of Tiirck de- cussa/te in the anterior commissure of the cord; like the tract previously described, it becomes gradually smaller from above downward, and ends in the lower part of the dorsal cord. The axis-cylinders of the multi- polar ganglion-cells of the anterior horns pass out through the anterior roots of the same side and terminate in end-plates of muscles. Dejerine, Oppenheim, Monakow, and other neurologists believe that each motor cortex sends fibers to both sides of the body, and that the decussation of the pyramids is not a complete one, a small number of the fibers running in the lateral pyramidal tract on the same side as the lesion. This is borne out clinically by the slight paresis and the plus knee-jerk on the same side, neither of which, however, approaches in degree the palsy and increased knee-jerk on the side opposite to the lesion. Pathologic confirmation of this view has been obtained by several observers, who have found degeneration in both latero-pyramidal col- umns in cases of a unilateral lesion in the motor cortex. Motor-fibers from the nuclei of cranial nerves after decussating join with motor-fibers of the internal capsule. The exact course of these fibers, however, has not been demonstrated anatomically. Since many of the muscles supplied by the cranial nerves functionate bilater- ally—e. g. the eye-muscles and the muscles of mastication.—the suppo- sition is that in addition to fibers from its own nucleus each motor cranial nerve receives fibers from the corresponding nucleus of the opposite side. It was Broadbent who first pointed out that parts that functionate bilat- erally are supplied from both sides of the brain. Having outlined the course of the fibers of the anterior and lateral Fig. 66. Fig. 65.—x, Peripheral sensory tract; 6, b'.b2, b3, cells in the short fibers, through the intercalation of which sensory impulses are conducted to the brain; c, continuation of the paths for sensory impulses leading to the cortex. Fig. 66.—1, Motor centers for the lower extremities; l1, motor centers for the upper extremities ; 2, motor centers for the nerves of the face; 3, 4, 5, lateral pyramidal tract (red); 6, 7, 8, anterior pyramidal tract (f/recni; py, pyramids (red); col (red and green), collateral fibers leading to gray substance. The Roman numerals (III, IV, etc.) indicate" the nuclei, and correspond with the numbers of the cerebral nerves; the letters (g, h, etc.) represent the points of decussation and the names of the individual nerves. DISEASES OF THE NERVOUS SYSTEM. 1017 or columns, it simply remains to describe those of the posterior column, which, as previously stated, are the columns of Goll and Burdach. The ganglion-cells on the posterior roots give rise to two fibers, fused for a short distance from the cell, but soon bifurcating. The longer of the two, the centrifugal fiber, extends to the surface and terminates in pointed or bulbous endings in the epidermis, or in special sensory nerve- endings in tactile cells, tactile corpuscles, or end-bulbs. The centripetal fibers or axons penetrate the cord, and divide in the white matter into ascending and descending fibers. The former may be either long short. The short fibers are ver- tical at first, but finally bend into the gray matter and end in rela- tion with certain neurons. Their collaterals end in a similar man- ner. The long fibers extend up the cord to the medulla, ending in the usual manner in the gray nuclei of the columns of Goll and Burdach; these are known as the nucleus gracilis and nucleus cune- atus, respectively. They also give off collaterals in their course. The descending fibers, on the other hand, are all short, and probably constitute the so-called comma tract of Schultze. The posterior roots on entering the cord divide into two groups, median and lateral. The former consists of large fibers that bifur- cate and send short branches downward and short and long branches upward. The course of the descending fibers is not defi- nitely known. The so-called " comma tract " of the posterior columns is said to be made up of these fibers. Of the ascending fibers, the short ones end in relation with cells of the anterior horns, and are con- cerned in reflex movements ; others probably cross to the gray matter of the opposite half of the cord. The long fibers course through the cord as far as the medulla, and end in relation with the cells of the nucleus gracilis and the nucleus cuneatus. These nuclei correspond to the multipolar ganglion-cells of the an- terior roots. Since fibers continue to enter the cord at different levels, those that have entered below are pushed more and more toward the median line. It will thus be seen that the column of Goll is made up almost entirely of long fibers, and that the column of Burdach also con- tains long fibers, although it is probable that the short ones predominate. The long fibers are concerned in muscular coordination and equilibrium. Sacral Fig. 67.—Diagram showing the groupings and plex- uses of the spinal nerves (redrawn after Baker). 1018 DISEASES OF THE NERVOUS SYSTEM. The lateral group of fibers of the posterior roots is smaller than that just described. The most external of them, constituting the Spitzka- Lissauer column, are situated near the substance of Rolando. They spring from the posterior roots, run a short distance up the cord, and then enter the posterior horn. The others terminate in relation with the cells of the column of Clarke. All these fibers give off collaterals; they are concerned in visceral and cutaneous sensibility. It will be remembered that the motor tracts have two decussation- areas—one in the lower part of the medulla, the other through the anterior commissure at various levels of the cord. The sensory fibers also cross at an upper and a lower level, the former (about to be de- scribed) being through the lemniscus, and the latter, as previously narrated, through the posterior commissure. The axons of the cells of the nucleus gracilis and nucleus cuneatus pass into the lemniscus, decus- sate with similar fibers from the opposite side, are joined by the sensory cranial nerves of the opposite side, give off collaterals in their course, and terminate finally in cells of the basal ganglia or in the cells of the cortex of the parietal, temporal, and occipital regions (vide Figs. 65, 66). In the crus they occupy the lower part already described as the teg- mentum, and in the internal capsule they are situated in the posterior limb, behind the motor fibers for the extremities, and between it and the fibers of the optic radiation. Since the post-natal growth of the vertebras is more rapid than that of the cord, it follows that the spinal nerves assume a more and more oblique position, until finally the spinal segments, each of which con- sists of an anterior and posterior nerve-bundle with a transverse plane of white substance, lie considerably above the vertebrae after which they are named (see Fig. 67). The following table (Starr, modified by Mills and Dana from the experimental and clinical studies of Thorburn and others) shows the localization of function (not organs) in the different segments of the cord: Localization of the Functions of the Segments of the Spinal Cord. Segment. First cervical. Second and third cervical. Fourth cervical. Fifth cervical. Ml'SCLES. Rectus laterales. Rectus capitis. Anticus and posticus. Sterno-hyoid. Sterno-thyroid. Sterno-mastoid. Trapezius. Scaleni and neck. Omo-hyoid. Diaphragm. Diaphragm. Deltoid. Biceps. Coraco-brachialis. Supinator longus. Rhomboid. Supra- and iufra-spi- natus. Deltoid. Biceps. Coraco-brachialis. Brachialis anticus. Supinator longus. Supinator brevis. Deep muscles of shoul- der-blade. Rhomboid. Teres minor. Pectoralis (clavicular part). Serratus magnus. Reflex and Centers. Hypochondrium (?). Sud- den inspiration pro- duced by sudden pres- sure beneath the lower border of the ribs. Pupillary (fourth cervi- cal to second dorsal). Dilatation of the pupil produced by irritation of the neck. Scapular (fifth cervical to first dorsal). Irrita- tion of skin over the scapula produces con- traction of the scap- ular muscles. Supinator longus. Tap- ping the tendon of the supinator longus pro- duces flexion of fore- arm. Sensation. Back of head to vertexr and neck. ^Occipitalis major, occipitalis mi- nor, auricularis mag- nus, superficialis colli, and supraclavicular.) Neck. Shoulder, anterior sur- face. Outer arm. (Supracla- vicular, circumflex, external musculocu- taneous, cutaneous.) Back of shoulder and arm. Outer side of arm and forearm to the wrist. (Supraclavicular, cir- cumflex, external cu- taneous, internal cu- taneous, posterior spi- nal branches.) DISEASES OF THE NERVOUS SYSTEM. 1019 Segment. Sixth cervical. Seventh cervical. Eighth cervical. First dorsal. Second dorsal. Second to twelfth dorsal. Muscles. Deltoid. Biceps. Brachialis anticus. Subscapular. Pectoralis (clavicular part). Serratus magnus. Triceps. Pronators. Rhomboid. Latissimus dorsi. Triceps (long head). Extensors of wrist and fingers. Pronators of wrist. Flexors of wrist. Subscapular. Pectoralis (costal part). Serratus magnus. Latissimus dorsi. Teres major. Triceps (long head). Flexors of wrist and fingers. Intrinsic hand-muscles. Extensors of thumb. Intrinsic hand-muscles. Thenar and hypothenar muscles. Reflex and Centers. Triceps (fifth to sixth cervical). Tapping el- bow tendon produces extension of forearm. Posterior wrist (sixth to eighth cervical). Tap- ping tendons causes extension of the hand. Anterior wrist (seventh to eighth cervical). Tap- ping anterior tendons causes flexion of wrist. Palmar ^seventh cervical to first dorsal). Strok- ing the palm causes closure of the fingers. Muscles of back and ab- domen. Erectores spinse. First lumbar. None. Second lumbar. Vastus internus. Third lumbar. Fourth lumbar. Fifth lumbar. First and second sacral. Third, fourth,and fifth sacral. Sartorius; adductors of thigh. Flexors of thigh. Extensors of knee. Abductors of thigh. Outward rotators. Flexors of knee. Flexors of ankle. Peronei. Extensors of toes. Calf-muscles. Glutei. Peronei. Extensors of ankle. Small muscles of foot. Perineal. Muscles of bladder, rec- tum, and external genitals. Epigastric (fourth to sev- enth dorsal). Tickling mammary region causes retraction of the epigastrium. Abdominal (seventh to eleventh dorsal). Stroking side of ab- domen causes retrac- tion of belly. Vaso-motor centers. Sec- ond dorsal to second lumbar. Cremasteric (first to third lumbar). Stroking in- ner thigh causes re- traction of scrotum. Patellar. Striking pa- tellar tendon causes extension of the leg. Gluteal (fourth to fifth lumbar). Stroking buttock causes dimp- ling in fold of buttock. Achilles tend.on. Over- extension causes rapid flexion of ankle, called ankle-clonus. Plantar (fifth lumbar to second sacral). Tick- ling sole of foot causes flexion of toes and retraction of leg. Genital center. Vesical center. Anal center. Sensation. Outer side and front of forearm. Back of hand, radial distribution. (Chiefly external cu- taneous, internal cu- taneous, radial.) Radial distribution in the hand. Median distribution in the palm, thumb, in- dex, and one half of the middle finger. (External cutane- ous, internal cutane- ous, radial, median, posterior spinal branches.) Ulnar area of hand, back, and palm, in- ner border or forearm. (Internal cutaneous, ulnar.) Chiefly inner side of forearm and arm to near the axilla. (Chiefly internal cutaneous and nerve of Wrisberg or 1 e s s- er internal cutane- ous.) Inner side of arm near to and in the axilla. (Intercosto-humeral.) Skin of the chest and ab- domen, in bands run- ning around and downward, corre- sponding to spinal nerves. Upper gluteal region. (Intercostals and dor- sal posterior nerves.) Skin over groin and front of scrotum. (Ilio- hypogastric, ilio-in- guinal.) Outer side and upper front of thigh. Lum- bar region. (Genito- crural, external cuta- neous.) Front and outer side of thigh. Inner side of leg and foot. Inner side of thigh, leg, and foot. (Internal cutaneous, long sa- phenous, obturator.) Back of thigh and outer side of leg and ankle ; sole ; dorsum of foot. (External popliteal, external saphenous, musculo- cutaneous, plantar.) Back of buttock and thigh, side of leg and ankle: sole; dorsum of foot. Circumanal region, anus, rectum, penis, urethra, vagina, per- ineum. (Small sciatic, pudic, inferior hemorrhoidal, inferior pudendal.) 1020 DISEASES OF THE NERVOUS SYSTEM. To the foregoing table, which illustrates spinal localization, should be added another, showing Avhat functions reside in the pons and medulla, as follows: Nuclei. III. IV. Sphincter. Ciliary muscles. Levator palpebrae superioris. Rectus internus (in convergence) Rectus superior. Rectus inferior. Obliquus inferior. Obliquus superior. (Upper facial group.) y f (Associated movement of levator palpebrae.) '' { Muscles of lower jaw. {Rectus externus. Rectus inter, of opposite side in lateral movements. VII.—Facial muscles. , ,T o • * \ IX. f Muscles of pharynx. XII. i (,V°T ?! gr°UP° ^- \ Muscles of esophagus. 1 Muscles of tongue. XI j Mugcles of ^^ Cerebrum.—The cortex of the cerebrum is composed of the follow- ing layers; considerable variation, however, exists in the structure of the cortex in different parts of the brain : (1) Neurogliar layer. (2) Molecular layer, composed of— a. Horizontal fibers of Kblliker and Exner ; b. Polygonal cells ; c. Fusiform cells ; d. Triangular cells. (3) Small pyramidal cell-layer. (4) Large pyramidal cell-layer, or layer of psychic cells of Cajal. (5) Polymorphous layer. (6) Fusiform cell-layer. The white matter of the cerebral hemispheres is made up of medul- lated nerve-fibers that arrange themselves in the following groups : (1) Projection-fibers. (2) Association-fibers. (a) Connecting various parts of the same hemisphere : Short or arcuate fibers ; Long association-fibers. (b) Connecting opposite hemispheres : Commissural fibers. (3) Terminal fibers. The projection-fibers have been divided into the cortico-afferent and the cortico-efferent, the former being chiefly sensory and the latter chiefly motor. The pyramidal fibers have already been described, and these constitute the main part of the cortico-afferent group. They take origin in the psychic cells of Cajal, and possibly from the small pyra- midal and polymorphic cells also ; they then pass as part of the corona radiata through the internal capsule, the foot of the crus cerebri, the pyramids of the medulla, and the anterior and lateral columns of the cord. In their course collaterals are given off, some of which pass through the corpus callosum to be distributed in the cortex of the oppo- DISEASES OF THE NERVOUS SYSTEM. 1021 site hemisphere. Others traverse the anterior commissure. Both these sets of collaterals are really commissural fibers. Some of the collat- erals terminate in relation with cells of the basal ganglia. The course of these efferent fibers has been ascertained almost solely through researches along pathologic lines. It is manifestly more diffi- cult to trace the afferent fibers, as their presiding cells are more distant. The ascending fibers of the antero-lateral columns of the cord termi- nate in the gray masses known as the nucleus magno-cellularis diffusus of Kblliker. The association-fibers connecting parts of the same hemisphere are both short and long, the short or arcuate fibers connecting adjacent convolutions, while the long ones bring into relation more distant parts of the cortex. The long fibers course in definite groups to which special names have been given, such as the uncinate fasciculus, superior and inferior longi- tudinal fasciculi, perpendicular fasciculus, cingulum fornix, fimbria, and bundle of Vicq d'Azyr. The association-fibers connecting the cerebral hemispheres are known as commissural fibers. They are the fibers of the corpus callosum and of the anterior commissure. Their exact origin and termination have never been ascertained, but it is believed that they unite symmetric cortical areas and consist of both axons and collaterals. It is supposed that they spring chiefly from the small pyramidal cells of the cortex, and that after crossing the commissural bridge they divide and spread out in a fan-shaped arrangement over wide areas. The anterior commissure connects the opposite temporal and occipital regions and olfactory lobes; other parts of the cortex are related through the corpus cal- losum. The terminal fibers are cortico-afferent fibers. These various fibers are the pathways for the conduction of nervous impulses to those regions of the cortex that preside over sensory, special sense, psychic, and motor functions. Mills says: " Too much stress is laid upon motor and sensory cells. The great function of all cells is trophic. Cells in sensory nerves do not feel, nor do they originate, sensation ; neither do motor cells spon- taneously generate motion. They are simply bodies placed in the great sensori-motor mantle to administer to the nutritive functions of the fibers which convey sensory and motor impressions." These motor cor- tical centers are not sharply delimited, but overlie one another (vide Fig. 68). An area exists in each center, stimulation of which produces more marked results than stimulation of any other part of the same center. From this point the response to stimulation becomes progressively less as the periphery of the area is approached, until a spot is reached where two sets of results are manifest, due to the overlapping of adjoining areas. Many observers discredit the idea that distinct motor centers exist, and believe that muscle and tactile sense-areas coincide in part or wholly with the motor region. This is probably true, and has the endorsement of such men as Hitzig, Fritsch, and Ilorsley, who claim that tactile and muscular sense are represented to a slight degree in the motor region. Owing to extensive sensory compensation, however, very 1022 DISEASES OF THE NERVOUS SYSTEM. little disturbance of a sensory nature is manifest in lesions involving the motor cortex. Some dulness in the paralyzed extremities is present. Perhaps the best confirmation of this view is had in those cases of epi- leptiform convulsions that are preceded by a sensory aura. Others be- lieve the motor zone to be distinct, but do not regard it as being spon- taneously motor. Ferrier believes that the motor zone, though anatom- ically separate, is both functionally and organically connected with the W ° I ° R Fig. 68.—Diagram of the cortical centers and areas of representation on the lateral aspect of the hemicerebrum (Mills). sensory. He further believes that association-fibers carry impulses from the sensory to the motor regions. Some observers have experimentally severed these connective fibers, with resulting paralysis, though electric stimulation of the motor cor- tex showed both it and the projection-tracts to be intact. Sensory Cortical Area.—Owing to the extensive compensation of sen- sory fibers, by means of which each side of the brain sends fibers to both sides of the body, it is impossible to map out the center with precision. It is generally believed, for reasons already stated, that the central convolutions (motor area) contain muscular and tactile sensory functions. These are also spread out over the parietal lobe, and it is possible, in- deed probable, that the sensory zone extends to the mesial surface of the hemisphere, as does the motor area. That this is the chief sensory center, as claimed by some observers, is, however, very questionable. From the cuneus, fibers pass to the pulvinar, forming an optic radia- tion of the Gratiolet. From the pulvinar they apparently pass to the external geniculate bodies, and thence to the anterior corpus quadrigemi- num. The optic tracts arise by two roots that curve round the crusta on either side and unite immediately in front of the tuber cinereum. Fibers from the two tracts pass to the homologous sides of both retinae; DISEASES OF THE NERVOUS SYSTEM. 1023 therefore the lesions posterior to the chiasm give rise to blindness of half of the retina on the same side. Visual Centers.—The exact center for ordinary vision is in the cor- tex of the occipital lobe of the inner surface in the region of the calca- rine fissure. A higher center exists, probably located in the angular gyrus, and a lesion of which produces mind-blindness: this is a condi- tion in which vision is not lost, but the seen objects are not recognized by the individual. Ferrier says that a lesion in this region sometimes gives rise to crossed amblyopia. The eye opposite to the lesions is chiefly affected, though vision is also restricted in the eye on the same side of the lesion (visual tract). Olfactory Center.—This is located in the anterior part of the uncinate convolution, on the inner surface of the temporal lobe. It is possible, too, that fibers pass from this region through the anterior commissure to the cortex of the opposite hemisphere. Auditory Center.—A lesion in the posterior part of the first temporal convolution produces a deafness in the opposite ear that is transient in cha- racter, owing to compensation. Bilateral lesions produce complete deaf- ness. Mind-deafness, or an inability to understand spoken words, has resulted from a lesion in the first temporal convolution of the left side. Speech Center.—The articulate speech center is located in the poste- rior part of the left third or inferior frontal convolution, and in the ad- jacent part of the ascending frontal in right-handed people (but on the right side in left-handed persons). It is not known exactly what part the island of Reil plays in articu- late speech. Word-blindness results from a lesion in the angular gyrus. Word-deafness results from a lesion in the posterior part of the first left temporal convolution. Taste Center.—The area of cortical representation is unknown. By some it is located in the gyrus hippocampus. Psychic Centers.—It is possible that the frontal lobes, anterior to the precentral fissure, contain the psychic centers. Such extensive compensation probably exists that no ordinary lesion produces mental aberration, but these centers are probably represented by the whole cortex. The Cerebellum.—The cerebellum, like the cerebrum, consists of a cortical layer of gray substance, within which is the medulla or white matter. The latter in turn encloses some gray nuclei. The cortex is made up of two layers: (1) The outer or molecular layer, and (2) The inner or granular layer. At the junction of these is found a layer of large cells, the cells of Purkinje, and from the upper part of the latter spring two or more mul- tibranching protoplasmic processes. The medulla contains both cortico- afferent and cortico-efferent fibers. Part of the afferent paths divide after entering the medulla, and the branches end in relation with the tufts of Purkinje's cells. Cajal has called these the scandent or climb- ing fibers. The afferent fibers to the granule-cells of the inner layer have irregular protoplasmic thickenings upon them, and suggested to Cajal the name of " mossy fibers." He looked upon them as the termina- tions of the cerebellar tracts of the cord. The efferent fibers run to the cerebrum, pons, medulla, and basal ganglia. The function of the cerebellum is that of coordination. Fibers pass 1024 DISEASES OF THE NERVOUS SYSTEM. from its cortex to that of the cerebrum, and vice versd. The impressions derived from the cerebrum are believed to be inhibitory. Peripheral impressions reach the cerebellum through the direct cere- bellar tracts of the lateral columns of the cord, and also from fibers de- rived from cells in the nuclei of the columns of Goll and Burdach. Motor impulses run from the cerebellar cortex to the motor region of the cerebral cortex by way either of the superior or middle peduncle, also by way of the inferior peduncle (restiform body) to the multipolar ganglion-cells of the anterior horns. GENERAL. AND TOPICAL. DIAGNOSIS. Nervous diseases are usually spoken of either as being functional or organic ; but, as our methods of research become more refined and our technic more perfect, the breach between these two groups is being gradually but perceptibly lessened. Granting this, they all really become organic diseases, though some in which neither macroscopic nor microscopic change has ever been discovered are called functional for the sake of convenience. Organic nervous diseases may be produced by two types of lesions: 1. Lrritative, causing an increase of function, continuous or inter- mittent. 2. Destructive, resulting in paralysis of motion or sensation, or both. Irritative lesions are prone to become destructive in course of time. They may be operative in the upper segment, which includes the brain and fibers leading to or from it as far as the ganglion-cells of the cord; or in the lower segment, including the multipolar ganglion-cells of the anterior horn, together with the peripheral motor and sensory nerves. When a complete pathway is involved a systemic disease is said to be produced. When two or more paths or neuron complexes are simul- taneously involved combined systemic disease results. Brain-lesions may be (a) focal or (b) diffuse. Cord-lesions are either (a) transverse, (b) focal, or (c) insular (a series of foci). Cord-lesions result in ascending or descending degeneration, the de- structive process travelling, as a rule, in the direction in which impulses are normally transmitted. In the fillet degeneration may extend up or down. The theory has been advanced that the vulnerability of the tracts of the spinal axis is in direct proportion to the degree of their functional activity; hence the reflex (sensory and pyramidal) tracts are more prone to degenerate under nutritional disturbances or toxic processes than other parts. It is Avell known, however, that the tardy myelination of the pyra- midal tracts predisposes to various nervous maladies, and particularly to those of a convulsive type. The following may be accepted as a general rule: the motor-nervous system is the last to develop, the first to lose, and the last to regain, its function; while the sensory nervous system is the first to develop, the last to lose, and the first to regain, its function. In making a diagnosis it is, therefore, of the utmost importance to try to determine the locality and extent of the morbid process, and to ascertain whether the lesion is a focal or systemic one. The symptomatology of GENERAL DIAGNOSIS. 1025 systemic diseases is pretty constant, and, except in their very incipiency, they are usually not difficult of diagnosis. The symptoms of focal dis- eases, on the other hand, vary, of necessity, according to the location of the focus. They are often difficult and at times impossible to diag- nose. Especially is this true of lesions occurring in the frontal lobes of the cerebrum, in the basal ganglia, and in the cerebellum. Since the study of the motor centers and tracts has been pursued with so much more success than that of the sensory system, positive or negative motor phenomena occurring in the course of nervous diseases furnish us with much more valuable information than do sensory mani- festations. Further, motor symptoms are objective, and consequently appeal to us in a much greater degree than the sensory symptoms, which are purely subjective, and the elicitation of which depends so much upon the mental capability of the patient. Irritative motor-lesions produce, according to the degree of irritation, either fibrillary muscular twitchings or mild or severe convulsions, tonic or clonic in character. Destructive motor-lesions, according to their extent, produce mere muscular weakness, paresis, or actual paralysis of a single muscle, groups of muscles, or of the entire musculature of one or more limbs. Irritative sensory lesions give rise to neuralgia, hyperesthesia, or hyperalgesia. Destructive sensory lesions cause a more or less complete absence of sensation, as analgesia, anesthesia, or loss of temperature-sense. Upper-segment or Upper-system Diseases.—A lesion occurring in the motor pathway anywhere between the cortex and the multipolar cells of the anterior horns (but not including the latter) gives rise to the following symptom-complex: Loss of motion, both automatic and vo- litional, and chiefly on the side of the body opposite to the lesion, though, if carefully sought for, some paresis will be found on the same side as the lesion, due to the fact that each motor cortex supplies both sides of the body, though most of the fibers cross to the opposite side. The paralysis is spastic in type, flaccidity never being present. The muscles resist passive movements, showing that their tone is increased. This is relative, and is due to the removal of cerebral inhibition, which allows the lower centers free play. They also tend to undergo shorten- ing, and contractures result. Reflexes are increased chiefly on the side opposite the lesion, but also on the same side, the increase being the result of the removal of cerebral influences. The bilateral character is due to the manner of crossing of the fibers, a unilateral cortical lesion giving rise to bilateral degeneration in the cord. Owing to inactivity, the muscles of the paralyzed members undergo a more or less marked atrophy, though there are no degenerative changes, since the neuron bodies are intact. For the same reason the response to electric stimulation is not interfered with. An irritative lesion of this upper system, particularly when operative in or upon the cortical region, gives rise to tonic or clonic convulsive movements. When the lesion is localized to a single center, focal or so- called Jacksonian epilepsy results. The cortex is wonderfully tolerant, when the lesion is of gradual onset and the parts accommodate them- 65 1026 DISEASES OF THE NERVOUS SYSTEM. selves to the slowly increasing pressure. However, a local irritative le- sion may at first cause widespread symptoms, due, as Nothnagel pointed out, to pressure, vascular disturbances, or irritative inhibition. Lower-segment or Lower-system Diseases.—This includes the periph- eral neuron system. Since there is no crossing of the fibers, the lesion and resulting paralysis are on the same side of the body. The paraly- sis, however, is of the flaccid, flail-like variety, hypotonus being present. The muscles offer no resistance whatever to passive movement, contrac- tures do not occur, and reflexes are lost. Extreme degrees of wasting occur in this type of paralysis, owing partly to disuse, but chiefly to the fact that the neuron body, the nutritional or trophic center for the fiber, is injured. Pathologic changes therefore take place in the muscles themselves, and form a true degenerative atrophy. The protoplasm first becomes granular, and then fatty; it then breaks down and is absorbed. Its place is taken by the connective tissue, which is both relatively and absolutely increased, so that in the course of time fibrous - masses alone remain. Electric changes also occur. The muscles first cease to respond to the faradic current, and soon respond in an abnormal manner to the galvanic. Instead of short, sharp contractions, they react in a slow, wavy manner, ACC being stronger than KCC. Irritative lesions of this system cause fibrillary muscular contractions and periph- eral convulsions, of which laryngismus stridulus is a type. I. DISEASES OF THE PERIPHERAL NERVES. ACUTE ASCENDING PARALYSIS. (Landry's Paralysis.) Definition.—An acute paralysis, beginning in the legs and ascend- ing by way of the trunk and upper extremities, and ultimately involving the medullary centers. It usually runs a short course, and, as a rule, terminates in death. Pathology.—Although in many cases neither gross nor microscopic lesions have been found, either in the cells, peripheral fibers, or muscles, it is believed to be either an acute myelitis or an acute polyneuritis, the weight of opinion seeming to favor the latter view. Ross arrived at the latter conclusion after an analysis of 93 cases. Nauwerck, Barth, and Centanni hold the same belief, and the latter has discovered a bacillus in the lymph-spaces of peripheral nerves. Remlinger1 has reported a case occurring in a young man in whom paraplegia developed acutely, and eleven days later death resulted from bulbar involvement. Postmortem the cord was found congested in the region of the anterior horns. Microscopic examination revealed the presence of inflammation and streptococci in the cervical cord. The organisms occupied the tissue between the multipolar cells of the anterior horns. These latter in many instances were severed from their processes. Pure cultures of 1 Gazette hebdomidaire de Medecine et de Chirurgie, Xo. 27, 1896. ACUTE ASCENDING PARALYSIS. 1027 streptococci were obtained from the cord at various levels, but they were non-pathogenic for the rabbit. R. and F. Schultze and Sinkler have also reported cases in which the only postmortem lesion was mye- litis, yet, as stated, the majority of observers believe it to be a neuritis. That it is primarily due to some toxemia, however, as originally claimed by Westphal, cannot be gainsaid. The prodromes, when present, are suggestive, and the enlargement of the spleen, which is a constant con- comitant, and more rarely the lymphatic enlargement and albuminuria are all confirmatory. That the poison should have a selective tendency, since the nervous involvement is chiefly or solely motor, is not unique. AVe meet with toxic paralysis of the motor muscles of the eye, also with lead-palsy. Etiology.—No definite cause is known. It has followed cold and exposure, traumatism, and the infectious fevers, including influenza. Remlinger's case, quoted above, followed malaria. It occurs in males • chiefly between twenty and forty years. Symptoms.—In the most acute cases there are practically no pro- dromal symptoms other than malaise and possibly chilly sensations. Weakness, followed in a few hours or a day or two by paralysis, de- velops in the lower extremities. One may be involved a few hours earlier than the other. It spreads toward, and soon involves, the trunk also, and in quick succession the arms. The third and usually fatal stage is reached when bulbar symptoms develop. Very rarely the upper extremities may be first attacked. Death may occur in forty- eight hours. The paralysis is a flaccid one ; the muscles can be passively moved without offering any resistance. Wasting sets in, but no electric changes. In less acute cases a decided febrile stage precedes the onset of paralysis, chills, fever, malaise, and possibly formication or even sharp pain. In any case the later symptoms are pre-eminently or solely motor. Sensory symptoms when present are very slight. Sensation may be delayed, and the reflexes are generally absent; accordingly, there is edema or sweating. The bladder and rectum are not implicated, nor do bed-sores develop. As stated, when the bulb is attacked death gen- erally follows, due to cardiac or respiratory failure or to interference with deglutition. There are no cerebral symptoms. Course.—Death may occur in from forty-eight hours to a few weeks. A few cases of recovery have been reported, however, in some of which paralysis had been widespread, even reaching the bulb, judging from the labored respiration. When improvement takes place, it does so in the reverse order to the onset, so that the part last affected is the first to recover. It is much slower than the invasion. Diagnosis.—The rapid onset of a paralysis that usually ascends, the relaxation of the muscles, slight wasting, if any, and the absence of electric changes and of sensory symptoms, with or without fever, serve to make the diagnosis, and to distinguish Landry's disease from polio- myelitis, neuritis, and spinal hemorrhage. For the differential diagnosis between Landry's paralysis and acute myelitis, see page 1072. Prognosis.—Always grave, particularly if bulbar symptoms occur, and especially if they appear early. The treatment is essentially the same as that for any acute disease of the cord or nerves—i. e. rest, freedom from all excitement or worry, 1028 DISEASES OF THE NERVOUS SYSTEM. moderate purgation and diaphoresis; ergot, belladonna, and iodids in- ternally. Should the patient survive, electricity and massage should be administered. NEURITIS. Definition.—An inflammation of a nerve or of its fibrous envelope. Pathology.—A true neuritis is almost always an inflammation of the nerve-sheath or of the septa between the fasciculi, and usually begins as a perineuritis. The so-called parenchymatous neuritis is really a degen- erative process ; it is prone to follow neuritis, the result of excessive or prolonged irritation or from pressure by the products of inflammation. The sheath becomes hyperemic and the seat of a round-cell infiltration. The affected nerve becomes red and swollen. We may have a perineuritis or an interstitial neuritis. Again, these may be focal or diffuse (disseminated), involving limited patches or con- tinuous areas of a nerve. Finally, many nerves may be simultaneously affected, constituting a multiple neuritis. In the parenchymatous form the ordinary signs of inflammation are absent. The nuclei of the sheath increase in size and number, and the protoplasm about them increases in amount. The white substance of Schwann becomes segmented, breaks up into droplets, then becomes granular and fatty, and is finally ab- sorbed. The axis-cylinder becomes discontinuous at the site of disorgan- ization of the myelin. Ultimately, there may be seen scattered promis- cuously among the more or less healthy fibers the withered nerve-sheaths, containing many nuclei, some granular debris, and pigment. Occasion- ally fatty aggregations occur along the nerve. Leyden has termed this condition lipomatous neuritis, but it is not worthy of a special name, as it is only a stage in the ordinary degenerative process. Parenchymatous degeneration is similar to the secondary or Wallerian degeneration previously mentioned. It is the chief lesion in multiple neuritis, though in this disease changes have also been found in the mul- tipolar ganglion-cells of the anterior horns. Etiology.—(a) Focal neuritis may be due to—(1) Exposure or cold (the so-called rheumatic neuritis). (2) Extension of inflammation from neighboring parts. (3) Traumatism—wounds, compression, excessive stretching resulting from fractures or dislocation. (4) Microbic and autogenetic poisons. (b) Multiple neuritis may be due to—(1) Poisons of extrinsic origin —alcohol, carbon bisulfid, lead, arsenic, mercury, ether. (2) Poisons resulting from the infectious fevers (typhoid, diphtheria, variola, typhus, leprosy, beri-beri, measles, syphilis, tuberculosis, septicemia, malaria, in- fluenza). (3) Cachexias, anemia, carcinoma. (4) Auto-intoxication. (5) Cases arise in which no definite cause can be ascertained ; these are the so-called idiopathic or spontaneous cases. Symptoms.—(a) Focal Neuritis.—In localized neuritis the symptoms vary according to the function of the nerve involved. In the case of a sensory nerve there will be pain, usually of a boring or shooting charac- ter, along its course and distribution. There will be also tenderness on pressure along the nerve, and especially at its points of emergence from NEURITIS. 1029 bony canals. Weir Mitchell believes this to be due to irritation of the nervi nervorum. The skin is generally hyperesthetic (though tactile sensation is often lowered), reddened, sometimes edematous, and local sweatings may occur. In the more chronic cases trophic symptoms eventually arise, as glossiness of the skin and an impaired growth of the nails. When a motor nerve bears the brunt of the attack, mus- cular twitchings will be observed in the area supplied by the affected nerve. This is soon followed by more or less impairment of motion, even amounting to paralysis; sometimes contractures occur, and ulti- mately wasting of the muscles, and even reactions of degeneration, take place. When both motor and sensory nerves are simultaneously in- volved the symptoms will necessarily partake of a mixed character. The constitutional symptoms are, as a rule, of little moment. (b) Multiple neuritis is an involvement of the peripheral nerves in various parts of the body, affected simultaneously or in quick succession, and due to endogenous or exogenous poisons. Lettsom's paper, pub- lished in 1789, embodied the first description of the disease. Among cases due to poisons of extrinsic origin is alcoholic neuritis. In 1822, James Jackson of Boston clearly gave its clinical history, though Dumesnil in 1864 was the first to publish the result of an autopsy upon a case. Other pioneers were Leyden, Buzzard, and Ross. This is the most common type of multiple neuritis, and occurs oftener among women than men. It results from spirit-drinking in moderate amounts and continued over a long time. The onset is generally slow, being preceded by gastric catarrh, insomnia, tingling of the extremities, a rapid, weak heart, and a tendency to sweating on exertion. Some mus- cular twitching and paresis may exist contemporaneously, but the loss of power soon becomes more marked—first in the lower and then in the upper extremities, the extensors being chiefly affected. Wrist-drop and foot-drop follow. Occasionally paraplegia and, more rarely still, a loss of control of the bladder and rectum take place. Fever is rarely pres- ent. Sensory symptoms may vary from the tingling or numbness already noted to burning or boring pains of great severity. The skin is hyperesthetic at first, at all events. Later, paresthesia develops, with anesthesia and a more or less decided loss of muscular sense. The mus- cles are tender when touched. The cutaneous reflexes are preserved unless the anesthesia is marked. The knee-jerks are generally lost, though exceptionally they may be in- creased. In the less severe cases a certain amount of incoordination may be present. When this is the case the absence of the knee-jerk, the loss of muscular sense, ataxia, and the pains in the extremities sim- ulate locomotor ataxia, and the term pseudo-tabes has been applied to the condition. Vaso-motor and trophic symptoms appear, and in some cases the special senses are involved (impairment of vision, amblyopia, limitation of the color-field). The cerebral symptoms are important. They may be so slight as to consist merely of loss of memory, irri- tability, perhaps an hallucination or illusion (particularly after night- fall, and especially if the patient has had insomnia), or they may be of the type and degree seen in general paralysis. The duration of an attack varies from a few weeks to a year or so. Arsenic neuritis differs from the above in that the head-symptoms 1030 DISEASES OF THE NERVOUS SYSTEM. are o-enerally absent. The onset may be much more abrupt and the course is usually shorter. Carbon bisulfid neuritis occurs chiefly in workers in rubber-factories. There are noted intense frontal headache, giddiness, marked excitability, muscular cramps, and possibly convulsions. Saturnine neuritis is con- fined to motor nerves, and especially to those of the upper extremities. Very rarely some disturbance of sensibility may result. Lesions of the anterior cornua are more likely to occur in saturnine multiple neuritis than in any of the other varieties. Head-symptoms are not common, but optic neuritis and convulsions may occur. Cases due to an attack of some infectious disease may be local or multiple, and generally present the same symptoms as neuritis due to any other cause. (1) Malarial Neuritis.—According to Romberg, malaria gives rise at times to "intermittent paraplegia." The legs of the patient suddenly become paralyzed, with or without alteration of sensation or loss of control of the sphincter. That the cause is probably malarial is shown by the fact that the condition is periodic, each attack subsiding with a critical sweat, and finally yielding to quinin. (2) Recurring Multiple Neuritis.—A few cases have been reported in which attacks of more or less widespread paralysis, due to neuritis, have recurred. (3) Endemic neuritis, or beri-beri, is a tropical disease, characterized by weakness, wasting of the muscles, paralysis, anasarca, anemia, numbness, pain, areas of anesthesia, and diminution or loss of tendon-reflexes. There are two forms, the acute and chronic. Its eti- ology is obscure, though it is apt to supervene upon any condition that impoverishes the physical or nervous vitality. Intestinal parasites have been said to cause it. Ogata of Tokio has described a specific bacillus; Pekelharing and Winkler, however, claim that it is clue to a micrococcus. Whatever its cause, the researches of these latter observers, together with those of Baelz and Sheube in Japan, prove it to be a peripheral multiple neuritis. The symptoms of the acute form are fever, anemia, general edema, effusion into the serous cavities, dyspnea, precordial pain, vomiting, and peripheral paralysis. Death often results, even in a few days, from emboli or thrombi in the pulmonary or systemic circu- lation. In the chronic form the symptoms are less pronounced. The face is apt to be puffy, and palpitation and serious cardiac dilatation may occur. The gait is tottering, the muscles are somewhat wasted, the tendon-reflexes are lost, and paresthesia develops. The cases associated with the cachectic states may be general, though usually they are local and of the interstitial variety of neuritis. The cases due to auto-intoxication are usually associated with fever, and at first simulate rheumatism or some infectious disease. Soon, however, the tingling, pain, palsy, loss of the knee-jerks, and anesthe- sia reveal the neuritis. Death may result from cardiac or respiratory paralysis. When life is spared the convalescence is exceedingly slow. Spontaneous or the so-called idiopathic neuritis does not differ from the general type of the disease, except that no cause can be discovered to account for it. Diagnosis.—This does not present any difficulty, as a rule. The spontaneous cases, in the early stages, may simulate acute spinal paraly- sis or acute ascending paralysis. The fever, palsy, electric change, and NEURITIS. 1031 the loss of knee-jerks are common to both, but in acute spinal paralysis there are never any sensory symptoms. The palsy in idiopathic cases rapidly spreads, but soon subsides again. In other forms of peripheral neuritis the onset is not only apt to be less abrupt, but some sensory symptoms are almost invariably present; the distribution of the palsy is more symmetric bilaterally, and after it has reached its acme no improvement takes place for a few weeks or months. In ascending paralysis there are no sensory symptoms, the knee-jerks are preserved, there is neither muscular atrophy nor electric change, and the order in which the paralysis supervenes differs from that of peripheral neuritis. Cases of pseudo-tabes are sometimes confounded with locomotor ataxia. The main points of differentiation are included in the following table: Pseudo-tabes. Locomotor Ataxia. The course is shorter, and often results The course is progressive from bad to in recovery. worse, and chronic in nature. Pain is never of the fulgurant type. Fulgurant pains often are present. Pain- crises are almost diagnostic. There is tenderness over the nerve-trunks. There is no tenderness over the nerves. Sensory disturbances are more marked Sensory disturbances are less marked. (tingling and numbness). Argyll-Robertson pupil is absent. Argyll-Robertson pupil is present. There is a "foot-drop," with the typical No "foot-drop." The toes are raised, and •'steppage" gait. the foot is brought down flatly, with the heel first. Paralysis is often present. There is no actual loss of power. Prognosis.—Peripheral neuritis may terminate in one of the fol- lowing ways, according to Drs. Gibson and Fleming.1: 1. In complete recovery; 2. With damaged peripheral nerves; 3. With injury to the central nervous system, such as to cause symptoms of ataxia, spastic paraplegia, or disseminated sclerosis; 4. In death, from failure of the organic centers, especially that of respiration. The prognosis is gen- erally good, though in the acute variety (from any cause) it should be guarded, and occasionally is grave. Exposure and chill, alcohol, diph- theria, and beri-beri give rise to the most serious types, and often cause death by failure of the heart or respiration or by coagula in the vessels. Mild cases may entirely recover in a few weeks, while severe ones often require a year or two. Treatment.—First ascertain the cause, and, if possible, remove it. It may be unwise in alcoholic cases to suddenly stop the alcohol, but each case must be judged on its merits. Rest is very important, and all sources of worry should be stopped. Locally, anodynes may be em- ployed and the part wrapped in cotton wool. In febrile cases, especially in the earlier stages, the salicylates are valuable. The general health should be toned up by strychnin and tonics, and by nourishing but eas- ily digestible food. Further medication will depend upon the etiology, quinin being demanded in malarial, and mercury or the iodids in syphi- litic cases. As soon as the acute symptoms have subsided massage and passive movements should be begun, galvanism applied to the muscles, and warm-water or sulphur baths administered. Contractures must be carefully guarded against. 1 Edinburgh Hospital Reports, vol. iii. 1032 DISEASES OF THE NERVOUS SYSTEM. NEUROMATA. Neuromata, or tumors of nerves, have been described as (a) true and (b) false. (a) True neuromata consist of medullated or non-medullated nerve- fibers (the myelinic and amyelinic varieties—Virchow), and rarely of ganglion-cells also. (b) False neuromata contain no nerve-elements. The growth is situ- ated on the nerve-trunk itself, and consists of either fibrous, myxoma- tous, gliomatous, or sarcomatous tissue. Neuromata have also been classified according to their situation as (1) Stump neuromata, or bulbous nerves; (2) Subcutaneous neuromata, or tubercula dolorosa; (3) Nerve-trunk neuromata; (4) Plexiform neuromata. (1) Stump neuromata develop on stumps or on the ends of divided nerves as the result of traumatism. They may consist of fibrous tissue, but are usually myelinic. (2) Subcutaneous tumors, or tubercula dolorosa, are painful, as the latter name implies, and are apt to be multiple. In individuals so afflicted nerve-trunk neuromata may coexist. (3) Nerve-trunk neuromata are usually multiple. In one case quoted by Gowers as many as 3020 were found. They may be true or false. In the former case the nerve-fibers are less apt to be interfered with than in the heterologous growth. (4) Plexiform neuromata consist of beaded and tortuous, interlacing neural cords. They are usually congenital. Htiology.—Neuromata may be due to traumatism. When multiple, however, they are usually hereditary, occurring in families of a neurotic or strumous diathesis. They are most commonly found in men. Symptoms.—There may be none. When present their character necessarily depends on the nature of the nerve involved and whether the lesion is an irritative or destructive one. More or less pain, numbness or tingling, paraesthesia, and palsy are among the most common symp- toms. Various reflex manifestations have been described, and epilepti- form convulsions have been attributed to their presence. Treatment.—Apart from anodynes, operative measures are alone of value, except when the tumors are the result of syphilis, as occasion- ally happens; in such cases specific treatment must be employed. It must not be forgotten, however, that stump neuromata may occur in those hereditarily predisposed, in which case, as Bowlby has pointed out, their removal will almost surely be followed by a return. NEURALGIA. Definition.—Neuralgia (nerve-pain) is the result of some irritation directly or indirectly applied to a nerve. While this is true of all pain, yet the special nerve-pain under consideration presents the following characteristics: 1st. In its distribution it follows the course of a nerve- NEURALGIA. 1033 trunk or its branches. 2d. It shows a tendency to shift from place to place. 3d. The presence of painful points (points douloureux). 4th. Intermission and remission of pain. The pain of neuralgia varies both as to character and intensity. It may be merely a mild ache, or, on the other hand, it may give rise to the most excruciating agony ; it may be of a throbbing, boring, tear- ing, shooting, or burning character, or it may come on in shock-like paroxysms. Any nerve in the body may be affected. Quite often one can find no definite cause of the neuralgia, and as we are not certain as to its ultimate pathology, it may be due to some slight inflammation of the nerve, or to hyperemia, ischemia, exudation, and the like. Among the predisposing causes are—(1) Age, the condition being most common in those between thirty-five and fifty years, and less so above that age. It is least common in children. (2) Sex. On the whole, neuralgia is most common in women, though the severer grades are found quite as frequently in men. Sciatica is more common in men, while trigeminal neuralgia occurs more frequently in women. (3) Heredity. Neuralgia is very prone to occur in a family in which hysteria, epilepsy, or other neurosis or psychosis is present. (4) The general physical condition. In persons reduced by illness or by mental or physical exertion, and in anemia, neuralgia is common. (5) Occupation. Painters and workers among metallic dust are specially predisposed. The exciting causes are—(1) Exposure to cold and wet. (2) Me- chanical, chemical, or thermal irritation, including compression. (3) Traumatism. (4) Neuromata. (5) Infectious diseases. (6) Rheuma- tism and gout. (7) Endogenous or exogenous poisons. We are hardly justified to-day in speaking of idiopathic neuralgia. Such cases probably result from some endogenous or exogenous poison, an auto-intoxication, or malaria, rheumatism, syphilis, some metallic poison, or alcohol or tobacco. Finally, a form exists which we speak of in no certain manner as " reflex neuralgia," and which is said to re- sult from disease of the sexual or other organs often remote from the painful nerves. General Symptomatology.—Neuralgia may be of sudden or slow on- set, with or without prodromata. When the latter exist they consist of a sense of uneasiness, perverted sensations, chilliness, and stinging or slight burning pains. The pain may be of the character previously de- scribed, either strictly localized or radiating to neighboring nerves, and may be aggravated by drafts, movements, or mental perturbation. On pressure certain tender or painful spots will be found, especially where the nerves emerge from deeper parts and become superficial. The affected part is usually hyperesthetic; occasionally, however, it is anes- thetic, and may continue so for some time after an attack. Reflex muscular contraction may be present in proportion to the in- tensity of sensory irritation. Vaso-motor symptoms manifest them- selves in the flushing or blanching of the affected part and in increased secretions, as sweating. Trophic disturbances may result in temporary or permanent changes. To the former belong the herpetic and urticarial eruptions, while the latter 1034 DISEASES OF THE NERVOUS SYSTEM. groups include change of color in, loss of, or overgrowth of the hair, various changes in the skin (as pigmentation and morphea, and even ulceration, though in the latter instance there is probably a more pro- found pathologic change than that which we regard as the cause of neur- algia). Unless the attacks are severe or prolonged, however, the general system seldom suffers. Neuralgia may be divided into the following groups : neuralgia of the head, neck, trunk, upper and lower extremities ; neuralgia of the genitals and rectal region ; and visceral neuralgias. NEURALGIA OF THE HEAD. Trigeminal neuralgia (Tic douloureux) may manifest itself in any one or all of the branches of the fifth nerve. Neuralgia of the First Branch (Ophthalmic Neuralgia).—The chief points of pain in this variety are the supra-orbital foramen (the exit of the nerve), the nose, the eyeball, and parts around the eye. Supra-maxillary neuralgia (involving the second branch of the fifth, the supra-maxillary nerve). The tender points here are the infra-orbital foramen (the exit of the nerve), the cheek, side and cavities of the nose, the upper lip and gums, and the zygoma. The infra-maxillary division, the third branch of the fifth. The men- tal foramen is the point of greatest tenderness ; other spots, however, are the temporal region, and along the tongue and lower lip. NEURALGIA OF THE NECK AND TRUNK. The cervical branches of the dorsal and lumbar nerves are involved in this group. 1. Cervico-occipital neuralgia, occurring in the occipital and posterior parietal region, is apt to be quite severe, but when not due to spondylitis (the result of caries) or neoplasms the prognosis is fair. It is sometimes the result of direct pressure, as in carrying heavy loads on the neck and shoulders. The painful spot is found between the mastoid process and upper cervical vertebrae. Falling of the hair may also occur. This is much more apt to take place, however, when the occipitalis minor is in- volved, as it is said that the latter is generally a syphilitic neuralgia. 2. Phrenic neuralgia has been described, but is a rare condition. The pain is in the lower anterior thoracic region, at the points of inser- tion of the diaphragm. 3. Intercostal Neuralgia.—The middle intercostal nerves are most liable to be affected, and generally on the left side. The posterior dorsal branches are seldom involved. When specially severe and persistent, intercostal neuralgia may be a symptom of disease of the cord or its membranes, aneurysm of the aorta, neoplasms, or disease of the vertebrae or ribs. Traumatism and cold also give rise to it. This form of neuralgia is most common in women, the painful spots being at the extremity and at the middle of the ribs. The pain is of a sharp, lancinating cha- racter and radiates along the nerve. It is intensified by all movements of the chest; hence the affected side is more or less fixed. Herpes may develop, but in such cases it is probable that a true neuritis exists. NEURALGIA OF THE EXTREMITIES. 1035 4. Mastodynia is really a variety of intercostal neuralgia, and occurs almost solely among women. It is very painful, and gives rise to the development of tender " lumps " in the breast, simulating malignant disease. The paroxysms are often accompanied by vomiting. 5. Lumbo-abdominal neuralgia is not a common form. The pain is chiefly in the lumbar region, though the hypogastrium, genitals, and buttocks may also be involved. NEURALGIA OF THE EXTREMITIES. Cervico-brachial neuralgia occurs in the distribution of the four lower cervical nerves. When the condition is bilateral we should look for disease of the cord or membranes, for new growths, or for disease of the vertebrae. When unilateral, any of the causes already enumerated may be operative. The radial and ulnar nerves are more frequently affected than the median. The pain is most apt to be distributed along the whole course of the nerve, but painful points are found in the following sit- uations—in the axilla; over the brachial plexus; on the shoulder, where the cutaneous branches of the circumflex nerve emerge through the deltoid muscle; about the middle of the outer surface of the upper arm; over the ulnar nerve; in the sulcus between the olecranon and epitrochlea; also near the wrist and at the bend of the elbow over the musculo-spiral nerve. Femoral or crural neuralgia is a somewhat rare type that attacks the anterior surface of the thigh, the knee-joint, and the inner surface of the leg and foot. Obturator neuralgia is distributed along the inner side of the thigh down to, and including, the knee-joint. This form is common in women subject to ovarian diseases. Sciatica stands next to trigeminal neuralgia in the order of fre- quency, and is by far more common in men than women. In addition to the ordinary causes of neuralgia—exposure, compression, trauma- tism—the condition may be an early symptom of tabes or it may be due to constipation or hemorrhoids. The painful points are in the gluteal region and the popliteal space or malleolar region, though ten- derness may be elicited along the whole course of the nerve. The pain is sharp and shooting, or more often of a tearing variety. Fine or coarse tremors or spasms may be present, together with some disturbance of sensation and loss of power. Herpes occasionally develops along the course of the nerve. This form of neuralgia is quite common, and is generally easy to recognize, but it may be simulated by hip-joint disease, psoas abscess, or lumbago. Sciatica may also be caused by neuritis, the result of exposure or compression by pelvic growths, or by the fetal head during labor. In such cases there is, as a rule, slight fever, and the tenderness on pres- sure and the degree of pain are infinitely more severe than neuralgia. In severe cases the patient is bed-ridden, but in milder attacks he can be about; walking greatly increases the pain, however. It is slightly mitigated by relieving the tension on the nerve, by bending the knee, and walking on the toes. It is an obstinate condition, and relapses are common. 1036 DISEASES OF THE NERVOUS SYSTEM. The diagnosis is generally not difficult. The distribution of the pain, the location of tender points, and the character of the gait suffice to pre- vent error, as a rule. A rectal or vaginal examination should be made to determine whether it is a primary disease or secondary to some pel- vic condition, for clearly, if the cause can be removed, the prognosis will be good. Neuralgia of the Genitalia and Rectum.—These varieties are not met with frequently. The former is sometimes a symptom of stone, prostatic disease, or stricture, and in women ovarian and uterine neu- ralgias are generally hysteric manifestations. Coccydynia, unless of traumatic origin, is almost solely found in women. The pain in the region of the coccyx is excruciating at times, and may even call for operation. Visceral Neuralgia.—As implied by the name, these forms are neuralgias resident in the various viscera. They most frequently attack the stomach or bowel, and are recognized as colic. Other viscera may also be involved (liver, kidney). Treatment of Neuralgia.—The first requisite in the treatment of neuralgia is to ascertain whether it is due to local or general causes. That of the former class may be caused by a cicatrix, neuroma, aneur- ysm, neoplasm, or by caries or traumatism; and the treatment must necessarily be directed toward the removal of the cause when possible. When the fault is a general one, the neuralgia may occur either as the immediate result of the systemic disease or remotely, as the result of the altered blood-state (anemia). This is particularly well illustrated by an attack of malaria, in which it is palpable that success can only be obtained by attention to the underlying cause.' If; is sometimes necessary to use an analgesic, of which morphin is certainly the best. Its thera- peutic value is most decided when the drug is given hypodermically, and if injected directly over the track of the painful nerve (e. g. supraorbital branch of the fifth), it not only affords immediate relief, but also obviates recurrences of the painful paroxysms in many instances. It is, however, scarcely necessary to urge the exercise of caution, for the morphin-habit is readily formed in these cases. The following may also be used; anti- pyrin, phenacetin, codein, veratrum viride, aconite, also counter-irritants and vesicants, including the galvanic current. The general tone of the system must be attended to, bad habits prohibited, the state of the bowels regulated, and the eyes examined and corrected for errors of refraction. Rest is a valuable adjunct to any form of treatment. In neuralgia of the upper extremities and in sciatica I have often obtained good results from putting the limb in splints. Sciatica is often very intractable. If it fails to yield to the salicyl- ates; counter-irritation, leeches, and the rest-treatment of Weir Mitchell may be used, or nerve-stretching, either by flexing the thigh upon the abdomen or, as a last resort, by cutting down upon the nerve itself. Other nerves are sometimes subjected to this method of treatment also, but less frequently than the sciatic. Absolute rest in bed, with the limb kept perfectly still by means of sand-bags or a long splint, always gives relief, and in some cases seems to cure. Alternating hot and cold douches also give great relief in some instances. Deep injections of DISEASES OF THE CRANIAL NERVES. 1037 thein, ether, or chloroform are sometimes used, and even distilled water may give relief when injected into the nerve. The use of guaiacol (THJ—ij— 0.066-0.1332) in association with chloroform (TTlx—0.666) by this method has yielded very encouraging results in my hands.1 DISEASES OF THE CRANIAL NERVES. OLFACTORY NERVE. The following morbid conditions have been described in connection with the sense of smell: (a) Hyperosmia or Olfactory Hyperesthesia.—The sense of smell is abnormally acute, so that objects, and even persons, can be recognized by this means. It occurs chiefly among hysteric women or, rarely, in those run down by debilitating illnesses. It is occasionally met with among the insane. (b) Parosmia (perverted sense of smell) is due to irritation either of the center or of the nerve-trunk. This perversion may occur for one or for many odors, and is often associated with an obtunding of the normal sense. (c) Subjective sensations of smell are due to the same causes as the above. An olfactory aura may precede an attack of epilepsy. Olfac- tory hallucinations occur occasionally in the insane. (d) Anosmia or olfactory anesthesia (loss of the sense of smell) may be caused by—(1) damage to the peripheral filaments in the mucous membrane, due to catarrhal thickening, exostoses, excessive dryness of the membrane (caused by paralysis of the fifth nerve, or by erosion and destruction of the nose, thus exposing the mucous membrane), and, finally, by occlusion of the nares by polypi or other tumors. (2) Injury to the nerve-trunk or bulb either directly or by blows upon the head, presumably resulting in a laceration of the nerve or the bulb, or both. Syphilitic or other bone-disease, tumors, abscesses, and meningitis are among the causes. Anosmia may occur during locomotor ataxia. Pungent and powerful odors have been said to have caused loss of the sense of smell, due to excessive stimulation. There may be a congenital absence of the olfactory nerves. (3) Centric lesions, as tumors in the anterior part of the temporo- sphenoid lobe. Hughlings Jackson has reported cases of unilateral anosmia associated with aphasia, believed to be due to simultaneous involvement of the outer limb of the olfactory nerve as it passes the island of Reil to reach the center and Broca's region. Opposite uni- lateral anosmia has been described, due to a lesion in the posterior part of the internal capsule. In testing the sense of smell it is advisable to use aromatic oils, as they only stimulate the olfactory nerve, while ammonia and such strong substances also stimulate the fifth nerve. It is obviously necessary to make a rhinoscopic examination. Treatment is generally unsatisfactory, though the cause must be 1 "The External and Internal Use of Guaiacol," Therapeutic Gazette, Mar. 15, 1895. 1038 DISEASES OF THE NERVOUS SYSTEM. removed when possible. Local treatment is seldom productive of much good, as the nasal disease has usually advanced too far when the patient seeks advice. DISEASES OF THE RETINA, OPTIC NERVE AND TRACT. Since the intra-ocular changes are an index of what is going on in the system in certain blood- and kidney-diseases, syphilis, and brain- troubles, and, indeed, as they sometimes foreshadow coming events, thereby proving a most valuable aid in diagnosis, the following brief description of the lesions, as seen with the ophthalmoscope, is given: The Retina.—Hemorrhage into the retina may be venous or arterial, single or multiple, monocular or binocular. It may be part of a general vascular change ; occasionally it occurs during parturition, but more often at the menopause ; it may be an indication of renal trouble or of some primary or symptomatic anemia, as in leukocythemia, pernicious anemia, or malaria. Hemorrhage is prone to occur also in depraved nutritional conditions, in purpura, and in scurvy. More or less complete loss of vision develops in these cases, either suddenly or gradually. If the hemorrhage is superficial, the eye-ground is red and swollen ; if deeper, the blood escapes between the fibers of the retina, spreads them out, and assumes a flame-shaped appearance. Mr. Hutchinson thought this was characteristic of gout, but it is now known to be absent in many undeniably gouty cases, and present in others in which no suspicion of gout exists. When multiple hemor- rhages occur the irritation consequent thereon causes a turbidity of the retina between the blood-spots (" retinitis apoplectica "). Retinitis.—Three forms of this condition are commonly described— the (1) albuminuric, (2) syphilitic, and (3) pigmentary, though Brudenell Carter regards the last named as the only true retinitis, and believes that if the other conditions are inflammatory, they are due to irritation in- duced by the presence of adventitious deposits. (1) Albuminuric retinitis is probably not a distinct affection, but part of a general fibro-vascular change associated with nephritis. The fail- ure of vision may precede the advent of albuminuria, but more often the two conditions are coincident. It occurs in chronic nephritis, espe- cially in the interstitial variety. The retinal changes, according to Gowers, are either hemorrhagic or degenerative. In the former the arterial blood occupying the interstices between the fibers assumes a striated or feathery aspect, while in the degenerative form white patches of fatty degeneration or deposits of cholesterin are dotted over the fundus ; they may also be grouped about the macula lutea, or around the disk. Occasionally the latter appears swollen, owing to the effusion of serum into the fiber-layer. (2) Syphilitic retinitis generally occurs in the later stages of ac- quired syphilis, and particularly in neglected cases. Failure of vision directs attention to the eye-ground, which is found to have either scat- tered or uniformly distributed whitish or slightly opalescent filmy patches upon it. The vitreous may be turbid also. Retinitis is far less common than choroiditis or chorio-retinitis. (3) Pigmentary retinitis, as stated above, is believed by Carter to be a true inflammation, attacking the retinal elements themselves and not DISEASES OF THE RETINA, OPTIC NERVE AND TRACT. 1039 the fibrous layer. It is essentially a chronic process, usually attacking young adults, and, as a rule, more than one member of a family. It may also occur in inherited syphilis and in low grades of vitality. The affected parts receive a deposit of pigment which specially follows the course of the main arteries. At the same time a circumferential an- nulus of pigment forms. This gradually encroaches more and more upon the disk, until finally atrophy ensues. Among retinal affections occur also— (a) Toxic Amblyopia.—This is due, as a rule, to tobacco or alcohol, and more rarely to certain drugs or lead-poisoning. Failure of vision is gradual and progressive, though it rarely reaches absolute blindness. The center of the field is chiefly affected, and a central scotoma for red and green exists; this is said to be caused by a chronic neuritis begin- ning in the fibers that are distributed to the macula lutea. (6) Hemeralopia, or day-blindness, may either be functional or a symptom of some retinal affection—e. g. hyperesthesia or albinism. Objects can either not be seen at all or only indistinctly during the day or in a strong artificial light; but at night vision is excellent. (c) Nyctalopia, or night-blindness, may either exist without apparent cause or it may be symptomatic. It occurs rarely during the course of wasting diseases, as in scorbutus, albuminuria, and anemia. Far more commonly it exists in connection with syphilitic retinitis or choroiditis, separation of the retina, or some congenital defect, and is always pres- ent in retinitis pigmentosa. In this condition vision may be normal during the day or in a strong artificial light, but after nightfall or in a darkened room objects can be seen only with difficulty or not at all. Hemeralopia and nyctalopia are often used in an entirely opposite sense from that employed here, but the definitions given are etymolog- ically correct, and have been adopted in the nomenclature of the Royal College of Physicians of England. Optic Nerve.—Three distinct pathologic conditions of the nerve ex- ist—viz. (1) Perineuritis, (2) Choked disk, and (3) Neuritis. They may merge into one another, and after lasting some time may lead to (4) Atrophy and complete blindness. (1) Perineuritis is met with in meningitis, and was suggested by Bouchut as a valuable diagnostic sign in obscure cases. This is not borne out in practice, however, since if looked for it would probably be found in certain cases of insolation or in any fever in which impairment of vision is a sequel. The sheath of the nerve is supplied by the blood- vessels of the pia, and, while the nerve itself derives its blood-supply from the anterior cerebral artery, therefore in perineuritis, in the early stages at least, the disk remains normal, but is surrounded by a zone of congestion and inflammation. If the action has been severe or pro- longed, either the direct pressure or that due to the contraction of the inflammatory material causes partial atrophy of the nerve and conse- quent interference with the vision. (2) Choked disk is almost always bilateral, and occurs in cases of intracranial granulomata or tumors, also in Bright's disease and syph- ilis. The disk is at first merely congested; soon, however, both the arterial and venous circulations are interfered with, and especially the return venous flow; then exudation of serum takes place. Sometimes 1040 DISEASES OF THE NERVOUS SYSTEM. secondary inflammatory changes follow. In the early stages vision is not impaired, but as the exudative elements contract, the interference with the circulation becomes more exaggerated, and in time atrophy of the disk supervenes. Should the process be arrested, the retinal dropsy subsides, and it will then be seen that the vessels are thickened and tor- tuous, and stand out in relief near the margins of the disk. White patches of atrophy may be scattered over the fundus. When the in- flammation and a dropsical effusion into the disk exist simultaneously, it is difficult or impossible to differentiate the condition from primary or descending optic neuritis. (3) Neuritis.—The optic nerve derives its blood-supply from the an- terior cerebral artery. Evidently, then, in cerebral hyperemia (arterial) from any cause we have an increased injection of the disk, but no venous engorgement; hence there is no dropsy and no tortuosity of the veins. Inflammation may begin in the disk or descend from above, giving rise to plastic deposits on the retina. Sight is early interfered with, owing to involvement of the conducting fibers, which atrophy in time unless the condition ceases. Then the disk appears white, and the vessels show upon it as thin filaments. This condition is met with in syphilis, Bright's disease, intracranial tumors, and rarely in anemia and lead- poisoning; it may be an advanced stage of perineuritis or choked disk. (4) Optic Atrophy.—This may occur as an hereditary affection known as Leber's disease, which chiefly attacks young males, or it may occur during the course of locomotor ataxia, certain toxemias, and diabetes. It may also be brought about either by conditions that produce brain- disease or as a result of the cerebral disease itself. In any case there is alteration of the field of vision, color-perception is abnormal, and there is more or less dimness of sight. In the hered- itary form the disk is less white than in the other, and the vessels are almost normal in appearance (Fig. 69). The Optic Tract.—The lesions of the optic tract are important rather on account of their situation than their nature. They may exist without corresponding changes in the retina, although when they have lasted for a long time there is usually some consecutive atrophy resulting from a descending degeneration of the optic nerves. Lesions of the chiasm usually affect the decussating fibers, causing blindness of the nasal halves of the retina, and, in consequence, temporal hemianopsia. This condition occurs in basal tumors especially of the hypophysis, and has therefore been observed in acromegaly, in tuberculous basal meningitis, and in hy- drocephalus. Lesions of either optic tract, if complete, causes homony- mous bilateral hemianopsia; if incomplete, there is irregular disturbance of the visual field, sometimes bilateral, sometimes unilateral. It may be involved in hemorrhage, tumors, softening or basilar meningitis; ordi- narily other structures are also involved, giving rise to symptoms of focal disease. Lesions anterior to the anterior corpora quadrigemina usually cause more or less destruction of some of the other cranial nerves, with the production of ocular palsies, or disturbances of the other special senses, or anesthesise or neuralgias of the face. A very valuable sign, that, however, cannot always be elicited, is the failure of the pupil to contract when light is thrown upon the blind half of the retina. This is explained by supposing that the pupillary reflex center is situated in pIG. 69.—Diagram of the visual apparatus (after Vialet): LO, LO', occipital lobes ; C, cuneus ; Rod. opt, optic radiation; TQa, anterior corpus quadrigeminus ; PU, PU', pulvinar; CGe, external geniculate ganglion ; BO, optic tract; CH, optic chiasm ; NO, optic nerve ; OJ>, right eye ; OU, left eye; RN, nasal half of retina (supplied by the opposite hemisphere); RT. temporal half ol the retina (supplied by the homolateral hemisphere); M, macula lutea. A total transverse lesion at 1, 2, or 3 would cause total blindness of the right eye. A lesion at 4, destroying the central part of the chiasm, would cause blindness of the nasal halves of the retinas, and therefore bitemporal hemianopsia. A lesion at 5 would cause blindness of the right halves of the retime, and therefore left homonymous hemianopsia. The pupillary reflex would be lost in the affected hall ot the eye in all these cases. A lesion in the optic radiation would cause symptoms similar to those of the corresponding optic tract, excepting that the pupillary reflex would be preserved. Lesions of the cortex cause various disturbances of vision according to the part affected. 66 1042 DISEASES OF THE NERVOUS SYSTEM. the anterior corpus quadrigeminus. If the lesions affect the optic thal- amus or the internal capsule, hemiplegia and hemianesthesia are also often present or may form the most important symptoms. Lesions pos- terior to the anterior corpora quadrigemina produce hemianopsia Avithout disturbance of the pupillary reflex. These lesions are divided into two groups, the cortical and the subcortical and they may be of two varie- ties, either irritative or paralytic. The irritative lesions give rise to hallucinations of sight, which may vary from the scotomata of migraine to most complex visions. Paralytic lesions ordinarily lead to hemian- opsia. Occasionally curious symptoms are produced, the visual field being sometimes irregular, whilst at others only certain elements of sight are affected, cases having been reported in which the hemianopsia only involved the recognition of colors, not of form. In all these cases the pupillary reflexes are not affected. Bilateral lesions do not always lead to total blindness: sometimes the macula lutea escapes and the patient is able to see only by direct fixation. Occasionally a single lesion will produce total blindness in one eye, but this is rare, and no satisfactory explanation has been found to account for it. Cortical lesions are those involving the occipital lobe. The center of visual perception appears to be in the cuneus and calcarine fissure; if this is destroyed, blindness occurs. The center for the recognition of the object seen is apparently upon the convex surface of the occipital lobe, probably in the second and third convolutions, but it may extend also into the temporal lobe. When this is destroyed the patient can see objects, but fails to recognize them; this is called mind-blindness; if total, this is the result of a bilat- eral lesion. Hemianopsia is very frequently merely a temporary symp- tom, and as such it may occur in uremia, apoplexy, migraine, and cer- tain intoxications, especially that of lead. It may also occur in brain- tumor, and disappear if the pressure is relieved, as by trephining. It is a permanent symptom only when the visual tract has been involved by some destructive lesion. If the patient is perfectly conscious and intelligent, it is not difficult to recognize it; nevertheless, its pres- ence can often be detected in young children and in those who are only partially conscious or unable to speak. This can be accomplished by taking a bright object, placing it behind the head, and then bringing it forward slowly, first on one side and then on the other. It will then be noted that the patient perceives it on the hemianopsic side only when it has been brought to the middle line, whilst when moved on the other side the eyes will turn toward it when it is still a considerable distance from this point. Another method is to bring a blunt object (a wisp of cotton) very nearly in contact with the cornea, first on the one and then on the other side of the median line. The palpebral reflex will occur upon the normal side whilst the object is still some distance away; on the blind side only when it has come in contact with the conjunctiva (see Fig. 69). DISEASES OF THE MOTOR NERVES OF THE EYEBALL (THIRD, FOURTH, AND SIXTH). The extrinsic ocular muscles are supplied by these three nerves, while the intrinsic are supplied by the third and the sympathetic. DISEASES OF THE MOTOR NERVES OF THE EYEBALL. 1043 I. The motor oculi, or third nerve, is purely motor, and sup- plies all the muscles of the eye except the superior oblique and external rectus, and controls in part also the ciliary muscle and the sphincter of the iris. Its apparent origin is from the inner side of the crus cerebri just anterior to the pons. It can be traced through the crus, how- ever, to its deep origin in a nucleus beneath the corpora quadrigemina, situated in the floor of the aqueduct of Sylvius. Above the crus it pierces the dura, passes between the two clinoid processes of the sphe- noid bone, along the outer wall of the cavernous sinus, where it receives some filaments from the cavernous plexus of the sympathetic; it then divides into two branches that enter the orbit through the sphenoid fissure. The superior and smaller division supplies the superior rectus and levator palpebrae superioris, while the inferior and larger branch subdivides into three portions, one going to the internal rectus, another to the inferior rectus, and the third to the inferior oblique. Lesions of the third nerve result in (1) spasm or (2) paralysis. Spasm rarely if ever occurs in all the muscles simultaneously. Any muscle may be affected, but the internal rectus and levator palpebrse are specially liable. The condition is met with in meningitis, hypermetropia, and hysteria; also in nystagmus, in which the spasm is clonic and bilat- eral ; it also occurs in albinism, occasionally in coal-miners, or it may be congenital. When the levator palpebrre is affected (lagophthalmus) inability to close the eye results. Stimulation of the center or nerve may cause contraction of the pupil (myosis), as occurs in locomotor ataxia. The same result is brought about by paralysis of the sympathetic. Paralysis.—Usually the nerve is involved as it passes through the dura or at the orbital foramen by some inflammatory process, rheumatic or syphilitic, or it may be the result of meningitis. Pressure due to a gumma or other tumor or to an aneurysm, and sometimes traumatism will bring about the same result. Paralysis may also be due to a neur- itis the result of diphtheria or some other infectious disease, toxemia, or locomotor ataxia. More rarely the nucleus is damaged by hemorrhage or inflammation. In such cases, however, owing to their intimate rela- tionship, the nuclei of the other eye-muscles will usually be involved, giving rise to general ophthalmoplegia. When the intra-ocular muscles alone are affected it signifies a central lesion. Relapsing and recurring palsy are two peculiar varieties. The former occurs chiefly in syphilitic subjects. One nerve becomes affected and partially recovers; the other one then becomes paralyzed, and par- tially recovers, relapses, and so on. The internal muscles may be involved. Recurring or periodic palsy, the migraine ophthalmique of Charcot, is a rare form. It occurs in both sexes, but women are especially sus- ceptible. It may begin in infancy and recur at intervals for years, the attacks being periodic, lasting a few days to six or eight weeks, and ending in complete recovery. Their exact nature is not understood, but they resemble migraine in that there are severe headache, pain, usually over one eye, and in their association with vomiting. Generally paralysis of the extra-ocular muscles is partial, and the symptoms will vary according to the muscles affected. When they are 1044 DISEASES OF THE NERVOUS SYSTEM. all involved there are ptosis, divergent strabismus, diplopia, and con- tracted pupil, with loss of the light-reflex and accommodation. Intra-ocular Paralysis.—(a) Cycloplegia, or ciliary muscle-paralysis, gives rise to a loss of the power of accommodation, so that "far-sight" is good, while "near-sight" is blurred and indistinct. This can be corrected by a convex glass. Bilateral cycloplegia is usually due to a nuclear lesion. It is met with quite often in diphtheria and in tabes dorsalis. (b) Iridoplegia.—The pupil may be dilated (mydriasis) from palsy of the sphincter or spasm of the dilator, or it may be contracted (myosis) from the antithesis of the above. The iris has three actions—two reflex and one associated: First, a reflex contraction of the sphincter on exposure of the eye to light; second, a reflex dilatation of the radiating fibers on stimulation of some cutaneous nerve; and, third, a contraction on accommodation, usually, but not necessarily, associated with convergence (Gowers). First, light-reflex iridoplegia. The iris reflex is lost in locomotor ataxia, and may be also in syphilis. Accommodation and convergence are, however, usually preserved (Argyll-Robertson pupil). When these also are lost the condition occurs to which Jonathan Hutchinson gave the name ophthalmoplegia interna. In testing this reflex care must be taken to avoid the contraction of accommodation. The patient should look at a remote part of the room; then a light is brought suddenly in front of, and three or four feet dis- tant from, the eye. One eye should be examined at a time, the other being covered, but not closed. Gowers has reported unilateral reflex iridoplegia occurring in tabes. It is extremely rare, however. The reflex path is as follows : the retina, optic nerve, chiasm, both optic tracts, corpora quadrigemina, third-nerve nucleus, third-nerve trunk, ciliary ganglion, and the ciliary nerves. Second, skin-reflex iridoplegia. Normally, painful stimulation of the skin of the neck causes reflex dilatation of the pupil, the afferent impulse being carried along the sympathetic. In locomotor ataxia myosis often exists. In such cases Erb showed that the skin-reflex was lost (spinal myosis). Third, accommodation iridoplegia, in which the power of accommo- dation is lost. The pupil does not become smaller when looking at near objects. II. The fourth nerve, or patheticus, the smallest cranial nerve, supplies the superior oblique muscle. Its superficial origin is to the outer side of the crus cerebri, just in front of the pons. The fibers can be traced backward to the valve of Vieussens, in the substance of which it decussates with its fellow. Its deep origin is in a nucleus in the floor of the aqueduct of Sylvius, immediately behind and in close connection with the third-nerve nucleus. After piercing the dura mater the nerve runs along the outer wall of the cavernous sinus and enters the orbit through the sphenoid fissure. Since the superior oblique muscle directs the eyeball downward and rotates it, paralysis causes defective down- ward and inward movements, and consequent diplopia with inclination of the head forward and to the sound side. When occurring alone it is probably due to a nuclear lesion. DISEASES OF THE MOTOR NERVES OF THE EYEBALL. 1045 III. The sixth nerve, or abducens, has its deep origin in the floor of the fourth ventricle in close proximity to the seventh-nerve nucleus. Its superficial origin is from the lower part of the pons, in the groove between it and the medulla. Emerging, it pierces the dura, runs in the cavernous sinus, and enters the orbit through the sphenoid fissure to supply the external rectus. Owing to its long course, this nerve is specially liable to injury, usually from pressure due to tumors or from syphilitic or other forms of meningitis. Paralysis of the muscle causes convergent strabismus, owing to an inability to rotate the eye outward and consequent diplopia. In nuclear lesions the external rectus of the same side and the internal rectus of the opposite side are paralyzed, conjugate deviation resulting, the eyes being directed away from the side of the lesion. This is due to the fact that the sixth nerve gives off a twig that runs to that region of the opposite third-nerve nucleus governing the internal rectus. This muscle is not wholly controlled by the sixth nerve, however, for in nuclear lesions of the latter no degenerated fibers are found in the third nerve; and, further, when the eye with the paralyzed external rectus is covered the opposite internal rectus will act, though less readily than normally. General Symptomatology of Paralysis of the Bye-muscles. —Loss of power in the ocular muscles is indicated by five kinds of symp- toms (Gowers): (1) Limitation of Movement.—The amount of limitation in the movement of the eyeball is in direct ratio to the degree of palsy. In complete palsy the globe is ultimately fixed, owing to contraction of the unopposed muscle. In partial paralysis, as the limit of movement is approached the motion is often jerky (paralytic nystagmus). (2) Strabismus.—Owing to defective movement the axes of the eyes do not correspond. " The deviation of the axis of the paralyzed eye from parallelism with that of the sound eye is termed the primary deviation." (3) Secondary Deviation.—" If the sound eye is prevented from see- ing the object, and the patient looks at this (is made to ' fix' it) only with the affected eye, the sound eye is moved still farther in that direc- tion, and hence the deviation of the visual axes is increased. This is called the ' secondary deviation,' and depends on the fact that two mus- cles normally acting in unison are equally stimulated (innervated) for any given movement. When one is weak, the amount of nerve-force employed to move the sound eye acts equally on the impaired eye, and hence the over-action. In paralytic strabismus fixation with the sound eye shows the primary deviation, while fixation with the affected eye reveals secondary deviation. In ordinary strabismus due to spasm this does not hold good ; it matters not which eye is used, deviation remains the same." (4) Erroneous Projection.—We judge of our relation to surrounding objects by the position of the eyeball as indicated to us by the degree of stimulation necessarily brought to bear on the ocular muscles. When one of these muscles is weak, the additional stimulation (innervation) necessary to move it in fixing an object impresses us with the idea that it is really farther away than is actually the case, and in attempting to touch it the finger goes beyond. This erroneous projection, or inter- 1046 DISEASES OF THE NERVOUS SYSTEM. ference of visual sense-impressions, causes a disturbance of equilibrium and gives rise to vertigo, which has been named "ocular vertigo." (.">) Double Vision.—This is not due alone to a difference in the axis of vision, causing images on non-corresponding portions of the retina, but also to the erroneous projection. " If the patient looks with both eyes, the field of the unaffected eye, being normally projected, does not correspond with the field of the affected eye; the images formed in the two eyes are mentally referred to different positions; objects are seen double " (Gowers). The " true image " is that one formed in the sound eye, while the retina of the affected eye receives the " false image." Homonymous or simple diplopia is that in which the false image ap- pears on the "same side of the other as the eye by which it is seen." This is due to paralysis of an abductor muscle—convergent strabismus. Crossed diplopia occurs in divergent strabismus, the result of paralysis of an adductor. The false image appears to be on the other side of the real object—i. e. toward the sound eye. Gowers' mnemonic is, " When the visual lines (prolonged ocular axes) cross, the diplopia is not crossed." Ophthalmoplegia, a paralytic condition of the eye-muscles, may be partial or complete. Either the internal or the external muscles may be involved, constituting ophthalmoplegia interna or externa, and, when both are affected, total ophthalmoplegia. The lesions may be nuclear or pe- ripheral. Pressure due to neoplasms, gummata, aneurysms, or basilar meningitis may produce it, or it may follow diphtheria. It also occurs in general paralysis, progressive muscular atrophy, and locomotor ataxia. It may be (a) of sudden onset, due to some vascular disturb- ance ; (b) acute—the polio-encephalitis superior of Wernicke—develop- ing in a few7 days or weeks ; or (c) chronic. In the latter case symptoms of bulbar palsy are apt to be present also. Von Graefe has described a form of bulbar palsy limited to the ocular nuclei under the name of progressive ophthalmoplegia. The Symptoms vary necessarily according to the muscles involved. The treatment consists in the removal of the cause when possible. In inflammatory cases counter-irritation is employed by blisters placed on the temples, behind the ears, or at the occiput, or by leeches. Inter- nally, the salicylates, mercury, iodids, and general tonics are useful. Rarely a case will recover spontaneously. Electricity is probably of little value. The diplopia, unless it can be obviated by a suitable lens, should be met by means of an opaque glass. DISEASES OF THE FIFTH NERVE. The trigeminus nerve has an extensive origin from the floor of the fourth ventricle. It supplies with sensation the whole region innervated by all the other cranial nerves except the first and second. It resem- bles a spinal nerve in that it has two roots, a motor and sensory, and on the latter a ganglion (Gasserian). From the latter arise three sensory branches—viz. the ophthalmic, superior maxillary, and inferior maxillary. A motor root joins the last named, the largest branch of the fifth nerve. Morbid conditions of the fifth nerve cause sensory, motor, or gusta- tory symptoms. The lesion may be—(1) Pontine hemorrhage, softening, DISEASES OF THE FIFTH NERVE. 1047 sclerosis, or tumor. (2) Disease or injury at the base of the brain— e. g. meningitis, gumma or other tumor, caries of bone. (3) Disease or injury of the branches, as neuritis, pressure due to aneurysm of the internal carotid or to a tumor in the pituitary or spheno-maxillary region, orbital cellulitis, and punctured wounds of the mouth and nose. (4) Rarely fracture of the skull. Symptoms.—Sensory Portion.—In the irritative stage the chief feature is pain ; this may be shooting, boring, or burning in character. Tenderness along the course of the nerve and hyperesthesia may also exist. Later anesthesia develops in the mucous membrane of the nose, mouth, lips, tongue, and, in some cases, of the hard and soft palate also. Muscular movements are slower than normally, due to sensory interference. The secretions are often increased, though at first they are lessened; hence the anosmia, due to dryness of the nasal mucosa. Loss of sense of taste may also occur. Other trophic changes are—inflammation and ulceration of the gums, looseness of the teeth, and inflammation of the eye. Corneal opacities, ulceration, sometimes perforation, and finally complete destruction of the eye—neuro-paralytic ophthalmia—are noted. This is especially apt to occur when the Gasserian ganglion is involved. Painful and intractable herpes may develop. Hemifacial atrophy may result from disease of the fifth nerve (Mendel). Motor Portion.—Spasm or Paralysis.—Partial or complete inhibition of the movement of the muscles in the region supplied—i. e. those of the jaw, the masseter, temporal, pterygoid, mylo-hyoid, and the poste- rior belly of the digastric. The degree of palsy can be ascertained by placing a finger on each masseter or temporal muscle while the patient alternately opens and forcibly closes the mouth. In external pterygoid paralysis movement toward the sound side is impossible, and on de- pression of the lower jaw it deviates toward the affected side. Ulti- mately wasting of the muscles, with deformity, takes place. The spasm (the so-called "masticatory spasm " of Romberg) may be tonic or clonic. In tonic spasm—trismus or lockjaw—the jaw is firmly set and the muscles are hard, rigid, and sometimes painful. This occurs in tetanus, in eertain cases of tetany and hysteria, in caries of the teeth, occasionally after exposure, and in irritative centric or peripheral lesions. Clonic spasm is more or less continuous or intermittent. The former consists of short, quick, vertical or rarely lateral movements (e. g. chattering of the teeth), usually associated with some other con- dition, as paralysis agitans, general convulsions, and the like, or it may exist alone, especially in women late in life. The intermittent form is rare and occasionally occurs in chorea. Contractions are single, forci- ble, and are separated by some little time. The tongue and cheeks may be bitten in the attack. Gustatory Portion.—Symptoms referable to this portion are not always present in disease of the fifth nerve. There may be a loss of taste with- out sensory disturbance, or vice versd, or both may exist contemporane- ously. Lesions of the nerve-root or middle-ear disease may cause it, but pontine lesions, as a rule, do not. A perverted sense of taste— parageusia—may be present in hysteria and insanity. Increased sensi- tiveness—hyper geusia—and subjective sensations of taste may result 1048 DISEASES OF THE NERVOUS SYSTEM. from irritative lesions, and the latter may precede an attack of epilepsy (as an aura). The diagnosis is not difficult as a rule. Anesthesia in the area sup- plied by the nerve, with loss of taste, is fairly conclusive. Spasm may be simulated in cases of rheumatism or rheumatoid arthritis involving the temporo-maxillary articulation. Treatment.—The underlying cause should be attacked when pos- sible, and mercury, the iodids, and the salicylates should be administered in specific cases and in those due to exposure. Analgesics, and even opiates, may be necessary. Sometimes vigorous counter-irritation is of value. Attention must be paid to the condition of the general system. The battery may be tried, preferably with the faradic current, or by means of electricity short and extremely rapid blows may be made over the nerve. DISEASES OF THE SEVENTH OR FACIAL NERVE. The nucleus of this nerve in the floor of the fourth ventricle is in relation with those of the sixth, eighth, and twelfth nerves. Like the spinal nerves, it has an upper and lower neuron or motor segment, the former extending from the cortical center in the lower Rolandic region to the nucleus, while the latter runs from the nucleus to the periphery. Lesions may involve any part of the tract, producing either spasm or paralysis. Spasm.—This may be idiopathic or organic. Etiology.—It sometimes follows paralysis, and may be reflex, show- ing carious teeth and intestinal worms. It is more prone to develop in individuals with neuropathic family histories. The variety following paralysis is most common in young adults and children, while the ordi- nary facial spasm almost invariably occurs later in life. Lesions in the facial center, or pressure on the nerve at the base of the brain by an aneurysm or tumor, may give rise to it. Symptoms.—Spasm is usually clonic, and occasionally tonic. It may be unilateral or bilateral, and one or two or all the muscles supplied by the seventh nerve may be involved. The eyelids alone are sometimes involved—blepharospasm—forming an associated symptom in certain eye- diseases, together with photophobia. The spasm is tonic. Clonic spasm —nictitation—occurs in hysteria and allied neuroses. Generally, how- ever, blepharospasm occurs with a spasm of the lateral facial muscles, with twitching of the eyelid and the side of the face. The frontalis is rarely involved. Voluntary movements, as in speaking or eating, and emotion, increase the spasmodic movements. No pain is present unless the fifth nerve is also disturbed. Loss of power occurs in progressive or- ganic cases. The palate is not affected. The course of the disease is apt to be slow, and often persists till death, with remissions or intermissions from time to time ; the prognosis, therefore, should be guarded. The treatment consists of tonic and hygienic measures. All causes of irritation should be removed if possible. Nerve-tonics—silver, vale- rian, zinc, asafetida, as well as strychnin hypodermically—are of little value. Electricity and sedative drugs are of more use as palliatives. DISEASES OF THE SEVENTH OR FACIAL NERVE. 1049 Counter-irritation may be applied over any tender spot or behind the ear. Finally, nerve-stretching may be tried. Paralysis (Bell's Palsy).—Depending on the seat of the lesion, we have—(a) supra-nuclear, (b) nuclear, and (c) infra-nuclear palsy. The following table presents the general differences between upper and lower neuron palsy : Supra-nuclear Paralysis. Nuclear and Infra-nuclear Paralysis. The upper part of the face is not af- All parts of the face involved, including fected, the muscles of the angle of the the orbicularis and frontalis. mouth being chiefly concerned. Voluntary movements are more impaired Voluntary and emotional movements than the emotional. equally affected. All reflex movements are normal. All reflex movements are lost. Electric reaction is normal, or only Reactions of degeneration are present. slightly impaired to both galvanic and faradic currents. There is no wasting. Wasting is present. (a) Supra-nuclear paralysis is generally associated with hemiplegia, the palsy of face and limbs being on the same side—i. e. opposite the lesion, which may consist of a hemorrhage, tumor, abscess, softening, or which may be the result of injury, and may be situated in the cortex, corona radiata, or the internal capsule. When the cortical face-center is alone involved, the limbs escape (monoplegia facialis). This form is rare. (b) Nuclear paralysis is due to hemorrhage, tumor, or softening at the site of the nucleus in the medulla. It may also result from an attack of diphtheria, and very rarely occurs in cases of antero-poliomyelitis. As already noted, the symptoms are similar to those of infra-nuclear paralysis. (c) Infra-nuclear paralysis is caused by pressure on the nerve at the base of the brain by tumors, meningitis, aneurysm, or hemorrhage. In the Fallopian canal the nerve may be damaged by bone-disease or some form of otitis. This is the seat, too, of the so-called " rheumatic neur- itis," the result of exposure. Fracture of the base of the skull or injury to the nerve as it emerges from the stylo-mastoid foramen may result in facial palsy. Diplegia facialis is rare, but may be caused by a single lesion in the pons, where the facial paths cross, or by two lesions, one on either side. The causes enumerated above, when bilateral, beget double facial paralysis. Lesions in the lower part of the pons may result in crossed hemi- plegia, the fibers being involved in their course between the nucleus and the point of emergence of the nerve, the side of the pons. The face will be paralyzed on the same side as the lesion, since this latter is below the decussation of the facial tracts, and involves the outgoing nerve, to- gether with opposite hemiplegia. In alternate or crossed hemiplegia the facial palsy is of the infra-nuclear type, while in ordinary hemiplegia the supra-nuclear type is met with. Certain symptoms of nerve-irrita- tion may precede the actual palsy or may be concomitant, such as slight pain and tenderness, some swelling in front of the ear, muscular twitch- ing, and occasionally vertigo. Symptoms.—The affected side is immobile and expressionless, and the 1050 DISEASES OF THE NERVOUS SYSTEM. normal lines are diminished or abolished. This is seen most markedly in those above middle life. The eye cannot be closed, owing to droop- ing of the lower lid, and, as the tears are not directed into their proper channel, the eye waters. Voluntary and emotional movements are lost. Whistling and smoking are performed with difficulty, if at all, and food collects between the teeth and cheek of the affected side, owing to paral- ysis of the buccinator; in drinking the patient inclines the head to the sound side to prevent escape of the liquid from the corner of the mouth. The dilator naris is paralyzed; hence sniffing is interfered with, and the sense of smell is lowered on that side. When the tongue is protruded it seems to be drawn toward the pal- sied side. This is not the case, however, the effect being due to con- traction of the unopposed muscles on the sound side. All reflex move- ments are lost. The palate is not affected, and sensation is not impaired. When the nerve is involved between the intumescentia ganglifvrmis and the origin of the chorda tympani, taste is lost in the anterior part of the tongue. When other parts of the nerve are diseased, taste is not inter- fered with, unless an ascending—or, more rarely, a descending—neur- itis develops. Hearing may be increased, owing to paralysis of the stapedius, with consequent unopposed action of the tensor tympani. In ear-disease and in disease of the base of the brain, involving both facial and auditory nerves, hearing is lessened. Some degree of wast- ing takes place in the affected muscles, and both quantitative and qual- itative electric changes quickly follow the palsy. The duration of an attack varies from a few days to several months or a year, and in rare cases it is permanent. The onset is usually prompt, and the acme of the attack may be reached in from a few hours to a couple of days. Diagnosis.—From the table previously given it will be easy to differ- entiate supra-nuclear from infra-nuclear palsy. In cases of long stand- ing, when contractures have taken place, owing to the furrows thus pro- duced the affected side may be taken for the sound side, but on getting the patient to whistle the true state of affairs will manifest itself. Treatment.—Search for the cause. If ear-disease is present, make provision for free drainage; if syphilis, give iodid of potash, mercury, or both. In cases due to cold, the so-called rheumatic palsies, counter- irritation is especially called for, and cantharidal collodion, fly-blisters, or the actual cautery behind the ear or over the occiput are very useful. The bowels should be freely opened, and diaphoretics or hot baths and alkaline diuretics administered; in the inflammatory stage small doses of mercury are of value, and later mercuric iodid or general tonics. Galvanism may be employed to stimulate the nerves and to help in maintaining the tone of the muscles. When contractures threaten in late cases the use of electricity should be dispensed with. DISEASES OF THE AUDITORY NERVE. The eighth nerve has its deep origin in the medulla. The center is connected by fibers with the cerebellum, probably by means of an equi- librial mechanism. The auditory fibers decussate in the region of the nuclei, passing in the posterior extremity of the internal capsule to the DISEASES OF THE AUDITORY NERVE. 1051 opposite hemisphere. The cortical center is in the middle of the first temporo-sphenoid convolution. Destruction of that of the left side re- sults in word-deafness; thus, spoken words may be heard, but are not recognized as such. This is not a common condition. Rarely the audi- tory tract may be involved between the cortex and the nucleus. The nerve may be implicated at the base of the brain by tumors, aneurysms, hemorrhage, meningitis, and traumatism. Erb has described a primary nerve-degeneration in tabes dorsalis. Disease may attack the laby- rinth, either primarily or secondarily to ear-disease. Drugs—quinin, apiol, salicylates—may cause deafness similar to the labyrinthine variety. In anemia and in other conditions in which the general health is below par, also in hysteria, hearing may be affected. The lesions give rise either to an increased or diminished sense of hearing: (a) Hyperaeusis, in which certain or all sounds are intensified. Paral- ysis of the stapedius muscle causes low notes to be heard with great in- tensity. Auditory hyperesthesia may also occur in hysteria or during the course of cerebral or general disease. (b) Dysacusis—difficult hearing—may be due to middle-ear disease, or it may exist as a "nervous deafness," the result of labyrinthine or nerve-disease. These may be differentiated by means of the tuning- fork. Normally, air-conduction is better than bone-conduction, and if in a deaf person a tuning-fork can be heard vibrating longer when held against the skull-vault or temporal bone than in front of the ear, there is some impairment of conduction in the meatus or middle ear. When the patient is deaf, and yet the normal relation is maintained between air- and bone-conduction, the labyrinth or the nerve is at fault. (c) Tinnitus aurium—irritation of the auditory nerve—a condition in which subjective sounds occur, such as whirring, buzzing, ticking, or ringing in character. In certain subjects they are worse at night than during the day, and at times they are paroxysmal; as a rule, in any case they are intensified when the general system is below par. Tinnitus may be caused by anemic or depraved nutritional states, intra-cranial aneurysm, pressure on the cervical sympathetic by enlarged glands, tumor, or aneurysm, impacted cerumen, otitis media, labyrinthine disturbance, blows upon the head, excessive auditory stimulation, loud noises, or it may occur during an attack of migraine or as an epileptic aura. In a neurasthenic individual the subjective noise, no matter what the cause, will be accentuated. The more complex and elaborate the sound, the greater the probability of its being of central origin. Treatment.—Careful search must be made for the cause of any of these morbid conditions just described, and when practicable they should be removed. The system should be brought into as good a condition as possible. In hyperesthesia bromids occasionally avail. In dysacusis little can be done when the cause is labyrinthine. The same is true when the nerve or its centers are involved. Counter-irritation and electricity may be tried externally, and iodids internally. These meas- ures should be employed in tinnitus, but with more hope of relief; in addition, sedatives are generally called for, and even morphin may be necessary in paroxysmal attacks. 1052 DISEASES OF THE NERVOUS SYSTEM. MENIERE'S DISEASE. Definition.—An aural or labyrinthine vertigo—originally described by Meniere in 1861; the cardinal symptoms are vertigo, deafness, noises in the ear, and sometimes vomiting. Pathology.—There may be an inflammation or atrophy of the nerve-endings. There are also changes in the labyrinthine membrane from any cause or from hemorrhage. Etiology.—Meniere's disease is most common after thirty, and is rarely met with before that age. It is twice as common in men as in women. The precise lesion is labyrinthine, and is the result of exposure, gout, syphilis, senile change, congestion, and, more rarely, hemorrhage. Any cerebral disturbance or gastric or other irritation is apt to induce an attack. Symptoms.—Vertigo is present, and varies from an extremely slight transient attack, and one that is entirely subjective, to one of almost explosive violence. The patient may have a sensation of having been struck, and then of falling heavily to the ground. The slight form may be continuous with more or less frequent severe attacks, or a complete intermission of days, weeks, or months may transpire. The attacks may arise without apparent cause, or as a result of a blow or even a sudden movement, and occur during both working and sleeping hours. The giddiness, when severe, causes nausea and vomiting, and, if pro- longed, bile is vomited as in ordinary bilious attacks. When the attack is very acute momentary unconsciousness supervenes. Nystagmus and diplopia may occur during an attack. Tinnitus and deafness usually exist together, the former being constant, but of slight degree, and pos- sibly worse during an attack; it may be entirely absent between the attacks. The latter (nervous deafness) is constant and of varying severity in different individuals. Diagnosis.—The occurrence of vertigo and tinnitus in a person with more or less nervous deafness, with or without gastric symptoms, establishes the diagnosis. The tinnitus and the character of the deaf- ness usually suffice to distinguish this from other forms of vertigo. In epilepsy with auditory aurse the period of unconsciousness is generally much longer, and on regaining consciousness the patient is dull and drowsy for some time. It is possible also, as a rule, to elicit a history of convulsions. Prognosis.—In some cases the condition grows progressively worse until deafness supervenes, when it ceases. Often, however, arrest or improvement, or even complete recovery, may be secured. In heart- disease the shock may prove fatal, and in the very acute but, fortunately, rare cases the prognosis is always bad. Treatment.—Counter-irritation over the mastoid process and the internal use of bromids to lessen the morbid sensibility will prove valu- able. The emunctories must be gotten in good condition, and any un- derlying disease, as syphilis or gout, must be treated. Charcot suggested the use of drugs that produce tinnitus—quinin, for instance. The cases were worse at the time, but some of them seemed to improve subse- quently. Gowers employs sodium salicylate in 5-grain (0.324) doses, thrice daily, believing that more good arises when such drugs are given DISEASES OF THE PNEUMOGASTRIC NERVE. 1053 in moderation. Apiol might be tried in this connection. Nitroglycerin and the nitrites are sometimes of value in cases associated with arterio- sclerosis. DISEASES OF THE GLOSSO-PHARYNGEAL NERVE. The ninth cranial nerve has its origin in the posterior part of the floor of the fourth ventricle, in close relation with the pneumogastric nerve. Our knowledge as to its function is not exact, both because it is seldom if ever involved alone, and also, on account of its many connec- tions (with the trigeminus, the facial, the pneumogastric, and the sym- pathetic nerves), it is difficult to say whether the terminal fibers in- volved represent the functions of its roots or of one of its connections (Gowers). Its fibers are distributed to the tonsils, the back of the tongue, the soft palate, the pharynx, the Eustachian tubes, and the tympanic cavity. It supplies both motor and sensory fibers, but not those of taste. This nerve is involved in the nuclear degenerations that are spoken of as bul- bar palsies. It may be also affected by meningitis or new growths. DISEASES OF THE PNEUMOGASTRIC NERVE. As already stated, the origin of the tenth cranial nerve is in intimate relation with that of the ninth. It is also continuous below with that of the eleventh, and all three are associated with the center for the hypoglossal nerve. The nerve proper arises from the side of the me- dulla, and runs on either side of the neck in the sheath of the carotid artery, lying behind that vessel. It enters the thorax in front of the subclavian artery on the right side, and between the subclavian and the carotid on the left; then it courses beside the esophagus, and is distrib- uted to the pharynx, larynx, lungs, heart, esophagus, and stomach, and sends fibers to the intestines and spleen. The esophageal fibers are both motor and sensory, gastric fibers being chiefly sensory. The vagus is in part the motor nerve of the intes- tines. It also contains both accelerator and inhibitory fibers for the respiratory center, is the cardiac inhibitory nerve and a vaso-dilator, and is said to contain trophic fibers for the heart and lungs. Etiology.—The nerve may be involved at its nucleus either by hemorrhage or softening. The nuclei of the ninth, eleventh, and twelfth nerves are simultaneously attacked, either wholly or in part, giving rise to a group of symptoms known as bulbar palsy. The tenth nerve at its superficial origin may be compressed by neoplasms, aneurysms, and the products of meningitis ; in its course down the neck it may suffer pres- sure, or may either be tied in ligating the carotid artery or cut in the removal of a tumor or enlarged glands. Very rarely it may be injured by incised or punctured wounds, or be the seat of neuritis due to expo- sure or to some toxemia. The morbid conditions of the pneumogastric are best studied by considering the branches of distribution separately. (a) Pharyngeal Branches.—The muscles and mucous membrane of the pharynx are supplied by branches of the pneumogastric and glossopha- ryngeal nerves, constituting the pharyngeal plexus. The pharynx may 1054 DISEASES OF THE NERVOUS SYSTEM. be the seat of spasm or paralysis : this is purely a " functional " condition. and usually occurs ui hysteric (globus hystericus) or in nervous indi- viduals. One of my own patients (a woman) after some domestic trouble became extremely nervous. She complained of increasing difficulty in swallowing, until finally she could scarcely take liquids, this symptom becoming aggravated when any one was watching her. She was cured by the daily passage of graduated esophageal bougies. Paralysis of the pharj7nx causes difficulty in swallowing, so that food remains in the mouth instead of being passed into the esophagus. Par- ticles often enter the larynx and give rise to paroxysms of coughing, and at times cause choking. When the soft palate is also paralyzed, the food is regurgitated into the nose. The lesion is generally nuclear, causing bulbar paralysis. The root of the nerve may be involved as it leaves the side of the medulla by meningitis or by pressure from a neo- plasm or an aneurysm. Rarely it may be caused by a toxic neuritis. (b) Laryngeal Branches.—The superior laryngeal nerve furnishes sensory fibers to the mucous membrane of the larynx above the vocal cords, and supplies also the crico-thyroid and epiglottidean muscles. The inferior or recurrent laryngeal nerve, which takes its origin in the superior thoracic region, winds around the arch of the aorta on the left side and around the subclavian artery on the right, reaching the larynx by running up between the trachea and esophagus. It is the sensory nerve of the larynx below the vocal cords, also of the entire trachea, and supplies all the muscles of the larynx except those named above. It has been shown that the motor fibers of the larynx come from the glosso-pharyngeal nucleus, the pneumogastric fibers being sensory. Spasm of the larynx is due to over-action of the glottis-closers (the adductors), though some cases described in this category are probably instances of abductor paralysis. The condition is rather rare in adults, but quite common in children (laryngismus stridulus), and particularly in rachitic subjects. An attack may also be induced in those predisposed by any form of nerve-irritation or catarrhal condition of the respiratory tract. It may be part of a general neurosis; it is sometimes seen in tabes dorsalis (laryngeal crisis); and Liveing reports that he has seen it take the place of an attack of migraine. Spastic aphoria consists of a spasm induced whenever an attempt to speak is made. Laryngeal spasms occur most frequently at night. Dyspnea is the most striking symptom, and is so intense in some cases that suffocation seems immi- nent. The patient may be cyanotic. Soon the retained carbonic acid gas causes relaxation, but, as the cords open slowly, the inspiration is accompanied by a crowing sound, and the expiratory sound is harsher than normal. Paralysis of the larynx may be the result of a nuclear degeneration (glosso-pharyngeal), producing chronic bulbar paralysis, as already mentioned; this form may occur in disseminated sclerosis, tabes dor- salis, general paralysis of the insane, and in certain toxemias. The paralysis is generally bilateral; rarely it is unilateral. Very rarely a cerebral cortical lesion in the laryngeal center may cause pseudo-bulbar paralysis. Since the two centers are compensatory, the lesion must be bilateral. The nerve may be involved at its root or in any part of the trunk, DISEASES OF THE PNEUMOGASTRIC NERVE. 1055 and such lesions are usually unilateral. The recurrent laryngeal nerve, especially the left, is more apt to be diseased than the superior, on account of its position. Thus, the arch of the aorta is more frequently the seat of an aneurysm than the subclavian; enlarged thoracic glands, neoplasms, and an enlarged thyroid can also damage these nerves. The peripheral filaments may be attacked as part of a multiple neuritis. In certain cases the muscles become weakened without being para- lyzed, this possibly being due to a local neuritis, or to a congestion and inflammation of the mucous membrane from over-use (clergymen's sore throat), or as the result of exposure. The following are the chief forms of paralysis: (1) Complete Paralysis.—By this is generally understood paralysis of all except the crico-thyroid and epiglottidean muscles, though occa- sionally these may also be involved. Since the cords are paralyzed, phonation is impossible. As a rule, there is no interference with respi- ration, though the pressure of the in-going air may bring the cords nearer together, and thus produce a certain amount of inspiratory harshness. As the cords cannot be closed, coughing is impossible, as the air escapes through the glottis, and no expulsive force can be given to it. When the paralysis is unilateral these symptoms will of necessity be modified, and some degree of phonation may be possible. The most common cause of this condition is an involvement of the recurrent laryngeal nerve; the lesion may, however, be nuclear or in the course of the nerve-trunk. (2) Paralysis of the Abductors.—The only special abductor muscles are the posterior crico-arytenoids. When they are involved the glottis fails to open in inspiration, and the unopposed adductors bring the vocal cords together. They are still more closely approximated during inspi- ration by the column of air, and hence the prolonged, stridulous inspi- ratory sound. Phonation and expiration are practically unchanged. It is quite likely that many cases supposed to be instances of hysteric spasm of the glottis are really cases of abductor paralysis. In unilateral paralysis the normal movements of the unaffected vocal cord prevent any marked degree of dyspnea and stridor: phonation is usually hoarse and of a low pitch. In cases of long duration the symp- toms become more marked as the unopposed adductors undergo second- ary contracture and still further narrow the glottis. This condition may be due either to central disease or to some local change. The abductor muscles may be degenerated, while all the other laryngeal muscles are healthy, or one or both recurrent nerves may be affected. These nerves innervate both the abductors and adductors, and it is not clearly understood why the abductors alone should suffer when the parent nerve-trunk is involved. At any time it might be a very grave condition, for should any swelling of the cords supervene nothing but a prompt laryngotomy could prevent suffocation. (3) Adductor Paralysis.—The cords move normally during respira- tion, and hence there is no stridor; as they cannot be approximated, however, phonation is impossible. This condition is met with in hys- teria, producing hysteric aphonia, in public speakers who overtax their voices, and also in laryngitis. 1056 DISEASES OF THE NERVOUS SYSTEM. The following table, from Gowers' text-book on Diseases of the Ner- vous System, enables one to get a comprehensive idea of the subject: Symptoms. Xo voice; no cough; stri- dor only on deep inspi- ration. Voice low-pitched and hoarse ; no cough ; stri- dor absent or slight on deep breathing. Voice little changed; cough normal; inspiration diffi- cult and long, with loud stridor. Symptoms inconclusive; little affection of voice or cough. No voice ; perfect cough ; no stridor or dyspnea. Signs. Both cords moderately ab- ducted and motionless. One cord moderately ab- ducted and motionless, the other moving freely, and even beyond the mid- dle line in phonation. Both cords near together, and, during inspiration, not separated, but even drawn nearer together. One cord near the middle line, not moving during inspiration; the other normal. Cords normal in position, and moving normally in respiration, but not brought together on an attempt at phonation. Lesions. Total bilateral palsy. Total unilateral palsy. Total abductor palsy. Unilateral abductor palsy. Adductor palsy. Sensory disturbances of the larynx are rare, and especially hyperes- thesia. Anesthesia may be due to hysteria, or to bulbar paralysis, or to disease of the superior laryngeal nerve. It is dangerous, as food may enter the windpipe. (c) Cardiac Branches.—These with branches from the sympathetic form the cardiac plexus. The vagus contains both accelerator and in- hibitory fibers, but the latter predominate; therefore irritation of the nerve, either centric or peripheral, will slow the heart's action. Czermak was able to slow the action of his heart by pressing a small tumor in his neck against the vagus nerve. When the function of the nerve is lowered, inhibition is removed and the heart's action becomes rapid. This may be brought about by a toxemic neuritis, by pressure, accidental ligature, or by incised or punctured wounds. Various emotions and nervous states may bring about the same result. (d) Pulmonary Branches.—Both accelerator and inhibitory fibers ex- ist, but in this case the accelerator influence predominates, so that irri- tation results in increased respiratory movements or even in bronchial spasm, since the bronchial muscles are also supplied by this nerve. It is this nerve that is supposed to be concerned in the production of asth- matic paroxysms. Therefore, when the nerve-function is lowered the respirations become much slower. The nerve is supposed to contain trophic fibers for the lungs. (e) Esophageal, (/) Gastric, and (g) Intestinal Branches.—The esoph- ageal branches are rarely damaged, and irritation (spasm) occurs more frequently than paralysis. The pneumogastric gives the sensory, and in part the motor, nerve-supply to the stomach, and irritation gives rise to increased contractions with some pain. Hunger is in certain people said to be connected with the vagus, and vomiting may result from direct or reflex irritation of the nerve. Par- DISEASES OF THE SPINAL ACCESSORY NERVE. 1057 alysis causes some diminution of the gastric contractions. Normally, the vagi accelerate intestinal peristalsis. Treatment.—It is almost ahvays impossible to remove the cause of the above conditions. Syphilitic lesions are probably the most amen- able, and in the various laryngeal palsies electricity may be employed, though it is of somewhat doubtful utility, and in abductor palsy may possibly exert a harmful influence by stimulating the adductors. Strych- nin and general tonics should be administered. Massage of the larynx may be tried, and in spasmodic conditions attention should be directed to the general physical state. All sources of nerve-irritation should be removed if possible, and bromids, or even chloral, should be given. DISEASES OF THE SPINAL ACCESSORY NERVE. This nerve consists of two parts—an external or spinal, and an in- ternal or accessory, portion. The latter has already been described in connection with the pneumogastric nerve. It forms the motor portion of that nerve, and is distributed to the laryngeal and pharyngeal mus- cles. The spinal element arises from the multipolar ganglion-cells in the anterior gray horns of the cervical cord, ascends and enters the cranium through the foramen magnum, and leaves it, after joining with the accessory part, through the jugular foramen. It supplies the sterno- mastoid muscles and in part the trapezius. Injury or disease of the nerve may result in spasm or paralysis. Only the spinal part is considered in this section. TORTICOLLIS. (Wry-neck) This may be a congenital or an acquired condition. Congenital torticollis, or "fixed wry-neck," is the result of an atrophy and shortening of the sterno-mastoid muscle, brought about by some intra-uterine condition or, possibly, by an injury at birth. The right muscle is most commonly affected. The head turns slightly to- ward the sound side ; the eye may deviate, and curvature of the cervical spine may develop. Facial asymmetry is a usual concomitant of this condition. The face on the same side as the lesion develops less rapidly than the other side, and in time secondary contracture of the unopposed muscles takes place. The torticollis can be cured by tenotomy, but the facial asym- metry persists. Fixation is necessary for a while when contracture exists. Spasmodic wry-neck may be tonic or clonic. These forms may co- exist, alternate, or occur independently in different individuals. The condition is met with almost exclusively in adults, and occurs most frequently in middle-aged men. Pathology.—No macroscopic or microscopic evidence of any lesion has been discovered, and the condition is probably dependent upon an over-activity of the neurons in the various centers that control the muscles of the affected part. Etiology.—The influence of sex and age has been mentioned; a 67 1058 DISEASES OF THE NERVOUS SYSTEM. neurotic heredity may also predispose. Torticollis may follow habit- spasm, or some injury to the head or neck, or exposure to cold, the lat- ter constituting the "rheumatic" type. Rarely, robust, healthy-look- ing individuals are attacked without any apparent cause. Cervical caries may cause rigidity of the neck, simulating torticollis. The spasm is usually tonic in such cases, as it is in those of the "inflammatory" type, where, in children particularly, enlarged and painful glands are found under the sterno-mastoid. Symptoms.—The occiput is drawn toward the shoulder of the affected side, the chin is elevated, and the face rotated more or less toward the sound side. The sterno-mastoid may alone be affected, or the trapezius may also be involved. In the latter case greater depression of the head takes place. Spinal curvature may ensue, the convexity being toward the sound side. This only takes place in cases that have existed for some time. Clonic spasm is infinitely more distressing and more apt to be permanent. Some pain and muscular twitching may precede the onset of the attack, though, as a rule, muscular contractions are the first indication. These are mild at first, and rarely abruptly, more commonly slowly, they increase in severity. As the case progresses other muscles, and even those of the arm, become involved. Cases have been described in which certain muscles or groups of muscles in the hand or arm have been primarily affected, the condition gradually spreading from them. The spasm usually ceases during sleep. An attack may cause pain, but, as a rule, it induces merely a feeling of fatigue in the muscles ; it is worse if the patient is excited or emotional. Bilateral spasm may occur, the muscles of both sides being equally affected (retro-collic spasm). Gowers speaks of a case in which the backward displacement of the head was so great that the face was horizontal and looked directly upward. Diagnosis.—As a rule this is not difficult. When spasm is in- duced by enlarged and painful glands beneath the sterno-mastoid the age of the patient will be of value in determining the true condition. This usually occurs in children; true wry-neck, on the other hand, very rarely commences before the thirtieth year. Hysteric spasm may also simulate spasmodic torticollis, but it generally occurs in young women, and usually other evidences of hysteria are also present. The rheumatic type and the rigidity induced by caries of the spine must be differentiated from one another and from spasmodic wry-neck. If the rigidity comes on suddenly, following exposure to cold or wet, and the pain is not in- creased at night or by depressing the head upon the spine, and is re- lieved by hot applications, the condition is probably rheumatic. When the rigidity and pain are of slow onset, without history of exposure, and the pain is both worse at night and is increased by depressing the head upon the skull, but is relieved by elevating the head, the condition is very probably one of caries of the spine. Prognosis.—Very rarely the torticollis may diminish or even cease after an existence of months or years. Usually, however, it is persist- ent, either being stationary or slowly increasing in severity and widen- ing in range. The prognosis must always be guarded, and in severe cases grave as to recovery, though the disease does not shorten life. Treatment.—Generally very little can be expected from medica- DISEASES OF THE HYPOGLOSSAL NERVE. 1059 tion. Bromids, morphin, chloral, hyoscyamus, or cannabis indica may be tried, as may the various forms of counter-irritation. Morphin, ad- ministered hypodermically, has been most effectual in some cases, but the danger of establishing the habit should not be forgotten in prose- cuting this method. Galvanism should be tried, the positive pole being placed over the occipital region and the negative over the affected mus- cles. Nerve-stretching and tenotomy of the affected muscles is of very little value. The only surgical procedure that has proved of any dis- tinct value is neurectomy, with excision of a part of the nerve to pre- vent reunion. This necessarily causes paralysis and atrophy of the muscles supplied, but, since it often abolishes the spasm, the slight loss of power and the interference with the movement of the head are com- paratively infinitesimal. The results, however, are not uniform even so far as the spasm is concerned. PARALYSIS OF THE SPINAL ACCESSORY NERVE. The accessory portion has been previously considered in describing the laryngeal branches of the pneumogastric. In the spinal portion the nuclei may be involved in degenerative lesions of the motor region of the spinal gray matter. The nerve-trunk may be damaged by pressure from exudative products (meningitis), tumors, or caries, with resulting paralysis and wasting of the sterno- mastoid and, in part, of the trapezius. This latter muscle is also sup- plied by the cervical nerves. The patient has difficulty in rotating the head to the side opposite that on which the paralysis exists, and the affected muscle does not stand out in movements of the head. Unless secondary contraction of the unopposed muscle sets in, no deviation oc- curs wrhen the head is at rest. The only portion of the trapezius that is involved in paralysis of the external part of the eleventh nerve stretches from the occipital bone to the acromion. The normal contour of the neck is in such cases lost, and the ability to raise the arm is in- terfered with because the trapezius cannot fix the scapula, the fulcrum of the deltoid. Bilateral paralysis may occur as in progressive muscu- lar atrophy ; if both sterno-mastoids are involved, the head falls back- ward ; if both trapezii, it falls forward. The treatment is that of the underlying cause. If the lesion is nuclear, practically nothing can be done. If the condition is due to pressure, in some cases relief may be obtained. Electricity and mas- sage should be employed during the recovery of the nerve. DISEASES OF THE HYPOGLOSSAL NERVE. The nucleus of the twelfth cranial nerve is in the most posterior por- tion of the floor of the fourth ventricle. It is said by some observers that the nuclei of the fibers for the palate and vocal cords that run in the spinal accessory nerve may be in the lower part of the twelfth- nerve nucleus. The cortical center for this nerve is in the lower part of the ascend- ing frontal convolution, in the neighborhood of the cortical facial cen- ter. This propinquity probably explains the simultaneous involvement 1060 DISEASES OF THE NERVOUS SYSTEM. of the facial and lingual muscles in some cases. The hypoglossal is the motor nerve for the tongue and for most of the muscles attached to the hyoid bone. Spasm or paralysis may follow disease of the nerve. Spasm may be either unilateral or bilateral. It is probably met with most commonly in hysteria, or as a part of some general convulsive condition, as epilepsy or chorea. It may also be associated with facial spasm, as mentioned above. Irritation of the fifth nerve (dental caries, ulceration of the gums) seems to be responsible for some cases. "Paroxysmal clonic spasm" is a form in which the tongue is rapidly thrust in and out. Various sensations in the affected region may pre- cede the attack. A rare form—aphthongia—is induced when an attempt to speak is made. The prognosis in this condition is good, and a gen- eral tonic treatment is indicated. Paralysis may result from supra-nuclear, nuclear, or infra-nuclear lesions. Supra-nuclear.—The lesion may be anywhere between the cortex (lower part of the ascending frontal gyrus) and the medulla, and causes paralysis on the opposite side. In this condition the affected muscles do not atrophy nor do they show any electric change. Nuclear.—The lesion is usually degenerative. It may either be of sudden onset (vascular), less rapid, but still acute (inflammatory), or it may be chronic, as in bulbar palsy or tabes dorsalis. The nuclei are so close together that the condition is almost invariably bilateral. Infra-nuclear.—The fibers may be injured by the pressure of neo- plasms or by the products of meningitis or of syphilis. Disease of the bone may also involve the nerve in its passage through the foramen. More rarely, some traumatism or disease of the upper cervical vertebrae may simultaneously injure the eleventh and twelfth nerves. Symptoms.—Paralysis and atrophy of one or both sides of the tongue and fibrillary twitchings may be noted, and if the condition be unilateral, the tongue when protruded deviates toward the affected side. Articulation, mastication, and swallowing are but very slightly interfered with. In the bilateral form, however, these are very much impaired; the tongue cannot be protruded and lies motionless on the floor of the mouth. The atrophy is muscular. This throws the mucous membrane into deep folds. Sensation and taste are unaltered. Diagnosis.—If the lesion is supra-nuclear, there is hemiplegia on the same side as the lingual paralysis, without atrophy of the tongue- muscles. When nuclear, it is, as has been said, generally bilateral and forms part of a bulbar paralysis. There is also wasting of the lingual muscles. When the fibers are involved in the medulla, there is paral- ysis of the tongue on one side, of the limbs on the other, and the tongue deviates from the paralyzed side of the body. Outside the medulla the condition is, as a rule, unilateral, and the spinal accessory fibers are frequently involved. In the nuclear and infra-nuclear varieties there is wasting of the muscles. The prognosis is usually unfavorable, and the treatment consists of a course of general tonics and of mercury and the iodids, with counter-irritation. Electricity may also be tried. DISEASES OF THE SPINAL NERVES. 1061 DISEASES OF THE SPINAL NERVES. DISEASES OF THE CERVICAL PLEXUS. Phrenic Nerve.—This nerve is usually involved as a result of some lesion of the ganglion-cells in the anterior gray horns at the level of the third or fourth cervical nerve. The trunk may be damaged by pres- sure, as by aneurysm or neoplasms, or by traumatism, or it may be the seat of neuritis. More or less immobility of the diaphragm follows, amounting in some cases to complete paralysis. This is not readily seen with the patient at rest, and in women it is specially hard to ob- serve, as their breathing is chiefly of the costal type. The abdomen moves in in inspiration, and out in expiration, forming the reverse of the normal movements. Immobility of the diaphragm may also occur in peritonitis, diaphragmatic pleurisy, and in large pleural effusions. Exertion readily causes dyspnea, and pulmonary diseases are apt to be exaggerated as the products of secretion accumulate. This is most apt to occur when the condition is bilateral, as it usually is in the presence of cord-lesions. Other muscles always suffer in this form in addition to the diaphragm. When the nerve alone is involved the affection is generally unilateral. DISEASES OF THE BRACHIAL PLEXUS. This may either be involved in toto, or any of its branches may be affected separately, or the nerve-roots that unite to form the brachial plexus. Considering first the roots, the only nerve worthy of notice arising from them is the .posterior thoracic, which supplies the serratus magnus muscle. This may be injured directly by pressure, as in the carrying of heavy loads on the shoulder or by a fall or other traumatism. Rarely, it follows exposure to cold. Its involvement may be a part of an ante- rior polio-myelitis or of progressive muscular atrophy. When the muscle is paralyzed the posterior edge of the scapula stands out prominently, and particularly when the arm is moved forward. Neuralgic pains in the neck generally precede the neuritis. The course of the disease is always slow. During the early stage counter-irritation, the iodids and mercury internally, and later electric stimulation to keep up the tone of the muscles, constitute the treatment. Combined Paralysis.—Two or more nerves, or even the entire plexus, may be involved at one time by new growths in the cervical region, neuritis, stretching or rupture of the nerves by wounds, fractures, or dislocations, and particularly by subcoracoid dislocation. Duchenne has described a form of palsy produced in infants during birth by pres- sure due to some malposition or to injury by the finger or a hook. Brachial neuritis may follow some injury to one of the nerve-branches (ascending neuritis), or it may be primary. The latter variety is rare, and usually occurs after middle life, especially in cases with a gouty history. Paroxysmal or continuous pain, increased by any movement of the arm and tenderness on pressure over the affected nerves, is the chief symptom. If on the left side, it simulates angina pectoris. Individual Nerves of the Arm.—These may be damaged by pressure 1062 DISEASES OF THE NERVOUS SYSTEM. due to a tumor, an aneurysm, or to callus. Sleep-palsy and crutch-palsy are both pressure-palsies. The nerves may also be contused or torn in fractures or dislocations, and palsy may follow a fall or blow upon the shoulder; I have seen it occur in a heavy man after a fall upon the hand. Primary or secondary neuritis may develop, and, very rarely, neuromata appear. The supra-scapular nerve supplies the supra- and infra-spinati mus- cles. Paralysis causes imperfect outward rotation of the humerus and rotation of the scapula, with elevation and inversion of the lower angle. Various movements of the arm are thereby interfered with, and the limb tires very readily. More work is thrown on the deltoid, and in time it hypertrophies, causing it to stand out more prominently against the infra-spinatus. The skin over the scapula is usually anesthetic. The circumflex nerve supplies the deltoid and teres minor and the skin over the deltoid and the shoulder-joint. Paralysis results in inability to raise the arm and in wasting of the muscles, with or with- out anesthesia. Adhesions may form in the joint. The musculo-spiral nerve is more often paralyzed than any other nerve of the arm, its position rendering it particularly liable to pressure. It supplies the triceps and supinator muscles, and is the extensor nerve of the arm. It also supplies the skin on the radial side of the dorsal surface of the hand, the back of the thumb, and the index and radial side of the middle finger. A lesion high up results in paralysis of the extensors of the elbow, wrist, and hand, and of the supinators. Prob- ably the point most commonly attacked is about the middle of the humerus. In such cases the triceps escapes. The characteristic symp- toms, however, are wrist-drop and finger-drop, consisting of an inability to extend the hand on the forearm, also the first phalanges of the fingers and thumb. In pressure-palsies the power of supination is usually lost also. Sensory symptoms vary, and are seldom pronounced. There may be slight impairment or tingling or burning sensations. This condition can usually be differentiated from lead-palsy by the rapidity of onset—by the fact that pressure-palsies are almost invari- ably unilateral, and that the supinators are involved. Lead-palsy has a slow onset and is bilateral, generally without supinator involvement. Loss of sensation precedes the pressure-palsy. The history too will generally throw some light on the case. I have seen a case of right- sided unilateral wrist-drop in a man who worked in lead with his right hand only. Bilateral wrist-drop may occur in any form of toxic neur- itis, but the involvement of other nerves, the manner of attack, and the history of the case will serve to simplify the diagnosis. Recovery follows in almost all cases of musculo-spiral nerve-involve- ment, though in cases in which qualitative nerve-changes have taken place it is necessarily delayed. The treatment is that of neuritis. The median nerve supplies the pronators, digital flexors, except the ulnar half of the deep flexor, the radial flexor of the wrist, the abduc- tor and flexor muscles of the thumb, and the two radial lumbricales. It furnishes sensation to the radial side of the palm and front of the thumb, and to the front and back of the first and second and half of the third fingers. This nerve may be the seat of an injury or of neuritis, but is DISEASES OF THE LUMBAR AND SACRAL PLEXUSES. 1063 seldom involved alone. The most striking symptoms are wasting of the thenar eminence and an inability to oppose the thumb to the tips of the fingers. Further pronation is only possible in so far as the supinator longus subserves that function—viz. the misposition. Ulnar flexion of the wrist alone remains. Flexion of the phalanges is interfered with. Sensation may or may not be lost. The ulnar nerve supplies the ulnar flexor of the wrist, the ulnar half of the deep flexor of the fingers, the muscles of the little finger, the adductor and inner head of the short flexor of the thumb, the inter- ossei, and some of the lumbricales. It supplies with sensation the front of one and a half and the back of two and a half fingers on the ulnar side. Paralysis causes radial deviation of the hand in flexion of the wrist, loss of adduction of the thumb, and inability to move the little finger. The hypothenar prominence disappears. The first phalanges cannot be flexed, and the second and third can- not be extended. This is exaggerated in old cases, though still it is not so marked as the "claw hand" of progressive muscular atrophy, since the first two lumbricales escape, being supplied by the median nerve. Sensory symptoms vary. The diagnosis is usually easy. It is well to remember that, since this nerve is the lowest in its point of origin of any considered in this group, ascending cord-diseases will involve it before any of the other brachial nerves. It may also be damaged by disease limited to the low- est part of the cervical enlargement of the cord. DISEASES OF THE LUMBAR AND SACRAL PLEXUSES. The lumbar plexus or its branches may be involved by abdominal growths, enlarged glands, psoas abscess, disease of the vertebrae, neuritis, and rarely by wounds or dislocation of the hip or during parturition. The Obturator Nerve.—When the power of adduction of the thigh is lost and the affected leg cannot be crossed over the other, outward ro- tation is somewhat impaired. Anterior crural nerve paralysis causes loss of power and wasting of the extensors of the knee, loss of knee-jerk, and anesthesia of most of the thigh and the inner side of the leg and foot. The superior gluteal nerve supplies the gluteus minimus and medius muscles. When it is involved adduction and circumduction of the thigh are lost. The sacral plexus and its branches may be damaged by pelvic neo- plasms or inflammation, neuritis (generally secondary to sciatic nerve- involvement), pressure during labor, wounds, dislocations, aneurysms, and diseases of the bone. The small sciatic nerve supplies the gluteus maximus muscle. It is seldom involved alone. Lesions cause difficulty in rising from the sit- ting posture and anesthesia of the back of the thigh and of the upper part of the leg posteriorly. The great sciatic nerve supplies the flexors of the leg and the mus- cles below the knee, and also sensation to the outer half of the leg, the sole, and part of the dorsum of the foot. Paralysis causes more or less 1064 DISEASES OF THE NERVOUS SYSTEM. interference with the act of walking, anesthesia in the part supplied, and wasting of the muscles. The external popliteal or peroneal nerve supplies the tibialis anticus, the peronei, the long extensor of the toes, and the ■ extensor brevis digitorum ; it also supplies sensation to the outer half of the front of the leg and to the dorsum of the foot. Paralysis causes foot-drop and toe-drop, rendering it necessary to lift the leg high in walking, so that the foot will clear the ground; this constitutes the steppage gait referred to in the section on Neuritis. The region supplied is anesthetic. The internal popliteal nerve supplies the popliteus, tibialis posticus, the calf-muscles, the long flexors of the toes, and the muscles of the sole. When paralyzed, flexion of the foot and toes is impossible, and sensa- tion is lost over the back of the leg in its lower part and over the sole. In old cases talipes calcaneus results. The plantar nerves are rarely, if ever, involved alone. II. DISEASES OF THE SPINAL CORD AND ITS MENINGES. DISEASES OF THE MENINGES. Meningitis is very rarely a primary condition. Both the dura and pia may be involved. In the former case the inflammation is usually due to some morbid condition of the vertebrae, while in the latter it is sec- ondary to some toxemia, as in pyemia, sepsis, pneumonia, typhoid, or the acute exanthemata. It may be part of a tuberculous condition (vide Tu- berculosis, p. 278) or of epidemic cerebro-spinal meningitis. Injuries and, it is said, exposure to cold, also lead to inflammation of the me- ninges of the cord. PACHYMENINGITIS. Definition.—Inflammation of the dura mater. The dura may be involved on its outer or inner surface (pachymeningitis externa or in- terna), or the loose connective tissue between the dura and bony canal may be the seat of a peripachymeningitis. Pachymeningitis externa is always secondary, and usually results from syphilitic or carious affections of the bone, or from pressure due to tumors or to traumatism. It may either be acute or chronic. Of the latter type, those cases due to Pott's disease are most common. The membrane is involved to a greater or less extent. The internal surface may escape entirely, or it may be slightly roughened and adherent to the arachnoid; externally, however, the dura is usually thickened, rough, and covered with a cheesy material. Pachymeningitis interna was first described by Charcot in 1871, and named "pachymeningitis cervical is hypertrophica." It is of obscure origin. The dura is generally much thickened, and gives the impres- sion of being made up of a number of concentric layers. The pia is ACUTE LEPTOMENINGITIS. 1065 only involved to a slight degree as a rule. Areas of degeneration may occur in the cord, as may also dilatation of its central canal. As implied by the name, this variety of pachymeningitis is found chiefly in the cer- vical region, and the clinical symptoms result from involvement of the nerve-roots. It is a chronic process, and has been divided into three periods, as follows: (a) The painful period, lasting, as a rule, two or three months, in which severe neuralgic pains exist, their location being determined by the roots involved. They are mostly in the occiput and upper extremities, however. Early there may be hyperesthesia, numbness, tingling, and, rarely, an herpetic eruption, (b) The Paralytic Period.— As a result of compression of the motor roots an atrophic paralysis of the upper extremities develops. A peculiar selective tendency is manifested, the radial nerve being spared, while the median and ulnar nerves are involved. This results in a modified "claw-hand" deformity and in an over-extension of the wrists, with flexion of the fingers. Anesthesia may be noted, (c) Spastic Paraplegia.—This results when the compression has produced degeneration of the cord. Generally, there are paresis of the lower extremities and increased reflexes, but no muscular wasting, since the trophic centers are intact. Occasionally, however, anesthesia and paralysis of the legs and bladder develop, bed-sores following, with death from exhaustion. The prognosis must be guarded, each case being carefully looked into and diagnosed from amyotrophic lateral sclerosis, syringomyelia, and from pressure by tumors. From the latter the condition is very difficult to differentiate, cervical spondylitis and neoplasmata often giving rise to the same symptoms. The first-named condition does not give rise to sensory disturbances; moreover, bulbar symptoms are often present, the lower extremities atrophy, and the bladder fuuctions are preserved. Syringo- myelia induces characteristic changes in thermic sensibility, and often anesthesia, but rarely severe neuralgic or radiating pains. Pachymeningitis hemorrhagica interna, or hematoma of the dura mater, may occur in any part of the cord, and is usually associated with a similar condition in the cerebral dura. Cysts may be found in the inner surface of the dura, containing broken-down blood-cells and hematoidin crystals, and in their neighborhood an increase of fibrous tissue may be noted. The condition occurs most frequently in alcoholics or general paralytics. Treatment is not of much avail. Counter-irritation, potassium iodid, and electricity are the chief measures. LEPTOMENINGITIS. Definition.—Inflammation of the pia mater. This may be either acute or chronic. ACUTE LEPTOMENINGITIS. {Acute Spinal Meningitis.) Pathology.—The vessels are injected, the membrane becomes cloudy, a sero-fibrinous or purulent exudate either surrounds the cord or may only exist in patches, and in the more severe cases the cord itself is involved (meningomyelitis). The spinal meninges alone may be in- volved to a greater or less extent, but as a rule, the cerebral meninges are similarly involved. 1066 DISEASES OF THE NERVOUS SYSTEM. Etiology.—Rarely is this a primary disease. It may be met with— (1) In tuberculosis, in which the cerebral symptoms predominate. (2) In cerebro-spinal meningitis, an epidemic, specific infectious disease. (3) As a condition secondary to one of the infectious fevers, as pneumonia, typhoid, and influenza. This, however, is very rare. It should be re- membered that many cases presenting clinically the picture of meningitis show absolutely no postmortem lesions of the cerebral or spinal membranes. This is especially true of pneumonia and influenza. The condition in such cases is probably a toxic encephalopathy. (4) In myelitis. In certain cases the pia becomes involved, due to extension from the cord. (5) In injuries. (6) As a result of cold and exposure, though probably rarely. Symptoms.—These are chiefly pain in the back, often excruciating, with fixation, retraction of the head, tenderness on pressure along the spine, tremors or spasm of the muscles, and various sensory disturbances. Reflexes are early increased, and later diminished or absent. Should the cord be involved, paralysis, incontinence of urine and feces, and even bed- sores, may develop. The symptoms are more fully discussed in speaking of the tuberculous and epidemic varieties. Diagnosis.—It is often very difficult to differentiate the several varieties of spinal meningitis, and equally so to decide whether the case is actually meningeal when some other disease is present. Even bulbar symptoms may be present without postmortem lesions; I have seen this typified in a case of Bright's disease. The tuberculous form is most read- ily diagnosticated, this being especially true if any collateral evidence of tuberculosis exists. It is a point of some value in the diagnosis to note the absence of marked leukocytosis in tuberculosis and its presence in purulent meningitis. Spinal paracentesis or lumbar puncture, first introduced by Quincke of Kiel in 1891, is a most valuable diagnostic measure and simple of ap- plication. He was first led to adopt it by the knowledge that a free communication exists between the subarachnoid spaces of the brain and spinal cord through the foramen of Magendie; hence he conceived the idea of a lumbar puncture supplanting the older method of tapping the lateral ventricles in cases of hydrocephalus. Later, he used it in menin- gitis. Therapeutically, it is of little value. The patient should be in a sitting posture with a slight forward inclination of the trunk. The punc- ture is then made between the third and fifth lumbar vertebrae and a little to one side of the middle line. Absolute cleanliness should be observed, and the needle introduced slowly until the fluid begins to flow by its own pressure. The prognosis is unfavorable as a rule, particularly in the tubercu- lous form. The treatment is the same as that of cerebro-spinal meningitis (vide p. 130). CHRONIC LEPTOMENINGITIS. It is doubtful if this disease ever occurs independently. It may fol- low the acute form or be due to chronic alcoholism, syphilis, trauma, or disease of the cord. Pathology.—The pia is cloudy and swollen, and often adherent to the HEMORRHAGE INTO THE SPINAL MENINGES. 1067 arachnoid, or all three membranes may be glued together. They are usually injected. An exudate fills the meshes of the arachnoid. The cord is occasionally affected in its cortical portion at the same time. Symptoms.—These are not well marked. Unless the nerve-roots are involved the symptoms are slight or none at all exist; however, pains of a radiating character, stiffness, tremors, hyperesthesia, herpes, and even paralysis, may occur. The course is slow, and may extend over many years. The prognosis is unfavorable ultimately. The treatment consists in the use of iodids and mercury internally, and the application of baths, and counter-irritation along the spine. HEMORRHAGE INTO THE SPINAL MENINGES. {Meningeal Apoplexy; Hematorrachis.) (a) Extrameningeal hemorrhage occurs when the blood is between the dura and spinal canal. (b) Intrameningeal hemorrhage is that in which the bleeding takes place within the dura. Large hemorrhages are very rare in any case, but are more common in the extrameningeal form ; they result from trauma or rupture of an aneurysm. The peridural space will accommodate a large amount of blood without giving rise to pressure-symptoms. Caries of the vertebrae or carcinoma may cause hemorrhage by erosion and rupture of a blood- vessel. The intra-meningeal form is somewhat more common, and may either result from meningitis or occur as a complication of any of the infectious diseases. In such cases the hemorrhages are small and scat- tered. It may also occur in convulsive disorders or in strychnin-poison- ing. Rupture of an aneurysm at the base of the brain may give rise to extensive hemorrhage, and in a case of syphilitic ventricular apoplexy in a young man I found, postmortem, that the blood had leaked out and infiltrated the spinal meninges for some distance. Symptoms.—When the hemorrhage is large enough to cause pressure, the symptoms are very acute, apoplectiform indeed, but consciousness is preserved. Generally, however, they are quite indefinite. In any case they depend upon the degree and location of the compression. Early they are irritative—viz. hyperesthesia, paresthesia, neuralgic pains that are radiating in character, herpes, muscular irritability, tremors, or con- tractions. Later, paralytic symptoms may develop, as anesthesia and bladder- and bowel-symptoms, girdle pains, or, when the lesion is high up, interference with respiration, and pupillary changes. The diagnosis is often difficult, unless the onset is sudden and explosive. The prognosis depends on the cause and extent of the hemorrhage. If small in amount, absorption is usually prompt, with little or no dis- turbance of function remaining. The treatment consists of rest, ice to the spine, counter-irritation, wet- or dry-cupping, leeches or venesection, ergot, opium or gallic acid internally, and later the iodids and electricity. In certain cases operative procedures, with a view to removing the clot, may be justifiable. 1068 DISEASES OF THE NERVOUS SYSTEM. DISTURBANCES OF CIRCULATION IN THE CORD. These include qualitative and quantitative changes in the blood, and morbid conditions of the vessel-walls. The blood-vessels may be the seat of peri- or endarteritis, and rarely miliary aneurysms may develop. Embolism and thrombosis also occur, the former much less frequently than the latter, which is prone to follow sclerotic changes in the vessels, giving rise to ischemia and ultimately to softening. Congestion.—We are justified in noticing this as a possible cord-lesion, but it is questionable if it has any clinical significance. It is safe to as- sume that it occurs in the general stasis of circulatory disorders, yet no characteristic symptoms develop. It is very rarely met with postmortem. Anemia.—This condition, like the preceding, rarely gives rise to symptoms. Dr. William A. Hammond has described a certain group of symptoms as due to spinal congestion, and another to spinal anemia, but his teachings on this point are not generally accepted. Simple anemia of the cord, per se, cannot be recognized clinically. During the past few years, however, many observers have reported certain and distinct post- mortem findings, with or without clinical evidences that the same have occurred during life, in cases of grave anemia, particularly in pernicious anemia and to a lesser extent in leukemia. Whether the anemia is the direct cause of the cord-lesions, or, what seems more likely, whether the anemia and cord-lesions are both produced by some toxemia, remains to be proved. Lichtheim was the first to recognize and call attention to the subject, although Leichtenstern in 1884 reported 2 cases of "tabes" associated with, anemia. He was unable to elicit any history of syphilis, nor had crises occurred. In 1887, Lichtheim reported 3 cases of perni- cious anemia that presented at the same time symptoms pointing to a lesion of the cord. The first had weakness, ataxia and rigidity of the legs, low- ered knee-jerks, paresthesiae, and normal pupillary reaction. The second case was similar, but the third had lancinating pains and absent knee- jerks. Autopsies were made upon the first two. More or less complete degeneration of Goll's columns was found, and the pyramidal tracts were also involved, but to a lesser extent. Small foci of degeneration were also found in the anterior and lateral columns. He regarded it as due to a toxic process. Later, his pupil Minnick published several cases in which no evidence of spinal-cord disease occurred intra vitam, yet in none of them was a normal cord found postmortem. Some showed the same changes that occur in hemorrhages of the cord, while others presented degenerative changes of varying degrees in the posterior columns. In all of them Clarke's and Lissauer's columns and the posterior roots were normal. Dr. K. Petren, a Swedish physician, has described a case in which Lissauer's column was also involved. He holds the same view as Lichtheim with reference to the cause, and significantly mentions the changes that take place in the nervous system in certain cases of diabetes evidently toxic in nature. Since then Williamson has reported 3 cases of diabetes mellitus in which degeneration of the posterior columns was found. Cord-changes have been found also in leukocythemia, chronic jaun- dice, and in persons reduced by other long-standing illnesses. Dr. Putnam has published a series of 8 cases belonging to this latter category. They HEMORRHAGE INTO THE SPINAL CORD. 1069 were adults past middle life, the majority being women in an enfeebled condition. Postmortem he found system-sclerosis of the spinal cord, asso- ciated with diffuse collateral degeneration. He also found some degener- ation of the cells of the gray matter, and, to a less extent, of the periph- eral nerves. Nonne and Eisenlohr in Germany, Taylor and Bowman in England, and Burr in this country, have also reported cases of cord- lesions associated with grave anemia. The chief symptoms described have been progressive weakness, paresis of all the extremities (particu- larly the lower), ataxia, and in some cases weakness of the bladder. The knee-jerks are either increased, diminished, or absent. There are sen- sory disturbances (paresthesia) and lancinating pains occur very rarely. Whatever part the anemia plays, it seems that the fundamental cause is a toxemia, and I venture to say that this fact may throw some light on those cases of tabes, and even of chronic myelitis, in which no history of syphilis or other predisposing cause can be obtained. Further, it seems to me that they may be compared with those toxic conditions described by Duke in England and McLane Hamilton in this country that have their chief incidence upon the cellular elements of the brain. Treatment.—The indications are to keep the emunctories active. High enemata should be given, flushing the bowel with large amounts of sterile normal salt-solution. Internally, calomel, salol, beta-naphtol, arsenic, and iron may be employed. HEMORRHAGE INTO THE SPINAL CORD. {Hematomyelia; Spinal Apoplexy.) This is a very much less frequent occurrence than cerebral hemor- rhage. It is usually due to traumatism, but may follow cold or exposure or some severe strain or over-exertion (in the latter probably only when the vessels are atheromatous). Hemorrhage may occur in cases of mye- litis, epidemic cerebro-spinal meningitis, syringomyelia, tumors of the cord, convulsive disorders, and infectious diseases; it is, however, usually small. If the hemorrhage is extensive, disruption of more or less cord- substance necessarily follows. An area may exist large enough to cause distention of the cord without rupture, and from this extravasations may take place in the cord-substance above and below. Unilateral hemorrhage may occur, the gray matter being chiefly involved. If of recent origin, fresh blood will be found postmortem ; but if of long standing, a brown or brownish-yellow area will be noted, consisting of disintegrated blood- corpuscles, cell-detritus, and hematoidin crystals. The symptoms necessarily vary according to the region involved, but one feature is common to all large hemorrhages, forming a pathognomonic sign—viz. the apoplectiform onset. This is not present, however, if the bleeding has taken place slowly. There is generally a backache, followed by paralysis, a loss of sensation and of the reflexes, and in some cases a loss of control of the bladder and bowel. In less grave cases the early symptoms will be those of irritation, while later paralytic symptoms supervene. If the hemorrhage is slight, absorption soon takes place, 1070 DISEASES OF THE NERVOUS SYSTEM. with complete recovery, but quite often more or less paralysis remains. Myelitis develops in some cases, the patient growing progressively worse and dying of exhaustion. Dr. C. E. Riggs has reported a rather unique case in a woman forty-five years of age who developed paraplegia after a nervous shock three years before coming under his observation. When he first saw her she had impaired sensation of the lower limbs and of the trunk as far up as the xiphoid cartilage. The legs were spastic, with increased reflexes. She had neither lancinating pains nor ataxia, but was profoundly anemic, and grew progressively worse until death ensued from exhaustion. Postmortem, an area of extravasated blood was found in the mid-dorsal region of the spinal canal, and hardening degeneration was noted in the anterior and crossed pyramidal tracts, direct cerebellar and posterior columns, and in Lissauer's tract. The degeneration ex- tended from the first cervical to the fifth lumbar vertebra. This ease was remarkable—first, from the fact that the hemorrhage of the cord was due to anemia; secondly, on account of the extent of the degeneration, and particularly because of the fact that Lissauer's column was involved. The diagnosis is always difficult, for when of sudden onset, unless aided by the etiology, it will be impossible to diagnose the condition from spinal meningeal hemorrhage. In other cases it must be differentiated from myelitis and multiple neuritis. Treatment.—Rest, ice locally, and the internal use of ergot and opium make up the treatment. ACUTE MYELITIS. [Myelitis; Acute Diffuse Myelitis; Transverse Myelitis; Spinal Malacia.) Definition.—An inflammation, with softening, of the cord, giving rise to various groups of symptoms depending upon the region or regions involved, and not, therefore, as constant in its symptomatology as the systemic nervous diseases (tabes dorsalis, lateral sclerosis). Pathology.—The cord may present little or no change to the naked eye, or in the most acute cases it may be diffluent. Between these ex- tremes many grades exist in which the pia will be found congested and adherent, the cord being more or less ingested and areas of softening, and even cavities, being found. Three forms of softening are spoken of by some writers—the red, yellow, and gray—depending upon the pre- dominance of blood, fat, or connective tissue respectively. The postmor- tem finding depends upon the duration of the disease; the more chronic the course, the greater the amount of nervous connective tissue (neurog- lia), and in consequence sclerosis will be the predominant feature. The nerve-cells and fibers are found in various stages of disintegration, the former being swollen, vacuolated, granular, and their processes broken and in many cases missing; while the latter swell, the myelin breaks up, un- dergoes fatty change, and is removed, and the axis-cylinders finally break up and disappear. A single area of degeneration may exist cen- trally, in one half of the cord, transversely, or many localized or widely- ACUTE MYELITIS. 1071 disseminated areas may be found ; but above and below all of them will be found degenerated fibers—ascending and descending degeneration— due to a solution of continuity between the cell-body and its axis-cylinder process. Etiology.—Myelitis may follow exposure (especially in alcoholics), the infectious fevers (chiefly measles and small-pox), and it may be due to traumatism or disease of the vertebrae (caries, malignant disease). Syphilis is also said to cause it, though it may only act as a predisposing agent. It has also been described as following peripheral neuritis, ascending neuritis, and we meet with some cases in which pregnancy seems to act as the predisposing cause. Embolism and thrombosis may rarely cause it. It is most common in males, generally from fifteen to thirty years of age. Symptoms.—These will vary according to the seat and extent of the lesion. In the most acute form the course of the disease is quite rapid, reminding one of hemorrhage into the cord or membranes ; the onset, however, is not so explosive, and, though rapid, it is not sudden. It is most apt to follow cold or exposure. The most acute case I have ever seen occurred in an alcoholic who had lain out one night in a drunken stupor. There may be chills and fever, malaise, backache, pains in the limbs, and, rarely, convulsions; quite often, however, there is no warn- ing. Motor weakness develops, and is rapidly followed by paralysis. Some irritative sensory symptoms appear, as hyperesthesia and pares- thesia, and then more or less complete anesthesia supervenes. The re- flexes are generally lost; there is incontinence of urine and feces, and bed-sores and cystitis develop with frightful rapidity. The temperature now rises to 105° F. (40.5° C.) or even higher, and typhoid symptoms, exhaustion, and death close the scene. I have seen 1 case that developed in a woman a few days after delivery and proved fatal in six days. Acute transverse myelitis is the type most frequently met with, how- ever, the lesion being generally situated in the dorsal cord. The consti- tutional symptoms marking the onset are more pronounced than in the previous type and are of longer duration ; but they are much less pro- nounced in the later stages. They are apt to simulate a rheumatic attack, with malaise, fever, muscular pains, anorexia, chills, and possibly sweating. In from a few days to a week spinal symptoms reveal them- selves, the motor generally appearing before the sensory symptoms, though they may be contemporaneous, or the sensory symptoms may even appear first. In any event, they are apt at first to be irritative. The limbs will feel tired and heavy and drag in walking, and tremors or twitching occur, even cramps, and later paralysis, partial or complete, in the region involved. The lower limbs may alone be involved, or when the lesion is in the cervical region paralysis and atrophy of the upper with a spastic condi- tion of the lower extremities may develop. The "breathing is generally diaphragmatic in cases in which the intercostal muscles are involved. If the lesion is still higher up, death will quickly take place from failure of respiration. Such cases, however, are more apt to occur in the type known as disseminated myelitis, in which bulbar symptoms are prone to appear. The sensory symptoms at first are those of a tingling or burning character, or formication. Later, certain or all forms of sen- sation may be lost, and, roughly speaking, the upper level of anesthesia 1072 DISEASES OF THE NERVOUS SYSTEM corresponds to the level of the cord involved. This " boundary re- gion" is apt to be hyperesthetic, and in it the "girdle-feeling" is ex- perienced. The reflexes may be lost at first, but soon return, and be- come exaggerated below the lesion. The condition of the trunk-reflexes may enable one to locate the position of the cord-lesion. There is not much wasting of muscles, as a rule, nor does the reaction of degeneration develop, unless the lesion is in the lumbar or cervical cord, when both will occur. Loss of control of the bowel and bladder may be among the earliest symptoms, though this is not the rule. While superficial ulcer- ation may occur in any neglected case, the most marked trophic changes take place in those in which the lumbar cord is involved, either directly or by extension. In such cases, despite the most assiduous attention, extensive bed-sores develop. The course of the disease depends on the cause and the extent of the lesions. Death may occur in a few weeks from exhaustion, heart or respiratory failure, or from kidney-disease sec- ondary to cystitis. Recovery is the rule, though with more or less per- manent damage due to degeneration of some of the paths of conduction. Diagnosis.—The distinction from hemorrhage into the cord or mem- branes has already been mentioned. From Landry's paralysis it can be separated by a reference to the subjoined table: Acute Myelitis. Landry's Disease. Paralysis is sudden and generally be- Paralysis begins in the feet and rapidly comes complete. spreads to the muscles of respiration and deglutition. Wasting and bed-sores are marked. Trophic disturbances are absent. Reactions of degeneration are distinct. No reactions of degeneration. Early involvement of the sphincters. Bladder and rectum are not involved. Girdle-pains sometimes mark the height of the lesion. Girdle-pains are absent. Anterior poliomyelitis is not accompanied by sensory symptoms. In pe- ripheral neuritis pain of a shooting character is more apt to be present, and is almost invariably the first symptom to appear. Motor symptoms may not appear for some days. This is not the case in myelitis. In compression of the cord sufficient collateral evidence can usually be ob- tained to differentiate it from myelitis. Hysteric paraplegia is occa- sionally misleading. The character of the patient and the previous his- tory should be thoroughly considered ; moreover, in this form there are no trophic changes, and as a rule no bladder-symptoms ; at any rate, there is no cystitis. Retention of urine may occur, but not incontinence. The diagnosis of myelitis can usually be made without great difficulty from the motor and sensory symptoms, the preservation of the knee-jerk, the vesical, rectal, and trophic symptoms, and often from the presence of the girdle-sensation in addition. Prognosis.—The most acute cases are fatal in from three days to a week. Less acute cases generally recover with more or less loss of motor power. Treatment.—Very little can be done to arrest the process in acute myelitis. The actual cautery should be tried as a counter-irritant, or an ice-bag may be applied to the spine. The patient should be placed on an air- or water-bed. Trophic changes should be looked for daily, and at CHRONIC MYELITIS. 1073 the first sign of their appearance alcohol or some stimulating liniment should be employed. If the skin is broken, absolute cleanliness must be observed, and the wounds dressed antiseptically. It is well, also, to change the patient's position from time to time to avoid too long-continued pressure in any one spot. Ergot and ergotin should be given internally, and, especially in specific cases, potassium iodid. A general tonic and sup- portive treatment is indicated, and later massage, electricity, and baths. CHRONIC MYELITIS. That there are both a subacute and a chronic form of myelitis is gen- erally conceded, though these types are not sharply circumscribed. As has been previously mentioned, it is quite likely that many cases exist in which the clinical symptoms do not seem to warrant the diagnosis of myelitis, and yet extensive areas of degeneration may be found post- mortem. Even some cases of supposed hysteria may have a distinct pathology. Pathology.—The lesions are most apt to be disseminated or diffuse, though there may be a single focus. Histologically, the chief differences from the acute variety consist in the greater amount of sclerosis, the thickened blood-vessels with contracted lumen, and an entire absence of recent hemorrhage. In some cases also the pia is much thickened in patches and firmly adherent. The nerve-cells are either seen to be in advanced stages of degeneration or they have actually disappeared. Secondary degenerations, above and below, proceed from the primary foci. Etiology.—Any of the causes capable of giving rise to acute mye- litis may cause the chronic variety, either by acting slowly over a long period of time or by their influence upon a person whose tissues are re- sistant. A process originally acute may become chronic, or a succession of acute attacks may give rise to a chronic condition. Gout, alcohol, and syphilis seem especially prone to cause chronic lesions. The condition may also be secondary to meningitis and to certain toxic blood-conditions other than those that have been mentioned. Symptoms.—Any symptom occurring in the acute may be dupli- cated in the chronic form, though the onset of the latter is gradual. The symptoms are more or less obtrusive according to the region of the cord that is affected. If the cervical and lumbar regions are not impli- cated, no definite symptoms will be present, and probably there will be nothing more than subjective sensations and progressive weakness, with possibly some muscular wasting. The most characteristic features of a well-marked case are the irregular and successive involvement of various parts. There will be motor weakness, possibly of an arm, followed sooner or later by sensory impairment. Then one of the lower extremities may become involved, and ultimately paralysis will supervene. When the lesion is single this irregular onset is less apparent. In chronic trans- verse myelitis of the lumbar region, for instance, there will be paresis of the lower extremities, simultaneously or successively involved. The on- 68 1074 DISEASES OF THE NERVOUS SYSTEM. set, however, is gradual, and months may elapse before the parajdegia will be complete. A girdle-sensation is apt to be present, together with lowered sensibility, and loss of sensation is very rarely absolute. The knee-jerk is increased, ankle-clonus is present, and in time the muscles become spastic. The sphincters are frequently implicated. Atrophy of the muscles is most pronounced when the anterior gray matter of the cervical or dorsal region is involved, but this may occur in any case. The reactions of degeneration can rarely be elicited. Diagnosis.—The chronic, and in many cases the irregular, onset will characterize this disease. In its various phases it may simulate almost any spinal-cord disease, and it is most apt to be confounded with tumor, pressure (carious or malignant), primary lateral sclerosis, progres- sive muscular atrophy, and syringomyelia. Pressure, whether due to a tumor, to caries, or to malignant disease, is apt to cause pain radiating in character, and the last two usually present collateral evidences in the deformity and cachexia. The symptoms, too, are always bilateral, while those of myelitis may be unilateral. From progressive muscular atrophy it may generally be diagnosed by the irregular course it pursues. Apart from the painless ulcerations that occur in certain cases of syringomyelia, it may be impossible to diagnose it from the latter disease. The prognosis is necessarily grave. Recovery may be possible, but it is extremely rare. The process, however, may be arrested in some cases and the strictly focal cases are less apt to prove fatal than the dis- seminated or diffuse. Treatment.—More can be expected from general hygienic measures than from the use of drugs. In the early stages rest is indicated, but it is well also to employ passive exercise, to prevent, if possible, a too great relaxation of the muscles. As soon as expedient—each case being judged on its merits—the patient should be taken out of doors. Change of air and scene are advisable, as are also baths and massage. Counter- irritation along the spine, and preferably the actual cautery, should be used early. General tonics, iron, quinin, arsenic, and strychnin, should be given, also mercury or the iodids. The greatest possible care of the bladder should be taken in order to avoid cystitis. ANTERIOR POLIOMYELITIS. ESSENTIAL PARALYSIS OF CHILDREN. (Atrophic Spinal Paralysis.) Definition.—A febrile disease of more or less rapid onset, associated with muscular paralysis and atrophy, occurring chiefly in children, and most frequently in those under three years of age. Pathology.—The condition is generally unilateral, and is a true focal myelitis; hence we find congestion, softening, and even cavity- formation. Microscopically, the chief feature observed is the de- struction of the multipolar ganglion-cells of the anterior horn. If the examination is ;iot made until months or years have elapsed since the ANTERIOR POLIOMYELITIS. 1075 onset, the condition will be about as follows : More or less asymmetry of the cord in the region affected, with sclerotic changes at the site of the lesion, and probably in the pyramidal tract also. The anterior nerve- roots of the same side will be found atrophied, and the muscles wasted, having undergone fatty degeneration and fibrous change. Etiology.—The precise cause is not known, but the following pre- dispose to the affection—viz. age, exposure, acute diseases (particularly those known to be infectious), and warm \yeather. The disease may occur at any age, but by far the greatest number of cases occur before the third year of life ; they are about equally distributed between the two sexes. Later in life the condition is more common in males, chieflv between the ages of ten and twenty-five. It is rare after this period. Epidemics have been described, and, notably, one occurring during the summer of 1894. Dr. Caverly of Rutland, Vt., then reported 126 cases occurring in Otter Creek Valley, a limestone region of Vermont. At the same time domestic animals—horses, dogs, and hens—were affected with a paralytic disease, this fact still further supporting the idea of an infec- tious origin. A similar epidemic has occurred in Ohio. Symptoms.—The onset is generally acute, and may be sudden, in which case it is due to hemorrhage. Such cases do not strictly belong to this category, but they have been included, since the nervous symp- toms are similar. Constitutional symptoms are absent as a rule. More- over, when prodromal febricula precede an explosive onset of paralysis (hemorrhagic), we are justified in regarding it as a case of poliomyelitis. Generally, the sequence is as follows : Fever (usually slight), malaise, possibly vomiting (especially in children), muscular twitching, headache, and restlessness. In a few hours, or after one or two days, paralysis su- pervenes and quickly spreads, involving a greater or less area; it then re- mains stationary for from two or four days to from five to eight weeks, when improvement takes place, beginning in the part last affected. In some cases, after a most trifling indisposition over night, paresis is met with in the morning. In a few weeks only that portion remains paralyzed that is to be permanently damaged. Wasting of the muscles will be noticed a week or two after the onset of paralysis ; these become flaccid and give the reactions of degeneration. Sensory symptoms are very rarely present—so seldom, indeed, that they need not be reckoned with. The reflexes are lost, both superficial and deep, and later contractures develop and result in various deformities. The growth of bone is seriously im- paired in some cases. Complete recovery rarely takes place, nor is it to be expected when we consider the destruction of the neuron-body. Diagnosis.—Usually this is not difficult, except, possibly, for the first few days in some cases. Close scrutiny will enable one to differen- tiate between this disease and a pseudo-palsy the result of pain on active or passive motion, as seen in rickets, scurvy, and in hip-joint disease. Prognosis.—Some impairment of motion and more or less wasting of the muscles almost invariably remain. Danger to life, however, is very remote, though the subjects of infantile paralysis are predisposed to intercurrent affections, since their natural degree of resistance is lowered. The more rapid the loss of faradic irritability the less the extent of recovery. Treatment.—I think we are justified in regarding this disease as due to a toxemia, micro-organismal or chemical in nature, and possibly as 1076 DISEASES OF THE NERVOUS SYSTEM. an auto-intoxication in some cases. If this is granted, it behooves us to act promptly and render the emunctories in good condition. If the case is seen early, a few doses of calomel may be given, and these followed by a saline. Copious enemata of boiled water thrown high up into the bowel should also be employed. Should the fever be high, it must be met, as in any other case, by sponging or even by a cool bath, cold compresses to the head, and internally by the bromids, aconite, and the spirits of nitrous ether. During the febrile stage, or at least for a few days or a week, it is advisable to keep the patient in bed. The affected parts should be wrapped in cotton, and counter-irritation may be applied to the spine. As soon as possible the child is to be taken into the fresh air. It is of vital importance to keep up the general systemic tone, and hence the ne- cessity for fresh air, change of scene, and for nourishing but easily digest- ible food. During this period massage and electricity should be employed, together with the administration of strychnin. In the later stages, when contractures have set in, mechanical appliances may be necessary to cor- rect deformity and to give support. ACUTE, SUBACUTE, AND CHRONIC POLIOMYELITIS IN ADULTS. 1. Acute atrophic spinal paralysis of adults, as the acute form is called, has essentially the same symptomatology as the corresponding disease in children, except that the onset is apt to be more pronounced. Convulsions, however, scarcely ever occur. When pain is a prominent symptom we should be guarded in making a diagnosis. Initial pain is significant of a nerve-lesion, particularly if sensory disturbances can be found, and such cases would indicate a neuritis and not a poliomyelitis. Presumably the incidence of the poison has been on the axon, and not on the neuron-body, this view being consonant with the complete recov- ery that is sometimes seen in adults. When true poliomyelitis has ex- isted complete recovery probably never occurs. 2. The subacute form has been described by Duchenne as "paralysis general spinale anterieure subaigue." It comes on, as a rule, without apparent cause, and the initial symptoms are very slight. In a few weeks failure of power is noticed in the limbs and paralysis gradually supervenes. After lasting for some time partial recovery follows, the paralysis and mus- cular atrophy remaining in a limited region only. 3. That chronic poliomyelitis exists has been proved by Oppenheim and other observers; yet it is probable that most cases described under this heading have been due to peripheral and not to central lesions. In neuritis, however, the paralysis is either unilateral or bilateral, and in the latter case it is symmetric, differing in this point from the irregular dis- tribution of centric disease. Pain is common, and there is also tenderness along the nerve-trunks as a rule. Recovery from neuritis may be perfect; at all events, it does not present the tendency that is met with in poliomyelitis to clear up per- fectly, except in a limited area. Treatment.—The general line of treatment that I have given for the infantile type is equally applicable in these forms. Ergot and bella- donna may be used in the early stages, and, later, mercury or the iodids in small doses. Electricity and massage are of the greatest value. UNILATERAL LESION OF THE SPINAL CORD. ABSCESS OF THE SPINAL CORD. 1077 It is rare for inflammation of the cord to give rise to pus, yet a few cases have been described. The suppuration is necessarily micro-organ- ismal in origin, and as a rule is either due to some septicemia or trauma- tism, or secondary to purulent meningitis. The symptoms are those of myelitis, but may be masked by any associated condition. UNILATERAL LESION OF THE SPINAL CORD. {Brown-Se'quard' s Spinal Paralysis.) This is not a distinct disease, but rather a grouping of certain symp- toms, first studied by Brown-Sequard,1 and hence bearing his name. It is met with particularly as a result of injuries (knife-thrusts and the like), though it may also be due to tumor or caries of the cord or to any inflammatory process causing compression of one-half of the cord. Such lesions intercept the motor impulses of the same side; the fibers having crossed in the medulla, the sensory fibers cross in the cord soon after entering, and hence sensation will be absent on the side opposite to the lesion (vide Fig. 70). A lesion in the cervical cord above the arm-nuclei causes motor paralysis of both arm and leg of the same side (spinal hemiplegia) and sensory paralysis on the opposite side. If in the dorsal or lumbar cord, the leg on the corresponding side is para- lyzed, while that of the other is anesthetic. Lesions are seldom strictly confined to one side of the cord, but overlap a trifle, so that there is apt to be some loss of power on the anesthetic side; this, however, may be due to the redecussation of a few motor fibers at a lower level. The side of the lesion is hyperesthetic—a fact for which no satisfactory explanation has ever been advanced. Muscular sense is diminished or lost on the same side. Above the hyperesthetic region an area of anesthesia commonly exists, and above this, again, an area of hyperesthesia. The reflexes Fig. 70.—Schematic representation of course of main tracts in the cord, represented for a single pair of roots (Erb): v, anterior roots; h, posterior roots: 1, paths for motor and vaso- motor conduction ; 2, paths for muscular sense; 3, paths for cutaneous sensibility on the right; 1', 2', 3', the same paths on the left. The arrows indicate the direction of physiologic conduc- tion. 1 Med.-Chir. Trans., 1889. 1078 DISEASES OF THE NERVOUS SYSTEM. are increased on the side of the lesion (inhibition being removed), and the temperature of that side is usually higher. On the anesthetic side the motor power, reflexes, muscle-sense, and temperature are all normal. LOCOMOTOR ATAXIA. {Tabes Dorsalis; Posterior Sclerosis.) Definition.—A systemic sclerosis affecting the posterior columns of the cord. In many cases foci of degeneration occur in the basal ganglia. The disease is characterized by a loss of coordination, ab- sence of the knee-jerk, fulgurant pains, and the Argyll-Robertson pupil. Pathology.—Macroscopically, it may be observed—1. That the posterior roots are more or less atrophied and grayish in color. 2. There is a thickening and adhesion of the spinal membranes, with some degree of congestion, particularly noticeable in the posterior region (not a constant change). 3. There is a slight change in the shape of the cord, and the affected regions assume a grayish tint. Change of color is well seen after the cord is hardened. Microscopically, degeneration of the peripheral sen- sory nerves will be found in certain cases to be more marked at the periphery and to diminish as the main trunks are reached. Rarely, changes in the motor nerves will be met with also, but only in cases in which the anterior horns are affected. The spinal ganglia are normal. Fig. 71.—Diagram of primary degeneration-areas and secondary degeneration of the fibers in the beginning stage of tabes (Leube): psb, pyramidal tract; ksb, cerebellar tract; hwf, posterior root-fibers; Iff, lateral entrance of delicate root-fibers; k, area of earliest degeneration * r, marginal zone; sg, substantia gelatinosa; cv, Clark's columns; i. anterior zones (remaining free); sc, sensory collateral fibers ; fire, collateral reflex of posterior column; sre, collateral reflex of the lateral column; -----, healthy fibers;-----, degenerated fibers. 4. There are degenerative changes in the posterior, and occasionally in the anterior roots (vide Fig. 71). 5. Cord-changes are present, consisting in the early stages of a de- generation of the fibers of the Spitzka-Lissauer column, of the post-root LOCOMOTOR ATAXIA. 1079 zone of Charcot, of the fibers going to the column of Clark, and of the comma tract. As the disease progresses more and more of the posterior columns—Goll and Burdach—is claimed, with the fibers of Gowers' col- umn, the intermedio-lateral tract, and even the direct cerebellar tract. This latter is only affected, however, when the cells of Clark's column are involved. While the chief incidence of the poison, whatever this may be, is upon the nerve-fibers, yet we do meet with cases in which the posterior root-cells are diseased; as already stated, the cells of the anterior horn may be diseased also. There is a connective-tissue overgrowth that takes the place of the degenerated fibers, and when the membranes are thickened the strands of connective tissue dipping into the cord take on added growth. (i. There are cerebral and medullary changes. There may be some change in the nuclei of the columns of Goll and Burdach and in those of some of the cranial nerves. In addition to changes in the nervous system, certain cases present some morbid condition of the osseous sys- tem, consisting of erosion of the interarticular cartilages and atrophy and absorption of the bony articulating surfaces. Etiology.—Race.—White races are more susceptible than negroes ; and the disease is less frequently met with among the Jews than among other white classes. Sex.—Males are more liable to the disease than females, in the proportion of 10 to 1. Age.—Most common between the ages of thirty and forty. Syphilis.—Since Fournier in 1875 first pointed out the relationship between these two diseases, the opinion has steadily gained ground, despite the view of Leyden and other German authorities, that a large majority of tabetic cases (observers differ as to the proportion) have an antecedent history of syphilis. It must be clearly borne in mind that locomotor ataxia is not syphilis of the cord and brain, but a distinct entity, in most cases of which, however, syphilis stands as a predisposing factor. It will be remembered that in the description of anemia of the cord, lesions resembling those of tabes are found as a result of various toxemias, and it was suggested that this might throw some light on those cases in which no syphilitic history can be obtained. Exposure and sexual excess are possible factors; likewise traumatism. Alcohol is said to cause tabes, but this is very doubtful; it may certainly give rise to pseudo-tabes, the peripheral form. In England, Gowers has noted that locomotor ataxia occurs more frequently among urban than among rural populations. Symptoms.—These may be grouped according as they occur in the early or late stages. The early or preataxic stage is one of variable duration; lasting, possibly, but for a few weeks in some cases; but as a rule it is distinctly chronic, even extending over many years. During this time pains of a peculiar type (fulgurant) develop. They are sharp and shooting, of sudden onset, and of just as sudden cessation; they do not recur in precisely the same place, but may occur in any part of the nervous supply of the affected region of the cord. Herpes may ap- pear along the course of the nerves. The knee-jerk is either diminished or absent in by far the largest number of tabetics, though should hemi- plegia occur later it will reappear. Ocular symptoms are characteristic—the myosis and the absent light- 1080 DISEASES OF THE NERVOUS SYSTEM. reflex, with normal response to accommodation, constituting the Argyll- Robertson pupil. Other ocular symptoms may be present, however, and one of the earliest to develop may be strabismus with or without ptosis. Diplopia may be the first evidence pointing to ocular involvement. Other eye-muscles may be affected also, producing ophthalmoplegia. Atrophy of the optic disk may be noticed at this stage. It usually begins as a circumferential change, and only gradually encroaches on the center; hence vision may not be noticeably impaired for some time. If an ex- amination be made, however, during this period, it will be found that the field of vision is contracted. Rarely the auditory nerve becomes diseased, causing deafness. After a variable period of time certain motor symptoms are super- added. The patient may notice that he experiences some difficulty when walking in the dark. He will stagger or stumble, or, while washing his face, he may observe that he cannot balance himself properly with his eyes closed. Later he finds that even in the daylight he has difficulty in maintaining his equilibrium. At first he cannot stand with his feet close together. This difficulty is greatly accentuated when the eyes are closed. Ere long the characteristic gait is manifest. The legs are spread wide apart, the patient leans forward, using one or even two canes, and with eyes fixed upon the ground a few feet in front of him throws one leg around, at the same time lifting the foot higher than is really neces- sary and bringing it down on the heel. Romberg's sign can now be elicited—viz. Avhen the eyes are closed, and particularly if the feet are held close together, it will be noticed that station is imperfect. As a general rule there is no muscular wasting, and hence there is no loss of motor power. A certain degree of incoordination of the arms is present in many cases, but is unobtrusive. Sensory Symptoms.—Apart from the pains already noted, these con- sist of paresthesia, numbness, tingling, burning; anesthesia and hyper- esthesia of irregular distribution; retardation of the transmission of sen- sory impulses; in some cases a peculiar condition in which a pin-prick on one leg, for instance, will be referred to the other (allochiria), or in which one point of contact made by some one is felt in many places at once (polyesthesia). Usually the patient feels as though he were walk- ing on cotton or felt. Muscle-sense is more or less impaired in every case; hence the difficulty, or even the utter impossibility, experienced by these cases in recognizing any position in which a limb may be placed. Certain visceral symptoms, or crises, as the French term them, are prone to occur. They are chiefly gastric (sometimes accompanied by vomiting of acid material), but laryngeal, nephralgic, and rectal crises have also been described. The pain is usually intense. Constipation is the rule, though in some cases incontinence of feces occurs, particularly if the stool is loose. There may also be retention of urine, with inconti- nence. Trophic Changes.—Apart from the herpes previously mentioned, the most striking trophic changes are those occurring in and around the large bony joints (the so-called tabetic arthropathies). Special attention was called to these by Charcot; they are not a»common condition, and are probably due to the influence upon the nerves that supply the joints. Occasionally the condition would appear to be excited by traumatism. LOCOMOTOR ATAXIA. 1081 The affected joints are not painful; they may be the seat of exudation which is rarely purulent. Arthropathies may supervene at any period of the disease, even the preataxic. These conditions affect primarily and chiefly the bones and cartilages entering into the larger joints. The in- volved osseous tissue becomes atrophied, brittle, and is finally destroyed. Muscular wasting is rare as an early condition, though it may occur later; it is due either to neuritis or to involvement of the anterior horns. Since the disease does not of itself prove fatal, these symptoms may last for years and the patient eventually die of some intercurrent affection. In other cases paralysis finally develops and the patient becomes bed- ridden. Hemiplegia may develop as a complication at an advanced stage, as may general paralysis or other forms of nervous disease. Course.—Rarely the disease runs a very rapid course. The preataxic symptoms—pain, loss of knee-jerk, Argyll-Robertson pupil with or with- out ptosis and diplopia—may only exist a few weeks before incoordina- tion develops. The latter will then reach its acme in twenty to thirty days. This is very unusual, however. As a rule, the first or preataxic stage extends over a period varying from months to even as long as twenty-five years. Dr. Wm. Egbert Robertson has related to me the case of a man aged fifty-eight who for fifteen years has had fulgurant pains and an absence of the knee-jerk, but neither ocular nor any other symptoms. In some cases the first stage may be absent. The second or ataxic stage—that of incoordination—is generally slowly progressive, finally reaching a point at which it remains ; rarely, more or less improve- ment may follow. When optic atrophy develops, ataxia either does not appear, or, having done so, fails to advance. The final stage in a few cases is only reached when the patient has become paralyzed and bedridden. Diagnosis.—This is readily made when we have a combination of the absent knee-jerk, fulgurant pains, and the Argyll-Robertson pupil. However, the loss of knee-jerk, associated with one of the other symp- toms in an otherwise healthy man, is, to say the least, highly suggestive of the disease; the addition of incoordination serves, of course, to clinch the argument. Differential Diagnosis.—Peripheral Neuritis.—The symmetric dis- tribution of symptoms, tenderness in the muscles, frequent herpetic rashes, motor weakness and wasting, pain (not fulgurant in type), greater prominence of parasthesia, absence of the Argyll-Robertson pupil, knee- jerk often increased (absent in diphtherial form, but other symptoms and history serve to distinguish it), and later, either diminished or absent, and the history of the case, are sufficient. Alcoholic'and more rarely arsenical poisoning give rise to a condition closely resembling true tabes in that there is the loss of knee-jerk, often sharp pain, and incoordina- tion, though the latter symptom is never as marked as in advanced tabes. The gait, however, is totally different, and consists of the high " steppage " gait described in the discussion of Peripheral Neuritis. General paralysis of the insane may present much difficulty. Spinal symptoms may occur in general paresis, and conversely in certain cases of tabes symptoms of general paresis develop. Time alone will solve the problem. Ataxic Paraplegia.—Apart from the absence of pain and anesthesia, 1082 DISEASES OF THE NERVOUS SYSTEM. incoordination is followed by a spastic condition. The knee-jerk is much exaggerated and the so-called ankle-clonus develops. Cerebellar Disease.—The incoordination does not resemble that of ataxia; optic neuritis is present; also headache and vomiting appear in well-marked cases. The knee-jerk is always present. There are certain conditions, already described under Anemia of the Cord, in which lesions of the posterior columns of the cord occur. Some of them are very much like tabes, but do not present the " combination of symptoms " seen in locomotor ataxia. As a rule, the Argyll-Robert- son pupil is absent, and less frequently the lightning pains also. The crises may be mistaken for disease of the various organs involved. Repeated attacks of acute pain, tabetic in character, and particularly in adult males, should, however, excite suspicion, and an absence of the knee- jerk and other characteristic evidences will always be present in ataxia. When the chief lesion is in the dorsal region the pain may be mistaken for that of spinal caries or even neuralgia or rheumatism. From caries it may be differentiated by the fact that in vertebral disease the pain is more or less localized, and that it is much increased by movements. More- over, the other symptoms of ataxia are wanting—e. g. ocular troubles, incoordination, and absence of the knee-jerk. The latter point also holds good in cases of rheumatism and intercostal neuralgia. For the diagnosis from hereditary ataxia vide p. 1084. Prognosis.—The outlook is not particularly bright. While, as already stated, the disease does not cause death, perfect recovery is never obtained. Of course the prospect is much brighter the earlier the case is taken in hand, and some improvement may be expected in most cases. The fact that the patient has had syphilis does not modify the prognosis one way or the other. Treatment.—Rest (first suggested by Weir Mitchell) is imperative when the patient commences treatment, and especially when pain is early complained of, massage and electricity being employed meanwhile to keep up the tone of the muscles. In my opinion the rest-treatment retards the progress of ataxia more effectively than any other measure, but it cannot be used with the expectation of producing a cure. The bowels should be moved daily, and the urinary functions especially looked to. In certain cases catheterization is necessary. The patient should then be taught, first, what surgical cleanliness means; and secondly, how to use the instrument. Counter-irritation along the spine is of very little more value than suspension. The diet should not be heavy, and if gas- tric crises occur special care should be taken in this direction. In cases giving a previous history of syphilis, mercury and the iodids should be used; it is, however, doubtful if they are of any direct benefit, although when the venereal disease is of comparatively recent date some improvement in the tabetic lesions is possible. Potassium iodid should be used freely. Mercury is best introduced into the system by inunction, and it is my custom to order one dram to be rubbed into the arm-pits, flanks, or inner surfaces of the thighs daily until the gums show the spe- cific influence of the remedy. Then the inunctions are discontinued, and the potassium iodid and mercuric chlorid are administered in combination three times per diem. The dose of the latter remedy should be small (gr. yV—0.0027), but the iodid may be used in ascending dosage. HEREDITARY ATAXIA. 1083 Electricity—so largely used, particularly by German neurologists, in the treatment of this disease—is scarcely deserving of professional con- fidence. The galvanic current is to be chosen, and Erb advises placing the medium-sized cathode over the cervical sympathetic and the larger anode near to the spinal column on the opposite side, moving it at brief intervals in the downward direction. This method must be continued for many months. Hydrotherapy is a serviceable measure if judiciously em- ployed. Neither cold nor hot baths are free from deleterious effects, but tepid baths (80°-90° F.—2(3.6°-32.2° C), combined with gentle friction of the body-surface, are signally useful. Among the numerous natural springs enjoying more or less popularity there are two in especially high favor—the carbonic-acid thermal saline springs of Oeynhausen-Rehme in Minden and Aix-la-Chapelle in Germany. The chief benefit may, after all, be credited to the invigorating effect of the changed environments. The fulgurant pains, or those of the various crises, are occasionally so severe as to require bromids, codein, or even morphin, though the use of the latter agent is always to be postponed until other means are exhausted. Antipyrin or salol and phenacetin may also be tried in this connection. In any case the patient should live a simple, regular life, avoiding ex- cesses of all kinds, and particularly sexual and alcoholic indulgences. HEREDITARY ATAXIA. {Friedreich's Disease) Definition.—An hereditary disease, first described in 1861 by Fried- reich. The symptoms are primarily manifested in early life, and the dis- ease is characterized by ataxia, defective speech, nystagmus, absence of the knee-jerk, and more or less secondary deformity, as spinal curvature or talipes. Pathology.—The postmortem findings are essentially those of loco- motor ataxia and ataxic paraplegia. The spinal membranes are some- what thickened and adherent, especially over the posterior part of the cord, and that, too, chiefly in the lumbar region. The posterior nerve- roots are generally atrophied and sclerosed. The columns of Goll and Burdach are degenerated, particularly in the lumbar region, and to a lesser extent in the cervical. Degeneration is also found in the lateral, and to a slight degree in the anterior, columns. The chief microscopic change is a marked neurogliar overgrowth, as shown by Dejerine. The nerve-cells of the cord are generally normal. Cerebral lesions also have been found in this disease. Etiology.—1. Family tendency (heredity) has a strong influence. A single case, however, may develop in a family. Age.—Most commonly the disease appears between the third and twelfth years, though it may appear earlier. Infectious fevers (in particular) and other acute diseases frequently precede the evolution of this complaint. Trauma and many other con- ditions have been described as exciting causes. 1084 DISEASES OF THE NERVOUS SYSTEM. Symptoms.—The first evidence of the disease is impaired coordi- nation, first in the legs, and, later, in the arms ; it is most marked when the eyes are closed. Attention is often called to this symptom by the fact that the child stumbles, ambles, and staggers, and cannot walk prop- erly. The gait, however, lacks the pronounced stamp of true ataxia. Rutimeyer has pointed out that in many cases the great toes are turned upward. Some children never learn to walk. Romberg's symptom is generally present. Movements of the arms, when these are ataxic, are irregular and jerky, and jerky movements of the head may also be ob- served. Bilateral nystagmus develops and the speech becomes affected. At first there is a mere impediment (a stuttering), but later syllables, or even Avhole words, are omitted and an unintelligible jargon results. The knee-jerks are almost always absent. There is no optic atrophy, nor are any sensory symptoms present as a rule. The sphincters are normal. There are no trophic changes in the skin or the joints, and no visceral crises. Vaso-motor symptoms—flushing, sweating—are sometimes ob- served. There is no mental change. Talipes and spinal curvature are generally met with after the disease has existed for some time. In old cases muscular weakness and wasting are present, but there is no electric change in the muscles. The course is always slow. It may last for many years, thirty or even more. Diagnosis.—Usually this is not difficult, and especially when more than one case exists in a family. The age, incoordination, shambling gait, nystagmus, scanning speech, and deformity are strikingly charac- teristic. Differential Diagnosis.—Locomotor ataxia appears later in life, and the preataxic stage (pain, absent knee-jerk, and ocular symptoms) is gener- ally well marked. It is absent in hereditary ataxia, nor does the latter present the sensory and visceral symptoms, met with in the true form. Further, the gait is very different. Ataxic paraplegia shows an exaggerated knee-jerk, the presence of ankle-clonus, and an absence of the ocular symptoms, nystagmus, and the scanning speech. Disseminated Sclerosis.—Tremors are almost always present, but these are fine and never coarse as in hereditary ataxia. There may be nystagmus, incoordination, and imperfect articulation, but the cases are isolated (i. e. they do not run in families). The prognosis is necessarily bad. The disease is progressive, though it does not kill directly. It may last thirty years or more. Treatment.—Little or nothing can be expected from it. The same general treatment should be pursued as for locomotor ataxia. SPASTIC PARAPLEGIA. {Primary Lateral Sclerosis; Spastic Spinal Paralysis) Definition.—A disease of the spinal cord characterized by loss of power, contractures, exaggerated reflexes, a peculiar gait, and by pre- cipitate micturition. Spastic paraplegia (spasm plus motor paralysis) is PRIMARY LATERAL SCLEROSIS. 1085 met with as the result of the various pathologic substrata. Any trans- verse cord-lesion above the lumbar region may cause motor paralysis, spasticity, exaggerated knee-jerk, and ankle-clonus. The same condi- tion results from a lesion in any part of the upper segment, from the cor- tical motor cells to the terminal arborization of the axon in the cord. It is believed that fibers of the pyramidal tracts may be primarily in- volved, and, since they course chiefly through the lateral cord-region, the resulting condition has been named primary lateral sclerosis. This is purely hypothetic, however, for an uncombined case has only once been found. This may be due to the fact that the disease does not tend to shorten life, and that therefore the same condition that caused degenera- tion of the pyramidal fibers may subsequently act on other fiber-systems. Since in the case of the lower segment it is the peripheral portion of the axon that, in many cases at least, first yields to the morbific influence, so may it be with the upper segment. Tn such an event, however, the de- generation would be an ascending one, and the converse of that which is usually met with in the motor tracts. Thus we see that the same clinical condition may be etiologically quite different. The following are the chief varieties : PRIMARY LATERAL SCLEROSIS. That this condition exists alone is questioned, as I have already stated. Von Stofella has reported a case, but no microscopic examination was made. Morgan's and Dreschfeld's case, published in 1881, seems to be the only one that may be regarded as a true type. The only pathologic change observed was in the pyramidal tracts of the anterior and lateral regions. Etiology.—It is most apt to occur when there is a neuropathic family tendency. Age, generally between twenty-five and forty, exerts an etiologic influence. Exposure, acute disease, and traumatism are all predisposing causes. Syphilis has been said to predispose to the condition, but if so it is rather rare. Symptoms.—In typical cases the onset is slow. The patient com- plains of feeling tired, and is less capable of exertion than formerly. Weakness of the legs develops, and with it increasing difficulty in walk- ing. Even at an early stage some rigidity of the muscles will be present when the limb is extended ; later this becomes a prominent symptom. The spasm is at first of little moment. It may only be noticed in the morning. When the disease has advanced, however, it becomes pro- nounced, so that it may not be possible to flex the limb, or, if flexed and an effort is made to extend it, it will often spring forward like a knife- blade in clasp-like rapidity. This spasticity is often so marked that in walking, so long as the ball of the foot touches the ground, clonic con- tractions occur ; these also appear when the individual is in a sitting posture unless his legs are extended. The gait is characteristic ; the legs are stiff, and move with an evident effort, while the toes scrape the ground. In some cases the adductor spasm is so great that the legs can- not only not be separated, but are actually overlapped in walking (cross- leg progression). In course of time the power of walking may be lost. The flexor muscles are usually weakened. The knee-jerk is very much 1086 DISEASES OF THE NERVOUS SYSTEM. exaggerated, a mere tap causing a sharp, quick response. Ankle-clonus can always be elicited. Pain and other sensory manifestations are often absent, though dull and fleeting pains in the back and limbs may be com- plained of. The arms are frequently unaffected. The sphincters are rarely involved, and ocular symptoms do not occur, though nystagmus is occasionally met with, Seguin states that the ability to retain the urine is lessened and precipitate micturition results. The diagnosis is not difficult. Certain hysteric cases may occa- sionally simulate it very closely, but these do not present the character- istic spasticity of the true form, nor is the knee-jerk increased quite as much, and ankle-clonus is either slight or absent. Then, too, in hysteria spots of anesthesia are commonly met with. Drs. Bastian and Russell Reynolds have described "paraplegia dependent on idea," in which no hysteric element entered. SECONDARY SPASTIC PARALYSIS. As I have already mentioned, transverse lesions above the lumbar region (caries, tumor, sclerosis, myelitis) are followed by degeneration of the pyramidal tracts, and as a result there are weakness in the limbs, increased reflexes, and more or less rigidity. In certain cases the latter may be absent, as Bastian has shown, and the limbs will be flaccid. CONGENITAL SPASTIC PARAPLEGIA. This condition, the symptomatology of which is practically that of the adult types previously described, is almost always the result of some in- jury at birth, either instrumental or due to a malposition, as first pointed out by Dr. Little and since abundantly confirmed by Spencer, Dr. Sarah McNutt, Sachs, and others. The disease is probably always due to men- ingeal hemorrhage. In recent cases more or less extravasated blood is always found over the central convolutions and often at the base. Later, cases show atrophy and sclerosis of the motor region, the blood having been absorbed. Nothing abnornal may be noticed for a few days or weeks, though rarely convulsions, or even bulbar symptoms, may early manifest themselves. Generally, the child is several months old when the mother first notices some impairment of movement, and not until the child tries to Avalk will she observe anything out of the way. The abnormality varies from a slight difficulty in walking, in Avhich the toes barely scrape the ground, to a total inability to walk, owing to the high degree of adduc- tion spasm. Between these extremes are various grades of talipes equinus and cross-legged progression. Sensation is usually normal. The bladder and rectum are not implicated. Some cases present evidences of impaired cerebral development—idiocy and imbecility. Some observers have also described what they believe to be an hereditary form of spastic paraplegia (notably Drs. Gee and Sachs). ATAXIC PARAPLEGIA. This name was given by Gowers to a condition in which spastic para- plegia and ataxia coexist, owing to simultaneous involvement of the lat- COMBINED SYSTEM SCLEROSIS. 1087 eral and posterior columns. The posterior root-zones escape, and hence the retained reflexes. This same morbid condition may be met with in Friedreich's disease (hereditary ataxic paraplegia), or primary lateral or posterior cases may extend and involve the posterior or lateral col- umns respectively. Disseminated sclerosis may possibly present the same symptoms. The type GoAvers describes occurs chiefly in males of middle age. Traumatism and exposure seem to predispose to the dis- ease, as does syphilis very rarely. Symptoms.—These develop insidiously. The patient tires rapidly, and some impairment of the poAver of Avalking is observed. In turning quickly he stumbles, and there is difficulty in walking in the dark, or even in standing when the feet are close together. The reflexes are in- creased at an early date, and spasticity supervenes and is progressive, though it never becomes as marked as in uncombined lateral sclerosis. The gait is someAvhat similar to that met with in locomotor ataxia, but it lacks the forcible stamp already described. When the arms are in- volved the same ataxia, with Aveakness, spasticity, and increased reflexes, is met with. Sensory symptoms are generally absent, and fulgurant pains are never present. When pain occurs at all, it is of a dull charac- ter and often in the sacral region. Optic atrophy does not occur. Nys- tagmus is often seen, though other eye-symptoms very rarely appear. Sexual power is lost. The sphincters are not usually involved, though retention of urine may occur. Ultimately, the case generally partakes more of the nature of a lateral sclerosis, but the features of a posterior sclerosis may rarely predominate. Mental symptoms often develop in the late stages. The diagnosis is easy in typical cases. The ataxia, with myotatic irritability and spasticity in the absence of sensory and ocular symptoms, is characteristic. COMBINED SYSTEM SCLEROSIS. Ormerod and Dana have published valuable treatises on this subject. In 1891, Dr. James Putnam of Boston described a group of system scleroses, with diffuse collateral degeneration, occurring in enfeebled persons past middle life, and more particularly in women. He had had 8 cases, and made autopsies on 4. In the white columns of the cord he found both recent and old degenerations and disintegration of the cells of the gray matter. In 1 case he found some degeneration in the pe- ripheral nerves. The chief symptoms were motor Aveakness of all four extremities, but especially the lower, with some impairment of sensation and general muscular wasting. In 3 cases there Avas an exaggerated knee-jerk with ankle-clonus; in 1 lancinating pains, and in another incoordination. The fatal cases ran a course of three or four years. Several of them showed lead in their urine, and Putnam thinks that this may have been an etiologic factor in some instances. The symptoms of combined sclerosis partake of the nature of loco- motor ataxia and spastic paraplegia, but are less marked than either of these diseases. The onset is slow, there is more or less incoordination, and Romberg's symptom can be elicited as a rule. There is loss of motor power, and the sensory symptoms are slight. There may be dull sacral pain. Optic-nerve atrophy very rarely occurs, though there are 1088 DISEASES OF THE NERVOUS SYSTEM. certain eye-symptoms. The reflexes are generally exaggerated, and " ankle-clonus " is present. The diagnosis is based upon the presence of paraplegia Avith in- creased reflexes, associated with sensory symptoms—paresthesias—and rarely pain. REFLEX PARAPLEGIA. Since this was at one time so warmly put forward by Brown-Sequard as a distinct entity, it seems justifiable to speak of it, though in the light of our present knowledge we are not disposed to give it any nosologic distinction. It Avas supposed to be due to anemia of the cord, and to be the result of irritation reflected from a sensory nerve to vaso-motor nerves. The so-called "urinary paraplegia" Avas included in this category. INTERMITTENT PARAPLEGIA. Romberg was the first to call attention to this condition. His orig- inal case was that of a woman aged sixty-four, in Avhom paraplegia de- veloped suddenly Avith involvement of the sphincters. The sensations Avere normal. In about twenty-four hours she Avas so much better as to be able to walk ; micturition was normal, but there was some Aveakness. Next day, however, the paraplegia returned. These attacks, with almost normal intervals assuming a periodic character, induced him to give qui- nin, which he did. Recovery was the prompt result. Erb and others have since reported cases, but it is now believed that they are due to involvement of the peripheral nerves rather than of the cord. Treatment of Spastic Paraplegia.—In general the treatment is the same as that of locomotor ataxia. This is especially true if syphilis is suspected. Little can be done, as a rule, for the disease is usually progressive in spite of all treatment. Belladonna or hyoscin seems to lessen the spasm in some cases. Attention should be given to the blad- der and bowel, particularly to the former. In the congenital form ope- rative measures are often requisite to overcome deformity. MULTIPLE SCLEROSIS. {Insular or Disseminated Sclerosis.) Definition.—A disease due to the development of sclerotic patches, occurring in an irregular manner throughout either or both the brain and spinal cord. It is characterized by paresis, intention-tremors, scanning speech, and mental disturbances. Pathology.—The sclerotic tissue occurs especially in the Avhite matter, though any part of the cerebro-spinal axis may suffer. The cortex is rarely implicated. The spots are usually Avell circumscribed, gray or grayish-red in color, and on section may be level Avith, raised from, or depressed beneath the normal line of section according as to whether it is in the early, hypertrophic, or cirrhotic stage. The cranial nerves may be involved at their origin, the first, second, and tenth being MULTIPLE SCLEROSIS. 1089 particularly vulnerable. The medullary sheath of nerve-fibers in the affected region degenerates early, but the axons are markedly resistant. Since they are not cut off from their trophic center, secondary de- generation is rarely met with. The blood-vessels show more or less proliferation of the adventitia, and endarteritis is not an uncommon condition. Whether this vascular change is primary or secondary is unknown. Microscopically, the sclerotic areas are made up of an over- growth of neuroglia-cells and fibers and of the ordinary connective tis- sue. In certain cases these patches exhibit some tendency to involve special parts of the nervous system, as the lateral or posterior columns. Etiology.—There is no definite and known etiologic factor. Among the possible predisposing causes may be mentioned emotions, trauma, heredity, exposure, infectious and exhausting diseases of any kind, and perhaps hysteria. It is important to remember, moreover, that it is frequently impossible to diagnose this disease in its early stage from hysteria. This point is dAvelt upon particularly by Buzzard and Bastian, and many cases of supposed hysteria have subsequently proved to be cases of multiple sclerosis. The difficulty is manifestly greater when the patient is a Avoman. Age and sex are also, in a sense, predispos- ing causes. The majority of cases occur between twenty and thirty years of age, though the condition may occur in children. Pritchard has collected over fifty published cases occurring between the ages of fourteen months and fourteen years, and about equally divided as to sex. Among adults disseminated sclerosis is met with somewhat more fre- quently in women. Symptoms.—These may be described under two headings: first, the general symptoms, or those common to all cases of the disease, and not explicable from the position of the sclerosis; and, secondly, those dependent on the locality of the lesions. The disease is ahvays chronic, and either remissions, or one or more intermissions occur, and in some cases may extend over several years. The first evidence of the disease is loss of power, first in one, then in the other, lower extremity. Later, paresis develops in the upper extremity. Sooner or later other general symptoms appear—viz. tremors, nystagmus, scanning speech, increased reflexes, and optic-nerve atrophy. The tremor is volitional (intention- tremor), and when the patient is at rest no abnormal movement is mani- fest, as a rule. On attempting to use the hands, or in walking, a fine, trembling motion of the limbs results. The head may be similarly in- volved, and some incoordination is commonly associated therewith. The nystagmus, too, is brought out Avhen the eyes are in use. It is more marked in lateral than in vertical movements. Speech is slow and deliberate (staccato or scanning), the tendon-reflexes are increased, ankle-clonus may be present, and optic-nerve atrophy is of frequent occurrence. No alteration of sensation occurs, other than perhaps some numbness or tingling. There is no wasting of, nor electric change in, the muscles, nor do bed-sores occur. Vertigo is usually present. The mental phenomena are at first hysteroid, and they may never progress beyond this point. In other cases dementia, or even acute maniacal out- bursts, are met Avith, but these are rare. During this stage epileptiform or apoplectiform attacks may occur. The symptoms directly resulting from the local lesions cannot be given in detail. Certain types result, 69 1090 DISEASES OF THE NERVOUS SYSTEM. however, that depend upon the tendency of the sclerotic areas to involve certain tracts, and these are—first, a form resembling lateral sclerosis, due to implication of the lateral tract; and, secondly, a form similar to locomotor ataxia, in Avhich the posterior columns especially suffer. The diagnosis is generally easy after the disease has lasted some time. The intention-tremor and the gradual and progressive loss of power, with increased reflexes, scanning speech, and mental deteriora- tion, are sufficient. The following table gives the differential points between this disease and paralysis agitans, locomotor ataxia, and hered- itary ataxia : Disseminated Sclerosis. Rarely occurs in children. Gen- erally between the twentieth and thirtieth years. No sensory symp- toms, as a rule. Sight may be im- paired, the hear- ing less frequent- ly. The Argyll- Robertson pupil is absent. Nystagmus is pres- ent, as a rule. Reflexes are exag- erated ; ankle- clonus is present. There may be ri- gidity. Scanning speech. A tremor is gener- ally present on voluntary move- ments only. If the tremor occurs during rest, it is fine. Oscillations of the head are frequent; of the trunk, less so. Mental disturbance is frequent. No particular atti- tude or gait. Paralysis Agi- tans. Occurs in persons over forty years of age. No sensory or spe- cial-sense symp- toms of any im- portance. A r - g y 11 - Robertson pupil is absent. Nystagmus is rare. Reflexes are nor- mal ; very rarely they may be plus. Slight rigidity is noted. Speech is slow and deliberate o n commencing a sentence, but soon it becomes hur- ried. Tremor when at rest. Voluntary movement may make it cease temporarily. The head may shake, with rather a vertical than an oscillatory move- ment. No mental phenom- ena. The head is bent back and arched; the face is immo- bile and mask- like. The gait is propulsion, fes- tination, retro- pulsion, or latero- pulsion. Locomotor Ataxia. Rarely before the twentieth year. Fulgurant pains an early symptom. Sight and hear- ing are commonly affected. Often diplopia and Ar- gy 11-Robertson pupil are present. No nystagmus. The knee-jerk, ankle-clonus, and rigidity are all absent. No speech-defects. No tremor. Inco- ordination is marked. No os- cillations of the head or trunk. Mental disturbance is rare. The gait is stamp- ing in character ; the legs are moved stiffly. Hereditary Ataxia. Usually before the twentieth year. Sensory symptoms are rarely pres- ent. Diplopia and Argyll-Rob- ertson pupil are absent. Nystagmus is fre- quent. The knee-jerk may or may not be present ; it is rarely increased. No rigidity. Speech is slow and scanning. Incoordination is present. Static ataxia may be noted—i. e. slow movements of the fingers and hands while at rest, and oscillations of the head and trunk. No mental disturb- ance. The gait is swaying and irregular, like that of a drunken man. It has notthe stamp- ing character. BULBAR PARALYSIS. 1091 The course usually extends over five to ten or even fifteen years, and death is generally the result of some intercurrent affection, though it may occur during an apoplectiform or convulsive attack. Rarely it is due to failure of the heart or respiration. The prognosis is always bad. Treatment.—No remedy is of any avail. Silver nitrate, mercury, the iodids, and arsenic may be tried. Rest and easily assimilable food are also of prime importance. BULBAR PARALYSIS. (G losso-labio-laryngeal Paralysis.) Definition.—An acute or chronic disease, due to involvement of the motor nuclei of the medulla oblongata. It is generally secondary to some condition affecting other portions of the motor path, and is characterized chiefly by a difficulty of speech or of deglutition. Three varieties have been described : 1. Sudden or apoplectiform, this being due to hemorrhage, embolism, or softening. The onset is always sudden, often with vertigo, and pos- sibly vomiting, Avith or without loss of consciousness. The power to articulate is impaired or lost. The lips and tongue are involved, and hence the pendulous loAver lip, the dribbling of saliva, and the atrophy of the lingual muscles. There are dysphagia and generally frequent attacks of choking. The symptoms are less characteristic than those of the degenerative form. They are less regular in type, and usually are widespread at first; later, some improvement takes place. In other cases, after more or less of a respite, degeneration sets in and they groAv progressively worse. The diagnosis of this type is not usually difficult. " Pseudo-bulbar paralysis " must be borne in mind, however, and is a condition due to a bilateral lesion of the motor cerebral cortex in the lower frontal parietal region or of the motor fibers in the course. There is great danger to life for some little while in these sudden cases. Later the prognosis is rather more favorable than in the other forms. 2. Acute Inflammatory.—Here the onset is less abrupt, requiring a feAv days to a week to develop. But for this fact the symptoms are much the same as in the preceding form. 3. Chronic Bulbar Paralysis.—This condition occurs chiefly in males beyond middle life. The cause can seldom be discovered, though cer- tain cases seem to be of toxic origin. It may develop in the course of progressive muscular atrophy, amyotrophic lateral sclerosis, insular sclerosis, or other disease of the cord. The symptoms are bilateral, the tongue being usually the first to suffer. The patient may notice that he cannot speak for any length of time without fatigue, and that he will then articulate indistinctly. Soon he observes that there is a marked and progressive impairment of speech. The muscles of the lips and other muscles of the lower part of the face 1092 DISEASES OF THE NERVOUS SYSTEM. atrophy. He can no longer whistle. Speech is rendered still more defec- tive, owing to paralysis of the lips. The loAver lip drops, and the saliva constantly dribbles from the mouth and may be greatly increased in amount. Difficulty in swallowing is ahvays present to a greater or less degree. OAving to the lingual paralysis, the tongue can neither be protruded nor can it be used to manipulate the food and make a bolus. It is atrophied and the mucous membrane is Avrinkled. Fibrillar trem- ors are present. The larynx is involved, so that phonation is imperfect, but it is not so marked as the implication of other parts. Particles that enter the larynx cannot be ejected, OAving to motor paralysis. There are no sensory symptoms, and the poAver of taste is normal. The mind generally remains clear, though the patient is often emotional, and cries or laughs Avithout apparent cause. This type of bulbar palsy is particularly liable to develop in the course of progressive muscular atrophy. The course of the disease is slow, and death is usually due either to inspiration-pneumonia or to interference Avith respiration or circulation. The diagnosis is not difficult, as a rule, the bilateral character of the symptoms rendering them distinctive. In the pseudo-bulbar form previously mentioned the limbs are often paralyzed also (double hemi- plegia). Tumors rarely, if ever, give rise to such regular bilateral symptoms. I have met Avith 2 cases of chronic bulbar palsy, and 1 occurring in the course of Bright's disease, in Avhich no postmortem lesion could be found that would account for the condition. In neither of the cases was there much atrophy, though otherwise they conformed to the regular type. Treatment.—The disease is incurable. Hypodermics of strychnin, or of strychnin, morphin, and atropin, are of value in controlling the salivary Aoav. Electricity is of no value. Semi-solid food is probably the most readily taken, and it is often necessary either to use an esopha- geal tube or to employ rectal alimentation. PROGRESSIVE MUSCULAR ATROPHY (MYELOPATHIC). {Amyotrophic Lateral Sclerosis.) Definition.—Progressive muscular atrophy of spinal origin is a disease characterized by a slow but progressive loss of power and by mus- cular atrophy. In certain cases there may also be more or less spasticity and myotatic irritability, and in the later stages there may be bulbar and even cerebral symptoms. According to Charcot, two distinct varieties exist: First, the proto- pathic, in which the motor cells of the anterior horns are degenerated, and also the fibers (axons) from them and the muscles supplied by the latter; second, the deuteropathic form, in which the pyramidal tracts are degenerated, and there is a consecutive degeneration of the motor cells and fibers, and also of the muscles supplied. This latter he termed "amyotrophic lateral sclerosis," though his opinion is not generally held to-day. They are considered to be manifestations of a single disease, the predominance of either type being dependent upon Avhether the degen- PROGRESSIVE MUSCULAR ATROPHY. 1093 eration is greater of the multipolar ganglion-cells or of the pyramidal tracts. It is obvious that if the degeneration of the cells is complete, that of the pyramidal tracts will not modify the clinical picture, how- ever gross the systemic involvement may be. The following are the salient features of this amyotrophic type, as given by Charcot: (1) Progressive Aveakness, ultimately paralysis of the upper extremi- ties, Avith muscular atrophy, fibrillation, and intention-tremors, myotatic irritability, and contractures. (2) After some months the loAver extremities become involved, and the same sequence is met Avith—i. e. paresis, atrophy, exaggerated re- flexes, and spasticity. The sphincters are not involved, and there are no sensory symptoms. (3) The stage of bulbar involvement, the symptoms being those of the labio-glosso-pharyngo-laryngeal type. Death may be due to cardiac or respiratory failure, or to some intercurrent disease. With this brief mention I will pass to the consideration of the disease according to the generally accepted vieAv of to-day. Pathology.—1. Degeneration of the peripheral motor fibers ; also, 2. Of the anterior roots, which are reduced in size. 3. Of the anterior root-fibers and anterior commissural white fibers of the cord. 4. The large cells of the anterior cornua are degenerated, being vacuolated, dis- torted, or even entirely removed. There is at the same time an over- groAvth of neurogliar tissue. 5. There is sclerosis of the anterior and lateral pyramidal tracts of the cord, frequently extending to the decus- sation in the medulla, and more rarely through the internal capsule, even up to the motor cortex. 6. In cases that have presented bulbar symptoms the motor nuclei of the medulla Avill be found to be degen- erated. 7. In every case the muscles will be Avasted, the fibers in a state of fatty degeneration (often entirely removed), and their places taken by connective tissue. Etiology.—In the majority of cases it is safe to assert that no particular cause can be assigned to the condition. The influence of cold and exposure bears about the same relation to this as to any other spinal degeneration. The disease is more prevalent in males than in females, and betAveen the ages of thirty and fifty years. Cases occur- ring in those under tAventy-five belong almost invariably to the myo- pathic type of progressive atrophy. Syphilis, it seems, may rarely act as a predisposing cause, and individuals Avith a neuropathic family his- tory are especially liable. Symptoms.—In a large majority of cases the disease first manifests itself in the upper extremities. Indefinite rheumatoid pains are occa- sionally felt in the region that is soon to atrophy. The Avasting may begin in any part of the limb, but it probably appears in the hand in most cases. The thenar eminence and interossei are the first to show the change. Owing to the unopposed action of the muscles that are antagonistic to the interossei the deformity knoAvn as "claw-hand"1 results. Other muscles are soon claimed by the process, until not only those of the arm, but also those of the shoulder and back and those that extend the head on the spinal column, are involved. This latter accounts for the difficulty in moving the head, and in some cases for the drooping of the head. The platysma does not waste; on the contrary, it fre- 1094 DISEASES OF THE NERVOUS SYSTEM. quently hypertrophies. The thoracic muscles are usually implicated; also often the diaphragm, and less frequently the abdominal muscles. The muscles of the lower extremity may escape entirely. They are seldom Avasted to the degree met Avith in the upper extremity, though this may occur in cases in which the lower limbs are primarily attacked. OAving to the unopposed action of the muscles that continue to function- ate, certain deformities develop, and among them is notably lordosis. Fibrillation is observed in the partially atrophied muscles and in those soon to become atrophic. There is ahvays a quantitative change in the electric reaction of the muscle. The strength of the contraction is in direct proportion to the muscle-substance remaining. Qualitative changes (reactions of degeneration) may not occur, but are usually met with in Avidespread and rapid cases of wasting. In certain so-called atonic cases the paralysis is flaccid and the reflexes are absent: on the other hand, we may have tonic atrophy in which there is more or less rigidity throughout, also exaggerated reflexes, and often contractures. There are no sensory symptoms other than the rheumatoid pains re- ferred to. The sphincters are not involved. Ocular symptoms are absent; atrophy of the optic nerve never occurs. The diagnosis is not at all difficult when the disease has existed for some time. In its earlier stages it may be mistaken for neuritis, but the absence of sensory symptoms and of an apparent cause, together with the progressive involvement of other parts, serves to identify it. Lead-palsy is a purely motor condition, and is apt to simulate it most closely; in any doubtful case the urine should be examined for lead. Idiopathic muscular atrophy occasionally commences in adult life, and in such cases is likely at first to be regarded as of myelopathic origin. The fact that there is generally more than one case in the family, however, Avith its onset in the lower extremities and its chronic course, will enable one to differentiate. In syringomyelia, too, the same character of mus- cular wasting is often seen, but it should present no difficulty when we elicit the peculiar sensory manifestations. The prognosis is unfavorable. The disease progresses in spite of all that may be done, and death usually results in three or four years either from bulbar involvement or from an intercurrent affection. The treatment is practically of no avail. Mercury, iodids, arsenic, strychnin, Avith massage and electricity, are useful, as are also plenty of fresh air, moderate exercise, and readily assimilable food. GoAvers says that he has been able to arrest the disease in 7 cases occurring in middle life by strychnin nitrate, given hypodermically. He advises gr. -j-^u (0.0006) increased to gr. -A^ (0.0015), once daily, and when the course of the disease has been arrested an intermission in this treatment for one week in three or four. SYRINGOMYELIA. Definition.—A neurogliar overgrowth of more or ' less vertical extent, and situated in the gray matter of the cord in the neighbor- hood of the central canal. Its symptomatology is not constant, but SYRING OMYELIA. 1095 the following have come to be looked upon as typical of most cases: viz. progressive muscular atrophy and dissociated anesthesia (i. e. impairment or loss of temperature—and pain-sense, with retention of the tactile and muscular sense and trophic and vaso-motor dis- turbances). Pathology and Etiology.—Tubular cavities of greater or less extent are met Avith in the cord as a result of two conditions existing separately or in conjunction—viz. (1) hydro my elia, a dilatation of the central canal (proved by the cubical cells lining it). This is either (a) congenital, according to Leyden, or (b) acquired, due to pressure (tumor), dilatation taking place above the point of obliteration. (2) Syringo- myelia, a name given by Olliver to a neurogliar overgrowth situated Avithin the gray matter of the cord. In this cavity-formation takes place as a result of hemorrhage or degeneration. The cavity is entirely Avithout the central canal; it never possesses an epithelial lining, and is not, therefore, as Leyden supposed, the remains of congenital hydro- myelia. While the new growth in many instances is gliomatous, being probably a rejuvenescence of some vestigial remnant, with subsequent hemorrhage or degeneration and cavity-formation, yet in others the structure is not identical with such neoplasms. The latter have been described particularly by Joffroy and Achard. They speak of it as a gliosis, a secondary overgrowth, and sclerosis of the neuroglia. In any case, hoAvever, the disease is most prone to develop in the cervical and upper dorsal region, groAving and invading the posterior and postero- lateral tracts. Breaks and crevices in the diseased material radiate from the main cavity. The onset of the trouble generally takes place some- where betAveen the fourteenth and twenty-first years of age. Symptoms.—OAving to the fact that different levels of the cord are involved, and that the extent claimed by the process varies in different cases, it will readily be understood that no account, however concise, will fit every case. The disease is of slow onset. Neuralgic pains develop in the muscles, and the latter progressively Avaste. The reflexes are increased, and more or less spasticity is present. The lower ex- tremities usually escape, though they too may be involved, when the condition presents much the same appearance as amyotrophic lateral sclerosis. The temperature- and pain-sense are lost, but the tactile and muscular senses are preserved. The special senses and the sphincters are normal. Ocular symptoms develop only when the cervical cord is extensively involved. Joint- changes may be met with, and various ulcerations, bulbous eruptions, or wounds may be present, the latter often being received without the pa- tient's knowledge, since loss of sensation is complete. These constitute a special feature of a type of the disease originally described by Morvan of Brittany in 1883. He had observed many cases prior to that time, but his attention was specially called to the matter by a case of whitlow which he incised, but to his surprise no pain whatever was experienced. He described the disease as affecting the upper extremities, with neur- algia, progressive paresis and Avasting, dissociated anesthesia, and, later, painless whitlows and necrosis of the phalanges. Joffroy and Achard have made three autopsies upon cases dying with this disease, and in each syringomyelia Avas found. In Gambault's case neuritis was 1096 DISEASES OF THE NERVOUS SYSTEM. present, and the current view is that Morvans disease is a combination of syringomyelia and neuritis. Diagnosis.—The loss of pain and thermic sense, with preservation of the muscular and tactile senses, plus the muscular Avasting, is most marked in the upper extremities ; and, particularly when associated Avith spasticity of the lower extremities, they constitute a group of symptoms that has come to be regarded as typical. Hypertrophic cervical pachymeningitis may be mistaken for this dis- ease, or vice versd. In this case, however, the pain is usually greater, the tactile sense is apt to be lost, and possibly the other senses also; but there is not the dissociation met Avith in syringomyelia. Amyotrophic lateral sclerosis presents neither sensory nor trophic symptoms, otber than the muscular Avasting. Disseminated sclerosis, apart from the tremor that is ahvays present, presents less trophic disturbance. The prognosis is ahvays unfavorable, though the disease runs a very chronic course, lasting even fifteen or twenty years. Treatment.—Nothing can be done, except by attention to hygienic and dietetic details. COMPRESSION OF THE SPINAL CORD. It is of importance to be able to recognize this condition. To be sure, it is not ahvays possible to diagnose it with certainty, but Avhen there is a reasonably surety the question of operation may arise. Since it has so many features in common with myelitis, the necessity for caution in arriving at a conclusion is manifest, since the latter condition Avould not be benefited by any operative procedure. Pathology.—The postmortem findings will depend upon the degree and duration of the pressure. The cord will be more or less flattened and distorted at the seat of pressure, and in the early stages hyper- emic, and possibly softened. Later it is hard, sclerosed, and of a gray- ish color, and above and beloAv the compressed region degenerated areas Avill be seen on sectioning the cord. Microscopic examination reveals the same changes as those met Avith in any other form of myelitis. The nerve-roots will be more or less damaged by compression. Etiology.—We may class the causes of compression under three headings—(a) traumatism (fractures), (b) inflammatory disease (caries of the spine), and (c) neoplasmata (including various tumors, gummata, and aneurysm), but these will receive separate consideration (infra). Symptoms.—These will vary according to the site of the lesion and the extent of involvement—i. e. the vertical extent, the degree of pressure exerted, and the amount of inflammation present. Two groups of symptoms are present in typical cases—first, those due to involve- ment of the roots, and, second, those dependent upon involvement of the cord itself— ascending and descending degeneration. The former gives rise to pain, neuralgic in character and radiating along the course of the nerves. The parts supplied are usually tender, and there may be paresthesia and formication. These irritative symptoms are fol- TUMORS OF THE SPINAL CORD AND ITS MEMBRANES. 1097 lowed sooner or later by those of paralysis, and hence the anesthesia. Areas of hyperesthesia may accompany the anesthesia (anaesthesia dolo- rosa). Motor symptoms are also irritative and paralytic, and hence the early twitching, or even spastic condition, and later the loss of power, or paralysis. The muscles of the affected parts waste, and qualitative and quantitative electric changes can be elicited. The second group, due to cord-changes, then develops, and its symptoms may set in either rapidly or slowly. If myelitis promptly supervenes and is extensive, cord-symptoms of a pronounced type develop quickly. The parts below the lesion will become weak, there will be girdle pains, and a sense of constriction or pain in the legs. Sensory symptoms may be absent. The reflexes are usually increased. If the tumor or other cause of com- pression ceases to fail to act for a time, some improvement takes place, due possibly to the subsidence of the myelitis. If the pressure is of slow onset, great tolerance is manifested. As is usually the case, sen- sation is recovered before motion. In certain cases, however, motor power is regained, while the muscular and tactile senses do not return. In such instances, in which the posterior columns bear the brunt of the trouble, incoordination results and secondary ataxia is met with. Diagnosis.—If the combined symptoms of peripheral and central origin develop sloAvly in the order named, compression is likely. Myelitis gives rise first to cord-, and only later to peripheral symp- toms ; hence the difficulty in cases in which myelitis develops quickly. Extensive root-symptoms are suggestive of mepingeal involvement. In any event, too much stress should not be placed on the nervous symp- toms alone. The spine should be carefully examined and palpated for points of tenderness. Careful note should also be taken as to Avhether there is any limitation of movement or deformity. The family history may suggest tuberculosis (caries of the spine). The prognosis depends entirely upon the cause. Having ascer- tained this, it then depends upon the possibility of its removal. Treatment.—In general the treatment is that of myelitis. In cer- tain cases a surgeon should be consulted, though operative cases are the exception rather than the rule, and most may be expected in cases of caries. It is well to impress upon the patient and relatives the chron- icity of the condition, but faithful and persistent efforts will yield good results. Rest is of vital importance, particularly when the disease is active. The patient should be kept in bed in a recumbent position until consolidation has taken place. Extension may be necessary. Good and easily assimilable food, and cod-liver oil and alteratives should be given. The nutrition of the muscles may be improved by gentle fric- tion (massage). As soon as possible a plaster jacket should be put on the patient, and he should be taken into the open air and sunlight. TUMORS OP THE SPINAL CORD AND ITS MEMBRANES. A great variety of neoplastic formations, both primary and second- ary in nature, may occur. The location is of course the most import- ant clinical feature; nevertheless, if Ave would institute successful medical 1098 DISEASES OF THE NERVOUS SYSTEM. or surgical treatment it is desirable to determine as nearly as possible the nature of the tumor. Extradural tumors may be, though rarely, exostoses from the peri- osteal lining of the spinal canal. More frequently lipomata or even an abnormal development of fatty tissue betAveen the bone and the mem- brane is present. Of the parasitic growths, the hydatid cyst is appa- rently the only one that occurs in this situation. The tumors of the dura mater itself are chiefly sarcoma, gumma, and myxoma; a rare form consists of the presence of plates of bone along the Avhole length of the cord. Occasionally growths from the bones, particularly carcinomata and sarcomata, may extend to the membranes. Inside the dural sac both hydatid cysts and the cysticercus may be found. Tuberculosis may occur either in the form of miliary tubercles or as tuberculous masses, particularly in the cervical region. In the pia mater and arachnoid, myxoma, lipoma, fibroma, endothelioma, sar- coma, and angio-sarcoma occur. Occasionally cylindroma and osteoma are also found. A case of the latter kind, of Avhich Joseph Sailer has the specimen, was obtained from an old Avoman Avho had syphilitic lesions in other parts of her body. In the cord itself the* commonest tumor is the glioma, either alone or in combination Avith myxoma or sarcoma, and sarcoma has also been observed. Gummata also occur (vide Syphilis, p. 327). Other tumors that occur infrequently are the fibro-sarcoma, glio-sarcoma, and the angio-sarcoma, mostly taking their origin from the pia mater and ex- tending into the cord. Cysts sometimes occur. The simplest form is ,the dilatation of the central canal knoAvn as hydromyelia; the common- est are those that occur as a result of gliomatous softening in syringo- myelia. Finally multiple neuromata may occur upon the nerve-roots. The changes that take place in the cord are destruction of the nervous tissue at the side of the tumor, pressure-myelitis, and systemic degen- erations in the various columns. Curiously enough, complete restoration of function can occur, even when the symptoms of degeneration in the pyramidal columns are pronounced, and there is wasting of the cord macroscopically, as in the case recorded by Gowers and Horsley. The etiology of these conditions varies of course Avith the nature of the groAvths. No difference can be said to exist in general between the sexes. Certain tumors, as lipoma and glioma, are more apt to occur in advanced life; others, as the tyroma, somewhat earlier. The symptoms depend upon the particular segment or segments affected, and the situation in the cord itself or its membranes. In gen- eral the dorsal or lower cervical region is most frequently involved. Disturbances of Motion.—If the tumor attains sufficient size to exert considerable pressure, paraplegia always occurs. This usually com- mences upon one side, and then more or less rapidly involves the other. Exaggeration of the tendon reflexes of the leg has been observed in all tumors above the first lumbar segment. Whenever this condition is at all advanced, there are disturbances of the functions of the bladder and rectum. Spasms are sometimes the earliest motor changes. Ordinarily they appear in the muscles of the trunk governed by the segment that has been involved; but sometimes they appear in the legs, and are usually more severe in one than in the other, and they may be due TUMORS OF THE SPINAL CORD AND ITS MEMBRANES. 1099 either to pressure upon the motor roots or to pressure upon the motor columns of the cord. It is not therefore permissible to draw definite conclusions from their location as to the site of the tumor. Paresis is commonly an associated symptom, and gradually deepens into para- plegia. In the latter stage contractures may also develop. Special Motor Symptoms.—If the tumor is situated in the lower portion of the cervical region there are often disturbances of motility in a certain definite group of muscles that are supplied by the brachial plexus. These disturbances may be ataxia, tremor, spasms, or paralysis. If the tumor be in the dorsal region, the cramp of the intercostal or abdominal muscles at a particular level may give rise to a girdle-sen- sation ; if in the lumbar region, to disturbances of motion similar in character to those described in the arm. In this locality, however, as the nerve-roots are longer, more of them are apt to be involved in the pressure, and the symptoms are more extensive. Sensory Symptoms.—Pain is usually the earliest symptom. It is, as a rule, sharply localized, severe, and paroxysmal, with symptoms of dull neuralgic aching between the exacerbations. Certain forms of pain are very common. Tumor in the cervical region gives rise to severe pain in one or both arms and to neuralgic pains in the neck and occiput. Tumors in the dorsal region cause the girdle-sensations before described, or intense backache, often associated with tenderness over the site of the tumor. Tumors in the lumbar region induce pain in one or both legs, often of a burning character, and sometimes re- ferred to the soles of the feet. Hyperesthesia of the skin is usually found at a level supplied by the segment in which the tumor is situated. Other sensory disturbances are tingling, numbness, and total anesthesia. A rare combination, in the early stages of the tumor of the spinal cord, is the presence of anesthesia in one-half the body below the tumor and of paresis or paralysis in the other half—that is, the symptom-complex of Brown-Se'quard: it almost invariably disappears in a short time. The reflexes are increased below the level of the tumor. If this is sit- uated in the lower cervical region, then the cutaneous reflexes of the thorax and abdomen are prompt and vigorous ; if in the dorsal region, they are normal above the site of the tumor, abolished in its neighborhood, and increased below, and at the same time there is an enormous exaggera- tion of the skin- and tendon-reflexes of the legs ; if in the upper portion of the lumbar region, there may be an abolition of the knee-jerk, while ankle-clonus is exaggerated; but ordinarily all reflexes are abolished. The muscles frequently degenerate, and the electric reactions of degen- eration are found in those regions that are supplied by the anterior horn, or the anterior roots that have been destroyed by the tumor. In those tumors situated in the lumbar region, involving a number of nerve- roots, the wasting of the muscles of the legs is usually very marked. Trophic disturbances occur late in the course of the disease, when ex- tensive bed-sores may develop, exactly as in transverse myelitis. Occa- sionally vaso-motor disturbances (tdche spinale, localized edema) may be observed in the early stages. Course.—Tumors usually grow sloAvly, and therefore the symptoms are gradual in their development. Ordinarily there are periods of arrest or even improvement that are followed subsequently by further 1100 DISEASES OF THE NERVOUS SYSTEM. advance. The duration of spinal tumors is variable. Those of malig- nant nature or rapid groAvth may produce death in a short time; those that simply exert pressure and enlarge very slowly may not produce total disability for several years. In general it may be said that from five to ten years is the ordinary limit after the first appearance of motor disturbance. Some tumors, hoAvever, particularly lipomata, produce only slight disturbances throughout life, or else no symptoms at all, remain- ing entirely latent. The diagnosis involves three points: first, the recognition of the presence of the tumor; second, of its site; and third, of its nature. The prodromal symptoms of spinal tumor are often confounded Avith neuralgia or lumbago. It is sometimes possible to make a differential diagnosis by means of the presence, in neuralgic conditions, especially of intercostal nature, of the sensitive points along the course of the ribs. and of the existence, in the case of tumor, of exaggerated knee-jerks and sensitiveness over certain portions of the vertebral column. In the paraplegic condition it may be confounded with a neuritis, such as one of alcoholic origin. In these cases the diagnosis is more difficult if the tumor is situated in the upper portion of the lumbar cord; nevertheless, the sensory disturbance is slight in alcoholic neuritis, whilst it is consid- erable in tumors in the lumbar region, and often presents the form of anaesthesia dolorosa, that is, diminished sensibility associated with con- siderable pain. There are also apt to be disturbances of the sphincters. The intrinsic diseases of the spinal canal give rise to much greater difficulty, especially myelitis and pachymeningitis cervicalis.. From the former the correct diagnosis may sometimes be suspected, OAving to the presence of severe radiating pains and symptoms more pronounced on one side than the other. Moreover, the symptoms of segmentary in- volvement are sharper and the root-symptoms more characteristic. From pachymeningitis cervicalis, a central tumor in the cervical region can be usually distinguished by the fact that the radiating pains are less severe and the symptoms not so distinctly bilateral. It may be impossible to distinguish a central tumor from syringomyelia unless the symptoms of root-pressure are quite distinct. Pott's disease, in its early stage, may also give rise to some difficulty. HoAvever, the rapid development of the kyphosis, and particularly the pain that is elicited by sudden pressure upon the head, renders it possible, after a reasonable period of observation-, to recognize the true nature of the case. The diagnosis of the position of the tumor has been largely discussed in the Symptomatology. The symptom-complex may, however, be con- siderably disturbed by the presence of multiple tumors. In these cases the majority ordinarily remain latent. It must not be forgotten, hoAv- ever, that the absence of the knee-jerk does not localize the tumor to the lumbar region of the cord, for it may be abolished when the tumor is situated in the dorsal region and compresses the posterior'columns. In general, it may be said that the presence of root-pains suggests a meningeal seat, whilst pronounced paraplegia, or the Brown-Se'quard symptom-complex, points to the presence of a tumor in the substance of the cord itself. Finally the recognition of the nature of the growth can often be made from the history of the existence of a tumor or an infectious process in DISEASES OF THE BRAIN AND ITS MENINGES. 1101 other parts of the body. It must be remembered, however, that it does not always folloAV that a tumor in the spinal canal is similar to that found elsewhere. The presence of cerebral as well as spinal focal lesions points very strongly to syphilis. The prognosis depends upon the severity of the symptoms, the rapidity of their development, and the nature of the growth, if this should be known. Complete subsidence of all the symptoms may occur, even after a spastic paraplegia has existed. Of course this is only likely in those cases in which the tumor can be removed by operation or ab- sorbed through the action of drugs. The treatment depends wholly upon the recognition of the nature of the tumor; if this be syphilitic, mercury and potassium iodid should be given in full doses. If, on the other hand, it is not specific, and appears to be extradural, operation would seem to offer a possibility of cure, the famous case of Gowers and Horsley having demonstrated the practicability of removal. As the prognosis is, in general, unfavor- able to cure and often gloomy as to life, the clinician should not hesitate to recommend surgical interference. LESIONS OP THE CONUS TERMINALIS AND THE CAUDA EQUINA. As the spinal cord terminates at the second lumbar vertebra, tumors or injuries below this point produce symptoms only in so far as they compress or destroy the lumbar roots. This destruction may be partial or complete. If partial, we have paralyses of various groups of muscles and circumscribed areas of anesthesia. There may or may not be a dis- turbance of the functions of the bladder and sphincters. If this be total, there are complete anesthesia, complete paraplegia, flaccid in character, with reactions of degeneration in the muscles, loss of the knee-jerk, and rectal and vesical incontinence. If only the cauda equina is involved, there may be isolated paralysis of the bladder and rectum. These lesions may consist of tumors, such as are found in the membranes of the cord or on the nerve-roots, and it should be noted that, probably on account of greater space for their development, tumors in this situation are apt to be larger than those in other parts of the spinal canal. They may also consist of fractures or lesions occurring as a result of congenital anomalies, such as spina bifida. III. DISEASES OF THE BRAIN AND ITS MENINGES. DISEASES OF THE DURA MATER. Inflammation.—This may be met with on the outer or inner sur- face (pachymeningitis externa or interna). Of the external variety the chief causes are (a) traumatism, (b) disease of the bone, (c) syphilis, and (d) middle-ear disease. That due to traumatism is often seen, and in 1102 DISEASES OF THE NERVOUS SYSTEM. the mildest form is of little moment. AVhen severe and accompanied by fracture Avith or Avithout displacement, infection of the membranes may either take place at once or later from diseased bone. That form due to caries or any other form of osteitis is always dangerous, OAving to the possibility of infection of the diploe. The brain-sinuses will then become affected, and infected emboli may pass into the circulation, Avith the development of pyemia. In the syphilitic variety the inner table of the skull is thickened and roughened, and more or less pus and gran- ular material is found between it and the dura (see also Syphilis of the Nervous System). Sinuses may communicate Avith the exterior. The symptoms are indefinite in mild cases, and may consist, perhaps, only of headache. In the severe forms there are headache, malaise, chills, fever, droAvsiness, and later stupor, and rarely convulsions and hemorrhage, or other symptoms of compression. The ophthalmoscope Avill reveal more or less evidence of choked disk. Rigors are suggestive of the onset of pyemia. The treatment varies with the cause. Antiphlogistic measures and counter-irritation are of value, and in the severe grades operative inter- ference may be necessary. The internal variety either occurs as a sim- ple inflammation or may be so acute as to cause extravasation of blood. This may organize, and, together with the products of inflammation, cause a pseudo-membrane. Rarely is pus found. Hemorrhage.—Hemorrhage may be (1) extradural—(a) traumatic and (b) due to rupture of a vessel by erosion, the result of caries; or (2) intradural—into the so-called arachnoid sac—(a) very rarely traumatic; (b) due to injuries at birth; (c) due to pachymeningitis interna; (d) met with in general paralysis of the insane; (e) occurring in the course of anemia, scurvy, or some other profoundly altered blood-condition; (/) in cardiac, renal, or pulmonary disease; (g) the result of strain—e. g. whooping-cough. The symptoms will depend upon the circumstances, whether the amount of blood is small or large and of gradual or rapid onset; they may be further obscured by the primary disease or by shock if the cause is some trauma. In the slight forms absolutely nothing characteristic exists. In others there are headache, vertigo, vomiting, and possibly mental confusion, convulsions, or coma; in fact, the ordinary symptoms of apoplexy. The treatment is that of cerebral hemorrhage; in some cases ope- ration is justifiable. Hematoma.—An inflammatory condition of the internal surface of the dura, Avith the formation of a vascular membrane into Avhich hemorrhage takes place. Pathology.—According to Yirchow, the first stage consists of the formation of a reticulated vascular membrane, very delicate and in some cases laminated, upon the inner surface of the dura. This is generally over the convexity, and is, as a rule, symmetrically arranged ; rarely it is basal. The second stage is that of hemorrhage, in Avhich blood is poured between the layers, forming one or more cysts, adherent to the dura externally, and either resting on or exerting more or less com- pression upon the arachnoid, pia, and the convolutions below. The cysts contain recent blood, clots, degenerated blood, and granular DISEASES OF THE BRAIN AND ITS MENINGES. 1103 debris, or merely clear serum, varying Avith the age. This view is, however, not generally held to-day. It is highly probable that the hemorrhage precedes the formation of the membrane. Occasionally the blood breaks through the inner layer into the arachnoid sac (interme- ningeal apoplexy). Etiology.—Hematoma is most common in infancy or old age, but may occur at any age. Males are more subject than females. It is a secondary condition, the result of trauma or occurring in the course of chronic alcoholism, insanity, or where there is a hemorrhagic tend- ency, anemia, and the like. Symptoms.—Hematoma is occasionally found postmortem, though never having been suspected during life. The laminated membrane is said to be due to a series of attacks, such cases extending over months or even years. The symptoms are nearly the same as those mentioned under Hemorrhage. Dr. Munro recently reported an interesting but unusual type of this condition: " Male; aged fifty, cooper ; ahvays healthy until he Avas suddenly seized with general convulsions. The attacks folloAved one another in rapid succession, each fit commencing Avith conjugate deviation of the eyes and head to the right ; then tonic, folloAved by clonic spasm of both legs and the right arm. It Avas noticed that the convulsions became almost restricted to the right side, though the left leg was still slightly involved. Consciousness was not regained. The mouth was draAvn to the right. The temperature rose to 106.8° F. (41.5° C.) before death. At the autopsy nothing of any significance was found in any other organ than the brain. On remov- ing the dura it Avas found to be lined on the left side above, below, and laterally by an adventitious membrane, firm and adherent; this mem- brane, however, could be stripped off, and was adherent to the pia and arachnoid only in the left olfactory-bulb region. It was reddish in color, and apparently of recent origin. There was no evidence of hem- orrhage macroscopically, but microscopically the membrane Avas found to consist of several layers of vascular and cellular fibrous tissue con- taining pigment, particularly in the portion nearest the dura. Dr. Munro believed the pseudo-membrane to be the result of repeated hemorrhages, both from the character of the pigment in it and from the fact that it could be readily separated from the dura mater. There Avas no recent change that would account for the status epilepticus. The diagnosis is always difficult. In children muscular contractions and convulsions are frequently met with ; in adults the sIoav onset may be the only difference between this condition and an attack of grand' mal. Of course there is a greater periodicity in epilepsy, but a repetition of the attacks occurs in hematoma, and, as already stated, the repeated hemorrhages are believed by some to be the cause of the lamination of the false membrane. The prognosis is extremely unfavorable in children, but is much less so in adults. The treatment calls for the use of leeches behind the ears and over the temples, the ice-cap, and counter-irritation. Free movement of the bowels is to be promptly secured, and later the iodids or mercurials are to be essayed. Tumors are considered in connection with Tumors of the Brain. 1104 DISEASES OF THE NERVOUS SYSTEM. DISEASES OF THE PIA. Inflammation (Leptomeningitis).—This is met Avith in the folloAv- ing conditions : (a) When tubercles develop on the membrane (vide Tu- berculous Meningitis); (b) During, or as a sequel to, some acute febrile disease, as pneumonia, erysipelas of the head and face, small-pox, measles, scarlet fever, typhoid fever, ulcerative endocarditis, and pyemia ; (c) Cerebro-spinal meningitis ; (d) Cachexia; (e) Gout and Bright's disease ; (/) Exposure to the sun ; (g) Traumatism, even when not ac- companied by fracture; (h) Disease of the bones—caries, or secondary to middle-ear disease ; (i) Extension from syphilitic involvement of the meninges. Inflammation of the pia (non-tuberculous) is more common in males than females, and occurs, as a rule, before the twentieth year. After that time it is rather rare. Pathology.—In the extent and degree of the inflammation great va- riations exist. It may be either (1) limited to the convexity, Avith or Avithout involvement of the sides; (2) limited to the base; or (3) gen- eral, involving both convexity and base. In the early stages and in the mild forms there may be no more than an injection of the part. Later, inflammatory products are met with and more or less adhesion exists. Pus is also present in some cases. This form of leptomeningitis, unlike the tuberculous variety, is prone to attack the convexity of the brain. I have made an autopsy on one child of tAventy months in which the in- flammation was slight on the convexity, and still less on the sides, but quite marked on the base, particularly about the Sylvian and cerebellar regions and the optic chiasm. A granular ependymitis Avas found, limited to the body of the lateral ventricles, and reminding one very much of a similar condition met with in paralysis of the insane. The ventricles were dilated, and contained an excess of fluid, due probably to occlusion of the foramen of Magendie, as Gee and BarloAv have pointed out. No tubercles were found, nor did the family history lead me to suspect tuberculosis. Symptoms.—These are very varied, and naturally depend on the seat and extent of the inflammation. Those cases in which symptoms point- ing to involvement of the base occur need not be discussed here, since they are considered in detail under the tuberculous variety. In any case headache, localized or general, is usually present. In children too young to talk its presence is often indicated by crying or putting the hand to the head. Delirium, insomnia, and coma are also met with in different cases. There are more or less fever, constipation, a coated tongue, vomiting, a rapid pulse, and the tdche cerebrate may be elicited. Spasmodic movements may occur, or even general convulsions. Of course in cases of inflammation of the base the cranial nerves become affected, and we have ptosis or strabismus, facial spasm or palsy, and, if the fifth nerve is involved, sensory and trophic changes. It must be borne in mind that meningeal symptoms are frequently simulated by the infectious diseases, and particularly by pneumonia (of the apical type generally; more especially in children and old people), typhoid fever, and influenza. Such cases are most likely due either to vascular disturbance of the meninges (congestion) or to a toxic encephalopathy. DISTURBANCES OF CIRCULATION OF THE BRAIN. 1105 Diagnosis.—Where no etiologic hint can be obtained the diagnosis is generally in doubt for two or three days. There may be nothing more than a reflex irritation (dental or gastro-intestinal), or possibly one of the infectious fevers. The symptoms should be studied in their entirety; one or two supposedly pathognomonic signs should not be allowed to cloud our vision. Having made the diagnosis of meningitis, it becomes important to differentiate the tuberculous from the non-tuberculous vari- ety. The family history is of importance, and Bastian believes that an examination of the blood is of value. In tuberculous meningitis he has found an excess of leukocytes that soon show ameboid activity; also the development of vacuoles and numerous surface-projections. In addition, granular protoplasm and granules of pigment are to be seen in the field. Recent observers, however, have found no leukocytosis in tuberculous, non-suppurative meningitis; and the fact is that Ave had no absolutely reliable means of diagnosing meningitis of any form (except the well-advanced diseases) before Quincke, in 1890, introduced his method of lumbar puncture. This is comparatively simple of applica- tion, and has become a Avell-recognized measure. The tubercle bacillus and streptococcus pyogenes, also the pneumococcus and micrococcus meningitidis, have frequently been found in the fluid withdrawn. Prognosis.—In Avell-marked cases, in which no doubt exists as to the diagnosis, the prognosis is always grave. The milder forms—the cortical cases, for instance—generally recover, but of the basal type very few survive, and those that do often retain evidences of the previous trouble in the shape of cranial-nerve involvement (strabismus, ptosis, facial palsy). That even tuberculous cases may recover is proved, however, by that of West, and even more strikingly by that of Baumann, Avho found the tubercle bacillus in the cerebro-spinal fluid. The case recov- ered, but died some months later from an intercurrent affection; the diagnosis gained additional confirmation from the postmortem, findings. Treatment.—This has been previously considered. It is only neces- sary to add that Ave are able to do no more in this form than in the tuberculous. We have no specific, and all that can be done is to meet the symptomatic indications. In certain cases—e. g. those secondary to middle-ear disease—operation may seem justifiable. When in doubt the physician should not delay action until too late, but should call in a surgeon while some benefit may still be hoped for. DISTURBANCES OF CIRCULATION OF THE BRAIN. HYPEREMIA. Definition.—An abnormal increase in the amount of blood in the cerebral capillaries. The condition is not in any way associated with the primary phenomena of inflammation. What has already been mentioned in the case of hyperemia of the cord is equally true in this case—viz. that while congestion undoubtedly may take place, there is nothing symptomatically pathognomonic in the 70 1106 DISEASES OF THE NERVOUS SYSTEM. fact, and hence Ave do not recognize it as a definite clinical entity. " Congestion of the brain " is rather a " diagnostic haven " and satisfies the patient, Avhile at the same time, provided the assumption is not made on too superficial evidence, it harms no one. Two forms of hyperemia have been described: 1. Active hyperemia is met Avith in men more frequently than in Avomen, and results from over-action of the heart and widespread ob- struction to the circulation, as Avhen the surface capillaries contract, or there is arterial dilatation, due to excessive mental activity from any cause or to drugs—alcohol, amyl nitrite, nitroglycerin. 2. Passive congestion is met Avith in cases of obstruction of the cere- bral sinuses and veins, and is due to pressure on the superior cava or the innominate or jugular veins by tumors or aneurysms; also in suffo- cation and strangling, in cases of excessive strain, and in tricuspid in- sufficiency. Pathology.—There are no marked changes in the brain in these cases. In the active form the gray matter Avill appear someAvhat darker than normal, and a macroscopic section of the Avhite matter shows the puncta vasculosa to be increased. It often leaves no trace postmortem. In passive congestion the veins and sinuses are engorged and more or less edema may be present. The symptoms are described under tAvo headings—1, those of irri- tation, and 2, of depression. Among the former are headache, vertigo, irritability, rapid pulse, restlessness, insomnia, and special nervous phe- nomena, as flashes of light, hyperacusis, and even convulsive movements. The latter is manifested by the obtunding of the senses; in fact, the antithesis of the other. The cerebral symptoms met Avith in febrile processes are probably due either to faulty metabolism or to some toxin, and should not be regarded as the result of hyperemia. Treatment.—The recumbent posture is of great importance. Leeching, Avet-cupping, and venesection are sometimes employed. Cold applications to the head, bromids internally, and attention to the bowels Avi!l be of assistance. Freedom from annoyance and Avorry of all kinds is necessary. ANEMIA. Definition.—A condition in Avhich an insufficient amount of blood circulates in the cerebral capillaries. It is due to exhausting discharges (diarrhea), an abnormally sIoav pulse or Aveak heart, to hemorrhage, obstructive endarteritis of the ves- sels supplying the brain, and to syncopal attacks and dilatation of the intestinal vessels, owing to the too rapid AvithdraAval of ascitic fluid. Pathology.—The gray matter is quite pale; the puncta vasculosa are diminished, and sometimes cannot be seen; the cerebro-spinal fluid is frequently increased. Symptoms.—The most exaggerated type is met Avith after a pro- nounced hemorrhage. There are pallor, weakness, vertigo, headache, flashes of light, subjective noises, rapid respiration, cool skin, possibly profuse SAveating, and in extreme cases coma, convulsions, and death. We are more familiar Avith the ordinary fainting-attack. AVhen cerebral anemia is brought about more slowly " irritable Aveakness " results. The EMBOLISM AND THROMBOSIS. 1107 patient is either somnolent, dull, and apathetic, or he may be a victim of insomnia. Headache, vertigo, tinnitus aurium, muscos volitantes, and lowered muscular poAver are present. The patient becomes irritable on the slightest provocation. Marshall Hall has described a group of symp- toms as " hydrocephaloid " from their resemblance to hydrocephalus; they occur especially in young children after diarrhea. There are pal- lor, hebetude, contracted pupils, and depressed fontanels. The som- nolence may deepen into a coma that often becomes more profound until death results. The treatment varies Avith the cause. The recumbent posture is ahvays indicated, and in some cases it is necessary to depress the head, administer stimulants, and even transfuse or inject a normal saline solu- tion. A light and easily assimilable diet should be given during con- valescence. EDEMA OF THE BRAIN. Definition.—An infiltration of serum into the pia and a greater or less increase of ventricular fluid, with or without infiltration into the brain-substance. Pathology.—The fluid is chiefly in the meshes and beneath the membrane. The ventricular fluid is increased in amount; the brain- substance is pale, and in some cases infiltrated and softened. Micro- scopically, lacunae may be seen in the cerebral tissue, the perivascular spaces are dilated, and some slight degree of nerve-cell degeneration is often present. Etiology.—Edema is met Avith in Bright's disease, in senile cere- bral atrophy, and as a result of active or passive hyperemia. Symptoms.—In general the symptoms are those of anemia, though nothing definite is knoAvn of them. Since the condition is ahvays sec- ondary, it may be that symptoms directly referable to the edema are masked by the primary condition. Cases of apoplexy are seen occasion- ally, in Avhich the only postmortem finding is an effusion of fluid into the pia and ventricles. This has been termed " serous apoplexy." The treatment is that of the primary condition. EMBOLISM AND THROMBOSIS. (Cerebral Softening) Embolism.—Definition and Etiology.—The obstruction of arteries or capillaries by material brought to the spot from some other part by the blood-current. The material, generally fibrin, usually comes from the heart, and is either a vegetation of a recent endocarditis or, more commonly, of chronic valvular disease; it may possibly be a fragment of the valve plus the fibrin in ulcerative endocarditis. In the latter case the plug is generally septic, giving rise to suppurative processes. An embolus may be washed from the auricular recesses, from an aneur- ysm of the aorta or carotid, or from atheromatous patches: rarely from the pulmonary veins. In puerperal women, and in certain febrile processes (diphtheria and pneumonia) the coagulability of the blood is increased. Heart-clots 1108 DISEASES OF THE NERVOUS SYSTEM. form, and fragments may be washed into the cerebral vessels. < "»" 1 —\— DATE 8 9 10 Fig. 75.—Chart of a case of sunstroke. J. D., aged forty years; steam-fitter. Recovery. 100° 99° 98° 97° 96° 95° 94° DATE g g g S s s s."n |_ bef'o're c'e e?athT .. i. p. vl __________ 1 l____>-T:20 p.m.1 _____e--rT T1 1 1 ___ lI —'■-■----- ''' o _____"-- "STlo f>. iv. b- Z,"i 25 P.M. 1 | BEFORE WARM E ATH *i — "*•-----Sv35 P.M. T AfJER " "| *^ 8:45 P.M. T '""" ~~tt ~~u—trr «> -~ .."KOO P^M So """""-Js :30 P. M. 1 --100:00 P. M. |~ >k. 10130 P.M, O 1 j lE-r 11 1i5 P-M- ICEBA'> "s I r+il 35'p M. | "j I. C | jl |l2i00 'MID-* GHT " ji 0 /i2:3p|a1m. U U «* ,1 lto'0 A. M, L ~U o > P* c <6 C> / ,153,0 A.M. U U /pp'AJM. U U _______ T J;3:0pAM. U ^ \ 3-30 |.U JJ U w i^ < :oo aJm. |n U "■4 5:00 A.MJ Li L fo Jf] L | L tt Cji^3P °l. M. ii__n P< i 7:oo A.m. i| U ? ^^--7J30 A.M. .j " ro — _. JJ^'SXIO ^ M. u ii ~" ^~4 :£> AjM. _.:sUs: >o a.iv. ii ,i 3 >»""?:! tf a. 1 a T"i 10 00 A.M. lojaoVtM. CD P ►1 +H< ill 00 A. M „ U »•. #+-- V ^ 12 o'o noon t7 rr Si,2 30 pl M.I L u _> 1:;oo p M. » _*. .*-■" 1 30 P1. M.j .i n c 0 CD X ^S ® O O — 2. c o rt- ^ >-< P cd5^ qs p go ©^ CD SJ ^ O P GO C5 CD O 3 O CD O. GO . a POQ c^ o K B h^3 P ® O CD CT5 iO ~? CD C CD O CO 3§ -. CD CD to a °^ • p o 1=1 B O 0 2. !-S ^1 GO CD^^ to co^ £ o o 7 CD cTb CD is V*-----p I GO GO 1 p to to 50 1230 THE INTOXICATIONS; OBESITY; HEAT-STROKE. thirst, drowsiness, yawning, epigastric or lumbar pains, numbness and tingling of the hands and feet). These are followed by coldness, clam- miness, and pallor of the surface, marked muscular weakness and pros- tration, a small, febrile, rapid pulse, sighing breathing, syncope, and col- lapse in the graver cases. The temperature at first is subnormal (95° to 97° F.— 35° to 36.1° C), though mild thermic fever of from 100° to 102.5° F. (37.7°-39.1° C.) may be present. Consciousness is rarely completely absent and is regained early. Recovery usually takes place within one or two days, and in milder cases, under prompt and appro- priate treatment the patient may be ready to go about in a few hours. In a few cases of extreme prostration in weakly persons death may ensue from cardiac failure. The sequelae of heat-stroke are quite interesting and peculiar in some instances. Osier relates the case of a patient who " Avas subse- quently so sensitive to temperatures in the neighborhood of 75° F. (23.8° C.) (italics mine) that at such times he lived comfortably only in the cellar, and finally sought refuge in Alaska." Chromatopsia, severe headaches, irritability and ugliness of temper, or delirium may occur in some patients as soon as warm weather sets in, and may be due occasionally to chronic meningitis (Wood). Diagnosis.—Bearing in mind the characteristic differences that are outlined above between sunstroke (including the asphyxial and hyper- pyrexia! forms) and heat-exhaustion, the diagnosis is not difficult. The history and circumstances attending the seizure are also important in making the diagnosis. From other affections, as acute alcoholism, men- ingitis, uremia, and cerebral apoplexy, the differentiation is readily made by noting the previous history, mode of attack, presence or absence of thermic fever, state of consciousness, urine, skin, pupils, pulse, respira- tion, and nervo-muscular apparatus. Prognosis.—This is usually favorable in cases of heat-prostration. It is less so in sunstroke, but in all cases it depends on the severity of the stroke, the previous health and habits of the patient, the complica- tions, and the promptness and facility of the treatment. The mortality- rate during a prolonged period of excessively hot and humid Aveather may be very high, ranging from 15 to 50 per cent. In New York City, during the week ending August 15, 1896, out of a total number of 1810 deaths, 648 were reported as due to sunstroke (Lambert).1 Treatment.—Prophylaxis.—This is highly imperative in hot, sultry weather, particularly in cities, in which persons must work in the sun or in poorly-ventilated and highly-heated, closed places. Workmen should be taught and Avarned privately and publicly, as through the medium of the press and Health Board circulars, to take extra pre- cautions during hot weather, to Avork and sleep in as Avell-ventilated rooms as possible, and to secure artificial ventilation, if necessary. They should live regular and temperate lives, avoiding alcohol and heavy eating; oat-meal Avater should be drunk, light-weight and light- colored clothing should be worn, and the direct rays of the sun should be avoided as much as possible. The condition of the skin should be Avatched and care taken that sweating continues freely. Shelter or rest should be sought at once if sweating stops. Cool wet cloths or green 1 Loc. cit. HEAT-STROKE. 1231 leaves should be worn inside a light straw hat, and sometimes it may be necessary for employers to shorten the hours of labor during the hot- test part of the day. Treatment of the Attack.—Cases of ordinary heat-prostration seldom require much treatment beyond the removal of the patient to the shade of a comparatively cool place, loosening all constricting clothing, spray- ing with cool Avater, the use of ammonia- or amyl-nitrite-inhalations, and of the aromatic spirits of ammonia or spiritus glonoini by the mouth. If the temperature is subnormal and collapse threatens, a hot bath is advisable. Strychnin and digitalis may be used for a day or tAvo to combat the nervo-muscular Aveakness. Heat-stroke, especially the hyperpyrexial cases, must be promptly treated by the application of the ice-bath (ice floating in a tub of water), temperature about 40° F. (4.4° C), or by rubbing, by the cold pack, or by the needle-spray Avith iced water. In the asphyxial cases venesection is frequently indicated. Exter- nal stimulation should be applied to the precordium by mustard and to the feet by hot bottles, and hypodermic injections of nitroglycerin, strychnin, atropin, brandy, camphor, or ether are useful. Ice should be rubbed over the head constantly. Care should, hoAvever, be taken to see that the temperature is not reduced too far. A temperature of about 102° F. (38.8° C.) should be the signal for cessation of the ice- bath, and for the removal of the patient to a cot, where he is to be rubbed dry and allowed to rest until an exacerbation of fever indicates the reapplication of the cooling measures. Ice-water enemata, Avith or with- out brandy, are often useful adjuvants. The needle-spray of cold water is an excellent nervous stimulant as well as antipyretic. It is given while the patient lies on a Kibbee or netting cot, or on a cot covered with a rubber sheet so arranged as to drain into a pail or trough. In- ternal antipyretics are seldom well absorbed, and their depressant action is so well known as to discourage their use in place of hydrotherapy. Hutchinson, Coplin, and Bevan recommend highly the use of morphin to control the convulsions of heat-stroke. Artificial respiration in the asphyxial cases, kept up until other measures and stimulants have time to act, may be the means of saving life. After the reduction of the hyperpyrexia the patient should be lightly covered on a cot placed in a cool place. An ice-cap should be applied to his head, and small pieces of cracked ice may be given to allay gas- tric irritability, with calomel to open the bowels if necessary. Albumin- water, skimmed milk, buttermilk, unfermented grape-juice, junket, and the like may be given for several days preparatory to the ingestion of heavier food. If, as sometimes happens, free diaphoresis does not come on after the reduction of most of the fever and the stimulating treatment, a hot bath may be given, and perhaps aided by the hypodermic injec- tion of pilocarpin in urgent cases. Sequelce must be treated on general principles. The increased susceptibility to repeated attacks of insolation (after the first attack) makes it necessary to avoid exposure to heat ever after, and, if possible, to seek a cooler climate during the hot months. PART XI. ANIMAL PARASITIC DISEASES. PSOROSPERMIASIS. Psorosperms belong to the lowest form of protozoa. They are also known as sporozoa, and, because of their parasitic relation to cells, as cytozoa. The amoeba coli of amebic dysentery belongs to the protozoa. Blood parasites (hematozoa), as the plasmodium malaria, are likewise closely related to the sporozoa. Various coccidia may occur in man to produce the disease indicated by this heading. The coccidium oviforme of the rabbit is the commonest variety, being found also in rats and mice. It escapes from the livers of the latter animals and passes into the dejecta; it produces an hepatic disease in which there are numerous Avhitish nodules studding the liver. These range in size from a pinhead to a split pea, and on section dis- close a bile-duct, the dilated portion of which forms the nodule. The ovoid coccidia are found in the epithelial cells of the walls of these biliary expansions. The coccidium perforans and coccidium bigeminum are found in the cells of the intestinal villi instead of in the liver of the hosts mentioned above. Among veterinarians a common form of sickle-shaped organism is knoAvn that is found within an ovoid body in the sarcolemma of the pig's muscle—(i. e. the so-called Rainey's tube). In man, hepatic disease similar to that found in the rabbit is pro- duced by the coccidium oviforme. The tumors formed by the coccidia may be palpable, and the liver may be quite tender. Some chilliness and fever, malaise, and stupor passing into coma have been observed. Death was caused on the fourteenth day in a case admitted to St. Thomas's Hospital (Osier). The necropsy showed whitish neoplasms in the peritoneum, omentum, and kidneys. In the intestinal variety of internal psorospermiasis nausea and vomiting, diarrhea, and the typhoid state may be manifested. Involve- ment of the kidneys has caused hematuria and frequency of urination. External or cutaneous psorospermiasis, one form of which was for- merly called keratosis follicularis, is characterized by lesions at first of a hard, crusty, papular type, later becoming confluent, and situated on the face, lumbo-abdominal, and inguinal regions. These papillomatous groAvths contain numerous parasitic sporozoa. In carcinoma, epithelioma, and Paget's disease of the nipple coc- cidia are readily found in and betAveen the pathologic epithelial cells, 1232 DISTOMIASIS. 1233 but whether they have an etiologic bearing upon these malignant affec- tions is still a matter of uncertainty. Prophylaxis consists in cleanliness and care in preparing such food vegetables as spinach, lettuce, cabbage, and other greens that may pos- sibly be contaminated by the excreta of the loAver animals liable to psorosperm-infection. The treatment of psorospermiasis is symptom- atic, though rectal injections of a solution of quinin (1: 5000 to 1:1000) may be tried. DISTOMIASIS. (Trematodiasis.) Various forms of trematodes, including the distomata, may become parasitic in man. Distoma Hepaticum (Liver-fluke).—Among the more common va- rieties of trematodes or flukes, is the distoma hepaticum or liver-fluke, a parasite found in animals (horse, goat, ass, sheep, rabbit) and acci- dentally ingested by man. It is almost 30 millimeters (1.1 inches) in length, and inhabits the biliary passages of the animal, and from them is discharged into the intestinal tract and evacuated with the feces. Under certain conditions of temperature and moisture, a ciliated embryo escapes from the egg, and is ingested by a gasteropod or snail (limncea truncatula), in Avhich it undergoes development into a sporocyst, that in turn gives origin to radios or parent nurses. These give birth to daughter-radiae or cerearia?, which leave the gasteropod or snail and attach themselves to aquatic plants, where they are in turn eaten by animals. Symptoms.—When present in sufficient numbers in the bile-passages the liver becomes greatly enlarged, with the occurrence of jaundice and ascites that may prove fatal. Other symptoms may also be present; thus pain was prominent in 41 out of 100 cases reported by Kurimato in Japan, and heart-murmurs were present in 42 of those cases. Late in the disease the liver may become nodulated and terminate in atrophy. On inspection in well-marked cases, a peculiar barrel-shaped bulging is sometimes seen, extending over the hepatic area, with tense abdom- inal Avails over the enlarged liver. This is a pathognomonic symptom of hepatic distoma. An endemic form occurring in Japan has been de- scribed ; it is characterized by marked emaciation, diarrhea, hepatic enlargement, and often by ascites. The prognosis of distoma hepaticum is absolutely fatal and the treat- ment is merely palliative. Among other trematodes may be mentioned (a) distoma lanceolatum (found also in cattle); (b) distoma crassum, which is larger in size than the preceding; (c) distoma sibiricum ; (d) distoma pulmonale (D. Rin- geri) ; (e) distoma spatulatum (endemicum) ; (f) amphistomum hominis; (g) distoma hematobium (Bilharz). Two of these deserve extra, though brief, mention. 78 1234 ANIMAL PARASITIC DISEASES. Distoma Pulmonale (D. Ringcri) (Bronchial-fluke; Parasitic He- moptysis).—This parasite is very common in Japan. It finds lodgement primarily in the lung, and its ova sometimes form emboli in the brain, liver, and other tissues, and may also be found in the form of little cysts throughout the body. The symptoms are a cough, a reddish-broAvn bloody sputum, and the presence of the flukes in the expectoration. The latter are club-shaped, and are about 8-10 mm. (^ in.) long. Distoma Hematobium (Bilharzia hematobia; Blood-flukes).— This hematode is a narrow Avorm with anterior abdominal sucking-disks. The male is shorter and thicker than the female; the former being 4-15 mm. (l—f in.) long; the latter, about 20 mm. (f in.). It prevails mostly in Egypt, Cape Colony, and other parts of Africa, and its en- trance into the human body is noAv believed to be through the skin of those who bathe frequently in the African rivers, in many of which it abounds. It is not unlikely that, as formerly held, infection may also occur in many cases from drinking the impure Avater of the rivers. The parasites or their ova are found in the bladder, the pelvis of the kidney, and the veins (especially the portal and mesenteric). The symptoms are hematuria, Avith some pain during urination. Pus, and some of the ova of the parasites, may also be found in the urine. No serious systemic disturbances occur in bilharziosis. Prophylaxis as regards d-rinking and bathing in African Avaters should be exercised. Fouquet affirms the value of the extract of male-fern internally in this form of distomiasis. NEMATODES. Helminthologists include in this class the cylindric worms, certain varieties of which are among the most common entozoa that infest the human body and inhabit the intestines. ASCARIASIS. Ascaris I/Umbricoides (Round-worm).—Natural History.—This species resembles the common earth-Avorm, and is the most frequent in occurrence of all the parasites. It usually appears in children be- tween the ages of three and ten years. The round-worm inhabits the upper portion of the small intestine, and occurs singly or in numbers. Its body is round, fusiform, and marked with fine transverse striae. It has a yellowish or reddish-broAvn color, and measures in the female from 7 to 14 inches in length (17.5-35 cm.), and from 4 to 8 inches in the male (about 20 cm.), its thickness being about that of an ordinary goose-quill. The cephalic extremity of the worm has three oval papillae. furnished with fine teeth; the caudal extremity is straight in the female and curved in the male. Lumbricoid Avorms develop from ova, which are about .05 to .06 mm. long, elliptic, dark-reddish in color, and have a thick, resisting envelope. There may be sixty million of them in a single female Avorm, and they sometimes occur in the feces in vast numbers. The development ASCARIASIS. 1235 of the embryo and Avorm external to the body is not accurately known. The eggs obtain entrance into the human intestine most probably through drinking-water, and it has been held that abundant mucus, and the pre- dominating starchy and saccharine diet of Avhich children so often par- take, offer a favorable nidus for the development of the ingested asca- ridian eggs. The round-Avorm sometimes, though rarely, migrates from the small intestine. It has been vomited up, and it has also craAvled into the pha- rynx, mouth, and nares, and has been AvithdraAvn thence by the patient's fingers. It has even passed into the larynx and trachea, causing fatal asphyxia or pulmonary gangrene. The Eustachian tube and biliary ducts may be invaded Avith such serious symptoms as perforation of the mem- branum tympani and hepatic abscess. The ascarides have also been found in the peritoneal cavity, postmortem, Avith intestinal perforation, due, most likely, to other causes. They may penetrate the pancreatic duct and enter fistulae connected with the intestine. Symptoms may be absent, and yet the worms be found repeatedly in the stools. Existing symptoms are indefinite, and point simply to an irritative condition of the boAvel. Serious symptoms may, however, result from the migration of the worm, as into the biliary passages, Eustachian tube, or larynx. Fever is not a necessary concomitant. Lumbricoid Avorms may give rise to any or all of the folloAving symp- toms : colicky pains, nausea, vomiting, indigestion, diarrhea (sometimes), restlessness, irritability, anorexia, itching of and picking at the nose, disturbed sleep Avith grinding of the teeth, salivation, and nervous tAvitchings. The child's abdomen and face may be swollen. Very ner- vous children may manifest epileptiform convulsions, choreic movements, dilated pupils, vertigo, cephalalgia, mental disturbances, and even con- tractures. Complications.—The development of jaundice will indicate obstruc- tion of the bile-duct, in cases in which the Avorms have been found in the feces. So also, suffocative symptoms coming on, especially at night, in a child Avith worms, may be due to a migrating lumbricoid. Perineal abscesses and inflamed herniae that have perforated externally some- times discharge the ascaris lumbricoides. Diagnosis.—This is positively determined only by discovering the worm or ova in the stools. In doubtful cases, judged symptomatically, the administration of a suitable purgative and inspection of the resultant passages will enable the physician to arrive at a diagnosis. The prognosis is good, unless serious complications arise (vide supra), when the case should be guarded accordingly. Treatment.—Prophylaxis.—The water used for drinking-purposes should be obtained from the purest sources. That from small streams, shalloAv wells, and the like is most likely to contain the ova of the lum- bricoides, and should be avoided. The use of filtered water should be encouraged. Before giving an anthelmintic, it should be borne in mind that no good result can be certainly obtained unless the gastro-intestinal tract be nearly deprived of food for from tAvelve to thirty-six hours, so that the toxic action of the drug used may be exerted directly upon the un- protected worm. 1236 ANIMAL PARASITIC DISEASES. Santonin is at once the most efficient and the most easily administered remedy. It may be given in doses of gr. ^ to 1 (0.0162-0.0648) of the crystals to a child, or from gr. ij to iv (0.1296-0.2592) to an adult, in the form of a troche, before breakfast. A little milk or other light nourishment may be alloAved, the troches being continued once or tAvice daily for two or three days. This treatment is to be followed by a brisk purge, preferably gr. j to iij (0.0648-0.1944) of calomel. I have sometimes combined small doses of calomel Avith the santonin in a troche, and Avith good effect. Xanthopsia or yellow vision, spasms, and even convulsions, and saffron-colored urine may follow the use of san- tonin in cases of idiosyncrasy or overdose of the drug. Oil of worm- seed (chenopodium) in doses of five to ten drops, in emulsion, capsules, or on sugar, may also be used Avith benefit. Another favorite remedy with some is the unofficial fluid extract of spigelia and senna, to be given in from 1- to 3-dram (4.0-12.0) doses. Finally, the fluid extract of spi- gelia alone (1 to 2 drams—4.0-8.0), followed by a brisk purge, may bring aAvay dead Avorms. Oxyuris Vermicularis (Seat-, Pin-, Thread-, or Maw-worm).— Natural History.—The ascaris vermicularis, as this worm is also called, inhabits the colon and especially the rectum. It is a small worm, as several of the commonly-used terms signify, and frequently it occurs in great numbers, sometimes agglutinated with mucus into feculent balls. It is most common in children, though found not rarely at any period of life. The female oxyuris is whitish in color and about ten or twelve millimeters (one-half inch) long, the male being about three or four millimeters (about one-sixth of an inch) in length. Oxyures develop from ova in about two weeks after the ingestion of the latter. The eggs are irregularly ovoid, about ¥^ in. (0.05 mm.) in length, and tena- cious of life. By the time the embryos have reached the cecum, they are sexually mature, and when the female arrives in the rectum, im- mense numbers of eggs are deposited that mature into great numbers of worms, the latter being discharged Avith the feces. Sometimes the worms craAvl out of the anus. Infection with the ova may take place through water and food (green, uncooked vegetables and fruit) that have come in contact with the hands of infected persons. Scratching the anus will permit of the reception of oxyuris eggs under the finger-nails (Zenker and Heller), and in careless, ignorant, and uncleanly persons the possibility of such an auto- or re-infection should be recognized and avoided. Symptoms.—Pruritus ani (itching of the anus), sometimes burning pain, and tenesmus, with restlessness and disturbed sleep, are the com- monest symptoms of the presence of this parasite. The itching is always worse at night, and may be paroxysmal. An herpetic or eczem- atous eruption around the anus should arouse suspicion, particularly in children, of the presence of the oxyuris in the rectum, and it ac- counts for the intense itching (Flint). Anorexia and anemia, rectal irritability, and " nervousness " may be associated. It is believed that the migration of the worms into the vagina of girls may set up pruritus and leukorrhea, and that habits of masturbation may be induced in both girls and boys by the sexual irritation caused by the worm. Inspection of the stools will reveal, in positive cases, the whitish, thread-like parasites. ASCARIASIS. 1237 Diagnosis.—The pruritus, indicating rectal trouble, will direct the physician's attention to the anus, Avhere the oxyures may be seen; if not found, their discovery in the feces or the discovery of the eggs by microscopic examination Avill suffice. The prognosis is good, and proper treatment is always effective. Treatment.—The exhibition of anthelmintics and purgatives, such as recommended for destroying and removing the lumbricoid Avorm, may be effective against seat-Avorms also, but mainly in reaching those lodged in the boAvel above the rectum. Attacking the oxyures directly, however, b}7 means of enemata is the most useful and rational treatment. The rectum should be Avell emptied of feces, so that the Avorms may be exposed to the action of the medicament injected, and for this pur- pose enemata of cold Avater, either simple or Avith salt or soap, may be resorted to. Injections containing the decoction of quassia (1 or 2 ounces—32.0 to 64.0—of the powder or chips to the pint—half liter— of Avater) are nearly always curative. Other useful remedies are carbolic acid, turpentine, tannin, vinegar, camphor, potassium sulphid, and the oil of eucalyptus. The injections should be repeated once or twice daily for at least ten days. It sometimes happens that killing the Avorms as directed above affords only temporary relief. The reason for this is obviously to be found in the fact that the oxyuris breeds in the cecum, and that only groAvn forms descend, reaching the rectum. Rectal irritation may be allayed by injections of laudanum and starch-Avater (gtt. iij-v to the ounce—32.0). Anal itching is often amenable to carbolized vaselin, applied at bed-time, or to belladonna ointment, or the folloAving, Avhich has been highly recommended: B/. Hydrarg. chloridi mitis, 9ij (2.592); Petrolati, Jss (16.0). M. et ft. ung. Sig.—Apply at bedtime. Ascaris Alata.—This is another name for the ascaris mystax, a species of worm found in the intestines of the dog and cat, and occa- sionally in man. It is a slender worm, Avith a closely-rolled spiral tail and a Avino--like projection on either side of the head. The female is about 6-7 centimeters (2.7 inches), the male about 4 centimeters (1.75 in.) in length. Scarcely ten instances, however, have been recorded in Avhich this parasite has occurred in man. Trichocephalus Dispar (Ascaris trichiura).—Natural History.— This worm measures about four or five centimeters (2 inches) in length, and is characterized by the very slender, hair-like appearance of the anterior two-thirds of its body, in contrast to the thick posterior por- tion, which is more or less straight and blunt-pointed in the female, but rolled into a spiral in the male. Its particular habitat seems to be the cecum, though sometimes it is also found in the colon. It may exist in great numbers. Europeans appear to be infected with the parasite more commonly than Americans. The trichocephalus has been found postmortem in many subjects dying with various diseases, as typhoid fever (Flint), meningitis (Barth), profound anemia (Osier), and beri-beri. Propagation is effected by the microscopic eggs, Avhich are ovoid, hard, nodular, brownish, and about 0.05 mm. (^ in.) in length. 1238 ANIMAL PARASITIC DISEASES'. Symptoms.—It is not certain that the parasite causes any symptoms, nor even that it aggravates those of an associated disease (vide supra). When occurring in great numbers the possibility of fecal accumulation may be mentioned. The diagnosis may be made by microscopy. The ova may be de- tected in the feces. The prognosis and treatment are not called for. ANKYLOSTOMIASIS. Ankylostomum Duodenale (Dochmius duodenal is).—Natural History.—This parasite belongs to the family of strongylida? of the nematoid worms. It Avas discovered in Milan, in 1838, by Dubini. The length of the female is from 8 to 18 mm. (|- inch), and of the male from 6 to 10 mm. (1 inch). Its body is thread-like, with a conical- shaped head, and a large, bell-shaped mouth surrounded by a horny capsule, and possessing four hook-like teeth, ventrally situated, and two smaller, vertical teeth on the dorsal side, by which the worm fixes itself to the mucous membrane. A bulbous-like SAvelling exists at the tail end of the male worm. It inhabits the jejunum and duodenum. The eggs are found in muddy water, and there liberate the embryos. These de- velop into larvae, which, Avhen taken into the human bowel through drinking-Avater develop into mature Avorms. Since the ankylostoma do not multiply within the intestine, " the number there present corresponds to the number of embryos which have been swallowed " (Flint). Pathology.—The ankylostomum is nourished by the blood it sucks from the intestinal vessels. It is found postmortem, sometimes, in the mucous or even submucous coat, rolled up in a little blood-cavity. Ec- chymoses, containing a central opening through which blood can ooze, are the usual result of the Avorm's action. Chronic catarrhal enteritis is usually associated. Hypertrophic dilatation of the heart is seen quite frequently, and the blood is notably deficient in corpuscular richness. Symptoms.—The chief symptom of the condition is anemia (second- ary). When the number of ankylostoma embryos introduced into the intestine is large, the anemia may develop acutely; Avhen but a feAv are introduced, the withdrawal of blood is more gradual, and chronic anemia develops. I think, however, it may be safely affirmed that the anemia is not wholly due to blood-sucking. In some cases the impoverishment of the blood has been so profound as to simulate closely a pernicious anemia. This parasite has been found to be the cause of the disease known as ^'Egyptian chlorosis," first described by Griesinger. Ankylostomiasis is not uncommon in tropical countries (Italy, Brazil). In Italy it has been termed tunnel or mountain anemia; in Belgium it is known as brickmaker's anemia ; again, it occurs among workers in coal-mines— miner s cachexia. In this country it is rare, though alleged to have been seen in the Southern States. The importation of infected Italian, Hungarian, and Polish laborers may, at some future time, cause the propagation of the ankylostoma parasite in the United States. The anemia of ankylostomiasis is progressive, and it is noteAvorthy that no or-ganic cause for it can be discovered. There may be in addition, TRICHINIASIS. 1239 slight gastro-intestinal disorder (anorexia, colicky pains, nausea and vomiting, and constipation alternating with diarrhea). In cases marked by an acute development of anemia considerable general weakness, dyspnea and sometimes dropsy may ensue. The areas of the apical cardiac impulse and of cardiac dulness are increased doAvmvard and laterally. Various murmurs—hemic—may be heard, and the pulmonic sound may be accentuated (vide Pernicious Anemia, p. 429). Diagnosis.—This is made by finding the eggs or mature Avorms in the feces. The former are oval-shaped, about 0.05 mm. (^^ inch) in length, and have a much thinner shell than the ova of the round-worm. They do not segment except Avithin the intestine. In any case of pro- nounced anemia in which the cause is obscure the patient's dejections should be carefully examined for the ankylostoma parasite or its eggs. A diagnosis is thus easily made. Duration.—The disease may last for months or for several years. Prognosis.—If left untreated, the affection may end fatally. Intense anemia, obstinate diarrhea, and profound nutritive disturbances consti- tute symptoms of grave import. Properly treated, the prognosis is quite favorable. A spontaneous cure may occur in some cases, by either the complete evacuation or death of the strongylus Avorm. Treatment.—Prophylactic.—Workmen in mines, tunnels, brick-yards, and in tropical localities especially, should be warned not to drink the water close at hand without previous boiling and then cooling to a wholesome and palatable degree. Medicinal.—Anthelmintics to kill the ankylostoma and purgatives to remove it from the intestine are indicated as for other intestinal parasites. The oleoresin of male fern in J- to 1-dram (2.0-4.0) doses, santonin, and thymol are very useful for the first named object. A preparation called doliarina is much used in Brazil, and is composed of the juice of the ficus doliaria, iron and aromatics (Flint). Ordinary cathartics or enemata may be needed to bring away the dead parasites, after Avhich the general state of the patient should be improved by the use of highly nourishing food, iron, and tonics. TRICHINIASIS. (Trichinosis) The parasite that gives rise to this affection is the trichina spiralis. Natural History.—The mature male worm is 0.8 to 1.5 mm. (-£$ in.) long and the female 2 to 4 mm. (TV~i in.)- Tne nead is pointed and unarmed, and the neck is long and more slender than the body, which has a round blunt end. The worm is viviparous. It inhabits the intes- tines of such animals as the rat, dog, cat, hog, and man. The embryo or muscle trichina is about 0.6 to 1 mm. (^ in.) long, and lies coiled up in a spiral form within an ovoid capsule in the sarcolemma- sheath of muscle-fiber. The life-history begins with the larval state of the trichina encysted in the muscles. When this flesh is eaten by another animal, or by man, the larvae are liberated during the digestive process. Passing into the intestines, they reach the adult stage in from two to four days, being then sexually mature, and in five to seven days more they produce hundreds of living embryos. 1240 ANIMAL PARASITIC DISEASES. The intestinal trichina? become fully grown, and then usually die in from four to five weeks. The female trichina may bring forth several broods of embryos during her life-period in the intestine. The living embryos leave the intestine at once, and invade the muscles through various channels—principally along the connective-tissue routes—so that the symptoms of muscular irritation develop in from seven to ten days after eating the trichinous meat. The embryos'attain to maturity (larval form) in about two weeks after entering the muscular tissues. Their presence causes a mechanical irritation that results in the formation of a fibrous capsule in from four to six weeks. Usually but a single Avorm is found within one capsule, though occasionally three and four are seen. Leuckart found numbers of embryos free in the abdominal cavity of in- fected animals ; they have also been found in the mesentery. The en- capsulated trichinae may live many years in the muscles, and cases have been reported in which infection from trichinous meat occurred twenty or even thirty years before the living trichinae were found (Huber). With increasing age the capsules become thicker and may be the seat finally of calcareous infiltration. Pathology.—The diaphragm is most thickly infested Avith the larval trichinae. Next in order are such trunk-muscles as the intercostals and abdominals, then the muscles of the neck, including the larynx, head, eyes, and extremities. Up to the seventh week of the disease the intes- tinal trichinae may be very numerous, as many as a dozen being found in a drop of intestinal mucus. There may be some intestinal inflammation (catarrh) and the mesenteric glands may also be swollen and appear like those of typhoid fever. In cases that proved fatal during the second month, Cohnheim noted an abundance of fat in the liver, a granular state of the renal epithelium and of the heart-muscle, broncho-pneumonic areas (occasionally), and hypostatic pneumonia (frequently). Microscopically, the muscles show "the changes characteristic of acute myositis" (Fitz) after the fifth week. The trichinous cysts in the muscles may be seen Avith the naked eye as small, grayish-white, opaque, " oat-shaped " specks, longitudinally disposed in the meat-fibers. Sources of the Trichina.—The trichina was first found in pork— the usual source of trichiniasis in man—by the late Joseph Leidy. It should be noted that some individuals may be dangerously infested with trichinae and yet give no symptomatic evidence of the presence of the parasite. Recent investigations show that the live trichinae may be found in the fatty as well as the fleshy portion of pork. The pig is infested by eating trichinous rats, trichinous pork, or possibly human or porcine ex- crement containing the embryos of propagating intestinal trichinae. The rat may be the original host of the parasites, or it may itself become in- fected by older rodents eating their fellows, or by eating trichinous pork or human or porcine excrement voided during the stage of intestinal infection. As to the frequency of the infection of hogs, it may be said that about 2 per cent, were found to be trichinous, according to Salmon's report (1884), of nearly three hundred thousand examinations of American pork. Other examinations, however, show a variation of infection of from .05 to 6 per cent, of hogs. In Prussia, according to Eulenberg's statistics, the ratio is decidedly less varying—from 1 to 2160 hogs (1876) to 1 to TRICHINIASIS. 1241 1817 (1889). According to Osier, " the dissecting-room and postmortem statistics show that from one-half to two per cent, of all bodies contain trichinae." Of course, man, as a rule, becomes infected by eating raw or partially cooked pork containing living muscle-trichinae (larvae). The habit of indulging in raw ham and sausages, so common among the Germans of Prussia (particularly during pic-nics) and in some parts of the United States where German immigrants have settled in large numbers, explains the comparative frequency of this parasitic disease in such localities. Trichiniasis has occurred in epidemic form in North Germany, France, Spain, Russia, the Scandinavian countries, and in several of the north- western United States. Symptoms.—The fact that the postmortem examination often reveals the presence of muscle-trichinae, whereas no history of trichiniasis or of any disease resembling it has been obtainable, shows that one may eat trichinous pork containing a small number of larvae without the develop- ment of any symptoms. It is to be recollected that to the migration of the parasites the principal symptoms of trichinosis are due. In Avell-marked cases of infection gastro-intestinal disturbances appear on the second or third day after the ingestion of the infected meat. Vom- iting, diarrhea, and colicky pains in the abdomen may be present. The diarrhea sometimes takes on the characteristics of a choleraic attack or may be followed by obstinate constipation. Extreme "muscular weariness" and bodily fatigue often occur for several days before the embryonic parasites can have begun to wander into the muscles. On about the tenth to the fifteenth day, when migra- tion usually commences, chills, followed by a temperature of 101.5° to 104° (38.6° to 40° C.) and marked myositis, come on. The muscles are stiff, tense, painful on pressure and motion, and somewhat swollen. The flexors of the extremities are particularly sore and often firmly contracted, causing the knees and elbows to be acutely bent. Mastication, deglu- tition, and phonation may be difficult and painful because of the involve- ment of the muscles of the jaws, pharynx, and larynx. Intense and distressing dyspnea is frequent on account of the involvement of the dia- phragm and intestinal muscles. The temperature shows marked remis- sions in most cases, and may even be subnormal. The fever lasts from three to seven weeks. The pulse varies with the temperature. Edema is characteristic in nearly all of the cases. It appears on about the seventh day after the infection, and begins in the face, usually being noted first in the eyelids, and extending thence to the extremities and trunk during the height of the muscular symptoms. It may last for several days, then disappear for several days or a week, and reappear. Ascites even has been observed. Edema of the larynx and bronchial catarrh, the latter rarely leading to broncho-pneumonia, may also super- vene and add to the gravity of the dyspnea. Profuse sweating may last for several weeks. Miliaria, urticaria, acne, furunculosis, herpes, and pruritus may occur as skin-manifestations. Insomnia, headache, a tempo- rary loss of the tendon-reflexes, and dilatation of the pupils (Rupprecht) have been noted among the nervous symptoms. Prolonged cases show a marked degree of emaciation and anemia. Complications, as a typhoid state, hypostatic pneumonia, and pleurisy 1242 ANIMAL PARASITIC DISEASES. may appear. Albumin, with casts, and occasionally red and white cor- puscles are found in the urine. Recovery is effected in mild cases within two weeks ; in the severe cases of infection from six weeks to several months may be occupied before convalescence begins. Diagnosis.—The following symptoms are regarded as pathogno- monic : sudden swelling of the face, coming on after the patient has suffered for several days from muscular soreness; loss of appetite, fever, and profuse sweats (Bohler); painful, tender, and "rubber-like" hard- ness of the muscles, with difficulty in movement; semiflexed extremities; gastro-intestinal catarrh, with a red, dry, coated tongue; dyspnea, diar- rhea, and edema of the extremities following the subsidence of that first noticed in the face. Friedreich also emphasizes the hoarseness due to invasion of the laryngeal muscles. Meat- and sausage-poisoning may be distinguished from trichiniasis by the more rapid course of the former, and by the dry throat and skin, jaundice, visual disturbances, more marked gastro-enteritis, and the ab- sence of edema and muscular symptoms. Direct examination of the passages and of the muscles may be resorted to. The discovery of the parasites in the pork a portion of which has been eaten by the sick of course establishes the diagnosis. A low-power microscope should be used to examine the intestinal mucus for the trichinae. Light purgation should precede this endeavor. Harpooning such muscles as the biceps for the purpose of removing some muscle-fiber, or directly incising a small portion under Schleich's method of infiltration-anes- thesia, may permit of a positive diagnosis in some cases. Acute rheumatism, cholera, typhoid fever, and acute polymyositis (pseudo-trichiniasis) may at times resemble trichiniasis. Epidemics of the parasitic disease are more readily diagnosed than an isolated case. Prognosis.—This depends upon the number of parasites ingested Avith the infected meat or sausage, and upon the number of embryos gen- erated in the intestines by the matured worms. Marked early diarrhea is favorable. The prognosis should be guarded, hoAvever, in all cases, as the mortality-rate may range from 5 to 35 per cent. Death, too, often occurs as late as from the fourth to the sixth week. Treatment.—Prophylaxis is of supreme importance, both as to the infection of the hog and the danger of eating infected pork. Care should be exercised in the feeding of swine, and the destruction of rats should be made as complete as possible in and about the styes. Pig-excrement should be removed and burned, and feeding with milk, bran, grain, and vegetables should be forced upon all keepers of swine. Rigid inspection of the meat-supply, as is done in Germany, should be carried out by sanitary officers employed by the government. It is held to be an impracticable measure Avhere immense quantities of meat are handled daily to examine microscopically simply a minute fragment of pork taken from each hog slaughtered. Decidedly the safest and most efficient Avay to prevent trichinosis is to thoroughly salt, smoke, and cook the pork that is to be used. Roasting should be particularly well done, in order that the heat may effectively reach the central portions of the meat. Putrefaction does not kill the parasites. The treatment of those who have eaten trichinous meat should be by FILARIASIS. 1243 a prompt evacuation of the bowel, especially within the first twenty-four hours, as after the embryo young have been brought forth and have passed into the muscles no known treatment is successful in attacking them. Calomel is one of the best drugs, and active purgation usually follows its use in large doses, succeeded by salines; rhubarb, senna, sul- phur, aloin, and large doses of oil or glycerin may also be tried. In combination with the purgatives some anthelmintic (male fern, santonin, thymol) should be used. The encysted or larval parasites are not acces- sible to treatment, although picric acid has been recommended. The symptoms to be met are the great muscular pains, insomnia, and weak- ness, which is often severe in protracted cases. Prolonged hot baths, anodyne embrocations, Avith hypodermics occasionally, may prove useful for the first; bromids, chloralamid, and the like for the second symptom ; and a concentrated liquid diet, strychnin, peptonoids, and the like for the last. Massage, electricity, and stimulating applications, as chloroform liniment, may be required during convalescence and for some time there- after to combat the muscular weakness, soreness, and stiffness. FILARIASIS. {Filaria Sanguinis Hominis.) There are several varieties of filariae that may be found in human blood. The two principal ones are the filaria sanguinis hominis nocturna and filaria sanguinis hominis diurna. The first is a white, opaline, thread-like worm, tapering toward the ends, which latter, however, are blunt. The male is 83 mm. (3.2 inches) long; the female 155 mm. (6.1 inches). The second worm is known only in embryonic form, and is distinguished by granulations in the axis of the body. Manson found them in the blood of Congo negroes, but only during the daytime. On the other hand, the nocturnal filaria is found only at night, or, if the host be either by habit, necessity, or choice, a day-sleeper, during this time, showing, then, that there is some condition of the body during quietude that is conducive to the appearance of the filaria in the blood (blood and chyle flow, Granville). This " filarial periodicity " is a curious and strik- ing characteristic of these parasites. The embryos are produced by the female in great numbers, and are so small that they readily pass through the capillaries. According to Man- son, who, in 1877, found the larvae of filaria sanguinis hominis in the stomach of a female mosquito, it is probable that after filling itself with the blood of an infested man during sleep, the mosquito seeks stagnant water, dies, and the larvae are set free. In this way it may happen that man takes in the embryos through the drinking-water. They find a permanent seat in the lymphatics of the human host, mature, and bring forth young, which may again infest the blood by passing through the lymph-ducts into the thoracic duct and general circulation. The geographic distribution of the filaria is limited mainly to the tropics and sub-tropics. Filariasis is most common in Brazil, the West Indies, Mexico, the Southern States, Southern China, India, Egypt, a part of Australia, and the southern Pacific islands, where it is quite endemic. The Symptoms of filariasis are in abeyance until some obstruction 1244 ANIMAL PARASITIC DISEASES. of the lymph-channels is caused by the parasite. There are several con- ditions or endemic diseases produced. Elephantiasis arabum is believed by Manson to be the effect of these parasites in a certain proportion of cases at least. In specimens of night-blood from 88 Cochin Chinese he s^m Fig. 77.—The movement of a single filaria during a series of four successive instantaneous exposures. The length of each exposure was one-fifth of a second, the entire series occupying less than five seconds. The magnification is to eight hundred diameters, with a Zeiss one-twelfth homoge- neous immersion lens (F. P. Henry). Fig. 78.—Filaria alive in the blood. Instantaneous photomi- crograph. Four hundred diam- eters magnification. • Four milli- meters Zeiss apochromatic (F. P. Henry). found filariae in 21; 14 specimens came from patients with elephantiasis, and only 1 showed filariae. This latter fact, he explains, is to be expected, since, in order to give rise to elephantiasis (due to an infarction of the lymphatic glands connected with the diseased areas), the adult filariae must lie on the distal side of the glands, which makes it impossible for the young filariae to pass into the general circulation. " Therefore the person least likely, in a filarial district, to have filariae in his blood is one who is the subject of elephantiasis."1 Hematochyluria and Chyluria.—The patient passes a white, opaque, milky urine, occasionally bloody, with a clotty sediment. This may be intermittent, and normal urine may be passed for many weeks before chyluria or hematochyluria reappears. There may be at the same time a slight degree of polyuria. Under the microscope, fat granules and white and red corpuscles are seen. The lively, wriggling embryo filariae may also be discovered in the urine, as well as in the blood at night. There is a dilatation of the lymph-vessels in the kidneys alongside of the tubules, and in the abdominal lymph-plexuses. Sometimes a little vesical irritation and straining during urination may be caused by the endeavor to pass chylous blood-clots. The thoracic duct above the diaphragm has been found impervious (Stephen Mackenzie). 1 British Med. Jour., June 2, 1894. DRACONTIASIS. 1245 Lymph-scrotum and lymph-vulva have been caused by the filariae. The parts are greatly swollen, thickened, and contain distended lymphatics filled with a turbid and either milk-Avhite, salmon-colored, or blood-red coagulable liquid that is discharged upon puncturing the varices. The filaria is not always found in the exuded lymph. The inguinal and femoral regions are often enlarged and doughy. An erysipelatous inflam- mation of the parts is not infrequent in these cases, and may be ushered in by a chill and high fever, lasting a day or two, and ending with a pro- fuse sweat. The filariae have also been found in a case of ascites (Winckel), in one of hemoptysis (Yamane, Japan), and, by the same observer, they were found in the feces (chylous diarrhea). Treatment.—Prophylaxis in regard to the drinking-water is essen- tial in order to avoid filariasis. Filtering, boiling, and storing the water in mosquito-proof receptacles is sufficient. Thymol in from 1- to 5-grain (0.0648-0.324) doses, given for from two to eight weeks, has caused the disappearance of the larval filariae in several cases. Methylene-blue appears also to have produced a cure in a case of chyluria reported by Flint, although Laveran and Henry believe that it is of little value. The latter states that he has " given this drug in larger doses than were used in the case reported by Flint, and for a much longer period, with- out the slightest effect upon the parasite."1 The adult filaria seems to be beyond the reach of any knoAvn medication that will not prove dangerous, either directly or indirectly, to its human host. DRACONTIASIS. (Guinea-worm Disease.) The parasite is the filaria or dracuneulus medinensis or persarum, common in the tropics of Asia, Africa, and America. It is only recently that the male guinea-worm has been found. It is usually solitary, and measures from 50 to 100 cm. (20 to 40 in.) in length and about 2 mm. (-jlj in.) in diameter. It is cylindric, whitish, with blunt papillated head, and a sharp, curved tail. The body is nearly filled by the uterus, Avhich contains innumerable embryos. The live young dracuneulus escapes from the intestines of an infested man, ox, horse, dog, or jackal, enters the body of a cyclops or small cray-fish, and there becomes a fully-devel- oped larva. It is then taken into the stomach and intestines of man through the contaminated drinking-water. The female enters the intes- tines by way of the mesentery, and the male worm, after fulfilling its sexual functions there, probably dies, while the female brings forth its young, which pass into the connective tissues of its human host. The worm has an inexplicable affinity for the subcutaneous and intermuscular tissues of the feet and legs, where it attains full development. Symptoms.—Wherever the parasite is situated, it may often be felt coiled up under the skin, which at that point becomes red, sore, and fluc- tuating like an abscess. When opened, either surgically or naturally by the worm, the head appears through the aperture. The favorite spot for perforation is the dorsum of the foot, though sometimes it extrudes from 1 Med. News, May 2, 1896. 1246 ANIMAL PARASITIC DISEASES. the legs, occasionally from the thighs, and very rarely from the thorax and abdomen. Treatment.—Prophylaxis in regard to the drinking-water and as to bathing where the intermediary host of the dracuneulus—the cyclops— has its habitat is essential for safety. The active treatment embraces the surgical measures necessary to re- move the worm entire and to promote the healing of the irritated tissues. The burrow should be opened, and the worm gradually coiled around a quill or a smooth, cylindric piece of wood until it can be withdrawn with- out being torn and allowing any embryos to escape into the tissues. Roth claims that after incision the application of compresses of carbolic acid (1 to 15) over the wound causes the worm to be removed in two or three days. Native Indian physicians commend highly the local application of the leaves of the " amarpattee " plant. Asafetida and sulphur have been recommended internally, but without any definite result. OTHER PILARIS. Among other filariae that have been found in man are the following: The filaria immitis, which causes hematuria and has been found in the por- tal vein, whilst the ova were discovered in the ureteral and vesical walls; filaria labialis, found in a lip pustule; filaria lentis, found in a cataract; filaria trachealis and bronchialis, seen in the trachea, bronchioles, and lungs ; filaria hominis oris, observed by Leidy in the mouth of a child; filaria loa, noticed in the tropics among negroes, its habitat being beneath the conjunctiva. OTHER AND UNCOMMON NEMATODES. Eustrongylus Gigas.—This parasite is exceedingly rare in man, but has been found in many of the carnivora and in some herbivora. It is supposed that fish act as the intermediate host for the larvae. The worm is enormous in size, the female being from 25 to 100 cm. (10 to 40 in.) in length and from 5 to 12 mm. (1 to 1 in.) long. It is a red, cylindric parasite with blunt-pointed ends. Its most common seat is the kidney, Avhich it may destroy, causing hematuria and, perhaps, the presence of the eustrongylus ova. Strongylus paradoxus has been found in the respiratory organs of the pig and in the dejecta of a pork-dealer. Anguillula stercoralis or intestinalis occurs in the stools of certain tropical endemic diarrheas. The parasites are oviparous, and the eggs may be taken through the drinking-water. They have been found in the biliary and pancreatic ducts, as well as in various parts of the intestines. Boiling the water as a prophylactic measure and the administration of thymol or male-fern are to be recommended. Echinorhyncus gigas belongs to the Acanthocephala (thorn-headed worms) and infests the intestines of the pig. The larval host is the cockchafer or floral beetle grub. In the only case reported, that of a boy (Lambl), a small echinorhyncus was found in the intestines. Echinorhyncus moniliformis occurs in rats, and one case, that of a Sicilian, has been reported by Calandruccio, in which the ova were found ECHINOCOCCUS DISEASE. 1247 in the feces. The larval host is probably the Blaps micronata. The ethereal extract of male-fern causes the expulsion of the parasite. OESTODES. ECHINOCOCCUS DISEASE. (Hydatid or Bladder-worm Disease.) The taenia echinococcus is also called tcenia nana by Van Beneden, but should not be confounded with the tenia nana of v. Siebold, a brief de- scription of which follows this article. It is the smallest tape-worm of our domestic animals, and lives between the villi in the small intestine, especially in the larger breeds of dogs, as the mastiff and Newfoundland. It has a length of from 4 to 9 mm. (| to £ in.), and consists of only three or four sections, the last one of which is mature. The rostellum project- ing from the small head has thirty or forty hooklets arranged in a double row. Hundreds and sometimes thousands of eggs are contained in the mature segment. The intermediary hosts for the larvae are rarely man, the horse, and the sheep, and more often the hog and ox. I/ife History.—The ova, embryos, or the proglottides even, of the adult tenia are voided by the dog, and in various ways, to be pointed out later, are ingested by man. The dog first becomes infected by eating the bladders or echinococcus cysts of some animal that harbors the larval form of the tenia, and the matured teniae appear in from eight to ten weeks. The liberated six-hooked embryos burrow through the intestinal Avail or enter the portal vein; they then pass into the solid viscera, as the liver, into the peritoneal cavity, the muscles, lungs, brain, etc. There they develop into the larval form and cause the formation of hydatid or echinococcus cysts. During the latter process the hooklets disappear. In the development of echinococcus cysts, about four weeks after the ingestion of the bladder-worm eggs, small nodules appear, about 1 mm. (2*5- in.) in size. In about five months the cyst-walls consist of two layers, an external layer and an inner, granular, parenchymatous layer (or endocyst), containing a clear liquid. As the reaction to the irritation caused by the parasite and its cyst increases, a fibrous investment forms around them. At this time, also, small daughter-cysts, or vesicular buds, form the minor granular layer of the mother-cyst, and contain the heads of the larvae. They are soon set free, and may themselves give rise to other or granddaughter-cysts in a similar way. These really become the breeding capsules of little cellular outgrowths that form the scolices or heads of future teniae. They show the four sucking disks and a circle of hooklets. Each scolex, when taken into the intestine of the dog, de- velops into an adult bladder-worm or taenia echinococcus. This endogenous mode of cystic growth is common in man (E. hydatidosus); but in some of the lower animals, and rarely in man, the daughter- and grand- daughter-cysts may develop between the two layers of the primary or mother-cyst, and then extrude (exogenous variety; E. granulosus). A third variety is the multilocular echinococcus (E. alveolaris, Buhl), 1248 ANIMAL PARASITIC DISEASES. affecting principally the liver. A large, hard tumor is seen that on sec- tion shows a firm connective-tissue framework surrounding alveoli that average a small pea in size. These alveoli contain small echinococcus cysts Avith thick, laminated Avails. They may contain scolices or hooklets, and sometimes they are quite sterile. The echinococci may be situated in the lymph-channels and bile-ducts (Zenker). The pure hydatid fluid is colorless, odorless, limpid, neutral in reaction, and has a specific gravity of 1005 to 1012. About 96 to 98 per cent, is water, and sodium chlorid, carbonate, and sulphate, traces of sugar (dextrose), and uric acid are found among the constituents. Among the changes that an echinococcus cyst may undergo the com- monest is that of the death of the echinococci, as from diminished nour- ishment due to intense proliferation of daughter- and granddaughter- cysts. The contents become thickened, putty-like, or granular, and even calcified. Remnants of these obsolete cysts, such as the chitinous sub- stance of the old and outer wall-layer and hooklets, may be found. Traumatism or chemical irritation may also cause the death of the echinococcus and obliteration of the cysts. Sometimes rupture of the cyst occurs, with serious consequences to the patient; on the perito- neum daughter-cysts or free scolices may be disseminated and grow. Or perforation into the respiratory, digestive, or urinary tracts and dis- charge of daughter-cysts and hydatid fluid may take place. Lastly, sup- puration and the formation of large hepatic abscesses may ensue, either spontaneously or on account of septic instruments used for tapping the cysts. Htiology. —Carelessness in the feeding and the keeping of dogs is the primary source of hydatid disease, and the preparing of food where dogs are allowed to roam about, to be petted, and so on, accounts for the majority of cases. Females are more often affected than males, and .chil- dren and young adults seem to be oftener affected than those older in years. As regards the geographic distribution, echinococcus disease prevails most extensively in Iceland, where man and dog live closely together. In Australia, also, many persons are affected. It is not so common in Europe, Asia, or Africa, and in America it is rare. Organs Affected.—The tenia echinococcus has an undoubted predi- lection for the liver. Next in order of frequency are the lungs, intes- tines, perhaps the urinary organs, brain, and spinal cord. The spleen, bones, muscles, the heart, and blood-vessels are involved with uncertain frequency. Symptoms.—Hydatids of the Liver.—Unless the cystic tumors com- press the portal area or the biliary passages, or invade the neighboring viscera, subjective symptoms may be entirely wanting. Not infrequently echinococcus sacs, partly calcified, have been found postmortem, not having produced any symptoms during life. Gradual but progressive loss of flesh and strength with the presence of a fluctuating tumor may be the only symptoms present until late in the disease. If the cysts attain a large size, a sensation of dragging, and of pain even, is often present; as a rule, however, pain is absent throughout the course of the disease. If the tumor displaces the diaphragm upward and compresses the lung, cough and dyspnea result. In some cases the sac has ruptured ECHINOCOCCUS DISEASE. 1249 into the bronchi, and given rise to cough and to expectoration of the fluid and vesicles. If the portal veins and bile-duct are compressed, splenic enlargement from passive congestion, ascites, and jaundice Avill occur, these symptoms being more common when the cysts are multilocular. Rupture may occur into the intestines (colon), into the pleura or pericardium, causing pyothorax or pyo-pericardium, or into the inferior vena cava, causing fatal pulmonary embolism. Fever is usually absent throughout, unless the contents of the sac become converted into an abscess; then rigors or chills, fever (hectic in type), and sweatings occur, with jaundice (more or less intense) and rapid emaciation. Not infrequently the cyst-wall becomes partly calcified and the con- tents are reabsorbed, with an entire absence of symptoms, the patient dying in after years of some intercurrent disease. When rupture occurs, unless the contents be evacuated through the respiratory or alimentary tract or externally, symptoms of collapse develop and are followed by death. The physical signs give on inspection fulness or bulging in the right hypochondriac region, especially if the cyst be single, of large size, and situated anteriorly. Palpation confirms inspection and shows a fluctuating mass or masses. A trembling impulse is felt sometimes on deep palpation, aided by light percussion over the opposite side of the cyst, constituting the so-called " hydatid thrill." This sign cannot always be elicited, but Avhen present is pathognomonic of the disease. The remainder of the liver shows uni- form enlargement. The spleen is often palpably increased in size from passive congestion. Percussion reveals, in addition to the hydatid fremitus, an increased area of dulness to the left or posteriorly, depending on the location and extent of the growths. If the left lobe be involved, the line of flatness may extend across the sternum to the left hypochondriac region. If the cysts are multiple and on the antero-inferior surface, the stomach may be displaced toward the left and dulness may extend across the epigastrium; if posteriorly, the pleural cavity may be encroached upon, causing an increased area of flatness upward in the postero-axillary line. Frerichs claims the line of dulness posteriorly in hydatid disease to be a curved one, whose convexity is upward. Auscultation gives, according to Santoni and others, a short sharp booming sound when the tumor is percussed, that may be likened to one nroduced by striking a membrane stretched over a metallic frame. Diagnosis.—In the entire absence of subjective symptoms and of characteristic physical signs, the diagnosis is impossible. If, however, the cyst be of sufficient size to give fluctuation and the liver be irregu- larly enlarged, with an absence of fever, pain, and marked emaciation, the disease may be strongly suspected. The only certain demonstration of the condition is the discovery of the characteristic hooklets in the as- pirated or discharging contents of the cyst. Among the conditions that may be misdiagnosed for hydatid disease are—(a) Dilatation of the gall- bladder, (b) hydronephrosis, (