STUDENTS' AIDS SERIES 
AIDS 
TO 
MEDICINE 
Part I (double part) 
HE GENERAL DISEASES, DISEASES 
OF THE LUNGS, HEART, BLOOD- 
VESSELS, AND LIVER 
BY 
C. E. ARMAND SEMPLE 
B.A., MB., Cantab.; L.S.A., M.R.C.P., Lond 
NEW YORK 
G. P. PUTNAM'S SONS 
27 & 29 WEST 23D STREET 
1883 
Robert Beall, 
Bookseller and Stationer, 
495 Pennsylvania Ave., 
WASHINGTON, D. C. Recent Medical Publications. 
Mann. A Manual of Prescription Writing. By 
Matthew D. Mann, M. D., Lecturer on Special Therapeu- 
tics in the College of Physicians, N.Y. i6mo, cloth, . 90 
A text-book containing clear and concise directions for correctly com- 
posing and writing prescriptions. Besides the rules for grammatical 
construction, this book contains a list of doses expressed in both the 
Apothecaries' and Metric systems ; a full account of the method of using 
the Metric system ; directions for correctly composing extemporaneous 
formulae of all the various kinds, and lists of the officinal preparations. 
Jacobi. The Question of Rest for Women during 
Menstruation. Being the Boylston Prize Essay of Harvard 
University, for 1876. By Mary Putnam Jacobi, M. D.,. 
Professor of Materia-Medica in the Women's Medical College, • 
N. Y. 8vo, cloth. With Sphygmographic Traces showing 
variations in Arterial Tension, and Tables giving results of 
850 Urea Analyses of Urine. Third Edition. 8vo, cloth, 
illustrated, . . . . . . . . . 2 50 
" Based on a wide range of observation, experiment and new sta- 
tistics, the accomplished author subjects her material to a searching 
analysis, and brings forward a series of original propositions regarding 
the sexual accidents of women, admirably stated and ably defended."- 
Phila. Medical b* Surgical Reporter. 
Otis. Stricture of the Male Urethra; its Radical- 
Cure. By Fessenden N. Otis, M.D., Professor of Genito- 
urinary Diseases in the College of Physicians and Surgeons; 
Surgeon to Charity Hospital, and President of the Medical 
Board, Octavo, very fully illustrated, . . . . 3 00 
" Gives the results of a very large experience. * * * the au- 
thor's views arc substantiated by facts and tests that cannot be gain- . 
said * * * and which must yield good fruit. He contends that 
stricture can be radically cured * * * should be studied by every 
practitioner engaged in this department."-N. P. Medical Record. 1 
Pott's Disease ; its Pathology and Mechanical Treat- 
ment. With remarks on rotary lateral curvature. By New- 
ton N. Shaffer, M.D., Surgeon in charge of the New York 
Orthopaedic Dispensary ; Orthopaedic Surgeon to St. Luke's 
Hospital. 8vo, cloth extra, 1 00 
G. P. PUTNAM'S SONS, 27 & 29 W. 23d St., N.Y. AIDS TO MEDICINE 
PART I. (DOUBLE PART) 
THE GENERAL DISEASES, DISEASES 
OF THE LUNGS, HEART, BLOOD- 
VESSELS AND LIVER 
BY 
C. E. ARMAND SEMPLE 
B.A., M.B., CANTAB. ; L.S.A., M.R.C.P., LOND. ; PHYSICIAN, NORTH EASTERN HOSPITAL 
FOR CHILDREN, HACKNEY ; PHYSICIAN TO THE ROYAL SOCIETY OF MUSICIANS ; 
LATE MEDICAL CLINICAL ASSISTANT AND SURGICAL REGISTRAR AT THE 
LONDON HOSPITAL ; LATE SENIOP. EXAMINER IN ABTS AT APOTHECARIES' 
hall; AUTHOR OF "AIDS TO CHEMISTRY (INORGANIC AND 
ORGANIC)," "AIDS TO BOTANY," "AIDS TO MATERIA 
MEDIOA AND THERAPEUTICS (INORGANIC AND 
ORGANIC)," "TABLETS OF MATERIA 
MEDIOA (ORGANIC)." 
NEW YORK 
G. P. PUTNAM'S SONS 
27 and 29 West 23d Street 
1882 PREFACE. 
The present volume is merely intended as an outline, 
or rather skeleton, of the subject with which it presumes 
to deal. 
The following pages really consist of an abstract of 
lectures delivered, during many years past, to pupils 
preparing for the Royal College of Physicians, the 
Apothecaries' Hall, and other medical examinations, 
and are published at the suggestion and request of 
numerous students. 
In preparing this, the second edition of 'Aids to 
Medicine,' Part I., the work has been very carefully 
revised, almost entirely re-written, and considerably 
extended; but, of course, in so limited a space it has 
only been possible to select the most important facts, 
to the exclusion of many matters of detail and theory. 
Inter alia, the following are the contents of the suc- 
ceeding parts of ' Aids to Medicine,' viz. : 
In Part II., The Pathology of the Urine, the Dis- 
eases of the Kidneys, Stomach and Throat. 
In Part III., The Nervous System. VI 
In Part IV. will be found, the Fevers, Skin Diseases, 
Worms, etc. 
It is hoped that the work will prove useful as an 
introduction to the study of the Practice of Medicine, 
and be found serviceable as a refresher to the memory 
after the large manuals have been carefully gone 
through. 
ARMAND SEMPLE. 
8, Torrington Square, W.C., 
October, 1882. TABLE OF CONTENTS. 
Inflammation, Phlogosis. 
Dropsy, Hydrops, Anasarca. 
Hyperaemia. 
Anaemia. 
Chlorosis. 
Cancer, Carcinoma. 
Sarcomata. 
Amyloid Degeneration. 
Tubercle. 
Scrofula. 
Rickets, Rachitis. 
GENERAL DISEASES. 
Fatty Degeneration. 
Atheroma. 
Calcareous Degeneration. 
Rheumatism. 
Gout. 
Leucocythemia, Leukaemia. 
Scurvy, Scorbutus. 
Purpura. 
Haematophilia. 
Syphilis. 
Erysipelas. 
DISEASES OF THE LUNGS. 
Bronchitis. 
Emphysema. 
Asthma. 
Pneumonia. 
Pleurisy. 
Phthisis. 
Pulmonary Apoplexy. 
Cancer. 
DISEASES OF THE HEART. 
Organic Diseases. 
Fatty Degeneration. 
Myocarditis. 
Cancer. 
Tubercle. 
Pericarditis. 
Endocarditis. 
Hypertrophy. 
Dilatation. 
Cyanosis. 
Inorganic or Functional Diseases. 
Palpitation. 
Syncope. 
Angina Pectoris. DISEASES OF THE BLOOD VESSELS. 
VIII 
Thrombosis. 
Embolism. 
Aneurism* 
DISEASES OF THE LIVER. 
Congestion. 
Hepatitis. 
Hepatic Abscess. 
Hypertrophy. 
Acute Yellow Atrophy. 
Cirrhosis. 
Hydatids. 
Cancer. 
Fatty Disease. 
Lardaceous Disease. 
Tubercular Disease. 
Syphilitic Disease. 
INFLAMMATION OF THE BILIARY PASSAGES. 
Jaundice. 
Hepatic Colic. 
Gall-Stones. 
Haematemesis. 
Haemoptysis. AIDS TO MEDICINE. 
GENERAL DISEASES. 
INFLAMMATION (in, in, and flamma, a flame). 
PHLOGOSIS (pAoywo7j, a burning). 
Varieties.-(1) Acute; (2) Chronic. 
ACUTE INFLAMMATION. 
Symptoms.-(1) Local. 
(2) Constitutional or General. 
Local Symptoms. -When External, these are pain, 
swelling, redness, and heat. The pain is produced by 
the pressure on the nerves by the surrounding swollen 
textures; the swelling and redness arise, the latter from 
the increased amount of red blood which the vessels of 
the part contain, the former from the same cause, and 
from the exudation of serum, lymph and leucocytes 
from the blood; it is further increased by the enlarge- 
ment and proliferation of these leucocytes, and of the 
connective tissue corpuscles and other cellular elements 
of the inflamed tissue. The heat never exceeds that of 
the blood, although it is greater than that of the other 
superficial and unaffected parts. 
1 2 
Wh en Internal, the symptoms are functional disturb- 
ance and pain; the former symptom is indicated in 
secreting organs by alteration, increase, diminution, or 
entire suppression of the proper secretions; in other 
organs there are varying conditions of excitement: in 
the lungs there is dyspnoea ; in the ear and eye, intoler- 
ance of light and sound ; in the heart, palpitation; in 
the brain, delirium. The pain is increased by pressure 
in those situations where pressure can be applied, or in 
milder forms of inflammation, pressure may produce pain 
in parts where it did not previously exist. 
Constitutional or General Symptoms.-These are 
known collectively under the name of Inflammatory 
Fever. They include thirst, furred tongue, pain in the 
limbs, back, and head, rigors, languor, and loss of appe- 
tite. The pulse is full, rapid or hard-its character, 
however, differing in different inflammations, being wiry 
(hard, small, and rapid) in serous inflammations and 
usually full and bounding in those of mucous and 
parenchymatous structures-the skin is dry, the urine 
scanty and high-coloured, and there is constipation. 
The blood when drawn, is, in certain inflammations, 
buffed and cupped, i.e., concave with a buff-coloured 
coating. When the inflammation occurs in unhealthy 
persons, or when it is severe and extensive, serious 
symptoms of constitutional irritation are induced, viz., 
great restlessness, rigors, hurried respiration, a sharp 
quick pulse, and low muttering delirium; death may 
occur from exhaustion. 
Terminations.-(1) Resolution or cure; (2) Meta- 
stasis or change of seat; (3) Effusion of serum; 
(4) Effusion of lymph; (5) Suppuration or formation 
of pus ; (6) Ulceration; (7) Gangrene, mortification or 
sphacelus. 3 
Causes.-The sanguine temperament, general weak- 
ness, febrile and cachectic conditions (especially the 
scrofulous), are said to predispose, while as exciting 
causes may be added, (1) Chemical and mechanical 
irritants ; (2) Heat and cold; (3) Morbid poisons in the 
blood ; (4) Local congestion; and (5) The excitement 
in the circulation which takes place in fevers. 
Modifications in the inflammatory character. These 
may be due to (1) The texture; and. (2) The condition 
of the system. 
(1) The Texture.-Serous membranes in acute in- 
flammation become the seat of adhesive inflammation, 
but very rarely of the suppurative; in the Mucous 
membranes inflammation gives rise to the production 
of pus, increased flow of mucus, and occasionally lymph, 
and these membranes are liable to suppuration, ulcera- 
tion, and softening, but rarely to adhesion of their sur- 
faces. The inflammation of the areolar tissue is termed 
Phlegmonous, and induces the secretion of serum, and 
frequently of lymph and pus, and it very commonly 
ends in abscess. Among Fibrous tissues, ligament and 
tendon are liable to become gangrenous, and cartilage 
may ulcerate. The parenchyma of organs may be 
softened by acute, or hardened by chronic inflammation : 
or the inflammation may end in abscess or in gangrene. 
Inflammation of the bones terminates in caries and 
necrosis. The skin resembles the mucous membranes in 
its liability to suppuration. In inflammation of the 
Serous membranes there is acute pain, there is an excess 
of fibrin in the blood, bleeding and depletory measures are 
usually well borne, and the blood is buffed and cupped, 
the heat of surface and muscular debility are increased, 
the frequency of the pulse is accompanied by hardness, 
and there is sometimes a tendency to delirium. In the 4 
Mucous membranes, on the contrary, the pain is often 
slight, bleeding and depletion are not well borne, the 
fibrin in the blood is not increased, and there is no buffed 
and cupped appearance of that fluid. A certain doubt- 
ful resemblance may be observed, however, between 
the mucous and serous membranes in the formation of 
those false membranes which occur in diphtheria and 
some allied diseases of the mucous membrane of the 
lungs and bowels. 
The condition of the system.-In Scarlatina, the 
mucous membrane of the pharynx and of the parts in 
its vicinity is liable to ulceration. In Measles there is 
inflammation similar to that which arises in an ordinary 
cold, and this inflammation may induce effusion of 
mucus and pus in the larynx and trachea. 
In Smallpox, suppuration and gangrene frequently 
follow the inflammatory action. 
Of Acute Adhesive Inflammation the indications 
are : a strong, hard, wiry, and rapid pulse, heat of skin, 
but no giddiness or headache (unless the membranes of 
the brain are affected), no alteration in the character of 
the urine, and bleeding and depletion are well borne. 
Suppuration is indicated by sharp, agonising pain, 
sometimes by repeated rigors succeeded by heat and 
sweating (Hectic Fever). In Gangrene the pain often 
ceases suddenly ; the entire system is in a state of 
collapse; the features are sunken, there are pallor and 
cold clammy sweats, delirium, a dry brown tongue, the 
pulse is feeble, small, and rapid, and the teeth are 
covered with sordes (the Typhous or Hyperpyrexial 
state). 
Pathology.-From the artificial production of in- 5 
flnmmation in the lower animals, this process has been 
found to consist in :- 
(1) Changes in the Blood-Vessels and Circulation. 
(2) Exudation of Liquor Sanguinis, and Migration 
of White Blood Corpuscles. 
(3) Alterations in the Nutrition of the Inflamed 
Tissue. 
(1) The first results of inflammation set up by irrita- 
tion of the mesentery (a transparent tissue) is a dilatation 
of the arteries, followed by the same condition in 
the veins, and accompanied by an acceleration in the 
blood-flow, lasting for about twelve hours. Then 
follows a considerable retardation in the circulation, 
the dilatation of the vessels still continuing. During 
this retardation the leucocytes or white blood-corpuscles 
congregate in the capillaries, and cling to the sides of 
the vessels. 
(2) The blood current passing over the accumulated 
leucocytes-these by their active movements permeate 
the vascular walls, and thus enter the surrounding 
tissues. In their passage button-like elevations appear 
to spring from the outer walls of the vessel, and these 
elevations by degrees assume the form of pear-shaped 
bodies. They then become severed from the wall, and 
thus complete their passage. The red blood corpuscles 
at the same time pass through the walls of the blood- 
vessels, but in far less number, and chiefly through the 
walls of the capillaries. 
The exudation of liquor sanguinis constitutes the so- 
called Inflammatory Effusion. In this a larger amount 
of fibrin and albumen is contained than in the transuda- 
tion of simple mechanical congestion, whilst the phos- 
phates and carbonates are also in excess. The large 6 
number of cell structures contained is remarkable, tbe 
particular tissue inflamed and the severity of the in- 
flammation occasioning considerable variation in the 
nature and quality of the effusion. 
(3) The nutritive activity of the cellular elements is 
always increased ; cells which ordinarily undergo no 
change in form or movement send out processes and 
alter variously in shape. Cell-proliferation is one of the 
earliest of tbe nutritive changes. 
The process of suppuration is a frequent result of in- 
flammation, and it may be broadly stated that accord- 
ing to the intensity of the inflammation so is the abun- 
dant formation of the pus. 
Pus is essentially composed of a liquid almost iden- 
tical with liquor sanguinis, and holding cells suspended 
in it. This liquid also contains albumen, pyin, chondrin, 
fatty matters, and inorganic substances. The pus 
corpuscles closely resemble the white globules of the 
blood, but they are somewhat rougher in outline, and 
contain more nuclei, although some authors believe them 
to be identical. They are spherical, semi-transparent, 
and vary from to tsW of an inch in diameter. The 
addition of acetic acid causes the cells to swell up, 
increasing their transparency, and rendering the nuclei 
more visible. The pus corpuscles are derived either 
from the blood (leucocytes) or from the cells of the 
inflamed tissue, and the suspending liquid is undoubt- 
edly the liquor sanguinis. 
Treatment.-In Acute inflammation the remedies 
are either general or local. 
The General remedies are blood-letting, purging, 
tartarated antimony, and mercurial preparations, and 
in slight cases saline aperients are generally useful. 
The Local remedies are leeches, scarification, and cup- 7 
ping, free incisions of the parts affected, fomentations, 
poultices, and counter-irritants. Nitrate of silver and. 
perchloride of iron are much employed in the treatment 
of exposed mucous surfaces. 
CHRONIC INFLAMMATION. 
This differs from the acute form in the lower degree 
of the severity of the irritation occasioning it, and in 
the duration of its action being in general much mere 
prolonged. The exudation of liquor sanguinis and 
blood corpuscles is not so abundant, and the tendency 
is eventually to produce an increase of the connective 
tissue in the part; the redness is more dusky in tint, 
the pain is sometimes very slight, and the heat of a 
mild character-an exception to this is, however, ob- 
served in the painful joints of chronic rheumatism. 
When the internal parts are affected, the secretions are 
performed languidly, and the quantity of the secretion 
is diminished. Should the areolar tissue be the seat, 
serous effusions are the usual result. 
When inflammation is the result of an injury, it is 
termed Traumatic; when it is due to septic influences, 
as in pyaemia and tuberculosis, it is called Infective; 
when the cause is not apparent, the name of Idiopathic 
is given; and as Specific inflammations may be instanced 
the " rash " of small-pox, the inflammation of the skin 
and mucous membranes in syphilis, and the inflamma- 
tion of the intestinal structures in typhoid fever. 
In the Treatment of Chronic inflammation, local 
remedies are chiefly of use. These may comprise leeches 
and cupping, or such alteratives as iodine, etc., but 
internal remedies, as tonics and cod-liver oil, are also 
very beneficial. 8 
DROPSY. HYDROPS (u^w^z water). 
ANASARCA (ava through aa^ the flesh). 
Definition.-Effusion of serum in the areolar tissue, 
and sometimes into serous cavities. 
Local effusions into the areolar tissue are known by 
the term (Edema, whilst to effusions into the different 
cavities of the body the following names are applied, viz.: 
Hydrocephalus (effusion in the head). 
Hydrothorax (effusion in the pleura). 
Hydropericardium (effusion in the pericardium). 
Ascites (effusion into the peritoneum). 
Hydrocele (effusion in the tunica vaginalis). 
Varieties.-(1) The Dropsy of Debility; (2) Febrile; 
(3) Renal; and (4) Conditions producing obstruction 
to the return of blood through the veins, such as is 
observed in certain cardiac, hepatic and pulmonary 
affections. 
Symptoms of Anasarca.-The first indications are 
usually a swelling of the feet and ankles, or of the 
face, the site varying with the cause. The parts affected 
pit on pressure. The skin is cold, dry, and pallid, and 
if there be much effusion the surface is tense and 
shining. After a time the effusion oozes at different 
points, and the surrounding skin becomes excoriated, 
or small blisters are formed, and sloughing may take 
place. 
Causes and Diagnosis.-Purely local dropsy may 
depend upon mechanical obstruction of some large 
vein ; thus the pressure of a tumour upon the descend- 
ing vena cava may produce oedema of the head, neck, 
and upper extremities. The dropsy of debility may 9 
be recognised by the absence of the causes of other 
forms of dropsy. 
Febrile dropsy may be known by the history of 
previous exposure to cold. 
Pulmonary dropsy may supervene upon acute bron- 
chitis, or when the lung has become solidified by 
tubercle or cancer. 
Cardiac dropsy commences in the feet, and may be 
caused by disease of the valves of the heart, inducing 
regurgitation of blood and the consequent congestion of 
the venous system by the obstruction of the venous 
blood in its passage to the lungs. 
Renal dropsy commences in the face, and can be 
recognised by the condition of the urine, and the 
absence of serious pulmonary and cardiac symptoms. 
The Treatment will, of course, depend upon the 
particular dropsy, and will be described in its appro- 
priate place. 
HYPEREMIA (^f, excess, al/xa, blood). 
Definition.-An excess of blood in the system. 
Divisions.-(1) General. (2) Local (congestions). 
Symptoms.-A general florid appearance, with in- 
jection of the capillaries of the surface of the body. 
The lips are red, and the conjunctivae injected. The 
bowels are usually confined, the skin is dry and per- 
spiring freely on exertion, the pulse firm, full and 
bounding. In strongly marked cases the pulse may be 
irregular and the extremities cold, there may be giddi- 
ness, spots before the eyes, severe headache, and noises 
in the ears. 10 
Terminations. - Haemorrhages, local congestions, 
and inflammations; gout, cardiac hypertrophy, and 
apoplexy. 
Causes.-A certain configuration of the body, a short 
neck and large chest, excessive indulgence in eating and 
drinking, sedentary habits ; in women the suppression 
of the catamenia. 
Varieties of Local Hyperaemia are : 
(1.) Active or Arterial, in which the arteries are 
dilated, a greater supply of blood being thus distri- 
buted through the parts, and so forming an important 
element in the commencement of sthenic inflamma- 
tions. 
(2.) Passive or Capillary.-Here the capillaries are 
chiefly involved ; a condition leading to atrophic and 
degenerative changes in tissues which may become the 
seat of asthenic and chronic inflammations. 
(3.) Mechanical or Venous.-In this form there is 
no excessive supply of blood, but merely a difficulty in 
the escape of this fluid. 
Treatment.-A spare diet and regular exercise, 
together with the frequent use of saline aperients, as the 
sulphates of soda and magnesia, and also occasionally of 
calomel and colocynth ; bleeding in some form may also 
be found of service, and indeed in some cases is abso- 
lutely necessary. 
ANEMIA (ay priv. blood). 
Definition.-A diminution in the amount of blood 
in the system, or rather of its red particles. 
Varieties.-(1) Anaemia induced by the direct loss 
of blood; (2) Chronic Anaemia; (3) Chlorosis. 11 
Symptoms.-The first variety may bo well illustrated 
by the condition called Syncope ; in this there are 
giddiness, loss of consciousness, the pulse and heart- 
beats are hardly perceptible; the surface is covered 
with perspiration ; there is extreme pallor of the gums, 
face, lips, and skin. 
Chronic Anaemia comes on gradually, lasts for a 
considerable time, and is produced by diminution of 
the red corpuscles. The skin, gums, lining membrane 
of the mouth, and the conjunctivae, are universally 
pale. The extremities are cold, and fainting fits are 
not uncommon. The pulse is small and quick, and 
there is palpitation upon the least exertion. The 
slightest noise produces agitation, and depression of 
spirits is a common symptom. 
Upon auscultation over the large veins of the neck, 
a venous murmur (bruit de diable) may frequently be 
heard, and by slight pressure upon the large arteries a 
blowing sound or bruit de soufflet is produced : this is 
of variable intensity, and may be either soft or harsh. 
Causes of Chronic Anaemia.-This disease is of rare 
occurrence in the male sex, and is generally caused by 
overwork, or working in dark or ill-ventilated rooms. 
It is usually connected in females with disturbances in 
the function of menstruation. 
Treatment.-Generous diet, outdoor exercise, change 
of air, and the employment of chalybeate waters ; but 
of chief importance is the exhibition of the various 
preparations of iron. For the anaemia connected with 
amenorrhoea aloetic purgatives combined with iron are 
chiefly to be relied upon. 12 
CHLOROSIS, or GREEN SICKNESS (x? green), 
is almost peculiar to the female sex, and is characterised 
by a peculiar greenish-yellow colour of the skin. The 
least exertion produces fatigue, the heart palpitates, the 
breath is short, there is pain in the back and loins, the 
breath is offensive, and the bowels are disordered ; a 
peculiar depravity of the appetite is not uncommon, the 
usual food being rejected, and chalk, and lime, and other 
similar substances are greedily eaten. Hysteria and 
Amenorrhoea are common accompaniments. 
The Treatment will be the same as that of Chronic 
Anaemia. 
A Progressive Pernicious Anaemia has been lately 
described, in which it is stated that in addition to 
the ordinary symptoms of anaemia there are pecu- 
liar changes in the blood, and a tendency to haemor- 
rhage and dropsy. It is closely associated with 
extreme cachexia, and steadily advances to a fatal 
issue. 
CARCINOMA.-CANCER (na^lvog, a crab). 
Description.-All true cancers are clinically highly 
malignant, i.e. they increase in size by infiltrating with 
cells and destroying the surrounding tissues, and tend 
to recur locally after their removal and reproduce 
themselves in the internal organs and lymphatic glands. 
Varieties.-These are four in number: 
(1) Scirrhus, Chronic or Hard. 
(2) Encephaloid, Medullary, Acute or Soft. 
(3) Epithelioma, Cancroid, or Epithelial. 
(4) Colloid, Alveolar, or Gelatiniform. 
All the cancers resemble one another in consisting of 13 
variously shaped cells, enveloped in a fibrous stroma 
without intercellular substance. The cells are large, 
and exhibit great diversity of form, being polygonal, 
round, oval, caudate, or fusiform. They vary in size 
from to j-joo of an inch in diameter, and contain 
large prominent nuclei inclosing bright nucleoli. 
There is no specific cancer-cell, since cells exactly 
similar to the above are observed in other tissues, 
normal or morbid, but their general nature, and their 
distribution in a fibrous stroma determine their cancer- 
ous character. A juice exudes from the cut surface. 
The stroma varies in amount in different forms of 
cancer; if the growth be rapid, the stroma, will con- 
tain numerous round, or fusiform cells; if it be slow, 
but few cells are exhibited, and the tissue is fibrous 
and dense. 
Blood-vessels are contained within the stroma, but 
these never encroach upon the alveoli in which the cells 
are contained. Lymphatics also accompany the blood- 
vessels, and these, communicating with the alveoli, may 
in a measure account for the tendency of cancer to 
involve the lymphatic glands. With regard to the 
development of cancer, many authors consider the 
epithelial cells to originate only from pre-existing 
epithelium, whilst others declare that they may origi- 
nate from the cells of connective tissue, or from migrated 
white corpuscles. But it appears reasonable to admit 
that both origins may be correct, and that where the 
epithelium is the source, the cells are more strictly 
epithelial, as in epithelioma, and when the connective 
tissue is the origin, the epithelial characters are less 
observable, as in Encephaloid and Scirrhus. 
The stroma is partly made up of the connective tissue 
of the seat of the cancer, and is in part a new growth. 14 
Of the Secondary Changes, fatty degeneration is the 
most important, and this always occurs in greater or 
less degree in all the cancerous varieties. Caseation, 
pigmentation, cancroid, and colloid degeneration may 
also occur, but calcification is very rare. 
The terms Osteoid, Chondroid, Cystic, Villous, aud 
Fungoid have been applied to cancers presenting certain 
peculiarities of appearance and structure, and the name 
of Melanosis, or black-pigment cancer, has been given 
to a cancer in which large quantities of pigment are 
contained. This form is most common in Encephaloid. 
SCIRRHOUS CANCER hard). 
This variety is characterised by the chronicity of its 
growth, and the large amount of its stroma. The epi- 
thelial growth quickly subsides, although at first it 
may be abundant. The stroma becomes indurated and 
contracted, and takes on the character of cicatricial 
tissue. The central portion of the growth may consist 
eventually of dense fibrous tissue, epithelial structure 
being only observed at the circumference. On section 
in scirrhus a white glistening surface is presented, with 
fibrous bands intersecting. The external portions are 
less firm than the central, and upon scraping these 
they exude a juice abounding in granules, nuclei, and 
cells. The exudation of this juice is very characteristic 
of cancer. The most common seats of scirrhus are the 
female breast and the alimentary canal, particularly 
the rectum, pylorus, and oesophagus. 
ENCEPHALOID the brain, sTdo;, like). 
This cancer differs from scirrhus in the greater rapidity 
of its growth, the smaller amount of its stroma, and its 15 
softness of consistence. There are all intermediate 
stages between scirrhus and encephaloid, so that these 
can hardly be considered as distinct varieties of cancer, 
their only distinction being the rapidity of their growth, 
and their physical characters. In encephaloid the 
epithelial growth is rapid and luxuriant, the cells soon 
becoming fatty. The stroma in proportion is very 
small, does not undergo cicatricial contraction, and is 
less fibrous than in scirrhus. Haemorrhage readily 
takes place from the abundance of the blood-vessels, 
and the softness and non-resistance of the tissues sup- 
porting them. Hence the formation of a bleeding mass 
called Fungus Haematodes. 
This form of cancer is of brain-like consistence, the 
central portions being frequently completely diffluent; 
on section a white pulpy mass is observed, often stained 
with extravasated blood. 
Encephaloid cancer occurs primarily in the articular 
ends of bones, the uterus, the testis, the eye, and else- 
where, and it is very commonly met with in internal 
organs as a secondary growth. 
EPITHELIOMA (Epithelium, tvi, upon, 
the teat). 
This form differs from the preceding in always grow- 
ing in connexion with cutaneous or mucous surfaces, 
and in its epithelial elements bearing a close resemblance 
to squamous epithelium. The cells are peculiarly ar- 
ranged, most of them being situated in irregular tubular- 
shaped lobules. As the cells increase in number they 
become grouped concentrically, forming globular masses, 
and as multiplication of the epithelium takes place, the 
peripheral cells become flattened by the pressure of the 16 
surrounding structures, the central cells remaining more 
or less spherical in shape. Thus are formed the 
epithelial nests or concentric globes, so characteristic of 
epithelioma. The stroma may be very abundant or 
wanting entirely. 
The first appearance presented by Epithelioma is as 
a foul ulcer with indurated edges, or as a sub-cutaneous 
nodule which eventually suppurates. On section of 
the tumour a greyish-white granular surface is pre- 
sented, with lines of fibrous tissue intersecting. Upon 
pressing the cut surface turbid fluid exudes, and in 
general a thick curdy material is yielded, coming out 
in a worm-like shape. This consists of epithelial scales, 
and upon mixture with water it separates into small 
visible particles, but does not diffuse like other cancerous 
juices. This form of cancer seems in many cases to be 
due to some external irritation. It is often found on 
the lower lip (at the junction of the mucous membrane 
with the skin) on the prepuce, scrotum (chimney sweep's 
cancer) the tongue, labia, cheeks, eyelids, the bladder, 
and in the cervix uteri, in which it constitutes the so- 
called Cauliflower excrescence. By its extension any 
tissue may become involved, viz., muscle, bone, tendon, 
and lymphatic glands. It is very rare in internal 
organs. 
COLLOID CANCER (%6XXa, glue, sTbog, like). 
Although this is often described as a distinct variety 
of cancer, it is probably only one of the preceding 
forms which have undergone a colloid or mucoid change. 
In colloid cancer the alveoli are large, and more or less 
spherical, and contain within them a gelatinous or 
colloid substance which is translucent, colourless, or 17 
yellow, and of a thin mucilaginous consistence. Within 
this colloid substance are contained epithelioid cells, 
which in their turn contain a similar colloid material. 
The most frequent seat of colloid is in the peritoneum, 
stomach and intestines. 
Of all the cancers the least malignant is epithelioma ; 
here local extension takes place, and the lymphatics 
may be involved, but reproduction in the internal organs 
rarely takes place. Encephaloid and scirrhus present 
very different degrees of malignancy ; the former being 
far more rapidly disseminated than the latter, in conse- 
quence of its greater rapidity of growth and its greater 
vascularity; both these forms are reproduced in the 
lymphatic glands and internal organs. 
Colloid bears a close resemblance to encephaloid in 
its degree of malignancy, and in the rapidity of its 
development. 
In all cancers the secondary growth is apt to repeat 
the characters of the primary one. This is most 
observable in colloid, epithelioma, and encephaloid. 
In scirrhus, the secondary growths in internal organs 
are usually different to the primary one. They are 
vascular and soft, and exhibit the characters of en- 
cephaloid. But in some cases the different varieties of 
cancer may replace one another. 
The symptoms of cancerous disease vary according 
to the organs attacked, and will be considered in 
describing these various organs. 
SARCOMATA flesh). 
Description. - Sarcomatous tumours consist of em- 
bryonic connective tissue, and retain that embryonic 18 
type throughout the whole of their growth. Amongst 
them are included the so called Fibro-plastic, Fibro- 
nucleated, Recurrent-fibroid, and Myeloid Tumours. 
Cells constitute nearly the whole of the growth, and 
present great variety of shape and form. The chief 
varieties are three in number, viz. : (1) The Round; 
(2) the Fusiform ; and (3) the Myeloid Cells. 
Many of the Round Cells are identical with white 
blood-corpuscles or lymphatic cells, whilst others are 
larger, present an indistinct nucleus with bright 
nucleoli, and closely resemble the granulation cells. 
The Spindle-Shaped, Fusiform, or "Fibro-plastic" cells 
are long and narrow, and at each end terminate in a 
fine prolongation; they usually contain an oval nucleus, 
with or without nucleoli, and exhibit a higher stage of 
development than the round cells. 
The Mother or Myeloid Cells are much larger than the 
two preceding varieties, and are analogous to the cells 
found in the inflamed medulla of bone. Their shape 
is very irregular, and they often have numerous off- 
shoots ; they contain many round or oval nuclei with 
bright nucleoli. 
All the sarcomata possess an intercellular substance 
(usually very small in amount), and their blood-vessels 
are very numerous. They always originate from con- 
nective tissue, and their growth takes place in two 
ways, viz., by: 
(1) A central growth, from multiplication of their 
own elements; 
(2) A peripheral growth, by the continuous invasion 
of their matrix. 
The peripheral growth is very characteristic of the 
sarcomata. 
These morbid growths rarely implicate other tissues 19 
indiscriminately, but they usually merely displace them, 
and cause them to atrophy by their pressure. 
Secondary Changes.-Amongst the secondary changes 
the most important is fatty degeneration; but calcifi- 
cation, ossification, and mucoid degeneration are not 
uncommon. 
Varieties of the Sarcomata.-From the different 
varieties of the cells, the following are known : 
(1) Round-celled Sarcoma; (2) Spindle-shaped Sarcoma, 
or Fibro-plastic Tumour; (3) Myeloid Sarcoma; and 
from the various secondary changes also (4) Osteoid 
Sarcoma, (5) Melanotic, and (6) Cystic Sarcoma are 
described. Glioma is the name applied to a variety of 
the round-celled Sarcoma growing from the " neuro- 
glia," or connective tissue of nerve. 
Clinically Sarcomatous tumours may be considered 
as semi-malignant. 
Histologically they differ from cancers in the fact that 
the cells are not grouped in alveoli, but are intimately 
mixed with the fibrous stroma. 
AMYLOID DEGENERATION. 
(a/avlan, starch ; tibos, like.) 
This process consists in the infiltration of the tissues 
by a peculiar morbid substance, the exact nature of 
which is even now not satisfactorily understood. 
Virchow gave to the new substance the name of 
" Amyloid," since he supposed it to be analogous to 
starch. It was at one time known under the name of 
"Lardaceous," since the infiltrated organs somewhat 
resemble Lard or bacon. Hughes Bennett considered 
the new material to be a derivative of albumen, and 
therefore termed it 
"Albuminoid." But Dickinson, after numerous 20 
experiments, considers it to be fibrin deprived of 
its alkali potash, and he therefore designates it 
" De-alkalized Fibrin," and from its association with 
purulent discharges in which the potash is removed, he 
calls the condition, " Depurative Infiltration." 
It is never a primary affection, but appears to be 
allied to certain cachectic states. In chronic diseases 
of bone, empyema, chronic phthisis, chronic pyelitis, 
and syphilis, where suppuration is prolonged and pro- 
fuse, the amyloid change is most frequently observed. 
Syphilis appears to take an active part in the causa- 
tion, apart from the suppuration so often produced by 
its various lesions. Every tissue and organ may be 
the seat of the change, but it is most prone to attack 
the liver, spleen, kidneys, and lymphatic glands. It 
may, however, be found in the stomach and intestines, 
in the oesophagus and pharynx, in the supra-renal cap- 
sules, in the bladder, prostate, and organs of generation, 
in the serous membranes, in the membranes of the 
brain, in which at times it forms small tumours, in the 
spinal cord, and in muscle. From the mucous mem- 
branes, e.g., the intestines, the exudation of lardaceous 
matter appears to pass off as a secretion, viz., by diar- 
rhoea and vomiting. It is usual to find several organs 
simultaneously the seat of the change. 
The amyloid material appears first in the walls of the 
capillaries and small arteries, and then involves the 
surrounding tissues, both cells and intercellular sub- 
stance are invaded, and the whole organ may eventually 
become infiltrated. As the cells become filled with 
amyloid substance, they gradually increase in size, their 
contour becomes less irregular, the nuclei disappear, 
and the cells themselves become converted into a 21 
structureless substance peculiarly translucent and 
shining. Many of the cells may coalesce, thus losing 
their distinctive boundaries. The organs affected by 
the change are usually increased in size ; their absolute 
weight and specific gravity are increased. The surface 
is smooth, and the capsule tense. The consistence is 
somewhat elastic. A glistening translucent appearance 
like wax is observed on section. 
The function and nutrition of the affected organs 
are gradually impaired, the cells undergo atrophy, and 
become fatty ; the vitality of the cellular elements is 
diminished, and their functions may be altogether 
arrested. 
Tests.-(1) When an aqueous solution of Iodine (to 
which some Iodide of Potassium is added) is applied 
to an amyloid organ, the morbid deposit acquires a 
deep reddish-brown colour. This gradually passes off, 
and the former appearance is regained. 
(2) By cautiously adding some Sulphuric Acid after 
the application of the Iodine, a violet or blackish-blue 
tint is obtained. Many objections are raised by some 
authors to this latter test, but the reaction with 
iodine alone is thoroughly characteristic, and is 
admitted by all writers. 
(3) Methyl-Aniline gives with the amyloid material 
a deep-violet stain, which is more permanent than the 
reddish-brown stain given by iodine. 
TUBERCLE (Tuberculum, a little tuber). 
Under this term are included certain morbid products. 
The affections characterised by the presence of these 
products are known collectively under the name of 
Tuberculosis, viz., Pulmonary Tuberculosis and Tuber- 22 
culosis of the mesentery; but the lungs are the most 
common seat selected by the tubercular deposit. 
Two Varieties of tubercle are usually described : 
(1) The Grey Miliary Tubercle, or Grey Granula- 
tion. 
(2) The Yellow, or Crude Tubercle. 
The miliary tubercle is of a grey colour, translucent, 
and varies in size from a millet-seed to a hemp-seed : 
It may be either hard or soft. 
The yellow tubercle is larger than the grey, softer, 
and more irregular in outline, less defined, and often 
merging insensibly into the surrounding tissue. Many 
of these yellow tubercles have a greyish white, trans- 
lucent margin, which may be moderately firm, while in 
the centre they are opaque, yellowish, or caseous. 
Collections of these tubercles may be found in the 
liver, spleen, and other parts, and in the peritoneum 
and cerebral meninges they give rise to tubercular peri- 
tonitis and tubercular meningitis respectively. 
Under the microscope the most characteristic appear- 
ance is the large multinuclear, so-called giant cell, from 
which numerous branching fibrillary processes extend 
in all directions, intimately interlacing, the mesh-work 
thus formed being filled with small cells identical 
with those of lymphatic or granulation tissue. A collec- 
tion of such systems constitutes the tubercle as seen by 
the naked eye ; it is, however, only in certain tubercles 
•which have developed slowly that the giant cell is 
found, i.e., when the "tubercular process" is of slight 
intensity. In more rapidly developed tubercle the 
structure is less definite. In this case the lymphoid 
cells are found, with other cells of various descriptions, 
according to the tissue affected ; thus, in the lungs is 
found the epithelium of the air-cells. 23 
It cannot be said that there is any absolute micro- 
scopical distinction between the grey and yellow forms 
of tubercle. 
The most recent view entertained of tubercle is that 
it is an inflammatory growth of an infective nature, 
produced by the irritation of particles derived from 
some morbid focus (most commonly a product of 
scrofulous inflammation), and conveyed by the vessels 
and lymphatics. 
Virchow considers the tubercular product as a 
neoplasm due to the proliferation of the connective 
tissue-cells. Bayle supposes the grey tubercles to 
remain unchanged for an indefinite period, but the 
latest microscopical researches seem to show that they 
eventually become opaque and soften, being infiltrated 
with fatty and granular matters. 
The grey and yellow tubercle may both undergo 
absorption, the affection being known as retrogressive, 
and the deposits of carbonate and phosphate of lime 
which sometimes take place in the latter variety have 
given rise to the name of obsolete tubercle, the process 
itself being termed calcification or cretification. 
Laennec considered the grey and yellow forms to be 
the same substance, and that the yellow was merely a 
progressive stage of the grey. Virchow considers the 
grey tubercle as the only true tuberculous product, and 
regards the yellow tubercle as the result of a degenera- 
tive change of different morbid products, including the 
grey tubercle; that it consists chiefly of the products 
of inflammation, which have undergone a cheesy meta- 
morphosis, and that in some cases the so-called yellow 
tubercle simply consists of inspissated pus. In the 
greater number of cases of u chronic pulmonary tuber- 
culosis," the disease is probably only chronic pneumonia 24 
supervening upon the production of the grey miliary 
granulations, and it is supposed that the pneumonia 
may take place without the granulations, just as the 
latter are not always followed by the former. 
It may be confidently asserted that whatever may be 
the relation between the two products known under 
the name of tubercle, they must both be considered as 
the expression of a morbid constitutional condition; i.e., 
they are the manifestation of a tuberculous cachexia. 
Tubercle can be easily produced in many of the 
lower animals, not only by inoculation but in other 
ways, and not necessarily by the introduction of 
tubercle itself, but by other morbid substances. 
SCROFULA (scrofa, a pig). 
The scrofulous diathesis chiefly occurs in children 
after infancy, and is characterised by its close resem- 
blance to tubercle; it is said to be indicated by 
enlargement of the head, swelling of the abdomen, 
tumefaction of the nose and upper lip, and laxity of 
the muscles. Cutaneous diseases, as eczema, impetigo, 
and lupus, chronic suppuration of joints (white swell- 
ing), caries and necrosis of the bones, and chronic 
inflammation of the intestines, may perhaps be re- 
garded as local expressions of the scrofulous diathesis ; 
however, it is certain that these various affections are 
not unfrequently observed where the glands of the 
neck are unaffected, and, on the other hand, the glands 
are often the seat of scrofula when the other so-called 
scrofulous affections do not exist. 
The term, in a restricted sense, implies an affection 
of the lymphatic glands, especially the superficial ones 
of the neck. The affected glands always become more 25 
or less enlarged by inflammatory products which may 
remain quiescent for an indefinite period, and may be 
removed by absorption ; but when absorption does not 
take place, softening may occur with but little inflam- 
mation ; the integument ulcerates, and there is dis- 
charge of the liquefied product, and finally, after a 
variable period, an irregular puckered characteristic 
scar results from the cicatrisation of the parts. 
The scrofulous products, like the tuberculous, may 
become cheesy, or become the seat of cretification 
(deposit of carbonate and phosphate of lime). 
RACHITIS. RICKETS. 
Definition.-Distortion of the bones, occurring in 
infancy and childhood, from deficiency of earthy mat- 
ters, especially lime salts. 
Causes. Predisposing.-Hereditary predisposition; a 
peculiar diathesis, probably allied to the scrofulous, but 
differing from it, since it is not associated with tuber- 
culous deposits in the lungs, or with enlargements of 
the cervical glands. 
Exciting.-Want of cleanliness, bad food, bad air, 
and bad nursing. 
Symptoms.-The rickety condition may begin soon 
after birth, often at five or six months old, but usually 
before the end of the second year, after which time it 
is very rare. At the commencement of the disease 
the child appears weakly, the body is emaciated, teeth- 
ing is late and slow in progress, the teeth becoming 
carious and loose. There is sweating of the head and 
general hypersesthesia ; the fontanelles and sutures are 
usually open, the head large in proportion to the face, 
the chest flattened at the side, the sternum project- 
ing (pigeon-breast), and beading of the ribs at their 26 
junction with the costal cartilages ; the epiphyses of 
the long bones become spongy, and the joints swell ; 
the enlargement of the joints is usually first ap- 
parent in the ankles and wrist. By degrees the 
long bones yield to the weight of the body, and 
by the action of their muscles they become twisted ; 
the pelvis is narrowed and distorted, and the spine 
becomes curved. If walking has been accomplished, 
the gait is waddling. The mental faculties are 
often unimpaired, and even more acute than usual. 
The spleen is often enlarged. The disease is rarely 
fatal. Recovery often takes place in mild cases, the 
joints gradually acquiring their natural size; but in 
severe cases the distortion becomes permanent and pro- 
duces hideous deformity. 
Pathology.-There is a deficiency of earthy matter, 
as carbonate and phosphate of lime, occasioned by de- 
fective nourishment or mal-assimilation of the food. 
Under the microscope, rachitic bone presents charac- 
teristic appearances. It is composed of isolated masses 
of unaltered cartilage, and of the promiscuous distribu- 
tion of completely or incompletely formed bone. The 
enlarged cartilage-cells are converted into lacunse 
through the imperfect ossification of the matrix. 
Treatment.-The general health should be improved 
by means of good food, fresh and pure air, extreme cleanli- 
ness, and sea-bathing; also by tonics, especially iron pre- 
parations, cod-liver oil, and a country life ; the bowels 
should also be carefully attended to. To supply the 
deficiency of lime-salts, phosphate of lime, phosphate 
of ammonia, and lime-water should be exhibited. The 
latter, with cod-liver oil, or milk and lime water, are 
especially useful 27 
The distorted limbs should be supported with padded 
splints or other mechanical contrivances, not interfer- 
ing with the action of the muscles, care being taken 
not to permit the weight of the body to rest on the 
parts exhibiting a tendency to bend or swell. 
FATTY DEGENERATION. 
In this condition the normal substance of the tissues 
is replaced by fat; the muscles are especially prone to 
the change, as is more especially observed in the heart, 
in which the characters of the muscular fibres are 
either impaired or lost. The tissues become propor- 
tionally softened, and there is a liability to rupture. 
The affected parts present a yellowish or tawny appear- 
ance, and the proper function of the structure is 
impaired. 
Fatty Growth or Infiltration must not be con- 
founded with fatty degeneration, since the former 
merely consists in an increase of the adipose tissue of 
the whole or a part of the body, while in the latter 
the adipose tissue replaces the normal elements of the 
affected part. 
Thus fatty degeneration may take place in the fibres of 
the voluntary muscles as a result of protracted disease, 
and a similar condition of the arterial coats, especially 
those of the minute cerebral arteries, is not uncommon 
in middle life and in aged persons : the vessels yield, 
haemorrhage occurs, and apoplexy or hemiplegia may 
result. In the fatty kidney the fat is deposited within 
the cells of the convoluted tubes; and in the like con- 
dition of the liver, fat may replace the hepatic cells. 
It is stated that cancer may undergo retrogression and 
cure by a fatty change. Persons of advanced age show 28 
fatty degeneration around the cornea (arcus Senins'), but 
this is not now held as reliable evidence of the fatty 
change in any other organ. 
In the heart, the power of the organ to carry on the 
circulation is impaired in proportion to the amount of 
the degeneration. 
Fatty degeneration of certain tissues may occur in 
lean as well as in obese persons. The fatty liver is some- 
times met with in persons who have died of phthisis, 
especially females, and is also one of the results of 
alcoholic abuse. 
ATHEROMA (a^pa, pap) 
Is a term signifying pulp or pap, and is a variety of 
fatty degeneration ; it especially affects the valves of 
the heart and the larger arteries, and consists primarily 
of a deposit beneath the lining membrane of the arteries 
or the valves, of a substance of a yellowish or white 
colour and creamy consistence. Microscopically it is 
composed of fatty granules, cholesterin crystals, and 
earthy constituents. A softening of the delicate mem- 
brane beneath which it is situated may ensue, and in 
this manner aneurismal dilatation of the arteries may 
take place. In the valves of the heart, rupture may 
occur, involving serious valvular obstruction or incom- 
petence. Atheromatous deposit often becomes calca- 
reous, leading to calcification of the valves. 
CALCAREOUS DEGENERATION. 
This condition is due to the deposition of earthy- 
salts, especially of phosphate of lime and magnesia, 
and carbonate of lime. It is known as calcareous 
degeneration, calcification, or cretification. It is gene- 29 
rally preceded by atheroma, and presents no bony 
structure (although it was once called ossification), but 
simply consists of earthy salts. Gangrena senilis is 
often attributable to obstruction to the circulation from 
calcareous degeneration of the arteries of the lower 
extremities, and apoplexy and hemiplegia are often 
occasioned by this degeneration. 
The serous membranes may, in rare cases, present 
plates of bony substance; in old pleurisy the pleura 
has become so hard and calcareous that it has been 
removed entire, retaining the form of a solid box ; 
cancer and tubercle may both be the seat of cal- 
careous change, which is also very common in the 
walls of hydatid cysts. 
RHEUMATISM a fluxion). 
Definition. - This term denotes a constitutional 
disease characterised by local manifestations situated 
in the articulations and fibrous tissues. 
Varieties : 
(1) Acute Articular Rheumatism, Acute Rheumatic 
Arthritis or Rheumatic Fever. 
(2) Sub-acute or Chronic Rheumatism. 
(3) Muscular Rheumatism. 
(4) Rheumatic Gout. 
ACUTE ARTICULAR RHEUMATISM. 
Symptoms.-There is high fever ; the pulse is very 
full and strong, and may reach 120 per minute, and 
the temperature usually fluctuates between 102° and 
110° Fahr. There is urgent thirst. The appetite is 
entirely lost or greatly impaired. The tongue is coated 30 
with white fur; the saliva is acid ; the bowels are 
usually constipated. The urine is diminished in quan- 
tity ; its specific gravity is high, since the quantity of 
urea is increased and the water diminished, the colour- 
ing matter is increased, and the urates are abundantly 
deposited on cooling, the chlorides are sometimes 
deficient, and there may at times be a slight amount 
of albumen. There is a notable increase of fibrin in 
the blood; wakefulness is very troublesome, and 
delirium is not unfrequent. The skin is covered with 
acid sweat; miliary vesicles often appear upon the neck 
and trunk. The Local symptoms are as follows: 
There is swelling of the joints (usually the larger joints) 
accompanied by heat, tenderness, redness, and pain. 
The pain is increased by the slightest movement, and 
pressure is very painful. The swelling is most notice- 
able in the knee, the wrist, the elbow, and the ankle. 
The Duration of the disease varies considerably, and 
may last from seven days to as many weeks, but it 
usually runs a course of about six weeks. The lining 
membrane of the joints is inflamed, but there is rarely 
any exudation of lymph or pus. 
Although rheumatism exhibits great irregularity in 
regard to the number of joints affected, still the local 
phenomena obey the law of parallelism ; corresponding 
joints are often affected together, or if this is not the 
case, the several joints affected are either on one side of 
the body, or joints on the two sides which are symme- 
trical, as for instance the knee and elbow, are affected 
in combination. It is therefore a bilateral disease. 
The great peculiarity of rheumatic inflammation is the 
tendency to what has been called metastasis, or change 
of seat; thus the inflammation may suddenly abandon 31 
one joint and reappear in another, and then subse- 
quently return to its original situation. 
Complications.-In acute rheumatism there is a 
great tendency to inflammation of the structures of the 
heart, and this event is the more to be feared in pro- 
portion to the youth of the patient. Endocarditis 
occurs in a large proportion of- cases, and pericarditis 
is common ; but rheumatic endocarditis and pericar- 
ditis differ from rheumatic arthritis in the fact of the 
former two leading to exudations of lymph and the 
formation of false membranes, which results are ex- 
ceedingly rare in the articular affections. Bronchitis, 
pneumonia and pleurisy are occasionally induced, and 
the meninges of the brain are sometimes affected. 
Rheumatism is very rarely fatal per se, and when fatal 
is generally so from complications, especially cardiac 
and cerebral. One attack is very liable to be followed 
by others. 
A liability to embolism may be stated as incidental 
to endocarditis : emboli may be formed in the left side 
of the heart, or a clot in the right side may cause 
plugging of the pulmonary artery or aorta, according 
to the side affected. 
Pathology.-The rheumatic diathesis is supposed to 
be due to a morbid principle in the blood. This was 
at one time said to be uric acid, but the supposition of 
Prout is now generally adopted, viz., that the "materies 
morbi" is lactic acid. 
Causes.-Cold; a special hereditary predisposition. 
It seldom appears before five years of age ; is most 
prevalent in humid changeable climates, and occurs 
most frequently in all climates within the temperate 
zone, being very rare in tropical or very cold climates. 32 
Treatment.-Although innumerable remedial mea- 
sures have been employed in this affection, such as 
calomel, bleeding, purging, colchicum, nitrate of potash, 
cyanides of zinc and potassium, propylamine and tri- 
methylamine, the plan generally adopted at the present 
day is the alkaline treatment. This consists in the 
administration of large doses at short intervals of the 
bicarbonates or tartrates of potash and soda, until the 
urine is decidedly alkaline. To these lemon-juice may 
be very advantageously added, and this has been some- 
times successfully employed by itself. To increase 
diuresis, the acetate, nitrate, or acid tartrate of potash 
or acetate of ammonia, with small doses of colchicum, 
may be given, but this last drug has no special reme- 
dial action in acute rheumatism. Opiates often afford 
the greatest relief, and are borne in large doses. For 
local applications, cloths saturated with alkaline and 
opiate solutions, and chloroform, are of great benefit, 
or simply wrapping the joint in cotton wool. Blister- 
ing the parts has found favour with some physicians. 
Salicylic acid and the salicylate of soda have been 
much employed of late years; and there is fairly 
strong evidence that these drugs exert a powerful 
influence in lowering the temperature, in relieving the 
pain in the joints, and probably in conferring some 
immunity from heart complications. They must how- 
ever be cautiously administered, and their lowering 
effects carefully watched. 
SUB-ACUTE OR CHRONIC RHEUMATISM. 
This may either follow the acute form or occur 
independently of it. If it follow the acute, the joints 
affected are left stiff, weak, and sometimes oedematous, 33 
and the pain is usually confined to particular joints, 
but it may in some cases shift from joint to joint. 
Gonorrhoeal Rheumatism is the term applied to a 
variety of synovitis affecting the knee-joint, and some- 
times other joints, and occurring in conjunction with 
gonorrhoea. 
If only one or two joints be affected, local applications 
are indicated, as leeches or blisters at a short distance 
from the affected joints, and friction. Electricity, 
whether by the machine or galvanism, is often very 
useful in chronic rheumatism. If the disease be obsti- 
nate, the vapour-bath or the thermal mineral waters of 
Aix-la-Chapelle, Wiesbaden, etc., are indicated. In 
the form known as " cold" rheumatism, in which the 
patient is warm and at ease in bed, guaiacum is specially 
efficacious, but in the other form, the "warm" rheu- 
matism, in which no relief is found in bed, colchicum 
affords the greatest benefit. Dover's powder and iodide 
of potassium are often serviceable. 
MUSCULAR RHEUMATISM. 
This is an affection undoubtedly allied to neuralgia. 
The pain is often excruciating; the affected muscles 
are usually more or less tender, but there are no local 
symptoms, as redness, heat, or swelling, and there is 
little or no constitutional disturbance. This form of 
rheumatism receives various names, according to the 
parts affected. Thus it is termed Lumbago if the loins 
are the seat; Pleurodynia when the muscles of the 
side are affected. 
The Treatment must consist of sinapisms, followed 
by soothing applications, rest, and anodynes. "Firing" 34 
is recommended. The bromides of potassium and 
ammonium with the salts of iron and quinine are 
specially valuable. 
RHEUMATIC GOUT. 
This term relates to an affection which is neither 
gout nor rheumatism, but presents certain characters of 
either or both of these diseases. Adams, of Dublin, 
terms it Chronic Rheumatic Arthritis ; Garrod pro- 
poses to name it Rheumatoid Arthritis. 
According to Flint, the anatomical characters which 
distinguish it from gout and rheumatism are as fol- 
lows : " A larger accumulation within the affected 
joints of synovial liquid, which in the course of the 
disease is absorbed ; absorption Of the inter-articular 
cartilages, eburnation of the ends of the bones denuded 
of cartilage, and enlargement of the ends of the bones 
by the deposit of bony matter ; the formation of carti- 
laginous bodies, which either remain attached to the 
synovial membrane, or are found loose in the cavity of 
the joint. With these changes is associated more or 
less thickening of the synovial membrane or ligaments. 
The ligaments are not unfrequently elongated by pro- 
longed distension from the synovial liquid, and complete 
or incomplete dislocations are apt to follow. The so- 
called chalky deposit of gout is wanting, but rheumatic 
gout may occur in persons who have this deposit as an 
effect of attacks of gout which have previously occurred. 
A peculiar distortion of the fingers is characteristic, viz., 
an inclination to the ulnar or outer side of the hand." 
There is no tendency to endocarditis or pericarditis. 
No classes of society are exempt, although the poor 
are the greatest sufferers. Females are said to be more 
often affected than males. 35 
Treatment.-Improve the general health by nutri- 
tious diet and tonics, avoiding depressing remedies. 
Iodides of potassium, and iron, arsenic, and guaiacum 
are sometimes useful, together with cod-liver oil, chaly- 
beate and tonic waters. Locally, small blisters and 
iodine, rest, passive motion, friction, and shampooing. 
GOUT (gutta, a drop). 
PODAGRA (■rouf, the foot; a/ga, seizure). 
The affection usually commences in the middle of 
the night by severe pain in the great toe of one foot, 
or of one of the thumbs, accompanied by rigors, and 
followed by feverish heat. The pain rapidly becomes 
excruciating, and the joint is so tender that the slightest 
pressure is insupportable. After a variable period the 
pain suddenly ceases, the skin becomes moist, the 
patient falls asleep, and sometimes wakes free from 
pain : usually, on awaking next morning, the painful 
swollen parts are of a deep red colour, shining and 
tense, the surrounding parts are cedematous, and the 
vessels turgid. After several nights and days with 
the continuance of the same symptoms, although in a 
milder form, the swelling subsides, the skin desquamates, 
and the joint either becomes healthy, or the chronic 
form of the disease sets in. One attack is usually 
followed by others at variable intervals; and after 
numerous attacks the joints become stiff, and are fre- 
quently the seat of the so-called chalky deposit. Other 
deposits occur in connexion with the cartilages of the 
external ear (tophi), in the kidneys, and in other 
parts. Attacks of gout are usually preceded by dys- 
pepsia, with irritability of temper and depression of 
spirits. If the inflammatory affection of the joints is 36 
not produced, but the gouty diathesis prevails in the 
system, an affection of some internal part may appear. 
Thus, if the Heart be attacked, angina, syncope, and 
palpitation may be observed. 
If the Stomach, there is great depression of spirits, 
succeeded by intense gastralgia, vomiting, nausea, and 
eructations. 
If the Lungs, dyspnoea, persistent cough, and asthma. 
If the Head, vertigo and headache, leading to para- 
lysis and apoplexy; if the Spinal Cord is attacked, there 
may be severe neuralgia, terminating in paralysis. 
These affections of internal parts, without local inflam- 
mation, have been termed Atonic or Misplaced Gout. 
Retrocedent Gout is the term applied when the 
inflammation of the joints comes on in the ordinary 
manner but does not attain its usual severity or con- 
tinue for the usual time, but suddenly ceases, the 
disease being transferred to some internal part. 
Pathology.-It is ascertained that in gout there is 
an excess of uric acid in the blood. In some cases, 
swelling is produced by the presence of crystalline 
urate of soda in the inflamed part, both upon the 
synovial membrane and within the substance of the 
cartilages and fibrous tissue themselves. 
Chronic gout may terminate in a severe form of 
Bright's disease (the granular kidney), a deposit of 
urate of soda taking place in the intertubular tissue 
and to a certain extent in the tubes. 
Causes.-Most common in males ; in adult age and 
middle life : seldom occurs before puberty, or between 
the ages of thirty and forty. 
It is often hereditary, and produced by plethora and 
high living, and is generally observed in the rich and 
seldom in the poor. The presence of lead in the 37 
system is said to predispose strongly to attacks of 
gout. 
Treatment.-This must be directed both towards 
the paroxysm and the constitutional condition. For 
the former, the exhibition of colchicum, opium, and 
saline aperients is demanded ; whereas, for the latter, 
it will be advisable for the patient to take plenty of 
exercise, to avoid excess of carbonaceous and nitro- 
genous food, and to abstain from saccharine wines. 
Gin and whisky may be allowed. Moderation in eat- 
ing must be enjoined, and the habitual use of the salts 
of potash and lithia is extremely important. 
Locally, wrapping the parts in flannel, wool, and 
fleecy hosiery often affords much relief. 
LEUOOCYTHJEMIA (Xsuxi?, white, xiro;, a cell, 
and al^a, blood). 
LEUKAEMIA (Xsuxor, white, blood). 
LYMPHjEMIA (lympha, lymph, and abza). 
Definition.-A condition characterised by the pre- 
sence of an abnormal proportion of white corpuscles in 
the blood. 
In health the white corpuscles are in the proportion 
of 1 to 300 of the red, and to constitute Leucocythiemia 
the relative number of white cells must be at least 1 to 
20 of the red. 
Varieties.-Splenic and Lymphatic.-These divi- 
sions were made by Virchow, who associated the 
former with enlargement of the spleen, and the latter 
with a similar condition of the lymphatics. 
Symptoms.-There is marked anaemia, with emacia- 38 
tion, sometimes febrile excitement, and when vital force 
is rapidly impaired, death may ensue from exhaustion; 
diarrhoea is occasionally observed, and haemorrhage from 
the nose and other situations may take place. The 
spleen is usually enlarged, and sometimes the glands; 
in many cases both. 
Pathology.-In marked cases the blood acquires a 
reddish-grey or chocolate colour, and this is particularly 
noticeable in the cerebral veins and sinuses; 
Microscopically there is a great increase in the pro- 
portion of the white corpuscles, and not unfrequently 
granular matter, probably arising from the disintegration 
of these bodies, is very noticeable. The spleen is usually 
found enlarged, and sometimes the liver, and in some 
cases the lymphatics in various parts of the body are 
enormously hypertrophied. 
Yellow or yellowish-green collections, soft, and re- 
sembling thick pus, are sometimes found in the right 
cavities of the heart, and in the large vessels, and 
similar collections have been observed in the veins of 
the cerebral meninges and in other situations. 
Virchow states that the number of white corpuscles 
is always increased when the lymphatics are the seat of 
irritation. An increase takes place in typhoid fever, in 
cancer with implication of the lymphatic glands, and in 
malignant erysipelas with enlargement of these glands. 
Hughes Bennett regards the ductless glands as agents 
in the production of the corpuscular blood constituents, 
and considers the red globules to be the free nuclei of 
the colourless ones, and concludes that inLeucocythaemia 
the blood-producing function is disturbed, and that the 
white globules, not being transformed into the red, 
appear in the circulation in morbidly increased quan- 39 
tities. Others think, however, that there is an increased 
formation of the white corpuscles. 
It is questionable whether Leucocythsemia can be 
considered as a special disease, or as merely incidental to 
certain affections. It should be regarded rather as the 
pathological element of a cachexia, the essential nature 
of which is yet to be determined. 
Treatment.-The same as of Anremia. 
SCORBUTUS-SCURVY. 
Symptoms.-These come on gradually, and are 
characterised by extreme debility, a sallow muddy 
complexion, foul smelling breath, wandering rheumatic 
pains over the whole body, and blotches on the legs. 
The temperature is lower than the normal. 
With the progress of the disease the gums become 
swollen, livid, and spongy, and bleed upon the slightest 
touch. In extreme cases the teeth may drop from their 
sockets, and haemorrhage occur from many situations, 
such as the mouth, nose, intestines, and stomach. 
Effusions of blood appear upon the skin. When very 
small, these effusions are termed petechias, when larger, 
vibices, and when of considerable area ecchymoses. 
Causes.-Predisposing are : great privation, marshy 
districts, bad food, and defective hygienic conditions. 
Exciting.-The want of fresh vegetables. 
Dr. Garrod believes scurvy to be occasioned by the 
absence of potash salts from the blood, since the 
disease may be cured by the administration of these 
substances. 
Termination.-Usually recovery, but when fatal 
may be so from general dropsy, pleurisy, pericarditis, 
bloody diarrhoea, or extreme exhaustion. 40 
Treatment.-Preventive measures should be adopted, 
such as lime-juice sweetened with sugar (one ounce of 
each), and taken daily, potatoes, oranges, or the freshly 
expressed juice of horseradish, mustard or water-cresses. 
At first milk and soups should be given, but when 
the digestion improves vegetables and fresh meat will 
be beneficial. 
To supply the deficiency of potash salts, the chlorate 
or tartrate of potash may be administered. 
PURPURA (purpura, a shell-fish yielding a purple 
dye). 
Symptoms. -This disease appears suddenly with 
slight fever, and is characterised by discolouration of the 
skin, which presents a number of circular spots varying 
in size from a pin's head to a pea, appearing first on 
the legs, and eventually spreading over the whole 
body, appearing like bruises. Blood may be effused 
into the different mucous membranes, and sometimes 
into the serous membranes. The gums are not spongy 
and livid. 
Varieties.-(2) Purpura Simplex ; 
(1) Purpura Hsemorrhagica. 
Purpura Simplex is a mild form, in which the con- 
stitutional disturbance is slight; there are very few 
spots, and the disease in general terminates in a few 
days. 
Causes.-Privation, bad diet, fatigue, and defective 
hygienic conditions. 
Purpura Hsemorrhagica is a very severe form, being 
specially remarkable for the effusion of blood' into 
mucous membranes. These effusions may be seen 
during life on the tongue, gums, and interior of the 41 
cheeks, and in fatal cases may be observed all through 
the digestive tract. 
The constitutional disturbance is very great. The 
spots are rapidly developed; they are at first bright 
red, but subsequently become deep purple. The skin 
becomes blotched and tender, and the slightest injury 
occasions haemorrhage. 
Blood may ooze from the gums, the haemorrhage 
being sometimes uncontrollable, and there may also be 
bleeding from the bowels, stomach, or lungs. Thus 
weakness, and anaemia, only may result, or the loss of 
blood may be great and fatal. 
Treatment.-There is no special remedial plan, ex- 
cept to give nourishing diet and rest, and to place the 
patient in a well-ventilated room. Quinine, mineral 
acids, ferruginous and other tonics may be exhibited, 
but antiscorbutic remedies are of no service. 
HEMATOPHILTA.-THE HEMORRHAGIC 
DIATHESIS. 
Consists in a peculiar liability to haemorrhage, which 
exists as a constitutional peculiarity in some persons. 
It is sometimes exhibited immediately after birth by 
bleeding from the umbilicus, is only checked with diffi- 
culty, and death from loss of blood not unfrequently 
results. It usually appears during or shortly after 
the period of dentition, being characterised by profuse 
bleeding from trifling wounds. The subjects of the 
haemorrhagic diathesis continue to lose blood from the 
slightest wound, the haemorrhage resisting all efforts to 
arrest it, sometimes proving fatal, and when not so, 
causing extreme anaemia. Extensive extravasations of 
blood beneath and within the skin often result, being 
produced by slight bruises. 42 
Passive haemorrhage may also take place, indepen- 
dently of wounds, from the nostrils, bronchial tubes, 
stomach, intestines, kidneys, and, in the female, from 
the uterus. 
When children are affected they seldom attain to 
adult age, but the diathesis sometimes ceases after 
childhood, and when present in a moderate degree may 
not prevent longevity. It is often hereditary, and is 
frequently confined to certain members of a family. 
Males are more liable to the disease than females. 
The blood is probably deficient in fibrin, or in the 
power of coagulation, but the exact character of the 
disease is at present unknown. 
The Treatment must consist in supporting the 
strength, avoiding wounds, and applying local haemo- 
static remedies. 
SYPHILIS (<ruk with, p/Xsw I love). 
Definition.-A specific disease contracted by contact 
with a peculiar secretion from the generative organs. 
Syphilis is most commonly the result of impure 
sexual connexion. At first a small red papule appears, 
succeeded by induration and hardness. After a few 
days enlargement takes place in the lymphatics of the 
groin. 
The papule now becomes scaly or surmounted by a 
thin crust, after removing which the surface beneath 
appears of a bright red colour, with scaly secretions. 
In about six or eight weeks after the appearance of the 
papule an eruption appears on the skin, red in colour, 
and accompanied by itching. 
Constitutional symptoms now commence : pari passu 43 
with the red eruption, or soon after its appearance, the 
throat becomes inflamed, the inflammation either leading 
to ulceration, or to the formation of flat circumscribed 
growths on the mucous membrane; other accompani- 
ments are baldness, pain in the bones, nail affections, 
iritis, or inflammatory conditions of the deeper structures 
of the eye. 
Terminations.-The symptoms disappear, health 
being restored in about twelve months from the time of 
infection, or, as is more usual, new crops of eruption 
appear and disappear on the mucous membranes and on 
the skin. These eruptions are of various kinds, such 
as roseola, impetigo, lichen, lepra, etc. ; but the most 
common are the squamous varieties, which form patches 
of a copper colour and of a circular shape, the scurf 
being renewed as soon as it is shed. Small papules are 
present on the tongue, and patches of psoriasis on the 
soles of the feet, palms of the hands, and other parts of 
the body. 
In weak and scrofulous subjects, suppurations may 
follow the eruptions, which then become encrusted and 
form ulcers, and subsequently cicatrise. The throat 
and nasal cavities may be the seat of ulceration, the 
bones being denuded and the nose depressed perma- 
nently, and tumours may occur in internal organs, the 
liver, the brain, and the testicles in particular. These 
tumours have been termed gummata, from the translu- 
cent appearance at the growing edges which they ex- 
hibit in the recent state. They consist of an increase 
of the elements of the connective tissue, and take their 
origin in the vascular walls; they subsequently lose 
their translucency and softness, becoming firmer and 
tougher. 44 
Phthisis may follow syphilis, as may also albuminous 
dropsy and lardaceous disease of the internal organs. 
Causes.-Constitutional symptoms may be occasioned 
by kissing, by syphilitic nurses, or by vaccination, 
when the lymph of the vesicle becomes mixed with 
the blood. 
The infant may be tainted with syphilis through 
either parent, and may exhibit syphilitic manifestations 
even at birth, but usually, from a few weeks to a few 
months, the nates may be the seat of mucous tubercles, 
red patches appearing upon the buttocks, hands, or 
feet. The lips and nose may also be fissured. The 
infant presents a peculiar old-man appearance, the skin 
hanging in loose folds; there have usually been the 
characteristic snuffles at birth. 
Congenital syphilis often produces a peculiar peg- 
shaped or screw-driver notched appearance of the upper 
central incisors of the permanent teeth, and the eyes 
may be affected with keratitis, or chronic inflammation 
of the cornea. 
Treatment.-All remedial measures are useless with- 
out the aid of mercury ; but it is unknown in what 
manner this drug acts. It may be employed as an 
inunction by means of the unguentum hydrargyri, or 
by fumigation, or by hypodermic injection of the 
perchloride, one grain of the salt being dissolved in 
100 minims of glycerine and water in equal propor- 
tions, 4 to 7 minims, or about A to of a grain of the 
mercurial being injected twice or three times daily. 
A better method, however, is by using the albuminate 
of mercury, rendered soluble, and 3 minims injected. 
The best situations for hypodermic injection are the 
back and sides of the thoraS* 45 
Condylomata or flat growths upon the mucous mem- 
brane of the anus may be dusted with calomel or 
iodoform. 
ERYSIPELAS I draw ; vshas, near). 
Definition.-An exanthematous inflammation, accom- 
panied by redness, swelling, and hardness of the skin, 
ending as a rule in resolution or desquamation, and 
sometimes by suppuration, and occasionally, though 
rarely, in gangrene. 
Symptoms.-The usual site of medical erysipelas is 
the face and head, beginning as a slight swelling by 
the side of the nose or one of the ears, spreading until 
the whole of the face and scalp is involved, the nose 
assuming an enormous size, and the eyes becoming 
obscured by the distended eyelids. There is generally 
feverishness, loss of appetite, and thirst. 
The affected parts are very stiff and painful, and the 
neighbouring lymphatic glands are swollen. The ac- 
companying fever is usually high-the temperature may 
rise to 105° Fah.; and when the redness fades, small 
vesicles may form. 
Period of Incubation.-From 5 to 7 days usually. 
Terminations.-As the inflammation decreases, sup- 
puration of the subcutaneous cellular tissue may take 
place and abscesses may form. 
Occasionally the membranes of the brain are attacked, 
and symptoms of meningitis may appear; or the disease 
may prove fatal by blood-poisoning, or by oedema of the 
glottis inducing suffocation. 
Complications.-Bronchitis, pneumonia, and acute 
desquamative nephritis. 
Treatment.-The patient should be placed in a well- 46 
ventilated room, and absolute quiet insured. At the 
commencement of the attack a calomel purge may be 
given. Chief reliance must be placed upon the ferru- 
ginous preparations, especially the tincture of the per- 
chloride of iron. 
Locally, the affected parts may be dusted with flour, 
starch, or oxide of zinc, and covered with flannel. 
The whole surface may be lightly touched with 
nitrate of silver or tincture of iodine, or a covering of 
castor-oil or collodion. 
DISEASES OF THE LUNGS. 
BRONCHITIS the windpipe ; itis, wm, to 
urge against, denoting violent action, used as a 
terminal to indicate inflammation). 
Definition.-An inflammation of the mucous mem- 
brane lining the bronchial tubes. 
Primary Divisions.-(1) Acute; and (2) Chronic. 
Varieties.-(1) Capillary (when involving the 
smaller tubes); (2) Confined to the larger tubes; 
(3) Plastic (with formation of false membrane). 
Causes.-Cold, and alternations of temperature ; the 
local irritation set up by dust and noxious vapours, or 
by mechanical operations, as needle-grinding. Septic 
influences in the blood, supposed to be present in 
kidney disease, and in such febrile maladies as measles, 
scarlatina, small-pox, etc. ; obstruction of the bronchial 
veins, as occurs in consequence of disease of the mitral 
valves ; rheumatism and gout. Most frequently occurs 
at the extremes of life, i.e., in childhood and old age. 47 
Pathology.-In the acute form: redness of the 
mucous membrane of the tubes, which are at the same 
time soft, thickened, and coated by frothy mucus. 
In the chronic form : increase of the muscular struc- 
ture with thickening and striation of the mucous and 
sub-mucous tissue. The tubes are usually constricted; 
but occasionally dilatation is produced (Bronchiectasis), 
a bronchial tube becoming so dilated as to form a pouch, 
or series of pouches. 
In the plastic form: exudation of false membrane 
upon the inflamed mucous surface. 
ACUTE BRONCHITIS. 
Symptoms :- 
Rational signs.-General fever symptoms, a full 
rapid bounding pulse, and hot dry skin, frequently 
urgent dyspnoea, with wheezing and sense of constric- 
tion across the chest. The tongue is furred, the urine 
high-coloured and scanty, often depositing lithates ; ex- 
pectoration of, at first, slightly viscid sputa, becoming 
afterwards abundant and frothy; in severe and pro- 
longed attacks the sputa become muco-purulent, and 
are accompanied by a ringing, noisy cough. 
Physical signs: 
Percussion.-Of no great value : the chest being 
equally resonant on both sides, since the lungs are un- 
affected. 
Auscultation.-The presence of " sonorous rhonchi" 
when the disease is limited to the larger bronchial 
tubes ; of " sibilant rhonchi," when the smaller ramifica- 
tions are affected ; and of " mucous rhonchi " when the 
capillary or smallest tubes are involved. 
All these signs may be present in one case. 48 
In the early stage of the inflammation two dry sounds 
are generally present, termed sonorous and sibilant 
rhonchus ; both of these indicate a partial narrowing of 
the aii tubes, of which the mucous membrane is dry 
and tumid. Sonorous rhonchus need occasion no alarm, 
since it shows that the larger bronchial tubes are alone 
involved. Sibilant rhonchus is a far more grave indi- 
cation, denoting that the smaller ramifications are 
affected. 
As the disease goes on, a viscid, transparent tenacious 
mucus is exhaled from the inflamed membrane ; two 
different sounds are now to be detected, viz., large and 
small crepitation, often called moist sounds, or mucous 
rhonchi. The air passing through the bronchial tubes 
becomes mixed with the mucous secretion, and thus 
numerous air bubbles continually form and burst. 
If this event takes place in the larger ramifications, 
the so called large crepitation, or bubbling rhonchus, is 
produced; when in the smaller, small crepitation. 
Terminations.-Acute Bronchitis, in the majority of 
cases, and especially in the young, ends in complete 
recovery, and indeed is rarely fatal except in old per- 
sons, but it may pass into the chronic form, and a com- 
plication termed brcticho-pneumonia, is not unfrequent. 
In favourable cases the affection declines about the 
fourth to the eighth day, and then entirely subsides or 
passes into the chronic form. 
If, however, no relief is afforded by remedies, or by 
the copious expectoration, great prostration of strength 
results, accompanied by signs of intense pulmonary con- 
gestion, partial asphyxiation follows, and death rapidly 
ensues. 49 
CHRONIC BRONCHITIS 
Is among the occasional sequela? of the acute form, but it 
may commence as an ordinary cold in middle-aged per- 
sons, and even in the young, and continue for a vari- 
able period. In old persons it is very frequent, and is 
notable for returning, sometimes year by year, with in- 
creasing severity. The pulse is usually small and weak, 
or unaffected. The strength may be greatly prostrated. 
The expectoration is scanty, or copious and even puru- 
lent. There is not unfrequently much pulmonary con- 
gestion with dyspnoea, or even orthopnoea. The physical 
signs are the same as those alluded to under Acute 
Bronchitis, varying with the respective parts involved. 
This affection is frequently observed in miners, knife- 
grinders, etc., from the nature of their occupation, and 
it may sometimes depend upon constitutional affections, 
such as rheumatism, gout or syphilis. Emphysema is 
one of the common sequelae of this chronic form, and 
disease of the right side of the heart may follow a long 
continuance of the disease. 
TREATMENT. 
Of Acute Bronchitis. In plethoric persons bleeding 
may be resorted to, or the exhibition of tartar emetic in 
doses of | grain to £ grain every three or four hours ; 
counter-irritants, as linseed or mustard poultices, Tinc- 
tura lodi Composita, Linimentum lodi, and blistering 
may in some cases be applied to the chest. Pulvis 
Ipecacuanhas, Pilula Conii Composita, and Vinuin 
Ipecacuanha? will be fcund serviceable. 
Of Chronic Bronchitis. It must be borne in mind 
that acute bronchitis is a sthenic disease, but the 50 
chronic form is one of asthenia, and therefore, in the 
latter, bleeding and depletory measures must generally 
be avoided. 
Ipecacuanha, squills, senega, and carbonate of am- 
monia, are often exceedingly useful, and when there is 
great constriction of the chest and difficulty in getting 
rid of the phlegm, an emetic of 20 grains of pulvis 
ipecacuanhas often acts like magic. With a history of 
gout colchicum will be indicated; excessive expectora- 
tion may be treated with tincture of benzoin and opium 
preparations ; and cough or spasm will derive benefit 
from steam and other inhalations, as of tar, chlorine, or 
iodine. 
Emetics, especially of Ipecacuanha, are of great 
value, since they not only relieve the bronchial tubes 
of the accumulated mucus, but also appear to act specifi- 
cally upon the mucous membrane. 
PLASTIC OR FIBRINOUS BRONCHITIS. 
Here the tubes are filled with plastic lymph. This 
form frequently accompanies or follows diphtheritic 
disease of the larynx and trachea. Arboriform casts of 
the bronchi are sometimes expectorated, and these have 
been termed "bronchial polypi." In addition to the 
ordinary symptoms of bronchitis, severe hsemoptysis is 
not unfrequent, and the cases are in general of a very 
serious character. It is more frequent in males than 
females, and occurs usually between ten and thirteen 
years of age. In those cases in which the minute 
bronchial tubes are invaded by plastic lymph, the 
disease is probably complicated with pneumonia. The 
indications for treatment in this form are emetics to 51 
remove the casts, and iodide of potassium is stated 
to be very serviceable. 
EMPHYSEMA (e^vada, I inflate). 
Definition.-An over-distension by air of the cells or 
intei lobular substance of the lungs. 
Varieties.-(1) Vesicular ; and (2) Interlobular. In 
vesicular emphysema the air-cells are dilated, and some- 
times communicate one with another. In the inter- 
lobular variety air is extravasated into the connective 
tissue, which also becomes distended. 
The first form of emphysema is termed vicarious, 
when the affected parts are dilated to compensate for 
the imperfect expansion of the lung; and substantive 
when occurring from causes primarily affecting the air- 
cells, as is seen in whooping-cough from the forcible 
expiratory efforts during closure of the glottis. 
Symptoms :- 
Rational signs.-Habitual shortness of breath, feeble 
cough, weak slow pulse, dusky hue of countenance, 
attacks of asthma, inability to take active exercise, fits 
of dyspnoea and orthopnoea, with expectoration of thin 
mucus mixed with tenacious clots, and filled with air 
bubbles. 
Physical signs :- 
Percussion.-Hyper-resonant. 
Auscultation.-The respiratory murmur is always 
diminished and distant. The heart sounds may be 
masked or feeble, and sometimes inaudible and the 
expiration wheezy. 
Inspection.-The chest is enlarged, and of a box or 
barrel-shape in the adult; forming the so-called pigeon- 
breast of the child. 52 
Pathology.-The lungs are distended, pale, and 
bloodless, feeling like wool The cells are enlarged, 
the lobules often ruptured, and communicating one with 
another, forming little bladders of air which are usually 
found around the thin anterior margins of the lungs. 
Terminations.-Congestion of the venous system ; 
hypertrophy and dilatation of the right side of the heart, 
and tricuspid disease of the heart. 
Causes.-Frequent attacks of bronchitis, producing 
impairment of elasticity and contractility of the air 
cells ; degeneration of the lung tissue through old age; 
violent and repeated exercise of the voice ; playing on 
wind instruments; whooping-cough. 
Treatment.-This can only be palliative, as the affec- 
tion is permanent. It may, however, consist of diffusible 
stimulants, Ammonia, Hyoscyamus, Tinctura Cam- 
phoraeComposita, Spiritus Chloroformi, Lobelia, JEther, 
warm clothing, daily use of the cold sponge or shower 
bath ; for the relief of wind and indigestion, aloetic 
purgatives and emetics. Smoking stramonium cigarettes, 
dr inhaling the vapour of burnt nitrate of potash 
papers, is often useful. 
ASTHMA {asS^a, laborious breathing). 
Definition.-A spasm of the white circular fibres 
of the unstriped muscles of the bronchial tubes, the 
admission of air to the lungs being thus limited or 
diminished. 
Varieties.-Idiopathic or Spasmodic, if uncompli- 
cated. 
Organic or Symptomatic, when associated with heart 
disease, bronchitis and other diseases. 
Symptoms.-The attack comes on in paroxysms 
occurring usually at night, and waking the patient from 53 
sleep. There is gasping for breath from the feeling of 
constriction and suffocation; the inspiration is con- 
vulsively violent, the expiration prolonged and com- 
paratively easy, both acts being attended by wheezing. 
Various postures are assumed to obtain relief, such as 
resting the hands upon some solid body to assist the 
muscles of respiration. The pulse is usually feeble, 
the countenance anxious and imploring, the eyes staring, 
the skin cold and clammy : after a time comes a re- 
mission ; during the intervals the patient is quite well. 
The attacks are often periodic. The affection is more 
frequent in males, and is often hereditary. 
Causes.-Some peculiar odour, as of hay or ipeca- 
cuanha, in certain individuals ; a cold wind; pulmonary 
and cardiac diseases. Asthma may also result from indi- 
gestion, due to over-eatiug, the stomach becoming dis- 
tended, and the diaphragm pressed upon. 
Complications.-Asthma, as a symptom, may accom- 
pany phthisis, aneurism, valvular disease, and fatty 
degeneration of the heart, bronchitis, and emphysema. 
Treatment.-During the spasm, or paroxysm, any 
tight clothing must be removed, and fresh air procured. 
Tobacco is often found useful, and stramonium in the 
form of pipe or cigarettes is of great service ; inhalation 
of chloroform may be tried. 
The fumes of burnt nitrate of potash papers, and 
nitrite of amyl, are sometimes of service. 
Stimulants, as ammonia, coffee, ether, and lobelia, 
are other remedies. 
During the interval.-Change of residence is fre- 
quently beneficial, not always from town to country, 
for at times the reverse does good. The bowels should 
be moderately purged, and over-eating carefully avoided. 
Tonics should always be given, and antispasmodics 
are often useful. 54 
PNEUMONIA -PNEUMONITIS ( 
the lung; itis.) 
Definition.-Inflammation of the lung substance. 
Primary Divisions :- 
(1) Acute, Plastic, Lobar, or Croupous. 
(2) Catarrhal or Lobular (Broncho-pneumonia). 
(3) Chronic, Interstitial, Cirrhotic, or Fibroid. 
Causes.-Exposure to cold ; fevers and febrile con- 
ditions ; disease of the kidneys and heart, especially of 
the mitral valves. It may arise spontaneously (idio- 
pathic), or result from injuries (traumatic). 
ACUTE PLASTIC OR LOBAR PNEUMONIA, 
Usually involves a considerable extent of the lung. It 
is characterised by the following stages :- 
(1) Engorgement, Congestion, Hyperemia or Spleni- 
sation. 
(2) Consolidation, or Red Hepatisation. 
(3) Purulent Infiltration, or Grey Hepatisation. 
Symptoms :- 
Rational signs -Severe rigors, followed by dull 
aching pain in the side ; general fever symptoms, thirst, 
skin pungently hot and dry, tongue white, urine thick 
and scanty; cough, accompanied by expectoration, 
which is thick, glairy, and voided in rounded masses, 
which adhere to the side of the vessel, gradually be- 
coming rust-coloured from the presence of altered 
blood-corpuscles, as the disease passes into the second 
stage; simultaneously with the second stage there is 
an absence or deficiency of the chlorides in the urine. 55 
Dyspnoea is present, the breathing being accelerated 
and oppressed, and twitching of the alee nasi is a 
characteristic sign in children; an herpetic eruption 
may appear upon the lips and nostrils. The pulse is 
full and quick, and delirium sometimes occurs at night. 
The average temperature during the height of the 
disease is 104° Fah. : the respirations being about 40 
in the minute (in health the respirations usually vary 
from ten to twenty per minute). One or both lungs may 
be affected. 
In favourable cases the severity of the attack declines 
in about a week or ten days ; but pneumonia sometimes 
continues for a long period, and produces very serious 
conditions The base of the lung is more liable to the 
disease than the apex. 
Physical signs of 1st stage :- 
Percussion. -U nimportant. 
Auscultation.-' Fine crepitation.* 
This physical sign may be compared to the rubbing 
of the hair between the fingers, or to the crackling 
emitted when salt is thrown upon the fire. 
It is probably due to the bubbling of air through the 
fluid in the vesicles, or to the fact of the vesicular walls, 
glued together by exudation, being forcibly separated by 
the air during inspiration. 
Physical signs of the 2nd stage :- 
Percussion.-Dull over the solidified portion. 
Auscultation.-Bronchial breathing, due to a per- 
meable bronchus passing near the consolidated mass, 
the sound traversing a solid conducting medium. 
' Bronchophony,' the voice being conducted through 
a solid medium. 
Absence of respiratory murmur and of crepitation. 
Palpation.-Increased vocal fremitus. 56 
Physical signs of the 3rd stage :- 
Percussion.-Dulness over the solidified portion. 
Auscultation.-More or less of the physical signs of 
the 2nd stage, with the addition of ' mucous gurgling.' 
Twenty-four hours may suffice for the change from the 
1st to the 2nd stage. 
One portion of the lung may be in the 1st, another 
in the 2nd, and a third in the 3rd stage ; and, therefore, 
the auscultatory signs may vary in different situations. 
Terminations:- 
(1) Resolution (entire recovery), preceded by the re- 
appearance of fine crepitation (' crepitatio redux '). 
(2) Purulent infiltration, recognised by mucous gur- 
gling. 
(3) Gangrene (rare), known by great foetor of breath, 
prostration, and hectic fever. 
(4) Abscess (also rare), described under Phthisis. 
(5) Unabsorbed deposits, becoming ' caseous,'leading 
to consumption. 
Pathology.-1st stage : Great congestion of lung 
capillaries ; the lung, consequently, redder and larger 
than usual. On section, blood, serum, and froth 
exude. The whole organ somewhat resembles the 
spleen ; its sponginess and elasticity are lessened, but it 
etill floats on water. 
2nd stage : The spongy character of the lung is lost, 
the organ becoming hard and solid, resembling liver; 
effusion of albumino-fibrine or plastic lymph, and 
coagulation of fluid in the vesicles. The lung sinks in 
water, and it breaks down when pressed by the finger. 
3rd stage : Diffused suppuration of the pulmonary 
tissue. Cavities of pus, and pus points bursting from all 
parts of the lung on pressure ; the lung sinks in water. 
N.B.-Pneumonia need not go through the three 57 
stages, and is not a fatal disease per se. It seldom 
exists alone, but is frequently associated with pleurisy 
and bronchitis as pleuro-pneumonia, and broncho- 
pneumonia. 
Treatment.-In plethoric patients: bleeding, calomel, 
ipecacuanha, and tartar emetic. In other cases, and 
these are the majority, keep the patient in bed, the 
temperature of the room being not lower than 65° F., 
the air kept moist by steam, and administer salines, as 
liquor ammonias acetatis, with spiritus aetheris nitrosi; 
in cases of exhaustion, brandy with milk and raw eggs 
and ammonias carbonas will be indicated. 
CATARRHAL OR LOBULAR PNEUMONIA 
(BRONCHO-PNEUMONIA), 
Usually occurs in the lungs of children, or may 
follow an ordinary cold in old or weakly persons, it is 
observed in those portions of lung which have become 
collapsed from bronchitis, single lobules with the small 
bronchi and the surrounding tissue being usually alone 
involved, these being red and firm. 
In this form the consolidation is limited to single 
lobules, and disseminated over the lung in variously 
sized patches. 
In plastic or lobar pneumonia the consolidation is 
massive. Again, lobular pneumonia is nearly always 
accompanied, or even preceded, by capillary bronchitis ; 
it is constantly associated with whooping-cough and 
measles. It may always be considered a morbid 
secondary process, seldom, if ever, occurring primarily. 
There is no dulness on percussion, unless the in- 
flammatory centres have united over a considerable 
portion of the lung substance, in which case certain 58 
dull areas may here and there appear, and auscultation 
may merely show the signs of bronchitis. The tem- 
perature is high ; both lungs are usually affected; there 
are no rusty sputa nor distinct rigors. 
The mortality is far greater than in the lobar variety. 
On section in a recent case, the lobules appear as ill- 
defined reddish-grey nodules; bloody fluid can be 
squeezed out, and the surface of the lungs is smooth 
instead of granular. 
INTERSTITIAL, CIRRHOTIC, OR FIBROID 
PNEUMONIA. 
In this form, the lymph which is always exuded in 
pneumonia, and usually thrown off by expectoration, 
remains in the lung, and degenerates into fibrous tissue 
and caseous matter. The lung substance is black or 
dark grey in colour, hard, and permeated by bands of 
fibres often enveloping old masses of tubercle. It is 
usually dependent on pre-existing inflammation. 
As increase and hardening of the connective tissue 
takes place, the air-cells are diminished in calibre, and 
are replaced by fibroid growth. 
When the growth is fully developed the lung is solid, 
and hard to the touch; its size is diminished, and on 
section it appears smooth and shining, and creaks under 
the knife. 
The term cirrhotic is adopted, since by some writers 
the change is regarded as the same which takes place 
in liver or kidney cirrhosis. 
The treatment should consist in placing the patient 
in a moist atmosphere, or in giving baths at 77° to 86° 
Fahr. 59 
Internally, senega, ammonia, and the general treat, 
ment of pneumonia may be employed. 
PLEURITIS-PLEURISY (^uga, the 
side; itis). 
Definition.-Inflammation of the pleura. 
Causes :-Inflammation of neighbouring organs; in- 
juries, as broken ribs and the bursting of abscesses 
from the lungs ; exposure to cold; febrile conditions, 
and diseases of the kidney. 
Stages.-(1) Early or Dry ; and (2) Advanced or 
Effusive. 
Symptoms:- 
Rational signs.-General fever symptoms, unhealthy 
look, hot dry skin, white furred tongue, anxious coun- 
tenance, headache, severe lancinating pain in the side, 
chiefly in the mammary region, increased by deep in- 
spiration, by coughing, or by lying upon the affected side, 
short dry cough, pulse wiry, i.e. hard, small, and rapid, 
vibrating under the finger like the tense string of a 
musical instrument, shortness of breath, and difficulty 
of breathing. The attack is generally sudden, and 
there may be no distinct rigor. 
Physical signs of the early or dry stage :- 
Percussion.-Little differing from the normal. 
Auscultation.-A friction sound, synchronous with 
the breaching, and due to the grating on one another of 
the opposed dry pleural surfaces. 
Physical signs of the advanced or effusive stage :- 
Percussion.-Dull over the affected part commen- 
surate with the amount of effusion and varying with the 
position of the patient. 
Auscultation.-The voice sounds are more or less 60 
distinct, according to-the effusion. When only a thin 
layer of fluid exists in the pleural cavity, a peculiar 
modification of the voice is heard, termed, ' JEgophony 
should the layer either become absorbed or increased, 
this sound will disappear; but when the effusion 
diminishes, aegophony reappears, like the redux crepita- 
tion of pneumonia. This sound may be compared to 
the bleating of a goat, or to the peculiar noise emitted 
by the itinerant performers of Punch. 
Palpation.-Absence of vocal fremitus when the 
effusion is great. 
Mensuration.-The affected part measures more than 
the other, but it must be remembered that in many 
cases the right side of the chest is naturally rather 
larger than the left. 
As the disease advances and the effusion increases, 
the patient no longer lies on the sound side, since by 
so doing, compression of the sound lung may take place. 
He therefore lies either upon his back or upon the 
affected side. 
Duration.-Variable; from five to six days to as 
many weeks. 
Pleurisy is usually simple, but the disease may ex- 
tend and constitute double pleurisy. 
Terminations.- 
(1) Resolution (very rare); usually in adhesions from 
organisation of the effused fluid. 
(2) Hydrothorax (effusion of serous fluid). 
(3) Empyema (conversion of effused serum or lymph 
into pus). 
Pathology.-(1) The surfaces of the pleura are at 
first dry from the arrest of the ordinary secretion con- 
sequent upon inflammation, and the subserous areolar 
tissue is injected. 61 
(2) Lymph, or serum, is effused, or lymph-flakes 
mingled with pus, and recent adhesions are to be ob- 
served. 
(3) The pleural sac is filled with pus. 
Effects.-The chest wall may be pushed out, the 
lung being flattened against the spine and appearing 
tough and leathery On section the lung texture 
is found to be devoid of air. The opposite lung is 
frequently congested, and puerile respiration is heard 
upon auscultation, If the effusion be upon the right 
side, the diaphragm and liver are displaced downwards ; 
if it be upon the left, the heart is pushed over to the 
right side. Lateral curvature of the spine may occur 
from contraction of the whole of the affected side, in 
consequence of the fluid being absorbed, and the lung 
incapable of expanding. 
Treatment.-Mustard and linseed poultices, and 
blistering, on the affected side in an early period of the 
affection, but after the occurrence of effusion repeated 
blistering, and the blisters kept open. Internally 
digitalis, iodide of potassium, and other salts of potash, 
squills, and liquor ammoniae acetatis must be adminis- 
tered. As a final resort paracentesis thoracis over the 
seat of the effusion between the 5th and 6th ribs 
posterior to their angles will be sometimes necessary. 
PHTHISIS I waste away). 
Definition.-A disease of the lungs characterised by 
the presence of a peculiar morbid substance called 
' Tubercle.' 
This disease may be conveniently divided into the 
following 
Stages.-(1) Deposition.-From the first appearance 62 
of the scattered miliary tubercles in the lungs until 
their aggregation into masses, and the consequent de- 
velopment of solidification of the lung-tissue at these 
points. 
(2) Softening. - From the breaking up of the 
tubercles until the formation of small abscesses or 
cavities. 
(3) Cavity.-The junction of the small cavities to 
form one or more large ulcerative cavities. 
Symptoms.-Rational signs (very characteristic.) 
(1) Cough (*hort and hacking) not relieved by 
ordinary remedies. 
(2) Emaciation (progressive.) 
(3) Pulse rapid and weak (120-130.) 
(4) Night-sweats. 
(5) Haemoptysis (important, but not always present; 
generally in early stages.) 
(6) Expectoration; mucous in first stage, muco- 
purulent in second, and purulent in third. 
(7) General anaemia. 
(8) Nails recurved and clubbed. 
(9) Eyes pearly and lustrous. 
Physical Signs of 1st stage :- 
Percussion 
at commencement ...Unimportant. 
at end Dull. 
at commencement ...Jerky, 'wavy' in- 
spiration. 
at end Inspiration harsh 
and expiration 
prolonged, be- 
coming 'tubular.' 
* Bronchophony.' 
Auscultation 
Physical Signs of 2nd stage :- 
Percussion ... Dall. 63 
Auscultation...'Muco-crepitant rhonchus,'or 'muco- 
crepitation.' 
Inspection ...Flattening above and below the clavi- 
cles of one or both sides. 
Physical Signs of 3rd stage:- 
Percussion 
over a superficial cavity Hyper-resonant, 
over a deep cavity ...Dull. 
over a cavity contain- 
ing pus and air Mucous-gurgle.* 
over a cavity contain- 
ing only air ' Amphoric or 
cavernous respir- 
ation.' ' Pectori- 
loquy.' 
Auscultation 
Pathology of Tubercle.-There are two kinds of 
tubercle, viz. :- 
(1) The grey miliary, or grey granulation tubercle; 
about the size of a millet seed, composed chiefly of 
albumen. Microscopically presenting a faint cellular 
organisation. 
(2) The crude or yellow tubercle; about the size of a 
pea or bean, consisting chiefly of albumen and fat 
globules. Microscopically presenting no cellular organ- 
isation whatever. Occasionally carbonate and phos- 
phate of lime are deposited in this variety, giving rise 
to a process called calcification or creiification, the 
tubercle being then termed obsolete. 
Most authors formerly considered that these varieties 
were merely stages of the same disease, that the same 
constitutional affection gave rise to both, and that the 
crude tubercle must be necessarily preceded by the 
grey miliary; but some later views of the pathogeny 
and progress of the disease seem to point to an out- 
growth of pre-existing disease of the lung, as in bron- 64 
cbitis, pneumonia, and pleurisy, and phthisis is thought 
sometimes to attend or follow general diseases, as 
syphilis and albuminuria. 
The more recent theory alluded to supposes that an 
inflammation, whether pneumonia, pleurisy, or bron- 
chitis, instead of undergoing resolution or its products 
becoming absorbed and thrown out (vide Pneumonia) 
leaves unabsorbed deposits which assume a fibroid 
character, termed cirrhotic, and give rise to yellow and 
miliary tubercle. 
The well-recognised hereditary tendency of phthisis, 
and the result of everyday experience in private 
practice, in Hospitals, Dispensaries, and Life Insurance 
Offices, would seem to point to the earlier views as 
being more generally applicable. 
Terminations. - Sometimes, when only miliary 
tubercles exist, Resolution may take place, but in other 
cases the tubercles soften and abscesses are formed 
which at length coalesce to form a large ulcerative 
cavity, or sometimes the cavity may become cicatrised 
and calcification may take place. The ordinary dura- 
tion is from six to twenty-four months; the disease 
being rarely fatal in less than three months except 
from complications. 
Causes.-Inherited or acquired, insufficient and bad 
food, impure air, dust in the air, confinement and 
sedentary occupations. 
Treatment.-In the first stage improve the condition 
of the blood and the tone of the system by cod-liver 
oil, iron, quinine, the mineral acids, especially phos- 
phoric acid, good diet, fresh air, moderate exercise, 
•warm but not too heavy clothing. Counter-irritation 
with sinapisms, blistering and painting with iodine 
and the use of the flesh brush will be useful; and to 65 
alleviate the cough, the exhibition of such sedatives 
as hyoscyamus and conium, and mild expectorants, 
especially ipecacuanha. In the second and third stage 
simply treat the symptoms. With regard to change of 
climate the following places are considered best : Tor- 
quay, Undercliff, Isle of Wight, and Hastings, Madeiia, 
Malaga, and especially Algiers, since the last-named 
climate is nearly unvarying throughout the whole year. 
For pure dry air, the higher regions of the Alps are 
now held in high estimation. 
N.B.-Hectic fever is common during the third 
stage, indicating the formation of pus, and it is chiefly 
characterised by flushings and night sweats. The 
microscope, in the second stage, often exhibits in the 
expectoration lung-tissue and pus-globules. To detect 
the elastic fibres of the lung-tissue, the sputa should be 
mixed with an equal quantity of caustic soda in dis- 
tilled water, about 18 to 100. The mixture should 
then be boiled, stirred frequently, three or four times 
the bulk of water added, and allowed to stand in a 
conical glass. The fibres are contained in the deposit. 
The wavy, jerky inspiration of the first stage must not 
be implicitly relied upon, since it may occur in hysterical 
and nervous subjects. 
In addition to the rational signs above described there 
are often dyspeptic symptoms; diarrhoea; notably 
thickening and ulceration of the larynx ; and a peculiar 
festooned appearance of the gums. 
In women the menstrual functions are more or less 
disturbed, and the catamenia generally cease. 
The above disease may be termed Chronic Phthisis, 
but a condition is known as Acute Phthisis, or Gallop- 
ing Consumption. This runs a very rapid course, and 66 
is a rare disease. Death may take place in Jess than 
five weeks. The onset is sudden, there are rigors and 
high fever, profuse sweatings, cough, and dyspnoea, 
with great prostration. Here the tubercular degenera- 
tion appears to depend upon catarrhal pneumonia, the 
consolidation breaking down into caseous matter, 
cavities of variable size being formed at times all over 
the chest. 
HYDRO PNEUMO THORAX 
Is an occasional result of phthisis. In this condition 
there is a perforation from the lung into the pleural sac 
which is partly filled with air and partly with fluid. 
It may also be caused by a fractured rib or by blows 
on the chest. 
The symptoms are sudden acute pain, dyspnoea and 
fainting. The lips become swollen and blue. On 
percussion there is either hyper-resonance or dulness, 
according to the amount of air or fluid present. 
Succussion yields a splashing sound, and upon auscul- 
tation ' metallic tinkling ' is heard, supposed to be 
caused by drops of fluid falling from the roof of the 
cavity into the fluid beneath. 
PNEUMORRHAGTA-PULMONARY 
APOPLEXY. 
This is of somewhat rare occurrence, and consists in an 
extravasion of blood into the air-cells of the lung, and 
sometimes in an infiltration of the interstitial tissue. In 
some cases it is incidental to bronchial haemorrhage in 
consequence of the violent inspiratory acts driving the 
blood backwards from the bronchial tubes into the air- 67 
cells. In fatal cases the morbid appearances are of two 
kinds: in one form solid masses or nodules varying 
from the size of a pea to that of a walnut are found in 
one or both lungs, these organs being solidified from 
the coagulation of the blood within the cells; the 
limits of the nodules are sharply defined by the lobular 
divisions, the nodules feeling like hard projecting 
tumours; upon section the organs appear dark or even 
black ; grumous blood may be scraped from the cut 
surfaces. In the other form the coagulated blood is 
more widely diffused; larger portions of the lung are 
solidified, and they are not bounded by the lobular 
divisions. Pneumorrhagia may be caused by violent 
blows upon the chest, or it may occur in purpura or 
scurvy, but in the greater number of cases it is pro- 
duced by congestion of the lungs, and by cardiac disease, 
especially of the mitral valves. 
The diagnosis is attended with considerable difficulty^ 
haemoptysis may be present in greater or less quantity. 
The respirations are hurried and laboured, and per- 
cussion will probably yield dulness over the solidified 
portions of the lung. Blood in the cells and smaller 
air-tubes may give rise to crepitant rhonchus within a 
limited space. 
All that can be done in the way of treatment is to 
palliate the symptoms and support the powers of life, 
since these cases usually proceed to a fatal termination. 
CANCER OF THE LUNGS 
May be either hard (Scirrhus) or soft (Medullary). It 
is usually the latter, commencing in the bronchial 
glands. In the former a white, hard, firm tumour is 68 
presented, yielding a juice which, under the micro- 
scope, is seen to contain caudate nucleated cells. The 
latter variety is soft, bloodstained and vascular. 
Cancer is found in various other parts of the body. 
Diagnosis may be said to be exceedingly difficult; 
there may be flattening of the chest, impairment of 
the respiratory movements, pain, emaciation, night 
sweats and cough; the expectoration is purulent and 
often mixed with dark coloured blood resembling red- 
currant jelly; and sometimes foetor of the breath is 
observed. The history of the patient, the absence of 
other pulmonary disease, and the presence of cancer 
in the neighbouring glands, will greatly aid the 
diagnosis. Death is the inevitable termination, and 
all that can be done is to treat the symptoms, and 
support the patient. 
DISEASES OF THE HEART. 
Organic Diseases. 
PERICARDITIS. 
(vipi, around ; xa^ia, the heart; itis). 
Definition.-Inflammation of the pericardium or fibro- 
serous sac containing the heart. 
Pathology.-In recent.cases lymph is observed, of a 
pale-straw colour, soft, tenacious and firm, and mixed 
with serum and flakes of fibrin. The surfaces of the 
serous membrane are shaggy and rough, and present 
honey-comb depressions; at later periods there are ex- 
udations of lymph and fibrinous serosity causing adhe- 
sions between the opposite surfaces which may ob- 69 
literate the pericardial cavity; where the powers of 
life are very low there is considerable serous effusion 
constituting dropsy of the pericardium (Hydroperi- 
cardium). Pus is rarely, but occasionally present (Pyo- 
pericardium) and sometimes tubercles are observed 
(Tubercular Pericarditis). 
Symptoms: 
Rational Signs. - None of these are diagnos- 
tic ; pain may be present, but it is a very fallacious 
symptom, since the worst cases have occurred with- 
out any pain at all. Pain may be elicited when 
absent, and increased when present, by deep pressure 
over the heart, by upward pressure against the dia- 
phragm, or by lying upon either side. There is general 
fever, the pulse is full, hard, and " jarring," often irre- 
gular and intermittent; a great feeling of oppression, 
extreme restlessness, the skin is either bathed in sweat 
or dry and hot, and the countenance expressive of great 
anxiety ; delirium is a very frequent symptom, inducing 
the belief that the brain is affected. 
Physical Signs: 
Percussion.-During the early periods is little dif- 
ferent from that of health. 
Auscultation.-A double friction sound, " attrition 
murmur," " to and fro" sound, or exocardial murmur is 
heard ; this sound has been compared to the rustling of 
silk, the unfolding of a crisp bank-note, or the creaking 
of a new boot; it is synchronous with the movements 
of the heart, and does not cease when the patient holds 
the breath, as is the case in pleurisy. 
Causes.-Cold, inflammation of neighbouring organs 
as of the pleura and lungs ; and pyaemia. Pericarditis 
is termed Traumatic when resulting from a wound, 
Rheumatic, when preceded by rheumatic fever, and 70 
Uraemic, if occasioned by kidney disease. 
Terminations: 
(1) In Resolution (complete recovery). 
(2) In Adhesions. 
(3) In Hydropericardium. 
(4) In Pyopericardium. 
HYDROPERICARDIUM. 
In this condition amber-coloured fluid distends the 
pericardium. It may follow inflammation of the peri- 
cardial sac or may occur as the result of kidney dis- 
ease. 
The heart's action is weakened, the pulse is small, 
feeble, intermittent, unequal, and irregular, and the 
leading symptoms are faintness, pallor, cold perspira- 
tions and the signs of impending death. The eflused 
fluid presses the apex of the heart from between the 
5th and 6th ribs up to the 2nd, 3rd, or 4th intercostal 
space, and the area of percussion dulness is continued 
up the sternum, following the course of the great vessels. 
On auscultation the heart's sounds are* indistinct, and 
on palpation the impulse is feeble and irregular or 
wavy. In extreme cases both the cardiac impulse and 
the sounds may be almost imperceptible. The line of 
dulness is variable; it is wider upon the patient lying 
down than when standing. It is also of a pyramidal 
shape, the apex of the pyramid being above. 
Hydropericardium is frequently accompanied by 
Hydrothorax and general dropsy. 
The greater number of cases of Pericarditis terminate 71 
in adhesions, and by some writers this condition is 
known as 
CHRONIC PERICARDITIS, 
but the term would appear misapplied, since the pre- 
existing inflammation merely produces such a con- 
dition. 
ADHERENT PERICARDIUM. 
The existence of this condition can only be assumed 
after the presence of the " double friction" sound. 
When there is adhesion to the spine strong jogging 
action of the heart is observed, and since the organ no 
longer moves freely in its sac, but both sac and con- 
tents move together there is dragging in of the, sternum 
at the ensiform cartilage, accompanied by the general 
symptoms of cardiac embarrassment. 
Treatment of Pericarditis.-Chiefly that of acute 
rheumatism ; the salts of potash, salicylic acid, opium, 
and rest. After effusion has taken place, cupping and 
leeches will be found serviceable, or blistering over the 
region of the heart, the blisters being kept open. In 
extreme cases of hydropericardium as a last resort the 
trocar and canula (paracentesis pericardii) must bo 
employed ; but this operation is itself attended by con- 
siderable danger. 
ENDOCARDITIS. 
(b'Sov, within ; xaodia, the heart; itis). 
Definition.-Inflammation of the lining membrane 
of the heart. Endocarditis can only be distinguished 
by the valvular lesions causing "murmurs." 
Causes.-Rheumatic fever, scarlatina, measles, and 
disease of kidneys. 72 
Symptoms.-Rational symptoms directly pointing to 
the heart are very obscure. 
VALVULAR DISEASES OF THE HEART. 
The valves may be the seat of- 
(1) Inflammation, giving rise to deposit of lymph 
upon or beneath the lining membrane. The valves 
lose their thinness and transparency, they become thick, 
puckered up, and adherent to one another or to opposite 
walls of the channel. 
(2) Warty vegetation or excrescence. 
(3) Atheromatous degeneration. 
(4) Calcification (deposit of carbonate and phosphate 
of lime). 
Results.-(1) Valvular obstruction. 
(2) Valvular insufficiency (Regurgitant disease). 
Both theses diseases may eo-exist, but they not un- 
frequently exist separately. 
Symptoms:- 
Rational Signs.-Diseases of the left side of the heart 
chiefly affect the arterial pulse, giving rise to irregu- 
larity and inequality : those of the right side affect the 
venous circulation, causing regurgitation into the iugular 
7 o o o u o 
veins (the venous pulse). 
Physical Signs.-The natural sounds are replaced or 
accompanied by " murmurs." The qualities of these 
murmurs may be harsh, rough, cooing, whistling, 
musical, etc., but a very loud murmur does not neces- 
sarily indicate extensive cardiac disease, nor vice versd. 
Murmurs are primarily divided into- 
(1) Organic or permanent. 
(2) Inorganic, functional, or temporary. 73 
The first name is applied when actual disease of the 
valves exists, but the second may be produced by a 
peculiar condition of the blood or of the vessels through 
which that fluid circulates. Thus in weak anaemic 
persons it is not uncommon to find a loud murmur over 
the heart, which is also audible in the carotid and sub- 
clavian arteries, but this peculiar sound will entirely 
disappear under the exhibition of the iron salts and 
upon restoration to health. 
Axiom I.-A murmur is not limited to any definite 
spot over the area of the heart, but its diagnostic value 
depends upon the place at which its intensity is greatest. 
A rhythmic period of the heart's action maybe roughly 
represented as follows :- 
Sys tole 
Diastole 
Seat of Presystolic 
Murmur, 
Sys tole 
Diastole 
CD 
02 
s 
Ph 
The first half of the period is occupied by the systole 
or contraction of the ventricles, during which the first 74 
sound of the heart is heard, the succeeding fourth by 
the diastole or dilatation of the ventricles, during which 
the second sound is heard, and the remaining fourth is 
a period of silence or pause before the next succeeding 
systole. By a systolic murmur is implied a morbid 
sound which accompanies the systole, and is almost 
synchronous with the pulse at the wrist; a diastolic 
murmur accompanies the diastole. A presystolic mur- 
mur is a morbid sound occurring in the last half of the 
pause, or last eighth of the whole rhythmic period, and 
immediately precedes the next systole. 
Axiom II.-Murmurs heard during the Systole are 
due to the passage of blood Out of a ventricle. 
Axiom III.-Murmurs heard during the Diastole are 
due to the passage of blood Into a ventricle. 
Inorganic murmurs are always systolic, since pre- 
systolic or diastolic murmurs always indicate structural 
disease. 
Mitral Obstruction, 
Otherwise called "Mitral Stenosis," or mitral constric- 
tion, is distinguished by a Presystolic murmur, the 
intensity of which is greatest at the apex of the heart, 
is faintly audible at the ensiform cartilage, is traceable 
along the left margin of the organ, and is occasionally 
heard at the inferior angle of the left scapula. 
Mitral Regurgitation 
Is recognised by a Systolic murmur, loudest at the apex, 
traceable in the same direction as the foregoing, and 
nearly always audible at the inferior angle of the left 
scapula. 
The fremissement cataire, or purring thrill on palpa- 75 
tion, is a frequent accompaniment of mitral disease, but 
this physical sign is not peculiar to valvular disease, 
since it may occur in any condition which produces a 
deficiency of blood in the heart. 
In mitral disease the pulse, if irregular, is usually 
found to be intermittent, soft, small, and weak. 
Of all the diseases of the valves mitral disease is per- 
haps the most common. 
Aortic Obstruction 
Is recognised by a Systolic murmur, loudest at the base 
of the heart, i.e., at the second right costal cartilage, and 
traceable to the right shoulder, following the course of 
the large vessels. The pulse is usually wiry and resist- 
ing, and sometimes visible. 
Aortic Regurgitation 
Is distinguished by a Diastolic murmur in the same 
position as the foregoing, 
In this form of aortic disease there is usually visible 
pulsation in many distant arteries, and the pulse is 
jerking ; the pulse of unfilled arteries often described as 
dicrotous, i.e., communicating a double impulse. 
Tricuspid Regurgitation 
Is recognised by a Systolic murmur upon the same level 
as that at which the mitral murmur is heard, but to 
the right of the ensiform cartilage, and extending 
downwards to the epigastrium. It may be said to 
occupy a circular area, of which the ensiform cartilage 
forms the centre. It is usually found that this con- 76 
dition is associated with dilatation of the right side of 
the heart, by which condition the tricuspid valves are 
mechanically spread apart, and the blood is allowed to 
regurgitate; the valves themselves are not commonly 
diseased. In this condition there is usually turges- 
cence and pulsation in the jugular veins. 
Tricuspid obstruction is so uncommon that its de- 
scription here is unnecessary. 
Pulmonary Valvular Disease 
Is so exceedingly rare, that any organic alteration of 
these valves is a pathological curiosity, and the dia- 
gnosis is attended with considerable difficulty; but 
when a murmur can be traced from the middle of the 
left edge of the sternum towards the left clavicle, is 
loudest above the second left costal cartilage, and is 
inaudible in the subclavian and carotid arteries, we 
may assume that it originates at the orifice of the pul- 
monary artery. 
Sequelae of Valvular Diseases. - Dilatation and 
hypertrophy of the heart; paralysis from softening of 
the brain substance caused by emboli; dropsy and 
gangrene of the leg. 
In distinguishing exo- or peri- cardial murmurs from 
endocardial, the following facts must be borne in 
mind: 
The Pericardial are more superficial, arealways double, 
are confined to the heart's area, and increased on pres- 
sure by the stethoscope. 
The Endocardial are less superficial, not always 
double, are propagated to localities beyond the heart's 
area, and are unaltered by pressure by the stethoscope. 77 
HYPERTROPHY (utsp, over; nourishment) 
OF THE HEART 
Is of three kinds, viz :- 
(1) Simple Hypertrophy (thickening of the wall 
without enlargement of the cavity). 
(2) Eccentric Hypertrophy, or Hypertrophy with 
Dilatation (thickening of the wall with enlargement of 
the cavity). 
(3) Concentric Hypertrophy or Hypertrophy with 
Contraction (thickening of the wall with diminution of 
the cavity). 
The second form is the one usually met with. 
Concentric hypertrophy is now believed by most pa- 
thologists to be a post-mortem or ante-mortem change, 
taking place during the act of dying, and occasioned 
by the slow contraction of the muscular fibres. 
Causes.-Overstrain upon the heart, as occurs in 
violent exercises of any kind, i.e., athletics, running and 
rowing. Any obstruction to the blood-stream demand- 
ing extra work from the heart, as in diseases of the 
valves, lungs, or kidneys. 
Emphysema, chronic bronchitis, and diseases of the 
left side of the heart will produce hypertrophy of the 
right ventricle; obstruction at the aorta will induce a 
similar condition in the left ventricle, and mitral ob- 
struction induces hypertrophy of the left auricle. 
Pathology.-This varies according to each form of 
hypertrophy. The normal size of the heart is about 
that of the closed fist, and the mean weight from eight 
to ten ounces; the size and weight may both be enor- 
mously increased. The shape of the hypertrophied 
organ is globular, its substance stiff and hard on section, 78 
and the walls do not collapse when emptied of blood. 
The whole heart may be hypertrophied, or one or more 
of its cavities may be so affected. The left ventricle 
appears to be the most common seat of the affection. 
Symptoms of simple hypertrophy :- 
Rational Signs.-The pulse at first is usually full 
and strong, but after a variable period it may become 
altered, and it is not uncommon sooner or later to find 
it small and feeble, even with a bounding heart. 
Since hypertrophy seldom exists alone it is usual to 
find symptoms varying according to the complications. 
Physical Signs:- 
Percussion.-When the right ventricle is chiefly 
affected, which is by no means common, the apex may 
be entirely formed by it, and the area of the heart is 
square; when the left ventricle is the seat, which is 
more often the case, the percussion area is elong- 
ated. 
Palpation.-The cardiac impulse is greatly increased, 
slow and heaving. 
Inspection.-When the left ventricle is the seat of 
disease, the apex beat is below the normal position, and 
there is violent pulsation in the carotids. When the 
right ventricle is chiefly affected the apex extends out- 
wards, and there is pulsation at the epigastrium, often 
accompanied by swelling and pulsation in the jugular 
veins. 
Auscultation.-The first sound is prolonged and in- 
distinct, the second is lower in pitch than it is normally, 
and when the right ventricle is most affected, this 
second sound is louder over the pulmonary than over 
the aortic valves. 
Roughly speaking, then, cardiac hypertrophy is recog- 79 
nised by the increased impulse of the heart, and the 
diminished audibility of its sounds. 
DILATATION OF THE HEART 
Is of three kinds, viz. . 
(1) Simple Dilatation (enlargement of the cavity, 
with normal thickness of the walls). 
(2) Dilatation with Hypertrophy. 
(3) Dilatation with Thinning of the Walls. 
Causes.-Any cause preventing the complete evacu- 
ation of any of the heart's cavities; diseases of the 
valves, and emphysema. In aortic regurgitation the 
left ventricle becomes dilated. Both ventricles may be 
affected together or separately. 
Symptoms of simple dilatation: 
Rational signs.-The pulse is feeble, small, inter- 
mittent, and irregular. There is extreme palpitation, 
blueness of the face and lips, and dropsy. 
Physical signs: 
Percussion.-The cardiac area is more square than 
normal, since the cavities are increased in capacity. 
The right side of the heart is more frequently the 
seat of dilatation than the left side. 
Palpation.-There is great diminution of the cardiac 
impulse, which is sometimes wavy and almost imper- 
ceptible. 
Inspection.-The apex beat is lower than normal. 
Auscultation.-The audibility of the heart sounds is 
much increased, the first sound being clear, sharp, and 
short, and similar to the natural second sound. 
Roughly speaking, cardiac dilatation is recognised by 
the diminution of the impulse of the heart, and the in- 
creased audibility of its sounds, 80 
Sequelae.-The lungs and liver may become con- 
gested, and disease of the cardiac valves, especially of 
the tricuspid, is induced. 
Hypertrophy and dilatation usually co-exist. When 
the former is greater than the latter the cardiac dulness 
is increased from above downwards, but when the dila- 
tation is greater than the hypertrophy the dulness is 
greater transversely. 
So long as the hypertrophy keeps pace with the dila- 
tation the patient is in comparative safety, since the 
former condition must be regarded rather as a compen- 
sation of nature than a morbid condition, but as soon 
as the dilatation acquires preponderance the condition 
is excessively dangerous. 
FATTY DISEASE OF THE HEART. 
Fat is naturally deposited about the heart, and an 
excess of this substance is called a fatty infiltration, i.e., 
fat is deposited in large quantities upon and between 
the muscular fibres. In this condition the functions 
of the heart do not appear to be much interfered with. 
FATTY DEGENERATION. 
Here the muscular fibres are replaced by fat, and 
pathologically the heart appears of a pale yellow colour 
and feels soft and greasy ; under the microscope the 
sharp edges and striae of the muscles are lost, and the 
tissue appears loaded with oil. This condition is 
usually met with in old or middle-aged persons, and is 
often associated with other diseases of the heart and 
arteries. Positive diagnosis may be considered almost 
impossible, but there will be feebleness and intermit- 
tency of the pulse, and cardiac impulse, and the patient 81 
suffers trom the most distressing palpitation or even 
syncope upon the least excitement. It has been stated 
that the arcus senilis, or white ring round the cornea, 
is an indication of the fatty heart. 
MYOCARDITIS (z^, a muscle; Kapdia, the 
heart), 
Or inflammation of the substance of the heart, is very 
rare, as an uncomplicated condition, but may accompany 
pericarditis. 
Pathologically the muscle is soft and dark red or 
hard and dense, and under the microscope the trans- 
verse striae appear lost, the muscle apparently consisting 
in the main of fatty and granular matter. 
Symptoms.-All the symptoms are uncertain, but 
the disease is said sometimes to terminate in abscess or 
to produce dilatation. 
CANCER OF THE HEART 
May occur as a part of the cancerous cachexia, or from 
the extension of cancerous disease from other organs, 
is purely pathological. 
TUBERCLE OF THE HEART 
May occur as a general condition, chiefly in the tuber- 
culosis of children. This is also purely pathological. 
CYANOSIS (%uavo?, blue, voces, disease); or, 
MORBUS CJERULEUS. 
By this term is implied a blue discoloration of th© 
skin, chiefly confined to early life and arising from 
some deficiency in the construction of the heart, viz. : 82 
(1) Permanence of the foramen ovale, permitting 
the passage of blood between the auricles. 
(2) Abnormal apertures in some part of the septum 
of the auricles or ventricles. 
(3) Origin of the aorta and pulmonary artery from a 
single ventricle. 
(4) Extreme contraction of the pulmonary artery. 
(5) Origins of large vessels of the heart being trans- 
posed, the pulmonary artery arising from the left, and 
the aorta from the right ventricle. 
(6) Continued patescence of ductus arteriosus, allow- 
ing the mixture of bloods of the pulmonary artery and 
aorta. 
Sufferers from this disease usually exhibit symptoms 
of coldness of the body, palpitation, fits of dyspnoea, 
frequent liability to syncope and dropsical effusions. 
FUNCTIONAL DISTURBANCES OF THE HEART. 
PALPITATION (Palpito, I throb). 
Although this may be only a functional derange- 
ment, yet at times it is a symptom of organic disease 
of the heart. 
Symptoms.-There are frequent, strong, tumultuous 
movements of the heart without any ascertainable 
organic lesion. When very severe the heart-beats may 
be heard and felt by the patient. These symptoms 
are often accompanied by a distressing sensation of 
sinking at the pit of the stomach. 
Causes.-The nervous temperament ; any strong 
mental emotions; excessive loss of blood; dyspepsia 83 
with flatulence ; intemperance; the abuse of tobacco; 
•want of sleep. It is very common, in chlorosis. 
Treatment.-For regulating the circulation digitalis 
combined with tonics is specially indicated, and for 
the relief of debility the salts of iron appear most 
beneficial. A belladonna plaster to the side often 
affords relief. 
SYNCOPE (ffu/xoVr-w, to cut down). 
Symptoms.-There is a sensation of intense distress, 
buzzing in the ears, failure of the eyesight, objects 
appear to swim before the eyes. The lips become 
blanched, the face pale, the surface of the body is 
covered by cold perspiration, the senses fail, and the 
sufferer falls senseless to the ground, the pulse and 
breathing becoming imperceptible. Recovery is indi- 
cated by a deep protracted sigh. The attacks usually 
last only for a short time. 
Causes.-Debility and nervous irritability; profuse 
discharges, especially of blood; severe pain and mental 
emotion. 
Treatment.-The recumbent posture, bringing the 
patient into the fresh air, and dashing cold water over 
the face and breast. 
ANGINA PECTORIS (ayp/w, to strangle; pectus, 
the breast). 
This is apparently a disease of the heart; it may be 
termed a kind of neuralgia of the heart and an affec- 
tion of the phrenic and perhaps the pneumogastric 
nerves. The attack has been supposed to be caused by 
spasmodic contraction of the small pulmonary and 
systemic vessels. 84 
Symptoms.-There is pain in the region of the heart 
extending to the left side or to the shoulder down the 
left arm and even to the lingers, and accompanied by a 
sensation of suffocation and fear of impending death. 
The heart's action is often irregular and intermittent, 
the pulse feeble and the body covered with cold sweat. 
The attacks occur in paroxysms at uncertain intervals, 
and may be associated with organic cardiac lesions, but 
not necessarily. They sometimes occur without warn- 
ing, sometimes when quickly walking up a hill. The 
attacks generally last only for a few seconds, but they 
may be prolonged even to an hour. Angina pectoris 
used to be regarded as a terribly fatal disease, but, when 
uncomplicated, it is not now so regarded, and patients 
have been known to suffer from the complaint for many 
years and then to die of some other affection. 
Causes.-Not precisely known, but affections of the 
valves of the heart, fatty degeneration, and calcification 
of the coronary arteries have all been stated to produce 
this affection, which, however, then becomes only a 
symptom. 
Treatment.-Sedatives, as opium ; stimulants and 
anti-spasmodics ; brandy and ammonia, often afford re- 
lief, and a belladonna plaster to the side will be found 
serviceable. The last remedy proposed is nitro-glycerine. 
THE GENERAL TREATMENT OF ENDOCAR- 
DITIS AND VALVULAR DISEASES. 
A principal point that demands attention in these 
diseases is the management of the acute rheumatism 
which either accompanies or precedes them ; if this 
affection can be effectually controlled, the supervention 
of cardiac inflammation need not be apprehended. 85 
Bleeding, at one time, found much favour, but it is 
never resorted to in the present day, and purging by 
strong cathartics and salines, which was once supposed 
to be beneficial, is now seldom practised. 
Calomel was once strongly recommended, but it cer- 
tainly has no effect in neutralising the poison of acute 
rheumatism, and its administration is, therefore, quite 
useless, if not injurious. 
Low diet should be enjoined until the generation of 
the poison has ceased and the function of nutrition 
begins to be carried on normally. 
Nitrate of potash was advocated some years ago by 
Dr. Basham, but subsequent experience has not con- 
firmed his favourable results. 
Lemon juice appears to exercise a very beneficial in- 
fluence in the treatment of acute rheumatism. 
Blisters to the inflamed joints have found much favour 
withf Dr. Herbert Davies, who is of opinion that the 
heart may, by this remedial measure, be saved from in- 
flammatory mischief, the pains in the joints being re- 
lieved, the rapidity of the pulse diminished, rapid con- 
valescence promoted, and the blood relieved of the 
materies morbi. 
Cold to the affected joints has been followed by 
relief. The whole body has of late years been plunged 
into cold water in cases of acute rheumatism, but the 
wisdom of this proceeding is doubtful. 
Propylamine and Trimethylamine, two metameric 
bodies, each having the chemical characters of an 
ammonia-the latter being obtained from herrings' 
brine-have been employed by Dr. Dujardin-Beaumetz, 
of Paris, who states that by their means benefit may 
be obtained in the short space of twelve hours. 
The Cyanides of zinc and potassium are highly 86 
recommended by Dr. Luton, of Rheims. It is possible 
that the efficacy of these salts may be due to the 
generation of prussic acid in the stomach. 
The Alkaline, Treatment by potash and its carbonates 
is, upon the whole, the most satisfactory. Dr. Dickin- 
son has shown that of 48 patients subjected to full 
alkaline treatment only one had pericarditis com- 
mencing after the treatment had begun. 
The Bicarbonate of potash should be given in toler- 
ably large and repeated doses (1 drachm every 4 hours). 
If it does not act as a specific, it neutralises extreme 
acidity. Lemon juice may be combined with the bi- 
carbonate, whereby a citrate of potash is formed, which 
is reconverted in the system into carbonate. The juice 
of six lemons may be given daily. 
Opium in all its forms is very useful. Pretty large 
doses are required-1 to 2 grains may be given every 
day or twice a day, or even oftener, or an equivalent 
dose of the tincture or of the morphia salts. If there 
be any objection to opium, henbane, in the form of 
extract or tincture, may be substituted in doses of 5 
grains, or of | a drachm to 1 drachm of the tincture. 
The diet is very important. This should consist of 
milk and water with weak beef-tea. A moderate 
amount of alcoholic drinks may be allowed, such as 
gin mixed with the lemon juice, pure brandy or pure 
whisky, light claret and hock, cream of tartar, seltzer 
water, and especially potash and lithia water. The 
latest internal remedy that has been employed is 
Salicylic Acid, which appears to have great influence in 
reducing the temperature. 
In the treatment of valvular disease all powerful 
exercises, as running, riding, rowing, dancing, or any 
means by which dyspnoea may be caused, must be 87 
avoided; the diet should be light, and should consist 
of soup, eggs, poultry, game, light wines, dry sherry, 
and bitter ale. 
Digitalis possesses a remarkable power of regulating 
the action of the heart, strengthening the organ when 
force is insufficient, and diminishing activity when it is 
excessive. It is useful in nervous palpitation, when 
the heart is either too weak or too strong, and in the 
former case it is often advantageously combined with 
iron. The apparently paradoxical action of digitalis is 
explained by the supposition that the drug causes con- 
traction of the muscular fibres of the heart, equalising 
the movements of that organ and other parts of the 
circulatory apparatus. 
Digitalis co-operates with Hypertrophy in assisting 
the driving power of the heart, and acts similarly in 
Dilatation, though not so successfully. A compara- 
tively small dose is required in hypertrophy, a much 
larger one is tolerated in dilatation. 
In Mitral Obstruction, digitalis proves beneficial by 
assisting the driving power of the heart, especially of 
the right ventricle. 
In Mitral Regurgitation, digitalis is also useful by 
assisting the hypertrophy of the right ventricle. 
In Aortic Obstruction nature generally does all that 
is needful, but digitalis may be employed as an adjunct; 
when the hypertrophy is adequate to the task, small 
doses generally suffice, since large ones may cause over- 
contraction. 
In Aortic Regurgitation the efficacy of digitalis is 
more than doubtful. Dr. Fothergill considers its admin- 
istration hazardous, since it may drive the ventricle into 
a state of contraction, from which it may never become 
relaxed. 88 
Tricuspid Regurgitation is generally associated with 
a dilated right ventricle, and therefore digitalis is utterly 
useless, since there is no counteracting hypertrophy. 
Tricuspid Obstruction is exceedingly rare, and we 
have no experience either to justify or to reject the use 
of digitalis. The diuretic action of the drug renders it 
exceedingly useful in relieving the dropsy which is often 
attendant upon the valvular affection. 
The dose of tincture of digitalis is from 10 to 15 
minims in aromatic water, repeated two or three times 
a day; of infusion of digitalis, half an ounce may be 
combined with expectorants, when the lungs are con- 
gested or inflamed, and with diuretics, as the salts of 
potash, if dropsy supervene; and digitalis may be very 
usefully combined with iron when the powers of the 
system are much reduced. 
DISEASES OF THE BLOOD-VESSELS. 
THROMBOSIS AND EMBOLISM. 
A thrombus is a coagulum which forms in some parts 
of the vascular system. It usually occurs iu one of the 
heart's cavities, or in a vein, but it may arise in an 
artery, as is the case with an aneurism. It may be 
caused by endocarditis, through the roughening of the 
lining membrane, with which it comes in contact, or it 
may ensue from the current of blood being retarded. 
A thrombus may become organised, blood vessels being 
developed iu it. in which case it is ultimately converted 
into connective tissue, and adheres closely to the vessel 
in which it arises; or the thrombus may soften, 
breaking up into a pulpy mass, which microscopically 89 
presents fat globules, altered blood corpuscles, and 
granular matters. 
An embolus is the term given to that portion of a 
thrombus, or of an excrescence, which becomes detached 
from the valves of the heart, and being driven on by 
the blood, at last meets with a vessel the calibre of 
which will not admit of its passage, and in which it 
therefore becomes fixed. 
Foreign matters introduced into blood induce coagu- 
lation on their surface, such as solid metallic bodies, Iron, 
Mercury, Pus, etc. A clot of fibrine in the blood-vessels 
tends to increase by addition, layer upon layer. 
Thrombosis may be caused by phlebitis, arteritis and 
endocarditis from solid exudations from the inner sur- 
faces of the membranes. A film of coagulum being 
formed upon a roughened and inflamed surface, layer upon 
layer is deposited, and it in time becomes a thrombus, 
one portion being attached and the other freely vibrating 
in the circulating fluid; portions will become detached, 
and at length meeting with a vessel whose calibre will 
not allow passage, an embolus is formed. 
The thrombus may reach from one side of a vessel to 
the other, and obstruct the passage of blood from below. 
Hence pouch-like dilatation and aneurism. Pus may 
be formed in the centre of a thrombus, and henco 
pyaemia. When a coagulum has formed in the right 
side of the heart the pulmonary circulation is most 
liable to be affected; when the mitral and aortic 
valves are the seat, the cerebral vessels are liable to be 
obstructed; when those organs the blood of which is 
returned by the portal vein, the liver may be obstructed. 
When the blood-stream is obstructed by an embolus, 
the functions of the parts thus robbed of their nourish- 
ment are destroyed. 90 
Paralysis may occur if a portion of the brain becomes 
anaemic by the pressure of an embolus. Congestion 
occurs in the surrounding vessels, and generally haemor- 
rhage takes place, unless the circulation is carried on 
through collateral branches,in which case the injury will 
only be temporary. Softening or suppuration takes 
place in the structures which are permanently deprived 
of blood. The brain is most frequently the seat of 
softening, since the emboli which impede its circulation 
are derived from the heart. In the liver and lungs, 
suppuration is more common, in consequence of the 
clots by which their vessels are obstructed being as 
a rule derived from veins obstructed by decomposing 
blood. 
ANEURISM - AORTIC (aoor^, the great artery, 
dvtu^vu, to dilate.) 
Varieties: 
(1) True Aneurism; all the coats of the artery 
dilating and uniting to form the walls of the pouch. 
(2) False Aneurism; the inner and middle arterial 
coats becoming ruptured, the walls being formed by 
the cellular coat and the surrounding parts. 
(3) Consecutive or Mixed Aneurism ; the three coats 
having first dilated, the middle and inner ones, as the 
distension increases, becoming subsequently ruptured. 
(4) Dissecting Aneurism ; when tiie two inner coats 
are ruptured and the blood forces itself by a false 
passage between them and the outer coat. 
(5) Varicose Aneurism; when communication has 
taken place between the aorta and pulmonary artery, 
or between the aorta and either of the venae cavae, or 91 
between the aorta and the right venticle, or the aorta 
and even the auricles. 
Causes.-Aneurism of the aorta is usually confined 
to advanced life. It may be caused by calcareous, athero- 
matous or fatty degeneration of the vascular coat. 
When the aneurismal tumour is of small size, it is 
seldom detected. 
Termination.-In death from haemorrhage, due to 
rupture of the sac, or in sudden death without rupture, 
as if from suffocation. Gradual sinking from exhaus- 
tion, resulting from the protracted suffering. Debility, 
due to repeated loss of small quantities of blood, or from 
accompanying pulmonary phthisis. 
ANEURISM OF THE THORACIC AORTA 
Is chiefly observed in the ascending portion or transverse 
part of the arch, but it may occur at the roots of the large 
vessels arising from the arch. 
Symptoms.-These are the same as those produced 
by any tumour in the chest of equal size, viz. : 
Dyspnoea, with more or less solidification of the lung 
in consequence of the pressure of the aneurismal tumour; 
harsh cough, with or without expectoration, from 
pressure upon the bronchi. 
Dysphagia, by pressure on the oesophagus. 
Aphonia and spasmodic constriction of the glottis, from 
tension of the inferior or recurrent laryngeal nerves. 
Neuralgia of the back, with Paraplegia, by pressure 
on the spine, succeeded by absorption of the vertebrae. 
Venous Obstruction, in extreme cases accompanied by 
dropsical effusion into the areolar tissues of the neck, 
chest, face and upper extremities, by pressure upon the 
large venous trunks. 92 
Inanition, by pressure upon the thoracic duct, has 
been also stated to result from aneurism. 
Thoracic aneurism is difficult to recognise if the 
tumour is of small size, or involves the orifice of the 
aorta. 
It is comparatively easy to recognise when the arch 
of the aorta or any of its branches is the seat of mischief, 
or when it has increased sufficiently to rise out of the 
chest; and the diagnosis is certain when the tumour 
causes the ribs or sternum to protrude, or leads to 
their absorption, especially when there is a strong 
heaving impulse over the tumour, and thoracic dulness 
in proportion to its extent. A peculiar thrilling 
sensation on palpation, and a rapid thrilling pulse, are 
sometimes present, and a bellows murmur may be 
heard in the locality of the tumour; but this sound 
must not be considered diagnostic unless confirmed by 
other symptoms, since it may be caused by the pressure 
of any tumour upon the large vessels at the base of the 
heart. When the arch of the aorta or the large vessels 
of the neck or upper extremities are the seat of the 
tumour some notable inequalities in the pulsations of 
the carotid and radial arteries may be found. Occa- 
sionally the pulse at the wrist, or in one or both 
carotid arteries, is absent; giddiness, fainting, and 
indistinct vision indicating disturbance of the cerebral 
circulation may sometimes appear. In the absence of 
symptoms of pulmonary phthisis, or of obstruction in 
the portal circulation, etc., haemoptysis or haematemesis 
will be of additional importance in the diagnosis of 
aneurism. With a large tumour dulness on percussion 
and bronchophony may be present, according to the 
extent to which the lung is compressed. 
Treatment must consist in perfect rest and moderate 93 
diet; the bowels kept freely open; digitalis in small 
and repeated doses may be exhibited, or a belladonna 
plaster may be applied to the side; treatment must also 
be directed to the accompanying symptoms as they arise. 
ANEURISM OF THE ABDOMINAL AORTA. 
Symptoms.-These will vary according to the situ- 
ation and the size of the tumour, and the viscera upon 
which pressure is exercised. 
If the Stomach be pressed upon, severe dyspeptic 
symptoms arise; 
If the Bowels, violent colic or obstinate constipation ; 
If the Nerves of the Solar Plexus, neuralgic pains ; 
If the Spinal Nerves, severe pain in the abdomen, 
loins or lower extremities, resembling rheumatism, 
psoas, or lumbar abscess, disease of the spine or sciatica. 
When the rectum has been pressed upon, stricture of 
that part has been suspected, and abdominal aneurism 
has been mistaken for hepatic, splenic, or renal 
disease. When the upper part of the abdominal aorta 
is the seat of the tumour, the diaphragm may be 
pushed up, and dyspnoea and other pulmonary symp- 
toms arise. The tumour, if carefully examined, may 
frequently be found in the situation of the aorta; it will 
be felt to pulsate strongly, the peculiar thrill is present, 
and the stethoscope will detect a bellows murmur. The 
pulsation over an aneurismal tumour is diffused more 
uniformly than over any other abdominal tumour 
seated in front of the aorta; the bellows murmur is 
also harsher, and of a more grating character than that 
occasioned by such tumours. A healthy aorta may, 
however, communicate pulsation to a loaded intestine 
or other kind of tumour lying over it. 94 
DISEASES OF THE LIVER. 
HEPATIC CONGESTION. 
This affection of the liver occurs under three forms, 
viz. (1) Active, (2) Passive, leading to (3) Biliary 
Congestion, (a condition in which the ducts are en- 
gorged with bile). 
The Active form arises from an excessive supply of 
blood to the organ, resulting from intermittent fever, 
excess in eating and drinking, or from residence in 
tropical climates. It may also be caused by morbid 
materials in the blood, or by the suppression of habitual 
discharges (catamenial or haamorrhoidal),or by sedentary 
habits. 
The Passive form may occur from obstruction to the 
circulation through the portal and hepatic veins, or 
from obstruction of the blood-flow into the heart, due 
to dilatation of the heart or valvular disease; from 
emphysema and other diseases of the lungs, in which 
the venous blood-flow through the right side of the 
heart is obstructed; but blows on the side, and in- 
temperance, especially when spirits have been freely 
indulged in, are common causes, of hepatic congestion. 
It may precede or accompany cirrhosis and other 
diseases of the liver. 
In the first two forms the liver is enlarged, its 
surface is smooth and dark red, with a hard and 
prominent margin, and on section blood flows freely. 
The so-called "nutmeg liver" (black spots upon a 
yellow base) is the result of long-standing congestion. 
Biliary Congestion usually gives rise to jaundice. 95 
Symptoms.-There is slight tenderness over the 
liver, the surface of which is smooth; pain and 
weight in the right hypochondrium, pain of a gnawing 
character, referred to the right shoulder, headache, 
vomiting or nausea, foul tongue, slight jaundice, ano- 
rexia and constipation ; fever is absent. 
In pleuro-pneumonia of the right side, similar symp- 
toms to the above are not unfrequently observed. 
In Chronic Congestion, the same symptoms are de- 
veloped, but they are generally much less severe. 
Treatment.-In the Active form : remove the cause, 
enjoin plenty of exercise and plain diet, as white fish, 
weak tea, rice; give aloetic purgatives, liquor potassae, 
followed by simple tonic infusions-senna, jalap, and 
podophyllin are, with small doses of mercury, occa- 
sionally very useful, and nitro-hydrochloric acid is of 
great service. 
In the Passive form, sulphate and carbonate of 
magnesia, sulphate of soda and sulphuric acid, aloes, 
senna, sulphate of iron and magnesia, leeches to the 
anus, and certain mineral waters-those of Carlsbad, 
Harrogate, etc.-simple diet, avoidance of stimulants. 
ACUTE HEPATITIS the Liver; itis). 
Definition.-Inflammation of the liver substance. 
This disease is very rare in England, but is common 
in tropical climates. It is usually met with in this 
country only as 
PERI-HEPATITIS, 
or inflammation of the peritoneal investment of the 
organ. It is generally accompanied by adhesions to 
neighbouring organs, and may occur with general peri- 96 
tonitis, or result from the irritation of an abscess of the 
liver, or from an hydatid or a cancerous tumour. 
Symptoms.-High fever, sometimes of a very severe 
character, and preceded by rigors. There is enlarge- 
ment of the organ, with fulness of the right hypochon- 
drium ; pain in the hepatic region of greater or less 
intensity, aggravated by pressure, cough, or deep 
inspiration ; inability to lie upon the left side. Jaun- 
dice is usually present, with dyspnoea, vomiting and 
hiccough. There is sometimes pain in the shoulder of 
a gnawing, aching character. These symptoms may, 
however, be absent in some cases, and the first indica- 
tion of the disease may be the bursting of an abscess 
into the lungs or oesophagus, or distinct fluctuation on 
palpation. 
Causes.-Inflammation of the pleura by extension 
downwards; mechanical injury ; suppurative inflamma- 
tion of a vein, by which the blood is contaminated with 
pus; hot climates and marsh fever, in which the func- 
tions of the liver become deranged; ulceration of the 
intestines, of the gall bladder or gall ducts; spirit 
drinking. 
Terminations:-(1) In Resolution ; (2) In Diffused 
Suppuration ; (3) In Circumscribed Abscess ; (4) In 
Gangrene. When the inflammation is spread pretty 
generally over the whole liver, softening or induration 
may result. When it is more circumscribed, and this 
is more common, then abscess frequently follows. 
HEPATIC ABSCESS, 
Besides being the result of hepatitis in hot climates, is 
generally observed either- 97 
(1) Connected with Disease of the Colon, or 
(2) Resulting from Pyaemia. 
In the first case the abscess is usually single and 
large, the pus being surrouuded by ragged, softened 
liver substance, or enclosed in a thick, tough mem- 
brane. 
In the second case small abscesses are observed in 
the course of the portal veins. 
When an hepatic abscess is single, it usually selects 
the right lobe of the organ. It may burst externally, 
or into the peritoneum, into the chest, or the canal of 
the intestine, or the pus may dry up and leave a cheesy 
mass. 
The single abscess is generally the result of acute in- 
flammation, but when pyaemia precedes, then numerous 
purulent deposits are occasioned. Solitary abscess is very 
rare, except from residence in the tropics, or in persons 
subject to dysentery, but when it does take place there 
may be bulging, tenderness on pressure, and obscure 
fluctuation over some part of the liver region; yet, in 
some cases, physical signs are wanting, and the diagnosis 
can only be a matter of conjecture. 
Multiple pyaemic abscesses may result from wounds 
or surgical operations, from internal abscess or ulcera- 
tion of the pancreas, stomach, or intestines. 
Hepatic suppuration is frequently preceded by 
dysentery, since the fcetid contents of the large in- 
testine, or the pus occasioned by their ulceration, are 
absorbed and rapidly carried to the liver. 
Other causes of abscess are ulceration of the rectum, 
bladder and vagina. 
Abscesses of the liver are sometimes of great size, 
and have been known to contain pints of pus. They 
may open into the peritoneum and set up fatal periton- 98 
itis. It is not unfrequent to find, however, that 
adhesive inflammation is set up in the portion of 
peritoneum immediately above the purulent surface, 
and the effused lymph glues the organ to the parts 
adjacent. The determination of abscess is towards some 
opening; it may point in various directions-to the 
chest, or abdominal parietes, or posteriorly, or in- 
ternally into the intestines, the windpipe or the 
oesophagus. 
The formation of abscess is indicated by chills or 
distinct rigors, hectic fever, and gastric disturbance. 
There is pain with extreme tenderness on palpation, 
and tension of the abdominal muscles; emaciation, 
dysentery or diarrhoea. 
Pathology of hepatitis :- 
(1) There is great Congestion of the capillaries of 
the liver, with consequent swelling. 
(2) Then effusion of Albumino-Fibrine or Plastic 
Lymph takes place. 
(3) The attack ends in (a) Resolution, with ab- 
sorption of the exsudate, (b) in Purulent Infiltration, 
(c) in Abscess, (d) in Gangrene. 
Treatment of a*eute hepatitis :- 
Salts of soda and potash, and salines generally, 
leeches, calomel, blue pill, ipecacuanha, fomentations, 
restricted diet, and complete rest in bed. 
After Suppuration; bark and ammonia, mineral 
acids, nitro-hydrochloric acid, quinine, opium, wine, 
and nourishing food. 
Puncture should be made with the trocar and 
canula or aspirator, if the surface of the abscess is 
adherent to the abdominal parietes. 99 
HYPERTROPHY OF THE LIVER. 
Definition.-Simple enlargement of the liver; it is 
not a very common disease. 
Symptoms:- 
Rational Signs.-None are diagnostic. 
Physical Signs.-On palpation the liver is felt to be 
enlarged. On percussion the area of hepatic dulness 
is increased. 
Causes.-Long continued congestion from residence 
in tropical climates or malarious districts, and as a 
result of intermittent fever. 
Hepatic Hypertrophy maybe associated with phthisis, 
dysentery, saccharine diabetes, and leucocythemia. 
A portion of the gland may be rendered useless by 
disease, and the cells of the healthy parts then become 
enlarged, preventing systemic derangement; this 
partial hypertrophy is then of a compensatory nature. 
Terminations.-Not a fatal disease, but curable by 
appropriate treatment. 
Pathology.-A simple enlargement characterised by 
an increase in the secreting cells, which may be either 
multiplied in number or increased in size. 
Treatment.-Painting with iodine, and the use uf 
iodide of potassium internally, since this latter pro- 
motes the absorption of tumours generally. 
The edge of the liver should be felt from time to time 
to ascertain if the organ is diminishing in size. 
ACUTE YELLOW ATROPHY. 
This is a rare disease, to which women are more 
liable than men, and young persons more so than old ; 
pregnancy appears to be a predisposing cause. 100 
The leading symptoms are the following : jaundice, 
diminution of the area of hepatic dulness, pain in the 
epigastrium, vomiting (sometimes of blood), headache, 
delirium, coma, rapid pulse, obstinate constipation, 
thirst, a dry brown tongue, haemorrhage from the nose, 
stomach, bowels, or uterus. In an early stage the 
amount of urine is considerably diminished. There is 
extravasation under the skin, consisting of petechiae or 
ecchymoses. It is a very rapidly fatal disease, usually 
running its course in about a week. The disease is 
very often not discovered until after death, and the 
causes are unknown, but it is supposed to depend 
upon a deficiency of nourishment. 
Two ingredients are found in the urine, and are 
almost characteristic, viz. :- 
(1) Leucine (C6H13NO2). 
(2) Tyrosine (C9HUNO3). These substances are 
obtained by treating the urinary residue with alcohol. 
Leucine when pure separates in "gland-like masses 
of leaves or scales (also like balls) whose contour is 
difficult of determination." 
Tyrosine forms an adhesive mass consisting of 
" shining long needles clustered together." 
Concentrated urine should be digested with cold 
absolute alcohol, and the residue treated with boiling 
spirits of wine; the leucine becomes deposited on 
evaporation. The liver leucine crystallises in little 
balls or spheres, in some of which a " radiated stellar 
arrangement " may be detected. Some authors regard 
leucine as a product of the too rapid destruction of 
tissue. Tyrosine is found wherever leucine occurs. 
Tyrosine with perchloride of iron free from acid gives a 
dark rich violet colour. Hoffman says "that nitrate 
of protoxide of mercury added to a boiling aqueous 101 
solution of tyrosine, causes the precipitation of red 
flakes, the clear liquid being of a deep pink or dark red 
rose colour." 
Pathology.-The liver is reduced in size; it is of a 
greenish-yellow colour, soft and flaccid. Microscopi- 
cally the lobules are indistinguishable, the hepatic cells 
have disappeared, and are replaced by a mass of pig- 
ment, granular matter and oil globules. The spleen is 
also usually enlarged. There appears to be a complete 
and rapid disintegration of the hepatic cells throughout 
the whole extent of the gland. 
Treatment.-Probably useless. The usual remedies 
employed are purgatives, followed by the mineral acids, 
with diffusible stimulants, large doses of quinine, and 
cold drinks. 
CIRRHOSIS (x/sgo?, yellowish). 
Definition.-An affection of Glisson's capsule (the 
fibrous investment of the hepatic vessels surrounding 
them, entering with them into the substance of the 
liver, and accompanying them to their ultimate ramifi- 
cations in the organ). 
Symptoms : 
Rational signs.-These are generally obscure and 
insidious; the only indications present may be dys- 
peptic symptoms, such as nausea, retching and vomit- 
ing in the morning, aversion to food, and craving for 
stimulants, flatulence and irregular bowels; the skin is 
of a brownish hue, and there is probably emaciation. The 
urine is thick, and often contains lithates, and there may 
be some dull pain in the right hypochondrium. If 
hmmatemesis occurs in addition to these indications, it 
may be regarded as almost diagnostic, and should ascites 102 
supervene, the nature of the disease is certain. Epi- 
staxis is an occasional symptom, and the bleeding from 
the nose has sometimes been very considerable. 
Physical Signs.-In the early stages of the disease 
the organ may be found enlarged on percussion and 
palpation, and the edges rounded, but in course of 
time the liver shrinks, and the edges will not be found 
at all. 
No symptoms are conclusive until the occurrence of 
ascites (abdominal dropsy), which is often the only 
diagnostic or pathognomonic sign of the disease. 
Roughly speaking, then, the leading characters of 
cirrhosis of the liver are, dyspeptic symptoms, fol- 
lowed by hsematemesis and terminating in ascites. 
There is no equivalent English term for cirrhosis ; 
it has sometimes been termed the gin-drinker's liver, 
but it has occurred in persons in whom there has 
been no history of drinking. By some authors it has 
been termed chronic hepatitis. Jaundice, although it 
does occur, is never well marked, and only appears 
very late in the disease; the duration of cirrhosis is 
about twelve months, or even more. 
Terminations.-Usually fatal, unless arrested early, 
death ultimately resulting from a weakened condition 
of the system. 
Pathology.-In health, the hepatic artery conveys 
the nutrient blood to the liver, the hepatic duct 
carries away the bile, the portal vein conveys blood 
from the viscera to form the bile, and the hepatic vein 
carries from the liver the waste blood ; but in cirrhosis 
there is a fibroid hypertrophy of the capsule of Glis- 
son, and, therefore, thickening and hardening of the 
liver, the edges of which become rounded, and the sur- 
face nodulated (hobnailed). 103 
In the early stages of the disease the organ becomes 
enlarged, but it eventually becomes shrunken and. shuts 
off the supply of blood by the hepatic artery, producing 
atrophy and pallor; this contraction of the liver ob- 
structs the circulation through the portal vessels, pro- 
ducing enlargement of the veins upon the surface of 
abdomen, and by compression upon the portal vein 
induces ascites, for since the blood stream is thrown 
back upon the intestines, no absorption takes place, and 
watery fluid is thrown out into the peritoneum. From 
pressure upon the hepatic duct the bile flow is arrested, 
and this fluid is not properly secreted. 
Microscopically the secreting cells are disintegrated, 
there is a multiplication of the fat cells, an increase in 
the colouring matter, and deposit of granular matter. 
The spleen may be enlarged, and haemorrhage may 
occur from congestion of the mucous membrane of the 
stomach and bowels. 
Treatment.-This should consist at first in allevia- 
ting the dyspepsia by plain food, sulphate of magnesia, 
podophyllin, mercury in moderation, nitro-hydrochloric 
acid, and certain mineral waters, etc. When the 
malady is thoroughly established, nitro-hydrochloric 
acid, mix vomica, bitter tonics and rhubarb are in- 
dicated, and iodine inunction may be sometimes bene- 
ficially employed. For the ascites, the indications aie 
squills, digitalis, scoparium, the potash salts, and ela- 
terium, pul vis jalapre compositus, nourishing food, milk, 
raw eggs, and stimulants in moderation; and as a last 
resource, paracentesis abdominis. Cupping and leeches 
should be avoided, and mercurials should be cautiously 
used, especially calomel, since this drug promotes cell 
disintegration. 104 
HYDATID TUMOURS (War?f, a vesicle). 
Hydatids are more common in the liver than in any 
other organ. They are sometimes met with in the 
spleen, omentum, brain, and uterus, and often attain 
an enormous size. The whole affected organ is enlarged, 
and the enlargement is not uniform, the increase being 
greatest near the affected part. The liver structure is 
quite healthy. 
A hydatid consists of a sac lined by a thin bladder 
or cyst, which is filled with a limpid, colourless fluid, 
in which float numerous smaller cysts called acepha- 
locysts, similar to the cyst lining the sac, and varying 
in size from that of a pea to a pigeon's egg. These 
cysts contain the echinococci which are developed from 
the ova of a tape-worm (Taenia Echinococcus), which 
infests the intestines of the dog. 
Each echinococcus is an oval-shaped animalcule 
having about 34 booklets arranged in a circle round its 
head, and when the creature is viewed with the head 
retracted, the circle of hooks appears like a ring in the 
centre of the body. 
It is supposed that the ova are expelled with the 
faeces of the dog, and find their way into the human 
economy through the food and drink. It is unknown 
how they enter the liver and other organs. 
Symptoms of hepatic hydatid:- 
Rational signs.-None of these are diagnostic. 
There may be a little local pain, but very little consti- 
tutional disturbance. 
Physical signs.-There is enlargement and fluctua- 
tion, and the " hydatid thrill." This thrill or vibration 
is found by percussion when the hydatid is near the 
surface, and is recognised by a trembling sensation 105 
communicated to three fingers of the left hand placed 
flat upon the tumour, the back of the left middle finger 
being sharply struck by the tip of the middle finger of 
the right hand. 
Terminations.-Not usually fatal, unless opening 
into one of the principal cavities. Hydatid tumours 
may compress the portal vein or vena cava, causing 
ascites and oedema of the legs. They may burst into 
the peritoneum, producing peritonitis, or into the lungs 
or intestines or abdominal wall. In the two latter 
cases the contents will be entirely discharged, and the 
sac closing up leaves the patient well. Sometimes 
recovery takes place by the secretion of a thick putty- 
like matter within the sac which chokes the hydatid. 
Treatment of hepatic hydatid.-Iodide of potassium; 
electricity; common salt; removal of the contents; 
tapping; injection of iodine solution, a drainage tube 
being subsequently inserted. 
HEPATIC CARCINOMA 
The liver may be the seat of every variety of cancer, 
but the soft form (medullary) is more common than 
the hard (scirrhus). 
Symptoms.-There are the general signs of malignant 
disease (the cancerous cachexia). The patient is feeble, 
anaemic, sallow and emaciated ; the pulse is weak ; there 
is absence of fever; jaundice may be present, caused by 
the pressure of enlarged cancerous glands upon the 
common bile duct. In cancerous jaundice the skin 
may be of a very deep yellow or even greenish-brown 
colour. There may be severe pain with tenderness on 
pressure in the right hypochondrium or epigastrium. 
Hepatic Cancer is frequently associated with cancer 106 
of some other organs, as the uterus, breast, or stomach, 
and with enlargement of the cervical glands. Dropsy 
of the abdomen and legs is occasionally, though rarely, 
present. The liver is enlarged, the enlargement not 
being uniform, but uneven, and bulging prominences 
may be detected. Cancer of this organ is usually circum- 
scribed, presenting itself as a tumour or tumours varying 
from the size of a pea to that of a child's head. 
In Medullary Sarcoma of the liver the enlargement 
is considerable, soft and doughy, and may communicate 
to the hand a feeling of fluctuation. 
In Scirrhus of the liver the enlargement is hard and 
knobby, slight projecting nodules being scattered through 
the organ. It is distinguished from cirrhosis, since it 
does not so commonly lead to atrophy or dropsy. 
Terminations.-Always fatal. Tumours are often 
found adherent to the diaphragm or abdominal wall, 
since local peritonitis is frequently set up in the vicinity 
of the tumours, by which means adhesions take place 
between them and surrounding organs. The disease is 
rare under 40 years of age, and death usually takes 
place within a year. 
Treatment.-Treat the symptoms. 
Hypodermic injections of morphia afford the most 
relief 
It will be observed that in each of the three con- 
ditions, hepatic abscess, hydatid tumours of the liver, 
and medullary sarcoma affecting that organ, there is 
fluctuation on palpitation. The diagnosis of these 
diseases is therefore a matter of great importance. 
In the Hepatic Abscess there will probably be the 
history of previous residence in the tropics, and the 107 
occurrence of severe rigors and vomiting ; the constitu- 
tional disturbance is also very great. 
The exploring needle will evacuate pus. 
The Hydatid Tumour usually gives rise to only a 
little local pain, the constitutional disturbance being 
never well marked. 
The exploring needle yields a thin colourless fluid in 
which the echinococci may be found. 
In Medullary Sarcoma of the liver the constitutional 
symptoms are well marked, the emaciation is extreme, 
and the pain severe. The exploring needle will pro- 
bably evacuate only a few drops of blood and a cancerous 
juice, in which may be observed caudate multinucleate 
cells. 
FATTY LIVER. 
Fatty disease of the liver is a frequent accompani- 
ment of pulmonary phthisis and fatty disease of other 
organs, and has been observed in syphilis, and after 
death from typhus fever, variola, etc. It frequently 
results from chronic alcoholism. 
Symptoms.-The organ is uniformly enlarged, and it 
feels rather soft and smooth. There is no pain 01 
tenderness on pressure in the right hypochondrium 
or epigastrium. The complexion is pasty, the skin is 
bloodless, resembling fine polished ivory, and there 
is constipation or diarrhoea ; haemorrhoids, and anaemia, 
and occasionally ascites, may be present. There is no jaun- 
dice, no albuminuria, nor dropsy. The symptoms com- 
plained of are indeed very indefinite, and are mostly 
those of uneasiness. The spleen is not usually enlarged. 
Pathology.-In the normal condition the liver con- 
tains a certain amount of oil, but in this disease the 
hepatic cells are crammed with oil-globules and their 108 
nuclei are obscured or disappearing. The edges of the 
liver are round and greasy to the touch, the whole 
gland being of a pale fawn-colour. The morbid process 
appears to commence in the circumference exterior to 
the lobules, and to spread towards their centre. The 
normal weight of the liver being 4| lbs., in this con- 
dition it may even exceed 12 lbs. 
It is a necessarily fatal disease, and may last about 
two years. 
LARDACEOUS LIVER. 
The gland may or may not be enlarged, but, when 
it is so, the enlargement is uniform. There is fulness 
with a feeling of smoothness and' hardness in the right 
hypochondrium, but no tenderness on pressure, accom- 
panied by anaemia, nausea, dyspepsia and flatulence, 
and sometimes, though rarely, severe pain, ascites and 
iaundice. The substance of the organ is hard, like 
wax, giving a brown staining when tincture of iodine is 
applied to the tissue. The disease is always fatal. 
Virchow applied the name ' Amyloid ' to this con- 
dition from a supposed analogy of the morbid material 
to starch (amylum). It may co-exist with the fatty 
liver, with cirrhosis or with syphilitic gummata, and 
is generally observed in connection with carious bones, 
drainages of pus, etc. The spleen is usually similarly 
affected and enlarged. The structure of the gland is 
converted into dense matter, and the abolition of its 
functions is occasioned by the destruction of the hepatic 
cells. The minute vessels, especially the arteries, are 
first affected, the morbid change then extending to the 
capillaries, and subsequently invading the proper ele- 
ments of the implicated texture. The cells in the 109 
middle of the lobules are generally first affected, the 
morbid change then spreading towards the centre of the 
lobules themselves. 
TUBERCLE OF THE LIVER. 
Deposits of tubercle are very rare in the liver. They 
are probably always connected with advanced tubercu- 
losis of other organs, especially of the abdominal 
viscera. The whole gland may be studded all over 
with semi-transparent miliary granulations, or with 
yellow cheesy deposits. 
SYPHILITIC LIVER. 
In this condition there are yellowish white firm 
tumours. They are generally observed upon the ex- 
terior of the organ and extending inwards. The 
lardaceous liver is often of syphilitic origin. 
INFLAMMATION OF THE BILIARY 
PASSAGES. 
The forms of inflammation to which the gall bladder 
and biliary ducts are liable are the three following :- 
(1) Catarrhal Inflammation.-In this form there is 
an increase of mucous secretion which becomes viscid 
or muco-purulent. Occasionally a firm plug of mucus 
may obstruct, for a time, the cystic or common duct. 
It is generally preceded by catarrh of the stomach and 
duodenum. 
(2) Plastic or Exudative Inflammation.-In this 
there are fibrinous products. Casts of the tubes are 
found blocking up these channels and causing dilatation. 110 
(3) Suppurative Inflammation, in which a thick 
kind of blood-stained mucus and pus are formed. 
Ulceration may follow; it is usual to find gall-stones 
when the gall bladder is ulcerated, but ulceration may 
be induced by decomposing bile, in the absence of 
calculi. 
Symptoms.-These vary very much. The hepatic 
ducts are less liable to inflammation than the gall 
bladder, and than the common and cystic ducts. In 
the catarrhal form there may be slight tenderness in the 
right hypochondriac and epigastric regions, with consti- 
pation and nausea. If many of the ducts are blocked 
by viscid mucus there will be jaundice. 
The biliary passages may become partially dilated 
from inflammatory swelling of the mucous membrane, 
from accumulated bile, from calculi, and from fibrinous 
or catarrhal exudations. A globular or pear-shaped 
tumour is sometimes formed, which may contain large 
quantities of fluid, in consequence of the obstruction 
allowing the entrance of bile, but preventing its exit. 
Treatment. - This must vary according to the 
symptoms, but amongst the remedies employed may 
be mentioned fomentations and sedatives, simple 
salines, ammonia and bark, nitro-hydrochloric acid, 
Carlsbad water, leeches to the anus or to the liver, 
calomel and blue pill. 
JAUNDICE (jaunir, to become yellow). 
ICTERUS (izwos, a yellow bird). 
Although jaundice is, strictly speaking, a symptom, 
still, since in a great many cases no positive cause for 
its presence can be assigned, it may be termed a disease 
per se. 
Causes.-(1.) Suppression of the biliary functions, by 111 
which the blood becomes charged with cholesterine and 
the colouring matter of the bile. 
(2.) Obstruction to the bile-flow into the duodenum, 
the bile, although properly formed, being re-absorbed 
by the blood. If this condition be of long continuance, 
suppression may also take place. 
Thus jaundice may occur from obstruction of the 
biliary ducts, either from spasm, atony, or sluggishness 
of these tubes. 
Symptoms.-There is a yellow colour of the skin, 
especially marked in the conjunctives. The stools are 
of a light colour, like clay, the urine is thick and of a 
deep red or brownish-black colour, usually loaded with 
lithates, and giving an iridescent play of colours with 
strong nitric acid. There is no fever, no thirst, and 
no pain, but the patient is much depressed. There is 
usually constipation, but occasionally, though rarely, 
diarrhoea. The pulse is weak, the appetite bad, the 
tongue is foul and coated, and itching of the skin is 
usually very distressing. Giddiness is sometimes com- 
plained of, and all objects may appear yellow; in ex- 
treme cases the sweat and saliva are yellow. Recovery 
is the usual termination, but if the disease continues 
long there may be stupor, delirium, and other signs of 
cerebral mischief. There is occasionally a tendency to 
hmmorrhage, such as bleeding from the gums or the 
nose, purpura, etc. 
Although jaundice may arise without any ascertain- 
able cause, and be only a transient affection, yet it must 
be borne in mind that it is often occasioned by very 
serious conditions ; thus structural disease, or cancer of 
the liver or pancreas, closure of the ducts from adhesive 
inflammation of the liver, the presence of gall-stones in 
the ducts, and the pressure of any tumour, may be 112 
causes of jaundice. Fsecal accumulations and enlarge- 
ment of the uterus have given rise to this condition, 
and it has been observed in severe forms of relapsing 
and intermittent fevers, and, in a mild degree, in pyae- 
mia, typhus fever and pneumonia. In all these in- 
stances, however, the jaundice is only a symptom, and 
in every case of the kind the most careful examina- 
tion should be made to ascertain the presence of 
any positive disease, for on the care with which this 
inquiry is made will the prognosis of each case mainly 
depend. 
If jaundice arise from Suppression, only those in- 
gredients of the bile which exist already formed in the 
blood are found in the urine ; but when it results from 
obstruction, the matters generated in the liver itself are 
also found, viz. : the bile acids. 
To discriminate between these conditions, about 
two fluid drachms of urine are generally added to half 
a drachm of strong sulphuric acid, with a small frag- 
ment of loaf sugar. Obstruction will be indicated by 
a purple or scarlet colour appearing at the line of 
contact of the two liquids, and caused by the oxida- 
tion of the bile acids. Suppression is shown by a mere 
browning of the sugar. 
Treatment.-Of simple jaundice without assignable 
cause. This should consist of mild mercurials, or podo- 
phyllin, colocynth, aloes, followed by hydrochloric acid 
and sulphate of magnesia. Some distinguished autho- 
rities, however, recommend alkalies, as potash and 
soda. When jaundice arises from known causes 
the treatment must be directed to the removal of the 
latter. 113 
HEPATIC OR BILIARY COLIC, 
Is caused by the passage of a gall-stone from the gall- 
bladder into the duodenum. 
Symptoms.-There is agonising pain in the epigastric 
and right hypochondriac regions, extending upwards to 
the right shoulder, usually relieved by pressure, and 
accompanied by nausea, vomiting, flatus and constipa- 
tion. Rigors are not uncommon. If the stone recedes 
into the .gall-bladder these symptoms will cease, but if 
it becomes impacted, dropsy of the gall-bladder may 
ensue, and the duct become ulcerated or gangrenous. 
If permanent obstruction takes place the jaundice in- 
creases, the liver progressively enlarges, and there is 
great distension of the gall-bladder. There is great 
danger of a fatal termination unless the stone be forced 
into the bowel, or adhesive inflammation be set up, or 
the stone finds its way through the abdominal parietes, 
or into the intestine after ulceration and perforation. 
The sudden cessation of pain shows that the stone 
has passed into the duodenum. 
If the evacuations be diluted with water, the gall- 
stones may be seen floating upon their surfaces. 
Treatment.-This must be directed to the relief of 
the spasms by such remedies as opium, chloroform, 
emetics, the hot bath and fomentations. 
GALL-STONES. BILIARY CALCULI. 
These stones may vary from the size of a pea to a 
walnut; in colour they are brown, greenish, or yellowish- 
brown. They are somewhat greasy to the touch, and 
of slight consistency. 114 
Their specific gravity is 1027. 
Gallstones may sometimes be simple, in which case 
they consist of pure crystallised cholesterine, bile resin, 
or soap and cholesterine; or they may be compound, with 
nuclei, which are surrounded by a shell, and a rind or 
crust. In chemical composition the compound biliary 
calculi consist of cholesterine (70 to 80 per cent.), and 
biliary colouring matter, sometimes blended with car- 
bonate and phosphate of lime. 
Cholesterine is a peculiar substance which exists in 
solution in healthy bile, but which under certain cir- 
cumstances becomes released from its solvent and 
assumes a crystalline form. In all cases the nucleus 
of the concretion consists of a small piece of solid 
biliary matter, or of inspissated bile cemented by 
mucus. Gall-stones are found in one or two states, 
either solitary (oval or globular), or multiple (with 
polished facets from constant friction). They occasion 
no pain or inconvenience unless the gall-ducts are 
obstructed, and as many as 300 have been found in a 
single gall-bladder, no symptom having arisen during 
life to indicate their presence. 
They are rare under the age of twenty-five, and occur 
with tolerable frequency after forty. 
They are more often observed in females than in 
males in the proportion of 3 : 2. 
The formation of gall-stones is favoured by sedentary 
habits, by tumours pressing upon the biliary passages, 
catarrh of the ducts or inflammation of the gall-bladder, 
or any cause tending to compress or obstruct the flow 
of bile. 115 
Definition.-A vomiting of blood. 
Symptoms.-Blood is brought up usually in large 
quantities, dark-coloured or grumous, and mixed with 
food. It is not frothy. There is nausea with tension at 
the epigastrium. Melama (discharge of dark-coloured 
blood from the bowels) is common, and there are 
symptoms of duodenal or gastric disturbance. 
Causes.-Cirrhosis of the liver; congestion and ulcer 
of the stomach, or the rupture of an aneurismal tumour 
into the stomach. Haematemesis may also occur in 
purpura, or be vicarious of menstruation in cases of 
amenorrhoea. 
Treatment.-Rest; abstinence from food for some 
hours, followed by farinaceous diet. When the 
haemorrhage is excessive, drinks of iced water or rough 
ice may be swallowed, or ice should be applied to the 
pit of the stomach. Mineral and vegetable astringents 
may then be given, as gallic acid, and diluted sulphuric 
acid, with tincture of opium; and, in fact, the general 
treatment of haemorrhage should be adopted. If vicari- 
ous of menstruation, leeches may be applied to the vulva 
or anus. In cases of purpura, tonics, quinine and the 
mineral acids are the most appropriate remedies. 
HEMATEMESIS (a/^a, blood, vomiting). 
HEMOPTYSIS (aifza, blood, KruG/t, spitting). 
Definition.-A spitting of blood. 
Symptoms.-The blood is coughed up, either in 
large or small quantities. It is mixed with the sputa 
and not with the food, and is of a bright florid-red 
colour, and frothy. There is occasionally dyspnoea, 
with pulmonary or bronchial symptoms, but there is no 
melaena. 116 
Causes.-The following is the order of frequency of 
the conditions in which haemoptysis occurs :-(1) 
Tubercular disease, (2) Vicarious, as in amenorrhoea, 
(3) In disease of the heart and the rupture of an 
aneurism, (4) Least in frequency is the haemoptysis of 
plastic bronchitis, but spitting of blood may occur in 
congestion of the lungs, as in pneumonia, or in gangrene 
of those organs or in pulmonary apoplexy, and in pur- 
pura. The blood is sometimes swallowed, and it may 
then be vomited, in which case it will present the cha- 
racters of haematemesis. 
Treatment.-Rest, complete repose, the exhibition of 
cold liquids and sucking ice; no speaking except in a 
whisper. Astringents, as mineral acids and acetate 
of lead with excess of acetic acid in doses of 5 or 6 
grains daily, and the treatment of haemorrhage 
generally. INDEX. 
PAGE 
Acute Bronchitis . .47 
„ Hepatitis . . 95 
„ Lobar Pneumonia . 54 
„ Phthisis . . .65 
„ Yellow Atrophy of 
the Liver . .99 
Adherent Pericardium . 71 
uEgophony . . .60 
Albuminoid Degeneration . 19 
Amphoric Breathing ? . 63 
Amyloid Degeneration . 19 
Anasarca .... 8 
Anaemia . . . .10 
Aneurism . . . .90 
,, Abdominal . 93 
,, Aortic . . 90 
,, Thoracic . . 91 
Angina Pectoris . . 83 
Aortic Obstruction . .75 
,, Regurgitation . 75 
Asthma . . . .52 
Atheroma. . . .28 
Attrition Murmur . . 69 
Biliary Calculi . . . 113 
„ Colic . . .113 
Bronchial Breathing . , 55 
„ Polypi . . 50 
PAGE 
Bronchitis. . • .46 
„ Acute . . 47 
„ Chronic . . 49 
„ Plasticor'Fibrin- 
ous . . 50 
Bronchophony . . 55, 62 
Broncho-Pneumonia . . 57 
Bruit de Diable. . .11 
„ Soufflet . . 11 
Calcareous Degeneration . 28 
Calcification • . .28 
Cancer . . . .12 
„ Cell ... 13 
,, of the Heart . . 81 
„ „ Liver . . 105 
,, „ Lungs . . 67 
Carcinoma . . .12 
,, Colloid . .16 
,, Encephaloid . 14 
,, Epithelioma . 15 
„ Scirrhus . .14 
Catarrhal Pneumonia , 57 
Cavernous Respiration . 63 
Chlorosis . . . .12 
Chronic Pericarditis . . 71 
,, Phthisis . . 65 
Cirrhotic Pneumonia. .58 118 
PAGE 
Cirrhosis of the Liver . 101 
Crepitatio Redux . .56 
Cretification . . , 63 
Cyanosis . . . .81 
De-alkalised Fibrin . . 20 
Depurative Infiltration . 20 
Dilatation of the Heart . 79 
Diseasesof the BloodVessels 88 
„ „ Heart . . 68 
,, ,, Liver . . 94 
,, ,, Lungs . . 46 
Dropsy .... 8 
,, of Debility . . 8 
,, Cardiac . .9 
Febrile . . . . 8, 9 
Pulmonary ... 9 
Renal . . . . 8, 9 
Echinococci . . . 104 
Emphysema . . .51 
„ Interlobular . 51 
„ Substantive . 51 
,, Vesicular. . 51 
,, Vicarious. . 51 
Embolism. . . .88 
Empyema . . . .60 
Endocardial Murmurs . 76 
Endocarditis . . .71 
Erysipelas. . . .45 
Exocardial Murmurs. . 69 
Fatty Degeneration . . 27 
,, ,, of Heart 80 
,, „ „ Liver 107 
Fatty Growth or Infiltration 27 
Fibrinous Bronchitis . . 50 
Fibroid Pneumonia . . 58 
Fine Crepitation .. . 55 
Friction Sound . . 59, 69 
PAGE 
Functional Disturbances of 
the Heart . . .82 
Gall Stones . . .113 
Galloping Consumption . 65 
General Diseases . . 1 
Gout . . . .35 
„ Atonic . . .36 
„ Misplaced . .36 
„ Retrocedent . . 36 
„ Rheumatic . .34 
Green Sickness. . .12 
Grey Hepatisation . .54 
Gummata. . . .43 
Haematemesis . . .115 
Haematophilia . . .41 
Haemoptysis . . .115 
Haemorrhagic Diathesis . 41 
Heart Diseases, the . . 68 
Hepatic Abscess . 96, 97 
Hepatic Carcinoma . . 105 
Hepatic Colic . . .113 
Hepatic Congestion . .94 
Hepatisation of Lung . 54 
Hydatid Thrill . . . 104 
Hydatid Tumours . . 104 
Hydropericardium . . 69 
Hydropneumothorax. . 66 
Hydrothorax . . .60 
Hydrops .... 8 
Hyperaemia ... 9 
Hypertrophy of the Heart. 77 
,, of the Liver . 99 
Icterus . . . .110 
Interstitial Pneumonia . 58 
Inflammation ... 1 
„ Acute . . 1 
„ Chronic . 7 
„ Phlegmonous. 3 119 
PAGE 
Inflammation of the Biliary 
Passages . . . 109 
Inflammatory Effusion . 5 
„ Eever . . 2 
Jaundice . . . 110 
Jerky Inspiration . .62 
Lardaceous Disease . ; 19 
Lardaceous Liver . .108 
Leucine .... 100 
Leucocythsemia. • .37 
Leukaemia . . .37 
Liver Diseases, the . .94 
Lobar Pneumonia . .54 
Lumbago . . . .33 
Lung Diseases, the . .46' 
Lymphaemia . . .37 
Medullary Sarcoma of Liver 106 
Melanosis . . .14 
Metallic Tinkling . . 66 
Mitral Obstruction . .74 
„ Regurgitation . 74 
Morbus Caeruleus . .81 
Muco-crepitant Rhonchus . 63 
Muco-crepitation . .63 
Mucous Gurgle . .56 
Myocarditis . . .81 
Nutmeg Liver . . .94 
Organic Diseases of the 
Heart . . . .68 
Palpitation . . .82 
Pectoriloquy . . .63 
Pericardial Murmurs . 76 
Pericarditis . . .68 
Peri-hepatitis . . .95 
Phlogosis . . . . 1 
PAGE 
Phthisis . • • .61 
„ Acute . • .65 
,, Chronic . . .61 
Plastic Bronchitis . . 50 
Plastic Pneumonia . .54 
Pleurisy . . . .59 
Pleurodynia . . ,33 
Pneumonia . . .54 
Pneumorrhagia. . .66 
Podagra . . . .35 
Progressive Pernicious Anae- 
mia . . . .12 
Puerile Respiration . . 61 
Pulmonary Apoplexy . 66 
Pulmonary Valvular Disease 7 6 
Purpura . . . .40 
Pus . .... 6 
Pyopericardium . 69, 70 
Red Hepatisation . .54 
Rheumatism . . .29 
„ Acute Articu- 
lar . . 29 
„ Chronic or sub- 
acute . . 32 
„ Muscular . 33 
Rheumatic Gout . .34 
Rheumatoid Arthritis . 34 
Rhonchi . . . .47 
„ Mucous. . 47 
„ Sibilant. . 47 
„ Sonorous . 47 
Sarcomata . . .17 
Scirrhus of the Liver. . 106 
Scorbutus. . . ,39 
Scrofula . . . .24 
Scurvy . . . .39 
Splenisation . . .54 
Suppuration ... 4 
Syncope . . . .83 120 
PAGE 
Syphilis . . . .42 
Syphilitic Liver - . 109 
Tsenia Echinococcus . . 104 
Thrombosis . . . 88 
Tricuspid Regurgitation . 75 
Tubercle . . . .21 
,, Crude Yellow . 63 
„ Grey Miliary . 63 
„ Obsolete . . 23 
„ of the Heart. . 81 
PAGE 
Tubercle of the Liver . 109 
,, ,, Lung . 63 
Tubercular Pericarditis . 69 
Tubular Breathing . . 62 
Tyrosine .... 100 
Valvular Diseases of the 
Heart . . . .72 
Wavy Inspiration . 62 
Wiry Pulse . . .59 
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