W. ■Xi. ■•**t^»i.i, ";-'!■ •'~,-^<'-'-'r m CORNELL UNIVERSITY MEDICAL LIBRARY ec — ^ — -4- to ITHAOA. DIVISION. A 3f CHARLES EDWARD VAN CLEEE. M.D. B. S. CX)HNEt,r4 UNIVERSITY, '71. Digitized by Microsoft® CORNELL UNIVERSITY LIBRARY 104 225 515 Digitized by Microsoft® This book was digitized by Microsoft Corporation in cooperation witli Cornell University Libraries, 2007. You may use and print this copy in limited quantity for your personal purposes, but may not distribute or provide access to it (or modified or partial versions of it) for revenue-generating or other commercial purposes. Digitized by Microsoft® THE SCIENCE AND PRACTICE MEDICINE. BY WILLIAM AITKEN, M.D., Edin., PKOFESSOR OF PATHOLO&Y IN THE ARMY MEDICAL SCHOOL. Third American from the Sixth London Edition, GREATLY ENLARGED, REMODELLED, CAREFULLY REVISED, AND MANY PORTIONS REWRITTEN ; ADOPTING THE NEW NOMENCLATURE, AND FOLLOWING THE ORDER OF CLASSIFICATION OP DISEASES PUBLISHED BY THE ROYAL COLLEGE OP PHYSICIANS OF LONDON. WITH ADDITIONS MEREDITH CLYMER, M.D. (Univ. Penn.), EX-PROrESSOR OF THE INSTITUTES AND PRACTICE OF MEDICINE IN THE UNIVERSITY OP NEW YORK ; FORMERLY PHYSICIAN TO THE PHILADELPHIA HOSPITAL; ETC., ETC. IN TWO VOLUMES, WITH STEBL PLATE, MAP, AND ONE HTJNDRED AND EIGHTY •WOODCUTS. VOL. L PHILADELPHIA: LINDSAY & BLAKISTON. 1872. -r Digitized by Microsoft® Entered according to Act of Congress, in the year 1872, By LINDSAY & BLAKISTON, In the Office of the Librarian of Congress, at Washington, D.C. SBEBMAN & CO., PRINTERS Digitized by Microsoft® THE MEMORY SIR JAMES CLAEK, M. D. (Edin.), K. C. B., F. R. S., EAEONET OF THE UNITED KINGDOM. Born December 14, 1788, and Died June 29, 1870, WHOSE LIFE "WAS A SUBORDINATION OF SELF TO PUBLIC INTEREST, TO THE ADVANCEMENT OF SCIENCE AND OF HUMAN PROGRESS A LIFE OF DEVOTION TO THE QUEEN — A LIFE WHOSE INFLUENCE WAS LARGELY FELT AND WISELY EXERCISED IN THE ADVANCEMENT OP GENERAL AND OF MEDICAL EDUCATION — AND, A LIFE WHOSE CONDUCT REMAINS A MODEL TO PUBLIC MEN. I Professionally, he largely contributed to promote, by exalting, the office of the Physician, by establishing the aim of the Science of Medicine as the means of Pre- venting Disease ; for " he was one of the earliest of those who saw the importance of Sanitary Science,,and one who was ever ready with time, thought, and influence, to aid its progress." To accomplish this end he secured the appointment and nomination of the first Health of Towns' Commission ; and he lived to see the hygienic measures he so zealously advocated, and was the main agent in securing, put into legal shape and active operation, first in most of our large towns and cities, and second, in reform- ing the hygienic regulations of Her Majesty's British and Indian Array and Navy; thereby helping to effect a great saving of human life — Civil, Military, and Naval — in every region of the world. He mainly aided to establish the College of Chemistry, " which has done so much to diffuse among our manufacturing and agricultural population a knowledge of applied chemistry, and to advance the Science by original research." He was especially earnest in the establishment of the Army Medical School, now stationed at Netley, for the special training of medical men in Military and Naval Professional duties ; and he continued to the last moment of his life to take the warm- est interest in everything connected with that institution. As a Member of the Senate of the London University, and always taking an active interest in education, he pointed out defects in Medical .education which have since been removed, particularly as to " making examinations as practical and thorough as possible ;" by bedside examination in Practical Surgery and Medicine — a method now generally adopted in testing the qualifications of candidates for a license to practice in civil life ; and in competitive examinations for those who seek to enter the military and naval services. He greatly aided (in 1842), in improving medical teaching, by pointing out to the Government of the day the urgent need for " a good and uniform system of Medical Education, which should be the same throughout the empire for every medical practitioner." Digitized by Microsoft® IV DEDICATION. " Modest in his nature, and singularly indifferent as to the recognition of his ser vices, provided the end was gained, he desired not that his share in it should he known ; so that much of what he did is scarcely now known ; and few, men knew the extent of his acquirements" (Obituary Notice, Royal Soc. Proceed., No. 126). Widely he laid the foundation of his medical knowledge and experience at home and abroad — and widely has that experience been beneficial to mankind — which, com- bined with great benevolence of character, made him so excellent a Physician, and secured for him the highest position in the medical world. He lived for many years to enjoy his retirement from the active practice of his pro- fession, continuing almost to the last hour of his life to take the warmest interest in every question connected with the improvement of our Schools of Medicine^the prog- ress of Hygienic Measures for the Prevention of Disease — the practical application of scientific knowledge for the improvement and happiness of his fellow-men and the promotion of human progress. The author was privileged by permission, in 1863, to dedicate to Sir Jambs Clark the Second Edition of this work ; and now, in 1871, he dedicates to His Memory this Sixth, hut still imperfect attempt to teach in a text-book the Science and Practice OF Medicine. Digitized by Microsoft® PREFACE TO THE THIRD AMERICAN EDITION. The appreciation of Dr. Aitken's " representative book," as a full and fair exposition of the Medical Art and Science of the day, by the profession of this country, has been abundantly shown by the sale of two American editions. The present, and third, American reprint is from the sixth London edition, which has been carefully revised, and in part rewritten. The incorporation by the Author of about four- fifths of the matter of the Editor in the last American edition, either in form or in substance, has rendered his duties compara- tively light in the present one. Besides new material in the chapters on Fevers, and Diseases of the Nervous System, there are additional articles by the Editor on : Camp Measles, Spinal Symptoms in Typhoid Fever, Typho-Malarial Fever, Chronic Malarial Toxcemia, Epidemic Cerehro-Spinal Meningitis, Chol- era Morbus, Cholera Infantum, Chronic Alcoholism, Delirium of Inanition, Chronic Fycemia, Syphilitic Disease of the Liver, Shaking Falsy, Myo-Sclerosic Paralysis, and Cerehro-Spinal Sclerosic Paralysis, &c. The Editor's additions are thus designated [ ]. 65 West Thirty-eighth Street, New York, August 1, 1872. Digitized by Microsoft® Digitized by Microsoft® PKEFACE TO THE SIXTH EDITION. FouETEEN years have passed away since the first edition of this work was published ; and five editions of it having been so favorably received since that time, I trust that this — the sixth edition — may deserve and continue to retain the confidence alike of Students of Medicine, of Teachers, and of the Profession. I have conscientiously endeavored to make each addition an improvement on its predecessor ; and as with previous editions, so with this one, I have aimed at giving as faithfully and as fully as I can, the ideas and the views of the more advanced and able Physicians of the time, desirous that this text-book should be "a representative book" of the Medical Science and Practice of the day, as actually understood and followed by the best men of our profession. It aims, indeed, at being a text-book for Students of Medicine, following such a systematic arrangement as will give them a con- sistent view of the main Facts, Doctrines, and Practice of Medi- cine in accordance with accurate physiological and pathological principles and the present state of Science. During the past eighteen months I have been engaged in a careful revision of the whole work (which has been out of print nearly twelve months) ; and stimulated by the great encourage- ment I have received, I have spared no exertion to improve it and make it worthy of continued confidence, as orthodox in its aim and practical in all its details. The plan of the work has been again remodelled, so as to Digitized by Microsoft® viii PREFACE TO THE SIXTH EDITION. embrace a consideration of the topics in the order of the classi- fication of the College of Physicians of London, whose nomen- clature I had already followed in the last edition, thereby tend- ing to remove the difficulties which arise from the complexity and indefiniteness of medical terminology. It is still, however, a subject of regret that the medical pro- fession do not adopt a uniform system of Nosology — so essential for the purposes of Diagnosis and the Registration of Diseases and of Deaths — indeed, altogether " indispensable for the gath- ering in of trustworthy statistical information and knowledge respecting disease." Fully impressed as I am with the necessity for such uniformity of nomenclature, the profession cannot hope to see it secured unless a uniform system of naming diseases be taught in the Schools of Medicine. To aid in this education, I have endeav- ored to adhere closely to the new nomenclature, more especially as it has become the authoritative nomenclature of the country. The Secretary of State for War, the Board of Admiralty, and the Secretary of State for India have all and severally adopted the work of the College of Physicians, and have distributed it to the medical officers of their respective departments. It is now also put, at the expense of Her Majesty's Govern- ment, into the hands of every registered practicer of medicine in England, Scotland, and Ireland. Thus, issued with the stamp of authority, its use is secured in the records of all the public services — most of the large public hospitals of the country having previously adopted, spontane- ously, the new nomenclature and classification. It would now also be a good example if the Fellows of the London College of Physicians would themselves individually adhere steadily, in their published writings, to their adopted and accepted nomenclature. Digitized by Microsoft® PREFACE TO THE S'lXTH EDITION. IX The amount of matter contained in these volumes has very greatly increased — an increase which implies many more con- siderable changes (which it is hoped are improvements), as well as additions, than can be made obvious in a preface. The addi- tions and changes thus made are widely and generally distributed throughout every chapter of the book. Compared with the previous edition, the new material added in the present is equivalent in bulk to a third volume added to the last edition ; yet the size of the work is not increased, as a special font of type was cast to enable the printer to preserve clearness without adding to the bulk of the volumes. Thus I have endeavored to embody an account of all the more recent advances in the Science and Practice of Medicine, which during the past fourteen years have been unusually numerous and important. Many chapters have been to a great extent re- written and remodelled, many new topics have been added, and every part has been thoroughly revised. The subjects composing Part I have been greatly expanded by " topics relative to pathology and morbid anatomy," which the classification of the College of Physicians rendered it neces- sary to notice as introductory to succeeding parts. Numerous additions have also been made where topics of importance had only been shortly noticed before ; while the sections on the Pre- vention and Treatment of Diseases have been more fully consid- ered and expressed. The work has been to a great extent, indeed, rewritten ; and descriptions of many diseases, altogether omitted in former edi- tions, are now introduced — so much has the new nomenclature and classification done to render uniform and to consolidate in- formation relative to diseases ; and to render necessary a notice of topics which otherwise were lost sight of from the absence of that consolidation and uniform connection which the authority of the College of Physicians has now given by their classifica- tion of diseases, and which no single person could have accom- plished. Digitized by Microsoft® X PREFACE TO THE SIXTH EDITION. The diagrams illustrative of the typical ranges of body-tem- perature in febrile diseases (which were given in the third edition of this work, in 1863, for the first time in a text-book) have been carefully reconsidered, together with the whole of this im- portant and practically useful subject now so generally adopted. The result has been that the diagrams have all, with few excep- tions, been redrawn and cut upon an improved model. Addi- tional woodcuts have been also introduced wherever it was thought they would render the descriptions in the text more in- telligible. In accomplishing this work I have again many obligations to acknowledge, as on former occasions, and especially to many kind fellow-workers in the profession, whom I do not personally know, but from whom I have received most useful hints in their oblig- ing communications, to be remembered by me with gratitude, and from which this edition has profited much. To my friend, Staff'-Surgeon Dr. Blatherwick, in charge of the large Lunatic Hospital at Netley, I am indebted for many valuable notes and practical suggestions concerning "Disorders of the Intellect." To Dr. Balthazar W. Foster, Professor of Medicine in Queen's College, Birmingham, and Physician to the General Hospital of that town, I am under great obligations for his kind revision of the sections relating to the use of the " Sphygmograph," for much valuable new matter and new " Sphygmographic Tracings" in the sections on "Diseases of the Heart and Arteries." To Dr. Morell-Mackenzie, Physician to the London Hospital, and to his Assistant, Mr. Lennox Browne, I have to acknowledge the kind assistance given me in the sections where the "Laryn- goscope" is described and applied to the diagnosis and treatment of "Diseases of the Throat and Larynx," and for which Mr. Lennox Browne has kindly executed new woodcuts ; while the text is partly based on the MSS. of Dr. Mackenzie's Lectures on "Diseases of the Throat," delivered at the London Hospital. Digitized by Microsoft® PREFACE TO THE SIXTH EDITION. XI To my friend Dr. T. W. Anderson, of Glasgow, I also owe my thanks for the woodcuts of parasitic diseases of the skin. ^ My thanks are also again especially due to my friend Dr. Thomas Graham Balfour, F.R.S., the Chief of the Statistical Branch of the Army Medical Department, for his kindness in revising and correcting the part on "Medical Geography." To him, to Dr. Henry Marshall, and to the late Sir Alexander M. Tulloch, science is largely indebted for our knowledge regarding "Medical Geography ;" and to the joint reports of these men may fairly be assigned the merit of having first called the atten- tion of the military authorities to the actual condition of the army in regard to health, and to the various deteriorating agen- cies by which the soldier comes to be affected in different regions of the world. That so distinguished an authority as Dr. Balfour should have been so kind as to revise that portion of my work which treats of these topics, as he has kindly done for all the previous editions, demands from me the most grateful acknowl- edgments. William Aitken. KoTAL Victoria Hospital, Nbtlet, November, 1871. Digitized by Microsoft® Digitized by Microsoft® CONTENTS OF VOLUME I. PAET I. TOPICS RELATIVE TO PATHOLOGY AND MORBID ANATOMY. CHAPTER I. Ov Medicine as a Scibnck and as an Art : its Objects and its Extent, Medicine to be Studied as a Science and as an Art, Medicine considered as a Science, Medicine considered as an Art, Topics of Human Knowledge which make up the Science of Medicine, Division of the Science into the Departments of — (1.) Physiology Pathology; (8.) Therapeutics; (4.) Hygiene,. The " Institutes," " Institutions," or " Theory of Medicine,", Principles of Pathology the most useful Guide to the Student, PAGE . 49 . 49 . 49 . 49 (2.) 49 50 50 CHAPTER II. 'B.ow THE Province ov Pathology is Mapped Out, 50 Inquiry into the Nature or Pathology of Diseases embraces certain Topics : . 50 1. Accurate Observation and Correct Registration of Pacts in Pathology, 50 2. Descriptive Pathology, General and Special, 50 Range or Province of Special Pathology, 50 Range or Province of General Pathology, 50 Accuracy of Observation the First Lesson for the Student to Learn, . . 50 Registration of Pacts in Pathology in Authentic and Permanent Forms, . 51 (a.) History of Cases of Disease from their Origin to their end ; (b.) Statistics of Disease, 51 Range or Province of Speculative Pathology, 51 Province of Pathology to Dictate the Maxims of Rational Practice, . . 51 Subjects Treated of in the first part of this Work, and General Plan of this Text-book 51 CHAPTER III. Relative Nature of the Terms "Life," "Health," "Disease," . . 52 52 52 52 52 52 52 52 Meaning implied by the Terih " Disease," Meaning implied by the Term "Life," . Conditions of " Health" have considerable Latitude, Many Degrees of Feebleness and Delicacy of Health, Indefinite Notions of "Normal Life," . Indefinite Notions of " Disease," .... Elements Required in a Definition of any State of Disease, Digitized by Microsoft® Xiv CONTENTS OF VOLUME I. CHAPTER IV. PAGE How THB Nature and Oattses of Diseases mat be Elucidated, . . 53 Aspects under which Diseases may Idb Studied, 53 1. Clinical Investigation and Instruction, 53 Natural History of Diseases a Special Subject of Study, 53 2. Special Pathology or Special Nature of Particular Diseases, . . 53 3. Primary Elements' of Disease or General Pathology, . . . .53 Subjects for Investigation by the Student, .... . . 53 Symptoms of Disease [Sympiomatology), and how Symptoms are Converted into Signs, 53 Causes of Disease (Etiology), 53 Localities of Disease (Pathogeny), 53 Morbid Alterations in Textures (Lesions and Morbid Anatomy), . . .53 Elementary Constituents of Disease (Mo?'6iiijEKstoioyy), 53 CHAPTEE V. Oi' Morbid Phenomena, Symptoms, and Signs op Disease, . . . .53 Meanings attached to the Terms "Symptom," "Sign," and "Diagnosis,"' . 53 How "a Diagnosis is made" by the Conversion of "Symptoms" into "Signs," 53 How " a Prognosis is made " by Forecast of Events, 54 Symptoms which are Pathognomonic of Disease 54 Methodical Examination of Patients necessary, 54 Works recommended for Study, 55 CHAPTER VI. Morbid Anatomy and Pathological Histology : the Special Means and Instruments by which the Nature of Diseases may be Investi- gated, 55 Definition and Province of Morbid Anatomy, 55 Morbid Anatomy is a record of Facts, ,55 Relation of Morbid Anatomy to Pathology, 55 Morbid Anatomy and Pathological Histology, .55 Medicine as a Science is Influenced by the Details of Morbid Anatomy, . 55 Historical Retrospect of Morbid Anatomy, .56 Practice of Medicine Dictated by Physiology and Nature of Diseases, . . 56 Physiology the Basis of Pathology, . . . . ' . . . .57 How the Science of Pathology is being Advanced, 58 Delicate Physical Instruments of Research 58 'Organic Chemistry and Histology, 58 Oharacteristics of Medical Research, 60 Probation and Progress Characteristic of the Practical Medicine of the day, 60 Province of Morbid Anatomy* as now distinctly Defined, ... Objects of the Science of Pathology, 2 CHAPTER VII. The Elementary Constituents oe Lesions, as shown by Morbid Anatomy AND other Means of Research, 63 The Material Effects or " Stamps " of Disease, 63 Means and Instruments of Research for the Investigation of these Changes, 63 Every opportunity to be taken of making Post-mortem Examinations, . . 64 Forms of the Constituent Elements of Disease, 64 A. Morbid Elementary Products, 65 B. Complex Vital Processes whose Phenomena, more or less combined. Constitute Diseases and Lesions, 66 Digitized by Microsoft® CONTENTS OF VOLUME I. XV CHAPTER VIII. PAGE Description of Complex Morbid States 67 Catarrh, g7 Definition of Catarrh .67 Pathology and Anatomical Characters of the Disease, 67 Regions of Local Catarrh, 67 Evidence of Chronicity of Catarrh, . 67 Kesults of Catarrh, 07 Inflammation, 68 Definition of Inflammation, .......... 68 Pathology of Inflammation, .68 Phenomena and Theory of the Inflammatory Process 69 Altered Conditions of Healthy Nutrition, 70 I. Alteration of Blood Supply and Bloodvessels, 70 Redness of Inflamed Parts, . . . . . . . . . .71 Dilated Bloodvessels in Inflammation, 72 Determination of Blood to a Part, 72 Active Congestion, 72 Condition of the Capillaries in Inflammation, 73 Professor Strieker's Observations, 73 Dr. William Addison's Observations regarding the White Corpuscles, . . 73 Dr. Augustus Waller's Observations, 73 Cohnheim's Experiments and Observations, 73 Soft, Yielding, and Permeable Nature of Living Capillaries, . . .73 Passive Congestion, . . . . . • , . . . . . .74 " Determination " and " Congestion " resulting from Irritation, . . .,74 II. Altered Constitution of the Blood as regards its adaptability to nourish the part, 74 The Altered State cannot be Chemically expressed, but may be Microscopi- cally Demonstrated in relation to the State of the Tissues, . . .74 Local Changes at the Inflamed Part, 74 Tendency of the Blood-corpuscles to Bun into Piles or Rouleaux, . . .75 The Yield of Fibrin in Inflamed Blood and in certain Diseases, . . .75 Fibrinous Coagula in Bloodvessels, 75 Results of Fibrinous Coagula in Bloodvessels, 75 Primary Seat of the Inflammatory Process, 76 ■ Effects of Irritants on Minute Elements of 'Tissue, 76 " Resolution " of Inflammation, 76 Structural Elements of Minute Arteries, 76 Structure of Capillaries, 77 Cause of Stasis or Stoppage of the Blood and Exudation of Liquor Sanguinis, 77 Theories regarding these Phenomena, ........ 77 Theory of Henle — the Neuro-Pathological Theory, 77 Simon's View opposed to Reflex Action, and in favor of a Direct Change affecting Blood, Blood-nerves, and Molecular Structure, . . . .77 Bennett's Belief in a Vital Force acting outside the Vessels, . . . .77 Paget and Lister's Belief in a Mutual Relation between the Blood, the Ves- sels, and the parts around, 77 Dr. C. J. B. Williams's Belief in the Accumulation and Adhesive Properties of White Globules, . . . . _ 78 Rokitansky and Wharton Jones's Explanation, 78 Parenchymatous Inflammation of Virchow, 78 Example of Parenchymatous Inflammation, 78 Observations of Goodsir, Allison, Simon, Virchow, and Lister, . . .79 Products, Effects, or Events of Inflammation, 80 Local Growth of Cells, 80 Process of Resolution, 80 Phenomena of " Delitescence " and " Metastasis," 80 Phenomena of Exudation and accompanying Changes, 80 Productive Effects of Inflammation, 81 Inflammatory Effusions or Exudations, 81 (l.J Serous Effusions and Examples of such, 81 Essential Characteristics of Inflammatory Effusions, . . . .82 Site of Serous Effusion sometimes an Element of Danger, . . .82 Digitized by Microsoft® XVI CONTENTS OF VOLUME I. \ ' PAGE (2.) Blood Effusions or Extravasation, 82 Post-mortem Evidence of Extravasation, 82 (3.) Inflammatory Lymph or Fibrin, . 82 Typical Elementary Forms of Growth in Lymph, 83 . Circumstances Modifying the Type of the Inflammatory Process, . . 83 Granular, Molecular, or Fibrillated Development of Fibrinous Products, 83 Corpuscular Forms of Fibrinous Products, . . . . . .83 Fibrinous and Croupous Forms, . . . . . . . .83 Plastic and Aplastic Forms, .83 Adhesive or Lymphy Inflammations, 84 False, Adventitious, or Pseud'o-membranes 84 Dysmenorrheal Membranes, . . .• 84 Corpuscular Forms seen in Lvmph-cells, Chyle and White Corpuscles of Blood, . . . " 84 Lymph of Herpes, ■ . . . .84 Primordial Cell-forms of Inflammation — their Modes of Growth and De- generation of Lymph, as described by Sir James Paget, . . . .85 Compound Granule-cell, Granule-cell, and Pus-corpuscles, . . . .85 Formation of the Compound Granule-cell, and Mode of its Disappearance and its Use or Function, 86 The Swelling of Inflammation and its Cause, 87 Local and General Symptoms of Inflammation, 87 Local Generation of Heat, 87 I. Inflammatory Fever, Symptomatic Fever, or Sympathetic Fever, . . .87 (1.) Condition of Nervous System in Inflammatory Fever, . . .88 (2.) Condition of the Vascular System, 88 (3.^ Condition of the Respiratory System, 88 , (4.) Condition of Digestive System, ........ 88 (5.) Condition of the Secerning System, . . . . . . .88 (6.) Condition of the Nutritive Functions 88 Date of Febrile Disturbance, 88 General Conclusions as to Febrile Symptoms, . . . . .89 Symptoms of Suppuration, ......... 89 Asthenic and Sthenic Indications, .89 Production of Pus, .......... 90 II. The Typhoid Fever of Inflammation, 90 Its Type, Asthenic or Adynamic, ........ 90 Nervous or Ataxic Symptoms, . . . . , . . . . .90 Causes of Inflammation, 90 (1.) Determining or Exciting Causes, 90 (2.) Predisposing Causes, 90 Irritation, the Starting-point of Inflammation, 90 Causes of Irritation Classified, ......... 90 Nerve Fibres having a Special " Trophic " Function, . . . .91 (3.) Predisposing Causes Classified, • . , .91 tjLCERATIVB INFLAMMATION, 91 Definition of Ulcerative Infiammation, .91 Pathology of Ulcerative Infiammation, 92 Formation of an Ulcer, 92 Meaning of the terms " Ulceration," " Abrasion," and " Excoriation," . 92 Appearance of Granulations, . . . 92 Three Processes which Progress to Ulceration, namely : Exudation, Growth, and Liquefaction, ........... 92 Healing by Granulation, ti2 Healing by Second Intention, . 92 Process of Granulation, '. 92 Grafting or Transplantation of Germ? of Skin, . . . . . .93 Eepair of Parts by Granulation, . . i . 93 Eeproduction of Original Tissue, how far it is accomplished, . . . .93 Nature of Cicatrix Tissue, 93 Sites of Ulcerative Inflammation, 93 SupptJKATivB Inflammation, .'.... 94 Definition of Suppurative Inflammation, . 94 Pathology of Suppurative Infiammation, 94 Evidence of Formation of Pus from Pre-existing Germinal Matter, . . 94 Digitized by Microsoft® CONTENTS OF VOLUME I. Xvii PAGE Mucinous Exudation appertains to certain Parts, 94 JW«c«s as a Characteristic of Inflammation, 94 Formation of Pus — Suppuration 94 Description of the Pus-cell, . 95 Good, Healthy, Praiseworthy Pus — Pus Laudabile, 95 Suppuration taljes place under Three Conditions, 95 (1.) Circumscribed Suppuration, 95 An Abscess, Boil, or Phlegmon, .95 Pyogenic Membrane, 95 Old or Chronic Abscesses, 95 Purulent Effusion into Cavities, 95 (2.) Diffuse Suppuration, or Purulent Infiltration, 95 Formation of " Sloughs " and " Sinuses," 96 Pointing of a Phlegmonous Abscess, . 96 (3.) Superficial Suppuration and Examples, .96 Proliferation, 96 Pus-cells, Mucus and Epithelial Cells, Anatomically but not Physiologically Equivalent, 97 Process of Growth and Origin of Deepseated Pus-formation, ... 97 T^o Different Modes of Pus-formation to be Distinguished, .... 97 Parenchymatous Inflammation, and Secretory Inflammation, ... 97 " Centres of Nutrition "of Goodsir, 97 Three Events of Inflammation, 97 Softening or Diminished Cohesion of Tissue, 97 Interstitial Absorption, 98 Pointing of ah Abscess, . . 98 Hectic J?ever and its Distinguishing Characters as the Result of Prolonged Pus-formation, . .98 Type of Hectic Fever, 98 Symptoms of Hectic Fever, 98 Description of Hectic by Dickens — (Death of Smike), . . . . . 99 Diagram of Body-Temperature in a Case of Hectic Fever, .... 100 Plastic Inflammation, 101 Definition of Plastic Inflammation, ........ 101 Pathology of Plastic Inflammation, 101 Soft Lymph of Plastic Inflammation, as seen Growing from Serous Mem- branes, 101 Sir James Paget's Description of the Process, 101 Changes in the Elements of Lymph, 101 Process of " Proliferation," 101 Proliferation of Lymph-cell Elements from Inflamed Pleura, . . , 101 Nuclei in the Fibrinous Products of Lymph developing into Fibres, . . 102 Fibro-Plastic Cells in Lymph developing into Fibres, 102 Perfect White Fibrous Tissue from Lymph, 102 Elements in the Lymph of Plastic Inflammation, . . . . .. ,. 102 Rhbumatic Inflammation, 103 Definition of Rheumatic Inflammation, . ....... 102 Pathology of Eheumatic Inflammation, 102 Textures Implicated in Eheumatic Inflammation, . ^ 102 GoTTTY Inflammation, . . . . , 103 Definition of Gouty Inflammation, . 103 Pathology of Gouty Inflammation, 103 Gonokkhceal Inflammation, 103 Definition of Gonorrhoea! Inflammation 103 Pathology of Gonorrhoeal Infiammation, 103 Peculiarities of Gonorrhoeal Inflammation, . . . . . . .103 Gangrene, . • • ^^^ Definition of Gangrene, • 104 Pathology of Gangrene, .... 104 Sphacelus, Caries, and Necrosis, 104 VOL. .1. 2 Digitized by Microsoft® XVIU CONTENTS OF VOLITMB I. PAGE Slough, Sequestrum, and Process of Sloughing, 104 Humid Mortification and Formation of Phlyctenie, . . . . 104 Dry Mortification, as from Ergotism, 104 Gangrene to be distinguished from Degeneration, . . ... 105 "Suspenned Animation " of Parts, 105 PaSSITB CONGBSTIOlf, 105 Definition of Passive Congestion, 105 Pathology of Passive Congestion, or Hypersemia, 105 Active and Passive Congestion to be distinguished, 105 Confusion regarding the use of the term Congestion, 106 Eelations between Active and Passive Congestion, 106 Examples of Mechanical Congestion, . . . . . . . . 106 Results of Mechanical Congestion of Veins, 106 Passive Congestion: how it differs from Mechanical Congestion in Seat and Cause, 107 Examples of Passive Congestion, and Combinations of the two Porms, . 107 Results of Passive Congestion, . . . 108 Eedness of Passive Congestion, . 108 Summary of the Causes of Passive Congestion, 108 Extravasation or Blood in Hemokrhaqb 108 Definition of Extravasation of Blood, . 108 Pathology of Hemorrhage — Spontaneous or Traumatic, .... 108 Hemorrhage by Exhalation of Blood, or Hemorrhage without Eupture, . 108 Examples of Hemorrhages from Mechanical Obstacles to the Circulation, . 108 Examples of Active and Passive Hemorrhages, 109 Seats of Hemorrhage and Technical Names of the Hemorrhages, . . 110 The Effects of Hemorrhage and Signs of Danger from it, . . . . 110 Examples of Secondary Hemorrhages, ........ 110 Conversion of Hydrocele into Haematocele, . . . . . . . Ill Cause of Hemorrhagic Pericarditis, Ill Hemorrhagic Diathesis, Hemophilia. Hsemorrhaphilia, Hsemorrhophilis — a disposition or constitutional liability to habitual hemorrhage, . . Ill Molimina Hsemorrhagicum, .......... Ill Symptoms of the Constitutional Tendency to Bleeding, .... Ill Congenital or Acquired Constitutional Tendency to Bleeding, . . . Ill Its Hereditary Transmission an instance of Atavism, 112 Kelation of the Diathesis to Scrofula and Scurvy, . ..... 11"2 Special Hemorrhages and their Nomenclature, ....... ll-S Results of Blood Extravasation, 113 Pigment in Apoplectic Cicatrix 113 Crystals of Hjematoidin in Different Forms, 113 Prognosis in Cases of Hemorrhage, ........ 114 Treatment of Hemorrhage in Cases of Hemorrhagic Diathesis, . . . 114 Dropsy, " . 115 Definition of Dropsy, 115 Pathology of Dropsy, . 115 Nature of the Fluid of Dropsy, . 115 Difference between Inflammatory and Dropsical Effusions, . . ... 115 Nomenclature of Dropsies, . 115 Constitution and Analysis of Dropsical Fluids, . . . . . .116 Origin of Dropsy, . 116 Wateriness of the Blood [Hydrcemia), 116 Combined Conditions Productive of Dropsy, 116 Distinction between General Dropsy and Local Dropsy, .... 117 Cardiac Dropsy (Dyspnoea), . . , 117 Kenal Dropsy, 117 Local Dropsy (Ascites) (Cirrhosis), 117 (Edema of Lungs (Mitral Obstruction), . ., 117 (Pneumatosis), 118 Digitized by Microsoft® CONTENTS OP VOLUME I. xix PAGE Fibrinous Deposit, X18 Definition of Fibrinous Deposit, Hg Pathology of Fibrinous Deposit, Hg Theories regarding the Production of Fibrinous Deposits, . . . ! 118 Polypi, Fibrinous Vegetations, and Emboli, 119 Alteration op Dimensions 119 Definition of Alteration of Dimensions, 119 Pathology of Alteration of Dimensions, 119 [a.) Dilatation and its Definition, . . 119 Pathology of Dilatation— Active Dilatation, Simple Dilatation, and Passive Dilatation, Ug Causes of Dilatation of Hollow Organs, ...... 119 How Dilatation tends to' Destroy Life, 119 (6.) Contraction and its Definition, 120 (c.) Htpertropht and its Definition, 120 Pathology of Hypertrophy, 120 Conditions Essential for Hypertrophy, 120 Diagrams illustrative of the Distinction between Hypertrophy and Hyperplasia, 121 (d.) Ateopht, 122 Definition of Atrophy, 122 Pathology of Atrophy, . . . 122 Senile Atrophy, ' . . 122 Progressive Muscular Atrophy, ........ 122 Phthisis, Consumption, Marasmus, 122 Degeneration, 122 Definition of Degeneration, .......... 122 Pathology of Degeneration, 122 Separation of Degeneration from Substantive Diseases, .... 122 Sir William Jenner's Account of the Nature of Degenerations, .- . . 122 The Characteristics of Degeneration, 123 Histolysis, 123 Degenerative Changes to be distinguished from Inflammation, . . . 123 How the Recognition of Degenerative Changes has influenced the Practice of Medicine, . . . ' . 124 (a.) Fatty Degeneration — the most widely spread, 124 Examples of Fatty Degeneration, 124 (b.) Mineral Degeneration distinct from Ossification, 126 Petrified Tissue — Petrifaction or Calcification, 126 Examples of Mineral Degeneration, 126 (c.) Pigment Degeneration — Pigmentation, . . . . . . . 127 Examples of Pigment Degeneration, 127 Melanasmia, 128 Post-mortem Evidence of Pigmentation, ...... 128 Origin of Blood-crystals, ......... 128 Crystals of Haematoidin, 128 Crystals of Hsemin, . -. 128 Crystals of Hsemato-Crystalline, ........ 129 (d.) Fibroid Degeneration, . 129 Examplesof Fibroid Degeneration, 129 IiARDACEOirs Disease, 129 Definition of Lardaceous Disease, 129 Pathology of Lardaceous Disease, 130 Nomenclature of Lardaceous Disease, 130 Chemical and Micro-chemical Investigation of Lardaceous Disease, . . 130 Directions which the Investigation of Lardaceous Disease have taken, . 130 Digitized by Microsoft® XX CONTENTS OP VOLUME I. PAGE Chemical Nature of the Lardaceous Lesion, ' . 130 Nomenclature of the Disease from its supposed Chemical Nature and Alli- ances, 132 Albuminoid : Nature of the Substance, 132 General Character and Anatomical Description of Tissues affected with Lar- daceous Disease, 133 Beaction with Iodine, . 134 Composition of Iodine Test for use in Post-mortem Koom, .... 134. Elements of Tissuie in which Lardaceous Disease has been Demonstrated, . 134 Diseased States with which Lardaceous Disease has been found associated, 135 Dr. Dickinson's View regarding the Nature of Lardaceous Disease, . . 135 Clinical History of Lardaceous Disease, . . . . . . . . 136 Signs or Symptoms associated with Lardaeeous Disease, . . . .136 Ctst .137 Definition of Cyst, ■. ... 137 Pathology of Cyst, . . ..137 Theories regarding the Formation of Cysts, . . . '. . . . 137 Three Modes of Cyst Formation, 138 (A.) Simple or Barren Cysts, 139 (B.) Compound or Proliferous Cysts, ........ 139 Examples of Simple or Barren Cysts, 139 (a.) Gaseous Cysts (Pneumatoses), 140 (b.) Serous Cysts, or Hygromata, 140 Nature of the Contents of Serous Cysts, 140 Usual Situation of Serous Cysts, 140 " Hydroceles of the Neck," . . . 140 Instance of Serous Cyst Development Proving Fatal, .... 141 Congenital Character of some Serous Cysts, 141 Cys.ts in the Gums and Mamma, ' . . 141 (c.) Synovial Cysts, 142 Three Modes of Formation, ; 142 (d.) Mucous Cysts, 142 Examples of Mucous Cysts, and Microscopic Character of Contents, . 142 (e.) Kanula, • 142 (f.) Sanguineous Cysts, 142 (g.) Cysts containing Oil or Fat, 142 (h.) Colloid Cysts, ............ 142 (C.) Proliferous or Compound Cysts, . . . . . . . . 142 Example of Complex Ovarian Cysts, 142 Parasitic Disease, 143 Definition of Parasitic Disease, 143 Pathology of Parasitic Disease, . . 143 Nature of Blight, 143 History of Parasitic Diseases, 143 Elementary Facts regarding Parasitic Disease, 144 Hypothesis of " Spontaneous Generation," 145 Wide Kange of Study required to obtain a Knowledge of Parasitic Disease, 145 ■ Classified List of Human Parasites, 146 Distinction between Mature and Immature Parasites, 147 Habitat of the Sexually Mature Entozoa, I47 Cystic or Vesicular Entozoa to be distinguished ; Non-vesicular Parasites Inclosed in' Cysts, 148 Examples of such Distinctions, 148 Process of Fecundation and Development of Ova, ...... 148 Migration of Parasites, 148 Examples of Alternate Generation or Metagenesis, 148 Lesions and Diseases caused by Parasites, ....... 149 Cerebro-spinal Symptoms caused by Parasites, 149 I. — Entozoa, I50 Class A. — Ccblelmintha, ok Hollow Worms, 150 Definition of this Class of Worms, . . 150 Pathology of the Coalelmintha, . .' 150 A Knowledge of the Generation of these Worms necessary, .... 150 Digitized by Microsoft® CONTENTS OF VOLUME I. XXI PAGE Tertility of the Round Worms enormous, I50 Description of the Ova and Organs of Generation in Eound Worms, . . 150 Development of the Ova in Water, 150 Period of Incubation of the Ova, 151 1. Description of the Ascaris Lumbricoides 152 2. Description of the Ascaris Mystax, 152 3. Desci'iption of the Triohocephalus Dispar, . ...... 152 4. Description of the Trichina Spiralis, 153 Its First observed Occurrence in the Human Body 153 Examples of the Parasite in the Encysted and non-Encysted State, . . 154 Drs. Cobbold's and Leuckart's Account of the Parasite, .... 154 Symptoms in the Human Subject induced by the existence of Trichina Spiralis, ............ 155 History of Cases of its Occurrence in Man, ..... 155-159 Its Occurrence in the Flesh of certain of the Lower Animals, . . . 156 Its frequent Occurrence in Subjects brought to Dissecting-Eooms, . . 157 History of the Development of the Parasite, 157 Occurrence of Severe Cases in Germany 158 Occurrence of Cases in America, recorded by Dr. Clymer, . . . 160 Eemedies for the Destruction of the Parasite, ...... 162 5. Description of the Filaria Medinensis, commonly called Guinea-worm or Dracunculus, . 163 Essentially a Tropical Parasite, . 163 Geographical Limits of its Occurrence, 163 Prevalence amongst Soldiers at different Stations, ..... 163 Duration of Illness caused by the Parasite, ...... 164 Deaths resulting from Guinea-worm, 164 Great Destruction of Tissue caused by the Parasite, 164 Number of Guinea-worms sometimes found in the Human Body, . . 164 Locality of the Body where it most frequently is found, .... 164 Migratory Powers exhibited by the Guinea-worm before Extraction, . 165 Structure of the Dracunculus, . . . . . . . . . 166 i^orms of the Head and Tail-end of the Worm, 166 Arrangement of the Intestine and Genital Organs, ..... 166 Parthenogenis supposed to occur with Guinea-worms, .... 167 Symptoms of Guinea-worm in the Human Body, 168 Phases of its Existence oi" Forms of Life, ' . 168 Period of the Tear when Dracunculus is most Prevalent, . . . 169 Annual periodic Recurrence of the Parasite, ' . 169 Periods of Annual progressive Increase of the Parasite, .... 169 Fixed Latent Period of Residence — a period of Incubation — in the Human Body, 169 Cases which fix the Period of Incubation, 169 Geological Features of Locality and Soil where the Guinea-worm is Endemic 170 History of the Guinea-worm and its Progeny unknown after it leaves the Body, 171 Spontaneous Evolution or Expulsion of the Parasite, .... 171 Vitality of the Guinea-worm in Water, ....... 172 Examination of Water, Mud, and Tanks recommended, .... 172 Description of the Tank-worm of India, . . ' 173 Generation and Propagation of the Guinea-worm, 174 Periods in its Natural History to be recognized, 174 Contagion of Guinea-worm, 174 Problems for Solution in th« History of this Parasite, . . . .' 175 6. Description of the Pilaria Oculi — two kinds, 175 7. Description of the Strongylus Bronchialis, 176 8. Description of the Eustrongylus Gigas, 176 9. Description of the SclerostomaDuodenalis, 176 10. Description of the Oxyuris Vermicularis, 176 Tkbatment of those Infested -with Round Worms,, .... 176 Class B.— Stbkklmintha, or Solid Worms, 178 11. Description of the Bothriooephalus Latus, 17S Regions where it Exists, 178 Structure of the Parasite and its Ova 178 Digitized by Microsoft® XXll CONTENTS OF VOLUME I. PAGE 12. Description of the Bothriocephalus Cordatus, . . . . . . 179 13. Description of Taenia Solium, 179 Varieties of Tape-worms found in Man, 180 Two only of Frequent Occurrence, 180 Head of the Taenia Solium, 180 Anatomy of the Tape- worm Segments, . 181 Process of Expulsion of Ova, . 181 Contraction of Proglottides 181 Structure of Tape- worm Ova, . 183 Development of Tape-worm Embryo, 185 14. (Described at page 187.) 15. Description of Taenia Mediocanellata, 185 16 Description of T^nia Aeanthotrias, . 185 17. Description of Taenia Flavopunctata, . . ... . . . 186 18. Description of Taenia Nana, ■ . . . 186 19. Description of Tajnia Lophosoma omitted. 20. Description of Taenia EUiptica, 186 Immature Tape-worms, Non-sexual, Cystic, or Vesicular Parasites, . 186 Description of (14) Cysticercus of the Taenia Solium, .... 187 Description of the (15a) Cysticercus ex Taenia Mediocanellata, . . 187 21. Description of the Cysticercus of the Taenia Marginata, 188 22. Description of the Echinococcus Hominis, ...... 188 Hydatids, or Echinococcus Cysts, ......... 188 Description of the Capsule and Embryo of the Echinococcus, . . . 189 Clusters of Bchinococci Embryos, 189 Description of the Head and Hooklets, 190 Description and Nature of Acephalocysts, . 191 Eelation between the Cystic and Cestoid Entozoa, ..... 191 Nature of the Experiments made to determine this Relationship, . . 192 Kuchenmeister's Experiments, 192 Von Siebold's Experiments, . . . . . . . . . . 192 Experiments of Leuckart and Cobbold, . 192 Elementary Pacts regarding Entozoa, . . . . . ,' . .194 Cyst-infected JBation-beef from the Punjaub, 194 Drawing of Cysts from Eation-beef — Natural Size, 195 Sources of Taenia Ova which Infect the Kation-beef, 196 Prevalence of Watery Bag or Hydatid Cyst in Commissariat Cattle, . . 196 Power of Preventing the Cyst-infection of Beef, ...... 197 Customs in India favorable to Parasitism, . ■ 198 Symptoms of the Presence of Tape-worm and Cystic Parasites, . . . 200 Prevention and Treatment of Tape-worm, 200 Prevention and Treatment of the Tape-worm and Vesicular Parasites, . 200 Medical Treatment of Tape-worm and Vesicular Parasites, .... 201 Medicinal Kemedies for Tape-worm 201 Description of Fluke-like Parasites, 202 The Eot in Sheep, 203 Egg of Distoma and Opalina, 203 Development of Distoma, 203 Distoma found in the Human Body, 204 Fasciola Hepatica, 205 Distoma Crassum, 205 Distoma Lancbolatum, 205 Distoma Ophthalmobium, 205 Distoma Hetbkophyes, 205 BlLHARZlA HiEMATOBIA, 205 Lesions from Bilharzia Haematobia, 205 Ova and Embryo of Distoma Haematobia, 206 'Tbtkastoma Eenalk, 206 Hexathyridium Venarum, 206 Hexathyridium Pinguicola, 207 Symptoms of Distoma, . 207 'Class C. — Accidental Parasites, ■ . 207 Description of Accidental Parasites, .... ... 207 Digitized by Microsoft® CONTENTS OP VOLUME I. XXlll PAGE Pbntastoma Constriotum in thb Lungs and Liver, . . • . 207 Pbntastoma Denticulatum, _. 207 Pbntastoma in the Human Liver, 207 Description of the Pentastoma Constrictum and the Lesions it Produces, . 208 Drawing of Parasite in situ in Portion of the Human Liver, . . . 208 Drawings of tlie Parasite Removed from the Cysts, 208 Drawings of Pentastoma Constrictum in Human Liver, from Specimens preserved in the Museum at Netley since 1854, ... . 211 Oestrus Hominis, 211 Anthomyia Canicularis, 211 Pathology and Treatment of Bulama Boil, . 212 Larva found in Bulama Boil, 212 II. Ectozoa, . . . ... . . . . . . . . 212 Description of Animals living upon the Skin and Hair, and the Lesions they Produce, 212 Phthiriasis, 213 Description of the Inguinal and Head Louse, ...... 213 !Nit or Egg-capsule of the Louse glued to a Hair, 214 Description of the Louse of the Eyebrows and Body Louse, . . . 214 Description of the Distemper Louse, ....... 215 Treatment of Lousiness, . 2l5 Description of the Itch Spider, Sarcoptes Scabiei, 216 Development of the Itch Spider, 218 Description of Demodex Polliculorum, 219 Description of Pulex Penetrans, Chigoe or Jigger, .... 219 III. Entophyta and Epiphyta, 220 Definition of Algae, Confervse, and Eungi, 220 The Structural Elements of Eungi, 220 Influence of Eungi on Disease, 222 Transmission of Fungi from the Lower Animals, 223 Pathognomonic Sign of Eungic Lesions, 223 Non-identity of Parasitic Eungi, 225 Di-morphism of Eungi, '226 Multiple Eorms of Eructification of Eungi, 226 Artificial Cultivation of Eungi 227 Apparatus required for Cultural Experiments, 228 Objects aimed at by the Cultivation of Eungi, 228 Calculus and Concretion, 228 Definition of Calculus and of Concretion, 228 Pathology of Calculus and Concretions, 228 Sources of Concretion, 229 (1.) Concretions of Protein Substances, 229 (2.) Concretions of Eats 229 (8.) Concretions of Pigment, 230 (4.) Concretions of TTric Acid and Urates, 230 (5.) Concretions of Lime Salts, ■ • • .231 (6.) Concretions of Ammonio-phosphate of Magnesia, 231 Elementary Constituents of Concretions and Calculi, . - . . . . 232 Malj-ormations, ^^^ Definition and Pathology of Malformations, 233 Origin of Malformations, 233 Classification of Deformities, ^34 Elementary Eaots in "Teratology," ^<>4 I. Malformations Kbsulting prom Incomplete Development or Growth ov Parts, 234 (a.) Of the Body generally j°J' (6.) Of the Nervous System, j°^ (c.) Of the Organs of Special Sense, jo^ (d.) Of the Yascular System, ^o^ (e.) Of the Respiratory System, j°J> (/.) Of the Digestive System, ■^<*o Digitized by Microsoft® XXIV ■ CONTENTS OP VOLUME I. PAGE (g.) Of the Urinary System, 236 (A.) Of the Male Organs of Generation, 236 (i.) Of the Female Organs of Generation, 236 II. Malfokmations Kesultinq prom Incomplete Coalescence of the Lateral Halves of Parts which should become Conjoined, 236 (a.) On the Anterior Median Plane, 236 [b.) On the Posterior Median Plane, .236 III. Malformations Resulting from Coalescence of the IiAtekal Halves of Parts which should remain Distinct, . . . 237 IV. Malformations Kesttltinq from the Extension of a Commissure be- tween THE Lateral Halves of Parts (causing Apparent Du- plication) 237 V. Malformations Resulting from Repetition or Duplication of Parts in a Single Fcetus, 237 VI. Malformations Resulting from the Coalescence of two Fcetuses, or of their Parts, 237 VII. Congenital Displacements and Unusual Positions of Parts of the Fcetus, 237 Examples of Double Monsters from One Germ, 238 Functional Diseases 238 Definition and Pathology of Functional Diseases, 238 Fever, 240 Definition and Pathology of Fever, 240 Natural History of Fever generally, 240 Galen's Definition of Fever, 241 Two points to be determined where Fever is present, namely: (l.'j.The Amount of the Preternatural Heat; (2.) The Amount of the Tissue • Change, 241 .The Sequence of Phenomena necessary to be known in Fever, . ... 241 Pernicious System of Naming Fevers from Names of Places, . . . 241 Defervescence in Fever and its Significance, 242 Significance of the Terms " Crisis," " Lysis," and " Insensible Resolution," 242 Usefulness of the Thermometer in Diagnosis, 242 The Usefulness of the Thermometer at the Bedside in the Diagnosis of Pyrexia, 242 Importance of determining the Thermometry of Disease, .... 243 Methods of Recording the Fever-heat of the Body 243 I. The Instruments, Methods, and Practical Rules for Observing and Record- ing the Temperature of the Human Body In Disease where Fever is present, 243 Description of Clinical Thermometers, 244 Diiferences in different Thermometers, 244 Verification of Instruments at Kew or Greenwich Observatories necessary, 244 Mode of Using the Clinical Thermometer, '...... 245 Scales of Temperature Compared 246,247 Blank Forms for Records of Temperature, Pulse, Respiration, and Ex- creta, 248, 249 II. Fluctuations of Temperature within the Limits of Health, and the Cor- relation of the Animal Heat with the Pulse and Respiration, . . 250 Development of Body-heat, 250 Normal Temperature of the Human Body, ...... 260 Periods of Minimum and Maximum Temperature, 250 Circumstances which Influence Body-heat, 251 Correlation of Pulse and Temperature, ....... 252 Bodily Temperature of Children, 252 III. Ranges of Temperature in Disease, 253 Instances of Disease indicated by the Thermometer, .... 254 Typical Ranges of Daily Temperature in certain Febrile Diseases, . . 266 IV. Ranges of Temperature in Diseases where Fever is present, as related to the Amount of Excreta, 259 Amount of Excreta Normal to the Body, 259 Digitized by Microsoft® CONTENTS OP VOLUME I. XXV PAGE Relation of Excreta to Fever-heat, ■ . . . 262 Eev. Samuel Haughton's Table for the Determination of Urea in Urine, 259, 260, 261 " Getting the Turn " of a Fever . . . 263 Table I. Abstract of Cases in which some of the Excretions are Increased in consequence of the Febrile State (Dr. Parkes), . . . 263 " II. Cases in which there was Diminution of the Excretions (Dr. Parkes), .263 " III. Table of Cases to show Local Lesions coincident with sudden Re- tention of the Excretions in Fever (Dr. Parkes), . . . 264 Large Amounts of Urea Excreted, 265 Retention of Water in the Febrile Body, 266 Condition of the Urine in Fever, ' 266 Condition of the Blood in Fever, . . . . ' 266 Condition of the Pulmonary Excretion in the Febrile State, . . .266 Condition of the Nervous System in the Febrile Statfi, 267 Conditions which combine to Produce the Complex Phenomena of Fever, . 267 CHAPTER IX. Types or Disease and their Tendency to Change, 269 Definition of the Type or Form of a Disease, 269 Results of Sanitary Science, 270 Agencies Modifying the Types of Diseases, 272 Change of Type in Continued Fever, . . 274 Examples of Change of Type in Disease, 275. Active Sources of Degeneracy, 276 Changes in the Medical Constitution, 278 CHAPTER X. Modes by which Diseases terminate Fatally, 279 Death from Decay of Life, by extreme Old Age, 279 Death by Syncope and Asthenia, 280 Death by Starvation, 281 Death by Suffocation, or Apnoea, 281 Death by Coma, . . 282 CHAPTER XI. ' Principles which Dictate the Treatment of the Two Complex Moruid Processes — Fever and Inflammation, 283 I. As regards Fevers or the Febrile State, 283 Four Modes by which Fevers may naturally Terminate, . . . 283 Combination of Measures necessary in the Treatment of the Febrile State, 283 (1.) To Reduce Excessive Heat, 283 Methods of Reducing the Heat of Fever, 284 Rules for the Use of Alcohol in Fever 286 (2.) To insure sufficient, but not excessive Excretion, and to Promote its Elimination in Fever, 286 (3.) Restorative Agents in the Febrile State, 287 II. As regards Inflammation, 288 Nature of Antiphlogistic Treatment, 288 Bloodletting, 289 Immediate Effects of Loss of Blood, . . ' 290 General Rules as a Guide to Bloodletting, 290 Indications as to the Repetition of Bloodletting, 292 Methods of Bloodletting, General and Local, 293 Other Antiphlogistic Remedies, . . . . . . . . 294 Use of Purgatives and Mercury, . . • . ■ 294 Use of Iodide of Potassium, Antimony, and Opium, .... 295 Use of Aconite, 295 Use of Alkalies, 296 Digitized by Microsoft® XXVI CONTENTS OF VOLUME I. PAKT II. PAGE Methodical Nosology — Systematic Medicine, or the Distinctions and Definitions, the Nomenclature and Classification of Diseases, . 297 CHAPTER I. The Aim and Objects of Nosology, 297 I. The Definition of Diseases 297 Method of Defining Diseases, 298 II. The Nomenclature of Diseases, 299 Principles influencing the Names of Diseases, 299 III. The Classification of Diseases, 300 Principles of Classifying Diseases, . ' 301 Systems of Classification of Diseases, . . . . . . • 301 I. According to the Nature of the ascertained Causes of Disease, . 301 II. According to the Pathological States or Conditions which attend Diseases, 301 III. According to the Properties, Powers, or Functions of an Organ or System of Organs being Deranged, ..... 302 IV. According as Diseases are Structural or Functional, . . . 302 V. According to the Pathological Nature of the several Morbid Pro- cesses, . . . . . . . . ■ ■ • 302 VI. According to the General Nature and Localization of the Morbid States, 303 VII. According to the Principles of a purely Humoral Pathology, . 303 VIII. According to the supposed Elements of Disease, .... 303 IX. Dr. Stark's Classes of Diseases, . . . . . . . 303 X. Classification of Dr. William Farr, 303 No perfectly Philosophical or purely Natural Classification, . 304 Conditions for a Philosophical Classification of Diseases, .... 304 Present State and Aim of Nosology, _ . 305 Origin of the New Nomenclature of Diseases by the College of Physicians of London, 306 Plan of the New Nomenclature, 307 Classification of Diseases by the College of Physicians of London, . . 307 General Diseases (arranged into two Sections) and Local Diseases, . . 307 Some Deficiencies of Practical Importance in the Nomenclature, . . 308 The Future Prospects of Nosology, 309 Provisional nature of the Nomenclature, 309 CHAPTER IL Tabulae View OF "The Nomenclature of Diseases," drawn up. by a Joint Committee appointed by the Royal College of Physicians of London (1869). General Diseases (Sections A and B), Local Diseases, ..... Arrangement of Local Diseases, . Names of Diseases of the Nervous System, " Diseases of the Eye, "°" Diseases of the Ear, " Diseases of the Nose, " Diseases of the Circulatory System, " Diseases of the Absorbent System, " Diseases of the Ductless Glands, " Diseases of the Respiratory System, " Diseases of the Digestive System, " Diseases of the Urinary System, " Diseases of the Generative System, " Diseases of the Male Organs of Generation, 310 311 311 312 312 313 313 314 314 315 316 316 318 318 818 Digitized by Microsoft® CONTENTS OF VOLUME I. XXVll Names of Diseases of the Female Organs of Generation in, the Unimpreg' nated State, " Affections connected with Pregnancy, . " Affections connected with Parturition, . " Ji flections consequent on Parturition, . " Diseases of the Female Breast, .... " Diseases of the Male Mammilla, .... " Diseases of the Organs of Locomotion, . " Diseases of the Cellular Tissue, .... " Diseases of the Cutaneous Sj'stem, " Conditions not necessarily associated with General or eases, Poisons. . Injuries, . Local Injuries, Local Dis 319 320 320 320 320 821 821 822 322 323 323 324 324 PART III. Thb Natttrb 01' Diseases, Special Pathology, and Therapeutics, . . 826 Objects of this Part, . .326 Nature of the Diseases comprehended in the Sections A and B of the Gen- eral Diseases, 326 Nature of the General Diseases comprehended in Section A, . . . 326 Specific or Miasmatic Fevers, 326 Malarious Fevers, 326 Epidemic Diseases, 326 Febrile Affections due to the introduction of Animal Matter in a State of Change, 826 Nature of the General Diseases comprehended in Section B, . . . 326 Constitutional Character of the Diseases, 326 Method to be followed in the Chapters relative to the Pathology of General Diseases, 326 Necessity fur Limiting and Fixing the Significance of the Terms " Mias- matic" and " Zymotic," 826 Pathology of Zymotic Diseases, ......... 327 Special Pathology, Special Diseases, 327 CHAPTEE I. On the Nature of the Specific ok General Diseases commonly called Miasmatic, The Blood generally is more or less Changed in the General Diseases, Specific Poisons believed to Affect the Blood, Nature and origin of " Acute Specific " or " General Diseases," Contagious Nature of the Specific General Diseases, Nature of the " Specificity " of these General Diseases, Essential Characters of the Specific Diseases, Causes and Origin of Specific Diseases, Communication of Specific Diseases, . . . . 327 327 828 328 328 328 328 329 332 CHAPTER II. Theory of Specific Diseases, Differences in the Constituent Elements of the Diseases in Sections A and B, Additional Distinguishing Elements of Specific Diseases, . . . . 832 Digitized by Microsoft® XXVm CONTENTS OF VOLUME I. CHAPTER 111. PAGE The Physiological Modes in which Poisons Act Illustk-atbd by Anal- ogy WITH THB Specific or Miasmatic Feveks, . ... . . 334 Action of Poisons Subject to Certain Laws, • . . 334 (1.) Definite and Specific Action of Poisons, ....... 335 (2.) Latency of Poisons, • 335 (3.) Modifications of Action by Dose, Temperament, and Constitution, . 335 Pbysiological Actions of Poisons, 336 Constitutional Susceptibility of some Persons to Poisons, .... 336 The Specific Action of Poisons which Produce Specific Disease, . . . 337 Peculiarities in the Action of Poisons which Induce Specific Diseases, . . 339 Multiplication of the Morbid Poison in the System, 340 Protective Influence of one attack from other attaeljs 340 Condition of the Blood in Specific Fevers, 341 Deaths from Specific or Miasmatic Diseases, ....... 342 Specific Disease Poisons, . . 343 Endemic and Epidemic Influences, 344 [Summary of Dr. MJurchison on the Pathology and Treatment of the Specific Pyrexiae in Miasmatic Fevers], . 344 CHAPTER IV. On THE Nature of Malaria and Malarious Fevers, Forms of Malarious Fevers, Specific Effect of Malaria Poison on the Body, Persistent Pernicious Influence of Malaria Poison, Causes and Modes of Propagation of Malarious Fevers, Conditions for the Development of Malarious Fevers, . Varieties of the Malarious Poison, .... CHAPTER V. On the Nature of Endemic, Epidemic, and Pandemic Influences Vy^hence Endemic Influences Result, ...... Conditions through which Endemic Influences become Active, Question as to the Spontaneous Origin of Specific Miasmatic Diseases, Nature of Epidemic Influence, Epidemic Influence on Constitution, and Evidence of its Presence, Laws of Epidemic Influence, and Conditions under which it Acts-, Nature of Pandemic Influence, and Evidence of its Existence, . Nature of Animal Malaria, 345 345 346 847 348 349 351 352 352 352 354 355 355 356 357 357 CHAPTER VI. Management, OF Epidemics; and on Proceedings which are advisable to be Taken in Places Attacked or Threatened by Epidemic Diseases, 359 Possibility of Extinguishing or "Stamping out" the greater number of Epidemic Disea.ses, 359 ' Elementary Facts which Dictate the Steps to be talieu, .... 359 Details of Proceedings advisable to be taken in Places Attacked or Threat- ened by Epidemic Diseases 359 Rules for the Management of Epidemics, 359 Rules for the Observation of Cases and the Government of Fever Hospitals, 362 Processes of Disinfection, . . . 362 Digitized by Microsoft® CONTENTS OF VOLUME I. XXIX CHAPTER VII. PAGE Pathology or the Enthetic, Implantbd, or iNootrLATED Kind of Specific OR General Diseases, 363 Sources of the Poison of such Diseases, 363 Definition of Poisoned Wounds, 363 How the Poison is Eeceived into the System, 36.3 How Germs of a Specific Kind become Directly Implanted, . . . 363 Specific, Local, and Constitutional Effects of an Inoculated Morbid Poison, 364 Example of the Action of a Poison from the Bite of a Bug, ... 364 Example of the Action of the Poison of a Cobra di Capello, . . . 364 Changes said to be Visible in the Blood-corpuscles subsequent to the Bite, . 365 Pathological Action and Pathologj' of Specific Venoms, .... 365 Nature of the Venom Secreted by Serpents, 365 Deaths from Snake Bites in India are very numerous, . . . . . 366 Names of the very Deadly Poison -snakes, 366 Nature of the Venom secreted by Serpents — its General Appearance and Properties, 366 Different Effects of the Venom according as it comes frqm Different Fami- lies of Snakes, 366 Effects of the Venom of the Cobra (iV«ja), ... . . ... . 366 Effects of the Venom of the Viper (Daboia), 366 Effects of the Venom of the Rattlesnake (CVoteZirfce), 366 Subsequent Effects of the Action of Serpent-venom 367 Analysis of the Symptoms from Rattlesnake-venom, 367 Chemical Analysis of Serpent-venom, . 368 Digestion Destroys the Poisonous Properties of Serpent-venom, . . . 368 Blood of an Animal killed by Snake- venom is itself Poisonous or Venomous, 368 Morbid Anatomy of Brain, Blood, and Tissues, after death from Snake Bite, 369 Effects of the Venom of the Cobra and Daboia Russellii, .... 369 Effects of the Venom of the Bungarus, 369 Question regarding " Antidotes" for the Venom of Snake Bites, . . . 370 No Antidote for Serpent-venom, . . . . . . . . . 370 Changes which the Absorbed Virus of Specific Diseases Undergo in the Hu- man Body, .... 371 How Specific Disease-poisons differ from Venom, ...... 371 Evidence of Increase of Virus of Disease-poisons within the Body, . . 371 Evidence of Transformation of their Virus, 371 Evidence of the Combination of Morbid Poisons wiWi some Blood Compo- nent, • . • . . .372 Evidence of Separation oi: Excretion of Morbid Poisons, .... 372 Rapid Effects of the Cadaveric Poison, 372 Tardy Process of Incubation of some JPoisons, 372 Varieties of Poisoned Wounds enumerated from the Nomenclature, . . 373 CHAPTER VIII. On the Nature of the General Diseases of a Specific or Miasmatic Kind comprehended in Section, B, . . . . . • . . 373 Nature of Constitutional Diseases, 373 A Cachectic State or Bad Habit of Body, 373 Course of Constitutional Diseases, 374 Personal Peculiarities, Temperament, Diathesis, Hereditary Transmission, and Predisposition, 374 Alternate Generations Suffer — Law of "Atavism," 374 Blood Diseases and Constitutional Diseases 376 • CHAPTER IX. Detailed Description of the General Diseases— Section A, . . . 376 Small-Pox, ^^^ Definition and Pathology of Small-pox, 376 Fever and Defined Course of Small-pox Eruption, 376 Digitized by Microsoft® XXX CONTENTS OP VOLUME I. PAGE Morbid Anatomy of Small-pox, 377 Nature of the Small-pox Eruption, and Anatomical Structure of the Small- pox Pustule, 377 Varieties and Symptoms of Small-pox, 379 Symptoms of Natural Small-pox, 379 Group A.— Unmodified or Natural Small-pox, . ' . . . . . 379 Symptoms of Distinct Small-pox 380 Course of the Disease, ........... 380 Typical Range of Temperature in a Case of Natural Small-pox and Fever of Suppuration, ............ 381 Description of Confluent Small-pox, .....;.. 383 Symptoms of Inoculated Small-pox, 385 Complications of Small-pox and Special Morbid Tendencies, . . . 386 Pyogenic Fever after Small-pox, ... 386 Sequelae of Small-pox, 387 Course of Small-pox after Vaccination, ... 388 Group B. — Small-pox after Vaccination — Varioloid, or Modified Small-pox, 388 Definition of Small-pox after Vaccination (Modified Small-pox), . . . 388 Symptoms, Course, and Modifications of Small-pox after Vaccination, . 388 Typical Range of Temperature in a Case of Small-pox Modified by Vaccina- tion, 389 Exhaustion of Susceptibility after an Attack of Small-pox, . . . 389 Coexistence of Small-pox with other Morbid States, . . . . . 390 Cause and Propagation of Small-pox, 390 Causes which Predispose to Small-pox, . 391 Prognosis and Causes of Death in Small-pox, . . . . . . 391 Diagnosis of Small-pox 392 Treatment of Small-pox, . . . . . . . . . : 393 (1.) Therapeutic, Curative, or Sanative Treatment of Small-pox, . . 394 Dietetic and General Medical Treatment of Small-pox, . . . 394 ■ Preventive Treatment of Small-pox 396 (2.) The Prophylactic, Sanitary, or Preventive Treatment of Small-pox, 397 Inoculation of Small-pox : Its Significance and Illegality, . . 398 Cow-pox, 398 Definition and Pathology of Cow-pox, . . 398 Pathology and Symptoms of Cow-pox, 399 Nature and History of Dr. Jenner's Discovery after 1780, .... 399 Evidence that Animals (including Monkeys, Sheep, and Cattle) sutfer from Small-pox 399 Evidence of Cases of Small-pox in Man communicating Variolous Disease to Cows, 400 Direct Inoculation of Small-pox into the Cow from Man, .... 401 Origin of all such Specific Poisons Unknown, 401 Means adopted to Modify the Disease amongst Animals, .... 402 Local Symptoms of Cow-pox in the Cow, ....... 404 Nature of Primary Vaccine Lymph, . '.. : 405 How to Procure Primary Vaccine Lymph direct from the Cow, . . . 405 Useful Substitute for Liquid Lymph, 405 Vaccination, 405 Discovery and Nature of Vaccination by Dr. Jenner, 405 Nature and Imperfection of the Vaccination Acts, . . . , . .' 406 Present Position of our Knowledge regarding Vaccination, .... 407 (1.) Nature and Evidence of the Protection conferred by Vaccination, . 407 Influence for Good of Vaccination, . . ' 408 Beneficial Influence of Perfect Vaccination, , . . . . 409 (2.) How the Protective Influence of Vaccination has been Impaired, . 411 No Deflnite Conclusion as to the Absolute Duration of Protection afforded by Vaccination, 411 Vaccine Virus apt to Deteriorate from Bad Vaccination, .... 413 Results of Spurious Vaccination, 414 The Operation of Vaccination, 415 Amendment of Vaccination Act of 1867 Proposed, 415 Recommendation of the College of Physicians relative to Revacoination, . 415 Signs of Successful Vaccination, ........... 417 Digitized by Microsoft® CONTENTS OP VOLUME I. XXXI PAGE Signs of Successful Revaccination, . 418 Characters of the Cicatrix after Vaccination, 418 Number and Quality of Vaccination Marks, 419 Four Degrees of Protection Indicated by Vaccination Marks, . . . 420 Selection of Lymph for Vaccination, 420 Ohickek-pox, . 421 Definition and Pathology of Chicken-pox, 421 Symptoms of Chicken-pox 422 Diagnosis of Chicken-pox, 422 Treatment of Chicken-pox, .......... 423 Measles, 424 Definition and Pathology of Measles, 424 Characters of the Eruption of Measles, ........ 425 Diagram representing the ilange of Temperature in a Case of Measles in which the Fever is Severe, 426 Symptoms of Measles, 428 Characteristics of Severe Forms of Measles, 429 [Camp Measles in the American Armies] 429 Diagnosis of Measles, 430 Prognosis in Measles, . 430 Causes of Measles, ............ 431 Propagation of Measles by Direct Communication and Infection, . . 431 Propagation of Measles, • .431 Communication of Measles by Inoculation, 431 Treatment of Measles, 432 Scarlet FeviSr, — Syn., Scarlatina, 434 Definition of Scarlet Fever, 434 Significance of Synonyms in the Nomenclature of Scarlet Fever, . . 434 Pathology and Morbid Anatomy of Scarlet Fever, ' . . . . . 434 Three Forms of Eruption, 435 Symptoms of Scarlet Fever, 436 Varieties of Scarlet Fever, 436 Albuminuria with Anasarca in Scarlet Fever, 436 Symptoms of Simple Scarlet Fever, 437 Typical Range of Temperature in a Case of Scarlet Fever, .... 439 Dropsy after Scarlet Fever, 440 Condition of the Urine in Scarlet Fever, 441 Anginose Scarlet Fever, . . . . . • ■ ■ • • • 442 Malignant Scarlet Fever, ■ • • 443 Symptoms of Malignant Scarlet Fever, 443 Special Lesions (or Localizations of them) in Scarlet Fever, . . . 445 Diagnosis of Scarlet Fever 446 Cause and Propagation of Scarlet Fever, 446 Propagation of Scarlet Fever through Milk, 447 Prognosis in Cases of Scarlet Fever, • ■ 448 Treatment of Scarlet Fever, 448 Preventive Treatment of Scarlet Fever, ...■..-. 462 Hybrid of Measles and Scarlet Fever 454 Definition of the Hybrid of Measles and Scarlet Fever 454 Pathology of the Hybrid between Measles and Scarlet Fever, . . • *r- Symptoms of the Hybrid of Measles and Scarlet Fever, 4oo Symptoms of " Eotheln," 456 Lesions Seen in Fatal Cases of " Eotheln," 4^' Diagnosis of "Eotheln," . . • • ■ ■ • • ■„„',: Table showing the most Prominently Distinguishing Characters oi Scarlet Fever, Rubeola, and Measles (Paterson), . . . . • ■ .J, Prognosis in Cases of "Rotheln," *°° Treatment of " Eotheln," ^'^^ T. ... 459 Dengue, 459 Definition of Dengue, . . Digitized by Microsoft® XXxii ' CONTENTS OF VOLUME I. PAGE Pathology and Symptoms of Dengue, 459 Diagnosis and Treatment, . 4tiO Typhus Fkter, 460 Definition of Typhus Fever, . . .460 Varied Significance of the Term Typhus, 460 Historical Notice of Typhus Fever, ......... 461 [Immunity from Typhus ^fever in the American Armies during the "War . of the Kebellion], 462 Causes of Disease in the British Army in the Order of their Greatest Influ- ence (Note) 462 Phenomena and Symptoms of Typhus Fever, 463 The Eruption of Typhus Fever, 464 Body-temperature in Typhus Fever, 464 Typical Range of Temperature i,n a Case of Typhus Fever, .... 467 Correlation of Temperature and Pulse, , . . . 469 Table showing Correlation of Pulse to Temperature, 470 General Indications in Typhus 470 Complications of Typhus Fever, 471 Occurrence of Convulsions and Cerebral or Head Symptoms in Typhus Fever, 471 Secondary Pulmonic Complications in Typhus Fever, . . . . . 473 Gangrene of the Pulmonary Tissue in Typhus Fever, 474 Secondary Cardiac Lesions in Cases of Typhus Fever, 474 Prognosis in Cases of Typhus Fever, 474 Cornbined Value of Temperature and Pulse in Cases of Typhus Fever, . 475 Summary of Prognosis in Typhus, 476 Combinations of Symptoms and Phenomena which are of extremely Unfa- vorable Import, 477 Combinations of Symptoms and Phenomena which may be regarded as of Favorable Import, 477 Modes of Fatal Termination, 477 Condition of the Blood in Typhus Fever, . . _ 478 Treatment of Typhus Fever, ^ . . . 478 General Indications for Treatment, 479 ■ Special Indications for Treatment, 479 Guide for the Administration of Alcoholic Stimulants in Typhus Fever, . 481 Forms of Alcoholic Stimulants in Use, . 483 Necessity of Careful Nursing, . . . . . . . . . 483 Treatment of Headache and Delirium in Typhus, 483 Origin and Propagation of Typhus Fever 486 Communication of Typhus Fever by Fomites, . . . . ■ . . 486 History of an Epidemic on Board the Egyptian Ship, " Soheah Geheld," at Liverpool in 1860, . . . .... . . . . .487 Question as to the Origin of Typhus Fever de novo, ..... 488 Summary of Evidence as to Contagious Nature of Typhus Fever, . . 488 Conditions Essential for Propagation, 490 Question as to the Period when a Typhus Patient ceases to Infect, . . 490 Latent Period of Typhus Fever, . . . . ; . . . . 490 Individual Susceptibility to Typhus Fever, . . . . . . . 491 [Epidemic Cerebeo-Spinal Mbninottis, 492 Definition of Epidemic Cerebro-spinal Meningitis, ..... 492 The Name " Epidemic Cerebro-spinal Meningitis " an improper one for this Aifection, 492' History and Geographical Distribution of Epidemic Cerebro-spinal Mening- itis, 492 Morbid Anatomy of Epidemic Cerebro-spinal Meningitis, .... 494 Symptoms of Epidemic Cerebro-spinal Meningitis, 496 Prognosis in Cases of Epidemic Cerebro-spinal Meningitis, .... 499 Mortality in Epidemic Cerebro-spinal Meningitis, 499 Diagnosis and Etiology in Epidemic Cerebro-spinal Meningitis, . . . 500 Question as to the Contagiousness of Epidemic Cerebro-spinal Meningitis, . 501 Nature of Epidemic Cerebro-spinal Meningitis, 502 Treatment of Epidemic Cerebro-spinal Meningitis, 503 Bibliography of Epidemic Cerebro-spinal Meningitis,] 505 Digitized by Microsoft® CONTENTS OF VOLUME I. XXXUl PAOK BnTKRIC ]?ElrBR — St/ii., Ttphoid Pbyee, 506 Definition of Enteric Fever, 506 Pathology of Enteric Eever, 506 Differences between Typhus and Enteric Eever, . ... . . . 507 Various Beliefs Entertained regarding Enteric and Typhus Pever, . . 508 Points of Differences between Enteric and Typhus Eever, .... 509 Morbid Anatomy of the Lesions in Enteric Eever, with Special Keference to the Phenomena and Progress of the Disease, 510 Anatomy of Special Lesions in Enteric Eever, 511 Anatomical Eorms of the Intestinal Glands, ... . . . . .- 511 Prevalence of Enteric Eever at Different Ages, 511 Elimination of the New Material from Peyer's Glands during Enteric Eever, 513 (1.) Elimination without Ulceration, ........ 513 (2.) Elimination by Ulceration, 514 Characters which distinguish the Ulcers of Enteric Eever from other Ulcers, 514 (3.) Elimination of Enteric Growths of Peyer's Patches by Sphacelus, . 515 (4.) Eeabsorption of Enteric Material, 516 Catarrh and Atrophy of Intestine in Enteric Eever, 516 Mesenteric Gland-lesion in Enteric Eever, 516 Enlargement of the Spleen in Enteric Eever, 516 Pulmonary (Secondary) Lesions in Enteric Eever, . . . ■ . . 516 Tendency to Ulceration of Mucous Membrane in Enteric Eever", . . . 517 Growth of Tubercle during Enteric Eever, 517 Erysipelas, Phlebitis, and Parotitis during Enteric Eever, .... 518 Microscopic Structure of the New Growth in Enteric Fever, . . .518 Symptoms, Course, and Duration of Enteric Fever, . .. . . . 519 Commencement of the Disease, 519 Characters of the Stools and the Pulse, 519 [Duration of Convalescence], 519 Condition of the Mind in Severe Cases of Enteric Eever during Eecovery, . 521 t Spinal Symptoms in Typhoid Fever, . . 521 )escription of the Spinal Symptoms in the Famine Fever of 1848] , . . 522 Eelapses of the Fever, 523 The Cutaneous Eruption in Enteric Fever, ' '. . 524 [A Miliary Eruption, of slight Diagnostic value, frequently occurs in Ty- phoid Fever, 525 Typhoid Fever in Children], 525 The Body-temperature during Enteric, Typhoid, or Intestinal Fever, . . 525 Duration of Attack and Mode of Recovery in cases of Enteric Fever, . . 529 Diagram Showing Eange of Body-temperature in a Severe and Prolonged Case of Enteric Eever, 530 Eelapses in Enteric Fever, .531 Condition of the Urine in Enteric Eever, 532 I. As to Normal Constituents, 532 IJ. As to Abnormal Constituents, 533 Diagnosis in Cases of Enteric Fever, 533 Tabular Statement of the Leading Diagnostic Points in Contrast, . . 534 [Certain Phenomena met with in Typhoid Fever, from which a certain and timely Diagnosis can be made], 534 Prognosis in Cases of Enteric Fever, _ . . ■ 535 Circumstances under which Death may occur in Cases of Enteric Eever, . 586 (1.) By Blood-poisoning ^^6 ■" ' By Implication of L_- „ „ - By Congestion of Important Organs, 536 (2.) By Implication of Excretory Organs, 536 536 (4.) By Heniorrhages, . " 536 (5.) By the Exhaustion of Diarrhcea, 636 (6.) By Peritonitis, l°° Origin and Propagation of Typhoid Eever, 537 Elementary Facts regarding the Propagation of Enteric Fever, . _ . .638 Preventive Measures, or Measures for Checking the Spread of Enteric Fever, 639 Details of Procedure for Checking the Spread of Typhoid Fever, . . .540 Question as to a Specific Poison and Origin of Enteric Fever, . . .640 Pythogenetic Eever of Dr. Murchison, . . ••.■„■ ' .■ [Chief Determining Causes of Typhoid Fever m the United States Armies during the Eebellion], 642 Treatment of Enteric or Typhoid Fever, oa*5- VOL. I. ^ Digitized by Microsoft® XXXIV CONTENTS OF VOLUME I. PAGE Question of Checking the Diarrhoea, 545 Good Eflfects of Calomel in Enteric Fever, 546 Necessity of Attending to Diet in Oases of Enteric Fever, .... 549 [Great Care and Vigilance necessary during Convalescence], . . . 550 Kblapsing Fbtkr 550 Definition of Relapsing Fever, 650 Pathology and Historical Notice of Relapsing Fever, 550 [History of Relapsing Fever in the United States], 552 Phenomena of Relapsing Fever, 554 The Primary Paroxysm in Relapsing Fever, 554 The Crisis of Relapsing Fever, . 555 Diagram of Temperature in a Case of Relapsing Fever (Herman), . . 556 The Relapse or Recurrent Paroxysm in Cases of Relapsing Fever, . . 557 Protracted Convalescence from Relapsing Fever, 557 Tendency to the Occurrence of Sudden ]3eath, 557 Duration of the Fever and Prolonged Duration of Convalescence, . . 558 Sequelse of Relapsing Fever, 558 Post-febrile Ophthalmitis (Mackenzie), 559 Treatment of Relapsing Fever, 559 Simple Coutiitubd Fever, 560 Definition of 'Simple Continued Fever, 560 Pathology of Simple Continued Fever, 560 Reasons for Retaining this Name as the Name of a Disease, .... 560 Anomalous Forms of Continued Fever, 561 Febkioula, 562 Definition of Fehricula, . . 562 Pathology of Fehricula, 562 Diagram of Typical Range of Temperature in a Case of Fehricula, . . 563 Typical Range of Temperature in a Case of Protracted Fehricula, . . 563 Diagnosis of Fehricula, . . 564 Treatment of Fehricula, . . . 564 .[Specific] Yellow Fever, . . . . 564 Definition of Specific Yellow Fever, 564 Pathology and Symptoms of Specific Yellow Fever, 564 Necessity of Separating and Distinguishing the Specific from the Malarious Forms of .Yellow Fever, 565 History of the " Eclair " Epidemic, 567 - Incubation of Specific Yellow Fev,er, . 567 Importation of Specific Yellow Fever, . . . . ' . . . . 568 History of its Importation into St. Naziaire, 568 Propagation of Specific Yellow Fever, . . . 569 [Facts Favorable to the Doctrine of the Transmissibility and Portability of Yellow Fever] 571 Symptoms of Specific Yellow Fever, 572 Types, Groups, or Forms of Specific Yellow Fever, ... . . . 573 » Several Types of Specific Yellow Fever, 573 Condition of 'the Urine in Specific Yellow Fever, 574 White and Black Vomit in Yellow Fever, 575 Prognosis in Cases of Specific Yellow Fever, ...... 676 Treatment of Specific Yellow Fever, 576 Composition of Chlorodyne {Note), 578 [Prevention of Yellow Fever], 579 Plague, 580 Definition of Plague, 580 Pathology and History of Plague, 580 Morbid Anatomy in Cases of Plague, 581 Symptoms of Plague, 582 Progress of the Bubo in Plague, 582 Varieties of Carbuncle in Plague, 582 Diagnosis in Cases of Plague, 683 Digitized by Microsoft® CONTENTS OF VOLUME I. XXXV PAGE Cause of Plagne, 683 Modes of Propagation of Plague, 584 Treatment of Plague, 584 Quarantine, 585 AavK—Syn., Intermittent Feter. 585 Definition of Ague, 585 Symptoms of Ague — Tha Paroxysm or Fit 585 [Number of Cases of Intermittent Fever in tlie United States Armies dur- ing the first two years of the Civil "War (Note)], 685 Varieties or Types of Intermittent Fever, 587 [Congestive Form of Intermittent Fever], . . . . . . . 587 Temperature in Cases of Intermittent Fever, 588 Diagram of Typical Range ctf Body-temperature in Intermittent Fever of Quotidian Type, 588 Diagram of Typical Kange of Body-heat in Intermittent Fever of Tertian Type, 589 Condition of the Urine in Ague, 590 Treatment of Intermittent Fever, . . • 591 Remittent Fever, 594 Definition of Remittent Fever, 594 Symptoms of Remittent Fever, 594 Varieties of Type of Remittent Fever, ........ 596 [Prevalence of Remittent Fever In the Middle, Southern, and Western Re- gions of the United States, . . . . . . . . . 596 Malignant Congestive or Pernicious Remittent Fever], .... 598 Treatment of Remittent Fever, . • . . 599 Professor "W. C. Maclean's Treatment of Remittent Fever [Note), . . 601 [Chronic Malarial Toxaemia, 603 Definition of Chronic Malarial Toxaemia, . 603 Morbid Anatomy of Chronic Malarial ToxEemia, ...... 603 Morphological Changes in the Bloofi in Malarial Fever, .... 604 Treatment of Chronic Malarial Toxaamia], 606 [Ttpho-Malarial Fever — Syn., Chickahomint Fever; American Fever, 607 Definition of Typho-malarial Fever, 607 History of Typho-malarial Fever, 607 Symptoms of Typho-malarial Fever, 607 Anatomical Character of Typho-malarial Fever, 608 Treatment of Typho-malarial Fever], 608 Malariotts Yellow Fbtek — Syn., Fbbkis Ictbrodbs Remittens, . . 608 Definition of Malarious Yellow Fever, 608 Pathology of Malarious Yellow Fever, 608 Nature of the Soil in Relation to Malarious Yellow Fever, .... 610 Malignant Cholera — Syn., Serous Cholera; Spasmodic Cholera; Asi- atic Cholera, - 611 Definition of Malignant or Asiatic Cholera, 611 Pathology of Malignant or Asiatic Cholera, , . .611 Theories Explaning the Pathology of Malignant or Asiatic Cholera, . . 611 Mr. Simon's Views regarding the Pathology of Malignant Cholera, . . 612 Second, Third, Fourth, and Fifth Theories, 617 Sixth Theory regarding the Pathology of Malignant Cholera, . . .618 Seventh and Eighth Theories— those of Pettenkoffer and Macnamara — as to the Nature of Malignant Cholera, 618, 619 Ninth Theory— Conclusions of Dr. Beasley, as expressed by Dr. Bryden, . 619 Conclusions regarding the Several Theories, ■ . 620 Quite as many False Facts as False Theories regarding Cholera, . . .620 Earliest Knowledge of the Progress of Cholera due to the late Sir James Clark, .620 Two points in which all the Theojies Agree, .620 Digitized by Microsoft® XXXVl CONTENTS OF VOLUME I. PAOE Differences between the Epidemic of 1866 and Pormer Epidemics, . . 621 Evidences of Importation or Transmission of tlie Disease, .... 621 Infection of England in 1866 at many different parts, 622 Occasional Circumstances which Eacilitate and give Energy to the Spread of Malignant Cholera, 624 (1.) Meteorological Conditions, . . . 624 . (2.) Local Causes, 627 Views of Bayer, Barton, Carpenter, Pettenkofer, and Snow, regarding Local Influences, 628 Impure "Water the Main Local Agent of Importance, 628 Precise Conditions which Aggravate Epidemics of Malignant Cholera, as determined by Dr. Greenhow, 629 Propagation of Cholera by Human Intercourse, ....'.. 630 Communication of the Disease from Excreta, ...... 631 Propagation through the Excreta of the Premonitory Diarrhcea, . . 633 [Prevalence of Cholera in the United States Army in 1866, . . . 633 Instances of the Portability of Cholera, 633 The Organic Theory as a Cause of Epidemics, ...... 635 Conclusions of Dr. Lionel S. Beale], 635 Endemic Area and Epidemic Spread of Cholera, ...... 636 Routes followed by Malignant Cholera, ....... 637 Countries which have remained Eree from Cholera, ..... 639 Dr. Macnamara's Characteristics of Malignant Cholera, .... 639 Morbid Anatomy in Cases of Malignant Cholera, 641 External Appearances, 641 Condition of the Intestinal Canal, . 641 Condition of the Visceral Organs, 641 Condition of the Lungs, 642 Dr. Johnson's Diagram of the State of the Heart and Lungs, . . . 642 Post-mortem Appearances in Cases of Eeaction after Cholera, . . . 643 Chemistry of the Blood in Asiatic Cholera 643 Microscopy of the Body in Cholera, . . 646 Question of Specific Fungi in Cholera Excreta, 646 Hallier's, Thome's, Klob's, and Parke's Account of Eungi in Rice-water Stools of Cholera, 646 Explanation of Engraved Plate, . . ■ 649 Special Inquiry as to Fungi in Cholera, suggested by the Professors of the Army Medical School, to be carried out in India, and the Scheme pro- posed by them, 651 Conclusions since arrived at regarding the so-called Cholera Fungi,* . . 653 Chemical Changes Undergone by the Body in the Progress of Malignant Cholera, 654 Question as to Epithelium in the Stools of Malignant Cholera, . . . 654 Composition of Malignant Cholera, Intestinal Contents and Eice-water-like E'racuations, 665 Symptoms and Various Forms of Cholera, 657 Stages of Malignant Cholera, 657 Period of Incubation of Cholera, 657 Usual Course of the Disease as seen in this Country, 658 Termination of Cases of Malignant Cholera, 659 Hours at which Death takes place, . 660 Typhoid Symptoms after Eeaction, 661 The Blood and Urine in Malignant Cholera, 661 Seven Stages of Cholera. distinguished by Thudichum, 662 Body- temperature in Malignant Cholera, 662 Duration of Malignant Cholera, . . - 664 Relation of Vomiting and Purging to Algid Symptoms, .... 664 Evidences of Reaction after Malignant Cholera, 665 Circumstances Predisposing to Malignant Cholera, as well as those which present Resistance to the Attack, 666 Prognosis in Cases of Malignant Cholera, 667 Treatment of Malignant Cholera, 668 Three Periods to be specially Provided for, 668 Conditions to be attended to in the Management of Cases of Malignant Cholera, 668 Circumstances Eegulating the Dose of Opium, 668 Formula for Antispasmodic Pills, 668 Digitized by Microsoft® CONTENTS OF VOLUME I. XXXVU PAGE Beneficial Influence of Opium, _. . . . 668 Management of Large Bodies of Men in Armies, Factories, or Offices, with a view to the Prevention of Cholera, 669 Elimination Treatment of Cholera by the Promotion of Purging and Vom- iting, 671 Dr. George Johnson's Treatment of Malignant Cholera by Castor Oil, . 671 Fallacies of the Theory of Elimination, on which Dr. Johnson's Treatment is Based, 672 Dr. Macnamara's Experience as to Castor Oil, 673 Aim of Treatment in the Algid Stage, 673 Formula of Medicines to promote Reaction in Cholera and Diarrhoea, . . 673 Question as to Use of Calomel in Reaction, . . ... . . 673 Treatment during the Reaction Stage, by Dr. Andrew Clark, . . . 674 [Mode of Treatment by Drs. Leclere and Barrant], 674 The Kind of Cases Benefited by Calomel, 674 Use of Water and Cold Compresses, 674 Drinks recommended, . 674 Injection of Medicated Fluid into the Veins, 675 Stimulants not to be used, 675 Prevention of Cholera, 676 Use of Disinfecting Agents, 676 [Cholera Mokbtts — Si/ra., Sporadic Cholbra; Simple Cholera; Cholera BiLiosA, 678 Definition of Cholera Morbus, 678 History of Cholera Morbus, 678 Nature and Pathogeny of Cholera Morbus, 678 Symptoms and Diagnosis of Cholera Morbus, 678 Comparison of the Symptoms of Cholera Morbus with those produced by Irritant Poisons, 680 Treatment of Cholera Morbus], 680 [Cholera Infantitm — Syn., Summer Complaint; Infantile Cholera, . 680 Definition of Cholera Infantum, 680 History of Cholera Infantum, . ■ • 680 Symptoms of Cholera Infantum, 681 Causes and Nature of Cholera Infantum 682 Effective Causes, — Age, High Temperature, Humidity, and Malnutrition, . 682 Malnutrition due to Several Sources, ' 682 The Necroscopic Characters of Cholera Infantum, 683 Treatment of Cholera Infantum], 683 Diphtheria,, ^^^ Definition of Diphtheria, 685 Historical Notice of Diphtheria, 685 Pathology and Morbid Anatomy of Diphtheria, 686 Condition of Urine in Diphtheria, 688 Albumen in the Urine of Diphtheria, 688 Phenomena and Symptoms of Diphtheria, 690 Varieties of Diphtheria, as Grouped by Sir William Jenner, . . " °°Y Diagnosis in Cases of Diphtheria, 691 Prognosis in Cases of Diphtheria, 69^ Sequels after Cases of Diphtheria, 69- Peculiar Paralysis Subsequent to Diphtheria, 69^ Propagation of Diphtheria, 69d Treatment of Diphtheria, °^* Topical Applications, ^°° Question of Tracheotomy in Diphtheria, ■ oao Importance of Feeding the Patient, o^" .... 696 HOOPINO-COTTGH, Definition of Hooping-cough, • „ • . ■ ■ ?q? Pathology and Morbid Anatomy of Hooping-cough, . , . . • • bab ^STei:'c'^Z^^^:A a ..Fit" or .■ Paroxysm'' of Hooping-cough; 698 Digitized by Microsoft® XXXVIU CONTENTS OF VOLUMK I. PAGE Complications in Cases of Hooping-cough, 699 Diagnosis in Caste of Hooping-cough, 700 Cause of Hooping-cough and Modes of Propagation, 700 Period of Latency of Hooping-cough, 701 Prognosis in Cases of Hooping-cough, 701 Ages of Fatal Cases, . . . 701 Treatment of Hooping-cough, 701 Dietetic and General Management of Cases of Hooping-cough, . . . 704 Mumps, 704 I Definition of Mumps, 704 Pathology of Mumps, 704 A symptomatic Parotitis as distinguished from the Idiopathic Parotitis of Mumps, .704 Spread of the Disease by Contagion, 704 Symptoms of Mumps, . . . . . . . . . . • 705 Treatment of' Mumps, 705 Influenza, . . . 705 Definition of Influenza, ........... 705. Historical Notice of Influenza, 706 Pathology of Influenza, 706 Symptoms, Course, and Complications of Influenza, 707 Special Pulmonary Complications, 707 Causes and Modes of Propagation of Influenza, ...... 709 Susceptibility to Influenza exhausted to a certain extent, not absolutely, . 709 Prognosis in Cases of Influenza, 709 Treatment of Influenza, 709 Glanders, 711 Definition of Glanders, 711 Pathology of Glanders, 711 Morbid Anatomy in Cases of Glanders, ........ 712 Symptoms of Glanders, "^713 Special Eruption in Cases of Glanders, 713 Acute and Chronic Glanders or Farcy, 714 Causes of Glanders, ........... 714 Transmission of Glanders from the Horse to Man, 7f5 Inoculation of the Poison of Glanders, 715 Period of Latency in Cases of Glanders, 715 Prognosis in Cases of Glanders, ......... 716 Diagnosis in Cases of Glanders, ......... 716 Treatment of Glanders, * . . 716 Preventive Treatment of Glanders, 716 Farcy, 717 Definition of Farcy, 717 Pathology of Farcy, , 717 Morbid Anatomy — "Farcy Buds" and "Farcy Buttons," . . . . 717 Equinia Mitis, 71S Definition of Equinia Mitis, . . . ' 718 Pathology of Equinia Mitis, 718 Affection known as " Grease " in Horses, 718 Morbid Anatomy — "Grapes" and other Lesions Produced by " Grease," . 718 Symptoms of Equinia Mitis, . . . 718 Treatment of Equinia Mitis, 718 Maligkant Pustule (Vesicle), 718 Definition of Malignant Pustule, 718 Pathology and Historical ZS'otice of Malignant Pustule, .... 719 Propagation of Malignant Pustule, 720 [Malignant Pustule occasionally of Spontaneous Origin, .... 720 Digitized by Microsoft® CONTENTS OF VOLUME I. XXXIX PAGE Diversity of Opinion regarding ttie Kisk of Eating the Flesh of Animals affected with Malignant Pustule (iVo^e)], 720 Phenomena and Symptoms of Malignant Pustule, ..... 720 [Malignant CEdeilia of the Eyelids, 721 Anatomical Characters of Malignant Pustule], 721 Treatment of Malignant Pustule, 722 Phagedena, 722 Definition of Phagedena, 722 Pathology of Phagedena, 722 Treatment of Phagedena, 723 SLOTjeHTNG Phagedena, . . 723 Definition of Sloughing Phagedena, 723 Pathology of Sloughing Phagedena, 723 Hospital Gangrene, 723 Definition of Hospital Gangrene, 723 Pathology of Hospital Gangrene, 723 Cases Prone to Hospital Gangrene, . 723 Ektsipelas, 724 Definition of Erysipelas, 724 Pathology of Erysipelas, 724 Lesions in Erysipelas not limited to the Skin, ...... 724 Probable Origin and Seat of Erysipelas in the Absorbents, .... 725 Suppurative Process and Effusion in Erysipelas, ...... 725 Morbid Anatomy in Cases of Erysipelas, 726 Symptoms of Erysipelas, 726 Diagnosis in Cases of Erysipelas, 727 Typical Range of Body-temperature in Cases of Erj'sijielas of the Pace, . 727 Local Symptoms of Erysipelas, 728 Phlegmonous and Gangrenous Erysipelas, ....... 729 Cause of Erysipelas, ........... 730 Internal Lesions Associated with Erysipelas, ...... 780 Propagation of Erysipelas by Inoculation and Pomites, .... 730 Identity with some Forms of Puerperal Fever, 731 Period of Latency of Erysipelas, 731 Prognosis in Cases of Erysipelas, ......... 731 Treatment of Erysipelas, 732 Local Applications in Cases of Erysipelas, ........ 733 Pyemia, 734 Definition of Pyaemia, 734 Pathology of Pysemia, 734 Pyogenic Fever, 735 Difference of Pyogenic Fever from True Pysemia, 736 Metastatioal Dyscrasiae and their Nature, 736. Literal Meaning of Pyemia, 736 Composition of Pus, 737 Eesults of the Decomposition of Pus, 737 Pyeemia a Collective Name for several different Lesions, 738 Morbid Anatomy — Secondary or Metastatic Abscesses, . ' . . 740' Difference of Pysemic Abscesses from Ordinary Purulent Collections, . . 740' Symptoms of Pysemia, 741 Body-temperature in Cases of Pysemia, 742: Diagram of Body-temperature in a Case of Pysemia (Binger), . . . 743 Diagnosis in Cases of Pysemia, 744 Prognosis in Cases of Pysemia, 744 Treatment of Pysemia, 745. [Chronic PTiEMiA, • • ■ '^^^' Description of Chronic Pysemia, 745- Digitized by Microsoft® xl CONTENTS OF VOLUME I. PAGE Prognosis in Chronic Pyemia, 746 Treatment of Chronic Pycemia], 746 Puerperal Peter, 746 Definition of Puerperal Fever, 746 Pathology of Puerperal Pever, 746 Alliance between Puerperal Fever and Erysipelas, 747 Origin of Cases of Puerperal Fever, 747 Dr. Hicks's Experience as to the Origin of Puerperal Fever, . . . 747 ■ Morbid Anatomy in Gases of Puerperal Fever, 748 Symptoms of Puerperal Fever, 748 Treatment of Puerperal Fever, 749 Puerperal Ephemera or Weed, 750 Definition of Puerperal Ephemera, ........ 750 Pathology of Puerperal Ephemera, 750 Symptoms of Puerperal Ephemera, 750 Treatment of Puerperal Ephemera, 750 OHAPTEE X. Pathological Summary reqarding the Nature of the General Dis- eases described under Section A, ...... . 750 Groups of those Diseases according to Natural Alliances, .... 750 Nature of Contagion and Infection, 751 Nature of the Poison-causing Particles, 751 Form is that of a Minute Germ or Granule, 751 Distinction to be made between Poison-reproducing General Diseases and those which do not Keproduce the Poison, ...... 752 CHAPTEK XI. Detailed Description of the General Diseases comprehended in Sec- tion B, 752 Explanation of the Term Diathesis, . . 752 Acute Rheumatism — Syn., Ehbumatic Fever, 752 Definition of Acute Eheumatism, . . . 752 Pathology of Acute Eheumatism, 753 Circumstances which point to the Constitutional Origin of Eheumatism, . 753 Parts affected in Acute Eheumatism, . 754 Eesults of Acute Eheumatism, 755 Heart Affection in Acute Eheumatism, 756 Lesions from which the Heart is apt to suffer in Acute Eheumatism, . . 756 Complex Lesions in Acute Eheumatism, 757 Morbid Anatomy in Cases of Acute Eheumatism, 758 Symptoms of Acute Eheumatism, 758 The Urine in Cases of Acute Eheumatism, 759 Body Temperature in Acute Eheumatism in a Severe Case, .... 759 Diagram of the Typical Eange of Body-temperature in a Case of Acute Eheu- matism affecting many Joints (Wunderlich), 762 Symptoms of Heart Complications in Eheumatism, 764 Pain and " Pains" in Chronic Eheumatism in relation to " Malingering," . 765 Diagnosis in Oases of Acute Eheumatism, 765 Prognosis in Cases of Acute Eheumatism, 765 Indications of Acute Eheumatism from Urinary Excreta, .... 766 Causes of Acute Eheumatism, 766 Treatment of Acute Eheumatism 767 Aim and Object of Purgative Eemedies, 769 Composition of the Eemedy known as the "OAeJsea Pensioner," . . . 770 Neutralizing and Eliminative Methods of Cure, 773 [Constant Galvanic Current in Chronic Eheumatism] 774 Digitized by Microsoft® CONTENTS 0¥ VOLUME I. xli PAGE GONOREHCBAL EhBUMATISM, 774 Definition of Gonorrhoeal Kheumatism 774 Pathology of Gonorrhoea! Rheumatism, 774 Theories regarding the Nature of Gonorrhceal Eheumatism, . . . 774 Symptoms of Gonorrhceal Eheumatism, 775 Treatment of Gonorrhceal Eheumatism, 776 Stnotial Ehetjmatism, 776 Definition of Synovial Eheumatism, 776 Pathology of Synovial Eheumatism, 776 Treatment of Synovial Eheumatism, 776 Muscular Eheumatism, 777 Definition of Muscular Eheumatism, 777 Pathology of Muscular Eheumatism, 777 Lumbago, 777 Stifi-neck and other Forms of Muscular Eheumatism, 777 Treatment of Muscular Eheumatism, 777 Chronic Eheumatism, 777 Definition of Chronic Eheumatism, 777 Pathology and Symptoms of Chronic Eheumatism, 777 Treatment of Chronic Eheumatism, 778 Acute Gout, 779 Definition of Acute Gout, 779 Pathology of Acute Gout, 779 Constitutional Origin of Gout, 779 Theories regarding Exo.ess of Uric Acid in the Blood, 781 Niemeyer's Theory regarding Gout, 781 Natural History of Acute Gout, 782 Causes of Acute Gout, 783 Most important Factors in the Production of Gout, 783 Varieties of Gout, 784 Morbid Anatomy in Cases of Acute Gout, 784 Urateof Soda(Fig. 84) (Wbdl), 784 Symptoms of Gout 784 Diagnosis of Gout, '786 Prognosis in Cases of Acute Gout,. 787 Treatment in Cases of Acute Gout, 787 Chronic Gout, ''^90 Definition of Chronic Gout, 790 Pathology and Symptoms of Chronic Gout, 790 Nature and Course of Eetrocedent Gout, 791 Gout as Afi'ecting Internal Organs, 791 Treatment of Chronic Gout, 792 Mineral Springs which Exercise the most Favorable Infiuenoe on Gout, . 792 Eules regarding the Use of such Springs, 792 Properties and Constituent Elements of the Mineral Waters at the Differ- ent Springs, '^92 Gouty Synovitis, '^96 Definition of Gouty Synovitis, 796 Pathology of Gouty Synovitis, 796 Treatment of Gouty Synovitis, 796 Chronic OsTEO-ARTHRiTis—zSt/ra., Chronic Eheumatic Arthritis, . . 796 Definition of Chronic Osteo-arthritis, 796 Pathology and Symptoms of Chronic Osteo-arthritis, . . . . . 79b Table Exhibiting the Differential Diagnosis of Gout, Eheumatism, and Chronic Osteo-arthritis (Dr. Garrod), 797 Treatment of Chronic Osteo-arthritis, '^o Digitized by Microsoft® xlii CONTENTS OF VOLUME.!. PAGE Syphilis, 799 Definition of Syphilis, 799 Pathology and Morbid Anatomy of Syphilis, / 799 History of Syphilis in Soldiers, 800 Keduotion of Venereal Diseases in the Army, ■ 801 Special Eeturns called for in the Army regarding this Disease, . . . 802 Nomenclature of Syphilis, 802 Professor Longmore's Directions for Drawing up a History of Cases of Syphilis, 803 Conclusions regarding the Venereal Poisons, 804 How the Vaccine Virus may Carry Syphilis, ...... 805 Nature of the Syphilitic Poison, 805 Anatomy of the Induration of a Syphilitic Sore, 805 Characters of the Venereal Sores, and especially of the " Infecting Sores," 806 History of the Identification of the several Venereal Poisons, . . . 806 Several Venereal Infections, .......... 806 Porms of Syphilitic or Infecting Sores, . . . 808 Clinical Characters of the Syphilitic Sore, . . . . . . . 810 Characters of True Syphilis and Pseudo-syphilis Contrasted, . . . 810 Period of Incubation of Sj'philis, 810 Contamination of the System and General Course of Syphilis, . . . 811 State of the Blood in Syphilis, 811 Fever of Syphilis, 811 Order of Evolution of Syphilitic Lesions, .812 Succession of Phenomena in Syphilis, ........ 813 Characteristics of Specific Induration, ........ 814 Tabular Order of Events regarding the ^ecific Lesions of Syphilis, . . 815 Cutaneous Affections in Syphilis, 815 The Early Affections of the Pauces, 815 Second Attacks of Syphilis, 815 The Soft or Suppurating Chancre, 816. Vehicles or Media by which the Specific Infecting Virus may be Inoculated, 817 Herpes Preputialis — its Characters, and how the Lesion is to be distin- guished from Syphilis, 817 Modes of Syphilitic Contamination, 818 Morbid Anatomy of the Secondary Lesions of Syphilis and of the Local Growths in the Internal Viscera 818 Gummata the Basis of the Characteristic Lesions of Syphilis, . . . 819 ' Development and Course of the Syphilitic Node, or Gummy Tumor, . . 820 (a.) In the Skin, 820 (b.) Syphilitic Lesion of Mucous Membrane, ...... 821 (c.) Affections of the Nails, . . . . . . . . . 822 (d.) The Syphilitic Lesions of the Testicles, 822 (e.) In the Substance of the Heart, . . ' 822 (f.) In the Bones, 823 (g.^ In the Brain and Nervous System, 825 (h.) In the Lungs, 826 (i.) In the Liver 826 (k.) Lesions of the Tongue, 827 Hints for the Investigation and Description of Syphilitic Ulcers, . . 827 Syphilization : its History and Nature, 828 Description of the Process of Syphilization, 829 Treatment of Syphilis, . ,, . 829 Question of Mercury in Syphilis, . 830 Porms of Syphilis for which Mercury is Unsuitable, 832 [Beneficial Effects of Mercury when Properly Administered], . . . 833 Preventive Treatment of Syphilis, ' . . 836 [Hebbditary Syphilis 837 Pathology of Hereditary Syphilis, 837 Syphilis may affect the Foetus at an Early Period, 838 Coryza the iSarliest and most Striking Symptom of Inherited Syphilis, . 838 Diagnosis of Inherited Syphilis, 839 Appearance of the Teeth in Hereditary Syphilis, . . , . . . 839 Several Affections of the Eye of Interest in the History of Hereditary ■ Syphilis], 840 Digitized by Microsoft® CONTENTS OF VOLUME I. xliii PAGE Cancbe — Sj/ra., Malignant Disease 841 Definition of Cancer, 841 Pathology of Cancer, 841 Constitutional Origin of Cancer, . . . . . . . . . 842 [Opinion as to the Local Origin of Cancer independently of a Constitutional Cause], 842 Very little known of the Conditions giving rise to Cancers, .... 845 Normal Course of Cancerous Tumors, 845 Idea of Cancers being due to Entozoa, ........ 845 Composition of the Local Exudations of Cancer-growths, .... 845 Characters of the Cancer-cell, 846 Practical Questions to be Solved with reference to Growths supposed to be Cancers, 846 Malignant Tumors indicated by certain Characters Described, . . . 847 (a.) Structure, 847 (b.) Grouping, 847 (c.) Infiltration, 847 (d.) Tendency to Ulcerate, 847 (e.) Progressive Growth towards Death, 847 Microscopic Characters of Cancer-growths, ....... 848 Microscopic Distinction of Cancer-elements, . 848 Mode of Extension of Cancer-growths, . 849 Varieties of Cancers described under various names, 850 (a.) Constituents and Definition of Scirrhus or Hard Cancer, and figure showing the Cancer-cells of Scirrhus, ...... 851 (b.) Elements of Medullary Cancer and Definition of it, . . . 852 Constituents related to Firmness and Softness, ... . . . 852 Process of Softening, 854 Characters of Epithelial Cancer or Cancroid Epithelioma, . . . 855 Sites of Epithelioma, 855 Question of Classifying Epithelioma with Cancers, .... 855 Essential Characteristic Elements of Melanotic Cancer, . . . 856 Characters of Melanotic Cancer or Melanosis, 856 fungus Hsematodes, 856 Woodcut showing the varied Elements of Epithelial Cancer, . . . 857 Osteoid Cancer and Villous Cancer, 858 Elements of Melanotic Cancer, 858 Causes of Cancer, 858 Theories or Hypothesis regarding Causes of Cancer, . . . . . 858 Diagnosis of Cancer, 859 Prognosis in Cases of Cancer, 859 Treatment of Cancer, . . . . ' 859 Colloid — Syn., Colloid Canckr, Alveolar Cancbk, 861 ' Definition of Colloid, 861 Pathology of Colloid, 861 Doubtful Affinity with Cancer, . 861 [Eorm of Colloid which belongs to the True Cancer Group, Anatomically and Clinically], • • • ®^^ LuPffS, . . 862 Definition of Lupus, 862 Pathology of Lupus, . 862 Symptoms of Lupus, 863 Diagnosis of Lupus, °63 Prognosis in Cases of Lupus, 863 Treatment of Lupus, 863 EoDENT Ulcer, 865 Definition of Rodent Ulcer, 865 Pathology of Eodent Ulcer, 865 True Leprosy— Syre., Elephantiasis GRiECORirM, 865 Definition of True Leprosy, 865 Digitized by Microsoft® xliv CONTENTS OF VOLUME I. PAGE Pathology of True Leprosy, . 865 Keport by the College of Physicians regarding True Leprosy, . . . 865 Hereditary Nature of True Leprosy, 865 Leprosy now Unknown in this Country, 865 Prevalence of Leprosy in this Country during the Middle Ages, . . . 866 Present Geographical Distribution of True Leprosy, 867 Porms of True Leprosy described, 868 Acute and Chronic, Tuberculous and Ansesthetie, 868 Morbid Anatomy in Cases of True Leprosy, 869 A. Analyses of Venous Blood in Norwegian Tuberculous Elephantiasis, by Danielssen and Boeck, . . . 870 B. Analyses of Venous Blood in Anesthetic Elephantiasis, by Danielssen, . 871 Minute Anatomy of the Infiltration of True Leprosy, 871 Chemical Analysis of the Exudation, 871 Symptoms of True Leprosy, 871 Summaryof Symptoms in the Two Forms of Leprosy, 872 Duration of True Leprosy, "873 Causes of True Leprosy, 873 Diagnosis in Cases of True Leprosy, 874 Prognosis in Cases of True Leprosyi 874 Treatment of True Leprosy, 874 Scrofula, 875 Definition of Scrofula, • . 875 Pathology of Scrofula, 875 Specific Porms of Scrofulous Disease, 875 Growth of the Peculiar Substance named "Tubercle," 875 Constitutional Conditions associated with Scrofulous Disease, . . . 875 Original Meaning of the terms "Phthisis," " Consumption," . . . 875 Predisposition to Scrofulous Growths, . . 876 Nature of the Constitutional State leading to the Development of Scrofula, . 876 Strumous Dyspepsia, 878 Diathesis expressive of the Latent Existence of Scrofula, . . . . 878 Morbid Anatomy of Tubercle, 879 Opinions entertained regarding the Nature of Tubercle, . . . . . 879 Definition of Tuberculization, 880 Eelation between Tuberculosis and Serofulosis, 880 Porms and Conditions under which Tubercle appears, 880 Gray and Yellow Tubercle — their Structure and Eelations, . . . . 880 Microscopic Structure of Tubercle, 880 Patty Degeneration of Tubercle, . •. 882 Basis of Tubercle-structure, 882 Development of Tubercle from Connective Tissue, 882 Tubercle in Earliest Stage of Growth, . . . . . . . .883 Cheesy Metamorphosis of Tubercle 883 Retrograde Changes in Tubercle, 884 Cretification — Calcification of Tubercle, 884 Chemical Composition of Tubercle, 884 Nomenclature of Tubercle, . . 885 Seat of Scrofulous Inflammation in Peritoneum and Mucous Membrane, . 885 Forms of Tubercle Ulceration, 885 Inflammation of Tuljercle, 885 Eelation of Bloodvessels to Tubercle and Cancer, ■ . 885 Distinction between Tubercle and Cancer, 886 Softening of Tubercle not constant, 886 Healing of Local Lesions in Scrofula, 886 Spontaneous Cure of Tubercle Lesions, 886 Symptoms of Scrofula or of the Cachexia which precedes and accompanies the Growth of Tubercle, ' . 886 The Dyspepsia of Tuberculosis, . 887 Cases of Scrofula referable to Impaired Assimilation of Nutrition Processes, 887 Strumous Dyspepsia of Tweedy Todd, i . . . 887 Conclusions regarding Dyspepsia in Phthisis, . ... . , 887 Characters of the Scrofulous Organization by Miller and Canstatt, . . 888 Scrofulous Constitution of Children 889 Type of Inflammation in Scrofulous Subjects, 889 Duration of the Phthisis Pulmonalis of Scrofula, . . . . . . 889 Digitized by Microsoft® CONTENTS OF VOLUME I. xlv PAGE Causes of Scrofula, 889 Development during Infancy, 890 Age in relation to Scrofula 890 Deficient Ventilation and Abeyance of Normal Exercise, .... 890 Influence of Occupations in causing Scrofula, 891 Moisture and Damp as a cause of Scrofula, 892 ■ Morbid States of the Parent, a cause of Scrofula in Children, . . . 892 Hereditary Prevalence of Scrofula, 892 Manifestation of Scrofulous Constitution in Children, 893 Influence of Eace in the Production of Phthisis, 893 Influence of Depressing Passions in producing Phthisis, .... 893 Is a Predisposition to Scrofula demonstrable anatomically or otherwise? . 894 Assemblage of Phenomena characteristic of Scrofula, 694 Great Care necessary in Physical Training, 894 Average Weight of Pull-grown Men at.twenty-five years of age, . . 894 Average Height of a Growing Lad at eighteen years of age, . . . 894 Correlation of Age, Weight and Height in the Growth of the Human Body, from eighteen to thirty years of age, 895 Correlation of Age, Stature, and Weight of Boys from nine to nineteen years of age 896 Correlation of Height and Circumference of Chest in 1270 Young Persons, . 896 Tear of greatest Increase in Stature, 896 Tear of greatest Increase in Weight, 896 Certain Individual Peculiarities suspicious, 896 Vital Capacity of Chest, 896 Indications of Functional Incapacity, 897 Relation of Anaemia to Scrofula, 897 Physical Training — Use of the Lungs, 897 Evil Effects of Vitiated Air and Over-exertion, 898 Progressive Atrophy indicative of Scrofula, 899 Necessity for Weighing Men to determine Eatio to Age and Height, so as to furnish a Standard for determining Progressive Loss of Weight, . 899 Progressive Eeduction in Weight in Phthisis, 899 General Treatment of the Scrofulous Cachexia, 899 Beneficial Influence of Cod-liver Oil, ........ 900 Modes of its Administration, 901 Its Immediate Action upon the Blood, 901 Influenceof Animal Pats and Oils, . . . . - P02 Question of Bloodletting in the Inflammations of Tubercular Exudations, . 902 Tonic Treatment of Scrofula, 903 Details of Hygienic Measures regarding Prevention and Management of Scrofula, . ■ . . . .903 ElCKETS 905 Definition of Eickets, 905 Pathology of Rickets, 905 Changes in the Bones in Eickets, 905 Symptoms of Eickets, 905 Treatment of Eickets, 907 Cretinism, 908 Definition of Cretinism, 908 Pathology and Phenomena of Cretinism, 908 Varieties of Cretinism, 908 Cretins generally subjects of Goitre, ........ 908 Geographical Districts where Cretinism Abounds, 908 Stature of Cretins, 908 Virchow's Dissections of Cretins' Heads, 908 Eelation of Cretinism and Goitre to Soil, 909 Symptoms of Cretinism, 910 Hygienic Measures for the Prevention of Cretin-ism, 910 Diabetes, ^ 911 Definition of Diabetes 911 Pathology of Diabetes, 911 Diabetes Mellitus a Constitutional Affection, 911 Digitized by Microsoft® Xlvi CONTENTS OF VOLUME I. PAGE Glycogenesis, 9ll Generation of Sugar by the Liver, 911 Prevention of Sugar Formation, . . . 912 Intermittent Diabetes, 913 Influence of Diet on Formation of Sugar, 913 Distinction of Sugar in the Blood in Health, 918 Formation of Sugar in the Liver ; . . . . 913 Keflex Excitement of Medulla Oblongata a Cause of Diabetes, . . . 914 Bernard's Experimental Production of Diabetes, 914 General Circumstances under which Melituria is Developed, . . . 914 Relative Occurrence of Diabetes in Males and Females, . . . . 914 Hereditary Origin and Transmission of Melituria, 914 Morbid Anatomy in Diabetes, 914 Secondary Lung Lesions, ...... .... 915 Question as to their being Tubercular, 915 Symptoms of Diabetes, 915 Progressive Emaciation in Diabetes, . 915 Condition of the Urine inDiabetes, 916 Tests for Sugar in the Urine, '. 916 Crystals of Diabetic Sugar from Diabetic Urine 916 Trommer's Test for Sugar in the Urine, 910 Fehling's Test for Sugar in the Urine, 916 Sources of Sugar in the Urine in Diabetes, . . . . . . . 917 Influence of Sugar, Starchy and Nitrogenous Food in producing Melituria, 917 Relation between Food and Sugar in Diabetes, . . . . ■. . 917 Sugar-formation at the Expense of the Muscles of the Body, . . . 918 Inosite or Muscle-sugar Crystallized, , . . 918 Relation of Urea and Sugar-formation in Diabetes, 918 Chronic Nature of Diabetes, 919 Duration of 100 Cases of Diabetes collected by Griesinger, .... 919 Complication of Diabetes with Pulmonary Lesion and with Defective Vision, 919 Cataract in Diabetes, 919 Amblyopia in Diabetes, 920 Prognosis in Diabetes, 920 Treatment of Diabetes, . 920 Management of Diabetes by Diet, 921 Animal Diet in Diabetes, 921 Mixed Diet in Diabetes, 921 Abstinence from Sugar and Starch, . . . 922 Milk Diet in Diabetes, 922 Bran Cakes and Bread in Diabetes, 922 Cod-liver Oil, . 923 General Conclusions regarding Management of Diabetes, .... 923 Purpura, 925 Definition of Purpura, 925 Pathology of Purpura, 925 Varieties of Purpura, 925 Simple Purpura, 925 Hemorrhagic Purpura, 925 Examination of Blood in Purpura, 925 Symptoms and Causes of Purpura, 926 Diagnosis between Purpura and Scurvy 926 Treatment of Purpura, 927 Scurvy, 928 Definition of Scurvy, 928 Pathology and Historical Notice of Scurvy, 928 Circumstances under which Scurvy has Prevailed, 929 Prevalence of Scurvy in the British and American Armies, . . . 929 Morbid Anatomy of Scurvy, 929 Chemical Pathology of Scurvy, 931 Symptoms of Scurvy, 932 Extravasations of Blood in Scurvy, 932 Sites of Scorbutic Ulcers, 933 Duration of Cases of Scurvy, 933 Scorbutic Dysentery, 934 Digitized by Microsoft® CONTENTS OF VOLUME I. xlvii PAGE - Night-blindness in Scurvy 03^ Tendency to Swoon in Scurvy, ■■....' 934 Intercurrent Chest AflFections in Scurvy, . . . . ' 934 Diagnosis of Scurvy, .' . ' ' 934 Prognosis in Scurvy, .' . " 934 Causes and Conditions under which Scurvy is Developed, '. ' ' .' 935 Summary of Conditions producing Scurvy, . . ' ' ' 936 Treatment of Scurvy, , _ ' ' " "937 Prevalence of Scurvy in the Merchant Service, . . '. ' ' 938 Prevention of Scurvy, '. . . 940' Anemia, .941 Definition of Ansemia g^j Pathology of Ansemia, .'.'.'"' 941 Eesults of Deficiency of Eed Corpuscles in the Bldod, . ". '. ' ' 941 Symptoms of Anaemia, [ ' g^2 Cardiac, Arterial, and Venous Murmurs in Ansemia, ...'.' 9i2 Characters of Ansemic Murmurs, " ' 943 Condition of the Urine in Anemia, ........ 944 Causes of Anaemia, .' ." ' ' 944 Treatment of Anaemia, .'.""" 945 Tonic Treatment of Antemia, ' ' " .' ' 945 Suggestions for the Use of Iron in Anasmia, ....... 945 Formula, for the Preparation of Syrup of the Phosphates of Iron, Quinine! and Strychnia, , g^g Chlorosis, . . . _ _ g^y Definition of Chlorosis, 947 Pathology and Symptoms of Chlorosis .'.'.' 947 Implication of the Nervous System in Chlorosis, ....!." 947 Disorder of Digestion in Chlorosis, . . 947 Condition of Eespiratory, Generative, and Vascular System in Chlorosis, . 948 Causes of Chlorosis, 943 Diagnosis of Chlorosis, . . 948 Treatment of Chlorosis by Pood and Medicine, .....'. 948 General Deopst, gjO Definition of General Dropsy, 95O Pathology and Symptoms of General Dropsy, 950 A Form of. Universal (Edema or Anasarca, 950 Phenomena of " Pitting " under Pressure, 950 Diagnosis of General Dropsy, ■ . _ 95O Treatment of General Dropsy, 9 50 Beriberi, . ggo Definition of Beriberi, 950 Pathology and Historical Notice of Beriberi, 95I Morbid Anatomy in Oases of Beriberi, 952 Symptoms of Beriberi, 952 Forms of Beriberi, . . . • 952 Causes of Beriberi, 954 Diagnosis of Beriberi, 955 Prognosis in Cases of Beriberi; 955 Sudden Death in Beriberi, 955 Treatment of Beriberi, 956 Composition of the Eastern Eemedy called " Treeak Farook," . . . 956 CHAPTEE XII. Inpltjence of Food on some Constitutional Diseases described in the Previous Chapter, 957 Principles of Construction of Dietaries for Large Bodies of Men, . . 958 Amount of Food consumed by a Man, . . 959 Digitized by Microsoft® xlviii CONTENTS OF VOLUME I. PAGE Kelatiou of Food to Body-weight 960 Kelation of Pood and Disease, . 961 Table of Nutritive Value of Foods (Parkes), in 100 parts, . . . .960 Table of Dietaries and their Nutritive Values (Letheby) 961 Table of. Nutritive Value of Foods (Letheby), 962 Mean Amount of the Four Classes of Aliments (Playfair), .... 962 Effects of Over-feeding ■ • 963 Pathology of Corpulence, 963 Dietary of Mr. Banting 964 Effects of Deficient Food, • 964 Death from Starvation, 965 The " Truck-system " and its Evil Effects, . 966 CHAPTER XIII. Genbkal Management oe the System Liable to Constittttional Dis- eases, 967 Prevention/, Control, and Arrest of Farther Development the Basis of Man- agement, ............. 967 General and Individual Hygienic Management, . . . . . . 967 Three Periods in the Development of Constitutional . Diseases relative to their Management, 968 Intervals of Abeyance of Disease or of Comparative Freedom from Disease to be taken advantage of in their Management, . . . " . . 968 Management of Disease by Regulation of Diet, . , . . . . . . 968 Management of Disease by the Use of Water, 970 Management of Disease by the Aid of Wines and Alcoholic Beverages, . 970 Properties of Wines and Alcoholic Beverages, . . . . . . 970 Medicinal Substances contained in Wines, 970 Rules for the Administration of Alcohol in Disease 970 Determination of the Amount of Alcohol in Wine, ..... 971 Determination of the Amount of Acidity in Wines, ..... 972 Determination of the Amount of Sugar in Wines, 973 Determination of the Amount of Solids in Wines, ..... 973 Use of Wine and Alcoholic Beverages generally in Constitutional Diseases, 974 CHAPTER XIV. General Nattteb of Local Diseases, 975 Diseases comprehended under this head, 975 Constitutional Symptoms of Local Affections, 975 Secondary Symptoms of Lesions, . . 975 Anatomical Forms' of the Local Lesions, ....... 975 CHAPTER XV. Diseases op the Neuvous System, 976 Section I. — Introduction to the Pathology of the Diseases of the Nervous System, 976 How the Varied Phenomena of the Nervous System are to be viewed, . 976 Constituents of Brain and Nerves, ......... 977 Chemical Composition of the Brain and Nerve-tissue, 977 Weight of the Brain and its Parts, 977 Absolute Weight of the Brain, 977 Table of Relative Averages of Body-weight, and the Weight of Cerebral Organs as to Age and Height, 978 Bulk of the Encephalon, 978 Specific Gravity of the Healthy Brain 978 Specific Gravity of Central Ganglia, 979 Pathological Relations of the Nervous Organs and Textures, . . . 980 Cardinal Facts in the Physiology of the Nervous System illustrative of its • Pathology 980 Digitized by Microsoft® CONTENTS OP VOLUME I. xUx PAGE Phenomena of Isolated Conduction, 980 Phenomena of Sympathy or Irradiation, 981 Phenomena of Intelligence, 981 Nervous Force from Gray Matter 981 Section II. — Guides to the Diagnosis ott Diseases of the Nervous System, 982 I. As to Locality or Site of Lesion, 982 Indications of the Cerebrum being Aflfeeted, 982 Indications of the Meninges being Ail'ected, 982 Indications of the Spinal Cord being AfTeoted 982 General Grounds on which a Diagnosis may be made, . . 982 Characters of Cerebral and Meningeal Diseases contrasted, . . 983 Characters of Gastric or Hepatic Vomiting contrasted with Cerebral Vomiting, 984 II. As to the Nature of the Affection, 984 (a.) Acute but Non-febrile Symptoms of Diseases of the Nervous System 984 (b.) Characters of Chronic Diseases of the Nervous System, . . 984 Symptoms of Loss of Function, 984 Symptoms of Irritation, 984 III. As to the Anatomical Condition, 985 IV. As to Urea in the Blood and Brain, 985 Detection of Urea— (1.) In Serum; (2.) In Brain, . . . .986 V. As to Morbid Textural Changes in the Brain, 986 Principles on which Diseases of the Nervous System may be Arranged and Considered in Groups, 987 Definition of Words in Common Use in Describing Diseases of the Nervous System, 987 VI. As to Physical Conditions, 988 (a.) Perversion of Sense of Touch and Power of Discrimination, . 988 Dr. Sieveking's ^sthesiometer and its Use, 988 Normal Distance Limits of Sensitiveness, ..... 988 Eules for the Use of the JSsthesiometer, ...... 989 (6.) Perversion of Muscular Power, ....... 990 (c.) Perversion of Body-heat, . 991 (d.) Perversion of the Power of Expressing Thought, . . . 991 Theories of the Localization of Brain Lesion in Aphasia, . . 992 Section III. — Diseases of the Brain and its Membranes, . . 993 Encephalitis, 993 Definition of Encephalitis, 993 Pathology of Encephalitis, .......... 993 Causes of Encephalitis 993 Morbid Anatomy in Cases of Encephalitis, ....... 993 Symptoms of Encephalitis, . . . . . . 994 Cerebral as Distinct from Meningeal Symptoms, ...... 995 Premonitory Symptoms of Cerebral Softening, ...... 995 Diagnosis of Encephalitis, 995 Treatment of Encephalitis, 995 Meningitis, 995 Definition of Meningitis, 995 Pathology and Morbid ii-natomy of Meningitis, 996 (1.) Inflammation of the Dura Mater, 996 (2.) Inflammation of Pia Mater and Arachnoid, 996 Phenomena of Arachnitis, 996 Serum in Arachnoid Cavity, 996 Suppurative Arachnitis, 996 Characters of Chronic Arachnitis, 997 (3.) Tubercular Meningitis (Acute Hydrocephalus), 997 Causes of Meningitis, 998 Symptoms and Diagnosis of Meningitis, 998 (a.) Simple Meningitis, 998 Mental, Sensorial, and Motorial Phenomena, 999 VOL. I. ^^ ^ Digitized by Microsoft® CONTENTS OF VOLUME I. (J.) Tubercular Meningitis in the Child, . . ■ Mental, Sensorial, and Motorial Phenomena, (c.) Tubercular Meningitis in the Adult, Mental, Sensorial, and Motorial Phenomena, General Characteristics of Tubercular Meningitis (d.) Acute Meningitis in the Aged, Mental, Sensorial, and Motorial Phenomena, (e.) Chronic Meningitis of the Aged, . Mental, Sensorial, and Motorial Phenomena Diagnosis of Meningitis, . . . ^ Treatment of Meningitis, TUBKKOULAR MENINGITIS, .... Definition of Tubercular Meningitis, Pathology of Tubercular Meningitis, . Acute Hydrocephalus, .... Morbid Anatomy in Acute Hydrocephalus, Symptoms of Acute Hydrocephalus, Earliest Signs of Acute Hydrocephalus, Diagnosis of Acute Hydrocephalus, The Vomiting Characteristic of Acute Hydrocephak Spurious Hydrocephalus or Hydrocephaloid, Diagnosis of this Porm of Hydrocephalus, . Prognosis in Hydrocephalus, Treatment in Acute Hydrocephalus, Bloodletting in Tubercular Meningitis, Use of Medicines in Tubercular Meningitis, Management of Diet in Tubercular Meningitis, Inflammation of the Brain Definition of Inflammation of the Brain, Pathology of Inflammation of the Brain, Morbid Anatomy in Inflammation of the Brain, Results of Inflammation of the Brain, . Symptoms of Inflammation of the Brain, Mental, Motorial, and Sensorial Phenomena, Treatment (see Encephalitis and Meningitis), Bbd Softening of the Brain, . . ' . Deflnition of Bed Softening of the Brain, . Pathology of Bed Softening of the Brain, . Several Morbid Conditions to he Distinguished within the Symptoms of lied Softening of the Brain, Mental, Sensorial, and Motorial Symptorns of Softening of- Combination of Symptoms indicative of Softening, Duration of Life in EamoUissement of the Brain, Diagnosis of Bed Softening of the Brain, . Prognosis in Cases of Bed Softening of the Brain, Treatment of Inflammatory Softening, Yellow Softening or the Brain, Definition of Yellow Softening of the Brain, Pathology of Yellow Softening of the Brain, Symptoms of Yellow Softening of the Brain, Conditions under which Softening (post-mortem) is seen, Conditions producing Softening, . Diagnosis of Softening, Treatment of Softening, Abscess of the Brain, .... Definition of Abscess of the Brain, Pathology of Abscess of the Brain, Morbid Anatomy in Cases of Abscess of the Brain, Locality" of Abscesses in the Brain, Causes of Cerebral Abscess, . the Brain, PASK 1000 1000 1001 1001 1001 1002 1002 1003 1003 1003 1003 1004 1004 1005 1005 1006 1006 1007 1007 1007 1008 1008 1008 1008 1008 1009 1010 1010 1010 1011 1011 1011 1011 1012 1012 1012 1012 1012 1012 1014 1014 1014 1015 1015 1616 1016 1017 1017 1017 1018 1018 1018 1018 1018 1019 1019 1019 1019 1020 1020 Digitized by Microsoft® CONTENTS OF VOLUME I. 11 PAGE Symptoms of Cerebral Abscess, . 1020 Diagnosis of Cerebral Abscess . 1020 Apoplexy, 1021 Definition of Apoplexy, . 1021 Pathology of Apoplexy, 1021 Group of Symptoms Characterizing Apoplexy, 1021 Local Lesions Inducing Apoplexy, . ." 1021 Theories to Explain the Apoplectic State, 1022 Morbid Anatomy in Cases of Apoplexy, 1022 Changes in the Blood Effused, 1023 Position of Blood Effused in Apoplexy, . . . . . . . 1024 (a.) Superficial or Ventricular Extravasation, 1024 (6.) Extravasation in the Substance of the Hemispheres, .... 1025 (c.) Extravasation in the Pons Varolii and other Parts, .... 1026 Comparative Liability of Parts of the Brain to Extravasation, . . 1027 Circumstances under which Extravasation Occurs, .... 1028 Symptoms of Apoplexy, 1028 I. Symptoms of Apoplexy from Congestion, 1028 Mental, Sensorial, and Motorial Phenomena, 1029 Precursory Symptoms or " "Warnings " of Apoplexy, . . . . 1029 Special Nervous Symptoms Characteristic of Congestive Apoplexy, . 1029 Diagnostic Value of Symptoms Combined in Groups, .... 1030 II. Symptoms of Apoplexy from Hemorrhage, 1030 A. Into the Cerebral Substance of the Hemispheres, .... 1030 The "Stroke of Apoplexy," 1030 Mental, Sensorial, and Motorial Phenomena, 1030 Combination of Symptoms Characteristic of Hemorrhage in the Hemispheres, 1031 B. Symptoms of Hemorrhage into the Ventricles, .... 1032 Mental and Motorial Symptoms, 1032 c. Symptoms of Arachnoid Hemorrhage, 1032 Combination of Symptoms Characteristic of Subarachnoid Hemor- rhage, . 1032 Causes of Apoplexy, 1033 Anatomical Lesions, 1033 Connection of Apoplexy with Heart and Kidney Disease, .... 1033 Influence of Temperature in causing Apoplexy, 1034 Influence of Moral Causes in producing Apoplexy, 1034 Influence of Mechanical Obstruction and Violence, . • . . . . 1034 Occurrence of Apoplexy in Childhood, ....... 1034 Influence of Sex, Progress of Digestion, and Conditions of the Body Pre- disposing to Apoplexy, . - 1034 Prognosis in Cases of Apoplexy, 1034 Treatment of Apoplexy, 1036 Question of Bloodletting in Apoplexy, 1037 Purgation in Apoplexy, . . . . . . . . . . 1038 Turpentine, Castor Oil, and Croton Oil Enemata, 1038 Dietetic Treatment of Apoplexy, 1038 Hjematoma of the Duba Matek, 1039 Definition of Hfematoma of the Dura Mater, 1039 Pathology of Hsematoma of the Dura Mater, 1039 Morbid Anatomy of the Blood Extravasation, 1039 Symptoms of Hsematoma, . . . . 1040 Treatment of Hsematoma, 1040 Sunstroke, 1040 Definition of Sunstroke 1040 Pathology and Symptoms of Sunstroke, 1040 Circumstances under which Sunstroke has Occurred, 1041 Sunstroke occurring on the March or in the Eield, 1041 Influence of Vitiated Air in producing Sunstroke, 1043 Condition of the Atmosphere and as to Heat, 1043 Sunstroke occurring " in Quarters " or in Tents, 1043 Premonitory Phenomena of Sunstroke, 1044 Digitized by Microsoft® lii CONTENTS OP VOLUME I. PAGE The Urine in Sunstroke, . . . 1044 Periods of Attack in Sunstroke, ... . . . . . . . 1045 Constant Symptoms of Sunstroke, . . . . .. ' . . . 1046 Body-temperature in Sunstroke, 1046 Heart's Action in Sunstroke, 1046 Symptoms of a Fatal End, . . - 1047 Mortality from Sunstroke, . 1047 Symptoms of a Favorable End, . . 1047 Morbid Anatomy in Cases of Sunstroke, 1048 Condition of the Blood in Sunstroke, 1048 Theories regarding Mode of Action of Heat in producing Sunstroke, . 1048 Modes of Death in Sunstroke, 1049 Causes of Sunstroke, . . ... . 1050 Treatment of Sunstroke, 1050 Measures for the Prevention of Sunstroke, . . . . . . . 1052 APPENDIX TO VOL. I. Circumstances connected with the Origin of Specific Yellow Fever, . . . 1054 Digitized by Microsoft® LIST OF ILLUSTEATIONS IN VOL. I. riG. PAGE 1. Dilated Bloodvessels in Inflammation (after Paget), 72 2. Pareucliymatous Inflammation, or Cloudy Swelling, as seen in a Convoluted Urinary Tubule taken from the Cortex of a Kidney in Bright's Disease (after Virchow), 79 3. Diagram showing Records of Temperature in a Case of Hectic Pever (Croft), 100 4. Lymph Cells from Inflamed Pleura (Paget and Turner), .... 101 5. Nuclei in Fibrinous Product of Inflammation De'veloping into Pibres (Ben- nett), 102 6. Eibro-plastic Cells of Lymph developing into Pibres (Bennett), . . . 102 7. Perfect "White Fibrous Tissue from Lymph (Bennett) 102 8. Pigment from an Apoplectic Cicatrix in the Brain (Virchow), . . .113 9. Crystals of Hjematoidin in different forms (Virchow), .... 113 10. Hepatic Cells— (1.) Normal; (2.) Affected with Hypertrophy ; (3.) Affected with Hyperplasy — Numerical Increase or Adjunctive Hypertrophy (Vir- chow), 121 11, 12. Kokitansky's Representations of the Minute Structure of Cysts, . 138, 139 13. Slightly Magnified Cyst of Trichina Spiralis (Virchow), .... 154 14. Trichina Spiralis removed from the Cyst (Virchow), 154 15. Diagram of the Head or Anterior end of the Guinea-worm (Bastian), . . 166 16. Various Forms of the Caudal End of the Guinea-worm (Busk, Carter, and Greenhow), 166 17. Dissection of a Guinea-worm (Bastian), . 167 18. Dissection of Anterior Extremity of Guinea-worm (Greenhow), . . . 167 19. A. Transverse Section of Adult Guinea-worm (Bastian), .... 168 B. Toung of the Guinea-worm more or less Spirally Curved (Bastian), . 168 20. Head of the Bothriocephalus Latus 178 21. Operculated Ova of Bothriocephalus, 179 22. Bothriocephalus Cordatus, Natural Size and Magnified, ' . . . . 179 23. Head and Neck of Taenia Solium, showing Circle of Hooks, . . . 180 24. Circle of Hooks in Head of Tajnia Solium, highly Magnified (Leuckart), . 181 25. Proglottis of Ttenia Solium, Magnified (Rokitansky), 182 26. Proglottides of Taenia in Various Stages of Contraction (Leuckart), . . 182 27. Development of the Ovum of Taenia Solium, 183 28. Head of the Tasnia Mediocanellata, 186 29. Groups of Echinococci (Erasmus Wilson), 189 (1.) and (2.) Singly Pediculated in Groups, 189 30. Echinococci from a "Hydatid Tumor," 189 31 . A. Transverse View of the Head of an Echinococcus, showing Suctorial Disks and Hooklets, 190' 32. B. Circle of (34) Hooklets seen on its Under Surface, 190 0. Lateral Views of Separate Hooklets, 190 33. Two Specimens of Cysticercus Mediocanellata, Natural Size, taken from a ■ Specimen of Ration-beef sent from the Punjaub, 194 34. Head of one of these Specimens Magnified 65 Diameters, .... 195 35. Head of Cysticercus Cellulose, to contrast with the Taenia Mediocanellata, . 195 36. (a.) Operculated Ovum of Distoma; (6.) Opalina, 203 37. (1.) Ovum of Distoma Haematobium ; (2.) Embryo (Ciliated) from Ovum Capsule; (3.) Embryo attached to the Ovum Capsule from HsBmatobia, at the Cape of Good Hope (Dr. John Harley) 206 38 Small portion of the Lung of an African Soldier with a Pentastoma Constric- tum curled up in its Cyst (Dr. Humphry C. Gillespie), . . . .208 Digitized by Microsoft® liv LIST OF ILLUSTRATIONS IN VOL. I. FIG. ' PA&E 39. Two Specimens of Pentastoma Constrictuni removed from their Cysts, and of the Natural Size (Dr. Humphry C. Gillespie), . . . . .208 40. Two Specimens of Pentastoma Constrictum, Magnified from 3 to 5 Diameters — (a.) the Shorter ; (5.) and (a.) Posterior and Anterior Aspects of the Longer Parasite (Dr. Humphry C. Gillespie), 209 41. Anterior Aspect of the Flattened Head of the Parasite, to show its five spots or marks (Dr. Humphry C. Gillespie), 209 42. Portion of Liver containing Encysted Specimens of Pentastoma Constrictum, from a Private in a West India Regiment, in the Museum of the Army Medical Department since 1854, Drawn by Dr. H. C. Gillespie, . . 211 48. Larva or Grub from Bulama Boil (Dr. Albert Gore), 212 44. Larva or Grub from Boil, Magnified, showing — n, a, Hollow Suction Tubes; (b.) Fine Red Spots and Hooklets over Body (Dr. A. Gore), . . .212 45. Hooklets, highly Magnified (Dr. A. Gore), 212 46. The Crab-louse, X 10 Diameters (Dr.. T. Anderson), 213 47. (a), Pedieulus Capitis (male) ; (6), Trachea and Stigmata; (c), Antennse (Dr. T. Anderson), 214 48. Nit, or Egg Capsule of the Louse, fixed to (6) a hair by a Glutinous Secre- tion (c, c, a), 214 49. Pedieulus Corporis — Female (Dr. T. Anderson), 215 50. Acarus Scabiei — Female (Dr. T. Anderson), 216 51. Acarus Scabiei— Male (Dr. T. Anderson), 217 52. Development of the Acarns Scabiei — a, b, c, d, e, Egg in Different Stages of advancement (Dr. T. Anderson), . 218 53. Larva or Young of Acarus Scabiei (Dr. T. Anderson), 219 54. Demodex Folliculorum (Dr. T. Anderson) 219 55. Crystals of Margarine (Robin and Verdeil), 229 56. Fat Cells, inclosing Crystals of Margarine (Wedl), . . . . . 229 57. Margario Acid (Beale), 230 58. Cholesterin Plates — (a.) Regularly Laminated ; (b.) Irregularly Laminated and Injured Forms, X 300 Diameters (Wedl), 230 59. Crystals of Uric Acid — [a.) Rhomboidal, Truncated, Hexahedral, and Lami- nated; (6.) Rhombic Prisms; (c.) Barrel-shaped Prisms; (rf.) Cvlindrical Forms, X 300 Diameters (Wedl),. " . . 231 60. [a.) Urate of Ammonia in Globules; (6.) As a Fine Sandy Concretion in Kidney Tubes of a Child; (c.) Angular Molecules, , 231 61. Crystals of Oxalate of Lime (Wedl), 232 62. Usual Forms of Triple Phosphate of Magnesia and Ammonia (Wedl), . 232 63. Double Embryo from a Fowl's Egg after sixteen to eighteen hours' Incu- bation, Magnified four times— (fi.) Germinal Area of Oicatrlcula; [b.) Transparent Area, containing two Primitive Traces of Embryos; (c, c.) Primitive Grooves of the Double Embryonic Trace, on each side of which are seen the Laminae Dorsalis (after Dr. Allen Thomson), . . . 238 64. Double Embryo from a Goose's Egg after five days' Incubation, Magnified four times; [g.) The Common Heart; (A.) Rudiments of the Superior; (i.) Of the Inferior Extremities ; (k.) The Common Cephalic Fold of the Am- nios; (i ) The Caudal Folds (after Dr. Allen Thomson), . . . .288 65. Curved Clinical Thermometer for Reading in situ the Bodily Temperature in the Axilla, 244 66. Phillips's Registering Maximum Thermometer for Clinical Investigation, . 244 67. Changes said by Dr. Halford to occur in the Blood-corpuscles subsequent to the Bite of the Cobra di Capello, x 1050, 365 68. Similar appearance x 400, \ 365 69. Diagram of the Typical Range of Body-temperature in a Case of Natural Small-pox (Wunderlich), 381 70. Diagram of Typical Range of Body-temperature in a Case of Smail-pox Modified by Vaccination (Wunderlich), 389 71. Diagram Representing the Range of Body-temperature in a Severe Case of Measles (Wunderlich), 426 72. Diagram Typical of Body-temperature in a Case of Scarlet Fever (Wunder- lich), 439 73. Diagram Typical of Body-temperature in Typhus (Wunderlich and Mao- lagan), 467 74. Range of Body-temperature in a Severe and Prolonged Case of Enteric Fever ,, (Wunderlich), 530 75. Diagram of Range of Body-temperature in a Case of Relapsing Fever (Her- ^i"). 556 Digitized by Microsoft® LIST OP ILLUSTRATIONS IN VOL. I. Iv MG. PAGl! 76. Diagram of Typical Eange of Body-temperature in a Case of Pebricula (Wunderlich), . ' 563 77. Diagram of Typical Eange of Body-temperature in a Case of Protracted Peb- ricula (Wunderlich), 563 78. Diagram of Typical JRange of Body-temperature in a Case of Intermittent Pever or Quotidian Ague (Wunderlich), 588 79. Diagram of Typical Eange of Body-temperature in a Case of Intermittent Pever of Tertian Type (Wunderlich), 5S9 80. Diagranmtic Eepresentation of the State of the Heart, Lungs, and Great Vessels, after Death, in Collapse of Cholera (after Dr. George Johnson), . 642 81. Diagram of Typical 'Eange of Body-temperature in a Case of Erysipelas affecting the Pace (C. L. Pox), 727 82. Diagram of Body-temperature in a Case of PyEeniia (Einger), . . . 743 83. Diagram Typical of Body-temperatureina Case of Acute Eheumatism affect- ing many Joints (Wunderlich), 762 84. Urate of Soda in Stellai-form Crystals (Wedl), 784 85. Appearance of the Teeth in Hereditary Syphilis 839 86. Cancer-cells of Scirrhus filling the Interstices among Bundles of Connective Tissue in the Skin of the Breast (Paget), 851 87. Varied Porms of the Elementary Cells of Scirrhus Cancer (after Wedl and Paget), 852 88. Varied Porms of the Elements of Soft or Medullary Cancer (after Paget and Wedl), 853 89. Various Typical Epithelial Cancer-cells and their Arrangement (after Paget and Eokitansky), 857 90. Various cells of Melanotic Cancer from the Orbit (after Wedl), . . . 858 91. Development of Tubercle from Connective Tissue in the Pleura — 300 Diame- ters (after Virchow), , . . 882 92. Crystals of Diabetic Sugar from Diabetic Urine (after Beale), . . . 916 93. Inosite, or Muscle-sugar, Crystallized partly from Alcohol and partly from Water (after Punke), 918 94. Nitrate of [Jrea (after Beale), 986 95. jEsthesiometer of Dr. Sieveking, 988 96. Dynamometer of Mathieu for measuring the Strength of Paralyzed Muscles, 991 Engraved Plate, showing Porms of Pungi as described by Hallier and others in Eice-water Stools of Cholera, to face jiage 649 Digitized by Microsoft® Digitized by Microsoft® THE SCIENCE Al^D PRACTICE OF MEDICINE. PAET I. TOPICS RELATIVE TO PATHOLOGY. CHAPTER I. OF MEDICINE AS A SCIENCE AND AS AN ART; ITS OBJECTS AND ITS EXTENT. The study of Medicine is prosecuted under two relations, namely, as a Science and as an Art. Considered as a Science, Medicine takes cognizance of all that relates to our knowledge of diseases ; and, especially, of the circumstances under which they become developed, of the conditions of their existence, of their nature and of their causes, in the widest sense of these terms. Considered as an Art (in so far as Medicine has that practical value), its object and aim is to distinguish, to prevent, and to cure diseases ; to alleviate human suffering, and to lengthen out human existence, by warding off or by modifying disease " as the greatest of mortal evils," and by restoring health, and even at times reason itself, " as the greatest of mortal blessings." In general terms, the practical view required to be taken of Medicine is, that " it is the art of understanding the nature of diseases, in order to appre- ciate their causes, and to prevent their occurrence when possible ; to promote their cure, or to relieve those who suffer from them." Many branches of human knowledge are combined in the constitution and elucidation of the Science of Medicine. The practice of the Art ought to be founded on principles and facts of universal applicability. A consideration of the different topics of human knowledge which together make up the Science of Medicine suggests its division into the following departments, namely : (1.) Physiology, which embraces the study of the healthy functions of which the human body is the seat or instrument ; (2.) Pathology, subdivided into Special Pathology and General Pathology, which together embrace a consideration of everything relative to the existence and nature of diseases ; VOL. I. 4 Digitized by Microsoft® 50 TOPICS EBLATIVE TO PATHOLOGY. (3.) Therapeutics, whicli expounds the various actions of remedies upon the diseased economy, or the means by which Nature may be aided in her return to health ; -, f- ■ (4.) Hygiene, which embraces a consideration of the means ot preventmg disease, or, in other words, of preserving health. Physiology, General Pathology, Therapeutics, and Hygiene are sometimes designated indifferently by the titles of the "Institutes," the " Institutwm, or the " Theory of Medicine." These departments of science are all preliminary subjects of study, and constitute a necessary and appropriate introduction to the Practice of Physic, in which Special Pathology and the treatment of special diseases are the leading topics of consideration. Each of these departments has grown or expanded itself into a great branch of science; and any single section is suf&cient of itself to occupy the lifetime of an individual in working out and studying it in detail. It is, therefore, not possible for the human mind to embrace all of these departments in their whole extent or relations to each other ; and, setting aside the consideration of theories and systems, it has been truly observed, " that no man possesses all the pathological knowledge contained in the records of his art" (Chomel). Still less possible is it to embrace in any single treatise a complete and con- nected view of the Science of Medicine in all of these departments. For the purpose of teaching the Science of Medicine in its application to practice, its elementary principles, as developed in the departments of Pa- thology, are the most useful guides to the student ; and the aim of the follow- ing chapters, relative to Pathology, is to elucidate these principles. CHAPTER II. HOW THE PEOVINCE OF PATHOLOGY IS MAPPED OUT. An inquiry into the nature of diseases embraces a consideration of the fol- lowing topics : (1.) The accurate observation and correct registration of Facts in Pathology. On the efficiency of the machinery devised for these important ends will rest our . power to curb the invasion of our science by the guesswork of theory ; and eventually to root out the traditional errors which so largely pervade medical literature. (2.) Descriptive Pathology, emhraeing General and Special Pathology. Special Pathology is intended to comprehend a consideration of the essential nature and origin of particular diseases as they occur in man and animals, and General Pathology to include those more general facts or principles which result from a comparison of particular diseases with each other. Althotigh . Special Pathology comes first in the order of Nature, yet, wherever the ar- rangements for medical education are complete. General Pathology is taught as an introduction to, or conjointly with, the special study of diseases, just as in other sciences ; for example, in chemistry it is found convenient to give a general view of the principles which have been established by experiment and observation, before entering upon the particular details of the science. All theory in Medicine, all Descriptive Pathology, all grounds for rational specu- lation regarding the nature of diseases, and for the framing of experiments, as well as all maxims of practice which aim at the prevention or cure of diseases, must rest ultimately on observed and recorded facts. Accuracy of observation is therefore the first lesson the student has to learn in all methods of investi- Digitized by Microsoft® THE PROVINCE OF PATHOLOGY. 51 gation, and the lesson is one of paramount importance. The best observa- tions, however, will avail but little unless the observed facts are recorded in such a way as to secure, their preservation ; and Descriptive Pathology mainly concerns itself, in the first instance, with the Registration of Facts, as em- braced, — (a.) In the Histm'y of cases of disease from their origin to their end. (6.) In the Statistics of disease. Such registration includes methods for preserving, in an authentic and per- manent form, the memory of Facts in Pathology as they occur. It thus eventually furnishes materials upon which future pathologists and statists will build a comprehensive and definite system of scientific Medicine. It will furnish the means of teaching all that is necessarily involved in our notions regarding the nature of diseases. The Descriptive Pathology, so arrived at, considers diseases as they exist, or have existed in man, in the lower animals, or in plants. It considers the conditions under which diseases originate ; it considers how far certain conditions are fulfilled before disease establishes itself; and it aims at demonstrating how far such conditions are inconsistent or incompatible with the maintenance of health. Subsequently, with ex- tended information. Descriptive Pathology may undertake to assign the con- ditions which give rise to certain diseases rather than to others. It will eventually define the elements necessary to establish, to originate, or to con- stitute particular diseases; and will show how the same disease, or class of diseases, may assume various forms, but in all of which definite elements are recognizable. Descriptive Pathology thus aims at determining and describ- ing the essential elements of a disease. (3.) Speculative Pathology assumes that we know what a disease is — that we know the eifects it produces — that we know the conditions necessary for its existence — that we know its relations to other diseases. It seeks to inquire how certain conditions or circumstances will operate in bringing about dis- ease. It seeks to determine the tendency in the future of a diseased state from certain observed facts in its course, or in the course of similar diseases. Statistical data are thus the main basis of its operations. (4.) Pathology dictates the maxims of rational practice. It is in the nature of the science of Pathology that it always ought to be in advance of our certain knowledge regarding the treatment of diseases. It is the basis of rational medicine; for it is rational to know the nature of a disease, in order (1.) To enable us to prevent it; (2.) To understand the principles which ought to guide us in the management of it. Such are the main divisions which the province of Pathology embraces. It is intended, however, in the first part of this handbook merely to guide the student to appreciate, — (1.) The relative nature of the tei-ms "Life," "Health," "Disease." (2.) How the nature and causes of diseases may be elucidated. (3.) The nature of morbid phenomena, symptoms, and signs of disease. (4.) The means ai;d instruments of investigation into the nature and causes -of disease. (5.) Some of the more elementary constituents of disease. (6.) Some complex morbid states associated with individual diseases, or with conditions of ill-health (cachexia). (7.) The modes by which diseases terminate fatally ; the types of disease,. and their tendency to change. (8.) The general treatment of the more complicated morbid states of the system comprehended under the name of General Diseases. In the subsequent parts of this work it is intended to consider some of the •details of the Science and Practice of Medicine : to furnish the student with, — (1.) A nosological system by which to classify and name diseases. ,(.2.) A detailed description of characteristic diseases in the respective classes- Digitized by Microsoft® 52 TOPICS RELATIVE TO PATHOLOGY. of that nosological arrangement. In this part a definition (provisional) and a history of the nature of each disease will be given ; the probable course and succession of events in the progress of each disease will be described, and the grounds on which an accurate diagnosis may be made, or a prognosis expected ; and, lastly, a detailed account of those rational modes of treat- ment which are consistent with the established principles of the Institutes of Medicine. (3.) An account of what is known relative to the geographical distribution of diseases. CHAPTER III. RELATIVE NATURE OP THE TERMS LIFJE, HEALTH, DISEASE. The word Disease is used in a general and also in a specific sense ; as when it is said that a person is diseased, without the nature of the afiTection being stated; or, that he suffers from a particular disease, such as small-pox. Attempts to give a precise definition of the term Disease have all been unsuc- cessful. The relations of the morbid state to the condition of health, and of health to the performance of the vital functions, are of such a kind that they can merely be described in connection, comparison, or contrast with each other, but not defined. If Life is understood to imply an active state, resulting from the concur- rent exercise of the functions of the body, then there are conditions of activity and of mutual adaptability of functions and of parts, both as regards body and mind, which are necessary to healthy existence. Our notions of the con- ditions of health have thus considerable latitude ; and Health is merely a name we give to that state or condition in which a person exists fully able, without sufiering, to perform all the functions and duties of life. Many degrees of Health are therefore at first sight obvious, from the possession of a feeble existence to the most robust condition of the body ; and there are even many degrees of feebleness and delicacy of Health without any disorder of the system. Our notions of normal life are thus so extremely indefinite that it is only by a forced abstraction the normal can be separated from the abnormal. Hence also our idea of Disease is very indefinite ; it cannot be separated by any well-defined boundary from our idea of normal life, and the two condi- tions are connected by a kind of debatable border land. When we regard, therefore, the phenomena of the living state and the con- ditions of health, we can readily observe when and how Disease is but A de- viation prom THE STATE OF HEALTH, CONSISTING POR THE MOST PART IN A CHANGE IN THE PROPERTIES OR STRUCTURE OF ANY TISSUE OR ORGAN, WHICH RENDERS SUCH TISSUE OR ORGAN UNFIT POR THE PERFORMANCE OP ITS ACTIONS OR FUNCTIONS ACCORDING TO THE LAWS OF THE HEALTHY FRAME. . It is now a received pathological doctrine that Disease does not consist in any single state or special existence, but is the natural expression of a combi- nation of phenomena, arising out of impaired function or altered structure. All attempts, therefore, to define disease by the use of such terms as " derange- ment," " modijieation," " alteration," " change," from the pre-existent state of health, show, in the first instance, that, in use, various ideas are attachable to the terms or to the state to which they are meant to ap^ply, and, secondly, that these terms point to a nosological division into structural and functional diseases, rather than to a state common to all forms of disease. A definition of any state of disease ought, therefore, to include all the cir- cumstances, whether functional or organic, which constitute the deviation Digitized by Microsoft® MORBID PHENOMENA, SYMPTOMS AND SIGNS OE DISEASE. 53 from health ; and for obvious reasons such a definition can only be approxi- mately expressed, very incompletely circumscribing the subject by shadowy outlines. CHAPTER IV. HOW THE -NATURE AND CAUSES OP DISEASES MAY BE ELUCIDATED. The nature of the derangements to which the human body is liable may be studied under the three following aspects : (1.) As diseases present themselves in individual cases, becoming thereby the subjects of Clinical Investigation and Instruction — a method of teaching in which the Natural History of the disease ought to be a special subject of study. (2.) As they constitute particular genera or species of disease, forming the topics of Special Pathology. (3.) As they may be reduced to and studied in their primary elements, forming thereby the science of General Pathology. But, in whatever aspect we may view disease, there is invariably presented to the student the same subjects for investigation, namely, — First, The morbid phenomena or symptoms by which we become aware that derangements have taken place in the economy. It is by a mental eifort that either the student or the physician converts these symptoms into signs of disease ; and hence arises the necessity of studying Symptomatology or Semeiology. Second, The agents by which derangements and diseases are produced, generated, or brought about, constituting the department of Etiology. Third, The seats or localities of disease, or of derangements, constituting Pathogeny. Here the peculiar nature, general forms, and types of disease must be studied, together with va- rieties in their course, duration, and termination. Fourth, The morbid altera- tions discoverable in the structure of the body before, l3ut more especially after death, constituting Morbid Anatomy. These alterations must be studied in connection with the symptoms, the causes, and the course of the disease. Lastly, The elementary constituents of disease-products, constituting Morbid Histology, must be recognized in the first instance, and contrasted with analo- gous constituents of the body in the healthy state. CHAPTER V. of morbid PHENOMENA, SYMPTOMS, AND SIGNS OF DISEASE. It has been stated that only by a mental effort is the student or physician able to convert symptoms into signs of disease. Therefore the idea associated with "sign" is of a much more comprehensive kind than that which is con- nected with the word " symptom : " the former implies the possession of more extensive knowledge — a knowledge such that comparisons may be instituted amongst the symptoms which present themselves. Certain symptoms of disease, or of disordered function, are thus recognized to be peculiar, charac- teristic, or significant of a particular morbid state. A symptom, is thus con- verted into a sign, and what is called a diagnosis of the disease is made. Symptoms and signs of disease derive their importance from the fact that they are capable of being connected with lesions of structure or disorders of Digitized by Microsoft® 54 TOPICS RELATIVE TO PATHOLO&Y. function ; and both of these conditions mutually act and react upon each other. Thus it is that such mutual reaction greatly aggravates any general disease. In place of the concurrent exercise of function, and the mutual co- operation of parts in a state of health, both as regards mind and body, we have symptoms of disease expressed in various ways, characteristic of the func- tion at fault, and incompatible with the normal existence of the part or organ affected, or of the body generally. From such phenomena the physician makes up his mind, — (1.) As to whether or not disease exists (2.) How far the condition of the patient is remoyed from the state of health usual to him. (3.) As to the nature of the disease, and how it is distinguished from other ailments, or in what respects it may differ from the same ailment in other people in similar circumstances. Thus a diagnosis is made by the art of con- verting symptoms into signs of disease. But the physician at the same time generally carries his misntal exertion a little further. He tries to arrive at a just estimate of the probable result or event of the malady, and so makes up his mind, — (4.) As to whether the ill- ness will terminate in the death of the patient, in permanent organic mischief of greater or less extent, in persistent impairment of the general health (cachexise), or in complete recovery. As in Politics, so in the Science of Medicine : the Politician and the Physician have each to deal with the future, as well as with the present. Both endeavor to forecast events ; and thus, in the Practice of Medicine, we are said to make or give a prognosis. (5.) The Physician must be able also to appreciate with reasonable rapidity those symptoms which are peculiar, and to recognize them when associated together as the signs of particular or definite morbid states. Such symptoms are then said to furnish pathognomonic signs of disease. (6.) The Physician must further discriminate, and try to put a fair and just value or interpretation upon, those symptoms which are only experienced by the sensations (subjective) of the patient himself, as contrasted with those which may be seen or appreciated by others — such as objective phenomena or physical signs. The interpretation of symptoms can only be successful after a close observa- tion of- the patient — often prolonged, and repeated for more complete investi- gation — so as to connect the results arrived at with his previous history. The utmost logical acumen is required for the due interpretation of symptoms. The individual value of each ought to be duly weighed ; one symptom must be compared with another, and each with all ; while the liability to variation of a similar symptom in different cases of a like kind must not be forgotten ; and the occasional absence of the usual pathognomonic signs may be some- times calculated upon. Thus only can the nature of a disease be clearly deter- mined — its severity and dangers fully appreciated — its treatment indicated, and the probability of recovery foretold. A close observation of the general symptoms of diseases, in all their details, is absolutely necessary ; and the investigation is aided practically by the improved instruments of the present day, and the better methods of examina- tion of patients. Above all things, methodical examination is essential for the student, if he would acquire the habit of carefully and accurately learning the nature of the cases of disease with which he will have to deal. Patients must be examined methodically, in order that the symptoms of disease may be correctly interpreted, and that nothing be overlooked or neglected. Directions have been given by many authorities for acquiring and habitually following a defi- nite system of examining patients, as to what are the essential data to be ■obtained and recorded in case-taking ; and although, as Dr. Acland justly remarks, a skilful practitioner can learn the truth of most cases in any order, or in no order, yet it is highly desirable that a regular order should be fol- lowed by learners ; and all cases observed by the student should be methodi- cally entered in a note-book for the purpose. This habit will thus eventually Digitized by Microsoft® MORBID ANATOMY AND PATHOLOGICAL HISTOLOGY. 55 become a necessity, and will be found most useful in after-life, and especially in consulting practice. The following works are recommended for study, and as guides for acquir- ing the best methods of observing and recording cases : (1.) A Manual of Medical Diagnosis, third edition, by A. W. Barclay, M.D. ; (2.) A Handbook of Hospital Practice ; or, an Introduction to the Practical Study of Medicine at the Bedside, by Robert D. Lyons, M.B., Professor of Medicine in the Catholic University of Ireland ; (3.) An Introduction to Clinical Medicine, by John Hughes Bennett, M.D., Senior Professor of Clinical Medicine in the Univer- sity of Edinburgh ; (4.) " Suggestions for taking Cases," by Dr. Beale, Archives of Medicine, vol. iii, p. 47. CHAPTER VI. MORBID ANATOMY AND PATHOLOGICAL HISTOLOGY: THE SPECIAL MEANS AND INSTRUMENTS BY WHICH THE NATURE OF DISEASES MAY BE INVES- TIGATED. Morbid, or, as it is also sometimes called. Pathological Anatomy, is that department of medical science which treats of the changes produced by disease in the solids and fluids of the body ; while Morbid or Pathological Histology treats of the origin, development, growth, and decay of the new products or new formations which are the elementary constituents of structu- ral or organic lesions. The anatomy of diseased parts stands in the same rela- tion to the development of morbid phenomena and conditions of disease that the anatomy of healthy structures and the histology of the textures do to the natural functions and processes of development, growth, and nutrition in the healthy body. The vestiges left by the prolonged existence of a morbid state, whether in the body of man or of the lower animals, have always claimed from the physi- cian a large share of attention. In proportion also as the knowledge of healthy anatomy and physiology has become extended, so has pathology and morbid anatomy gradually but steadily acquired an important and prominent position among those branches of study on which Medicine rests its claims as a science. Morbid Anatomy is a department of medical science which has gradually grown out of the accumulated experience and observation of ages; but Pathological Histology, as a science, is of modern origin. It is but yet in process of development, although, its foundations may be traced in the works of the earliest medical writers of antiquity. All of them refer to changes which they merely supposed had taken place in the internal organs ; and they were doubtless led to this assumption by observing the connection that existed between structural lesions of the external parts and their accompanying symp- toms. Hippocrates describes the deposit of tubercles in the lungs, the symp- toms occasioned by them in a crude state, and those which attend their soft- ening and discharge. The science of Morbid Anatomy is a record of facts. In its relation to the progress of Medicine it is a living record — a history whose pages must be ever open to receive the observations which are constantly being made by those engaged in pathological pursuits — a record from which one may ascer- tain at any time the conditions under which morbid changes or new forma- tions in the body have taken place. The pages of this history show that at the present day the department of pathology is in a transition state ; and the position of Medicine, as a science, must eventually result from a rearrange- ment of the innumerable details which the sciences of morbid anatomy and histology may disclose and unfold. It is necessary, therefore, and often advan- Digitized by Microsoft® 56 TOPICS RELATIVE TO PATHOLOGY. tageous, to look back upon the past, and see 'what has already been done, so that its venerable facts may not be lost sight of, but grouped in series with the extensively verified experiments and observations, of the present day. In so doing, if we pause and contemplate the steps which have been taken to arrive at our present position, such a contemplation may stimulate the youthful student to the noblest exertions of his intellect, as he cannot fail, with exten- sive study, to see before him, and on every side, much unlabored but produc- tive soil. Such a retrospect will at the same time have the effect of placing in a prominent aspect the varied influences which Morbid Anatomy has had on the Science of Medicine, the conditions under which it has flourished, and the legitimate objects of its investigations. The art of printing had not been long invented when books on morbid an- atomy began to issue from the press ; and although the early period of the fifteenth century has left little enduring literature of any kind (but has been mainly distinguished by the number of colleges then founded), yet about this time pathological anatomy in the medical school of Florence shows the earliest evidences of an existence. The facilities for study which the art of printing introduced soon stirred up ardent students ; and the sixteenth and seventeenth centuries produced much that will ever remain famous in the annals of medical science. Eustachius, Tulpius, Ruysch, Harvey, Malpighii, and Leuwenhoeck are names familiar as household words to the student of Medicine. The earlier attempts of this period to form a system of pathological anatomy are characterized by abortive endeavors to explain all results upon some exclusive and general principle. A spirit of speculation marks the character of the age. The men of that time had observed but few facts ; and on these facts they preferred to speculate and dogmatize, rather than prosecute the further interpretation of nature, or record more observations. Accordingly, theories in abundance successively led captive the minds of the medical world, and, disappearing one after the other, demonstrated the unstable foundations on which the science of Medicine had been placed. The leader of each sect founded his so-called school or system, all of them distinguished by a due amount of arrogance and con- tempt for predecessors and contemporaries — a feeling unhappily not yet quite extinct. The " vital agency," the " influence of the himiors," and of the " solid organs," have each been considered by turns as the only orthodox belief; and each has had their school and sect respectively designated as the Vitalists, the Hwnoralists, and the Solidists. The theories of Galen, of Paracelsus, and others, have all been famous in their time, but are now unheard of, and almost unknown. The same fate awaits the false theories and absurd con- ceits of more recent times, although, as in the case of Stahl, Cullen, Brown, and Broussais, they have had a wide prevalence in the schools of Europe, and made impressions on the sentiments of the profession which yet influ- ence their modes of practice and the reasons of their belief Broussaisism, Hahnemanmsni, and some other systems, "the fruits of a luxuriant fancy and of few facts," must all descend, as others have done, the same inev- itable slope to oblivion ; but the vast collection of facts which the founders and followers of such systems eventually accumulate and bring to notice, remain unchangeable, and will continue to recur in the daily experience of our profession, just as they appeared to the venerable fathers of medicine centuries before the Christian era. The practice of medicine, as based upon rational principles and a knowledge of the nature of diseases, has thus oscil- lated through these varied systems and innumerable theories, and the science of Morbid Anatomy has been marked throughout by unmistakable periods of progress, of stationary existence, or even of retrogression, according as one or other exclusive system had the ascendency, or as each principle or theory of practice challenged for itself a supreme importance. The modern doctrines relative to the nature of diseases and the practice of Digitized by Microsoft® PHYSIOLOGY THE BASIS OF PATHOLOGY. 57 Medicine are guided by the dictates of Physiology, and of what is known regarding the development and growth of the human body. Ordinary dissec- tions alone, or post-mortem examinations of the body, have long since ceased to furnish us with facts before unknown ; and new modes of extending obser- vation and research, by taking advantage of every physical aid to the senses, are diligently looked for by the modern anatomist, physiologist, and physi- cian ; and the means and instruments which advance the science of physiology are well able to advance our knowledge regarding the nature of disease- processes. A belief is now rapidly gaining ground, and acquiring a hold on the pop- ular mind, that advances in the science of Medicine in future years will be mainly due to a better appreciation of the causes of disease ; and just in propor- tion as our knowledge of physiology and pathology becomes more exact and extended, so will the causes of disease be appreciated, and the occurreiice of disease on a large scale prevented. An amiable and large-minded physician, the late Sir John Forbes, emphatically recorded the observation, more than twenty years ago, that " here the surest and most glorious triumphs of medical science are achieving, and are to be achieved." He himself lived to see great and good results ; to see improvements in social and sanitary matters which continue to be realized, and whose rapid progress is characteristic of the present period. Within the last half century laud-draining and town-sewering have ripened into sciences. From rude beginnings, insignificant in extent, and often in- jurious in the first instance, the systematic sewering of towns and draining of land have become of the first importance. Land has thus, in not a few in- stances, doubled its value. Town-sewering, with other social regulations, have contributed to prolong human life from 5 to 60 per cent, as compared with previous rates in the same district. Agues and typhoid fevers are reduced in the frequency of their occurrence. Since 1840 an annual mortality in English towns of 44 in 1000 has been reduced to 27 ; an annual mortality of 30 has been reduced to 20, and even as low as 15. Not less remarkable reductions have taken place in the mortality and loss of strength in the army and navy ; so that generally it may be said that human life has now more value in Eng- land than in any other country in the world — a result entirely due to better sanitary arrangements (Rawlinson " On Sewering of Towns," 8oc. of Arts Journal; vol. x, p. 276). The political economist, therefore, cannot now regard Medicine in any other light than as a productive art ; and the labors of the physician, whether in civil or in military life, cannot be regarded as unproductive labor. But the science of Physiology (on which much of our sanitary improve- ments are based) has immeasurably outstripped the science of Pathology in the comprehensiveness of its views and in the value of its results ; while Pa- thology, in its turn again, has always been, and ought to be, in advance of Therapeutics. The best physiologists have distinctly recognized that the basis of their science must include not only a knowledge of animals below man, but a knowledge of the entire vegetable kingdom. Without such an exten- sive survey of the whole realm of organic nature, we cannot possibly under- stand human physiology, and far less comparative physiology. The science of Pathology, therefore (whose aim is to expound the nature of all diseases), must be, a fortiori, very far behind Physiology. The diseases of the lower animals, for instance, rarely form any part of the study of the student of Medicine. The diseases of plants are almost entirely neglected. Yet it is clear that until all these have been studied, and some steps taken to generalize the results, every conclusion in pathology regarding the nature of diseases must be the result of a limited experience from a limited field of observation. How do we know that the blights of plants, or the causes of them, are not commu- nicable to animals and to man? We know how intimately related the dis- eases of man and animals are with famines and unwholesome food ; and of Digitized by Microsoft® 58 TOPICS RELATIVE TO PATHOLOGY. famines with the diseases of vegetable and animal life, as much as with the destruction and loss of food. To Physiology, therefore, in its most comprehensive sense, and to a knowl- edge of the natural and normal development of animal and vegetable beings, we must look for future progress in pathology ; while the means and instru- ments which advance physiology will simultaneouly advance our knowledge regarding the nature oj diseases — a sound knowledge of which can alone enable us to " appreciate their causes," and so arrange measures for tlie prevention of many of them, based on the great truths of science. Organic chemistry, the microscope, the ophthalmoscope, the sphygmograph, the laryngoscope, and such-like instruments, have opened up new fields of labor, which are being diligently cultivated ; and while alterations in the ultimate tissues and organs are more especially attended to, the first beginnings of dis- ease, the development of new formations, and the examination of excretions, and of specific products, claim a large share of attention. Histology, or the study of the development and arrangement of the tissues in the formation of normal and healthy organs, is characteristic of the ana- tomical investigations of the present day ; while the histology of morbid prod- ucts and chemico-physiological investigation into the nature of morbid changes is characteristic of the pursuits of- the science of modern Pathologi- cal Anatomy. It is also a significant fact that now, in the nineteenth century, some of the leading doctrines of the humoral pathology which prevailed in the seventeenth are again revived. The experience and learning of that erudite period are now being made available for modern uses. By the improved means, instru- ments, and methods of research of modern times, important truths may be sifted from the errors and theories with which they are mixed up in the ancient chronicles of medical science ; and when we get analogous conditions of disease with which the phenomena described by the ancients may be com- pared, " not a few of the apparently modern beliefs are daily found to have a time-honored reputation unappreciated before." The chemist and the histologist now combine their researches, and, working hand in hand, we regard them as the most inquisitive anatomists of the time. They lend assistance of the most important kind in laying the foundation of our knowledge regarding the nature of diseases, the details of which can only be made more certain and perfect by taking advantage of every kind of scien- tific knowledge which can be brought to bear upon medical research, and more especially, — (1.) By physical aids to the senses, extending our means for the actual inspection and appreciation of phenomena. The use of the thermometer, the sphygmograph, microscope, ophthalmoscope, laryngoscope, the stethoscope, and specula of various kinds, aided by a careful study of the writings and labors of the men who have more particularly devoted their attention to observations by such means, may be quoted as examples (Laen- NEC, Louis, Walsh, Stokes, Hope, Bennett, Quekett, Viechow, Wun- DEELicH, Traube, Vogel, ]3eale, Graefe, Czeemak, and others). (2.) By the knowledge (gradually being made more extensive) of the textures, organs, and functions of the body, whose normal exercise constitutes a healthy existence (Longet, Mullee, Shaepey, Valentin, Allen Thomson, Cae- PENTEE, KiEKEs, Paget, Kollikee). (3.) By an intimate knowledge of the normal development of the human textures, as well as those of plants and animals from the fecundated ovum (Bischoff, Costa, Allen Thomson, Huxley, Newpoet, and Kollikee). (4.) Besides these kinds of mvestiga- tions, the science of practical medicine has been, and is being, advanced by operations and experiments upon the internal organs of living animals, oppro- briously termed vivisections. At some of our great schools of medicine such investigations are now being actively but judiciously prosecuted and taught. Successful inquiries into Pathology, or the nature of diseases, cannot be said Digitized by Microsoft® HOW THE SCIENCE OF PATHOLOGY HAS BEEN ADVANCED. 59 to have commenced till the middle of the eighteenth century, when the great work of Morgagni issued from the press. It was the work of his lifetime. In the eightieth year of his age, and not till then, did he consider himself war- ranted to publish his observations, De Sedibus et Causis Morborum (1761); a work whose material and circumstances of publication read us the practical lesson, that the more frequently a disease occurs, the more necessary it is that its phenomena should be carefully mvestigated. And when we think of the prudent reserve, the anxious and the conscientious delay exhibited by Har- vey, Morgagni, and Jenner, in the publication of their respective researches, we cannot but contrast the circumstances with those under which the exuber- ance of medical publications are now given to the world. Morgagni modified and corrected many of thcviews entertained and promulgated by his prede- cessors ; and the study of the nature of diseases was carried into the com- mencement of the present century by Cullen, De Haen, William and John Hunter, Poetall, and Bichat. Our knowledge regarding the nature of disease-processes has advanced simultaneously with that ot general anatomy; and when the component parts of an organ, and of the human body, came to be distinguished, it was observed that membranes and tissues might be individually diseased, while neighboring membranes and tissues remained untouched. Bichat's idea, therefore, of de- composing the animal body into its elementary parts, must be regarded as the foundation of modern special pathology, and Morbid Anatomy. He pointed out the necessity of studying diseases with reference to the different tissues as separately and specially affected ; and it has been since shown, in a remarkable manner, how general anatomy, deduced from the physical proper- ties of parts and crude observation, may coincide with more minute investiga- tions of a chemical and microscopical kind. The membranes and tissues of the human body, roughly torn asunder by Bichat, are now themselves being daily subjected to a more inquisitive analysis of an anatomical and chemical nature, which unravels them into still more minute histological elements. Although, therefore, Bichat entertained the view that .each tissue had its own diathesis, it is to Cullen and the Hunters, in this country more especially, that the application of the distinction of tissues was made to illustrate the nature of disease-processes. Cullen's descriptions of diseases are descriptions of groups of phenomena which comprise complex morbid states. The written labors of the Hunters form but a small part of the memorials of what they did to elucidate the nature of diseases, and it is only those who have had the opportunity of carefully examining their museums, preserved in London and in Glasgow, that are able to form any conception of the compre- hensive nature of their labors, or to assign to them a proper place among those who have successfully advanced the science of Medicine. They hold a position in science at least one hundred years in advance of the age in which they lived. Bichat, Cullen, and the Hunters, in their respective countries, have thus reciprocally influenced and advanced the progress of our knowledge regarding the nature of diseases. And although it was reserved for Bichat to complete a more perfect system of general anatomy, it must not be forgotten that Dr. Carmichael Smith, in 1790, applied his knowledge of textural anatomy to elucidate the nature of disease-processes ; and that Pinel, after him, in his NosograpUe Philosophique, made the distinction between the membranous and other animal structures the foundation of his pathology. The classic work of Baillie (his Morbid Anatomy), published in 1793, closed the labors of the past century. If we look now to the tendency of the studies and researches of those men just named, including Bichat, the truth gradually asserts itself, that it was necessary to study alterations of structure so as to connect morbid changes Digitized by Microsoft® 60 TOPICS KBLATIVB TO PATHOLOGY. with the symptoms of diseases during life, and with the operations of ascer- tained causes of morbid action. The nature of the morbid changes was ob- sei-ved to be more apparent in the progress of external diseases ; and, therefore, surgical experience was brought to bear upon the elucidation of internal dis- ease-processes. One especially marked result of this nature is to be seen in the modern application of the ophthalmoscope, which reveals information the most important, for the diagnosis of many general diseases, from an examina- tion of the interior of the eye. Thus the progress of Morbid Anatomy is, in a great measure, a record of the history of Medicine ; and we can trace the science of special morbid anat- omy, giving a character to the various systems of the healing art which have prevailed from time to time. All the writers up to the time of Bichat, Laennec, and Abercrombie, were pure morbid anatomists, who did not connect the effects of disease with their causes, and who recognized the changes of disease as important only in pro- portion to their magnitude as apparent to the senses. They are, therefore, regarded as pure solidists, whose researches doubtless contributed much towards a correct knowledge of the changes in the organs of the body, while the con- dition of the fluids was neglected, as well as the relations of the textures, organs, and fluids, in the combined exercise of their functions. Simple func- tional disturbances were thus wholly overlooked, and the constitutional con- nection of local afiections entirely lost sight of The contemporaneous surgery of the period previous to Bichat was marked by its unwillingness to recognize anything but material facts, mechanical processes, and contrivances. The surgeons of those days desired to know nothing but anatomy and mechanics; and, accordingly, it may be recognized as the period of pure anatomical and mechanical surgery, distinguished by the writings of men whose works bear ample testimony that the surgery of the period was founded on exact and even minute anatomical knowledge. No allusion is made, however, by them to medicine, — ^they make no applica- tion of physiological truths, and they encourage no therapeutic tendency apart from mechanical or instrumental interference. The purely solidist, as well as the purely humoral principles by which the nature of diseases have been explained, may be said to have died a natural death long ago ; but, as already noticed, the remembrance of what is valuable in the results of both are preserved in modem pathology, which takes its stand upon anatomical and physiological facts, connected by simple methods of inductive observation with the symptoms and signs of disease as seen and expounded to the student by the distinguished professors of Clinical Medicine and Surgery at most of our celebrated schools, where clinical instruction is given. In this field of instruction it would be invidious to mention here the names of men still living. For their own sakes, as well as for science, may they be long deprived of being thus honorably and respectfully mentioned. As teach- ers, they are in our own country familiar to every student. As recorders of what they observe at the bedside and in the post-mortem room, they are not less celebrated abroad than appreciated at home. Tested by extensive clinical observations, the character of the present period in the history of Practical Medicine is one of probation as well as of progress, marked by a close inductive examination of past generalization and classifica- tion of facts, however remotely connected, which illustrate the nature of dis- eases and their treatment. Side by side, since 1816 and 1819, the microscope and the stethoscope have advanced our knowledge of the nature of diseases with a regular and accele- rated velocity ; but they have only done so as assistants and in subordination to laws and facts whose knowledge we have acquired, by a close observation of general symptoms, of which such instruments have never been intended to Digitized by Microsoft® CHARACTERISTICS OF MEDICAL RESEARCH. 61 take precedence. They have never accomplished, nor can they ever accom- plish, useful practical results, to the exclusion of such other methods of obser- vation as have just been noticed. We are not to confound relative smallness with absolute simplicity, and believe that because a simple organic cell is a small object — ^because we can see around it, through it, and on every side of it — the lunctions and conditions of its existence are less complex or less obscure on that account than are those of a more large and complex organ, or the functions of a living body. We are not to suppose that because the stethoscope enables us to detect a mitral murmur, or a crepitation in a lung, we are justified at once in adopting one, and only one, method of treatment. It is this exclusive use of instru- ments, to the disregard of general symptoms and signs of disease, derived from close observation and knowledge of the living functions, which leads to the repudiation of the use of such instruments by the sagacious and experienced physician, who sees the numerous errors not unfrequently committed by his younger brethren, who trust too exclusively to instruments in the diagnosis of disease. Like the stethoscope, the microscope has been unjustly and unnecessarily burdened with labor, and has been equally unjustly blamed, and brought into unmerited discredit, when it has failed to elucidate the nature or even pres- ence of a morbid state, the existence of which could not be doubted, but which the sense of sight could not appreciate, even when presented in small quanti- ties greatly magnified. In such instances the microscope has been applied to uses which it was not the nature or province of the instrument to detect. The gravimeter or hydrostatic balance, the microscope, the stethoscope, the ophthalmoscope, the laryngoscope, the pleximeter, the sphygmograph, and the thermometer, are merely instruments of pathological inquiry, each one adapted for the determination of particular classes of facts. They can only elucidate disease when they are brought to bear upon physical properties, the nature of which they are able to appreciate ; and it is only from their combined and appropriate use, in connection with a history of the general signs and symp- toms of disease in each particular case, that our knowledge of the nature of diseases will be advanced. The industrious employment of these aids to diagnosis, and an intimate acquaintance with the results, are attended with this further advantage, that such practice and knowledge enable their possessor to appreciate the general symptoms of disease with infinitely greater certainty than heretofore. This is the usual consequence of training in all exact methods of observation. The thorough study of these aids to the senses in appreciating disease leads directly to the possibility of dispensing with them in many instances. By means of auscultation and percussion, for example, our attention has been drawn to numerous conditions of the thorax, which enable us to make the diagnosis at the first glance, which hitherto was not possible ; because the conditions for diagnosis could never have been recognized without such physical aid to the senses as that derived from auscultation and percussion. In many cases, from the mere inspection of a patient, a well-instructed clinical student may decide upon the existence oi pleurisy, pneumothorax, emphysema, or pulmonary tubercle. The initiated are thus frequently enabled to dispense with percussion and auscultation ; but if they had never acquired the practical knowledge of the subject — ^if they had never examined numerous patients by means of these instruments as physical aids to diagnosis — and so learned thus to determine with great exactness the significance of the various forms and movements exhibited by the thorax, they would never have been able to appreciate their significance. So, also, the physician well instructed in the use of the ther- mometer may, in hundreds of cases, without its aid, draw conclusions with great certainty, incomprehensible to others not so instructed ; but if, led away by this skilfulness, he is induced to dispense with exact thermometrical control. Digitized by Microsoft® 62 TOPICS EBLATIVE TO PATHOLOGY. he may soon fall into gross errors. So it is with the ophthalmoscope, sphyg- mograph, specula, and all other more or less exact physical aids to diagnosis. Let them be in constant and appropriate use, but the results must always be taken and compared in connection with other general symptoms of disease. _ In all the temperate regions of the world, histology, as applied to morbid products, has been cultivated, and has advanced our knowledge regarding disease ever since 1838. In warmer latitudes our knowledge of practical Medicine has been advanced by extensive observations on physical climate, medical topography, and by organic chemical analysis applied to obtain thera- peutic agents from the vegetable world. Those may be said to be the charac- teristics of the researches of our own country, Germany, France, and America, as contrasted with the nature of the observations mostly prosecuted in India. No exclusive doctrine will now stand the test of well-directed pathological inquiry, the main object of which is to connect all organic changes (lesions) and functional derangements, with their symptoms and causes, with the view of applying rational remedies and prophylactics. The too exclusive study of pure organic pathology and morbid anatomy leads to no distinction between the signs and causes of disease ; and the obvious tendency of such exclusive study is to exaggerate the importance of the principles it may establish, to hold out no hopes of cure, and to undervalue the power of remedies and remedial measures. To obviate this tendency, it is necessary to have recourse to inductive reasoning, so as to connect all the morbid changes seen or appre- ciated after death with the signs and symptoms of disease observed during life. Thus it is that links in the chain of disease-processes which, from a one-sided or exclusive view, appear isolated and localized, are really found to be connected with each other. It may be, also, that they are connected with a long but intelligible series of processes developed during life through the metamorphosis of tissue, and going on in apparent health, or in an obviously morbid exercise of fiinction. The constitutional origin of many local diseases, otherwise inexplicable, then becomes apparent. Among the more eminent exponents of this rational school of pathology, who at an early period in this country discerned and appreciated such doc- trines, we find the names of Allen, Golding Bird, Sie Robert Carswell, Gregory, Hope, Hodgkin, Marshall Hall, Prout, William Stark, John Thomson, Tweedy Todd, and many others, who, although now no more, have left behind them imperishable evidence of their labors. The younger pathologists of the present day, whose name is Legion, follow in the footsteps of these men, extending the fields of observation and the boundaries of the science of Medicine. By them the importance of morbid anatomy is suificiently appreciated, and its province distinctly defined and limited as follows, namely: (1.) To detect the "stamps of disease," or the changes which have taken place during the course of diseases in the structure of tissues and organs of the body ; (2.) To demonstrate the exact seat of these " stamps of disease," or local alterations which have become established during the progress of disease. The investigation and elucidation of the nature, course, and causes of those changes, constitute the prominent objects of the science of pathology. By the aid of clinical observation during life, and morbid anatomy after the death of the body, pathology seeks to establish the relations of the changes which lead to the lesions, and so to connect the general progress of disease with its symptoms and signs. Morbid Anatomy goes beyond its province when it attempts to point out the nature of the proximate cause of disease. It is only by the application of inductive reasoning that the connections of causes and morbid effects can be shown, and such constitutes the main object, and is the highest aim, of the science of Pathology. The morbid anatomist finds a lesion or change for what ought to be the Digitized by Microsoft® FORMS OF THB CONSTITUENT ELEMENTS OF DISEASE. 63 natural structure, appearance, or condition of a part. The pathologist seeks to connect such lesions with signs and symptoms during life, that the practical physician may suggest a remedy to the disease, and that the nosologist may give it a name, distinguishing characters, and a place in his classification. CHAPTER VII. THE ELEMENTARY CONSTITUENTS OF LESIONS AS SHOWN BY MOEBID ANATOMY AND OTHER MEANS OF RESEARCH. Where the material effects or "stamps" of disease can be rendered obvious, they are found to consist, for the most part, of — ■ 1. Morphological changes in the elementary textures of the body generally, and altered conditions of the fluids. 2. The presence of new formations foreign to the normal condition of an organ or system of organs. 3. Change in the position or form of some of the organs or parts of organs. 4. Deposits within or surrounding the elements of tissues, or changes of a degenerative or retrograde kind in them. The object of prosecuting the anatomy of disease is, therefore, in the first instance, to institute a comparison between the known appearances or standard of health, and an altered state of the parts as evidence of disease. Such a comparison is, in the first instance, founded on an intimate knowledge of the doctrines stated at p. 56. Means and Instruments of Eesearch. — To institute investigations such as those indicated at p. 61, advantage must be taken of almost every branch of human knowledge. The methods of carrying on pathological research are therefore extremely varied, but may be shortly enumerated under the follow- ing heads : 1. The opening of dead bodies, to ascertain the condition of their organs and tissues in all that relates to their structural, chemical, and physical prop- erties (ROKITANSKY, HaSSE, ViRCHOW). 2. Application of various instruments, such as the microscope, and of means to ascertain the absolute and specific weight of organs or parts, the relations, size, form, and colors of structures, and the like (Quekett, Bennett, BealE, Peacock, Boyd). 3. Application of chemical investigations to the diseased products (Vogel, Simon, Day, Lebeet, Gluge, Beale, Gareod, Christison, Parkes, Vir- CHOw, Frerichs, Gairdner). 4. Application of statistics to determine various points of interest in refer- ence to the nature, course, and complications of diseases (Wm. Fare, Guy). 5. Means to preserve objects for further study by the microscope, or any other mode of examination (Tulk, Henfrey, Beale, Quekett, Van dee KOLK, LOCKHART ClARKE). 6. Experiments instituted on living animals, and, in certain cases, on man, with the view of artificially producing a morbid condition. A careful study of such experiments by the previously mentioned "means affords valuable in- formation, for the causes in action are more under control than those which are spontaneously brought about by disease in the living body (Beenaed, Harley, Pavy, Kuchenmeister, Zenker, and others). The immediate object of such investigations is to obtain information re- garding the material changes in the different parts of the body which accom- pany or produce morbid symptoms, and to connect these changes with symp- Digitized by Microsoft® 64 TOPICS RELATIVE TO PATHOLOGY. toms and signs of disease during life. We thus learn how morbid products are formed at first and gradually perfected ; and by combining these two kinds of knowledge we learn the relative connection of two orders of phenomena — namely, how the perverted properties, disordered actions, or altered structures give rise to perverted or impaired secretions ; disordered and irregular motions ; deranged, impeded, or interrupted functions. In other words, the "order of invasion of disease-processes " is learned from such investigations ; and we are thereby taught how parts, once the seat of morbid change, return by various pro- cesses of nutrition, growth, repair, or reproduction, to their normal condition. The questions arising out of such investigations are, or ought to be, the first object of thought to the conscientious medical practitioner. It is his duty, from an attentive consideration of the signs and symptoms of disease, to form an idea, as accurate as possible, of the nature aijd extent of the morbid action or change which is going on, or which may be set up, in the tissues, organs, and fluids of the living body. If, therefore, he does not avail himself of every means and instrument by which he can ascertain the existence of change in the dead body, and its alteration from some standard of health — if he does not, embrace every oppor- tunity of making post-mortem examinations — ^if he contents himself merely with observing signs or symptoms of disease, without witnessing the changes of structure, if any, which may give rise to them — he can have little conscious satisfaction in the study of Medicine as a science, or in the practice of the healing art. In the words of Cruveilhier, he will, during his lifetime, "see many patients, but few diseases." Such a practitioner is not to be trusted. Forms of the Constituent Elements of Disease. — The histologist has now ascertained the various simple organic forms which compose the textures in their normal state, and the mode in which these textures are arranged and combined so as to form the organs and systems which carry on the healthy functions of the body. The pathologist has made out (although with less completeness), by the methods of observation and experiment already indi- cated, the various simple organic forms which constitute the elements of those material changes whose phenomena of growth, decay, and varied change are associated with the manifestations of disease. By classifying and arranging these forms, we obtain more or less clear ideas of lesions ; and we ascertain that the, morbid processes follow, in their development, a very definite order of change, but not yet determined with absolute certainty in each disease. An anatomical investigation of morbid parts, conducted with the aid of the microscope and other instruments of research, shows that the material of which their substance is made up is of very various structure, sometimes combined in forms of one kind throughout, and sometimes varied by the development and combination of many elementary forms, more or less solid, soft, or fluid. An analysis of the morbid material, carried as far as scientific means at present enable us, shows that the elementary conditions in which morbid prod- ucts are found may be described as follows : 1. Fluid matter and hyaline substance, more or less soft, soluble, and prob- ably nutrient to surrounding or imbedded morbid elements. 2. Simple elementary forms of the nature of deposits, sometimes of a min- eral or inorganic character: e. g. (a) amorphous granules; (6) crystalline -Structures in a granular state. 3. Simple, but organized products (minute rounded particles, nuclei, or germinal matter) capable of growth, i. e., which live, change, convert or ger- minate : e. g. (a) amorphous masses (plasm gernis, bioplasm, protoplasm) ; (6) nuclei or granules ; (e) compound corpuscles ; (d) simple cells ; (e) fibres. The various appearances and conditions which these simple forms may assume in disease, as well as the functional states with which they are fre- quently associated, lead to a further enumeration and classification of morbid elementary products, as well as of more complex disease-processes, as below: Digitized by Microsoft® MORBID ELEMENTARY PRODUCTS. 65 A. — MoBBiD Elementary \Peoducts. I. Exudations more or less soft, semi-fluid, or fluid, and formed OF, — a. Germinal, plastic, and formed material, wliich has sometimes been called blastema, plasma, bioplasm, protoplasm, coagulable lymph, false membrane, or fibrin, as seen adhering to free surfaces. b. Aqueous matter, as seen in the morbid state termed "dropsy," and "mdema," of parts. e. Gaseous exudations, as seen in the variuus forms of pneumatosis; e. g., emphysema, flatulency, tympanites, pneumothorax. II. Exudations more or less consolidated, and consisting of, — a. Molecular or granular material, from the 800th of a line to an immeas- urably small size, and consisting chiefly of the simple forms of, — (1.) Forms of an organic kind capable of growth, which live, grow, con- vert, or germinate, and invariably take origin from a pre-existing structure, (bioplasm, protoplasm, &c.) (2.) Fatty molecules or granules. (3.) Deposits of an inorganic kind, generally calcareous salts. (4.) Pigment granules. b. Coagulable compounds, resisting the action of most reagents, such as are seen in the elements of tubercle, scrofula, oleo-albuminous formations, lardaceous degenerations. c. Exudations of a transitional nature, organized, which are capable of growth, which may become vascular, which grow from pre-existing structures, and which are composed of, — (1.) Consolidated homogeneous material, passing to (2.) A fibrinoid arrangement of the molecular or granular particles com- posing connective substance, and a subsequent formation of fibres in it or from it. (3.) The formation of pyoid cells, and fibro-plastic or connective tissue cells, passing into fiisiform cells and fibres as the material becomes consoli- dated. (4.) The formation or exudation of fluid matter holding pus, or other more compound cells. III. Growths and Exudations of a specific kind. a. Lymph of small-pox and cow-pox, just removed from the vesicle, con- tains a great number of extremely minute particles. To these the active prop- erties of the lymph are entirely and solely due (Beale). b. Matter of glanders, of malignant pustule, and of the plague, contain similar particles. c. Fluid of infecting chancre, and of some forms of secondary syphilitic lesions, containing multitudes of living particles. d. Material of tubercle and scrofula. (?) e. Material of cancer. /. The growth in Peyer's glands during typhoid fever. g. The growth in Peyer's glands in cases of cholera. h. Melanotic or pigmentary germs. The minute elements of all of these resemble »each other so much in their microscopic appearances, that they cannot be distinguished from each other, or from pus ; and pus containing speciflc contagious properties cannot be dis- tinguished from ordinary pus, except in the matter of vital power or virulent specific properties, as evinced by its effects. The experiments and observa- tions of Dr. Burdon Sanderson tend to show that the specific material of each of these diseases consists of living germs ; and many there are who now believe VOL. I. ° Digitized by Microsoft® 66 TOPICS RELATIVE TO PATHOLOGY, that the day is not far distant when we shall be able to demonstrate the material poison of each specific disease, just as the chemist is able to show the active principle of substances like opium, cinchona, and the like. IV. Material of a complex kind. a. Media of repair and reproduction of injured or lost parts — substance of granulations and cicatrices. b. Hypertrophy of parts. m (innocent. c. iumors, { ,. ' ( malignant. d. Concretions. V. Parasitic Formations. B. — Complex Vital Morbid Processes whose Phenomena, more or LESS COMBINED, CONSTITUTE DISEASE. 1. Catarrh. 2. Inflammation, comprehending the following forms : (a.) Ulcerative. (b.) Suppurative. (c.) Plastic. (d.) Rheumatic. (e.) Gouty. (f.) Pycemic. (g.) Syphilitic. (h.) Scrofulous. (i.) Gonorrhoeal. 3. Gangrene. 4. Passive congestion. 5. Extravasation of blood — Hemorrhage. 6. Dropsy. 7. Fibrinous deposit. 8. Alteration of dimensions. (a.) Dilatation. (b.) Contraction. (c.) Hypertrophy. (d.) Atrophy. 9. Degenerations. (a.) Fatty degeneration. ~) rri (b.) Mineral degeneration I ^'^^ components of atheroma and so- pr Petrifaction. ) called os«t/Jca S ? s .,,. ^ 03 S i ,,., •< — . s»' K sa 1 5 ,,., • > ta ^. 0. 5 .... ^ ■ffl s a ..< y ^ si 1 S .... t^ 5; 5- - t ,,,, y>. ^. .. "" iM SS 0. n=; iii' 1 5 E s m* — . j^ ,.,. ^ ^ E iir- --■ S: S 1 .... ■>> "S. s§ n 3 i 5 .... ,. ^ 03 2 .... .z ,.., ^ K 4 E 1 .... ..r SW' " §5 «> i 5 .... , ■: ^. ,. ?« >« s .... .i.f >^ j» ■■ ■ .... S3 V .... .... .:< ->■■ ^ ■ig ; Italian Eq., Inflammaziane Reumatica. Definition. — Inflammation concurrent with an attack of rheumatism; or in a person liable to such attacks. Pathology.— As the subject of rheumatism will be afterwards fully con- sidered, a notice merely of the peculiarities of rheumatic inflammation is all that is required here. Certain textures are especially liable to rheumatiq inflammation — namely, the fibrous tissues of the joints, aponeuroses of muscles, sheaths of tendons, neurilemma, periosteum, muscles, and tendons. The in- flammation is attended with great pain (but not so great as in gout), and its severity is probably owing to the dense and unyielding nature of the textures especially implicated, and which are subjected to stretching and pressure in their elements by the dilated capillary vessels and local inflammatory redema. Such inflammation is generally held to be rheumatic when these fibrous tissues are implicated m an idiopathic way, and independent of any traumatic origin. There is also a great tendency for the inflammatory lesion in rheumatism to pass from the part first aflfected to others of analogous structure and function. In rheumatic inflammation of joints, the synovial capsule of one or more is generally the texture most deeply implicated ; but the inflammation seldom reaches a great degree. Fluid exudation into the cavity of the joint is not apt to be copious, nor fibrinous, nor very purulent. Inflammatory ojdema of Digitized by Microsoft® PATHOLOGY OF GOUTY AND GONORRHCEAL INFLAMMATION. 103 the connective tissue round the joint accounts for any visible swelling. A predisposition to rheumatic inflammation is certainly inherited, and those who have had an attack are very liable to others. Recovery is the usual termi- nation, by a gradual and not always regular diminution of symptoms. GOUTY INFLAMMATION. Latin Eq., Inflammatio Podagra; French Eq., I. GouUeuse; German Eq,, Gicht- ische Enizundung ; Italian Eq., Inflammazione Oottosa. Definition. — A form of inflammation characterized especially by the intensity of pain, by oedema of the part, and desquamation of the cuticle when superficial structures are attacked; and occurring in those predisposed to gout. 'Pathology. — As the nature of gout will be afterwards fully considered, the character of the inflammation attending that general disease alone requires a short notice here. The pain of the inflammation is very intense, and difiers from that produced by injury. The oedema also is peculiar, and may not at first be obvious on account of the great tension of parts, when inflammation is violent, and the skin is distended and shining. When the inflammation begins to subside, pitting is then easily produced, and the presence of fluid made evident. In this respect it differs from rheumatic inflammation, in which oedema is not local. After complete subsidence of the gouty paroxysm, desquamation of the cuticle takes place. It is most usually observed from about the feet and hands, and but rarely from the knees; and, according to Dr. Garrod, the desquamation seems to bear some relation to the amount of the previous oedema, and consequent distension of the skin. Now and then the nails have been shed after a severe attack of gout. The presence of much excrementitial matter in the blood of gouty people tends to influence the products of inflammation ; but it is rare indeed that inflammation in gout is followed by suppuration, although, at first sight, when the disease is most intense, and the part is swollen, red, hot, and tender, suppuration looks as if it were inevitable. The cases which come to suppuration are those in which the gouty concre- tions (of urate of soda), acting as a foreign body, or local irritant, establish suppuration. The inflammation of gout is indeed "characterized by an explosive local appearance of uric add; and on consideration of the circum- stances under which this explosion occurs, the inference suggests itself, that materials transformable into uric add were previously accumulated in the texture which inflames" (Simon). GONORRHCEAL INFLAMMATION. Latin ^q. , Inflammatio Gonorrhoica ; Frknoh Eq.,/. Blennorrhagique ; German Eq., Gonurrhoische Entziindung , Tripperariige Entzundung ; Italian Eq., hiflainma- zione Blennorragica. Definition. — A form of inflammation arising about flve days after the direct contagion of gonorrhceal pus within the orifice of the urethra. Pathology. — Although the process of inflammation in the mucous mem- brane of the urethra, which constitutes a gonorrhoea, is not different from the process of inflammation in any other portion of a mucous membrane, and is an example of a catarrh, yet as the inflammation is peculiar in being due to a specific cause, and gonorrhoea, therefore, is a specific disease, the inflamma- tion requires a short notice here. The peculiarities of gonorrhoeal inflammation are: 1. Its cause distinguishes it from all other catarrhs which affect the mucous Digitized by Microsoft® 104 TOPICS RELATIVE TO PATHOLOGY. membrane of the urethra or of other regions, and the disease never arises otherwise than by contagion. 2. The nature of the specific poison is as little known as that of small-pox, or other communicable poison; it is only certain that it produces a specific result, invariably the same, case after case. The viriis is a something fixed and specific, conveyed in the secretion of a diseased mucous membrane, by contact with which secretion, in those susceptible of infection, a similar com- plaint is transmitted from person to person. 3. Between the period of contagion and the obvious expression of the dis- ease, there is a certain interval — three to eight days — known as the period of incubation ; earlier or later periods are exceptional. 4. The susceptibility to gonorrhoeal inflammation varies greatly in difierent persons; and the causes of increased or diminished susceptibility are quite unknown. • 5. Certain portions only of mucous membrane seem susceptible of gonor- rhceal inflammation. These are,— -the urethra, the female genitals, the con- junctiva, and the rectum ; all other parts of the mucous membrane remain incapable of undergoing the specific infiammation of gonorrhoea. Diflferent portions of the urethra also are more susceptible to the influence of the poison 'than others; and although the infecting secretion acts first upon the orifice of the urethra, the chief site of the gonorrhoeal infiammation is in the fossa navie- ularis. During the first and second, week of the disease, the anatomical changes are entirely confined to this portion of the urethra, a portion which is very vascular, and very richly furnished with glands. Many complica- tions may be associated with gonorrhoeal inflammation, all of which will be fully noticed when the disease is treated of in a subsequent part of this work. GANGRENE. Latin Eq., Gangrcena ; French Eq., Gangrine; German "Kq,., Brand — Syn., Gan- gran ; Italian Eq., Gangrena. Befinition. — Incomplete mortification, or death of a portion of a soft organ or tissue, while the rest remains alive. Pathology. — When complete death of the part is accomplished, the condi- tion is termed sphacelus. In the hard parts, as in bones, a somewhat similar distinction obtains in using the terms caries and necrosis. Necrcemia means a corresponding death of the blood. Particular names are also given to the dead parts. A dead piece of tissue is called a slough. A dead piece of bone is called a sequestrum. Progressive gangrene of soft parts is usually called sloughing. Mortification of the soft parts may be white or black in appearance, humid or dry. The mortified part has a black aspect when the blood is extravasated through the walls of the bloodvessels into the afiected tissues, giving to the part a purple or dingy hue, while to the touch it is soft, inelastic, and doughy. It may appear white, when, by the action of cold, the blood has been driven from the part before its death commences, which subsequently freezes per- fectly white. Humid mortification occurs when the blood transudes in a fluid state, and after its exudation separates into its constituent parts, so that the serum, set free, dissolves in it the red globules, raises up the cuticle in bladders, and forms what are termed " phlyctence." Air, generated by a process of com- mencing putrefaction, is not unfrequently contained in the phlyctence, and gives, to the finger touching the part, a sensation of crepitation. Dry mortification is rare, and has sometimes been caused by the ergot of rye, or other diseased grain, used as food, giving rise to the condition known Digitized by Microsoft® PATHOLOGY OF PASSIVE CONGESTION. 105 as ergotism. In the year 1716, dry mortification appears to have been to a certain extent epidemic at Orleans, fifty cases having been treated at the H6tel Dieu of that city. Dodard described it as beginning generally in one or both feet, with pain, redness, and a sensation of heat or burning like that produced by fire. At the end of some days the part became cold, as black as charcoal, and as dry as if it had been passed through fire. Sometimes a line of separation was formed between the dead and the living parts, and the com- plete separation of the limb was effected by nature alone. In one case the thigh separated in this manner from the body at the hip-joint. In other cases amputation was necessary. Mr. Solly has given an interesting case of this description, which occurred in the practice of Mr. Bayley, of Odiham. The patient was a child three years and seven months old, from whom, by this spontaneous process of nature, both arms were removed above the elbow, the left leg below the middle of the thigh, and the right foot above the ankle- joint, being a remarkable instance, in modern times, of this destructive disease (see " Ergotism," and Med.- Chir. Trans., vol. xxii, p.. 23). The bones, the brain, the lungs, the liver, the spleen, and the kidney, are all liable to sphacelus and gangrene; so are the different tissues, as the areolar, cutaneous, nervous, and serous. The muscles, tendons, aponeuroses, and blood- vessels, are likewise all liable, but in a less degree. It is necessary to distinguish the incomplete death of soft parts, or gangrene, from the condition afterwards to ' be described as degeneration ; and which sometimes precedes complete death of the degenerate part. The degeneration of a part is to be distinguished from gangrene, or actual death, by this, — " that the degenerate part never becomes putrid ; and that no process ensues for its separation or isolation, such as we can see in the case of a dead part" (Paget). A tissue, however degenerate, remains in con- tinuity with the parts around it, or is absorbed. If the tissue were dead, the parts surrounding it would separate from it, and the dead portion would be ejected from them. But there are also some conditions of parts where it is impossible to say whether they are dead or alive ; a condition which may be termed "suspended animation." Thus, the end of a finger, in a case of diseased heart, may be cold, livid, insensible, and shrunken for three days ; or the foot of an old man cold, livid, purple, mottled, and numb for a whole week; and during these times it could not be told whether the parts were alive or dead. But, as both parts afterwards regained all the signs of life within the days mentioned by Mr. Paget, time alone showed that both parts had been in a state of " sus- pended animation." In the same way parts that are frozen, as by the mode of inducing local anaesthesia by the ether-spray, introduced by Dr. Richard- son, or parts that are crushed or otherwise severely injured, have their "ani- mation" or vitality "suspended" for a time. PASSIVE CONGESTION. Latin Eq., Congeslio Prtssivn; French Eq., Congestion Passive; German Eq., Passive Congestion; Italian Eq., Covgesiione Passiva. Definition. — Overfulness of blood in the capillary vessels of apart; as with impairment of the vital relations between the blood and minute elements of the texture, as the cause of the sluggish flow of the blood in, the capillaries. Pathology. — The term congestion, or hypercemia — meaning, literally, a mere excess of blood in a part, or over-bloodedness— has always been regarded as of two kinds, namely, active and passive. The former, or active congestion, cannot be separated from inflammation of a texture, of which it forms a stage or part of the morbid process, as already described, and, in fact, leads up to it; while Digitized by Microsoft® 106 TOPICS RELATIVE TO PATHOLOGY. the latter, or passive congestion, merely predisposes to inflammation from trifling injuries, obstructs recovery, tending to molecular degeneration of tissue, and to atrophy ; and, farther, it leads to dropsy. Much confusion exists as to the use and interpretation of the term conges- tion; and as no one has put the subject in a clearer light than Professor Eokitansky, and also Dr. Moxon, in his very interesting Lectures, at Guy's Hospital, on Analytical Pathology, the account here given is based mainly on his exposition, in Med. Times and Gazette, July 16, 1870, and that of Eokitansky, in vol. i, p. 107. The relations between active and passive congestion have been described as simply, that, too much blood being brought into a part, active congestion, or hyperemia, is established; on the other hand, when too little blood passes out of a part in proportion to what passes into it, the state of passive congestion is established. But, in the first case, the description falls short of the truth, inasmuch as too much blood passes out of the part as well as into it ; and the congestion is not only active, as regards the flow of blood to the part, but also as regards its flow out of it. In the second case, the description oi passive con- gestion involves two forms of congestion, difiering in their causes, and also in their results. The; causes of one form are purely mechanical, the causes of the second are truly passive. Examples of purely mechanical congestion are to be studied in the following morbid conditions : Narrowing of the mitral orifice of the heart, by the mechan- ical stoppage of the blood at the obstructed valve, inducing a very intense congestion of the lung. Condensation of the tissue of the lung is the conse- quence of the persistence of the mechanical obstruction ; and, at last, some of the minute vessels of the lung tissue may burst, causing pulmonary apoplexy. The results of congestion due to mechanical obstruction of the venous cur- rent are, — (a.) Distension of the veins behind the obstruction, leading to stretching and straining of their walls, and so, apparently, to leakaga of serum through the distended veins into the tissue, producing cedema in connective tissue, or dropsy into serous cavities. Habitual use of a tight garter will occasion such results of mechanical congestion of the leg ; so will a tumor in the popliteal space or -the groin, or habitual distension of the lower bowel by feculent matter. (b.) Effusion of blood, either from rupture of overdistended vessels behind the obstruction ; or, reasoning from the observations of Addison, Waller, Cohnheim, and others, who contend that the blood-corpuscles find their way through the tissue of capillary vessels without any rupture of them, those cases are capable of ex;planation where a free and fatal hemorrhage may come from the stomachal mucous membrane, without any trace of a ruptured vessel or solution of continuity of the mucous surface. Examples of effusions of blood from vessels behind the mechanical obstruc- tion are to be seen in pulmonary apoplexy, in the free escape of blood into the stomach in cases of cirrhosis of the liver obstructing the portal vein, or in cases of obstructive heart disease, in the cerebral hemorrhage that results from infan- tile convulsions, and in hemorrhage from varicose veins. (c.) A thrombm or coagulum of blood may form during life in the obstruct- ed vein. Such clots or thrombi are to be found in the portal veins in cases of cirrhosis of the liver ; and in the veins of the bend of the thigh, and pros- tatic plexus, in cases of cardiac dropsy. These clots begin to form behind the valves of the mechanically distended veins, in the stagnant eddies of blood which occupy the hollows behind the valves. Portions of clots so formed in these veins may break away and pass into the current of the circulation, and passing up the veins through the right side'of the heart, may lodge in the pul- monary artery, and cause either sudden death or pulmonary apoplexy. This is one form of thrombosis ; and the primary formation of the clot in this Digitized by Microsoft® RESULTS OF MECHANICAL CONGESTION. 107 form is to be distinguished from formation of the clot in veins during life, which is due to inflammation of the vein, or close to its wall. Such inflam- matory coagula constitute another form of thrombosis. They form wherever veins are subjected to irritation, such as in cerebral sinuses, in cases of trau- matic or other inflammation of the cranium, the veins of unhealthy stumps after amputation, such clots being sometimes mixed with true pus ; and when such clots pass into the lung, inflammation of the part of the lung supplied by the artery is the result. (d.) Gangrene may be a result of mechanical congestion, as in the limbs and scrotum, from obstructive disease of the heart, or the too tight bandaging of a limb may lead to gangrene of finger or toe. These four results of congestion succeed each other . as the results of suc- cessive increments of mechanical force, and are the natural consequences of such mechanical obstruction. Passive congestion difiers from this mechanical congestion both in its cause and in its seat. Severe emphysema of the lungs and chronic bronchitis fur- nish examples of passive congestion of different parts of the body. In emphy- sema there is a general lividity of the surface — so constant that it constitutes a valuable sign in diagnosis between emphysema and heart-disease, especially when the presence of a tricuspid murmur in emphysema, or bronchitis in mitral disease, makes the one very like the other. In the case of mitral disease, there is free entry of plenty of air into the lungs, but there is little blood passing through them. The flow through the mitral orifice is a small stream ; but it is well aerated blood, and as such freely passes through the capillary vessels and into the veins, where it begins to meet the first mechan- ical impediment to its farther progress, and is detained in the veins, then in the right heart, and then in the lungs. These being the parts congested, and not the systemic capillary vessels, lividity is generally absent in mitral dis- ease. On the other hand, in emphysema of the lungs, the hlood circulates freely through the lungs; but not so the air. It is with difiiculty, and in an imperfect way, that air is renewed in the lungs. The blood, therefore, is insufficiently aerated, and so passes to the systemic capillaries in an impure state, where a true passive congestion is the result. The normal vital relations between the impure blood and the minute elements of tissue are impaired, by the unfitness of the blood to nourish the textures. Hence the skin becomes livid, as the capillaries are gorged with a slowly moving purple current of blood. Thus the seat and the cause of true passive congestion are different from the seat and cause of mechanical congestion. The seat of passive congestion is the capillaries of the part, and is largely due to deficient activity in the vital in- terchanges between blood and texture of the part. In mechanical obstruc- tion, the seat of the congestion is in the veins, and the cause is not vital, but mechanical. The two forms may be combined in cases of general languid action of the heart, where imperfect circulating force is at the same time a mechanical obstacle to the current of blood, and congestion is at the same time both pas- sive and mechanical. Other examples of passive congestion are seen in the blueness of cold hands, redness of the extremities, ears, and noses of people with languid, weakly, or feeble circulation ; in the prolonged redness or lividity of fauces following severe tonsillitis ; hypostatic hyperaemia of the dependent parts of the lungs in fever, where the air fails to pass into the air-vesicles during the imperfect respiration. In all these cases the congestion is passive, and secondary to local inactivity in the vital changes between the tissue-elements and the blood. Eokitansky believes passive congestion to depend upon direct palsy of the nervi vasorum, wherewith is commonly associated a depressed energy in the remainder of the nervous system. Such palsy may originate in the nerve- Digitized by Microsoft® 108 TOPICS RELATIVE TO PATHOLOGY, centres, or it may be peripheral, and is often determined by a morbid condi- tion of the blood, especially by its decomposition. The passive congestion of asthenic inflammation in organs exhausted by excess of functional activity, enfeebled by active congestion, or paralyzed-^o also hypostatic hypersemia of the lungs, abdominal and pelvic organs, and the common integuments of dependent parts, developed under diminished impulse from the heart— are examples of such paralysis, causing congestion. The direct results of such passive congestion are, that the tissue becomes depraved, becoming atrophied, with more or less molecular change of a de- generative kind, and such texture is thereby greatly predisposed to fall readily into inflammation under trifling injuries, when the passive congestion will be replaced by the active congestion of inflammation, and the power to recover from such lesions is very greatly reduced. . . , t • i The redness of passive congestion is always of a dark or livid hue. Little or no heat is felt in the part ; a sense of weight or dulness is experienced rather than pain ; and there is neither obvious tension, induration, nor in- creased proliferation in the part. The causes of passive congestion may be thus shortly stated, as — (1.) Pre- vious perverted vascular function, such that vital interchange between the textures and the blood is diminished. It may thus come to be a result of previous inflammation or active congestion: Thus local debility of a part from any cause favors the depression of textural vital function, and therefore to passive congestion. (2.) Diminution of the normal proportion of fibrin in the blood renders its fluid portion more transudable, and so favors passive con- gestion in dependent parts, as in the lungs in fever. (3.) General debility is favorable to passive congestion. EXTRAVASATION OF BLOOD — HEMORRHAGE. Latin Eq., Srr_^z■ sire to be left alone and un- (/.) Wandering or delirium. j disturbed. Secondary Hemorrhage. — Effusions of blood are also apt to occur in connec- tion with the inflammatory process ; but such hemorrhages are generally from rupture of the vessels of the inflammatory products which have recently become vascular (Rokitansky). These new vessels are peculiarly delicate, and being apt to rend, like the vessels of new granulation, with a very slight Digitized by Microsoft® CONSTITUTIONAL TENDENCY TO BLEEDING. Ill force, especially when they are made turgid or dilated by an attack of inflam- mation of the newly-formed material in which they lie, they may be sources of considerable bleeding, especially in the stages of congestion and of stasis (Paget). Such is probably the explanation of the conversion of a hydrocele into a hcematocele ; the inflammatory products of the hydrocele becoming vas- cular, and being subjected to slight violence, the new vessels are ruptured, and blood pours into the sac. Hemorrhagic pericarditis acknowledges a similar mode of causation. To these effusions of blood Mr. Paget gives the name of Secondary Hemorrhages. Primary efflisions of blood in inflammation, i. e., the effusion of blood direct from the ruptured vessels of inflamed parts, min- gling with the inflammatory products, are common in pneumonia, in which the extravasated blood gives the sputa their characteristic rusty tinge in that disease. In the inflammatory red softening of the brain, the blood is also effused direct from the vessels of the inflamed part. Other morbid conditions are also liable to hemorrhage ; for example, such as are highly vascular, as encephaloid and other cancers, and the highly vas- cular walls of cysts. In all these, the hemorrhage is generally capillary. Hemorrhag^ic Diathesis — a disposition or liability to habitual hemor- rhage — has been described under the names of hceinophilia, hamorrhaphilia, hcemorrhophilis, and occurs in some persons as a constitutional peculiarity. The tendency is congenital, and is sometimes made manifest immediately after birth by the dilEculty with which bleeding from the umbilical cord can be subdued, and in some cases death of the infant takes place from such loss of blood. In after-life, and shortly after dentition — after the sixth or eighth year — the tendency is expressed by the obstinacy of traumatic hemorrhages, profuse and dangerous bleeding from very slight wounds, by spontaneous bleedings from the gums, nose, bronchi, stomach, intestines, or kidneys ; also, as ecchymosis into the texture of the skin and subcutaneous areolar tissue. Such spontaneous hemorrhages, however, do not usually occur till after the patient has suffered repeatedly from traumatic hemorrhages — the frequent loss of blood tending to hypinosis (diminution of fibrin of the blood), and to impair its coagulability. Such spontaneous hemorrhages are generally pre- ceded by certain phenomena moving or struggling towards the crisis {molim- ina) which eventuates in the hemorrhage. Such phenomena constitute the " moliw.ina hcemorrhagicicm," and are expressed by cardiac palpitation, tend- ency to stupor or indifference, signs of cerebral congestion, pains in the limbs, and, in some cases, painful tumefaction of the joints, especially of the wrists, knees, and ankle-joints (Niemeyee), with ecchymosis, and fever (Miller),— symptoms which continue about a fortnight. . The accidents of a traumatic kind which give rise to these alarming hemorrhages are usually extraction of a tooth, a leech-bite, biting the tongue, puncture, slight cut, abrasion, or laceration, as of the hymen ; and sometimes the slighter the apparent wound,, the more obstinate and dangerous is the bleeding from it. The blood oozes from the surface, or wells up from the puncture or cut, as if from a sponge, or like a continuous spring of water, although no bleeding vessel can be dis- covered. No styptic can stanch the flow ; and the bleeding may persist for days, and many cases even prove fatal by syncope. At first the blood may appear normal, but gradually it grows thin and watery, and coagulates loosely,, if at all. The complexion becomes pallid, waxy, and anaemic ; color passing from the lips and mucous membrane of the mouth. When the bleeding ceases, as it may after a few days, the patient is left in a. state of the most extreme exhaustion, .approaching collapse, and recovery is. very slow, from the effects of the enormous loss of blood which sometimes amounts to many pounds. The slightest contusion, bruise, or pressure on the skin of such hemorrhagic patients, sometimes leads to extensive extravasations beneath the skin. This peculiar state of the system is either congenital or becomes developed Digitized by Microsoft® 112 TOPICS RELATIVE TO PATHOLOGY. afterwards as life advances. Those born -with the diathesis have usually in- herited the constitution chiefly through the male line. It usually descends from a family, one of the members of whom, in previous generations, has suffered from the same affection. In its hereditary transmission it furnishes, like gout, instances of atavism— i. e., it may in transmission through four gen- erations, skip over or miss one, the grandchildren inheriting the disease, but not the children. Thus, lost in one generation, the disease reappears inthe next. But all cases^are not so inherited, and even when an inheritance, it is rare for every member of the family to be affected, the males being more liable than the females of the family. Many cases die young, and if the tendency is great, the period of childhood is rarely survived. On the other hand, eases disclose themselves at a very early age, and, abating as age advances, the tendency to bleeding; ceases alto- gether, and the patient lives to a good old age. The tendency to bleeding also seems to fluctuate; the least abrasion or scratch may at one time threaten fatal loss of blood ; at another time bleeding from any similarly slight injury will scarcely attract attention. Distinct periods of remission and exacerbation are also experienced. The "molimina hcBmorrhagicum," already noticed, marks the periods of exacerba- tion, which continue about a fortnight. The diathesis has points of resemblance on the one hand to scrofula, and on the other to scurvy ; but with marks sufficiently characteristic to separate it from both. The most prominent are an obviously delicate constitution — ■ usually a fair complexion — a thin transparent skin, irritability of the circula- tion at all times, occasional attacks of fever. But the cause does not lie in the constitution of the textures only, for there is a morbid condition of the blood as well as of the bloodvessels. There is a preternaturally delicate and vulnerable structure of the coats of the vessels associated with a thin and watery condition of the blood. It is deficient in the due proportion of fibrin, and in the power of coagulation. Even when wholly at rest, it is incapable of forming a dense firm coagulum. An undue tendency to congestion of the capillary vessels is a consequence of these changes in the blood and in the vessels ; so that when they are cut, not only do they contain too much blood, upon which they are unable to contract, remaining open and uncontracted, passively pour- ing out their thin contents ; but that blood is deficient in the most important of Nature's hemostatics, — the power of coagulation. The minute arterial twigs seem to be devoid of any middle substance. They are of a thin feeble appearance, and unusually capacious, impaired in contractile power and tone. They are friable and easily torn ; hence slight bruises produce serious and ex- tensive ecchymosis ; coughing may induce a dangerous haemoptysis, a sneeze may bring on uncontrollable epistaxis, and extravasations within internal cavities not unfrequently follow a very slight cause. But it is necessary in all such cases to find out, if possible, the source of the depraved blood and constitutional impairment of texture. Some of the organs having to do with nutrition, may be contributing a permanent supply of nox- ious material to the system. Hence it is of importance to discover the defi- nite tissue or organ from which the derangement in the constitution of the blood proceeds. Numerous instances of the hemorrhagic diathesis have pointed to a definite organ as its source — namely, either a Vnorbid condition of the spleen or the liver ; and in cases of leukaemia, usually towards the close of life a genuine hemorrhagic diathesis is developed, and hemorrhages ensue, occurring with special frequency in the nasal cavity (as an exhausting epis- taxis), and also in or from other parts of the body, as in apoplectic clots in the brain, or melsena from the intestinal canal. _ The liver, spleen, and lymphatic system of glands require special investiga- tion in all cases of hemorrhagic diathesis. Digitized by Microsoft® FORMS AND EFFECTS OP HEMORRHAGES. 113 The following are the special hemorrhages, extravasations of blood, or hem- orrhagic lesions, which call for special notice in this text-book ; namely, — • 1. Cerebral hemorrhage, or the sanguineous form of apoplexy. 2. Spinal hemorrhage, or spinal apoplexy. 3. Choroidal hemorrhage, or choroidal apoplexy. 4. Epistaxk, or hemorrhage from the nose. 5.. Hcemoptysis (a) from passive congestion; (6) from pulmonary extrava- sation, or pulmonary apoplexy. 6. Hemorrhage into the pericardium. 7. Hcematemeds, or hemorrhage from the stomach. 8. Intestinal hemorrhage. 9. Hsemorrlioids, internal and external.. 10. Hemorrhage from the rectum. 11. Hamaturia renalis, or hemorrhage from the kidneys. 12. Hcematuria vesicalis, or hemorrhage from the bladder. 13. Hcematocele, or hemorrhage into the tunica vaginalis. 14. Hemorrhage into ovary. 15. Peri-uterine, or jielvio hcematocele, or hemorrhage underneath the peri- toneum, or within the fold of the broad ligament of the uterus. 16. Pelvic hcematocele, hemorrhage into the areolar tissue of the pelvis. [15 and 16 are sometimes described under the name of retro-uterine htematocele.] 17. Uterine hemorrhage, and menorrhagia. 18. Hemorrhagic cysts. Each and all of these forms of hemorrhage will be considered in detail un- der the respective organs implicated in the lesion. Fig. 9. Fig. 8. — Pigment from an apoplectic cicatrix in tlie brain (Vircliow's Archiv., vol. i, pp. 401, 454, plate iii, Fig. 7). {a. I Blood-corpuscles which have become granular, and arc in process of decolorizatiun ; (&.) Cells from the neuroglia, some of them provided with granular and crystalline pigment; (c.) Pigment- granules; (d.) Crystals of htematoidin ; (/.) Obliterated vessel, with its former channel filled with granular and crystalline red pigment : 300 diameters ( Virehow, Cellular Pathology, p. 144). Fig. 9. — Crystals of hiematoidin in different forms : 300 diameters (1. c, p. 1431. There remains now to be noticed the results of blood extravasations. The immediate effects of hemorrhage, besides the anremia consequent upon great effusion, either out of the body or into its cavities, are lesions of contin- uity in textures, impairment or destruction of function, paralysis of the organ affected, as in cerebral and muscular hemorrhage. The irritation, too, of the extravasated blood, acting as a foreign body, may set up inflammation of sur- rounding textures, with eventual organization of the effused products, result- ing in a callous condensation of texture surrounding the lesion, and the isola- tion, by inclosure of the hemorrhagic clot in a more or less dense capsule. It is rare for the hemorrhagic lesion to become purulent. A slight hemorrhage is usually cured by absorption of the effused fluid, so Digitized by Microsoft® 114 TOPICS RELATIVE TO PATHOLOGY. that the injured and distended textures recover their resiliency. ' The liberated red pigment, however, frequently resists absorption, even in slight hemorrhages, remaining in a state of minute molecules, scattered over a membrane, or be- tween the minute elements of a texture, as a minute or black pigment. Every extravasation may also leave behind it a contingent of hsematoidin crystals (Fig. 9), which, when once formed, remains in the interior of the organ in the shape of compact bodies endowed with the greatest powers of resistance. From the numbers of such remains any number of old apoplectic attacks may be counted, with remains like Fig. 8. Prognosis in cases of hemorrhage is unfavorable under the following condi- tions : (a.) Into serous cavities, unless limited by other lesions. (6.) Into the substances of organs. (c.) Under the influence of the hemorrhagic diathesis. Treatment. — As.the details for treatment of each of the hemorrhages already named will be considered under the account of the respective diseases, there only remains to indicate here the treatment suitable for cases of the hemorrhagie diathesis, which only finds a place here. Nutritious diet, outdoor life, and tonic remedies generally, express the line of treatment. Medicinal tonics are of first importance, and must be patiently persevered in, consistently with the capacity to assimilate food with them. Smart purgative doses of sulphate of soda are of benefit in two ways : first, as a purgative and hydragogue, diminishing the amount of serum in the blood ; second, as a chemical salt, which has the efieet of increasing or promoting the firm coagulation of the blood. Acetate of lead and opium also favor coagulation, and tend to calm the circulation. They must be administered in Sill and sustained doses. Opium seems to have a tonic and astringent efieet on the capillary vessels, and tends to sustain life under the great depression from loss of blood. Sulphate of alum and sulphate of potass, in doses of fifteen to twenty grains ; or gallic acid, in doses of twelve grains, frequently repeated, i. e., every two, four, or six hours ; or infusion of matico or oil of turpentine, may each be used by turns, and according as the stomach will tolerate one rather than another ; but the sulphate of soda must not be given in conjunction with the acetate of lead. The efficacy of gallic acid is increased by combining it with fifteen or twenty minims of aromatic sulphuric add. It may also with benefit be com- bined with alum. Gallic add should have a fair trial, before giving acetate of lead. From two to five grains of ergot of rye (secale cereale), or the liquid ex- tract, in doses of twenty or thirty minims, frequently repeated, say every hour or half hour, has been of use. The oil of turpentine, to the extent of ten to twenty drops, is to be given in mucilage every two or three hours. Nutritive but non-stimulant food must be given in small quantities, and frequently. It is best given as animal jelly, coagulated soups, or soup in the jelly form, rather than in the fluid watery form. Alcoholic stimulants are to be avoided. One well-selected plan must be persevered in, so as to avoid capriciously and rapidly shifting from one remedy to another. As to local remedies, the actual cautery should never be employed, but every trust must be placed in gentle pressure over applications of strong tinc- ture of matico, and solution of the perchloride of iron. As a last efibrt in a case apparently hopeless, transfudon of blood may still be tried. Consult also the articles on Scurvy and Purpura. Digitized by Microsoft® DEFINITION AND PATHOLOGY OF DEOPST. 115 DEOPSY. lii.TiN 'E,(i., Hydrops ; Pkknch Eq., i/i/c^ropme; GekmanEq., Wassersucht; Italian Bq. , Idropisia. Definition. — Dropsy is a contraction for Hydropsy, mid signifies the accumu- lation of a watery fluid in one or more of the serous cavities ; or a diffusion of watery fluid through the areolar tissue of the body, or its organs ; or a combination of all these conditions. Pathology — The distinctive characteristic of dropsy is in the nature of the fluid which forms the accumulation. The fluid is not liquor sanguinis, but water containing more or less constituents of the blood-serum. In the preceding pages, 81 to 83, the nature of the results are described, when liquor sanguinis, and blood, are effused as products of the inflammatory process. In dropsies, however, tiie fluid seems to be devoid of all coagulating elements, or of elements tending to growth or development. The liquid is clear, like the serum of the blood; and in the so-called "fibrinous dropsies," where the fluid contains coagulated fibrin in greater or less amount, the fluid is not the fluid of dropsy, but is generally the result of more or less inflamma- tion, involving the texture of the serous sac in which the fibrinous fluid is found. In all true dropsies the texture of the part where the fluid exists is unimpaired by inflammatory changes ; and the lesions giving rise to the dropsy must be sought for generally in some other organs of the body. The fluid collections in the pleura of pleuritis and hydrothorax contrast in these respects. The fluid of the former is the result of inflammation, and generally contains flakes of coagulated fibrin ; the fluid of hydrothorax is a true drop- sical effusion. The prefix hydro or hydrops is used to express the fact that the lesion is a true dropsy of a serous sac ; and dropsies receive different names according to their situation. Thus, dropsy of the belly, where the peritoneum is distended with watery fluid, is sometimes called hydroperitoneum, but is usually now called ascites ; dropsy of the brain or head, where the ventricles are distended with watery fluid, is called hydrocephalus ; dropsy of the chest, where the pleural sac is filled with serous fluid, hydrothorax ; dropsy of the pericardium, where that sac contains the fluid, hydropericardium ; dropsy of . the eye, hydrophtJialmia ; dropsy of the womb, hydrometra ; dropsy of the tunica vaginalis testis is termed hydrocele ; dropsy of the areolar tissue of a part is termed cedema, and is a lesion common to the areolar tissue of internal organs, as well as to the subcutaneous areolar tissue of the body generally. Hence there is mdema of the lungs and of the liver, and when fluid effusion exists in the tissue of these organs, they are said to be oedematous. When cedema of the subcutaneous areolar tissue is general over the body, this dropsy receives the name of anasarca ; and the combination of anasarca, with dropsy of one or more of the large serous sacs, is usually named general dropsy. There are also dropsies of other parts, which receive characteristic names. Thus, dropsy of the lachrymal sac Js called a fistula lachrymalis, or lachrymal hernia. The water of dropsy has the serum of serous membranes as the basis of the fluid accumulation ; but the exact constituents of the dropsical fluid differ in different cases as regards the ingredients held in solution ; and, generally in all, more of the water of the blood than of the solids of the serum passes out of the vessels in these dropsies. The specific gravity of the fluids also varies in diflferent parts, the fluid of hydrocephalus and spina bifida being the least, pericardial SinA ovarian dropsy- the greater. The following table gives the results of Dr. Marcet's analysis, but it greatly wants verification : Digitized by Microsoft® 116 TOPICS RELATIVE TO PATHOLOGY. In 1000 Grains of Fluid. Speoiflo Gravity. Total Solid Contents. Animal Matter. Saline Matters. Muid of Spina Bifida, . " Hydrocephalus, " Ascites " Ovarian Dropsy " Hydro thorax, " Hydrops Pericardii, .... " Hydrocele, " A Blister, " Serum of the Blood, .... 1007.0 1006.7 10150 1020.2 1012.1 1014.3 1024.3 1024 1 1029.5 Grains. 11.4 9.2 33.5 26.6 33.0 ■ 80.0 100. 6 Grains. 2.2 1.12 2-5.1 i8'.8' 25.5 71.5 go'.s' Grains. 92 8 08 8.4 8.0 7.8 75 85 8.1 9.2 Generally, the fluid of hydroihorax will be lighter than that of pericardial fluid ; and the fluid of dropsy is but an augmentation of the kind of efiiision or secretion natural to the part, and not merely a sweating or escape of serum. In its reaction, the fluid of dropsy is mostly alkaline, but may be faintly acid or neutral : in its purity it is colorless, or pale straw color, and of a clear and limpid appearance, and in the quality of its ingredients it is analogous to the serum of the blood, although in consistence it is thinner. Chemically, it con- sists of water, albumen, fat (generally as cholesterin), pigments, extractive matter, and salts {chloride of sodium preponderating over the earbonaies and phosphates of alkalies'), and of alkaline earths. Urea is sometimes present when the kidneys are at fault. The albumen is subject to the greatest fluc- tuation ; and is generally pure as the albumen of blood-serum, or it exists as an albuminate of soda or othSr well-known forms, as well as in forms and modifications as yet unknown. The fluid of pleural dropsy (hydrothorax) is richer in albumen than the fluid of ascites (Lehmann) ; and there is still less albumen in the fluid of arachnoid dropsy, or that of the cerebral ventricles (hydrocephalus) than in the fluid of ascites. The fluid of dropsy into the sub- cutaneous areolar tissue {anasarca) is the poorest of all in albumen. When the albumen is in great abundance (as in the ascites from ovarian disease), the fluid becomes viscid and adhesive, like synovia. A red coloration is due to_ blood-pigment ; a yellow or yellowish-green, generally to bile-pigment ; a milky whiteness, opalescence, or whey-like turbidity, may be due to accidental mixture with epithelium or fat, as fine cholesterin crystals (often seen glis- tening in the fluid of old hydroceles), or it may be due to albumen precipitated by an excess of water relative to the saline contents. The origin of dropsy is due to several causes, acting singly or in two or more combinations ; and, like congestion, it may be sometimes purely mechanical, as (1) when it is the result of retention of blood in the veins through mechanical hindrance to the circulation. The interruption to the venous circulation as a chief cause of dropsical efiusion was first experimentally demonstrated by Lower, who tied the vena porta of a living dog, thereby causing its death by dropsy. The extensive distribution of the dropsical effusion varies in accord- ance with the site of the obstruction ; and is great in ptoportion as the cen- tres of the circulation are implicated. The fluid also will be in abundance proportionally to the fluidity or excessive wateriness of the blood {hydrcemia), and IS exuded mainly from veins. (2.) In dropsy resulting from general de- bility, hydrwmia in parts tlmt are paralyzed, effusion takes place mainly from capillary vessels. Thus three important conditions may act singly or in combination in the production of dropsy ; namely,— (a) Mechanical impediment to the circula- tion, and especially the free passage of blood through one or other of the great organs, namely, the heart, lungs, or liver; (6) Altered condition of the blood, by excess of water diminishing the density of blood-serum; or, by un- Digitized by Microsoft® ORIGIN OF DROPSY. 117 eliminated excreta, such as biliary or urinary elements in hepatic or renal diseases ; (c) A poor, watery, exhausted blood. Dropsy is never a primary aifection, or substantive disease, but only a symptom of disease, and always dependent on some antecedent morbid condi- tion, the mechanism of whose action is implied in the physical conditions just mentioned. An important distinction is made between genefral dropsy and local dropsy. In the former, more or less extensive anasarca is associated with effusion of fluid into one or more serous cavities, especially the peritoneum or the pleura. The subcutaneous appearance of the fluid is generally expressed first by a puffiness of the face, especially in the morning, under the eyelids, and next in the feet and ankles in the evening, or in the hands and forearms, particularly the left ; or it appears at once in all of these seats, and gradually extends throughout the body, associated with which the accumulation in the serous cavities may be also considerable. All such cases of general dropsy at once point either to obstructive lesions affecting the central organ of circulation, or to a morbid condition of the blood, or to both combined. Associated with the first condition, it is a symptom of disease of the heart, and is then known by the name of cardiac dropsy. It is attended with great difficulty of breathing (dyspnoea), labored action of the heart, and livid con- gestion of the skin. Although called generally cardiac dropsy, it arises from obstruction to the current of blood through the heart, lungs, or liver ; either primarily in the heart — as in valvular disease of the left side — or primarily in the lungs, and secondarily in the heart — as in emphysema and chronic bronchitis, one or both producing dilatation and inefficient action in the right heart, and a consequent retrograde effect throughout the venous system. Associated with the second condition, general dropsy is usually a symptom of disease of the kidney ; and it is then known by the name of renal dropsy. Drs. Bright, Christison, and Gregory were the first to furnish numerous proofs of the frequency of structural lesion of the kidneys with dropsical effusions. The lesion of the kidney is generally some one of the varied forms of Bright's disease, in which the serum of the blood becomes greatly altered, being deprived of its albumen, which passes in the urine, and rendered impure by retention of excreta such as urea. The countenance and skin are especially pale in such cases. Associated with changes in the blood, general dropsy is sometimes a conse- quence of severe malarious poisoning, giving rise to protracted intermittent , fever, in which the blood becomes greatly altered, as in extreme ansemia ; and a similar general dropsy has been known to attend the ansemia of over-pro- longed lactation, and in chlorosis after large hemorrhages, or other exhausting discharges, also in starvation from deficient, watery, vegetable, or unwhole- some diet, as in the dropsy often prevalent among the poor in times of scarcity. In local dropsy, one serous cavity, or one organ, or one part of the subcuta- neous aseolar tissue, is the seat of the dropsical accumulation. The perito- neum is the most frequent serous sac so affected, and the accumulation is gen- erally the result of obstruction to the circulation through the liver by the ve.na porta, a result of hepatic disease generally in the form of the complex lesion known as cirrhosis, under which this form of dropsy will be more particularly described. But it may be here stated that the effect of the obstruction in the liver, as in cardiac dropsy, is carried back till its effects are felt in the reniotest capillaries of this section of the venous system; and hence the ascites which is the usual expression of such hepatic obstruction. An example of local dropsy may also be seen in the oedema of the lungs, resulting from the cardiac lesion of mitral obstruction. Fibrinous concretions obstructing the vena caw and internal iliac vems, or tumors, or a psoas abscess pressing upon these vessels, Digitized by Microsoft® 118 TOPICS EELATIVB TO PATHOLOGY. are also sometimes causes of local dropsy. Disease, by enlargement of the spleen, gives another cause for local dropsy, and is often the result of malaria. Special details regarding dropsies will be found under the several lesions of which dropsy is a result.* FIBRINOUS DEPOSIT. Latin Eq., Fihrina Deposita; French Eq., D^pot Fibrineux : German Eq., Faser- stuffablagerung — Syn., Fibrinose Ablagerung ; Italian Eq., Deposito Fibrinoso. Definition A morbid condition in which a great tendency exists for fibrinous matter to separate from the blood, more or less rapidly, and to be deposited in va- rious parts. Pathology. — The exact nature of this form of lesion is -not well known, but if the quantity of fibrin be considerable at any one time, it forms a solid mass, of which, perhaps, the best examples are those large yellow pyramidal blocks often seen in the spleen. If, on the other hand, as is more common, a slow and gradual separation occurs, a formation of fibroid tissue takes place, causing thickening of membranes, or similar changes in more solid parts (H. Jones, Path. Trans., vol. vi, p. 96). These fibrinous deposits present a light red or yellowish white color, and occur in a more or less wedge-shaped form, with the apex centripetal and the base of the wedge towards the periphery of the organ. Miscroscopically the deposit consists of a granular material. Two views are entertained regarding the production of such deposits — namely, either that they result from minute particles of fibrin being continu- ously detached at points of the circulating system, more or less remote from the local deposit, but carried there by the current of the circulation ; or they have been regarded as an exudation of fibrin from the capillary circulation. (See Path. Trans., vols, iii, viii, xiii.) There are cases where a tendency, either on the part of the blood to pre- cipitate its fibrin, which seems increased in quantity, or there is a tendency * Pneumatoses, or the accumulation of various gases, both within textures, and more par- ticularly in every cavity of the body and of its organs, ought to find some notice here. It does not find a place in the new nomenclature of the College of Physicians. Eoki- tansky describes the modes in which gas accumulations originate, as follows: (a.) Gas accumulated in the textures or in cavities is generally atmospheric air, which has penetrated from without. For example, most kinds of emphysema, gas accumu- lations in the pleural sac, gas accumulations in the stomach, and perhaps also, the more rare instances of gas collections in the uterus and urinary bladder : also gas in the blood, after injury to veins, particularly those of the neck, are collections of at- mospheric air. Interstitial emphysema and pneumothorax are results of lesions of continuity, through wounds or ulcerations in the bronchial passages, or in the lungs. If air be long retained in any of those situations, it undergoes changes similar to what it undergoes in the lungs. Its oxygen becomes exchanged for carbonic acid, with the superaddition of aqueous vapor. But some gaseous accumulations are the products of decomposition ; as, for example gas development in stomach and intestines, the result of impaired and imperfect digestion. Its morbid increase constitutes flatulency and tympanitis ; the former term implying movement of the gas (borborygmus), and its final expulsion by mouth or by anus; the latter term implies its retention, causing distension, with augmented resonance on percussion of the abdomen. This tympanitis is sometimes witnessed to a painful extent in cases of lientery, where the great bowel gets so distended with gas and paralyzed by distension, that death has ensued with symptoms similar to intestinal obstruction. The mucous membrane itself is also believed to secrete gas. Such putrefactive gas development also takes place out of blood mass; or from decaying normal textures or morbid products, such as sloughing cancers. It has also been observed that the subcutaneous areolar tissue, when slightly inflamed, may secrete air in such abundance as to produce emphysema. Dr. Graves relates a ease in which gas was secreted to a considerable amount in the cavity of the pleura. Digitized by Microsoft® FIBRINOUS DEPOSITS. 119 to the spontaneous coagulation of the fibrin, it being natural as to quantity, but thus altered in quality. Instances of this exist in cases of phlegmada dolens, especially those occurring as a sequence to typhoid fever. The ten- dency also exists in those cases where decomposing clots of fibrin are found at times in the cavities of the heart, especially in the appendices of the auri- cles (J. W. Ogle, Path. Trans., vol. vi, p. 32). Fibrinous deposits, or concretions of fibrin, -within the heart, are called polypi or fibrinow vegetations. When such fibrinous deposits are found in blood- vessels, having been carried from a distance into them, and not formed where they are found, the term Emboli has recently been applied to denote such deposits. ALTERATION OF DIMENSIONS. Latin 'Bq, , Magnitudo Mutata; French 'Eq., AllSrations de Dimension; German Eq , Verdnderungen der Gestalt und Grosse; Italian Eq., Cangiamenti di Dimen- sione. Definition. — Alteration of dimension is expressed by an increase or decrease in the volume or bulk of an organ when compared with the normal volume as ex- pressed by the cubic inches of water it will displace. Pathology. — Such alterations of dimensions are comprehended under the following lesions — namely, dilatation, contraction, hypertrophy, atrophy. The terms dilatation and contraction are usually applied to hollow organs, such as the heart; while hypertrophy and atrophy have reference to an increase or diminution of the specific texture composing any organ or part. (a.) DILATATION. Definition — Expansion of the walls of a cavity, so as to inclose greater con- tents. It is generally coupled with hypertrophy of the walls of the dilated organs, when it is known as active dilatation. When the inclosing walls of the cavity are of normal thickness, the dilatation is known as simple dilatation ; conjoined with thinning, attenuation, or atrophy of walls, it is known as passive dilator tion. The causes of dilatation of hollow organs may be expressed as follows : 1. Mechanical impediments, obstructing the free passage and egression of the contents of the different canals and reservoirs, and occasioning dilatation either beyond or behind the impediment. They are expressed in the following lesions ; namely : (a.) Constriction of calibre, through pressure from without ; e. g., by ab- scess or tumors. (6.) Coarctation or stricture, consequent upon hypertrophy and change of texture in the walls of the organ. (e.) Foreign bodies, or secretions obstructing canals. 2. Paralysis of the contractile elements in the walls of the organ. 3. Degenerative lesions. 4. Inflammations. Dilatation tends to destroy life through paralysis, simply, or by the con- currence of asthenic inflammations, or by gangrene, the retained contents of dilated cavities contributing, by decomposition, to pnewnatoses and farther dilatation, as in paralysis with distension of the large intestine and urinary bladder. Digitized by Microsoft® 120 TOPICS KBLATIVB TO PATHOLOGY. (J.) CONTEACTION. 'Definitio'D..— Contraction, coarctation or stricture, are also terms applied to diminished capacity or calibre of hollow parts or passages, — such, for example, as heal contraction of bile-duets, or of urethra, or (esophagus, stomach, or any part of intestinal canal. (c.) HYPEKTEOPHY. Definition. — A lesion in which the enlargement of a part is effected by in- crease, growth, or development of its natural tissue, with proportional retention of its natural form, and with increase of power in proportion to increase of growth (Paget). Pathology. — Hypertrophy of the heart is a common example ; and, in its genuine form, the muscular tissuie is developed to more robustness. Its fibres become not only larger or more numerous, but firmer, more highly colored, and stronger. It is an instance in which the individual elements of the structure take up a considerable amount of matter,- and thereby become larger ; by which, and in consequence of the simultaneous enlargement of a number of elements, at last the whole of an organ may become swollen or enlarged. When a muscle becomes thicker, all its primary fasciculi become thicker. So also a liver becomes enlarged by hypertrophy, simply in conse- quence of a considerable enlargement of its individual cells. It is a genuine hypertrophy without new formation (Viechow). In the pregnant uterus also, such fibres are formed as are not seen in the unimpregnated state. They are not a new kind of fibre, but they differ in size and shape, and are much more powerful than those which compose the uterus in its unimpregnated condition. It is an enlargement of the organ effected through increase by development of its natural tissue. It is the hyperplasia of Virchow. Such hypertrophy of pregnancy is natural ; but it is imitated in disease, when, by the growth of fibrous tumors in the uterus, the womb attains the size, the structure, and full capacity of action of the pregnant organ, so that even the course of labor is imitated, and the fibrous tumor is expelled by the con- tractile power of the uterus, as if it had been a foetus (Paget). Hypertrophy involves an abnormal activity of nutrition, and also at the same time pre- serves the proportional natural form of the part. Thus simple hypertrophy is scarcely to be distinguished from the results of nutritive irritation; but, on the other hand, mer6 nutrition increase, mthout irritation (which is equiva- lent to exercise), will not produce hypertrophy. Mr. Paget, therefore, has well stated the essentials for hypertrophy to consist of the following condi- tions, namely : 1. Increased exercise of a part in its healthy functions (or irritation short of exciting inflammation^ 2. An increased accumulation in the blood of the particular materials which a part appropriates to its nutrition or in secretion. 3. An increased afflux of healthy blood. As examples of the first, the arm of a strong blacksmith, whose muscles acquire bulk and power from constantly recurrent and vigorous contraction from exercise in the use of the hammer, or the great robust heart of a man who has suffered from some disease producing an obstacle to the movement of the blood. In the great majority of cases of hypertrophy of the heart, the lesion is due to valvular disease, which presents an obstacle to circulation of blood through the organ. So also is the urinary bladder hypertrophied in consequence of stricture of the urethra. "The bladder," says Mr. Hunter, "in such cases having more to do than common, is almost in a constant state of irritation and action, by which, according to a property in all muscles, it Digitized by Microsoft® DEFINITION AND PATHOLOaY OF HYPERTROPHY. 121 becomes stronger aud stronger in its nruscular coat ; and I suspect tliat this disposition to become stronger, from repeated action, is greater in the involun- tary muscles than the voluntary ; and the reason why it should be so is,_I think, very evident, for, in the involuntary muscles, the power should be in all cases capable of overcoming the resistance, as the power is always per- forming some natural and necessary action ; for whenever a disease produces an uncommon resistance iu the involuntary parts, if the power is not propor- tionally increased, the disease becomes very formidable ; whereas, in the vol- untary muscles there is not that necessity, because the will can stop whenever the muscles cannot follow ; and if the will is so diseased as not to stop, the power in voluntary muscles should not increase in proportion" (Mr. Paget's Catalogue of College of Surgeons, vol. i, p. 3; and Hunter's work, vol. ii, p. 299). "Thus it is that the oesophagus, the stomach, the intestinal canal (as often as any portion is the seat of stricture) becomes hypertrophied as to its muscular coat above the seat of stricture. DiaRrams of hepatic cells.— (^.) Their simple physiological appearance. (B) Hypertrophy ;^ a, sim- ple • b with accuiuulation of fat (fatty deseiieration, fatty liver). (C.) Hyperplasy (numerical luorease M acljimctive hypertrophy); a, cell with nucleus and divided nucleolus; b, divided nuclei; c, c, divided cells. (After Viechow.) It is Still undecided whether, in muscular hypertrophy, the increase of size is owing exclusively to enlargement of primitive fibrillaj, or whether new fib- rilke are produced. If new fibrilla are produced, the enlargement, accord- ino- to Virchow, would be hyperplastic and not hypertrophic. In hyperplasia new or more numerous anatomical elements are generated, which contribute to the enlargement of a part, by real increase of new material, and which must be distinguished from that enlargement of a part which is a genuine hypertrophy. It will thus appear obvious that mere enlargement of a part is not necessarily hypertrophy of the part; and, therefore, it is important patho- logically to distinguish real hypertrophy from apparent or false hypertrophy A liver or spleen enhirged by lardaceous degeneration furnish examples of fake hypiertroplaj ; such liver or spleen, as to structure, being really in a state of atrophy from wasting of the normal elements. Cases in which an enlargement takes place in consequence of an increase m the mimber of the elements, are examples of hyperplasia. Thus, a liver may become enla'ro-ed by a very abundant development of a series of small cells in place of the ordinary cell development ( c, Fig. 10, ante). Hyperplasia may therefore be considered as a numerical hypertrophy, due to a proliferation or reproduction of tissues similar to the original part, and the condition ot the pregnant uterus is thus one of hyperplasia rather than genuine hyjiertrophy. Digitized by Microsoft® 122 TOPICS RELATIVE TO PATHOLOSY. (d) ATEOPHY. Definition. — A deficiency of the formative process, by which a part simply wastes and is reduced in size, with little or no change of texture, or with gradual and eon- tinuous degeneration (Paget). Pathology. — As, there are two forms of hypertrophy — the one with growth, the other with development (the hyperplasia of Virchow)— so there are two modes of atrophy ; the one with simple decrease, the other with gradual and continuous degeneration of tissue. In both forms, there is invariably a loss of functional power in the part : but, in the one form — that of simple decrease — the loss is due to deficient quantity ; in the other form — that of degeneration — ^the loss is due to deteriorated quality of the tissue. Atrophy does not necessarily imply diminution in the bulk of an organ. The atrophied organ may, in reality, be increased in size, as in the false hypertrophies already noticed, especially fatty and lardaceous degenerations. Atrophy is sometimes a natural process, as in the decline of gland textures, when the need for their existence, or natural term of their special life, has ceased ; for example, the thymus gland, Peyer's patches after forty or fifty years of age, the ovary, testicles, and gen- ital parts generally in old age. Progressive atrophy of all the organs and tex- tures is incident to old age, and is called senile atrophy. In some instances cer- tain tissues waste continuously or progressively; for example, the muscles in that form of disease which will be described as "progressive muscular atrophy," and where the volume of the affected muscles is markedly diminished, as they become successively implicated in the disease. Atrophy, with diminution of volume, is also illustrated in certain chronic diseases of the kidneys, marked by contraction of their bulk ; and also in cirrhosis of the liver. The emacia- tion of scrofula, with or without tubercle, is an example of atrophy afiecting the fatty or adipose tissue especially ; and it is especially expressed by the terms phthisis, consumption, marasmus. It is thus a general atrophy ; and its efiects exhibit themselves in the wasted appearance of the body as a whole. The conditions giving rise to atrophy may be shortly stated as the opposite or reverse of those producing hypertrophy, already noticed. DEGENERATION. Latin Eq., Degenera.tio ; Pkbnoh Eq., Degenireseence ; &ekman Eq , Degeneration — Syn , Entartung ; Italian Eq , Degenerazione. Definition. — Degeneration of tissue implies such a departure from the normal state as gives rise to a granular disintegration or detritus within its minute ele- ments, or to any deterioration by exudation or deposit, which, by the functional actions of repair in the normal state, could not have been left in the texture. Pathology. — The separation of degenerations from substantive diseases is one of the greatest advances in modern Medicine, as Sir William Jenner has well shown in the address to the British Medical Association at Leeds, July 28, 1869. By degeneration is meant, — (1.) Retrograde metamorphosis; and what is that? Shortly, it may be ^stated, that we are always changing, therefore something is always being removed and replaced ; but in degeneration a passive change goes on, distinct from living processes. The result is a granular disintegration of tissue. This is_ especially expressed in the form of fatty degeneration, rotting and 'Calcification, or petrifaction. These same changes occur post mortem, and after tissues are removed from the body and preserved in the bottles of the museum. (2.) Changes accompanied by thickening by hyperplasia generally, and diminished elasticity of certain tissues, occurring especially in advancing life. Digitized by Microsoft® IMPORTANCE OF RECOGNIZING DEGENERATIONS. 123 The general diffusion of these degenerations is characteristic of advancing age. The circumstances under which degenerations occur are of the nature of decay and death. For example, degeneration occurs to an immense extent in the tissues of the aged, especially in the heart and arteries, and to a less extent in the voluntary muscles and the hard textures. Towards the close of the life of a part of the body, degeneration takes place ; as, for example, in the textures of the placenta, when utero-gestation is nearly complete. To such degenerations Virchow has given the name of necrobiosis, because death and degeneration seem to be brought about by altered life at the close of natural existence. In this respect it may be truly said, that " As we begin to live we begin to die." "To degenerate and die is as normal as to be developed and live." A spontaneous wearing out of living parts goes on, so that de- struction and annihilation are immediately consequent upon life. Alterations in consistence are marked characteristics of degeneration. Elas- ticity is impaired, and softening is often the ultimate result of such degenera- tion, which becomes palpable chiefly by the decided friability of the parts. The minute elements of tissue lose their coherence, and at last really liquefy, so that pulpy or fluid products . take their place. When it is remembered, also, how abundantly a granular fatty transformation occurs after death, the nature of degenerations becomes more intelligible ; and my friend Dr. Lyons, Professor of Medicine in the Catholic University of Ireland, instituted a series of observations which beautifully demonstrated a process of morphic changes of tissues through dissolution and decay, till the mortal parts of our body return " ashes to ashes " and " dust to dust." To these morphic changes he has given the name of " Histolysis." To the same end are the demonstrations of Dr. Quain, regarding the conversion of muscle into fat, and of crude flesh generally into adipocere, accounting for the enormous fattiness of certain geo- logical strata in which animal remains are abundant (MiCHiELis, quoted by Simon). Such experiments and observations as those of Panum, Melsens, Asch- erson, Gluge, Lyons, Simon, Burdach, Wagner, Michselis, and others, and in which granules, vesicles, and cell-forms appear to rise spontaneously out of homogeneous albuminous fluid, will go far to explain many of the conflicting accounts which are given of the nature of the inflammatory products just described, and of the degenerations. Such forms may undoubtedly arise, as these observers show ; and having arisen, they decompose and advance through changes such as Dr. Lyons has described under the name of histolysis. On the other hand, the productive results of inflammation undoubtedly grow from pre- existing tissue-elements, as already described. From this point of view, struc- tural changes in the valves of the heart are the result of one of three con- ditions : (a.) Imperfect development. (b.) Endocarditis. (e.) Degenerative changes. These last rarely occur till middle life ; not usually till advanced life in civ- ilians. They seem to be frequent in soldiers at early ages. Our knowledge of such degenerations enables us to appreciate lesions of cerebral textures following such degeneration of arteries and the capillaries of the brain. Degenerative changes in coats of larger arteries can be traced in series up to aneurisms through all stages of local dilatations. They do not occur in childhood or early youth ; they are concomitants of old age especially, but are seen at early ages amongst soldiers. All the degenerations are examples of atrophy with changes of texture (Paget), as distinguished from atrophy resulting from simple decrease of bulk, the organ or tissue otherwise retaining its usual form, and to some extent its flinction. To recognize the following degenerations of tissue after death, the employment of the higher powers of the microscope is essential. Digitized by Microsoft® 124 TOPICS RELATIVE TO PATHOLOGY. The recognition of the following degenerations has very much modified our practice and opinions of recent years, e. g., the diagnosis and treatment of degenerative heart diseases, also of certain forms of apoplexy. In illustration of this, Sir William Jenner gives the following apt illustration in one of the most terse and suggestive lectures of^the time : "Although with regard to the virtues of this or of that particular drug, and to the mode of action of this or of that particular class of remedies, there is, and always will be diiferences of opinion — the evidence that satisfies A. being insufficient from the constitution of his mind to satisfy B. — with regard to the value of drugs in the abstract, with regard to the value of treatment, there is really little difference of opinion among physicians equally well informed as to the present state of medical knowledge, and equally experienced in practice. " I say, among men equally well informed. Let me illustrate my mean- ing. I was one of three who met in consultation concerning a case of apo- plexy. In the opinion of one of my colleagues and myself, the only treatment to be adopted was as follows : To place the patient in the recumbent position, with head and shoulders raised, to enforce absolute rest, to keep the bowels so far loose as to prevent excitement and straining ; to apply cooling substances to the head in the event of any heat of the part occurring ; to support the patient with light nutritive food, having regard to his habits. The third gen- tleman protested a,gainst the modern system of doing nothing ; he was anxious to bleed, to purge, to blister ; and, when opposed, was not sparing of the term skeptic, &c. " Now, the difference of opinion in this case was not due to skepticism on the one side and justifiable faith — i. e., faith justified by knowledge — on the other ; but to knowledge on the one side,, and absence of knowledge on the other. " The case was one of degenerative change, retrograde metamorphosis, of the arteries ; one had become so rotten that its wall had given .^.way, its contents had escaped, a clot had formed, and by its mechanical effects had given rise to the symptoms. The heart shared in the degenerative changes ; the bleed- ing had ceased. To those who understood the real nature of the case the lesions present, and the mode in which they had been produced — in short, the pathol- ogy of the case — belief in the efiicacy of so-called active treatment appeared to be not merely unjustifiable faith, foundationless faith, faith without knowl- edge, but to be faith in opposition to knowledge, which in Medicine is the worst form of skepticism, inasmuch as it is doubt of truth and belief in error — doubt which may prevent the saving of life, and belief which, embodied in practice, may kill" {The Practical Medidne of To-day, p. 4). (a.) Fatty Degeneration. Amongst the degenerations which are brought about by the spontaneous wearing out of living parts, the most widely spread, and the most important, is unquestionably fatty degeneration. It is attended by a continually increas- ing accumulation of fat, which replaces the minute elements of tissue in dif- ferent organs ; and Simon concludes generally, regarding the presence of such oil or fat in textures uninfiamed, that it is essentially a sign of weakness or of death, representing decomposition of efiective material. In such necrobiosis the elements of the normal tissue completely perish, and are replaced by fat- granules. Examples of this degeneration may be seen in the minute elements of muscle, especially of the heart ; in the acini of the liver, contiguous to the capillaries into which the branches of the portal vein break up. In such degeneration the cells ultimately disappear, lea'ding to loss of substance and atrophy of the gland. It may be seen in the bloodvessels, in the corpora lutea Digitized by Microsoft® • CAUSES OF FATTY DEGENERATION. 125 of the ovaries, in the renal epithelium, and in many pathological products, such as pus, tubercle, cancer, and the like, when in process of decay ; and, in short, in nearly all cell-structures, this degeneration is known to occur. In every texture this degeneration becomes evident in a similar manner. Isolated, extremely minute globules of fat appear in the substance of the cells, and becoming more abundant, they gradually replace the normal cell-ele- ment. Usually the fat-granules appear at some distance from the nucleus ; but ultimately they lie as close to each other as in the colostrum corpuscles of milk. At last the nucleus is no longer visible, and the membrane of the cell finally disappears — probably by a species of solution. If the degeneration occurs in the more rigid structures — as, for example, in the walls of arteries — ^the fatty granules retain the form of the cell-structure which they replace. Such degeneration in arteries is first seen in the tissue composing the inner- most layer of the internal coat. Afterwards the intermediate substance softens, the degenerate fat-granule masses fall asunder, and the current of blood may carry away the particles of fat with it. Thus a number of uneven places (cicatricial-like loss of tissue) may be produced upon the surface of the larger vessels without any appearance of ulceration (Vikchow). In fatty degeneration of the substance of the heart there is discoloration of its whole substance. It assumes generally a pale yellow hue, with peculiar spots on the papillary muscles. Short yellow streaks, which communicate with each other, are to be seen in the direction of the primitive fasciculi, and pervading the substance of the papillary muscles. Yellow softening of the brain is a form of fatty degeneration ; and the yellowness is due to the accumulation of finely granular fat. At every point where fatty degeneration attains a high pitch, great opacity always presents itself The primitive cells of tissues are always transparent in their normal state; but fat in excess renders them opaque. Thus a transparent part becomes opaque, as in the cornea, where the fatty clouding marks the areus senilis, described by the late Mr. Canton, in persons past middle life, and regarded by him as an index to the existence of fatty degeneration of other more important organs, although the importance of the sign may have been exaggerated. In some form of Bright's disease the uriuiferous tubules become filled with fattily degenerated epithelium, which appear as opaque spots on the surface of the kidney. Additional examples of this fatty degeneration are to be seen in the fatty liver, and in mollities ossium, atrophied renal capsules, and thymus gland, and the muscles — voluntary as well as involuntary — the fatty degenerations of the placenta, of cartilage, of bone, and of morbid growths ; indeed, there is no kind of tissue, healthy or morbid, which may not undergo fatty degeneration. When the normal structure of the part is thus transformed into fat, it is ultimately destroyed, and the place of the histological elements is gradually occupied by a purely emulsive mass — a kind of milk or fatty debris — that is, an amorphous accumulation of fatty particles in a more or less highly albu- minous fluid (ViECHOw). Practically it is of importance to know what leads to such degeneration. The conditions are mainly as follows : (a.) Impediment to the flow of blood to the textures, due to calcification or petrifaction of the coats of arteries. Anything damaging to nutrition of a part favors such degeneration. Thus the hypertrophied heart ceases in time to yield the proper physical signs of hypertrophy. Degeneration comes on, and the signs of hypertrophy are obscured and ill-expressed, being overlaid by those of degeneration. Thus, in hypertrophied hearts, degeneration is really a preservative lesion. From this point of view we ought always to discriminate clinically valve- lesions arising from endocarditis, as distinguished from degenerative changes Digitized by Microsoft® 126 TOPICS RELATIVE TO PATHOLOGY. ^ due to old age and other causes, and also distinguish the results of changes due to structures damaged from acute inflammation. Fatty heart and fatty arteries are concomitants. With reference to fatty degeneration in particular organs, see the account given of local diseases. (6.) Mineral Degeneration — Petrifaction. The process followed by tissues undergoing this form of degeneration is very similar to that described in the previous paragraphs ; but it is necessary to distinguish forms of mineral degeneration as distinct from ossification. Formerly every kind of tissue condensed to the same degree of hardening as a bone was considered to be ossified, and the condition was described as " ossification." But although a part may have lime in its intercellular sub- stance, and although stellate cells may be present in it, yet it may be merely " calcified " or "petrified " tissue, and this condition Virchow briefly described as "petrifaction." Pathological ossification presupposes that the tissue or part which ossifies is called into existence by growth, and not that a previously existing tissue or part merely assumes the form or hardness of bone by absorbing calcareous salts. Ossification always begins by a growth of new tissue ; and deposition of calcareous salts in its substance does not take place till a comparatively late period. Calcification or Petrifaction is a degeneration comparatively more frequent in the peripheral arteries, and occurs most commonly in cases where there is a tendency to calcifications generally, and where calcareous salts are set free at other points in the system, to circulate with the juices (Virchow). The lesion, in its purity or genuine form, is to be distinguished from athe- roma of the arteries, which implies a combination of the fatty with the cal- careous material — the so-called ossification. In both conditions the artery may be felt to be a hard and rigid tube, with a calcareous feel to the knife or the touch. A careful examination microscopically will show that the degen- eration is in the middle coat, that calcification or petrifaction of the minute muscular cell-elements has taken place, and that the fibre-cells of the circular fibre coat are transformed into calcareous spindle-shaped bodies, mixed with more or less fat. The degeneration may also invade surrounding parts, while the internal coat of the artery may be unchanged. The larger arteries are often brittle, from the mineral degeneration of their tissue — associated with fatty degeneration (atheroma). Patches or plates of the mineral substance may be seen imbedded in the middle coat after the inner membrane is stripped oflf. When the smaller vessels undergo the mineral degeneration, the deposit resembles particles of oil ; and the nature of such an appearance can only be determined by the microscope after the application of mineral acids, which will dissolve the mineral matter with effervescence. Nerve-cells, the fibrous membrane of the brain, the pia mater, and the choroid plexus, are all liable to undergo the mineral degeneration. Exu- dations and new growths are similarly liable. Dr. Bennett has seen the gall- bladder converted into a calcareous shell, and the pericardium into an un- yielding box of mineral matter inclosing the heart. The cardiac valves are thus often covered with mineral incrustations. Cancer and tubercle-growths may be transformed by the mineral degeneration ; and Dr. Bennett has shown how the calcareous transformation of tubercles is the natural mode of arrest- ing their advance. The degeneration may follow upon the metastasis of calcareous salts, not excreted by the kidneys, in cases of caries of the bones, necrosis, or osseous cancer. I have seen specimens in the most mteresting collection of Professor Digitized by Microsoft® PIGMENT DEGENERATION. 127 Virchow -which show that metastatic deposits of bone-earth have taken place in the lungs and in the stomach under such circumstances. Considerable portions of the pulmonary tissue were calcified or petrified, without any appar- ent injury to the permeability of the respiratory passages. The lesion in the lung looked like a portion of fine bathing sponge. The mucous membrane of the stomach was in like manner transformed into a calcified ot petrified mass. It felt like a rasp, and grated under the knife, so that the stomach- tubes seemed imbedded in a stiffened mass. The basis of such degeneration, in which the lime-salts find a resting-place, are the fine fibrous or connective tissues ; and hence the degeneration is seen to occur in fibrous tumors, in serous membranes, in the parenchyma of lungs and stomach (as in the in- stance just mentioned), in cicatrix tissue on the skin, in the valves of the heart, in the connective tissue of muscle sheath, as well of the heart as of common muscle ; in the tunica albuginea, in the fibrin coagula in the heart's cavities, in aneurismal sacs, and in the thyroid and pineal glands. The creti- fication of fibrin, of pus, of tubercle, of cancer, of vegetations, of coagula, all pertain to this form of degeneration ; and the process may be traced through all stages of progressive degeneration, from the pulp-like condition to cement- like, compact, calculous concretion, as in the phlebolite of veins ; also in the turbid, chalky, speedily condensing juice of the cysts of the choroid plexus, and the cell-incrustations of the pineal gland concretions, as well as in the calcification of sarcomata and cancers. With regard to the degeneration as seen in tumors, Mr. Paget describes two methods by which it advances — namely, a peripheral and an interstitial calcification. The former is the rarer of the two. In this form of degeneration the fibrous tumor is seen to be coated with a thin, rough, nodulated layer of chalky or bone-like substance. In the interstitial form the degeneration is interspersed throughout the tumor, and so arranged that by maceration a heavy hard mass is obtained, variously knotted and branched, like a lump of hard coral (Paget, Surgical Pathology, vol. ii, p. 139). (c.) Pigment-Degeneration — Pigmentation. In this degeneration pigment takes the place of the minute tissue-elements, as fat or lime did in the previously-described conditions. It is seen in mucus- corpuscles, as in catarrhal pneumonia, in the pulmonary epithelium, in the acini of the liver, in the epidermic tissue, in the corpuscles of the blood in ague and melancemia. As in the former degeneration, so in this one, a dis- tinction must be carefully made between fat granule-cells and pigmentation, for in both cases apparently the same image is offered to view. The fat granule-cells appear as brownish-yellow corpuscles, but their indi- vidual particles have no positive color ; whereas the pigment-cells contain unquestionable gray, brown, or black molecules of pigment, which are opaque (ViECHOW). The diagnosis between the two is important, as in the brain, for example, where both sorts of granule-cells, namely, pigment-cells and fat- cells, may exist side by side. The former points to apoplexy having existed,, the pigment originating probably in a solution of the coloring matter of the effused blood, the fat to cerebral softening. Therefore it is of importance for the pathological interpretation of the diseased condition to distinguish between pigment and fat in the granular form. Such pigment or coloring matter is insoluble in potash and acids — even in nitric acid. In mucus-corpuscles or catarrhal cells the pigment exists in the form of grayish-black granules. They give rise to the smoky gray spots which are brought up in great quantity in the sputa in catarrhal states of the pulmonary passages ; and to an extreme degree where accumulating masses of prolifer- ating epithelium take place, as in catarrhal pneumonia and in the phthisis of Digitized by Microsoft® 128 TOPICS RELATIVE TO PATHOLOGY. colliers, so well described by Dr. Wm. Thomson (Med.-Chir. Trans., vols, xx and xxi). In the condition known as melancemia (which, like leukoemia, has cells cir- culating in the blood, having made their way into it from definite organs) the cells contain black pigment ; in the latter case (leukoBmia) the cells are colorless. In melancemia colored elements are met with in the blood which do not belong to it (Stiebel, Viechow, Schonlein, Heineigh, Meckel, Feeeichs, and Tigri). These pigment-cells in the blood were first seen to occur in melanotic tumors, and were supposed to be due to the passage of particles from the tumors into the blood. This is not yet verified by obser- vation. On the other hand, it is to enlarged spleens pervaded by black pig- ment that the change in the blood is to be ascribed in such cases, the color being due to the absorption of colored particles from the spleen. The class of cases which are the most fruitful source of black pigment in the blood are those of malarious diseases, e. c/., intermittent fevers, and especially in persons who have been long afflicted with a considerable enlargement of the spleen. In such cases, Virchow, found in the blood of the heart cells containing such pigment ; and the cells that bore the color resembled in size and form the colorless blood-corpuscles ; but there were also other cells of an oblong form and nucleated, within which a greater or less number of large black granules were to be seen. It is in the more severe forms of intermittent fever that such pigment-degeneration occurs. Such pigment is seen to accumulate in the minute capillaries of the brain, attaching to the points of division of the small vessels, and sometimes associated with the comatose and apoplectic forms of intermittent fever. Such pigment is also seen in the minute hepatic vessels (Feerichs), where it ultimately gives rise to atrophy of the paren- chyma of the liver. In a specimen of liver preserved at the museum of the Military Medical School, a deposition of melanotic pigment in a granular form is visible amongst the interlobular connective tissue, following mainly the course of bloodvessels in an irregular manner ; and this case, like all the others yet recorded, was associated with a large black spleen. The contami- nation of the blood in these cases seems due to a degeneration commencing in the spleen. In post-mortem lesions the textures are thus seen to be very variously tint- ed, red, yellow, brown, green, or black, generally resulting from chemical alteration in the coloring matter of the blood or bile. The red pigments, as a rule, are due to the altered hsematin, originally of a yellow color ; and which is the common origin of three difierent kinds of crystals : (1.) Crystals of Hcematoidin are the most frequent products of blood-degeneration (Vie- chow). (Fig. 9, p. 113, ante.) These are formed spontaneously in the body out of hsematin ; and in their most perfect form present the shape of oblique rhombic columns, of a yellow-red color, or, in thicker pieces, of a deep ruby- red. In little plates it frequently bears a considerable resemblance to uric acid. In the majority of cases the crystals are of extreme minuteness — diffi- cult to see clearly, even with a power of 300 diameters. They are insoluble in alcohol, ether, dilute mineral acids, and alkalies ; and exhibit a peculiar play of green, blue, rose-tint, and yellow colors, under the action of concen- trated mineral acids. If large masses of extravasated blood continue to lie for any length of time, this is the substance into which the blood is trans- formed. An apoplectic clot in the brain, for example, is repaired by a large portion of the blood undergoing this transformation, and the color of the re- sulting cicatrix is due to the crystals of hxematoidin. When a young woman menstruates, also, the cavity of the Graefian vesicle, from which the ovum escaped, becomes filled with coagulated blood, and ultimately hcematoidin crystals are the last memorials of the event (Viechow). Hcematoidin is also allied to the coloring matter of the bile. (2.) Crystals of Hcemin, arising out of hcmatin, differ from hcematoidin in Digitized by Microsoft® DEFINITION OF LARDACEOUS DISEASE. 129 this, that hitherto they are only known as artificial products which have not yet been seen in the human body. They are of a dark-brown color. (3.) Rectangular crystals or spicules of Hwniato-arygtalline. The yellow pigments are due to blood very much dissolved or dispersed, as in ecchymosis, or to bile, when it is absorbed in the blood and tinges all the textures. Coloring matter due to bile may be recognized in the urine by the play of colors it gives with nitric acid. A small quantity of acid gives a green hue ; and, as more acid is added, blue, purple, violet, and a red or brown- yellow color will ultimately appear. Of the brown and dark pigments there are two kinds. One kind loses color on the addition of nitro-muriatic acid or chlorine water ; the other resists not only these agents, but even the action of the blow-pipe. This latter pigment consists of carbon. The former is a pecu- liar secretion formed within cells, or is a transformation of the coloring matter of the blood (Bennett). Blue and purple pigments have been seen in urine containing uroxanthin, or the Indican of Schvmk ; and illustrate the close con- nection subsisting between animal and vegetable coloring matters (Parkes On Urine, p. 198). For much more interesting observations on the nature of pigmentation, consult Bennett's Principles and Practice of Medicine, p. 249. (d.) Fibroid Degeneration. Definition. — A very gradual transformation of tissue, with scarcely any percep- tible exudation of material capable of growth, into a material having a fibre-like appearance. Pathology. — This fibroid transformation is chiefly found in membranous structures. It takes part in the gradual thickening of serous membranes and areolar tissue ; and on the surface of such organs as the spleen and pericardium covering the heart (white spot), it very much resembles cartilage, by its dead white appearance, as if the capsule of the spleen or covering of the heart had undergone cartilaginification (Rokitansky). But there is no resemblance beyond appearance between the degenerate formation and cartilage. The capsule of the liver is sometimes similarly thickened, and so are the sheaths of the vessels composing the capsule of Glisson similarly impaired in some forms of cirrhosis. The degeneration is the result of long-continued pressure (condensation), perhaps with friction ; or may be a sequence of chronic inflam- mation with an exudation. It is a form of sclerosis telw cellubsce of new-born children (hide-bound''. It takes part in the wheals and knolls of skin in elephantiasis, and constitutes cicatrix tissue. In synovial membranes it ap- pears first as a fibro-serous plate, of milk-white hue, from which the serum is ultimately expelled, leaving a dense fibroid band of union, or a thickened, opaque, bluish-white, tough patch, as in the arachnoid, pleura, peritoneum, pericardium, and endocardium. It is especially so on the heart's valves, which become rough, indurated, and thickened under the influence of this degenera- tion. LARDACEOUS DISEASE — SYN., AMYLOID DISEASE, WAXY DISEASE. Latin Eq , Morbus Lardaceun—Jdem valent, Morbus Amyloidex, Morbus Cereu.i ; French Eq., Lardacle—Syn., Maladie Amylo'ide ; German Eq., Speckige oder Amylolde oder Wachsartige Degeneration; Italian Eq., Z/arrffflcco.— Syn., Malattia Amiloidea. Definition. — A lesion in which the normal textural elements of many organs- and tissues are transformed into, or infiltrated with, a peculiar substance, sug- gesting, on the one hand, an alliance (in some respects only) with the_ chemical characters of amyloid compounds, and, on the other hand, with albuminous sub- stances similar to those which pervade the tissues of fcetal life. Digitized by Microsoft® 130 TOPICS RELATIVE TO PATHOLOGY. Pathology. — The London College of Physicians no longer regards this lesion as a degeneration, but classes it with other local lesions as a substantive disease. Professor Virchow, of Berlin, was the first to collect the facts regarding this peculiar form of disease, and to put them prominently forward. He proved the frequent occurrence in the animal economy of a degeneration, distinguished by the production of the peculiar substance to be described, which gradually takes the place of normal elements in the tissues so diseased. But Drs. Gairdner and Sanders, of Edinburgh, had anticipated many of the ■ views and descriptions of the Berlin Professor, and, quite independently of Virchow, they initiated in this country the first steps in the elucidation of this very remarkable disease. They showed that the waxy condition of the liver and kidney was due to the same change as that which was seen to take place in the spleen. These valuable communications were made to the Phys- iological Society of Edinburgh ; and an account of them may be read in the Edinburgh Monthly Journal of Medical Science for Feb., 1854, p. 186, and also in May of the same year. Notwithstanding these researches, and those of Drs. Harris, Aldridge, and others in this country, we have much still to learn regarding (1.) The conditions under which this disease occurs ; (2.) The forms in which it exists ; and (3.) The symptoms of the lesion. This disease or degeneration has been long known by a variety of names. For many years the morbid anatomist has been familiar with a "bacon-like" or "lardaceous" infiltration of several solid organs of the body, and especially Xii the spleen and the liver. Portal and Abercrombie described the morbid condition in the liver as a " lardaceous degeneration ; " and Hodgkin and Bright described the same disease as an " albuminous infiltration." In 1842 Rokitan- sky was the first to give a clear account, and to describe in detail the " lar- daceous" infiltration of the kidney with an "albuminous" transparent sub- stance. The lesion so described constitutes his eighth form of " Bright's disease." But Rokitansky made no chemical examination of the infiltrated material. He simply assumed, from its general appearance, that it was of an albumi- nous nature, and he rightly recognized its pathogenetic relations to certain cachexias. Budd has described the disease as "scrofulous enlargement of the liver." Oppolzer and Schrant have described the lesion by the name of "colloid," and Baron by the name of " carnification." The pathologists of this country have hitherto described organs so diseased under the term of "waxy degeneration." Such are the names, derived from appearances generally, under which the peculiar disease has been described before microscopic examination demon- strated the condition of the structures implicated. Chemistry and micro-chemical investigations have modified the views regarding the nature of the disease, and now and then have led to modifica- tions in the nomenclature. Under this kind of inquisitive investigation it has been described (1.) By Virchow under the name of "animal amyloid". he believing, from the behavior of the transformed substance with iodine :and sulphuric acid, that the substance must be classified with the vegetable carbo-hydrogens — cellulose and starch. (2.) Meckel retains the name of •"lardaceous" or "cholesterin disease," believing that the essential character ■of the degeneration consists in the development of a peculiar fatty or larda- ceous matter, of the nature of cholesterin. (3.) The more extended and •definite examinations by Friedreich and Kekul6 have shown that the sub- .stance of the purest amyloid degeneration more closely resembles the albumi- nous principles than any other substance we know of; and (4.) Schmidt has arrived at the same conclusion. The question, therefore, is not yet defini- tively settled as to the exact nature of the substance into which the tissues are transformed, but the weight of evidence points to its being albumen in .some form ; and the albuminoid deposits in the spleen of children, so well Digitized by Microsoft® NATURE OP LARDACEOUS DISEASE. 131 described by Dr. Jenner, must be classed as examples of this disease, and probably also the special lesions in rickets. Investigations relating to lardaceous disease have taken especially three directions. Pathologists have endeavored — (1.) To trace the extension of the process of disease or degeneration throughout various tissues and organs of the body. (2.) To determine the essential nature of the material into which the tissue is converted. (3:) To determine the conditions under which the disease is brought about. Virchow first stated that the large Malpighian sacculi in the spleen (which, in some instances, looked like boiled grains of sago) were sometimes com- posed of a substance which gave the chemical reactions of cellulose, as seen in plants. Cellulose and starch are both vegetable constituents — "isomeria" forms of some common material ; and what gave special interest to the obser- vation of Virchow was the discovery that cellulose is also an element in the covering or skin of the "Tunicata" — a genus of acephalous mollusca — and therefore not a constituent of only vegetable organization. Dr. Robert McDonnell, of Dublin, has also shown that the bloodvessels of the foetus, at a certain stage of development, are of the same albuminoid matter. This discovery of cellulose in animal tissue induced Virchow to look for it or its analogue — namely, " starch" — in the human subject. He recognized it in the corpora amylacea of the brain. These contain a substance chemically related to starch or cellulose ; and these bodies were first seen and named by Purkinje, who gave them the name they have, not on account of chemical characters, but because he observed them to be laminated like starch. Of these corpora amylacea there are two kinds, nam'ely, — (1.) Mineral bodies with concentric circles more or less soluble in mineral acids ; (2.) Others which assume a blue tint with iodine, and a violet color on the subsequent addition of sulphuric acid. The relations of these two kinds to each other are still unknown. The first are the calcareous particles known as brain- sand ; and both were at first described under the name of " corpora amylacea " by Virchow, which has led to some confusion. The term ought to be restricted to those bodies which, by physical and chemical characters, are assimilated to starch. The mineral bodies erroneously described as corpora amylacea are chiefly found in the cysts of the choroid plexus and in the pineal gland. On the other hand, the starch-like bodies have been found by Virchow, Rokitan- sky, Scherer, Kolliker, Busk, and other observers, in the ependyma of the ventricles, the septum lucidwn, the fornix, the auditory and the optic nerves, and also in the prostatic ducts. Concentric lamination of these bodies is not always present ; nor is the reaction with iodine and sulphuric acid constant. For these reasons Virchow began to examine those organs whose morbid state was described by the names already mentioned as having been given to the fatty or waxy spleen. He applied solutions of nitric acid, which, when hot, gave a yellow hue ; he applied caustic ammonia, which gave a brown color ; and from behavior with reagents generally, he concluded that the substance was " ALBUMINOID " iu its nature. Iodine and sulphuric acid were subse- quently tried. Iodine alone gave a strong yellow-red ; sulphuric acid being added, developed a blue color, passing into a strong violet hue. An excess of acid destroyed the violet hue, causing a dark brown-red color, passing into yellow. Meckel, subsequently to these observations of Virchow, came to_ the conclusion that there were four forms 'of this waxy material — that the basis of them all was a peculiar fat allied to cholesterin rather than to starch — that various saponaceous products are formed, ending in the development of choles- terin ; and although he did not sustain his statement by anything like suf- ficient proof, he made the important discovery that it was the system of small arteries and capillaries which first suffered in this disease. The inquiry into the chemical nature of the lesion becomes still more inter- Digitized by Microsoft® 132 TOPICS EELATIVE TO PATHOLOGY, esting when connected with the observations and discoveries of Bernard, Pavy, and others, on the "sugar-producing" functions of the liver, and on the material so formed, which may be separated by chemical processes, and has been recently shown by Dr. Kobert McDonnell to be a substance which enters largely into the constitution of most of the tissues of the embryo (Proceed. Royal Society, vol. xii, p. 476). The results of these inquiries bring the " starchy substances " of animals in very close physiological alliance, and also in alliance with morbid results. The material so found has been called indif- ferently " glycogene," " amyloid matter," " zoo-arnyline," or " animal-starch." It owes it origin, not to any direct function of the organ, but its formation seems to take place almost immediately upon contact with albuminous mat- ter, when this remarkable product is the result, and which may be obtained as a white powder. It seems capable of being produced in greatest abun- dance by the hepatic tissue ; but its formation may proceed at any part of the vascular capillary system. If, therefore, it is thus formed normally, it may also be formed, retained, or transformed in a morbid way. In diabetes we have an instance of the transformation of the product into sugar at the ex- pense of the tissues at large ; and which sugar is so discharged by the urine. The disease now under consderation has thus had various names to denote its presumed chemical nature, namely, — (1.) Cellulose degeneration; (2.) Amyloid degeneration; (3.) Cholesterin disease; and now (4.) Albuminoid degeneration. The analysis of the pure matter is very defective. Such as it is, it shows the substance to be albuminoid, and combined with nitrogen rather than starch; and those who describe the reaction of cellulose and starch with iodine and sulphuric acid, seem only to agree with each other in giving singularly diversified descriptions of color, which, perhaps, to those familiar with the writings of the late Dr. George Wilson, on color-blindness, may be accounted for. Such diversity may be explained in some measure, also, by the fact that the degree of concentration of the reagents materially concerns the results ; for, as Virchoweorrectly observes, the blue coloration is only got after a con- siderable period, and in practiced hands, and it may pass from a bright pur- ple to a very blue or even black color ; in fact, the blue-black color is an error resulting from the decomposition of the iodine solution, by excess of sul- phuric acid, throwing down the iodine, which blackens the tissue. Neverthe- less, the action of iodine solution on the lardaceous tissue is peculiar and definite, independently of a blue color. It is of the nature of a chemical reaction. The appearance of a chemical reaction, which gives a hue different from the mere dyeing with the iodine, and which suddenly deepens in tone, from the moment it begins to take eifect, to a deep brown-red color, is sufladently characteristic. When this takes place with the solution of iodine alone, it distinguishes at once the substance from cellulose and cholesterin. By way of chemical analysis very trustworthy results seem to have been arrived at by Friedreich and Kekule. On submitting the white amyloid matter to ultimate analysis, thev obtained the following composition in equivalents per cent. (Med.-Chir. Review, 1861, p. 59). Amyloid, =53.58 7.0 15.04 But the composition of albumen, according to Dumas and Cahours, Lieber- kiihn, and Ruling, is as follows : *^- H- N. Albumen, ....=( 53 5 .... 7.1 .... 158 7.2 Dumas and Cahours, ) 53.4 ^53 5 LieberkiihD, . . . 53.5 Riiling, 53.8 73 7.0 7.1 15.7 157 15fi 15.5 Digitized by Microsoft® ANATOMICAL CHARACTERS OF LARDACEOUS DISEASE. 133 These results show an almost perfect chemical identity between albumen and the morbid substance found in the so-called waxy or lardaceous spleen ; and demonstrate that the waxy disease, in the spleen, at least, is due to a peculiarly modified albuminous material, and not to starch. On the other hand, the chemistry of the corpuscular variety of the corpora amylaeea occur- ring as a deposit in various parts — e. g., in the brain, the prostate, and the ependyma of the ventricles — shows a reaction almost identical with starch. The corpuscles also have concentric laminse, and, according to some, resemble starch-granules when polarized. As regards the corpuscles of the prostate, sugar has been chemically produced from them, and demonstrated by Trom- mer's test. Many of these corpuscular varieties of amylaceous bodies are no doubt of the same nature as starch ; and therefore the direction which inquiry ought now to take will be to determine "whether or not there is any chemical affinity on the part of the formless matter of lardaceous disease with the cor- puscular variety of the amylaceous concretions?" Such an affinity has been assumed hitherto; but, so far as observation has gone, the evidence of any affinity seems to be getting less and less. On the other hand, the modifying effects of admixture and of growth are very remarkable as regards these pros- tatic concretions. Some of them iodine will not color blue, not even after sulphuric acid has been added ; and as growth proceeds, any starchy matter they contain gradually disappears. Many admixtures of organic and inor- ganic substances give various shades of color ; and the yellow-brown colored deposits failed to give forth sugar to Paulizky's attempts. General Characters and Anatomical Description o^ Tissues affected with Lardaceous Disease. — The cut surface of an organ so affected has a semi- transparent appearance. It feels like a. piece of soft wax, or of wax and laM combined (Wilks). It cuts into portions of the most regular shape, with sharp angles and smooth surfaces; and the thinnest possible slices may be removed by a sharp knife for microscopical examination without any special preparartion. The tissue is abnormally translucent. Water, alcohol, and acids do not produce any change upon the transformed parts, which may be kept for a length of time without decomposition. The organs affected are increased in volume, in solidity, and in weight, absolute and specific. Anaemia is predominant ; but the color of blood or of tissue shines through the semi- transparent morbid substance. Lardaceous disease is generally widely diffiised ; so much so, that a consti- tutional state of ill-health seems associated with its production ; and in cases preceded by a local disease, such as caries of a bone, the lesion may be found in the adjacent lymphatic glands only (Billroth). This is the earliest appearance of the disease yet recognized. The small vessels of the tissue — the more minute arteries in particular — are, as a rule, the first structures attacked. The coats of the arteries become granular and thickened, apparently by exaggeration of their transverse fibres, and at last pellucid, transparent, and hyaline. Their calibre is reduced, and their cut section remains patulous. It is the transverse fibres of the middle or muscular coat of the vessels which first change. Each fibre-cell becomes a compact hyaline, pellucid, transparent particle, with an indistinct outline, and all the tissue involved becomes at last uniform, clear, and transparent. The diseased artery looks like a compact, homogeneous, silvery cord or thread, of a clear and glassy appearance, with a lustre like molten glass without polish, or like rough ice. This colorless, hyaline, diseased tissue is very tough, but not hard nor brittle, like the calcareous degenerate parts. All degenerations tend to obscure the original texture, by making it more opaque. This disease, on the contrary, renders the affected tissue more transparent and pellucid. The specific cells of the functional parenchyma, when the disease affects a solid organ like the Digitized by Microsoft® 134 TOPICS RELATIVE TO PATHOLOST. liver or kidney, next undergo the change, which finally spreads to the nutrient vessels amongst the connective tissue. According to Dr. Dickenson, the mor- bid matter penetrates the coats of the minute vessels, and gradually works its way into the surrounding tissue; and the changes which thenceforth result vary according to the organ' affected. In the solid viscera the lardaceous material remains about the vessels, and fills the interstices of the texture. Thus, the organs so affected, especially the liver and spleen, increase in size, becoming hard, gray, and semitransparent, as if uniformly infiltrated with wax. The kidneys, suprarenal capsules, and lymphatic glands are all apt to assume the same firmness and wax-like transluceucy. In the spleen the deposit often exaggerates the Malpighian sacculi, till they are larger even than grains of boiled sago — more like tapioca, I have seen them in many instances. In the mucous membranes of the small intestines the vessels are similarly altered in appearance ; but Dr. Dickenson believes that the exuda- tion, instead of being retained, is passed oflT by diarrhoea ; or, if the stomach is afiected, by vomiting. When a solution of iodine is brought in contact with the afiected part, a very deep violet-red color is produced. This deep-red color seems to be alone a sufficiently characteristic test of the existence of the disease, especially when in a few seconds the color increases iu depth , from the moment it begins to take effect. The morbid material seems to have a strong affinity for the reagent, " absorbing it readily, holding it tenaciously, and assuming its full color," while the healthy parts take only a faint and superficial yellow tinge. Hence the contrast which the deep reddish-brown of the morbid parts pre- sents, against the uniformly faint yellow of the normal tissue in which it may be placed (Dickenson). It is of the nature of a chemical reaction which ensues between the iodine solution and the morbidly degenerate part. The best test-solution is composed as follows : Twelve grains of Iodine is to be dis- solved with twenty-four grains of Iodide of Potassium, and mixed with three ounces of Water. Such a test-solution ought always to be at hand in the dead-house, or on making a post-mortem examination anywhere. Elepients of Tissue in which lardaceous Disease has been demonstrated. I. Nervous System : Ligamentum spinale cochlese : atrophied parts of brain and spinal cord : gelatinous softening, and tumors. • 2. Spleen : Cells of the Malpighian sacculi and pulp : thickened walls of the . arteries in all stages : the trabeculse. 3. Liver: The hepatic cells and intralobular vessels, and intercellular tissue. 4. Kidneys: Malpighian tufts and afferent vessels, the walls of which become enormously thickened : areolar tissue in the vicinity of the papillaiy ducts. 5. Muscular tissue of the heart and the uterus. 6. Bloodvessels of the villi and mucous membrane of the alimentary canal. 7. Osseous tissue. 8. Lymphatic glands. 9. Old deposits in serous membranes, having lost their fibrous character, becoming dense, more vascular, and semitransparent, undergo this metamor- phosis (Gaiedner). 10. Tubercle also becomes lardaceous (Gaiedner). II. The cancerous nodules in a waxy liver also become lardaceous (Gairdner). 12. In some cases of inflammation with exudation on the mucous membrane, the exudation has become lardaceous (Virchow). 13. The fibrin of a hsematocele (Friedreich). The extensive range of organs in which this remarkable lesion has now been demonstrated clearly shows that it cannot be regarded as merely of local im- portance. Its occurrence seems rather to point to some general pathological Digitized by Microsoft® RESULTS OF LAKDACEOUS DISEASE. 135 state of which the lesion is the expression. In the first instance it is found more particularly affecting the functional capillaries of the most important organs of the body — e. g., the kidney, the liver, the spleen, the intestines, as well as the minute arteries of nutrition of those organs, and of the pia mater, bone, and lymphatic glands. The results of such a disease must therefore be sooner or later destructive, — (1.) To the function of the invaded organ ; ■ (2.) To its nutrition ; and we can only arrive at a correct pathology of this degen- eration by a close observation of the circumstances, condition, relations, and symptoms under which the lesion manifests itself These must be studied especially in relation to the functional or physiological anatomy of the organs implicated. As yet the lesion has been recognized with certainty only in the dead-house. There it has been found associated with certain diseased states ; and all the cases agree in this particular, namely, that the constitution of the patients has been broken up by ill health (cachexia) of some considerable duration before death. So it has been amongst the soldiers dissected at Fort Pitt and atlSTetley ; and the following statement is a summary of diseased conditions, in the order which furnishes the greatest number of cases of larda- ceous diseases : Diseased States with which Lardaceous Disease has been found associa- ted, or upon which it is engrafted. 1. Diseases of the hones, especially caries and necrosis in scrofulous subjects. Rickets also leads to the amyloid liver and spleen, as observed by Glisson, Por- tal, Eokitansky, Lambe, Lceschner, Frerichs, arid Jenner. 2. Syphilis, especially in its ulcerative forms, the cachexia having been prolonged. Syphilitic children have been the subject of it when newly born. 3. The malarious cachexia, especially intermittent fever. 4. Mercurial cachexia and marasmus. 5. Pulmonary and intestinal forms of tubercle. 6. Albuminuria and anasarca. 7. Diseases of large arteries. It has been more recently urged by Dr. Dickenson that the degeneration is always the result of extensive purulent formation of long duration. He believes that its mode of origin has to do with the removal of alkalies from the system ; which long-continued suppurations' tend to do, leaving a relative increase of fibrin. Five-sixths of the cases recorded by him were connected with suppuration. Hence he proposes the term depurative infiltration as sig- nificant of its pathology. Pus is an albuminous fluid rich in alkaline matter, containing about 1 per cent, of alkaline and earthy salts, in the proportion of ten of alkaline to one of earthy salts. Next to suppuration, albmninuria, when connected with nephritis, is the most frequent antecedent of lardaceous disease ; the long-continued discharge of albumen carrying alkali with it. As to the origin of the lesion or degeneration, Frerichs has propounded two questions, namely, — (1.) Is the lesion due to deposits from the blood of the albuminoid matter in some primordial form, and which is generated in the; blood in consequence of a local disease, such as caries of the bones or other' suppurative processes ? (2.) Is the albuminoid matter developed locally in. the affected tissue by the transformation or degeneration of the tissue into. albuminous matter ? Arguments are put forward by Virchow and Frerichs to show that the lesion may be due to a deposit from the blood ; and Dr. W. H. Dickenson comes to the conclusion that the deposit essentially consists of an exudation of a pecu- liar material differing from the proper constituents of the body. He considers the Substance essentially fibrous; and so deposited in consequence of the absence of alkali necessary to hold it in solution. Hence he names it " de-al- -kalinized fibrin," and not a form of albumen. He believes it to be fibrin, rather than albumen, on account of the strong tendency it shows to undergo contraction after its deposition. It becomes converted into fibroid tissue as a Digitized by Microsoft® 136 TOPICS RELATIVE TO PATHOLOGY. coagulum in the arachnoid or as vegetations on the valves of the heart. In certain cases also it is identical in appearance and reaction with the hyaline casts of the kidney tubes, believed to be fibrinous. Fibrin can be also con- verted into the lardaceous substance by removing the alkali it naturally con- tains, or only neutralizing it. Conversely, if potash or soda be added to the morbid matter, it ceases to give the characteristic reaction with iodine. It will not decompose the color of sulphate of indigo, as healthy tissues contain- ing alkali will do. Analysis of lardaceous livers show a diminution by one- fourth of alkaline salts, and the earthy salts exist in larger quantity than in health. ■ • x' i. But there is also undoubted evidence to show in some parts it is of the nature of a degeneration. For (1.) In cases where the lesion follows afiec- tions of the bones, the lymphatic glands adjoining the diseased bones are im- plicated before the kidneys, liver, or mucous membrane of the intestines. (2.) General causes of ill-health (cachexia), pointing to impoverished blood, are in operation, and organs situated in different parts of the body are simul- taneously affected. (3.) The. fibrin of the blood itself has been observed to undergo the degeneration ; for Friedreich found a substance which gave the amyloid reaction with iodine in the old fibrinous layer of the sac of a hsema- tocele. In this remarkable lesion or degeneration an acquaintance with a new fact in pathology must be recognized — i. e., since 1854 — associating itself with grave constitutional disease, and distinguished from every other morbid condi- tion hitherto known, by the physical, chemical, and physiological characters just described. The Clinical History of Lardaceous Disease is,remarkably deficient. The effect of the degeneration is to interfere with function of organs and nutrition of parts ; and the injurious effects are the more marked as the lesion extends through many important organs. For example, hepatic cells cease to take part in the formation of sugar or the secretion of bile. Bloodvessels lose their power of transmitting fluid through their walls, and become impervious as to their canals. Hence those who suffer from lardaceous disease have an appear- ance of general ill-health, denoted by paleness of the surface, by symptoms of anaemia, hydrsemia, or by leuka3mic affections of the blood ; and the more so as the constitution is enfeebled by such morbid processes as suppurative ulcera- tion of bones, syphilis, tuberculosis, albuminuria, or malaria. The sequence in which the different organs degenerate is uncertain. In most cases of caries and necrosis the kidneys seem to be first attacked after the lymphatic glands. In cases of intermittent fever, it is usually the spleen which is first affected ; and generally it seems rare to find several or all the organs affected to the same extent. Signs or Symptoms associated with this Degeneration discoverable dur- ing Life. — On these points data are wanting upon which to found any state- ment. The pathological change is of so recent discovery, that well-recorded cases, terminating in death, with verification of the symptoms by post-mortem inspections, are very few indeed. There is no subject, therefore, more full of interest, or one more likely to repay close observation and well-directed patho- logical inquiry, than the diagnosis of lardaceous degeneration. Cases in hos- pital ought to be most carefully noted, and especially such ambiguous cases ' as those where marasmus, ansemia, or dropsy are primary symptoms, and which are not to be accounted for even after the blood has been examined mi- croscopically during life, and the condition of the liver, heart, spleen, and lymph-glands carefully inquired into, without evincing signs of disease. In a remarkable ease recorded by Friedreich and Kekul6, and quoted in the Medico- Chirurgical Review for October, 1860, diarrhoea and vomiting were of frequent occurrence, with a systolic murmur of the heart, and high-col- ored and albuminous urine, with a specific gravity of 1.019. The patient, a Digitized by Microsoft® DEFINITION AND PATHOLOGY OF CYSTS. 137 female, after suifering from tertian ague for twelve months, .became dropsical and emaciated. The intestines throughout, the stomach, the colon, the jeju- num, and especially the capillary vessels of its villi, were affected, as well as the vessels of the kidneys. The urine should be watched as to albumen, or deposits, and its amount in relation to body-weight should be recorded. When albumen appears, it goes on gradually increasing ; and hyaline gases increase with the increase of albumen. Dr. Stewart, of Edinburgh, records twenty cases and nine dissections in cases of Bright's disease, where he considered lardaeeous disease to have been present (Edinburgh Medical Journal for February, 1861). He records that large quantities of urine were passed in the early stage of supposed waxy de- generation, and of a specific gravity from 1.005 to 1.015. In all the cases there was a striking general correspondence in the other symptoms ; and Dr. Stewart thinks that from this similarity of symptoms, and from other consid- erations, he is warranted in believing that lardaeeous disease existed in the eleven cases that did not die. The history of all Dr. Stewart's cases is markedly different from that of the fatty kidney which Dr. Bright figured in his first plate, and illustrated in his first case. Almost all of the cases were associated with long-continued wasting disease; and it has been long known that the form of renal affection accompanying phthisis, syphilis, and other wasting maladies, is this lardaeeous disease. Of the twenty cases related by Dr. Stewart, six were associated with phthisis, six with syphilis, two with caries, two with intemperance, one with cancer, one with chronic rheumatism, and two with no particular disease. The lesion is much more common than is generally supposed. It has been observed very frequently amongst the soldiers who have been dissected at the Military Hospital for Invalids, formerly at Fort Pitt, and now at Netley. The microscope and iodine test can alone determine its presence; and without microscopic examination the absence of the degeneration cannot be deter- mined. For a detailed account of lardaeeous disease in the various organs, see the descriptions given under Local Diseases. CYST. Latin Eq., Cystis; PRENcn Eq., Kyste ; German Eq , Cyste ; Italian Eq., Ciste. Definition. — A cyst, sac, or hag (to the exclusion of capsules or sheaths forming round foreign bodies, extravasations, or parasites), filled with some substance which may be regarded as entirely, or for the most part, its product, whether as a secretion or as an endogenous growth. Pathology. — Many theories have been put forward to explain the forma- tion of cysts; but no single hypothesis has yet been sufficient to account for their formation in all situations where they have been found. It has been extensively taught that the structure of a cyst consists of an excessive augmen- tation of volume of the alveoli of the areolar tissue, composed of condensed and modified filamentous tissue. Bichat urged many objections to this view, and held that cysts, being in many respects analogous to serous sacs, they ought to have the same origin. He held that cyst-growths were aberrant forms resulting from unnatural growth of germs in and amongst areolar tissue, and that the contents increased with the enlargement of the cyst by growth. Rokitansky subsequently followed very much the idea of Bichat, regarding the cyst, from its organization and secretory function, as a definite hollow ■structure, whose essential rudiment is a definite functional elementary germ_ or granule. But there are no doubt some cyst formations due to the dilatation and growth of natural ducts, sacculi, or follicles, as well as others which form by the enlargement and fusion of areolar spaces in connective tissue. Digitized by Microsoft® 138 TOPICS RELATIVE TO PATHOLOGY. Thus there are three modes in which cysts may be formed, namely : (1.) Cysts ^vhich are a substantive new growth, having a distinct elementary groundwork, derived from cells or the nuclei of cells, pursuing a morbid course of growth from their origin, and reaching an enormous development. Fig. 11. (2.) Cysts which are formed by obstruction, dilatation, and growth of natural ducts or sacculi. Examples of such cyst-formations are seen in sebaceous or epidermal cysts formed from enlarged hair follicles, and the cysts formed by dilated mucous tubes ; also certain cysts, containing milk, from enlarged jsarts of lactiferous tubes; ovarian cysts from overgrown Graetian vesicles; and lastly, cysts formed froni dilated bloodvessels shut off from the main stream. (3.) Cysts formed by enlargement and fusion of the areolar spaces in con- nective tissue. The tissue of the wall of such cysts becomes condensed, and the inner surface secretes fluid like a serous sac. Although the observations of Rokitansky and Simon point to the growth of cysts in the kidney from the original primary cell elements, yet the obser- vations of Drs. Gairdner and George Johnson equally explain their forma- tion by local obstruction of viriniferous tubules, and their dilatation into cysts above or between the points of obstruction. But whatever may be the source of their formation, Ave have yet to learn, as JMr. Paget specially notes, why they tend continually to grow. The Figs. 11 aud 12 are Rokitansky's representations of the minute struc- ture of cysts of the kidney. They represent "nests" of delicate vesicles, from a size just visible by ild to jth lens to the size of a millet-seed, imbedded in a red-gray whitish substance. They represent proliferous cyst-formations from the cortical substance of the kidney, as a sequel to Bright's disease. The two figures illustrate well Roki- tansky's history of proliferous cyst-development, and at the same time what he understands by the often-occurring expression, "alveolar type or arrange- ment." Digitized by Microsoft® CLASSIFICATION OF CYSTS. 139 Fig. r2. lu Fig. 11 we have the cyst in all its phases, a is a simple cyst, arising out of the expansion of the elementary granule, first into the nucleus, from this into the cell, and progressively into the cyst. But it has remained barren, and contains only a diaphanous viscid serum within a simple cyst-membrane. h ' represents a parent C5'st, the early history of which accords with that of the barren cyst ; within it, however, new granules have formed, and gradu- all}' became developed into vesicles or cysts con- taining other nuclei, un- til the parent cyst has become replete with them, and, from being spherical, they are ren- dered polyhedrieal by nmtual compression. In an adjoining parent cyst, many of the filial cysts have remained barren ; others contain nuclei in the act of splitting, c, c, c, c, represent another form of develo]3nient of the parent Cj'st. Here, again, the parent cyst has gone through the same phases, from the elementary granule upwards. But, as the cell dilates into the cyst, a granule forms centrally to the latter and expands into a filial cyst, centrally to which a third granule opens out in the same manner; and so on. These intracystic cysts in their dilatation ulti- mately close upon the parent cyst, forming secondary, tertiary, and ulterior layers, to which an external fibrous layer is generally added out of the sur- rounding blastema. Or this fibrous coat occurs in the alveolar shape. Fig. 11 affords several examjjles of this. It is, however, better seen in Fig. 12 — Where a is the fibrous sheath in progress of development out of d, the elongated and caudate nuclei coursing around the parent cyst or aggre- gation of parent cysts. They eventually break up into the requisite fibres. e is to represent the point-molecule, within an amorphous blastema, out of which the nuclei (b) form. They are at first spherical, afterwards elongated, and ultimately broken into fibrillation. TJiis constitutes what the author designates as the " alveolar type or arrangement." Kokitansky teaches that the nucleus grows to be the cyst, whether it be simple or barren ; and that the outside layers of the cyst-walls, if they are complex and thick, are made uj) of endogenous growths, of nuclei, of cells, or of any other structures. Thus, a classification of cysts has been conveniently arranged into (a.) Simple or barren; and into (b.) Compound or j'jroliferou.i. Simple or barren cysts contain fluid or organized matter ; comjjound or proliferous cysts contain variously organized bodies (Facet). The simple or barren cysts may occur singly or many together (when they are called "multiple cysts"), and contain a fluid like that of a serous sac (mammary cysts, choroid plexus cysts, synovial cysts). Some are full of blood, or colloid stuff (glue-like ), or other peculiar or abnormal fluid. Others (transitional between barren and proliferous cysts) contain specific secretions, such as milk, semen, mucus, saliva ; and they are thus named, according to Digitized by Microsoft® 140 TOPICS RELATIVE TO PATHOLOGY. contents, as lactiferous, seminal, mucous, salivary, Qolloid, sanguineous, synovial, serous. The simple or barren cysts contain one or other of the following materials : (a.) Gaseous cysts (examples o{ pneumatoses, see p. 118, ante) are mentioned by Mr. Paget, on the authority of Hunter, Jenner, and Cavendish, and the preparation is preserved in the Museum of the College of Surgeons, No. 153-4 ; but beyond the description of Plate xxxvii in Hunter's Works, vol. iv, p. 98, nothing is known concerning such gaseous cysts. (6.) Serous cysts, or hygromata, are the most frequently seen. They include nearly all which have thin liquid or honey-like contents, of a yellow or brown color. They are most frequently found near the secreting or vascular glands ; and there is scarcely a part of the body in which they may not be found. So common are they in and amongst gland-structures, that they are believed to arise from the same germinal elements of membranes that furnish the per- petual growth of glandular or secreting elements. Thus, in such sites they are held as examples of perverted epithelial or gland-cells. But they are no doubt independent of such origin, as in bones, connective tissues, muscles, nerves, and fibrous tumors, where their origin is quite independent of gland- cells. So complicated are the contents of some cysts, as in bone, that perfect ciliated epithelium has been observed in them (Wedl). Serous cysts occur chiefly in the neck, the mammary gland, and the gums. In the neck they are sometimes described as " hydroceles of the neck." They may be single or multiple to the extent of hundreds, having many cavities, either separate or communicating. A case of this description proved fatal at Netley Hospital in November, 1870. The patient was a young soldier, only eighteen years of age, and of five years' service. The left side of the neck was enlarged from many cysts, which had been opened into during life, and which, at death, were in a state of active suppuration, so that the original connection of the cysts was not traceable. On the right side of the neck a smooth tumor, about the size of a turkey's egg, occupied the lateral region, extending beneath the platysma myoides, and lying between the fibres of the deep muscles of the neck, from an inch and a half below the ear to an inch and a half above the clavicle. Commencing small cysts were seen posterior to the tissue of the left tonsil, and the pressure of the diseased parts, especially from the left side, caused extensive cedema of the pharyngeal and laryngeal mucous membrane. The cysts had no connection either with the thyroid or lymphatic glands of the neck. Another mass of cystic growths occupied the entire pelvis, and was apparently divided into four large lobules. These growths pushed the bladder over to the right side, pressing upon it anteriorly, and from the left. There was also another development of large cysts in the soft parts about the left hip, and upper part of thigh, but the joint was in no way implicated. Some of the cysts had been opened in the thigh by a trocar, and had commenced to suppurate. The cysts, which were entire, contained clear serous fluid, highly albuminous, of a straw color, and having a specific gravity of 1.017. The fluid was frequently examined during life, several pints having been removed from time to time, but neither during life nor after death were any evidences of parasitic development (such as echinococcus) discoverable. The cysts were obviously developed in and amongst the areolar tissue of the neck, pelvis, and thigh ; but the origin of the cysts is extremely obscure. It is most probable they had their origin in the corpuscular elements of the connective tissue or juice canal system, which permeates that tissue. The subject of this cystic disease had been considered to be suffering from scrofula, and had been 129 days in hospital at Gibraltar. The exciting cause of the swellings was attributed to sleeping in a wet tent, when encamped with his regiment at "Windmill Hill. Thence he was invalided to Netley, where the cystic nature of the tumors in the neck and hip was recognized. On admis- Digitized by Microsoft® EXAMPLES OF SEllOUS CYSTS. 141 sion, there was enormous swelling of the left neck from the ear to the clavicle, and from the region of the left parotid gland to th^ Ugamentum niwlue. Several small openings existed, from which a thin watery discharge exuded. He complained of pains in the left hip, simulating rheumatism, accompanied with a moderate general swelling of the joint. Respiration sounds were normal. He was a spare ansemic lad, badly nourished, and of unhealthy aspect. For two months after admission to Netley, the swelling in the neck progressively increased in size, and the patient continued to lose flesh, and became more and more cachectic. A puncture was made with a small trocar, in two places, by Staff Surgeon-Major Mackinnon, C. B., and serous fluid, to the extent of six ounces, escaped. The fluid, however, accumulated again very rapidly ; and ten days later, about half a pint of blood-serum was removed and care- fully examined for parasite developments, but with a negative result. At this time swelling about the hip-joint was observed. It was of a uniformly rounded contour; and the circumference of the upper part of the left thigh was five inches in excess of the corresponding part of the opposite limb (right side, 15^ inches ; left side, 20^). There was much tenderness on pressure over the joint ; but pressure on the condyles of the femur, in an upward direc- tion, did not cause pain in the hip-joint, neither was there lengthening or shortening of the limb. Five days later, sixteen ounces of fluid were evacua- ted from the facial tumor, and eleven ounces on the following day. After another five days, Mr. Mackinnon made an incision over a tumor at the lower part of the neck, and exposed a dense glistening membrane — the wall of another cyst — from which serous fluid escaped as from the others. Five days afterwards, another tumor was observed on the right side of the neck, rounded, smooth, and fluctuating, and this gradually continued to increase till death. It was left unopened. The openings by trocar, into the cysts in the left side of the neck, led to a depth of several inches ; and two of the cysts communi- cated ; two others opened into were isolated. Much pain was subsequently experienced in the region of the left hip, and in eighteen days the circumfer- ence of the thigh had increased three inches. An opening was now made by trocar into one of the swellings over the hip, and a pint of fluid evacuated : five days later, twenty ounces more escaped. The fluid was of the consistence of very thin arrowroot, and with a tendency to stringiness between the fingers, consisting almost entirely of an albuminous solution, coagulating into a solid white mass on boiling. Soon after, a large tumor, firm and round, containing fluid, was detected in the pubic region, giving a sensation to the hand similar to a contracted uterus. It was tender on pressure, and much pain was expe- rienced on micturition. The excessive daily discharges from the several open- ings and cyst surfaces, combined with the acute pain in the hip, and the onset of laryngeal irritation from oedema and pressure on larynx and trachea, eventu- ally terminated fatally. In young children such serous cysts are often congenital (hyt/roma colli oys- tieum congenitum). Some are connected with the thyroid gland, others are transformations of vascular tumors, such as erectile vascular growths or nsevi (Paget). Cysts in or near the gums, with contents of a thick honey-like consistence, and generally sparkling with crystals of eholesterin, are usually found lying behind the reflection of the mucous membrane from the gum to the cheek. From their tough thick walls in that situation, they are apt to simulate dis- ease of the antrum. Cysts in the mammary gland are often due to dilated ducts, portions of which assume a cystic form. They may contain milk. Mr. Birkett records numerous cases of this kind, from one of which he evacuated ten pints of milk. Some contain the remains of milk, such as fat and epithelial scales ; or they may be filled with transparent watery fluid, uncoagulable. More commonly they contain serous fluid, pure or tinged with blood. They may Digitized by Microsoft® 142 TOPICS RELATIVE TO PATH0L08Y. also originate (like those of the kidney) independently of the gland-tubes (BiEKETT, Paget). Mr. Paget lays down the general rule that the cysts which contain the simplest fluids, and which have the simplest walls, are apt to grow to the largest size. Synovial cysts acknowledge three methods of formation : (a.) From widen- ing of spaces in areolar tissue, forming, by condensation, bursse as the result of pressure ; (b.) Cystic transformation of cells inclosed in the fringe-like processes of the synovial membrane of the sheaths of tendons, such as those near the wrist-joint, forming ganglions, as they are called. They resemble the cysts of the choroid plexus, which grow from the villi at the margins of the plexus (Rokitansky). (c.) The mouths of subsynovial follicles, which normally open into the cavity of the joint, become obstructed, and the folli- cles undergo such dilatation as converts them into subsynovial cysts (GossB- LiN, quoted by Paget). Such synovial cysts vary as to contents, being some- times serous, gelatinous, or honey-like. Mucous cysts are formed in connection with simple mucous membranes, or ducts of mucous glands, such as those about the cervix uteri, giving rise to Nabothian cysts; or connected with Cowper's glands in the male, forming Cowperian cysts. Similar cysts form in connection with cutaneous follicles. Examined microscopically, such cysts contain epithelial scales, free fat, tables of cholesterin, crystals of triple phosphate, and small hairs in various pro- portions. Many abscesses projecting into the vagina have their origin in glands near the orifice (Baetholino), which become cystic (Paget). Mucous cysts are recorded also in the antrum ; in the mucous membrane of the stomach and other parts of the alimentary canal ; in the uterus ; in the posteriorwall of the trachea, forming cystic tumors lying between the trachea and oesophagus (Viechow) ; in the back of the epiglottis, and covering the upper orifice of the larynx (Dueham). Ranula is an analogous aflTection of the duct of the sublingual gland. Sanguineous cysts contain blood, and are probably the result of hemorrhage into the cavities of serous cysts, like the transformation of pericarditis into hemorrhagic pericarditis, or of a hydrocele into a hcematooele. Such blood-con- tents are generally coagulated or thick. Others have their origin in vascular ncevi. Oysts containing oil or fat are rare, except as the residue of fatty degenera- tion of other matters. Colloid cysts embrace cysts containing all those mor- bid materials described as "pellucid," "jelly-like," "flickering," "half-solid," "glue-like." Such material is common in the cysts of bronchoceles and in kidney cysts. The density of such contents varies from that of serum to that of a firm jelly, and in color it may be of any hue. The second kind of cysts are the proliferous or compound cysts, and are so named from the occurrence of secondary growths in the interior of the origi- nal cysts — cysts growing within cysts, or upon their walls, as in complex ova- rian cysts. These secondary growths may hang pendulous from the walls ; and immense proliferous power exists in ovarian cysts from Graefian vesicles. On this subject the student must consult Mr. Spencer Wells's treatise On Dis- eases of the Ovaries. The mammary and thyroid glands are also often the seat of similar prolif- erous cysts ; and there are proliferous, cysts described by Mr. Paget as recur- ring and as cancerous ; while there are others developing skin structures (sebaceous), and others developing teeth (dentigerous). For more details regarding those, the student must consult Mr. Paget's Lectures on Surgical Pathology, a work which has mainly furnished the mate- rials for this account of cysts. Digitized by Microsoft® DEFINITION AND PATHOLOGY OF PARASITIC DISEASES. 143 PARASITIC DISEASE. Latin Eq., Morbus Parasiticus; French Eq., Maln,die Parasiiaire ; German Eq., Paradtiche Krankheit ; Italian iiq., Matatiia Parasitica. Definition. — Forms of disease in which a great variety of lesions, and of symptoms of organic disorder, are brought about by the presence of animal or PLANT life, finding a subsistence within or upon some tissue, organ, or surface of the human body, or of other animals or plants. Pathology. — Parasitic diseases may be considered as due either, — (1.) To the existence of parasites from the animal kingdom; or (2.) To parasites from the vegetable kingdom ; any one or more of which may live either upon some surface, or within a cavity of the body, or within the substance of some of its tissues or organs. From the animal kingdom we have the entozoa and the epizoa, and from the vegetable kingdom the parasitic diseases are due to epiphytes and entophytes. It is only recently that we have been able to point with distinctness to a vege- table parasite finding its way actually into the substance of animal tissues, and there progressing in development. Dr. H. V. Carter, the Professor of Anatomy and Physiology in the Grant Medical College of Bombay, has described a " 'fungus disease' of the foot, in which numerous minute tubercles, resembling fish-roe, lie beneath the muscles," and affect the tissues from the Bones to the skin {Trans, of the Med. and Phys. Society of Bombay). Plants, as well as man and animals, have their peculiar parasites and para- sitic diseases. The mistletoe is a familiar example of a vegetable pjarasite; and the oak apple, or gall-nut, is a familiar example of an animal parasite affecting a plant. It is known, and in many instances it is capable of experimental proof, that some of these parasitic diseases (vegetable as well as animal) may be transmitted or communicated indifferently from animals to man, and from man to animals. The tape-worms, the encysted, vesicular, and round ivorms, are examples of parasites intercommunicable among animals ; and Tinea, from the "Dartre tonsurante" of the horse, ox, and cat, having been commu- nicated from these animals to man, are instances of vegetable parasites inter- communicable among animals. It may be that the so-called blights of plants, or the causes of them, are also communicable to animals and to man. We know that some of the diseases of man and animals are intimately related with famines and unwholesome food, and that famines are due more often to diseases of vegetable and animal life than to destruction or loss of food. The records of history furnish numerous examples of periods of blight in the vegetable kingdom, associated with epizootics among the lower animals, and with epidemics affecting the human family. (See Sir William Wilde's History of Ireland, compiled in connection with the census taken twenty years ago [1871].) The relative connection of these events has scarcely yet attracted the attention of pathologists, in human or comparative anatomy. Here, indeed, is a wide field for investigation — a territory almost yet unex- plored. The medical service of Her Majesty's British and Indian armies gives golden chances for observation, if the chances are seized at the moment, and the observations connected with facts already known. To the more salient of these facts the attention of the student is here directed. Since the beginning of the present century, when Rudolphi published his systematic work on the entozoa (1808), almost every year has contributed new and important facts, which render the subject of Parasitic diseases one of increasing interest to the pathologist and the physician. The subject abounds with most puzzling riddles in natural histoiy and pathology, especially con- cerning the reproduction, the development, and the propagation of parasites. Digitized by Microsoft® 144 TOPICS RELATIVE TO PATHOLOGY. So long as 180 years ago (1691), the independent nature of such structures as the "hydatid cyst" was established by Tyson {Phil. Trans., cxciii, p. 506) ; and it was stated by Pallas, iij 1766, that all the cystic worms were forms of tape-worms belonging to one species — namely, the cystic or hydatid tape- worm ; but it was not then known how their generation and propagation was effected. For a very long time the received doctrines regarding the genera- tion and development of living beings were tacitly set aside in behalf of such "existences." They were believed to arise spontaneously. Inquiry was thus set at rest, curiosity seemed satisfied, or investigations followed a fruitless direction — as when observations were made on such cysts, in the hope of dis- covering in them some evidence of the existence of organs of generation, or evidence of some process of generation analogous to what prevails in other animals. Ova were looked for, and organs of generation were looked for, where neither ova nor organs of generation existed. The calcareous particles visible in the tissues of those animals were at one time mistaken for eggs, and described as such, in the membrane of the Cysticercus (1841). At last, in 1842, a great insight was obtained regarding the nature of the generation and development of these and other parasites by the publication of facts which showed that amongst a certain class of minute Cerearice (worms of a microscopic size found in stagnant water), the generation of them was carried on through a series of broods produced from one parent, each brood differing from the parent and from each other. The discovery of this fact was due to Steeustrup. He described the phenomena under the name of " alternation of generation " amongst these Cerearice which ultimately live within the body of differen't mollusca (Planorbis and Lymnmus). These observations gave quite a new direction and impetus to investigation ; and Steenstrup himself foretold that the hydatid cysts would be proved to be undeveloped tape-worms, each cyst capable of producing a tape-worm after its kind. This view was at once taken up, and independently worked out, by Eschricht, Nordmann, Von Siebold, Kuchenmeister, Krsemar, Zenker, Leuckart, Weinland, in Germany ; Von Benedin, in Belgium ; Dujardin, Blanchard, and Robin, in France. Many physiologists and physicians of this country have been no less accurate observers. Barker, Bristowe, Nelson, Erasmus Wilson, Gulliver, Gull, Jenner, Busk, Rainy, Cobbold, and Bastian, may be particularly noticed ; and many valuable records have been published in isolated papers by officers of the Army Medical Department. The conjoint researches of these extensive workers have found most philosophical expositors in this country in Dr. E. A. Parkes, the Emeritus Professor of Clinical Medicine in University College, and now Professor of Hygiene in the Army Medical School {Brit, and For. Med. Review, 1853); in Dr. Allen Thomson, Professor of Anatomy in the University of Glasgow {Glasgow Med. Journal, No. x, July, 1855); and lastly, in Dr. William Brinton, in the Brit, and For. Med.-Chir. Review for 1857. From these and many other later sources the following account is given relative to parasitic diseases, and their rational treatment. Kuchenmeister and Von Siebold were the first to prove by experiment that the hydatid or vesicular worms were the young or larval states of tape-worms ; and they demonstrated — (1.) That each parasite had an independent life of its own. (2.) That most animals have each their own peculiar parasites ; that even parasitic animals are themselves infested with parasites. " So naturalists observe a flea Has other fleas on him to prey, And these have other fleas to bite 'em, And so proceed, adinfinitum." > (3.) That some parasites pass or migrate from the body of one animal Digitized by Microsoft® ELEMENTARY PACTS IN PARASITIC SCIENCE. 145 into that of another (including man), or from one part of the same animal to another cavity or viscus in it. Such migrations are required for the intro- duction of the entozoa or their ova into the animals they inhabit, and where they undergo those series of changes about to be described, by which they reach maturity. (4.) That thus, through food or drink, or both, or by bathing in impure water, entozoa pass into the human body, finding their way into the most delicate tissues, as minute ova or embryos, or as fecundated females like the Guinea-worm. (5.) That they undergo progressive changes of development towards matu- rity in each of the new localities where they find subsistence and protection. These are elementary facts in parasitic science ; and the student of Medi- cine cannot now rest satisfied with a mere knowledge of the general appear- ance of these so-called " worms " as they are found in man and animals. It behooves the physician to ascertain their origin, their source, and their mode of entrance into the body they inhabit. The easy but unsatisfactory hy- pothesis of "spontaneous generation" can no longer be entertained. On the contrary, it is now clearly established that all the parasitic entozoa are pro- duced more or less directly from fecundated ova. The general and minute anatomy of these " worms " must be studied, as well as their modes of gene- ration, reproduction, and phases of progressive development ; the various met- amorphoses of their individual forms ; and, their transmigrations from one animal into another. We must become acquainted with their existence even in and upon plants, as well as in other animals besides man, especially in such animals or plants as constitute the food of man — fish, flesh, fowl, mollusca, and Crustacea, — and especially also all fresh-water plants, or plants which grow on moist ground. But domestic animals which are not generally eaten, but which, being the companions of man, come, like him, to be infected with parasites, and so tend to promote their propagation alike in man and other animals, require atten- tion, as to their feeding and habits. A knowledge of details relative to the generation and reproduction of para- sites is also absolutely necessary .in order to appreciate the nature of parasitic diseases. Indeed,' without such knowledge no advance is likely to be made in the prevention of these diseases. It is this kind of knowledge which has recently led to most important practical results in the history of animal para- sites ; and which most of all seems capable of extending our knowledge of parasitic diseases, especially in relation to human pathology, to the rational treatment of parasitic diseases, and especially their prevention. Parasites of animal organization exist in man and animals in every grade of development ; and the first lesson for the student to learn is, — how to distin- guish entozoa which are sexually complete from those parasitical productimis which are destitute op sexual organs, which are immature larvae, or NON-SEXUAL PARASITES, b\d u'hich have long been regarded as distinct animals. The following is a classified list of Human Parasites, as given by the Royal College of Physicians of London, in the Appendix to their Nomenclature, p. 232. 10 Digitized by Microsoft® 146 TOPICS RELATIVE TO PATHOLOST. HUMAN PARASITES. The Parasites are to be returned as registered under Local Diseases. SUBDIVISIONS. 1. Entozoa. 2 ECTOZOA. 3. Entophyta and Epiphyta. ENTOZOA. A. CcBLBLMiNTHA. English synoni/m,Jl-ol\ow 'Worms. Definition: Worms with an abdominal cavity. B. Stebelmintha. English synonym. Solid worms. c. Accidental Parasites. Definition : Internal parasites, having the habits, but not referable to the class, of entozoa. Class A. Ccelblmintha. 1. Ascaris lurnbrieoides. (Linnseus.) Habitat: Intestines. 2. Ascaris my stax. (Rudolph!) Habitat: Intestin-es. 3. Trichocephalus dispair. (Rudolphi.) Habitat: Intestines. 4. Trichina spiralis. (Owen) Habitat: Muscles. ^ 5. Eilaria medinensis. (Gmelin.) Synonym, Dracunculus medinensis. English synonym, Guinea- worm. Habitat: Skin and subcutaneous tissues. 6. Pilaria oculi. (Nordmann.) Si/noni/m, Filaria lentis. (Diesing.) Habitat: Eye. 7. Strongylus bronchialis. (Cobbold ) Habitat: Bronchial tubes. 8. Eustrongylus gigas. (Diesing.) Habitat: Kidney and intestines. 9. Sclerostoma duodenale. (Cobbold.) S't/momym, Anchylostomum duodenale. Habi- tat: Duodenum. 10. Oxyuris vermicularis. (Bremser.) English synonym. Thread-worm. Habitat: Bectum. Class B. Sterblmintha. 11. Bothriocephalus latus. (Bremser.) T. lata. (Linnaeus.) Habitat: Intestines. The broad tape-worm endemic to man in some localities only. Its embryo is ciliated and developed in water (Knoch). 12. Bothriocephalus cordatus. (Leuckart ) Habitat: Intestines. Recently found in North Greenland. 13. Taenia solium. (Linnaeus.) Habitat: Intestines. 14. Cysticercus of the Taenia solium. Synonym, Cysticercus telse cellulosae. (Rudol- phi.) The larva or scolex of the T. solium 15. Taenia mediocanellata. (Kiichenmei.ster.) Habitat: Intestines. 16. Taenia acanthotrias (Weinland.) Habitat: Intestines. 17. Taenia flavopuneta. (Weinland.) Habitat: Intestines. 18. Taenia nana. (Siebold.) Habitat; Intestines. 19. Taenia lophosoma. (Cobbold.) Habitat: Intestines. 20. Tasnia eliiptica. (Batsch.) ifaftite^.' Intestines. 21. Cysticercus of the Taenia marginata. Synonym, Cysticercus tenuicollis. 22. Echinococcus hominis, or Hydatid of the Taenia echinococcus. (Siebold.) 23. Pasciola hepatica. (Linnaeus.) Habitat: Liver. 24. Distoma crassum. (Busk) Habitat: Duodenum. 25. Distoma lanceolatum. (Mehtis.) Habitat: Hepatic duct ; intestines 26. Distoma ophthalmobium. (Diesing.) Habitat: Eye. 27. Distoma heterophyes. (Siebold.) Habitat: Small intestines. 28. Bilharzia haematobia. (Cobbold.) i/uAiiai.- Portal and venous blood. 29. Tetrastoma renale. (Delia Chiaje.) Habitat: Tubes of the kidney. 30. Hexathyridium venarum. (Treutler.) Habitat: Venous blood. 31. Hexathyridium pinguicola. (Treutler.) Habitat : Ovary. Class C. Accidental Parasites. 32. Pentastoma denticulatum. (Siebold.) Habitat: Liver; small intestines. Digitized by Microsoft® MIGRATIONS OF PARASITES. 147 33. Pentnstoma constrictura. Habitat: Liver and lung; Negroes on West Coast of Africa. 34. Oestrus hominis. (Say.) English synonym, Larva of the gad-fly. Habitat: In- testines. 35. Anthomyia canicularis. (A. Parre.) Habitat: Intestines; and exciting causes of boils by their larva. ECTOZOA. 36 Phthirius inguinalis. (Leach.) English synonym, CTahAoase. 37. Pediculus capitis. (Nitzsch.) 38. Pediculus palpebrarum. (Le Jeune in Guillemeau.) 39. Pediculus vestimenti (Nitzsch.) English synonym. Body-louse. 40. Pediculus tabescentium. (Burmeister.) 41. Sarcoptes scabiei. (Latreille.) Synonym, Acarus. English synonym. Itch-insect.* 42. Demodex folliculoriim. (Owen.) 43. Pulex penetrans. (Gmelin.) English synonym. Chigoe. Habitat: Skin and cel- lular tissue. Entophyta and Epiphyta. 44. Leptothrix buccalis. (Wedl. Robin.) English synonym, A\gSi o{ the moath. 45. Oidium albicans. (Link.) English synonym, Thrush fungus. Habitat: Mouth in cases of thrush, and certain mucous and cutaneous surfaces. 46. Sarcina ventriculi. (Goodsir.) Habitat: Stomach. 47. Torula oerevisise. (Turpin.) Synonym, Cryptococcus cerevisiffi. (Kiitzing.) English synonym. Yeast-plant. Habitat: Stomach, bladder, &c. 48. Chionyphe Carteri. Definition: A cotton fungus occurring in the disease called Mycetoma. Habitat: Deep tissues, and bones of the hands and feet. 49. Achovion Schonleini. (Remak.) Habitat: Tinea favosa. f 50. Puccinia favi. (Ardsten.) Habitat: Tinea favosa.f 51. Achorion Lebertii. (Robin ) Synonym, Trichophyton tonsurans. (Malmsten.) Habitat: Tinea tonsurans. f 52. Microsporon Audouini. (Gruby.) Habitat: Tinea decalvans.f 53. Trichophyton sporuloides. (Von Walther.) Habitat: Tinea Polonica.-j- 54. Microsporon furfur. (Eichsladt. ) Habitat: Tinea versicolor. f 55. Microsporon mentagrophytes. (Gruby.) Habitat: Follicles of hair in Sycosis or Mentagra.f The foregoing list might be extended by the addition of various parasitic vegeta- tions, which have been reported under the names of Algse, Eungi, Mycoderms, Leptomiti, &c., but the characters or the existence of which are still the subject of inquiry. The distinction between mature and immature parasites has not been main- tained in the classification ; but in the description about to be given, it is . necessary that this distinction shall be maintained. The sexually mature entozoa inhabit either the alimentary canal of animals or the cavities of the lungs ; or, to express it generally, they inhabit such parts of the body as are in immediate or free communication with the exter- nal air. On the other hand, the non-sexual or immature entozoa, while para- sitic, all live inclosed in cysts ; such cysts being situated either in the parenchyma of organs, like the liver or lung, or in close internal cavities — e. g., the peritoneum, pleura, pericardium, or eye, within secreting tubes, blood- vessels, and the like. In such places these non-sexual parasites are all proved to be incomplete animals. They are the embryos, larvse, or early forms of entozoa, which only attain to sexual maturity by migration from the place of their earlier abode into the alimentary canal, or pulmonary, or other open cavity of different animals. Or, leaving their encysted parasitic state in the condition of larvse, they reach maturity in a free state (i. e., liberated from their encysted condition), when they are developed in water, in earth, mud, or upon moist plants, or in other conditions favorable for them. * The disease Scabies to' be returned amongst the parasitic diseases of the skin, f To be returned amongst the parasitic diseases of the skin. Digitized by Microsoft® 148 TOPICS RELATIVE TO PATHOLOGY. The cystic or vesicular entozoa (established by Rudolphi as a separate order of parasites) are to be distinguished from those which are not vesicular, but which are also inclosed in cysts. Some of the early parasitic forms of round -worms, as well as others, are thus inclosed in cysts ( Trichina spiralis) ; but they are not cystic or vesicular. Fig. 33, is an example of a cystic parasite — e. g., Cysticercus twnia mediocanellata ; Fig. 13, p. 154, of an en- cysted round worm — Trichina spiralis. All entozoa so encysted, whether they be cystic or round worms, are found to be immature ; and in no instance has the encysted entozoon been known to attain sexual completeness, however well grown it may appear to be, so long as it remains inclosed in a cyst. Sometimes cysts only are found, which may be identified as pathologically altered conditions of cystic or encysted entozoa. When free, all these entozoa come at last to acquire sexual organs, and, when they have arrived at matu- rity, they exercise the function of sexual reproduction. The number of fecun- dated ova which most of them produce is enormous. In a tape-worm or ascaris, there are many millions ; but " the struggle for existence " consigns the greater part of them to death as the food of others, such as birds, or fish, or animals unfavorable to their growth as parasites. The process of fecundation and the development of the embryo from the ovum have now been actually observed in a considerable number of the para- sitic entozoa ; and it is to be remembered, as a general fact, that the develop- ment of the ova rarely takes place in the same animal, or in the same part of an animal, where the parent parasitic entozoon has passed its life and has exercised the generative iunction. There is either a migration from a para- sitic to a free condition for a time (e. g., Chdnea-worm, Ascarides, Cercarice) ; or from one animal into another animal, the free condition intervening (e. g., Bothriocephalus) ; or, lastly, the migration may take place from one part to another of the same animal who is the unfortunate host (e. g., Trichina spi- ralis; and cases of tape-worm giving rise to Oysticercus). Some entozoa, known only as incomplete or immature animals in the parasitic mode of life, attain to sexual maturity in the free state ; others again, and perhaps the greater number, after living free for a time, become sexually complete in the parasitic condition (e. g., the Ascarides and the JBothriocephalus). " The migrations or changes of habitation of the entozoa, or their ova or embryos, appear to take place in a variety of ways : first, by their being passed out of the body of the inhabited animal with the faeces or other excre- tions ; second, by their being introduced into the bodies of inhabited animals with their food or drink ; third, by their directly piercing the integument or other tissues ; fourth, by their piercing the membranes and parenchyma, en- tering the bloodvessels, being distributed through them, and subsequently piercing their coats to attain other situations. "Some of these entozoa are directly developed from their ova, without undergoing more remarkable changes than those which are known usually to accompany the process of embryonic evolution in many other animals. Other entozoa are subject to individual metamorphoses, or the embryo passes through successive stages of development of so remarkable a character as to mark the regular sequence of the phenomena of progressive formation. There are others of the entozoa which are subject to still greater changes in the progress of their existence, — changes upon which great light has recently been thrown by the remarkable researches of Steenstrup and others, in regard to what has been called alternate generation or metagenesis. Thus some of the_ entozoa, by a non-sexual process, undergo that peculiar form of multipli- cation in which the immediate progeny of development from the ovum is dis- similar from the parent, but produces, without the aid of sexual organs, another progeny, which either itself, or by repetition of an analogous process, returns to the parental form. This is a process of the nature of an internal or Digitized by Microsoft® MIGRATIONS OF PARASITES. 1"49 external gemmation, which is often attended with a prodigious multiplication of the number of individuals. In some entozoa, again, metamorphosis and metagenesis are combined. It is obvious that the external conditions neces- sary to maintain these varieties of the vital states must be diiferent" (Allen Thomson, Glasgow Med. Journal, 1. c). The lesions and diseases caused by the existence of parasites rather tend to embitter existence than to cause death ; and they are especially frequent amongst soldiers. With one exception — namely, in the case of the immature cystic parasites — the disorders induced are, as a rule, not severe ; indeed, it is a condition of parasitism that it should not actually destroy the life of the animal from which it derives its own subsistence. It is the immature parasites which tend to destroy the life of their host, by the severe lesions they induce, and the destruction of the parts which they cause, when they pass from one place to another, or from one state to another onwards to maturity. Thousands of mature worms infest children, yet they do not appear ill. But such is not always the innocent history even of the mature worms, — undefined illnesses, violent and sudden pains, febrile phe- nomena like typhoid or rheumatic fever, chronic inflammations, wastings, convulsions, chorea, epilepsy, amaurosis, apoplexy, giddiness (staggers in sheep and horses), are the grave results which sometimes befall human or other animals who may become the unfortunate hosts of such undesirable guests as mature or immature parasites. Dr. Heslop, of Birmingham, has especially called my attention to the fact, that the accounts given of the cere- brospinal symptoms of worms are remarkably defective ; and he kindly sen{ me part of an essay of his on the subject, originally printed in the Dublin Quarterly Journal, No. 55. The following are his conclusions : "1. That in the great majority of cases of tape-worm, and, though with lesser frequency, in cases of other intestinal worms, more or less serious and peculiar nervous disturbances are apt to arise. "2. That the most frequent of these are headache, giddiness, various troubles of the special senses, especially singing in the ears, flashes and dark spots before the eyes, imperfect amaurosis, and trembling of the limbs. " 3. That various ansssthetic, and, on the contrary, neuralgic phenomena, are very frequent, usually connected with general lassitude and sense of mus- cular feebleness. "4. That, though less frequent than those previously cited, convulsive seizures, partaking of the nature of epilepsy or acute eclampsia, or sudden attacks of insensibility, mixed with syncope, and, in the female sex, severe forms of hysteria, are also often directly traceable to worms. " 5. That the last symptoms (No. 4) are more common in childhood and the earlier periods of life than afterwards, and are more frequently caused by the round and thread-worms than by tape-worm. " 6. That chorea does not appear to be often excited by the irritation of worms. " 7. That a feeble state of the general health generally accompanies the presence of worms ; often, in cases of taenia, proceeding to marked ansemia, so as even to lead to the suspicion of the possible existence of Bright's disease. " 8. That the irritative phenomena of the digestive tube, even when asso- ciated with various symptoms referred to the fiinctions of that tract, do not warrant the diagnosis of the presence of taenia ; and that their absence does not absolutely indicate the absence of -the parasite. " 9. That the frequent appearance of the nervous symptoms above related, without a well-marked relation to any special lesion of the nervous system, especially if alternating, with periods of perfect or nearly perfect freedom, should engender the suspicion that worms are present. If to these symptoms are added various ill-defined disturbances of the functions of assimilation. Digitized by Microsoft® 150 TOPICS RELATIVE TO PATHOLOGY. including occasionally colicky pains, without marked vomiting, pain after food, or decided emaciation, it is in the highest degree probable that -worms are the source of the symptoms. " 10. That it is probable that many of the symptomatic phenomena of ver- mination are connected not with their direct irritation of the mucous mem- brane with which they are in relation, but with a general disorder of the sys- tem, partly resulting from the parasites, and partly the cause of their main- tenance and development in the intestinal tract." Sometimes even death is the result. But in any case the prevalence of parasitic disease in animals comes in the end to be a national loss, affecting the health and wealth of nations, by rendering the flesh of many animals used as food innutritions, or altogether unfit for use. Following out the arrangement in the Table at pp. 146-147, a detailed de- scription of those parasites will now be given, and of the lesions associated with them, commencing with — I. — Entozoa. CLASS A. — CCELELMINTHA, OE HOLLOW WORMS. Definition. — Worms of an attenuated cylindrical form, with an abdominal cavity, in which an intestinal canal is suspended free. They are possessed of a mouth and anus, and have the sexes distinct. Patholog'y. — In their mature state these worms inhabit the alimentary canal, the pulmonary tubes or areolar tissue of man and animals. In their immature state some are encysted in the human body, and others come to maturity in the open waters. In the human subject they are represented by the Asearides, the Oxyurides, the Triehinm, the Sclerostoma, the Strongylus, the Speroptera, and the Filarice. A knowledge of the generation of these round worms is of the utmost impor- tance for preventing their occurrence in man. The generative organs of these nematoid worms are adapted for the reproduction of an enormous number of fertile ova. They are male and female; but the males, as a rule, are scarcer and smaller than the females. The fertility of these animals is enormous. Dr. Eschricht has made an elaborate calculation regarding the A. lumbricoides, the commonest parasite of man. The ova being arranged like flowers upon a stem in the ovary tubes, he has counted fifty in a circle, or in every transverse section. The thickness of each ovum he estimates -j-J^th of a line (= -j^-^th of Jjth = g^ijtli of an inch) ; so that in every line of length of the worm there would be 500 wreaths of 50 eggs each, == 25,000 eggs. The length of each horn of the uterus is taken at sixteen feet, which gives 2304 lines ; and for the two horns it will give 4608 lines. The eggs, how- ever, gradually get as large as -jJoth of a line, so that only sixty wreaths of eggs come to be on one line, or about 3000 ova ; and an average gives 14,000 ova in a line — i. e., sixty four millions of ova in every mature female Ascaris. What becomes of all these ova? The embryo is not developed within the body of all of these parasites ; and the source of the various Asearides which inhabit man is not yet fully known. The ova being discharged by millions, many of them in large cities are carried into streams of water. An extremely small proportion is ever likely again to find their way into the alimentary canal of the animal which was the dwelling-place of the parents of these ova. Thus they become food for numerous inhabitants of the water, and therefore stand in the same relation to many of these animals as the cerealia in the vegetable kingdom to the Digitized by Microsoft® INCUBATION OF OVA OP ROUND WORMS. 151 higher animals on land. Indirectly they thus contribute to the sustenance of man and animals. But on the other hand, there are many circumstances which tend to show that the A. lumhricoides is most frequently introduced as a minute embryo with water, or with fresh uncooked vegetable food. Dr. Paterson, an eminent physician in Leith, observed that certain families who drew water from a public well in a particular street there, were very subject to the A. lumhricoides; while towards the other end of the same street . the families were supplied by the pure water which supplies Edinburgh and its vicinity ; and these families were free from the parasite. The water of the well came from a dirty pond or lake in the vicinity (called Lochend), and in its water numerous vermiform animalcules existed, such as the Anguillula fluviatilis, perhaps the embryonic form of an Agearis. Another point to be remembered in all inquiries of this kind is the intense tenacity of life, and revival from a state of apparent death, exhibited by these parasites ; and in no class of animals has the origin by spontaneous genera- tion been more strenuously contended for than in regard to these entozoa. For example, there is a minute worm of a nematoid kind which is a parasite upon wheat grains (the Vibrio tritiei) ; some of these being dried, and then remoist- ened after a lapse of four to seven days, they resumed their living active state (Bauee, in Phil. Trans., 1823, p. 1, quoted by Owen). Dr. Blainville has given other similar instances of revival after desiccation ; and mature entozoa will even resist the effects of such destructive agents as extremes of heat and cold, to a degree beyond the endurance of any other minute animals. Owen relates that a nematoid worm has been seen to exhibit strong contortions — evident vital movements — after having been subjected above an hour to the temperature of boiling water with a codfish which it infested. Eudolphi mentions of some entozoa which infest herrings annually sent to Berlin hard frozen and packed in ice, that .they do, when thawed, exhibit unequivocal signs of restored vitality (Owen, Lectures on the Invertebrata, p. 80). lAgulm are often found alive in undercooked codfish. Eudolphi found individuals of Ascarides (spiculigerd) -stiff and hard in the gullet and stomach of a bird (eormoranf) kept in spirits of wine for eleven days, and which returned to life in warm water. Miram has seen individuals of the Ascarides (acus) from the pike become dry, and remain sticking to a board, where they would revive again by being placed in water, and in some instances they would move a part of the body which had imbibed the fluid, while the remaining part con- tinued shrivelled up, and adherent immovably to the board. I have seen the same results in the Ascaris which infests the peritoneal covering of the mack- erel. Such being the tenacity of life on the part of the mature animal, how •much more do the ova possess the powers of endurance? Without losing latent life, they even develop themselves under circumstances of the most im- probable kind. Dr. Henry Nelson and Dr. Allen Thomson have observed the development of the ova of the A. mystax to proceed for several days, while the parent bodies containing them were immersed in oil of turpentine. I have once seen the same occurrence ; and also I have seen the development of the embryo proceed in spirits of wine for about three weeks before signs of vitality had ceased. Periods of Incubation of the Ova. — The eggs are ovoid, and covered by a trans- parent envelope or chorion, which, after fecundation and segmentation, becomes . tuberculated. Hence the various accounts given as to their surface appear- ance. They are expelled with the fseces in the case of the A. lumhricoides. They have been placed in water and taken care of for various lengths of time, and Richter records, that at the end of eleven months each ovum contained a living embryo. In August, 1853, Verloren and Richter put a fragmennt of a mature female Ascaris (marginata of the dog) into water, so as to keep the ova moist merely ; and he examined them from time to time with the micro- Digitized by Microsoft® 152 TOPICS RELATIVE TO PATHOLOGY. scope. Segmentation having commenced, the development of the young was completed in fourteen days. They moved with great briskness within the egg-shells, hut did not break through them. In this imprisoned or encysted state they continued throughout autumn a-itdujinter; the movements of the embryos gradually diminishing, and at last entirely ceasing during the winter months, to recommence in the following spring, and become again distinct in summer. But, they never broke through the shell. The condition of these Ascarides from the encysted state of inclosure within the egg is only changed under favorable circumstances — ^namely, when the animals are liberated and carried on to further development ; and now it is known that the embryo of nematoid worms may pass the winter in a torpid state, floating about in the open waters, or lying in moist places. , The fully- formed embryo is cylindrical, its length y^th of an inch ; the mouth is not furnished with the three characteristic papillae of the genus, and the tail ter- minates suddenly in a point. It is highly probable, from the evidence, that the embryos are directly transferred to the alimentary canal of man from river and pond-water. 1. The Ascaris lumbricoides, or round worm, is perhaps the most anciently known, and is the most common of human entozoa. It is now regarded as specifically distinct from the A. megaloc&phala of the horse and the A. suilla of the hog (DujAEDiN, Moquin-Tandon, Cobbold). It is much more common in children and adults than in old people. The body is long (six to sixteen inches), round, elastic, and attenuated towards both extremities, but more attenuated towards the anterior end. It is of a grayish-red color, and suf- ficiently translucent to permit its viscera to be seen through its coverings. The Ascarides inhabit chiefly the small intestines, but may pass up into the gall-ducts, the stomach, the oesophagus, the nostrils, the mouth, or frontal sinuses ; and there are cases on record and specimens in museums where the worm has evidently penetrated the coats of the intestine, and got into the peri- toneum or into the pleura. It sometimes makes its way by the bile-ducts into the liver, and leads to hepatic abscesses. An interesting example of this may be seen in a preparation in the museum of the Army Medical Department at Netley. In some cases they are so numerous as absolutely to obstruct the intestines ; in others only a solitary worm, or a pair, may be found. Three distinct tubercles surrounding the mouth characterize the genus. The pos- terior end is obtuse ; but is straighter and thicker in the female than in the male. It is abruptly acute and curved in the male. An anus is situated in both sexes close to the tail, and in form is like a transverse fissure. In the female the body presents a constriction at thejunctionof the anterior Avith the middle third ; and here the vulva is situated. The parasite throughout is marked with transverse furrows and with fine striae. Longitudinal equidis- tant lines run from the head to the tail, and are independent of the exterior ■ envelope. 2. The A«earis mystax, which infests every domestic cat, must now be regarded as a human parasite (Pickells, Bellingham, Cobbold). It varies from an inch and a half to two or three inches long, its head end being spear- shaped, in consequence of two lateral processes, from which it has been named A. alata. The ova have the embryo developed within them before they escape from the parent, and in this respect they resemble the Oxyuris vermicularis. (See description of the Oxyuris vermicularis.) 3. The Trichocephalus dispar occurs in the caecum and colon, and was first noticed by Morgagni. A little more than a hundred years ago (1760-61) a student of Gottingen was dissecting the valve of the colon of a girl five years of age. He accidentally opened the gut, and several of these entozoa came out. Wrisberg and other students considered the worm a new one ; but the demon- strator of anatomy maintained that it was an Ascaris or an Oxyuris, and a dis- pute arose. At last the new parasite got a name as a new worm, and was Digitized by Microsoft® DESCRIPTION OF THE TRICHINA SPIRALIS. 153 called a Triohinalis or hairtail. But it afterwards turned out that its^eacZwas hair-like, and not its tail, so it has been since called Trlahocephalus. About this same time an epidemic raged in the French army stationed at Gottingen, and the disease was described under the name of the Morbus mucosits. This entozoon was frequently found in the bodies of the soldiers who died during the epidemic of this mucous flux. It is said to be very common in persons attacked with typhus fever; and is found in those dying with excessive discharges from the bowels, as in cholera and diarrhoea. It is found in France, England, Egypt, Ethiopia, and rarely in Italy ; abounding particularly in the caput ccecum. It is generally thought to be scarce in England — a persuasion which Dr. Cobbold thinks has probably arisen from " the negligence of pathologists, whose arduous duties connected with the superintendence of post-mortem examinations have, perhaps, left them little time for these inquiries." On the other side of the Channel this parasite is so abundant in some localities, that not less than one-half the inhabitants of Paris are affected by it (Duvaine). These parasites are males and females, in separate sexes, varying from one and a half to two inches. The anterior extremity, carrying the head, is the narrow hair end, and it is usually buried in the mucous membrane of the intestines, while the remainder of the body moves freely in the midst of the mucous secretion, generally coiled upon itgelf.' The males are shorter than the females, and less thick posteriorly, with a long spiculum. The eggs are oval, with resisting shells jTijth of an inch in length. 4. The Trichina spiralis was first seen by Tiedemann in 1822, and de- scribed by Mr. Owen in 1835 from a specimen taken to him by Mr. Paget. It has since been often recognized chiefly as a dissecting-room curiosity. The student tries in vain to clean the fibres of the muscle he is dissecting, which, however clearly displayed, still looks as if it were " sprinkled over with the eggs of some insect." Instances of the T. spiralis in the muscles of the human body are of much more frequent occurrence than has generally been supposed. Most probably, from their very minute size, they have hitherto been overlooked, and the symptoms of illness produced by their presence been mistaken for enteric fever and rheumatism,. Virchow had not seen a" case before 1859, after which he met with no less than six in one year. It is perhaps more common in man than even the Cysticercus. Zenker, of Dresden, found Trichince in four out of 136 dissections — i. e., one in thirty-four. Of late, however, much interest has been excited in this subject ; for, in place of the T. spiralis being quite a harmless parasite, as has been hitherto the belief, Zenker has lately shown that it is the source of a new and most alarming form of disease ; that, in place of remaining harmless and encysted in its capsule, only to cretify or degenerate, it may free itself from this cyst, and, migrating amongst the muscles, may give rise to symptoms of the most serious kind, causing death in a strong and healthy person after a few weeks of painful suffering. It seems, indeed, to be the most dangerous of all parasites — not even ex- cepting the Ecliinoeoocus ; and it behooves the physician to know something about the nature, origin, and development of this entozoon, seeing that its pathological relations are now known to be of extreme importance and interest. Hitherto the T. spiralis has been known as a minute round worm, inclosed in a more or less transparent capsule, lying between the sarcolemma_ of the primitive muscular fibres (Figs. 13, 14) ; but when the parasite is free, it finds its way within that sheath. It forms the type of a distinct genus of nematodes, having no genetic relations with the Trichocephalus dispar, as was supposed ; Digitized by Microsoft® 154 TOPICS RELATIVE TO PATHOLOGY. but is reproduced viviparously. The non-encysted Trichiim may exist in the flesh of animals without being visible to the naked eye. In the encysted state they are difficult of detection without the aid of a lens, if cretification has not commenced in the cyst. The cysts are round or elongated, and appear, according to their shape, like small round dots, granules, vesicular, or streaks, FlQ. 13. Slightly magnified cyst of TrUMna spiralis i,after Virchow). 100th of an inch X -MO. The Trichina spiralis removed from its cyst (after Virchow). grayish-white or opaque, and quite distinct from the red transparent muscle. When the cyst has loecome calcareous, its limey material may be dissolved away by acetic or hydrochloric acid with the evolution of gas, and the para- site is then seen coiled up within (Fig. 13). The following account of this parasite is given by Dr. Cobbold, from his own observations and those of Leuckart : "(DThe Trichina qnralis, in its mature state, is an extremely minute nematode helminthe ; the male, in its fully developed and sexually mature condition, measuring only y'gth of an inch, whilst the perfectly developed female reaches a length of about y ; body rounded and filiform ; usually slightly bent upon itself, rather thicker behind than in front, especially in the males ; head narrow, finely pointed, unarmed, with a simple central minute oral aperture ; posterior extremity of the male furnished witli a bilobed caudal appendage, the cloacal or anal aperture being situated between these diver- gent appendages ; penis consisting of a single spicula, cleft above, so as to assume a V-shaped outline ; female shorter than the male, bluntly rounded posteriorly, with the genital outlet placed far forward, at about the end of the first fifth of the long diameter of the body ; eggs measuring ^t}^-^" from pole to pole ; mode of reproduction viviparous. (2. ) The sexually mature trichina inhabits the intestinal canal of numerous warm-blooded animals, especially mammalia (also of man), and constantly in great numbers. ( 3.) At the second day after their introduction, the intestinal trichiuaj attain their full sexual maturity, lose their spiral figure and become stretched, whilst they grow rap- idly, and their generative organs are developed. (4.) Most females contain from three to five hundred ova. In six days the female parasites will contain perfectly developed and free embryos in the interior, and these, on attaining full size, pass out at the vaginal opening. The eggs of the female trichina are developed, within the uterus of the mother, into minute filaria-like em- bryos, which from their sixth day are born without their egg-shells. ( 5.) The Digitized by Microsoft® DESCRIPTION OP TRICHINA SPIRALIS. 155 new-born young soon afterwards commence their wandering. They pene- trate the walls of the intestines, and pass directly through the abdominal cavity into the muscles of their bearers, where, if the conditions are otherwise favorable, they are developed into the form hitherto known. (6.) The direc- tion in which they proceed is in the course of the intermuscular connective tissue. (7.) The majority of the wandering embryos remain in those sheathed muscular groups which are nearest to the cavity of the body (abdomen and thorax), especially in those which are smaller, and most supplied with con- nective tissue. (8.) The embryos penetrate into the interior of the separate muscular bundles, and here already, after fourteen days, acquire the size and organization of the well-known Trichina spiralis. (9.) Soon after the intru- sion of the parasite, the infested muscular fibre loses its original structure. The fibrillse collapse into a finely granular substance, whilst the muscular corpuscles change into oval nucleated cells. (10.) The infested muscular bundle retains its original sheathing up to the time of the complete develop- ment of the young trichinae, but afterwards its sarcolemma thickens and be- gins to shrivel at the extremities. (11.) The spot inhabited by the roUed-up parasites is converted into a spindle-shaped widening, and within this space, under the thickened sarcolemma, the formation of the well-known lemon- shaped or globular cysts commences by a peripheric hardening aud calcifica- tion. One cyst may have from one to three trichinae. (12.) The migration and development of the embryos also take place after the transportation of impregnated trichinse into the intestines of a new host. (13.) The further development of the muscle trichinse into sexually mature animals is altogether independent of the formation of the calcareous shell, and occurs as soon as the former have reached their completion. The male and female individuals are already recognizable as sexually distinct in their larval state." (Entozoa : an Introduction to the Study of Hdminthology, with reference more particularly to the Interrml Parasites of Man, by T. Spencer Cobbold, M.D., F.R.S. Lon- don, 1864.) The symptoms of the disease induced by this parasite are at first of a febrile nature, having a close resemblance to some forms of specific fevers. Dr. Philip Frank, lately Assistant Surgeon on the Staff of Her Majesty's Army Medical Department, was the first to send an account of this remarkable disease from Germany to this country. He described a case of its occurrence in the Medical Times and Gazette of May 26, 1860 ; and recently Dr. Parkes has given a short notice of trichina disease in the Sanitary Report of the Army Medical Depart- ment for 1860, p. 351. The history of the case referred to by Dr. Frank is as follows : In January, 1860, a servant girl about twenty years of age died in the Dresden Hospital from the effects of the T. spiralis; and the muscles of her body furnished materials for numerous observations and experiments, which have thrown much light on the origin and development of this parasite. The illness of the patient commenced about Christmas, 1859 ; and the symptoms may be arranged into two sets: (1.) Extreme lassitude, depression, sleepless- ness, loss of appetite, and eventually febrile phenomena which were well ex- pressed, so much so, that the case was set down as one of typhoid fever ; but grave doubts prevailed, for (2.) A new train of symptoms developed them- selves — namely, the whole muscular system became the seat of excruciating pain, especially in the extremities. Contractions of the knee and elbow joints supervened, and associated with such extreme pain as to render extension of the limbs impossible. Oedema of the legs followed; and the case terminated fatally by pneumonia, about the twenty-eighth or thirtieth day after the first symptoms of illness. A post-mortem examination of the body showed the muscles moderately developed, of a pale reddish-gray color, and dotted over with specks, which turned out to be groups of non-encapsuled Trichinm, lying free upon and within Digitized by Microsoft® 156 TOPICS RELATIVE TO PATHOLOGY. the sheaths of the muscular fibres. They were alive — some coiled up and others lying straight ; and they appeared to be in all stages of development, diffused throughout all the striated muscles of the body, not even excepting the heart itself. They abounded in such vast numbers that as many as twenty Trichince -were seen in the field of view through a low magnifying power, the muscular tissue being everywhere in a degree of very marked de- generation. In the jejunum were found sexually mature Trichince. Death was due to the development of the T. spiralis, whose existence fully explained the anomalous symptoms which attended the ease. On looking into the history of the girl, it was found out that she had been a servant in a farm-house, and had been taken ill very soon after the killing of two pigs and an ox — animals which it is customary to kill about Christmas. Pigs are known to be infested with the T. spiralis — so are oxen ; and Professor Zenker went to the master's house, and found some ham left of the identical pig that had been there killed, and also some sausages. The flesh of the pig was examined microscopically, and every specimen examined showed that the pig's flesh was infested with Trichince in the encysted state. At same time Professor Zenker learned that, soon after the girl had been taken ill, the housekeeper also became unwell, with similar symptoms, but in a less severe degree ; and all the servants about the farm became more or less ill about the same time. The house of the butcher who had killed the pig was then visited by Professor Zenker, who was informed by the wife of the butcher that he had been very ill since that event. He had been three weeks in bed, suffering from rheumatic pains in the limbs, and had been as if paralyzed over his body — unable to move his arms, legs, or neck. He had never suffered anything of the kind before, but had always been a he'althy and strong man. He thought he had caught cold the day he killed the pig; but when it is known to be a habit of German butchers to taste the meat they kill, in the raw condition, the history of these cases, to Professor Zenker, became a history of trichinatous disease — the development and growth to maturity of the T. spiralis in the muscles of those who lived at the farm-house, as well as of the butcher who had killed the pig, and who no doubt had eaten some of its flesh. Numerous experiments were made with the flesh of the girl who died in this remarkably morbid state. Portions of the flesh were sent by Zenker to Professor Virchow at Berlin. He fed a rabbit with some of it, and this rabbit died about a month after the feeding, with symptoms of general muscular paralysis, and myriads of young Trichinae were seen in its muscles. Other rabbits were fed with the flesh of the first rabbit, and they too died with similar phenomena. Virchow found the villi of the intestines of the rabbits loaded with the ova or prospermice of the entozoa ; and he found mature Trichince of both sexes moving freely in the mucus of the intestine. The males were filled with sperm corpuscles, while the females were densely stocked with ova and their germs, and with young ones in the eggs, coiled up like little snakes. Another observer had before made similar experiments. Herbst, in 1852, fed three young dogs with the flesh of a badger whose muscles were saturated with Trichinm. The dogs in their turn became trichinatous; being killed after a few, months, the parasites were seen in their flesh. Pigeons also were fed with moles' flesh known to be trichinatous; and free Trichinae were found in the flesh of the neck, the wings, and the thighs of the pigeons in eighteen days. But Herbst did not examine into the relation between the capsuled and the free Trichina, as Virchow and Zenker have done. The Trichina spiralis is now well known not to be limited to the muscles of man. It occurs in eels, cats, dogs, badgers, hedgehogs, pigeons, moles, and swine. It has been found in the horse, ox, sheep, and other ruminants; also in rabbits, rats, mice, and guinea pigs fed with trichinous flesh. Thus the Digitized by Microsoft® EXPERIMENTS WITH THE TRICHINA SPIRALIS. 157 debris of an animal eaten by carnivora may become fatal to rodents, or a car- cass near a marsh or rivulet may communicate the parasites to man or ani- mals drinking such water (Devaine). In the summer of 1860, a subject was received into the dissecting-room of the University of Edinburgh; and the muscles of that subject contained numerous flesh-worms. Dr. Turner (then Demonstrator of Anatomy, and now Professor) took the opportunity of verifying the experiments of the Ger^ man professors. He fed kittens with portions of the human flesh containing the worms, which were observed to move, though somewhat languidly, on rupturing the cysts. To one cat, on the 7th, 13th, and 16th of. July, he gave portions of the flesh, and in the intervals fed it on bread, milk, and fish. He killed the cat on the 24tli of the month. Nothing could be seen with the naked eye in the fluid of the small intestines ; but on placing a drop below the microscope, thread-like worms were seen actively moving about in it, or coiling themselves up in a spiral form. Every drop of fluid taken contained one or more. Each of these thread-like worms was about ^j'^th of an inch long, and -,-^^0*^ of ^^ ii'ch broad, with a pointed and a rounded end, and about two-thirds smaller than the mature flesh-worms met with in the muscles of the cat. These had migrated from the intestines, and after working their way between the fibres of the muscles, had become encapsulated — the cap- sules being perfectly transparent. Herbst and Virchow have found the flesh- worms both in the mesenteric glands and in the mesentery, and therefore, presumably, in transitu between the intestines and the muscles. All the phenomena described occurred within the space of a single month ; and even as early as three weeks after feeding, Virchow found the young brood equal in size to those administered at the commencement. The genesis, develop- ment, and migrations of these flesh-worms are thus proven to be astonishingly rapid. Dr. Thudichum has also very recently verified these experiments ; and at the conversazione of the British Medical Association, held at Downing College, Cambridge, on 4th August, 1864, he exhibited the parasite, living, in various stages of development, which he obtained from the muscle of a rabbit infested with them, and also from some pork chops (Brit. Med. Journal, August 13, 1864). Thus the T. spiralis has been shown to be a bisexual parasite, producing its young alive in the intestines of the animal whose muscles it may infest. So long as it remains in the capsule, it is immature and non-sexual, and so far they are harmless. In the mucus of the intestines the mature TrichincB find a suitable place for growth and breeding, their progeny finding their way to the muscles, where they eventually become encysted ; and their favorite haunt there seems to be the small muscles of the larynx (Zenker). According to Virchow's conclu- sive testimony, all these phenomena occur within the space of a single month; and, in his experiments, even as early as three weeks after ingestion, the young were found to equal in size those that he administered at the commencement ; but even in the seventh and eighth week, living Trichince have been found in the intestines, filled with eggs and embryos, rendering it not improbable that the intestinal Trichince bear young repeatedly, which pass into the muscles at difierent times ; hence also the exacerbations of the disease. The genesis and migrations of Triehinm are therefore astonishingly rapid, and probably with- out parallel in this class of parasites (Cobbold). Since the discovery by Leuckart of the round worm, of which the T. spiralis is the immature condition, since the case recorded by Zenker, and since the more complete knowledge that has been acquired by experiments of the won- derful migrations of the young Trichince, attention has been especially directed to the possibility of the triehinatous disease in man being much more common than was anticipated. In December, 1860, Professor Wunderlich met with a ease of prolonged fever, which did not correspond in its course Digitized by Microsoft® 158 TOPICS RELATIVE TO PATHOLOGY. with any of the well-known specific fevers. The patient was a butcher. He eventually got quite well, and so far negatived the diagnosis of acute tuber- culosis which had been made. A second butcher, from the same establish- ment, came into the hospital with the same symptoms of high fever, with immense depression ; but the course of the disease again did not correspond with any of the known fevers. Here, as in the first case, the muscles were particularly implicated, but in a less degree. There was not only muscular pains, but absolute soreness of the muscles on pressure. This man, too, eventually got well. A third and a fourth butcher, from the same house, were also taken ill with similar severe febrile symptoms, but they were not seen by Wunderlich. These men had been killing a number of pigs ; and, as is the custom, they ate of the raw flesh. Eight men so ate, and four of them were afterwards attacked with these anomalous but severe febrile symptoms. Unfortunately none of the pork had been preserved, and the possibility of IHehince existing in it had therefore not been proven. Moreover, none of these men died, and no evidence of the parasite existing in their muscles was obtainable. But looking to the undoubted fact that the use of the raw meat brought on the disease, and to the great probability that the wanderings in large numbers of the Trichinas, will produce these symptoms, Professor Wunderlich deems him- self justified in thinking that there are some grounds for considering these febrile attacks to have been due to triehinatous disease. That individuals enjoy good health, although the muscles are infested with the encapsuled Trichince, is now well known, from the number of cases that have been seen in dissecting-rooms. Cases are also referred to by Mr. Curling, of its being recognized in the muscles of men killed by accident, when engaged in severe manual labor (London Med. Gazette, Jan., 1838; also Turner, in Edin. Med. and Surg. Journal, 1860, p. 209). The distinguished teacher of clinical sur- gery at Berlin, Professor Langenbeck, related to the Medical Society there, in 1863, the case of a man from whom he had recently removed an epithelial cancer situated in the neck. During the operation, the platysma myoides exhibited a singular appearance, which, on careful inspection, was found to arise from the presence in the muscle of innumerable dead IHehince, con- tained in calcified capsules. On inquiry, the following facts were elicited: In the year 1845 there was a "church visitation" (whatever that may mean, and it seems to imply some jovial meeting), in which eight persons took part, and of these, seven afterwards sat down to a breakfast consisting of ham, sausages, cheese, roast veal, and white wine. In the course of three or four days every one of the seven persons was seized with diarrhoea, pains in the neck, oedema of the face and extremities. Of the seven, four died, and the three who survived (among whom was the man operated upon eighteen years afterwards by Professor Langenbeck), remained ill for long afterwards. The suspicion arose that poisoning, through the agency of white wine, had taken place; and an investigation was made, but without any result. The innkeeper, however, at whose house the breakfast was given, being still under suspicion, was obliged to give up his business and emigrate. The importance of such a case in its forensic aspects cannot be overrated; and it becomes an important subject of inquiry whether some of our cases of death from suspected but un- proved poisoning may not be due to trichina disease, which is now known to be much more prevalent than has hitherto been supposed, both in this country and in Germany. Very recently attention has been again awakened on the subject by an occurrence almost tragical. About the middle of October, 1863, there was a festive celebration at Heltstadt, a small country town in Prussia, near the Hartz Mountains, numbering from 5000 to 6000 inhabitants. One hundred and three persons sat down to an apparently excellent dinner, mostly men in the prime of life. Within a month more than twenty persons had died, Digitized by Microsoft® OCCURRENCE OF TRICHINA SPIRALIS IN MAN. 159 and more than eighty persons were then suffering from the fearful malady, while those who were apparently unscathed were in hourly fear of an outbreak of the encapsuled flesh-worms. The dinner had been ordered at a hotel, and it was arranged that the introduction to the third course should consist of " Rostewurst." The sausage-meat was therefore ordered at the butcher's the necessary number of days beforehand, in order to allow of its being properly smoked. The butcher, on his part, went to a neighboring proprietor of pigs, and bought one of two pigs from the steward of the pig-farm. The steward unfortunately sold a pig which his master intended should not be sold, because it was not considered to be in good condition. Nevertheless, for this time, at least, the 'butcher got "the wrong sow by the ear." The ill-conditioned pig was the one that was killed and worked up into sausages. These were duly smoked and delivered at the hotel; and after being toasted before the fire (so as to be warmed through merely), they were served to the guests at the dinner-table. On the day after, several persons who had eaten the dinner were attacked with great irritation of the bowels, loss of appetite, great prostration, and fever. The' number of persons attacked rapidly increased; so much so, that great alarm was felt in so small a town lest an epidemic of typhoid fever was about to set in. But one of the physicians at last conjectured that some poison must be at the bottom of the outbreak, and an active inquiry into all the circumstances of the dinner was instituted ; and when the muscles of the calves of the legs of some of the sufferers began to be affected, the description of Zenker's case (already described, pp. 155, 156, ante) was at once remem- bered. The remnants of sausages, and of pork employed in the manufacture of them, were examined with the microscope, and found to be literally swarm- ing with encapsuled flesh-worms. From the muscles of several of the suffer- ing victims small pieces were excised, and under the microscope they were seen to be charged with Trichince in all stages of development. It could therefore no longer be doubted that as many of the 103 persons as had dined together and partaken of the "Rostewurst" were affected with trichinous dis- ease by eating the trichinous pork, the flesh- worms of which had not been killed by the smoking and toasting. On the contrary, the subdued heat of toasting would rather foster their vitality. This catastrophe awakened sympathy and fear throughout the whole of Germany. Most of the leading physicians were consulted in .the interest of the sufferers ; and some visited the neighborhood where most of the affected patients were. None could bring relief or cure. Case after case died a slow and lingering death, by exhaustion from nervous irritation, fever, loss of muscu- lar power, inflammation of the lungs, or of organs essential to life. The cases have been observed with great care and chronicled with skill. All the fea- tures of the remarkable disease have been registered in such a manner that hereafter there can be no difiiculty in recognizing the disorder. The disease begins a few days after eating the meat in which there were Trichince, with loss of appetite, general discomfort after eating, irritation of the stomach, vomiting, and diarrhcea. These symptoms last from four to eight days, till the progeny are born. Severer symptoms may set in, and continue till the parasites are encapsuled, if not previously fatal. These symptoms are, — <3outinued. diarrhoea and fever ; oedema of the eyelids ; also pain, or at least painful sensation of weakness in the limbs ; oedema of the joints, sometimes of the whole body; difiiculty in moving the tongue; profuse clammy perspiration ; and those patients who do not become convalescent die either unconscious, with symptoms of typhoid fever, or, in a few cases, remain conscious to the end, complaining of inability to breathe freely. The suf- ferer generally lies on his back, with his legs drawn up, unable to move or speak. The only important symptom of typhoid fever said to be absent in the disease is the enlargement of the spleen ; and it is very probable that Digitized by Microsoft® 160 TOPICS RELATIVE TO PATHOLOGY. some of the so-called epidemics of typhoid fever in former days were caused by the propagation of TrichiruB in the human body. But the epistaxis, the pains and gurgling on pressure in the right iliac region, the rose-colored erup- tion, characteristic of typhoid fever, cannot exist in trichinous disease ; while the earlier irritation of the stomach and bowels, with oedema of the face and severe muscular pains, especially on motion, with breathlessness increasing to dyspncea, or almost asphyxia, ought to render the parasitic disease easy of diagnosis from enteric fever. Pneumonia or peritonitis may be suddenly fatal in mild cases. Since the disease has become better known, a great many cases have been observed in Germany, and several cases in the United States. On this sub- ject, Dr. Clymer records, in the second American edition of my book, that — "In 1859, 1860, and particularly in 1862, many cases were noticed at Blankenbourg, chiefly amongst the soldiers. In 1862, of 60 attacked, 2 died (ScHOLz). Two cases were seen by Wunderlich in Leipsic in 1861 ; and Wagner describes 5 eases which occurred there in 1863 {Archiv. der Heil- kunde, 1854). Landois met with 12 cases in the island of Riigen in 1861, and Wentzel with 20. In that year, at Cosbach, 3 persons of the same family, who • had eaten of fresh pork, and in whose muscles Zenker found trichinae, were affected. In the same year, 300 fell ill with the disorder in Magdebourg, and 2 died. In the summer of 1862, at Calbe, 30 persons, in a population of 1200, were attacked — 9 males, 25 women and 4 children; and 8 died — 1 male, 6 women, and 1 child. In the spring of 1862 there was an outbreak at Plauen, in Saxony, and several died (Bohler). In the autumn of 1863 the Heltstadt epidemic occurred, already described. There was an outbreak at Hedersleben in 1865 (300 cases and 40 deaths) ; at Zittau, in 1866 (57 cases) ; and at Gorlitz (80 cases and 1 death). " But few cases of the trichinous disease have been recognized in the United States. The first cases reported are believed to be those of Dr. Joseph Schnet- ter, of New York ; 2 cases after eating underdone pork-steaks ; neither were fatal (January, 1864) ; and 5 eases and 1 death (February, 1864), of persons who had eaten raw ham, in which trichiase were subsequently found.* About the same time. Dr. Voss, of New York, had 4 cases on board one of the Bre- men steamers, then in the harbor. Dr. Voss verified his diagnosis by cutting down on the deltoid muscle of one of the affected persons, and removing a portion for microscopical examination ; it proved to be filled with trichinse.f Dr. J. R. Lothrop, of Buffalo, has reported a case.| Nine cases have hap- pened in 1866 in one family at Marion, Iowa, and been reported by Dr. Joseph H. Wilson.§ About the 5th of May, six persons in the family of Mr. Bemiss, of that place, were taken ill, with the characteristic symptoms of the trichinous disease, which was not, however, at first recognized, and the disorder was looked upon and treated as typhoid fever. On the 14th of May, three other members of the family became similarly affected. It appeared that towards the end of April a couple of smoked hams had been bought, and from that time until the 5th of May all the nine had eaten of it sliced raw, and all had been taken ill in from five to ten days. Five of the nine died. Two post-mortem examinations were made, and trichinse were found in large numbers, and very active, in the muscles, in the lungs, and spleen. All the organs appeared healthy to the eye. It is stated that one of the family ate some of the meat 'rarely done,' and was affected but slightly, and another, * Observations on Trichina Spiralis, by John C. Dalton, M.D. The Transactions of the New York Aoaderiiy of Medicine, vol. iii, 1864. •)■ Dalton, I. c. I ATreatiseon the Principles and Practice of Medicine, by Austin Flint, M.D., 1866. I St. Louis Medical Reporter, July 15, 1866 ; Chicago Medical Journal, August, 1866 Digitized by Microsoft® CASES OF TRICHINA SPIRALIS IN THE UNITED STATES. 161 when well cooked, who was unaffected. No portion of the offending ham was got for examination ; but it was shown that some of it had been given to a healthy sow, who died on the 1st of June, ' with all the symptoms of hog- cholera ; and on some of her meat being examined, it was found swarming with trichinse.' Dr. H. Ristine, of Marion, Iowa, has also reported six cases,* happening in the same country, in four families living in the same neighbor- hood, all children, their ages ranging from seven to seventeen years. It appears that on the 25th of April, 1866, they had all eaten chips of raw ham. ' On the 27th they were, most of them, seized with diarrhcea, followed in two or three days by the other characteristic symptoms. In the oldest girl the order of succession was reversed, the muscular pains preceding the diarrhoea.' The ' counterpart of the eaten ham, put up in brine, was examined and found to contain trichinous cysts.' The same meat, it is stated, was eaten by the family of the owner, when well cooked, and with no bad effects. We have no data at present to estimate the degree of prevalence of trichinous disease amongst the hogs of this country. " The symptoms of the disorder in the pig are said to be loss of appetite, a hoarse voice, and aversion to movement, particularly to running ; and when this is attempted there is dragging of the extremities (Cobbold). Still it is positively asserted that the animal may be infested, and yet show no signs. Cobbold mentions an instance where a pig appeared remarkably healthy, and yet the butcher who ate his flesh died of the disease. Delpech says, in his Report to the French Government : ' It is rare that any symptoms are spon- taneously developed in the infected animal which would lead to any suspicion of the disorder : it has the appearance of perfect health. The butchered meat, too, looks well.'t Dr. H. Jardine states (foe. cit.) that, in his vicinity, the opinion prevails that the trichina spiralis exists in the flesh of animals affected with hog-cholera, the symptoms of this disorder being diarrhcea, swelling of the neck, stiffness of the limbs, debility, and cough ; but the opinion has not been yet verified by microscopic examination. "The Chicago Academy of Sciences appointed in the spring of 1866 a com- ,mittee of physicians, 'to examine into the facts concerning the supposed existence of trichinse in pork raised in this country.' The results of their well-conducted observations were, that having procured and examined por- tions of muscles taken from 1394 hogs in the different packing-houses and butcher-stalls of Chicago, they found trichinaj in the muscles of twenty-eight hogs ; from which they conclude, that in the hogs brought to that city, 1 in 50 is affected with trichiniasis in a greater or less degree ; which would indi- cate that trichiniasis in pork is even more common in this country, or in that of the Northwestern States, than in Germany. In the town of IBrunswick, North Germany, where a most careful inspection of 19,747 hogs was made in the years 1864-65, only two were found to have trichinse in their muscles ; 'the proportion being 1.10000 to 1.50 in the Chicago pork. 'J One of the tables of the Chicago committee shows the great variation in the number of helminthes infesting the several muscles examined. An approximation only to the number existing in a cubic inch of a given muscle could be obtained. The method adopted was to count the trichinse existing in several different portions of a muscle, each a cubic jgth of an inch in size, and to multiply the average number to a cubic inch. Of twenty-eight specimens examined with this view, only three of them contained over 10,000 to the cubic inch, — 18,000, 16,000, and 15,000 respectively. The remaining twenty-five were infested to a much less degree — from 48 to 6000 in the cubic inch. It was * The Medical Record, New York, August 6, 1866. f See the Report officially made to the French Minister of Commerce by MM. Del- pech and Raynal, Bulletin des Academic de Medecine, May, 1866 i Chicago Medical Examiner, April, 1866. VOL. I. 11 Digitized by Microsoft® 162 TOPICS RELATIVE TO PATHOLOGY. calculated that a person eating an ordinary meal of the pork from which the specimen containing 18,000 to the cubic inch was taken, would soon become infested with not less than 1,000,000 of young trichinse* " With regard to the muscles of the hog which are the most common site of trichin», the observations of the Chicago committee do not agree with those of European observers. In Germ9,ny, the inspectors of pork are instructed to examine microscopically nine different sets of muscles, — ^namely, those of the diaphragm, tenderloin, shoulder, front and back of neck, extensors of the fore-arm, flexors of the leg, and the ipuscles of the larynx. In the trichinous- infested muscles examined by the Chicago committee, more than one-half were spinal muscles, which are not named in the German list. " In conducting an examination of the trichinatous pork, the tendinous extremities of muscles should be selected, as here they are usually most numerous. The cysts are visible to the naked eye as whitish, round, or ovoid specks, sprinkling the surface of the muscle. If a very small piece of muscle is cut off with scissors, and then torn in shreds with a needle, freeing the cysts from the flesh, and these are touched with a drop of hydrochloric acid, the lime is dissolved and the white coloring disappears ; or a piece of the sus- pected flesh may be put into a watch-glass with liquor potasse (1 part to 8 of water), when it becomes changed to a mucus-like, clear mass, and the cap- sules will be seen as sharply defined minute white specks (Leuckabt). But it is always better, if possible, to use the microscope, and trichinae not yet encysted can only be recognized by the microscope. A thin layer of the sus- pected flesh should be cut out with a sharp knife, and spread over a glass plate, moistened with a drop of water, covered with a thin piece of glass, and examined by a magnifying power of 50. Their intimate structure cannot be recognized with a less power than 200 (ALTHAUS)."f The vitality of the Trichince is not destroyed in the meat or in other sub- stances, such as sausages, in which they may be located, below the tempera- ture of boiling water ; and it is fully proved that if subjected for a sufficient time to insure that every particle has been acted upon by that degree of heat, they are found incapable of further development, and are, in fact, destroyed. Salting, smoking, and toasting trichinous meat, as is usually done, does not appear to be sufficient to destroy the worms in all parts of the meat. Picric acid (acidum picro-nitrieimi) has failed. In trichinous pork of a pig killed with picric acid the worms were found alive (W. Mullee, of Hom- berg). Benzine, too, has failed. Carbolic add has also been recommended ; and any of these may kill or render the parasite inert if it is still in the stomach ; but if its progeny have bred, and commenced to penetrate the tissues, nothing seems able to remedy the 6vil till the parasite becomes encapsuled. A few doses of calomel and castor oil repeated occasionally, even although diarrhoea may be present, is advised by Ruprecht to remove intestinal Trichince. He also recommends wet-sheet packing, to relieve the sleeplessness and the copious sweats. When this flesh-worm was seen more than thirty years ago, it was little thought that the bit of muscle sent to Owen contained the germs of a disease * As many as 2,000,000 trichinae have been estimated in the muscles of a man who died of the disorder ; and Prof. Dalton counted in a piece of muscle (in one of Dr. Schnetter's cases) ^\th of an inch square, and ^^th of an inch thick, where they were in average abundance, twelve trichinae, which would give in round numbers over 85,000 to the cubic inch ; and in the portion of inusclft taken from the living subject, in Dr. Voss's case, they numbered a little over 7000 to the cubic inch (Dalton, I. c). In one of Dr. Wilson's cases, which proved fatal, 104 trichinas were counted in'a piece of the rectus femoris muscle measuring -jJ^th of an inch square, and Jjth of an inch thick, which would give nearly 180,000 to the cubic inch (Clymer). f On Poisoning by Diseased Pork; being an Essay on Trichinosis or Flesh-worm Disease; its Prevention and Cure. By Julius Althaus, M.D. London, 1866. Digitized by Microsoft® DESCRIPTION OF GUINEA -WORM. 163 which might be carried in a living pig from Valparaiso to Hamburg, and then kill almost the entire crew of a merchant vessel. It has been recently- related that a pig so diseased was shipped at Valparaiso, and killed a few days before arrival at Hamburg. Most of the sailors ate of the pork in one form or another. Several were affected with the flesh-worm, and died. One only escaped being ill. Numerous cases of fever, and epidemics of inscruta- ble peculiarity, are now claimed by medical writers, with much show of reason, as outbreaks of the flesh-worm disease. _ Professor Eckhardt, of Giessen, has obtained permission to produce the disease in a criminal condemned to die, and to try various remedies on him. (For a very interesting account of Trichinoua or Flesh-worm disease, the reader is referred to the recent work of Dr. Althaus on this subject.) For the diagnosis' of Trichince in the muscles of man, Kuchenmeister has proposed to harpoon the muscles; but this seems a very severe operation. Welcker believes that the best place to look for them is under the tongue, close to the frsenum : in cats they can be easily seen in this situation. Whether it is so in man is not yet known (Virchow's Archiv., 1861, p. 453, quoted by Dr. Parkes, 1. c). 5. The Filaria medinensis, commonly called Guinea-worm, or Dracunculus, livesamongst the connective tissue of man and of some animals. In this situa- tion it is only known as a female, containing in its germinal sac an enormous quantity of young Filaria, and resembles a long piece of uniformly thick white whip-cord. In this country few are familiar with its appearance, or with the lesions it produces ; and we therefore look for our knowledge regard- ing the main points in the natural history of this parasite to be furnished to us by observers in Africa or Asia ; who we hope will fill up the gaps which still exist. The Guinea-worm is essentially a tropical parasite. It is endemic in the hot intertropical regions of Asia and Africa, extending from Egypt, about 23° or 24° north latitude, to Sumatra and adjacent islands, as far as 10° or 12° south. But it is only in some districts within these tropical limits that the parasite abounds. For example, it is endemic in Arabia Petrea, the borders of the Persian Gulf and of the Caspian Sea, the banks of the Ganges, Upper Egypt, Abyssinia, and Guinea. Its occurrence in Guinea (although it has its common name from this place) is extremely capricious. In some districts every native who comes off to the ships seems to be affected by it ; in other places in Guinea it is very rarely seen. The F. medinensis is unknown in America, unless the person in whom it exists has been in the places where the Dracunculus is endemic. The only exception is the Island of Cura9ao. It is sometimes so extensively dissemi- nated that it has been said to prevail after the manner of an epidemic. Although this parasite rarely causes death, still it is often the cause of great distress and loss of strength to regiments quartered in those places where it is epidemic. In the Statistical Sanitary and Medical Reports of the Army Medical Depart- ment for 1860, the admissions for Dracunculus into the hospital may be shown as follows : I.— EUROPEANS. stations. Average Strength. Total Admissions. Ratio per 1000. Home Stations,* . . Mauritius, . . . . Bengal, Madras, . . . . . Bombay, 97,703 1,886 42,371 10,696 11,388 28 17 51 19 114 .3 9.0 1.2 1.7 10.0 * It is of course to be inferred that these men had served abroad in countries where Dracunculus is endemic. Digitized by Microsoft® 164 TOPICS RELATIVE TO PATHOLOGY. II.— BLACK TKOOPS AND ASIATICS. Stations. Average Strength. Total Admissions. Eatio per 1000. Sierra Leone, . . . Gold Coast, ^outh China, . . . 379 313 2611 1 77 73 26 246 26.0 In India, the average number of days which those affected with the Guinea- worm remain in hospital increases progressively with advancing years. During the first period of life (18 and under 20 years of age), the average number of days under treatment — during which period each person was rendered ineffec- tive — was 14.8 ; during the second period (20 and under 25 years), it was 16.188 days ; during the third period (25 and under 30 years), it was 18.001 days ; during the fourth period (30 and under 35 years), it was 22.718 days ; during the- fifth period (35 and under 40 years), it was 24.290 days; during the sixth period (40 and under 45 years), it was 31.620 days (Ewart). Dr. Leith, in the Bombay Mortuary Reports, records 133 deaths from Dror eunculus in eight years (from 1848 to 1857). A fatal result generally takes place from hectic (Loeimee) and exhaustion, consequent on the copious dis- charges which sometimes follow the presence of the parasite, or from abscesses forming and bursting into the abdominal cavity (Ewaet). Death has fol- lowed from tetanus (Drs. Minas and McKenzie, Trans, of Hydrabad Med. and Phil. Society). Great destruction of tissues sometimes results from sloughing ; and deep-seated inflammation may attend its existence, with the formation of abscesses and deep-seated sinuses. The death of one person is recorded by Dr. Minas at Sirsa, in whom the whole body and skin was a network of Guinea-worms. As a rule, however, the patient is unconscious of the presence of the Dracunculus till it is matured and ready to make its exit. The Number of Worms observed in any one individual is very various. In the rnajority of cases only one is present, or known to be making its exit at one time. But there are remarkable exceptions to this rule. Mr. Forbes men- tions that most of those affected have had two worms extracted ; but many have had four, five, and six ; and when he wrote he was then treating a man in hospital in whom no less than fifteen were exposed to view, and many of these were extracted. Dr. A. Farre mentions that as many as fifty worms have been met with in one person. Such cases, however, are confessedly rare even in India, where fifteen worms is about the greatest number observed. Seat or Locality of the Parasite. — The lower extremities are by far the most frequently affected — or rather, the parasite most frequently tends to make its exit there ;— 98.95 per cent, of the parasites do so. Two cases are recorded by Lorimer, remarkable in this respect, that one gave vent to seven and the other to thirteen parasites. In the case where seven parasites were extracted, two were from the left foot, three from the left leg, one from the right leg, and one from the left forearm. In the case where thirteen parasites were extracted, four were taken from the left foot, two from the right foot, two from the left leg, one from the right leg, one from the right thigh, and three from the right forearm. The Dracunculus has made its appearance in the socket of the eye, in the mouth, m the cheeks, and below the tongue (Scott). Dubois records its exit from the nose, the ears, and the eyelids. Dr. Kennedy records cases in which the parasite made itself apparent in the back and muscles of the loins One preparation exists in the Museum of the Army Medical Department, in which a great number were removed from beneath the scalp. Instances are recorded m which the worm has been found in the internal viscera. All such cases are regarded as extremely rare. It is of importance to notice, however, that Digitized by Microsoft® GUINEA -WORM IN HORSES AND DOGS. 165 both Dr. Scott and Dr. Van Someran agree in stating that the men who carry water in India, in leathern bags on their back, are infested by the Bra- cuncuhts on all that part of the skin that has often been wetted ; while Drs. Qhisholm and Scott state that the legs of persons who walk among grass (especially during the rainy season, and particularly gardeners and agricul- turists, and those who are obliged to wet themselves frequently) are at all seasons liable to Dracumculi. Some animals are said to be affected by the parasite. Forbes says that horses and dogs are so affected, and relates that a "tatoo" (a small Indian horse) was exhibited at Dharwar, having a Dra- cuneulus protruding from its right hind fetlock. The parasite was of the usual size, and made its appearance as a boil; and no difference could be perceived in any respect in it from the Drammeulus which infests man. Clot Bey remarks that dogs are also sufferers; but on this head information is greatly to be desired. Assistant Surgeon Adam Taylor, of the 1st Goorkha Light Infantry, wrote me from Bootan, in 1866, that during the rains of August, 1862, he being in medical charge at Hissar, a sandy district about seventy miles from the desert of India, he saw a favorite bull-terrier with swollen feet. From a fluctuating tumor in one of the hind feet he liberated four ounces of serum, and eighteen inches of a Guinea-worm; four inches more the next day; and the remainder, about iifteen inches, was wheedled out by a native barber the following day. The worm was exactly the same as those found in man ; and he has repeatedly seen Dracunculus in horses, and heard of their existence in camels. He believes the habitat of the para- site is sandy soils and not water. Migratory Powers exhibited by the Guinea-worm before Extraction. — Dr. Smyttan relates the cases of two officers, in one of whom the Dracunculus could be felt, and traced with the fingers like a cord under the skin at the top of the shoulder. By and by it made its way to the elbow, where it was equally distinct ; and in a few weeks it gradually worked its way to the wrist, whence it was extracted. In the other case the Guinea-worm was observed under the skin inside the biceps, and about the middle of the upper arm. It then passed round the elbow-joint and down to the middle of the forearm, then back to the region of the inner condyle of the humerus, whence it was extracted. It was three months engaged in this migration. Dr. Baton records similar cases {Edin. Med. and Surg. Journal, 1806, vol. ii, p. 151) ; and Dr. Morehead says of his men, that when they had felt the Guinea-worm in the thigh, in the first instance, it had subsequently been ejected from the foot. He has distinctly noticed the corded feeling of the worm below the skin, and observed that it was entirely gone the next day he examined the part. Dr. L. W. Stewart, of the Madras Medical Service, relates a very dis- tressing instance of this kind which happened to an officer, from whose scro- tum a Guinea-worm fifteen inches long had already been extracted. Ten days afterwards he experienced an unpleasant sensation in the posterior aspect of the left thigh. Day by day the sensation shifted lower down, till it reached the popliteal space. A few days later the sensation was experienced in the calf. Hitherto nothing was visible; but at the end of sixteen days from the first sensation in the thigh, the convolutions of a Guinea-worm could be distinctly traced at the outer side of the ankle-joint. Dr. Stewart now wished to cut down and extract the parasite, but the evening was too dark, and he delayed till the following morning. By the morning visit, however, the parasite had again fled, and had taken up a position in the deeper muscles of the foot. Not a trace of the worm could be recognized in the place which he had evacuated. Many abscesses now formed, and severe inflammation of the foot resulted, which confined the patient for three months before he was free of this wandering parasite. Dr. Ewart says he has seen the worm change its position from the upper part of the lateral aspect of the thorax to the Digitized by Microsoft® 166 TOPICS RELATIVE TO PATHOLOGY. groin in the course of twenty-four hours ; but he has never seen the creature travel from below upwards {Indian Annak, vol. vi, p. 490, July, 1859j. Structure of tJie Di'acuncuius. — It is often a matter of extreme difficulty to extract the whole worm without breaking it, and on account of its remarkable elasticity (for it may be extended to twice its apparently natural length), good measurements of any large number of worms are not easily obtained (Busk). Of forty Indian specimens, Ewart gives the average length at 25.25 inches, the shortest being 12| inches, the longest 40 inches. Clot Bej' records their length at from 6 inches to 4 feet, in Egypt. Carter gives their dimen- sions in India at about 28 inches long, -Jth of an inch in diameter. He has dissected five. Busk gives the dimensions at from 4 to 6 feet, and y'^th of an inch in diameter ; and he has made out that it grows in ^^°- ^^- the human areolar tissue at the rate of about an inch a week. H. C. Bastian, Professor of Pathology, University College, has recentlj^ read an account of the anatomy of this parasite at the Linnsean Society ; and from the records of these excellent observers we have now a very complete account of the anatomy of the Guinea-worm. The anterior end of the worm (Fig. 15) may be recog- I)ia,i,'rara of the head or anterior end of the Guinea- worm ; showing (a) Puncti- form mouth l-2J00th of an inch in diameter; (?j.i Upper large papillae ; (c.) One of small lateral papillje ; (d.) One of four crucial white lines meeting at the month, and occupying intermuscu- lar spaces (H. (J. Bastian). nized by a "punctum" in its centre, -ji/onth of an inch in diameter, surrounded by rugae in circles, the external of which was ^^j of an inch in diameter. Above and below are two papillae opposite each other, with a trans- parent area iu the centre of each. These are rather oval, ^f5-th of an inch in diameter, with a transparent area of jTrooth of an inch. Besides these, two lateral tubercles exist, much smaller, more indistinct, and farther from the punctum than tlie upper and lower papillas. They are Tp\,T7th of an inch in diameter. It is difficult to obtain a good view of the head ; for, as it is the first part to protrude through the skin, it is usually rubbed off" or destroyed by the treatment adopted for extraction. Great varieties in form are presented by the tail or posterior end of the worm^ (Fig. 16). The remains of the attenuated extremity of the young Filaria, being more or less persistent in the form of a hook or spikelet, was Fig. 16. Various forms of the caudal end of the Guinea-worm: (a, b, c.) After Busk— all of them proligerous- (D.) After Oaetee; (B.) After GuEENllow. believed at one time to be the penis of a male; and such specimens as showed such spikelets have been mistaken for male Guinea-worms. All these forms, as Busk showed, have been found iu specimens containing living young ones (proligerous). All are females that have yet been found, and no males are known to exist in the human body. The strengtli of the tissue of the Dra- cuncidm is such that a loop of the parasite will suspend a weight of llf ounces (Scott), and it is elastic to a remarkable degree. On opening the body, two longitudinal muscular bands are seen on the dorsal, and two on the Digitized by Microsoft® STRUCTURE OF THE GUINEA -AVOKM. 167 ventral aspect, nmniiig from end to end ; while circular or transverse rugre mark the whole extent of the worm ; and these are approximated or apart "as the worm is contracted or extended. The body of the worm (Fig. 17 ) contains an alimentary canal, which commences at the' " punctum" and' terminates in the concavity of the tail end. It is of a yellow color, nearly uniform in size throughout its extent, and in its course through the body winds several times round the genital tube (Bastian). No outlet has yet" been detected. It is distinct from the tube containing the young (Forbes). The genital organs consist of a large uterine sac or tube, occupying nearly the whole length of the worm, and terminating abruptly at either extremity m a much smaller tube (probably ovarian), about three-quarters of an inch m length. No vagina or vulva can be discovered (Bastiax). The whole extent of this uterine sac or capsule is crowded with innumerable young, and, with the exception of a transparent half inch or so of the worm, the" whole extent of the parent seems to be a uferm, a matrix, or a proligerous capsule, carrymg a countless offspring, to which no parturient female of any animal can be compared for productiveness ; and from the fact that no inlet has ever been dis- F'o- i"- Fig. is. covered to the genital organs, and from va- a rious other circumstances, Mr. Bastian has endeavored to show that this innumerable progeny has been produced by a process of parthoiogenesis similar to that with which we are so familiar in the Aphis. If a living worm recently extracted be well lit up by an argaud lamp, the hair-like filaments may be seen in motion with a good simple lens ; and if a section be made across the parasite after it has been hardened in glue, the young may be demonstrated in situ (Fig. 19 ). When the animal is mature, and present- ing its head through the skin, it jwotrudes the extremity of the proligerous capsule through one of the small jiapillas or puncta, carrying forward a prolongation of something in the form of a loose corrugated sheath ( Fig. 18). It gradually assumes the form of a di- lated vesicle filled with limpid fluid — the contents of the proligerous capsule — contain- ing flocculent granular matter and young Guinea-worms. Carter tells us that, if kept moist, the full-grown parent will live many hours ; and in this state the young will live till the parent begins to decompose ; and when the head end of the worm during its extraction may have been dried up for several days outside the wound, the remain- ing part with the young still remains alive. Mr. Busk says that the young survive after havmo^ underp;one a considernble de^rree of ^'^^'^^ ovarian tube; (6.) Termination of drying up. lliey are exceedingiy numerous, and constitute the bulk of the contents of the parent's body; but are less numerous towards the tail end. Each young one may be said to consist of a body and a tail, hair-like and finely pointed. The body con- stitutes f ths, and the tail |ths of the whole length. The anterior extremity Fig. 17. — .-1. Anteriorextremity ofworm, slit open and magnified, showin.L;, {a.) Up- per and lower cephalic p:i|iil!i.L- in profile ; (6.) Junction qfcesophaiius with intestine, and constriction of peritoneal sheath; (c.) Anterior termination of uterus, with short ovarian tube. B. Po.«iterior extremity of worm, slit open and magnified in same way, showing its hook-like termination; and (a.) Posterior termination of uterus intestine (Bastjan). Fig. 18. — Anteriorextremity. The ovisac (a) is protruded, dilated, and contains young: (&.) A funnel-shape sheath sur- rounding the protruding ovisac (Green- how). Digitized by Microsoft© 168 TOPICS RELATIVE TO PATHOLOGY. has a blunt end, with a rounded oval orifice communicating with a cavity occupying about one-half of the whole length of the body, and terminating coecally. Symptoms of the Q-uinea-worm in the Human Body.—A.s a parasite in the human body 'it may be studied during two periods of existence ; but from the beginning to the end of its cycle of development its history embraces at least three, if not Jour, phases of existence or forms of life: A. lOOths of an inch X 5 diameters. lOOths of an incli X 50 diameters. A. Appearance of transverse section of adult Guinea-worm, as seen througliout the greater part of its length.— (n, a, a, a.) Sections of tlie/our longitudinal muscles ; ih.) The intestine flattened, and lying along the edge of one of the longitudinal muscles; (c.) Walls of the uterine sac, often adherent to the parietes of the body. B. Young of the Guinea-worm more or less spirally curved (B-4stianj. (1.) During the first period of its existence in the human body the Guinea- worm parasite is latent, residing in the connective tissue, at variable depths from the surface. During this period it does not exert any irritating influ- ence on the surrounding tissue, as has been shown by dissections (Busk). (2.) The second period of existence comprehends that of ripening or matu- ration of the worm and its progeny, when the worm makes itself felt, and be- gins its exit through the skin. This period is marked by characteristic symptoms. Drs. Scott, Forbes, Morehead, Lorimer, and Van Someran all agree in stating that the earlier symptoms are a pricking, itching heat, which is felt at the part where the worm exists, seldom amounting to pain till after the lapse of three or four weeks. A small vesicle forms over the part, which iitimediately precedes the appearance of the anterior end of the worm. Dr. Scott was himself a sufferer, and writes feelingly on this point (see Med.- Chir. Review, 182-3). This itching may happen before va\j vesicle forms; and when the vesicle forms, it rapidly enlarges — so rapidly that in a few hours it attains the size of a good large filbert (Lorimer). If this vesicle is opened earhf, it is seen to contain a clear and limpid fluid (the fibrinous serum of irritation ?) ; but if untouclied for a day or two, its contents become turbid, and sometimes bloody, from the rupture of the proligerous sac, and the discharge of the young Filnria amongst the serum. These greatly add to the irritation; so much so, that when the cuticle is removed, an angry-looking ulcer is exposed, in the centre of which the parasite may be seen presenting itself, with a thin transparent tendril about an inch in length hanging from its point. After the appearance of the vesicle or blister, it is sometimes weeks before the worm protrudes itself. The contents of the blister, when turbid, are a discharge from the tube of the animal ; as Wilkins, of 4th Light Dragoons, first surmised, and as shown afterwards by the independent observations of Forbes, who found that the best way to procure the young Guinea-worm for microscopic examination was to lay open this vesicle before the delicate membrane of the proligerous cap- sule burst. After the escape of the serum from the vesicle, the delicate trans- parent membranous tube or eul de me is sometimes protruded from the extrem- Digitized by Microsoft® PERIOD OF INCUBATION OP THE GUINEA-WORM. 169 ity of the worm ; and if cold water is gently poured in a constant stream upon this protrusion, the dilatation and protrusion increase, till an innumerable quantity of young is ejected from the ruptured orifice of the dilated tube. Forbes says that he has often repeated this experiment ; and in one instance the transparent tube was again retracted within the limb, after three emis- sions of young Guinea-worms. On the following day the tube was found again protruding as before; and the same result (namely, emission of young) followed the gentle application of the stream of water. The animal will emit its young daily in this way for some time; and when it ceases to emit them, it is then time to begin the extraction of the parasite (Forbes). The Period of the Year when Draeunculus is most prevalent seems to vary con- siderably in different parts of India, and the probable causes of these diifer- ences are of great interest in regard to the origin and spread of this parasitic afiection. At Madras and its vicinity Guinea-worm annually appears with greater prevalence during the hot season (Lobimer), comprehending February, March, April, May, and June. At Dharwar and its vicinity the admissions to hospital for Guinea-worm generally commence in April and May. At this time water is scarce, every tank is dried up, wells yield a scanty supply, and the natives are obliged to remain at the bottom of the wells by turns, till the required supply is obtained; and when the monsoon sets in (rainy season), the admissions gradually increase through June, July, August, and September. The increase of the disease amongst soldiers or residents seems to advance • with length of residence, generally during the rainy season. In the Bombay and Matoongha districts the admissions to hospital begin in May or June (irrigation of fields by the natives being common at this time), but it chiefly prevails during the rainy months of June, July, August, and September, and is rare after October (Smyttan). Dubois, a missionary at Sattimungalum, says that its annual endemic prevalence in the Carnatic villages is in Decem- ber, January, and February, during which time more than half the inhabi- tants are affected. Dr. Morehead's experience at Kirkee and vicinity gave March, April, May, June, and July as the months of gradual increase and prevalence; and September, October, November, December, and January as those of comparative exemption. In the Bheel districts Guinea-worm begins to increase in frequency in Feb- ruary ; it is four times as frequent in March, and six times as common in April, as in February. It reaches the monthly maximum of prevalence in May. It prevails to a great extent in June, and continues to be common throughout the monsoon months of July and August. During September, October, No- vember, December, and January it is least of all prevalent. The half of the year comprising the hot and rainy season is, therefore, the period when Dra- eunculus abounds, abruptly commencing with the initiation of the former, and terminating more abruptly still with the exhaustion of the monsoon in Sep- tember (Ewart). All the records agree in assigning to this parasite — (1.) An annual periodic recurrence; (2.) Periods (annual) of progressive increase and subsidence; (3.) A probably fixed latent period of residence in the connective tissue — a period of incubation — of not less than twelve months (Lorimer, Mitchell) ; or of twelve to eighteen months (Busk). The Guinea-worm never makes itself manifest in the human body before the second season of residence in the places where it is endemic, a complete season being requisite to mature the worm. There are some remarkable cases which fix the period of incubation of the Guinea-worm in a very decided way. For example, in some excellent remarks on this subject by J. Mitchell, Esq., in the supplement to the Madras Times, of December 18, 1861, and January 13, 1862, it is related of a gentleman, well known to be extensively acquainted with natural history, that when he Digitized by Microsoft® 170 TOPICS RELATIVE TO PATHOLOGY. ■was travelling in the Northern Circars, the tents were pitched near a tank, of bad repute. He was accompanied by five friends, who, against his advice, bathed m the tank. Each of these five persons subsequently became affected with the (3ruinea-worm. In the Indian annals many accurate accounts are given which fix the period of incubation at about twelve months. Geological Features oj Locality and Soil' where the Bramncuiusis Endemic. — Evidence of a circumstantial kind tends to connect the parasite with some- thing geologically characteristic in the soil, mud, moisture,^ or water of the places where the parasite is endemic; yet information is still very imperfect on these points. Morehead believes that all the districts where Dracunoulus prevails are composed of the secondary trap rock — i. e., of igneous forma- tion, as in the villages of the Deccan and Northern Concan, where the para- site is indigenous. In the country between the Western Ghauts and the sea- coast, where the parasite is rare, the soil is a conglomerate ironshot clay, of a red color. Chisholm's investigations on this point led him to the conclusion_ that the districts where Guinea-worms abound (i. e., in man) are of volcanifi origin, with an argillaceous soil, holding much moisture, impregnated with salts or percolated by sea-water. Dr. Carter's evidence as to soil is, that the para- site abounds where the soil is a decomposing trap, of a clayey consistence, and of a yellow color. Every regiment which has occupied the lines at Secunderabad, "near the large tank called the ' Hansen Saughur,' " has suffered from the Dracunmlus (Lorimbe). The cause of the disease exists in or near the lines at that place ; and the soil is marshy which borders on the tank. The experience of the 19th, the 4th, 5th, 1st, and 35th Eegiments of Native Infantry all fix the locality of the Guinea-worm germs to be "in or near these lines." For example, the 19th Regiment arrived at Vepery on the 20th May, 1838. It had been free from Dracunculus for five years before : twelve months after its arrival twenty-eight cases of Guinea-worm appeared, and several cases amongst the followers and children. The 45th Regiment occupied the same lines previous to the arrival of the 19th Regiment; and the disease appeared amongst them at the same season of the year and after twelve months' residence. The Guinea-worm had not been amongst them for many years before. At Peram- pore (in the 1st Regiment, N. I.) it manifested itself, after twelve months' residence, in March, April, and May. For many years previously Guinea- worm had been unknown in the regiment. Those who suffer most in canton- ments are those who use water of the filthiest kinds. On the authority of Scott, Smyttan, Chisholm, and Duncan, Guinea-worms are said to have been found in the earth or soil, and that they have been dug out of moist earth. There can be little doubt, however, but that the worms so found were specimens of the Gordiacece. In some form or another the Guinea-worm has an existence in moist earth and mud ; and it is probable that the hair-like worms found by gardeners in India coiled up together may be the young filaria of the Guinea-worm in sexual congress; whose progeny, as Zoosperms, or as filiform female worms in process of parthenogenesis (like the Tank-worm of Carter), make their way into the body. It is known that the Gordius aquaticus, when young, enters the bodies of large water-beetles, and at a certain stage of life it leaves its abode in the beetle and goes into the water, where it becomes a variety of Tanh-Yiona. It appears that there are white and brown Tank-worms — nay, that there are no fewer than seventeen species of minute Filaria (Caeter, Mitchell) ; and some say that all Tank-wonns are white at first, but become black after a time in the water (Gunthee). Observations are greatly wanted on these points. According to observations collected by Pallas and quoted by Vogel, it appears that even in Europe thread-worms like the G. aquaticus. Digitized by Microsoft® SPONTANEOUS EXPULSION OF THE GHINEA-WOEM. 171 common in stagnant water and moist earth, can in certain cases infest the human subject CDe Infestis Viventibus intra Viventia, p. 11). The most obscure and incomprehensible parts of the history of this parasite are — (1.) The phase of its existence and that of its young after it leaves the body of man; and, (2.) The future life of the young, and their sexual differ- entiation. The parasite may be removed in several ways by surgical interference — either by cutting down upon it, or, after it begins to show itself, to commence winding it on a stick, gently pulling a portion of it out every day. But there is a natural termination to all diseases ; and it is a fair subject of inquiry as to what becomes of the Dracunoulus if left to itself, and its expulsion unaided by art. How would it be expelled, and what becomes of the progeny ? Is it probable that they would ever be placed in circumstances where they could lead an independent existence, becoming sexual and multiplying their kind ? In reply to these questions it is to be observed that there are undoubted ex- amples of the spontaneous evolution or expukion of the Guinea-worm. Scott once observed about five inches of the worm to start suddenly out, firm, elastic, and spirally twisted like a cork-screw, showing evidence of resistance to a progressive force from behind. So firm was the parasite that it supported itself for a little time perpendicularly to the limb. It is only when the animal dies that great mischief happens to the part where the parasite is. Then and there it acts as a foreign body ; but alive it does not cause disturbance (John Hunter, On the Blood, 4to, 1794, p. 208). The part first protruded is the head ; and its future progress, though slow and invisible, becomes in time very obvious (Scott). As an example of its spontaneous evolution or expulsion, Dr. Forbes relates that on one occasion eight Sepoys were admitted with Guinea-worm, and all of them had a characteristic vesicle on the ankle. These vesicles were opened on the fourth or fifth day. The loose skin was cut away with scissors, and a stream of cold water was poured daily on the part. Under these circum- stances the young were daily ejected from the proligerous tube of the parent parasite, and continued to be so for fifteen to twenty days. After this time a watery fluid only was emitted, without any young, but sometimes containing particles of a white flaky appearance, which continued two or three days longer. The Guinea-worm then became flaccid, and was discharged spon- taneously, without pain or swelling. The only exception was in one case, where the worm was constricted by the pressure of a band of areolar tissue, which led to retention of the young, and sloughing. Dr. Kennedy relates an anecdote which has an interesting bearing upon the spontaneous evolution and the probable future of the Guinea-worm after expulsion. "In 1791, when marching up the Ghauts with a Sepoy battalion, an African stepped out of the ranks and requested permission to go to a rapid running stream of water near by, in order to relieve himself, after his own fashion, of a worm in his ankle. The man unbound a bandage from his foot, loosened the worm (of which a part was extracted) from the cloth round which it was secured, and plunged his naked foot into the current of the stream. The constant but gentle force of the running water was sufficient to- stimulate the worm to come forth, and it was extracted almost immediately."" Another custom, recorded by Dr. Lorimer, illustrates the spontaneous evolu- tion, and points, at the same time, to the probable future of the Guinea-worm.. He says, "Many people belonging to the bazaars in the vicinity of the lines,, affected with the parasite, came for the express purpose of extracting the worm to the same tank where the men of the regiment bathe. The people so infested swim about in the water with the worm hanging loose, drawing the limb quickly backwards and forwards through the water, and from side to side, till expulsion is effected." The natives do not believe that they get the para- site from bathing in the water. Digitized by Microsoft® 172 TOPICS RELATIVE TO PATHOLOGY. In these and similar cases the parent, being carried away in the stream, finds a place to die, and so gives freedom to her immense brood of young. The water seems congenial to the parent Guinea-worm, and sooner than any- thing else induces her to leave her position in the human body, and so to extricate herself, perhaps by stimulation of the muscular structures. This water method of extraction was also recommended by Dr. Helenus Scott, of Madras (Edin. Med. and Surg. Journal, vol. xviii). Vitality of the Parasite in Water. — It has been stated that young Dracunculi die in four, five, or six days, if placed in pure water from well or tank (and that is the case with many animals), simply for want of food. Water not pure is, no doubt, the proper element for them (Mitchell). Those artificially kept in impalpable red clay, partially covered with water, and exposed to the sun, were found alive after fifteen, eighteen, and twenty-one days, burrowing into the fine soft and ochry mud. Forbes experimented on two pups five or six months old. He poured down their throats water containing the young Guinea-worm Filarim. After three minutes the first pup became uneasy, sick, and vomited; the watery part of which was found to contain the animal still alive. Four hours after this the pup was killed, when abundance of Filaria were seen in the mucus of the stomach and duodenum ; but none showed signs of life. The other pup was killed twenty-four hours afterwards, but none were alive, although abundant in the mucus. Lorimer tried upon himself and others if the parasite could be prop- . agated by inoculation of the young Filarice emitted from the parent's orifice. Five besides himself were inoculated. He naively remarks that he is sorry to say they did not hatch in any, although in his own case he put them in their favorite place — ^namely, the foot and ankle. Such experiments were not likely to succeed, from the delicate nature of the young Filarim, and because they were introduced under unnatural circumstance-s. Inflammation and pus are inimical to the life of the worm. Besides, it is most probable that they enter the body in some other form. They seem to go through another stage of existence, and become sexual ; for it is only females, and these impregnated ones, which are found in the body of man. The impregnated females only of the progeny of sexual Filariae would therefore seem to be the Dracuneulus of man. Dr. Ewart, in his able paper on the vital statistics of the Meywar Bheel corps, writes as follows : " I am inclined to believe that Guinea-worm is prop- agated by a female and impregnated Zoosperm, and not directly from either the young of the full-grown female Guinea-worm or from tank- worms" {Indian Annals, vol. vi, July, 1859). Its generation is another example of parthenogenesis. Examination of Water, Mud, and Tanks. — In the months of August and September, 1837, Dr. Forbes examined several of the tanks in the vicinity of Dharwar, and found the mud on their banks, and in half-dried beds, abun- dantly supplied with animalcules {Filarice), some of them very much resem- bling those produced by the Guinea-worm when infesting the human limb. Their vermicular motion in the water is exactly the same; their general appearance is the same; and they are active and equally numerous. The point of a penknife inserted into the mud will raise up abundance for exami- nation. They are most numerous where the water assumes a variegated ap- pearance, with a pellicle floating on its ochry surface; and the fine, soft, impalpable mud just above water-mark contains most, and the best time to find them is about three or four o'clock in the afternoon. Two kinds may generally be detected in the soft mud: one kind is seven or eight times the size of the Guinea-worm young Filarim, the other exactly resembles them. The larger one may be the more mature form of the progeny after becoming sexual. The smaller one may be the first generation born of that sexual Digitized by Microsoft® THE TANK-WORMS OF INDIA. 173 progeny — whose females, being fecundated, enter the body of man in this young and minute condition. Dr. Carter had medical charge of a school containing nearly 400 children. " One morning a case of Guinea-worm in a child little more than four years old was reported to him. There having been only two cases of this disease in the school during the previous eight years, Dr. Carter, who had before noticed the resemblance of the aquatic Filaria of Bombay to the larva of the Guinea- worm, was led to make inquiries, when he learned that the child was the son of the sergeant of the Industrial School, situated about three miles off, and had been only a little more than three months in the school. Upon further inquiry, he found that the sergeant's wife had then a Guinea-worm in her ankle, and that twenty-one out of fifty boys had been afiected with Guinea- worm during the past year. Some boys had had as many as five extracted, ' and ten more were then suffering from the disease, all of whom had been in the school more than a year. None of those who had been less than twelve months in the school had been admitted to hospital on account of Guinea- worm. " The boys were living in an embanked inclosure that had been taken in from the shore, the fourth side of which was formed by a cliff of the mainland, on which resided the sergeant and his family. In this inclosure were two small tanks, ten feet square, sunk in decomposing trap, one being six feet, the other three feet deep : the first furnished drinking-water, in the latter the boys bathed. The sergeant also obtained his bathing-water from these tanks, but the drinking-water from a well at some distance. " These tanks contained Confervm ; and every small piece as large as a pea contained twenty or thirty of the tank-worms. At the Central Schools, where there had been no cases, or only two in eight years, the Conferva} of the tanks failed to yield worms after the closest scrutiny. Hence he argues, and with apparently good reason. No tank-worm — No Guinea-worm; but that persons who bathe in water in which the former is found may expect to have the latter. " Dr. Carter further states that the Industrial School is situated near an old artillery barrack, now in ruins and overgrown with weeds, which had to be abandoned in consequence of the havoc made among all ranks, ofiicers as well as men, by this fearful parasite" (Mitchell, 1. c). The habit of the tank-worm is to bury itself under any organic debris that may be in the water in which it is found ; and if it be disturbed, it will imme- diately seek a hiding-place, nor rest until again covered. This implies that its proper habitat is the bottom of tanks, wells, or other reservoirs, among the decayed and decaying organic matter. It may be assumed that the water- carriers referred to by Dr. Morehead were Army Bheesties, who as such probably had access to good puckah wells (Dr. Morehead having found that Guinea-worm was not more common among them than among other people), and as the tank-worm, habitually resident in the mud at the bottom, would only be disturbed when the water became very low, and would get back again to its retreat, if possible, the fact of water-carriers being as little affected with Guinea-worm in the upper part of the body as other people does not carry so much weight as at first it would seem to do, and as it would in reality if the tank-worm was in the habit of swimming at the surface like many other aquatic animals. It has not been said that the worm finds its way into the body by any of the natural cavities of the body, such as the alimentary canal. On the contrary, it is supposed that the water may be drunk with impunity, as known by experience, and from the experiments of Forbes already notice* The young Filaria can work its way into a proper receptacle by its pointed extremity, " which is a long cone, ending in a point so inconceivably fine that the point of a cambric needle is a large marlinspike in comparison with it." But notwithstanding its exceeding tenuity, it appears tolerably rigid ; and as Digitized by Microsoft® 174 TOPICS RELATIVE TO PATHOLOGY. the proper receptacle referred to is one of the sudoriparous ducts, a ready-made aperture exists for a distance quite long enough to contain so small a creature ; and it is by no means inconceivable to one who has seen its active exertions, that it should be able thus to hide itself in a foot or leg kept for some time in the water. It is unnecessary perhaps, to do more than allude to the well-known native custom of going into a tank to take water. In these tanks water-car- riers may often be seen standing for five or ten minutes at a stretch, chatting and washing themselves. They of course stir up the bottom mud, and if the tank-worm be there, and is the origin of the Guinea-worm, they certainly aiford it every opportunity to effect a lodgment. , One circumstance which makes this the probable mode of entry is, that natives et.re much more subject to attack than Europeans. Thus the evidence is very strong which refers the entrance of the parasite to bathing, walking, or lying on moist places where the tank-worms abound. Greenhow states that the sepoys of the Maiwara Battalion bathe in and drink the water of a well sunk in the limestone rock, which generally contains about twenty-eight feet of water, clear and sweet ; while the prisoners of the jail at Beaur use similar water from another well ; but they never bathe, which the sepoys do every day. The result is, that Dracunculus is much more preva- lent among the sepoys, compared with the prisoners, in the proportion of three to two. Again, amongst " Puchallies " the numbers affected are four times as great as among the men of the regiments. The former frequent the tanks more than the men of the regiments. Generation and Propagation of the Guineorworm. — The following periods 'may be recognized in its natural history : (1.) , It is probably got by bathing in tanks or places where the young and impregnated females abound. (2.) A period of maturation in the human body takes place. (3.) A time favorable for extraction coines, when the animal seems to seek delivery from its imprisonment, to fulfil a new law of its existence. The adult animals perish annually. It is necessary they should die, that the young may live ; and, indeed, the Guinea-worm of the human body is not adapted to live. It has no functional arrangements for life. Men being exposed to the cause about the same time, the period for extrac- tion will arrive about the same time in all, but with just sufficient variation (as to time)_as to suggest the idea of contagion (Scott, Med. and Surg. Jour- nal, vol. xvii, p. 99). But the idea of contagion or infection from one man to another (as Bruce, McGrigor, and Paton wished to establish) is quite untena- ble. The evidence is all the other way. In Paton's cases onboard Her Maj- esty's ship "Cirencester," from 30th May, 1805, to 9th August of the same year, the origin of the disease is quite traceable to the preceding July and August, when the ship lay in Bombay harbor {Med. a7id Surg. Journal, 1806, vol. ii, p. 151). Sir J. McGrigor's cases in the 88th Regiment, and the absence of Guinea-worm among tlie a.rtillery on shipboard, related in his medical sketches, were not fully investigated. "We have no account of the water supply previous to embarkation. Afterwards he wrote a paper, or rather an account of the sickness in the regiment from all diseases, in the Edin. Med. Journal, vol. i, p. 270, and from this it appears that the regiment had been quartered in the Fort of Bombay, which is 'partly surrounded by a wet ditch; and several months after leaving this place most of the eases of Guinea- worm occurred. Bombay is well known to be extremely infested with Guinea- worm. Mosely is reported to have said that " there is as much foundation for believ- ing Dracunculus to be contagious as that a thorn in the foot is contagious." As observed by Rudolphi, the parasite is known to occur in persons who have neither eaten nor drank in the countries where it is endemic, but who have exposed themselves to its moisture and its mud. The moisture contained in Digitized by Microsoft® CONTAGION OP GUINEA-WORM IMPROBABLE. 175 native canoes is sufficient to have carried to a ship oiF the coast the germs of the Guinea- worm, which find their way into the seamen of the ship, who are in the habit of going into these canoes with bare feet. JS"egative evidence, which would attempt to show that tank-worm does not exist, cannot be received. Most of the examinations on whicli such negative evidence rests have been imperfect; having been made with instruments confessedly imperfect, and perhaps by men not accustomed to use the instru- ment. I speak only of written and published statements, and on the authority of Dr. Lorimer. Problems for Solution. — Forty years ago Dr. Scott suggested that a patient and careful investigation of soils and waters ought to be made wherever Dra- cunculus is known to be endemic, and especially the soil round brackish wells and the beds of tanks. Morehead, in 1833, recommended that the following points be attended to, namely : (1.) Geological structure of the ground and nature of the site generally ; (2.) Nature of soil, wells, and well-water ; (3.) Nature of rocks through which wells are sunk ; (4.) Abundance or scarcity of water ; (5.) Seasons of increase or decrease of the disease; (6.) Opinions of natives. I desire very much to obtain specimens of Guinea-worm taken from the dead body long before the parasite arrives at maturity. The occurrence of Gninea-worm is sometimes defined by a distance of a few miles. So it is with many algse and minute water animals and plants as to habitat.* 6. Filaria oculi. Length, /^jths to ."oths ; width, ^th of an inch. The body is, thick posteriorly, filiform, and ending in a pointed tail, transparent, and partly coiled up in a spiral form. The alimentary canal is surrounded by the folds of the oviduct. This Filaria (F. lentis) is very imperfectly known, and the female only has been seen. It was detected by Nordmann in the liquor Morgagni of the cap- sule of a crystalline lens of a man whose lens had been extracted for cataract by the Baron Von Grafe. In this instance the capsule of the lens had been extracted entire ; and upon a careful examination half an hour after extrac- tion, there were observed in the fluid two minute and delicate Filaria coiled up in the form of a ring. One of them presented a rupture in the middle of its body (probably made by the extracting needle), from which rupture the intestinal canal was protruding. The other was entire, and measured about yljths of an inch in length.. It presented a simple mouth, without any apparent papillae, such as are seen to characterize the large Filaria which infests the eye of the horse ; and through the transparent integument could be seen a straight intestinal canal, surrounded by convolutions of the oviducts, and terminating at an incurved anal extremity (Owen, p. 64). * My friend, H. C. Baotian, Esq., M.B., Professor of Pathology in University Col- lege, London, has recently furnished a most interesting account of the anatomy of the Guinea-worm to the Linnasan Society, and has been kind enough to furnish me with drawings of his observations. He writes to me as follows ; " Since I saw you last I have discovered several species of Carter's ' tank worms ' in soft mud, &c. (at J'almouth) ; that is, small Nemaioids, agreeing in almost every respect with those found by him in Bombay. The more I see of these, the more thoroughly am I convinced of the undoubted relationship existing between them and the Guinea-worm, coinciding as they do in their anatomy even to minute details, and in many respects where there is a salient distinction between the anatomy of the Dracunculus and that of the Aacari- des. One which I sketched to-day had an exsertile rigid, sharp-pointed oesophagus. " The great difficulty in the theory is to account for the fact of the localization of the disease, whilst these animals are probably so widely spread ; and I suppose it is one particular species which is limited in its diffusion ; but I suspect that many of those others will hereafter be discovered as parasites in animals or vegetables. The Vibrio tritico I have examined, and find it to be a worm essentially similar ; and Dr. Cobbold tells me that he has found a long thread-like worm in the subcutaneous tissue of the back of a water-bird. The whole question wants working out." Digitized by Microsoft® 176 TOPICS RELATIVE TO PATHOLOGY. A Filaria oculi vel lachrymalia has been described as not uncommon among the negroes on the Angola coast, where it is called loa; also at Guadaloupe, Cayenne, and Martinique. Its length is l/^ths to.ly'pths of a line. It is a filiform, slender worm, pointed at one end, obtuse at the other, tolerably firm, and of a white-yellow color. This parasite has been considered a Strongylus by some, by others a young Guinea-worm, and by others as an Oxyuris vermicularis. 7. The Strongylus bronehialis was first discovered by Treutler, in 1791, infesting the enlarged bronchial glands of an emaciated man. The parasite is cylindrical, slightly narrowed anteriorly, filiform, but somewhat compressed at the sides, semitransparent posteriorly, and of a blackish-brown color. It measures from, half an inch to three-quarters of an inch in length. 8. The Eustrongylus gigas is fortunately rare in man, though common in a great variety of animals, such as weasels. It inhabits the kidney, destroy- ing the substance of the organ, the walls of which become the seat of calcare- ous deposits. 1 9. The Sclerostoma duodenale is known to be tolerably common throughout Northern Italy; and, according to Pruner, Bilhartz, and Griesinger, it is so remarkably abundant in Egypt, that about one-fourth of the people are con- stantly suffering from a severe anaemic chlorosis, occasioned solely by the presence of this parasite in the small intestines. " Its length is about one-third to half an inch, its width about one-twentieth of its length. Its head has a round apex, and its extremity, which is bevelled at the expense of its posterior surface, is provided with booklets that occupy converging papillse. The mouth contracts, to open into a thick muscular pharynx, which, widening as it passes downward, ends, after occupying one- seventh of the body, in the intestine. The sexual differences of the male and female are very interesting. Its pathological significance is chiefiy due to the hemorrhage caused by these parasites, which are often present in thousands between the valvidm connivenies of the duodenum, jejunum, and Ueum, and not infrequently in the submucous areolar tissue. In short, the physician practicing in Egypt must never forget that the chlorosis of this climate is often the result of repeated and small hemorrhages from the intestine, caused by these parasites. Turpentine, as Griesinger points out, promises to be the best remedy both as a styptic and as a vermifuge" (Brit, and For. Med.-Chir. Review, I.e.). 10. The Oxyuris vermicularis was known to Hippocrates, and is one of the most troublesome parasites of children, and occasionally of adults. It is a minute, white, thread-like worm, the male being about a line and a half in length, and the female five or six lines. They inhabit chiefly the rectum, where they are often found in clusters, rolled up in balls of considerable size, and from the rectum may creep into the vagina or urethral orifice. Some- times they give rise to profuse and exhausting bloody discharges from the vagina. The eggs of this parasite have embryos developed within them prior to their escape from the parent; and in this respect they differ from the A. lumbricoides and the Trichocephalus on the one hand, and from the viviparous Draeunculm on the other. In this character, however, they resemble the A. mystax. In all probability the young escape from the eggs soon after the latter are expelled,, or migrate per rectum, and, like others of the Nematelmia, gain access to the human body with our vegetable food or water whilst still in a sexually immature condition. Treatment of those Infested by the Round Worms. The habitat of the Ascarides being fpr the most part a collection of mucus, tiie means used* for their expulsion are such as may expel mucus. Four grains Digitized by Microsoft® REMEDIES FOK EXPULSION OF ROUND WORMS. 177 of compound scammony powder, ■with five grains of aromatic poivder ; or two to three grains of calomel and ten grains of jalap, taken at bedtime, are useful. In weakly children, small doses of Epsom salts will ultimately effect the same object, and with less distress to the patient. Many persons place great confi- dence in calomel as a medicine capable of destroying round worms ; but it does not appear to act beneficially except as a purgative, expelling the mucus. The day after the administration of the purgative, the patient ought to be kept on low diet, without solid food ; only a little beef tea being taken ; and on the second day — the day succeeding the purgative — from five to ten grains of the ethereal extract of santonin may be given during the day ; or from three to four grains of santonin itself.* About three doses are suflicient ; one every second night, followed by a brisk cathartic the morning after each dose. It may be compounded as troches, containing one or two grains in each ; or two to six grains may be dissolved in one ounce of castor oil, and a teaspoonful given every hour till the oil ope- rates. A santonate of soda is also recommended by Kuchenmeister in doses of two to four grains. Santonin seems to be a specific for the destruction otAscaris lumbricoides ; but it may be necessary to state to the patient or his friends, that the sight sometimes becomes perverted as to color, after a few doses, and color- less objects may be seen to be blue or yellow. The Oxyurides, or small vermicular Ascaris, being situated so near the rec- tum, enemata have at all times been much used in the treatment of these cases ; and injections of oil have been much commended, especially of castor oil, olive oil, or sweet oil. But these animals will live from thirty -six to forty- eight hours in castor oil. Indeed, very little benefit has been derived from any such local treatment. Warm water injections tranquillize the intestine, and give more temporaiy relief than anything else. The Oxyurides are killed by cold ; and injections of cold water, with a little vinegar, are very efiica- cious. If the child is a vigorous child, large injections of very cold water may be administered, with vinegar or a few drops of ether or of alcohol. In obsti- nate cases, a weak solution of corrosive sublimate, in the proportion of one quarter of a grain to two ounces of enema. Injections of the following bitter substances have been found very useful in the treatment of the Ascaris ver- micularis : Three or four ounces of a strong infusion of quassia repeated three or four times, or of steel and quassia and aloes, or a solution of common salt in gruel, or a similar quantity of lime-water, has been found of service. At the same time it is also well to administer internally some bitter medicines ; — for example, half an ounce (or any dose suitable to the age and strength of the child) of compound decodion of aloes, taken in the morning fasting, once or twice a week ; and three ounces (or other suitable dose) of infusion of quassia may be taken every morning that the aloes is not taken. Chloride of sodium, to the extent of an ounce in a pint of quassia infusion, has also been found a useful injection ; so also has an enema composed of aloes, carbonate of potash, and mvailage of starch. But whatever local reme- dies are used, it is necessary to attend to the general health, which usually is at fault, and to persevere in the use of enemata twice a week for several months. The digestion is generally slow and imperfect, the secretions from the mucous membrane of the alimentary canal being abnormal. For this condition, small doses of the extract of nux vomica, with sulphate of iron, in extract of gentian or aloes, or in rhubarb or colocynth pill mass, taken twice a day, will be found of great service. i .^ * Santonin is a crystalline neutral princi^ile obtained from the Artemisia Sanionica, or Semen Contra, — which is not a seed, but is the unexpanded flower-head of a species of Artemisia imported from Kussia, and is the only so-called worm-seed which yields Santonin in quantity worth extracting. It is a tasteless and pleasant vermifuge for children (Squire). VOL I. 12 Digitized by Microsoft® 178 TOPICS KELATIVE TO PATHOLOGY. From what has already been written, it will be seen how important it is, in the treatment of all these parasitic diseases, to take every means of utterly destroyittf/, by huridng or by chemical agents, all debris or excreta which may be passed by patients suffering from these parasites, and also how necessary it is to look lueil to the purity of all luater supply used either for the purposes of food, drinking, or bathing, and to the quality of pork or bacon, especially in connec- tion with the Trichina spiralis; the use of bad tiour in connection with the eggs or larvte of Ascaris or Oxyuris (Stein). CLASS B. STERELMINTIIA, OR SOLID WORMS. 11. Bothrioceplialus latus. — Although classed with tape-worms, Bvthriu- cephali differ essentially from Tcenia. Two species have been found in man, namely, — (1.) Bofhriocephalus latus ; and (2.; Bothrioc£pjhahis cordatus. The Bothriocejjhalus latus is endemic chiefly in the north of Europe, .and is found more especially in Russia, Sweden, Norway, Lapland, Finland, Poland, and Switzerland. The inhabitants of the French provinces adjoining Switz- erland are infested with both species. Instances of Bothriocejjhalus latus are said to have occurred both in Eng- land and France; but, when carefully inquired into as to their history, it will be found that this parasite maintains a very fixed geographical distribution. For example, — of the six specimens in the College of Surgeons of England, one is from a native of Switzerland ; one from a Russian, belonging to the Russian embassy in London ; one from a person who had been travelling in Switzerland ; a fourth happened in the practice of Dr. Gull, in the person of a little girl from Woohvich, where there is always a number of foreign ships and sailors, bringing with them native food and water ; another was passed b}' a native of Russia, who, after a long residence in England, paid a tempo- rary visit to his birthplace, and returned to England with this parasite as a pleasant memento of his native country. The liability to this form of parasitic disease appears to be greatest towards the seacoasts and along river districts. Huss, of Sweden, describes it as extremely common on part of the Lapland frontiers, in Finland, and on the shores of the Gulf of Bothnia. On the extreme coast there is scarcely a family together free from it — old and young, rich and poor, native and emi- grants, alike suffer from this worm; and in one or two large towns on the mouths of rivers, at least two per cent, of the population experi- Fm. 20. gn(,g ;^g attacks. On passing inland the frequency of the disease diminishes, until, eight or ten leagues from the coast, rivers, or lakes, it almost ceases to be found. The natives believe it to be hereditary. Dr. Huss attributes it to the use of salmon {Brit, and For. Med. Review, 1. c. ). The head of the Bothriocephalus latus is peculiar, and very different from the T. solium. It is of an elongated form (Fig. 20), compressed, with an anterior obtuse prominence, into whicli the mcjuth opens ; an opaque tract extending from the mouth separates two lateral transparent parts, which are supposed to be depres- sions. There are no traces of joints till about three inches from the head ; and throughout the entire body the segments have more length than breadth. The whole length of the mature parasite varies from six to twenty feet. It is of a grayish-white or yellow color ; and the ova are very brown, giving the mature segments a very marked appearance. The neclc is not always obvious, for the worm has the power of making it long and thin or thick and short; and there are no joints or segments to be seen in it, but merely prominent ridges. The segments, when they become first apparent, are nearly square : but after- wards they become much wider than they are long. There are two orifices Digitized by Microsoft® BOTHRIOCEPHALUS CORDATUS. 179 Fig. 21. on one of the flat surfaces of each segment; the anterior orifice is connected with a male organ of generation, the posterior is connected with the female. The proglottides are never passed singly, but always ^"^^ -^"■ in chains of many links, and particularly in February, March, October, and S'ovember. The ova (Fig. 21) are always discover- able in the fmces, of an ovoid form, with a perfectly translucent operculated capsule, through which the segmented yolk is dis- tinctly visible; and at the period of discharge of the "proglottides the ova show merely the stage of segmentation of the yolk. The six-hoohed embryo, cased in a numtle studded with vibratory cilia, develops itself after segmentation, protected by the capsule in fresh water, for several months after the expulsion of the proglottides. When so far matured, the lid of the capsule opens up, and the cili- ated embryo escapes (Fig. 21rt.), and becomes globular in shape, and moves actively about for a considerable period (a week ). If during this period they do not succeed in obtaining access to the intestine of an animal adapted for their development, they lose ^^^ ,,, the ciliated mantle, and perish. When these em- bryos are introduced by experiment into the intes- tines of mammals, the scolices and mature Bothrio- cephalus were found. Experiments in which living embryos were introduced by implantation between the brain and dura mater, and into the eyes of dogs, also under the skin of frogs, and by injection into the bloodvessels of mammals, give a negative result; quoad the development into cystieerci or scoHces. So, also, feeding experiments with the scolices of the Bothriocephalm found in various-fish lead to negative results; just as the feeding of fish with the eggs themselves. It is therefore justifiable to assume that drinking-water from lakes and rivers is the medium through which the living embryos of the Bothrioceph- alm lahis find their way into the intestines of men and of mammals (Dr. J. Knoch, Petershurger Medi- einische Zeitschrift, 1861; Cobbold, 1. c). 12. Bothriocephalus cordatus This species (Fig. 22, a) is new to science, and has only very recently been described by Leuckart, who received about twenty specimens from Godhaven, in North Green- land, one of which was from the human intestine. The parasite measures about a foot in length, and exists in dogs in considerable abundance. It differs from Bothriocephalus latus in the form of the head, which is heart-shaped (Fig. 22, b and b'), or obcor- date, short, and broad, and set on to the Ijody with- out the intervention of a long neck. The segments are distinct from the very commencement, near the head ; and so rapidly do they increase in width, that the anterior end of the body becomes lancet-shaped. About fifty joints are immature ; and in the largest example Leuckart counted a total of 660 joints. It displays a greater number of the calcareous corpus- cles, and a greater number of lateral uterine pro- cesses (Leuckart ; Cobbold, " Remarks on the Human Entozoa," in Proceedinns of Zooloriicnl ("> Soihr,«,phahn cordaiy.^ ri • , -XT -tonk\ J •' J naliiral sizi^ ; (/j.) Head, back liOCiety, JNOV., lobZj. view, maninflwl Ave diameters; 13. Taenia solium.-In their mature condition the Z^^::^^Sl^^^'"'^' Digitized by Microsoft® .J*^ 180 TOPICS RELATIVE TO PATHOLOGY. tape-worms are all more or less jointed eutozoa, of a riband-like form, marked with bands, or girdled. Each mature joint or segment is of hermaphrodite conformation, containing at once male and female reproductive organs, which produce fecundated ova. In their immature condition the embryo jjenetrates the tissues, and becomes encysted. In this stage of development they are known as the " cystic eutozoa," because they terminate in a bag or cyst. Eight varieties of true tape-worms have been found in man, and the t^Y'o varieties of the BotJiriocephalus already noticed. But two only of the true tape-worms are of frequent occurrence — namely, the T. solium and the T. mediocanelkda. The former is the one endemic in this country ; the latter is the more common tape-worm on the Continent, in South Africa, and India. These tape-worms have been known for a very long period ; but they have not always been distinguished from each other. Indeed, the distinguishing characters are but recently known. They have often been confounded together imder the name of "solitary worm," because it was believed they lived singly. This, however, is a mistake. The 1\ solium and T. mediocanelkda appear at first sight to be very similar to each other in general appearance. The latter is much the larger of the two. It is only in the alimentary canal — the small intestines of man and other animals — that Tamice become sexually mature, in natives and native animals of all countries. The Tien.ia is very common ^"'- 23- in natives of Abyssinia ; — so common is it there, that its absence is the exception to the rule. The affection is there looked upon as a natural occurrence ; and so general is this belief, that when a slave is sold into Abyssinia he provides himself with a plentiful supply of kousoo — the local remecly for expelling the parasite. The Tcenia solium is a common tape-worm of this country. It is composed of segments of variable size, numbering from 800 to 1000 ; and these being endowed with considerable contractile power, the length of tape-worms varies greatly, and so also does the width and thickness. Nine to thirty-five feet may be quoted as average measurements of length. The body narrows from the posterior to the anterior extremity, till towards the head it becomes a mere thread. The parenchyma is soft and white, with microscopic calcareous particles, sometimes mistaken for ova (because they are round or oval), scattered through nearly every part. The Head (Fig. 23) is very small, but it may be seen with the naked eye to be of a globate or triangular form, with black pig- ment ingrained into its substance, which may be the remains of blood. On the most ante- rior part of the head, with the aid of a lens magnifying twenty-three or twenty-five di- ameters, four circular projections, equidistant from each other, may be seen. Each has a circular disc or cup, surrounded by a rim of dense tissue. The parasite is able to elongate so that, while opposite ones are put forward, Head and neck of Tainia solium. (a.) Circle of hooks. and retract these projections ; Digitized by Microsoft® ANATOMY OF TAPE-WORM SEGMENTS. 181 Fig. 24. the two others are kept back. Between the suckers, aud anterior to them, is a couvex protuberance or rudimentary proboscis, which is impervious, and surrounded by a double row of liooks (Fig. 22, a, also Fig. 23). These are siliceous, and number twelve to fifteen in each row. The shape of these i.s peculiar. They consist of a straight stem or handle, a middle nob, aud a dis- tinct hook or claw, surrounded by a sheath or sac. Bremser believes that a tcEnia loses these as it gets old ; or it may shed them periodically by rows ; and being lost, they may not be renewed, and so the parasite may be got rid of in the course of nature. The head terminates a long and slender neck, on which there are trans- verse markings, but no visible joints or articulations. Such joints distinguish the body ; and these joints, segments, or zoonites are united end t(j end in a single linear series. The characters of the segments vary at different parts of the l)ody. They are square or oblong ; and in the mature part of the animal the length of them is equal to twice the width. The anterior border of each segment unites with the anterior or previous segment, aud is thinner than the posterior border, aud also narrower. The posterior border is thick, and projects or overlaps the border of the. segment next in order, and is undulating or indented. The lateral margins incline to each other anteriorly. The two surfaces are flat or slightly elevated towards the centre. Each mature segment contains male and female organs of generation. The opening at the side of each segment is the sexual aperture, indicated by a prominent fiapilla. These openings are sometimes at one edge, and sometimes at the opposite edge. Two, three, or four consecutive seg- ments may have them on the same edges, or on opposite ; but there is no regular alterna- tion. With a lens a cup-shajjed depression may be seen, sho\\'ing two mesial apertures. From one of these a lemniscus or rudimen- tal penis projects, connected with a horizon- tal (deferent) canal (sometimes indicated by a dark pigmentary material ) from a vesic- ular body in the middle of the posterior end of the segment (Owex). Behind this male orifice is the opening to the female organs, by a canal leading to a lobulated organ, wdiich is the ovary or germ- stock. These parts are more distinctly developed the farther the segments examined are from the head end of the worm. While the head continues to adhere, by its circles of booklets and oscula, to the mucous merabraue of the intestine, the last or caudal joints, when they have arrived at sexual maturity, are separated one by one, or in numbers together, and new joints are at the same time gradually formed behind the head. The total number of joints in a twnia, ten feet long, has been counted, and found to number upwards of 800 ; and the joints ajjpear to be sexually mature about the four hundred and fiftieth segment from the head. Thus growth and development take place mainly towards the neck of the parasite, by a process of transverse fission ; and thus a segmented individual or compound animal appears to grow. This seg- mentation of individual links by transverse fi.ssion ceases when the organs of generation begin to develop themselves in them ; and when those are com- plete, the segment or link has arrived at sexual maturity or completeness. It is now called a ■proglottis. Thus all the new segments come to be developed between the head and those which are advancing to sexual completeness ; and if the characters of complete sexual development be taken as the distinctive Circle of hooks more lii^^lily magnified (after Licuckakt). Digitized by Microsoft® 182 TOPICS RELATIA'B TO PATHOLOGY. mark of individuality, then each segment of the tape-worm may be looked upon as a distinct animal ; and this separation by iission or segmentation may be considered as analogous to what takes place in the medusaj or polypes— a kind of alternate generation, in which, Fig. 25. the segments, zoonites, or 217-ogloUides may be regarded as making up a col- ony of animals. It is only in the ali- mentary canal of man and other ani- mals that the tape-worms, or cestoid entozoa, attain to sexual maturity; and in all of them the ova are fecunda- ted before being discharged, and may often in the T. solium be perceived to have undergone the first stage of their development before they are excluded from the oviduct of the mature seg- ment. The expulsion of the ova oc- curs in some one of the following ways : ( 1.) The impregnated segments sep- arate from each other, and passing out of the body singly or in numbers with the faces or without any fecal evacua- tion, become decomposed, and so the eggs are set at liberty. The activity of these separate segments is retained for a considerable time after passing out of the body — a circumstance which led to their being at one time taken for a distinct species of worm, to which the name of Vermes cucurhitini (from re- semblance to a pumpkin-seed) was ap- plied. The contracted ajipearances of a segment during its movements out of the body are represented by the forms shown in the accompanying woodcut (Fig. 26> One may feadily observe the activ- ity displayed by these beauties of na- ture as they disport themselves on the recently extruded excrement of almost every constipated dog. The expelled joints may be seen to become violently contracted shortly after their expul- sion, as if the stimulus of physical cli- mate in their new situation provoked excessive contortions. The long single joints thus expelled become still more elongated by contractions of their trans- verse fibres, while the alternate contractions of these fibres with the longitu- dinal ones cause shortening of the joint to such an extent that its breadth ex- ceeds its length. Such a sequence of contractions produces movements which simulate those of progression in a worm, and thus these segments may be seen to move some little distance from the spot on which they may have first fallen, discharging ova during their march from the interior of the segment. Thus they may move about for a time; but the growth of the myriads of embryos in the interior of the proglottis causes it sooner or later to burst, when the • embryos become scattered over grass or ground, dispersed in drains, sewers, ditches, surface water, or waste places, while wind and insects help to diffuse them still farther. Proglottis of TccTtia solium magnified. — (a.) Geni- tal pore, witli its preputial cover or slieath-skin ; (?).} Lemniscus or penis; (c.) The oviduct; {d.) The seed-vessel ; fe.) The uterus; (/.) The water vascular system of vessels (after Rokitansky). Proglottides of a Tamia (medwcavellata) in va- rious stages of contraction (after Leuckart). Digitized by Microsoft® STRDCTUBE OF TAPE-WOKM OVA. 183 12) (2.) Eggs are thus discharged through the genital pores of tlie mature seg- ments; and if the segment be sliglitly squeezed, the ova may be pressed out. (3.) The mature joints of the adult tape-worm seem, in some instances, to vuidergo a disintegration within the intestine of the animal they live in. Thus, Kuchenmeister on one occasion found the wall of the large intestine of a dog occupied by a white sandy powder, the particles of which, on examination under the microscope, turned out to be innumerable ova of a T. serrata which lived higher up the bowel, accompanied by its separated joints. Such contingencies, as in (2) and (.3), are not un- likely to happen within the rectum, when, by constijia- tion or otherwise, the matured joints are retained, and constitute one of the most serious dangers which the matured tape-worm inflicts on the animal it inhabits, and one of the strongest indications for its removal. It has been recently ascertained that in one or two in- stances the presence of a Cydicercm tehv celhihscv (the embryo of the T. solium ) has been found to coexist with the previous prolonged existence of a T. solium in the intestinal canal of the human subject. The mature segments are often expelled from the human rectum at the rate of six or eight a day, some- times with the excreta, and sometimes ^;fr se; and they exhibit evidence of very active vitality for some time. Moisture is favorable for maintaining their existence, and for favoring the spread of the eggs over herbs, grass, ground, fruit, or vegetables, wdiicli may become the food of man or of cattle. The structure of these ova (Fig. 27) is peculiar; and the provisions possessed by their coverings for preserv- ing the embryo are important points for consideration in connection with their transmissions through ap- parently impossible conditions into the bodies of ani- mals,' where they become further developed; and in conuection with their powers of resistance to therapeutic agents (which have been called anthelmintics or vermi- fuges) administered for their removal. It is only in their earlier stages of development that they are really the analogues of ordinary ova. In the blind extremities of the oviducts of the mature joint of the tape-worm the shells of the ova appear to be com- posed of a calcareous transparent substance; antl by the time the ova reach the central segments of the tube their hitherto transparent calcareous shell becomes not only much thickened, but is converted into a dark- yellow or brown mass, in the interior of which the em- bryo is formed. The egg at first is of the simplest structure, and very minute, Ix'ing only about v-g^th , part of an inch in size. The admixtvire^ of these or- ganic elements with the calcareous shell imparts to it that extraordinary power of resistance to chemical, and even mechanical, violence which it certainly possesses. Dilute acids and alkalies have little immediate effect r. (a, CL) iiui- inflammation in the neighboring lymphatics, and ten- io^otiierdo[s'on dcrness of the glands to which they run. On the evac- uation of the small abscess in the boil these sj'mptoms gradually disappear, but a persistent red mark remains at the original seat of the disease. The treatment con- sists in poulticing until the little animal appears, when it can be withdrawn. If allowed to suppurate, it must be treated in the usual way of a boil under similar cir- cumstances. The natives put in a mixture of salt and palm oil, which takes out the little grub. "Etiology and Pathology.— This little worm cannot be the chigoe or Pukx penetrans of the West Indies, although it may result from the ova deposited by some similar aphanipterous insect. The (Mgoe chiefly attacks the toes or intervals between them, and causes a series of painful ulcers. It is also of a black color. This small grub is white, causes a boil or two in any portion of the body, most commonly in the tliigh, arm, or abdomen; it "is sporadic, although endemic. They have one symptom in common — viz., the extreme itchiness. But this is complained of in nearly every case of disease resulting from insect or other living organisms." The same grub magnified by a low power, low suction-tubes red .spots. The the body are hooklets, Fic. 45. ^ f Two of the hooklets highly magnified. These drawings were furnished by Dr. Gore. II. ECTOZOA. Definition. — Animak living vpon the d-in and hair. Pathology.— These parasites are of three kinds— namely, lice, mites, ticks or spiders, and fleas. 1. The first kind belong to the fiimily of "lice" (Ped^iculidcv), of the class Insecta, amongst the annidose or artictdated animals. They belong to the order Anoj>lura, all of which are parasites and destitute of wings. They un- dergo no regular metamorphosis, as most other insects do ; but in their growth to maturity they shed their skin a certain number of times, which may to some extent explain the irritation and forms of lesion to which they give rise. Almost all animals- man, quadrupeds, birds, aud reptiles— are liable to be infested with these parasites ; and were it not for our instinctive feelings of Digitized by Microsoft® THE INGUINAL AND HEAD LOUSE. 213 disgust witli regard to them, as opposed to our notions of cleanliness and pro- priety, the study of their forms and habits is of considerable interest to the pathologist. Upwards of 500 species of lice have been described — universally diffused over the animal kingdom in different climates of the world. Their superabundance upon the persons of the human race is associated with some severe lesions of the skin ; and authentic cases are related of death from lousi- ness. A technical name has been given to this condition, namely : Phthiriasis. — Lousiness is a morbid state in which lice develop themselves to such an extent that a pruriginous eruption is produced (Prurigo jjedieii- laria). The skins of persons liable to constitutional skin diseases in which watery or secreting eruptions (such as eczema) prevail, are those most favor- able for the development of lice. Five forms of lice infest the skin of man. One variety is met with on the hair of the head — the Pediculus capitis; a second variety infests the other hairy parts of the body, but especially the pubis ; and hence its name — Pe- diculus pubis; the third form lives on the general trunk of the body — ^the Pediculus corporis; a fourth is the Pediculus palpebrarum; and a fifth the Pediculus tabescentium. The first four species, although they live in close proximity to one another, yet strictly limit themselves to the regions mentioned. In a clinical point of view the P. corporis is the most important. 2. The second kind of animals associated with diseases of the skin belong to the family of "mites" or "ticks" (Acaridce), of the class Arachnida, amongst the annulose or articulated animals. Some of these are free, others are parasitic, and vary somewhat in their structure accordingly. Those which live a parasitic life have the mouth in the form of a sucker. Such are the "ticks," which fasten upon dogs, cows, sheep, horses, and other animals. They bury their' suckers so deep in the skin that it is impossible to detach them without tearing the skin to which they fix themselves ; and they multiply so rapidly that oxen and horses attacked by them have been known to die of mere exhaustion. The harvest ticks (Leptidce), one species of which, the Ijcptus autumiialis, well known as the harvest bug, is common in autumn in grass and herbage, from which it gets on the body of man, and, though ex- ceedingly small, produces extreme irritation of the skin. One only of these parasitic Acari has been found to live entirely in the skin of man — the Sarcoptes gain vel Acarus scabiei — producing the disease called the itch. (3.) The third kind includes the common flea, Pulex irritans, and the Pulex penetrans or chigoe. 36. Phthirius inguinalis, or the Crab Louse (Fig. 46), has a shield-shape, and a much broader body in proportion to its size than any other form of louse; and there does not appear to be any distinct ^^^ ^^ separation between its thorax and abdomen. It has been met with on all the hairy parts of the body except the head, but more especially on the hair of the pubis. It does not run about like other lice, but grasps the stems of the hairs with its fore legs, and adheres so firmly that it is difficult to remove it without pulling out the hair. The nits or egg capsules are attached to the hairs in the same way I i i i i i i i i i I as on the head. Pruriginous or eczematous erup- loothsofan inch x lo diameters. tions, which mav become pustular, are the results The Crab Louse (after an- /. .1 '. . , •' ^ A \ DERSON). 01 their existence (Andeeson).. 37. Pediculus capitis, or the Head Louse (Fig. 47), is considerably smaller than the body louse. Its legs are larger in proportion to the size of the body than those of the P. corporis; and the abdomen is more distinctly divided into seven segments, separated from each other at the margins by deep notches. They propagate with astonishing rapidity, and by their irritation produce Digitized by Microsoft® 214 TOPICS RELATIVE TO PATHOLOGY. Fig. 47. an eczema, fromwhich tlie fluid exudes abundantly, and crusts are formed, involving the cuticular debris or exuviae of tbe lice and the remains of epidermis. The hairs become glued together ; partly by the fluid from the eczema and partly by the secretions of the insects as they deposit their ova in the capsules which they fix to the hairs (Fig. 48). These capsules are commonly called nits; and they adhere with great tenacity to the hairs. 38. Pediculus palpebrarum, the Louse of the Eyebrows, is a doubtful variety. 39. Pediculus vestimenti. — The Body Louse f Fig. 49) is of a whitish color, and varies from half a line to two Hues in length ; the body elongated and the ab- dominal portion broad, its margins lobu- lated and covered with little hairs. The thoracic portion is very narrow, and car- ries three legs on each side. The legs are hairy, jointed, and terminate in claws. The insect secretes itself amongst the folds of the clothing, and causes extreme itchi- Betweeu the irritation of the insect, the (a) Pediculus capitis (male); {b) Trachea and stigmata ; (c) Anteuna (after Andehsonj. ness of the skin where it comes to feed. Fig. 48. lOOths of an inch X 200 diameters. Kit, or Egg Capsule of tlie Louse, lixed to (b) a hair, by the glutinous secretion (p, c, c, c). debris of its exuviie, and the scratching of the skin by the patient, papula arise, the summits of which being torn oflT, give rise to a pruriginous eruption, which Digitized by Microsoft® TREATMENT OF LOUSINESS. 215 may even become pustular. This eruption is met with most frequently on the neck, back, and shoulders, and round the waist — the parts most tightly embraced by the clothing; and where the clothes are most frequently gathered iuto folds, between riG.49. which the lice are imbedded, and where they de- posit their eggs, or egg capsules, which are crystal- line, shining, yellowish, opaque bodies. The lice seem to multiply fastest where eruptions, such as eczema, prevail. A case is reported by Mr. Bryant as having occurred in Guy's Hospital, in which the whole of the body was literally covered with lice. The patient had been a governess, about thirty years of age ; and the irritation was so great that excoriations and scabs were produced. On admis- sion into hospital she was put into a warm bath, her clothes were destroyed, and every precaution taken to remove all the insects ; but in two hours afterwards her body was again covered with lice, ' ' ''''''''' although she had been laid in a clean bed. She ^'Z^lV^'^^^ZZr was again thoroughly washed, but the vermin re- * "^ '"aSjeeson)"""' appeared immediately. Some of the insects and their ova no doubt remained adhering to the skin, hidden amongst the scabs of the excoriations ; and they are known to multiply with a rapidity propor- tioned to the favorable nature of the soil afforded by the morbid condition of the skin of the affected person (Anderson, I.e., p. 108). Bernard Valentin relates the history of a man, forty years of age, afflicted with unsupportable itching over the whole body, and having his skin covered with little tuber- osities. The physician, unable to assuage the itching, made an incision into one of the small tumors, and gave exit to an enormous quantity of lice of different forms and sizes. The same operation was performed on the other tumors with a similar result (quoted by Andeeson, p. 110). The following instance is related by Dr. Whitehead, in his work On the Transmission from Parent to Offspring of some Forms of Disease, p. 173, and quoted by Dr. Tanner: A farmer forty-three years of age, strong, and of sanguine com- plexion, contracted syphilis in April, 1840. Seven months afterwards he suffered from secondary symptoms. At the end of 1841 he became so an- noyed by the presence of lice about his person, chiefly on the trunk, that he sought again medical aid and advice. He was scrupulously clean in his habits, and had never before been troubled with these vermin. They in- creased in number, and produced such mental distress that fears were enter- tained for the integrity of his intellect. An examination of the skin showed a multitude of irritable-looking points on the front and sides of the chest, fi'om which 7iits could be detached by lateral pressure. At this period the generation of the lice was so considerable and rapid that a flannel vest put on clean in the morning was crowded with them by the end of twenty-four hours. The usual remedies had only a temporary effect, till iodide of potassium and prussic add, taken internally, seemed to render the system unsuitable for the further development of the vermin. 40. Pediculus tabescentium, or Distemper Louse, is^ of a pale yellow color, having a rounded head and long antennse ; the thorax is large and quadrate, the abdomen large, and the segments intimately united. It is doubtfully British. Treatment of Lousiness consists in tbe destruction of the insects and sooth- ing the irritation. To accomplish the death of the parasites the following sub- stances are efficient — namely, carbolic add, sulphur, mercury, staphisagria, sabadilla, pyrethrum, the essential oils, and alcohol (Anderson). Carbolic add may be used as a soap (Calvert's or Macdougal's), or oint- ment, or as a lotion, in the following proportions : Digitized by Microsoft® 216 TOPICS RELATIVE TO PATHOLOGY. Crystallized carbolic acid, two drachms ; Spirits of Rosemary, one ounce ; Eectified spirit, half an ounce : Distilled water, to make up a lotion to six ounces, with which the parts are to be sponged night and morning. Sulphur is used in the form of vapor baths or fumigations, or the simple or compound sulphur ointment of the Pharmacopoeia. Mercury may be employed as simple mercurial ointment, or by fumigations with cinnabar, or in solution of the bichloride, in the proportion of two to three grains to an ounce of water, to which some alcohol has been added. Staphisagria is employed as an ointment in the proportion of an ounce of staphisagria with four ounces of lard ; or an infusion of staphisagria may be made with vinegar. Sahadilla may be used in powder or as an ointment ; an ounce of lard being used to incorporate a drachm of sabadilla. The hair should be cut short when lice infest the head ; and a lotion of the bichloride of mercury, or some of the ointments above named, applied at once to cause the death of the insects. The nits may be dissolved away by alcohol or dilute acetic acid (Hebra). The scalp should afterwards be repeatedly washed in warm water with soap, and the eruptions treated according to their nature. Sometimes the nits and the debris of the lice are involved in the substance of these eruptions, so that care must be taken to kill any insects that may remain and be so hidden. With regard to body lice, it is necessary either to destroy the clothes or to expose them to a temperature of at least 150° Fahr., by steaming them, or ironing them over with a sufficiently hot iron, or to boil them. In extreme cases, such as those related at p. 215, it has been found that a mixture of iodide of potassium and prussic acid in full doses cured the diseased state of the system which favored the development of lice in such numbers. After sixteen or eighteen doses in the case recorded by Whitehead, the cure was permanently completed. The Pedicidus jnibls is best got rid of by rubbing a lotion of bichloride of mercury amongst the roots of the hairs, taking care that it is brought in con- tact with every insect. The application should not only be applied to the hair of the pubis, but to that in the neighboi-hood, such as that of the scrotum, perinceum, and anus; and the ajiplication should be continued twice a day for a week at least. Mer- curial ointment is equally ef- ficacious ; but care must be taken not to induce saliva- tion : the hairs, rather than the skin, are the parts on which the lotion or ointment ought mainly to be applied. 41. Sarcoptes scabiei. — The full-grown itch spider or Acarus is of a whitish-yellow color, and is just visible to the naked eye. The female (Fig. 50) varies in size from ith to Fig. so. |th of a line in length, and to -^th of a line in Acarus scabiei.— tenvAa (after Dn. T. Andeeson). from j\-jth breadth. It is of an ovoid form, broader anteriorly than Digitized by Microsoft® DESCRIPTION OF THE ITCH SPIDER. 217 posteriorly. The anterior segment carries the head and four limbs, two on each side of the head, which are set very close to it. The head projects con- siderably beyond the body, is of a rounded form, and marked by a central fissure provided with mandibles. The limbs are altogether eight in number, the four posterior limbs being placed about the middle of the under surface of the body. These limbs are of a conical form, tapering towards a point. They are each composed of several jointed segments ; and the four anterior limbs are each provided with a stalked sucker. The extremity of each of the hind limbs terminates in a long curved hair ; and several short hairs spring from beside the root of each sucker on the anterior limbs. The body is marked by numerous regularly disposed wavy lines ; the dorsal surface is convex, pro- vided with numerous little angular spines and little round tubercles, from each of which also springs a short conical spine. From each side of the body two hairs project ; and four project posteriorly ; so that, including those springing from the hind legs, the posterior half of the body is provided with twelve long hairs. The male Acarus seabiei (Fig. 51) is considerably smaller than the female ; and the innermost pair of posterior limbs are provided with stalked suckers as well as the anterior limbs ; while the parts corresponding to the genital organs are very distinctly marked (Hebea, Anderson). fig.si. It is now impossible to say who discovered the itch insect. Avenzoar hinted at the existence of an insect in the vesicles of itch ; but Moufet, in his Theatrum Iiisectormn, first mentioned it in a particular manner in 1663. Hauptmann first published a figure of it, and represented it with six feet. Redi Lorenzo, Cestoni, and Bonomo ex- amined numbers of them, having removed them from the papules or vesicles of the skin. They dis- covered also the eggs of the parasite, and even ob- served their extrusion. Morgagni, Linnaeus, De Geer, Wichmann, and Waltz confirmed these ob- servations ; but, nevertheless, the existence of the parasite up till 1812 was still called in question. About this time, therefore, a considerable prize was ofiered by the Parisian Academy of Sciences for its demonstration ; and M. Gales, an apothe- cary of the St. Louis Hospital, tempted by the reward, is said to have defrauded the Academy and gained the prize (Anderson). His investigations are re- ported to have been witnessed by many members of the Institute ; but never- theless, he managed to conceal beneath the nail of his thumb the common cheese-mite, and having opened with a lancet the pustule of a patient affected with scabies, he dexterously produced the cheese-mite from beneath his nail, pretending to have removed it from the patient (Anderson). Many others attempted to find the Acarus in the pustules or vesicles ; and the circumstance of such men as Galeoti, Chiarugi, Biett, Lugol, and Mourouval having failed in finding the animal, occasioned fresh doubts regarding its existence. Their failures arose from having followed the cue given them by M. Galls in search- ing for the parasite in the papules or vesicles. Moufet had long before stated that they were not to be found in the pustules, but by their sides. Casal made nearly a similar observation ; and Dr. Adams remarks that they are not found in the vesicles, but in a reddish line going ofi" from one of its sides, and in the reddish firm elevation at the termination of this line, a little dis- tance from the vesicle. Seventeen years after Gales's demonstration the Academy discovered, through Easpail, that they had been defrauded ; and in 1834 M. Renucci, a medical student from Corsica, showed the physicians Digitized by Microsoft® 218 TOPICS RELATIVE TO PATHOLOGY. of Paris the mode of discovering the Acams, "which is the same method as that which had been formerly mentioned by Dr. Adams. Since that time, as Rayer remarks, the existence of the A. scabiei has been placed beyond a doubt ; and after the demonstrations of MM. Lemery, Gras, and Eenucci (all of whom showed him the method of detecting it ), Rayer has been able to extract it several times himself. Raspail has given an excellent description and figure of the parasite. M. Albin Gras enters into researches as to the share it has in producing the eruption, and he instituted experiments on the Aearus itself, which have an important bearing on the treatment of scabies. The habits and natural history of the parasite have been carefully investi- gated by Hebra ; and Dr. Anderson has given an excellent account of these investigations, from which this description of the parasite and the disease is mainly taken. The discovery of the male Acarics is claimed by several observers. Accord- ing to Hebra, it was first discovered by Danielssen and Boeck in Norwe- gian scabies. According to Dr. Anderson, M. Bourgogne, the maker of microscopic preparations in Paris, claims to be the discoverer. According to Devergie, the honor is due to M. Lanquetin, a pupil of St. Louis. It is the female only which burrows in the epidermis of the human skin. All the male Aeari go free on the surface of the epidermis, where sexual in- tercoui-se laetween male and female Acari is said to take place. When an impregnated female is placed on the surface of the skin, it seeks a suitable spot to penetrate, and raising its head at right angles to the surface, it digs, burrows, or eats its way between the scales into the deep layers of the epider- mis, where it imbeds itself, derives nourishment, and goes through the process of paturition till she dies. Having found a suitable place, an egg is laid, and each day another, the animal penetrating a little further each time, leaving its deposited eggs to occupy the space previously inhabited by itself. The direction of the canal is ololique, the portion first formed being of course, nearest the surface. As the old epidermis is thrown off, new layers of cuticle being formed from the deeper strata, the first-laid eggs are gradually thrust upwards to the surface, where they are finally extruded, while the recently deposited ova remain in the canal close to the parent female, whose instincts , lead her to make the canal in such a way that her eggs reach the surface about the time the young ones are ready to come out of the shell. The newly- hatched Acari (males and females) having arrived at the surface, crawl about the skin, and enter into sexual congress. The females in due time become impregnated, and, like their parent, repeat the process of burrowing and par- turition just described. The length of time which intervenes between the laying and hatching of an egg is said to be fourteen days ; and as the Aearus is found to lay one egg daily, there are rarely more than fourteen eggs in one (a.) Erk in the first staR-B; (S.) In the second stase, their granular contents being yellow ; (f.) Egg in ' the third stage, the form of the Acnrui becoming apparent; ( Fig. 61. — (a.) Quadratoctahedrals of oxalate of lime ; (ft.) The basal plane of an octahedron forming a rectangle ; (c.) Compound forms ; (rf.) Imperfect forms (dumb-bell cryatals) : X 300 diameters (Wedl). Fig. 62. — The more usual forms of triple phosphate of magnesia and ammonia ; various metamorphic, hemihedral forms of the fundamental figure — the rhombic vertical prism : X 300 diameters (Wedl). In the formation of calculi and concretions these elementary constituents are classed by Rokitansky under two series, namely : (1.) Those made up essentially oi protein substances ; or into such as consist of gluten and fat, with the phosphates and carbonates of lime and magnesia. In this series are included the following : (a.) Protein concretio'ivi, as coagula within bloodvessels (vegetations); free bodies in serous cavities. (b.) Gluten-like colloid substances, commonly encysted, or eonified concre- tions, as the valve-vegetation of the heart. (c.) Fat, as in the contents of fattj^ cysts, or accumulations of fat in serous cavities, or in combination with — (d.) Bone-earth concretions, as in cretification and ossification of fibroid and cartilaginous textures (see "Mineral Degeneration," p. 126, ante). (2.) Into such as have a more varied composition, and are especially marked by the specific substances which they contain, e. g., bile, urine, &c. In this second series of concretions there are two varieties : (a.) Genuine stony concretions or calculi, which when diminutive, are termed "gravel" or "sand," resulting from the precipitation of one or of several of the specifio components of a secretion, the animal matter entering into their compo- sition as a bond of union or cement. The size of such calculi are extremely varied, from a fine but just perceptible sand-grain to that of a concretion fill- ing up the largest secretory canals and reservoirs. The smaller are usually spherical ; the larger have their shape in some measure determined by the form of the canals or reservoirs in which they occur — as, for example, gall- titones in the bile-ducts, and calculi in the urinary bladder. Where many concretions coexist, they acquire more or less smooth facets from reciprocal pressure and friction — as, for example, numerous calculi in tie gall-bladder or in the urinary bladder. The consistence and specific weight of calculi depend on their composition. They may be free in a cavity, or firmly impacted, or glued to a surface by the medium of a fibrinous exudation. Digitized by Microsoft® DEFINITION AND PATHOLOGY OF MALFORMATIONS. 233 In structure they are extremely varied. A nucleus is sometimes recogniza- ble, composed of an amorpho-granular precipitate, round which concentric strata or crystalline formations form ; or they may be altogether crystalline, as the lithic acid calculus, or of cholesterin, as the white gall-stones. Some- times a foreign body may form a nucleus, introduced from without, as into the urinary bladder ; or a coagulum of blood or fibrin, or inspissated bile, or bile-pigment, to a cholesterin calculus in the gall-bladder. Examples of such calculus formations will be found described in calculi of the urinary bladder, salivary calculi, calculi of the lachrymal sac, prostatic calculi, gall-stones, and intestinal concretions. (6.) Inspissation and desiccation of some fluid of secretion. The ingredients of the secretion form the substance of concretion or calculus, including a con- siderable amount of animal matter, combined with the specific elements of secretion. In proportion to the inspissation is the hardness of the concretions. Cyst-like dilatation of follicles gives space for such concretions to accumulate ; for example, the follicles of the skin, mucous follicles, the tonsils, nasal and pharyngeal cavities, glands and prepuce, intestinal concretions, especially in divertipula of the intestines, inspissation of colloid or other cyst-contents. A microscopical analysis of concretions is essential for a determination of their source and character, and ought never to be omitted. (See Wedl, p. 121, for an instructive illustration of this part, too long for quotation.) MALFORMATIONS. Latin Eq., Deformitas Ingenita ; French Eq., Vice de Conformation; German Eq., Missbildung ; Italian Eq., Vizio di Conformazione, Definition. — Deviatiotis from the normal development of the organism of the body occurring in the earlier period of gestation, or at least previously to the termi- nation of foetal existence. Pathology. — The imperfections consequent on such primitive malformations result in more or less permanent deformity, to which the harsh name of mon- strosity has been given ; and the doctrine of such congenital deformity is now comprehended under the scientific name of "Teratology" (Tipa<;, signifying monster).. The superstitions, absurd notions, and strange causes assigned to the occurrence of such malformations are now fast disappearing before the lucid expositions of those famous anatomists who have made the development and growth of the ovum a subject of special duty. It is sufficient to mention here the names of J. Muller, Rathke, Bischoff", St. Hilaire, Burdach, Allen Thomson, G. and W. Vrolik, Wolff", Meckel, Simpson, Rokitansky, and Von Ammon, as sufficient evidence that the truths of science will in time dispel the mists of ignorance and superstition. Nevertheless, much mystery still enshrouds the origin of malformations ; and opinions concerning the origin of them may be considered in the two main issues, namely, — (1.) Are they due to original malformation of the germ? (2.) Or, are they due to subsequent deformities of the embryo by causes operating on its development? With regard to the first issue, it is believed that the germ may be origin- ally malformed or defective, owing to some influence proceeding either from the female or from the male ; as in the case of the repeated procreation of the same hind of malformation by the same parents, deformities on either side being transmitted as an inheritance. Farther evidence of original germ-defect is held to exist in the hereditary deformities extending over more than one generation ; such, for example, as harelip, excessive number of fingers, hypo- spadias, and the like. With regard to the second issue, namely, whether subsequent deformation may not follow an originally well-formed germ, it has been said, — (1.) That such deformation may be produced by mental impressions on pregnant women ; but of this there is an absence of positive proof. Digitized by Microsoft® 234 ■ TOPICS RELATIVE TO PATHOLOGY. (2.) It has been proved that external injury, suffered by women during pregnancy, will bring about deformation, as in the congenital deformity of hydrops ventrieulorum cerebri. (3.) The late Sir James Simpson has shown how diseases of the ovum and foetus will bring about deformation of the child. The diseases are chiefly acute and chronic inflammation of the placenta, attachment of pseudo-membranes to the foetus, and adhesions of the foetus to the placenta. Self-amputations are thus also explained. Moles, mother's marks, and cutaneous spots, are ascribed to morbid states of the coats of the ovum. (4.) A very generally recognized cause of malformation consists in im- peded development of the foetus, the cause of which is not always obvious, but is for the most part concealed. The impediment may be confined to one part or extended to many, to more than one region of the body, for example, and to more than one apparatus. To understand the results of impeded development, the student requires to know the natural forms through which the several parts of the foetus pass in their normal development to completeness. If he does not know these, he cannot appreciate an "arrest of development" where it ceases at a cert.ain point, and advances no farther. The increased growth and progressive nutri- tion of the normal portions of the body also impart important modifications to the final result. Transient forms of the human foetus are comparable to persistent forms of many lower animals ; hence, malformations resulting from arrest of development often acquire an animal-like appearance. Many are unfit for life after birth. The following elementary facts in "teratology" are essential to a proper understanding of malformations : 1. Dissimilar parts are never fused or united ; only parts that are not origin- ally dissimilar, but which are developed from a common mass. 2. Malformed parts are restricted to their determinate place. 3. No malformed organ ever loses entirely its own character, nor a mal- formed animal its generic distinction — a distinct gradation and natural order are observable throughout. Thus, there are different degrees of malformation in the same deformity, varying from the greatest possible degree to the very least. 4. Deformities do not take place by chance, and double deformities are always of the same sex. No suitable classification of deformities can yet be given ; but taking embryo- genesis as a basis, a grouping may be made, useful alike for physiological and medical practice. Such is that originally given by F. A. Von Ammon and W. Vrolik. The same principle seems to have guided the College of Physi- cians in the following grouping of malformations (p. 237, Appendix to Nomenr cloture o/ Diseases') : I. — Malfoemations resulting from Incomplete Development oe Growth of Parts. (a.) op the body generally. Head absent, or rudimentary. (Nine types are described by Vrolik.) Cranium defective. Lower jaw absent or defective. Upper and lower extremities absent. Lower extremities absent. One lower extremity absent. Hands and feet articulated to scapulae and pelvis Fingers and toes deficient in number. Digitized by Microsoft® Referable to very early periods of develop-- ment. CLASSIFICATION OF DEFORMITIES. 235 (6.) OF THE NERVOUS SYSTEM. Brain absent, with exposure of base of skull. Brain rudimentary or incompletely developed — several types, accord- ing to incompleteness. Spinal cord absent or imperfect, witb more or less exposure of spinal canal. Continuity of nerves -witli nerve-centres incomplete. (e.) OF THE ORGANS OF SPECIAL SENSE. Eyes absent. Eyes imperfect. Eyelids incomplete. Eyelids remaining united. (Symblepharon.) External ear absent. Pinna adherent. Meatus externus closed. Internal ear imperfect. Nose absent. Nose imperfect. Nose resembling a proboscis. (d.) OF THE VASCULAR SYSTEM. Heart absent. Cavities of heart deficient in number. a. One auricle and one ventricle. b. Two auricles and one ventricle. Septa incomplete. a. Auricular. b. Ventricular. Orifices obstructed or imperfect. a. Right auriculo-ventricular aperture. b. Pulmonic aperture. c. Left auriculo-ventricular aperture. d. Aortic aperture. Foramen ovale prematurely closed. Ductus arteriosus prematurely closed. Origins of aorta and pulmonary artery transferred. Origin of ascending aorta from left ventricle, and of descending aorta from right ventricle, through the ductus arteriosus. Commencement of descending aorta contracted or obliterated. Foramen ovale persistent. Ductus arteriosus pervious. Cardiac valves imperfect. Pericardium absent. (e.) OF THE RESPIRATORY SYSTEM. Lung (one or both) absent. Pulmonary lobes deficient in number. Larynx and trachea absent or imperfect. (/.) OF THE DIGESTIVE SYSTEM. (Esophagus impervious. Intestine impervious, or deficient in various regions. Anus impervious. Anus in unusual situations. Liver preternaturally small. Digitized by Microsoft® 236 TOPICS RELATIVE TO PATHOLOGY. Gall-bladder absent. Biliary ducts impervious. Uracbus patent. Vitelline duct patent. (ff.') OF THE URINARY SYSTEM. Kidney (one or botb) absent. Kidney lobulated. Ureters absent or impervious. Uracbus persistent. (h.) OF THE MALE ORGANS OF GENERATION. Penis diminutive, resembling clitoris. Prepuce abbreviated — elongated. Testicle (one or both) absent. External organs absent. (i.) OF THE FEMALE ORGANS OF GENERATION. Ovary (one or botb) absent. Uterus absent. Vagina absent. Vagina impervious. Vagiila a cul-de-sac. External organs absent. [Hymen imperforate.] II. — ^Malformations resulting from Incomplete Coalescence of the Lateral Halves of Parts which should become Conjoined. (a.) on the anterior median plane. Fissure of the face. " " iris. Coloboma. " lip. a. Single harelip. b. Double harelip. " " palate. a. Hard palate. b. Soft palate. " " nose. Naso-buccal fissure. " " sternum. " " diaphragm. " " abdominal walls. " " pubic symphysis. " " anterior wall of urinary bladder (with extroversion of the posterior half). Epispadic fissure of the urethra. Hypospadic fissure of the urethra. Fissure of the scrotum. (b.) on the posterior median plane. Fissure of the skull. " " spinal column. Spina bifida. a. Complete. b. Partial. 1. Cervical region. 2. Lumbar " 3. Sacral Fissure of the spinal cord. Digitized by Microsoft® CLASSIFICATION OF DEFORMITIES. 237 IIL-MaLFORMATION RESULTING FROM COALESCENCE OF THE LATERAL ±1ALVES OF Farts which should remain Distinct. Lower extremities conjoined. Syreniform foetus Fingers or toes conjoined. Coalescence— webs Monoculus. Cyclops. Double kidney. IV.— Malformations resulting prom the Extension of a Commis- sure BETWEEN THE LATERAL HALVES OP PaRTS (CAUSING AP- PARENT Duplication). ^ Double uterus. Double vagina. V.-Malformations resulting from Eepetition or Duplication of Parts in a Single Fcetus. Supernumerary fingers and toes, cavities to heart, valves. VI.— Malformations resulting prom the Coalescence of two Fe- tuses, or of their Parts. xwo j^ce DoubL fetus""" ^^'' ■'''''*°*' ''°'^^'*''*^^g ^ ^^"^"^ covered by integument. a. One perfect. The other an appendage. 0. Both more or less perfect. 1. The middle parts united. The upper and lower distinct. I. Ihe upper parts umted. The lower distinct. 6. The lower parts united. The upper distinct. VIL-CONGENITAL DISPLACEMENTS AND UnUSUAL POSITIONS OF PaRTS of the Fcetus. , -lAitia Transposition of yhcera.-[Influence of fcetus as always developed lymg on left side, as a rule, to be considered here 1 Merma or ectopia of the bram. " heart. " " " lungs. " " intestines. Varieties : Through diaphragm. Syn., Diaphragmatic hernia. ihrough abdominal walls. Syn., Abdominal hernia Ihrough umbilicus. Syn., Umbilical hernia i-xtroversion of posterior wall of bladder. Testis retained in abdomen. " inguinal canal. Digitized by Microsoft® 238 TOPICS RELATIVE TO PATHOLOGY. In the case even of double or duplex deformities only one germ seems to^ be concerned. In illustration of this, Dr. Allen Thomson has given the following demonstrations (Figs. 63 and 64). He has shown that on one yolk, and on one germinal membrane or blastodermic vesicle, two primitive grooves may be Fig. 6.5. Fir, 63.— From a fowl's egg, after sixteen or eighteen liours' incubation, magnified four times, {a.) The germinal area of the cicatrieula; (h.) The transparent area, containing two primitive traces of embryos; (c, c.) Primitive grooves of the double embryonic trace, on each side of which are seen the laminje dor- sales (after A. Thomson). Fig. 64. — Double embryo removed from a goose's e^^^, after five days' incubation, magnified four times, ig.) The common heart; (A.) Kndiments of the superior ; (i.) Of the inferior extremities; (A.) Thecom- liion cephalic luld of the amnios ; {I.) The common folds (after A. Thomson). formed, which, in their ulterior development, shall probably (certainly, if they live ?) form a double monster, as maj^ be seen in Fig. 64, taken from a goose's egg after five days' incubation. The formation of such a primitive groove in a single ovum is sufficient to explain the origin of the principal types of double monsters. Such malformations of the ovum have been overlooked by the Col- lege of Physicians, and are omitted in the table just quoted. These are the earliest examples of double deformity that have ever been recorded ; and no student of Medicine should remain ignorant of them. FUNCTIONAL DISEASES. Latin Eq., Vilin Naturnrnini Aeliomim. ; French 'S.q,., Maladies Fvnciionelles ; Gbr- MAN Eq , Fiinctionelle KravkheUen oder AJf'cctionar j Italian Eq , Malattie di Funzlone. Definition. — All those diseases in. which the concurrent living action of the parts or organs (i. e., the concnrTent exercise of function^ is not maintained, or in which the contractility, tonicity, nutrition, secretion, sensation, or motion of parts may be increased, diminished, or perverted, and that without fever or inflam- mation. Pathology — Hitherto the complex morbid processes which have been described embrace nearly all the important forms of disease which affect the various organs which the eye can appreciate, assisted or not by the micro- scope, or which can be appreciated by other physical aids, such as by chemical analysis or reagents ; all of which are now comprehended in the science of morhid anatomy, and demonstrated by anatomical investigations. Morbid changes which are not visible, or which are not yet ascertained by any physi- cal means of observation, are described as functioned or dynamic. They em- Digitized by Microsoft® ...^ PATHOLOGY OF FUNCTIONAL DISEASES. 239 brace all those_ diseases in which the action, the secretion, or the sensation of a part is impaired, without any primary alteration of structure of the organ or tissue affected, so far as our imperfect means of research can ascertain. It is possible, however, as physical aids to the senses increase and become more practical, thereby improving the means of observation, that the now so-called functional changes may eventually be shown to depend upon some concomi- tant anatomical change or alteration of structure (molecular it may be), which at present is not appreciable. The appreciable morbid forms of disease which have been described, and which are either permanent or more or less persistent after they are formed, are described in the science of morbid anatomy as lesions. They are common to a greater or less number of individual diseases, hereafter to be considered and described in this Text-book of the Practice of Medicine. It will then be seen that such lesions do not essentially constitute the disease, but are rather the results of disease, and are serious or otherwise according to their nature, their site, and the amount of the structural change involved. It is the duty of the pathologist and the physician to connect them with signs and symptoms of disease, with the object of adopting remedial measures for their prevention, or cure, or for the relief of such inconveniences as they may cause. But the class of complex morbid states, known as "functional," are often notless strikingly formidable in their symptoms than those attended with obvious lesions ; they are, in many instances, the cause of much suffering. They are_ usually, also, of long duration, without fever, generally difficult of cure, having a strong tendency to recur, and to terminate eventually in organic changes capable of demonstration. The occasional exciting causes of such diseases act upon the vital functions, or the usual manifestations of life and action in the various organs and struc- tures._ They will be considered in detail under the various organs whose functions are thus specially implicated. They have hitherto been described under the name of " JSTeuroses;" but, year by year, as a knowledge of morbid anatomy has extended, the number of these functional diseases has diminished. They were so named because " functional " diseases were believed to have their origin in the nervous system, and were indicated by disordered sensa- tion, volition, or mental manifestation, without any evident lesion in the struc- ture- of the part, and without any material agent producing them. Broussais attributed them to a state of irritation of the brain and spinal marrow. In the Nomenclature of the College of Physicians of London, the functional diseases of the nervoiis system constitute a group which embraces all affec- tions, of which the cause is either undefined or variable, whether its probable seat be the brain, the cord, or the nerves. Its components are so far hetero- geneous as to include such discordant elements as hydrophobia, epilepsy, neuralgia, tetanus, cramps, chorea, shaking palsy, hysteria, catalepsy, trance, and hypochondriasis. At present the following are functional diseases, which, comprehended under " Neuroses," are of unknown anatomical origin : Functional diseases of the heart ; of the nervous system, such as chorea, tetanus, epilepsy, acute epilepsy of infants and children, hysteria, catalepsy, hypochondriasis; while colic, vomiting, diarrhoea, constipation, have been regarded as " neuroses," or functional diseases of the alimentary canal. But when it is remembered that every function of the animal body consists of one or more, sometimes of several individual but concurrent and successive actions (actiones) ; that each action is performed by one or more organs con- structed for the pui-pose ; that each organ consists of certain elementary tissues, arranged in a certain form ; that each elementary tissue not only possesses a definite arrangement of its minute particles or constituent atoms, but is en- dowed with certain physical and vital or physiological properties (facultates'), by virtue of which it is enabled, with its particular arrangement and the me- Digitized by Microsoft® 240 TOPICS RELATIVE TO PATHOLOGY. chanical form in which it is disposed, to concur in the accomplishment of the actions assigned to it; then, every derangement of function (i. e., every fime- tional disease) depends on the derangement of some of its constituent actions. But it is doubtful how far any action can be deranged without some change in the properties of the elementary tissue of the organ; and it is still to be determined to what extent these properties can be impaired, disordered, or annihilated, without some corresponding change in the elementary atoms which constitute the intimate structure of the organ (Ceaigie). At present, the pathological explanation of these so-called functional diseases is, to a very great extent, a matter of theory merely. Of the morbid states named at p. 66 as elementary forms of _ disease, there remains to be considered one very complex condition, implying variations of fiinctional tension to an extreme extent, and which will be found to take part in the expression of many diseases, both local and general: namely,— FEVEE. Latin Eq., J'eJris; Frknch Eq., i?'iS»?-e; German Eq., i^'ieJer; Italian Eq., J'eftST-e. Definition A complex morbid state which accompanies many diseases as part of their phenomena, more or less constantly and with a defined regularity, but va- riously modified by ilie specific nature of the disease which it accompanies. It essentially consists in elevation of temperature, which must arise from an increased tissue-change, and have its immediate cause in alterations of the nervous system (ViECHOW, Paekes). Pathology. — In describing the nature of fever, the following statements are principally compiled from the Gulstonian Lectures of Dr. Parkes, delivered before the College of Physicians in 1855, and from a review by Dr. Jenner, " On the Proximate Cause of Fever,." in The British and Foreign Medico- Chirurgical Review for 1856. Knowing how difficult it is to convey an ortho- dox account of the nature of fever ; fully impressed with the great importance of the subject ; and believing " that so consistent a theory of the nature of fever, and one so largely supported by facts, has not been placed before the profession as that developed by Dr. Parkes, I only hope I may be able to do it justice in the attempt to lay it before the student of Medicine in the follow- ing form. In the eloquent language of Dr. Parkes, ' I shall have to allude to inexplicable phenomena, to vast spaces still unfilled by solid facts, to spots unknown to observation, and to regions lighted only by the dim and treacher- ous ray of speculation.' " , The practical object aimed at in the exposition about to be given, is to fix the scientific principles which ought to guide clinical investigation in determi- ning, the Natural History of fevees generally ; and especially the scientific . principles which must define the differences which subsist among specific fevers ; and so aid in determining the conditions under which they are generated or propagated — their development, course, or progress, and their defervescence. " A hot skin, a quick pulse, intense thirst, scanty and high-colored urine," are phenomena common to ipany diseases ; and when they are present it is said that the patient is feverish, or that he suffers from fever or pyrexia. There are some diseases in which such symptoms constitute the prominent, and almost ■ the only appreciable phenomena, and which run a more or less definite course, without the necessary development of any constant local lesion. Such diseases have been emphatically termed " fevers," or sometimes specific, primary, or idiopathic fevers. When diseases marked by local lesions — such, for instance, as the local inflammations — are attended by the symptoms just stated, then the pyrexia, fever, or feverish symptoms which attend them, are said to be secondary or symptomatic ; and the physician is accustomed, when he deals Digitized by Microsoft® NATURE OF FEVER. 241 with such cases, to abstract the symptoms of fever from the other symptoms proper to the special affection. In other words, he prescribes for, and tries to cure the special affection, and not the fever, because he knows that when he has subdued the local disease the femer will subside. Not so, however, with the fever of specific diseases like small-pox, typhus, or enteric fever. The physi- cian cannot cure such a fever ; but he may guide its course, by judicious management, as an experienced pilot may guide a ship and preserve it through a storm ; and this is true of all specific fevers. It is to the nature of fever (whether primary and specific, or secondary and symptomatic), considered in its abstract relations, that the attention of the student is here directed, and not to any particular fever, such as ague, typhus fever, traumatic fever, or the like. It is to fever in general, or in the abstract, that the following observations apply. It is to the pyrexial symptoms which are common to many diseases (such as to smallpox, scarlatina, measles, typhus, ague, pneumonia, nephritis, meningitis), and which, " like shadows to substance, are necessary to the very existence of such diseases, but yet are not, per se, any one of these diseases," tha,t the following description refers. Galen defined fever as a preternatural heat — "Calor prceter naturam." Subsequently many other additional clauses were added to this definition, such as a " quick pulse," " turbid urine," and the like ; but still, the improved definition would not meet the requirements of every case ; and now it is fully recognized that of all the clauses and phrases in the usual definitions of fever, "preternatural heat" is the- only one whose accuracy is unimpeachable. In all cases, therefore, where fever is present, there are two points to be deter- mined ; namely,- — (1.) The amount of the preternatural heat determined by ac- curate measurement ; (2.) The amount of the tissue-change, as represented by an estimation of the amount of all the excreta relative to the body weight. It is the exact sequence of phenomena we desire to know in every case where pyrexia is present, as well as the meaning and correlation of the phe- nomena : and symptoms sufiiciently characteristic usually become developed and superadded to the febrile phenomena, by which the physician is able to define the specific nature of the disease or fever as a whole, and to say of this case or of that, " It is an enteric fever," or " It is an ague," or " It is a rheu- matic fever," or " a, pneumonia," or "a dysentery," or any other form of illness where pyrexia is present, which we are able clinically to recognize. It is not very long since we were able to do this. Up till within a comparatively short time ago the classification and diagnosis of " Fevers" was not such as to dis- tinguish and separate their varied forms and varieties from each other. " Common continued fever," for example, was a comprehensive name which included many very different types of fever ; and no means of observation have been of late so exactly discriminating, so as to distinguish one form of disease from another where fever coexists, as accurate observations on the temperature of the patient, determined by the thermometer. In acknowledg- ing this great fact, it is important to observe that the absence of such exact observation, and the trusting to general signs alone, have hitherto led to great confiision — a confusion which has been unfortunately increased by a pernicious system^becoming too common — of naming " Fevers " from the place or locality where supposed varieties of fever have prevailed as epidemics ; or by the use of local or provincial native names. For example, the Walcheren Fever, Levant Fever, Mediterranean Fever, Crimean Fever, Bulam Fever, African Fever, Fernando Po Fever, Lisbon Fever, Bengal Fever, Pucca Fever, Gall-sickness of the Netherlands, Hong Kong Fever, and other names not less barbarous, may be quoted. Except as matter of history, and as bea- cons to warn us from a great danger to science, let these and such-like names be consigned to oblivion. With the exact means at the disposal of the physi- cian as aids to diagnosis (and which are about to be described), every variety VOL. I. 16 Digitized by Microsoft® 242 TOPICS KELATIVE TO PATHOLOfiT. of illness where fever takes a part may be accurately distinguislied, its t3rpe recognized, and its place fixed in nosology ; or, if it should be anomalous^ its exact departure from the type may be not less accurately defined and described. The phenomena which thus call for special investigation are those which are strictly related to the development and progress of the febrile state. They ought to be determined by clinical observation in all case? of disease where fever may be present. The facts to be ascertained are not less sig- nificant of the abatement, subsidence, or "defervescence" of the febrile state than of the advent of local lesions. The term " defervescence," in fever, is a comparatively new one in English pathology. It was first used by Professor Wunderlich, and subsequently adopted in this country by Dr. Parkes. It signifies the period during which the temperature of the fevered body is de- clining to its normal amount from that intense degree of heat attained m the state of accession of the febrile phenomena. This "defervescence" may be sudden, when it is regarded as a "crisis;" or it may be gradual, and is then described as a "lysis" — the "insensible resolution" of the older authors; or it may be partly sudden and then slow, when it may be described as "wave-like," with gradual and sometimes regular alternations of high and low temperature, as Dr. Parkes was the first to point out ( The Composition of the Urine in Health and Disease, p. 270). The Usefulness of the Thermometer at the Bedside in the Diagnosis of Pyrexia. One hundred and seventeen years ago (1754), Antonius de Haen (the first teacher of clinical medicine in the Hospital of Vienna) impressed his pupils with the necessity of attending to the temperature of the body in disease, as measured by a thermometer, instead of being estimated merely by the sensation of heat imparted to the hand laid on the skin of the patient. He showed that even in the cold stage of ague, with the teeth chattering and the body shivering, the temperature of the blood is rapidly rising, although the pallid skin may really be colder than usual — its supply of blood being diminished by the contraction of the bloodvessels. He first demonstrated with measured accuracy how much the heat of the blood, and therefore of the body, is aug- mented under the influence of the febrile state ; and when the crude appli- ances and the rough instruments of a hundred years ago are compared with the delicacy and refinements of "the instruments of precision" of the present day, it may be of interest now to observe how the progress of knowledge and the powers of modern research have not suffered the valuable pathological lessons to be lost sight of which are to be learned from the clinical use of the ther- mometer, as De Haen taught a hundred and seventeen years ago. When the hand of the physician alone is used to judge of the temperature of a patient, or when the feelings of the patient are alone taken as a measure of his tem- perature, it can easily be understood how such kinds of observation are extremely fallacious, doubtful, and unsatisfactory. The determination of the amount of heat in fever cases is stamped by a much more early appreciation of its importance and value than even since the time of De Haen ; for, ever since the days of Hippocrates, the physician and the surgeon have been in the habit of applying the hand to the skin of the patient, to appreciate the pres- ence of abnormal heat. But the practical application of the thermometer in place of the hand, while it is obviously a more accurate method, has never come into general use, mainly on account of the difficulty of getting instru- ments^ sufficiently sensitive and trustworthy — instruments, in fact, of sufficient precision. The time and trouble required to work with crude and inefficient instruments soon brought them into disuse and discredit; but now the in- struments required may be obtained so delicate and accurate, and the time taken to apply them is so insignificant, that the student of medicine and the Digitized by Microsoft® METHODS FOR RECORDING THE FEVER -HEAT OF THE BODY. 243 n Kr? r ? °° 5^^?®- ^°'' ^eglecting to use them. When it is remembered also, that Galen's definition of fever is still the one whose accuracy remaS not only unimpeachable, but fully demonstrated and recognized; thatTt de^ scribes fever to consist in " a preternatural heat,"^it is obviously e sential that we should be able to measure this heat, and so learn the significance of such increase of temperature m every case of disease where fever may be present The careful physician counts the puke and the respirations in all cases of Al- ness; It IS not less incumbent on him to measure the amount of heat. By means of a delicate thermometer he has in every case of fever an accurate meas urerof Its amoun ; and the student of medicine, as one of the earliest clS lessons m hospital wards, should be taught to look to the excreta, and o the various physiological conditions of the patient, for the products of the meta! morphosis of tissue equivalent to the amount of heat in each disease Ji.ver since the publication of the second edition of this work when the thermometer as a means of measuring the heat in cases of fever wLs first ex! tCi ortancJ o? he°fh '°' ^''^'r*^' ' ^^"-^ ^^^'^ ^^^^l^ P^--*^ t° -" th^t the importance of the thermometer, as an instrument in the diagnosis and prognosis of disease, has become more and more apparent. There is ample evi^ dence of this m the contributions to the literature of this subject from t\7pe^^^^^^^^ M fie ' oX p'' T*°°' ^'^f'^y'"^.' C°™eli^i« Fox, Grimshaw, Mackgan, Millei, Ogle, Perry, Prior, Sidney Einger, Stevenson Smith, Reginald E Thompson, and othere, since the second edition of this text-book Lpeared' The thermometer is now as much of a necessity and as much of a companion to the medical man as the stethoscope. ptuwu t J^' tlie^om^try of disease is thus practically shown to be important from two points of view, inasmuch as,-(l.) The continuous daily «se of the ther- mometer greatly fanhtates the clinical recognition of diseases; and iids us in acquiring an accurate knowledge of various diseases. It aids the busv practi- tioner m coming to more certain and safe conclusions than heretofore; and so relieves him of much anxiety of mind in doubtful cases. (2.) The use of the tfuirmometer tends to elucidate the course, tendencies, and results-in short Tn^ JNATUEAL History— o/ all diseases where fever is present heads^- P'"°P°®®*^' ^lierefore, to illustrate this subject under the following four .7, ^■J^'I'^f^'-'^^fs^ Methods, and Practical Rules for Observing and Recordinq the fempm-ature of the Human Body in Diseases where Fever may he present Animal heat has been determined in two ways— namely, either bv the ordi- nary mercurial thermometer, or by the thermo-electric apparatus. The latter may mdicate fractions of a degree, and in this respect surpasses the powers 01 ttie most delicate mercurial thermometers. MM. Becquerel and Bresohet employed such an apparatus to determine the temperature of internal parts iHe apparatus consisted of two wires, of different metals, soldered together and having their free ends brought into communication with a thermo-electric multiplier having an index showing tenths of a degree. The fine points of tHe wires being passed through difierent parts of the body (like acupuncture needles) indicated the temperature of the tissues at the point of contact of me two metals. For example,— passing the wires an inch and a half into tiie calf of the leg, the temperature was found to be 98° Fahr., while at the depth of the third of an inch it was only 94° Fahr., showing some cooling of the body towards the surface compared with the interior. The superficial lascia of the biceps was nearly 3° Fahr. lower than the temperature of the muscle Itself But notwithstanding the greater delicacy of the thermo-electric apparatus, a sensitive mercurial thermometer, finely graduated and compared with a standard one, is the only instrument of practical usefulness, as yet, wl ^°^^ clinical purposes; and for obvious reasons. W hatever thermometer is used, it is necessary to compare it with a standard one, and note the diflTerences between every degree. A thermometer is bad, and Digitized by Microsoft® 244 TOPICS RELATIVE TO PATHOLOGY. all but useless, if the differences between various degrees are unequal ; but it is quite serviceable if the same sum is to be added or subtracted for each degree. The price of such an instrument need ^"''■'''- Fig. 06. jjQ^ now render it difficult nor expensive for a A^~^ student to acquire a competent practical knowl- edge of " the thermometry of disease." It is necessary to have an instrument which will determine the temperature in the mouth, axillfe, rectum, or other parts of the body. Such an instrument is named a " clinical thermometer;" and it must be of unquestionable veracity. If the instrument is not absolutely accurate, its errors require to be known. Differences in the diameter of the bore (in calibration ), throughout the entire length of thermometer, seem to be almost una- voidable, as yet, in their manufacture. The majority of the instruments at present made seem to indicate a temperature sometimes higher and sometimes lower, at different parts of the scale, than is correct. For example, Dr. C. Fox quotes a certificate of verification from the Kew Obser- vatory of one in his possession, as follows : At .52° Pahr. + 0.1 " 62° " —0,1 " 72° " + 0.1 That is to say, at 52^ Fahr. Jj must be added, at 62^ Fahr. Jj requires to be subtracted; and again, at 72^, y'u must be added. As no two faces are alike, so no two thermometers seem to be alike. > Dr. Prior of Bedford, in comparing five instru- ments, one with another, found that "no two of them jjrecisely corresponded at any one time;" and, as Dr. C. Pox very justly observes, the want of complete agreement between the observations of physicians on temperature is doubtless partly due to the differences of the readings of the ther- mometers employed, and also to the fact that all observers do not take the temperature of the same parts of the body. Tlie rectum is about two- fifths of a degree of Fahr. warmer than the mouth ; and the mouth four-fifths of a degree warmer than the axilla or the groin (Fox), unless precautions are taken, as afterwards shown, to render the axilla a closed cavity. In meteorological observations, only those ther- mometers are employed which have been verified by means of a comparison with the standard instruments in the Greenwich or Kew Observato- ries. How much more important is it that clinical thermometers (where life or death may hang on the difi'erence of a degree) should be verified and certified to in the same way, so that the proper corrections may be made for errors which seem to be inevitable ? Although the accuracy of the instru- ment, or delicacy of it, may be guaranteed by the manufacturer, it cannot be depended on. Dr. Fox gives an illustration, among several, in which the Digitized by Microsoft® ?irf/ MODE OF USINa THE CLINICAL THERMOMETER. 245 following results were returned in the certificate from the Kew Observatory, — namely, at 85°, -j% must be subtracted ; at 90°, -f% ; at 95°, j% ; at 100°, ^% ; and at 105°, y^ must be deducted — errors varying from fg to j\, or half a degree. The only safe rule, therefore, is, that each instrument ought to be sent to Kew for verification, to be returned to the owner with a certificate containing the corrections for its several readings, if any are requisite. A fee of half a crown is charged at Kew for this certificate of verification ; and if the makers would do this, and charge the fee to the price of the instrument, it would save a great deal of trouble.* A good clinical thermometer ought to have a uniform and correct scale, having a range from 90° to 112° Fahr., exhibiting also fifths Fahr. of degrees, and be one-fifth of an inch apart from each other. It ought to be a sensitive, mercurial maximum self-registering (Fig. 66) one (known as " Phillip's maxi- mum ") ; which does not require to be read in situ, but may be removed from contact with the part, and read when convenient. The bulb of mercury should be as thick as the diameter of the stem, and not more, so as to expose a sufficiently large surface to the part of the body whose temperature is to be determined. An Ordinary but very Sensitive Thermometer (Fig. 65), made with a curve, in order that its bulb may be the more easily and perfectly fitted into the axilla, while the stem, being carried upwards, renders the reading in situ more easy, is a useful instrument for teaching students to observe dn clinical classes ; but is less useful in general practice than the maximum self-register- ing instrument. Directions for Use. I. The Curved Thermometer (Fig. 65).— Its bulb must be well fitted into the arm-pit, being introduced below the fold of the skin covering the edge of the peotoralis major muscle, and so kept in close contact with the skin, completely covered and firmly surrounded by the soft parts. In very thin or very old persons this adjustment requires special care. The instrument must be retained in situ during a period of not less than four minutes ; and the height of the mercury in the graduated stem must be read while the thermometer is still undisturbed in the axilla, care being taken that the axis of vision falls perpendicularly on the column of mercury in the tube. II. The Straight Thermometer (Fig. 66), which is self-registering, m/ust have its index set before commencing to take an observation. ]^N.B. — The Index is the bit of mercury detached from the column in the stem OF THE INSTRUMENT,] 1. This index is to be set by bringing the bit of detached mercury down into the clear part of the stem, just below the lines which indicate the de- grees. This is done by taking the bulb and stem of the instrument firmly in the hand, and then by a single rapid swing of the arm the index will come down the stem ; and this swing of the arm must be repeated till the top of the index is at least below the lines which indicate the degrees. 2. After the index has thus been set, the bulb of the instrument may then be applied to the axilla, or between tjie thighs, or any part which is com- pletely covered; and being retained in close apposition (by strapping, if necessary) with the surrounding soft parts for a sufficient length of time, the instrument is to be carefully and gently removed, when the top of the index — i. 6., the end farthest from the bulb — will denote the maodmum temperature during the period the instrument has been in perfect contact with the parts. The patient should have been at perfect rest in 'bed for at least one hour be- * Cassella of Hatton Garden, Hawksley of Blenheim Street, London, and Harvey and Reynolds of Leeds, are the most careful makers of clinical thermometers, in my experience. ■ Digitized by Microsoft® 246 TOPICS KBLATIVE TO PATHOLOGT. fore observations on temperature are made, and he ought to lie on the side, so as to completely close the axillary space which is the seat of the thermometer, con- verting it into a close cavity. III. The Observations ought to be continuous daily, and regularly taken at 'the same hour every day, throughout the whole period of sickness. The most useful periods for observation are — (1.) Between 7 and 9 o'clock in the morning ; (2.) At noon ; (3.) Between 5 and 7 o'clock in the evening ; (4.) At midnight. For most practical purposes, it is sufficient to note the tem- perature twice daily, — morning and evening, with an occasional observation at midnight. IV. In all observations of temperature the pulse and the respirations should be noted at the same time. In less important cases, the physician may make at least one observation daily himself, and leave the others to the friends of the patient or the nurse, if either of them are sufficiently intelligent. This arrangement, however, is only justifiable so long as the observations correspond with those typical of the particular disease, and so long as they are in harmony with the other general signs of its course ; but as soon as notable deviations from these con- ditions are observed, the physician ought to make the observations for him- self. A difference of 2° Fahr. is not of any practical importance unless it is persistent. In prolonged and severe cases an examination of the records of temperature made during the course of the disease will recall to mind the nature of the case more effectively than the most detailed written history. For this pur- pose it is desirable to exhibit on paper the daily thermometric changes, in the form of an angular line or a curve, and to note in the proper places short memoranda of the more important incidents or therapeutic events which have taken place during the progress of the disease. Details illustrative of the changes in the pulse and the respiration, and amount of excreta, ought to be entered in the same sheet, as exhibited at pp. 248 and 249 following.* * Some thermometers are graduated to Centigrade as well as to Fahrenheit on the same glass stem ; and some have the Centigrade scale marked on the wooden tubes which inclose the thermomfter. The presence of two scales on one thermometer is too confusing for delicate ob.«ervation ; and it is better to have only one, converting that one scale into the other, if necessary, by calculation or by means of the tables commonly employed for this purpose ; the form for filling up giving (as at pp. 248, 249) the double scale of Fahrenheit and Centigrade. Pahrenhbit Scale Comparbd with Centigrade and Ebaxjmitr's. * Fahr. Cent. Reau. Fahr. Cent. Beau. 1120 44.44 35 55 1010 88.33 30.66 111.2 44 35.2 100.4 88.0 80.4 111.0 43.88 35.11 100 37.77 30.22 110.0 43.33 34.66 99.0 37.22 29.77 109.4 43 34.4 97.6 37 29.6 109 42.77 34.22 97.0 36.11 28.88 108.0 42 22 33.77 96.8 860 28.8 107.6 42.0 33.6 96.0 35.55 28.44 107.0 41.60 38.38 95.0 35 28 106.0 41 11 32.88 94.0 34.44 27.55 105.8 41.0 32.8 98.2 34 27.2 105.0 40.55 3244 93.0 38.88 27.11 104.0 40.0 32.0 92.0 33.88 26.66 103.0 39.44 81.55 91.4 83 26.4 102.2 39.0 81.2 91.0 32.77 26 22 102.0 38.88 31.11 90.0 32.22 25.77 Digitized by Microsoft® SCALES OF TEMPEBATUKE COMPARED. 247 In chronic eases, when febrile attacks and their^concomitant dangers may- be expected, as well as in acute cases, after return of the normal blood-heat, one daily observation will be found sufficient. This single observation may be best made in the afternoon, evening, or midnight. It is advisable to induce nurses, friends, or other attendants on the sick (whenever they seem apt pupils), who may make notes of any considerable excitement or restlessness, or take notice of hot hands, or increased heat of head, rather to consult at once the thermometer than trust to their sensations. They may thus, perhaps, tranquillize the patient and his friends when the instrument does not indicate any material increase of heat ; but the sudden appearance of any considerable increase of temperature would always be (as stated) a fact of vital importance. It has been recommended by some to place the thermometer under the tongue, as the best place. On the contrary, the cavity of the mouth is the worst place in which the thermometer can be put, in patients not accustomed to such obstructions, because ■ the temperature there is continually varying according to the quantity and temperature of the air used in respiration ; and if the atmosphere is cold; and deep inspirations are made, large differences may be observed, compared with the temperature in the axilla. Therefore observations made with the thermometer in the mouth are not generally trust- worthy, unless verified by observations in the axilla, groin, rectum, or bladder. Five minutes is found quite sufiicient for the application of the thermometer, if certain precautions are taken. The simplest and most convenient way is to heat the instrument before inserting it into the patient's axilla, just as the surgeon heats the catheter before he introduces it into the urethra. Neglect of this precaution is apt to lead to an uiider statement of temperature. It may be heated by holding the thermometer in the warm hand till the mer- cury shows a temperature of 98°; and after the instrument is properly placed, be satisfied if two ohaervations at intervals of one to two minutes give exactly the same result. Comparison- of the Scales fob bach Tenth of a Degkbe. Cent., , Fahr., . Reau., , Fahr., Cent., , Eeau., , Eeau , Fahr., Cent., , 0.1 0.18 0.08 0.1 0.06 0.04 0.1 0.22 0.12 0.2 03 0.36 0.54 0.16 0.24 0.2 0.3 Oil 17 0.09 0.13 02 0.3 45 0.67 0.25 0.37 0.4 0.72 0.32 0.4 0.22 0.18 0.4 0.9 0.5 0.5 0.9 0.4 0.5 0.28 0.22 0.5 1.12 0.62 0.6 1.08 0.48 0.6 0.33 0.27 06 1.35 0.75 0.7 1.26 0.56 0.7 0.39 0.31 0.7 157 0.87 0.8 1.44 0.64 08 0.44 36 0.8 1.80 1.00 0.9 1.62 0.72 0.9 0.5 0.4 0.9 2.02 1.12 1.0 1.8 0.8 1.0 0.56 0.44 1.0 2.25 1.25 To convert degrees Centigrade atove zero to degrees Fahrenheit : multiply by 1.8, and add 32, or multiply by 9, divide by 5, and add 32. To convert degrees Centigrade below zero to degrees Fahrenheit : multiply by 1 8, and subtract from 32. To convert degrees of Centigrade into those of Reaumur : multiply by 4, and divide by 5. To convert degrees Reaumur above zero to degrees Fahrenheit ; multiply by 2.25, and add 32. To convert degrees Reaumur belo-w zero to degrees Fahrenheit : multiply by 2.25, and subtract from 32. To convert degrees Reaumur into those of Centigrade : multiply by 5, and divide by 4. To convert degrees of Fahrenheit into those of Cen- tigrade: deduct 32, multiply by 5, and divide by 9. To convert degrees of Fahren- heit into those of Reaumur : deduct 32, divide by 9, and.multiply by 4. In De Lisle's thermometer, used in Russia, the graduation begins at boiling-point, which is marked zero, and the freezing-point is 150. Digitized by Microsoft® 248 TOPICS RELATIVE TO PATHOLOGY. RECORDS OF TEMPERATURE, PULSE, In the case of. JE!tat. ...., Occupation. .Ward . DATES OF«C? OBSERVATIONS °*YS OF ^^ DISEASE ""^ TEMPEPATtRE CENTIGRADE TEMPERJTUR FAHRENHEIT E TIME TMI£ ANl;P^ TIME rn-pn r/nE m- PN TIME AM' PM 71HE AM- PB TIME AH- PN TIME AM-PK TIME m . PAi TIME AM-PN TIME AM^PN TIME Tim Tim AM^PN AM.-PHAH.PII 4I» 106° 3 40' ' - 1050 - 104° 3S'~ - 103° . ' .' "■ 38' ' - 101° i - j ■ ■ ; - 100° z 8 - 99° 2 ■ 37 • - 1 • TEMPERJITURE - 38" S • = 97° i ; 8 f - 96° : : ! ; PULSE PEB MINUTE RESPIRATIONS PER MINUTE "«l«^ tc'^ns REACTION OF - SPECF.GR.OF COLOUR OF CLEARorTURBID UREA (amount) SUGAR IN ALBUMEN IH SOLIDS IN MICROSCOPIC SEIDIMENTS • - ' STOOLS NUMBER I. CHARACTER • Digitized by Microsoft® RECORDS or TEMPERATURE, ETC. 249 EESPIEATION, AND EXCRETA (See p. 246). Disease Termination.. Begister Folio 1 TIME AM-PW rai/r AM-PM r/4f£ AM'PW TIME 4IH- PH TIME AM. PN TME AM■P^ TIME AM- P» TIME AM- PM AM • PN AM- PN TIMC: AM-PM AM- PiV TIME m ■ p^ AM-PN 7-/»£- TIME AM- PN AM-PM TIME AH- P» - ; t • 1 1 : • J Digitized by Microsoft® 250 TOPICS RELATIVE TO PATHOLOGY. The rapidity witt wliicli the mercurial column rises depends on the degree of temperature present. The rapidity of the rise of temperature ought to he noted, as well as the maximum height. If the temperature be above the nor- mal standard, a sensitive thermometer will indicate that fact within the first minute; and as the quickness of the rising depends upon the existing tem- perature, the physician is able, after some experience in the use of a particular instrument, to form an approximative judgment of the amount of rising of tem- perature to be expected in any particular case from the slowness or rapidity of the rise of the mercury after half a minute. II. Fluctuations of Temperature within the Limits of Health ; and the Corre- lation of the Animal Heat with the Pulse and the Respiration. Several observers in Germany, France, England, and the Tropics, have now determined these fluctuations with great accuracy, so that ample and sufl[icient data are on record to furnish a standard for comparison in cases of disease. The temperature of the body is the result of the opposing action of two factors : 1st, Development of heat from the chemical changes of the food, and by the conversion of mechanical force into heat, or by direct absorption from without; and 2d, and opposed to this, Evaporation from the surface of the body, which regulates internal heat (Parkes's Hygiene, p. 432). With reference to the normal range of temperature, our most trustworthy information is mainly due to Valentin and Traube, in Germany ; to Edwards, Becquerel, Breschet, and Bernard, in France; to Dr. William Ogle, in Eng- land ; and to Dr. Alexander Rattray, Surgeon ia the Eoyal Navy, in tropical and temperate climates. It is generally agreed that the ranges of tempera- ture vary in different parts of the human body ; but, as a general practical result, it is equally agreed that in temperate regions the normal temperature, at completely sheltered parts of the surface of the human body, amounts to 98.4° Fahr., or a few tenths more or less at different times of the day ; and a rising above 99.5°, or a depression below 97.3° Fahr., are sure signs of some hind of disease, if the increase or depression is persistent. Valentin proved by many experiments that all warm-blooded animals sur- rounded by an atmosphere of 50° Fahr. to 68° Fahr. have a temperature of about 99.5° in the back of the mouth, the rectum, or other accessible internal parts; and at completely sheltered parts of the surface it is about 97.5° to 98.4° or .5°. According to Ringer and Stewart, in persons under twenty-five, the average maximum temperature is 99.1°; over forty years of age, it is 98.8°. In the second childhood of old age it again rises (Albutt). Dogs have a temperature similar to that of men. A knowledge of thermometry, there- fore, in the diseases of animals, will prove not less valuable in veterinary pathology than in human, and perhaps more so, inasmuch as animals de- prived of speech are unable to express their feeling. In the cattle plague of 1866-67, the use of the thermometer was found of great practical value in diagnosis. The observations of Dr. John Davy, originally communicated to the Royal Society, have been shown by Dr. William Ogle to be so full of errors, that they are really without value. The following records are believed to be the most trustworthy : The minimum temperature is from 1.30 A.m. to 7.30 a.m. (Jdegensen). The lowest temperature occurs about daybreak, about 6 a.m. At this time a rise begins, which continues till late in the afternoon, and it commences while yet the body is in complete repose, and when no food has been taken for ten or twelve hours ;. but coincidently with this rise there is an increase in the exhalation of carbonic acid (Ogle) and of urea ; so that the rise is doubtless due to increased chemical change or resumed activity of organic functions, as the intensity of sleep diminishes towards morning. The highest range of daily temperature is maintained between 9 a.m. and Digitized by Microsoft® NORMAL TBMPBRATUKE OF THE HUMAN BODY. 251 6 P.M. After this time the temperature falls slowly and continuously, if no alcohol be taken ; but if alcohol be taken with the evening meal, the fall is more sudden (Ogle). Otherwise food seems to have little influence on nor- mal temperature, except, perhaps, with infants. Although the records may vary somewhat, yet one elementary fact stands clearly out — namely, that in a healthy man the limits of fluctuation, imder various conditions, are very narrow, and independent of external temperature. This constancy of the bodily temperature is a consequence of the remarkable regulation of evolu- tion and loss of its heat, and is the expression of their difference. The average variation in the course of twenty-fours is about 1.5° Fahr. A general average for the day may be stated as follows : Before Breakfast. 11 A.M. 2 p.m. 3 P.M. 5 P.M. 6.80 P.M. 7.30 P.M. 9 p.m. 10 P.M. 12 P.M. 12.30 A.M. 12.30 A.M. 1 A.M. 3 A.M. 5 A.M. 5.30 A.M. 6.30 A.M. 8 A.M. 9 a.m. 97.73° 98,2° 98 36° 98.63° 98° 97.96° 97.9° 97. -5° 97 2° 97.6° Dr. Rattray's observations were made by placing an ordinary Fahrenheit, thermometer under the tongue thrice a day during a voyage from England to Bahia (lat. 11° S.) and back — i. e., across the Equator — extending over sixty days (fifty-three in the tropics, and seven in the latitude of England, 51° N.). During this period the temperature of the air in the shade on the verge of the tropics was 72° Fahr.; at the equator, 84° Fahr.; and the average of the tropics generally, 76.9° Fahr. The atmospheric humidity ranged from 0° to 7.5° ; the average being 3.8° of a Mason's hygrometer. In England, with a temperature ranging from 60° to 70° Fahr., the average temperature of the body was 98.3° Fahr. ; it rose in the tropics to 98.6°, and in the equatorial doldrums to 99° Fahr., and occasionally even to 100° Fahr. In the tropics the temperature of the body is greatest during the afternoon, when the sun is high, and the body most active, and least in the morning. The pulse is likewise highest and lowest at these times. The totals show 99° Fahr. to be the most frequent bodily temperature, while 99.5° and 100° Fahr. form 22 per cent, of all the observations, and the range of temperature about 2° Fahr. daily (Proceedings of Royal Society, No. 122, p. 613, June 16, 1870). The following are the collateral circumstances which mainly influence animal heat in our daily life, and which require to be remembered, in order that erroneous conclusions may not be drawn: (1.) Active exercise (not carried to the extent of exhausting fatigue) raises the temperature proportionally to the degree of muscular exertion made. (2.) Exposure to cold without exercise lowers the temperature. (3.) Sustained mental exertion reduces the tempera- ture about half a degree. Lombard states the reverse to be the fact. (4.) The amount of heat is also at first reduced after a full meal and after alcohol; but it rises again as digestion advances. According to Df. William Ogle, it causes a rise most marked after breakfast, less so after lunch, and which is reduced after dinner to a mere retardation of the fall, which without it would occur. (5.) Alcohol (claret) causes an immediate rapid fall, which is tempo- rary, and a reaction occurs by which the temperature is carried to as high a point, or even higher, than it would have reached if no alcohol had been taken. Tea causes an elevation of temperature. (6.) Sex, race, latitude, seasons, weather, habits of life, and idiosyncrasies go for very little in influ- encing the temperature of healthy persons. (7.) On the other hand,_the tem- perature in disease is more readily and rapidly afiected — more sensitive, so to speak — than either the pulse or the respiration, and the increase or variations are persistent as long as disease exists. The amount of abnormal increase of temperature is usually proportionate to the degree of frequency of the pulse, and to the other signs of general Digitized by Microsoft® 252 TOPICS RELATIVE TO PATHOLOGY. disease. Yet such congruity of phenomena is sometimes in part or wholly- absent or incomplete ; and in the cases in which a disproportion or incongruity exists between the increase of temperature and the pulse, or other febrile phe- nomena, it is the accurate measurement of the temperature which is most of all to be relied upon. As a general rule, the correlation of pulse and temperature may be stated as follows, namely : An increase of temperature of one degree above^ 98° Fahr. corresponds with an increase of about eight beats of the pulse per minute, as in the following table : A temperature of 98° " 99° " 100° " • 101° " 102° " 103° 104° " 105° " 106° Corresponding with a pulse of 72 (Health) Ought to correspond with a pulse of 80 u u u 88 " " " 96 a 11 11 108 11 II 11 112 '1 11 " 120 " " " 128 11 11 11 136 This statement is, however, in some respects arbitrary, and is given for the convenience of comparing different diseases with some standard. In some diseases a high temperature is found with a low pulse, and a low temperature with a high or rising pulse. The pulse, too, sometimes rises in rapidity when the temperature falls, or falls when the temperature rises. Dr. John Beddoe, Physician to the Bristol Royal Infirmary, records a pecu- liar case of enteric fever, in which the most notable point was the coexistence of an elevated temperature with an abnormally slow pulse, and but a mode- rate rate of wasting. . _ In children the records are contradictory. For example: According to the observations of M. Roger and Dr. Holland, the temperature of children is somewhat higher than adults, when placed in conditions favorable to suste- nance. At birth the temperature of the infant is the same as that of the mother, but quickly falls to 93.4°, or 95.5°, rising in the course of twenty- four hours to 97.7°, — i. e., more than half a degree below adult heat (Mac- lagan). Between four and six years of age, M. Roger found the tempera- ture to be 98.9^ Fahr.; and between six and fourteen years, 99.16° (Caepen- tee). Dr. Bennett states generally, that in children the heat of the body is about 2° higher than in adults. On the other hand, among numerous written statements sent me on this subject, from actual observation, I find results are varied, — many opposed to the preceding statements. For example, during an epidemic of measles in Glasgow, in 1866, Mr. James P. Cassels, while using the clinical thermometer, was much struck with the low temperature recorded in some eases after com- plete recovery. The following shows the result of six observations on a baby, 16^ months old, and in perfect health since birth, taken wh&n asleep, and every source of error carefully avoided. His observations show results below those of adult life : Date of Observation. Hour. Tempera- ture of Boom. Temperature of Body. Respi- rations per Minute. Pulse per Min- ute. 106 106 100 112 100 120 Time during which Thermo- meter If as in close contact ■with Skin. Phillip's Thermo- meter. Curved. Thermo- meter. July 3, 1866. July 5, 1866. JulV 6, 1866. July 11,1866. July 28, 1866. July 30, 1866. 10.20 P.M. 10 20 P.M. 10 30 P.M. 10.30 P.M. 10.20 P.M 12 midnight. 65° Fahr. 65° Fahr. 64° Fahr. 69° Fahr. 68° Fahr. 68° Fahr. 96^° 96f° 96r 97^° 97f° 97§° 96i° 96 1° 96|° 964° 97i° 97f° 23 22 22 22 25 22 25 minutes. 30 minutes. 25 minutes. 40 minutes. 25 minutes. 20 minutes. Digitized by Microsoft® USEFULNESS OF THE CLINICAL THBRMOMBTEK. 253 III. Ranges of Temperature in Disease. Having satisfied ourselves as to the delicacy and accuracy of the thermom- eter, and obtained a standard for comparison, we are prepared to appreciate the ranges of temperature in febrile diseases as measured by such an accurate instrument. The maintenance of a normal temperature, within the limited fluctua- tions just noticed, under all these varying influences, gives a complete assur- ance of the absence of anything beyond local and unimportant disturbances ; and, long before the subject was worked out so thoroughly as it has been, it was often casually observed that any acute disease, however slight, elevates abnormally the temperature or animal heat ; " and its undue degree of eleva- tion (as Dr. Davy clearly enunciated) is some criterion of the intensity of the diseased action" {Phys. Researches, vol. i, p. 56). In short, it is now placed beyond a doubt by the observations of Gierse, Roger, Valentin, Von Bseren- spriing, Wunderlich, Friedlander, Virchow, Traube, Jockmann, Greisinger, Billroth, and others, in Germany ; by MM. Becquerel, Breschet, and Bernard, in France ; by Parkes, Jenner, and Ringer, in this country, that while this preternatural heat varies in amount in different diseases, in different persons, and at different times of the same day, it is this preternatural heat which is the essential symptom in fever, which proves fever to be present, and which exists to the extent of 4°, 6°, or even 8° Fahr. over the natural limits of health, and must be estimated by the temperature in the axilla or rectum, as indicated by the thermometer. This preternatural heat is never absent in fever, and without it fever cannot be said to exist. Rigor, which is also some- times present, is a mere peripheric phenomenon. The coldness of the skin, so much complained of by the patient, is usually a subjective sensation, pro- duced by the state of the peripheral nerves, and is not due to any actual decline of temperature; for even "while the outer parts feel cold to the by- stander, the inner parts are abnormally warm. While the outer parts freeze, the inner burn " (Viechow, Pakkes, Jenner). There are many cases now on record in which the physician, without ther- mometric observation, does not appreciate the existence of fever or of danger. Wunderlich gives numerous examples of this ; but long before he brought this subject so forcibly to the notice of medical men, we have the testimony of Dr. John Davy in this country, given quite incidentally, and therefore all the more valuable as an unbiassed testimony of the usefulness of the ther- mometer in detecting latent disease not otherwise indicated by general symp- toms. When Dr. -Davy was collecting his extensive observations on the normal temperature of the body, he was surprised to find that one person exhibited for many weeks a persistent temperature of 104° Fahr. This person was a lunatic soldier ; and Dr. Davy remembered that the insane do not seem to suffer from cold nor heat like ordinary individuals, and that there are certain organic lesions which are apt to occur in them unaccompanied by the usual symptoms. For example, tubercle and cavities of the lungs occur with- out cough or difficult breathing ; and although no warning nor any indication may be given, the disease runs its course, terminating in death as certainly and as rapidly as if indicated by the ordinary train of symptoms. Discovering, then, as it were by accident, that the temperature in this lunatic was as high as 104.5° Fahr., and that his pulse was rapid, Dr. Davy's attention was more particu- larly aroused ; and although the man made no complaint, but had a good appetite, with his digestive functions, so far as was known, acting well, yet disease of the lungs was thus discovered ; and was confirmed by the examina- tion of his chest yielding the usual physical signs of disease. The lunatic died in a month, of acute tuberculosis, "not otherwise expressed by symptoms beyond the great, persistent, and continuous elevation of temperature thus incidentally noticed. There were ulcers of the larynx found after death, but there tad been no affection of the voice ; there were vomicw and tubercles in Digitized by Microsoft® 254 TOPICS RELATIVE TO PATHOLOGY. the lungs, but there had been no cough ; there were ulaerations of the intestines, but there had been no diarrhoea ; there was disease of the testes, vesieuke seminales, and prostate, of a severe kind, but these lesions had been equally latent during life, except hardening and enlargement of the testicle without pain, — all which conditions were only casually observed. In this very instructive case a temperature of six degrees Fahr. above the normal standard was the earliest indication of disease {Researches, Physiologi- cal and Anatomical, vol. i, p. 206). But it is mainly to Wunderlich, the Professor of Medicine in Leipsic, that we are indebted for an elaborate exposition and persevering advocacy of the usefulness of daily records of the temperature of fever patients, and the con- stant employment of the thermometer as a means of diagnosis at the bedside. On this subject he has written much, from an extensive experience, embra- cing at least half a million exact thermometric observations, following the continuous progress of individual diseases, the results of which he has com- pared in more than 5000 patients. He constantly employs the thermometer in his private practice, and bears unqualified testimony to its sterling value in the early detection of disease, and as often furnishing an important guide to treatment. When the physician once becomes accustomed to the investi- gation of disease by the thermometer, he regards its daily employment as in- ' dispensable, for it imparts a certainty to his observations, attainable by no natural penetration, and which no other method of investigation can convey (Medical Times and Gazette, June 19, 1858, and September 28, 1861). Wunderlich gives some striking instances of disease being indicated by thermometric observation before it could be detected by any other means : In ague, several hours previous to the paroxysm, the temperature of the trunk of the patient's body begins to rise ; and when the disease seems to have disappeared, an increase of temperature may be detected periodically, unac- companied by any other symptom. So long as this periodic rise of tempera- ture continues, the patient is only apparently, but not really cured. In enteric fever, during the exacerbations especially, the rise of temperature or its abnormal fall may indicate what is about to happen three or even four days before any change in the pulse, or other sign of mischief, has been observed. A sudden and marked reduction of temperature has thus denoted hemorrhage from the sloughs of Peyer's patches in typhoid fever several days before it appeared in the stools. A case of this kind is recorded by Dr. Parkes. It occurred in a female twenty-five years of age. Diarrhoea was considerable, and blood was largely passed in fluid stools the night before the seventeenth day of the fever. On the morning of that day the temperature was as low as 93° Fahr., rising in the evening to 101° Fahr. _ It is rare, however, that a definite diagnosis or prognosis can be based on a single observation ; but sometimes certain conclusions may be arrived at, as in the following instances : When the temperature is increased beyond 98.5° or 99° it merely shows that the individual is ill, and suffering from some disease ; and that when considerably raised, as with a temperature of 101° to 105° Fahr., the febrile phenomena are severe ; that when a great height is reached, as at temperatures above 105° Fahr., the patient is in imminent danger ; and that with a rising . temperature above 106° Fahr., to 108° or 109° Fahr., a fatal issue mayalmost without doubt be expected in a comparatively short time. The highest tem- peratures before death have been observed in cases of scarlet fever and of tetanus. A definitive diagnosis may also be based on a single observation, under the following circumstances : A person who yesterday was healthy, but exhibits this morning a tempera- ture above 104° Fahr., is almost certainly the subject of an attack of ephem- eral fever or of ague; and should the temperature rise up to or beyond Digitized by Microsoft® USEFULNESS OF THE CLINICAL THERMOMETER. 255 106.3° Fahr., the case will certainly turn out one of ague, or some other form of malarious fever. A girl eighteen years of age, supposed to be suffering from hysteria, but . simulating a case of cerebro-spinal meningitis. A. temperature of 103.5° con- firmed the diagnosis of meningitis and negatived that of hysteria. The case terminated fatally (Compton). Again, in a patient whose temperature rises during the first day of illness up to 106° Fahr., it is certain he does not suffer from typhus nor enteric fever ; and of a patient who exhibits the general typical signs of pneumonia, but whose temperature never reaches 101.7° Fahr., it may be safely concluded that no soft infiltrating exudation is present in the lung. Again, if a patient suffer from measles, and retains a high temperature after the eruption has faded, it may be concluded that some complicating disturbance is present. Single observations of temperature, combined with a careful consideration of all the symptoms, will often determine whether the disease is one of danger or not. . In enteric fever a temperature which does not exceed on any evening 103.5° Fahr. indicates a probably mild course of the fever — and especially if the increase of temperature takes place moderately, towards the beginning of the second week. A temperature of 105° Fahr. in the evening, or of 104 Fahr. in the morning, shows that the attack is a severe one, and forebodes danger during the third week ; on the other hand, a temperature of 101.7° Fahr. and below, in the morning, indicates a very mild attack, or the commencement of convalescence. In pneumonia a temperature of 104° Fahr. and upwards indicates a severe attack. In acute rheumatism a temperature of 104° Fahr. is always an alarming symptom, foreboding danger, or some complication, such as synovial or pericardial inflammation. In a case of jaundice otherwise mild, an increase of temperature indicates a pernicious turn. In a puerperal female an 'increase of temperature indicates approaching pelvic inflammation. In tuberculosis an increase of temperature shows that the disease is advancing, or that untoward complications are setting in. In short, a fever temperature of 104° to 105° Fahr. in any disease indi- cates that its progress is not checked, that complications may still occur, and that the case is a precarious one. But it is by continuous daily observations that the most important results have been arrived at, especially in the hands of Wunderlich, Greisinger, Traube, Billroth, Parkes, Jones of Augusta, Einger, and others who are now working most actively in this fleld of labor. Certain febrile diseases have been found to have typical ranges or daily fluctuations of temperature throughout their course. In pure unmixed and uncomplicated cases, this is found to be so constant that the differential diagno- sis may be established by accurate observation of the temperature continuously from day to day. This has now been determined, especially in cases of mala- rious fever, typhus, enteric fever, small-pox, scarlatina, measles, rheumatism, pyaemia, pneumonia, acute tuberculosis. In each of these diseases the tem- perature is one of the most certain (although not the only) means for deter- mining the real state of the patient as regards morbid, disturbances or complica- tions ; and a careful observation of temperature from day to day, considered in relation with other signs, is indispensable for judging as to the prognosis. Frequently it affords the only ultimate means of deciding in doubtful cases, and often it is the best corrective of a too hasty conclusion : for example, the characteristic variations of the temperature, in a typical case of enteric fever, are of such a kind that they are not found in any other disease. Intestinal catarrh, severe forms of pneumonia, malarious fever, acute tuberculosis, men- ingitis, some stages of Bright's disease, may each simulate enteric fever, and may exhibit some of its most characteristic symptoms ; but observation with Digitized by Microsoft® 256 TOPICS EELATIVB TO PATHOLOGY. the thermometer as to the patient's temperature from day to day, will at once, or after a very, few days at most, establish the distinction with certainty. In the course of many diseases, whose diagnosis has been accurately deter- mined, if the temperature departs from its normal or typical range, the ther- mometer will furnish the best and the earliest indication of any untoward event, such as the additional development of disease, or of visceral complica- tions in its course. When once the typical range of temperature (normal to the particular disease) is determined, an important point in its natural history has been fixed, and a basis is laid for appreciating irregularities or complications in its course in particular cases. For example, a patient exhibits symptoms of fever of the typhoid type, but during the progress of the first week his temperature becomes normal, for however short a space of time ; — the occurrence of this event proves that the fever is not what it was supposed to be. Again, a patient may suffer from all the general symptoms of incipient pneumonia ; but there still is a doubt as to whether infarction of the lung has taken place. The sputa being suppressed, or not procurable, does not assist the diagnosis. If, i •however, the temperature is found to be normal, it is certain that no croupous exudation has taken place in the lung, and that there is no pneumonia. Again, if a tuberculous patient has a sudden attack of hsemoptysis, and if the temperature of his body is normal during and subsequent to the attack, no reactive pneumonia, nor any exacerbation of the tuberculous exudation, need be expected. This is a new field open for investigation in cases of phthisis. Again : In all cases of convalescence, so long as the defervescence proceeds regularly as measured by the temperature, no relapses need be feared : on the other hand, delayed defervescence in pneumonia, the persistence of a high evening temperature in general diseases, and the incomplete attainment of normal temperature in convalescence, are signs of great significance. They indicate incomplete recovery, supervention of other diseases, or local lesions, unfavorable changes in the products of disease, or the continuance of other sources of disturbance requiring to be carefully examined into. The onset of even a slight elevation of temperature during convalescence is a warning to exercise careful watching over the patient, and especially for the maintenance of a due control over his diet and actions. Continuous daily observations by the thermometer show the typical ranges of temperature in particular forms of fever, and supply the grounds or basis by which it is determined whether any individual case is progressing as it ought to do. Such knowledge can only be acquired by repeated observation of numerous cases ; and deviations from the normal temperatui-e in certain diseases are stable in proportion to the typical character and full development of the particular disease. But even in such diseases we may have an increase or decrease of temperature proper to the disease brought about by aocidental influences. Such instability, however, is only temporary, and of short dura- tion, when the aocidental influences act but transitorily. For example, the temperature proper to the disease may be lowered under the influence of a profound sleep, bleeding, epistaxis, the relief of constipation or of the reten- tion of urine, and the like ; or it may be raised after excitement of a mental kind. But any such alterations, unless they are dependent upon a change in the disease-process itself, will become effaced after twelve or twenty-four hours at the most, when the temperature again resumes the typical character diag- nostic of the particular disease. In continued fevers the temperature is gen- erally less high in the morning than in the evening. Stability of temperature from morning to evening is a good sign ; on the other hand, if the temperature remains stable from evening till the morning, it is a sign that the patient is getting or will get worse. When the temperature begins to fall from the evening to the morning, it is Digitized by Microsoft® USEFULNESS OF THE CLINICAL THERMOMETER, 257 a sure sign of improvement ; on the other hand, a rise of temperature from the evening tilHhe morning is a sign of his getting worse. When it is found, in a bad case of enteric fever, that some morning about the third week the temperature has fallen to 99.5°, the reparative stage has begun— the healing of Peyer's patches ; and when a similar fall of tempera- ture is observed in the evening, convalescence has commenced. In pnnmionia, when a marked fall of temperature occurs in the evening, the period of crisis has arrived. In measles, when the maximum severity of the eruptive stage has been reached, the temperature falls. A sinking from a considerable height down to a normal temperature sud- denly (within twenty-four hours), occurs in a few eruptive fevera,~measles, variola, rarely in pneumonia, tyj)Iius, and pyasmia. In scrofula, especially in its acute form, with deposition or growth of tuber- cle, the persistent maintenance of a uniformly high temperature will alone show that no arrest in the progress of the disease has occurred. The correlationof pulse, respiration, and temperature is of great importance to be determined in many acute diseases ; and especially in pneumonia, if the mean of the temperature is not above 104° Fahr., and that of the pulse is not above 120 iu a minute, and the mean of the respirations not over 40 in the same time, the case must be considered a slight one ; and if the patient is otherwise healthy, he will surely begin to get well in from eight to twelve days, without any medical treatment beyond attention to antiphlogistic regimen. In typhus fever, a falling temperature with a rising pulse forebodes danger. Convalescence is known to commence when the disease-process ends ; and riiis precise point can only be fixed by continuous thermomctric observation. The morbid process does not end till the normal temperature of the body returns, and maintains itself unchanged through all periods of the day and nidit. Regularly continuous observations of the temperature exhibit the precise point at which the disease-process terminates, and the degree of its complete development. When this point has been determined on, a retrospective view may be taken of the character of the disease, as to the purity of its typical form or its complexity, and a prognosis may be hazarded as to the probability or doubtfulness of recovery. The morbid process has not terminated till the normal temperature of the body returns, and remains unchanged in the eve- nmgs and throughout all periods of the day. The transition from the febrile state into _ defervescence being either slow (lysis) or rapid (crisis) ; and regu- larly continuous defervescence is always a sure sign of convalescence. Irreg- ular defervescence, on the contrary, indicates a disturbed and protracted course of convalescence, which requires careful watching and judicious nursing. It is of practical importance to know that the fall of temperature during the period of recovery, in eases of considerable morning remissions, as well as m those of continued defervescence, may be abnormally large, arid sink as low as 28° R. = 95° Fahr., or even lower. Such events constitute collapses during defervescence, which must be counteracted by artificial heat, the administration of warm drinks, or even of such stimulants as wine or camphor, unless some unexpected new danger should interfere with an otherwise favor- able course of the disease. During pouvalescence the recurrence of a high temperature is generally the first sign of an approaching relapse, or the onset of a new disease, the characteristic symptoms of which it may precede by several days. The per- sistence of even an inconsiderable degree of abnormal temperature after apparent return to health, is a certain, and frequently for a long time the only, sign of incomplete recovery, or the existence of some lingering secondary VOL. I. 17 Digitized by Microsoft® 258 TOPICS RELATIVE TO PATUOLOGT. disease. The temperature should therefore be closely watched during conva- lescence; and the thermometer should be applied every alternate_ evening at the very least. As long as the temperature remains normal, nothing need be feared; but every rise of temperature should act as a warning. It may be due to mere error in diet, or to leaving bed too early; but in such cases the temperature soon sinks again, on greater precautions being taken. Kegularly continuous observations on the temperature alone, or in coiinec- tion with other symptoms, may enable the physician to predict a fatal issue with certainty, or the probably near approach of death. On this point one of two conditions may be observed. (1.) The temperature may rise continuously and considerably above 106.2° Fahr., when it is a bad sign; or it may even reach 110° Fahr., when a fatal issue is almost certain ; and it not unfrequently happens that, after the apparent occurrence of death, the temperature still continues to rise one or two-tenths Fahr., or even a degree, the cooling of the body taking place very slowly. Wunderlich records a case of spontaneous or rheumatic tetanus in which the temperature exceeded the maximum that has ever yet been observed in any disease. The heat only began to increase within the last twenty-four hours before death ; but the other symptoms before that time had been very violent, the respirations being accelerated, and the pulse at 102. During the night previous to death the temperature suddenly rose 3.3° Fahr., while the velocity of the pulse and the frequency of the respi- rations diminished, and the other symptoms did not increase in severity. Shortly before death, the heat rose to 110.75° Fahr., the pulse being then at 180; and at the moment of death the thermometer, was at 112.5° Fahr. After death the temperature still rose, and was found to be 113.8° Fahr. an hour after the fatal event. It then slowly diminished ; and thirteen and a half hours after death the temperature had not yet fallen to the normal average of the living body. (2.) The temperature may become more or less moderated, while the pulse is increased in frequency, and the other symptoms become more and more threatening. Such diminution of temperature, amidst conditions which do not harmonize with it, must be regarded as a pretty certain sign of approach- ing dissolution (see cases published by Dr. Muller of Dundee in Brit, and For. Med. and Chir. Review, Oct., 1868). But, on the other hand, there are cases in which the observation of the temperature yields the most favorable signs for prognosis. For example, when it is found, in a bad case of enteric fever, that the temperature has fallen some morning to 99.5° Fahr., we know that the reparative stage is entered upon ; and when a similar fall of temperature is observed in the evening, con- valescence has commenced. In pneummiia, when a marked fall of tempera- ture occurs in the evening, it shows that the period of crisis has arrived. When the temperature falls in measles, the maximum severity of the eruptive stage has been reached ; and when, in the first stage of variola, we observe a quick return to the normal temperature, we may feel certain that a slight form of the disease, free from danger, is likely to ensue. A decrease of temperature helow the normal is rare. It happens sometimes transitorily, anouncing thereby a favorable crisis, by preceding the return to a normal temperature. It is also met with som'etimes during the morning remission oi remittent fever ; also during the apyrexia of intermittents ; in acute collapse, preceded or not by fever ; in chronic wasting diseases ; and sometimes, also, on the approach of death, especially in typhus fever, in which the car- diac symptoms have been dangerous. A remarkable inequality in the distribution of the temperature over dif- ferent parts of the body (face, hands, feet, &c.) may occur during the shiver- ing preceding fever, in collapse, and in the agony of approaching dissolution. Sometimes, also, such unequal distribution may occur in disorders of the chest and abdomen, in some local skin diseases, and in partial paralysis. This fact Digitized by Microsoft® CORRELATION OP BODILY HEAT WITH EXCRETA. 259 is not of importance or utility for diagnosis or prognosis; but it requires to be known, in order that erroneous conclusions may not be drawn. . r, 9^ *^^ -Karejres 0/ Temperature in 'Diseases where Fever is present as related to the Amount of the Excreta. The particular degree of heat and the waste in every febrile disease are represented hy— something. The physician sees the fevered patient wasting before his eyes. Every tissue is wasting, and, in correlation with the exces- sive generation of heat, how is this waste expressed ? As a rule, it is expressed by the amount of excreta. _ To Dr. Parkes in this country, to Dr. Jones of Augusta (in cases of mala- rious fever), to Virchow and Wunderlich in Germany, is the merit mainly due ot having demonstrated, by clinical and experimental observation, that the morbid development of heat, as measured by a thermometer, is associated in some cases with more abundant, in other instances with less abundant excreta trom the body than in health;— that the temperature and the amount of the excretions bear some undetermined relation to each other;— and that the loss ot weight of the patient is due to increased and rapid elimination of material with increased tissue-change, associated with the increase of temperature. • ^ i!" ^1 P'lysiological facts have elucidated the normal generation of heat in the healthy body, so far has the abnormal generation of heat essential to the febrile state been clearly made out. In health the normal temperature produced by chemical change in the body is represented in the excretions by so much urea, sulphuric add, carbonic acid, excretive volatile acids of the skin and the like; but m the febrile body a higher temperature is represented in the excretions, m some cases by a larger, and in others by a smaller quantity oturea, sulpliune acid, and probably carbonic acid (Paekes). In the study of special diseases the student ought frequently to estimate the quantity of excreta passed by the urine, as one of the best methods for ena- blmg him to appreciate the changes which go on in the body during disease, fd him m prosecuting such researches, he is recommended to consult the work of Dr. Parkes On the Composition of the Urine, and to follow the direc- tions given on the Exami7iation of the Urine, towards the end of the second volume of this text-book, for obtaining quantitative results by the volumetric method. Here the following general results may be given : Average quantity of Urine passed in twenty-four hours, " amount of Solids, " " u Urea, " Chlorine, " " Free Acid, " " Phosphoric Acid, " Sulphuric Acid, " Uric Acid, Speciiic gravity, 52| to 56 ounces. 954 grains. 512 " 126 76 " 33 " 48.80 " 81.11 " 8.5 " 1.020 Two grams of urea per pound weight of the body is the minimum given by Haughton and others, eliminated as the product of vital work alone The urmary solids maybe estimated by multiplying the number of ounces of urine passed m the twenty-four hours into the number representing the speciiic gravity— the product being the weight of the solids in grains. A convenient table (see pp. 260 261) is given by Dr. Houghton, founded on many observa- inos t!^ '°® '^°}^ ^"^ ^«^^t^ aii'^ i'a disease, of specific gravities from 1003 to J.UZ8. ihe results are approximations to the daily excretion of urea in all cases where sugar and albumen are absent. The table is one of double entry and IS used by finding the daily excretion of urine in fluid ounces and its specific gravity by means of a carefully graduated urinometer. These data peing found, and the corresponding columns referred to in the table, at the intersection of the columns, the excretion of urea is given in grains. Ihe most opposite statements have thus been made regarding the amounts Digitized by Microsoft® 260 TOPICS RELATIVE TO PATHOLOGY. 05 H H I— I I— I M P P^ O o h-l H H fi H O m o H w p <^ w p w p DC 2 & o 1 CO 0-^QOC<>«OOrJMt- — ioo> b-CiOIMCO'>*SCt-010 — COrttCOt-COOi-HCOTjiiOt-COOS^C^-^iOtD NiMCQCCOeD«D50<© S !L0O«Ct-W.ACftCl«OO^C0o^cOTfiot-QOOr-ff-OC^ur300.-C-<*(b-OCOeOOi(MOQO i«eCCOOlOC^Ci^-d'Ot-QOOSi-lNCr3iO<;Cr-COO^'N'*iO«5l>-010i-l — NCO-#«Ct-C0Os.-IM«3^eDt-00a. O ^ifteOt-COC— iM!C-*«5t-000»0(MSC-*OtcaOOS=: — !W-^»i^«;i>- N(NMNfNeo«iCCeOCOMMK>iW-*->*-*-«*rf*-*TfiTt*Ou^iOOiOiOiO o cou^t-QOO.-'ffo-^«oi^oa--'?C'*b-Q0aD0)O — (MtMCO-^ifttDtOt-OO «,_,_i,_i^cs)(Meiiffqc^e«C-rH — OseO>*(MOSt-'-*C^a>t-iaN ^,_i^^r-..^rtlMCq(N(N(M(M(M(MM(N(M(MNCOM50COCOCi:icO«CC o 1-1 o (DNOJilOCOOtDCOOb-'^Ob-"^— 'CO-^— 'OOiftCqOOmiMOseOfMOSO CO o I-H oeo?00»eO!MOJi«C^COin--co-!C— t--!!Hot>.eooeDW50JeONOS»fllM o OlH.(MCOTtOtOCMCO-=J'0«0--l^-«5dS»«-Jb-CO o sSSSBssSSSssSSIsssgiSSBIiliil e o OS o o 00 o o COaOa>OTOO--^-Hr-4C2C2MM^|*'*|AOeOeOt-gKoOoaOS=»<^g o o 1-H ^H^oo-^oao'©COee3)(Mio«.— TH5COsC^»OOOOMeO lOiftOtOeCt-t-t-t-QOOOOOOOSOSOSCOO^ — <— — N(N(NSOeCCO l-H eot«t-Osi-'Mini>-'3s--H >0 I— I t~ CO 01 O o cq M CO OS Ssiglilliissliiii55S5SII3ilS O ifs o eD "3 eo t- t- w M N cq 2 O "O O lO O ITS meococoffocociicoffQ-^ sH^SgSSi.S|S||s|gg|||g|s|sg|gsg|| , '~''~^'~''~''~''-<'-''-''-"-fr- "''^^* °^ impeded circulation through the lungs and the left side of the heart. A feeble arterial pulse will notTsuch rjaSr * °'''""^' and stimulants are n'ot inc^mpS: S i^ LST/'^^T °^ the membrane or organ afifected must always be considered be ac Sv"^ fl ' P^Tf '^ °^. '^^^^'^^S- If ^ «<^rous membrane, for ° nrtalcT is uTuSl^ ^^f'^'l'- *^^ P/^tient, for the most part, bears bleeding weH and tZ3^ ^TiZ 't^y^^ ^^ '^- ^'^^ respect to organs, it is fould thatTn flammationof thebramisless influenced by bleeding than inflammaSon of Sst of the'^ m'^^'T"*^"? i'^' ^^'' than inflammftion of theX^s The f t n^ S 7^<^^°°e brought forward in Dr. Markham's very able aiK^ inter! tWn^- fl °'''''° Lectures establishes the special efiicacy of venesec ion in nd" itrrffZe tf "V? r"-P--d 'with obstructfons oTTe tidi c the cu e of ac^L^nfl ' ^* ''° °°* ^^^t^ *° ^^ '''^^^'' "O"- i^^J^rious in erly ^ed anAl T'^f °°' generally, if its remedial functions are prop- remprW ' v. ^ advantage gained be duly followed up by appropriate f" 1 b i^^ '° ^' ^''''''''^ "f -'^^ ^he symptom's w'hirSnd danger-natX !^rr'''''" ^ '^'?i those which indicate the greatest strong hard ^i,T- I /^'■''''"' "'T^^^ beginning suddenly, with full, fl^hLAf V^ pulse-urgent dyspncea, even orthopncea-swellino and Ji^'^ingofthefacejrequemyand violence of cough, wUh scanty or truly pneu- Digitized by Microsoft® 292 TOPICS KBLATIVK TO PATHOLOGY. monic expectoration, aggravating the pain which extends through the chest. When such symptoms are seen within three days of their commencement, especially in those of robust and full habit in the prime of life, bloodletting is the remedy to be used, — everything else is trifling, and it is not safe to dispense with it. The nearer a case answers this description, the more sure we may be that the effect of bloodletting will be satisfactory, and its repetition, if the symptoms shall recur, will be well borne (Alison). But if the inflammation be so limited that it produces little or no appreciable impediment to the respiratory or cardiac functions, when the temperature does not exceed 104° Pahr., when the pulse does not exceed 120, and when the respirations do not exceed 40 in the minute, such cases of pneumonia will get well by regimen and absolute rest alone. 9. It is found in practice, also, that this most powerful of therapeutic agents in the cure of inflammation requires the greatest caution in its repetition, for there is a line beyond which bleeding becomes destructive instead of remedial. Two indications are of great use in determining as to the propriety of a second bloodletting, namely, — (a) As to how the first bleeding is borne — a test first suggested by the late Dr. Marshall Hall. If much blood flow from an ordinary-sized opening, be- fore any tendency to syncope manifests itself, venesection is then considered to be well borne ; if, on the contrary, the patient soon faints after a vein is opened, the judicious practitioner desists from further depletion. The urgent symptoms, being thus relieved for the moment, may again return, after a longer or shorter interval, and thus demand a repetition of the remedy, to be now judged of (b) by the reaction of the system generally, as indicated by the state of the local symptoms, their urgency for relief, the character of the pulse, and the appearance of the blood first drawn. The reaction may be of such a kind that a sthenic state oiinflammatory fever still continues, or returns after temporary subsidence. The inflammatory process having been inter- rupted, so far modified, but not arrested, the remission proves transient, and the reaccession may be more fierce than the onset. A repetition of bloodlet- ting is demanded so soon as such reaction has declared itself. On the con- trary, the reaction may be asthenic, or of nervous character, the pulse being rapid, soft, and jerking, the breathing oppressed, headache and tinnitus avr rium present, with general nervous excitement ; bleeding under such circum- stances, is not to be repeated. A full opiate will allay the nervous excitement. 10. The next consideration is, " What indications for bleeding are to be drawn from the state of the blood ?" The blood offers certain indications, either for bleeding or refraining from it, when the symptoms would otherwise demand or forbid this operation. Th.e, firmness of the coagulum, for example, has been considered at all times as a mark of the tonic state of the system, and as a warranty for repeating the bleeding when the part is hs yet unre- lieved, and the reaction continues of the sthenic type. The thickness, and especially the firmness, of the buffy coat, if lifted on a pin, was one of the leading characteristics of the existence of acute inflam- mation, amongst others already noticed, and was much founded upon by Dr. Gregory, as guiding his practice in the treatment of inflammation. On the contrary, a looseness of texture of the clot is a sure sign of great debility, so that, unless other circumstances strongly indicate the necessity of bleeding, it ought not to be repeated when the yellow or huffy substance on the surface is loose and not thick and firm. 11. The proportion of the serum to the clot, and also its occasionally altered characters, are arguments for or against bleeding. When the quantity of serum is unusually large, unless the clot be very firm, bleeding ought not to be repeated. Also, when the properties of the serum are so altered that it coagulates and forms one mass with the clot, bleeding is constantly prejudi- cial ; and, lastly, it has been observed that when the serum, which has little Digitized by Microsoft® METHODS OF BLOODLETTING. 293 or no affinity for the red globules in health, readily dissolves them, and as- sumes a red color (red-colored serum), it is an unerring sign that further bleeding should be avoided. In some of the febrile diseases the fibrin never augments, remains often in normal quantity, and is also often diminished. In the acute inflammatoryfever, on the contrary, there is a constant aug- mentation of this principle, compared with the red globules, as observed by Andral. It is this excess of fibrin which gives firmness to the clot, and is the cause of its being "buffed" and "cupped." The immediate effect of bleeding, according to the same high authority, is to reduce the red globules, but not so with the fibrin ; for a reduction of the fibrin does not take place till after a certain time. Such is the state of the blood in the sthenic inflammatory states. There are many reasons, however, for not esteeming the bufied and cupped state of the blood, denoting an excess of fibrin, as a sufficient warranty for bleeding ; for these conditions are often present in erysipelas, phthisis, or the early stages of typhus fever ; and in either of these cases the loss of a moderate quantity of blood might hurry the patient to his tomb. Again, in acute rheumatism the blood is not only buffed and cupped, but contains a maximum quantity of fibrin ; yet the best practitioners seldom think it neces- sary to take blood, considering that mode of treatment as neither affording present relief nor shortening the course of the disease. The fact, then, of the blood being buffed and cupped does not in all cases warrant venesection. It is also well known that the sthenic or buffed characters of the blood are often greatly modified by the manner in which the blood is drawn ; thus, if an in- dividual be bled in both arms, and the blood allowed to flow with different velocities — ^that is, in a full stream from one and slowly from the other — the blood drawn is identically the same ; yet a thick buff will be wanting in the latter and be present in the former. And if the apertures be of different sizes, the same differences will result ; the blood from the larger orifice will be bufifed, while no such effect is seen in the blood drawn from the smaller one. Again, the form of the vessel which receives the blood, as to whether it be flat or conical, and also its temperature, or whether the blood be re- ceived into one that is cold or warm, will also affect the phenomena of its coagulation. There are many circumstances, therefore, which prevent the blood from being an unerring guide for bleeding in cases of inflammation ; but the assem- blage and succession of symptoms must decide as to the propriety of bloodletting in doubtful cases. 12. An improvement in the character of the secretion or excretion from the inflamed part contraindicates the repetition of bloodletting ; for instance, in pneumonia, if the character of the expectoration, from being scanty, tenacious, and tinged with blood, becomes copious and free, much may be expected from this natural tendency to cure. 13. It is an object to effect the sanative result with as little expenditure of blood as possible ; but the amount to be taken can only be judged of by the effects produced. The patient should be bled, if possible, in the upright posi- tion, and a full stream of blood allowed to flow from a sufficiently large ori- fice in a vein. To accomplish this fully, it may sometimes be necessary to open a vein in each arm, so that the flow may be from both at the same time. Bloodletting may be employed either generally or locally. General bleed- ing is best adapted to subdue acute inflammation of visceral organs, because it makes a more decided and rapid impression upon the system. Local blood- letting, by leeching, scarification, or cupping, is more useful in chronic inflam- mation and in inflammations affecting membranes, such as the pleura, perito- neum, meninges, and articular membranes, by diverting the blood through the superficial vessels from the deeper arteries which supply the inflamed parts (see the observations of Steuthers and Turnee in Edinburgh Monthly Jour- nal). It is sometimes advantageous to combine the two methods of taking Digitized by Microsoft® 294 TOPICS RELATIVE TO PATHOLOaY. blood. In the case of external visible inflammation, the direct abstraction of blood from the inflamed part during the congestive period of the inflammatory- process, is seen to exercise a benign influence over the progress of the inflam- mation. Purgatives. — The next most important class of antiphlogistic agents in the treatment of inflammation consists ot purgatives, especially the resinous cathar- tics, likajahp, scammony, and gamboge. (1.) They free the stomach and intes- tines from accumulated food and faeces, or other irritating and acrid matters. (2.) They subdue the inflammatory tendency by the discharge of a large quan- tity of serous fluid, charged with albumen, from a large extent of mucous membrane. Thus they tend to check effusions and diminish the force of the heart's action. Their use is especially indicated in encephalic inflammations and hepatic congestions ; but they are less efficient in subduing thoracic inflam- mation ; while in the enteric inflammations they ought not to be pushed beyond merely unloading the alimentary canal. Combined with diaphoretics, they promote the elimination of morbid material through the glands. Mercury varies in its influence with its mode of administration and the constitution of the patient. It is followed, in large doses, by an increased flow of watery evacuations from the bowels, and an increased flow of saliva.* If the use of the remedy is continued, especially in small and repeated doses, combined with opium, so that it is not passed oS by the bowels, this mineral induces salivation — that is, saliva flows profusely, the gums become tender, red, swollen, and ulcerated on the margins in contact with the teeth. The patient gets rapidly thin during its use. The blood is decomposed, the red corpuscles are rapidly destroyed to the extent of one-sixth or more ; the fibrin is dimin- ished by one-third of its amount ; the albumen by one-seventh; and, at the same time, it may become loaded with a fetid matter, the product of decom- position (Weight). "Thus it is an agent of terrible activity, and we may well be cautious how to handle it" (Headland). Its sanative power is believed to consist in controlling or preventing the coagulation of lymph ; and for this purpose it is used as an auxiliary to bloodletting, and next to that as a remedy, and superior to purgation. It is only useful in the sthenic forms of inflammatory action. Bichloride of mercury is certainly of great use in iritis, and in inflammations of the deeper seated parts of the eye. It is also of service in the inflammations of serous membranes, in which it appeal's not only to subdue the inflammation, but to promote the absorption of the effused prod- ucts of the disease. Wherever coagulable lymph is effused, or about to be effused, wherever adhesive inflammation exists, gluing parts together, and " spoiling the texture of organs," there mercury is of service. The system should then be brought as speedily as possible under its specific influence — a result which is known by its effects on the gums and on the breath of the patient. The gums grow red and spongy, and the patient complains of their being sore, and that he has a metallic taste — a taste like copper — in his mouth. At the same time, an unpleasant and very peculiar fetor is to be smelt in his breath; and which, when once experienced, is easy of recognition again. Beyond this physiological point the effects of mercury ought not to be allowed * Concerning the action of mercurial salts in the secretion of bile, the most oppo- ;site statements have been made. The experiments of Dr. George Scott, of Southamp- ton, throw considerable doubts on the hitherto generally received opinion that calomel in large and purgative doses increases the flow of bile; on the contrary, such doses soe.m, in the first instance, to diminish the flow of bile; and it is a matter for further experiment to determine whether small and frequent doses of calomel, continued for a length of time, so as to produce the speciflo action of mercury upon the system, will really ultimately avigmentthe biliary secretion ( Beale's Archives, vol. i, p. 209). Since then many experiments have been made on animals and on healthy men, from which it would appear that the secretion is rather diminished than increased. Nevertheless, the experience of generations speaks as strongly in support of the assertion that in some ■diseases the flow of bile is increased by mercury. Digitized by Microsoft® ANTIPHLOGISTIC REMEDIES. 295 to advance ; but these symptoms may require to be maintained for some time. Such results are best obtained by giving small equal and repeated doses of calomel, combined with just as much opium as will prevent its passing off by the bowels._ Two or three grains of calomel with a third or a quarter of a grain of opium, given every three, four, or six hours, according to the necessity of the case, will effect the results indicated in the course of 36 or 48 hours. Previous bloodletting renders the body more readily susceptible of the influence of mercury, and the two remedies will accomplish, by their joint power, what neither of them might be able to accomplish singly. If the inflammation has been slow and chronic, the influence of mercury must be also slowly brought about, as the lymph can only be slowly and gradually taken up again by the specific action of the drug, sustained for a considerable length of time (Wat- son, Simon). It is decidedly hurtful in cases of erysipelas disposed to gan- grene, in scrofulous states of the system, in debility, and in cases where the nervous system is in an irritable condition, and the condition of the patient tending to the so-called typhoid state. The specific influence of mercury is recognized by the tenderness of the gums which it induces, by the increase in the quantity of saliva, and by the peculiar mercurial fetor of the breath. This is the utmost action which should ever be induced, and salivation espe- cially ought to be avoided. Mercury thus employed tends to prevent effusion and to favor absorption of efflised products. It is advantageously employed in membranous inflam- mations, and such as go on slowly. Iodide of Fotassiiim, by its administration, in addition to mercury, removes more quickly the inflammatory eflTusions, such as occur in pleurisy, and in the inflammatory thickening of organs. Antimony is antiphlogistic, by tending to increase all the secretions ; but particularly those from the skin and lungs. It is especially useful in those sthenic inflammations which are rapid, and in which a sudden and powerful action is desired ; and also where the direct sanative influence of bloodletting is to be maintained. It is thus indispensable in croup, extremely efiicacious in sthenic pneumonia, and highly useiul in bronchitis. As an agent to keep up the sanative influence obtained by bloodletting, the action of antimony is invaluable ; for when bloodletting has weakened the force of the heart, by diminishing the pressure on the vessels, then antimony maintains this dimin- ished pressure in proportion as it weakens the force of the heart. A perse- verance in its use produces a watery condition of the blood, diminishing especially the amount of fibrin. The production of nausea is an indication that it has taken sufiicient effect. Opium is one of the most important antiphlogistic remedies at present known. In various forms of inflammation of the abdomen and chest, it is a universal remedy; and if administered less in affections of the pulmonary mucous membrane, it is only because there is a fear that by lowering the respiratory process, it may tend to prevent expectoration. Sore throats, bad colds, and ulcers heal rapidly under its influence. As soon as a cause of in- flammation begins to operate, treatment by opium ought to be commenced ; a grain every three, four, or six hours, according to the indications, so as to keep the patient under its narcotic influence by renewed doses of the drug. Aconite is now also proven to be a powerful agent in counteracting inflam- mation and in subduing the inflammation, and its tendency seems rather to arrest or cvi short an inflammation than to remove the products of inflamma- tion when they are formed. It requires, therefore, to be used very early ; but so long as the inflammation is extending, aconite will do good. Acute inflam- mation of any of the tissues may be subdued by the early administration of the tincture of aconite (two to five drops every three hours, according to age). In the inflamed parts, like the tonsih or the mucous membrane of the throat, the good effects of aconite may be seen, and its good results are most apparent when the inflammation to be subdued is not extensive or severe, as in the Digitized by Microsoft® 296 TOPICS RELATIVE TO PATHOLOGY. catarrh of children, tonsillitis, or acute sore throat. Under its influence the large, livid, dry, and glazed tonsils will have their appearance completely- altered in a day, so that the mucous membrane is moist and bathed with mucus or pus, after which a little glycerin of tannin applied to the part will complete the cure. The remedy ought to be given at the earliest stage, when the chill is yet upon the patient. " In a few hours," says Professor Kinger, " the skin, which before was dry, hot, and burning, becomes comfortably moist, and in a little time longer it is bathed in profuse perspiration, which may be so great that drops of sweat run down the face and chest. With this appear- ance of sweat, many of the distressing sensations, such as the restlessness, the chilliness, or heat and dryness of the skin, are removed. At the same time the quickened pulse is much reduced in frequency, and, in a period of twenty- four or forty-eight hours, it and the temperature have reached their natural state. It is rare that a quinsy or sore throat, if caught at the commencement, cannot be disposed of in twenty-four or forty-eight hours by its use. The sweating may continue for a few days after the decline of the fever, on slight provocation, but it then ceases." Aconite has had for a long time a reputa- tion as a depressant of the heart's action,, and capable, as such, of lowering the force, or slowing the circulation. The admirable account of the physio- logical properties of aconite given in the inaugural dissertation of Dr. Flem- ing, of Birmingham, brought its usefulness more to the notice of the profession ; but still it has never come into general use, chiefly on account of its highly poisonous nature, and from the want of precise rules as to the class of cagfes demanding its administration. For a long time several eminent members of the profession have attributed the very highest value to aconite as an anti- phlogistic, and Mr. Listen highly advocated its use in the treatment of ery- sipelas. Dr. Wilks, of Guy's Hospital, has been in the habit of using it for many years, when favorable cases occurred, that is, cases seen at the very commencement of an inflammatory process. He has used it in pneumonia, acute rheumatism, hoopingcough, and chronic catarrh, in doses varying from three to five drops of the tincture of aconite every four hours (The Practitioner, vol. i, p. 334). Dr. Ringer has used it with success in cases of catarrhal croup, severe colds, tonsillitis, pharyngitis, and in pericarditis ; when the heart throbs violently, thus producing extreme pain, aconite will quiet the heart and ease the pain. Dr. Ringer gives of the tincture lialf a drop or one drop in a teaspoonful of water every ten minutes or a quarter of an hour for two hours, after which to be continued hourly. Alkalies dissolve the fibrin of the blood and retard its formation ; and the ingredients of the urine produced out of the destruction of the albuminous compounds of the body are increased largely in amount by the administra- tion of alkalies. They generally pass out of the body as salts, having com- bined with acids in the system, and tending to leave behind them an excess of alkali in the blood. All treatment ought to be judiciously regulated by the knowledge of the tendency of the disease to a spontaneous favorable termination — the acci- dental symptoms of urgency requiring treatment and control in many eases, rather than the disease itself. In every case, details of treatment must be considered and fixed upon ; for general principles of treatment must so result to have any practical value. It is not possible to lay down one rule based on general principles applicable to every case. Every case must be studied and managed in accordance with its individual requirements ; and it is especially the duty of the clinical teacher to instruct the student in this kind of knowl- edge, because it is a kind' of instruction which mu^t be seen to be appreciated. To teach the art of applying remedies is the duty of the clinical instructor. The text-book of practical medicine can only faintly indicate the principles by which treatment ought to be guided. "When individual diseases are con- sidered, whether involving fevers of a specific kind or inflammations, the details of treatment applicable to each will be set forth in detail. Digitized by Microsoft® THE SCIENCE AND PRACTICE OF MEDICINE. PAET II.' METHODICAL NOSOLOGY— SYSTEMATIC MEDICINE, OE THE DISTINCTIONS AND DEFINITIONS, THE NOMENCLA- TURE AND CLASSIFICATION OF DISEASES. CHAPTER I. THE AIM AND OBJECTS OF NOSOLOGY. Nosology, regarded as a distinct department of the Science of Medicine, embraces three separate objects of consideration — namely. First, the Distinc- tion and Definition of particular diseases, or of the genera and species of diseases ; Secondly, The Nomenclatuee of diseases, or the assignment of the names by which they are to be designated, so that each disease may be dis- tinguished and known by an appropriate name ; and. Thirdly, The Aeeange- MENT or Classification of diseases in some methodical and convenient order, by which they may be distributed into classes, orders, genera, or species. These three divisions of Nosology are respectively known as the Definition, the Nomenclatuee, and the Classification of diseases. Of these in their order. I. The Definitions of Diseases. — The first object of Nosology is to obtain such brief enumerations of the peculiar characters of diseases as are sufficient, provisionally, to define them ; and the practice of attempting to define dis- eases so as to lead to their being easily recognized was begun before the time of Galen. In modern times the great advantages that have arisen from establishing definitions in natural history upon fixed and determinate princi- ples, not only of its various objects individually, but also of the groups under which it was found possible to arrange them, suggested to medical men the idea that much advantage might also result to the Science of Medicine from defining diseases, and such groups of diseases as might be found expedient to recognize, under general terms or common names, based upon some fixed and determinate principles. Sydenham recommended that definitions or brief descriptions of diseases should be framed after the model of those that are given of plants ; and he lays down various judicious rules for the proper exe- cution of this object in the preface to his work On Acute Diseases, first pub- lished in 1675. The precepts of Sydenham were never reduced to practice in Digitized by Microsoft® 298 METHODICAL NOSOLOGY — SYSTEMATIC MEDICINE. his day ; but about fifty-seven years after his work On Aaide Diseases was published, the idea was taken up and acted upon by Franciscus Boissier de Sauvages, a distinguished physician and eminent professor of medicine at Montpellier. He attempted to arrange diseases, as botanists have done plants, into classes, orders, and genera. He endeavored to lay down the characteristic phenomena of each, and to enumerate their principal varieties. The outlines of his nosological system were first published in 1732, and followed, thirty years afterwards, by his Nosologia Methodica — a work which marks an important era in the history of Medicine, as having led to much greater accuracy in the distinction of diseases than was previously observed. At present the only useful method of defining diseases seems to be an artifi- cial one. It is assumed by nosologists that the proper foundation for the distinction of particular diseases is the occurrence of constant and uniform combinations of morbid phenomena or symptoms, presenting themselves in concourse or in succession. Thus some of the essentials of a definition are obtained, so that each disease may be marked out by such a brief enumeration of its leading characters as might serve to distinguish it from every other. A series of nosological definitions, more or less correct, may be thus provisionally established, so that the same things are designated by the same terms. Ob- jections have been urged to methods of this kind, on the ground that diseases are unsteady and variable in their character ; but the aids to science are now so numerous that physicians are becoming more and more able to distinguish diseases from one another, and to tell by what marks, or upon what grounds, they do so distinguish them. Such are the marks or grounds of distinction by which each disease ought to be defined ; and as often as we attempt to es- tablish a distinction among diseases, either the deficiencies or the errors of our definitions will be the more easily, perceived ; and the attempt will lead to a more accurate consideration of observations previously made, as well as to a greater degree of accuracy in subsequent observations. Definitions of diseases are therefore not only of much service to methodical nosolog)'^, but they help to render the diagnosis of diseases more perfect. Pathologists, how- ever, are not agreed as to whether the definitions of diseases should be derived from the external phenomena that present themselves in their course, or from the internal pathological conditions on which these phenomena are supposed to depend ; and particularly such of these conditions as consist in lesions or structural alterations discoverable after death, or a combination of all. Cullen was in favor of definitions derived from symptoms of diseases ; but he believed that the information derived from pathological anatomy might guide to more correct and definite distinctions among them. Defining diseases by their supposed proximate causes may lead to error, inasmuch as in many cases these causes are disputable, and may long continue to be so. Whatever principle of defining diseases be adopted, it is absolutely necessary that it should be independent of every theoretical view ; for any theory employed, however specious, however much we may be persuaded of its truth, may not appear in the same point of view to others, and may therefore occasion end- less confusion (Cullen). If no uniform principle can be laid down for arriving at precise definitions of disease, we must be content with such methods of definition as will serve the main purpose of coupling intelligible general notions regarding the disease with given modes of expression. For example, although we cannot give such a definition of mauy a disease as will embrace even all the leading' phenomena of every case, we may assuredly give such a definition as shall apply with reasonable accuracy to the disease we intend to designate, so that no one may suppose we mean thereby either small-pox or the gout when we mean typhus fever or dysentery : and, in a pro- gressive science like medicine, definitions must always be provisional. " They are, indeed, not for the present state of medical science. They can only in- Digitized by Microsoft® PRINCIPLES INFLUENCING THE NAMES OF DISEASES. 299 completely circumscribe their subject, and must have shadowy outlines" (Paget). II. The Nomenclature of Diseases. — This, the second object of Nosology, has given rise to many disputes, and has furnished much scope for the display of classical erudition. From the earliest periods of medicine, the names im- posed upon diseases have been derived from several different sources ; but the following considerations have generally regulated the naming of a disease : First: Some names have been taken from the part affected — e. g., peripneu- monia, podagra, ophthalmia, dysentery. Secondly : The most characteristic symptoms have furnished the name — e. g., ileus, tenesmus, paralysis, diarrhoea, dyspruxa, coma. Thirdly : Some names have been taken from these two cir- cumstances combined — e. g., cephalalgia, otalgia, cardialgia, odontalgia, hyster- algia. Fourthly : An alteration of tissue upon which subsequent changes depend being recognized as the essential element of the disease, it is named accordingly — e. g., pleuritis, peritonitis. Fifthly : Such alteration not being discovered, the first tangible link in the chain of causation has been used instead — e. g., melancholia, cholera, typhus. Sixthly : When a lesion ttending to sudden death at once follows the application of a cause, that cause may name the disease — e. g., lightning, prussic acid, arsenic, burn, scald, sunstroke, cut, stab, frost-bite, &c. Seventhly : A considerable number of names of diseases have been derived from some imaginary resemblance to external objects — e. g., elephantiasis, cancer, polypus, anthrax, &c. Lastly: There are still many names the origin of which it is not now easy to trace. It is obvious from these statements, that the names of diseases must chahge as our knowledge changes and becomes more precise ; and many diseases which were once named after their symptoms are now named according to the lesion from which most of those symptoms proceed. An apt illustration of this is to be found in paralysis, which is no longer regarded as a disease per se, but is merely a symptom of several structural alterations of the brain and spinal marrow. The progress made in our knowledge of disease from time to time rendered it obvious that some diseases, now only sufficiently recognizable, are different from any other diseases hitherto known. In separating them it became neces- sary to invent new names for the distinct diseases, or a choice had to be made from amongst those names previously in use! Hence the jumble of Greek, Latin, and mongrel names which hitherto has pervaded medical nomencla- ture. The idea also of rendering medical nomenclature uniform, by deriving the names of diseases from one source only, or from a certain or mixed com- bination of sources, has caused many to attempt the reform of medical nom- enclature, and especially since morbid anatomy has been so much prosecuted that it might serve as a useful guide in distinguishing the disease or dictating its name. By some it is maintained that "the name of each disease or species should be so characteristic and significant that a person slightly acquainted with the language and the subject should, on hearing it, immediately understand what is the nature of the disease it designates " (Ploucquet). In this respect the name ought to be composed out of the same elements as the definition of the disease — ^in fact it ought to be the definition converted into a name, and derived either from the symptoms of the disease or from the supposed proxi- mate cause. But a name which is expressive only of the nature, seat, or proximate cause of a disease may be erroneous in respect of each of these facts singly, or of all of them together. The history of the nomenclature of fever, especially enteric, would amply illustrate these statements — e. g., putrid fever, adynamic fever, bilious fever, pythogenic fever, typhoid, meningogastric fever, nervous fever, gastric fever. The example of lardaceous disease (see that article, p. 133, ante) may furnish another illustration. Both are very mild examples of nomenclature and of confusion, which ought to make a Digitized by Microsoft® 300 METHOCICAL NOSOLOGY — SYSTEMATIC MEDICINE. man pause before he attempts to construct a new name. Naming diseases, such as fevers, from the names of places (for example, Crimean fever, Bulam fever, Mediterranean fever), is also extremely objectionable. It is inexpedient, also, to abandon (except when unavoidable) the names of distinct diseases received and recognized by our forefathers in the science ; or to substitute new ones in their place, without an extreme necessity. Sauvages insisted much on this point, and Cullen entertained the same opinion. "Words," says the former, "are good only in respect of their signification." In dealing, therefore, with ancient nomenclature, which, for the time being, may appear objectionable, it is surely better to extend, if possible, the signi- fication of the word, "name, or term, than to alter it. At the same time it must always be permitted to give new names to new diseases, and to select the best out of those which are in use, when a great number have been used to designate one and the same thing. There are some principles, therefore, which it is well to recognize as influencing the judicious choice of a name. Such names, for example, as involve or attempt to indicate a proximate cause, are more liable to lead to error than those which are derived from leading symptoms. If names were to be based on supposed causes, new names of diseases would be required whenever a new hypothesis is started. Look, for example, at the names of enteric fever, already mentioned, and the systems of Linnaeus, Vogel, Pinel, and even Mason Good, will show that medical nomenclature has been repeatedly changed without any urgent necessity; and great inconvenience has especially resulted from incorporating particular and often peculiar pathological doctrines with the language and nomenclature of diseases. So much has this been the case that the language of medical science has been in danger of becoming " a curious mosaic of the chief specu- lations of ancient and modern times." The passion for inventing new terms retards also, in a wonderful degree, the progress of the student of medicine, and tends to involve him in difiiculty and doubt. It will, therefore, be well for the student of medicine and for the science if the teachers of the various schools will absolutely adhere, for at least the next ten years, to the definite form of nomenclature as at present agreed to, and published by the London College of Physicians, and given in this Text-book. III. The Classification of Diseases From time to time physicians have considered it advisable or advantageous to arrange the whole of the diseases they are able to define, and to name, under more or less comprehensive groups. A consideration of the different plans which may be pursued in such arrangements, and of the advantages to be derived from them, forms the third object of Nosology. It is obvious that any single character, or combination of characters, in respect of which diseases agree with or differ from each other, may be made the basis of methodical arrangement, under a larger or smaller number of divisions, or of higher or lower genera (language of logicians), or of classes, orders, and genera (language of naturalists). By ingenious devices of the mind the physician or the statist may classify and arrange his knowledge so as to bring it all more readily within his reach for any special purpose, — so as to make it, in fact, more at his disposal— to facilitate and pave the way for further investigation. Such are the legitimate objects and the results of all methodical arrangements. Classification, therefore, being only a method of generalization, there are, of course, several classifications of disease which may be used with advantage for special purposes. The physician, the pathol- ogist, the jurist, the hospital statist, the army or navy medical officer, may each legitimately classify diseases from his own point of view, and for his own purposes, in the way that he thinks the best adapted to facilitate his inquiries, and to yield him general results. The medical practitioner may found his main divisions of diseases on their treatment, as medical or surgical ; the pathologist, on the nature of the morbid action or product ; the anatomist or Digitized by Microsoft® PRINCIPLES OF CLASSIFYING DISEASES. 301 the physiologist, on the tissues and organs involved ; the medical jurist, on the suddenness, slowness, violent, or unnatural mode of the death ; the hos- pital statist, on the kind of diseases which are treated in its wards ; and all of these points of view may give useful and interesting results (Fare). There is thus no question on which more diversified opinions are legiti- mately entertained than on that of classification. Although it is the aim of all systematic writers and observers to arrange the objects of study in the most natural order possible, and although diseases are named as if they were individual entities, yet they present so great varieties that they will not admit of that definite and, in many respects, natural species, of classification which can be made with objects of natural history. Manifest reasons of convenience and facility for work can therefore be assigned as the great incentive to classi- fication ; and numerous reasons exist for classifying diseases in various ways : (1.) Men diflTer in their estimation of the characters on which different arrangements may be founded. (2.) The facts and phenomena of diseases on which classifications may be made are not all regarded from the same point of view. Most systems are avowedly artificial, being arranged with the view to elucidate or support a theory, or otherwise to effect a definite end. For example, by classifying diseases and recording the causes of death, the most valuable information is obtained relative to the health of the people, or of the unwholesomeness and pestilential agencies which surround them. " We can take this or that disease," says Dr. Farr, " and measure not only its de- structiveness, but its favorite times of visitation ; we can identify its haunts and classify its victims." We are able to trace diseases also as they percep- tibly get weaker and weaker, or otherwise change their type, as some have done from time to time. We know from the valuable returns of the Regis- trar-General, prepared periodically by Dr. Farr, that certain diseases are decreasing, or growing less and less destructive ; that certain other diseases have ceased in some measure ; while other severe diseases have exhibited a tendency to increase. The advantages, therefore, of adopting some system of classifying diseases, which can be put to such useful practical purposes, must be obvious to every one. To some extent, other systems are natural in their arrangement, in so far as they attempt to express or exhibit some of the natural relations which subsist among diseases ; but the mere expression of one man's interpretation of peculi- arities of disease of the same species, and the elevation of such diseases in a classification as specifically distinct, are apt to be based on insufiicient evidence as regards natural relations. Principles of Classification — Many systems of Nosology have been adopted from time to time ; and as valuable general principles have been adduced from some, the grounds on which diseases have been classified may be briefly described under the following ten divisions, namely: I. ■ The nature of the ascertained causes of disease. On this principle two classes of diseases are recognized, namely, — (1.) Diseases arising from general causes; (2.) Diseases arising from specific causes. II. The pathological states or conditions which attend diseases. The principle of this classification consists in determining alterations of the structure or the chemical composition of parts, from which names are given to the disease — e. g., pleuritis, pneumonia, &c. The distinctions of Sauvages were generally derived from symptomatic and pathological characters, or external symptoms alone; Cullen, following (1792), adopted similar grounds of classification ; but, with much more comprehensive views than Sauvages, a more lucid order, and a happier simplicity, he excelled in accuracy of definitions all who had gone before him. His descriptions of disease received no coloring from his theories. They are faithful to nature, consistent with the knowledge of his day ; and, greatly in advance of his time, his original and inventive mind dwelt much on the causes of disease in all his reasonings and explanations upon medical Digitized by Microsoft® 302 METHODICAL NOSOLOGY — SYSTEMATIC MEDICINE. subjects. Aware, however, of the imperfections of the Art of Medicine, he did not attempt to arrange diseases according to their proximate causes, but according to a method founded partly on their symptoms, partly on their causes, and partly on their seats (Cueeie). A methodical arrangement of this kind has generally been considered the most desirable, as being likely to bring together diseases corresponding not only in some very important relations as regards their symptoms, but also in the indications and means of treatment which they suggest and require. But it is obvious that such an arrangement must vary according to the progress of knowledge and of opinion ; for a disease which may at present be supposed to depend upon one pathological condition may be found at a future time to proceed from another. Besides, the arrange- inent involves a principle which tends to separate diseases bearing a striking resemblance to one another in their external phenomena, though depending on different pathological conditions ; for example, different species of apoplexy and epilepsy. It is an arrangement, also, bringing together diseases which though belonging to the same natural family, may be respectively charac- terized by groups of symptoms that do not bear any very obvious resem- blance. Thus the hemorrhages at once bring together apoplexy and haemop- tysis in this classification. III. Tlie properties, powers, or functions of an organ or system of organs being deranged, dictates a classification in which the most prominent effects or phe- nomena of morbid states are considered as the disease — e. g., palpitation, diarrhoea. It is an arrangement which brings diseases into approximation with one another according to the part of the body principally affected and the function principally disturbed. When disease consists in perverted powers or functions, it is then denomi- nated a dynamic affection or disorder. When it depends on change of struc- ture, it is termed an organic lesion or disease. This third basis of classification is Physiological, and was adopted by Drs. Young and Mason Good, in imitation of Ploucquet, of Tubingen. It has been the most popular arrangement of diseases, and perhaps the best adapted for lectures, or for treatises on the practice of physic, because it brings together the different diseases of the same organ, and of those organs most intimately related to one another; but, to profit by the arrangement, the student must be previously instructed in the general doctrines of disease. IV. The diseases comprehended under the two latter principles of classifi- cation are sometimes inaccurately and loosely brought together under the heads of Structural and Functional diseases. The diseases of function; for instance, being made to embrace the neuroses, hemorrhages, and dropsies; while inflammation, tubercle, cancer, melanosis, hypertrophy, and atrophy are sub- ordinate classes of the diseases of structure. The diseases of function embrace all those diseases in which the action, the secretion, or the sensation of a part is impaired, without any primary alteration of structure of the organ or tissue affected, so far as our imperfect means of research can ascertain. Thus mania, catalepsy, neuralgia, are neuroses of the brain or other portions of the nervous system. Colic, vomiting, diarrhcea, and constipation, are neuroses of the alimen- tary canal ; and so on of other parts. Hemorrhage, or the effusion of blood, and dropsies, or an effusion of water into the shut cavities of the body, as that of the head, chest, or abdomen, are also instances of functional disease. Such are the grounds of classification adopted by the late Dr. Williams, of St. Thomas's Hospital, London. V. A basis of classification has been adopted, founded on the pathological ■nature of the different morbid processes, but the arrangement of the orders and subdivisions is determined by the anatomical arrangement of the textures and organs of the animal body, as originally developed by Bichat. Such is the principle and mode of classification adopted by Dr. Craigie (1836). Digitized by IVIicrosoft® SYSTEMS OF CLASSIFICATION OF DISEASE. 303 VI. A ground of elassiiication exists, having reference to the general nature and localization of the morbid states. It comprehends three classes, — (1.) Dis- eases which occupy the whole system at the same time, and in which all the functions are simultaneously deranged. These have been named general dis- eases, such as fevers. (2.) Constitutional affections, meaning thereby diseases which display themselves in local lesions in any part, or in several parts of the system, but not in all parts at the same time — e. g., rheumatism, gout. (3.) Local morbid processes. Such is the classification adopted by Dr. Wood, of Pennsylvania (1847). VII. Applying the principles of a purely, humoral pathology, we have a classification consisting of: a. Fevers, b. Dyscrasiee — e. g., tabes, chlorosis, scorbidus, dropsy, diabetes, pywmia, tuberculosis, carcinoma, c. Constitutional diseases, induced by — (1.) Specific agents ; (2.) Vegetable substances. Such is Wunderlich's arrange- ment of diseases (1852). VIII. M. de Savignac, Professor of Clinical Medicine at the NaVal School of Toulon, propounded (1861) a Nosological arrangement founded on what he believes to be the " elements " of disease. To each of the classes he so defines, the question would at once suggest itself, and require solution, as to what the " element" may be on which the particular class is made to stand alone. He merely subjoins the word " element " to an adjective formed from the name of each class of diseases. Thus the class Neuroses is distinguished as the neurosie element; the class Rheumatalgiaj, as the 7'heumatie element ; and so on to the number of fourteen classes. In the formation of orders, genera, or groups of diseases under this classification, no fixed principle can be recognized. IX. Dr. Stark, of Edinburgh, proposed (1864) an arrangement embracing sixteen classes, namely: (1.) Fevers; (2.) Diseases of the brain, &c.; (3.) Diseases of the heart and organs of circulation ; (4.) Diseases of organs of respiration ; (5.) Diseases of organs of digestion ; (6.) Diseases of urinary organs ; (7.) Diseases of organs of generation ; (8;) Diseases of organs of loco- motion ; (9.) Diseases of skin and cellular tissue ; (10.) Diseases of uncertain seat; (11.) Malformation; (12.) Debility at birth, and premature birth; (13.) Old age; (14.) Sudden deaths; (^15.) Violent or unnatural deaths; (16.) Causes not specified. X. Upwards of thirty years ago a classification was proposed by Dr. Wil- liam Farr, of the Registrar-General's Office, which recognized the following five large classes of disease, namely : 1. Epidemic, endemic, and contagious diseases. 2. Sporadic diseases of uncertain or variable seat. 3. Sporadic disease of special systems and organs. 4l. External causes, poisoning, asphyxia, injuries. 5. Developmental diseases. To the first of these classes he assigned the name of Zymotic diseases, to express the fact that a materies morbi was introduced into the body, and which remained for a time unperceived in the system, and that, after an indefinite period of incubation, leavened the whole mass of the circulating fluid ; a pathological series of facts, however, which cannot be asserted positively of each form of disease comprehended in the class. Moreover, the larger number of diseases strictly preventible by efficient sanitary arrangements are compre- hended in this class, so that the so-called zymotic diseases came to be synony- mous with preventible diseases, and for statistical purposes it has become com- mon to point to a large number of deaths from zymotic diseases, or zymotic sickness in any locality, as an index of faulty sanitary arrangements. In that class were comprehended typhus, thrush, diarrhoea, rheumatism, syphilis, a group of diseases each one of which is now known to be composed of very different pathological elements, and, as a group, impossible to represent the existence of any definite or even similar cause. The class zymotic was thus made to Digitized by Microsoft® 304 METHODICAL NOSOLOGY — SYSTEMATIC MEDICINE, include diseases of which the origin and mode of propagation are wholly dissimilar ; and the group was subdivided into " miasmatic, enthetic, dietic, and parasitic dseases," a subdivision involving no common principle. Even the miasmatic groups, implying diseases due to miasm (on which many medical men are at one as to the main features) is not a congruous group. Thus quinsy, a simple inflammation of the fauces, is placed next to scarlatina ; ery- thema, simple redness of the skin, stands as a subordinate variety of erysipelas, which it is not. Diarrhoea stands between dysentery and cholera, and has no place among diseases of the intestinal canal, and the order concludes with ague and rheumatism., ignoring alike the malarious origin of the one, and the con- stitutional origin of the other — gout standing at the head of constitutional dis- eases. As to parasitic diseases being zymotic, it is now getting more and more difficult to understand even the analogy to such a pathological process (Med.- Chir. Review, O, 1869). None of these methods lead to a perfectly philosophical or purely natural classification, because diseases are not yet sufficiently understood to permit us to see clearly their mutual relations ; and the best recommendation of any one of them would be a negative one — -namely, that of doing the least possible violence to our very imperfect knowledge regarding the natural affinities or alliances of diseases, of which we have at present only a sort of instinctive recognition. But the tendency of modem investigations by the varied instru- ments and methods of research tends to prove that many diseases hitherto supposed to be altogether functional are really accompanied with changes of structure of an anatomical, physical, or chemical kind. It is therefore not unreasonable to anticipate that all the so-called functional maladies will be found to depend upon some concomitant alteration of sttueture ; and when we are unable to detect an alteration either of the solid or fluid parts of the body, in cases where the existence of disease cannot be doubted, we may attribute our failure to the imperfection of our means and instruments of observation, or our modes of using them. In the present imperfect state of our knowledge, therefore, diseases cannot be philosophically classified, nor arranged according to natural or true patho- logical relations, dependencies, or alliances. Nevertheless, a great advan- tage inevitably results from the institution of nosological classification, on account of the necessity which every such attempt imposes on those who en- gage in it, of marking very accurately the characteristic phenomena of partic- ular diseases ; and every one acquainted with the progress of natural history must know that the study of details, and the repeated attempts to systematize them, have mutually promoted and supported each other. It is the same with regard to diseases ; and if a Methodical Nosology cannot be rendered perfect, it is a certain proof that, for the time being, the details of which it must be composed are neither accurate nor complete, and are not likely to be so till attempts to observe, investigate, and systematize have made further progress. Every attempt to reduce to system tends to enlarge our stock of facts ; and though we may fail to obtain a perfectly philosophical arrange- ment, yet the very attempt to attain it must be of advantage, by leading to useful discussions regarding the Pathology and History of diseases (Cullen). No one could be more convinced than Cullen was that " perfect division and definition is the summit of human knowledge in every department of science, and requires not only the clearest, but the most comprehensive views, such, as (with respect to diseases) we can arrive at only by often-repeated attempts and much study." A no less distinguished pathologist — M. Bayle — -in discussing the difficulties connected with classification, recommends us "to follow the plaii which presents fewest imperfections, remembering liiat- the determination of specific characters is what is most essential in Nosology, arrangement being the least important ; for each arrangement will have its defects, will present its deficiencies, and exhibit some forced approximations." Every plan of Digitized by Microsoft® PRESENT STATE AND AIM OF NOSOLOGY. 305 arrangement ought, therefore, to be accepted for what it is worth, and appre- ciated at its true value ; namely, as to how far it fulfils the object for which it was mainly devised. Cullen, also, in his lectures and in his writings on this subject, everywhere speaks with the utmost modesty and diffidence, and endeavors at all times to impress upon the mind the fact that Nosology, like other branches of medical science, must necessarily be progressive in its ad- vancement ; and that it is only by frequent and multiplied trials that it can be brought to any degree of perfection. A perfectly philosophical or natural system of classification aims at having the details of its plan to agree in every respect with all the facts as they exist in nature. To effect this end, arrange- ments, as they naturally exist, require to be traced out, not devised. The tracks in which such a pursuit must be followed up, and in which our knowledge is as yet deficient, may be shortly indicated under the following heads, namely : (1.) The affinities or alliances of diseases with each other. (2.) The morbid anatomy of diseased parts. (3.) The communication, propagation, inocula- tion, generation, development, course, and spontaneous natural termination of diseases. (4.) The connection of the phenomena recognized during life ■ with the facts of morbid anatomy. (5.) The geographical distribution of diseases. (6.) The succession of diseases, so far as they can be traced through past ages ; the peculiarities they have exhibited at different periods in the world's history, or within comparatively recent cycles of years. But the time has not yet come for a classification on a basis so comprehensive — simply be- cause the material does not yet exist ; and attempts to make so-called natural systems of arrangement must end in disaiDpointment, on account of the uncer- tain and fluctuating data on which they must be based. Such attempts are apt to suggest the serious question, " Whether such Nosology promotes or retards the progress of Medicine ?" Present State and Aim of Nosology. — The most distinguished physicians and statists have recently lent their aid to obtain a nomenclature and classi- fication of diseases which can be applied to the wants of the civil and military population in every country. Dr. William Farr devised a system of Nosology which was discussed at several meetings of the Statistical Congress of the Great Powers of Europe, convened for the purpose, amongst other business, of devising and adopting a uniform system of nomenclature for recording diseases and the causes of death from them. The Congress met in Paris on the 10th of September, 1855, when a nomenclature of the causes of death was agreed upon, essentially the same as that used in England and Geneva. At a third Conference, held at Vienna in 1857, a nomenclature substantially uni- form was agreed upon for adoption in all the states of Europe ; and fatal cases were to be registered on a uniform plan. Dr. Farr's system of nomen- clature has been in use now for many years by the Registrar-General of this country, and more recently by the Army Medical Department. It was also adopted in previous editions of this Text-book ; and although it had many imperfections and defects, it was still practically the most useful and authori- tative Nosology. " In the English list of names," proposed and adopted by the College of Physicians, " it seemed desirable that as little deviation as pos- sible should be made from those employed by the Registrar-General of Eng- land ; otherwise his settled plans, and his forms of returns, which have been followed for years, would require to be remodelled ; the comparison of future years with past returns would be made difficult and perplexing, if not impos- sible ; and a damaging break would be caused in evidence which becomes more and more trustworthy and valuable in proportion as it is prolonged and continuous." The important task of devising a " Provisional Nomenclature and Defini- tion of Diseases," consistent with the progress of medical science, engaged the attention of a committee of the Royal College of Physicians of London during the ten years from 1857 to 1867. After many interruptions and much con- voL. I. 20 Digitized by Microsoft® 306 METHODICAL NOSOLOGY — SYSTEMATIC MEDICINE. sideration, the committee at last completed their work, and submitted a Pro- visional Nomenclature to the College on. the ,3d of August, and again on the 28th of November, 1867, when it was unanimously adopted.* . 1:^ * The eireumstanees of the origin and progress of this great work are of historical importance, and are thus recorded by the College: " The idea which led to the forma- tion of a general Nomenclature of Diseases originated in a correspondence between Dr. Dumbreck. of the Medical Department of the Army, and Dr. Sibson, respecting the need of such a nomenclature for use in the Army Medical Service. But at the Comiiia majora of the Koyal College of Physicians, held on the 9th July, 1857, it was resolved, on the motion of Dr. Nairne, in consequence of a letter addressed to the Col- lege by the Hospitals' Committee of the Epidemiological Society, ' That a committee be appointed to prepare a Nomenclature of Diseases, and that such committee have full power to co-operate with other bodies.' " The following Fellows of the College were appointed members of the committee by the President of the College : Drs. Mayo, Alderson, Hawkins, Jeaffreson, Pitman, Bence Jones, Risdon Bennet, Munk, Babington, Addison, Nairne, Barker, Budd, Gull, Baly, Barclay, Sibson, Parkes. At the first meeting of the committee Dr. Sib- son was appointed Secretary. " The following representative members afterwards consented to co-operate in car- rying into effect the objects of the committee : Mr, Stanley, President of the Koyal College of Surgeons ; Dr. Druitt, Kepresentative of the Master of the Worshipful Society of Apothecaries ; Sir John Liddell, Director-General of the Medical Depart- ment of the Navy ; Dr. Logan, Director-General of the Medical Department of the Army; Sir Ranald Martin, Representative of the East India Company ; Dr. Parr, Kepresentative of the Registrar-General ; Mr. Simon, Medical Officer of the Privy Council ; Mr. Holmes, Secretary of the Hospitals' Committee of the Epidemiological Society. " The meetings of the committee were suspended in 1858, in consequence of the passing of the Medical Act of that year, and of the alterations thereby rendered necessary in the constitution and regulations of the College. They were resumed in 1863, and the following members were then or subsequently added to the com- mittee : "Sir Thomas Watson, Bart., President of the College of Physicians; Mr. Luke, President of the Koyal College of Surgeons ; Dr. Bryson, Director-General of the Medical Department of the Navy ; Dr. Balfour, Deputy Inspector-General of Hospi- tals and Head of the Statistical Branch at the Army Medical Board ; Dr. Stark, Kepresentative of the Registrar-General of Scotland ; Dr. N. M. Burke, Representa- tive of the Registrar-General of Ireland; Dr. Mackay, R.N., Deputy Inspector-Gen- eral of Fleets ; Mr. Moore, Surgeon to the Middlesex Hospitals ; and Drs. C. J. B. Williams, Barlow, Arthur Parre, Black, Frederick Weber, Charles West, Chambersj' Monro, George Johnson, Quain, Kirkes, Wilks, Bristowe, Henry Thomson, Hermann Weber, Gueneau de Mussy, McWilliam. "A Classification Sub-Committee was formed, consisting of — Sir Thomas Watson Bart. (Chairman), Drs. Parr, Barclay, Balfour, C. J. B. Williams, Quain, Sibson, Mr! Simon, and Mr. Holmes. " A Definition Sub-Committee was also formed, consisting of — Drs. Barlow Arthur Faire, West, Chambers, Monro, George Johnson, Barclay, Sibson, Parkes, 'Kirkes Wilks, Bristowe, Balfour, Mr. Moore, and Mr. Holmes. " ' ' " Mr. Gaskill and Dr. Nairne (Commissioners in Lunacy) attended the meetings of the committee when the subject of Insanity was under consideration. "Mr. Cartwright and Mr. Tomes attended the meetings when the diseases of the Tebth were under consideration. " The Latin Nomenclature was prepared by Dr. Henry Thomson, and revised bv Dr. Black. •' "The French Nomenclature was prepared by Dr. Gueneau de Mussy. " The German Nomenclature was drawn up by Dr. Hermann Weber, and revised by Dr. Frederick Weber. " The Italian Nomenclature was drawn up by Dr. Frederick Weber. " The List of Deformities was drawn up by Dr. Arthur Parre. "The entire work has been edited by the Secretary, Dr. Sibson; with whom Dr. Barclay took part in editing more especially the Medical portion. The Surgical por- tions of the Nomenclature were prepared and, in conjunction with the Secretay edited by Mr. Moore and Mr. Holmes. "Official changes during the period of the existence of the committee led also to the introduction into it of the -following additional members : Mr. Partrido-e as President of the Royal College of Surgeons ; Drs. Birkett, Owen Kees, Handfield Jones, Basham, Herbert Davies, Guy, Peacock, Wegg, as Censors of the College of Digitized by Microsoft® ORIGIN OP THE NEW NOMENCLATURE. 307 This is a great achievement. The Registrars-General of England, Scotland, and Ireland, the chiefs of the Medical Department of the Army and Navy, and of the British troops in India, have all concurred with others in framing the Nomenclature ; and therefore it is not unreasonably expected that greater accuracy, certainty, and uniformity, for comparison, than heretofore will char- acterize the statistical records of disease, alike in civil life and in the public services. To facilitate the work becoming international, the College has trans- lated its nomenclature into Latin, French, German, and Italian equivalents. The methods of gradually improving the Nomenclature of Diseases in Medicine have some analogy to the methods of gradually improving Repre- sentative Reform in Politics. A nomenclature of diseases and a policy of parliamentary representation, judicious and proper a quarter of a century ago, must each eventually give place to the influence of progressive knowledge and power, which invariably come with the rapid movements of the age in which we live. But reform, whether of political representation or of medical nomen- clature, to be generally acceptable, cannot be the work of one man, nor the accomplishment of a limited period of time. To be on a broad basis and free of prejudice, each work ought to be the combined result of the best men of the time— each man being willing to yield, adapt, and mould his convictions on entering into a mutual arrangement to achieve a common end. Men thus brought together, who diifer very seriously as to certain points, may yet, by mutual discussion and concession, come to a definite and reasonable agree- ment for practical purposes — the terms of the compromise being settled, doubtless, at the expense of some personal bias, which often has a firmer hold the more imperfect the information of the holder, but which mutual delibera- tion clears away. Knowing how biassed in opinion individual members of professional and political bodies are apt to be, the unanimous adoption of a Provisional Nomenclature by the London College of Physicians is undoubt- edly a great and a bold achievement; and although essentially a compro- mise of conflicting, and sometimes even of opposing views, the result is a work beyond all praise. It is thus, and thus only, that, in an uncertain science like medicine, any approach to truth can be attained. The plan of the "Nomenclature" is, first, "to give an English name to the disease, employing the terms in popular use whenever they are not absolutely inac- curate; and to use only one word, or as few ivords as possible, in naming a dis- ease." Definitions have been attached to the English names in some instances only, as where there might be some ambiguity as to the signification which the College desires to attach to them. Thus the definitions have been framed for the purpose of identification only, not as explanations of the phenomena of disease. Secondly, the classification adopted is based upon anatomical considerations, on this principle, — General Diseases, or such as affect the whole frame, subdivided into Sections A and B ; and Local Diseases comprehend the classification. "Section A comprehends those disorders which appear to involve a morbid condition of the blood, and which present, for the most part, but not all of them, the following characters : They run a definite course, are attended with fever and frequently with eruptions on the skin, are more or less readily com- municable from person to person, and possess the singular and important property of generally protecting those who suffer them from a second attack. They are apt to occur epidemically." Some of the so-called Zymotic diseases of Dr. Farr are comprehended in this classification. Physicians. Dr. Alderson's iirst ofBcial act after his election as President of the Col- lege was to appoint Sir Thomas Watson chairman of the committee." These names are the names of men who hold, or have held, the highest place as representative men in the Science of Medicine ; and are at once a guarantee of the intellect and practical knowledge which have been brought to bear upon the work. The preface to the Nomenclature, from the pen of the chairman of the committee, is extremely suggestive ; and the work ought to be in the hands of every student of Medi- cine, and the handbook of evjer.v flne who haito do with the Eegistration of Diseases. 808 METHODICAL NOSOLOGY — SYSTEMATIC MEDICINE. " Section B comprises for the most part disorders whicli are apt to invade diiferent parts of the same body simultaneously or in succession. These are sometimes spoken of as constitutional diseases, and they often manifest a tendency to transmission by inheritance." Some of the Constitutional diseases of Dr. Farr are comprehended in this classification. • Many older physicians may regret the absence of those classes of disease familiar to them ever since they commenced the study of medicine, and which they learned from Cullen's Nosology — then the safest guide to classifi- cation which the student could follow. But the conflict of opinion rendered it impossible, we are told, for the Committee of the College to subdivide into smaller groups the larger divisions of diseases which have been adopted. To each individual, therefore, and especially to each teacher of medicine, must be left the formation of such groups as may facilitate to himself and to his pupils the study of the science from that particular standpoint which forms the groundwork of his study or his teaching (Med.-Chir. Rev., O, 1869). No fact could be predicated of any number of diseases which was not either too wide in its compi'ehensiveness, or too narrow in its exclusiveness, or which did not imply a theory which might have been found to be true of certain members of a group, but could only be applied theoretically to the remainder. There- fore the committee abandoned all attempts to subdivide the diseases into groups, beyond arranging under the two Sections A and B all that ought strictly to be called general diseases. To give any definition of either section was also found impossible, because no definition would absolutely embrace the whole of its members, and yet seem to exclude those belonging to the other division. A conception of the dominant character of each section would be more readily found by a simple enumeration of its constituent members than by any expo- sition of it in the set terms of a definition. . Thus the general diseases of the College embrace the original classes 1 and 2 of Dr. Farr's classification. The local diseases follow nearly the same order as Class 3 of Dr. Farr (p. 303, ante'). The primary distinction between the general and local diseases is recognized in this : that the first comprehend those which more or less pervade the whole system, and in which any local afiection, whether essential or accidental, is due to the previous existence of some general malady; while the second, or local diseases, are those which affect certain organs, and in which, when any other part of the body is involved, it is so only as a consequence of the primary disorder or local lesion. In studying the. Science of Medicine systematically, a methoCical nosol- ogy ought to be regarded as a table of reference to aid the student in naming diseases, and so preserving uniformity in his records and diagnosis, and a system to guide him generally in acquiring a knowledge of his profession, especially with reference to' the practical questions of the day. The Nosology of the Royal College of Physicians of London ought, therefore, to be accepted simply as a contrivance to aid us in giving the same name to similar condi- tions of disease, and ."for perfecting the statistical registration of diseases, with a view to the discovery of statistical truths concerning their histoiy, nature, and phenomena." Tlie nomenclature takes no note of causation, it deals only with the pathological fact, and the arrangement is really, in its main features, anatomical,^ — the organs are viewed as portions of tissue, which have deviated from the healthy standard. Such a nomenclature of diseases as that now recommended for general adoption, is a great boon alike to the medical profession and to the public ; and as it will still enable future regis- tration to be compared with the past registration of the Registrar-General, it will gradually and eventually supersede that system for the registration of disease in Civil Hospitals, and in the Public Services. Numbers are intro- duced with each disease for the purpose of easy reference in double entries. But practically there is sometimes a difficulty here, as shown by my friend Dr. Steele, in the application of the nomenclature and classification to the Digitized by Microsoft® THE FUTURE PROSPECTS OF NOSOLOGY. 309 registration of diseases in Guy's Hospital. In framing the report of that hospital for 1868, and in the attempt to adhere to the numerical arrangement in the construction of the statistical tables, Dr. Steele found himself frequently at a loss for a numerical indicator corresponding to the particular complaint. This arose from two causes : the first depending on the exclusively anatomical character of the terminology, which does not provide for diseases of a dupli- cate or multiple character, such as broncho-pneumonia, pneumoniaAyphus, pleuro-pneumonia, disease of joint, &c. ; and the other attributable to the too rigid definitions which, in many cases, and then not always, could only hope to be revealed by post-mortem examination. Many obscure afiections of the heart, brain, &c., can only be entered as " disease of heart, or brain," as the case may be, without corresponding numbers to escape the possibility of " reck- less conjecture" in the absence of a post-mortem examination. In the regis- tration of disease in an hospital, a column should be added to the disease table, to be filled in from the post-mortem register (as has been done by Dr. Steele), indicating the more immediate cause of death. Such is especially useful where a difiiculty has been experienced during life in selecting, fixing, upon, or specifying any one particular form of disease, where two or more have contributed to the fatal issue. Dr. Steele's statistical tables, which have been annually published for the past twenty years, relative first to the Glas- gow Infirmary, and subsequently to Guy's Hospital, London, are models of the construction of such tables for hospital registration, and of the resulting information to be obtained from them. The Science of Pathology, we know, is yet too young to base a scientific classification upon ; and as the Science of Pathology and the Art of Practical Medicine advance, so must Nosology. But there are many nice questions which always will arise, relative to the nature of diseases, on which it is in vain to expect physicians and statists to agree unanimously ; and therefore no system even of naming, far less of classifying, the diseases of mankind can we hope to see, otherwise than as a provisional one, ready to assimilate itself to the progressive advance of the Science of Medicine, which is a plant of slow but of sure growth. There is every reason to hope, however, that, by the numerous inquisitive researches of the day, Pathology and Nosology will grow even more rapidly than hitherto. The mere enumeration of diseases has almost doubled since Cullen's Nosology was written ; while our knowledge of facts relating to disease has greatly more than doubled. Cullen's Nosology became effete and useless at last, under the pressure of increasing, knowledge acquired* and effected with resources Very inferior to those we now possess, and far less extensive. The nomenclature and classification thus adopted by the College is therefore strictly provisional, being " subject to decennial revision," as stated on the title-page. It would be well, then, if the Colleges of Physicians and Surgeons in Scotland and in Ireland (who unfortunately do not seem to have taken part in the preparation of the nomenclature) would unite with that of London in this eminently practical work, and appoint committees to commu- nicate with each other in revising and readjusting such nomenclature at the end of every ten years ; and so stamp with their united authority the progres- sive improvements in the Science of Medicine which are capable of being indi- cated or expressed in the Nomenclature and Definitions of diseases. Such systematic arrangements, if consistent with existing knowledge, never cramp or hamper a man in carrying out scientific investigations ; on the contrary, they enable him to see more clearly in what direction his labor must be advanced, and demonstrate more forcibly than otherwise the deficiencies of his knowledge. The "Provisional Nomenclature" of the Royal College of Physicians of London, comprehended in the following list, has therefore been adopted in the text of this edition (sixth) ; while the synonyms, equivalents, and definitions have also been incorporated at the places where the diseases are described m the text, throughout both volumes. Digitized by Microsoft® 310 THE NOMENCLATURE OF DISEASES. CHAPTEK II. TABULAR VIEW OF "THE NOMENCLATURE OF DISEASES" DRAWN UP BY A JOINT COMMITTEE APPOINTED BY THE ROYAL COLLEGE OF PHYSICIANS OF LONDON (1869). GENERAL DISEASES. 1. Small-pox. Group A (unmodified). Group B (modified).' Fa Wefies, applicable to both groups : a. ConflueDt. h. Semi-confiuent. c. Distinct. Syn, Discrete. d. Abortive. Syn., Varicel- loid. Svbordinate Varieties: e. Petechial. /. Hemorrhagic. ff. Corymbose. 2. Cow-pox. 3. Chicken-pox. 4. Measles. 5. Scarlet fever. Syn., Scarlatina. Varieties : a. Simple. . 6. Angmose. c. Malignant.^ 6. Dengue. 7. Typhus fever. 8. Cerebro-spinal fever. Syn., Malignant purpuric fever ; Epidemic cerebro-spinal me- ningitis. 9. Enteric fever. Syn., Typhoid fever; and in children is often named Infantile re- mittent fever.^ 10. Relapsing fever. H. Simple continued fever. 12. Febricula. 13. Yellow fever. 14. Plague. 15. Ague. Syn., Intermittent fever. Varieties : a. Quotidian, fc. Tertian. Sub-variety : Double tertian. c. Quartan. Sub-Variety : Double quartan. d. Irregular. (101b.) Brow Ague. 16. Remittent fever.* 17. Simple cholera. 18. Malignant cholera. Syn., Ser- ous cholera ; Spasmodic cholera; Asiatic cholera. a. Choleraic diarrhcea. 19. Diphtheria. a. Diphtheritic paralysis. 20. Hooping-cough. 21. Mumps. 22. Influenza. 23. Glanders. 24. Farcy. 25. Equinia mitis. Syn., Grease. 26. Malignant pustule. 27. Phagedsena. 28. Sloughing phagedsena. 29. Hos{}ital gangrene. 30. Erysipelas. Varieties : a. Simple. Syn , Cutaneous. &. Phlegmonous. Syn., Cel- lulo-cutaneous. c. Diffuse inflammation (of cellular tissue).' 31. Pysemia.^ 32. Puerperal fever."' 33. Puerperal ephemera. Syn., Weed. 34. Acute rheumatism. Syn., Rheumatic fever. (a.) Subacute rheumatism. 35. Gonorrhoeal rheumatism. 36. Synovial rheumatism. 37. Muscular rheumatism. Local varieties : a. Lumbago. &. Stiff neck. 38. Chronic rheumatism.' 39. Acute gout, 40. Chronic gout. 41. Gouty synovitis.^ 42. Chronic osteo-arthritis. i^n.. Chronic rheumatic arthritis. 43. Syphilis. A. Primary syphilis. Varieties : Hard chancre. Indurated bubo. Soft chancre. Suppurating bubo. Phagedsenic sore. Sloughing sore. B. Secondary syphilis." c. Hereditary syphilis. 1. Local syphilitic affections.*' * The definitions are omitted in this table, because they are given in the text, with the description of each disease. ' Scarlet fever occurs occasionally without any rash or sore throat being observed. ^ Fevers symptomatic of worms, teething or other sources of irritation, should not be included under this head. * The malignant local fevers of warm climates are usually of this class. ' In slighter cases, occurring on the surface of the body, diffuse inflammation is identical with phlegmo- nous erysipelas. In registering cases of phlegmonous erysipelas, and of diffuse inflammation arising from injury, surgical operation, or local disease, the cause should be specified. " In returning cases of pyaemia, specify the affected organs. , ■" In returning cases of puerperal fever, the more important local lesions, such as peritonitis, effusions into serous and synovial cavities, phlebitis, and diffuse suppuration should be specified . ^ Cases attended with deposit of urate of soda are to be returned as chronic gout, and those in which there is marked distortion as chronic osteo-arthritis. ^ Retrocedent gout is a term applied to cases of gout in which some internal organ becomes affected on the disappearance of the disease from the joints. It should be referred to acute or chronic gout. ^° Tertiary syphilis is a term sometimes applied to the later symptoms, when separated by an interval of apparent health from the ordinary secondary syphilis. " la returning local syphilitic affections, specify whether the case be one of primary syphilis, secondary syphilis, syphilitic deposit, or syphilitic inflammation. Local syphilitic affections, local cancer, local colloid, and local scrofulous affections are to be returned In the following order: 1. Brain. 2. Spinal cord. 3. Nerve. 4. Eye. .5. Eyelid. 6. Orbit. 7. Auricle. 8. Internal ear. 9. Face. 10. Nose. It. Pericardium. 12. Heart. 13. Lymphatics. 14. Lymphatic glands. 15. Bronchial glands. 16. Thyroid gland. s following c 17. Thymus gland. 18. Suprarenal capsule. 19. Larynx. 20. Bronchi. 21. Lungs. 22. Pleura. 23. Mediastinum. 24. Lips. 25. Mouth. 26. Cheek. 27. Jaws. 28. Gum. 29. Tongue. 30. Fauces. 31. Tonsils, 32. Salivary glands. Digitized by Microsoft© THE NOMENCLATTJEB OF DISEASES. 311 44. Cancer. Syn., Malignant dis- . ease.* Varieties : [cer. a. Seirrhus. Syn., Hard ean- b. Medullary cancer, ^i^^., Soft cancer.^ c. Epithelial cancer. St/n., Cancroid epithelioma. d. Melanotic cancer. Syn., e. Osteoid cancer.' 1. Local cancer.^ 45. Colloid. Syn., Colloid cancer; Alveolar cancer. 1. Local colloid.* Arrangement op non-malig- nant Tumors and Cysts.* Fibrous tumor."' Fibro-cellular tumors.^ Fibro-nucleated tumor. Fibro-plastic tumor.^ Myeloid tumor. Fatty tumor. Syn., Lipoma. Osseous tumor, a. Of bone. Syn., Exostosis, Varieties: 1. Ivory. 2. Cancellated. 3. Diffused. &. Of the soft parts. Cartilaginous tumor. Syn., Enchondroma. Fibro-cartilaginous tumor. Glandular tumor. Syn., Ade- nocele. Vascular tumor. Nievus. Sebaceous tumor. Cholesteatoma. Molluscum. "Warty tumor and warta. Condyloma. Cheloid. Villous tumor. Simple or barren cysts. a. Serous. 6. Synovial. Syv-.^ Bursal. c. Mucous. d. Suppurating. e. Sanguineous. /. Hemorrhagic. a. Aueurismal. k. Oily. i. Colloid or gelatinous. j. Seminal. Compound or proliferous cysts. a. Complex cystic tumor. Syn., Cysto-sarcoma. 1. With intracystic growths. &. Cutaneous or piliferous cyst. Syn., Dermoid. c. Dentigerous cyst. 46. Lupus. Varieties : a. Chronic lupus. b. Lupus exedens. 47. Eodent ulcer. 48. True leprosy. Syn., Elephan- tiasis GrEecorum. 49. Scrofula." VaHeties : a. Scrofula with tubercle. 6, Scrofula without tuber- cle. 1. Local scrofulous affections." Tubercular meningitis. Scrofulous ophthalmia. Tubercular pericarditis. Scrofulous disease of glands. Phthisis pulmonalis. HEemoptysis.^^ Acute miliary tuberculosis. Tabes mesenterica. Tubercular peritonitis. 50. Rickets. 51. Cretinism. Varieties : a. Complete cretinism. Syn., . Incurable cretinism. b. Incomplete cretinism. Syn., Curable cretinism. 52. Diabetes. Syn., Diabetes mel- litus. (935a.) Ergotimi?^ 53. Purpura. Varieties : a. Simple. 6. Hemorrhagic. 54. Scurvy, 55. Anffimia.'^ 56. Chlorosis. Syn., Green sick- ness. 57. General dropsy." 58. Beri-Beri. Catarrh. Inflammation. LOCAL DISEASES. ARRANGEMENT OF LOCAL DISEASES. I Ulcerative inflammation. I Suppurative inflammation. Plastic inflammation. (31.) Pycemic inflammation.^^ 33. Pharynx. 34. CEsophagus. 35. Stomach. 36. Intestines. 37. Rectum. 38. Anus. 39. Liver. 40. Hepatic ducts gall-bladder. and 41. Pancreas. 42. Spleen. 43. Peritoneum. 44. Mesenteric glands. 45. Kidney. 46. Bladder and urethra. 47. Prostate gland. 48. Penis. 49. Scrotum. 50. Testicle. 51. Ovary. 52. Fallopian tube. 53. Uterus. 54. Vagina. 55. Vulva. 56. Female breast. 57. Male mammilla. 58. Bone. 59. Skull. 60. Joint. 61. Spine. 62. Muscle. 63. Tendon. 64. Fascia. 65. Cellular tissue. 66. Skin. ^ In returning cases of cancer in more than one organ, specify in which the disease is primary, and in which secondary. State also the kind and duration of the disease in each case, and the nature of all operations, with their dates and results. ^ Fungus haamatodes is a term applied to some cases of medullary cancer, which are more than usually vascular. Hard encephaloid is a designation sometimes applied to medullary cancers of unusually firm consistence. These two forms of the disease should be returned under the title of Medullary cancer. ^ Cancer in mucous membranes, when covered by a villous growth, has received the name of Villous cancer. * In returning cases of local cancer, specify the variety of cancer, by adding, after "44," the letter a, 6, c, d, or e, according to the nature of the case (as above). They are to be returned in the order specified in the foot-note (*'j of previous page. * Cases of local colloid are to be returned in the order specified in the foot-note {") of previous page. ^ In order that the malignant and non-malignant growths may appear together, the non-malignant tumors and cysts are inserted here. They should, however, be returned among the local diseases, under "Non-malignant tumors," and they are not, therefore, numbered at this place. 1 When the tumor contains cysts, it has received the name of Fibrocystic. When it contains earthy matter, it has been named Fibro-calcareous. When it grows from bone, and is partly ossified, it consti- tutes the non-malignant form of the disease known as Osteo-sarcoma. When it contains involuntary muscle, as when growing in the uterus, it has received the name of Fibro-muscular. When it contains fat, it has been named Fibro-fatty. Other fibrous tumors have been named according to their seat, e. g.,. Neurpma. Painful subcutaneous tumor. , ^ When occurring as a pendulous outgrowth from a mucous surface, it constitutes the chief varieties of Polypus. ' When the fibro-cellular or fibro-plastic tumor, but more especially the latter, slowly involves the adjacent soft structures, and returns after removal, it has received the name of Recurrent fibroid, "* The constitutional tendency which has received the name of the Scrofulous Diathesis, when unat- tended by local lesions, is not to be returned as a disease. " These and all other cases of local scrofulous affection are to be returned in the order specified in the foot-note (") of previous page. ^^ When the cause of this affection has been ascertained, the case should be returned under the head of the primary disease, the secondary affection being also specified. " The diseases printed in italics are to be returned, not among the local diseases, but under the head- ings referred to by number. " Local dropsies, such as ovarian, and effusions into the serous cavities, as hydrothorax or ascites, when not connected with anasarca, should be returned as local diseases. " The Local Diseases have been drawn up in accordance with the following arrangement, and the Digitized by Microsoft© 312 THE NOMENCLATURE OF DISEASES. Rheumatic inflammation. Gouty inflammation. (43^J Syphilitic inflammation. (49'-.) Scrofulous inflammation. Gonorrhceal inflammation. Gangrene. Passive congestion. Extravasation of blood. Hemorrhage. Dropsy. Fibrinous deposit. Alteration of dimensions. Dilatation. Contraction. Hypertrophy. Atrophy. Degeneration. Fatty and calcareous. Syn., Atheroma. Ossification. Fibroid. Lardaceous disease. Syn., Amyloid disease. Waxy disease. (43^.) Syphilitic disease. (44'.) dfctTicer. (45\) CbUoid. Non-malignant tumors. Cyst. (49*.) Scrofula. (49*a.) a. With tubercle. (49'b.) b. Without tubercle. Parasitic disease. Calculus and concretion. I Malformation. (992, &c.) Injury.. (1014, &c.) Foreign body. Functional diseases. DISEASES OF THE NERVOCTS SYSTEM.i Diseases of the Brain and its Membranes. 59. Encephalitis.'* 60. Meningitis, 1. Inflammation of the dura mater ^ 2. Inflammation of the pia mater and arachnoid. (49'.) 3. Tubercular meningitis. Syn., Acute hydrocepJv- alus. (8.) Cerebrospinal fever. 61. Inflammation of the brain. 62. Red softening (of the brain). 63. Yellow softening (of the brain). 64. Abscess (of the brain). 65. Apoplexy. Varieties : a. Congestive. b. Sanguineous. Syn., Cer- ebral hemorrhage. 66. Sunstroke. 67. Chronic hydrocephalus. 68. Hypertrophy (of the brain). 69. Atrophy (of the brain). 70. White softening (of the brain). Syn., Atrophic softening.* (43'.) Syphilitic disease. (44*.) Cancer. 71. Fibrous tumor. 72. Osseous tumor. (49'.) Tubercular d^osit. a. Miliary or granular ttt- bercle.^ 6. Yellow tubercle. 73. Parasitic disease. Return cases of this class ac- cording to the list at pp. 146 to 148. 73*. Malformations. jReturn such cases here ac- cording to the list atpp. 234 to 238. 74. Diseases of the cerebral ar- teries, a. Fatty and calcareous de- generation. Syn.f Ather- oma, Ossification. &. Aneurism. Diseases of the Conjunctiva,' 111. Conjunctivitis, Syn., Oph- thalmia. c. Impaction of coagula. 1. Thrombosis. (Local coagulation.) 2. Embolism. (Coagula conveyed from a dis- tance.) Diseases of the Spinal Coed AND its Membranes, 75. Inflammation.^ Varieties : a. Spinal meningitis. b. Myelitis. 76. Hemorrhage (Spinal). Syn., Spinal apoplexy. 77. Attophy (Spinal). Syn., Tabes 78. White softening (of the Spinal cord). (44*.) Cancer. 79. Non-malignant tumors. Return, such tumors here ac- cording to the list at p. 311. 80. Malformations. Return such cases here ac- cording to the list atpp. 234 to 238. a. Spina bifida. Diseases of the Nerves. 81. Inflammation. 82. Atrophy. (44^.) Cancer. 83. Neuroma. 84. Paralysis."' (108.) 1. Paralysis of the insane. Syn., General paralysis. 85. 2. Hemiple^ria."' 86. 3. Paraplegia.'' 87. 4. Locomotor ata-xy.'' (797.) 5. Progressive muscular atro- phy. 88. 6. Infantile paralysis.' 89. 7. Local paralysis.'' a. Facial paralysis. b. Scrivener's palsy. (1 9a.) 8. Diphtheritic paralysis.'' (908b.) 9. teadpaXsy. (.966a^) 10. Paralysis from Laihyrus. DISEASES OF THE EYE. 112. Catarrhal ophthalmia. 113. Pustular ophthalmia. 114. Purulent ophthalmia. Functional Diseases of the Nervous System. 90. Tetanus. 91. Hydrophobia. 92. Infantile convulsions. 93. Epilepsy. a. Epileptic vertigo. Syn., Petit mal. 94. Convulsion*) '' 95. Spasm of muscle. 96. Laryngismus stridulus. Syn., Spasm of the glottis, Spas- modic croup. Child-crow- ing. 97. Shaking palsy. (907a.) Mercurial tremor. 98. Chorea. Syn., St. Vitus's dance. a. Acute. b. Chronic. 99. Hysteria. 100. Catalepsy. (243.) Syncope. 101. Neuralgia. Principal Varieties: a. Facial. Syn., Tic dou- loureux. 6. Brow ague. Syn., Hemi- crania. c. Sciatica. d. Pleurodynia.' e. Irritable stump. 102. Hyperaesthesia.' 103. Ansesthesia.'' (938a.) Delirium tremens. 104. Hypochondriasis. Disorders of the Intellect. 105. Mania. a. Acute mania. ■* 6. Chronic mania, 106. Melancholia.^ 107. Dementia. a. Acute dementia. b. Chronic dementia. 108. Paralysis of the insane. Syn., General paralysis. 109. Idiotcy (Congenital). 110. Imbecility (Congenital). 115. Purulent ophthalmia of in- fants. Syn., Ophthalmia neonatorum. nature of the lesions comprehended in such local disease has been .described in the first part of this Text- Toook, from p. 67 to the end of Part I, as "Topics relative to Pathology." * The diseases printed in italics under this heading are inserted for the sake of local classification only, and are not to be registered here, but at the place referred to in each instance by number. ^ This term is to be used only when the precise seat of the inflammation has not been ascertained by post-mortem examination, ' This form of inflammation is almost invariably the result of injury or disease of the bones of the akuU; in such cases the injury or disease by which it is caused ought to be specified. * This form of disease is the result of imperfect nutrition, owing to deficient supply of blood, and is in most instances dependent upon mechanical obstruction, or degeneration of the cerebral arteries. * To-be referred to tubercular meningitis. ^ This term is to be used only when the precise seat of the inflammation has not been ascertained by post-mortem examination. t When the cause of this afffection has been ascertained, the case should be returned under the head of the primary disease, the secondary affection being also specified. ^ Cases of so-called monomania are to be classed under chronic mania or melancholia, according to their character. " Register the diseases priuted here in italics, not under this heading, hut at the place referred to in each instance, by number. Digitized by Microsoft© THE NOMBNCLATURB 01' DISEASES. 313 (49*.) Scrofulous ophthalmia. Syn., Strumous opMhalmia. 116. Exantheiuatous ophthalmia. 117. Gonorrhceal ophthalmia. 118. Chronic ophthalmia. 119. CEdema of the subconjunc- tival tissue. %7i., Chemosis. 120. Pinguecula. 121. Pterygium. 122. Fatty tumor. 123. Parasitic disease. Return cases of this class ac- cording to the list atp. 146. 124. Metallic stains. a. From nitrate of silver. &. From lead. Diseases op the Coknea. 125. Keratitis. 126. Chronic interstitial keratitis. 127. Keratitis with suppuration. Syn., Onyx. 128. Ulcer. 129. Opacity. Syn., Leucoma. 130. Conical cornea. 131. Arcus senilis. 132. Staphyloma. 133. Parasitic diseases in the an- terior chamber. Return cases of this class ac- cording to the list atp. 146. Diseases of the Sclerotic. 134. Sclerotitis. 135. Staphyloma. Diseases of the Ieis. 136. Iritis. 137. Traumatic iritis. 138. Rheumatic iritis. 139. Arthritic iritis. (43*.) Syphilitic iritis. (49*.) Scr of ulo^Ls iritis. 140. Gonorrhoeal iritis. 141. Sequelse of iritis. 142. Malformations. Return such cases here ac- cording to tJie list atp. 234. Diseases of the Choroid and Retina. 143. Choroiditis, 144. Retinitis. 145. Choroidal apoplexy. 146. Amaurosis. 147. Impaired vision. 148. Muscffi volitantes. 149. Albinism. Diseases of the Vitreous Body. 150. Synchysis. 151. Various morbid deposits. Diseases of the Lens and its Capsule. 152. Cataract. Varieties : a. Hard. b. Soft. c. Fluid. 153. Parasitic disease. Return cases of this class ac- cording to the list atp. 146. 154. Malformations. Return such cases here ac- cording to the list at p. 234. a. Congenital cataract. 155. Traumatic cataract. "^ General Affections of the Eye. 156. Glaucoma. 157 Hydrophthalmia. (44'.) Cancer. (49*.) Scrofulous deposit within the eyeball. 158. Total disorganization of the eye from injury. 158*. Malformations. Return such cases here ac- cording to the list a£p. 234. Various Defects of Sight. 159. Short sight. 160. Long sight. 161. Faulty perception of colors. Syn., Color blindness. DISEASES OF THE EAR.i 162. Hemeralopia 163. Nyctalopia. 164. Astigmatism. Diseases op the Lachrymal Apparatus. 165. Lachrymal obstruction, 166. Abscess and fistula. 167. Dacryolith. 168. Diseases of the lachrymal gland and its ducts. Diseases of the Eyelids. 169. Inflammation. 170. Hordeolum. 171. Abscess in the Meibomian glands. 172. Epicanthis. 173. Entropium. 174. Ectropiuin. 175. Trichiasis. 176. Madarosis. Syn., Loss of the eyelashes, 177. Tarsal ophthalmia. 178. Blepharospasmus. (44*,) Cancer 179. Cyst of the lids. (895,) Phlhiriasis. 179"=. Malformations. Return such eases here ac- cording to the list atp. 234, Diseases within the Orbits. 180. Abscess in the orbit. 181. Strabismus, 182. Protrusion of the eyeball. Syn., Proptosis. (282.) Exophthalmic bronchocele. (250.) Orbital aneurism. (44*.) Chncer. 183. Non-malignant tumors. Return such tumors here ac- cording to the list at p. 311. 184. Parasitic disease. Return cases of this class ac- cording to the list atp. 146. 185. Affections of the orbital nerves. Injuries of the Eye are given atp. 324. Diseases of the Auricle. 186. Gouty and other deposits. 187. Heematoma auris. (44*.) Ckincer. 188. Non-malignant tumors. Return such tumors here ac- cording to the list atp. 311. (827, &c.) Cutaneous affections. 189. Malformations. Return such cases here ac- cording to the list atp, 311. (1012.) Injuries. Diseases of the External Meatus. 190. Inflammation. a. Acute. b. Chronic. 191. Abscess. 192. Accumulation of wax. 193. Polypus, 194. Sebaceous tumor, Syn., Mol- luscous tumor. 195. Osseous tumor of bone. Syn., Exostosis. 195*. Malformations. Return such cases here ac- cording to the list at p. 234. (1014.) Foreign bodies. Diseases OF the Membrana Tympani. 196. Inflammation. 197. Ulceration. 198. Perforation. (1012.) Injuries. Disease of the Eustachian Tube. 199. Obstruction, Diseases of the Tympanum. 200. Disease of the mucous mem- brane. 201. Disease of the ossicles. 202. Disease of the mastoid cells. Diseases op the Internal Ear. 203. Organic disease. 204. Necrosis of the petrous bone. 205. Deafness. Varieties : a. Functional or nervous. b. From disease. c. Deaf-dumbness. (44*.) Cancer."^ 205*. Malformations. Return such cases according to the list atp. 234. DISEASES OF THE NOSE.i 206. Hypertrophy. Syn., Lipoma. 207. Wart. 208. Sebaceous cyst. (44*.) Ckincer of the skin. (46.) Lupus. 209. Ozffina. 210. Ulceration of the pituitary membrane. 211. Abscess of the septum. 212. Perforation of the septum. 213. Epistaxis,' 214. Hypertrophy of the pituitary membrane. (44*.) Cancer. Syn., Malignant po- * Register the diseases printed here In italics, not under this heading, but at the place referred to in each instance by number. - When any of these affections implicate the brain, carotid artery, or lateral sinus, the fact should be stated, ' When the cause of this affection has been ascertained, the case should be- returned under the head of the primary disease, the secondary affection being also specified. Digitized by Microsoft© 314 THE NOMENCLATURE OF DISEASES. 215. Polypus nasi. Varieties : a. Gelatinous. 6. Fibrous. 1. Naso-pharyngeal polypus. 216. Non-malignant tumors of the septum. 217. Hh]:noliths. 217*. Malformations. Setum such cases here ac- cording to the list al pp. 234 to 238. (1015.) Foreign bodies. 218. Loss or perversion of the sense of smell.* DISEASES OF THE CIRCULATORY SYSTEM.^ Diseases of the Heart and its Membeanes. diseases of the peeicaedium. 219. Pericarditis. 220. Suppurative pericarditis. (49*.) Tvbereular pericarditis. 221. Adherent pericardium.'' 222. Dropsy. / (44*.) Cancer. 223. Malformations. Return such cases here ac- cording to the list at p. 234. (1056.) Injuries. DISEASES OF THE ENDOCAKDIUM. 224. Endocarditis.* 225. Valve-disease. 1. Aortic. 2. Mitral. 3. Pulmonic. 4. Tricuspid. Varieties : a. Vegetations. 6. Fibroid thickening. c. Fatty and calcareous degeneration. Syn., Atheroma, Ossifica- tion. d. Aneurism. e. Laceration. /. Simple dilatation of orifice. g. Malformations. Jteturn such cases here according to the list at p. 234. Obstruction to the circulation and Regurgitation should be specially noted when they accom- pany the valve- disease. 226. Fibrinous concretions in the cavities of the heart.' DISEASES OF THE MUSCULAR STRUCTURE OF THE HEART. 227. Myocarditis, 228. Abscess.^ 229. Hypertrophy. a. Of left side. b. Of right side. 230. Dilatation. a. Of left side. 6. Of right side. 231. Atrophy, 232. Excess of fat. 233. Fatty degeneration. 234. Fibroid degeneration. 235. Aneurism. 236. Acute aneurism."* 237. Rupture.^ (44*.) CSancer. 238. Parasitic disease. Return cases of this class ac- cording to the list alp. 146. 239. Disease of the coronary ar- teries. 240. Malformations. Return such cases here ac- cording to the list at pp. 234 to 238. 241. Cyanosis. ('1056-58.) Injuries o;fthe heart. 2i2. Angina pectoris.* 243. Syncope.* Syn., Fainting fit. 244. Palpitation and irregularity of the action of the heart * Diseases of the Blood- vessels." DISEASES of the ARTERIES. 245. Arteritis. 246. Fatty and calcareous degen- eration. Syn., Atheroma, Ossification. 247. Narrowing and obliteration. 248. Occlusion. a. From compression. b. From impaction of co- agula. i. Thrombosis (local co- agulation). 2. Embolism (coagula conveyed from a dis- tance). 249. Dilatation. 250. Aneurism. Tn returning such cases, state whether the aneurism be— a. Fusiform, h. Saccular, or c. Diflfused (sac formed by the surrounding 251. Rupture of artery. a. From disease of artery. b. From disease external to artery. 252. Partial rupture of artery. Syn., Dissecting aneurism. 253. Traumatic aneurism. 254. Arterio-venous aneurism. 255. Aneurismal varix. Varieties : a. Traumatic, b. Spontaneous. 256. Varicose aneurism. Varieties : a. Traumatic. b. Spontaneous. 257. Cirsoid aneurism. Syn., Ar- terial varix. 258. Aneurism by anastomosis, 259. Malformations. Return other cases of this class here according to the ■ list alp. 234. a. Commencement of the descending aorta (con- tracted or obliterated), (1009, &c.) Injuries of arteries.^'- Qmtusion. LaceraMon. a. Of the. whole vessel. b. Of the outer coat. e. Of the inner coat. Wound. DISEASES of the VEINS. 260. Phlebitis. Varieties : a. Adhesive. 6. Suppurative. 261. Phlegmasia doleus. 262. Fibrinous concretions in the veins. 263. Obstruction. 264. Obliteration, 265. Phlebolithes. 266. Varicose veins. 267. Nsevus vascularis. 268. Parasitic disease. Return cases of this class ac- cording to the list at p. 146, Nos. 28 and 30. (109, &c.) Injuries of veins.^^ Rupture, without external wound. Wound of vein, with en- trance of air. DISEASES OP THE ABSORBENT SYSTEM.12 269. Inflammation of lymphatics. | 270. Suppuration of lymphatics. | 271. Inflammation of glands. * When the cause of this aflection has been ascertained, the case should be returned under the head of the primary disease, the secondary affection being also specified. ° Register the diseases printed here in italics, not under this heading, but at the place referred to in each instance by number. ^ This terra includes partial adhesions and calcareous and ossific deposits. * In returning such cases, state, if possible, the valve or valves affected. * Cases are to be returned under this head only when the condition has evidently existed during life, and is believed to have been the cause of death, " Abscess dependent on pyaemia should be referred to that disease. "* This term has been applied to those cases in which blood becomes effused into the substance of the heart, owing to inflammatory softening and rupture of the endocardium and muscular tissue. ^ In returning cases of aneurism and rupture, the situation ought to be stated. a The vessel affected should in all cases be specified. *" When the aneurism has burst, state the part or viscus into or through which the rupture has taken place. *' Return these among the Local Injuries under the Injuries of Vessels, and in the order here employed. (See Nos. 1009, 1013, 1043, 1057. 1072, 1087, 1095, 1119.) '® Register those diseases printed here in italics, not under this heading, but at the place referred to in each instance by number. Digitized by Microsoft© THE NOMENCLATURE Oi' DISEASES. 315 272. Suppuration of glands. 273. Hypertrophy of glands. a. Chronic enlargement of glands. 274. Atrophy of glands. 275. Lymphatic fistula. (1142.) Foreign bodies and concre- tions. 270. Obstruction of the thoracic duct.' 277. Obstruction, obliteration, and varicosity of lymphatics. 278. Bursting of lymphatics. ^48^) Syphilitie bubo. (43'.) Syphilitic inflammaMon qf f44\) Cancer. (49'.) Scrofulous disease of glands. (49'.) Summration. (1143.) Wound of lymphatics. Diseases op the Bronchial Glands. (340.) Inilammation. (341.) Abscess. (342.) Enlargement. (44'.) Cancer. (343.) Non-malignant tumors, (49'.) Tubercle. DISEASES OF THE DUCTLESS GLANDS.^ Diseases op the Thyroid Gland. 279. Inflammation. a. Acute. 6. Chronic. 280. Goitre. 281. Cyst. 282. Exophthalmic bronchocele. 283. Pulsating bronchocele. (44'.) Cancer. Diseases of the Thymus Gland. 284. Hypertrophy. (44',) Cancer. 285. Non-malignant tumors. Return such tumors here ac- cording to the list at p. 311. Diseases of the Suprarenal Capsules. ^44'.) Cancer. (49'.) Tubercular degeneration. 286. Addison's disease. Syn., Bronzed skin. Melasma Addisoni, DISEASES OP THE KESPIRATOKT SYSTEM.2 Diseases of the Respikatohy System not Strictly Local. 287. Hay asthma. (22.^ Influenza. (20.) Hooping-cough. 288. Croup. (19.) Diphtheria. (995,) Asphya^a.'' Disease of the Nostrils.* 289. Coryza. Syn., Nasal catarrh. Diseases op the Larynx. 290. Inflammation of the epi- glottis. 291. Ulceration of the epiglottis. 292. Laryngeal catarrh. 293. Laryngitis, a. Acute. 6. Chronic. 294. Ulcer.* 295. Abscess. 296. (Edema of the glottis. 297. Necrosis of cartilage (see the previous note), 298. Contraction. (44'c.) Epithelial cancer. 299. Warty growth. 300. Polypus. 301. Cyst. 301* Malformations.'' Retwn such cases here ac- cording to the list at p. 234, (992-1039.) Injuries. (1044.) Foreign bodies in the larynx. .302. Aphonia.^ 303. Paralysis of the glottis.^ 304. Spasm of the glottis.^* (96.) Laryngismus stridulus. Diseases op the Trachea and Bronchi. 305. Bronchial catarrh. 306. Bronchitis. a. Acute. 6. Chronic. 307 Ulcer. 308 Casts of the bronchial tubes.= 309 Necrosis of the cartilages of the trachea." 310 Dilatation. 311 Contraction. (44'.) Cancer. 312 Non-malignant tumors. Return such tumors here ac- cording to the list alp. 311. (49'.) Tubercle. 313 Parasitic disease. Eetum cases of this class ac~ carding to the list al p. 146, No. 7. Malformations.^ 313. Return such cases here ac- cording to the list at p. 234. (1044.) Foreign bodies in the bronchi. 314. Asthma. Diseases of the Lung. 315. Pneumonia. Variety : a. Lobular.' 316. Abscess. (31.) Pycemic inflammation and ab- scess. 317. Gangrene. 318. Passive congestion.^ a. Hffimoptysis.^ 319. Pulmonary extravasation. Syn., Pulmonary apoplexy." a. Hiemoptysis." 320. (Edema.' 321. Cirrhosis. 322. Emphysema. a. Vesicular.' . 6. Interlobular.'' 323. Atelectasis. 324. Collapse." (43'.) Syphilitic deposit. (44' ) Cancer. (49' (49' ) Phthisis. ) Actiie miliary tuberculosis. 325. Acute pneumonic phthisis. 326. Chronic pneumonic phthisis. 327. Parasitic disease. Heium cases of this class ac- cording to the list at p. 146, 327. Malformations.^ Return such cases here ac- cording to the list at pp. 234 to 238. (1054-1058.) Injuries. (1044.) Foreign bodies. 328. Millstone makers' phthisis. 329. Grinders' asthma. 330. Miners' asthma. Diseases of the Pleura. 331. Pleurisy. 332. Chronic pleurisy. 333. Empyema. 334. Adhesions, including thick- ening and ossification. 335. Hydrothorax.=' 336. Pneumothorax. (41'.) Cancer. 337. Non-malignant tumors. Return such tumors here ac- cording to the list at p. 311. (49*.) Tubercular pleurisy. (1053-1054.) Injuries. Diseases op the Mediastinum. 338. Abscess. (44'.) Cancer. 339. Non-malignant tumors. Return such tum.ors here ac- cording to the list aip. 311. (284-285.) Diseases of the thymus gland. Diseases of the Bronchial Glands. 340. Inflammation. 341. Abscess. 342. Enlargement. (44'.) Cancer. 343. Non-malignant tumors. Return such tumors here ac- cording to the list atp. 311. (49'.) Tubercle. ■ The cause of the obstruction should be stated. Register the diseases printed here in italics, not under this heading, but at the place referred to in each instance by number. ^ When the cause of this affection has been ascertained, the case should be returned under the head of the primary disease, the secondary affection being also specified. For the diseases of the nose, see p, 313. ' When chronic laryngitis, ulcer of the larynx, or necrosis of cartilage, is due to phthisis or syphilis, the terms (43'.) syphilitic or {4^'.) phthisical should be prefixed to the designation of the disease, and the case ought to be returned under the head of the jprimary affection, " When this affection is due to phthisis or syphilis, the terms (43'.) syphilitic or (49'.) phthisical should be prefixed to the designation of the disease, and the case ought to be returned under the head of the primary affection. ' The term secondary has been applied to Pneumonia when it occurs as a complication of some other disease ; such cases ought to be returned under the head of the primary affection. Digitized by Microsoft© 316 THE NOMENCLATURE OF DISEASES. DISEASES OF THE DIGESTIVE SYSTEM.i Diseases of the Lips. The affected lip ouglU to he specified. 344. Ulcer. (43'.) SypkilUio tdeer. 345. Fissures. (44^) Cancer. (59'.) Scrofulous hypertrophy. 346 Cyst. 347. Malformations. Jieturn such cases here ac- cording to the list atp. 234. a. Hare-lip. Diseases of the Mouth.^ 348. Stomatitis. 349. Ulcerative stomatitis. 350. Thrush. £^w., Aphtha, Vesic- ular stomatitis. 351. Abscess of the cheek.^ 353. Cancrum oris. Syn.^ Gan- grenous stomatitis. 354. Cyst of the cheek. 355. Ranula. (44^) Cancer, 356. Parasitic disease. a. Parasitic thrush. 8yn., Parasitic aphthse."' ■ Metum cases of this class ac- cording to the list at p. 146. Diseases of the Jaws, includ- ing THE Antrum.' 357. Adhesion of the jaws by cica- trix. 358. Abscess of the antrum. (44\) Cancer. 359. Fibrous tumor. 360. Myeloid tumor. 361. Osseous tumor. a. Hypertrophyof thebones of the face. 362. Cartilaginous tumor. 363. Vascular tumor. 364. Cyst. (1016.) Foreign bodies in the antruTYb. Diseases, Malformations, and Injuries of the Teeth, Gums, AND Alveoli. 365. Teething." Diseases of the Dental Tissue. 366. Caries. 367. Necrosis. 368. Exostosis. 369. Absorption. Diseases of the Dental Pulp. 370. Irritation. 371. Inflammation, 372. Ulceration. 373. Gangrene. Diseases op the Dental Periosteum. 374. Granulation or polypus. 375. Calcification. 376. Inflammation. 377. Gum-boil. 378. Chronic thickening. 379. Rheumatic inflammation. Diseases of the Gums. 380. Inflammation. 381. Ulceration. 382. Hypertrophy. 383. Atrophy. 384. Induration (in infancy). (44'.) (kincer. 385. Non-malignant tumors. Return such tumors here ac- cording to the list atp. 311. a. Polypus. 6. Cartilaginous tumor, c. Vascular tumor. 386. Epulis. Diseases of the Alveoli. 387. Inflammation. 388. Necrosis. 389. Caries. 390. Exostosis. 391. Dentigerous cyst. 392. Absorption. Specific Diseases affecting THE Dental Periosteum, Gums, ok Alveoli. 393. Mercurial inflammation. 394. Phosphoric inflammation and necrosis. (908c.) Blue gum from lead. (54.) Scurvy. Irregular Dentition. Irregularity in the time of erup- tion of the — 395. Temporary teeth. 396. Permanent teeth. Irregularity in the position of the— 397. Temporary teeth. * 398. Permanent teeth. Irregularity of the number of the— 399. Temporary teeth. 400. Permanent teeth. Irregularity in the form of the — 401. Temporary teeth. 402. Permanent teeth. Abnormal development of the — 403. Dental tissue. 404. Enamel. 405. Dentine. 406. Cementum. 407. Alveolar portions of the jaws, in size. 408. Alveolar portions of the jaws, in form. 409. Defective growth of lower jaw. 410. Mechanical injuries of the alveoli and dental perios- teum. a. Hemorrhage. 6. Fracture! 411. Mechanical injuries of the teeth. a. Fracture. b. Dilaceration. c. Dislocation'. d. Friction. Diseases op the Tongue. 412. Glossitis. 413. Ulcer. 414. Aphthous ulcer. 415. Abscess. 416. Hypertrophy. f43*A.) Primary syphilis. (43'b.) Secondary syphilid. (44^) Cancer. 417. Vascular tumor. 418. Tongue-tie. (89.) Paralysis.''' Diseases of the Fauces and Palate. 419. Sore throat. 42X1. Relaxed throat. 421. Ulcerated throat. 422. Quinsj^. Syn., Cynanche ton- sillaris. 423. Tonsillitis. 424. Sloughing sore throat. Syn., Putrid sore throat. Cyn- anche maligna.8 (19.) Diphtheria. 425. Enlarged tonsils. (44*>) Cancer of the tonsils. (49'.) Scrofulous disease of the tonsils. 426. Elongated uvula. 427. Perforation of the palate. 428. Stricture of the fauc6s. (43'.) Syphilitic affection of the fauces and tonsils. (44*.) Cancer. 429. Non-malignant tumor. Return such tumors here ac- cording to the list atp. 311. a. Fibro-cellular tumor. b. Fibro-cystic tumor. 430. Malformations. Return such cases here ac- cording to the list a^p. 234, a. Cleft palate. Diseases of the Pharynx. 431. Pharyngitis. 432. Ulcer. a. Superficial ulcer. b. Perforating ulcer. 433. Abscess. 484. Sloughing. 435. Adhesion of the soft palate. 436. Dilatation."" (43S) Syphilitic affection. (44^) Cancer. (1047.) Injury by corrosive svb- (1045.) Foreign bodies. (89.) Paraly^.'' Diseases of the Salivary Glands. 437. Inflammation. 438. Salivation, Syn., Ptyalism."" 439. Abscess. 440. Salivary fistula. (21.) Mumps. (44^) Canc&r. 441. Non-malignant tumors. Return such tumors liere ac- cording to the list atp. 311. 442. Salivary calculus. Diseases of the (Esophagus. 443. CEsophagitis. 444. Ulceration, 445. Perforation ,■* 446. Stricture."" (44^) Cancer. (1046.) Foreign bodies. 447. Malformations. Return such cases here ac- cording to the list atp, 234. (1047.) Injury by corrosive sub- stances, j (89.) Paralysis.'' I 448. Dysphagia. * Register the diseases printed here in italics, not under this heading, but at the place referred to in each instance by number. 3 Whenever any of the affections of the mouth, throat, or parts connected therewith, depend on syph- ilis, scurvy, local irritants, or any other specific cause, the fact should be stated. ^ 352 has been accidentally omitted. * The name of the Thrush parasite is given at p. 147, No. 45. " The affections of the alveoli are to be returned with those cf the teeth. " Any affection, such as convulsions and paralysis, induced by this condition should be specified. ■* When the cause of this affection has been ascertained, the case should be returned under the head of the primary disease, the secondary affection being also specified. ^ This affection must be dia^rvSi^^^i^^ct^jamii&aiiAic^ski^ fever. THE NOMENCLATURE OF DISEASES. 317 Diseases op the Stomach. 449. Gastritis. (906, &c.) a. FroTninntaTii poisons. (For the list of poisons, see v. 323.) 450. Chronic ulcer. 451. Hsematemesis.* 452. Perforation.^ 453. Dilatation.^ 454. Stricture.^ 455. Gastric fistula. 456. Hernia. (44.^) Cancer. (45.^) Colloid. 457. Non-malignant tumors. Return such tumors here ac- cording to the list dtp. 3U. 458. Parasitic disease. Seturn ca^es of this class ac- cording to the list at p. 147, Nos. 46, 47. (108S-1071.) Injuries. (1074.) Foreign bodies. 459. Spontaneous laceration. 460. Dyspepsia. 461. Gastrodynia. 462. Pyrosis. 463. Vomiting.* Diseases of the Intestines. 464. Enteritis. 465. Typhlitis. 466. Dysentery. 467. Ulceration. 468. Perforation. 469. Abscess in the subperitoneal tissue. 470. Fecal abscess. 471. Fistula. a. Fecal fistula. Syn.^ Arti- ficial anus. (561.) Vesico-intextinal fistula. 472. Hemorrhage. 473. MelEena. 474. Dilatation.* 475. Tympanites.* ' 476. Obstruction.^ 477. Stricture, 478. Intussusception. 479. Internal strangulation. a. Mesenteric. 6. MesocoUc. 480. Hernia. a. Reducible. 6. Irreducible. c. Obstructed. d. Inflamed. e. Strangulated. ' 1. Diaphragmatic. , 2. Epigastric. 3. Ventral. 4. Umbilical. 5. Lumbar. 6. Inguinal. a. Oblique. 6. Direct. c. Incomplete. d. Scrotal. e. Congenital. /. Infantile. 7. Femoral. 8. Obturator. 9. Perineal. 10. Pudendal. 11. Vaginal. 12. Ischiatic. 481. Diseases of hernial sacs. a. Inflammation. b. Fibrinous effusion with closure. c. Suppuration. d. Dropsy. e. Movable bodies. /. Laceration. (44.*) Cancer. (45.') Colloid. 482. Non-malignant tumors. Hettirn such tumors here ac- cording to the list at p. 311. a. Polypus. 483. Parasitic disease. Return cases of this class ac- cording to the list at pp. 146 to 148, Nos, 1-3, 8-13, 15-20, 24, 25, 27, 32, 34, 35. (1075.) Concretions, 483*. Malformations. With the exception of hernia, which will appear under 480, retu7-n such cases here ac- cording to the list at p. 234. ( 1075.) Foreign bodies. (1066-1071.) Injuries. 484. Diarrhoea. fl7.J Simple cholera. (18.) Malignant cholera. a. Choleraic diarrhoea. 485. Paralysis.' 486. Colic. (908a.) Lead colic. 487. Constipation. Diseases of the Rectum and Anus. 488. Ulceration. 489. Abscess. 490. Fistula in ano. (562.) Recto-vesieal fistula. (600.) Recto-urethral fistula. (676.) Recto-vaginal fistula. 491. Haemorrhoids. a. Internal. b. External. 492. Hemorrhage from the rec- tum. 493. Fissure of the anus. 494. Prolapsus. 495. Stricture.' (43*.) Syphilis of the rectum. 496. Condyloma of the anus. (44'.) Cancer of the rectum, (44*,) Cancer of the anus. 497. Non-malignanttumorsof the rectum. Return cases of this class here according to the list at p. 311. 497*. Parasitic disease. Return cases of this class here according to the list at p. 146, see No. 10, 497. Malformations.* Return such cases here ac- cording to the list at p. 234. n081-1082.) Injuries. (1089.) Foreign bodies inthe rectum. 498. Neuralgia, 499. Spasm of the sphincter ani. 500. Pruritus ani. Diseases op the Liver. 501. Hepatitis, 502. Abscess.'' (31,) Pycemic inflammaiion and ab- ' scess. 503. Acute atrophy. 504. Simple enlargement, Syn., Congestion of the liver, 505. Thickening of the capsule. ! 506. Cirrhosis, 607, Fatty liver. 508. Fibroid deposit. 509. Lardaceous liver. Syn., Amv- loid disease of the liver. Waxy liver.* (43'.) Syphilitic deposit. (44'.) Cancer. (45*.) Colloid. 510. Non-malignant tumors. Return such tumors here ac- cording to the list at p. 311. 511. Cyst. (49'.) Tubercle. 512. Parasitic disease. Return cases of this class ac- cording to the list at pp. ]46 147, Nos. 14, 21-23, 25, 23- 34, 35, 512^ Malformations. Return such cases here ac- cording to the list at p. 234, (1066-1071.) Injuries. 513. Jaundice. Syn.^ Icterus. 514. Obstruction of the vena por- tce. Diseases of the Hepatic Ducts AND GaLI^BlADDEK, 515. Inflammation, 516. Ulcer, 517. Perforation. a. Biliary fistula. 518. Obstruction. (44*.) Cancer. 519. Parasitic disease. Return cases of this class ac- cording to the list at p. 146 No. 25. 520. Gallstones. a. Passage of gallstones through the duct. 520*. Malformations, Return such cases here ac- cording to the list at p. 234, (1066-1071.) Injuries. Diseases op the Pancreas, 521. Abscess. 522. Obstruction of the duct. (44'.) Cancer. (45*.) Colloid. 523. Calculi. Diseases op the Spleen, 521, Splenitis. d'25. Abscess. (31.) Pycemic inflammation and ab- scess. 526. Congestion. %ra,, Ague cake. 527. Fibrinous deposit. 528. Hypertrophy, a. Leucocythcemia. ^529. Lardaceous spleen. Syn., Amyloid disease. Waxy spleen. (44*.) Cancer. (4.5*.) Colloid. (49'.) Tubercle. 530. Parasitic diseases. Return cases of this class ac- cording to the list at p. 146, No. 22. (1066,) Rupture. Diseases op the Peritoneum, 531, Peritonitis. (719,) a. Metro-peritonitis. Syn. , Puerperal peritonitis. b. Chronic peritonitis. c. Suppurative peritonitis. * When the cause of this aflfection Aas been ascertained, the case should be returned under the head of the primary' disease, the secondary affection being also specified. ^ The cause of the perforation, when ascertained, should be stated. ^ When abscess of the liver is associated with dysentery, injury, or any other condition, the fact should be stated, * Such cases have been described under the name of Scrofulous disease of the liver. Digitized by Microsoft© 318 THE NOMENCLATURE OF DISEASES. (49^) d. Tubercular peritonitis. e. Adhesions of the perito- neum. 532 Ascites.^ 532*. Non-malignant tumors.''' jteturn such tumors here ac- cording to the list at p. 311. (44^) Cancer. (45'.) Colloid. 533. Parasitic disease. Return cases of this class ac- cording to the list at p. 146, Ms. 4, 14, '12. (1067-1070.) Injuries. Diseases of the Mesenteric Glands. 534. Inflammation. 535. Ahscess. 536. Enlargement, (44*.) Cancer. 537. Non-malignant tumors. Return such turgors here ac- cording to the list at p. 311. (49*.) Tubercle. (49^) Tabes mesenterica. DISEASES OF THE XXRINAEY SYSTEM.^ Diseases of the Kidney. 538. Bright's disease. *S^n., Albu- minuria. 1. Acute Bright's disease. Syn., Acute albuminu- ria. Acute desquama- tive nephritis, Acute re- nal dropsy. •2. Chronic Bright's disease. Syn., Chronic albumin- uria. Subdivisions : a. Granular kidney. Syn., Contracted granular kidney, Chronic des- quamative nephritis, Gouty kidney. &. Fatty kidney. c. Lardaceous kidney. Syn.^ Amyloid disesfee. Waxy kidney. 539. Suppurative nephritis. 640. Abscess. 541. Pyelitis. 542. Fibrinous deposit. 543. Hydronephrosis. 544. Hypertrophy. 545. Atrophy. (44'.) Cancer. 546. Non-malignant tumors. Jieium such tumors here ac- cording to the list at p. 311. 547. Simple cyst. 548. Urinary cyst (from injury). (49'.) Tubercle. 549. Parasitic disease. Return cases of this class according to the list at p. 146. 550. Calculus. 551. Calculus in the ureter. 552. Malformations. Return cases of this class according to the list ai p. 234. (1066-1071.) Injuries. 553. HEcmaturia renalis.' 554. Suppression of urine. Syn., Ischuria renalis.' (52.) Diabetes. Syn., Diabetes mel- liius. 555. Diuresis.* 566. Movable kidney. Diseases op the Bladder. 557. Cystitis, fi'yn.i Catarrh of the bladder. a. Acute. h. Chronic* 558. Ulceration. 5n9. Suppuration. 560. Sloughing. 561. Vesico-intestinal fistula. 562. Recto-vesical fistula. (660.) Utero-vesical fistula. (675.) Vesico-vaginaljistvla. 563. Hypertrophy. 564. Distension.' a. Sacculated bladder. 6. Rupture. 565. Inversion. 566. Extroversion. 567. Hernia. (44*.) Cancer. 568. Fibrous tumor. 569. Villous tumor. 570. Calculus. a. Uric acid. b. Urate of ammonia. c. Uric oxide. Syn., Xan- thic oxide. d. Oxalate of lime. e. Cystic oxide. /. Phosphate of lime. g. Triple phosphate. h. Fusible. i. Carbonate of lime. k. Fibrinous. I. Urostealith. m Blood calculus. Foreign bodies. 571. Hsematuria (Vesical).* 571*. Malformations. Return such cases according to the list at pp. 234 to 238. (1083, 1091.) Injuries. 572. Paralysis.* 573. Irritabiiity.' 574. Spasm.^ 575. Neuralgia.' 576. Incontinence of urine.' 577. Ketention of urine.' Diseases op the Prostate Gland. ^ * 578. Inflammation. a. Acute. 6. Chronic, 579. Ulceration. 580. Abscess. 581. Atrophy. (44'^.) Chncer. 582. Non-malignant tumors. Syn., Enlarged lobe of the pros- tate. 582*. Chronic enlargement. 583. Cyst. (49'.) Tubercle. 584. Calculi. GONOBKHCEA AND ITS COMPLICA- TIONS.' '* 585. Gonorrhoea. a. In the male. \ b. In the female. 586. Balanitis. (841.) Herpes prepuiiaXis. 587. Phimosis. 588. Paraphimosis. 589. Bubo. 590. Lacunar abscess. (580.) Prostatic abscess. 591. Epididymitis. Syn., Gonor- rhceal orchitis. a. Abscess. 692. Abscess of the spermatic cord. 593. Condyloma. a. In the male. b. In the female. 694. Gleet (631.) Inflammation of ovary. 595. Abscess of the vulva, fll?.) GonorrhoMl ophthalmia. (140.) Gonorrhceal iritis. (35.) Gonorrhceal rhemnaiism. Diseases of the Male Urethra. 595*. Urethritis. 596. Stricture.* a. Organic. b. Traumatic. c. Spasmodic. d. Inflammatory. 597. Ulcer. 598. Urinary abscess. 599. Urinary fistula. 600. Recto-urethral fistula. 601. Extravasation of urine. 601*. Impacted calculus. a. Foreign bodies. 601t. Malformations. Return such cases according tothelistatp-'2^4:. (1078-1091.) Injuries. DISEASES OF THE GENERATIVE SYSTEM.^ DISEASES OF THE MALE ORGANS OF GENERATION.^ Diseases op the Penis. 602. Inflammation. 603. Abscess. (505a-.) Gonorrhcea. (593*.) Condyloma. 604. Gangrene. 605. Priapism.* f43'.) Syphilis. (44'.) dancer. '■ "When the cause of this aflfection has been ascertained, the case should be returned under the head of the primary disease, the secondary aflfection being also specified. ^ Non-malignant tumors in the abdomen of uncertain seat must be returned under this heading. ' Register the diseases here printed in italics, not under this heading, but at the place referred to in each instance by number. * These diseases, which rank properly under the Diseases of the Generative System, are inserted here on anatomical grounds. * When the cause of the stricture is known, it should be stated. ^ It has been found convenient, on anatomical grounds, to place the Diseases of the Prostate and Gon- orrhcea, which rank properly under Diseases of the Generative System, between the Diseases of the Blad- der and those of the Urethra. Digitized by Microsoft© THE NOMENCLATURE OF DISEASES. 319 a. Of tJie prepuce. b. OS the body. 606. Non-malignant tumors. Return such tumors here ac- cording to the list at p. 311. (1078,) Injuries. 607. Malformations. Return such cases according to the list at p. 234. a. Phimosis— congenital. BiSEASES OP THE SCROTUM. 608. Sloughing. 609. (Edema. 610. Elephantiasis. (834.) Prurigo. (43^) Syphilis. (44'.) Cancer. (44'.c) Epithelial cancer. Syn., Chimney-siveepers* cancer. 611. Non-malignant tumors. Return such tumors here ac- cording to the list aip. 311. 611*. Malformations. Jieturn such cases here ac- cording to the list aip. 234. DrSEASES OP THE COBD. 612. Hydrocele. Varieties : a. Encysted. 6. Diffused. 613. "Varicocele. 614. Non-malignant tumors. Retui-n such tumors here ac- cording to the list dtp. 311. 615. Neuralgia. Diseases of the Tunica Vaginalis. 616. Inflammation. 617. Hydrocele. Varieties : a. Congenital. 6. Infantile. c. Encysted. 618. Hgematocele. 619. Loose bodies. Diseases of the Testicle. 620. Orchitis. a. Acute. 6. Chronic. 620*. Epididymitis. 621. Abscess. 622. Protrusion of tubuli. Syn., Hernia testis. Fungus testis. 623. Atrophy. (43^) Syphilitic disease. (44^) Cancer. 624. Non-malignant tumors. Retwn such tumors here ac- cording to the list at p. 311. 625. Cystic disease. (49'.) Tubercle. (1078.) Injuries. 626. Malformations. Return such cases according to the list at pp. 234 to 238. a. Fcetal remains in the testicle. &. Malposition. 627. Spermatorrhoea. 628. Impotence. 629. Neuralgia. DISEASES OF THE FEMALE ORGANS OF GENERATION IN THE TJNIMPREGNATED STATE. 6. Rectocele. (44'.) Cancer. 678. Non-malignant tumors. a. Polpyus. 679. Laceration. 679*. Malformations. Return such cases here ac- cording to the list at pp. 234 to 238. 631. 632. 633. 634. (44' 635. 636 637. Diseases of the Ovaby. Inflammation. Abscess. Hemorrhage. Atrophy. Hypertrophy. .) dancer. Fibrous tumor. Encysted dropsy. Complex cystic tumor. Syn., Alveolar, gelatinous, and colloid tumor. Cystosar- coma. a. With intracystic growths. 638. Cyst, containing tegumentary structures. a. Cutaneous or piliferous cyst. Syn., Dermoid cyst. b. Dentigerous cyst. (49*.) Tubercle. 639. Parasitic disease. Return cases of th,is class ac- cording to the list aip. 146. 640. Dislocation. a. Transplantation. 641. Hernia. 642. Malformations. Return such cases according to the list aip. 234. Diseases of th:e Fallopian Tube. 643. Abscess. 644. Dropsy. 645. Stricture, 646. Occlusion. (41^) Cancer. 647. Cyst. (49*.) Tubercle. 648. Dislocation. 649. Hernia. Diseases of the Broad Ligament. 650. Inflammation. a. Pelvic peritonitis. 6. Pelvic cellulitis. 651. Abscess. 652. Cyst. 653. Periuterine or pelvic haema- tocele. Diseases op the Uterus, INCLUDING the CeRVIX. 654. Catarrh. Syn., Leucorrhoea. a. Hydrorrhoea. 655. Inflammation. 656. Granular inflammation. 657. Abrasion. 658. Ulcer. 658*. Rodent ulcer. 659. Abscess. 660. Utero-vesical fistula. 661. Stricture of the orifice. 662. Stricture of the canal. 663. Occlusion of the orifice. 664. Occlusion of the canal. 665. Hypertrophy. a. Elongation of the cervix. 666. Atrophy. (44^.) Qincer. a. Scirrhus. ■ b. Medullary cancer. c. Epithelial cancer. 667. Non-malignant tumor. a. Fibrous tumor.' h. Polvpus.^ (49'.) Tubercle. 668. Displacements and distor- tions. a. Anteversion. &. Retroversion. c. Anteflexion. d. Retroflexion. e. Inversion. /. Prolapsus. 1. Procidentia. g. Hernia. 669*. Malformations. Return such cases according to the list at pp. 234 to 238. Diseases of the Vagina. 670. Catarrh. Syn., Leucorrhoea. 671. Inflammation. 672. Abscess. (585M Gonorrhoea. 673. Cicatrix or band. 674. Vaginal fistula. 675. Vesico-va^inal fistula. 676. Recto-vaginal fistula. 677. Hernia. a. Cystocele. Diseases of the Vulva. 680. Inflammation of the labia. 681. Pruritus. (843.) Eczema of the labia. 682. CEdema of the labia. 683. Abscess. 684. Gangrene. 685. Hypertrophy.^ 686. Occlusion. 687. Imperforate hymen. (266.) Varicose veins. (43'.) Syphilis. (44',) Chncer. 688. Vascular tumor of the meatus urinarius. 689. Mucous cyst. (593&.) Condyloma. 689*. Malformations. Return such cases Jiere ac- cording to the list at p. 234. Functional Diseases op the Female Oegans of Generation. 690. Amenorrhcea. Syn., Absent menstruation. Varieties : a. From original defective formation, 6. From want of develop- ment at the time of puberty. c. From mechanical ob- struction. d. From temporary sup- pression. 691. Scanty menstruation. Syn., Deficient menstruation. 692. Vicarious menstruation. 693. Dysmenorrhcea. Syn., Pain- ful menstruation. ' Letters have been here substituted for the omitted numbers. ^ Under this head should be returned all pedunculated tumors growing from the cavity or neck of the uterus, whether mucous, cellular, or fibrous. ^ Specify the part. Digitized by Microsoft© 320 THE NOMENCLATURE OF DISEASES. 694. Menorrhagia. Syn., Exces- t 694*. Hemorrhage, give menstruation. | I (56.) Chlorosis. Syn., Green sick- ness. AFFECTIONS CONNECTED WITH PREGNANCY. Disorders of the Nervous System.* Neuralgia. Varieties : a. Odontalgia. h. Cephalalgia. c. Mastodynia. Chorea. Convulsions. Hypochondriasis. Mania. Diseases of the Circulatory System.* Varicose veins — a. Of the lower extremities. 6. Of the labia, c. Of the rectum. Hemor- rhoids. Serous exudation. Varieties : a. Ascites. &. (Edema of the labia, c. (Edema of the lower extremities. Syncope. Palpitation. Disorders of the Bespira- tory System.* Dyspncea. Orthopncea. Cough. Disorders of the Digestive System.* Salivation. Depraved and capricious ap- petite. Nausea and vomiting. Cardialgia or Heartburn. Pyrosis. Intestinal cramp — colic. Constipation. Diarrhcea. Jaundice. Disorders op the Urinary System.* Albuminuria. Dysuria. Incontinence of urine. Retention of urine. Disorders op the Generative System. 695. Metritis. Syn., Hysteritis. 696. Discharge of watery fluid from the uterus. Hydror- rhoea. 697. Rheumatism of the uterus. 698. Hysteralgia. 699. Spurious pains and cramps. (670.) Catarrh of the vagina. Syn., Leucorrlma. 700. Sanguineous discharge. Syn., Menstruation. 701. Hemorrhage. 702. Displacements of the uterus. Varieties : a. Prolapsus. h. Hernia. c. Retroversion, (681.) Pruritzts of the vulva. 703. Abortion. 704. Premature labor. 705. Extra-uterine gestation. AFFECTIONS CONNECTED WITH PARTURITION. 706. Atony of the uterus. 707. Overnlistension of the uterus. a. From excess of liquor amnii. 6. From twins, triplets, &c. 708. Mechanical obstacle to the action of the uterus; a. From occlusion of the os uteri. 6. From rigidity. (1.) Ofthe OS uteri. (2.) Of the vagina. (3.) Of the perineum. c. From cancer of the cervix uteri. d. From narrowness of the vagina. e. From cicatrix or band in the vagina. /, From vaginal cyst. g. From prolapsus of the bladder. h. From stone in the blad- der. i. From distended rectum. k. From prolapsus of the rectum. I. From tumor. Varieties : 1. Uterine, 2. Ovarian. 3. Pelvic. 4. Of external parts, m. From polypus. n. From fractured pelvis, 0. From exostosis. p. From distorted or con- tracted pelvis. q. From dislocated lumbar vertebrffi into pelvis. Syn., Spondylo listhe- sis. r. From anchylosed coccyx. s. From diminutive pelvis. t. From extrem,e antever- sion of the uterus (with pendulous abdomen), w. From excessive size of the fcetus. V. From malposition of the fo3tus. w. From malformation of the foetus. z. From enlargement of the fcetus from disease. y. From unusual thickness of the foetal mem- branes. z. From unusual shortness of the funis. 709. Hemorrhage. a. From placenta prsevia. Syn., Unavoidable hem- orrhage. 6. From accidental detach- ment of the placenta. Syn., Accidental hem- orrhage. c. From thrombus of the cervix uteri or labium. 710. Rupture or laceration ofthe — uterus. 711. vagina. 712. urinary bladder. 713. perineum. 714. Retention of the placenta. a. From atony of the uterus. b. From irregular or hour- glass contraction. c. From preternatural ad- hesions. 715. Inversion ofthe uterus. 716. Convulsions. AFFECTIONS CONSEQUENT ON PARTURITION. 717. Post-partum hemorrhage. (33.) Puerperal ephemera. 718. Milk fever. (32. ) Puerperal fever. 719. Metro-peritonitis. >^n.., Puer- peral peritonitis, a. Metritis. (531.) b. Peritonitis. {2&0,) Phlebitis. ('2,61.) Phlegmasia dolens. (650b.) Pelvic celluliiis. 720. Iliac and pelvic abscesses. 721. Sloughing of the cervix uteri. 722. " " vagina. 723. Sloughing of the perineum, 724. *' " bladder. 725. " " rectum. (660.) Utero-vesical fistula. (675.) Vesico-vaginal fistula. (676.) Rectovaginal fistula. (729.) Infiamniation of the female breast. (730.) Abscess of the female breast. 726. Puerperal mania. [tion, a. Connected with parturi- b. " " lactation. 727. Puerperal convulsions. Syn,, Eclampsia. 728. Sudden death after delivery. a. I^om shock or nervous exhaustion. 6. From impaction of coag- uli in the heart and pulmonarj'^ artery. 1. Thrombosis. 2, Embolism. c. From entrance of air into veins (from separation of the placenta). (902.) Still-born. (903.) Premature birth. DISEASES OF THE FEMALE BREAST. 729. Inflammation. a. Acute. 6. Chronic. 730. Abscess. 731. Sinus. 732. Galactorrhcea. 733. Deficiency of milk. 734. Hypertrophy. 735. Atrophy. 736. Depressed nipple. 737. Chapped nipple 738. Ulcerated nipple. (44\) Cancer, a. Scirrhus. b. Medullary cancer. * These aflfections are secondary, and are therefore not numbered. Digitized by Microsoft© THE NOMENCLATURE OF DISEASES. 321 c. Epithelial cancer, (45^) Colloid. 739. Non-malignant tumors.* a. Fibrous tumor. Syn., Painful subcutaneous tumor. 6. Fibro-iilastic tumor. c. Fatty tumor. d. Osseous tumor. e. Cartilaginous tumor. Syn., Enchondroma. /. Chronic .mammary tu- mor. Syn.,' Adenoid tumor. g. Vascular tumor. 746. Cyst. 747. Complex cystic tumor. Syn.y Cysto-sarcoma. 748. Parasitic disease. Return cases of this class ac- cording to the list at p. 146. 749. Hypersesthesia. 750. Mastodynia. ;%n., Neuralgia. DISEASES OF THE MALE MAMMILLA.^ 751. Inflammation. 1 753. Non-malignant tumors. 1 754. Cyst. 752. Hypertropliy. Return such cases according (UK) Cancel: \ to the Ust aip. 311. | DISEASES OF THE ORGANS OF LOCOMOTION.^ Diseases of Bones." 755. Ostitis. a. Periostitis. 1. Nodes. 756. Dififuse periostitis. Syn., Acute periosteal abscess, a. Acute necrosis. 757. Osteo-myelitis. 758. Chronic abscess. 759. Caries. 760. Necrosis. 761. MoUities ossium. 762. Hypertrophy. 763. Atrophy. 764. Spontaneous fracture, (The causfe, if known, should be stated.) (43^) Syphilitic disease. (44*.) Qincer. 765. Non-malignant tumors. a. Fibrous and fibro-cystic. b. Myeloid. c. Cartilaginous. Syn., En- chondroma. d. Osseous tumor. Syn., Exostosis, Varieties : 1. Ivory. 2. Cancellated. 3. Diffused. 766. Cyst. (50.) Rickets. .(49.) Scrofulotcs disease. 767. Parasitic disease. Return cases of this class ac- cording to the list aip. 146. 767*. Malformations, Return such cases here ac- cording to the list at pp. 234 (0 238, Diseases of Joints.'* 768. Acute synovitis. 769. Chronic synovitis. a. Pulpy degeneration of synovial membrane. (49S) h. Scrofulous disease of the joints. (49^) 1. Morbus coxce. 770. Ulceration of cartilage. 771. Abscess. (31a,) Pycemic abscess. 772. Anchylosis. a. Deformity from anchy- losis. 773. Dropsy of joints. (35,) Gonorrhceal rheuTnatism. (36.) Synovial i'heumatism. (41.) Gouty synovitis. (42.) Chronic osieo-arthritis. Syn., Chronic rheumatic arthritis. 774. Degeneration of cartilage, and of the articular sur- faces of bones. 775. Perforation of joints.* 776. Loose cartilage. Syn., Loose body. 777. Relaxation of ligaments. 778. Displacement of articular cartilage. 779. Knock-knee. 780. Bow-leg, or out-knee. (44'.) Cancer. 781. Non-malignant tumors. Return such cases here ac- cording to the list at p. 311, 782. Neuralgia of joints. Diseases op the Spine. 783. Ulceration of ligaments and cartilages. 784. Caries and necrosis. a. Spontaneous fracture of the odontoid process, 785. Psoas, lumbar, and other abscesses. 786. Angular deformity. Syn,, Kyphosis. 787. Lateral curvature. Syn., Skoliosis. 788. Anterior curvature. Syn., Lordosis. (50.) Rickety curvature. 789. Anchylosis. (42.) Chronic osieo-arthritis. 790. Non-malignant tumors. Return such cases here ac- cording to the list at p. 311. (44\) Cancer. 791. Parasitic disease. Return cases of this class ac- cording to the list at p. 146. 792. Malformations. Return such cases here ac- cording to the list at p. 234. a. Deformity from malfor- mation. (SOa.) h. Spina bifida. Diseases of the Muscular System."^ diseases of the muscles. 793. Inflammation. 794. Abscess. 795. Gangrene. 796. Atrophy. 797. Progressive muscular atrophy. 798. Fatty degeneration. 799. Ossification. (43\) Syphilitic deposit. (44'.) Cancer. {45'.) Colloid. 800. Non-malignant tumor. a. Erectile tumor. 801. Cyst. (1144.) Rupture. (88.) Infantile paralysis. 802. Parasitic disease. Return such cases here ac- cording to the list at p. 146, iVo. 4. a. Trichinosis. (95.) SpasTn. 803. Exhaustion.'' (89b.) Scrivener's palsy. (19a.) Diphtheritic paralysis. DISEASES OF TENDONS. 804. Inflammation. (865*.) Thecal abscess. 805. Adhesion of tendons. (44'.) Cancer. 806. Non-malignant tumors. 807. Contraction of tendons, fas- ciae, or muscles. 808. Club-foot. a. Talipes varus. 6. " valgus. c. " equinus. d. " calcaneus. e. " calcaneo- varus. /. " eqaino-valgus. Syn., Flat-foot. 809. Club-hand. 810. Contracted palmar fascia. 811. Wry-neck. (1145.) Rupture. DISEASES OF THE APPENDAGES OF THE MUSCULAR SYSTEM. 812. Enlarged bursa patellas. Syn., Housemaid's knee. 813. Enlargement of other bursje (specify which). 814. Bursal tumor. 815. Bursal abscess. 816. Bunion. 817. Ganglion. a. Diffusecl palmar ganglion. ' Letters have been here substituted for the omitted numbers. ^ Register the diseases printed here in italics, not under this heading, but at the place referred to in each instance by number. ^ In all cases the bone affected must be specified. * In all cases the joint affected is to be specified. \ This refers to perforation by disease, and in returning it the original affection should be stated. '"' In all cases the aflfected muscle or muscles should be stated. '' When the cause of this affection has been ascertained, the case should lie returned under the head of the primary disease, the secondary affection being also specified. VOL. I. Digitized by Microsoft© 322 THE NOMENCLATURE OF DISEASES. DISEASES OP THE CELLULAR TISSUE. i 818. Inflammation. 819. Abscess. 820. Inflammatory induration in the newly born. 821. Slough. (30b.) Phlegmonous erysipelas. (862.) Carbuncle. Syn., Anthrax* 822. Obesity. 823. Hemorrhage.'* (653.) a. Pelvic hcematocele. 824. Non-malignant tumors. Metum such cases according to the list at p. 311. (44^) Cancer. 825. Parasitic disease. Return cases of this class ac- cording to list alp. 146. (1146.) Foreign substances. 826. Emphysema.** DISEASES OF THE CUTANEOUS STSTEM.i^ (30.) „ . 827. Erythema. (This term in eludes 1. Erythema Iseve. 2. Erytliemafugax. Syn.^'R. volaticum. 3. Erythema marginatum. 4. " papulatum. 5. " tuberculatum. 6. " nodosum.) 828. Intertrigo. 829. Roseola. (This term includes 1. Roseola eestiva. 2. " autumnalis. 3. " symptomatica. 4. " annulata.) 830. Urticaria. Syn., Nettle rash. a. Urticaria acuta. 6. " chronica. (Under one or other of these heads are included 1. Urticaria febrilis. 2. " evanida. 3. " perstans. 4. " conferta. 5. " subcutanea. 6. " tuberculata.) 831. Pellagra. 832. Acrodynia. 833. Asturian rose, 834. Prurigo. 835. Lichen. (This term includes 1. Lichen simplex. 2. " pilaris. 3. " cireumscriptus. 4. *' agrius. 5. " tropicus. Syn., Prickly heat.) (The so-called Lichen lividus is really a form of Purpura.) 836. Strophulus. Syn., Red gum. Tooth rash. (This term includes. 1. Strophulus intertinctus. 2. " confertus. , 3. " Candidas.) (Strophulus albidus is referred to Acne. " Tolaticus to Ery- thema.) 837. Pityriasis. (This term in- cludes Pityriasis capitis. Syn.^ Dandriff.) (Pityriasis versicolor is re- ferred to Parasitic Affec- tions as a Synonym of Tinea versicolor.) 838. Psoriasis. (This term in- cludes Lepra.) a. Psoriasis vulgaris. Syn., Lepra vulgaris. 6. Psoriasis guttata. c. Psoriasis diffusa, ' d. " gyrata. e. " inveterata. *840. Miliaria. a. Sudamina.* 841. Herpes."* a. Herpes phlyctenodes. 6. " circinatus. c. " iris. d. " zoster. Syn., Shingles. 842. Pemphigus. Syn., Pompho- lyx. a. Pemphigus acutus. b. " chronicus. c. " solitarius. 843. Eczema. a. Eczema simplex. 6. " rubrtim. c. " impetiginodes. d. " chronicuni. 844. Impetigo. a. Impetigo sparsa. &. " confluens. 1. Figurata. 2. Larvalis. Syn., Porrigo larvalis. 845. Rupia. a. Rupia simplex. 6. Rupia prominens. c. Rupia escharotica. Syn., Pemphigus gangrteno- sus. 846. Ecthyma. 847. Acne. a. Acne punctata.** ])^ " inflnT'!i.t.a_ Syn., al~ 848. Sycosis. mdurata. rosacea. strophulosa. Strophulus bidus. Syn., Mentagra.8 849. Stearrhcea. • a. Stearrhcea simplex. &. " nigricans. 850. Ichthyosis. a. Ichthyosis vera. 6, " cornea. 851. Xeroderma. Syn., Sclero- derma, Scleriasis. 852. Leucoderma. (This term in- cludes Vitiligo.) 853. Albinismus. 854. Canities. 855. Melasma. (286.) 3Ielasma Addisoni. English name, Addison's disease. Syn., Bronzed sMn. 856. Lentigo and Ephelis. Syn., Freckles. 857. Chilblain. 858. Frostbite. 859. Ulcer. 860. Fissures. (35S.}Cancrum oris. 861. Boil. 862. Carbuncle. Syn., Anthrax. (26.) MalignarU pustule. 863. Onychia. 864. Onychia maligna. 865. Whitlow. a. Thecal abscess. 866. Gangrene. 866a. Senile gangrene. 866b. Bed sore. 867. Hypertrophy. 868. Corn. (816.) Bunion. 869. Elephantiasis Arabum. Syn.^ Barbadoes leg, Elephas. (48.) True leprosy. Syn., JSl^kan- tiasis GrcBCOi'wn. 870. Atrophy. a. Linear atrophy. b. Alopecia. c. Atrophy of nails. (44*.) Cancer. 871. Fibro-cellular tumor. 872. Fatty tumor. (267.) Ncstms vascularis. 873 Naevus. S'yn., Port-wine stain. 874. Nsevus pilaris. Syn., Mole. 875. Sebaceous tumor. a. Steatoma. 876. Cornua. 877. Warts. 878. Condyloma. 879. MolIus(ium. 880. Cheloid. 881. Frambcesia. Syn., Yaws. 882. Delhi boil. 883. Aleppo evil. (46.) I/upus. (49.) Serofulous disease. 884. Ingrown nail. (912^.) Silver stain. (992.) Bums and scalds. 884*. Cicatrices (state the cause).^ (102.) Hyperoisihesia. 885. Pruritus. (103.) Ancesthesia. 886. Ephidrosis. 887. Anidrosisi' pIrasitic diseases of the skin.'" 888. Tinea tonsurans. Syn.^ Ring- worm. Parasite, Achorion Lebertii. Syn., Trichophy- ton tonsurans. , Tinea decalvans. Syn., Alo- pecia areata, Porrigo decal- vans. Par., Microsporon Audouini, ^ Register the diseases printed here in italicSy not under this heading, but at the place referred to in each instance by number. ^ When the cause of this affection has been ascertained, the case should be returned under the head of the primary disease, the secondary affection being also specified. 3 Where the disease is local, its situation should be specified. * No. 839 has been accidentally omitted. * This affection is almost invariably symptomatic, ^ All the varieties which have been named from their locality only are to be included under the term Herpes. 1 When the Demodex foUiculorum is discovered, its presence should be stated. ^ When the Microsporon mentagrophytes or the Demodex foUiculorum is discovered, its presence should be stated. ^ Under this heading are only to be returned cases presenting a definite morbid character. " For a list of the parasites found in the parasitic diseases" of the skin, all of which are to be returned here, see pp. 146 to 148. (Nos. 5, 36^3, 45, 48-55.) Digitized by Microsoft© THE NOMENCLATURE OF DISEASES. 323 890. Tinea favosa. Syn.^ Favus, Porrigo favosa. Par., Acho- rion Schoenleinii; Puccinla Favi. 891. Tinea versicolor. Syn., Pity- riasis versicolor. Far., Mi- crosporon furfur. 892. Tinea Polonica, Syn., Plica Polonica. Par., Trichophy- ton sporuloides. 893. Mycetoma. Syn., Madura foot. Par., Chionyphe Carter!. 894. Scabies. Syn., Itch. Par., Sarcoptes scabiei. 895. Phthiriasis. 896. Irritation caused by a. Pediculus capitis. h. " palpebrarum. c. " vestimenti. d. " tabescentium. e. Phthirius inguinalis. 897. Irritation caused by Pulex penetrans. English Syn., " Pulex irritans. [Chigoe. 898. " Cimex. 899. " Leptothrix autumnalis. English Syn., Harvest- bug. 900. " Wasps, bees, and other stinging insects. (985a^^» [ing plants. 901. " Nettles and other sting- CONDITIONS NOT NECESSARILY ASSOCIATED WITH GENERAL OR LOCAL DISEASES. 902. Still-born. 903. Premature birth. Metals and their Salts. 906. Arsenic. 907. Mercury. a. Mercurial tremor. (393.) b. Mercurial inflammaiion of the dental periosteum. 908. Lead. a. Lead colic. Syn., Paint- er's colic. 6. Lead palsy. c. Blue gum. (124b.) d. Stain of the conjurtctiva from lead. 909. Copper. 910. Antimony. 911. Zinc. 912. Silver. a. Silver stain. (124a.) 6, Stain of the conjunctiwa from nitrate of silver. 913. Iron. 914. Bismuth. 915. Chromium. a. Bichromate of potash. Caustic Alkalies. 916. Potash. 917. Soda. 918. Ammonia. 919. Alkaline salts. Metalloids. 920. Phosphorus. (394.) a. Phosphoric inflammation and necrosis of the alveoli. 921. Iodine. Acids. 922. Sulphuric acid. 923. Nitric acid. 924. Hydrochloric acid. 925. Phosphorous acid. 926. Oxalic acid. 927. Tartaric acid. Vegetable Poisons. 928. Savin, (Juniperus sabina. — Idnnceus.) 929. Croton oil. (Crotpn tiglium. — Linnmis.) 930. Elaterium. (Ecbalium offici- narum.— ^icA.) 931. Colchicum. (Colchicum au- tumnal e. — Linnmus.) 932. Black hellebore. (Helleborus niger. — lAnnosus. ) 933. White hellebore. (Veratrum album. — Linnceus.) a. Veratria. 934. Squill. (Scilla maritima.— IdnncBUs.) 935. Ergot of rye. (Sphaeria pur- purea. — Pries.) a. Ergotism. I 904. Old age.^ POISONS.'* 936. Opium. (Papaver somnife- rum. — ZAnnceits.) 937. Indian hemp. Cannabis Indica, (Cannabis sativa. — Linnmu^.) 938. Alcohol. a. Delirium tremens. 939. Ether vapor. 940. Chloroform vapor. 941. Henbane. Hyoscyamus. (Hyoscyamus niger. — Idn- nceus.) 942. Deadly nightshade. Bella- donna. (Atropa belladonna. — lAnnmus.) a. Atropa. 943. Thorn apple. Stramonium. (Datura stramonium. — Lin- nisus.) 944. Prussic acid. a. Oil of bitter almonds. 6. Laurel water. 945. Cyanide of potassium. 946. Nitro-benzole. 947. Wourali. Curara. Woorara. (Strychnos toxifera. — Schomburgk.) 948. Hemlock. Conium. (Conium macu latum. — XAnnceus.) 949. Monkshood. Aconite. (Acon- itum napellus. — Linnceus.) a. Aconitia. 950. Foxglove. Digitalis, (Digi- talis purpurea. — lAnncsus^ a. Digitalin. 951. Tobacco. (Nicotiana taba- cum. — lAnncBiLS.) a. Nicotia. 952. Hemlock dropwort, (CEnanthe crocata. — IdnncBus. ) 953. Nux vomica. (Strychnos nux vom ica. — Linnceics. ) a. Strychnia. b. Brucia. 954. Upas tieute. (Strychnos tieute. — Leschenhault.) 955. Upas antiar. (Antiaris toxi- caria. — Leschenhault.) 956. Calabar bean. (Physostigma venenosum. — Balfour.) 957. Fool's parsley, ( JLthusa cyn- apiu m . — Linnceus. ) 958. Water hemlock. (Cicuta virosa. — Linnceus.) 959. Camphor. (Cinnamomum camphora. — F. Nees and Ohernfiaier.) 960. Cocculus Indicus. (Anamirta cocculus. — Wight and Ar- nott.) 961. Darnel. (Lolium temulen- tum. — Linnceus.) 962. Indian tobacco. Lobelia. (Lobelia inflata. — Lin- nwus.) I 905. Debility.^ 963. Laburnum. (Laburnum vul- gare. — Griesbach.) 964. Yew. (Taxus baccata. — Lin- nceus.) 965. Poisonous fungi. a. Mouldy bread. 966. Poisonous grain. a. Lathyrus. (Lathyrussati- vus.) ^Paralysis from Lathy- rus. Animal Poisons. 967. Spanish fly. Cantharides. 968. Decayed and diseased meat. 969. Poisonous meat. 970. Poisonous cheese. 971. Poisonous milk. 972. Poisonous fish. a. Mussels. Gaseous Poisons. 973. Ammonia. 974. Nitrous acid vapor. 975. Chlorine. 976. Carbonic acid. 977. Carbonic oxide. 978. Coal gas. 979. Cyanogen. 980. Sulphuretted hydrogen. (939.) Ether vapor. (940.) Chloroform vapor. 981. Putrid and morbid exhala- tions. 982. Other noxious effluvia. Mechanical Iekitants. 983. Pounded glass. 984. Steel filings. Poisoned Wounds, Varieties : 985. a. By venomous animals. 1. Snakes. 2. Scorpions. 985' 3. Stinging insects. (900.) Cases of death from stinging insects should be entered here, and those of irritation only from that cause at No. 900. 6. By animals having infectious disedse. (23, Glanders. (24. Farcy. (25. Equinia mills. (26, Malignant pustule. (91. Hydrophobia, Rabies. (2-) Cow-pox. 986. c. By dead animal matter. * Cases of irritation from stinging insects should be entered here, and those of death from that cause under poisoned wounds. "^ This mode of return is only to be employed when the cause of death is not traceable to definite ^ When the cause of this aifection has been ascertained, the case should be returned under the head of the primary disease, the secondary affection being also specified. • In returning cases of P^^^o^^^/to^^giy i§?^i)J^,^/^^^ 324 THE NOMENCLATURE OP DISEASES. 987. d. By morbid secretions. 988. e. By vegetable substances. General Injuries. 992. Burns and scalds.^ 993 Lightning stroke. 994. Multiple injury. (The cause and extent to be stated.) 995. Asphyxia. Syn.., Apncea. Injuries of the Head and Face, a.— op the head. 1000. Contusion. a. Cephalhaematoma. 1001. Scalp-wound; bone not ex- 1002. Scalp-wound ; bone exposed. 1003. Concussion of the brain. 1004. Fracture of the vault of the skull.'' [pression. a. Simple, without de- &. " with depression. c. Compound, without de- pression. d. " with depression. 1005. Hernia cerebri. [skull. 1006. Fracture of the base of the 1007. Wound of the skull.'' 1008. Laceration of the brain, without fracture. 1009. Injuries of vessels.''*^ (Spe- cify which.) 1010. Injuries of the cerebral nerves. B.— OF THE FACE. 1011. Contusion. 1012. Wound.' 1013. Injuries of vessels.' ^^ (Spe- cify which.) 1014. Foreign bodies in the ear. 1015. ^ " nose. 1016. " " antrum. 1017. " " soft parts. 1018. Fracture of the facial bones. 1019. " " lower jaw. (410, 411.)" 1020. Dislocation of the jaw. Injuries of the Eye, 1021. Contusion. 1022. Contusion, with rupture of the sclerotic. Syn.^ E'Up- tured globe. 1023. Contusion, with dislocation of the lens. 1024. Contusion, with hemorrhage into the globe. 1025. Foreign bodies in the cornea . or conjunctiva. 1026. Foreign bodies in the cavity of the eye.* 1027. Wound of the eyelid. 1028. " " conjunctiva. 1029. " " sclerotic. 1030. " " cornea. 1(131. " » lens. 1032. " " iris. I 989. 1. Poisoned arrows. I (947.) Wourali. INJURIES. a. From Drowning. b. *' Hanging, c. " Strangling. d. " Plugging of air- passages ; e. ff., With bread; with e. " Overlying, [blood. LOCAL INJURIES.* 1033. Dislocation of the globe. (158.) Total disorganisation of the- ei/efrom injury. 1034. Wounds and injuries of the parts within the orbit. 1035. Chemical injuries of the eye- lids and eye. 1036. Burns and scalds. iNJtmiES OF THE NECK. 1037. Contusion of the soft parts. 1038. Fracture of the hyoid bone. 1039. *' " cartilages of the larynx. 1040. Rupture of the trachea. 1041. Dislocation of the hyoid bone. 1042. Wound. a. Superficial. 6. Cut throat.' c. Gunshot.'' d. From the mouth. 1043. Injuries of vessels.'' ^^ (Spe- cify which.) (992,) Burn and scald of the larynx. 1044. Foreign bodies in the air- 1045. " " pharynx. 1046. ■ " " oesophagus. 1047. Injury of the pharynx and oesophagus by corrosive substances. INJURH-S OF THE ChEST.^ 1048. Contusion. 1049. Fracture of the ribs (includ- ing costal cartilages), with- out injury to lung. 1050. Fracture of the ribs (includ- ing costal cartilages), with injury to lung. 1051. Fracture of the sternum. 1052. Wound of the parietes. 1053. Perforating wound of the chest.'' ^ 1054. Penetrating wound of the pleura or lung.'' ^ 1055. Wound of the anterior me- diastinum.^ 1056. Wound of the pericardium and heart. ■' ^ 1057. Injuries of vessels.'^ ^ ^ (Spe- cify which.) 1058. Rupture of the heart or lung without wound or fracture/ Injuries of the Back. (Includ- ing the whole spinal region.) 1059. Contusion. 1060. Sprain. [. 990. 2. Subcutaneous injection.* I 991. /. By mineral substances. /. From Crushing. g. " Gaseous poisons. (See list at p. 323.) 996. Privations.^ Syn., Starvation. 997. Exposure to eoid.^ 998. Infant exposure." m^. Neglect.^ 1061. Wound.' « 1062- Fracture and dislocation of the spine." 1063. Injury of the cord, without known fracture. Injuries of the Abdomen. 1064. Contusion. 1065. Contusion with rupture of muscles."' 1066. Contusion with rupture of viscera. 1067. Wound of the parietes.^ 1068. Wound of the parietes, with protrusion of uninjured viscera. 1069. Wound of the parietes, with protrusion of wounded viscera. 1070. Wound of the parietes, with wound of unprotruded viscera. 1071. Wound of viscera without wound of parietes.^ 1072. Injuries" of vessels.'' ^ ^ (Spe- cify which.) 1073. Foreign bodies in the peri- toneal cavity. [ach. 1074. Foreign bodies- in the stom- 1075. Foreign bodies and concre- tions in the intestine. 1076. Fistula from injury, and ar- tificial anus. Injuries of the Pelvis. 1077. Contusion. 1078. Wound of the male perineum, scrotum, and penis.^ 1079. Wound of the female peri- neum and vulva. 1080. Wound of the vagina and internal female organs.' 1081. Wound of the rectum.' 1082. " " anus. 1083. " " bladder. 1084. Rupture of tlie bladder with- out wound. 1085. Ruptureof the bladder from fracture.*^ 1086. Injuries of the pregnant uterus. 1087. Injuries of vessels.' ^ ^ (Spe- cify which.) 1088. Foreign bodies in the va- gina. 1089. Foreign bodies in the rec- tum. (570, 601*.) Foreign bodies in the bladder and urethra.^^ ' In returning such cases, specify the agent employed. * Including explosions. When limited to one part of the body, the part is to be specified ; e.g.. Scald of the larynx. ^ Any affection that may have been induced by this cause ought to be stated. * In all cases of injury specify whether accidental, judicial, homicidal, self-inflicted, or in battle. * In such cases state the main features in the fewest words possible. •^ If from gunshot, to be so stated, 1 In such cases state the main features in the fewest words possible. ^ Specify when from gunshot. ^ Return such cases in the order given at pp. 310 and 311. *° Injuries of the alveoli and teeth are to be returned with the other aflfections of those parts. ^' The seat of the injury and the existence and extent of paralysis to be stated; " Rupture of the bladder from accumulation of urine is usually from stricture, and must be returned under the appropriate heading (592). ^= Return such cases with calculus in the bladder and urethra. Digitized by Microsoft© THE NOMENCLATUEB OF DISEASES. 325 1090. Fracture and dislocation of the pelvis. 1091. Fracture and dislocation of the pelvis, with rupture of the bladder or urethra. IKJUETES OF THE UPPER EXTfiEMITIES. 1092. CoBtusion. 1093. Sprain. (Specify which joint.) 1094. Wouud.^ = 1095. " of joint. 1096. Injuries of vessels.^ =>* (Spe- cify which.) 1097. Foreign bodies imbedded.^ 1098. Separation of epiphyses. 1099. Greenstick fracture, or bending of bone. (Specify which bone.) 1100. Fracture. (State whether simple or compound.) 1101. Fracture of clavicle. 1102. " scapula. 1103. " humerus. 1104. " forearm. 1105. " carpus, meta- carpus, and phalanges. 1106. Ununited fracture, or false joint. (Specify which bone.) 1107. Dislocation. (When com- pound, to be so stated.) 1108. Dislocation of the sterno- clavicular joint. 1109. Dislocation of the acromio- clavicular joint. 1110. Dislocation of the shoulder, nil. " " elbow. 1112. " " wrist and carpus. 1113. " " thumb. 1114. " " phalangeal joints. Injuries of the Lower Extremities. 1115. Contusion. 1116. Sprain. (Specify which joint.) 1117. "Wouud.='=' 1118. " of joint, 1119. Injuries of vessels.^ " ^ (Spe- cify which.) 1120. Foreign bodies imbedded.^ 1121. Separation of epiphyses. 1121*. Fracture. (When com- pound, to be so stated.) 1122. Fracture of the femur. 1123. " cervix femoris. 1124. " Intracapsular. 1125. " trochanter ma- jor. 1126. " patella. " leg, both hones. 1127. 1128. " tibia alone. 1129. " fibula alone. 1130. " bones of the foot. 1132. 1133. 1134, 1135, 1136, 1137, 1138, 1139, 1140, 1141, 1142, Ununited fracture, or false joint. (Specify which bone.) Dislocation. (When com- pound, to be so stated.) Dislocation of the hip. " patella. " knee, " head of fibula. " foot, at the ankle. Dislocation of the foot, at calcaneo-astragaloid, and seapho-astragaloid joints. Dislocation of the foot, at astragalus. Dislocation of the foot, at OS calcis. Dislocation of the foot, at other tarsal bones. Dislocatiou of the foot, at metatarsus, and phalanges. 'Injuries of the Absorbent System. 1142*. Foreign bodies and concre- tions. 1143. Wound of lymphatics. Injuries not Classified. 1144. Rupture of muscle. 1145. Rupture of tendon. 1146. Foreign substances in the cellular tissue. * Return such cases in the order given at pp. 310 and 311. ^ In such cases state the main features in the fewest words possible. ^ Specify when from gunshot. The topics of the Appendix — namely, Human Parasites and Congenital Malformations — have been already described at pp. 146 to 148, and 234 to 238, where the lists are printed under the subjects which they embrace as topics relative to Pathology. Digitized by Microsoft© THE SCIENCE AND PRACTICE OF MEDICmE. PAKT III. THE NATUKE OF DISEASES— SPECIAL PATHOLOGY AND THEKAPEUTICS. It is my object in this part of the Text-book to treat of the diseases compre- hended in the two groups or classes into which the London College of Physi- cians has arranged diseases — namely, into General and Local. The first, namely, General Diseases, comprehend the two sections, A and B, as defined at p. 307. Section A commences with what are generally known as specific or mias- matic fevers ; terms which may be sufiiciently understood, but are far from un- objectionable. Next come the malarious fevers, and then follow the epidemic disorders, which diflTer more or less distinotly from the previous members of the group. Lastly, come those febrile affections which are either solely or occa- sionally excited by the introduction of some animal matter in a state of change. In section B, constitutional diseases are described, together with those forms of disordered nutrition in which the affection, whether localized or not, has' a tendency to invade more organs than one in the same individual, either si- multaneously or in succession. In the following series of chapters on topics relative to the pathology of the General Diseases, it is intended to describe. Firstly, The common proper- ties or characters peculiar to specific or miasmatic diseases. Secondly, The nature of malarious diseases. Thirdly, The nature and management of epi- demics of disease. Fourthly, The nature of constitutional diseases ; and Fifthly, To describe in detail the several diseases individually, their general nature and causes; pathology and morbid anatomy ; symptoms, course, and com- plications; diagnosis, prognosis, and treatment. The employment of the words miasmatic and zymotic, as they are terms in common daily use, expressive of preventible diseases, whose causes are remova- ble, ought not to be understood as signifying more than this, and not express- ing scientifically any rigidly defined group of diseases. The terms are used to bring together those diseases which possess the peculiar character, in com- mon, of suddenly attacking great numbers of people, at intervals, in unfavora- ble sanitary conditions. In the language of Dr. Farr, the " diseases of this class distinguish one country from another — one year from another ; they have formed epochs in chronology ; and, as Niebuhr has shown, have influenced not only the fall of cities, such as Athens and Florence, but of em- pires ; they decimate armies, disable fleets ; they take the lives of criminals that justice has not condemned ; they redouble the dangers of crowded hospi- tals ; they infest the habitations of the poor, and strike the artisan in his Digitized by Microsoft® NATURE AND OlliaiN OE SPECIFIC DISEASES. 327 strength down from comfort into helpless poverty ; they carry away the infant from the mother's breast, and the old man at the end .of life ; but their direst eruptions are excessively fatal to men in the prime and vigor of age. They are emphatically the morbi popularca." The name Zymotic (first suggested by Dr. William Farr, to designate scientifically such a class of diseases) is not to be understood now as implying the hypotliesis that these diseases are fermentations, which the derivation of the term would lead one to believe. It has become extensively used of late as applied to the diseases whose characters as a class are already indicated, and for which some convenient term was required. The class, then, to which the term zymotic has been applied was intended to comprehend all the prin- cipal diseases which have prevailed as epidemics or endemics,— all those which are due to paludal or animal malaria, and those which are due to specific dis- ease poisons, capable of propagation from one human being to another, and communieable either by direct contact, or indirectly through various channels of human intercouree, contaminating drinking-water or infecting the air, or by animuls in. a date of disease, as well as dietic and parasitic diseases. For reasons already stated at p. 307, the general diseases of section A can- not be subdivided into groups, scientifically distinct from each other, to permit of their being defined. " So many points of contact exist among them, that there is no one fact that could be predicated of any number which was not either too wide in its comprehensiveness, or too narrow in its exclusive- ness, or which did not imply a theory which might have been proved to be true of certain members of the group, but could only be applied theoretically of the remainder." The term zymotic, in the returns of the Registrar-General, has been mg,de to include diseases of which the origin und mode of propaga- tion are wholly dissimilar. The class, as originally described by Dr. Farr, compreliend "diseases that are either epidemic, endemic, or contagious, induced by some specific body, or by the want or bad qualities of food," which incongruous group was subdivided into miasmatic, enthetic, dietic, and paranitic diseases, — a subdivision having no common principle involved in details of their description. Even the miasmatic group (concerning which there is a more general agreement among medical men as to the characters of diseases due to a miasma than regarding others) include diseases of very doubtful origin, and others altogether incongruous. Quinsy, a simple inflam- mation of the fauces, is placed next to scarlatina; erythema, a simple redness of the skin, is associated as a subordinate variety of erysipelas. Diarrhoea stands between dysentery and cholera, and has no place among diseases of the intestinal canal; and the order concludes with ague and rheumatism, "ignor- ing the malarious origin of the one, and the constitutional character of the other." The following chapters are therefore intended to set forth the salient points in the- Pathology of Class A of the General Diseases, so far as they can be conveniently grouped together. CHAPTER I. ON THE NATURE OF THE SPECIFIC OR GENERAL DISEASES, COMMONLY CALLED MIASMATIC. "In a rude manner, the General Diseases may be classed as the fii-st section of local diseases — the blood itself being regarded as the organ affected." In the greater number of the diseases of the group to which the name spe- Digitized by Microsoft® 328 SPECIAL PATHOLOGY — SPECIFIC DISEASES. cifie or miasmatic may be given, the blood is generally more or less changed, and by some is presumed to be the primary seat of diseases which result from specific poisons, of organic origin, either derived from without or generated within the body. These specific poisons tend to produce in the blood an excess of those decomposing organic compounds which physiology teaches us are always present in the circulating current. The diseases of this kind, which are to be first described, constitute a group of diseases sometimes termed "a&ute specific" (Walshe), or "general dis- eases" (Wood), because they primarily and essentially implicate the entire system; and all of them may be comprehended under the term "general diseases." Throughout their course, and from the first, they each variously modify the composition of the blood, the calorification and the innervation of the body. Each and all of them, also, during their progress, give rise to some lesions in the textures, of a special anatomical character, when the disease is not too rapidly fatal to allow of these pathological features to become developed, as is sometimes the case in yellow fever, typhoid fever, plague, cholera. These maladies run an acute and rapid course ; they are attended with more or less fever ; and in the majority of instances, the fever which accompanies them has a fixed duration. The greater number of them are contagious, or capable of being propagated from person to person, under certain conditions not yet well understood ; and, lastly, all of them are pro- duced by an extrinsic poison, either of a miasmatic or specifically contamina- ting nature, or by the implanting of a spedfie virus. The specificity, so to speak, of these diseases, consists in certain characters which distinguish each of them from any other disease, and in the constancy by which, from time immemorial, such characters have continued to distin- guish them. Although medical opinions regarding their pathology may change, yet the essential characters of these "specific diseases" are not known to change. Each of these diseases observes a constancy and regularity of plan in the construction and development of its morbid processes (Paget). Each of them has some essential character or characteristics by which they are severally distinguishable. The course of the febrile phenomena is found to be distinctive, the duration of the febrile state not less so, as well as the anatomical signs which distinguish the local lesions, the development of which are concurrent with the general or constitutional phenomena. Of all truths relating to the phenomena of disease, the most important are those which relate to the order of their succession. Specificity cannot be denied to those diseases in which, during their natural course, we find that every phenomenon is related (in a uniform manner, so far as exact investigation has extended) to certain phenomena that coexist with it, and to others that have preceded and will follow it. When it is found that a series of phenomena occur in (thousands, millions) x number of instances in the same order, within similarly uniform periods of time, and altogether with so much regularity that those who are instructed, on visiting a patient for the first time, can not only affirm what has gone before, but may predict what is to come after (the highest achievement of science) — it is impos- sible to avoid concluding that such an invariable sequence has as constant a cause. This conclusion flows from the very constitution of our nature, and is in- evitable ; and on our knowledge of the facts relating to such order of succession is founded every reasonable anticipation of future events, and whatever power we possess of influencing those phenomena in the management of the disease, to the advantage of our patients and the community at large. When it is found, moreover, that there are many series of these phenomena, which may be called a, b, c, d, &c., occurring in difierent persons, and at different times, all perfectly distinguishable, and never by any chance capable of being con- founded by a properly trained pei-son, it is impossible to avoid concluding that the causes of A, b, c, d, &c., are not identical, and must be in fact dis- ■ Digitized by Microsoft® NATUKB AND ORIGIN OF SPECIFIC DISEASES. 329 similar. Moreover, mere uniformity in the sequence of such phenomena as obtains in the natural course of the respective diseases is of itself enough and sufficient (to most minds) to warrant the belief that the diseases they represent are specific. This view of the specificity of each of these diseases may be held indepen- dent of the causation of them being also specific ; but the term " specific," from this point of view, necessarily means that such unlike effects must have unlike causes ; and the term " specific," as we use it, is derived simply from the fact that (following the analogy of natural history) the different diseases just named A, b, c, d, &c., have been considered as so many diflferent species, preserving their individuality through all time, as the rose, the apple, the dog, the whale, or any other animal or plant preserves theirs. Like animals and plants, also, such specific diseases may disappear from off the face of the earth, when they can no longer "struggle for existence" against the well- directed measures of sanitary science. These measures may eventually be capable of rendering the existence of many specific diseases an impossibility — as much so as the existence of a megatherium or even a wolf would now be an impossibility in this country. The origin of all specific diseases, or "how their respective first oontagia arose," is alike unknown. "This in Pathology is just such a question as in Physiology is 'the origin of species.' Indeed, it is hardly to be assumed as certain that these apparently two questions may not be only two phases of one. Hourly observation tells us that the contagium of small-pox will breed smallpox, that the contagium of typhus will breed typhus, that the contagium of syphilis will breed syphilis, and so forth ; that the process is as regular as that by which dog breeds dog, and eat cat, — as exclusive as that by which dog never breeds cat, nor cat dog ; and prospectively we are able to predict the results of certain exposures to contagion as definitively as the results of any chemical experiment. But retrospectively we have not the same sort of certainty ; for we cannot always trace the parentage of a given case of small-pox or measles" (Simon, Sixth Report on Publie Health, p. 54). The same may be said of animals ; given any individual calf, cat, dog, or child, we cannot always trace its parentage.* * "And here," says Mr. Simon, " notwithstanding the obvious diffiuulties of proof either way, some persons will dogmatize that there must have been an overlooked inlet for contagium, while others will dogmatize that there must have been in the patient's body an independent origination of the specific chemical change. Presuming (as may pretty confidently be presumed) that in the history of mankind there was once upon a time a first small-pox case, a first typhus case, a first syphilis case,